Rules of smile design in orthodontics for creating beautiful smile.

1. Dr. Ishfaq Ahmad
BDS, BCS, MCPS, MS
Rajshahi Medical College Dental Unite
Ten Rules For One Perfect Smile

3. Smile
 Smile, a person’s ability to express a range of
emotions with the structure and movement of the
teeth and lips, can often determine how well a
person can function in society.

4. Types of smile
Different types of smile: A) commissure
smile; B) social smile; and C) spontaneous
smile.
A B
C

5. Why Should Smile Be
Perfected?
 "The smile is our business card" must always be
respected and considered, since there is scientific
evidence that the smile is the most important
element in the context of dentofacial esthetics.
 It is determining not only in the perception of
facial attractiveness, but also with the perception
of one's psychological characteristics. Whenever
patient's smile undergo esthetic changes they
become more attractive and young with positive
changes in psychological terms.

6. Ten Rules Of One Perfect Smile
 Smile arc — Maxillary incisors in vertical position
 Maxillary central incisors ratio and symmetry
 Anterosuperior teeth ratio
 Presence of anterosuperior space
 Gingival design
 Levels of gingival exposure
 Buccal corridor
 Midline and tooth angulation
 Details — Tooth color and anatomical shape
 Lip volume.

7. Rule one — Smile arc : Maxillary
incisors in vertical position
 Vertical positioning of maxillary incisors is
determining to achieve an attractive, young smile.

8. Maxillary incisors in vertical position
 The incisal edge of maxillary central incisors must
be bellow the cuspid tip of canines, ensuring
dominance of central incisors.

9. Smile Arc

10. configuration of smile arc
Smile arcs are of three types:-
 Consonant
 Straight
 Non consonant

11. Types of smile arc
Figure -Different types of smile arc: A) convex or curved; B) plane or straight;
and C) inverted or reverse.

12. Ideal Incisor Contour Design
 The step between central and lateral incisors
must range from 1.0 to 1.5 mm for women and
from 0.5 to 1.0 mm for men.

13. Need for individualizing orthodontic
bracket bonding

14. Rule Two— Ratio and symmetry of
maxillary central incisors
 2nd rule asserts that ideal width-height (W/H)
ratio and symmetry of central incisors must be
achieved. Subsequently, the clinician must plan
75 to 85% ratios which are considered more
esthetic (Fig 9A). Values tend towards 75%,
central incisors will have a longer pattern widely
accepted by women, whereas in 85% ratios,
incisors will have a wider pattern widely accepted
by men.

15. Ratio of maxillary central incisors

16. Clinical Consideration
 Figure 10 shows a patient whose chief complaint was
having a big tooth in the esthetic zone. His right
central incisor was 9.1-mm wide and 9.5-mm high,
thereby producing a W/H ratio of 95%, highly
unesthetic. His left central incisor, however, was 8.0-
mm wide and 9.5-mm high, thereby producing a W/H
ratio of 84% which is within normality. Thus, treatment
comprised 0.5-mm interproximal wear on the mesial
and distal surfaces of right central incisor, followed by
orthodontic space closure. As a result, ideal W/H ratio
remained on the left side, whereas it changed on the
right side. Subsequently, with a view to fulfilling the
2nd commandment, left central incisor reconstruction
was repeated so as to achieve maximum symmetry

17. Clinical Consideration

18. Symmetry of maxillary central incisors
 The nearer the midline, the greater the need for
symmetry, and the further from the midline, the
higher the number of slight asymmetries clinically
acceptable.

20. Rule Three— Proportion between
antero superior teeth
 Once the ideal vertical positioning of maxillary
incisors is achieved and W/H ratio as well as
maximum symmetry between central incisors is
attained, the proportion between anterosuperior
teeth is then adjusted. This feature is widely
considered in Dentistry and it is based on the
golden ratio.In frontal view, there exists a width
proportion of teeth seen in perspective. This fact
is shown by Figure 13 in which visible lateral
incisor width accounts for 62% of central incisor
width, while canine width accounts for 62% of
lateral incisor width.

21. Teeth Proportion

22. Clinical Consideration
 The case described in Figure 15 shows
asymmetrical proportion between antero superior
teeth. The golden ratio grid makes it easier to
clearly identify the discrepancy, revealing that the
right lateral incisor had reduced mesio distal
dimension. Orthodontic treatment opened up a
space in the lateral incisor area which would
undergo further esthetic restoration so as to fulfill
the 3rd rule which is the proportion between
antero superior teeth. Furthermore, reshaping
was performed to improve symmetry between
central incisors and adjust the step between
central and lateral incisors, emphasizing the
dominance of central incisors in one's smile.

23. Figure 15 - Clinical case illustrating the importance of proportion between anterosuperior
teeth: A) initial closed-up view in the esthetic zone showing right lateral incisor of
reduced width (blue arrow); B) initial smile; C) final result showing adequate proportion
between teeth in the esthetic zone; D) final smile.

24. Rule Four- Presence of
anterosuperior space
 All midline diastemas must be closed either by
orthodontic or multidisciplinary treatment.
 According to the literature, small midline
diastemas (not greater than 2.0 mm) might go
unnoticed by laypeople.
 If space is to remain after orthodontic treatment,
the distal surface of lateral incisors should be the
area of choice.

25. Clinical Consideration

26. Rule Five — Gingival design
 Some dental textbooks bring the following
parameter of ideal esthetic gingiva: "Canine
gingival margin must coincide with central incisors
gingival margin, where as lateral incisors gingival
margin must be slightly below this line" (Fig 18A).
Indeed, such parameter provides maximum smile
esthetics. However, should clinicians follow the
aforementioned parameter in cases in which
canines and central incisors are equal in length,
they might position central incisors incisal edge at
the same level or above canines. As a result,
plane or inverted smile arcs might be produced,
and so are unesthetic smiles.

27. Gingival design

28. Gingival design
 Results reveal that incisal smile design (white
esthetics) is the most important factor of dental
esthetics. Thus, in addition to what is
recommended in the 1st commandment (smile
arc), one may opt for a modified gingival design in
which the gingival margin of central and lateral
incisors coincide and are slightly (0.5 - 1.0 mm)
below canines, the gingival margin of central
incisors is below canines (0.5 - 1.0 mm) and the
gingival margin of lateral incisors is below central
incisors (0.5 mm) (Fig 18B).

29. Gingival asymmetry
 After determining ideal gingival design, whether
classic or modified, the clinician should focus on
correcting potential asymmetries, provided that
they are evident at smiling.

30. Figure 19 - Two clinical cases with gingival asymmetry in the esthetic zone requiring
different treatment procedures: A) real need for intervention due to great gingival
asymmetry exposure at smiling; and B) smile without gingival asymmetry exposure and
with no need for treatment.

31. Management of gingival discrepancy
Cases of gingival discrepancy between central
incisors (Fig 20) are basically corrected by either
one of the following three treatment methods:
 a) gingivoplasty of the lowest incisor;
 b) intrusion and incisal restoration of one central
incisor;
 c) extrusion of one central incisor with posterior
incisal wear.

32. Rule Six — Gingival exposure
 High smile with gingival exposure not greater
than 3.0 mm is more esthetic, followed by
medium and low smiles.

33. Clinical Consideration
 Figure 23 shows a smile with great gingival tissue
exposure. Orthodontic treatment was performed
with extraction of first premolars and, after
removing the fixed appliances, the patient was
referred to gingivoplasty and manufacture of
dental veneers in the esthetic zone.
Subsequently, with the aid of dermatological
procedures that included the use of botulinum
toxin, gingival tissue exposure was minimized,
thereby favoring satisfactory esthetic outcomes.
Importantly, despite being a case of gingival
smile, the 1st commandment was fulfilled with an
ideal smile arc as well as proper design of incisal

34. Clinical Consideration
Figure 23 - Clinical case illustrating gingival smile treatment: A) initial smile; B)
orthodontic treatment outcome, illustrating ideal incisal design; and C) final smile.

35. Rule Seven— Buccal corridor
 intermediate buccal corridors are ideal, followed
by narrow or nonexistent ones. Thus, cases of
wide buccal corridors require rapid maxillary
expansion and/or dental expansion so as to
enhance smile esthetics.

36. Figure 24 - Different types
of buccal corridor: A) buccal
corridor at smiling; B) wide
buccal corridor; C)
intermediate buccal
corridor; and D) narrow
buccal corridor.

37. Rule Eight— Midline and tooth
angulation
 Midline deviations equal to or greater than 2.0
mm and any degree of changes in tooth
angulation must be corrected.
 According to the literature, midline deviations not
greater than 3-4 mm are not identified by
laypeople but minimal changes of 2.0 mm in
angulation of anterior teeth in frontal view are
considered unesthetic by laypeople.

38. Clinical Consideration
 Figure 26 shows a case with both problems:
Midline deviation and changes in tooth angulation
in the esthetic zone. One can easily notice that
correcting the second is prioritized over the first.
Mini-implant was used to correct changes in tooth
angulation. Additionally, once parallelism between
the incisal edge line of central incisors and
interpupillary line was restored, esthetic benefits
were evinced.

39. Figure 26 - Clinical case illustrating the negative impact of changes in incisor angulation
in frontal view: A) initial frontal photograph and smile photograph; B) intermediate
result after incisal plane and angulation correction with the aid of mini-implant.

40. Rule Nine —
Tooth color and anatomical shape
 The 9th commandment basically determines
three procedures to aid esthetic refinement:
a) Dental bleaching;
b) Adjustment of contacts;
c) Reshaping of incisal edges in the esthetic
zone.

41.  Figure 27A shows a case of orthodontic finishing. A closed-
up view of teeth in the esthetic zone reveals the presence of
black triangles and absence of papillae in interproximal
spaces (Fig 27B). Papillae must fill interdental spaces up to
the contacts. However, when contacts are inappropriate,
interdental spaces might remain. Papilla/contact relationship
in central incisors is of 1:1, for this reason, interdental space
is half occupied by the papilla and half occupied by contact
(Fig 28). Thus, interproximal wear was carried out to position
the contact in the mid portion of clinical crowns, thereby
favoring closing of black triangles and ideally filling the
papillae (Fig 27C). With a view to enhancing incisal edges
contour, slight wear was also carried out to minimize incisal
embrasures, thus improving esthetics and giving the smile a

42. Figure 27 - Clinical case illustrating the importance of detailing and tooth anatomical
shape: A) orthodontic finishing phase; B) closed-up view of the esthetic zone showing
black triangles caused by inappropriate contact; C) final results after teeth reshaping.

43. Figure 28 - Diagram illustrating the
ideal position of contact between
central incisors so as to favor filling
of interproximal spaces by
interdental papillae.
Figure 29 - Diagram illustrating the
ideal disposition of incisal embrasures,
showing a natural and progressive
increase from central incisors to
canines.

44. Rule Ten — Lip volume
 The last commandment is related to the structure
that frames the smile: the lips. The current
standard of beauty comprises not only a beautiful
smile, but also voluminous lips and greater
maxillary incisor exposure at smiling, at rest or
while speaking.

45. Clinical Consideration
 According to the literature, anteroposterior
positioning of teeth plays a key role in
determining lip volume. As an example, Figures
30 and 31 show a 38-year-old patient with deep
bite and severe reduction in lip vermilion
exposure. Once deep bite and incisor proclination
(particularly of lower incisors) were corrected,
there were significant improvements in lip volume,
thereby enhancing lip esthetics and giving the a
younger look.

46. Figure 30 - Case
report illustrating
increased lip
volume after
orthodontic
treatment: A)
initial; B) final; C)
initial profile
showing thin lips;
and D) final profile
showing increased
lip volume.

47. Figure 32 - Clinical case illustrating
multidisciplinary
treatment associating Orthodontics
and
Dermatology to correct smile and lip
volume:
A) initial; B) final; C) initial profile
showing thin lips;
and D) final profile showing
increased lip volume
after using filling agents for lip
augmentation.

48. FINAL CONSIDERATIONS
 The 10 Commandments of smile esthetics may
be considered a starting point for clinicians who
aim at achieving maximum esthetic in dental
treatment. Special attention should be given to
the first four commandments associated with
dominance of central incisors at smiling.