SMILE ETHICS IN ORTHODONTICS

SMILE ETHETICS IN
ORTHODONTICS
T Rohini
2nd MDS
Department of orthodontics
VSDCH

Contents
Introduction
Anatomy of smile
Ideal characteristics of smile
And examination
Smile classification
Classification of esthetics
Treatment consideration for macroethetics,
miniesthetics and microesthetics
Extraction v/s Non extraction on smile
esthetics
Conclusion
References

INTRODUCTION
A facial expression in which the eyes brighten and the corners of the mouth curve
slightly upward and which expresses especially amusement, pleasure, approval, or
sometimes scorn
Merriam Webster
 Impairment in smiling has been associated with a higher incidence of depression.
 Dental deformities have forced many to either consciously or unconsciously cover
the teeth with the lips, hiding the dentition and precluding a pleasing smile.
 The goal of orthodontic treatment should be to attain of the possiblebest possible
occlusal relationship while maintaining or enhancing facial aesthetics.

4
Important
feature in
facial
esthetics
34% eyes
10% hair
5% skin
5% shape
of nose
15% overall
facial
proportions
31%
smile
Goldstein surveyed the general public on their view of what feature was considered
most important in facial esthetics
Roy S. The eight components of balanced smile. J Cl'm Dent 2005; 39(3): 155-67

ANATOMY OF
THE SMILE
The upper and lower lips frame the display zone of
the smile.
the components of the smile are the teeth and the
gingival scaffold.
The soft-tissue determinants of the display
zone are
6
Intercommiss
ural width
Lip thickness
& interlabial
gap
Smile index
(width/height)
Gingival
architecture
Matthews TJ. The anatomy of smile. J Prosthe Dent 1978 Feb;78 (2);128-34.

The Vertical Aspects Of Smile
Anatomy
In a youthful smile, 75-100 % of the maxillary central incisors should be positioned
below an imaginary line drawn between the commissures.
MORLEY RATIO
Maxillary anterior tooth display
Upper lip drape
Gingival display
Matthews TJ. The anatomy of smile. J Prosthe Dent 1978 Feb;78 (2);128-34.

IDEAL CHARACTERISTICS OF
SMILE

1) Smile arc: Maxillary incisors in vertical position
2) Ratio and symmetry of maxillary central incisors
3) Proportion between anterosuperior teeth
4) Presence of anterosuperior spaces
5) Gingival design
6) Gingival exposure’
7) Buccal corridor
8) Midline and tooth angulation
9) Tooth color and anatomical shape
10) Lip volume
Andre Wilson Machado; 10 commandments of smile esthetics. Dental Press J Orthod. 2014 July-Aug;19(4):136-57.
What Should Be Assessed In A Smile

Maxillary Incisors In Vertical Position
The incisal edge of maxillary central incisors must be below the cuspid tip of
canines, ensuring dominance of central incisors.
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.
11
The smile arc is defined as the contour of the incisal edges of the maxillary
anterior teeth relative to the curvature of the lower lip during a social smile.

12
Convex Or Curved Plane Or Straight Inverted Or Reverse

14
ideal ratio (75 - 85%) long teeth (ratio < 75%) short or squared teeth (ratio > 85%)
 Take note of width/height ratios for maxillary central incisors.
 Aim at esthetic proportion (75 – 85%) and maximal symmetry.
 75%, central incisors will have a longer pattern widely accepted by women
 85% incisors will have a wider pattern widely accepted by men

3. Proportion Between Anterosuperior Teeth
16
It is based on the golden ratio initially proposed by Levin in 1978
Dental esthetics and the golden proportion Edwin I. Levin, B.Ch.D. Journal of Prosthodontic Dentistry Sep 1978
In its simplest form it is the proportion between a larger part and a
smaller part
When the ratio between B and A is in the golden proportion, then B
is 1.618 times larger than A.
A golden propotion also exists in the dentition:
When viewd facially, the witdh of each anterior tooth is 60% of
the adhacebt tooth. (mathematical ratio 1.68:1:0.68)

 Studies reveal that the golden ratio should be applied with caution
 the value of 62% must be interpreted as a mean rather than a
standard to be pursued.
 Furthermore, greater proportions (67% and 70%) have been
highlighted as being more esthetic, thereby revealing that there
seems to exist a strong preference for wider instead of narrower
incisors
Bukhary SMN, Gill DS, Tredwin CJ, Moles DR. The influence of varying maxillary lateral incisor dimensions on
perceived smile aesthetics. Br Dent J. 2007;22(12):687-93.

4.Presence Of Anterosuperior Spaces
18
Although esthetics is highly subjective, all midline diastemas must be closed
either by orthodontic or multidisciplinary treatment

5. Gingival Design
19
 Gingival tissue architecture must also be taken into account in esthetic
treatment.
 The terms "pink esthetics" and "red esthetics" have been used to describe
ideal gingival contour at smiling

 Gingival margin of central incisors must be leveled or slightly bellow (0.5
to 1.0mm) canines.
 Gingival margin of lateral incisors must be leveled or slightly bellow (0.5
mm) central incisors.
 Multidisciplinary treatment is necessary for ideal gingival design
adjustment.

.
21
6.Gingival Exposure
Different smile lines according to Tjan et al
High Smile,
• Total exposure of
clinical crowns
• continuous strip of
gingival tissue
Medium Smile
• greater (75%) or total (100%)
exposure of clinical crowns
• interdental or interproximal papillae
Low Smile
• characterized by
clinical crown
exposure not greater
than 75% and no
gingival tissue.
 Assessing the number of teeth and gingival tissue exposure in the esthetic zone is
of paramount importance for smile esthetics
 According to the literature, gingival tissue exposure at smiling is not a negative
feature
 Gingival exposure less than 3 mm is not unesthetic.

22
7.Buccal Corridor
wide buccal corridor intermediate buccal
corridor
narrow buccal
corridor
Yang IH, Nahm DS, Baek SH. Which hard and soft tissue factors relate with the amount of buccal corridor space during
smiling?. The Angle Orthodontist. 2008 Jan;78(1):5-11
Buccal corridor is the bilateral space between the vestibular surface of
visible maxillary posterior teeth and lip commissure at smiling.
there are three types of buccal corridors:
1. wide, usually followed by narrow maxillary dental arch
2. intermediate, followed by dental arches of intermediate transverse
dimensions
3. narrow or nonexistent, associated with severe transverse dental
arches

 Buccal corridor is not critical in smile esthetics.
 Intermediate buccal corridor is more attractive, compared to wide buccal
corridor (narrow smile arch)
 Wide buccal corridor should be avoided and maxillary expansion should be
indicated whenever necessary.
Yang IH, Nahm DS, Baek SH. Which hard and soft tissue factors relate with the amount of buccal corridor space during
smiling?. The Angle Orthodontist. 2008 Jan;78(1):5-11

8.Midline And Tooth Angulation
 While midline deviations are hardly noticed by laypeople, changes in tooth
angulation in the esthetic zone are extremely deleterious to one's smile.
 According to the literature,minimal changes of 2.0 mm in angulation of anterior
teeth in frontal view are considered unesthetic.

 Midline deviation is less relevant than changes in tooth angulation in the esthetic zone.
 Midline deviation equal to or greater than 2.0 mm and any degree of changes in tooth
angulation must be corrected.
 Rufenacht and Goldstein agree that the midline should be placed in the center of the
smile and its location be guided by symmetry and balance of that smile rather than facial
anatomy

9.Tooth Color And Anatomical Shape
The shape, size and color of teeth should be harmony for an attractive and
beautiful smile.
The teeth appear lighter and brighter at a younger age, darker and duller as aging
progresses.
Shade of six front teeth naturally vary. The two front teeth i.e. centrals are the
lightest, laterals are slightly less bright than the central incisors. The next adjacent
teeth are cuspids least bright
Shape is as noticeable as shade. Each front tooth has a particular ratio of
width to height of each tooth and a relative proportion to the other front teeth.
Stewart’s Clinical Removable Partial Prosthodontics 3rd edition by Rodney D. Phoenix, David R. Cagna and
Charles F. Defreest

Although there is no anthropological basis for masculinity or femininity in
teeth in some cases the shape of the teeth gives 2 types of smile.
1. feminine type smile
2. masculine type smile
Feminine type smile-nicely curved and rounded teeth give a feminine look
Masculine type smile-more squarish and angular teeth
give a masculine look
27
Charles F. Defreest

 Procedures comprising are usually performed in the orthodontic
finishing phase.
 determines three procedures to aid esthetic refinement:
i. Dental bleaching
ii. Adjustment of contacts
iii. Reshaping of incisal edges in the esthetic zone.

 Papillae must fill interdental spaces up to the contacts.
 when contacts are inappropriate, interdental spaces might remain.
Papilla/contact relationship in central incisors is of 1:1
 interproximal wear can carried out to position the contact in the mid
portion of clinical crowns, thereby favoring closing of black triangles
and ideally filling the papillae
 Contact adjustments are necessary to correct potential black spaces.
the ideal position of contact between
central incisors so as to favor filling
of interproximal spaces by interdental
papillae.

30
10.Lip Volume
 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.
 According to the literature, anteroposterior positioning of teeth plays a key
role in determining lip volume
 Teeth retraction must be carefully considered, since lip volume may
decrease, thereby resulting in thinner unesthetic lips

8
Peck et al introduced a classification of smile based onthe anatomic studies of Rubin
According to them smile can be
1.Posed
2.Unposed or Spontaneous
Ackerman & Ackerman modified peck et al’sclassification by designating
Stage I – Posed smile
Stage II – Unposed
smile
Orthodontics current Principles and techniques – GraberT.M., 5rd edition

• Elicited by laughter or great
pleasure, is involuntary.
• It results from maximum contraction
of the upper and lower lip elevator
and depressor muscles, respectively.
Resulting in full expansion of lips,
with maximum anterior tooth
display and gingival show
POSED
Social Smile
UNPOSED
Enjoyment Smile
• The smile typically used as a greeting,
is a voluntary, unstrained, static facial
expression.
• The lips part due to moderate
muscular contraction of the lip
elevator muscles, and the teeth and
sometimes the gingival scaffold are
displayed.
Orthodontics current Principles and techniques – GraberT.M., 5rd edition

:
1.The commissure smile
most common pattern
seen in approximately 67% of the population.
typically Cupid's bow, the corners of the mouth are
first pulled up and outward, followed
by the levators of the upper lip contracting to show
the upper teeth.
In this classic smile pattern, the lowest incisal edges
of the maxillary teeth are the central incisors. From
this point, the convexity continues superiorly with the
maxillary first molar being 1 to 3 mm higher than the
incisal edge of the centrals.
A spontaneous smile results in a maximum
movement of the commissure from 7 to 22 mm.
SMILE STYLES
Neuromuscular Smile Patterns; Rubin
Abhishek Bansal,Arihant Jain, Sugnesh Patel, Atri Naik, Charu Deshmukh, V
akiChinde3,
AsmaFatima,Afshan; Mini and Micro Esthetics in Orthodontics: Review on Clinical
Considerations in Orthodontic Diagnosis ;Archives of Dental and Medical ResearchV
ol1
Issue 1(2017)

2.The cuspid smile
• 31% of the population.
• The shape of the lips is commonly visualized as a diamond.
• This smile pattern is identified by the dominance of the levator
labii superioris. They contract first, exposing the cuspid teeth,
then the comers of the mouth contract to pull the lips upward and
outward. However, the corners of the mouth are often inferior to
the height of the lip above the maxillary cuspids.
• Eminent personalities with cuspid smiles include Elvis, Tom
Cruise, Drew Barrymore, Sharon Stone, Linda Evangelista and
Tiger Woods.
akiChinde3,
ol1
Issue 1(2017)

• characterizes 2% of the population.
• The shape of the lips is typically illustrated as two parallel
chevrons.
• The levators of the upper lip, the levators of the corners of the
mouth, and the depressors of the lower lip contract
simultaneously, showing all the upper and lower teeth
concurrently.
• The key characteristic of this smile is the strong muscular pull
and retraction of the lower lip downward and back.
• In this smile pattern both maxillary and mandibular incisal planes
are generally flat and parallel. Some celebrated personalities
with complex smiles include Julia Roberts, Marilyn Monroe,Will
mith and Oprah Winfrey.
36
3.The complex smile
akiChinde3,
ol1
Issue 1(2017)

High smile
Reveals the total cervico-incisal length of the
maxillary anterior teeth and a continuous band
of gingiva.
Average smile
Reveals 75% to 100% of the maxillary anterior
teeth and 4he interproximal gingiva
only.(Fig.27)
. Low smile
Displays less than 75% of the anterior teeth.
3.SMILE LINE
Anthony H. Tjan 1984
Textbook of Orthodontics -op.kharabanda,2ndedition

Although there is no anthropological basis for masculinity or femininity in
teeth in some cases the shape of the teeth gives 2 types of smile.
1. feminine type smile
2. masculine type smile
Feminine type smile-nicely curved and rounded teeth give a feminine look
Masculine type smile-more squarish and angular teeth
give a masculine look
38
Charles F. Defreest

CLASSIFICATION OF SMILE ESTHETICS
Microesthetics
Miniesthetics
Macroesthetics

CLASSIFICATION OF ESTHETICS
MACRO
ESTHETICS
MINI ESTHETICS MICRO ESTHETICS
Facial Proportion
Profile
Symmetry
Lip posture
Throat form
Tooth-lip
Relationships
Smile analysis
Buccal corridor space
Midline
Smile symmetry
Transverse cant
Tooth proportions
Incisal edge position
Incisal connectors
Embrasures
Gingival shape ,height
and contour
Tooth Shade and
Color.

Macro-esthetics
• The face in all three planes of space
• Aspects that would be noted in this step would
be asymmetry, excessive or deficient face
height,mandibular deficiency or excess etc

First step in macroesthetics is to determine the facial
proportions.
FACIAL PROPORTIONS

43
VERTICAL DIVISION
The face is ideally divided into equal thirds:
•Upper: tragion to glabella
•Middle: glabella to subnasion
•Lower: subnasion to menton
Color Atlas of Dental Medicine Orthodontic Diagnosis 1st Edition
Thomas Rakosi

The lower third of the face is further divided into two unequal parts:
a.Subnasion to stomion (one-third or 18 to 20 mm)
b. stomion to menton (two-thirds or 36 to 40)
Color Atlas of Dental Medicine Orthodontic Diagnosis 1st Edition
Thomas Rakosi

HORIZONTAL DIVISION
• An ideally proportional face can be divided into
central , medial ,and lateral equal fifths.
• The separation of the eyes and the width of the eyes
,which should be equal ,determine the central and
medial fifths.
• The nose and chin should be centered within the
central fifth, with the width of the nose the same as or
slighly wider than the central fifth
• The interpupillary distance should equal the width of
the mouth.
• This is called “ the rule of fifth”
45
Contemporary Orthodontics ;William R Proffit ;6th Edition

BALANCE AND SYMMETRY
 Facial symmetry is defined by the
facial midline.
 The midline runs through the center of
the face and a philtrum of the lip
(cupid‘s bow), dividing it into right
and left sides.
 The more symmetric and identical the
sides, the more inherently harmonious
and beautiful the face (horizontal
symmetry).

FACIAL PROFILE
 Two lines, one dropped from the bridge of the nose to the base of the upper lip, and a
second one extending from that point downward to the chin.
 An angle between them indicates either profile convexity (upper jaw prominent relative
to chin) or profile concavity (upper jaw behind chin).
 A convex profile therefore indicates a skeletal Class II jaw relationship,
 whereas a concave profile indicates a skeletal Class III jaw relationship.
47

Evaluation Of Lip PostureAnd Incisor Prominence
 Detecting excessive incisor protrusion or retrusion is important because of the effect on
space within the dental arches
 Incisor protrusion can cause lips to protrude and are difficult to bring into function over
the protruding teeth. (bimaxillary protrusion)

The teeth protrude excessively two conditions are met:
(1) The lips are prominent and everted
(2) the lips are separated at rest by more than 3 to 4 mm (which is
sometimes termed lip incompetence).

 Excessive protrusion of the incisors is revealed by prominent lips that are separated
when they are relaxed
 For such a patient, retracting the teeth tends to improve both lip function and facial
esthetics.
 If the lips are prominent but close over the teeth without strain, the lip posture is
largely independent of tooth position.
 For that individual, retracting the incisor teeth would have little effect on lip function
or prominence

Lip posture and incisor prominence should be evaluated by viewing the profile with
the patient’s lips relaxed.
Relating the upper lip to a true vertical line passing through the concavity at the base
of the upper lip (point A) and by relating the lower lip to a similar true vertical line
through the concavity between the lower lip and chin (point B)
•
•
If the lip is significantly
forward of this line, it can be
judged to be prominent; if the
lip falls behind the line, it is
retrusive.

Throat form is an important factor in establishing optimal facial esthetics,
 Evaluated in terms of the contour of the submental tissues (straight is
better), chin–throat angle (closer to 90 degrees is better), and throat
length.
 Both submental fat deposition and a low tongue posture contribute to a
stepped throat contour, which becomes a “double chin” when extreme.

Contemporary Orthodontics – William R. Profitt , 6th edition.

The objectives of this study were to evaluate
1. the impact of maxillary incisor inclination on the aesthetics of the profile view
of a smile,
2. to determine the most aesthetic inclination in the profile view of a smile and
correlate it with facial features,
3. to determine if dentists, orthodontists, and laypeople appreciate differently
incisor inclination in smile aesthetics.
It was concluded upper incisor inclination affects smile aesthetics in the profile
view.
Orthodontists tend to prefer labial crown torque in comparison with
lingualcrowninclination.
53
Aesthetic Evaluation Of Profile Incisor Inclination.
Nathalie Ghaleb, Joseph Bouserhal and Nayla Bassil-Nassif; European Journal of
Orthodontics 33 (2011) 228–235.

MACROESTHETICS DESIGN ELEMENTS
TOOTH REVEAL:
 amount of tooth structure or gingiva that shows in various views
and lip positions.
 Even the most beautiful anterior teeth will have little esthetic value
for the patient if the amount of reveal is unflattering to the face.
54
Morley J, Eubank J. Macroesthetic elements of smile design. The Journal of the American Dental Association. 2001 Jan
1;132(1):39-45.
“M” Position :
• By having the patient say the letter “M” repetitively and then allow his or her
lips to part gently, the clinician can assess minimum tooth reveal.
• The amount of maxillary or mandibular teeth that show in this position has
been demonstrated to be different at different stages of life.
• younger patients may show between 2 and 4 mm of maxillary incisal edge
in this position, in elderly the maxillary incisal edge reveal shrinks and
even disappears.
• In some the mandibular incisal edges begin to show. Carefully locating the
“M” position reveal and creating the smile accordingly can have the fluid
effect of making smile age-

“E” Position:
• Patients say the letter “E” in an
uninhibited and exaggerated way; the
clinician can ascertain the maximum
extension of the lip.
• During photographic analysis of the
smile, everything that shows can be
considered to be in the esthetic zone.
Morley J, Eubank J. Macroesthetic elements of smile design. The Journal of the American Dental Association. 2001 Jan
1;132(1):39-45.

INTERCOMMISSURE LINE AND
LOWER LIP FRAMING
 In broad smile position, imaginary line drawn
through the corners of the mouth.
 Intercommissure line, or ICL.
 Amount of maxillary tooth reveal below ICL
interacts with the viewer’s perception of the
patient age.
 youthful smile, approximately 75 percent to
100 percent of the maxillary teeth would show
below this line.
 When the visual space created between upper
and lower lip in full smile is considered, the
maxillary anterior teeth should fill between
75% to 100% of that space to create a youthful
look.
56

VESTIBULAR SPACE
 In a broad smile, the amount of reveal of the maxillary posterior
teeth also can become esthetic consideration.
 In-patients who have narrow arch from and wide lip extension, tooth
reveal behind the canines can be in shadow or disappear completely.
 This condition has been called Deficient Vestibular Reveal, or DVR.
DVR may have negative esthetic consequences in certain patients.
57

Mini-esthetics
• The smile framework
• Bordered by the upper and lower lips
• includes assessments such as excessive
gingival display on smile, inadequate
anterior tooth display, inappropriate
gingival heights, and excessive buccal
corridors

59
It is important to evaluate not only the characteristics of the face, but the relationship of
the dentition to the face
A second aspect of dental to soft tissue relationships is the vertical relationship of the
teeth to the lips, at rest and on smile.
A third important relationship to note is whether an up-down transverse rotation of the
dentition is revealed when the patient smiles or the lips are separated at rest. This
often is called a transverse cant of the occlusal plane

SMILE ANALYSIS
Facial attractiveness is defined more by the smile than by soft tissue relationships at rest.
For this reason, it is important to analyze the characteristics of the smile
There are two types of smiles:
• the posed or social smile, and the emotional smile.
• The social smile is reproducible, and is the one that is presented to the world
routinely.
• The emotional smile varies with the emotion being displayed .The social smile is
the focus of orthodontic diagnosis. In smile analysis, the oblique (3/4) view as
well as the frontal and profile views are important. Three things need to be
considered.
Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part II. Smile analysis and treatment strategies.
Am J Orthod Dentofacial Orthop 2003; 124; 116-27.

1.Amount of Incisor and Gingival Display
• Elevation of the upper lip on smile should stop at or near the gingival margin, so that
all of the upper incisor is seen.
• Some display of gingiva is acceptable and can be both esthetic and youthful
appearing.
• Lip elevation that does not reach 100% display of the incisor crowns is less
attractive.
• It also is important to remember that the vertical relationship of the lip to the incisors
will change over time, with the amount of incisor exposure decreasing.
61

The amount of vertical exposure in smiling depends on the following
six factors.
Upper lip length
Incisor inclination
Lip elevation
Vertical maxillary
height
Crown height
Vertical dental
height

2.Transverse Dimensions Of The Smile Relative To The Upper Arch
Depending on the facial index, i.e., the width of the face relative to its height, a broad smile
may be more attractive than a narrow one
width of the maxillary dental arch as seen on the smile should be proportional to the width
of the midface.
63
• Excessively wide buccal corridors (sometimes called
"negative space") are unesthetic.
• Widening the maxillary arch can improve the
appearance of the smile if cheek drape is significantly
wider than the dental arch.
• It should be kept in mind, however, that arch expansion
can be overdone, must be avoided

3.The Smile Arc
• The smile arc is defined as the contour of the incisal edges of the
maxillary anterior teeth relative to the curvature of the lower lip
during a social smile.
• For best appearance the contour of these teeth should match that of
the lower lip.
• If the lip and dental contours match, they are said to be consonant.
• if not then it is said to be flat, or non consonant
64

Dynamic smile analysis: Changes with age
Desai S, Upadhyay M, Nanda R
American Journal of Orthodontics and Dentofacial Orthopedics.
2009 Sep
• objective :define age-related changes in the smile.
• This study established age- related dynamic norms.
• As a person ages, the smile gets narrower vertically and wider transversely.
• The dynamic measures indicate that the muscles’ ability to create a smile
decreases with increasing age.

66
Dynamic smile evaluation in different skeletal patterns
Siddiqui N, Tandon P, Singh A, Haryani J. The Angle Orthodontist.
2016 Nov
• Objective :To evaluate dynamic smile in different skeletal patterns and to correlate
vertical smile parameters with the underlying causative factors.
• Different skeletal patterns exhibit their characteristic smile features.
• Upper lip length is not responsible for increased incisal display during smile.
• Increased incisal display during smile is more closely associated with upper lip
elevation than vertical skeletal and dental factors.

SMILE EVALVATION
Smile analysis is traditionally performed in 1 view—the frontal view.
But just as a person’s overall appearance is 3-dimensional, according Sarver and
Ackerman smile analysis must include 4 dimensions-
1. Frontal,
2. Oblique,
3. Sagittal,
4. Time
67

Frontal Dimension
• To visualize and quantify the frontal smile, Ackerman and Ackerman developed
a ratio, called the smile index that describes the area framed by the vermilion
borders of the lips during the social smile.
• The smile index is determined by dividing the inter-commissure width by the
interlabial gap during smile.
• This ratio is helpful for comparing smiles among different patients or across time

Frontally, we can visualize and quantify 2 major dimensions of the smile:
1. VERTICAL
2. TRANSVERSE
VERTICAL CHARACTERISTICS of the smile are broadly categorized into 2 main
features:
a) incisor display
b) gingival display
 Other vertical smile characteristics are the relationships between the incisal edges of the
maxillary incisors and the lower lip, and between the gingival margins of the maxillary
incisors and the upper lip.
 The gingival margins of the canines should be coincident with the upper lip and the lateral
incisors positioned slightly inferior to the adjacent teeth.

70
TRANSVERSE CHARACTERISTICS
1. Arch form
2. Buccal corridor
3. Transverse cant of the maxillary occlusal plane.
 Arch form plays a pivotal role in the transverse dimension of the smile.
 Recently, much attention has been focused on the use of broad, square arch forms
in orthodontic treatment.
 When the arch form is narrow or collapsed, the smile may also appear narrow and
therefore present inadequate transverse smile characteristics.

Transverse Cant Of The Maxillary Occlusal Plane.
 Can be due to differential eruption and placement of the anterior teeth or skeletal
asymmetry of the mandible resulting in a compensatory cant of the maxilla.
71
 Diagnosed by asking the patient to bite on a
tongue blade or a mouth mirror in the premolar
area during the clinical examination

2.OBLIQUE DIMENSION:
• shows characteristics of the smile not obtainable on the frontal view and certainly not
obtainable through any cephalometric analysis.
• In the most desirable orientation, the occlusal plane is consonant with the curvature
of the lower lip line i.e., the smile arc.
72
B

3.SAGITTAL DIMENSION
The 2 characteristics best visualized in the sagittal dimension are overjet
and incisor angulation.
 The amount of anterior maxillary projection also greatly influences smile
characteristics in the frontal view, even in terms of transverse smile
dimension.
 When the maxilla protrusive, the wider portion of the dental arch is
positioned more posteriorly relative to the anterior oral commissure.
 This creates the illusion of greater buccal corridor in the frontal
dimension.
73

4.THE FOURTH DIMENSION: TIME
Growth, maturation, and aging of the perioral soft
tissues have a profound effect on the appearance of
both the resting and smiling presentations.
Orthodontic patients can be categorized as
preadolescent, adolescent, and adult.
 In preadolescent patients, the facial soft tissues
are still in a growth phase, while Adolescent
patients, growth of the skeletal subunits and
have roughly achieved their facial soft tissue
“look.”
 In adults, nuances in the aging of perioral and facial soft tissues become
increasingly important.
74

Measurements used to evalvate smile esthetics
Measurements on frontal photographs.
a)Smile width (mm)- Intercommissure width at smiling
b)Smile height (mm)- Interlabial gap during smiling.
c)3-3 distance (mm)-most distal points of maxillary canines
d.) 4-4 distance (mm) -most distal points of maxillary first
premolars
e.) Visible dentition width (mm) - Distance between most
lateral left and right points of visible maxillary dentition
during smiling.
f). Maxillary gingival display (mm) - Amount of maxillary
gingival exposure between inferior border of upper lip and
marginal gingiva of maxillary central incisors
75
Erdal Is¸ ıksal, Serpil Hazar and Sercan Akyalçın. Smile esthetics: Perception and comparison of treated and
untreated smiles Am J Orthod Dentofacial Orthop 2006;129:8-16.

76
g)Smile index (ratio)- Smile width divided by smile height
h)3-3 distance/smile width (ratio)- Intercanine distance divided by
intercommissure width
i)4-4 distance/smile width (ratio) - Interpremolar distance divided by
intercommisure width
j)Visible dentition width/smile width (ratio) -Visible dentition width divided by
smile width
k)3-3 distance/visible dentition width (ratio) -Intercanine distance divided by
visible dentition width .

DIRECT BIOMETRIC MEASUREMENTS
a)Width of central incisor (mm) -Distance measured
between most distal and mesial points of maxillary
central incisor crowns
b)Height of central incisor (mm) - Distance measured
between marginal gingiva and incisal edges of
maxillary central incisor crowns.
c)Height of central incisor during smiling (mm) -
Distance measured between most superior and inferior
points on maxillary central incisor crowns during
smiling.
d)Upper lip length at rest (mm) -With mandible and
lips in rest position, distance from subnasale to inferior
border of upper lip.

Upper lip length during smiling (mm) -
Distance from subnasale to inferior border of
upper lip during smiling.
Sn to incision distance (mm)- Distance from
subnasale to incisal edge of maxillary central
incisor.
Maxillary incisor display (ratio %) -Height
of central incisor during smiling divided by
actual height of central incisor.
Upper lip length/Sn to incision (ratio) - Lip
curtain over incisors at rest: upper lip length
distance divided by subnasale to incision
distance.
Upper lip length during smiling/Sn to incision (ratio)- Lip curtain over incisors
during smiling upper lip length during smiling divided by subnasale to incision
distance.
Upper lip length during smiling/upper lip length (ratio)-Upper lip contraction
during smiling: the ratio of upper lip smiling length to actual upper lip length.

Micro-esthetics
• The teeth
• This includes assessment of
tooth proportions in height
and width, gingival shape
and contour, connectors and
embrasures black trianguIar
holes, and tooth shade

HEIGHT AND WIDTH REALATIONSHIP
80
Two proportions must be considered:
1.The relation between height and width of each tooth,
2. the relation of height and width among the teeth.
Gillen et al found the following proportions of width among the upper
anterior teeth:
 lateral incisors have 78% of the width of the central incisor
 lateral incisor has 87% of the width of the canine
 canine has 90% of the width of the central incisor

 Gillen et al suggests that the height of upper lateral incisor must be 82% of the height
of the crowns of the central incisor and canine.
 Most authors define the height/width ratio of 0.80 for the upper central incisor as a
standard
 Chu et al developed a proportionality gauge (commercialized by Hu-Friedy®) uses a
formula, for dental proportions that are visually available in a color scale that must be
considered by the professional
Chu SJ. Range and mean distribution frequency of individual tooth width of the
maxillary anterior dentition. Pract Proced Aesthet Dent. 2007;19(4):209-15.

PRINCIPLES OF GOLDEN PROPORTION (LOMBARDI)
 Suggest that there is an ideal mathematical ratio of 1.6:1:0.6 exist between the actual
widths of the centrals, laterals and cuspids when they are viewed simultaneously from
the front.
 The principles of golden proportion are generally used as a guide rather than a rigid
mathematical formula.
82
Levine 62%proportions:
Levin EI. Dental esthetics and the golden proportion. J Prosthet Dent. 1978 Sep;40(3):244-52.

Connector area
•Morley & Eubank introduced the term connector area as a useful tool and a visual
goal to optimize smile esthetics in dental patients.
•The most esthetic relationship of connector area between the maxillary anterior teeth is
referred to as the 50-40-30 rule.
83
The contact point between central incisors must correspond to 50% of the height of the
crown, and must gradually reduce, turning into 40% between central and lateral incisors,
and 30% between lateral incisor and canine.

EMBRASURES
 The embrasures (the triangular spaces incisal & gingival to the contact) ideally are
larger in size than the connectors
 Short interdental papillae -“black triangles”
84
 Reshaping of teeth by orthodontic root paralleling and
flattening of the mesial surfaces of the central incisors,
followed by space closure, will lengthen this contact area and
correct the black triangles

Gingival height, shape and contour
• The central incisor has the highest gingival level, lateral incisor is 1.5 mm incisal
and canine is at the same level as central incisor.

86
Gingival Zenith
The gingival zenith (GZ) is defined as the most apical point of the marginal gingival scallop
can be orthodontically defined by
1. the position of the bracket bonded to the upper anterior teeth
2. second-order bends on orthodontic wires, also known as artistic
bends that define the mesiodistal tippings of these teeth.

Chu et al quantified the position of the gingival zenith of upper anterior teeth:
 1 mm distal to the line that following the long axis of the tooth, on the upper
central incisor;
 0.4 mm distal to the line following the long axis of the lateral incisor;
 At the center of the line that represents the long axis of the upper canine
The mesiodistal angulation patterns which are used for the anterior teeth, the greatest tipping
is established for the lateral incisors and canines which have the zenith less distally displaced
if compared to the central incisor

TREATMENT PLAN :
MacroEsthetic, Miniesthetic, microestehtic Consideration

TREATMENT PLANNING
Macro-Esthetic Considerations : Skeletal Problems
Treatment planning depends on the diagnostic information from the macroesthetics part
of the clinical examination and considering the possibilities for correcting facial
disproportions.
There are three possibilities:
(1) Orthodontic camouflage
(2) Orthognathic and/or plastic surgery
(3) Orthodontic growth modification, for growing patients only,

Orthodontic Camouflage
 orthodontic camouflage of mandibular deficiency by retracting the
upper incisors tends to be more successful in a northern European–
derived population, in which most people have a convex profile.
 Camouflage of mandibular excess by retracting the lower incisors
can be effective in patients of Asian descent, who often have
prominence of the lower lip more because of protruding incisors
 In these situations and with other jaw discrepancies, it still is up to
the patient to decide whether tooth movement alone would be
successful treatment

Surgery
 Genioplasty, the most frequently used adjunct to orthodontics ,
enhances facial appearance by adding volume to the lower face
 Orthognathic procedures that decrease volume (mandibular setback
and superior repositioning of the maxilla) improve facial proportions
but can make the patient look older.
 For that reason, almost all surgical Class III treatment now includes
maxillary advancement, which often is combined with mandibular
setback in prognathic patients.

Growth Modification
 Jaw growth in all three planes of space can be modified, with a combination of
restraint of excessive growth and stimulation of favorable growth.
 greater growth modification is possible in Class III than in Class II patients—just the
reverse of the possibilities for camouflage
 CLASS 3 Cases :fixed and removable explanders,Implant supported expansion, FR
III Functional appliances, reverse pull head gear
 CLASS 2 cases: head gear, fixed and removable class 2 correctors

Mini-Esthetic Considerations: Improving the
Smile Framework
The primary goal of mini-esthetic treatment is to enhance the smile by correcting the
relationship of the teeth to the surrounding soft tissues on smiling.
In the development of the problem list, the examination focuses on three aspects of the
smile:
 vertical relationship of the lips to the teeth,
 transverse dimensions of the smile,
 smile arc

Vertical Tooth–Lip Relationships
If the tooth display is inadequate, elongating the upper teeth improves the smile, makes
the patient look younger
Orthodontic treatment approaches,
• extrusive mechanics with archwires,
• judicious use of Class II elastics to rotate the occlusal plane down anteriorly
• Rotating the maxilla down in front as it is advanced surgically can
improve smile esthetics, especially in patients with maxillary
deficiency

Three possible treatment approaches to excessive gingival display
1. intrusion of the maxillary incisors using segmented arch mechanics
2. intrusion using temporary skeletal anchorage
3. orthognathic surgery to move the maxilla up
Overgrowth of the gingiva may contribute to the initial excessive display, and if so,
recontouring the gingiva to gain normal crown heights is an important part of
correcting the problem.

Transverse Dimensions of the Smile
Transverse expansion of the maxillary arch, which decreases buccal corridor width,
improves the appearance of the smile if the buccal corridor width was excessive before
treatment.
correction can be done by dental expansion or by opening the midpalatal suture.
That depends on the amount of expansion that is needed to meet the other goals of proper
occlusion and long-term stability

The SmileArc
• If smile arc is too flat, putting the maxillary central incisor
brackets more gingivally would increase the arc of the
dentition, make the smile arc more consonant.
•
If the smile arc had been flattened during
treatment, step bends in the archwire would be an alternative
to rebonding brackets to correct it.

Micro-Esthetic Considerations: Enhancing the
Appearance of the Teeth
Treatment plans for problems relating directly to the appearance of the teeth fall into three
major categories:
(1) reshaping teeth to change tooth proportions
(2) orthodontic preparation for restorations to replace lost tooth structure and correct
problems of tooth shade and color
(3) reshaping of the gingiva.

Reshaping Teeth
• When minor reshaping is planned, it must be considered when brackets are placed, and
it may be easier to do this before beginning fixed appliance treatment
• Changing Tooth Proportions: primarily done when one tooth is to substitute for
another, and the most frequent indication is substituting maxillary canines for
congenitally missing maxillary lateral incisors

Correcting Black Triangles
 Can be accomplished by removing enamel at the contact point so the teeth can be
moved closer together .
 The proportional relationships of the teeth to each other the and progression of
connector heights should be maintained

Interaction Between Orthodontist and
Restorative Dentist
 When the teeth are small or if tooth color or appearance is to be improved by
restoration, during orthodontic treatment it is necessary to position them so that the
restorations will bring them to normal size and position.
 In modern practice, the restorations are either composite buildups or ceramic laminates
 Laminates being used particularly when it is desirable to change tooth color and shade
in addition to the size of the crown

Reshaping Gingival Contours:Applications of a
Soft Tissue Laser
It can be done using a diode laser
A laser of this type, in comparison to the carbon dioxide (CO2) or erbium: yttrium-
aluminium-garnet (Er:YAG) lasers has two primary advantages:
It does not cut hard tissue, no risk of damage to the teeth or alveolar bone if it is used
for gingival contouring,
It creates a “biologic dressing” because it coagulates, sterilizes, and seals the soft tissue
as it is used. There is no bleeding, no other dressing is required, and there is no waiting
period for healing.

103
Extraction vs Nonextraction: Smile Esthetics
Extraction treatment results in narrower dental arches which, in turn, are associated
with a less esthetic smile because the dentition is less full during a smile.
In addition, this arch width reduction creates unaesthetic black triangles at the
corners of the mouth and ‘negative’ spaces lateral to the buccal segments.
Eunkoo Kimet al. conducted a study and concluded that neither extraction nor
nonextraction treatment has a preferential effect on smile esthetics
Hsin-Chung Cheng and Yi-Chun Wang; Effect of nonextraction and extraction orthodontic treatments on smile
esthetics for different malocclusions. Am J Orthod Dentofacial Orthop 2018;153:81-6.

104
Effect of nonextraction and extraction orthodontic treatments on smile
esthetics for different malocclusions.
Hsin-Chung Cheng and Yi-Chun Wang; Am J Orthod Dentofacial Orthop
2018;153:81-6.
differences in esthetic perceptions and smile
variables between extraction and nonextraction treatments for different
malocclusions was evaluated
concluded that extraction subjects (overjet > 4mm) were rated higher than the
nonextraction subjects by dental professionals. A smile with greater maxillary
incisor show, number of displayed teeth, and buccal corridor ratio was
considered more esthetic.

Smile esthetics: Perception and comparison of treated and untreated
smiles
Isıksal, Hazar, and Akyalçın; Smile esthetics;Am J Orthod Dentofacial Orthop
2006;129:8-16.
The purposes of this study were to compare smile esthetics among extraction and
nonextraction patients , to assess certain dentofacial characteristics, and discuss how
these features relate to smile esthetics.
It was concluded that:
1. Subjects with ideal occlusions and Class I patients treated with or without
extractions were not differentiated in smile esthetics by 6 panels of judges
(orthodontists, plastic surgeons, artists, general dentists, dental professionals, and
parents).
2. Transverse characteristics of the smile appeared to be of little significance to an
attractive smile.
3. Maxillary gingival display and the ultimate positions of the anterior teeth have
definite effects on smile esthetics.
4. Treatment modality alone has no predictable effect on the overall esthetic
assessment of a smile.

Smile esthetics after orthodontic treatment with and without extraction of
four first premolars
Darryl K. Johnson and Richard J. Smith; AM J ORTHOD DENTOFAC ORTHOP
1995;108:1627.
Standardized frontal photographs were taken of the face during smiling for 60
retention patients;
Thirty patients had been treated with extraction of four first premolars, and 30
with no extractions.
Smile esthetics were judged by a panel of 10 laypersons. There were no significant
differences in the mean esthetic score of extraction and nonextraction patients.
The results indicate that there is no predictable relationship between the extraction of
premolars and the esthetics of the smile.

Smile outcome comparison of Invisalign and
traditional fixed-appliance treatment
Christou et al; Am J Orthod Dentofacial Orthop 2020;157:357-64.
Treated with traditional fixed appliances by integrating 15 variables such as Smile
width, Lip symmetry, Smile index, Smile cant, Buccal corridor, Upper lip thickness
Lower lip thickness, Gingival display, Maxillary dental midline, Maxillary incisor
position, Maxillary incisor inclination, Lip shape, Smile arc, Lip line.
orthodontic treatment with fixed appliances in patients with Class I nonextraction
produces greater changes in the patient's smile than Invisalign treatment.
Fixed appliances appear to be more effective in improving the variables that quantify
posttreatment–smile outcome.
However, Invisalign treatment may be of shorter duration
Neither of the 2 treatment modalities have any significant effect on the lips at rest or
on smiling.
107

Dynamic smile analysis in young adults
Christopher Maulik and Ravindra Nanda
(AJODO 2007)
The purposes of this study were to provide averages for various components of the
smile and to compare some of these in orthodontically treated and untreated
groups.
Also, smiles of patients with and without rapid maxillary expansion
(RME) were compared.
108

the study established dynamic norms for the smile and shows that orthodontic
treatment might not flatten the smile arc as previously suggested, and, furthermore,
that RME appears to be associated with a decreased buccal corridor.
109

• An ideal smile based on academic considerations may not be perceived as
the most attractive by laypeople.
• Due to the variation in esthetic perception by each person, participation
between orthodontists and patients for decision-making and treatment
planning is crucial to generate successful results.
Perception Of Smile Esthetics By Laypeople Of Different Ages;
Chompunuch Sriphadungporn and Niramol Chamnannidiadha, Progress in
Orthodontics (2017)

conducted to identify how different types of orthodontic interventions affect the esthetics
of the smile, any time after orthodontic treatment.
It was concluded that Orthodontic treatment affects the esthetics of the smile in three
dimensions.
There was slight evidence that extractions do not affect the smile width and buccal
corridors area.
Evidence on palatal expansion was controversial. The remaining existing data evidence
that investigated smile esthetics after orthodontic treatment was uncertain.
Clinical effectiveness of orthodontic treatment on smile
esthetics: a systematic review
Christou et al; Clinical, Cosmetic and Investigational Dentistry 2019:11 89–
101

Three-dimensional evaluation of smile characteristics in subjects with
increased vertical facial dimensions
Rana Demir, andAsli Baysal 2020AJODO
Study aimed to compare the smile characteristics of subjects with different
vertical facial dimensions and to use stereophotogrammetry to evaluate the
changes in facial animation upon smiling
2 groups according to their vertical facial height: increased and normal
Results showed that when smiling, horizontal movement of commissures was
less, upper lip elevation was higher and the upper lip was shorter in the
vertical group than in the normal group.
In the vertical group, the interlabial gap was increased both at rest and when
smiling.

Effect of buccal corridors on smile esthetics
Ramya KS1, Mahesh HV ; Indian Journal of Orthodontics and Dentofacial Research;2020
Evaluate the influence of buccal corridor space on smile attractiveness as
judged by lay persons and orthodontists
The difference in the judgement of lay persons and orthodontists pertaining
to the influence of buccal corridors on smile aesthetics was not significant.
Both lay persons and orthodontists rated small buccal corridor space as
having more attractive smile than the ones with large buccal corridor
space.

Effect of maxillary incisors, lower lip, and gingival display relationship on
smile attractiveness Hande Tosuna and Burc¸ak Kaya; AJO-DO 2020
 This study aimed to evaluate the effect of the relationship between maxillary incisors and
lower lip in conjunction with the maxillary gingival display on perception of smile
attractiveness.
 It was concluded that Elimination of maxillary gingival display helps to improve smile
attractiveness, whereas the coverage of maxillary incisor edges has a negative influence.

115
CONCLUSION
Today, well occluding casts and pleasing profiles can no longer be considered to be
adequate treatmemt goals for the orthodontist.
The ideal components of the smile should be considered not as rigid boundaries, but as
artistic guidelines to help orthodontists treat individual patients who are today, more
than ever, highly aware of smile esthetics.
Thus, the smile management of a patient starts right from understanding the patient’s
perceptions, concepts and needs of a beautiful smile and integrate it with our diagnosis,
treatment plan, and biomechanics so that at the end of day when treatment finishes both
the clinician and the patient has a reason to smile.

References
Orthodontics current Principles and techniques – GraberT.M. 5rd edition
Contemporary Orthodontics – William R. Profitt , 6th edition.
Textbook of Orthodontics -op.kharabanda, 2nd edition
116
Noshi Siddiqui; Pradeep Tandon; Alka Singh; Jitesh Haryani; Dynamic smile
evaluation in different skeletal patterns Angle Orthod. 2016

Abhishek Bansal, Arihant Jain, Sugnesh Patel, Atri Naik, Charu
Deshmukh, Vaki Chinde3, Asma Fatima, Afshan; Mini and Micro
Esthetics in Orthodontics: Review on Clinical Considerations in
Orthodontic Diagnosis ; Archives of Dental and Medical Research Vol 1
Issue 1(2017)
Dynamic smile visualization and quantiﬁcation: Part 2. Smile analysis and
treatment strategies David M. Sarver, DMD, MS,a and Marc B.
Ackerman,AJO-DO August (2003)
Morley J, Eubank J. Macro esthetic elements of smile design. J Am Dent
Assoc2001;132:39-45.
117
Smile analysis in orthodontics: Sapna Singla, Gurvanit Lehl; Indian
Journal of Oral Sciences Vol. Issue 2 May-Aug 2014
Dynamic smile analysis in young adults.Christopher Maulik and Ravindra
Nanda. Am J Orthod Dentofacial Orthop 2007;132:307-15
Buccal corridors and smile esthetics. Theodore Moore, Karin A. Southard,
John S. Casko, Fang Qian, and Thomas . Southard.Am J Orthod
Dentofacial Orthop 2005;127:208-13

SMILE ETHICS IN ORTHODONTICS

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