Esthetics in orthodontics

Esthetics in OrthodonticsEsthetics in Orthodontics
www.indiandentalacademy.comwww.indiandentalacademy.com

 IntroductionIntroduction
 Collective versus individual aesthetic judgmentsCollective versus individual aesthetic judgments
 ‘‘Averageness’ as the idealAverageness’ as the ideal
 Multiple-motive’ hypothesis of attractivenessMultiple-motive’ hypothesis of attractiveness
 Aesthetic standards—sources of evidenceAesthetic standards—sources of evidence
 Artistic guidelinesArtistic guidelines
 CephalometryCephalometry
 Anthropometric evidenceAnthropometric evidence
 Perceptions of a balanced facial profilePerceptions of a balanced facial profile
 Facial ProportionsFacial Proportions
 Facial Proportions And The Golden ProportionFacial Proportions And The Golden Proportion

 Smile arc and Buccal corridor spaceSmile arc and Buccal corridor space
 Interdisciplinary management of anterior dentalInterdisciplinary management of anterior dental
estheticsesthetics
 Esthetics and anterior tooth position: CrownEsthetics and anterior tooth position: Crown
lengthlength
 Esthetics and anterior tooth position: VerticalEsthetics and anterior tooth position: Vertical
positionposition
 Esthetics and anterior tooth position:Esthetics and anterior tooth position:
Mediolateral relationshipsMediolateral relationships
 Esthetics and anterior tooth position: TransverseEsthetics and anterior tooth position: Transverse
DimensionDimension

IntroductionIntroduction

 The improvement of a patient's facialThe improvement of a patient's facial
appearance is an objective common to a varietyappearance is an objective common to a variety
of clinicians including, of course, orthodontists.of clinicians including, of course, orthodontists.
 Planning an improvement requires guidelines, orPlanning an improvement requires guidelines, or
some kind of generally agreed ‘ideal’ set of facialsome kind of generally agreed ‘ideal’ set of facial
proportions. These presently exist in a variety ofproportions. These presently exist in a variety of
forms, from ‘atlas’ presentations of soft tisssueforms, from ‘atlas’ presentations of soft tisssue
facial landmarks involving linear and angularfacial landmarks involving linear and angular
parameters and ratios (e.g. Powell andparameters and ratios (e.g. Powell and
Humphries, 1984) to a plethora of cephalometricHumphries, 1984) to a plethora of cephalometric
analyses, albeit in the latter case, somewhatanalyses, albeit in the latter case, somewhat
handicapped by the inclusion of two-dimensionalhandicapped by the inclusion of two-dimensional
soft tissue data alone.soft tissue data alone.

 It is interesting how rarely one comesIt is interesting how rarely one comes
across an attempt at defending theacross an attempt at defending the
validity of recommended guidelines, evenvalidity of recommended guidelines, even
in established texts. However, there arein established texts. However, there are
some other fundamental questionssome other fundamental questions
relating to the achievement of facialrelating to the achievement of facial
attractiveness that deserve to beattractiveness that deserve to be
considered first, beginning with theconsidered first, beginning with the
question of the validity of collectivequestion of the validity of collective
assessment of attractiveness itself.assessment of attractiveness itself.

Esthetics OR Aesthetics?Esthetics OR Aesthetics?
 The word itself has provoked disagreement:The word itself has provoked disagreement:
should (Aesthetics properly begin with an "a“ orshould (Aesthetics properly begin with an "a“ or
an "e"? The term is derived from aisthesis, thean "e"? The term is derived from aisthesis, the
Greek word for "perception“ or "sensation."Greek word for "perception“ or "sensation."
Surprisingly, the application of this word to theSurprisingly, the application of this word to the
study of beauty was not a Greek idea, but ratherstudy of beauty was not a Greek idea, but rather
the creation of an 18the creation of an 18thth
century Germancentury German
philosopher, Alexander Baumgarten. He coinedphilosopher, Alexander Baumgarten. He coined
the word "aesthetica“ for a scholarly treatise,the word "aesthetica“ for a scholarly treatise,
written in Latin, exploring the harmonious naturewritten in Latin, exploring the harmonious nature
of poetry.of poetry.

 Baumgarten's "aesthetica" entered theBaumgarten's "aesthetica" entered the
English lexicon in the mid-18th century asEnglish lexicon in the mid-18th century as
aesthetics, a neologism with the Latinizedaesthetics, a neologism with the Latinized
"ae" digraph remaining affixed to the"ae" digraph remaining affixed to the
Greek word stem. Modern scientific andGreek word stem. Modern scientific and
technical usage has settled on esthetics,technical usage has settled on esthetics,
discarding the silent "a" from its beginning,discarding the silent "a" from its beginning,
the same as has been done for similarlythe same as has been done for similarly
hybridized words, such as aetiology andhybridized words, such as aetiology and
aether.aether.

Collective versus individualCollective versus individual
aesthetic judgmentsaesthetic judgments
 Clearly, when a clinician sets aboutClearly, when a clinician sets about
improving someone's appearance, it isimproving someone's appearance, it is
important first to know whether his mentalimportant first to know whether his mental
picture of the anticipated improvement willpicture of the anticipated improvement will
coincide with that of the patient, thecoincide with that of the patient, the
patient's family and acquaintances, andpatient's family and acquaintances, and
indeed, the public at large.indeed, the public at large.
*R. J. Edler, Background Considerations to Facial Aesthetics: Journal
of Orthodontics, Vol. 28, No. 2, 159-168, June 2001

 In other words, is it possible to makeIn other words, is it possible to make
collective judgements about the quality ofcollective judgements about the quality of
facial appearance? Or is there truth in thefacial appearance? Or is there truth in the
adage that ‘beauty is altogether in the eyeadage that ‘beauty is altogether in the eye
of the beholder’, as pointed out byof the beholder’, as pointed out by
Margaret Hungerford in l878.Margaret Hungerford in l878.

 This latter viewpoint, namely thatThis latter viewpoint, namely that
individual judgements are paramount andindividual judgements are paramount and
indeed, that collective assessments mayindeed, that collective assessments may
vary according to the whims of fashion canvary according to the whims of fashion can
be found in a variety of texts involvingbe found in a variety of texts involving
authors as diverse as Proffit (2000) to theauthors as diverse as Proffit (2000) to the
feminist writer Naomi Wolf (1990).feminist writer Naomi Wolf (1990).

 This would seem at first, therefore, to be aThis would seem at first, therefore, to be a
controversial topic, but perhaps thecontroversial topic, but perhaps the
answer lies in the sheer magnitude ofanswer lies in the sheer magnitude of
change in appearance that is beingchange in appearance that is being
proposed for a particular patient.proposed for a particular patient.

 From the psychological literature, it becomesFrom the psychological literature, it becomes
clear that agreement on attractiveness ratingsclear that agreement on attractiveness ratings
has been shown to be high in a number ofhas been shown to be high in a number of
cross-cultural studies, such as that undertakencross-cultural studies, such as that undertaken
by Bernsteinby Bernstein et alet al. (1982) in comparing Chinese. (1982) in comparing Chinese
and Caucasian attitudes.and Caucasian attitudes.
 Similarly, Thakera and Iwawaki (1979) whoSimilarly, Thakera and Iwawaki (1979) who
showed that English, Asian, and Oriental femaleshowed that English, Asian, and Oriental female
raters tended to show very close agreement inraters tended to show very close agreement in
assessing the attractiveness of a selection ofassessing the attractiveness of a selection of
Greek males.Greek males.
Bernstein, I. H., Lin, T. D., and McClellan. P. (1982) Cross-vs. within-
racial judgements of attractiveness, Perception & Psychophysics, 32, 495–503
Thakera, J. N. and Iwawaki, S. (1979) Cross-cultural comparisons in
interpersonal attraction of females towards males, Journal of Social Psychology,
108, 121–122. www.indiandentalacademy.comwww.indiandentalacademy.com

 In reciprocal studies, Maret (1983) firstIn reciprocal studies, Maret (1983) first
showed that a combined group ofshowed that a combined group of
male/female raters of White and Cruzanmale/female raters of White and Cruzan
(Native of US Virgin Islands) racial origin(Native of US Virgin Islands) racial origin
similarly assessed a group of Cruzansimilarly assessed a group of Cruzan
subjects in terms of attractiveness.subjects in terms of attractiveness.
 Maret and Harling (1985) subsequentlyMaret and Harling (1985) subsequently
found that a similarly constituted groupfound that a similarly constituted group
of raters also agreed on the relativeof raters also agreed on the relative
attractiveness ratings of Caucasians.attractiveness ratings of Caucasians.
From these and other studies, it isFrom these and other studies, it is
possible to conclude that perception ofpossible to conclude that perception of
attractiveness is, in fact, universal, i.e.attractiveness is, in fact, universal, i.e.
cross-cultural.cross-cultural.
Maret, S. M. (1983) Attractiveness ratings of photographs of blacks by
Cruzans and Americans, Journal of Psychology, 115, 113–116www.indiandentalacademy.comwww.indiandentalacademy.com

 Certainly, at the level at whichCertainly, at the level at which
orthodontists and their surgical colleagues'orthodontists and their surgical colleagues'
function, it seems reasonable to assumefunction, it seems reasonable to assume
that we all share a common perception ofthat we all share a common perception of
what our clinical objectives should be.what our clinical objectives should be.

 This being the case, it is interesting toThis being the case, it is interesting to
speculate as to how this perception ofspeculate as to how this perception of
attractiveness originated????attractiveness originated????
 On the one hand, it was once assumed thatOn the one hand, it was once assumed that
attitudes to attractiveness were assimilated fromattitudes to attractiveness were assimilated from
early childhood via stereotypes throughearly childhood via stereotypes through
contemporary culture, i.e. by images through thecontemporary culture, i.e. by images through the
media, press, cinema, etc. The sort ofmedia, press, cinema, etc. The sort of
preferences for attractiveness shown amongstpreferences for attractiveness shown amongst
children towards their peers from 3 or 4 years ofchildren towards their peers from 3 or 4 years of
age (Berscheid and Walster, 1974; Dion andage (Berscheid and Walster, 1974; Dion and
Berscheid, 1974; Langlois, 1986) were in effect,Berscheid, 1974; Langlois, 1986) were in effect,
environmentally induced, i.e. a product ofenvironmentally induced, i.e. a product of
indoctrination.indoctrination.
Berscheid, E. and Walster, E. (1974) Physical attractiveness,In: Berkowitz,
L. (Ed.), Advances in Experimental Social Psychology,Academic Press, New
York, pp. 157–215. www.indiandentalacademy.comwww.indiandentalacademy.com

 However, there is a body of evidence to indicateHowever, there is a body of evidence to indicate
that perceptions towards attractiveness are, inthat perceptions towards attractiveness are, in
fact, genetic in origin.fact, genetic in origin.
 Some studies on infant perception (LangloisSome studies on infant perception (Langlois etet
alal., 1987; Samuels and Ewy, 1985) indicate that., 1987; Samuels and Ewy, 1985) indicate that
infants as young as three months of age areinfants as young as three months of age are
able to discriminate between faces previouslyable to discriminate between faces previously
judged by adults as either attractive orjudged by adults as either attractive or
unattractive, with a high level of agreement.unattractive, with a high level of agreement.
Langlois, J. H., Roggman, L. A., Casey, R. J., Ritter, J. M., Rieser-
Danner L. A. and Jenkins, V. Y. (1987) Infant preferences for attractive
faces: rudiments of a stereotype? Developmental Psychology, 23(3), 363–369.www.indiandentalacademy.comwww.indiandentalacademy.com

 LangloisLanglois et alet al. (1987) showed that when infants. (1987) showed that when infants
in two age groups, namely 3 and 6 months, werein two age groups, namely 3 and 6 months, were
shown slides of faces previously assessed asshown slides of faces previously assessed as
either attractive or unattractive, they showedeither attractive or unattractive, they showed
distinct signs of preference for the attractivedistinct signs of preference for the attractive
faces.faces.
 Maurer (1985) indicated that during the first yearMaurer (1985) indicated that during the first year
of life, infants show evidence of being able toof life, infants show evidence of being able to
make judgments about faces.make judgments about faces.
*Maurer, D. (1985) Infants' perception of facedness,In: Social Perception of
Infants,Ablex, Norwood, pp. 73–100.

 There is evidence that very young infantsThere is evidence that very young infants
show preference for one face over anothershow preference for one face over another
by the length of time they spend in lookingby the length of time they spend in looking
at each face (Fantz, 1965; Fantzat each face (Fantz, 1965; Fantz et alet al.,.,
1975). Indeed, adults as well as children1975). Indeed, adults as well as children
tend to look longer at faces judged astend to look longer at faces judged as
attractive (Dion, 1977; Hildebrandt andattractive (Dion, 1977; Hildebrandt and
Cannan, 1985).Cannan, 1985).
*Fantz, R. L. (1965) Visual perception from birth as shown by pattern
selectivity,In: H. E. Whipple (Ed.), New Issues in Infant Development,Annals of
New York Academy of Science, ll8, 793–81
**Dion, K. K. and Berscheid, E. (1974) Physical attractiveness and peer
perception among children,Sociometry, 37, 1–12www.indiandentalacademy.comwww.indiandentalacademy.com

 Accordingly, it would seem thatAccordingly, it would seem that
our perceptions of attractivenessour perceptions of attractiveness
are both inherited (or inherent)are both inherited (or inherent)
and, additionally, are universal orand, additionally, are universal or
cross-cultural.cross-cultural.

 The principle that perception ofThe principle that perception of
attractiveness is instinctive, based on aattractiveness is instinctive, based on a
common perception of an ‘ideal’ provokescommon perception of an ‘ideal’ provokes
the question asthe question as what this commonwhat this common
denominator might be?????denominator might be?????

‘‘Averageness’ as the idealAverageness’ as the ideal
 From the literature, there appears to be aFrom the literature, there appears to be a
general view that the mean is an importantgeneral view that the mean is an important
component of attractiveness, in that the outcomecomponent of attractiveness, in that the outcome
of a proposed orthognathic/orthodonticof a proposed orthognathic/orthodontic
treatment, for example, would hopefully be thattreatment, for example, would hopefully be that
the patient's facial morphology wouldthe patient's facial morphology would
subsequently conform more closely to the meansubsequently conform more closely to the mean
of the relevant population, than hitherto.of the relevant population, than hitherto.

‘‘Multiple-motive’ hypothesis ofMultiple-motive’ hypothesis of
attractivenessattractiveness
 An established approach to determineAn established approach to determine
what facial proportions make a facewhat facial proportions make a face
attractive or otherwise, has been toattractive or otherwise, has been to
measure a variety of facial components inmeasure a variety of facial components in
those faces selected by raters asthose faces selected by raters as
particularly attractive and then toparticularly attractive and then to
determine whether those particular facesdetermine whether those particular faces
shared common characteristics.shared common characteristics.

 Keating (1985) constructed ‘Identi-kit’ compositeKeating (1985) constructed ‘Identi-kit’ composite
portraits of male and female faces, in theportraits of male and female faces, in the
process altering the relative size of eachprocess altering the relative size of each
particular component such as eye size, lipparticular component such as eye size, lip
thickness, etc. Female raters selected menthickness, etc. Female raters selected men
faces that had ‘dominant‘, ‘mature’ features suchfaces that had ‘dominant‘, ‘mature’ features such
as relatively large jaws, small eyes, and thin lips,as relatively large jaws, small eyes, and thin lips,
whilst the opposite features were selected bywhilst the opposite features were selected by
males assessing females, in the processmales assessing females, in the process
preferring mainly ‘non-dominant’ features.preferring mainly ‘non-dominant’ features.
Keating, C. F. (1985) Gender and the physiognomy of dominance and
attactiveness, Social Pyschology Quarterly, 48(1), 61–70.

 Cunningham's (1986) experiments on theCunningham's (1986) experiments on the
relationship between specific female featuresrelationship between specific female features
and male response indicated that men wereand male response indicated that men were
especially attracted to faces demonstratingespecially attracted to faces demonstrating
those features that Keating had demonstrated asthose features that Keating had demonstrated as
‘non-dominant’ or ‘neo-natal’ in type, having‘non-dominant’ or ‘neo-natal’ in type, having
large foreheads, large, wide set eyes, smalllarge foreheads, large, wide set eyes, small
nose and chin, and full lips.nose and chin, and full lips.
 It was suggested that these characteristicsIt was suggested that these characteristics
tended to stimulate a nurturing or caring instincttended to stimulate a nurturing or caring instinct
in the male observer as these features arein the male observer as these features are
particularly characteristic of infants (Enlow,particularly characteristic of infants (Enlow,
1990).1990).
*Cunningham, M. R. (1986) Measuring the physical in physical attractiveness:
quasi-experiments on the sociobiology of female facial beauty, Journal of
Personality and Social Psychology, 50(5), 925–935 .www.indiandentalacademy.comwww.indiandentalacademy.com

 In their study on female perception of male facialIn their study on female perception of male facial
attractiveness, Cunninghamattractiveness, Cunningham et alet al. (1990). (1990)
concluded that females were attracted to malesconcluded that females were attracted to males
who had dominant or mature characteristicswho had dominant or mature characteristics
such as wide jaws, strong chins, and relativelysuch as wide jaws, strong chins, and relatively
thin lips, but that the most attractive menthin lips, but that the most attractive men
additionally had some neonatal features, i.e.additionally had some neonatal features, i.e.
expressing both ‘ruggedness’ and ‘cuteness’expressing both ‘ruggedness’ and ‘cuteness’
*Cunningham, M. R., Barbee A.P. and Pike, C. L. (1990) What do
woman want? Facialmetric assessment of multiple motives in the perception of
male physical attractiveness, Journal of Personality and Social Psychology, 59(1),
61–72 www.indiandentalacademy.comwww.indiandentalacademy.com

 Additionally, a third feature, namelyAdditionally, a third feature, namely
‘expressiveness’ was also present‘expressiveness’ was also present
amongst those male and female facesamongst those male and female faces
judged to be the most attractive, and thesejudged to be the most attractive, and these
would include width of smile, and thewould include width of smile, and the
presence of high-arched eyebrows,presence of high-arched eyebrows,
indicating sociability and responsiveness.indicating sociability and responsiveness.

 Thus, these three features—neoteny,Thus, these three features—neoteny,
maturity, and expressiveness—allmaturity, and expressiveness—all
contribute to the ‘multiple-motive’contribute to the ‘multiple-motive’
hypothesis of attractiveness, indicatinghypothesis of attractiveness, indicating
that male attractiveness is based on athat male attractiveness is based on a
combination of these three features withcombination of these three features with
maturity or dominance particularlymaturity or dominance particularly
emphasized, whilst female attractivenessemphasized, whilst female attractiveness
places more emphasis on neoteny.places more emphasis on neoteny.

Aesthetic standards—sourcesAesthetic standards—sources
of evidenceof evidence
 Guidelines for the ‘ideal’ in facialGuidelines for the ‘ideal’ in facial
attractiveness have been presented in aattractiveness have been presented in a
number of ways, namely: artistic,number of ways, namely: artistic,
cephalometric (including growth studycephalometric (including growth study
material), and anthropometric.material), and anthropometric.

Polykleitos’ ‘The Lance Bearer’, fifth century BC. The head and
face comprise two of the 15 equal vertical parts dividing the figure

Aphrodite, fourth century BC

Facial transection, as originally described by Vitruvius
(c. 70–c. 25 BC)

The face divided equally into vertical
fifths, Powell and Humphries (1984)

Drawing of the proportions of the
head (and eye). Da Vinci

Sagittal and vertical relationships within
the face: (a) Da Vinci – proportions of head

Durer

 However, despite the undoubted brillianceHowever, despite the undoubted brilliance
of the Renaissance and later Baroqueof the Renaissance and later Baroque
artists, their recommendations were ofartists, their recommendations were of
course essentially anecdotal in nature. Itcourse essentially anecdotal in nature. It
would be hard to describe their aestheticwould be hard to describe their aesthetic
guidelines as ‘evidence-based’.guidelines as ‘evidence-based’.

 Greater validity in the search for idealGreater validity in the search for ideal
proportions (i.e. a modified form ofproportions (i.e. a modified form of
averageness) would require several otheraverageness) would require several other
criteria to be satisfied including details of thecriteria to be satisfied including details of the
population sample and how they werepopulation sample and how they were
selected:selected:
1.1. the accuracy and precision with which thethe accuracy and precision with which the
measurements were taken;measurements were taken;
2.2. together with an assessment of reproducibility;together with an assessment of reproducibility;
3.3. presentation of the raw data from which meanspresentation of the raw data from which means
and standard deviations were calculated.and standard deviations were calculated.

CephalometryCephalometry
 A discussion on the background to facialA discussion on the background to facial
attractiveness must obviouslyattractiveness must obviously
acknowledge the enormous impact thatacknowledge the enormous impact that
cephalometry has had and the manner incephalometry has had and the manner in
which it has been used to provide a vastwhich it has been used to provide a vast
array of data useful for the representationarray of data useful for the representation
of ideal proportions.of ideal proportions.

 There are three areas of deficiency inThere are three areas of deficiency in
cephalometrics that need to becephalometrics that need to be
addressed:addressed:
1.1. population data from which mean datapopulation data from which mean data
was derived is not clear in many studies.was derived is not clear in many studies.
2.2. Most of the data presented are two-Most of the data presented are two-
dimensional in nature and thusdimensional in nature and thus
incomplete.incomplete.
3.3. Most of these studies were undertakenMost of these studies were undertaken
long ago raising the question as to theirlong ago raising the question as to their
current validitycurrent validity

Anthropometric evidenceAnthropometric evidence
 Direct measurements taken from living subjectsDirect measurements taken from living subjects
would seem an obvious source of valuable data.would seem an obvious source of valuable data.
 As pointed out by Ward (1989) and RogersAs pointed out by Ward (1989) and Rogers
(1974), the advantages of this approach include(1974), the advantages of this approach include
its non-invasiveness, simplicity, cheapness and,its non-invasiveness, simplicity, cheapness and,
above all, the fact that there is a comprehensiveabove all, the fact that there is a comprehensive
dataset of age- and sex-matched standardsdataset of age- and sex-matched standards
(albeit presently limited to Caucasians) to which(albeit presently limited to Caucasians) to which
patients' measurements can be compared.patients' measurements can be compared.

Perceptions of a balanced facial
profile
 In recognition of the confusion that seems to
exist over standards and norms for the human
face, a study was conducted in the orthodontic
department at the University of Oklahoma in
which an effort was made to develop an ideal
facial profile for white people without any
distractions.
 The objective of the study was to develop a
series of facial profiles based on an ideal
constructed profile for evaluation by members of
the dental profession.
*Czarnecki ST, Nanda RS, Currier GF. Perceptions of a balanced facial
profile. Am J Orthod Dentofacial Orthop 1993;104;180-187.www.indiandentalacademy.comwww.indiandentalacademy.com

 By varying the size of the lips, nose, chin,
angle of facial convexity, and facial angle,
it was hoped to assess the combinations
most acceptable, as well as those least
desirable.
profile. Am J Orthod Dentofacial Orthop 1993;104;180-187.

ResultsResults
 It was noted that for both men and women, the
nose and chin configurations preferred were
close to the constructed normal or slightly larger.
 In the men, comparatively retruded lip contours
were preferred. The least-favored positions of
nose and lips were the most protruded (Fig 4,
row 1, number 7), whereas the least-favored
chin contours were the most retrusive for both
men and women.

 The profile with the most retrusive lips and
a large chin (Fig 4, row 3, number 1) was
considered to be the worst by 62% of the
participants.
 A slightly more pronounced chin (Fig 5,
row 1, number 5) was favored for the men,
when compared with the choice for
women.
 Overall, a preference for a straighter
profile was shown for both men and
women (Fig 5, row 2, number 3).

 This study showed that the judgment of
both lip protrusion and lip retrusion were
dependent on the positions of the chin and
the nose.
 More lip protrusion was acceptable for
both male and female profiles when either
a large nose or a large chin was present.
 However, three times more lip protrusion
was allowed with a large chin than with a
large nose.

 This finding is highly significant because it has a
major impact on the consideration of treatment
plans.
 With a relatively larger nose and chin, a more
protrusive dentition and fuller lips are more
acceptable for harmonizing the face.
 In such "borderline cases" (extraction versus
nonextraction), the clinician should favor a
nonextraction orthodontic treatment approach.

Facial Harmony and Growth in
Treatment
 Longitudinal lateral head cephalograms of
40 white individuals, 17 men and 23
women, were selected from the records of
the Child Research Council in Denver.
 Whereas the mean aggregate increase in
upper and lower lip lengths in the male
subjects was 6.9 mm, in the female
subjects it was only 2.7 mm.
Nanda RS. Cephalometric study of the human face from serial roentgenograms.
Ergebnisse der Anatomic und Entwicklungs-Geschichte 1956;35:358-419.www.indiandentalacademy.comwww.indiandentalacademy.com

Clinical ImplicationClinical Implication
 It is obvious from the small growth changes in
the female upper and lower lip lengths that a
protruding dentition at 7 years will not change
much relative to the lips during growth.
 The treatment of choice, if so indicated, may
require extraction of first premolars. However,
with growth in the lip lengths of the males, some
accommodations are possible.
Nanda RS. Cephalometric study of the human face from serial roentgenograms.
Ergebnisse der Anatomic und Entwicklungs-Geschichte 1956;35:358-419.www.indiandentalacademy.comwww.indiandentalacademy.com

Facial ProportionsFacial Proportions
 The great Renaissance artist and thinkerThe great Renaissance artist and thinker
Leonardo da Vinci emphasized theLeonardo da Vinci emphasized the
importance of harmony between art andimportance of harmony between art and
science.science.
 Leonardo defined proportion as the ratioLeonardo defined proportion as the ratio
between the respective parts and thebetween the respective parts and the
whole.whole.

 The distance from the hairline to theThe distance from the hairline to the
inferior aspect of chin is one tenth of ainferior aspect of chin is one tenth of a
man’s height.man’s height.
 The distance from the top of the head toThe distance from the top of the head to
the inferior aspect of chin is one eight of athe inferior aspect of chin is one eight of a
man’s height.man’s height.

 These proportions have important clinicalThese proportions have important clinical
implications.implications.
 If a patient’s vertical proportions are to beIf a patient’s vertical proportions are to be
altered with surgery, the treatment plan mustaltered with surgery, the treatment plan must
take into account the proportion of the patient’stake into account the proportion of the patient’s
total face height to his or her standing height ortotal face height to his or her standing height or
stature.stature.
 The use of absolute numeric values of facialThe use of absolute numeric values of facial
measurements rather than facial proportions canmeasurements rather than facial proportions can
be misleading, because the vertical facial heightbe misleading, because the vertical facial height
of a patient who is six feet tall is different from aof a patient who is six feet tall is different from a
patient 5 feet tall.patient 5 feet tall.

Facial Proportions And The GoldenFacial Proportions And The Golden
ProportionProportion
 An often quoted but rarely substantiatedAn often quoted but rarely substantiated
concept is that of the ‘concept is that of the ‘Golden Proportion’.Golden Proportion’.
 In his edition of Euclid’s Elements, theIn his edition of Euclid’s Elements, the
mathematician Luca Pacioli (1509)mathematician Luca Pacioli (1509)
renamed the golden proportion as “divinerenamed the golden proportion as “divine
proportion” because he thought theproportion” because he thought the
concept could not be rationalized.concept could not be rationalized.

 Later in that century (1597), the firstLater in that century (1597), the first
known calculation of the golden proportionknown calculation of the golden proportion
as a decimal was given by Maestlin in aas a decimal was given by Maestlin in a
letter to his former pupil, Kepler.letter to his former pupil, Kepler.
 The no. is 0.618 for the length of theThe no. is 0.618 for the length of the
longer segment of a line 1 when it islonger segment of a line 1 when it is
divided in the golden proportion.divided in the golden proportion.

 There has been attempts to correlate idealThere has been attempts to correlate ideal
facial proportions with the goldenfacial proportions with the golden
proportion.proportion.
 However, in a three dimensional studyHowever, in a three dimensional study
analyzing the face of professional models,analyzing the face of professional models,
the authors found they did not fit thethe authors found they did not fit the
golden proportion &, interestingly, thatgolden proportion &, interestingly, that
they had various malocclusions & a widethey had various malocclusions & a wide
variety of cephalometric values.variety of cephalometric values.
Ricketts R M:The biologic significance of the devine proportion and
Fibonacci series AJODO 1982; 81: 351- 70

 In another study of the estheticIn another study of the esthetic
improvement of patients havingimprovement of patients having
orthognathic surgery, the authors foundorthognathic surgery, the authors found
that , whereas most subjects werethat , whereas most subjects were
considered more attractive after treatmentconsidered more attractive after treatment
than before, the proportions were equallythan before, the proportions were equally
likely to move away from or toward thelikely to move away from or toward the
golden proportion.golden proportion.
Baker B W, Woods M G; The role of the devine proportionin the esthetic
improvement of patients undergoing combined orthodontic/orthognathic
surgical treatment Int J Adult Orthod Orthognath Surg 2001

Interdisciplinary management ofInterdisciplinary management of
anterior dental estheticsanterior dental esthetics
 Sequencing the planning processSequencing the planning process
 Beginning with esthetics in mindBeginning with esthetics in mind
 Maxillary incisor inclinationMaxillary incisor inclination
 Determining gingival levelsDetermining gingival levels
 Arrangement, contour and shadeArrangement, contour and shade
 Developing an esthetic plan for the mandibularDeveloping an esthetic plan for the mandibular
teethteeth
 Steps to integrate function and estheticsSteps to integrate function and esthetics
 Determining if adequate structure exists for toothDetermining if adequate structure exists for tooth
restorationrestoration
 Biology: Last but certainly not the leastBiology: Last but certainly not the leastwww.indiandentalacademy.comwww.indiandentalacademy.com

Sequencing the planning processSequencing the planning process
 HistoricallyHistorically
Biological AspectsBiological Aspects
Restoration
of the
resulting
defects
Function of
teeth and
condyles
Esthetics
Older conceptPresent scenario
+
Frank M Spear: Interdisciplinary management of anterior dental esthetics: JADA 2006;
137: 160-9

Types of SmileTypes of Smile
 According to the classification of Rubin, there
are 3 smile styles.
i. In the commissure smile, the corners of the
mouth turn upward due to the pull of the
zygomaticus major muscles. This is sometimes
called “the Mona Lisa smile.”
ii. In the cuspid smile, the upper lip is elevated
uniformly without the corners of the mouth
turning upward; the entire lip rises like a
window shade.
iii. In the complex smile, the upper lip moves
superiorly, as in the cuspid smile, but the lower
lip also moves inferiorly in a similar fashion.

Smile Index

Beginning with esthetics in mindBeginning with esthetics in mind
 Position of upper central incisor in relationPosition of upper central incisor in relation
to upper lip.to upper lip.
 Upper lip should be at rest.Upper lip should be at rest.
 Using a millimeter ruler or a periodontalUsing a millimeter ruler or a periodontal
probe, we determine the position of theprobe, we determine the position of the
incisal edge of the maxillary central incisorincisal edge of the maxillary central incisor
relative to the upper lip.relative to the upper lip.

 An acceptable amount of maxillary incisorAn acceptable amount of maxillary incisor
display depends on the patients age.display depends on the patients age.
 Studies have shown that with advancing age,Studies have shown that with advancing age,
amount of incisal display decreasesamount of incisal display decreases
proportionally.proportionally.
 For example, in a 30 year old a 3mm of incisalFor example, in a 30 year old a 3mm of incisal
display at rest is appropriate. However in a 60display at rest is appropriate. However in a 60
year old, the incisal display could be 1mm oryear old, the incisal display could be 1mm or
less.less.
 The change in incisal display with time probablyThe change in incisal display with time probably
relates to the resiliency and tone of the upper lip,relates to the resiliency and tone of the upper lip,
which tends to decrease with advancing age.which tends to decrease with advancing age.

 Studies have shown that a shift inStudies have shown that a shift in
maxillary dental midline of 3- 4 mm are notmaxillary dental midline of 3- 4 mm are not
noticed by laypersons if the long axis ofnoticed by laypersons if the long axis of
teeth are parallel to the long axis of theteeth are parallel to the long axis of the
face.face.
 Perhaps the most important relationship toPerhaps the most important relationship to
evaluate is the mediolateral inclination ofevaluate is the mediolateral inclination of
the maxillary central incisors.the maxillary central incisors.
Maxillary Dental MidlineMaxillary Dental Midline

 Researchers have found that if theResearchers have found that if the
incisors are inclined by 2mm to the right orincisors are inclined by 2mm to the right or
left, laypersons regard this discrepancy asleft, laypersons regard this discrepancy as
unaesthetic.unaesthetic.

Maxillary incisor inclinationMaxillary incisor inclination
 Labiolingual inclination of teeth.Labiolingual inclination of teeth.
 Usually evaluated by lateral cephalogram.Usually evaluated by lateral cephalogram.
 Clinically?????Clinically?????
 By comparing the labial surface of the maxillaryBy comparing the labial surface of the maxillary
central incisors to the maxillary occlusal plane.central incisors to the maxillary occlusal plane.
 The labial surface should be perpendicular toThe labial surface should be perpendicular to
the maxillary occlusal plane.the maxillary occlusal plane.
 This relationship permits maximum direct lightThis relationship permits maximum direct light
reflection from the labial surface of teeth, whichreflection from the labial surface of teeth, which
enhances their aesthetic appearance.enhances their aesthetic appearance.
Frank M Spear: Interdisciplinary management of anterior dental esthetics: JADA 2006;
137: 160-9 www.indiandentalacademy.comwww.indiandentalacademy.com

 After the position of maxillary centralAfter the position of maxillary central
incisors has been established, the incisalincisors has been established, the incisal
edge of maxillary lateral incisor andedge of maxillary lateral incisor and
canines, as well as the buccal cusps ofcanines, as well as the buccal cusps of
the maxillary premolars and molars, canthe maxillary premolars and molars, can
be established.be established.
 The levels of these teeth generally areThe levels of these teeth generally are
determined by their esthetic relationship todetermined by their esthetic relationship to
the lower lip when the patient smiles.the lower lip when the patient smiles.

Determining gingival levelsDetermining gingival levels
 Gingival levels should be assessed relative toGingival levels should be assessed relative to
the projected incisor edge position.the projected incisor edge position.
 The key to determining correct gingival levels isThe key to determining correct gingival levels is
to determine the desired tooth size relative toto determine the desired tooth size relative to
the projected incisor edge position.the projected incisor edge position.
 Using the gingiva to position the incisal edge isUsing the gingiva to position the incisal edge is
risky, because the gingiva can move withrisky, because the gingiva can move with
eruption or recession.eruption or recession.

 Therefore, the ideal gingival levels areTherefore, the ideal gingival levels are
determined by establishing the correctdetermined by establishing the correct
width to length ratio of the maxillarywidth to length ratio of the maxillary
anterior teeth, by determining the desiredanterior teeth, by determining the desired
amount of gingival display and byamount of gingival display and by
establishing symmetry between right andestablishing symmetry between right and
left sides of the maxillary dental archleft sides of the maxillary dental arch

Papillary MarginsPapillary Margins
 Research has shown that 50% ofResearch has shown that 50% of
interproximal region is papilla and 50% isinterproximal region is papilla and 50% is
contact.contact.
 If the contact is significantly shorter thanIf the contact is significantly shorter than
papilla it indicates moderate to severepapilla it indicates moderate to severe
incisal abrasion, which tends to shortenincisal abrasion, which tends to shorten
the crown and, therefore shortens thethe crown and, therefore shortens the
contact between central incisors.contact between central incisors.

 If the contact is significantly longer than theIf the contact is significantly longer than the
papilla, it could suggest that the gingivalpapilla, it could suggest that the gingival
contours or scallop over the central incisors iscontours or scallop over the central incisors is
flat, which could be caused by altered passiveflat, which could be caused by altered passive
or active eruption of the teeth.or active eruption of the teeth.

Esthetics and anterior toothEsthetics and anterior tooth
position: Crown lengthposition: Crown length
 Ideal maxillary central incisors are equal inIdeal maxillary central incisors are equal in
length and the lateral incisors are slightlylength and the lateral incisors are slightly
shorter.shorter.
 The gingival margins of the lateral incisor areThe gingival margins of the lateral incisor are
located more incisally than the central incisor.located more incisally than the central incisor.
 The maxillary canines are about the same lengthThe maxillary canines are about the same length
as the central incisors, and their cusp tips areas the central incisors, and their cusp tips are
located at the same level as the incisal edges oflocated at the same level as the incisal edges of
the centrals.the centrals.

 The gingival margins of the canines are at theThe gingival margins of the canines are at the
same height as the central incisors.same height as the central incisors.

 The following options exist for correctingThe following options exist for correcting
crown length discrepancy:crown length discrepancy:
1.1. Gingival surgery to correct the soft tissueGingival surgery to correct the soft tissue
formform
2.2. Intrusion and restoration of shorter toothIntrusion and restoration of shorter tooth
3.3. Slow extrusion and equilibration ofSlow extrusion and equilibration of
longer tooth.longer tooth.

position: Vertical positionposition: Vertical position

1.1. When incisal plane, interpupillary lineWhen incisal plane, interpupillary line
and maxillary occlusal plane areand maxillary occlusal plane are
coincident but there is a gummy smilecoincident but there is a gummy smile
 Correction usually requires maxillaryCorrection usually requires maxillary
surgery to correct the vertical maxillarysurgery to correct the vertical maxillary
excess.excess.

2.2. Incisal plane deviates from theIncisal plane deviates from the
interpupillary line, but is coincident withinterpupillary line, but is coincident with
maxillary occlusal planemaxillary occlusal plane
 Etiology: the entire maxilla devlopedEtiology: the entire maxilla devloped
asymmetrically due to uneven growth ofasymmetrically due to uneven growth of
mandibular rami.mandibular rami.
 Treatment : Maxillary surgery to intrudeTreatment : Maxillary surgery to intrude
maxilla on over erupted side, level themaxilla on over erupted side, level the
occlusal and incisal planes, and correctocclusal and incisal planes, and correct
the vertical discrepency.the vertical discrepency.

3.3. If the maxillary incisal plane deviatesIf the maxillary incisal plane deviates
from interpupillary line and does notfrom interpupillary line and does not
coincide with the maxillary occlusalcoincide with the maxillary occlusal
planeplane
 Check the length of right and left centralCheck the length of right and left central
incisors, if symmetrical then the problemincisors, if symmetrical then the problem
can be solved orthodontically either bycan be solved orthodontically either by
intrusion or extrusion of teeth.intrusion or extrusion of teeth.
 If the crown lengths are unequal, it showsIf the crown lengths are unequal, it shows
an oblique wear of teeth requiringan oblique wear of teeth requiring
restoration following completion ofrestoration following completion of
orthodontic treatment.orthodontic treatment.

position: Mediolateral relationshipsposition: Mediolateral relationships
 Common problems in mediolateralCommon problems in mediolateral
dimensiondimension
1.1. Asymmetric crown widthsAsymmetric crown widths
2.2. Inadequate pontic widthInadequate pontic width
3.3. Midline deviationMidline deviation
4.4. Improper angulation of maxillary incisorsImproper angulation of maxillary incisors

 The 3 transverse characteristics of theThe 3 transverse characteristics of the
smile in the frontal dimension are archsmile in the frontal dimension are arch
form, buccal corridor and the transverseform, buccal corridor and the transverse
cant of the maxillary occlusal plane.cant of the maxillary occlusal plane.
position: Transverse Dimensionposition: Transverse Dimension

Smile arc and Buccal corridorSmile arc and Buccal corridor
spacespace
 Two aspects of esthetics have recentlyTwo aspects of esthetics have recently
received great attention:received great attention: smile arc andsmile arc and
buccal corridor space.buccal corridor space.
 Frush and Fisher were among the first toFrush and Fisher were among the first to
publish the concept of smile arc. Theypublish the concept of smile arc. They
identified the notion of buccal corridoridentified the notion of buccal corridor
spaces.spaces.
Frush JP, Fisher RD. The dynesthetic interpretation of the
dentogenic concept. J Prosthet Dent 1958;8:558

 By definition, buccal corridor spaces wereBy definition, buccal corridor spaces were
the negative space created between thethe negative space created between the
buccal surfaces of the posterior teeth andbuccal surfaces of the posterior teeth and
the inner wall of the cheek.the inner wall of the cheek.
 Too much buccal corridor resulted in largeToo much buccal corridor resulted in large
empty spaces, while too little lookedempty spaces, while too little looked
artificial and was considered the essenceartificial and was considered the essence
of bad prosthetic denture esthetics.of bad prosthetic denture esthetics.
Frush JP, Fisher RD. The dynesthetic interpretation of the
dentogenic concept. J Prosthet Dent 1958;8:558

 The buccal corridor is measured from theThe buccal corridor is measured from the
mesial line angle of the maxillary firstmesial line angle of the maxillary first
premolars to the interior portion of thepremolars to the interior portion of the
commissure of the lips.commissure of the lips.
 It is often represented by a ratio of theIt is often represented by a ratio of the
inter commissure width divided by theinter commissure width divided by the
distance from first premolar to firstdistance from first premolar to first
premolar.premolar.

 Some orthodontists currently advocateSome orthodontists currently advocate
maxillary expansion in the absence ofmaxillary expansion in the absence of
cross bites in an attempt to reduce buccalcross bites in an attempt to reduce buccal
corridor space.corridor space.
 Hulsey, on the other hand, found thatHulsey, on the other hand, found that
buccal corridor spaces did not contributebuccal corridor spaces did not contribute
significantly to smile esthetics. This findingsignificantly to smile esthetics. This finding
was recently confirmed by Ritter et al..was recently confirmed by Ritter et al..
McNamara JA. Maxillary transverse deficiency. Am J Orthod
Dentofacial Orthop 2000;117:567–70.
Hulsey CM. An esthetic evaluation of lip-teeth relationships
present in the smile. Am J Orthod 1970;57:132–44.

 Hulsey quantified the smile line as a ratioHulsey quantified the smile line as a ratio
to the lower lip. He found the smile line toto the lower lip. He found the smile line to
be an important contributing factor to anbe an important contributing factor to an
attractive smile and suggested thatattractive smile and suggested that
orthodontics affects the smile line byorthodontics affects the smile line by
adversely flattening it.adversely flattening it.
 Ackerman et al. retitled the term smile lineAckerman et al. retitled the term smile line
to smile arc.to smile arc.
Hulsey CM. An esthetic evaluation of lip-teeth relationships
present in the smile. Am J Orthod 1970;57:132–44.

 The transverse smile dimension (and theThe transverse smile dimension (and the
buccal corridor) is related to the lateralbuccal corridor) is related to the lateral
projection of the premolars and the molarsprojection of the premolars and the molars
into the buccal corridors. The wider theinto the buccal corridors. The wider the
arch form in the premolar area, the greaterarch form in the premolar area, the greater
the portion of the buccal corridor that isthe portion of the buccal corridor that is
filled.filled.

 Arch expansion might fill out theArch expansion might fill out the
transverse dimension of the smile, but 2transverse dimension of the smile, but 2
undesirable side effects could result, andundesirable side effects could result, and
careful observation is needed to avoidcareful observation is needed to avoid
these, if possible.these, if possible.
 First, the buccal corridor can beFirst, the buccal corridor can be
obliterated, resulting in a denture-likeobliterated, resulting in a denture-like
smile.smile.
 Second, when the anterior sweep of theSecond, when the anterior sweep of the
maxillary arch is broadened, the smile arcmaxillary arch is broadened, the smile arc
may be flattenedmay be flattened

ConclusionConclusion
 Orthodontic history, beginning with Angle
and Wuerpel, has taught us that the “art of
the smile” lies in the clinician’s ability to
recognize the positive elements of beauty
in each patient and then create a strategy
to enhance the attributes that fall outside
the parameters of the prevailing esthetic
concept. The difference between
contemporary orthodontic practice and
that of our predecessors is that we now
can dynamically visualize and quantify our
patients’ smiles.

 Orthodontic diagnosis has, in a certain
sense, come full circle. But the focus on
the lineaments of the smile is not a step
back in time; rather, it represents a
reemphasis of the importance of physical
diagnosis and the appreciation of the soft
tissues that both drive our treatment
planning and limit the treatment response.
New technology simply enhances our
ability to see our patients more
dynamically and facilitates the
quantification and communication of
newer concepts of function and
appearance.

Esthetics in orthodontics

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