Smile esthetics in orthodontics

smile esthetics in orthodontics

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

2. Contents

3. 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. T he goal of orthodontic treatment should be to attain of the possible best possible occlusal relationship while maintaining or enhancing facial aesthetics.

4. 4 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

5. ANATOMY OF SMILE

6. 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 Matthews TJ. The anatomy of smile. J Prosthe Dent 1978 Feb;78 (2);128-34.

7. 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. Matthews TJ. The anatomy of smile. J Prosthe Dent 1978 Feb;78 (2);128-34.

8. How to assess smile

9. IDEAL CHARACTERISTICS OF SMILE

10. 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 IDEAL CHARACTERISTICS OF A SMILE 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

11. 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 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.

12. 12 Different Types Of Smile Arc Convex Or Curved Plane Or Straight Inverted Or Reverse

13. 14 2. Ratio And Symmetry Of Maxillary Central Incisors 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

14. 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)

15. 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.

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

17. 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

18. 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.

19. . 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.

20. 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: wide, usually followed by narrow maxillary dental arch intermediate, followed by dental arches of intermediate transverse dimensions narrow or nonexistent, associated with severe transverse dental arches

21. 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

22. 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.

23. 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

24. 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

25. 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. feminine type smile 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 Stewart’s Clinical Removable Partial Prosthodontics 3rd edition by Rodney D. Phoenix, David R. Cagna and Charles F. Defreest

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

27. 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.

28. 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

29. SMILE CLASSIFICATIONS

30. 8 Peck et al introduced a classification of smile based on the anatomic studies of Rubin According to them smile can be 1.Posed 2. Unposed or Spontaneous Ackerman & Ackerman modified peck et al’s classification by designating Stage I – Posed smile Stage II – Unpose d smile Orthodontics current Principles and techniques – Graber T.M. , 5 rd edition

31. 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 – Graber T.M. , 5 rd edition

32. : 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, 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)

33. 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 . 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)

34. 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 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)

35. 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,2 nd edition

36. 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. feminine type smile 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 Stewart’s Clinical Removable Partial Prosthodontics 3rd edition by Rodney D. Phoenix, David R. Cagna and Charles F. Defreest

37. CLASSIFICATION OF SMILE ESTHETICS Microesthetics Miniesthetics Macroesthetics

38. 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.

39. 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

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

41. 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

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

43. 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

44. 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).

45. FACIAL PROFILE T wo 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

46. Evaluation Of Lip Posture And 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: The lips are prominent and everted the lips are separated at rest by more than 3 to 4 mm (which is sometimes termed lip incompetence ).

47. 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

48. 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 .

49. 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.

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

51. The objectives of this study were to evaluate the impact of maxillary incisor inclination on the aesthetics of the profile view of a smile, to determine the most aesthetic inclination in the profile view of a smile and correlate it with facial features, to determine if dentists, orthodontists, and laypeople appreciate differently incisor inclination in smile aesthetics. It was concluded u pper 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 .

52. 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-

53. “ 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.

54. 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

55. 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

56. 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

57. 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

58. 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.

59. 1. Amount of Incisor and Gingival Display E levation 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

60. 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

61. 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 E xcessively wide buccal corridors (sometimes called " negative space ") are unestheti c. W idening 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

62. 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

63. 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 establish ed 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.

64. 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.

65. 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- Frontal, Oblique, Sagittal, Time 67

66. 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

67. Frontally, we can visualize and quantify 2 major dimensions of the smile: VERTICAL TRANSVERSE VERTICAL CHARACTERISTICS of the smile are broadly categorized into 2 main features: incisor display 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.

68. 70 TRANSVERSE CHARACTERISTICS A rch form B uccal corridor T ransverse 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.

69. 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

70. 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

71. 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

72. 4. THE FOURTH DIMENSION : TIME G rowth , 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 ph a se, 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

73. Measurements used to evalvate smile esthetics Measurements on frontal photographs. Smile width (mm )- Intercommissure width at smiling Smile height (mm) - Interlabial gap during smiling. 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.

74. 76 Smile index (ratio) - Smile width divided by smile height 3-3 distance/smile width (ratio )- Intercanine distance divided by intercommissure width 4-4 distance/smile width (ratio) - Interpremolar distance divided by intercommisure width Visible dentition width/smile width (ratio) -Visible dentition width divided by smile width 3-3 distance/visible dentition width (ratio) -Intercanine distance divided by visible dentition width .

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

76. 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.

77. 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

78. 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

79. 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.

80. PRINCIPLES OF GOLDEN PROPORTION (LOMBARDI) S uggest 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 .

81. 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.

82. EMB R ASURES 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

83. 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. 85

84. 86 Gingival Zenith The gingival zenith (GZ) is defined as the most apical point of the marginal gingival scallop can be orthodontically defined by the position of the bracket bonded to the upper anterior teeth second-order bends on orthodontic wires, also known as artistic bends that define the mesiodistal tippings of these teeth.

85. 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

86. TREATMENT PLAN : MacroEsthetic , Miniesthetic , microestehtic Consideration

87. 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: Orthodontic camouflage Orthognathic and/or plastic surgery Orthodontic growth modification, for growing patients only ,

88. 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

89. 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.

90. 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

91. 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

92. 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

93. Three possible treatment approaches to excessive gingival display intrusion of the maxillary incisors using segmented arch mechanics intrusion using temporary skeletal anchorage 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.

94. 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

95. The Smile Arc 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.

96. 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.

97. 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

98. 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

99. 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

100. 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.

101. 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.

102. 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.

103. 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: 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). Transverse characteristics of the smile appeared to be of little significance to an attractive smile. Maxillary gingival display and the ultimate positions of the anterior teeth have definite effects on smile esthetics. Treatment modality alone has no predictable effect on the overall esthetic assessment of a smile.

104. 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.

105. 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

106. Dynamic smile analysis in young adults Christopher Maulik and Ravindra Nanda (A JODO 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

107. the study establish ed 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

108. 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)

109. 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

110. Three-dimensional evaluation of smile characteristics in subjects with increased vertical facial dimensions Rana Demir , and Asli Baysal 2020 AJODO 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.

111. 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 .

112. 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 .

113. 115 CONCLUSION Today, well occluding casts and pleasing profiles can no longer be considered to be adequate treatmemt goals for the orthodontist. The id e a l c om p on ents of the smi le should be c onsid e r e d not as ri g id bou n d a ri e s, but as a rtistic 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.

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

115. 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 Assoc 2001;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