Daltro Enas Ritter1 Luiz Gonzaga Gandini Ary dos Santos Pinto2 Dirceu Barnab Ravelli2 Arno Locks3

[Au: Please provide academic degrees (eg, DDS) for all authors] Jr2

ANALYSIS OF THE SMILE PHOTOGRAPH

Optimal facial esthetics is one of the objectives in orthodontic treatment and an important issue in modern society. In this context, orthodontic treatment permits individuals with dental malpositions to achieve improved dentofacial esthetics. To reach this result, the orthodontist needs to recognize the characteristics considered normal and pleasant in dental arches and smiles. The objective of this article is to review and discuss criterion adopted by dental literature to technically analyze the smile, such as dental midline, smile line, dental exposure, negative space, dental proportion, and symmetry. This article proposes a way to visualize an ideal smile fi00 each patient. World J Orthod 2006;7:xxxx.

1Orthodontic

Postgraduate Student, UNESP, Araraquara, Brazil; Professor, UFSC, Florianpolis, Brazil. (AU: Please spell out name of universities and provide department) 2Professor, Department of Children Clinic and Department of Orthodontics, UNESP, Araraquara, Brazil. 3Professor, Department of Orthodontics, UFSC, Florianpolis, Brazil. CORRESPONDENCE Dr Daltro E. Ritter Rua Nereu Ramos, 69 Sala 611 Ed. Belo EmpresarialCentro 88015-010 FlorianpolisSC Brazil E-mail: daltroritter@hotmail.com

ptimal facial esthetics is one of the principal objectives in orthodontic treatment, and an important issue in modern society. An individuals dentofacial appearance influences social attraction and relationships.13 In this context, orthodontic treatment enables individuals with dental abnormalities to improve their dentofacial esthetic patterns. There are numerous studies about dental position, intercuspation, and occlusion, but less has been written about the relationship between teeth and oral soft tissues, and how this relationship affects smile esthetics.4 Therefore, the orthodontist can have difficulty in technically assessing a smile, because there are few published articles showing standard patterns.5,6 The purpose of this article is to review the literature and discuss tooth position aspects that influence facial esthetics.

tion. Through the smile photograph, the clinician can identify and analyze anterior tooth and adjacent soft tissue relationships. 7 It is recommended that a frontal partial smile photograph be used as an orthodontic clinical record standard to aid in initial diagnosis and treatment progress.58 The clinician must have standardized smile photographs to permit comparison of treatment progress. How patients see themselves in the mirror during a smile differs from an orthodontic analysis of tooth disposition in occlusion with lip retractors (Fig 1).9 For this reason, it has been recommended that the patient be in a natural head position, with eyes looking to a distant point, during the smile photograph.4,5,10,11 In addition, it is possible to use a cephalostat to standardize the patient head position.12

SMILE CLASSIFICATION THE SMILE PHOTOGRAPH

The cephalometric radiograph, a helpful diagnostic tool, does not record lip-tooth relationships during speech and smiling. Clinical observation and photographs of the face at rest and with smile are necessary to obtain this valuable informaThere are 2 types of smiles described in the literature, forced and spontaneous (Fig 2).12,13 The forced smile, or social smile, is voluntary, static, and perfectly reproducible.9 The spontaneous smile, or involuntary smile, cannot be reproduced because is activated by joy and

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b a

Fig 1

Patients (a, b) and orthodontists (c) view of a smile.

Fig 2 Smile classification: Forced and posed smile (a) ; spontaneous, not forced, smile (b).

emotion. It has been recommended that smile photographs be standardized with a forced smile, due to its reproducibility, in the natural head position.9,14,15

a worsening in smile and lip line relationships in 32% of a group of orthodontically treated patients. Therefore, the clinician must be careful to avoid the creation of a reverse smile line during treatment.

SMILE LINE DENTAL MIDLINES

The smile line is a curve that passes through the incisal margins of the maxillary incisors and canines, making an arch.16 Sarver13 showed the importance of the smile line in dentofacial esthetics. When the incisal margins of the maxillary central incisors appear below the canine cusps, the smile line has a convex aspect that can harmonize with the lower lip line (Fig 3a) [ A U : I s e d i t c o r r e c t ? ] . The socalled reverse smile line results when the canine cusps appear more occlusal than the maxillary central incisor tip margin, creating a concave aspect (Fig 3b). The literature says that the convex smile line aspect is more esthetic than the concave smile line.11,16,17 Other researchers have found some preference for the convex smile line, but a straight smile line in males was also acceptable, thus showing gender differences.18,19 Orthodontic treatment appears to influence the smile line. Ackerman et al9 found Morley and Eubank7 wrote that in smile architecture the initial step is to identify the facial midline. Due to the many patients with asymmetric eyes, nose, and chin, these authors suggest identifying the facial midline using the midpoint between the eyebrows (nasion), the nose base, and the filtrum, or the midpoint of the arch in the upper lip (Fig 4). To attain optimal esthetics, the facial midline must coincide with the maxillary and mandibular central incisor midline or, minimally, these lines must be parallel.16,1921 A differing view has suggested that the positioning of the dental midline exactly over the facial midline can contribute to artificiality; with this premise, a small discrepancy of about 1.5 to 2 mm is acceptable, giving a natural appearance to dentition.16,22,23,24

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Fig 3 (a) Convex smile line following the lower lip line. (b) Reverse smile line (concave).

Fig 4

(a) Reference points for facial midline determination. (b, c) Facial midline definition.

MAXILLARY INCISOR AND GINGIVAL EXPOSURE

Exposure is the term used to quantify the dental structure or gingiva that appears during a smile. The amount of dental and gingival exposition during speech and smiling varies from person to person, due to individual variables such as: (1) upper and lower lip muscle mobility and strength; (2) lip vertical length; (3) clinical crown length; and (4) skeletal relationships, especially vertical maxillary length. These factors must be taken into consideration when conducting an individual smile photograph analysis.2,16 During a smile, maxillar y central incisor exposure varies from three quarters of clinical crown to 2 mm of gingival exposure; in general, the gingival smile is a more common characteristic of females.2,5,6,11,25 Peck and Peck2 found that women show, on average, 0.7 mm of gingiva during a smile, while in males, 0.8 mm of the clinical crown is covered by the upper lip, on average (Fig 5).2 The anterior gingival margin symmetry is another important esthetic aspect; asymmetry is acceptable when minimal, but rarely acceptable when it occurs with the maxillary central incisors.11,26

Another useful reference in smile photograph analysis is the maxillary central incisor crown proportion located from a line between the lip commissures. Youthful smiles reveal between 75% and 100% of these teeth above the commissure line (Fig 6). This proportion can become 40% or less, causing the smile to age.4 With age, there is a decrease in maxillary tooth exposure during a smile, and an increase in mandibular incisor exposure.7,27,28 This phenomenon occurs due to natural tooth wear and the loss of elasticity of the lips.21

THE BUCCAL CORRIDOR

The buccal corridor, or negative space, is the space created between the buccal surface of the posterior teeth and the lip corners when the patient smiles, giving depth and a natural aspect to the smile.16,29 The use of the buccal corridor avoids the so-called 16 teeth smile or piano smile, which characterizes a fullmouth total prosthesis.16 This negative space is affected by the smile, the maxillary arch width, the facial muscles, the position of the buccal surfaces of the posterior maxillary teeth, and also by the

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Fig 5 (a) Female characteristic smile, showing some gingiva above maxillary central incisors. (b) Male characteristic smile with maxillary central incisor clinical crown partially covered by upper lips, and showing more mandibular incisor.

Fig 6 (left) Both maxillary central incisors are located completely above commissure line, giving a youthful smile aspect. Fig 7 (right) Johnson and Smith 34 method to measure the negative space proportion. ID, intercommissure distance; AW, arch width; NS, negative space.

Fig 8 Light conditions influence the number of teeth exposed and the buccal corridor proportion during smile photograph.

maxillary anteroposterior position related to the lips.13,30 Some authors have advocated that the buccal corridor area is not critical and could be visually judged.16,31 Others believe it is important to reach proper buccal corridor dimensions to increase smile esthetics.13,23 Some research has shown that broad smiles, showing more posterior teeth, are considered more pleasing than smiles that show fewer posterior teeth.11,32,33 The method developed by Johnson and Smith34 has been proposed to measure negative space proportion during a smile. In this method, the width of the maxillary dental arch in a smile photograph is measured, and the proportion of this value in relation to distance of the lip commissure is found (Fig 7).34 This can be used to verify the proportion occupied by the dental arch relative to intercommissure distance.

Johnson and Smith 34 also analyzed the smile esthetics in 60 orthodontic patients treated with and without premolar extraction.34 The negative space proportion in extraction cases reached the average of 9% of the intercommissure distance; in the nonextraction cases, this value was 8%, showing that orthodontically indicated tooth extractions did not significantly increase the proportion of negative space. It is important to note that as teeth are situated more posteriorly in the arch, reduced lighting creates a gradual darkening and hiding of the posterior teeth. 19,35 This gradual lack of light reduces focus on details, and increases the illusion of distance and depth.7,36 It should be also noted that the proportion of negative space is dependent on lighting conditions, thus requiring standardization during photography (Fig 8).12

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Fig 9 (a) Incisal frames. (b) Teeth disposition with adequate incisal heights between central incisors, lateral incisors, and canines.

Fig 10 (left) Mesiodistal proportion of the maxillary anterior teeth, seen in frontal view. Fig 11 (right) Smile mesh example.

1.618 1.0 0.618

INCISAL FRAMES
The pattern created by incisal frames and a dark background helps to define a pleasing smile.37 This space between the tooth incisal is called embrasure space, or incisal frames (Fig 9a). This space follows a pattern that develops between the central incisors and progresses laterally, increasing in size between the teeth located more posteriorly. 7 It has been suggested that the clinician maintain or create the incisal frames, with the maxillary lateral incisors shorter than the central incisors and canines (Fig 9b), thus indicating absence of incisal wear and characterizing a young smile. 27,38,39 To achieve this, 0.5- to 1.0-mm steps occur between the maxillary central incisors and lateral incisors, always with the lateral incisor margins more gingival than those of the central incisors (Fig 9b).11

incisors must appear propor tionally 0.618 shorter than the central incisors, and 1.618 longer than than the canines (Fig 10).29,38,40 Another way of analyzing anterior tooth disposition during a smile is to use the golden percentage.41 This percentage represents the width of the maxillary intercanines visible in a frontal photograph, so that each central incisor takes 25% of this length, the lateral incisors take 15% each, and the canines 10% of the total length. Some authors have used computerized programs to take smile measurements.9,12,24 In these methods a smile photograph is digitized, and after positioning the picture to facial and tooth references, a mesh is created (Fig 11). In this way, the orthodontist can quantify many smile characteristics, such as incisor and gingival exposition, buccal corridor, smile line, midline deviations, intercanine width, and lip length.

SYMMETRY AND PROPORTION

The 1.618/1 proportion, also called the golden proportion, has long been considered esthetically pleasing to the human mind.36 Applied to the human dentition, in the frontal smile view, the teeth must be in this proportion and symmetric in such a way that the maxillary lateral

TOOTH CONTACTS AND INCLINATIONS

In the frontal view, axial inclinations of the anterior teeth are slightly progressive as the teeth are positioned posteriorly, with the gingival portions of the crowns more distal than the incisal portions (Fig 12).

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Fig 12 (left) Maxillary anterior teeth with adequate axial inclinations. Fig 13 (right) Anterior tooth contact areas in frontal view; these are called space connectors.

50

40 30

Fig 14 Gingival exposure reduction during smile, due to maxillary incisor intrusion. This clinical case shows initial smile (a) and final smile (b).

Smiles with diastema are not often socially acceptable, with the exception of those in older people.37 In a multi-ethnic study, rejection due to maxillary central diastema was verified in Asian evaluators, but European evaluators were more accepting of this characteristic.18 The space where anterior teeth appear to touch each other in a frontal smile photograph is called the connector space (Fig 13).4 An esthetic relationship, called the 50-40-30 rule, exists between the anterior teeth. It defines the ideal connector space between the maxillary central incisors as being 50% of the total vertical length of the central incisor. The connector space between the central and lateral incisors is 40% of the total length of the central incisor crown, and the connector space between the lateral incisors and canines is 30% of the central incisor crown.

CLINICAL CASE
In addition to the tooth malpositions evident in this clinical case, excessive exposition of the maxillary central incisors and gingival margin of all maxillary anterior teeth had compromised the dentofacial esthetic (Fig 14a). During treatment with a fixed appliance, the teeth were leveled and aligned, anterior teeth were intruded, respecting the balance between smile line and lower lip, thereby diminishing gingival exposition and enhancing patient smile esthetics (Fig 14b).

CONCLUSION
There is not an ideal smile. The most important esthetic objective must be to achieve a balanced smile, which can be described as an adequate positioning of teeth within themselves, and with the gingiva and soft tissues. The orthodontist must know the esthetic principles that govern facial and dental harmony, achieving optimal tooth positioning within the soft tissue and skeletal characteristics of each patient.

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