CASE REPORT

Smile makeover and the oral facial

harmony concept in a new era:
relationship between tooth shape
and face configuration

Giuseppe Romeo, MCDT

Oral Design Center
Clinical Assistant Professor, Division Restorative Science, University of Southern
California, Los Angeles, USA

Correspondence to: Giuseppe Romeo

Oral Design Center, Piazza Peyron 15, Torino 10143, Italy; Email: romeo.giuseppe@email.it

202 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021

Abstract
The patient’s facial characteristics play an essen-
tial role in achieving a customized smile restoration
with appropriate individualized tooth shapes. By ini-
tially studying the patient’s face, an approach can be
determined to plan new individual tooth shapes to
achieve a satisfactory outcome. The dental esthetic
rehabilitation taking the facial proportion into account
The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
ROMEO
involves a complex planning process. To successfully
realize such a project, several factors must be evalu-
ated when designing the restoration, including dental
alignment, crown dimension, color, occlusion, and
facial proportions. Understanding all the anatomical
parameters is essential to creating a harmonious es-
thetic restoration.
(Int J Esthet Dent 2021;16:2–8)
| 203
CASE REPORT
Introduction
The facial type of a patient is not only defined
by facial symmetry, asymmetry or anthro-
pology but also by an awareness of things
through the physical senses (perception);
the way things seem, look or feel (impres-
sion); and the perceiver’s personal interpre-
tation of esthetic excellence and attractive-
ness (beauty). Other aspects of the face
that can be defined for the purposes of the
restoration project include strong, dynamic,
delicate, and calm.1,2 Nowadays, many pa-
tients seek a more attractive appearance.
There are several techniques available to
perform esthetically pleasing restorations.
Ongoing research is being conducted in
this area, for instance, the concept known
Fig 1 The lateral lines of the face present an initial approach to plan the future
transition lines of the maxillary central incisors.
204 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
as oral facial harmony.3,4 Dentists have been
conducting orofacial analyses for decades,
a process that involves applying mathemat-
ical rules and geometry principles to create
parallel or perpendicular lines on a patient’s
face. The aim is to achieve harmony rather
than symmetry in the redefinition of the
smile, because people’s faces are naturally
asymmetric. The idea, then, is to create a
balanced harmonious smile in relation to
the patient’s face, which is more important
than trying to create a mathematically per-
fect symmetrical smile.5
Patients sometimes further request a
new design of the face (beautification con-
cept), which is performed with facial har-
mony procedures using hyaluronic acid
and botulinum toxin (Botox).6 The new face
configuration is then analyzed as a guide to
realize the future individual tooth shapes for
the customized patient smile.
The patient cases presented in this ar-
ticle report on a system that gives dental
professionals specific skills and tools to go
beyond the usual standard of creativity in
esthetic oral rehabilitation.
Technical approach
The restoration of esthetics in the pros-
thetic treatment of patients is an aspect of
dentistry where computer technologies are
becoming more widely used to achieve the
desired outcomes.7-9 Today, good-quality
dental software programs are available on
the market that offer systems of smile de-
sign assessment according to the overall
facial context of the patient. All smile de-
sign concepts and systems require a facial
photograph of the patient, smiling naturally.
The expression on the patient’s face forms
the first impression and has a high social
value.1,10,11 The facial contour assumes an
important role, especially for the definition
of the future maxillary central incisors12-16
(Figs 1 to 3).
 ROMEO

a b c

Fig 2a to c Realization of the new individual tooth shape and customized smile.

a b

c d

Fig 3a to d Final smile and new tooth shapes in relation to the patient’s face.

Case report 1 The treatment plan began with a digital

A young female patient presented who had
been treated with veneers 18 months previ-
ously. She was unhappy with the result, par-
ticularly concerning the shape and color of
the veneers. She was also dissatisfied with
the design of the restoration, which she felt
was inappropriate in the context of her face.
Furthermore, the veneers presented some
cracks on the facial surface and showed
cervical imprecisions (Fig 4).
examination of the bitemporal, bizygomatic,
and bigognatic areas of the patient’s face,
drawing the hypothetical anatomical configu-
ration of the tooth on top of the face surface.
This configuration is mainly related to the as-
pect of the two maxillary central incisors.17
Facial analysis was then performed
without the use of mathematical rules and
geometric principles. The primary objective
was not to create a mathematically perfect
smile with no dynamic effects. A further

The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021 | 205
CASE REPORT
Fig 4 Preoperative situation: existing veneers from lateral to lateral. The image
clearly shows the crack and the cervical imprecisions as well as the issues
concerning shape and color.
and related objective was to avoid giving
all the teeth exactly the same incisal level,
which would result in a flat anatomy. In this
author’s opinion, an esthetic rehabilitation
must show a dynamic harmony between
the asymmetric facial details and the final
individual tooth anatomy. A human face
has asymmetric areas; furthermore, natu-
ral teeth are not anatomically identical and
symmetric in their position, facial transition
lines, and incisal margin aspects (Fig 5).
Based on the anatomical concepts and
facial details, a new classification system
of tooth form known as Dental Anatomical
Combinations was taken into consideration
to create the technical approach in the lab-
oratory.18 This concept aims to help dental
professionals to produce different tooth anat-
omies that extend beyond the standard tooth
shapes. The basic principle of the concept is
the segmentation and recombination of two
or even all three of the basic tooth forms.
206 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
Fig 5 Facial analysis divided into two components.
The vertical component guides the evaluation of the
relationships among the facial midline, dental midline,
and tooth axis in order to understand the dental midline
shift and the tooth axis cant with the face. The
horizontal component focuses on the relationships
among facial anatomical features such as the inter-
pupillary line, the commissural line, the mandibular
angle, and the ramus, establishing the relationships with
the occlusal plane and incisal edges of the maxillary
teeth.
First, the perimeter of each tooth form
is sectioned into smaller segments. By sec-
tioning the tooth into three different seg-
ments, a mesial, distal, and incisal segment
is obtained. If necessary, these three seg-
ments can be further divided, resulting in six
half-segments: mesial cervical, mesial body,
mesial incisal, distal cervical, distal body,
and distal incisal19 (Fig 6).
After this initial digital and technical ap-
proach, the mock-up was performed in the
clinician’s office. Then, final feldspathic ve-
neers were created and cemented in the
patient’s mouth.
The customized smile shows the dynamic
appearance of the redefined smile. The in-
dividual tooth anatomy has a new anatomi-
cal configuration. Due to the patient’s Asian
ethnicity, the facial transition lines of the two
maxillary central incisors were performed with
a larger volume, characteristic of the tooth
appearance of Asian people (Figs 7 and 8).

Triangular Ovoidal
Ovoidal
Square
Triangular Triangular
Fig 6 Individual tooth planning with anatomical
segmentation analysis.
a b
Fig 8a to c Posttreatment photographs of the patient showing a new, customized smile in harmony with the face.
Case report 2
A 27-year-old male patient was concerned
about the esthetics of his facial contour as
well as his teeth and smile. The shape of his
face was clinically analyzed as having a nar-
row configuration of the chin and jaw. His
teeth had a yellow-orange color, similar to
ROMEO
Fig 7 Final rehabilitation with the new anatomical configuration.
c
shade A3.5, and the presence of a diastema
presented an additional esthetic challenge.
The patient’s expectation was to improve
the esthetics of both his dental and facial
appearance.
The clinical plan was to manufacture
four veneers for teeth 12, 11, 21, and 22,
and two fragments for teeth 13 and 23 to
The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021 | 207
CASE REPORT
15 deg
a b
Fig 9a and b Contour of the patient’s face before (left) and after (right) the derma filler treatment. Note the
change in the mandibular angle from 15 to 9 degrees.
reduce the large embrasures. Direct com-
posite resin has been suggested as a way
to conservatively improve the buccal corri-
dor, and this method was considered in this
case to facially increment teeth 14 and 24. A
study of the patient’s facial proportions was
executed,20 and a lack of jaw and chin sup-
port was noted. The clinical evaluation was
to make derma filler using hyaluronic acid
at the jaw angle to alter the natural shape
of the face to a square facial standard with
minimum intervention, which is what the
patient wanted.
The dental technician then digitally ana-
lyzed the transformed facial shape to create
a suitable design for the future veneers based
on the new facial details.21 This facial analysis
is an appropriate technique to digitally plan
an individual tooth design after face modifi-
cations through derma filler treatment.
208 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
9 deg
On analyzing the initial image, it was
found that the natural angle between the
zygomatic and mandibular branch was 15
degrees; after the oral facial harmony anal-
ysis, the newly created angle was 9 degrees
(Fig 9). It has been shown in the literature
that the masculine facial standard with a
highlighted mandibular angle is representa-
tive of attractiveness, and the global facial
standard has become a squarer-shaped
face for this gender.
After this facial transformation, the tech-
nician measured the distance of the bitem-
poral, bizygomatic, and bigognatic areas,
drawing facial reference lines (Fig 10).
In the next step, the practical part of the
treatment began with the diagnostic wax-
ups. The dental technician used a specific
technique to create the individual teeth, es-
pecially the two maxillary central incisors.
 ROMEO

a b

Fig 10a and b Tooth types before (left) and after (right) the oral facial harmony analysis. The new tooth shapes
have wider facial transition lines compared with the more triangular shape of the preoperative teeth.

This technique works with the mesial, distal,
and incisal fragments joined together, and
produces a variation of the Dental Anatom-
ical Combinations concept. The laboratory
made specific silicone and thermoplastic
tools (keys) for use by the clinician to create
a clinically calibrated preparation for the fu-
ture veneers (Figs 11 and 12).
After the definition of the new squarer
facial standard, the oral test drive of the
smile was performed following the new
tooth configuration. The patient was pho-
tographed and filmed to demonstrate the
modifications. After he approved the new
smile design based on the facial harmony
concept, the calibrated minimally invasive
preparation was performed using the sec-
tioned silicone keys.
A calibrated preparation is recom-
mended to avoid an aggressive tooth
reduction. The incisal space should be at
least around 2 mm with a butt margin de-
sign.21 To better preserve the unit, the butt
margin should be prepared from the in-
cisal-lingual to the incisal-facial aspect, with
a 45-degree inclination. In the incisal-lingual
area, 1 mm of reduction is sufficient. With
this procedure, the clinician can maintain
more tooth structure, especially in the in-
cisal-lingual area. With this incisal design,
the technician can layer the ceramic effects
on the incisal third of the tooth (Fig 13).
The calibrated preparation was per-
formed using the sectioned silicone keys,
which helps the clinician to better evaluate
all the suitable spaces for the future veneers
(Fig 14).
The stratification of the ceramic involved
a sophisticated multilayer technique using
a variety of ceramic masses to simulate the

The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021 | 209
CASE REPORT

Figs 11 and 12 Wax-up and sectioned silicone keys for the future oral try in and tooth preparation.

45 deg

Fig 13 Butt margin design with a 45-degree inclination of the Fig 14 Sectioned silicone key in the mouth for the calibrated
incisal margin. preparation.

210 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
 ROMEO

Fig 15 Ceramic layering technique.

natural contrast effects inside the tooth.22 In

the incisal area, the double incisal wall tech-
nique was applied, brushing ceramic masses
with different degrees of opacity, translu-
cency, opalescence, and fluorescence ef-
fects. Modifiers and stains were added in
the incisal area to reproduce a natural ap-
pearance. Both the facial and incisal-lingual
areas were treated with the same layering
technique (Figs 15 and 16).
After the layering technique, the final
texture was evaluated, and the different lines
were made onto the entire facial surface of
the veneers using several burs. At this point,
Fig 16 Crack liners and incisal effects after the first bake.
the veneers were ready to be glazed and
manually polished. The final shape of the
veneers respected the new transition lines
of the face configuration that had changed
due to the derma filler treatment. his expectations. The new smile was based
The veneers were tested in the patient’s on the realization of the personalized tooth
mouth for the final try-in and then ce- shapes in accordance with the oral facial
mented. The patient was satisfied with his harmony concept and appropriate treat-
new customized smile design, which met ment (Figs 17 to 23).

The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021 | 211
CASE REPORT

Fig 17

Fig 18a and b Final shape and texture design of the veneers on the
b
cast.

Figs 19 and 20 Intraoral views of the final case with the appropriate new tooth shapes.

212 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
 ROMEO

Square Triangular

Square Ovoidal

Ovoidal Triangular

Fig 21 New individual tooth segmentation based on the oral facial Fig 22 Exposure of the incisal third of the two maxillary central
harmony concept. incisors with the lips at rest.

Fig 23 Oral facial harmony

showing the relation among the
anatomical shape of the teeth,
the entire customized smile, and
the facial esthetic treatment.

The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021 | 213
CASE REPORT
Discussion
Digital technology is widely used nowadays
for facial recognition through face detec-
tion from photographs as well as through
the analysis of facial contours. The con-
tinual development of technology and the
increasing availability of information in the
field of esthetic dentistry have led to in-
creased patient demand, which, in turn, has
prompted dental professionals to question
certain aspects of customization. The area
of esthetic odontology has also been ex-
panding according to this patient demand.
Dental professionals today have the possi-
bility of evaluating a patient’s facial propor-
tion and function in terms of both sophisti-
cated facial esthetics and customized smile
redefinition.23,24
In this article, Dental Anatomical Com-
binations was described, a classification
system that makes use of a segmentation
technique to create new tooth forms. This,
together with the oral facial harmony con-
cept, aims to allow dental professionals to
produce different tooth anatomies that ex-
tend beyond the standard tooth shapes.
The second patient case described
herein showed how, after derma filler treat-
ment, the dental technician was able to plan
digitally and then manually the new ana-
tomical configuration of the patient’s maxil-
lary central incisors. For this step, excellent
communication is essential among the pa-
tient, clinician, and dental technician.
There has been much discussion in the
dental field regarding exactly what con-
stitutes a minimally invasive preparation. A
calibrated preparation that precisely grinds
the teeth using sectioned silicone keys to
avoid unnecessary hard tissue reduction is
an excellent way to treat a patient safely and
naturally. The attainment of beauty is not
the creation of transformation in the patient
but rather the creation of a natural harmony
of the smile in the context of the face.
214 | The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
Conclusion
The main purpose of esthetic dental treat-
ment is to achieve a beautiful smile. One of
the most significant challenges for the clin-
ician and dental technician is to recreate
the beauty of the smile with natural-look-
ing teeth. There are different points of view
concerning esthetic parameters. Dental
Anatomical Combinations, supported by a
customized smile makeover in combina-
tion with analog and digital procedures, is
a constructive way to ensure harmonious
unity between the patient’s facial type and
the teeth. Digital facial maps provide reli-
able and fast identification of the facial type
while smiling.
This study of the customized tooth based
on facial configuration enabled the creation
of a digital design for a precise and esthetic
prosthetic restoration of the anterior teeth.
To obtain an optimal outcome, it is neces-
sary for the dental professionals involved
to interpret exactly how the new custom-
ized smile is in harmony with the patient’s
face. The esthetic oral rehabilitation and
facial contouring described in this article is
focused on patient need, with an esthetic
treatment selected according to the pa-
tient’s facial shape. In order to perform the
ultimate smile makeover in this new era of
Dental Anatomical Combinations, based on
facial configuration and taking into account
oral facial harmony, excellent communica-
tion between the clinician and dental tech-
nician is essential as well as a high standard
of work and strict protocols.
Acknowledgments
The author is thankful for the intense clinical
cooperation and high level of performance
of Drs Sillas Durate, Pascal Magne, and
Jin-Ho Park of the University of Southern
California, Los Angeles, USA, as well as Dr
Carolina Brito, Goiânia, Brazil.

References
1. Rhodes G. The evolutionary psychol-
ogy of facial beauty. Annu Rev Psychol
2006;57:199–226.
2. Gürel G, Paolluci B, Iliev G, et al. The art
and creation of a personalized smile: Visual
Identity of a Smile (VIS). Quintessence Dent
Technol 2019,42:31–48.
3. Borelli C, Berneburg M. ‘‘Beauty lies in
the eye of the beholder’’? Aspects of beauty
and attractiveness. J Dtsch Dermatol Ges
2010;8:326–330.
4. Bashour M. History and current concepts
in the analysis of facial attractiveness. Plast
Reconstr Surg 2006;118:741–756.
5. Pereira Silva B, Mahn E, Stanley K, Coach-
man C. The facial flow concept: an organic
orofacial analysis – the vertical component.
J Prosthet Dent 2019;121:189–194.
6. Altamiro F. Dermal Fillers for Facial Har-
mony. Chicago: Quintessence, 2019
7. McCrae R, Costa PT Jnr. A contemplated
revision of the NEO Five-Factor Invento-
ry. Personality and Individual Differences
2004;36:587–596.
8. McLaren EA, Culp L. Smile analysis – The
Photoshop smile design technique: Part I. J
Cosmet Dent 2013;29:94–108.
9. Zimmermann M, Mehl A. Virtual smile de-
sign systems: a current review. Int J Comput
Dent 2015;18:303–317.
10. Wolffhechel K, Fagertun J, Jacobsen
UP,
P et al. Interpretation of appearance: the
effect of facial features on first impressions
and personality. PloS One 2014;9:e107721.
doi:10.1371/journal.pone.0107721.
11. Davis LG, Ashworth PD, Springs LS.
Psychological effects of aesthetic dental
treatment. J Dent 1998;26:547–554.
12. Gizatdidinova Y, Surakka V. Automatic
localization of facial landmarks from expres-
sive images of high complexity. Department
of Computer Sciences, FIN-33014, Universi-
ty of Tampere, 2008.
13. Gupta S, Markey MK, Bovik AC. Anthro-
pometric 3D face recognition. Int J Comput
Vis 2010;90:331–349.
14. Ibrahimagić-Šeper L, Celebić A,
Petricevic N, Selimović E. Anthropometric
differences between males and females
in face dimensions and dimensions of
central maxillary incisors. Medicinski glasnik
2006;3:58–62.
15. Yankov B, Iliev G, Filtchev D, et al. Soft-
ware Application for Smile Design Automa-
tion Using the Visagism Theory. Proceed-
ings of the 17th International Conference
on Computer Systems and Technologies,
CompSysTech’16, June 23–24, Palermo,
Italy. ACM International Conference Pro-
ceeding Series, vol 1164. New York: ACM
Inc, 2016:237–244.
16. Shi J, Samal A, Marx D. How effective
are landmarks and their geometry for
face recognition? Computer Vision
The International Journal of Esthetic Dentistry | Volume 16 | Number 2 | Summer 2021
ROMEO
and Image Understanding 2006;102:
117–133.
17. Rufenacht CR. Fundamentals of Esthet-
ics. Chicago: Quintessence, 1990.
18. Phark JH, Romeo G. Dental anatomical
combinations: a guide to ultimate dental
esthetics. Quintessence Dent Technol
2013;36:183–204.
19. Kataoka S, Nishimura Y, Sadan A. Na-
ture’s Morphology: An atlas of tooth shape
and form. Chicago: Quintessence, 2002.
20. Farolch-Prats L, Nome-Chamorro C.
Facial contouring by using dermal fillers and
Botulinum Toxin A: a practical approach.
Aesthetic Plast Surg 2019;43:793–802.
21. Magne P P, Belser U. Bonded Porcelain
Restorations in the Anterior Dentition. A
Biomimetic Approach. Berlin: Quintessence,
2002:293–321
22. Romeo G. Multilayer ceramic layering:
systematic approach technique for the
ceramic build up between the facial and the
lingual area. Smile Dental J 2017;12:10–16.
23. Farolch-Prats L, Nome-Chamorro C.
Facial contouring by using dermal fillers and
Botulinum Toxin A: a practical approach.
Aesth Plast Surg 2019;43:793–802.
24. Harrar H, Myers S, Ghanem AM. Art or
Science? An evidence-based approach to
human facial beauty. A quantitative analysis
towards an informed clinical aesthetic prac-
tice. Aesthetic Plast Surg 2018;42:137–146.
| 215
Copyright of International Journal of Esthetic Dentistry is the property of Quintessence
Publishing Company Inc. and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder's express written permission. However, users
may print, download, or email articles for individual use.