Smile Analysis

Systematic examination of facial and dental appearance

should be done in the following three steps:
1.Facial proportions in all three planes of space (macro-
esthetics).
2.The dentition in relation to the face (mini-esthetics).
3.The teeth in relation to one another (micro-esthetics).
 Macro-Esthetics
*Frontal Examination
1. Facial proportions and symmetry
2. Vertical facial thirds
3. Hypertelorism

*Profile Analysis
1. Establishing whether the jaws are proportionately positioned in the anteroposterior
(AP) plane of space.
2. Evaluation of lip posture and incisor prominence .
3. Evaluation of mandibular plane angle .
4. Evaluation of submental soft tissue form(Throat form).
Facial proportions and symmetry
*Central, medial, and lateral equal fifths .
*The separation of the eyes and the width of the eyes,
should be equal .
*The nose and chin should be centered within the central fifth .
*width of the nose the same as or slightly wider than the central
fifth.
* The interpupillary distance should equal the width of the mouth.
*The lip commissure height is being related to
the central philtrum height .

*The width of the nose is being related to the

interocular width.

A B
A small degree of bilateral facial asymmetry
exists in all normal individuals
This can be appreciated most readily by
comparing the real full-face photograph with
composites consisting of two right or
two left sides (normal asymmetry)

A B C
Facial measurements for anthropometric
analysis are made with either
(A) bow calipers or
(B) straight calipers
Facial Anthropometric Measurements (Young Adults)

Ma l e (SD) Female (SD) A B

Parameter
137 (4.3) 130 (5.3)
1. Zygomatic width (zy-zy) (mm)

97 (5.8) 91 (5.9)
2. Gonial width (go-go)

33 (2.7) 32 (2.4)
3. Intercanthal distance

11
3
33 (2.0) 31 (1.8)
4. Pupil-midfacial distance
1 4

12
5
35 (2.6) 31 (1.9)
5. Nasal base width 7
2 9 13

53 (3.3) 50 (3.2) 8 10
6. Mouth width 6
121 (6.8) 112 (5.2)
7. Face height (N-gn)

8. Lower face height (subnasale-gn)

72 (6.0) 66 (4.5) C D E

8.9 (1.5) 8.4 (1.3)

9. Upper lip vermilion

10.4 (1.9) 9.7 (1.6)

10. Lower lip vermilion

99 (8.0) 99 (8.7)
11. Nasolabial angle (degrees)

131 (8.1) 134 (1.8)

12. Nasofrontal angle (degrees)

Obtuse Obtuse
13. Labiomental sulcus
 Vertical facial thirds

*The lower third includes thirds:

The mouth should be one-third of the way
between the base of the nose and the chin.

*In modern Caucasians, the lower facial third

often is slightly longer than the central third.
1 /3 1 /3

2 /3
2 /3

A B
 Hypertelorism
Low-set ears or eyes that are unusually far apart
may indicate either the presence of a syndrome
or a microform of a craniofacial anomaly.

If a syndrome is suspected, the patient’s hands

should be examined for syndactyly .
 Profile Analysis. ( poor man’s cephalometric analysis)
This is a vital diagnostic technique for all dentists. It must be mastered by all those who will
see patients for primary care in dentistry, not just by orthodontists.

Careful examination of the facial profile yields the same information, although in less detail
for the underlying skeletal relationships, as that obtained from analysis of lateral
cephalometric radiographs.

Three goals of facial profile analysis are done by three steps:

1. Establishing whether the jaws are proportionately positioned in the anteroposterior (AP) plane of space.
2. Evaluation of lip posture and incisor prominence .
3. Evaluation of mandibular plane angle .
4. Evaluation of submental soft tissue form(Throat form) .
 Establishing whether the jaws are proportionately positioned in the anteroposterior (AP) plane of space

*Placing the patient in the physiologic

natural head position (NHP)
This can be done with the patient either
sitting upright or standing but not reclining
in a dental chair and looking at the horizon
or a distant object.
*Two lines, one dropped from the bridge
of the nose to the base of the upper lip,
and a second one extending
B Straight
from that point downward to the chin A Convex C Concave

*Large angle between them

(>10 degrees or so)
*profile convexity or concavity results
from a disproportion in the size of the jaws
but does not by itself indicate which jaw is at fault.
 Evaluation of lip posture and incisor prominence
*Detecting excessive incisor protrusion (which is relatively common) or
retrusion (which is rare).
*In the extreme case, incisor protrusion can produce ideal alignment of the
teeth instead of severely crowded incisors, at the expense of lips that protrude
and are difficult to bring into function over the protruding teeth.
This is bimaxillary dentoalveolar protrusion

*The teeth protrude excessively if (and only if) two conditions are met:
(1) The lips are prominent and everted
(2) the lips are separated at rest by more than 3 to 4 mm
(which is sometimes termed lip incompetence).

*Lip prominence is strongly influenced by racial and ethnic

characteristics and to a considerable extent also is age-dependent

A B C
Some patients with short lower face height have everted and
protrusive lips because they are overclosed and the upper lip presses
against the lower lip, not because the teeth protrude.

One indicator of lip protrusion caused by overclosure is the labiomental

fold angulation (the angle between the labial surface of the lower lip
and the labial surface of the chin). Under normal conditions this
is usually somewhat obtuse; a greatly decreased angle indicates
overclosure.
Evaluation of mandibular plane angle
Inclination of the mandibular plane to the true horizontal should
be noted.
The mandibular plane is visualized readily by placing a
finger or mirror handle along the lower border

*Steep mandibular plane angle usually accompanies long anterior facial

vertical dimensions and a skeletal open bite tendency, whereas a
*Flat mandibular plane angle often correlates with short anterior
facial height and deep bite malocclusion.

Mandibular plane angle is 22

Evaluation of submental soft tissue form(Throat form)

* Chin–throat angle (closer to 90 degrees is better).

* Throat length (longer is better, up to a point).

* Both submental fat deposition and a low tongue

posture contribute to a stepped throat contour,
which becomes a “double chin” when extreme.

A B
• During the macro-esthetic examination, and in other parts of the
clinical examination,
• it is important to note not only what is wrong, but also what is right.
After all, you don’t to damage some of the good attributes of
dentofacial appearance while treating the bad ones.
 Mini-Esthetics
Mini-Esthetics(The dentition in relation to the face)
(Tooth–Lip Relationships)
(dental–soft tissue relationships)

1. Dental–Skeletal midlines .
2. Amount of incisor and gingival display .
3. Transverse cant of the occlusal plane .
4. Smile Arc .
 Types of Smiles
There are two types of smiles:
1.Posed or Social smile .
2.Enjoyment smile (also called the Duchenne smile) .

The social smile is reasonably reproducible and is the one that is presented
to the world routinely.
The enjoyment smile varies with the emotion being displayed .

The social smile is the focus of orthodontic diagnosis .

 Dental–Skeletal midlines
The lower incisor midline relative to the midline of the mandible, and the upper
incisor midline relative to the midline of the maxilla(dental–skeletal midlines) .
Amount of incisor and gingival display
* vertical relationship of the teeth and gingiva to the lips at rest and on smile .

• Causes of excessive incisor display :

1. long lower third of the face (the usual cause ).
2. short upper lip.

• Recording lip height at the philtrum and

the commissures can clarify the source of
the problem.
*Using computer-altered photographs .

*Ideal elevation of the lip on smile for adolescents

is slightly below the gingival margin with 2 mm of
tooth coverage, so that most but not quite all of
the upper incisor can be seen.

More important, the acceptable range of

tooth display is from minimal tooth coverage
of 1 mm up to 4 mm coverage of the incisor
crown. Beyond that, the smile appearance
is less attractive.
• Remember, that whatever the cause of excessive
display, this tends to decrease with advancing age,
so what looks like a problem at a younger age may not
be as the patient gets older .

A B C
Transverse cant of the occlusal plane

*Also called ( transverse roll of the esthetic line of the dentition)

*up–down transverse rotation of the dentition is revealed when the
patient smiles or the lips are separated atrest
*Neither dental casts nor a photograph with lip
retractors will reveal this.
*Dentists detect a transverse roll at 1 mm from
side to side, whereas laypersons are more
forgiving and see it at 2 to 3 mm .
* The transverse width of the dental arches
can and should be related to the width of the
face .
A B
Transverse dimensions of the smile relative to the upper arch
* Amount of buccal corridor that is displayed on smile (especially the premolars) and the inside of the cheek

*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 .

*A dimension of interest to prosthodontists, and more recently to

orthodontists, is the amount of buccal corridor that is displayed on smile—

that is, the distance between the maxillary posterior teeth (especially the

premolars) and the inside of the cheek

A B

• Prosthodontists consider excessively wide buccal corridors (sometimes called

“negative space”) to be unesthetic, and orthodontists have noted that widening

the maxillary arch can improve the appearance of the smile if cheek drape is

significantly wider than the dental arch

• Although minimal buccal corridors are favored by most observers,

especially in females

• Too broad an upper arch, so that there is no buccal corridor is unesthetic

 Smile arc
*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, these curvatures should
be parallel .
*If the lip and dental contours match, they
are said to be consonant .
A flattened (nonconsonant) smile arc can pose A B

either or both of two problems:

1. It is less attractive.
2. It tends to make you look older (because older individuals often have wear of
the incisors that tends to flatten the arc of the teeth) .
*Another feature that draws negative attention to the smile is
excessive inclination of the upper teeth as they tip toward the left
or right .
*Inclination exceeds a 2-mm deviation from the normal, but tolerate a tilt less
than that .
*Full face view (i.e., when they are looking into
a large mirror mounted so that they can see
their whole face at about 2-feet distance—
the normal social distance of interaction .
*The smile arc is judged most attractive
than when judged using the smaller mirror
(hand-held mirror that shows only part of
the face)
 Micro-Esthetics
* The teeth in relation to one another
Close-up Dental Appearance.

1. Width Relationships and the “Golden Proportion” .

2. Height–Width Relationships .
3. Connectors .
4. Embrasures .
5. Gingival Heights .
6. Gingival shape and contour .
7. Tooth Shade and Color .
Width Relationships and the “Golden Proportion.”
Tooth widths in relation to one another

Height–Width Relationships.
1.0

the width of a visible tooth should be about 80% of its 10.

4

height to m
11.2
m
0.8

8
.
A 3
7
-
9
There are several possible causes:
1. Incomplete eruption in a child, which may
correct itself with further development .
2. loss of crown height from attrition in an older
patient, which may indicate restoration of the
missing part of the crown .
3. Excessive gingival height, which is best treated
with crown lengthening .
4. Inherent distortion in crown form, which suggests a
more extensive restoration with facial laminates or
a complete crown
 Connectors
• The connector (also referred to as the interdental contact area .
• is where adjacent teeth appear to touch and may extend apically
or occlusally from the actual contact point .
• The connector includes both the contact point and the areas above
and below that are so close together they look as if they are touching.
3
• The normal connector height is greatest between the central incisors
Con 4 0
nect 0 %
%
or
and diminishes from the centrals to the posterior teeth, moving 50%
Contact
apically in a progression from the central incisors to the premolars
Em
and molars. bras
ure

Embrasures
• The triangular spaces incisal and gingival to the contact .
• Ideally are larger in size than the connectors, and the gingival embrasures are filled by the interdental papillae.
 Black Triangles
Short interdental papillae leave an open gingival embrasure
above the connectors, and these “black triangles” can
detract significantly from the appearance of the teeth on
smile.
• Black triangles in adults usually arise from loss of gingival
tissue related to periodontal disease A B

• Crowded and rotated maxillary incisors are corrected

orthodontically in adults, the connector moves incisally
and black triangles may appear, especially if severe
crowding was present .
C D
• Patient should be prepared for reshaping of the teeth to
minimize this esthetic problem.
Gingival Heights
The central incisor has the highest gingival
level, the lateral incisor is approximately
1.5 mm lower, and the canine gingival
margin again is at the level of the central
incisor. A B

Maintaining these gingival relationships

becomes particularly important when canines
are used to replace missing lateral incisors
C D

or when other tooth substitutions are

planned.
 Gingival shape and contour
refers to the curvature of the gingiva at the
margin of the tooth.
For best appearance, the gingival shape of
the maxillary lateral incisors should be
a symmetric half-oval or half-circle.
The maxillary centrals and canines should
exhibit a gingival shape that is more
elliptical and oriented distally to the
long axis of the tooth .
The gingival zenith (the most apical point of the gingival tissue) should be
located distal to the longitudinal axis of the maxillary centrals and canines; the
gingival zenith of the maxillary laterals should coincide with their longitudinal
axis.
Tooth Shade and Color

* The color and shade of the teeth change with

increasing age, and many patients perceive this
as a problem.

* The teeth appear lighter and brighter at a younger

age and darker and duller as aging progresses .
A B
This is related to the formation of secondary
dentin as pulp chambers decrease in size and to thinning of the facial enamel, which results in a decrease
in its translucency and a greater contribution of the darker underlying dentin to the shade of the tooth.

* The maxillary central incisors tend to be the brightest in the smile, the lateral incisors less so, and the
canines the least bright. The first and second premolars are more closely matched to the lateral incisors.
They are lighter and brighter than the canines.
CHU FORMULA
• simple method for determining the optimal sizes of anterior
teeth
This is needed because of the frequency of anomalous and missing maxillary lateral incisors.
In addition other factors that create challenges for the dentist and orthodontist when designing
an esthetic and occlusally sound dentition are attrition, trauma, transposition, erosion, and
caries.
Optimal esthetics and occlusion require correctly sized teeth in proportion to themselves and the
other teeth.
• Maxillary central incisor (in millimeters) = Y
Maxillary lateral incisor = Y – 2 mm

Maxillary canine = Y – 1 mm

Mandibular central incisor (in millimeters) = X

Mandibular lateral incisor = X + 0.5 mm

Mandibular canine = X + 1 mm
• When several anterior teeth are anomalous, missing, or not
ideally sized, the width of the mandibular central incisor can be
used to calculate the ideal sizes of the other teeth because it is
the least variable tooth among the 12 anterior teeth. Therefore,
its width can be measured to establish ideal maxillary incisor
widths. This is accomplished by recognizing that the maxillary
central incisor is typically 3 mm wider than the mandibular
central incisor. The formula is shown below:
 Bolton Analysis
• Bolton analysis determines the ratio of the mesiodistal widths of the
maxillary teeth to the mandibular teeth using a formula introduced by
Dr. Wayne A. Bolton. It shows whether there is any tooth size
discrepancy between the upper and lower teeth. This analysis is
recommended only in the permanent dentition, after the eruption of
all the permanent teeth.
• When treating patients, instead of going through a time-consuming
process of doing diagnostic set-ups, using the Bolton Analysis
intermaxillary ratio can be used to assess maxillary or mandibular
arch length deficiencies or tooth size discrepancies. This provides the
clinician with a quick diagnostic tool to approximate how to finish in
an “excellent occlusion” with ideal overbite and overjet.
 If the overall ratio is less than 91.3% it indicates that there is maxillary tooth material excess.
If the overall ratio is more than 91.3 It indicates that there is Mandibular tooth material excess

If the anterior ratio is less than 77.2%, it indicates maxillary anterior excess.
If the anterior ratio is more than 77.2%, it indicates mandibular anterior excess