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Dynamic
Dynamic
Dynamic
ESSENTIALS OF A SMILE
The upper and lower lips frame the display zone of the smile.
Within this framework, the components of the smile are the teeth and
the gingival scaffold
Although the commissures of the lips form the lateral borders of the
smile, the eye can perceive inner and outer commissures
A PERFECT SMILE
It is characterized by a medium lip line, an incisal line running against the
upper border of the lower lip, an upper lip presenting an upward curvature.
the mouth corners are symmetrically aligned to the papillary line and leave a
proportional bilateral negative space.
LIP LINES
LIP LINE
The lips define the esthetic zone and frame the smile
While low lip lines can sometimes be a cover for poor dentistry the high
lip line is more of an esthetic challenge to handle.
The ideal lip line is when smiling the lip elevates to the interdental
gingival margin
NEGATIVE SPACE
It is the dark space that appears between the jaws when laughing and smiling. It
promotes the dental composition by providing contrast. These lateral spaces are
due to the difference in width between the maxillary arch and the breadth of the
smile.
The application of the
divine proportion to
dentistry was attributed to
Lombardi and then
developed by Levin.
Using calipers that open at a constant divine proportion between the
larger and smaller parts, Levin observed that in esthetically pleasing
dentitions viewed from the front the width of the central incisors in the
golden proportion to the lateral incisor which is in golden proportion to
the anterior part of the canine.
It is desirable to establish harmony and continuity of the gingival form of the free
gingival margin.
The gingival margins of the two centrals must mirror each other and the level of
gingival attachment of the laterals incisor must be more incisal yet symmetrical to
the other lateral incisor.
The cuspid’s marginal gingival must be at the same level as that of the central
incisor and the premolar somewhat more coronal.
The most apical point of gingival tissue is located distal to the long axis of
the central incisor and canine. In the mandibular incisors and the maxillary
lateral incisor the zenith is located along the tooth axis
The gingival height in class II div 2 incisors:
The horizontal level of the gingival margin of the lateral incisor is located at a
higher level than the centrals and also tends to overlap the centrals.
Iin a Class I occlusion the gingival margin is symmetric parallel and horizontal
arrangement is esthetically pleasing.The margins of the two central incisors mirror
each other, the lateral gingival margins are lower and symmetric and the canines
are at the same/slightly higher level as the central incisors.
Contemporary orthodontic evaluation attempts to evaluate and examine
static and dynamically the anatomic and physiologic jaw tooth relationships.
Not only is the problem oriented treatment planning being followed, the
orthodontist as an architect of the smile needs to identify and quantify the
elements of the smile that needs correction, enhancement and improvement
as well as identifying the positive elements of the smile that must be saved.
The orthodontist of today must evaluate patients not only in the profile but
also vertically and transversely as well as the fourth dimension of time.
Growth and maturation as well as aging of the perioral soft tissues have a
profound effect on the appearance of the resting and smiling
presentations.
SKELTAL AND SOFT TISSUE FACIAL CHANGES IN
YOUTH, ADOLESCENTS AND ADULTS
Both upper and lower lips grows more than the skeletal lower face in children
.
In both absolute and proportional terms the lower lip grew more than the upper
lip. (Subtelny)
The upper lip showed rapid increase in length from age 1-3. The rate of growth
was then reduced from age 3-6 when again an upswing occurred till the age of
15.
The growth curve for the upper lip was similar to the growth curve for the
general body growth curve. (Vig and Cohen )
The clinical relevance of this study
In Subtelny’s study the upper lip attained a greater thickness in the vermillion region
than over point A.
This increase in thickness at the vermillion border was approximately equal to the
increase in length of the lip.
In both males and females the upper lip increased in thickness from ages 1-14.
After the age of 14 the lips continued to become thicker in males but not in females.
Similarly in the lower lip the gain in thickness was greater at vermillion border than at
Pogonion or point B
Lip thickness increase for males form ages 1-18 was around 7mm while for females it
was around 6mm.
Mamandras in his study of lip thickness found that the female lip thickened till the
age of 14 after which it remained the same till the age of 18 beyond which it showed
thinning.
Males attained maximum lip thickness by age of 16 after which they too showed
thinning.
Horizontal thickness of both sexes completed by age15.
Nanda slightly differed from Mamandras. He found that lip thickness increased
uniformly from age 7-18, females attained full lip thickness by age 13 with slight
thinning starting then.In males however the thickness continued till the age of 18.
Clinical applications of this data:
The differential in the two sexes with respect to lip thickness implies
that the treatment result of extraction therapy of the facial profile will
be more noticeable in female than male patients.
Because female lips do not thicken with age , any extraction plan for
females with straight to convex profiles should be cautiously
considered.
Class II patients exhibited a more pronounced elevation of the bridge of the nose
than class I. the dorsum of the class II cases also shoed an increased general
convexity. Class I tended to have straighter noses.
Females did not show such a spurt in growth like males but had a more steady
increase in nose growth.
There was a spurt in male’s nasal growth from 10-16 with a peak around 13-14
years
• This was of importance because an orthodontist treating a class II girl aged 12
could expect only minimal increases in nasal projection over the next few
years.
• However in a male of a similar age any treatment that causes upper lip
retraction in combination with several mm of nose growth might produce a less
than optimal final relationship between the lips and nose.
• The increased prominence of the nasal hump in boys coincides with pubertal
spurt and nasal projection in girls peaks between 9-10.
THE CHIN
Genecov’s study documented that soft tissue chin thickness in females from age
7-9 was greater than males .Females only had a 1.6mm increase upto age 18
whereas the males had a 2.4mm increase in soft tissue drape over the chin. As a
result both sexes had a similar soft tissue thickness at age 17.
In Nanda’s study, the soft issue thickness over the chin. symphysis thickness and
the length of the mandibular corpus, all 3 distances increased with age, the males
showing the largest increments.
Till 7 years the size of the mandibular corpus was the same for both sexes. and
the curves progressed parallel to each other till the age of 15 when the male
sample had larger increases than the female. Increased chin projection seen in the
males is due to the mandibular growth than the increase in soft tissue chin
thickness.
THE MATURE FACE
The reasons why the orthodontist should understand about the aging of the
face is because
•the orthodontist when treating an adolescent is making decisions about how
the individual will look for the rest of his life.
•the increasing demand for adult orthodontics and orthognathic surgery
increases the need to understand the facial aging process.
•an increase in the complexity of treatment plans and the expectations of the
patients is also a factor.
•The age usually having orthognathic surgery includes 28-35 and they soon
move into middle age when aging becomes most apparent. The blame may
be easily placed on orthodontics by the patient.
The general soft tissue changes in males between the ages of 18-42 included
the following finding:
In females:
The profile did not become straighter and the lips did not become more
protrusive
The nose increased in size in all dimensions.
There was decreased soft tissue thickness at the Pogonion.
There was upper lip thickness and slightly increased lower lip thickness
THE AGING FACE:
Behrents
In young adulthood, 17-41 subjects tended to be specific to their craniofacial
patterns.
In other words ClassII subjects grew as class II while class III grew as class III.
In later adulthood vertical dimensional changes were common to all subjects. they
became less protrusive with greater facial height increase. the males exhibited
counterclockwise rotation of the mandible. The percentages of change in the
females were less and growth tended to be more vertical.
Nasal changesThere was an increase in nasal projection and the nasal tip moved
more inferiorly.
Lip thickness: the lips became less prominent and were located more inferiorly. that
is the upper lip tended to rotate down and back from the base of the nose. This would
naturally imply that less maxillary incisor would be exposed at rest and smile which
is corroborated clinically.
Nasolabial changes:With the decrease in lip prominence and the lowering of the tip
the nasolabial angle became more acute.
Dental changes:In females the maxillary incisors became more upright and the
lower incisors became more proclined.the lower molar uprighted in males and moved
forward in females. The upper molar tilted forward in the male but uprighted in the
females.
FEATURES ASSOCIATED WITH
AGING:
The second factor is that the patient changes with age, the impact of
hard and soft tissue aging cannot be minimized.
RECORDS IN THE TREATMENT OF THE SMILE
The critical first stage is clinical examination with the evaluation of the lip tooth
relationship both statically and dynamically.
These are taken from a frontal and oblique direction to record a three dimensional
description of the smile characteristics.
The records therefore needed for smile visualization and
quantification are
1)static
the additional photographic images needed are:
profile and oblique smile and oblique and frontal smile
close ups.
2) dynamic
WHY DIGITAL VIDEOGRAPHY ?
Capturing patient smile images with conventional 35mm photography has some
major drawbacks.
The videos are recorded in a standardized fashion with the camera at a fixed
distance from the subject. One segment is taken in a frontal direction and
another in a oblique direction.
These clips are taken before and after treatment and help to assess the
changes in smile characteristics bought about by orthodontic treatment.
first the clinician should assess tongue posture and lip function, particularly during
speech. Immature oral and pharyngeal function with unfavorable tongue posture
can easily be detected.
The frame that best represents the patient’s social smile is selected, saved as a JPEG
file.
The smile image is then opened in a program called SmileMesh, which measures 15
attributes of the smile
This methodology was first used manually by Hulsey and later modified
and computerized by Ackerman
Its most significant advantage is that the orthodontist can quantify such
aspects of the smile as maxillary incisor display, upper lip drape, buccal
corridor ratio, maxillary midline offset, interlabial gap, and
intercommissure width in the frontal plane.
The flaw in traditional smile analysis has been that many of the vertical
and anteroposterior calculations related to anterior tooth display are made
from the tracing of the lateral cephalogram, which is taken in repose. As a
result, incisor position has been determined from a static rather than a
dynamic record.
Direct Biometric measurements:
Oblique
Vertical parameters:
•Incisal display
•Gingival display
•Relationship between the incisal margins of the upper incisors and the lower
lip
•Gingival margin with the upper lip
CAUSES OF LIP INCOMPETANCE
Short philtrum
V-Y cheiloplasty
Excessive overjet
orthodontics
EXCESSIVE UPPER INCISOR SHOW
AT REST AND ON SMILE
The reasons could include both hard and soft tissue
factors
Short philtrum
V-Y cheiloplasty
Vertical maxillary excess
Maxillary impaction via Le Fort I osteotomy
Long incisor crown height
Crown height reduction
Hyper-mobile smile
Cartilage or spacer technique
Kamer technique
De-torqued incisors
Orthodontic incisor torque
INSUFFICIENT UPPER INCISOR SHOW AT
REST AND ON SMILE
Long philtrum
Not often seen, no procedure
Vertical maxillary deficiency
Maxillary downgraft
Short incisor crown height
Gingival procedures like gingivectomy
Crown lengthening
Flared maxillary incisors
Orthodontic retraction and up righting
Diminished anterior dentoalveolar eruption secondary to chronic digit
habit
Orthodontic leveling
Surgical correction
Inadequate curtain on smile
MAXILLARY INCISOR DISPLAY
The amount of the incisor show at rest is a critical esthetic parameter because a sign of
aging is decreased show of the maxillary incisor.
The age of the patient plays a role because primary incisors measures only 4-5mm
vertically. Incomplete eruption of the crowns could also present as short clinical
crowns
Thick fibrotic gingival tends to migrate slowly so this must be ruled out.
The treatment also varies depending on whether the lack of clinical crown length
is due to gingival encroachment or loss of tooth structure incisally.
SMILE CURTAIN
A smile curtain is the amount of mobility and elevation of the upper
lip. Patients with an excessive smile curtain simply have and greater
than average range of smile activity than normal. therefore to
attempt to correct a hyper mobile smile through impaction would
adversely affect the incisor lip relation at rest adversely and would
age the patient. The upper lip would also thin and the curvature of
the resting lip would worsen.
The Kamer technique is simpler than the spacer technique and produces the
same result.
Kamer in his technique excised a horizontal strip of labial mucosa and attached
an inferiorly based mucosal flap from the opposing alveolar mucosa which
effectively decreases the height of the gingival
ALTERED PASSIVE ERUPTION:
Aberration in normal development where a large portion of the anatomic crown
remains covered by gingiva.
Unaesthetic for two reasons:
The normal scalloping is absent, teeth are short and squat.
A potentially medium lip line is converted to a high lip line.
Type IA: 1mm present between Cemento enamel junction and osseous level
( treated by gingivectomy)
Type 2A : osseous level close to the Cemento enamel junction (treated by a flap
and osseous resection)
METHODS OF DEVELOPING GINGIVAL HARMONY:
SURGICAL ORTHODONTICS
Additive gingival techniques extrusion
Resective gingival techniques intrusion
edges
Smile arc flattening during orthodontic treatment can occur in
several ways.
Normal orthodontic alignment of the maxillary and mandibular arches may
result in a loss of the curvature of the maxillary incisors relative to the lower lip
curvature
Broadening out a narrow arch can have two disadvantages, first the
buccal corridors could be obliterated, and second the broader arch form
could flatten the smile arch.
Smile asymmetry
Could be due to asymmetric smile curtain
Differential eruption of anterior teeth
Skeletal asymmetry
Arch form:
The patient’s archform—and particularly the configuration of
the anterior segment—will greatly influence the degree of
curvature of the smile arc. The broader the archform, the less
curvature of the anterior segment and the greater the likelihood of
a flat smile arc.
OBLIQUE DIMENSIONS:
This view shows smile characteristics not seen with the frontal view, especially
relevant in sagittal skeletal discrepancies. In an esthetically pleasing smile the
cant of the occlusal plane is consonant with the curvature of the lower lip.
The two characteristic of the smile that are best viewed in this view is the
overjet and incisor angulations .
*Posterior positioning of the maxilla in the sagittal plane can increase the
buccal corridors in the frontal plane.
Consideration should be given to the vertical and lateral attributes of the smile
as well as to the cant of the transverse occlusal plane
Next, the cant of the maxillary occlusal plane relative to Frankfort horizontal
should be assessed visually on the lateral cephalogram and measured on the
tracing.
Vertical and anteroposterior skeletal and dental relationships are noted.
Finally, the plaster study casts are evaluated for static occlusal relationships
and tooth-size discrepancies.
Clinical Implications for Low and Average Smile Types
In most deep overbite cases, intrusion will tend to hide the maxillary anterior
teeth behind the upper lip in normal conversation. Such a mistake can go
undetected by the orthodontist unless the patient's tooth display and smile are
analyzed from the front.
With increasing age and concomitant drooping of the upper lip, an unaesthetic
anterior tooth display may worsen.
In most orthodontic patients, except those with marked "gummy" smiles, active
intrusion of the maxillary incisors is undesirable.
The best treatment strategy in the majority of deep overbite cases is to actively
intrude the mandibular incisors, using double tubes on the mandibular first
molars and continuous or segmented base arches or utility arches
Another common mistake in orthodontic finishing is to create a straight (or even
reverse) maxillary incisal curve relative to the smile line
Parallelism of the incisal curve and the inner contour of the lower lip in smiling
should be produced .
this appearance can be achieved if the maxillary central incisors are symmetrically
positioned .5-1mm longer than the lateral incisors
If the lower lip shows a marked curvature in smiling, the distoincisal edges of the
maxillary central incisors can be ground slightly without affecting functional
occlusion
Clinical Implications for High Smile Types
Treatment alternatives include various combinations of orthodontic,
periodontal, and surgical therapy.
Treatment designed around the profile simply ignores the way that others see
our patients and how our patients see themselves.
The three quarter view of the face often reveals dentofacial characteristics,
which although not measurable, yield valuable information in both diagnosis
and treatment planning.
Facial symmetry and vertical canting of the occlusal plane are important.
When possible, computer imaging should be utilized to simulate the soft tissue
facial outcome that would most likely result from the proposed hard tissue
changes. This allows for the patient’s input in the decision-making process.
In summary, the 3 basic requirements for assessing dentofacial esthetics in
orthodontics are:
3. An analysis of the dental and skeletal volume of the face as it effects the
soft tissue facial mask.
When possible this should be an interactive process with the patient and is
best facilitated through the use of graphic images via computer
simulation.