Orthodontics

Waeil Batwa
Balpreet Grewal and Daljit Gill

Smile Analysis: What to Measure

Abstract: Patients seek dental treatment to improve oral function as well as their attractiveness. In order to improve smile attractiveness,
clinicians need to carry out a comprehensive smile assessment. The aim of this paper is to help clinicians to adopt a systematic approach
toward smile assessment by introducing a smile assessment form.
Clinical Relevance: Smile analysis is an essential part of smile diagnosis. A smile assessment form will assist clinicians in identifying and
recording smile features for diagnosis and treatment planning.
Dent Update 2014; 41: 483489

The smile, which is often used to show

pleasure and amusement, can be defined as
the facial expression that is characterized by
upward curving of the corners of the mouth.1
It is the second facial feature, after the eyes,
that people tend to look at when evaluating
the attractiveness and beauty of others,2 and
it is equally important for both genders.3

Types of smile
Generally, there are two types of
the smile, the posed and the spontaneous
smile.3,4 The posed smile is a voluntary
smile that is not elicited or accompanied
by emotions; it is unstrained and static
in the sense that it can be sustained
with fairly reproducible lip animation.4
The reproducibility of the posed smile in
natural head position makes it amenable

Waeil Batwa, BDS, MSc, MOrth RCS(Eng),

FFD Orth(RCSI), Assistant Professor and
Consultant Orthodontist, King Abdulaziz
University, Faculty of Dentistry, Saudi
Arabia, Balpreet Grewal, BDS, IQE, MJDF,
Honorary StR in Orthodontics, Barts and
the Royal London Hospital, London and
Daljit Gill, BDS(Hons), BSc(Hons), MSc,
FDS RCS, MOrth RCS, FDS(Orth) RCS(Eng),
FHEA, Consultant Orthodontist, Great
Ormond Street NHS Foundation Trust/
UCLH Eastman Dental Hospital, London,
UK.
July/August 2014

to orthodontic treatment planning.3 The

spontaneous smile is an involuntary smile
with animated lip elevation induced by joy.
It is dynamic in the sense that it bursts forth
but is not sustained. It can be said that it
expresses authentic human emotion.4

relevant to the patient, smile analysis serves as

a guiding tool, which can be used effectively
by both the dentist, to bring together all
options of treatment that can improve the
patient's smile, and the patient, to decide
what parameters in the smile are important.

Why smile analysis is important

Ethnic and gender influence on

smile perception

When patients attend for a

consultation with various concerns about the
smile, it is important that a clinician can assess
the smile in an objective manner in order
to determine the reason for dissatisfaction.
Once a cause of the problem has been
established, it is possible to undertake a riskbenefit analysis of the treatment approaches
that would be required to address the
patient concerns. In many cases, there may
be anatomical limitations that do not allow
the patient concerns to be addressed and
an understanding of smile analysis can help
these limitations to be identified and outlined
as part of the process of consent.
A clinician should be fully aware
that the perception of the need for dental
treatment can differ considerably between
patients and dentists. Dentists are known
to be less tolerant and more critical than
patients, who are generally less critical about
their own smile aesthetics.5,6 It is important
to remember that aesthetic values should be
judged by what the patient wants and not
by what we want as a clinician. Although all
components of the smile analysis may not be

Different ethnic groups can

differ significantly in their smile perception.
For example, dental protrusion is a common
feature in Afro-Caribbean patients and is
well accepted. However, in Caucasians, it
might be perceived as unaesthetic.
Females tend to favour more
upper gingival exposure during smiling
than males. However, males are less critical
than females when evaluating a smile.7
This implies a difference in tolerance
level between genders and reflects the
importance of considering the individual
patients concerns during smile analysis.

Smile analysis
A smile can be assessed clinically
whilst examining the patient, on a still
photograph or by using a digital video of the
smile.3,8 Clinically, not all the measures can
be made with ease, moreover, it is also time
consuming for the patient and dentist. A still
photograph can overcome these difficulties
and allows a detailed assessment of the
smile. The smile mesh can be used with a
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still photograph and consists of vertical and

horizontal lines placed onto the frontal smile
photograph.3 The horizontal lines are on the
vermilion borders of the upper and lower lips
and on the incisal edge of the upper right
central incisor. The vertical lines pass through
the distal of the maxillary canines, the inner
and outer commissures of the lips and
the dental midline (Figure 1). Quantitative
measurements can then be taken from
these lines.
A dynamic method for smile
analysis has been introduced involving the
capture of the smile with a standardized
digital video technique. A cephalostat
is used to position the patients head in
a natural reproducible position. Then
the mounted video camera captures
five-second long clips. These clips are
transferred to a computer and the frame
representing the best social smile is
selected and analysed manually or using
computer software.9 This method has
the advantage of capturing the most
reproducible spontaneous smile frame for
analysis.
In addition to analysing the
smile in three planes, sagittal, horizontal
and vertical, in static and dynamic positions,
age should be considered as a fourth
dimension.10 This is significant since patient
maturation and growth could play a role
in smile attractiveness. A good example
is reduced upper incisor show as a result
of an increased upper lip length in older
individuals.

themselves to have discoloured teeth.11 A

lighter tooth shade is considered preferable
since it reflects a youthful appearance.12
Teeth within the arch show some shade
variation, where the maxillary tooth shade
from the central incisor to the canine tends
to darken. Maxillary incisors and premolars
are similar in shade. The shade of each
of the maxillary anterior teeth should be

Figure 1. Smile mesh.

Components of the smile

The smile is a sum of a number
of features that contribute to it, either
positively or negatively. It can be broken
down into three major components:
The lips;
The surrounding gingival scaffold; and
The teeth.
Each of these components
may be further subdivided. To ease the
smile assessment and analysis, a form
was developed and divided into thirteen
distinctive features (Figure 2) as follows.
1. Shade of teeth

A recent survey in the United

Kingdom showed that people are mainly
concerned about the colour of their teeth,
where half of the respondents considered

484 DentalUpdate

Figure 2. Smile assessment form.

July/August 2014

Orthodontics

recorded using a shade guide in natural

light conditions.
2. The smile line

During a full smile the gingiva

is exposed superior to the maxillary teeth.
This is described as the smile line and can
be assessed as high (>2 mm gingival show),
average (12 mm gingival show) or low (no
gingival show), depending on the degree of
gingival display (Figure 2). For an attractive
smile, the display of upper central incisors
in addition to 1 mm of gingiva is ideal.9
The amount of maxillary gingival display
during smiling is dependent on a number
of factors, including anterior vertical
maxillary height, the muscular capability to
raise the upper lip,13 upper lip length and
incisor crown height. The smile line should
be documented (high, average, low) while
the amount of gingival and tooth display
should be recorded in mm with the patient
at smile and rest positions (Figure 3).
Upper lip length (see Figure 2: Smile assessment
form)

The upper and lower lips act as a

frame for the display zone of the smile.8 The
teeth and the gingival scaffold lie within this
framework. A degree of tooth and gingival
display is desirable to produce optimal
smile aesthetics; the upper lip length can
influence this. For a caucasian adult male,
the average upper lip length is 22 mm,
while it is 20 mm for an adult female. This
is measured from the base of the nose
(subnasale) to the lower end of the upper
lip (stomodium superioris) when the lip is
in the rest position. It is crucial to consider
the patient age during smile assessment,
since ageing is usually associated with an
increased upper lip length, which leads to a
lowering of the smile line.14

impact on smile aesthetic perception. On

the other hand, the redness and swollen
appearance of inflamed gingivae could
contribute to a less aesthetic smile.
Gingival shape

The gingival shape of the

mandibular incisors and the maxillary
lateral incisors should be symmetrically
half oval or half circular (Figure 4). The
maxillary centrals and canines should
exhibit a gingival shape that is more
elliptical.17
The gingival level

Symmetrical gingival display

is a significant factor in a satisfactory
smile appearance. Asymmetry in gingival
display can be judged negatively and
may be correlated with personality.3
The criteria for ideal gingival level are
described as follows:18
The height of the gingival level of the
central incisors and canines should be
the same;
For the lateral incisors, the gingival
level should be slightly more incisal than
that of the centrals and canines;
The gingival level of the contralateral
teeth should be symmetrical.
4. Black triangles

Three aspects of the gingiva are

of great importance in the perception of the
aesthetics of a smile: gingival colour, shape
and level.15 It should be kept in mind that
the smile line height is highly correlated
with gingival margin display.16
Gingival colour

A pale pink gingival colour

reflects healthy gingival tissue, which has an
July/August 2014

Figure 3. (a) A high lip line, assessed as more

aesthetic. (b) A low lip line, assessed as less aesthetic.

Figure 4. The shape of the gingival margins

of the maxillary central incisors (Arrow 1) and
canine (Arrow 3) is elliptical while the maxillary
lateral incisor is half oval (Arrow 2); embrasures
are shown in blue.

Black triangles (Figure 5)

are triangular black spaces that form
gingival to the contact area and have a
significant aesthetic impact. Risk factors
for formation include recession, poor
root angulations and triangular-shaped
crowns.19 Often, a multidisciplinary
team approach is required for their
management.
5. Tooth form

3. Gingival tissue

Based on shape, incisors

can be generally classified as square,
triangular or round. Round incisors were
found to be more aesthetic, especially in
female smiles.20

Figure 5. Black triangle between the central

incisors.

With ageing, and toothwear, the embrasure

spaces reduce in size.
7. Tooth proportions

6. Embrasures

The embrasures are the

triangular spaces incisal to the contacts
and ideally they should get larger as the
teeth progress posteriorly (Figure 4).

The ideal length to width

proportion of the maxillary central incisor is
approximately 10:8; on average, the upper
central incisor length should be 10.411.2
mm with a width of 8.49.3 mm.15 Once
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the size of the central incisors has been

established, the golden proportion can be
used to determine the appropriate relevant
size of the lateral incisors and canines. The
golden proportion has been suggested
as a method to assess the proportions of
anterior maxillary teeth in frontal view.
According to it, the width of the lateral
incisor should be 62% of the width of the
maxillary central incisor. The main problem
with the golden proportion is that it is not
dominant within the population. Another
suggested method to determine the ideal
tooth proportion is the golden percentage,
where the width of each tooth is as follows:
canine 10%, lateral incisor 15% and central
incisor 25% of the total width of the anterior
segment. The golden percentage was found
to be suitable in defining the proportionality
of maxillary anterior teeth if the percentage
is adjusted to take into account the ethnicity
of the population.21 Recent research would
suggest that there might not be one ideal
aesthetic standard to suit all patients, which
highlights the importance of seeking the
views of individual patients.
8. The smile arc

The smile arc (Figure 6) is the

relationship between two imaginary lines,
one representing the lower lip curvature
and one connecting the incisal edges of
the maxillary anterior teeth and premolar
tips in a posed smile.22 This relationship can
be either parallel (consonant), increased,
reversed or straight. An ideal smile arc has a
parallel relationship between the maxillary
incisal edges and the lower lip curvature.
Smiles with flatter arcs are said to be less
attractive.7,22 The smile arc may be flattened
during treatment (especially orthodontics)
in a number of ways,7 such as changes
in incisor vertical position, unfavourable
maxillary growth patterns (counter
clockwise rotation of the maxilla) and habits
such as digit-sucking, which cause upper
incisor intrusion.
9. The dental centre line

Patients relate their maxillary

midline to the upper lip. They consider
dental midline discrepancies a factor
in reducing smile attractiveness;
discrepancies of 2 mm or more have 56%
chance of being noticeable by laypeople.23
Therefore, the upper dental centre line

486 DentalUpdate

should be assessed in relation to the

facial midline and its direction and
position should be recorded.
10. The buccal corridors

The buccal corridor is defined

as the space between the facial surfaces
of the posterior teeth and the corners of
the lips. It is calculated as follows:22
Buccal corridor ratio =
intercommissure width visible maxillary dentition x 100
intercommissure width

The smaller the ratio (the

smaller the buccal corridor) the more
aesthetic is the smile.24 Orthodontic
treatment has been claimed to reduce
buccal corridors, where patients treated
with rapid maxillary expansion showed
less buccal corridor than untreated
groups.25
11. Dental and facial symmetry

Asymmetry in the face

and dentition is a naturally occurring
phenomenon. Dental asymmetry can
be treated by surgery, prosthodontics,
periodontics or orthodontics. Facial
asymmetries may be addressed
surgically to some extent after growth
has stopped. Smile asymmetry can
be seen as a result of contra-lateral
unevenness in crown length, crown
width, papilla height, the smile line,5
and the lip thickness. Any asymmetry
should be identified and quantified
(in millimetres). Interestingly,
although asymmetry can impair smile
attractiveness, some asymmetry is
acceptable to most individuals.
12. Tooth display

should be assessed from an occlusal view

of the patient's study models to determine
arch form.
In order to demonstrate the use
of the smile assessment form developed, the
authors captured and analysed the smile in
Figure 7. Figure 8 shows a completed smile
form, based on the smile in Figure 7.

An overview of treatment
Smile reconstruction or
improvement starts with diagnosis and
understanding the important features of
the smile will aid the clinician in identifying
what factors may be contributing to the
patient's concerns. Table 1 summarizes some
possible treatment approaches based on the
identified problem.

Conclusion
Smile analysis is an important
procedure prior to smile reconstruction.
The use of a smile assessment form helps
to provide a systematic method of smile
analysis and communication between
clinicians. Its crucial to consider the patient
age, ethnic background and gender while
carrying out smile analysis, and to remember
that there is no one ideal formula for all faces

Figure 6. The consonant smile arc. There is a

parallel relationship between the maxillary incisal
edges (blue line) and the lower lip curvature (red
line).

Smiles that display first molar

to first molar are usually rated the most
attractive.26 This is followed by smiles
displaying premolar to premolar. The
least attractive smiles are the ones that
display only canine to canine.
13. Arch form

Tooth display is related to

arch form; with more tooth display
expected with oval and square than
tapered arch forms. The maxillary arch

Figure 7. Patient smile that will be assessed with

smile assessment form.

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References

Figure 8. A completed smile assessment form to assess the smile in Figure 7: note that the smile line
was drawn in green, gingival shape in red, black triangle in black and tooth form in blue, following the
colour coding of the assessment form.

and that our decision should be guided

by the patient concerns and a careful riskbenefit analysis.

The authors would like

to thank Dr Derek Baram for his
contribution of Figures 1 and 3.

1. Krishnan V, Daniel ST, Lazar D, Asok

A. Characterization of posed smile by
using visual analog scale, smile arc,
buccal corridor measures, and modified
smile index. Am J Orthod Dentofacial
Orthop 2008; 133: 515523.
2. Hassebrauck M. The visual process
method: a new method to study
physical attractiveness. Evolution
Human Behavior 1998; 19: 111123.
3. Van der Geld P, Oosterveld P, Van
Heck G, Kuijpers-Jagtman AM. Smile
attractiveness: self-perception and
influence on personality. Angle Orthod
2007; 77: 759765.
4. Ackerman JL, Ackerman MB, Brensinger
CM, Landis JR. A morphometric analysis
of the posed smile. Clin Orthod Res
1998; 1: 211.
5. Kokich VO, Kokich VG, Kiyak HA.
Perceptions of dental professionals and
laypersons to altered dental esthetics:
asymmetric and symmetric situations.
Am J Orthod Dentofacial Orthop 2006;
130: 141151.
6. Batwa W, Hunt NP, Petrie A, Gill D.
Effect of occlusal plane on smile
attractiveness. Angle Orthod 2012; 82:
218223.
7. Geron S, Atalia W. Influence of sex
on the perception of oral and smile
esthetics with different gingival display
and incisal plane inclination.Angle
Orthod 2005; 75: 778784.
8. Sarver DM. The importance of incisor
positioning in the esthetic smile: the
smile arc. Am J Orthod Dentofacial
Orthop 2001; 120: 98111.
9. Ackerman MB, Ackerman JL. Smile
analysis and design in the digital era.

J Clin Orthod 2002; 36: 221236.
10. Sarver DM, Ackerman MB. Dynamic
smile visualization and quantification:
part 1. Evolution of the concept and
dynamic records for smile capture.

Am J Orthod Dentofacial Orthop 2003;
124: 412.
11. Alkhatib MN, Holt R, Bedi R. Prevalence
of self-assessed tooth discolouration in
the United Kingdom. J Dent 2004; 32:
561566.
12. Dunn WJ, Murchison DF, Broome JC.
Esthetics: patients perceptions of
dental attractiveness. J Prosthodont
1996; 5: 166171.

Acknowledgment

488 DentalUpdate

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Problem

Possible Treatment

Shade of teeth
Dark or discoloured teeth

Micro or macroabrasion
Bleaching
Composite or laminate veneers
Crowns

Smile line and upper lip:

Increased vertical gingival and tooth show

Botox to elevator muscles of upper lip

Orthodontic intrusion of anterior teeth
Gingivectomy
Orthognathic surgery, involving
maxillary impaction
Lip lengthening after completion of
growth (less efficient)

Decreased vertical gingival and tooth show

Orthodontic extrusion of anterior teeth

Tooth build-up (crowns, veneers or
composite)

Orthognathic surgery with maxillary set
down

Surgical lip lift or Botox after growth

completion (less efficient)
Gingival tissue
Colour
Enforced oral hygiene instruction and
treatment
Asymmetric level and shape

Gingevectomy
Gingival graft

Black triangles

Interproximal enamel reduction and

orthodontic space closure
Gingival graft
Change tooth angulation with orthodontics

Tooth form and proportion

Can be adjusted through restorative

procedures (grinding, stripping, build-up
veneers or crowns) orthodontics

Smile arc
Flat or reversed

Orthodontic treatment to intrude or

extrude upper labial teeth
Restorative procedures (grinding, build-
up veneers or crowns)

Buccal corridors, tooth display and arch form

Increased buccal corridors, reduced tooth
display

Orthodontic treatment to expand

maxilla
Orthognathic treatment to

expand the maxilla surgically

Table 1. Summary of the possible treatment approaches to improve a smile.

July/August 2014

13. Peck S, Peck L, Kataja M. The gingival

smile line.Angle Orthod 1992; 62:
91100.
14. Van der Geld P, Oosterveld P, Berge SJ,
Kuijpers-Jagtman AM. Tooth display
and lip position during spontaneous
and posed smiling in adults. Acta
Odontol Scand 2008; 66: 207213.
15. Sarver DM. Principles of cosmetic
dentistry in orthodontics: Part 1.
Shape and proportionality of anterior
teeth. Am J Orthod Dentofacial Orthop
2004; 126: 749753.
16. Peck S, Peck L. Selected aspects of
the art and science of facial esthetics.
Seminar Orthod 1995; 1: 105126.
17. Rufenacht CR. Fundamentals
of Esthetics1st edn. Chicago:
Quintessence, 1990.
18. Kokich VG, Spear F. Guidelines for
managing the orthodontic restorative
patient. Seminar Orthod 1997; 3: 320.
19. Sharma AA, Park JH. Esthetic
considerations in interdental papilla:
remediation and regeneration. J Esthet
Restor Dent 2010; 22: 1828.
20. Anderson KM, Behrents RG, McKinney
T, Buschang PH. Tooth shape
preferences in an esthetic smile. Am J
Orthod Dentofacial Orthop 2005; 128:
458465.
21. Fayyad AM, Jamani KD, Aqrabawi J.

Geometric and mathematical
proportions and their relations to
maxillary anterior teeth. J Contemp
Dent Pract 2006; 5: 6270.
22. Frush JP, Fisher RD. The dynesthetic
interpretation of the dentogenic
concept. J Prosthet Dent 1958; 8:
558581.
23. Johnston CD, Burden DJ, Stevenson
MR. The influence of dental to facial
midline discrepancies on dental
attractiveness ratings.Euro J Orthod
1999; 21: 517522.
24. Parekh SM, Fields HW, Beck FM,
Rosenstiel SF. The acceptability of
variations in smile arc and buccal
corridor space. Orthod Craniofacial Res
2007; 10: 1521.
25. Maulik C, Nanda R. Dynamic smile
analysis in young adults. Am J
Orthod Dentofacial Orthop 2007; 132:
307315.
26. Tjan AH, Miller GD, The JG. Some
esthetic factors in a smile.J Prosthet
Dent 1984; 51: 2428.
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