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Smile Design Requirements

Introduction:
A smile is not a static form; it is an action with so many dynamic elements
surrounding the teeth to display the smile, which makes it important for dental
professionals to understand the involvement of those elements to give
patients the best customized and proportionate result.
“Smile design” as a term doesn’t completely grasp the concept of the process,
as many confuse it with only digital visualization of the end result, “smile
analysis and design” gives a better description, if we were to define Smile
Design it’s not the treatment we perform on the patient, but rather the plan or
the blueprint that the clinician decide upon the look and functioning of the
teeth, by pre-visualizing the outcome before executing the treatment.
In this paper the aim is to define the principles of smile design to determine
the main factors that a clinician should look into for smile reformation, and
draw a checklist of the measures taken to get the best long term functional
and aesthetically pleasing outcome.
Review:

Throughout the world beauty standards are continuously evolving, with the
emergence of social media and the rise of the selfies, people have grew more
conscious of their looks and how they would like to be perceived, which is prevalent
in the use of Photoshop in the media or pre-set filters with many apps to whiten the
teeth and widen smiles, this collective beauty evolution have put aesthetic or
cosmetic dentistry on demand, and it has revolutionarily changed from being a need
or treatment necessity into a desire-driven, elective service.
Beautiful smiles got interpreted socially to represent youth, success and wealth,
which was met with development in tooth colored restorative systems and bonding
materials, producing dental aesthetics that beautifully mimics nature while
enhancing function and making patients demands and expectations attainable
(Wilson, 2015: 2-3).
Having many options and variation of problems made it even more important to
have a plan and to pre-visualize the outcome, with that we were represented with
several planning concepts and prepping techniques.

Modern concepts of smile design:

A-Functional smile design: the principle is based on aiming for a better function
to achieve a better design.
If the process of functional smile design is well understood and followed we can get
a functionally stable outcome with highly pleasing esthetics, and having a mounted
cast is extremely important if not the most important step in the process, because it

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is the most certain way of knowing the correct relationship between upper and lower
anterior teeth and establish anterior guidance with mutually protected occlusion.
It is critical in the planning stage to analyze the TMJ and if it is rested in centric
relation and if there is any signs of tenderness we cannot proceed with the
treatment.
Planning Essentials:
a. Facebow –mounted cast in the centric occlusion.
b. Establish anterior guidance.
c. Mutually protected occlusion
d. Provisional cannot be trusted from the wax-up alone and must be checked in the
mouth to determine the matrix of functional anatomy.
e. The incisal edge of maxillary anteriors should in harmony with the envelope of
function.
The critical decisions outlined in this concept to produce a smile harmonious with
function are:
1- The position of each anterior tooth.
2- The contour of each anterior tooth
Failing to follow the rules of functional occlusion can lead to:
 Overload on posterior teeth.
 Uncoordinated muscle hyperactivity.
 Overload to anterior teeth.
 Excessive wear
 Hypermobility
 Tooth fracture/ restoration fracture.
Key Elements:
 Anterior teeth should be in harmony with the esthetic zone.
 In harmony with the lips.
 Phonetics.
 Centric relation.
 Envelope of function (Dawson,2007:150).
B-Proportional smile design: the principle is built around the concept of
designing the smile to be in harmony with the face, as well as relating the length of
the teeth with the height of the patient, and adapting one of the proposed methods
to determine the width of the maxillary anterior.
The proposed methods:
1. Golden proportion: it is one of the oldest methods, in which the formula was
based on ancient Greek art and science, which found 1:1.618 to be the most
pleasing ratio to develop attractive and symmetrical proportions. Loumbardi first
introduced it to dentistry, concluding that the form an arrangement of the teeth
determine how esthetically pleasing is the smile (Wilson, 2015:11).
However, recent studies showed that golden proportions do not exist in natural
attractive smiles.
2. Natural proportion: several studies have been made around the world for an
estimate of natural proportion, which makes it important to take in consideration
the variations of natural proportions that differ according to the region and
ethnicity of the subjects studied.
This was found to be an unreliable method due to the many factors affecting the
result of the studies, such as age of the subject and incisal wear, as well as the
wide range of variation in different countries (Calamia et al, 2015:624-625).

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3. Recurring Esthetic Dental Proportion:
Levin suggested the golden proportion to the dental design as the anterior teeth
are viewed from the front should be in golden proportion which is 62%(0.618)
successively moving laterally from the centrals.
Lombardi suggested a repeated ratio consistently applied, established from the
central incisor in relation to the lateral and so on.
With combining the two concepts Ward came up with what is called the
Recurring Esthetic Dental (RED) proportion.
The RED proportion is defined ‘the proportion of successive width of the teeth as
viewed from the frontal should remain consistent as one moves distally’ it’s more
flexible unlike the golden proportion where the percentage is locked to 62%,
With RED proportion the dentist is in charge of choosing any percentage that fits
the face, skeletal features and body type as long as the percentage is consistent
moving distally (Ward, 2001: 145-146)

4. Golden percentage: this percentage suggested by Snow, where the width of


each tooth should be: canine 10%, lateral 15%, central 25%, central 25%, lateral
15%, and canine 10% of the total distance across the anterior segment.
In a study by Murthy and Ramani (2008: 16-21) the results showed that the golden
percentage was more applicable to individuals with natural dentition compared to
Golden Proportion, which doesn’t exist in natural dentition, or the inconsistent RED
Proportion.
Key Elements:
 Always take in consideration the ethnicity of the patient.
 The size and the sex of the patient should be thought of in terms of the
proportion.
 Patient preference should be examined.

C-Esthetic smile design:

With esthetic smile design the planning process starts with esthetics moving into
functionality and biology.
It is essential for the dentist to use the geometry and mathematic parameters
objectively as guidelines; but it must not be used mechanically because esthetic
dentistry is a mixture of scientific principles and artistic implementation.
The main focus for an esthetic dentist is the teeth hens a vast knowledge of tooth
form and anatomy is fundamental; but to achieve an optimum esthetic design the
dentist should start expanding his outlook and pay attention to the frame
surrounding each structure starting with line angles and axial inclination framing a
single tooth, gingival edges around the teeth, the lips surrounding the oral cavity
ending with the face that gathers all the structures together in harmony; and all
these structures whether static such as the teeth and gingiva or dynamic such as
the lips and facial soft tissue relate to each other proportionally by horizontal and
vertical imaginary reference points (Gürel, 2003:59-63)

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Main Factors In Smile Planning:
I. Smile Arc: the maxillary central incisors are the most prominent and
attention grabbing structure in the smile; so it’s only logical to start with it
as the first step in planning an esthetic treatment.
The vertical position of the maxillary incisor determined according to the type
of smile arch: convex, curved, consonant, deep plate-shaped, etc and ideally
the incisal edges slightly rest on the contour of the lower lip and it must be
bellow the cuspid tip of canines to achieve central incisors dominance.

II. Maxillary Incisor Ratio And Symmetry: the dentist should determine the
proportional mathematical method to adapt it to the patient characteristic
personality, size, ethnicity, facial structure and sexuality; in respect to
symmetry between incisal edges.
III. Anteriosuperior Teeth Ratio: once vertical position and length to width
ratio is set the anteriosuperior teeth is adjusted with attention to lateral
incisors not to appear too narrow because it leads to unaesthetic look.
There are some tricks to alter or give an illusion to the teeth without
disturbing the function or invading the biological standers:
 We can create depth with shadows.
 Light can increase prominence.
 Manipulating vertical lines give a perception of length to the tooth.
 Width can be emphasized with horizontal lines.
IV. Presence Of Anteriosuperior Space: the esthetic zone is the center of
the attention in the smile so we should always pay extra care in the design
shape and gingival attachment as small black spaces (black triangles) and
diastemas could draw attention and can be unaesthetic therefore, it’s
important to plan through interdisciplinary approach, such as grafts,
gingivoplasty, orthodontics or pink ceramics to manage these problems
ahead.
V. Gingival Design: pink esthetics possesses a huge impact on the smile.
A thorough evaluation of cementoenamel junction should be done by:
clinical probing, periapical radiographs or tomography to determine the
feasibility of a gingivoplasty.
The gingival margin of central incisors should be around 0.5-1.0 mm.
bellow the canine and the lateral incisor should be slightly 0.5 the central
incisor for esthetically pleasing results.
VI. Level Of Gingival Exposer: the level of the smile line determines gingival
exposer, which can be high, medium or low smile line.
At smiling up to 3.0mm. Of gingiva showing is acceptable esthetically.
In the planning stage the gummy smile treatment should be dictated by the
etiology.
VII. Buccal Corridor: buccal corridor is controversial among dental
practitioners, it is defined as the negative bilateral space between the
vestibular surface of visible posterior teeth while smiling, it’s affected
mainly by the width of the maxillary dental arch; a narrow arch is
unfavorable and gives a wide buccal corridor and therefore should be
avoided and maxillary expansion should be indicated whenever necessary
VIII. Midline And Toot Angulation: in literature midline deviation is acceptable
if it doesn’t exceed 2mm. however, it is controversial as it may be hardly
noticeable by laypeople, but there are variations in the features of each

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individual so it’s best to relate it to the nearest central structure as much as
possible, in case midline deviation is combined with any change in
angulation in the esthetic zone it’s extremely unaesthetic. Therefore,
angular deviation must be corrected based on guidelines in literature; the
incisal edge line must be parallel to the interpupillary line and the
angulation must be assisted from a frontal and lateral view.
IX. Characterization(Tooth Color And Anatomical Structure): ‘love of
beauty is taste, the creation of beauty is art’ – Ralph Waldo Emerson
Dental material have revolutionary changed over the years, so much that
we are able to imitate nature in its most appealing form. With that the
dentist and lab communication is of paramount importance; and should
provide the technician with detailed records and shade stunt to design the
restoration to the highest individualized esthetic standard.
Dental bleaching should be considered to improve the final result and we
should pay attention to the contacts and emergence profile to avoid
potential black spaces.
X. Lip Volum: the beauty standards nowadays emphasis full lips, but beauty
trends change over the years and a conversation between the dentist and
the patient about their expectations and perception of what they might
think of as beautiful is essential so that any esthetic modification such as
(lip enhancement, fillers, lip reduction which raconteur the smile line or
Botox) should be done before the smile makeover (Machado, 2014: 136-
157)
Key Elements:
a. Multidisciplinary treatment to achieve the best functional and esthetic results.
b. Minimally invasive practice.
c. Patient, clinician and lab communication.
d. Pink/white/black spaces should be respected and planned thoughtfully.

D-Digital smile design


The digital smile design is a conceptual tool that facilitates communication between
the dental team including the lab technician, and helps adequately transfer what we
gather in the checklists and questionnaires into the design of the restoration.
Drawing the lines on photos help pre-visualize the outcome thus, helps the team
evaluate the risks and limitations or any violation of esthetic principles.
There are several software’s that can be used such as (Microsoft PowerPoint,
Keynote, Photoshop, etc.) to name a few.
Advantages are: esthetic diagnosis, communication, feedback, patient management
and education)
Protocol:
 Intraoral and extraoral photos taken: three basic views are necessary: ‘full
face with a wide smile and the teeth apart, full face at rest, and retracted view
of the full maxillary arch with teeth apart. A short video is also
recommended’.
 After digital analysis with the digital caliper and ruler, the digital mock up is
created all the measurements gets transferred to the cast, we then get the
diagnostic wax-up fabricated using the design guides and transfer the new
incisal length to the wax-up with a caliper.

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 The guided diagnostic wax-up could be used for surgical, orthodontic,
restorative procedures by producing surgical stents, orthodontic guide, and
implant guide.
 Clinical try-in and getting the patients approval and prototypes can be
adjusted bearing in mind to practice minimal invasive dentistry (Coachman
and Calamita, 2012:1-9)

Key Elements:
 Digital dentistry facilitates the communication and visualization of the
outcome.
 Quality dental images are essential for the analysis
 Characterization of the treatment for each individual.
 Biological and functional modification must be scientifically merged into
the esthetic design.
 Interdisciplinary approach.

Conclusion:

Beauty is objective and conceptual, therefore it is fairly trend driven, so a clinician


communication skills are of dire importance to reach the optimum result for each
individual and to keeping up with the beauty industry revolution, the dentists should
always keep up to date with latest trends and respect the biology and function.
The smile design helps clinicians to communicate among the dental team members
because it’s an interdisciplinary approach, and have a blueprint beforehand to assist
the limitation of treatment and the risks for predictable results, this will give the
clinician the confidence to move forward in every step of the treatment.
Without the smile design a lot of problems may arise for leaving it up to the
technician to apply whatever might look esthetically pleasing on the cast, without
even meeting the patient or knowing what might work for their features or what
might be deemed a failure, not to mention the functional stability and time wasting in
sending the restorations back and forth for adjustments; this arbitrary way can lead
to patient dissatisfaction and loss of trust.
In the end we should remember while we design that ‘art not only imitates nature,
but also completes its deficiencies’-Aristotle

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References:

Calamia, J. et al (ed.), (2015) Modern Concepts in Aesthetic Dentistry and Multi-


disciplined Reconstructive Grand Rounds, Vol. 59, No.3, Philadelphia: Elsevier

Coachman C., Calamita M. (2012) ‘Digital Smile Design: A Tool for Treatment
Planning and Communication in Esthetic Dentistryt’, QDT, pp. 1-9

Dawson, P. (2007) Functional Occlusion: From TMJ to Smile Design, Missouri:


Mosby Elsevier

Gürel, G. (2003) The Science And Art Of Porcelain Laminate Veneers, London:
Quintessence Publishing Co. Ltd

Machado A. (2014) ‘10 commandments of smile esthetics’, Dental Press Journal of


Orthodontics,pp. 136–157.

Ward, D. (2001) ‘Proportional Smile Design Using The Recurring Esthetic Dental
(RED)Proportion’ , Dental Clinics Of North America Journal vol.45, no.1 pp.143-154

Wilson, N. (2015) Essentials Of Esthetic Dentistry: Principles And Practice Of


Esthetic Dentistry, Vol.1, London: Elsevier