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Dynamic smile analysis: Changes with age
Shyam Desai, Madhur Upadhyay, and Ravindra Nanda
Philadephia, Pa, and Farmington, Conn
Introduction: The objective of this study was to
define age-related changes in the smile. The areas of in-
terest were upper lip length at smile and repose, upper
lip thickness at smile and repose, maxillary incisal dis-
play at smile, interlabial gap height at smile, smile in-
dex, percentage of buccal corridors, intercommissural
width at rest, smile height, and smile arc. A secondary
objective was to study the perioral changes from rest
to smile and compare them on the basis of age.
Methods: Video equipment was used to capture im-
ages of 261 subjects, who were divided into 5 groups by
age. Two frames for each subject were selected, 1 frame
representing the lips at rest and the other representing
the widest smile. After 40 subjects were excluded, the
data for the remaining 221 were analyzed by using
1-way analysis of variance (ANOVA) with the Fisher
LSD post-hoc test.
Results: There was a decrease of 1.5 to 2 mm in
maxillary incisor display during smile with increasing
age, but the smile index showed a significant increase.
In accordance with some other studies, most subjects
(78%) had average smile height. No subject in the 50
and over age group had a high smile, and no subject
in the 15-to-19 year group had a low smile. All dynamic
measurements indicated a pattern of decreasing change
from rest to smile, especially evident after ages 30 to 39
years.
Conclusions: This study helps to establish age-
related dynamic norms. As a person ages, the smile
gets narrower vertically and wider transversely. The
dynamic measures indicate that the muscles’ ability to
create a smile decreases with increasing age.
Read the full text online at: www.ajodo.org,
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Am J Orthod Dentofacial Orthop 2009;136:310-11
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Copyright Ó 2009 by the American Association of Orthodontists.
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310
EDITOR’S SUMMARY
Faces obviously do change with time, and a treat-
ment that is appropriate at a younger age might not be
as appropriate later on. These researchers used video
equipment to capture subjects from 15 to 50 years or
older in the act of smiling. Then they extracted the
frames of each smile at its greatest width and analyzed
them. This method of standardization minimizes some
of the error inherent in trying to capture a smile with
a single snapshot. You can view 2 of the 5-second videos
on our website. [online, go to www.ajodo.org].
This article provides clues to assist the clinician in
making some of the more difficult treatment decisions.
The study appears to have been well framed and orga-
nized, and the results are clear. As patients age, they
might not display the same smile reaction to stimuli as
they did in the past. They might not be as emotional
as younger persons, or they just might not feel like pro-
ducing a ‘‘large’’ smile.
An important element of smile analysis is photo-
graphic lighting. Orthodontic photographs often have
huge variations in the amount of lighting, and this can
especially affect the appearance of buccal corridors.
To be most accurate, lighting must be measured with a
light meter in the buccal corridors, and lighting sources
must be standardized parallel to the occlusal plane.
Consideration should be given to guiding clinical
decisions affected by the results of this study. For
instance, should vertical dimensions be increased
(extruding molars), should maxillary incisor intrusion
be avoided in some instances, or should arches be
expanded to reduce buccal corridors? Because of con-
cern about muscle function in the upper lip, what might
be the implications of Botox treatments or lip augmen-
tation on producing lip height? These are difficult deci-
sions clinicians will face when trying to comply with the
results of this study. Taking into account all the dynamic
measurements that were examined, it can be said that
the muscles’ ability to create a great smile decreases
with age.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 3
Fig 1. Measurements on the rest frame: 1, upper lip
length; 2, upper lip thickness; 3, intercommissural width.
Q&A
Editor: Was this study difficult to accomplish with
the variety of data being collected and evaluated?
Nanda: I would not say that this study or the collec-
tion of the data was difficult to accomplish, but, yes,
definitely it was a huge challenge and required
detailed planning and meticulous execution. The dif-
ficult part probably was the interpretation of the large
amounts of data from a broad range of patients from
approximately 15 to 60 years of age. These subjects
were divided into 5 categories to streamline the anal-
ysis. We also tried to allude to the possible clinical
implications of this study, but going beyond what
was mentioned will be difficult because of the wide
age distribution of the sample.
Editor: In the next study of smile esthetics, what
would you do differently to improve the reliability
of the results?
Nanda: Since time has been introduced as the fourth
dimension of treatment planning, long-term knowl-
edge of dentofacial changes are paramount to clinical
success. Therefore, ideally, more accurate informa-
tion of age-related changes on the perioral tissues
can only be obtained in a long-term, prospective, lon-
gitudinal study, but, because of methodological and
financial constraints, these studies can be difficult
to execute.
However, we have just completed a follow-up study
along the same lines, looking into maxillary and man-
dibular incisor display during speech in various age
Desai, Upadhyay, and Nanda 311
Fig 2. Measurements on the smile frame: 1, upper lip
length; 2, upper lip thickness; 3, maxillary incisal display;
4, maxillary incisal edge to lower lip; 5, interlabial gap
height; 6, outer intercommissural width; 7, inner inter-
commissural width; 8, widest maxillary dental display.
groups.1 In addition, future studies could also evalu-
ate the attractiveness of measurements that have not
been widely studied including, but not limited to,
smile index, lip thickness, and the lower lip covering
the maxillary incisor edges with advancing age.
Editor: Do you think that this type of information
has a major impact in orthodontic treatment out-
comes, or are the results more subtle?
Nanda: If these results are judiciously applied for ac-
curate diagnosis and treatment planning, we think that
treatment results will be esthetically more appealing,
healthier, and longer-lasting. Any definitive clinical
implication of this study that can be applied in a clini-
cal setting will depend on the patient’s age, dentoske-
letal features, and primary treatment objectives.
However, interpretation of the features of a dynamic
smile is just 1 factor that must be considered for appro-
priate treatment planning. It’s up to the clinician to
further interpret these data and apply them appropri-
ately to the malocclusion, so that the results are both
functionally and esthetically stable. The facial mor-
phology of patients obviously does change with
time, and an age-appropriate treatment at 1 time might
not be appropriate later.
REFERENCE
1. Yaghoubzadeh A, Nanda R. Dynamic analysis of the dental dis-
play during speech from the ages of 12 to 60 years [thesis].
Farmington, Conn: University of Connecticut; 2009.