Mechanics to Enhance Facial and Smile

Esthetics
Andre Wilson Machado

The parameters for achievement of treatment success sometimes differ

between patients and orthodontists, while patients focus on esthetics,
orthodontists usually emphasize occlusal criteria. Although smile esthetics
is an extensive topic, clinicians must understand the main principles of an
ideal smile in order to use the appropriate orthodontic mechanics to enhance
facial and smile esthetics. The objectives of this paper are: 1) to review the
two main principles of a beautiful and youthful smile to guide the clinician to
visualize the main esthetic goals of orthodontic treatment, and 2) to present
two clinical situations where appropriate orthodontic mechanics were used
to obtain optimal facial and smile esthetics results. (Semin Orthod 2020;
26:117–125) © 2020 Elsevier Inc. All rights reserved.

Introduction depreciate smile esthetics and/or facial esthetics.

The most common clinical example is the correc-
lthough obtaining a functional occlusion is
A a mandatory goal of any orthodontic treat-
ment, laypeople usually seek treatment for
tion of a deep bite by means of upper incisor
intrusion. The level of overbite may be corrected
but, often, along with deterioration of esthetics.1
esthetic purposes.1,2 Thus, the expectations from
With this thought in mind, the main principles
orthodontic treatment are no longer restricted
of an ideal smile must be understood in order to
to occlusal criteria; patients seek a beautiful and
incorporate this information into the orthodontic
harmonious smile and, more recently, facial
diagnosis and treatment plan. Since “smile
youth.3 5 In other words, the parameters for
esthetics” is an extensive topic and also a subjec-
achievement of treatment success sometimes dif-
tive issue, just what are the most important param-
fer between patients and orthodontists. While
eters that should guide the clinician during the
patients generally focus on esthetics, orthodont-
orthodontic diagnosis and treatment planning
ists concentrate on occlusal criteria. A study con-
stages? In other words, how can orthodontic
ducted by Schabel et al6, for example, revealed
mechanics enhance facial and smile esthetics?
no strong relationship between well-finished
The objective of this paper is twofold: first, to
orthodontic cases from an occlusal standpoint
review the two main principles of a beautiful and
and smile esthetics. Thus, while planning each
youthful smile to guide the clinician to visualize
case, the orthodontist must carefully attend to
the main esthetic goals of orthodontic treatment
not only the occlusal criteria but also the
and, second, to present two clinical situations
patient’s expectations to obtain complete suc-
where the ideal mechanical approach was used
cess, including both facial and smile esthetics.
to obtain optimal smile esthetics results.
This aspect is of vital importance because, some-
times, the orthodontic mechanical approach
improves the occlusal criteria but might Main Principles of an Ideal Smile
Smile analysis is a broad subject that involves sev-
Department of Orthodontics, Faculty of Dentistry, Federal Univer- eral characteristics such as: 1) Incisal design; 2)
sity of Bahia, Salvador, Bahia, Brazil. Maxillary central incisor ratios and symmetry; 3)
Corresponding author. Faculdade de Odontologia, Universidade
Proportions among maxillary anterior teeth; 4)
Federal da Bahia (UFBA), Rua Ara
u jo Pinho, n. 62. 7 andar. CEP
40110-150, Salvador, Bahia, Brazil E-mail: awmachado@gmail.com Presence of spacing in the maxillary anterior
© 2020 Elsevier Inc. All rights reserved.
teeth; 5) Gingival design; 6) Gingiva exposure on
1073-8746/12/1801-$30.00/0 smiling; 7) Buccal corridors; 8) Midline and
https://doi.org/10.1053/j.sodo.2020.06.008 tooth angulation (occlusal cant); 9) Detailing:

Seminars in Orthodontics, Vol 26, No 3, 2020: pp 117 125 117

118
Tooth color and anatomical shape, and 10) Lip
volume.1
Among all these characteristics, there is a con-
sensus that the noblest area of the smile is the
maxillary anterior teeth (canine to canine or first
premolar to first premolar), the so-called
“esthetic zone”. In addition, central incisors are
known as key elements and characterize the ter-
minology “focus on centrals”. In summary, cen-
tral incisors must be highlighted as the true
protagonists of the smile.1
Recognizing the sovereign role of the upper
central incisors, what would be the most impor-
tant characteristics to be achieved? Due to space
limitations, we will discuss the two main charac-
teristics to achieve a great “focus on centrals”: 1)
Incisal design1,7 9 and 2) Maxillary central inci-
sor proportions and symmetry.1,2,10,11
#1: Incisal Design
The incisal design is the most important charac-
teristic in a smile analysis and corresponds to the
design formed by the incisal edges of the teeth in
the esthetic zone.1 It is also described in the liter-
ature as incisal curvature12 and smile arc.13 The
ideal incisal design forms a gentle curve that
gently follows the contour of the lower lip and is
classified as: convex, curved, and consonant,
among others (Fig. 1).12,13
In fact, it is not mandatory that the incisal
edges of the teeth in the esthetic zone follow the
contour of the lower lip, this anatomical area is
simply a reference guide. On the other hand, the
incisal edges in the esthetic zone must form a
Figure 1. Two characteristics of the ideal incisal design: 1) incisal edges must form a gentle and upward curve bilater-
ally (dotted yellow line); 2) incisal edges of the central incisors must be parallel to the ground (dark blue line).
Machado
gentle and upward curve bilaterally. In addition,
it is mandatory that the incisal edges of the cen-
tral incisors be parallel to the ground or the
inter-pupillary line (Fig. 1).1
To assist the clinician in visualizing the incisal
design, it is suggested to mark a point on the inci-
sal edge of all teeth in the esthetic zone, in the
intraoral or close-up smile photos, and connect
the dots. Thus, it becomes easier to visualize pos-
sible problems in the incisal design and/or pres-
ence of an occlusal cant. When the incisal design
does not go up bilaterally, is classified as straight
or reverse, and these types are not attractive as
the ideal arrangement (Fig. 2).1,12,13
Interestingly, a comparison between the most
attractive design (convex) and the most unattrac-
tive (reverse) raises the following question: why
are they complete opposites from an esthetic
standpoint? First, in terms of beauty, the curved
contour of incisal edges in the esthetic zone is
considered as the most important factor of den-
tal esthetics.14 Second, in terms of joviality, the
more curved the incisal design, and the greater
the focus on the centrals, the younger the smile
looks; whereas, the more reverse, the more aged
it looks.1 Additionally, according to the litera-
ture, the older someone is, the less maxillary inci-
sor exposure and the more mandibular incisor
exposure there will be, both at smiling, at rest or
while speaking.15,16
With these thoughts in mind, the identifica-
tion of these characteristics is the starting point
of any esthetic planning of the smile and, among
the teeth in the esthetic zone, the central incisors
are the most important. So, in order to proceed
 Mechanics to Enhance Facial and Smile Esthetics 119

Figure 2. Different types of incisal design: A) convex or curved; B) flat or straight; and C) inverted or reverse.

during treatment planning, the following ques-
tion must be answered: At the end of the treat-
ment, where would we like to place the incisal
edges of the teeth in the esthetic zone, especially
the central incisors?
To answer this question, we need to under-
stand that vertical alterations in the upper cen-
trals imply the alteration of three characteristics:
1) the central-to-lateral incisal step, 2) the gingi-
val design among the teeth in the esthetic zone,
and 3) the amount of gingival exposure in the
central incisor area. Among these aspects, the
central-to-lateral step is the most important.7 For
a long time, the specialty used an esthetic param-
eter without scientific evidence: “the ideal step
between central and lateral incisors is 0.5 mm”.
Due to this gap in the literature, several different
vertical positions of the upper central incisors
were tested and slightly extruded centrals were
found to be more attractive than intruded cen-
trals.7 9 The results of these studies indicated
that the central-to-lateral ideal incisal step
should be 1-2 mm for female and male patients
(Fig. 3.)7 9
And what is the impact of this information on
the execution of orthodontic mechanical plan-
ning? All intrusion or extrusion movements are
able to change this characteristic and implementa-
tion starts from the initial bonding phase for fixed
orthodontic appliances or with the virtual plan-
ning stage for aligners. With this concept in mind,
from the initial stages of orthodontic treatment,
depending on the vertical position of the upper
centrals, we can already define an attractive and
youthful, or unattractive and aged, smile.
For instance, during bracket placement, small
differences in the position of the upper central
incisors can have a great impact on smile
esthetics. A variety of bracket prescription recom-
mendations suggest that upper central bracket
positions (X) should be identical to the canine
(X)17 or slightly above the position of the canines
(X + 0.25; X + 0.5; X + 1.0).18,19 Interestingly, if
we use the same bracket height for centrals and

Figure 3. Ideal central-to-lateral incisal step.

120 Machado
Figure 4. Different width-to-length proportion of central incisors: A) ideal, between 75 and 80%; B) long teeth
with ratio < 75%; and C) short or squared teeth with ratio > 85%.
canines and consider that they have the same
anatomical crown length, after proper aligning
and leveling phases, their incisal edges might be
even. According to the results shown previ-
ously8,9, if we don't accomplish an ideal incisal
design (a gentle and upward curve bilaterally),
the smile could be perceived as unattractive.
Therefore, it is mandatory to incorporate smile
characteristics into orthodontic diagnosis and,
then use this information to properly position
maxillary anterior brackets: upper central inci-
sors should appear more extruded than intruded
in order to guarantee an ideal incisal design and
proper central-to-lateral incisal step. In other
words, we must avoid routine intrusion of the
upper central incisors for the reasons described
previously.
#2: Proportion and symmetry between central
incisors
After establishing the ideal vertical position of the
upper central incisors, we need to adjust the width-
to-length (W/L) proportions and symmetry.
Treatment must be conducted to obtain cen-
tral incisor W/L proportions between 75 and
80%, since it is considered more attractive
(Fig. 4).20 In most clinical presentations of adult
patients, the W/L ratio is altered due to incisal
wear inherent to aging of the dentition and, thus,
the proportion tends to increase (> 85%). Inter-
estingly, when this type of wear occurs, the nega-
tive esthetic impact also affects the incisal design
as it decreases the central-to-lateral incisal step
(Fig. 4B). The correction of this characteristic
commonly involves multidisciplinary treatment by
means of crown lengthening for upper centrals
with incisal restorations and/or gingivectomy.1
After correcting the proportions, maximum
symmetry between central incisors must be
achieved. The concept that reinforces the impor-
tance of this guideline is based on the clinical
assumption that, the closer to the midline, the
greater the need for symmetry and, the further
away, slight asymmetries are clinically accept-
able.14 In order to test this hypothesis, the
esthetic impact of incisal edge asymmetries was
evaluated in the upper incisors.2,10,11 The results
confirmed the need for maximum symmetry
between centrals, since a slight 0.5 mm incisal
edge asymmetry was detected by orthodontists
and laypeople. However, small asymmetries
(1.0 mm) between upper laterals may not be
detected2,11, while even greater asymmetries may
not be detected at the canines and premolars. In
other words, the incisal edges of the centrals are
the most important area and, thus, maximum
symmetry is a vital characteristic.
Case Illustrations
Case #1
The first clinical example is very instructive. A 34-
year-old female patient presented to our office
with the chief-complaint that she was unhappy
with her smile and that the appearance of her
teeth was aging her.
She had a Class I malocclusion with a slight ante-
rior open bite tendency (Fig. 5). As discussed
before, by assessing her smile, it is easy to recognize
a reverse incisal design but the overall appearance
of her teeth was very attractive, such as: tooth color,
adequate tooth anatomy, centrals W/L proportion
of 80%, and good symmetry (Fig. 6).
The objective was to modify the incisal design
by selectively extruding the maxillary incisors.
Orthodontic treatment was basically aligning and
leveling the maxillary arch with fixed appliances
and the key aspect was to customize the vertical
 Mechanics to Enhance Facial and Smile Esthetics 121

Figure 5. Initial intra-oral photos. Note the reverse incisal design (black line).

(Fig. 7A). The difference between the initial posi-

Figure 6. Initial close-up smile photo.
position of the brackets in the esthetic zone
(Fig. 7). This bonding customization can be pre-
dicted by moving the upper incisors to the final
positions using templates on the computer
tion and final position can be measured and the
amount of tooth extrusion assessed. In this case,
both upper laterals were extruded 0.5 mm, the
right central 2.5 mm, and the left central
2.0 mm. Those numbers were transferred to the
brackets and a customized bonding procedure
was performed (Fig. 7B). From the mechanical
standpoint, by using continuous arches, it was
expected that the extrusion force in the anterior
incisors would result in upper incisor retroclina-
tion. In this situation, that side effect was not con-
sidered a problem due to the initial overjet and
initial incisor torque.
Final intraoral photographs show mainte-
nance of the Class I occlusion and open bite cor-
rection (Fig. 8). The smile photo displays a

Figure 7. A) Digital illustration showing final incisor positioning; B) alignment and leveling outcomes with alter-
ation in the bonding protocol following the ideal incisal design.

Figure 8. Final intra-oral photos. Note the curved incisal design (black line).
122
Figure 9. Final close-up smile photo.
beautiful and youthful result, achieving the ideal
incisal design with the ideal central-to-lateral inci-
sal step which guarantees a great focus on cen-
trals (Fig. 9).
Case #2
In contrast to the previous case, this patient dis-
played both smile problems previously described:
incisal design deviation with severe occlusal cant-
ing and altered W/L proportion of the upper
centrals.
A 20 year-old male patient presented with the
chief-complaint that he was very unsatisfied with
his smile and facial appearance. In addition, the
patient refused orthognathic surgery as an
option.
Pretreatment intraoral photographs showed a
slight Class III malocclusion on the right side
and severe canting of the occlusal plane
(Fig. 10). Esthetically, he exhibited an unattrac-
tive smile with a severe cant in the esthetic zone,
straight incisal design, altered upper central
Figure 10. Initial intra-oral photos. Note the straight incisal design and severe canting of the occlusal plane (black line).
Machado
W/L proportions (right central was 91% and left
central was 88%) and an asymmetric gummy
smile (Figs. 11 and 12).
The treatment goal was to correct the incisal
cant and, then, to adjust the ideal tooth propor-
tions in the esthetic zone with gingivectomy. This
option consisted of aligning and leveling the
maxillary arch with continuous arches and, then,
intruding the maxillary right side by means of
skeletal anchorage (i.e.: on the buccal side, one
mini-plate and, on the palatal side, one mini-
implant) (Fig. 13). The purpose of applying two
forces was to prevent any side effects, such as buc-
cal or palatal dental inclination. After creating an
open bite on the right side, the lower dentition
was extruded and slightly distalized with inter-
maxillary elastics using the mini-plate as anchor-
age. After correcting the occlusal cant, the smile
esthetics improved, as evident during the frontal
smile analysis (Fig. 14). After finishing orthodon-
tic treatment, the patient was referred for gingi-
vectomy to re-establish ideal W/L proportions in
the esthetic zone.
 Mechanics to Enhance Facial and Smile Esthetics 123

Figure 11. Initial close-up smile photo.

Figure 12. Illustration of the severe occlusal canting. White line displays the inter-pupillary line.

Post-treatment photos showed that the occlu- Conclusion

sion was highly optimized with Class I canines
and molars, and overjet and overjet within nor-
mal limits. Esthetically, the two main principles
of smile esthetics were fulfilled: incisal design
slightly moving upward bilaterally and central
incisor W/L proportions of 77% and highly sym-
metrical (Figs. 15 and 16).
In order to allow orthodontic mechanics to
enhance facial and smile esthetics, clinicians
must carefully focus on two important aspects: 1)
incisal design where incisal edges of all teeth in
the esthetic zone must form a gentle and upward
curve bilaterally and; 2) upper central incisor
124 Machado

Figure 13. Dentoalveolar intrusion of the right side: on the buccal side (A), there is one mini-plate, and on the
palatal side (B), there is one mini-implant.

Figure 14. Illustration of the result on smile esthetics after correction of the severe occlusal canting. White line
displays the inter-pupillary line; red line shows the initial central incisor incisal edges, and; green line shows the
final central incisor incisal edges.

Figure 15. Final intra-oral photos. Note the curved incisal design (black line).
 Mechanics to Enhance Facial and Smile Esthetics
Figure 16. Final close-up smile photo.
width-to-length (W/L) proportions need to be
between 75 80%, and upper centrals must be
symmetrical.
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