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Analysis of the smile photograph

Article  in  World Journal of Orthodontics · February 2006

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Daltro Enéas Ritter1
Luiz Gonzaga Gandini
Ary dos Santos Pinto2
Dirceu Barnabé Ravelli2
Arno Locks3
[Au: Please provide aca-
demic degrees (eg,
DDS) for all authors]
ANALYSIS OF THE SMILE PHOTOGRAPH
Jr2
Optimal facial esthetics is one of the objectives in orthodontic treat-
ment and an important issue in modern society. In this context,
orthodontic treatment permits individuals with dental malpositions to
achieve improved dentofacial esthetics. To reach this result, the
orthodontist needs to recognize the characteristics considered nor-
mal and pleasant in dental arches and smiles. The objective of this
article is to review and discuss criterion adopted by dental literature
to technically analyze the smile, such as dental midline, smile line,
dental exposure, negative space, dental proportion, and symmetry.
This article proposes a way to visualize an ideal smile fi00 each
patient. World J Orthod 2006;7:xx–xx.

1Orthodontic Postgraduate Student,
UNESP, Araraquara, Brazil; Profes-
sor, UFSC, Florianópolis, Brazil. (AU:
Please spell out name of universi-
ties and provide department)
2Professor, Department of Children
Clinic and Department of Orthodon-
tics, UNESP, Araraquara, Brazil.
3Professor, Department of Orthodon-
tics, UFSC, Florianópolis, Brazil.
CORRESPONDENCE
Dr Daltro E. Ritter
Rua Nereu Ramos, 69
Sala 611
Ed. Belo Empresarial–Centro
88015-010 Florianópolis–SC
Brazil
E-mail: daltroritter@hotmail.com
ptimal facial esthetics is one of the
O principal objectives in orthodontic
treatment, and an important issue in
modern society. An individual’s dentofa-
cial appearance influences social attrac-
tion and relationships.1–3 In this context,
orthodontic treatment enables individu-
als with dental abnormalities to improve
their dentofacial esthetic patterns.
There are numerous studies about
dental position, intercuspation, and
occlusion, but less has been written
about the relationship between teeth
and oral soft tissues, and how this rela-
tionship affects smile esthetics.4 There-
fore, the orthodontist can have difficulty
in technically assessing a smile,
because there are few published articles
showing standard patterns.5,6 The pur-
pose of this article is to review the litera-
ture and discuss tooth position aspects
that influence facial esthetics.
THE SMILE PHOTOGRAPH
The cephalometric radiograph, a helpful
diagnostic tool, does not record lip-tooth
relationships during speech and smiling.
Clinical observation and photographs of
the face at rest and with smile are nec-
essary to obtain this valuable informa-
tion. Through the smile photograph, the
clinician can identify and analyze ante-
rior tooth and adjacent soft tissue rela-
tionships. 7 It is recommended that a
frontal partial smile photograph be used
as an orthodontic clinical record stan-
dard to aid in initial diagnosis and treat-
ment progress.5–8
The clinician must have standardized
smile photographs to permit comparison
of treatment progress. How patients see
themselves in the mirror during a smile
differs from an orthodontic analysis of
tooth disposition in occlusion with lip
retractors (Fig 1).9 For this reason, it has
been recommended that the patient be
in a natural head position, with eyes
looking to a distant point, during the
smile photograph.4,5,10,11 In addition, it is
possible to use a cephalostat to stan-
dardize the patient head position.12
SMILE CLASSIFICATION
There are 2 types of smiles described in
the literature, forced and spontaneous
(Fig 2).12,13 The forced smile, or social
smile, is voluntary, static, and perfectly
reproducible.9 The spontaneous smile,
or involuntary smile, cannot be repro-
duced because is activated by joy and

1
 Ritter et al
b c
a Fig 1
a b
emotion. It has been recommended that
smile photographs be standardized with
a forced smile, due to its reproducibility,
in the natural head position.9,14,15
SMILE LINE
The smile line is a curve that passes
through the incisal margins of the maxil-
lary incisors and canines, making an
arch.16 Sarver13 showed the importance
of the smile line in dentofacial esthetics.
When the incisal margins of the maxillary
central incisors appear below the canine
cusps, the smile line has a convex aspect
that can harmonize with the lower lip line
(Fig 3a) [ A U : I s e d i t c o r r e c t ? ] . The so-
called reverse smile line results when the
canine cusps appear more occlusal than
the maxillary central incisor tip margin,
creating a concave aspect (Fig 3b). The
literature says that the convex smile line
aspect is more esthetic than the concave
smile line.11,16,17 Other researchers have
found some preference for the convex
smile line, but a straight smile line in
males was also acceptable, thus showing
gender differences.18,19
Orthodontic treatment appears to influ-
ence the smile line. Ackerman et al9 found
2
WORLD JOURNAL OF ORTHODONTICS
Patient’s (a, b) and orthodontist’s (c) view of a smile.
Fig 2 Smile classification: Forced and
posed smile (a); spontaneous, not
forced, smile (b).
a worsening in smile and lip line relation-
ships in 32% of a group of orthodontically
treated patients. Therefore, the clinician
must be careful to avoid the creation of a
reverse smile line during treatment.
DENTAL MIDLINES
Morley and Eubank7 wrote that in smile
architecture the initial step is to identify
the facial midline. Due to the many
patients with asymmetric eyes, nose, and
chin, these authors suggest identifying
the facial midline using the midpoint
between the eyebrows (nasion), the nose
base, and the filtrum, or the midpoint of
the arch in the upper lip (Fig 4). To attain
optimal esthetics, the facial midline must
coincide with the maxillary and mandibu-
lar central incisor midline or, minimally,
these lines must be parallel.16,19–21 A dif-
fering view has suggested that the posi-
tioning of the dental midline exactly over
the facial midline can contribute to artifi-
ciality; with this premise, a small discrep-
ancy of about 1.5 to 2 mm is acceptable,
giving a natural appearance to denti-
tion.16,22,23,24
VOLUME 7, NUMBER 3, 2006
Fig 3 (a) Convex smile line following
the lower lip line. (b) Reverse smile line
(concave).
a b
a b
Fig 4 (a) Reference points for facial midline determination. (b, c) Facial midline definition.
MAXILLARY INCISOR AND
GINGIVAL EXPOSURE
Exposure is the term used to quantify the
dental structure or gingiva that appears
during a smile. The amount of dental and
gingival exposition during speech and
smiling varies from person to person, due
to individual variables such as: (1) upper
and lower lip muscle mobility and
strength; (2) lip vertical length; (3) clinical
crown length; and (4) skeletal relation-
ships, especially vertical maxillary length.
These factors must be taken into consid-
eration when conducting an individual
smile photograph analysis.2,16
During a smile, maxillar y central
incisor exposure varies from three quar-
ters of clinical crown to 2 mm of gingival
exposure; in general, the gingival smile is
a more common characteristic of
females.2,5,6,11,25 Peck and Peck2 found
that women show, on average, 0.7 mm of
gingiva during a smile, while in males,
0.8 mm of the clinical crown is covered
by the upper lip, on average (Fig 5).2 The
anterior gingival margin symmetry is
another important esthetic aspect; asym-
metry is acceptable when minimal, but
rarely acceptable when it occurs with the
maxillary central incisors.11,26
Ritter et al
c
Another useful reference in smile pho-
tograph analysis is the maxillary central
incisor crown proportion located from a
line between the lip commissures. Youth-
ful smiles reveal between 75% and 100%
of these teeth above the commissure line
(Fig 6). This proportion can become 40%
or less, causing the smile to age.4
With age, there is a decrease in maxil-
lary tooth exposure during a smile, and
an increase in mandibular incisor expo-
sure.7,27,28 This phenomenon occurs due
to natural tooth wear and the loss of elas-
ticity of the lips.21
THE BUCCAL CORRIDOR
The buccal corridor, or negative space, is
the space created between the buccal
surface of the posterior teeth and the lip
corners when the patient smiles, giving
depth and a natural aspect to the
smile.16,29 The use of the buccal corridor
avoids the so-called “16 teeth smile” or
“piano smile,” which characterizes a full-
mouth total prosthesis.16 This negative
space is affected by the smile, the maxil-
lary arch width, the facial muscles, the
position of the buccal surfaces of the
posterior maxillary teeth, and also by the
3
 Ritter et al
a b
a b
maxillary anteroposterior position related
to the lips.13,30
Some authors have advocated that
the buccal corridor area is not critical
and could be visually judged.16,31 Others
believe it is important to reach proper
buccal corridor dimensions to increase
smile esthetics.13,23 Some research has
shown that broad smiles, showing more
posterior teeth, are considered more
pleasing than smiles that show fewer
posterior teeth.11,32,33
The method developed by Johnson
and Smith34 has been proposed to mea-
sure negative space proportion during a
smile. In this method, the width of the
maxillary dental arch in a smile photo-
graph is measured, and the proportion of
this value in relation to distance of the lip
commissure is found (Fig 7).34 This can
be used to verify the proportion occupied
by the dental arch relative to intercom-
missure distance.
4
WORLD JOURNAL OF ORTHODONTICS
Fig 5 (a) Female characteristic smile,
showing some gingiva above maxillary
central incisors. (b) Male characteristic
smile with maxillary central incisor clini-
cal crown partially covered by upper
lips, and showing more mandibular
incisor.
Fig 6 (left) Both maxillary central
incisors are located completely above
commissure line, giving a youthful
smile aspect.
Fig 7 (right) Johnson and Smith 34
method to measure the negative space
proportion. ID, intercommissure dis-
tance; AW, arch width; NS, negative
space.
Fig 8 Light conditions influence the
number of teeth exposed and the buc-
cal corridor proportion during smile pho-
tograph.
Johnson and Smith 34 also analyzed
the smile esthetics in 60 orthodontic
patients treated with and without premo-
lar extraction.34 The negative space pro-
portion in extraction cases reached the
average of 9% of the intercommissure
distance; in the nonextraction cases, this
value was 8%, showing that orthodonti-
cally indicated tooth extractions did not
significantly increase the proportion of
negative space.
It is important to note that as teeth
are situated more posteriorly in the arch,
reduced lighting creates a gradual dark-
ening and hiding of the posterior
teeth. 19,35 This gradual lack of light
reduces focus on details, and increases
the illusion of distance and depth.7,36 It
should be also noted that the proportion
of negative space is dependent on light-
ing conditions, thus requiring standard-
ization during photography (Fig 8).12
VOLUME 7, NUMBER 3, 2006
Fig 9 (a) Incisal frames. (b) Teeth dis-
position with adequate incisal heights
between central incisors, lateral
incisors, and canines.
a b
Fig 10 (left) Mesiodistal proportion of
the maxillary anterior teeth, seen in
frontal view.
Fig 11 (right) Smile mesh example.
1.618 1.0 0.618
INCISAL FRAMES
The pattern created by incisal frames
and a dark background helps to define a
pleasing smile.37 This space between the
tooth incisal is called embrasure space,
or incisal frames (Fig 9a). This space fol-
lows a pattern that develops between the
central incisors and progresses laterally,
increasing in size between the teeth
located more posteriorly. 7 It has been
suggested that the clinician maintain or
create the incisal frames, with the maxil-
lary lateral incisors shorter than the cen-
tral incisors and canines (Fig 9b), thus
indicating absence of incisal wear and
characterizing a young smile. 27,38,39 To
achieve this, 0.5- to 1.0-mm steps occur
between the maxillary central incisors
and lateral incisors, always with the lat-
eral incisor margins more gingival than
those of the central incisors (Fig 9b).11
SYMMETRY AND
PROPORTION
The 1.618/1 proportion, also called the
golden proportion, has long been consid-
ered esthetically pleasing to the human
mind.36 Applied to the human dentition,
in the frontal smile view, the teeth must
be in this proportion and symmetric in
such a way that the maxillary lateral
Ritter et al
incisors must appear propor tionally
0.618 shorter than the central incisors,
and 1.618 longer than than the canines
(Fig 10).29,38,40
Another way of analyzing anterior
tooth disposition during a smile is to use
the golden percentage.41 This percentage
represents the width of the maxillary
intercanines visible in a frontal photo-
graph, so that each central incisor takes
25% of this length, the lateral incisors
take 15% each, and the canines 10% of
the total length.
Some authors have used computer-
ized programs to take smile measure-
ments.9,12,24 In these methods a smile
photograph is digitized, and after posi-
tioning the picture to facial and tooth ref-
erences, a mesh is created (Fig 11). In
this way, the orthodontist can quantify
many smile characteristics, such as
incisor and gingival exposition, buccal
corridor, smile line, midline deviations,
intercanine width, and lip length.
TOOTH CONTACTS AND
INCLINATIONS
In the frontal view, axial inclinations of the
anterior teeth are slightly progressive as
the teeth are positioned posteriorly, with
the gingival portions of the crowns more
distal than the incisal portions (Fig 12).
5
 Ritter et al
a b
Smiles with diastema are not often
socially acceptable, with the exception of
those in older people.37 In a multi-ethnic
study, rejection due to maxillary central
diastema was verified in Asian evalua-
tors, but European evaluators were more
accepting of this characteristic.18
The space where anterior teeth
appear to touch each other in a frontal
smile photograph is called the connector
space (Fig 13).4 An esthetic relationship,
called the 50-40-30 rule, exists between
the anterior teeth. It defines the ideal
connector space between the maxillary
central incisors as being 50% of the total
vertical length of the central incisor. The
connector space between the central and
lateral incisors is 40% of the total length
of the central incisor crown, and the con-
nector space between the lateral incisors
and canines is 30% of the central incisor
crown.
6
WORLD JOURNAL OF ORTHODONTICS
Fig 12 (left) Maxillary anterior teeth
with adequate axial inclinations.
Fig 13 (right) Anterior tooth contact
areas in frontal view; these are called
50 40 30 space connectors.
Fig 14 Gingival exposure reduction
during smile, due to maxillary incisor
intrusion. This clinical case shows initial
smile (a) and final smile (b).
CLINICAL CASE
In addition to the tooth malpositions evi-
dent in this clinical case, excessive expo-
sition of the maxillary central incisors and
gingival margin of all maxillary anterior
teeth had compromised the dentofacial
esthetic (Fig 14a). During treatment with
a fixed appliance, the teeth were leveled
and aligned, anterior teeth were intruded,
respecting the balance between smile
line and lower lip, thereby diminishing gin-
gival exposition and enhancing patient
smile esthetics (Fig 14b).
CONCLUSION
There is not an ideal smile. The most
important esthetic objective must be to
achieve a balanced smile, which can be
described as an adequate positioning of
teeth within themselves, and with the gin-
giva and soft tissues. The orthodontist
must know the esthetic principles that
govern facial and dental harmony, achiev-
ing optimal tooth positioning within the
soft tissue and skeletal characteristics of
each patient.
VOLUME 7, NUMBER 3, 2006 Ritter et al

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