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Case Report

Smile Enhancement With Anatomic Diagnostic Wax-Up and

Comprehensive Esthetic Smile Designing
Shivani Kohli, Ang Yee
Department of Prosthodontics, Faculty of Dentistry, MAHSA University, Selangor, Malaysia

Abstract
Esthetic smile design is a conceptual tool that can reinforce diagnosis, improve communication, and enhance certainty of the
treatment. Analysis of the facial and gingival features in relation to the teeth can be achieved by evaluating facial, dento-labial,
and dentogingival parameters, which are crucial steps in smile designing. Following this, diagnostic wax-up, which is an imperative
tool, was carried out on maxillary anterior teeth to satisfy the smile design and to establish an anterior guidance. Diagnostic wax-up
allowed the dentist to effectively communicate with the patient concerning the final esthetic outcome with improved smile line. Esthetic
pre-evaluative provisional prepared from the diagnostic wax-up permits the dentist and the patient to appraise the appearance of the
future restorations during smile and function. Hence, the aim of this case report was to highlight smile enhancement with the aid of
anatomic diagnostic wax-up following principles of esthetic smile designing.

Keywords: Diagnostic Wax-Up, Esthetics, Smile, Smile Designing

Introduction
Novel expertise has heightened our capacity to examine
our patients more precisely due to accessibility to
innovative concepts of esthetics and function.[1] Nowadays,
patients are becoming even more conscious of their teeth
and, for many, esthetics has become one of the key motive
for pursuing dental treatment.[2,3] The societal appeal of
young adult may perhaps be affected by their dentofacial
appearance.[4-8]
“Smile line” is a universally used parameter to assess and
classify a person’s smile. It is a curve that passes through
the incisal margins of the maxillary central incisors and
canines making an arc. The smile arc is convex when
the incisal edge of the maxillary central incisors appears
below the canine cusps and concave when the cuspal tips
of the canine are more occlusal than the incisal edge of the
maxillary central incisors, and when they lie in a straight
line, the smile arc is considered to be straight.[9]
According to recent prototype, nothing is more imperative
than facial esthetics in dentistry,[10] and attaining acceptable
esthetics and harmony among the orofacial structures is
the prime objective of dental treatment.[11-14] Studies in the
past have found that the symmetry of the smile is positively
associated with a “good smile,” and asymmetrical smiles
were not given higher smile scores.[15] An asymmetric smile
can be due to various factors, e.g. disparity in tooth size,
tooth shape, or uneven papillary height.[16] The diagnostic
information must direct the treatment phases, integrating
all of the patient’s needs, personality, function, and
biologic concerns into an esthetic treatment plan.[17-19]
The objective of esthetic treatment is to achieve an
improved appearance that gives a vivacious and realistic
look to the patient. This article focuses on significance of
diagnostic wax-up and historically acknowledged smile
design concepts with various smile parameters.
Case Presentation
A 51-year-old female patient reported to the dental clinic.
She had lost both her maxillary central incisors and left
Address for correspondence: Dr. Shivani Kohli,
Department of Prosthodontics, MAHSA University,
Jenjarum 42610, Selangor, Malaysia.
E-mail: shivani@mahsa.edu.my

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DOI: How to cite this article: Kohli S, Yee A.  Smile enhancement with
10.4103/jioh.jioh_191_17 anatomic diagnostic wax-up and comprehensive esthetic smile
designing. J Int Oral Health 2019;11:221-7.

       ©
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Kohli and Yee: Smile enhancement with smile designing

Figure 1: Preoperative view with removable partial denture and without denture

lateral incisor 10  years ago in an accident. Since then

she was wearing acrylic removable partial denture. She
complained of unesthetic appearance and altered speech
with her existing denture. Her prime concern was to seek
the best treatment to restore her smile and speech with
a fixed replacement alternative [Figure 1]. There was no
tenderness on percussion on the abutment teeth and all the
interferences that prevented complete range of anterior
guidance functional pathways were removed. Further
radiographic investigations were conducted, wherein
orthopantomograph [Figure 2] revealed no evidence of
pathologic lesions and bone loss around the abutment
teeth. Intraoral periapical radiograph [Figure 3] showed
satisfactory crown-to-root ratio with absence of periapical Figure 2: Orthopantomograph
radiolucencies with respect to 13, 12, and 23.
Different treatment options were given to patient
including dental-implant-supported crowns and bridge
and fixed bridge (including all ceramic and porcelain
fused to metal bridge) to replace the upper anterior
edentulous region using 12, 13, and 23 as abutments. Due
to the acceptable esthetics, durability, and cost concern,
patient agreed for porcelain fused to ceramic bridge.
Tooth-supported fixed partial dentures have an expected
survival rate of 85% at 15  years; hence, prognosis was
excellent.[20]
The final treatment plan was to fabricate a fixed partial
denture replacing missing teeth using maxillary right
lateral incisor, and right and left canine as abutments.
Diagnostic impressions and models were made to be Figure 3: Intraoral periapical 12, 13 (left), and 23 (right)
mounted on a semi-adjustable articulator.
and (5) dental analysis (the intratooth and intertooth
Diagrammatic view of the future bridge was designed
relationships, i.e., shape and position of the tooth).[20,21]
according to the smile analysis and discussed with
the patient before proceeding to the next phase. Smile
design involves the evaluation of elements in a specific Facial and Dentofacial Analysis
sequence: (1) facial analysis (overall facial equilibrium), Smile analysis begins with facial analysis at the macro
(2) dentofacial analysis (relating dental midline to the face), esthetic level, which includes examining patient’s facial
(3) dento-labial analysis (relating the teeth to the lips), form and balance and then proceeding toward individual
(4) dentogingival analysis (relating teeth to the gingiva), teeth. Any unbalance will result in unesthetic smile.

      
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Kohli and Yee: Smile enhancement with smile designing
Following this, oral-facial analysis was conducted to
determine the maxilla-mandibular relationship.[22,23]
Ideally, the dental and facial midlines should coincide, but
rarely it happens. In one of the study, Kokich concluded
that a discrepancy of up to 4 mm will normally not be
perceived as unesthetic as long as the dental and facial
midlines are parallel to each other.[15]
Dento-labial Analysis
It was conducted to assess the relationship of the lips to
the teeth, i.e. visibility of teeth both at rest and function.
Regarding the incisal edge position, minimum exposure of
incisal edge by 2 mm at rest position is required for esthetic
results.[24] Gull wing pattern, wherein the incisal edges of
the maxillary anterior teeth follow the curvature of the
lower lip, is considered to be very esthetic [Figure 4].[25,26]
A negative space that appears between the buccal surface of
the posterior teeth and the corner of the lip when the person
smiles, giving depth and natural aspect to the smile, is called
as buccal corridor space.[27] A wide smile with a negligible
buccal corridor is believed to be most appealing.[9]
Dentogingival Analysis
It comprises of esthetic gingival relationship: gingival line
(relation of free gingival margins of the maxillary teeth)
and positioning of tip of the papilla, gingival contour,
scalloping, and gingival color. Arranging lateral incisor
1 mm incisal to the central incisor is generally perceived as
esthetic. The distance between the gingival scallop to the tip
of the papilla should be between 4 and 5 mm [Figure 2].[1]
Dental Analysis
Intertooth relationship: After measuring esthetic outcomes
on many patients in the University of California–Los
Figure 4: Pretreatment dentofacial and dentogingival analysis
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Angeles, the dentists have determined the esthetic zone
for the central incisor to be between 10.5 and 12 mm. The
width-to-length esthetic relationship has been discussed in
the previous studies to be 70%–80%.[1]
Intratooth relationship: Golden proportion has been
considered as a mathematical tool for assessing proportion
among anterior teeth though it is considered debatable
in developing esthetically pleasing smiles.[28] Henceforth,
golden percentage was used for intratooth analysis for this
patient with value of 22% for centrals, 15.5% for laterals,
and 12.5% for canines as these values are mostly applicable
to natural dentition [Figure 5].[29]
Following the smile analysis, diagnostic wax-up was
conducted on maxillary anterior teeth to satisfy the
smile design and to establish an anterior guidance that
disoccluded posterior teeth in all eccentric movements
[Figure 6]. Putty index was prepared on the diagnostic
wax-up to replicate it into the provisional restoration.
Tooth preparations were conducted on 12, 13, and 23
for porcelain fused to metal bridge following correct
principles. The provisional restoration was fabricated and
left in the patient’s mouth for 2 weeks to assess esthetics,
phonetics, and function in reference to anterior guidance
[Figure 7].
At the subsequent appointment, the patient was verified
for comfort and esthetics. It was evaluated that the
established functional pathways were in harmony with the
envelope of function. Maxillary alginate impressions were
made along with provisional restorations and mounted
after face bow transfer [Figure 8]. The anterior guidance
was customized with the autopolymerizing acrylic resin to
transfer exact details of anterior guidance to the dental
technician [Figure 9]. With this guidance, as discussed
by Dawson,[17] the technician could mimic the functional
movements of the jaw and recreate a perfect functional
and comfortable incisor guidance for the patient. Final
Figure 5: Pretreatment dental analysis
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Kohli and Yee: Smile enhancement with smile designing

Figure 6: Diagnostic wax-up

Figure 7: Provisional restoration

Figure 8: Face-bow transfer

restorations were prepared following the planned smile
design and anterior guidance. They were evaluated and
cemented with RelyX cement [Figures 10 and 11].
Posttreatment: Dental Esthetics Evaluation
Optimum facial esthetics is one of the imperative goals of
prosthodontic treatment. In this case, the facial form and
balance were improved along with the labial support. The
dento-labial esthetics was improved by achieving the 3 mm
display of maxillary central incisors at rest. Smile line
followed the gull wing pattern according to the curvature
of lower lip [Figure 12]. Pertaining to the dentogingival
analysis, the lips and the gingiva frames the teeth. The ratio
of tooth to gingival tissue was synchronized to prevent
an overdominance of any element. An esthetic gingival
relationship that constitutes gingival line and scalloping
was achieved considerably. In normal dentition, the
contour of the gingiva to the tip of the papilla is between
4 and 5 mm. However, in this case it was less than 4 mm

      
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Kohli and Yee: Smile enhancement with smile designing
Figure 9: Customized incisal guidance table
Figure 10: Post-cementation: Intraoral frontal view
Figure 11: Post-cementation: Intraoral occlusal view
as the longer pontic was needed to cover the edentulous
region [Figure 13].
As length of the teeth also affects esthetics, acceptable
width-to-length relationship, which is best between
70% and 80%, was achieved.[1] Golden percentage was
used to accomplish an ideal interdental proportion by
redistributing the available spaces among maxillary
anterior teeth during designing of a six-unit anterior
bridge. Thus, with the aid of anatomic wax-up, the
esthetics and function as desired by the patient was
achieved.
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Follow-up and Evaluation
The patient was called for follow-up appointments
at a regular time interval. The soft-tissue response at
6  months was exceptional with good papilla support
and expected emergence profile. After almost 2  years,
there have been no clinical problems and the patient was
very pleased with the results. She felt very comfortable
with the fit and was maintaining good oral hygiene
[Figure 14].
Patient’s consent was taken to use any photographs for
records or publication.
Discussion
An attractive smile can be an enormous asset to one’s
personality. The facial, gingival, and dental components
can be manipulated to design a beautiful smile.[30] The
color, shape, proportion, and position of the teeth
can be worked with to create a pleasing smile.[25] The
gingival architecture can also be altered. An appropriate
white and pink esthetic balance is the solution in smile
designing.[31]
The goal of an esthetic rehabilitation is to develop a stable
masticatory system, where the teeth, supporting structures,
and joints all function in harmony (Dawson[32]).[33]
Amendment of dental esthetic inconsistencies desires
cautious evaluation, planning, and multidisciplinary
approach. Anatomic wax-up is one of the most vital
tools when planning to alter the patient’s smile. It
allows the clinician to visualize the alterations needed
to achieve a pleasant smile and assist them in treatment
planning.[34] Recreation of the lost anterior guidance
was achieved because of the acceptable performance
with interims, which was transferred to the laboratory.
Hence, the permanent restorations were fabricated
precisely.[35] Therefore, acquaintance of smile design,
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Kohli and Yee: Smile enhancement with smile designing

Figure 12: Post-cementation: Dento-labial analysis

Figure 13: Post-cementation: Dentogingival analysis

Figure 14: Preoperative and postoperative extra-oral view

together with latest technologies, allows the dentist to Informed consent

diagnose, plan, create, and deliver esthetic smile to the
patient.[36,37]
Conclusion
Dentists require adequate information for meticulous
decision-making to formulate treatment that is acceptable
as per the desires of the patient. Henceforth, esthetic
principles must be incorporated to provide data that can
aid the dentist to create a beautiful smile for our patients.
Patient’s consent was taken for crown and bridge
treatment and to use any photographs for record keeping,
educational, publication, or research purpose.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and
other clinical information to be reported in the journal.

      
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Kohli and Yee: Smile enhancement with smile designing
The patients understand that their names and initials will
not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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