Aus dem Department für Zahn-, Mund- und Kieferheilkunde

Klinik für Zahnärztliche Prothetik

des Universitätsklinikums Freiburg im Breisgau

Esthetic guidelines in dentistry and interdisciplinary work with plastic

surgery: a systematic review

INAUGURAL – DISSERTATION

zur

Erlangung des Zahnmedizinischen Doktorgrades

der Medizinischen Fakultät

der Albert-Ludwigs-Universität

Freiburg im Breisgau

Vorgelegt 2018

von Aida Seyidaliyeva

geboren in Gach, Aserbaidschan

Dekan (kommissarisch): Prof. Dr. Norbert Südkamp

1. Gutachter: Prof. Dr. Wael Att

2. Gutachter: Prof. Dr. Olga Polydorou

Jahr der Promotion: 2018

2
List of abbreviations

3d- three dimensional NAC- North American Caucasian

4d- four dimensional ’- soft tissue landmarks

al- alar Ort- the point joining the TVL and

THL
app- application
p- processus
cm- collumella
pg- pogonion
ch- chellion
prn- pronasale
DSD- digital smile design
s- sellasa- superaurale
DSS- digital smile system
sba- subaurale
DSLR- digital single-lens reflex
sm- supramental
en- endocanthion
SMAS- Superficial muscular
ex- exocanthion
aponeurotic system
g- glabella
sn- subnasale
gn- gnathion
sl- sublabialis
hi- pupillae left
SLR- single-lens reflex
hr- pupillae right
stms- stomion superior
li- limbus inferior
stmi- stomion inferiror
lm- limbus medialis
TFI- total facial index
ls- limbus superior
THL- true horizontal line
M.- musculus
tr- trichion
N.- nervus
TVL- true vertical line
n- nasion
zg- zygomatic prominence
n.a- not available

3
 Table of contents

1. Introduction .......................................................................................................................... 8
1.1 Anatomy of the head .......................................................................................... 9
1.1.1 Bone anatomy ............................................................................................... 9
1.1.2 Soft tissue .................................................................................................... 10
1.1.3 Facial soft tissue landmarks ........................................................................ 10
1.2 Facial and dental esthetics: Methods of analysis .......................................... 10
1.2.1 Image/ video capture and editing ................................................................ 10
1.2.1.1 Photography and video capture ............................................................ 10
1.2.1.2 Three-dimensional (3D) imaging systems and face scanners .............. 12
1.2.1.3 Four-dimensional (4D) imaging system .............................................. 14
1.2.1.4 Innovations in the digital planning ...................................................... 15
1.2.2 Cephalometry of the head ........................................................................... 16
1.2.3 Phonetic Analysis........................................................................................ 16
1.2.4 Model Analysis of the relationship of teeth ................................................ 17
1.3 Patient expectation and communication ........................................................ 17
1.4 Facial analysis .................................................................................................. 18
1.4.1 Reference lines ............................................................................................ 18
1.4.2 Facial symmetry .......................................................................................... 18
1.4.3 Facial shape and facial index ...................................................................... 19
1.4.4 Facial profiles.............................................................................................. 20
1.5 Dentolabial analysis ......................................................................................... 23
1.5.1 Lip movement and upper lip length ............................................................ 23
1.5.2 Tooth exposure at rest position ................................................................... 23
1.5.3 Smile analysis ............................................................................................. 24
1.5.3.1 Smile classifications............................................................................. 24
1.5.3.2 Horizontal smile lines .......................................................................... 25
1.5.3.3 Smile width .......................................................................................... 29
1.5.3.4 Buccal corridor..................................................................................... 29
1.5.3.5 Facial midline vs. dental midline ......................................................... 30
1.5.3.6 Occlusal plane ...................................................................................... 30

4
 1.6 Dental analysis.................................................................................................. 30
1.6.1 Anatomy and features of the anterior teeth ................................................. 30
1.6.1.1 Maxillary anterior teeth........................................................................ 30
1.6.1.2 Mandibular anterior teeth ..................................................................... 31
1.6.2 Tooth analysis ............................................................................................. 32
1.6.2.1 Tooth shape .......................................................................................... 32
1.6.2.2 Tooth color and surface texture ........................................................... 32
1.6.3 Tooth composition analysis ........................................................................ 33
1.6.3.1 Tooth arrangement and its relation to the dental arch.......................... 33
1.6.3.2 Interdental contact area and incisal embrasures................................... 34
1.6.3.3 Axial inclination of the teeth................................................................ 34
1.6.4 Interarch relationships of the anterior teeth ................................................ 35
1.6.4.1 Relationship between the maxillary and mandibular interincisal lines 35
1.6.4.2 Overjet and overbite ............................................................................. 35
1.7 Phonetic analysis .............................................................................................. 36
1.7.1. [m] sound ................................................................................................... 36
1.7.2 [i:] sound ..................................................................................................... 36
1.7.3 [f]/[v] sounds............................................................................................... 36
1.7.4 [s] sound ...................................................................................................... 37
1.8 Gingival Analysis ............................................................................................. 37
1.8.1 Anatomical characteristics of gingiva ......................................................... 37
1.8.1.1 Free gingiva ......................................................................................... 38
1.8.1.2 Attached gingiva .................................................................................. 38
1.8.1.3 Interdental gingiva ............................................................................... 38
1.8.2 Anatomical characteristics of alveolar mucosa........................................... 39
1.8.3 Characteristics of the healthy gingival tissue.............................................. 39
1.8.3.1 Color and the stippling of the attached gingiva ................................... 39
1.8.3.2 Architecture of the gingival tissue and periodontal biotype ................ 39
1.8.4. Analysis of the gingival margin outline ..................................................... 40
1.8.4.1 Gingival margin location and symmetry.............................................. 40
1.8.4.2 Gingival zenith ..................................................................................... 40
1.8.4.3 Interdental papilla and gingival embrasures ........................................ 41

2. Aim of the study ................................................................................................................. 42

5
3. Materials and Methods ...................................................................................................... 43
3.1 Focused Question ............................................................................................. 43
3.2 Search strategy ................................................................................................. 43
3.3 Selection criteria............................................................................................... 43
3.4 Data extraction ................................................................................................. 45

4. Results ................................................................................................................................. 49
4.1 Macroesthetics: Facial measurements ........................................................... 55
4.2 Macroesthetics: Measurements of the lip parameters .................................. 55
4.3 Macrosethetics: Nasal measurements ............................................................ 59
4.4 Macroesthetics: Chin measurements ............................................................. 59
4.5 Miniesthetics ..................................................................................................... 60
4.6 Microestehtics ................................................................................................... 60
4.7 Influence of race and age on the mean value of the parameters ................. 61
4.7.1 Extraoral parameters, comparison between racial groups .......................... 61
4.7.2. Extraoral parameters, perioral changes during aging ................................ 61
4.7.3 Intraoral parameters, comparison between different racial and age groups61
4.8 Ideal human face, overview of literature ....................................................... 79
4.8.1 Enface view. ................................................................................................ 79
4.8.2 Profile view ................................................................................................. 81
4.8.2 Profile view ................................................................................................. 82
4.8.3 Smile analysis ............................................................................................. 84
4.8.4 Dental analysis and tooth arrangement ....................................................... 85
4.9. Summary of results ......................................................................................... 86
4.9.1 Average facial and dental parameters in various populations and genders, based on
the results tables ................................................................................................... 86
4.9.2 Parameters for performing a comprehensive aesthetic analysis ................. 87

5. Discussion ........................................................................................................................... 98
5.1 Materials and methods .................................................................................... 98
5.1.1 Systematic review ....................................................................................... 98
5.1.2. The PICO format........................................................................................ 98
5.2 Results ............................................................................................................... 99
5.2.1 Comparison across populations and age groups ......................................... 99
5.2.1.1 Comparison between different populations ......................................... 99

6
 5.2.1.2 Comparison among age groups, age related soft- tissue and dental changes 101
5.2.2 Validity of the ideal human face in nature ................................................ 103
5.3 Facial parameters necessary for facilitating collaboration between dentists and
plastic surgeons in comprehensive aesthetic rehabilitation ............................. 106
5.4. Proposed guidelines for the interdisciplinary treatment planning........... 108

6. Conclusion ........................................................................................................................ 114

7. Summary........................................................................................................................... 115

8. Zusammenfassung ........................................................................................................... 116

9. Bibliography ..................................................................................................................... 117

10. Acknowledgements ........................................................................................................ 137

11 Curriculum Vitae ............................................................................................................ 138

7
1. Introduction

Aesthetics belongs to a branch of philosophy, and is associated with the conception,

constitution, and assessment of beauty. The word “aesthetics” takes its source from the Greek
word aisthanomai - “I perceive”. German philosopher Alexander Gottlieb Baumgarten
brought this word to science in the first volume of his “Aesthetica” (1750-1758) (Karrer
2002). According to paleodontological research, some forms of cosmetic dentistry existed in
ancient times in many cultures, in the form of dental decoration and modifications, tattoos, or
the intentional dental mutilation of anterior teeth. Egypt, China, Rome, Greece, India,
Mesopatamia, and some other ancient civilizations had distinct and characteristic aesthetic
styles. According to Socrates, the beautiful was coincident with the good. Plato observed that
proportion, harmony, and unity are the components of beauty. Aristotle characterized the
universal elements of beauty, such as order, definiteness, and symmetry. Since ancient times,
aesthetics has been associated with mathematics. The Golden Ratio is a well-known concept
today, often considered the formula of perfect beauty. In the 15th century, Leonardo da Vinci
called it the “sectio aurea”, a notion based on the handbook of the Roman architect Marcus
Pollio Vitruvius. The Italian mathematician Luco Pacioly presented in his book “The Golden
Ratio” thirteen effects of the divine proportion and stated, “there is no art without
mathematics”. Mathematical considerations such as symmetry and complexity are appropriate
for analysis in theoretical aesthetics (Metiu 2014). In the 18th century in Germany, two
aesthetic theories were dominant: traditional theories of the aesthetic experience as a special
form of the cognition of truth, and the newer theories of aesthetic experience as a play of
cognitive mental powers and the vicarious experience of emotion. Several German
philosophers and aestheticians, among them Christian Wolff (1679-1754), Johann Christoph
Gottsched (1700-1766), Alexander Gottlieb Baumgarten (1714-1762), Immanuel Kant (1724-
1804), Karl Philipp Moritz (1756-1793), Gottfried Wilhelm Leibniz (1646-1716), and Georg
Friedrich Meier (1718-1777), were associated with the topic of “aesthetics” (Guyer 2008).
Over time, the definition and understanding of the word “aesthetic” changed depending on the
expectation and requests of the society. Today, natural beauty is more favorable than
mathematical beauty. Some authors have confirmed the tendency that within facial beauty,
minimal asymmetry is more pleasing than perfect symmetry (Langlois et al.1994, Kowner
1996). According to Grammer and Thronhill (1994), horizontal facial symmetry and
averageness of facial parameters are two factors that are directly correlated with facial
attractiveness. Although the average face is more preferred and favorable in all populations,

8
the “average face concepts” vary across populations. Although norms of beauty vary among
cultures and races, and depend on the expectations of each society, physical appearance and
the so-called “halo effect” play an important role in social interactions and relationships in
each population. According to psychologists, physically attractive persons are preferred as
potential friends and are more social and successful than less attractive persons. (Eli et al.
2001). A pleasing smile is one of the major factors of beauty, and the teeth are a key element
of the smile. However, dental appearance is an important factor in multiple social contexts
and situations. Because an attractive smile is an important part of attractiveness as a whole,
patient requests and expectations have increased noticeably in the modern era. Treatment
planning should be conducted with fulfilling these expectations and achieving patient
satisfaction as the primary goals. Today, multiple checklists are available for performing
facial, dental, and smile analyses. The checklists of Kopp and Belser (1980), Fradaeni (2004),
Greenberg (2010), Wolfart (2014), and Calamia and Wolf (2015) are examples of commonly
used checklists in aesthetic dentistry.

During the comprehensive aesthetic rehabilitation, the interdisciplinary work between dentists
and plastic surgeons is often confusing. The question is, whether the dental or the plastic
treatment should be performed first, if the patients undergoing lip shortening or lengthening
procedures or face lifting surgery for instance. Overview of the existing work and available
research about this interdisciplinary workflow, provides beneficial information and guidelines
regarding the collaboration between the dentists and the plastic surgeons.

1.1 Anatomy of the head

1.1.1 Bone anatomy

The skull is composed of the union of particular bones. The function of the cranium is to
surround and structurally support the brain. The facial skeleton has three main functions:
structural support, projection, and protection of sensory organs (the eyes), and fixture for the
muscles of mastication and facial expression (Steele and Bramblett, 1988). The facial skeleton
consists of three parts: the frontal bone superiorly, the bones of the midface, and the mandible
inferiorly. (Prendergast 2013). The stronger bones of midface, such as the maxillary,
zygomatic, sphenoid, and frontal bones, join with each other and surround the sinuses,
pneumatic cavities, nasal airway, and fragile bones of the midface, and create the buttress
system. The maxilla consists of a body and four processes: the frontal p., the zygomatic p., the
palatine p., and the alveolar p. The mandible consists of the body of the mandible (its base in

9
addition to the alveolar portion) and the ramus of mandible. The mandibular ramus has two
terminal processes: the coronoid p. and the condylar p. The mandible is connected with the
cranium, movable through the condylar process, and forms the temporomandibular joint
together with temporal bone.

1.1.2 Soft tissue

The skin is the superficial tissue of the face. The underlying soft tissues are arranged from
superficial to deep in the following order: 1. Superficial fat compartments; 2. Superficial
muscular aponeurotic system; 3. Retaining ligaments; 4. Mimetic muscles; 5. Deep plane,
including the deep fat compartments (Kesmas et al. 2010; Prendergast 2013). The skin
consists of the superficial epidermis and fibrous dermis. Facial aesthetic units are determined
along the surface of the face (Gonzalez-Ulloa 1954). The actual classification of the facial
aesthetic units is in the following order: forehead unit, nasal unit, eye lid units, cheek, upper
lip unit, lower lip unit, mental unit, auricular unit, neck unit (Prendergast 2013).

1.1.3 Facial soft tissue landmarks

Facial surface landmarks are the reference points visible to the human eye, but which cannot
be assigned to discrete parts of the face. Measurements and detection of the facial soft tissue
landmarks are conducted with the head in the Frankfort horizontal position. Facial soft tissue
landmarks are determined by conventional methods, for example palpation, anthropometric
measurements on two- dimensional photos and radiographs, and digital methods; for example,
three-dimensional assessment of the soft tissue landmarks on three-dimensional facial scans
(see §1.2.2). The facial soft tissue landmarks are described in Figure 1.1 (Toma et al. 2009).

1.2 Facial and dental esthetics: Methods of analysis

1.2.1 Image/ video capture and editing

An objective facial and dental analysis can be obtained using a variety of methods; for
example, conventional and digital photography, video capture, and face scanning.

1.2.1.1 Photography and video capture

Photography provides an optimal two-dimensional quantitative aesthetic analysis.

Photographs give the dentist the chance to visualize and analyze points that are not clinically
noticeable.

10
The basic equipment required for dental photography are a camera body, lens, and flash.
Dental photography can be divided into conventional and digital photography. Examples for
conventional camera formats are 35 mm, medium, large, and instant cameras.

Conventional 35 mm single lens reflex (SLR) format cameras are the most ideal of the
conventional cameras for dental photography, while the medium format is utilized for
extraoral and laboratory photographs, and the large format is preferable for unique dental
laboratory photographs for publishing. Instant cameras are most useful for immediate imaging
of periodontal disease, pathology, or crown aesthetics (Ahmad 2004). Compact and digital
single lens camera are two different types of digital cameras. A major advantage of compact
cameras is that they are light and portable. Digital single lens reflex cameras (DSLR) are the
most useful cameras and they offer the widest array of opportunities in dental photography.
Unlike the digital viewfinder of compact cameras, DSLRs frame the picture directly through
the lens. This option enables accurate control of the imaging process; for example, the
photographer can check the sharpness and depth-of-field of the picture in real time (Bengel
2006). True macro lenses, especially with a focal length of 100 or 105 mm, can achieve the
best results. Another important piece of equipment for qualitative dental photography is the
flash. Two types of flashguns are available for intraoral dental photography: ring and double
flashguns. Flash photography gives clinicians the following advantages: Because of the short
duration of flash, negative effects of camera shake are eliminated and little heat is produced,
which makes the process more comfortable for patients, high light intensity permits smaller
apertures and, as a result, greater depth-of-field. The light and compact flashguns are
compatible with handheld photography (Bengel 2006). For qualitative imaging, one should
adequately prepare the environment, a task, which can be divided into three areas: preparation
of the patient, preparation of the background (extraoral photographs) and intraoral sites, and
preparation of the camera and equipment (Desai and Bumb, 2013). During extraoral imaging,
the patients should sit erect and a mirror can be used to determine the natural head position.
Black or white backgrounds are preferred. The camera should be in a stable position. The
technical parameters, for example, ISO, flash power, lens aperture, focus, speed, auto or
manual focus, white balance etc., should be adjusted according to the standards for qualitative
extraoral photography. The following images are required for a comprehensive aesthetic
evaluation: frontal (at rest, while smiling, and during an open smile with teeth apart); profile
(at rest, while smiling); ¾ facial (at rest, while smiling).

11
All of the photos should be captured as both portrait and lip photographs (Cintra et al. 2012).
For intraoral photography, the target area should be free from saliva, blood, air bubbles, and
materials (for example, impression material and cement). Plastic retractors and front-coated
chromium, rhodium, or titanium mirrors are used for the various intraoral images. The
technical parameters should be set according to the standards for qualitative intaroral
photography. Frontal (in maximum intercuspation, during protrusion, and with the teeth
apart), occlusal (upper and lower jaw), and lateral (left and right) viewing angles should be
captured for the appropriate aesthetic analysis (Cintra et al. 2012;2014). Depending on the
camera model, CompactFlash or Secure Digital cards are available to store digital images.
Using presentation software, it is simple to define reference points and lines to perform an
aesthetic analysis. Digital video and computer technology allow the dynamic recording and
aesthetic analysis of the smile. Digital video cameras under effective lighting are used for
video recording. The videos are recorded at a fixed distance from the patient during speech
and smiling, and should be taken from the frontal and oblique perspectives. A natural head
position of the patient is preferred during video recording (Sarver and Ackerman, 2003). After
transfer of the video to a computer, several software packages are available for editing (e.g.
Adobe Premiere, Microsoft Corporation). Using such a program, the video can be converted
into the 30 individuals photographic frames per second. The natural smile can be selected by
the examiner and saved as a JPEG file. For analysis, the Smile Mesh program can be used,
which consists of an adjustable grid system. The 5 horizontal and 7 vertical grid lines can be
adapted to correspond with hard and soft tissue landmarks (Figure 1.2) (Schabel et al. 2010).
The video captures can be used to perform the phonetic analysis and examine the mandibular
movements (see §1.2.3).

1.2.1.2 Three-dimensional (3D) imaging systems and face scanners

Two-dimensional analyses are limited to the data which is identifiable along two axes (x and
y). 3D analysis is performed on three axes (x, y, z), which acquires information regarding
depth, shape, and orientation; this is not possible in 2D analysis. Because of this major
advantage, the use of 3D techniques has recently become popular in dentistry. Several
methods are currently available for 3D imaging, for example stereophotogrammetry, laser
scanning, computed tomography scanning, optoelectronic devices, and light and spatial
scanning, digitizers (Da Silveira et al. 2003). Scanners operate on one of two basic principles:
ranging and triangulation. Ranging scanners are used to measure distance.

12
Figure 1.1: g (glabella)- most prominent midline Figure 1.2: Horizontal grid lines: 1)
point between eyebrows. n (nasion)- deepest Superior upper lip, 2) Inferior upper
point of nasal bridge. en (endocanthion l/r)- inner lip, 3) Incisal line, 4) Superior lower
commissure of the left and right eye fissure ex lip, 5) Inferior lower lip. Vertical grid
(exocanthion l/r)- outer commissure of the left lines: A) Outer left commissure, B)
and right eye fissure. ps (palpebrale superius l/r)- Inner left commissure, C) Left upper
superior mid-portion of the free margin of upper first premolar (it can be canine, too),
left and right eyelids. pi (palperable inferius l/r)- D) Midline, E) Right upper first
Inferior mid-portion of the free margin of upper premolar (it can be canine, too) F)
left and right eyelids. prn (pronasale)- most Inner right commissure, G) Outer
protruded point point of the apex nasi. sn right commissure
(subnasale)- midpoint of angle at columella base.
al (alare l/r)- most lateral point of left and right Dentolabial grid was modified from
alar contour. ls (labiale superius)- midpoint of the Fradeani (2004).
upper vermilion line. li (labiale inferius)-
midpoint of the lower vermilion line. cph (cristha
philtri l/r)- point on left and right elevated
margins of the philtrum just above vermilion line.
ch (cheilion l/r)- point located at left and right
labial commissure. pg (pogonion)- most anterior
midpoint of the chin.
Modified from:
http://hifisnap.com/photos/13/how-to-draw-
human face/a7d6175d d8135 da ae775f99412
460dfc-jpg

The ranging scanning procedure can be further subdivided into two methods: laser pulse time-
of-flight and the phase comparison method. In time-of-flight scanners, the measurement of
the distance from the transmitter to the object (reflecting surface) is based on the calculation
of the time between the signal transmission and its reception. The difference between time-of-
flight and phase comparison scanners is that in the latter, the distance between the transmitter
and the object is calculated via the determination of the phase difference between the trans-

13
mitted and received wave (Boehler and Marbs, 2002). Two triangulation systems also exist:
single-camera and dual-camera solutions. The scanning system consists of a transmitter, one
(single-camera solution or two (dual-camera solution) cameras, and the object. The
transmitter emits laser beam which renders the object detectable by the camera. The triangle
created between these three vertices can then be used to calculate the 3D position of a given
point on the object (Boehler and Marbs, 2002). Depending on the interaction between the
scanner and the scanned surface, contact and non-contact scanners are available. All of the
face scanners are of the non-contact variety. Stereophotogrammetry, laser scanning, and
structured light techniques all function based on the triangulation principle. These techniques
are used in the different types of face scanners. Face Hunter (Zirkonzahn), 3DMD (3DMD),
DI3D (Dimensional Imaging), and Galileos (Sirona) are some examples of commercially
available face scanners. The 3D description of the face is obtained in stereophotogrammetric
systems through the conversion of multiple 2D photographs into 3D images. The laser
scanning systems consist of a laser, light sensor, and the object. The laser spots or lines move
over the object’s surface. Through the captured scan images, a 3D image of the object is
produced (D'Apuzzo 2006). In structured light systems, white-light patterns are projected onto
the surface of the object. The reconstruction of the 3D image is performed by matching the
detected and projected stripes with each other and subsequently calculating the coordinates of
the corresponding points (Hajeer et al. 2004; Gateno et al. 2011).

1.2.1.3 Four-dimensional (4D) imaging system

The aim of the development of the 4D imaging system is the digital simulation of the jaw
movements. The working principle of this system is based on the generation of time-lapsed
3D data and subsequent transformation to 4D models. Before the imaging procedure, the
cheek and lips should be retracted using cheek retractors and fluorescent polymer
microspheres (beads) should be applied to the hard and soft tissue of the upper and lower
jaws. This area should be equal to the width of approximately six teeth. The fluorescent
polymer microspheres produce a high-contrast random optical pattern for the imaging system.
Imaging is performed using a special digital camera consisting of three 8-bit digital
monochrome cameras, each of which is mounted at a low angle. The imaging frequency of
each camera is 8 Hz; that is, each camera simultaneously produces 8 images per second. The
whole system (three cameras) generates 24 individual captures - 8 triplets - per second. The
3D surface of the bead-prepared area is then computed from each of the triplets. During
imaging, the data are stored into RAM for later transfer to the dental laboratory. The EOS sys-

14
tem software PhotoModeler is used for the creation of 3D surfaces in silico. In this system,
the 3D points from the capture of the center and left cameras and from the center and right
cameras are first meshed. Next, these two-point meshes are integrated into a single mesh and
3D images are composed. The final step is the creation of 4D models using the time-lapsed
3D files. For this, a reference frame is defined for the upper arch and articulation of the lower
arch can be defined using the lower arch data displacement with respect to the reference
frame (Lauren, Mark and McIntyre 2013;Lauren, M. 2014).

1.2.1.4 Innovations in the digital planning

Digital smile design is an innovation in the dentistry, which facilitates a preview of the
prospective results of the dental treatment. The missions of the DSD are to manage patient
expectations, to motivate the patients, to see the results of the treatment beforehand, to
evaluate the possibilities, and to improve communication between the dentist and dental
technician. The basic steps of the smile design are in the following order: documentation —›
definition of the reference lines —› calibration —› creation of the smile frame —›
transformation of the 2D information to 3D. Various methods are available for performing
each of these steps, depending on the smile design software. The Digital Smile Design (DSD),
Digital Smile System (DSS), Cerec Smile Design, Smile Composer, Smile Designer Pro,
Romexis Smile Design and G Design are all examples of smile design systems. DSD is a
more well-known smile design system, which has been represented by Cristian Coachmann.
For documentation, the video shooting should be performed from different aspects: from
frontal view (full face retracted and unretracted), from profile (resting, during smiling),
occlusal, during speech and phonetic analysis, and intraoral. DSD is performed using various
presentation software applications (Keynote, Powerpoint). Transformation of the 2D
information to wax-up could be achieved through either the conventional or digital workflow.
Unlike DSD, full-frontal photographs during smiling are sufficient for Cerec Smile Design.
This software is a module of the whole Cerec System. Utilizing this software during the CAD
design process allows direct 3D design in the aesthetic area. Through the BioCopy CAD
design application, the scanned mock-up can be accurately copied to final prosthesis. For the
DSS system, the frontal full-face smile photographs should be taken with the special eyewear,
which contains the reference points for creating the true dimension during the insertion of the
photograph in software. One disadvantage of the DSS system is the absence of a “see-
through” option for positioning the smile frame over the 3D model, which is a possibility in

15
DSD. Another innovation in digital planning is the Guided Esthetic Treatment App.
developed Mauro Fradeani (http://www.fradeanieducation.com/en/getapp-fradeani/). This
application aids the dentist in creating the optimal treatment plan, in order to fulfill patient
expectations and lead to pleasing results. This application is available for Android and iOS
devices. After installing the program, all information, such as patient anamneses and
expectations should be entered. In next step, dentists are guided through the application to
perform esthetic analysis. After uploading all information, the program analyzes the input
data. As the last phase, the optimal treatment planning for the patients could be achieved.

1.2.2 Cephalometry of the head

Cephalometry is the science of measuring the head of living individuals, and usually refers to
the human head on a cephalogram. Cephalometric analysis is conducted using reference lines
and facial landmarks to determine dental and skeletal relationships of the head and teeth.
There are two types of cephalometry: 2D and 3D. 2D analysis is performed on posteroanterior
and lateral conventional radiographs, and 3D analysis with cone- beam computed
tomography. Some of the problems of 2D cephalometry are the impossibility of measuring
certain crucial parameters and a geometric distortion of the anatomical structures being
imaged. Because of these disadvantages, 3D cephalometry has recently become a more
common method for cephalometric analysis. 3D cephalometric analysis gives full information
regarding four basic parameters: size, shape, position, and orientation of the different facial
units. The following measurements between different reference points and lines can be
performed in 3 dimensions: line-line angles, line-plane angles, plane-plane angles, and point-
line distance (Gateno et al. 2011).

1.2.3 Phonetic Analysis

The relationship between the lips, tongue, and the teeth during speech should be taken into
consideration for satisfactory esthetic outcomes of the prosthetic rehabilitation. Phonetic
analysis gives us information about tooth position and length and appropriate vertical
dimension of occlusion. During the pronunciation of the phonemes [m], [s], [f], [v], and [i:],
some functional and aesthetic parameters can be evaluated (see §.1.7) (Fradeani 2004): incisal
length- [m], [f], [v], and [i:] sounds; incisal profile- [f] and [v] sounds; tooth position- [s]
sound; vertical dimension- [m] and [s] sounds.

16
1.2.4 Model Analysis of the relationship of teeth

Measurements in model analysis can be performed digitally (on digital models) and/or
conventionally (on casting models). The following are the detectable factors in models: the
symmetry of the dental arches (relative to the face and to each other), the width of the dental
arches (relative to the face, the basal bone, and the dentition), the shapes of the dental arches
(in both the primary and permanent dentition), the symmetry of the dental arches, mesio-distal
angulation and bucco-lingual inclination of the teeth, tooth rotations, tooth size analysis
(Bolton analysis), overbite and overjet, the occlusal plane, and the curve of Spee and Wilson,
the occlusal relationship of molars (Angle’s classification), the movement paths of the
mandible, the static and dynamic occlusion, and the canine rule. Model analysis is performed
through the use of articulator-mounted models. The articulators visualize the
temporomandibular joint and movements of the lower jaw. These movements can be
represented in two ways: conventional (through mechanical articulators and plaster models)
and digital (digital articulators on digitized models).

1.3 Patient expectation and communication

The aim of the first appointment with the patient is to establish a good conversation. The
dentist should get information about the patient’s psychosocial, emotional, social status, and
expectations. Depending on education, sex, age, previous experience with the dentists, and
their own character, some patients require more intensive communication than others.
Dentists should listen to patients’ requests attentively and without judgment, take them
seriously and interpret each patient’s expectations. However, it is sometimes impossible to
fulfill a given patient’s expectations aesthetically, functionally, or financially. Therefore, there
are some important points that patients should be objectively informed of beforehand:
duration, cost, difficulty, and aesthetic outcomes of the treatment. Actually, managing
patients’ expectations is one of the important factors that can enhance a patient’s satisfaction
with the treatment results. Two notions of satisfaction can be described: satisfaction with
attitude and care, and satisfaction with the treatment outcome. Generally, the communication
skills of the dentists have a clear influence on patient satisfaction. Dentists should take into
consideration that aesthetics tend to be subjective and try to fulfill patients’ requests as often
as possible. Patients are more satisfied with treatment outcomes when they look in the mirror
and see what they wished. Moreover, analysis showed that older patients are more satisfied
than younger patients, and that patients of female dentists are more satisfied than patients

17
of male dentists (Douglass and Sheets, 2000; Sondell et al. 2002).

1.4 Facial analysis

1.4.1 Reference lines

The aesthetic analysis is performed through the drawing of some lines, which are created with
the connection of the appropriate reference points. The first vertical reference line of the face
is the facial midline. The facial midline is the line joining the midpoint of the glabellar region
and runs midway between the eyebrows, the tip of the nose, mid-philtrum of the upper lip
(Cupid’s bow), and the midpoint of the chin. Further vertical references are the smile lines,
which are drawn to the facial midline through the bilateral landmarks (Figure 1.3). Horizontal
reference lines of the face are the hairline, ophriac line, interpupillary line, interalar line, and
commissural line. The hairline is the borderline between the hair and forehead. The ophriac
line is drawn over the eyebrows. The interpupillary line is the line extending through the
center of the pupils. The interalar line crosses the wall of each of the nares.

The commissural line is the line between the junction of upper and lower lips (Figure 1.3)
(Fradeani 2004; Naini 2011; Calamia and Wolff, 2015). The reference lines divide face into
vertical and horizontal proportions, which described in §4.8.1.

1.4.2 Facial symmetry

The facial midline divides the face into left and right sides. Symmetry is the harmony of an
object, such that one side of the object is the mirror image of its other side. Ideal symmetry
(static symmetry) of the human body is never encountered. Some methods can be used to
create a perfectly symmetrical face, in order to establish the effect of facial symmetry and,
therefore, facial attractiveness. The chimera technique is one such commonly used technique,
and involves mirroring one side of the face in a photograph to the other side. Although this
technique can achieve perfect symmetry of the face, it was shown that this type of symmetry
is not perceived as attractive, because abnormal structural appearances arise from the image
mirroring process; for example, a wide or narrow face or nose. Another method for creating a
symmetrical face is the placement of the facial landmarks ideally and symmetrically on both
sides of the face. Unlike the first method, symmetry created with this method is perceived as
more attractive (Komori et al. 2009). In contrast to static symmetry, dynamic symmetry is
interpreted as more natural and attractive, arising from the existence of two similar but not
identical parts.

18
There are two types of asymmetry: fluctuating and directional. Fluctuating asymmetry is a
slight asymmetry between right and left sides of the face, and is a consequence of
environmental or genetic stresses during development. However, some facial asymmetries are
not correlated to stress factors, and occur with a consistent bias to the left or right side, and
are known as directional asymmetries. Asymmetry might be noticeable by the human eye, if
the difference is higher than 3%. Sufficient asymmetry is viewed as more natural, interesting,
and attractive than the perfect but artificial symmetry (Fradeani 2004).

Figure 1.3: Horizontal and vertical reference lines of the human face: 1) Facial midline.
2)Hairline. 3)Ophriac line. 4) Interpupillary line. 5) Interalar line. 6) Comissural line
Modified from: http://hifisnap.com/photos/13/how-to-draw-human face/a7d6175d d8135 da
ae775f99412 460dfc-jpg

1.4.3 Facial shape and facial index

Facial shape is one of the important factors to be considered during aesthetic analysis of the
face. Facial shapes are defined by the mutual ratios of the temporal width, bizygomatic
breadth, maxilla-chin breadth, mandibular breadth, and physiognomic facial length (Xu et al.
2010). There are different classifications for the human facial shape. According to one
common classification (in sketching and art), there are four human facial shape types: round
face, thin face, broad face, and square face. Xu Rukang et al. (1984) represented the face
shape classification in human observation. They classified the facial shapes based on
lineament essentially and eye observation indirectly. They ordered the shape types into ten
classes: ellipse, roundness, ovoid, inverse ovoid, squareness, rectangle, trapezoid, inverse
trapezoid, diamond, and pentagram (Xu et al. 2010). The face classification in anthropometry
is defined through facial index measurements. Facial index is the relation of the facial length
to facial width (mean TFI (n-gn/zy-zy) x 100%). Five facial types have been determined using

19
this classification: hyperleptoprosopic (very long face), leptoprosopic (long face),
mesoprosopic (round face), euriprosopic (broad face), and hypereuriprosopic (very broad
face) (Jahanshahi et al. 2008). In another classification using pattern recognition, face shapes
are classified into these groups: round face, elliptical face, square face, two angle face, and
others (Xufeng et al. 1999.).

1.4.4 Facial profiles

Face profile analysis is an important part of aesthetic evaluation in dental rehabilitation. There
are two conventional classifications for human facial profiles: one based purely on
cephalometric analysis, and one based on the relationship of the anatomical structures (for
example, lips, nose, etc.) to reference points and lines of the face (Schwarz 1961). He
represented the nine possible human face profiles with respect to the cephalometric analysis:
straight ante-, average and retroface; oblique ante-, average and retroface, the jaw slanting
forward; oblique ante-, average and retroface, the jaw slanting backward. While all three
types of the straight face are variations of the esthetic profiles, all another six forms of the
oblique face are defined as unaesthetic facial profiles. The face profile types are determined in
this classification through the two cephalometric angles: J and F angles (Figure 1.4). In the
straight average face the F angle equal 85°. He described also the relationship between the
soft tissue landmarks and the face profile types such as (Figure 1.5):

Straight average faces: Upper lip comes in contact with the Pn line. Lower lip is in the front
third and in the middle of the KPF.

Straight anteface: Parallel displacement of the reference points forward.

Straight retroface: Parallel displacement of the reference points backward.

Subtelny (1959) classified the face profile types in relation to facial convexity. He described
three types of facial convexity:

Convexity of the skeletal profile: The reference points of this measurement is the nasion -
point A (Down’s A point – the deepest point on the anterior contour of the upper alveolar
arch) - pogonion (Figure 1.6.1).

Soft tissue profile convexity: Measurements of this angular convexity are conducted
excluding the nose. The line is drawn between the soft tissue nasion- subnasal- soft tissue
pogonion (Figure 1.6.2).

20
Total soft tissue profile convexity: In measurements of total soft tissue profile convexity, the
nose is taken into account. In this evaluation, three reference points are joined together: soft
tissue nasion - tip of nose - soft tissue pogonion (Figure 1.6.3).

Figure 1.4: Reference lines and angles for
craniometric analysis (Schwarz (1961)): N
(nasion) - deepest point of the nasal bridge.
Se (sella) - midpoint of sella turcica. NSe
(nasion- sella or cranial base plane) - a line
connecting sella to nasion. H (Frankfort
horizontal plane) - the line between the
lowest point of the orbit and the top of the
osteal acoustic meatus. A - most concave
point of anterior maxilla. NA (facial plane)
- a line connecting A point to nasion. pd -
hard palate. vp - soft palate. SpP (Spina
palate plane) - a line connecting anterior
nasal spine to the most superior convexity
of the palatal contour. Pn plane -
perpendicular plane to Frankfort horizontal
from soft tissue nasion. F angle - the angle
created at the juncture of the nasion - sella
plain and nasion - point A plane. J angle -
the angle created the juncture of the Pn
plane and Spina palate plane.
Modified from Schwarz (1961)
Figure 1.5 Relationship between the soft
tissue landmarks and the face profile types
such as (Schwarz 1961): Tr (trichion) –
midline of hairline. N (nasion) - deepest
point of the nasal bridge. O (orbital point) –
most inferior point of the orbit. H
(Frankfort horizontal plane) - the line
between the lowest point of the orbit and
the top of the osteal acoustic meatus. Sn
(subnasal) – the junction point in the
midline where base of the columella of the
nose meets the upper lip. Gn (gnathion) –
point located perpendicular on mandibular
symphysis midway between pogonion and
menton. Pn plane - perpendicular plane to
the Frankfort horizontal from soft tissue
nasion. Po plane – perpendicular to the
Frankfort horizontal from the orbital point
downward. KPF (Kiefer- Profile Field) –
the jaw- profile field enclosed by Pn and
Po
Modified from:
http://www.craftsy.com/blog/wp-
content/uploads/2013/07/AdultChildPro
files.png

21
Nowadays, the face profile analysis is performed on the natural head position based on the
aforementioned conventional classifications with some modifications. The natural head
position is determined by using the Frankfort plane as a reference. The Frankfort plane is the
plane between the lowest point of the orbit and the top of the ostial acoustic meatus. It is
parallel to the horizon or aesthetic plane if the patient bends his head slightly forward. In the
new classification, the soft tissue profile convexity is used to define the facial profile form.
The profile angle of 165-175° is correlated with a normal profile. A reduced angle is
characteristic for the convex profile, while the increased angle is the feature of concave
profile. (Fradeani 2004; Millar and Wilson 2014) (Figure 1.7). Another reference line for
profile analyses is the E-line (Esthetic line) drawn from the tip of the nose to the tip of the
chin. Based on this study, some variation in the lip positions could be classified as anterior
and posterior positions of the lips (Figure 1.8.1). Furthermore, nose-lip relationships are an
important factor in the facial profile, which is defined through the nasolabial angle. According
the most authors the nasolabial angle is the intersection of the line from the lower border of
the nose and the tangent of the upper lip (Figure 1.8.2). Several authors measure nasolabial
angle at intersection between the line drawn through the midpoint of the nostril aperture and
the line drawn perpendicular to the horizontal plane while intersecting the subnasal.

Figure 1.6: Methods of evaluating facial
convexity (Subtelny (1959)): 1) Convexity
of the skeletal profile. 2) Soft tissue profile
convexity. 3) Total soft tissue profile
convexity.
Figure 1.7: Face profile types (Fradeani
2004): 1) Convex profile. 2) Straight
profile. 3) Concave profile

Figure 1.8: 1) Esthetic line (E-Line). 2) Nasolabial angle.

22
1.5 Dentolabial analysis

The tooth-lip relationships in different phases of speaking and smiling are one of the
important factors that should be taken into consideration during aesthetic analysis. Detailed
information about the tooth-lip relationships can be obtained through dentolabial analysis.
This analysis is performed at rest position, during speech, and while smiling.

1.5.1 Lip movement and upper lip length

Lip movement should ideally be parallel to the horizon and interpupillary line. To evaluate
movement of the lip, the clinician should conduct the conversation or take a video in a relaxed
atmosphere, and before anesthesia, if anesthesia is to be administered in this appointment. The
clinician should attempt to produce a natural smile in the patient. Anesthesia, stress, anxiety,
and several other environmental factors have an influence on lip movement. Additionally,
variable tonicity of the perioral muscles and neuromuscular disorders are two examples of
physiological factors that induce variable lip motility among patients (Fradeani 2004). Upper
lip length is the distance between subnasal and the lowest point of the upper lip in the
midline. The upper lip of females is approximately 2-3 mm shorter than that of males. A
review of the available literature concludes that the mean upper lip length of females is 20
mm, and of males, 23 mm (Sabri 2005).

1.5.2 Tooth exposure at rest position

In the resting position of the teeth, the lips are slightly apart, and there is no contact between
the maxillary and mandibular teeth. The incisal part of the maxillary incisors is visible. The
visible portion of the maxillary incisors depends on several factors; for example, gender, age,
and lip length. Regarding gender and lip length, female subjects tend to display a greater
portion of the maxillary incisors than male subjects, an observation due to the decreased
upper lip length in females relative to males. Subjects with shorter upper lips show larger
portions of the anterior teeth at rest than subjects with longer upper lips. There are no
significant differences among different races with respect to tooth exposure at rest (Al
Wazzan 2004). Regarding age, the visibility of maxillary incisors is decreased in older
subjects, while visibility of the mandibular incisors is increased at rest position. This is due to
an increasing upper lip length with age (approximately 4 mm). This increase in upper lip
length is explained by the reduction of the perioral muscle tone.

23
1.5.3 Smile analysis

Smile analysis is an important part of aesthetic analysis, and it directly affects the results of
prosthetic rehabilitation. In the smile analysis, the correlation of the smile components and
reference lines is evaluated on the patients’ extraoral face or lip photos during smiling.

1.5.3.1 Smile classifications

There are multiple smile classifications, each of which considers different parameters during
smiling. Both old and new classifications of the smile are summarized below.

Smile types in relation to emotion (Ackerman and Ackerman 2002):

Social smile (posed smile): This type of smile is a voluntary smile, generally used to greet or
show politeness. It is correlated with a moderate contracture of the m. levator labii
superioris/inferioris. In these situations, the teeth and sometimes the gingival scaffold are
visible.

Enjoyment smile (unposed smile): The enjoyment smile occurs during laughing and is a
more natural and involuntary smile. Maximal contraction of the muscles induces a maximum
exposure of the anterior teeth and gingiva.

Smile styles: Smile styles depend on the dominant muscle groups during smiling. The
classification of the smile (Rubin 1974; Tarvade and Agrawal 2015) is in the following order:

The cuspid (commissure) smile: This is the most common smile, encountered in 67% of the
population. In this smile, the upward and outward movements of the mouth corners occur
first. The maxillary teeth and gingival scaffold are visible (Figure 1.9.1).

The complex (complete denture) smile: 2% of the population has a complex smile.
Characteristic for this smile is exposing both the upper and lower teeth (Figure 1.9.2).

Mona Lisa smile: This smile is seen in 31% of the population. Exposure of the maxillary teeth
is features of this smile style. (Figure 1.9.3).

Stages of a smile: The four stages follow each other during smiling as follows (Philips 1999):
Stage I- lip close; Stage II- resting display; Stage III- natural smile; Stage IV- expanded smile
types of a smile. Depending on the visible teeth and periodontal tissues smiles are divided
into five types (Philips 1999):

24
Type 1- maxillary teeth only; Type 2- maxillary teeth and greater than 3 mm gingiva; Type 3-
mandibular teeth only; Type 4- maxillary and mandibular teeth; Type 5- neither maxillary nor
mandibular teeth.

Figure 1.9: Smile styles: 1) Cuspid smile. 2) Complex smile. 3) Mona Lisa smile
1.5.3.2 Horizontal smile lines

Horizontal smile lines are the reference lines used in smile analysis to describe a mouth
aesthetic in detail. The horizontal smile lines are: the cervical line, the papillary line, the
contact points line, the incisal line, the upper lip line, and the lower lip line (Figure 1.10).

The cervical line (Figure 1.10.1) is the line extending through the most apical points of the
maxillary canines and the lateral and central incisors. There are some variations of the of the
cervical line in relation to occlusal plane (Camara 2010):

Convex: the apexes of the maxillary canines are higher than the lateral incisors and at the
same level as the central incisors. This is the most pleasing variant of the cervical line.

Plane: the apexes of the lateral incisors are at the same level as the canines and central
incisors.

Concave: the lateral incisors have more apical position than the canines. This is a more un-
Pleasant appearance among these variations.
Asymmetrical: the positions of apical points of the teeth are unharmonious.

Lines drawn through the most apical points of the central incisors and maxillary canines
should ideally be parallel to the incisal and lower lip lines, as well as to the occlusal plane and
commissural and interpupillary lines (Fradeani 2004;Tucker 2008).

The papillary line (Figure1.10.2) is the line drawn across the tips of the gingival papillae
between the maxillary anterior teeth. In the literature, the ideal relation between the heights of
the papillae has not yet been determined. The heights of the papillae between the maxillary
incisors are equal to half the size of the teeth (Kurth and Kokich, 2001). Thus the papilary

25
height decreases progressively from anterior to posterior depending on the size of the contact
areas between adjacent teeth. Based on these characteristics and the maxillary teeth
relationships, a papillary line which is convex and parallel to the contact points line can be
considered ideal (Câmara 2010).

The contact points line (Figure 1.10.3) is the line connecting the contact points of the teeth.
The position of each contact point depends on the tooth position. The position of the contact
points between the maxillary central incisors is lower than the contact points between the
central and lateral incisors and canines (Fradeani 2004). In the ideal position and form of the
teeth, the contact points line is parallel to the incisal line. It is considered more aesthetic if
there is a contact between the teeth over a broader area rather than a single point such as
connector band. In this case, the reference point for the contact point line is the most apical
site of the contact area. The length of the connector band is decreased distally along the arch.
(Morley and Eubank, 2001; Kirtley 2008).

The incisal line (Figure 1.10.4) is the line following the edge of the maxillary anterior teeth.
The incisal line is divided into three groups depending on its curvature: convex, flat, and
concave (Figure 1.11). In a pleasing tooth composition, the maxillary central incisors are
longer and the canines are shorter than the lateral incisors. Therefore, the incisal line is a
convex curve from the frontal view and ideally follows the concavity of the lower lip line.
Alternatively, the incisal line can be flat or concave. The incisal line is slightly convex in
dental Class I patients. In Class III patients it tends to be flat. The convexity of the incisal line
is more observable in Class II patients. The flat or concave incisal curve occurs in
consequence of abrasion (Fradeani 2004).

The lower lip line (Figure 1.10.6) is the upper margin of the lower lip during smiling. The
relationship between the incisal curve and lower lip line in a posed smile is defined as the
smile arc. The smile arc plays an important role in evaluating a smile as pleasing or
unpleasing. Two types of the smile arc are described in the literature: consonant and
nonconsonant. The incisal and lower lip line should ideally be parallel in a posed smile, this is
the consonant smile arc. In nonconsonant smile smiles, the incisal curvature appears flatter
than the lower lip line (Sarver 2001; Wong et al. 2005). Regarding parallelism, there are three
possible situations for relationships between the incisal and lower lip lines (Figure 1.11)
(Dong et al. 1998; Passia et al. 2010):

26
Parallel: The incisal line is convex. The incisal edges of the maxillary anterior teeth are
parallel to the lower lip line during smiling.

Straight: The incisal line is flat and appears straight in relative to the upper border of the
lower lip.

Reverse: The incisal line is concave and curved to the lower lip line.

Parallel and straight smiles are perceived as more aesthetically pleasing than the reverse smile
(Dong et al. 1998). According to the current systematic review, the parallel smile line is the
most frequent and the reverse smile line is the less common (Passia et al. 2010). The
relationships of the incisal curve to the lower lip line is divided into three categories, which
depend on the maxillary anterior teeth position and the height of the lower lip line:
“contacting”, “not contacting”, and “covering” (Figure 1.12). If there is a gap between the
incisal and the lower lip lines, this relationship called “not contacting”. In the “contacting”
situation, the maxillary anterior teeth are just touching the lower lip. In some cases, the lower
lip covers the maxillary anterior teeth, which called the “covering” situation. While the “not
contacting” smile is received as the most pleasant, the “contacting” smile is received as
particularly pleasing, and the “covering” is the most unpleasant smile.

Upper lip line (Figure 1.10.5): The upper lip line is the lowest edge of the upper lip. It is one
of the important lines used to evaluate the smile. Regarding the relationship between the
positioning of the corners of the mouth and the center of the lower border of the upper lip
during smiling, there are three types of the upper lip line: upward, straight, and downward
(Figure 1.13). If the corner points of the mouth are at the same level with the central point of
the lower line of the upper lip during smiling, this type of upper lip curvature is classified as
straight. In the upward and downward upper lip curvatures, the position of the corner points
of the mouth is higher and lower than the central point of the upper lip line, respectively. The
upward and straight upper lip line are more aesthetically pleasing than the downward smile
line (Dong et al. 1998; Al-Johany et al. 2011). The results of the study of Dong et al. (1998)
indicate that the upward upper lip curvature (12%) is less common than the straight (45%) or
downward upper lip curvature (43%).

Another considerable factor in the smile analysis is the relationship between the incisal line
and the upper lip line. Depending on this relationship, the smile line is divided into three
types: low, average, and high. In the literature, multiple authors have given different descript-

27
tions for this classification. Recently, a description was suggested based on the classification
of Tjan et al. (1984), and lists the three smile lines in the following order (Figure 1.14)
(Fradeani 2004; Passia et al. 2010):

Average smile line: 75%-100% of the anterior teeth and the interproximal papillae is
displayed during smiling.

Low smile line: The anterior teeth are exposed less than 75% during smiling.

High smile line: The total anterior teeth and the gingival band are exposed.

According to the results of the current systematic review, a low smile line is less common
than the average or high smile lines (Passia et al. 2010). Female subjects show a higher
prevalence of high smile lines than male subjects. The male subjects show low smile lines
more frequently than the high and average smile lines. Several studies also reported that the
height of the smile line decreases with age (Dong et al. 1998; Desai et al. 2009).

Figure 1.10: Horizontal smile lines: 1)
Cervical line. 2) Papillary line. 3) Contact
points line. 4) Incisal line, 5) Upper lip
line, 6) Lower lip line.
Figure 1.11: Incisal curve: 1) Convex
(parallel to the lower lip line). 2) Flat
(straight in relative to the lower lip line).
3) Concave (reverse in relative to the
lower lip line)

Figure 1.12: Relationship between the
incisal and lower lip lines: 1) “Not
contacting”. 2) “Contacting”. 3)
“Covering”
Figure 1.13: The relations between the
positioning of the corners of the mouth
and the center of the lower border of the
upper lip: 1) Upward. 2) Straight. 3)
Downward.

Dentolabial grid was modified from Fradeani (2004).

28
1.5.3.3 Smile width

Smile width is the distance between the right and left outer commissure. Depending on the
number of visible teeth the smile width is divided into four groups (Tjan et al. 1984; Bidra
2011): narrow, medium, wide, and extra wide smiles. In the narrow smile, subjects show six
anterior teeth; in the medium smile, six anterior and the first premolar; in the wide smile, six
anterior teeth and both premolars; and in the extra wide smile six anterior teeth, both
premolars, and molars. Maulik and Nanda (2007) have reported that the most frequently
visible posterior maxillary tooth is the second premolar.

1.5.3.4 Buccal corridor

The buccal corridor describes the lateral negative space between the maxillary posterior teeth
and the corner of the mouth in smiling. The smile fullness is defined by the ratio of the visible
maxillary dentition to the inner commissure width. The buccal corridor corresponds to the
space between the visible maxillary teeth width and the inner commissure width. Thus, the
inner commissure width, consists of the smile fullness in addition to the right and left buccal
corridors and it is considered to be 100% full. Five different sizes of smile fullness can be
discriminated based on these ratios: narrow (28% buccal corridor), medium-narrow (22%
buccal corridor), medium (15% buccal corridor), medium-broad (10% buccal corridor), and
broad (2% buccal corridor) (Moore et al. 2005; Oshagh et al. 2010). Fradeani (2004) and
Calamia et al. (2011) describe three variations of the buccal corridor: normal, wide (or
deficient), and absent (or over-filled) (Figure 1.15). In the literature, there are different
hypotheses regarding the influence of the buccal corridor on smile attractiveness. According
to the systematic review, buccal corridor size, in isolation, has no significant impact on
perceived smile attractiveness (Janson et al. 2011).

Figure 1.15: Variations of the buccal

Figure 1.14: Description of the smile corridor: 1) Normal. 2) Wide. 3) Absent.
line: 1) Average smile line. 2) High
smile line. 3) Low smile line Dentolabial grid was modified from

29
1.5.3.5 Facial midline vs. dental midline

The dental midline is defined as the interincisal line of the maxillary central incisors. If the
maxillary incisors are mediolaterally inclined, the reference for the dental midline is the
interdental papilla between the maxillary central incisors. Orthodontists can notice midline
deviations greater than 2.2 mm, while laypersons can only detect midline deviations greater
than 3 mm. An axial midline angulation of 10° (2 mm measured from the midline papilla and
the incisal edges of the incisors) is noticeable by an observer (Janson et al. 2011; Janghu et al.
2015). According to literature, in 70% of the subjects, the dental midline coincides with the
facial midline (Fradeani 2004). Although patients prefer no deviation between the facial and
dental midline, according to prosthodontics, a slight deviation can give patients a more natural
look (Rosenstiel and Rashid, 2002).

1.5.3.6 Occlusal plane

The occlusal plane is the plane joining the incisal surface of the maxillary anterior and the
occlusal surface of the posterior teeth. The anterior part of the occlusal plane is called the
incisal plane. The occlusal plane should ideally be parallel to the Camper’s plane. The
reference for the perfect incisal plane is the horizontal reference lines. The incisal plane
should be parallel to the interpupillary and commissural lines, with an angle of 0°. For
creating a positive smile line, some alterations are performed in the occlusal plane angle.
According to the results of a study on the effect of the occlusal plane angle on smile
attractiveness, patients prefer a 10° smile line and clinicians find the 15° smile line more
attractive than the 0° and 20° smile lines (Batwa et al. 2011).

1.6 Dental analysis

Dental analysis is an important aspect of aesthetic dentistry. In aesthetic analysis, the

maxillary and mandibular anterior teeth are given higher priority than the others.

1.6.1 Anatomy and features of the anterior teeth

1.6.1.1 Maxillary anterior teeth

From the labial view of the central maxillary incisors, there are three (the mesial medial, and
distal) lobes and two depressions (concavities) created through these three lobes. These three
lobes form three mamelons on the incisal margin. A fourth lobe, called the cingulum, appears

30
on the lingual surface. While the mesioincisal angle is straight or slightly rounded, the
distoincisal angle is more rounded than the mesioincisal angle. In the incisal third, the crown
is broader than the cervical third (Scheid 2007). From the profile, three portions can be
determined on the buccal surface: cervical, middle, and incisal. These portions are tilted in
different planes. The maxillary central incisors have the longest and widest crowns of the
human teeth (Magne et al. 2003). The average length of the maxillary central incisors is 10.4 -
11.2 mm, the average width is 8.3 – 9.3 mm, and the ideal width/length ratio is approximately
75% - 80% (Rosenstiel et al. 2000; Zimmermann and Mehl, 2014). In older patients, the
crown length is reduced due to abrasion. In some young patients, the gingival margin is
positioned coronally to the cementoenamel junction, thereby giving the impression that the
tooth length is decreased. The form and main features of the maxillary lateral incisors are
reminiscent of the central incisors; nevertheless, there are some noticeable differences
between the two: the crowns of the lateral incisors are smaller and less symmetrical than the
central incisors. The average length of the maxillary lateral incisors is 9.75 mm, the average
width is 7.07, and the width-to-length proportion is 73% (Magne et al. 2003). The maxillary
canine is the strongest tooth in the dentition. While the mesial portion of the maxillary
canines resembles the incisors, the distal portions look like the premolars from the labial
view. The mesio- and distoincisal ridges can be observed observed on the top of the crown.
The maxillary canines are approximately 1 mm narrower than the central incisors. Mesially
and distally, concavities divide the smooth tooth surface into three parts. From the lingual
view, the well-developed cingulum, lingual, mesio- and distoincisal ridges (which begin from
the cusp tip), and two prominent concavities between these ridges can be observed (Ash and
Nelson, 2003).

1.6.1.2 Mandibular anterior teeth

The crowns of the mandibular incisors are narrower than the other teeth of the mouth, and the
width of the mandibular central incisors is even the smallest. The average widths of the
central and lateral mandibular teeth are 5.3 mm and 5.5 mm, respectively. The average length
of the crown mandibular central incisors is 8.8 mm, and that of the mandibular lateral incisors
is 9.4 mm. The crown of the central mandibular incisors is very symmetrical and
differentiation of the left teeth from the right is difficult. Conversely, the distal contour of the
lateral mandibular incisor is more convex than the mesial (Scheid 2007). Mandibular canines
are highly similar to the maxillary canines, although their crowns are narrower and they are
0.5-1mm longer (Ash and Nelson, 2003).

31
 1.6.2 Tooth analysis

Factors to be considered in the tooth analysis are tooth type and shape, color, macro- and
microtextures, anatomic form dimension, and proportions.

1.6.2.1 Tooth shape

There are three basic tooth shapes: square, ovoid and tapered (Figure 1.16) (Fradeani 2004;
Wolfart et al. 2004; Ahmad 2005). There are different considerations in the literature
regarding the correlation between tooth shape and sex, age, and personality. One view,
according to Fischer (1956), gives that sex, age, and personality are related to form of the
anterior teeth. In contrast, Wolfart et al. (2004) reported that there is no significant correlation
between tooth shape and gender. Paolucci et al. (2012) investigated the relationship between
tooth shape and personality or temperament. They described four basic forms of the tooth,
depending on temperament: rectangular, triangular, oval, and square. Rectangular tooth shape
is characteristic for choleric individuals (strong temperament), a triangular tooth shape for
sanguines (dynamic temperament), an oval tooth shape for melancholics (sensitive
temperament), and a square tooth shape for phlegmatics (calm temperament). For female
subjects, the ovoid and square- ovoid form of the tooth is preferable.

Figure 1.16: Tooth shapes: 1) Square. 2) Ovoid. 3) Tapered

1.6.2.2 Tooth color and surface texture

The color of different teeth in the same subject, and even the color of different parts of the
same tooth can vary. The mandibular anterior teeth are whiter than the maxillary anterior
teeth without any major significance. The hue of the maxillary central and lateral incisors is
same, but the value and intensity of the maxillary incisors is greater than that of the lateral
incisors. The color of the canines is more saturated (more chromatic) than the incisors.
Therefore, they generally seem darker than the adjacent teeth (Fradeani 2004; Joiner 2004).
The tooth color is best determined in the middle portion of the tooth. In the cervical area of

32
the tooth, the enamel thickness is reduced (0.3 mm). The marked color of the dentin gives the
cervical area a more saturated appearance. Additionally, because of the light scattering from
the gingiva, the cervical area appears darker. On the contrary, the enamel thickness is
approximately 1mm in the incisal region of the teeth, which causes the evident translucency
in the incisal third. The tooth color is more yellow and darker in older subjects than in
younger ones. The tooth surfaces have some characteristic texture, divided into macro- and
microtexture. The microtexture is comprised of the horizontal grooves in the facial surface of
the tooth. The lobes in the buccal face of the tooth create concavities and convexities, which
constitute the macrotexture of the tooth. The tooth surface is rougher and more evident in
younger than in older subjects. Young patients present specific characteristics on the surface
of the maxillary anterior teeth (Erdemir et al. 2016).

1.6.3 Tooth composition analysis

The relation between the teeth has an important influence on the aesthetic outcome. In the
analysis of tooth composition, the relation of each tooth to teeth in the same arch and to the
corresponding tooth in the antagonizing arch should be taken into consideration. Regarding
the relationship between each tooth and teeth in the same arch (tooth to tooth proportions),
there are several concepts, described in §4.8.4.

1.6.3.1 Tooth arrangement and its relation to the dental arch

Three types of dental arches are described in the literature: square, ovoid, and tapered
(Noroozi et al. 2001; Fradeani 2004).

In the square arch, there is sufficient space for the maxillary anterior teeth. The maxillary
anterior teeth are positioned essentially along a straight line without any rotation or overlap.
In the ovoid arch, the anterior teeth are aligned along a curved line. Normally, no rotations
or overlaps appear. In the tapered arch, the maxillary anterior teeth are arranged along a
narrow curvature line, and the dominance of the central incisors is more prominent. This is
the narrowest type of arch. The position of the maxillary lateral incisors in relation to the
central incisors and the canines from the frontal view is one of the important factors to be
taken into consideration during analysis. In the pleasing tooth composition, the maxillary
lateral incisors should be positioned between two lines: one of them is drawn through the
apical point of the central incisors and canines, and another joins the incisal edges of the
maxillary incisors and canines (Chiche and Pinault, 1994) (Figure 4.10).

33
1.6.3.2 Interdental contact area and incisal embrasures

The interdental contact area or connector space is the area over which adjacent teeth make
contact area, it occupies of 50% of the length of maxillary incisors. The ideal proportions of
the contact areas are described in the Figure 4.10. If there is an interproximal contact area
between the teeth, the reference for the interproximal contact point is the incisal of the
connector band (Morley and Eubank, 2001; Kirtley 2008; Bhuvaneswaran 2010). No contact
areas between the teeth make the smile unpleasant. Incisal embrasures are the triangular, dark
spaces appearing between the proximal surfaces of adjacent teeth. Through abrasion, the
incisal embrasures can be reduced or disappear, giving the smile an “aging” effect. In the
ideal tooth composition, the depth and volume of the incisal embrasures between adjacent
teeth increases from central to canine, and depends on the position of the contact areas or
contact points. The contact point between the maxillary central incisors has the most incisal
position and the contact points show apical movement posteriorly. This leads to an increasing
size of the incisal embrasures, which give subjects’ smiles a natural effect. The shape of the
incisal embrasure between the maxillary central incisors is ideally triangular. The form of the
incisal embrasure can vary depending on the tooth shape and roundness of the mesio- and
distoincisal angles of the teeth.

1.6.3.3 Axial inclination of the teeth

The axial inclination of the teeth is determined from the frontal view, compared to the
midline. In the pleasant tooth composition, the teeth show apical distoinclination and incisal
mesioinclination. The inclination of the maxillary central incisors is least noticeable. The
prominence of tooth axis inclination increases from anterior to posterior (Figure 1.17) (Kirtley
2008). The visible axial inclination of the tooth is the result of inclination of the tooth in all
planes: mesiodistal and labiolingual directions. In the normal tooth composition, the maxillary
central incisors are straight or tilted slightly in the labial direction. The incisal edge of
maxillary lateral incisor should be tilted slightly labial and the cervical part tucked in. Unlike
the maxillary incisors, the position of the cervical part of the canines is more labial and the
cusp tip tilted in the lingual direction (Bhuvaneswaran 2010).While the maxillary central
incisors should show perfect axial symmetry and mirror imaging with each other, some slight
variations in the lateral incisors and canines can be permitted. Although the maxillary canines
should have a symmetric form, the slight asymmetry of the buccolingual inclination of the
maxillary canines is permissible (Chiche and Pinault, 1994; Fradeani 2004).

34
1.6.4 Interarch relationships of the anterior teeth

The relationship between the maxillary and mandibular interincisal lines, overjet, and overbite
are factors which should be evaluated in an aesthetic analysis.

1.6.4.1 Relationship between the maxillary and mandibular interincisal lines

Unlike the relationship between the maxillary incisal line and facial midline, the relation
between the maxillary and mandibular interincisal lines is not a decisive factor for an
aesthetic appearance. According to the literature, a deviation between the maxillary and
mandibular interincisal lines was found in 75% of cases (Miller et al. 1979; Bhuvaneswaran
2010). During prosthetic rehabilitation, creating a slight coincidence between the maxillary
and mandibular interincisal lines can appear more natural (Fradeani 2004).

1.6.4.2 Overjet and overbite

Overjet is the distance from the inner part of the incisal edge of the maxillary incisors to the
buccal face of the lingual incisors. Overbite is defined as the coverage of the maxillary
incisors over the mandibular antagonists along the vertical axis (Figure 1.18). In the normal
craniofacial anatomy (in dental Class I cases), the average amount of overbite and overjet
ranged from 2 to 4 mm.D eep overbite (>6mm) and open bite (no overlap) are variations of
the overbite (Daniels and Richmond, 2014). The two variations of the overjet are increased
overjet (>6mm) and reverse overjet (mandibular incisors are positioned more buccally than
the maxillary incisors) (Daniels and Richmond, 2014). While increasing overjet and overbite
can be frequently observed in dental Class II subjects, in dental Class III subjects, the overjet
and overbite can disappear due to head-to-head contact between the incisors. In dental Class
III subjects, even reverse bite can occur (Fradeani 2004).

Figure 1.17: The axial inclination of the teeth in Figure 1.18: 1) Overjet. 2) Overbite
an ideal tooth composition.
Tooth grid was modified from Fradeani (2004).

35
1.7 Phonetic analysis

Aesthetic and functional diagnosis or outcomes can be evaluated during speech through
phonetic analysis. In phonetic analysis, the pronunciation of the sounds of [m], [s], [f] /[v] and
[i:] is requested and the evaluation of adequate parameters can be performed simultaneously
or later on the recorded video of the patient during phonetic exercises. The patient should be
seated upright during speech (Bhuvaneswaran 2010).

1.7.1. [m] sound

After the subjects utter [m], the lips come into rest position and stay slightly apart (Morley
and Eubank, 2001). In this position, the assessment of the vertical interarch space and the
exposure of the maxillary anterior teeth is helpful to determine the vertical dimension and
incisal length of the maxillary anterior teeth, and therefore the necessary corrections.
Normally, the vertical interarch space should be approximately 2-4 mm (Fradeani 2004).

1.7.2 [i:] sound

During the exaggerated and prolonged pronunciation of the [i:] sound, the lips are extended to
a maximum (Morley and Eubank, 2001). This position of the lips corresponds to the position
of the widest smile. When the subjects pronounce [i:] space partially occupied by the
maxillary incisors appears between the upper and lower lips (Hess 2006). The incisal of the
incisal length of the maxillary incisors is based on the percentage of this space is filled
through the maxillary teeth during pronunciation of the [i:] sound. Fradeani (2004) and
Calamia et al. (2011) described that, while in the young subjects this space should be filled by
the maxillary incisors almost completely (more than 80%), in the elderly subjects this
coverage should be no more than 50%.

1.7.3 [f]/[v] sounds

By the pronunciation of the [f]/[v] sounds, the evaluation of the length and the horizontal
position of the maxillary anterior teeth can be performed. The [f]/[v] sounds are generated by
contact between the maxillary incisal edges and the vermilion border (Roumanas 2009; Bidra
2011). Normally, the maxillary anterior teeth should slightly touch at the vermillion border
and not beyond it horizontally. If the tooth length is decreased or the teeth are protruded, the
subjects cannot pronounce [f]/[v] sounds correctly (Fradeani 2004).

36
1.7.4 [s] sound

The [s] sound is produced by passing air between the tongue and lingual surface of the
maxillary anterior teeth (Calamia et al. 2011). Through this phonetic examination, the vertical
dimension and the correct position of the maxillary and mandibular incisors can be
determined. During the pronunciation of [s] edge-to-edge positioning of the upper and lower
incisors without contact takes place. Increasing the space between the upper and lower
incisors leads to a lisping pronunciation of [s] sound. By increasing the vertical dimension,
incisors come into contact and disturb the speech of the [s] sound (Fradeani 2004). Two types
of mandibular movements can be observed during phonetic examinations of the pronunciation
of [s]. While some of the patients move the mandible from a retracted position to anterior
until the edge-to-edge position of the upper and lower incisors is reached, others hold the
lower jaw in the retracted position and only vertical movements occur (mandibular incisors
against hard palate). In subjects with anterior movements, any lingualizations of the maxillary
incisors or buccalizations of mandibular incisors lead to difficulties pronouncing [s] due to the
undesirable contact between the upper and lower incisors. Conversely, by increasing the
overjet, subjects pronounce [s] with a lisp, because the tongue compensates by filling the
increased space (Fradeani 2004).

1.8 Gingival Analysis

Because of the gingival display during smiling, especially in the subjects with average or high
smile lines, the appearance of the gingival tissues has a considerable influence on the
aesthetic outcome. The color and surface of the gingival tissues, gingival line, gingival
margin outline, and gingival zenith are important points, and should be analyzed
comprehensively.

1.8.1 Anatomical characteristics of gingiva

The gingiva is composed of gingival connective tissue and an epithelial covering. With
exception of the interdental col region, the entire surface of the gingiva is keratinized. The
coronal borderline of the gingiva, known as the gingival margin, extends apically to the
mucogingival junction. At the mucogingival junction it joins the alveolar mucosa. While the
thickness of gingiva is approximately 1mm, the height can vary from 1 to 9 mm, depending
on the region. The gingiva is comprised by free gingiva, attached gingiva, and interdental
gingiva (Zuhr and Hürzeler, 2012) (Figure 1.19).

37
1.8.1.1 Free gingiva

Free gingival tissue extends in the horizontal direction along the buccal and lingual surfaces
of the teeth and in the vertical direction from the gingival margin to the borderline of the
attached gingiva. Normally, the coronal borderline of the attached gingiva coincides with the
cementoenamel junction and appears as the gingival groove in 30-40% of subjects (Zuhr and
Hürzeler, 2012). The color of the gingiva is usually light pink, and their average depth is 0.5-
2 mm. In the interproximal region, the free gingival tissue is thicker than the contact region
with the surface of the teeth.

1.8.1.2 Attached gingiva

Attached gingival tissue is the segment of the gingiva between the apical border of the free
gingiva and the mucogingival junction. It is normally pink in color and has a stippled surface.
It is attached firmly to the underlying tissues. Strong keratinization makes the attached
gingiva resistant against traumatic factors such as mastication and brushing. The vertical di-

mension of the attached gingiva can vary depending on subject anatomy, for example
muscular insertions and tooth positions (Fradeani 2004; Zuhr and Hürzeler, 2012).

1.8.1.3 Interdental gingiva

The gingival tissue filling the space between the adjacent teeth is called the interdental
gingiva. The interdental gingiva consists of the buccal and lingual papilla and the depression
between the two papillae- interdental col. Determining factors for the shape of the interdental
gingiva are the proximal surfaces of the adjacent teeth, the contact area between the adjacent
teeth, and the interdental bone septum. Increasing distance between the two papilla leads to a
progressive increase in the width of the col (see § 1.8.4.3.). The interdental gingiva gives the
gingival margin its scalloped design through the dentition (Zuhr and Hürzeler, 2012; Lindhe
et al. 2015).

Figure 1.19: Anatomy of the gingiva: 1) Interdental gingiva. 2) Free gingiva. 3) Attached
gingiva. 4)Mucogingival junction. 5) Alveolar mucosa

38
1.8.2 Anatomical characteristics of alveolar mucosa

The alveolar mucosa begins at the mucogingival junction, and is composed of the submucosa,
which contains fat and connective tissue, a lining mucosa, and a non- keratinized epithelial
covering. The color of the alveolar mucosa is dark red (because of a rich blood supply and
non-keratinized epithelial covering) and its surface is smooth. Unlike the attached gingiva, the
alveolar mucosa attaches only loosely to the underlying tissues (Brand and Isselhard, 2013).

1.8.3 Characteristics of the healthy gingival tissue

A healthy state of the gingival tissue can be determined through several characteristics, for
example color, stippling, and tissue architecture.

1.8.3.1 Color and the stippling of the attached gingiva

The pink color is one determining factor for a healthy attached gingiva. The pink color can
vary slightly from person to person. The red color of the attached gingiva indicates
inflammation of the tissue. Root discolorations in endodontically treated teeth produce a
discolored appearance of the gingiva in this area, especially in subjects with a thin gingival
biotype (Fradeani 2004). On the healthy attached gingiva, tiny depressions can be observed in
most adults. These are the result of the attachment of connective tissue fibers to the
epithelium above and called a “stippled” appearance (Lindhe et al. 2015).

1.8.3.2 Architecture of the gingival tissue and periodontal biotype

One of the characteristics of the healthy gingival tissue is the presence of the scalloped design
of the gingival outline. The interdental gingiva is positioned more coronal than the buccal
aspect of the gingiva, thus causing the scalloped design of the gingival margin. Depending on
the decreasing height of the interdental papilla from anterior to posterior, the scalloped design
is more evident in the anterior portion of the gingiva (Fradeani 2004).In the literature, two
types of the gingival architecture are described: a “pronounced scalloped” or thin gingival
biotype, and a “flat” or thick gingival biotype. For subjects with the “pronounced scalloped”
gingival biotype, tapered, long, and slender teeth with fine cervical concavity are
characteristic. The contact areas between the adjacent teeth are small and located just apically
from the incisal edge, and a high papilla is therefore observed in these subjects. The free
gingiva around the teeth is thin and the location of the gingival margin is at the same level as
or more apical than the cementoenamel junction. The high scalloped design of the gingival

39
outline appears as a consequence of these anatomical characteristics. In the subjects with the
“flat” gingival biotype, squared incisors with evident convexity are typical. The large and
more apically situated contact areas between adjacent teeth lead to a decreased height of the
interdental papilla. The surrounding gingiva of the maxillary anterior teeth is thick and wide.
The scalloped design of the gingiva is prominent (Lindhe et al. 2015).

1.8.4. Analysis of the gingival margin outline

In addition to the aforementioned characteristics of the gingival tissues, the alignment of the
gingival margin has a great influence on aesthetic appearance, especially in patients with a
high or average smile line.

1.8.4.1 Gingival margin location and symmetry

The gingival margin of the maxillary central incisors and canines should be at the same level
and the hypothetical line joining the apical point of the central incisors and canines and this
line should be parallel to the incisal line, the lower lip line and the interpupillary line
(Fradeani 2004; Tucker 2008). Regarding the gingival level of the maxillary lateral incisors
relative to the gingival level of the maxillary central incisors and canines, three variations can
be differentiated: the gingival margin level of the lateral incisors is apical, at the same level,
and coronal to the aforementioned hypothetical line. A coronal location of the gingival margin
level of the lateral incisors to the hypothetical line is the most aesthetic variant (Figure 1.20),
while an apical location gives the subjects an unaesthetic appearance (Chiche and Pinault,
1994; Tucker 2008; Demirel 2016). A minor lack of gingival symmetry in the maxillary
central incisor region is more visible, and the gingival margin of the maxillary central incisors
should show a high degree of symmetry. (Chiche and Pinault, 1994).

1.8.4.2 Gingival zenith

The most apical position of the gingival margin called the gingival zenith. In gingival
aesthetics, the position of the gingival zenith relative to the tooth axis is a key consideration.
Variations to this relationship can be observed as follows: the gingival zenith can be located
distally to the axis, at the tooth axis, or mesially to the tooth axis. A gingival zenith distal to
the tooth axis is the most preferable and aesthetic situation (Figure 1.21). The mesial location
of gingival zenith relative to the tooth axis gives the teeth a tilted appearance, which looks
unaesthetic (Fradeani 2004; Tucker 2008).

40
 1.8.4.3 Interdental papilla and gingival embrasures

The interdental papilla is the portion of the gingiva, which fills the interdental space and
creates the scalloped architecture of the gingival margin. Depending on the location of the
contact areas between the teeth in the aesthetic tooth composition, the interdental papilla
between the maxillary central incisors is the longest and the height of the interdental papilla
decreases progressively from anterior to posterior (Figure 1.22). Through the recession of the
interdental papilla, black triangles (open gingival embrasures) beneath the interdental contact
areas are created which have a strongly negative impact on the subject’s smile, especially if
they are greater than 3 mm. The divergence of the root angulation and the distance between
the adjacent teeth is one of the factors which influence the recession of the papillae. If
adjacent teeth are positioned far apart, the contour of the interdental papilla appears flat and
the interdental gap can be observed, which gives patients an unattractive appearance
(Fradeani 2004). The distance between the alveolar crest and the contact point or the apical
point of the contact area strongly influences the presence and height of the interdental papilla.
In the healthy periodontal tissue, this distance is 5 mm and can increase during periodontal
disease through bone loss. Additionally, patients with a thin biotype have a higher tendency
toward recession of the interdental papilla, which leads to open gingival embrasures (Sharma
and Park, 2010).

Figure 1.20: Gingival margin location Figure 1.21: Position of the gingival
and symmetry in an ideal tooth zeniths in an ideal tooth composition.
composition.

Figure 1.22: Position of the interdental papilla in an ideal tooth composition.

Tooth grid was modified from Fradeani (2004).

41
2. Aim of the study

The aim of this systematic review is to demonstrate the ideal human face, average values of
facial parameters in various populations, as well as the interaction between plastic surgery and
aesthetic dentistry.

The ability describes the relationship between multiple geocultural and genetic parameters
and a given individual’s facial and dental features can help facilitate communication and
cooperation between plastic surgeons and dentists. That is, during comprehensive aesthetic
treatment, the cosmetic procedures and dental treatment could be planned as individual
elements of the whole aesthetic rehabilitation.

The focused points of the systematic search in this dissertation are as follows:

• the aesthetic relationship between facial and dental parameters

• available aesthetic checklists

• the average values for the facial and dental measurements among various populations,
females and males, and multiple age groups.

42
3. Materials and Methods

This systematic review was performed according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

3.1 Focused Question

The focused question was formulated based on the PICO format.

• P (population)- Human adults with no prosthetic rehabilitations in the visible area, no

plastic, orthognathic surgery, or various cosmetic rehabilitations in history

• I (intervention)- Esthetic analysis

• C (comparison)- Different populations, age groups, and genders

• O (outcome)- Esthetic guidelines for dentists and plastic surgeons to make

comprehensive esthetic rehabilitation planning

3.2 Search strategy

An electronic search for suitable articles for this systematic review was performed in the
PubMed database (MEDLINE - National Library of Medicine). The articles were not limited
with respect to publication date. Determined search terminologies for the systematic review
are in the following order: “Aesthetic”, “Esthetics”, “Dentistry”, “Guidelines”, “Analysis”,
“Beauty”, “Face”, “Lip”, and “Nose”. The search was conducted using various combinations
of the determined keywords and MeSH Terms (Table 3.1). Hand-searching was performed in
Google Scholar, Library of the Medical Center - University of Freiburg, and in the
bibliographies of identified articles. Identified articles were collected in the reference
management software (EndNote®) and duplicates were discarded automatically using the
appropriate tool of the program.

3.3 Selection criteria

Inclusion and exclusion criteria are determined for the selection of the identified papers. The
study selection on the basis of the inclusion and exclusion criteria are described in Table 3.2.

43
Inclusion criteria:

• Human studies with at least 10 participants

• Studies in English or German

The inclusion criteria of the participants of the studies:

• ≤ 12 years old; no conspicuous facial deformities or defects;

• No history of plastic or orthognathic surgical operations;

• No dental or skeletal deformities;

• Angle class I;

• No prosthetic or conservative restorations in the visible area;

• No missing teeth in the visible area;

• No visible periodontal defects

Exclusion criteria

• Systematic reviews and literature reviews

• Case reports and survey studies

• Studies evaluating the esthetic perception of the population

• Studies in which results are based on the assessment or evaluation of the parameters
by the population

Articles remaining after the review of abstracts were included in the full-text analysis. Initial
full-text analyses were performed for potential exclusion of articles for which irrelevance
could not be determined from title and abstract alone. During a second full-text analysis, the
data was extracted from studies which met the inclusion criteria.

44
3.4 Data extraction

Identified articles were comprehensively analyzed and the examined parameters classified
into three groups in accordance with the three major components of the esthetic analysis:
macro-, micro-, and miniesthetics. In each group, parameters considered “do not fall within
the scope of this review” or “not relevant” during the esthetics-based comprehensive
rehabilitation were excluded. Excluded parameters were the following:

• parameters relevant only to the upper third of the face, for example, the height of the
upper face, the prominence of the forehead, nasofrontal etc.

• parameters relevant only to the eyes, for example, eye variations, interocular
dimensions etc.

• parameters relevant to the facial anatomy but not to the bones of the maxilla and
mandible.

Included parameters, which should be considered during esthetic analysis, are subdivided into
the three subgroups: the parameters could be examined from the frontal, oblique, and profile
views (Table 3.3).

45
Search Electronic search Items found Imported Discarded

Search ("nose"[MeSH Terms] OR "nose"[All Fields]) AND ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All
#8 442 327 115
Fields]) AND ("analysis"[Subheading] OR "analysis"[All Fields])

Search ("nose"[MeSH Terms] OR "nose"[All Fields]) AND ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All
#7 45 27 18
Fields]) AND ("guideline"[Publication Type] OR "guidelines as topic"[MeSH Terms] OR "guidelines"[All Fields])

Search ("lip"[MeSH Terms] OR "lip"[All Fields]) AND ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All
#6 394 108 286
Fields]) AND ("analysis"[Subheading] OR "analysis"[All Fields])

Search ("lip"[MeSH Terms] OR "lip"[All Fields]) AND ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All
#5 34 15 9
Fields]) AND ("guideline"[Publication Type] OR "guidelines as topic"[MeSH Terms] OR "guidelines"[All Fields])

Search ("face"[MeSH Terms] OR "face"[All Fields]) AND ("guideline"[Publication Type] OR "guidelines as topic"[MeSH Terms]
#4 13 8 5
OR "guidelines"[All Fields]) AND ("beauty"[MeSH Terms] OR "beauty"[All Fields])

Search ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All Fields]) AND ("dentistry"[MeSH Terms] OR
#3 283 225 58
"dentistry"[All Fields]) AND ("beauty"[MeSH Terms] OR "beauty"

Search ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All Fields]) AND ("dentistry"[MeSH Terms] OR
#2 1946 1892 54
"dentistry"[All Fields]) AND ("analysis"[Subheading] OR "analysis"[All Fields])

Search ("esthetics"[MeSH Terms] OR "esthetics"[All Fields] OR "aesthetic"[All Fields]) AND ("dentistry"[MeSH Terms] OR
#1 241 241 0
"dentistry"[All Fields]) AND ("guideline"[Publication Type] OR "guidelines as topic"[MeSH Terms] OR "guidelines"[All Fields])

Table 3.1: Search strategy to identify the studies.

46
Table 3.2: Study selection for the systematic review.

47
Parameters From frontal view From profile From oblique view

Macroesthetics Facial analysis: facial shapes and types;
vertical and horizontal proportions and
reference lines; facial height and width;
lower face height.
Lip analysis: vertical lip position and lip
proportions (lips length, vermillion lip
height, interlabial gap)
Facial analysis: facial profile types; convexity of Lip analysis: lip projection
the facial profile (sagittal position of the mandible
Chin analysis: chin projection
and maxillae).
Lip analysis: anteroposterior lip position; lip
thickness; lip volume; lip proportions (lip length,
vermillion lip height)
Nose analysis: nasal length; nasal tip projection;
nasal tip rotation, nasal prominence

Chin analysis: chin height; chin projection

Miniesthetics Tooth exposure at rest position: Occlusal plane; overjet; overbite Occlusal plane, overjet; overbite
mandibular, maxillary teeth; tooth and
gingival exposure during smiling;
horizontal smile lines; smile width; buccal
corridor

Microesthetics Tooth surface, width, length, proportions;

tooth arrangement; gingival arrangement

Table 3.3. Included parameters for data extraction.

48
4. Results

2980 studies were identified after electronic and hand searching. 101 of these were then
selected for full-text analysis. After full-text screening, 31 studies were excluded (Table
4.1). 70 studies met the inclusion criteria and have been analyzed systematically with
respect to the focused points of this systematic review. The publication dates of these
papers vary between 1967- 2016. The study with the smallest cohort size is Hulsey (1970),
and that with the largest cohort is Kim et al. (2010), having 20 subjects and 2065 subjects,
respectively. The minimum age of the subjects is 13 years. The maximum age could not be
defined, because in some articles the ages of the participants are given as ≥ 18 years. All of
the included studies were prospective studies and, according to the quality assessment
guidelines, the articles were rated “good” in this systematic review. There were not enough
similarities among the included studies to permit meta-analytical statistical analysis of the
sampled data. The included studies have been listed in Table 4.2.

Author (year) Reason for exclusion

Vig and Brundo (1978) No information regarding cohort size

Fanous (1987) Pre- and postoperative measurements after one surgical technique

Crumley and Lanser Assessment of nasal prominence by experts and evaluation thereof using different
(1988) methods

Al- Jasser (2000) Parameters do not fall within the scope of this review

Erbay et al. (2002) Comparison between the dental normal and dental- skeletal group

Erbay and Caniklioglu

Comparison between attractive and non-attractive groups
(2002)

Bisson and Grobbelaar

Comparison between models and non-models
(2004)
Rhee et al. (2004) No information regarding age of participants

Al- Jasser (2005) Parameters do not fall within the scope of this review

Matoula and Pancherz

Comparison between attractive and non-attractive groups
(2006)
Ferring and Pancherz
Assessment of the average deviation (%) of divine proportions
(2008)
Van Der Geld et al.
Comparison between posed and spontaneous smile
(2008b)

49
 Comparison between females and males using balanced angular and proportional
Rhee et al. (2009)
analysis (BAPA)

Sforza et al. (2009) Comparison between attractive and normal women

Torsello et al. (2010) Assessment of the validity of the neoclassical canons

Iglesias- Linares et al.

No information regarding age of participants
(2011)
Mommaerts and
Comparison between contemporary and antique beautiful faces
Moerenhout (2011)

Nandini et al. (2011) Prediction of parameters by orthodontists

Patients underwent rhinoplasty and evaluation of parameters by the plastic

Armijo et al. (2012)
surgery attending staff, residents, and office staff
Hochman et al. (2012) Classification of the smile line was different from our schema

Hu et al. (2012) Measurements of the parameters do not fall within the scope of this review
Difference between of 2-dimensional perceived tooth widths with 3-dimensional
Lee et al. (2012)
measurements
Hu et al. (2012) Measurements of the parameters do not fall within the scope of this review

Sunilkumar et al. (2013) Assessment of the validity of the facial golden proportions

Tuncel et al. (2013) Subjects underwent primary rhinoplasty

Calcada et al. (2014) No information regarding age of participants.
Fortes et al. (2014) Comparison between pleasant and unpleasant smile

Patients underwent dental rehabilitation and evaluation of parameters by dentists

Mehl et al. (2014)
before and after rehabilitation

Rosati et al. (2014) Comparison of lip surface between two age groups

Kim et al. (2015) Comparison between attractive and normal populations (control group)
Comparison of the parameters between the derotated, ideal, and overrotated nasal
Choi et al. (2013)
tips
Table 4.1: Excluded studies with reason for exclusion.

50
 Number of Age of range patients Type of
Author and year Type of study Gender Race and nationality
patients (mean age) evaluation
Burstone (1967) Prospective 32 13-15 females, males Caucasian Anthropometry
Hulsey (1970) Prospective 20 15-25 females (10), males (10) Caucasian Photogrammetry
Lavelle (1972) Prospective 120 18-28 females, males Caucasian, Mongolian, African Model analysis
Scheideman et al.
Prospective 66 20-35 (27.5) females (24), males (32) Caucasian Cephalometry
(1980)
Farkas et al. (1984) Prospective 189 18-25 females (89), males (100) North American Caucasian Anthropometry
Tjan et al. (1984) Prospective 454 20-30 females (247), males (207) - Model analysis
Connor and American Caucasian, African
Prospective 100 18-50 females (50), males (50) Cephalometry
Moshiri (1985) American
Sommerville et al.
Prospective 103 18-38 females (41), males (62) Caucasian Photogrammetry
(1988)
Chiu and Clark
Prospective 59 19-30 (22.5) females (31), males (28) Southern Chinese Cephalometry
(1992)
Lew et al. (1992) Prospective 72 19.2-23 (21.1) females (36), males (36) Chinese Photogrammetry
Peck and Peck
Prospective 88 15-34 females (46), males (42) North American Caucasian Anthropometry
(1992)
Zylinski et al.
Prospective 29 22-32 (26.2) males (29) Caucasian Cephalometry
(1992)
Gillen et al. (1994) Prospective 54 18-35 females (20), males (34) Caucasian, African American Model analysis
Ofodile and
Prospective 69 20-63 (37.7) females (41), males (28) African American Anthropometry
Bokhari (1995)
Arnett et al. (1999) Prospective 46 ≥18 females (26), males (20) Caucasian Cephalometry
Borman et al.
Prospective 1050 20-30 females (525), males (525) Turkish Anthropometry
(1999)
Sterrett et al.
Prospective 40 ≥20 females, males Caucasian Model analysis
(1999)
Alcalde et al.
Prospective 211 20- 28 females (119), males (92) Japanese Cephalometry
(2000)
Choi et al. (2000) Prospective 28 19-38 (21.5) females (28) Korean Cephalometry
Ferrario et al.
Prospective 180 18-32 females (90), males (90) White northern Italian 3D cephalometry
(2000)
Porter and Olson
Prospective 108 18-30 females (108) African American Anthropometry
(2001)

51
Fernandez- Riveiro
Prospective 212 18- 20 females (162), males (50) European Caucasian Photogrammetry
et al. (2002)
Hwang et al.
Prospective 102 17.5-35 females (57), males (45) Korean, European-American Cephalometry
(2002)
Le et al. (2002) Prospective 180 18-30 females (90), males (90) Chinese, Vietnamese, Thai Anthropometry
Ochi and Ohashi
Prospective 60 20-47 (33.0) females (33), males (27) Japanese Anthropometry
(2002)
Owens et al. African American, Caucasian,
Prospective 253 18-41 females (109), males (144) Photogrammetry
(2002a) Chinese, Hispanic, Japanese, Korean
Owens et al. African American, Caucasian,
Prospective 253 18-41 females (109), males (144) Photogrammetry
(2002b) Chinese, Hispanic, Japanese, Korean
Al- Jasser (2003) Prospective 40 20-30 females (20, males (20) Saudi Cephalometry
Basciftci et al. n.a (females: 22.14,
Prospective 105 females (50), males (55) Anatolian Turkish Cephalometry
(2003) males: 22.61)
Fernandez- Riveiro
Prospective 212 18- 20 females (162), males (50) European Caucasians Photogrammetry
et al. (2003)
Al Wazzan (2004) RCT 473 20-60 females (260), males (213) Arabian, African, East Asian Anthropometry
Choe et al. (2004) Prospective 72 18-35 females (72) Korean American Photogrammetry
Jain et al. (2004) Prospective 100 18-49 males (100) Himalachi Photogrammetry
Hasanreisoglu et 3D and model
Prospective 100 n.a (22) females (50), males (50) Turkish
al. (2005) analysis.
Uzun et al. (2006) Prospective 108 18-30 (22.31) males (103) Turkish Anthropometry
African American, North American
Farkas et al. (2007) Prospective 100 18- 25 females (50), males (50) Cephalometry
Caucasian
Maulik and Nanda
Prospective 230 14-35 females (131), males (99) n.a Video analysis
(2007)
Anić-Milośević et
Prospective 110 23-28 females (58), males (52) Croatian Photogrammetry
al. (2008)
Kalha et al. (2008) Prospective 60 ≥18 females (30), males (30) South Indian Cephalometry
Van der Geld et al.
Prospective 122 20-55 males (122) Caucasian Photogrammetry
(2008a)
Al-Habahbeh et al.
Prospective 247 18-67 (34.3) females (144), males (103) Jordan Anthropometry
(2009)
Desai et al. (2009) Prospective 261 15-70 females, males n. a Photogrammetry
He et al. (2009) Prospective 119 18-25 (22.7) females (63), males (56) Han Chinese Photogrammetry

52
Malkoc et al.
Prospective 100 19-25 females (54), males (46) Turkish Photogrammetry
(2009)
3D
Sawyer (2009) Prospective 70 21-49 females (32), males (38) Caucasian Stereophotogram
metry
females (24.4- 19.5),
Uysal et al. (2009) Prospective 133 females (66), males (67) Anatolian Turkish Cephalometry
males (24.8- 20.4)
Anić-Milośević et
Prospective 110 23-28 years females (58), males (52) Croatian Photogrammetry
al. (2010)
3D
females: 20-31, males:
Dong et al. (2010) Prospective 289 females (143), males (146) Chinese Stereophotogram
22-29
metry
Husein et al.
Prospective 102 18-30 females (102) Indian American Photogrammetry
(2010)
females (939), males
Kim et al. (2010) Prospective 2065 18-29 (21.6) Korean Photogrammetry
(1126)
Chinese-American, Korean-
Wong (2010) Prospective 197 15-44 (29.5) females (109), males (88) American, North American 3D Imaging
Caucasian
Al-Johany et al.
Prospective 50 ≥18 females (50) n.a Photogrammetry
(2011)
Anić-Milośević et
Prospective 110 22-29 females (58), males (52) Croatian Photogrammetry
al. (2011)
Condon et al.
Prospective 133 18-25 females, males Irish Model analysis
(2011)
Gode et al. (2011) Prospective 40 19-35 (23.9) females (20), males (20) Turkish Photogrammetry
Patil et al. (2011) Prospective 100 18-35 females (100) Indian Photogrammetry
Chetan et al.
Prospective 200 15-50 females (100), males (100) n.a Photogrammetry
(2012)
Ku et al. (2012) Prospective 80 25-39 females (40), males (40) Korean Photogrammetry
Miron et al. (2012) Prospective 72 20-40 (30.49) females (36), males (36) n.a Anthropometry
Brown and n.a (females: 37,
Prospective 20 females (10), males (10) n.a Photogrammetry
Guyuron (2013) males:38)
Eliakim-
Ikechukwu et al. Prospective 477 18-35 females (187), males (290) African American Photogrammetry
(2013)
Jayaratne et al. Stereophotogram
Prospective 103 18-35 females (52), males (50) Chinese
(2013) metry

53
 Liang et al. (2013) Prospective 188 20-35 females (100), males (88) Han Chinese Video analysis
Shindoi et al.
Prospective 49 18- 30 females (30), males (19) Japanese Cephalometry
(2013)
Singh et al. (2012) Prospective 195 15-55 females (96), males (99) n.a Photogrammetry
Li et al. (2014) Prospective 900 17-24 females (501), males (299) Chinese Han Photogrammetry
Gibelli et al. 3D Model
Prospective 40 21-65 females (20), males (20) Caucasian
(2015) analysis
Moshkelgosha et
Prospective 240 16-18 females (110), males (130) Persian Photogrammetry
al. (2015)
Zhang et al. (2015) Prospective 200 20-35 females (100), males (100) Chinese Han Photogrammetry
Drummond and Photogrammetry
Prospective 265 19-60 females (143), males (122) n.a
Capelli (2016) (Video editing)
Table 4.2: Included studies and annotated description.

54
4.1 Macroesthetics: Facial measurements

Facial height and lower face height are the important factors in the facial analysis from the
frontal view. These data were extracted from 10 studies, listed in Table 4.3. While all of these
studies provide information regarding the lower face height, information about the facial
height has been found only in 7 studies. Based on the table it can be concluded, that males
have both higher facial and lower face heights than the females.

For the profile analysis, some measurement types were examined: skeletal convexity, soft
tissue facial convexity excluding the nose, and total soft tissue convexity. 7 relevant articles
were selected and the results tabulated in the Table 4.4. In all studies, the soft tissue facial
convexity is examined. 4 authors and their teams reported the amount of total soft tissue
convexity. The papers found no significant difference between females and males regarding
the soft tissue facial convexity independent of inclusion of the nose (total soft tissue
convexity). Only 1 study provided information regarding skeletal convexity; that is, a
comparison was not impossible.

4.2 Macroesthetics: Measurements of the lip parameters

For the vertical measurements of the lips, selected parameters were lip length, length of the
vermillion border, and the interlabial gap (Table 4.5). 12 appropriate studies were identified
for the investigation of these parameters. Upper lip length was characterized in 11 papers.
Data on lower lip length was found in 7 studies. It was noticed, however, that authors chose
used different reference points to measure lip length. The height of the upper and lower
vermillion border and interlabial gap have been ascertained in 3 studies. According to results
from these papers, it can be concluded that males have longer upper and lower lips than
females. Vertical lip parameters are similar in males and females.

The measurement of lip thickness has been described in 9 articles. From the available data, it
can be summarized that males have thicker lips than females (Table 4.6). Results regarding lip
volume in the closed position have been extracted from 3 articles and provided in Table (4.7).
The table shows no marked difference between males and females, regarding this parameter.

55
Author (year) Population Gender Facial height (mm), Lower face height (mm),
(na’-me’) (sn-me’)
Mean±SD (Range) Mean±SD (Range)

Scheideman et al. Caucasian Females 124.0±5.3 (n.a) 69.7±3.3 (n.a)

(1980) Males 132.0±7.1 (n.a) 75.0±5.0 (n.a)
Arnett et al. (1999) Caucasian Females 124.6±4.7 (n.a) 71.1±3.5 (n.a)
Males 137.7±6.5 (n.a) 81.1±4.7 (n.a)

Choi et al. (2000) Korean Females n.a 72.64±3.34 (n.a)

Fernandez-Rieviro et Caucasian Females n.a 65.4±4.3 (n.a)
al. (2002) Males n.a 71.4±5.7 (n.a)
Anić-Milośević et al. Croatian Females n.a 63.47±3.38 (n.a)
(2010) Males n.a 71.16±4.70 (n.a)
Kalha et al. (2008) South Indian Females 122.03±7.03 (n.a) 63.13±9.07 (n.a)
Males 132.73±8.80 (n.a) 72.40±7.41 (n.a)
Uysal (2009) Anatolian Females 124.9±5.8 (n.a) 68.7±4.5 (n.a)
Turkish Males 135.7±6.3 (n.a) 76.5±5.5 (n.a)
Gode et al. (2011) Turkish Females n.a 67.4±7.3 (n.a)
Males n.a 64.8±6.5 (n.a)
Shindoi et al. (2013) Japanese Females 126.4±7.3 (n.a) 71.7±4.8 (n.a)
Males 135.9±8.8 (n.a) 78.3±5.5 (n.a)

Moshkelgosha et al. Persian Females n.a 61.1±4 (50.81-73.35)

(2015) Males n.a 64.70±6.36 (50.81-73.35)
Table 4.3: Mean values of some vertical measurements of the face.

Author (year) Population Gender Skeletal Soft tissue facial Total soft tissue
convexity (°), convexity convexity (°), (n’-
(n-A-pg) excluding nose pr-pg’)
Mean±SD (°), (n’-sn-pg’) Mean±SD (Range)
(Range) Mean±SD
(Range)
Lew et al. (1992) Chinese n.a n.a 169.5°±3.5° (n.a) n.a
Chiu and Clark Southern Females n.a 163.4°±5.3° (n.a) n.a
(1992) Chinese Males n.a 163.3°±6.6° (n.a) n.a
Zylinski et al Caucasian Males 177.9°±.4.6° 166°±4.9° (n.a) 130.4°±5.4° (n.a)
(1999) (n.a)
Al- Jasser (2003) Saudi n.a n.a 165.5°±4.58° n.a
(n.a)
Anić-Milośević et Croatian Females n.a 169.05±4.69° 130.19°±3.47° (n.a)
al. (2008) Males n.a (n.a) 130.47°±3.73° (n.a)
168.78±4.97°
(n.a)
Malkoc et al. Turkish Females n.a 168.78°±5.44° 142.57°±5.29° (n.a)
(2009) Males n.a (n.a) 142.35°±5.36° (n.a)
170.60°±6.5°
(n.a)
Moshkelgosha et Persian Females n.a 165.9°±4.1° (n.a) 139.2°±4° (n.a)
al. (2015) Males n.a 165.17±4.51° 137.85°±3.95° (n.a)
(n.a)

Table 4.4: Mean values of the three types of measurements to determine the facial profile
convexity in both genders and across various populations.

56
 Lip length (mm) Vermillion border (mm) Interlabial gap
Author (year) Population Gender Mean±SD (Range) Mean±SD (Range) (mm)
Upper lip (sn’- stms) Lower lip Upper lip (ls- stms) Lower lip (stmi-li) (stms- stmi)
Mean±SD
(Range)
Burstone (1967) Caucasian Females 20.1±1.9 (17.0-23.0) (stmi- me’)
Males 23.8±1.5 (21.5-26.0) 46.4± 3.4 (n.a) n.a n.a n.a
49.9±4.5 (n.a) n.a n.a n.a
Scheideman et Caucasian Females 22.4±1.6 (n.a) (stmi- me’) n.a 0.7±1.1 (n.a)
al. (1980) Males 23.9±2.5 (n.a) 47.3±2.8 (n.a) n.a n.a 0.1±0.2 (n.a)
51.1±3.4 (n.a) n.a
Farkas et al. North American Females 19.6±2.1 (n.a) (stmi-sm) 7.7±1.1 (n.a) 9.0±2.2 (n.a) n.a
(1984) Caucasian Males 22.7±2.3 (n.a) 16.7±2.0 (n.a) 7.4±1.7 (n.a) 8.8±1.5 (n.a) n.a
18.8±2.5 (n.a)
Peck and Peck North American Females 21.2±2.4 (14-26) n.a n.a n.a n.a
(1992) Caucasian Males 23.4±2.5 (19-30) n.a n.a n.a n.a
Zylinski et al. Caucasian Males 23.7±2.3 (19.7-30.5) (stmi- me’)
(1992) 57.5±3.0 (52.0-63.2) n.a n.a n.a
Alcalde et al. Japanese n.a 23.40±2.58 (17.20- n.a n.a n.a n.a
(2000) 31.20)
Choi et al. Korean Females 24.24±1.69 (n.a) (stmi-me’)
(2000) 46.84±6.37 (n.a) n.a n.a n.a
Ferrario et al. White northern Females 17.40±1.88 (n.a) n.a n.a n.a
(2000) Italian Males 18.78±2.42 (n.a) n.a n.a n.a n.a
Al-Jasser Saudi n.a n.a n.a n.a n.a 2.46±1.14 (n.a)
(2003)
Fernández- European (stmi- sm’)
Riveiro et al. Caucasian Females 21.43±1.82 (16.8-25.5) 17.48±1.92 (12.6-23.1) 7.43±1.39 (3.6-11) 8.59±1.52 (4.9-14.5) n.an.a
(2003) Males 23±2.6 (18.3-28.4) 19.01±0.76 (13.6-24) 7.27±1.65 (3.7-10.5) 8.36±1.78 (5.3-14.1)

Gode et al. Turkish Females 18.0±2.9 (n.a) n.a n.a n.a n.a
(2011) Males 17.8±3.2 (n.a) n.a n.a n.a n.a
Moshkelgosha (stmi- sm’)
et al. Persian Females 19.1±2.0 (15.56-24.71) 16.2±1.5 (11.54-18.96) 6.9±1.2 (3.88-10.02) 8.4±1.1 (6.17-10.87) 0.7±0.4 (0-1.56)
(2015) Males 21.42±2.67 (13.63- 18.71±2.26 (12.54- 6.12±1.45 (5.03- 8.90±1.60 (5.46- 0.81±0.4 (0.06-
25.37) 24.37) 10.96) 12.92) 2.14)
Table 4.5 Reported values for vertical lip measurements in both genders and in multiple populations.

57
 Author (year) Population Gender Upper lip (mm) Lower lip (mm)
Mean± SD (Range) Mean± SD (Range)
Lew et al. (1992) Chinese n.a 15±1.5 (n.a) (n.a)
Arnett et al. (1999) Caucasian Females 12.6±1.8 (n.a) 13.6±1.4 (n.a)
Males 14.8±1.4 (n.a) 15.1±1.2 (n.a)
Alcalde et al. (2000) Japanese n.a 15.11±2.48 (n.a) (n.a)
Choi et al. (2000) Korean Females 12.9±1.39 (n.a) 13.63±1.36 (n.a)
Basciftci et al. (2003) Anatolian Females 12.58±2.30 (n.a) (n.a)
Turkish Males 15.22±2.39 (n.a) (n.a)
Kalha et al. (2008) South Indian Females 12.3±2.01 (n.a) 13.03±1.56 (n.a)
Males 13.58±2.72 (n.a) 14.80±2.43(n.a)
Uysal et al. (2009) Turkish Females 12±1.8 (n.a) 10.2±1.6 (n.a)
Anatolian Males 14.7±1.4 (n.a) 11.3±1.4 (n.a)
Shindoi et al. (2013) Japanese Females 13.8±1.5 (n.a) 14.4±1.4 (n.a)
Males 15±1.1 (n.a) 16.1±1.2 (n.a)
Gibelli et al. (2015) Caucasian Females 8.7±1.7 (n.a) 12.7±3.8 (n.a)
Males 10.8±0.9 (n.a) 14.5±4.5 (n.a)
Table 4.6: Reported lip thickness values in both genders and multiple populations.

Lower lip Total lips

Upper lip
volume volume
volume (cm³)
Author (year) Population Gender (cm³) (cm³)
Mean± SD
Mean± SD Mean± SD
(Range)
(Range) (Range)
2.14±0.58 4.45±1.02
White Northern Females 2.31±0.60 (n.a) (n.a) (n.a)
Ferrario et al. (2000)
Italian Males 3.16±0.62 (n.a) 2.85±0.80 6.02±1.18
(n.a) (n.a)
Females 2.8±n.a (n.a) 2.7±n.a (n.a) 5.5±n.a (n.a)
Sawyer et al. (2009) Caucasian
Males 3.0±n.a (n.a) 2.9±n.a (n.a) 5.9±n.a (n.a)
Females 1.5±0.3 (n.a) 1.3±0.4 (n.a) 2.8±0.6 (n.a)
Chinese
Males 1.2±0.4 (n.a) 1.6±0.6 (n.a) 2.8±0.1 (n.a)
Wong et al. (2010)
Females 1.2±0.3 (n.a) 1.3±0.5 (n.a) 2.5±0.6 (n.a)
Korean
Males 1.1±0.3 (n.a) 1.4±0.5 (n.a) 2.5±0.7 (n.a)

Females 1.1±0.3 (n.a) 1.4±0.6 (n.a) 2.4±0.7 (n.a)

Caucasian
Males 0.9±0.3 (n.a) 1.3±0.5(n.a) 2.2±0.6(n.a)

Table 4.7: Reported lip volume values in the closed position in both genders and across
various populations.

58
4.3 Macrosethetics: Nasal measurements

One of the most important factors for the cooperation between dentists and plastic surgeons is
the nasolabial angle. Measurements of the nasolabial angle have been performed in 21
studies. 20 authors and their teams used the same reference lines (collumella- subnasal-
tangent of the outer edge of the labialis superior) to determine the nasolabial angle, while the
reference lines from Brown and Guyuron (2012) are different (the line drawn through the
midpoint of the nostril aperture and the line drawn perpendicular to the horizontal plane while
intersecting the subnasal). All data pertaining to the nasolabial angle have been collected in
the Table 4.8. The studies found that females have more obtuse nasolabial, that is, more nasal
tip rotation than males. To determine nasal prominence, the authors have investigated the
relation of the nasal tip to various reference lines. The reference lines have been described in
Table 4.9. The studies concluded that males have more prominent noses than females. For
linear measurements of the nose, the amount of nasal tip projection, nasal bridge length, nasal
height, and nasal width have been extracted from 13 studies. The results are presented in
Table 4.10. Nasal tip projection data was found in 8, nasal bridge height in 7, nasal height in
11, and nasal width in 11 studies. While in 4 studies the authors found that males show
greater nasal tip projection than females, 3 studies showed no marked difference between the
two genders. In 1 study, participants were only females. Based on the results of the 3 studies,
it can be concluded that males have a longer nasal bridge than females. Li et al. (2014)
noticed no marked difference between females and males. In 3 studies, only one gender
participated. Ochi and Ohashi (2002) did not separate results by gender. While 8 teams
demonstrated that males have increased nasal height relative to females, one study reported
the opposite. Two studies have been performed with one gender. All studies investigating
nasal width in both genders showed that males have wider noses than females

4.4 Macroesthetics: Chin measurements

For chin analysis, vertical and angular parameters of the chin were investigated. Chin
prominence, cervicomental angle, mentocervical angle, and labiomental angle were chosen as
parameters to be within the scope of this review. The results are described in Tables 4.11 and
4.12, respectively. While 4 studies report that males have increased chin prominence relative
to females, 1 study found the opposite to be the case, and 1 study showed the equal values for
females and males. Only 1 paper was identified which investigated the cervicomental angle,
and concluded that males have more obtuse cervicomental angles than females.

59
Authors of 2 studies reported more obtuse mentocervical angles in males than females, while
1 study showed the contrary and 1 study showed equal results in both genders. Labiomental
angle data was found in 5 studies, which concluded females have more obtuse labiomental
angles.

4.5 Miniesthetics

For smile analysis, the first factors to be investigated are horizontal smile lines. The
relationship between the horizontal smile lines is the most important factor when defining
smile beauty. Eight authors examined the relationship between the horizontal smile lines; the
results are presented in Table 4.13. From this, it can be concluded that the average smile line,
straight upper lip line, parallel incisal line to lower lip line and “not contacting” and
“contacting” relationship between the lower lip and the incisal line are more common than
other variations. Females tend to have average-to-high smile lines, and upward-turning upper
lips; on the contrary, males have lower smile lines than females, and straight and downward
upper lip lines. Regarding the parallelism between the incisal and lower lip lines, no marked
difference was found between females and males. While the females show more “contacting”
relationships with a marked difference, males show more “not contacting” relationships with
a marked difference and more “covering relation”, with this difference being non-significant.
Additional parameters to be considered during smile analysis would be tooth exposure at rest
position, the width of the buccal corridor, and displayed teeth in smile. The results of the
literature are described in Tables 4.14, 4.15, and 4.16, respectively. These tables show that the
majority of populations show first and second premolars during smile, but the identified
studies provided no information comparing males and females. Papers about tooth display at
rest conclude that females tend to show more maxillary and males tend show more
mandibular teeth at rest. Regarding the buccal corridor, only one study compared females and
males; the authors did not find any notable difference.

4.6 Microestehtics

Regarding microesthetics, all data regarding teeth length, width, and proportions in the
maxillary anterior area/aesthetic area have been extracted from appropriate papers and the
results have been collected in Tables 4.17 and 4.18. After searching, five studies have been
found which provide information about the length and width of maxillary anterior teeth.
Analysis of this data shows clearly that males have longer and wider maxillary incisors and

60
canines than females. The results of eight papers describing tooth proportions lead to the
conclusion that the mean tooth proportions in maxillary anterior teeth do not vary
significantly between men and women.

4.7 Influence of race and age on the mean value of the parameters

It has been verified in the literature, that the aesthetic parameters vary across populations and
age groups. Articles describing this variation have been selected and represented in this
chapter.

4.7.1 Extraoral parameters, comparison between racial groups

The authors of 13 studies examined the difference in extraoral measurements among the
various cohorts (Table 4.19 and Table 4.20) A summary of the results and comparison of
racial groups has been described in §4.9.1.

4.7.2. Extraoral parameters, perioral changes during aging

Literature comparing the visibility of the anterior teeth at rest and during smiling, gingival
exposure in the anterior area during smiling, and upper lip length and thickness, have been
selected from all included articles. Eight studies were identified which recorded age-related
perioral alterations of the human face (Table 4.21). The results and conclusion of all identified
studies are similar. Decreases in tooth exposure, gingival exposure, and lip thickness, as well
as an increase in lip length during aging can be clearly noticed in the table.

4.7.3 Intraoral parameters, comparison between different racial and age groups

The variations of the intraoral parameters among the various populations and age groups have
been examined separately from the extraoral parameters. Table 4.22 lists results from the
literature.

61
Author (year) Population Gender Mean± SD (Range)
Burstone (1967) Caucasian n.a 73.8°±8.0° (60°-90°)
Scheideman et al. (1980) Caucasian Females 111.9°±8.4° (n.a)
Males 111.4°±11.7° (n.a)
Chiu and Clark (1992) Southern Chinese Females 97.4°±10.5° (n.a)
Males 90.1°±14.6° (n.a)
Lew et al. (1992) Chinese Females and 95°±3° (n.a)
males
Zylinksi et al. (1992) Caucasian Males 110.8°±7.6° (125.6°-96.7°)
Arnett et al. (1999) Caucasian Females 103.5°±6.8° (n.a)
Males 106.4°±7.7° (n.a)
Borman et al. (1999) Turkish Females 95.7°±10.42° (64°-126°)
Males 97.79°±9.13° (68°-124°)
Choi et al. (2000) Korean Females 90.36°±8.10° (n.a)
Fernández- Riveiro et al. European Caucasian Females 107.57°±8.5° (76.5°-134.5°)
(2003) Males 105.2°±13.28° (71.7°-137.6°)
Anić-Milośević et al. Croatian Females 109.39 ±7.84 (n.a)
(2008) Males 105.42 ±9.52 (n.a)
Kalha et al. (2008) South Indian Females 103.47°±3.08° (n.a)
Males 97.27°±9.42° (n.a)
He et al. (2009) Han Chinese Females 100.05°±11.30° (n.a)
Males 98.50°±10.54° (n.a)
Uysal et al. (2009) Anatolian Turkish Females 108.1°±8.3° (n.a)
Males 106.8°±10.6° (n.a)
Kim et al. (2010) Korean Females 92.9°±9.1° (n.a)
Males 90.6°±9.1° (n.a)
Anić-Milośević et al. Croatian Females 109.39 ± 7.84 (n.a)
(2011) Males 105.42 ± 9.52(n.a)
Gode et al. (2011) Turkish Females 119.2°±9.7° (n.a)
Males 103.1°±5.3° (n.a)
Patil et al. (2011) Indian Females 96.75°±8.3° (n.a)
Brown and Guyuron n.a Females 98.5°±2.6° (n.a)
(2013) Males 95.6°±2.7° (n.a)
Shindoi et al. (2013) Japanese Females 99.9°±5.3° (n.a)
Males 94.8°±6.4° (n.a)
Li et al. (2014) Chinese Females 98.97°±10.23° (n.a)
Males 100.99°±15.33° (n.a)
Moshkelgosha et al. Persian Females 111.2°±7.9° (92.62°-129.73°)
(2015) Males 107.28°±11.96° (79.96 °-132.49°)
Table 4.8: Mean values of the nasolabial angle in both genders and in different populations.

62
 Author (year) Reference points Population Gender Mean (mm)

Arnett et al. (1999) Prn to TVL Caucasian Females 16.0±1.4 (n.a)

Males 17.4±1.7 (n.a)
Choi et al. (2000) Prn to TVL Korean Females 13.53±1.76 (n.a)

Fernández-Riveiro et Prn to TVL European Females 21.89±3.1 (16.1-34.9)

al. (2002) Caucasians Males 25.29±3.75 (19.2-35.1)

Prn to Sn- Sm line Females 12.39±1.9 (8.5-17.2)

Males 13.44±2.52 (5.9-19.3)
Al to Prn
Females 27.41±2.5 (21.3-34.2)
Males 30.6±3 (23.6-35.5)
Kalha et al. (2008) Prn to TVL South Indian Females 14.40±2.40 (n.a)
Males 15.32±1.79 (n.a)
Uysal et al. (2009) Prn to TVL Anatolian Females 16.1±1.8 (n.a)
Turkish Males 17.4±1.8 (n.a)
Shindoi et al. (2013) Prn to TVL Japanese Females 13.3±2 (n.a)
Males 14.1±2.4 (n.a)
Moshkelgosha et al. Prn to N-Ort line Persian Females 21.5±2.6 (15.07-27.91)
(2015) Males 22.19±3.17 (16.03-
31.92)

Table 4.9: Reported values about nasal prominence in both genders and in different
populations.

63
Author (year) Population Gender Nasal tip projection Nasal bridge length Nasal height (mm) (n- sn) Nasal width (mm) (al-
(mm) (sn-prn) (mm) (n-prn) Mean±SD (Range) al)
Mean±SD (Range) Mean±SD (Range) Mean±SD (Range)
Scheideman et al. (1980) Caucasian Females 20.1±1.4 (n.a) n.a 54.3±4.8 n.a
Males 21.5±1.8 (n.a) n.a 57.1±4.2 n.a
Ofodile and Bokhari African Females 20.4±0.32 (n.a) n.a 49.3±0.42 (n.a) 40.0±0.40 (n.a)
(1995) American Males 23.1±0.36 (n.a) n.a 52.4±0.44 (n.a) 43.5±0.39 (n.a)
Borman et al. (1999) Turkish Females n.a n.a 54.48±4.03 (n.a) 33.28±2.08 (n.a)
Males n.a n.a 55.15±4.57 (n.a) 33.62±2.12 (n.a)
Fernádez- Riveiro et al. European Females 11.1±1,7 (7-16.7) n.a 49.86±3.7 (40.6-59.2) n.a
(2002) Caucasian Males 11.6±2.2 (7.6-16.8) n.a 52.53±4.12 (45-61.8) n.a
Ochi and Ohashi (2002) Japanese n.a n.a 47.7±4.2 (n.a) n.a 36.3±3.4 (n.a)
Uzun et al. (2006) Turkish Males n.a 55.26±0.36 (n.a) 56.92±0.44 (n.a) 33.63±0.27 (n.a)
He et al. (2009) Han Chinese Females 16.54±1.75 (n.a) 50.54±3.87 (n.a) 58.23±3.73(n.a) 34.75±2.22 (n.a)
Males 18.24±2.35 (n.a) 51.80±3.94 (n.a) 60.33±3.87(n.a) 39.30±2.57 (n.a)
Dong et al. (2010) Chinese Females n.a 46.68±n.a (n.a) n.a n.a
Males 48.84±n.a (n.a) n.a n.a
Kim et al. (2010) Korean Females 19.7±1.8 (n.a) 36.8±2.3 (n.a) n.a 36.7±2.2 (n.a)
Males 21.1±2.0 (n.a) 39.7±2.5 (n.a) n.a 40.2±2.5 (n.a)
Gode et al. (2011) Turkish Females n.a n.a 46.5±3.0(n.a) 37.5±3.1 (n.a)
Males n.a n.a 45.6±4.1(n.a) 39.0±4.0 (n.a)
Patil et al. (2011) Indian Females 16.3±1.4 (n.a) 37.27±4.5 (n.a) 43.26±2.9(n.a) 35.6±2.2 (n.a)
Li et al. (2014) Chinese Females 19.26±2.3 (n.a) 48.34±4.71 (n.a) 53.87±4.43 (n.a) 35.8±4.13 (n.a)
Males 19.09±2.45 (n.a) 48.43±4.43 (n.a) 54.19±4.02(n.a) 36.12±3.29 (n.a)
Moshkelgosha et al. Persian Females 11.05±1.5 (8.03-14.77) n.a 48.32±3.5 (41.14-56.68) 33.6±2.1 (29.27-39.86)
(2015) Males 11.85±1.5 (7.50-16.12) 50.52±2.84 (42.77-59.56) 35.39±3.32 (23.07-
41.82)

Table 4.10: Reported values about some important linear measurements of the nose in both genders and in different populations.

65
 Author (year) Population Gender Mean±SD (Range)
Arnett et al. (1999) Caucasian Females -2.6±1.9 (n.a)
Males -3.5±1.8 (n.a)
Choi et al. (2000) Korean Females -2.90±2.21 (n.a)
Fernandez- Riveiro et al. (2002) European Caucasian Females -2.75±6.82 (-19.3- 20.2)
Males 1.95±8.56 (-14.3- 26)
Kalha et al. (2008) South Indian Females -6.90±3.40 (n.a)
Males -5.48±3.34 (n.a)
Uysal et al. (2009) Anatolian Turkish Females -6.4±5.0 (n.a)
Males -6.4±5.6 (n.a)
Gode et al. (2011) Turkish Females -4.1±3.0 (n.a)
Males 3.8±1.9 (n.a)
Shindoi et al. (2013) Japanese Females -11.1±3.7 (n.a)
Males -9±6 (n.a)

Table 4.11: Reported values about chin prominence (mm) (Pg’/TVL) in both genders and in
different populations.

Author Populatio Gender Cervicomental angle Mentocervical Labiomental angle

(year) n (°) (SM-Th-N) angle (°) (G-Pg/C- (°) (Li-Sm-Pg)
Mean±SD (Range) Me) Mean±SD (Range)
Mean±SD (Range)

Somerville Caucasian Females 121.11±13.58 (n.a) n.a n.a

et al. (1988) Males 126.01±13.01(n.a) n.a n.a

Jain et al. Himalachi Males n.a 99.88±n.a (n.a) n.a

(2004)
Anić- Croatian Females n.a n.a 134.50±9.08 (n.a)
Milośević et Males n.a n.a 129.26±9.55 (n.a)
al. (2008)
Malkoc et Turkish Females n.a 95.64±7,74 (n.a) 137.19±10.93 (n.a)
al. (2009) Males n.a 104.86±9.86 (n.a) 130.19±8.50 (n.a)
Eliakim- Nigerian- Females n.a 125.1±0.92 (n.a) n.a
Ikechukwu Ibo, Males n.a 125.6±0.54 (n.a) n.a
et al. (2013) Nigerian-
Yoruba
Females n.a 126.8±0.68 (n.a) n.a
Males n.a 125.6±0.54 (n.a) n.a
Jayaratne et Chinese Females n.a n.a 141.3±9.6 (n.a)
al. (2013) Males n.a n.a 138.9±13.5 (n.a)
Moshkelgos Persian Females n.a 97.02±5.6 (n.a) 132.2±9.5 (n.a)
ha et al. Males n.a 100.44±8.3(n.a) 129.3±7.23 (n.a)
(2015)

Table 4.12: Mean values of the important angles in chin region.

66
Autho Population Gender Upper lip line vs Incisal Upper lip line Lower lip line vs Incisal line
r line
Parallelism Relationship
(year)
High Aver Low Upward Straight Down Parallel Straight Reverse Not Contac Coveri
smile age smile (%) (%) ward (%) (%) (%) contacti ting ng (%)
line smile line (%) ng (%) (%)
(%) line (%)
(%)
Hulsey Caucasian n.a n.a n.a n.a 65 10 25 n.a n.a n.a n.a n.a n.a
(1970)
Tjan et n.a Females 13.79 73.71 12.50 n.a n.a n.a 83.57 14.49 1.93 27.63 57.89 14.47
al. Males 6.76 63.28 29.95 n.a n.a n.a 85.77 13.56 0.6 43.35 39.31 17.34
(1984)
Peck North Females 54 31 15 n.a n.a n.a n.a n.a n.a n.a n.a n.a
and American Males 26 41 33 n.a n.a n.a n.a n.a n.a n.a n.a n.a
Peck white
(1992)
Desai n.a n.a 17.6 73.8 6.3 n.a n.a n.a 48.4 31.7 3.6 n.a n.a 16.3
et al.
(2009)
Al- n.a n.a 20 80 0 62 36 2 78 22 0 42 34 24
Johany
et al.
(2011)
Miron n.a Females 55.6 36.1 8.3 n.a n.a n.a n.a n.a n.a n.a n.a n.a
et al. Males 22.2 41.7 36.1 n.a n.a n.a n.a n.a n.a n.a n.a n.a
(2012)
Liang Chinese Han Females n.a n.a n.a 35 44 21 n.a n.a n.a n.a n.a n.a
et al. Males n.a n.a n.a 15.9 35.2 48.9 n.a n.a n.a n.a n.a n.a
(2013)
Zhang Chinese Han Females 53 43 4 72 10 24 n.a n.a n.a n.a n.a n.a
et al. Males 38 48 14 34 6 36 n.a n.a n.a n.a n.a n.a
(2015)

Table 4.13: Relation between some horizontal smile lines in both genders and in different populations.

67
Author Population Gender Maxillary teeth Mandibular teeth
(year)
Central incisors Lateral incisors Canines Central incisors Lateral incisors Canines
Mean±SD (Range) Mean±SD (Range) Mean±SD (Range) Mean±SD (Range) Mean±SD (Range) Mean±S
D
(Range)
Burstone Caucasian n.a 2.3±1.9 (n.a) n.a n.a n.a n.a n.a
(1967)
Al- Saudi n.a 3.21±1.45 (n.a) n.a n.a n.a n.a n.a
Jasser
(2003)
Al- Jordan Females 3.02±1.96 (n.a) 1.43±1.37 (n.a) 0.35±0.67 (n.a) 0.82±1.32 (n.a) 0.79±1.22 (n.a) 0.57±0.9
Habahbe Males 2.63±1.15 (n.a) 1.87±1.27 (n.a) 0.94±0.91 (n.a) 1.09±1.17 (n.a) 0.98±1.07 (n.a) 8 (n.a)
h et al. 0.87±1.2
(2009) 3 (n.a)
Al Arabian, Females 2.91±1.89 (n.a) 1.35±1.41 (n.a) 0.29±0.73 (n.a) 0.78±1.25 (n.a) 0.74±1.18 (n.a) 0.60±1.1
Wazzan African, East Males 2.66±1.50 (n.a) 1.89±1.35 (n.a) 0.89±1.05 (n.a) 1.14±1.20 (n.a) 1.05±1.12 (n.a) 2 (n.a)
(2004) Asian 0.91±1.1
6 (n.a)
Miron et n.a Females 3.86±0.25 (n.a) n.a n.a n.a n.a n.a
al. Males 2.08±0.28 (n.a) n.a n.a n.a n.a n.a
(2012)

Table 4.14: Reported values about tooth exposure at rest (mm).

Author (year) Population Gender Average buccal corridor Type of the smile fullnes
(%) (Classification according to Moore
Mean±SD (Range) et al. (2005))
Maulik and Nanda (2007) n.a Females 10.0%±n.a (n.a) Medium-broad & broad
Males 12.3%±n.a (n.a)
Total 11%±3.9% (2-24%)

Desai et al. (2009) n.a n.a 12.04%±5.29% (n.a) Medium-broad & broad

Table 4.15: Mean amount of the average buccal corridor.

68
Author (year) Population Gender Displayed teeth in smile

Canines First Second First molars Second molars

premolars premolars
Tjan et al. (1984) n.a n.a 7.01% 48.6% 40.65% 3.74% 0%

Maulik and Nanda (2007) n.a n.a 2% 22% 51% 25% 0%

Al-Johany et al. (2011) n.a Females 0% 8% 60% 32% 0%

Table 4.16: Mean exposure of maxillary teeth in smile.

Author Population Gender Tooth length (mm) Tooth width (mm)

(year) Mean±SD (Range) Mean±SD (Range)

Maxillary Maxillary lateral Maxillary Maxillary Maxillary lateral Maxillary

Central incisors incisors canines Central incisors incisors canines

Gillen et al. Caucasian, Females R:9.53±0.82 (n.a) R:8.12±0.82 (n.a) R:9.23±0.91 (n.a) R:9.12±0.58 (n.a) R:7.01±0.57 (n.a) R:8.03±0.49 (n.a)
(1994) African L:9.60±0.82 (n.a) L:8.20±0.80 (n.a) L:9.20±0.85 (n.a) L:9.39±0.63 (n.a) L:8.20±0.80 (n.a) L:8.06±0.38 (n.a)
American
Males R:10.55±1.02 (n.a) R:9.02±1.25 (n.a) R:10.67±1.36 R:9.34±0.63 (n.a) R:7.50±0.72 (n.a) R:8.56±0.55 (n.a)
L:10.84±0.87 (n.a) L:9.10±1.28 (n.a) (n.a) L:9.18±0.22 (n.a) L:9.10±1.28 (n.a) L:8.54±0.48(n.a)
L:10.76±1.26
(n.a)

Sterrett et al. Caucasian Females 9.39±0.86 7.79±0.99 8.89±0.97 8.06±0.66 6.13±0.59 7.15±0.40
(1999) (7.50-11.33) (5.75-9.78) (7.05±10.93) (6.80-9.50) (4.78-7.18) (6.59±8.23)
Males 10.19±0.94 8.70 ±0.78 10.06±1.02 8.59±0.47 6.59±0.45 7.64±0.33
(8.10-11.90) (6.60-10.20) (7.70±11.70) (7.60-9.40) (5.80-7.70) (6.95-8.23)

Condon et al. Irish Females 9.93±0.97 (n.a) 8.58±0.97 (n.a) 9.34±1.00 (n.a) 8.87±0.59 (n.a) 6.89±0.59 (n.a) 7.82±0.44 (n.a)
(2011) Males 10.37±1.24 (n.a) 8.84±1.10 (n.a) 10.14±1.24 (n.a) 9.33±0.74 (n.a) 7.34±0.68 (n.a) 8.40±0.47 (n.a)

Table 4.17: Tooth length and width in maxillary anterior area in unworn dentition.

69
 Author Population Gender W/L ratio Mean L/L ratio Mean W/W ratio
(year) Mean (Range) Mean (Range) Mean (Range)
Maxillary Maxillary Maxillary Central/L Central/Ca Canine/Late Central/Lat Central/Ca Canine/
central lateral canines ateral nine ral eral nine Lateral
incisors incisors
Gillen et Caucasian, Females R: ≈0.96 R: ≈0.86 R: ≈0.87 R: ≈1.18 R: ≈1.04 R: ≈1.14 R: ≈1.31 R: ≈1.14 R: ≈1.14
al. African (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a)
(1994) American L: ≈0.97 L: ≈0.88 L: ≈0.87 L: ≈1.18 L: ≈1.05 L: ≈1.12 L: ≈1.28 L: ≈1.14 L: ≈1.14
(n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a)
Males R: ≈0.89 R: ≈0.83 R: ≈0.80 R: ≈ 1.18 R: ≈1.00 R: ≈1.18 R: ≈1.25 R: ≈ 1.09 R: ≈ 1.14
(n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a)
L: ≈0.87 L: ≈0.83 L: ≈0.80 L: ≈1.21 L: ≈1.02 L: ≈1.18 L: ≈1.26 L: ≈1.10 L: ≈1.19
(n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a) (n.a)

Sterrett Caucasian Females 0.86 (0.72- 0.79 (n.a) 0.81 (0.68- ≈1.21(n.a) ≈1.05 (n.a) ≈1.14 (n.a) ≈1.31 (n.a) ≈1.13 (n.a) ≈1.17
et al. 1.04) 0.97) (n.a)
(1999) Males 0.85 (0.65- 0.76 (n.a) 0.77 (0.66- ≈1.17 (n.a) ≈1.01 (n.a) ≈1.16 (n.a) ≈1.30 (n.a) ≈1.12 (n.a) ≈1.16
1.02) 0.97) (n.a)
Hasanrei Turkish Females 0.912 (n.a) 0.834 (n.a) 0.873 (n.a) n.a n.a n.a n.a n.a n.a
soglu et Males 0.887 (n.a) 0.821 (n.a) 0.834 (n.a) n.a n.a n.a n.a n.a n.a
al.
(2005)
Condon Irish Females ≈0.89 (n.a) ≈0.80 (n.a) ≈0.84 (n.a) R: 1.17 R: 1.02 (n.a) R: 1.15 (n.a) ≈1.29 (n.a) ≈1.13 (n.a) ≈1.13
et al. (n.a) L: 1.02 (n.a) L: 1.16 (n.a) (n.a)
(2011) L: 1.17
(n.a)
Males ≈0.90 (n.a) ≈0.83 (n.a) ≈0.83 (n.a) R: 1.17 R: 1.06 (n.a) R: 1.10 (n.a) ≈1.27 (n.a) ≈1.11 (n.a) ≈1.14
(n.a) L: 1.06 (n.a) L: 1.10 (n.a) (n.a)
L: 1.16
(n.a)
Ku et al. Korean Females ≈0.8 (n.a) n.a n.a n.a n.a n.a n.a n.a n.a
(2012) Males ≈0.85 (n.a) n.a n.a n.a n.a n.a n.a n.a n.a

Table 4.18: Reported values about tooth proportions in a normal dentition.

70
Author (year) Porter and Hwang et al. Owens et al. Le et al. Choe et al. Farkas et al. Husein et al. Wong et al.
Olson (2001) (2002) (2002 a) (2002) (2004) (2007) (2010) (2010)

Compared population I African I. Korean I African I Chinese I Korean I African- I Indian I Chinese-
American II European Americans II Thais American American American American
II North American II Caucasians III II North II North II North II Korean-
American III Chinese Vietnamese American American American American
Caucasian IV Hispanics IV North Caucasian Caucasian Caucasian III North
V Japanese American American
VI Koreans Caucasian Caucasian
Nasolabial n.a I F:92.00±9.55 I 90.0±15.8 n.a I 92.1±9.2 n.a I 92.1±9.2 n.a
Angle (°) M: 91.11±8.12 II 109.5±11.1 II 104.2±9.8 II 104.2±9.8
(Cm-Sn-Ls) III 92.5±14.2
Mean±SD II F:109.71±7.60 IV 105.1±12.7
M: 112.05±9.86 V 97.1±10.2
VI 92.9±12.4
Labiomental (°) n.a IF:130.64±11.88 I 138.5±19.7 n.a n.a n.a n.a n.a
(Li-Sm-Pg’) M:123.10±12.36 II 139.3±15.2
Mean±SD III 138.8±13.0
I F: 132.99±9.08 IV 136.7±16.0
M:133.34±11.75 V 136.5±19.0
VI 142.0±13.8
Profile convexity (°) n.a n.a I 161.6±5.4 n.a n.a n.a n.a n.a
(G-Sn-Pg’) II 163.8±4.9
Mean±SD III 164.8±4.8
IV 163.2±5.2
V 164.9±0.4
VI 167.7±6.2
Upper lip to E-line n.a I F: 0.02±1.89 I 0.3±2.6 n.a n.a n.a n.a n.a
(mm) Mean±SD M: -0.55±2.08 II -7.5±3.2
III -1.0±2.3
II. F: -6,46±2.8 IV -4.1±2.5
M: -6.37±2.54 V -1.9±2.6
VI -1.5±1.7
Lower lip to E-Line n.a I F: 1.40±2.23 I 2.9±3.6 n.a n.a n.a n.a n.a
(mm) Mean±SD M: 0.98±2.06 II -5.2±2.8
III 0.8±3.5

71
 II F: -3.98±2.23 IV -2.6±2.6
M: -4.63±2.50 V -1.2±2.6
VI -0.5±2.2
Upper lip to S-Line n.a I F: 2.60±1.74 n.a n.a n.a n.a n.a n.a
(mm) M: 2.62±2.17
Mean±SD II F: -3.06±1.93
M: -2.87±2.26
Lower lip to S-Line n.a I F: 2.97±2.07 n.a n.a n.a n.a n.a n.a
(mm) M: 2.87±1.80
Mean±SD
II F: -1.74±2.19
M: -2.07±2.15
Mouth width (mm) I F: 51.6±0.34 n.a n.a I 47.8±5.1 I 50.2±4.0 I F: 53.6±4.0 I 51.1±5.2 I F: 47.1±4.9
(ch-ch) II F: 50.2±3.5 II 47.9±2.9 II 50.2±3.5 M: 54.6±4.2 II 50.2±3.5 M: 50.5±4.2
Mean±SD III 48.0±4.8 II F: 50.2±3.5 II F: 45.6±3.1
IV 51.7±3.9 M:54.5±3.0 M: 47.8±3.4
III F: 55.2±3.7
M: 46.9±3.3
Forehead height I I F: 55.7±0.72 n.a n.a n.a I 57.7±6.4 n.a I 54.2±6.3 n.a
(mm) (tr-g) Mean±SD II F: 52.7±6.0 II 52.7±6.0 II 52.7±6.0
Forehead height II I F: 68.9±0.71 n.a n.a I 66.8±7.2 I 73.7±7.0 I F: 67.1±5.9 I 63.9±7.4 n.a
(mm) (tr-n) Mean±SD II F: 63.0±6.0 II 66.1±5.6 II 63.0±6.0 M: 72.0±7.8 II 63.0±6.0
III 64.3±.4.6 II F: 63.0±6.0
IV 64.5±6.9 M:67.1±7.5
Lower face height I F: 67.5±0.46 n.a n.a I 69.6±5.4 I 66.8±5.6 I F: 71.5±5.2 I 57.8±7.5 n.a
(mm) (sn-gn) II F: 63.0±4.0 II 67.5±4.8 II 64.3±4.0 M: 78.7±7.3 II 64.3±4.0
Mean±SD III 67.4±4.8 II F: 64.3±4.0
IV 67.2±5.8 M:72.6±7.5
Facial width (mm) I F:135.0±0.53 n.a n.a I 140.4±4.8 I 139.0±8.6 I F:130.5±4.8 I 125.9±10.1 I F: 136.5±5.8
(zg-zg) Mean±SD II F: 130.0±4.6 II 142.7±5.9 II 130.0±4.6 M: 139.0±5.3 II 130.0±4.6 M: 140.8±8.2
III 139.2±3.7 II F: II F: 127.5±2.2
IV 130.0±4.6 M: 144.1±5.3
133.2±6.5 M:139.1±5.3 III F:128.8±5.6
M: 138.7±9.9
Nasal bridge length I F: 48.0±0.40 n.a n.a I 52.6±3.1 I 51.8±4.4 I F: 48.8±3.7 I 45.6±3.5 n.a
(mm) (n’-prn) II F: 50.6±3.1 II 50.5±2.7 II 50.6±3.1 M: 51.8±3.1 II 50.6±3.1
Mean±SD III 51.3±3.5 II F: 50.6±3.1
IV 52.1±2.8 M:54.8±3.3

72
 Nasal width (mm) (al- I F: 38.0±0.28 n.a n.a I 38.2±2.5 I 35.5±3.4 I F: 40.1±3.2 I 35.6±3.3 I F: 37.3±2.4
al) Mean±SD II F: 31.4±2.0 II 40.5±2.7 II 31.4±2.0 M: 44.1±3.4 II 31.4±2.0 M: 41.2±3.4
III 40.0±2.1 II F: 31.4±2.0 II F: 36.0±2.2
IV 32.6±2.6 M:34.9±2.1 M: 40.7±2.5
III F: 31.8±2.1
M: 36.0±2.8
Intercanthal distance I F: 31.4±0.26 n.a n.a I 37.1±3.3 I 36.9±3.4 I F: 34.4±3.4 I 31.2±3.7 I F: 34.3±2.8
(mm) (Mean±SD II F: 31.8±2.3 II 26.6±2.8 II 31.8±2.3 M: 35.8±2.9 II 31.8±2.3 M: 35.2±2.3
III 36.7±2.5 II F: 31.8±2.3 II F: 35.1±2.7
IV 32.3±2.6 M:33.3±2.7 M: 35.4±2.1
III F: 30.6±2.8
M: 32.0±2.9
Eye fissure width I F: 32.1±0.18 n.a n.a I 28.9±1.5 I 27.3±2.0 I F: 32.4±2.4 I 30.6±2.4 n.a
(mm) (en-ex) II F: 30.7±1.2 II 29.4±2.0 II 30.7±1.2 M: 32.9±1.7 II 30.7±1.2
Mean±SD III 29.2±2.1 II F: 30.7±1.2
IV 30.9±1.2 M:31.3±1.2
Ear length (mm) (sa- I F: 57.4±0.39 n.a n.a I 59.2±3.9 I 67.6±4.8 I F: 57.2±3.5 I 58.6±6.9 n.a
sba) Mean±SD II F: 59.6±3.4 II 61.4±4.6 II 59.6±3.4 M: 60.5±4.1 II 59.6±3.4
III 59.9±2.6 II F: 59.6±3.4
IV 61.0±3.8 M:62.7±3.65

Table 4.19: Comparison of mean value of extraoral parameters in different populations, regarding macroesthetic.

73
 Author Age of the Gender Racial and ethnic Teeth exposure (mm) Upper lip Upper lip
(year) patients (years) groups length (mm) thickness
(mm)
Teeth At resting At resting At resting
(Mean±SD) (Mean±SD) (Mean±SD)
Al Wazzan 20-60 n.a East Asian Maxillary central incisors 2.88±1.75 n.a n.a
(2004) Maxillary lateral incisors 1.66±1.47
Maxillary canines 0.61±0.94
Mandibular central incisors 1.18±1.45
Mandibular lateral incisors 1.01±1.34
Mandibular canines 0.75±1.27
Arabian Maxillary central incisors 2.78±1.75 n.a n.a
Maxillary lateral incisors 1.56±1.42
Maxillary canines 0.51±0.92
Mandibular central incisors 0.92±1.23
Mandibular lateral incisors 0.90±1.16
Mandibular canines 0.75±1.14
African Maxillary central incisors 2.40±1.76 n.a n.a
Maxillary lateral incisors 1.32±1.27
Maxillary canines 0.39±0.70
Mandibular central incisors 0.60±0.91
Mandibular lateral incisors 0.61±0.90
Mandibular canines 0.59±1.02
Connor and 18-50 Females Caucasian Maxillary central incisors 4.09±2.27 21.50±3.55 n.a
Moshiri Males 1.82±2.80 24.13±2.59
(1985) Females North American black Maxillary central incisors 2.61±1.51 26.34±2.89 n.a
Males 1.52±1.70 27.72±2.46
Farkas et al. 18-25 Females African American n.a n.a 24.5±3.0 n.a
(2007) Males 26.1±2.5
Females North American n.a n.a 20.1±2.0 n.a
Males Caucasian 22.3±2.1
Husein et al. 18-30 Females Indian American n.a n.a 18.6±3.2 8.3±1.0
(2010)
Females North American n.a n.a 20.1±2.0 8.7±1.3
Caucasian

Table 4.20 Comparison of mean value of extraoral parameters in different populations, regarding miniesthetic.

74
Author Population Gender Age Teeth exposure (mm) Upper lip length (mm) Lip thickness (mm) Gingival
(year) groups exposure
(years) Teeth At resting During At resting During At resting During during
Mean±SD smiling Mean±SD smiling Mean±SD smiling smiling
Mean±SD Mean±SD Mean±SD (mm)
Mean±SD
Choi et al n.a Females 20-29 Maxillary ≈1.7 ≈7.6 n.a n.a n.a n.a n.a
(2000) and males 30-39 central ≈1.2 ≈6.6
40-49 incisors ≈0.9 ≈6.5
50-59 ≈-0.1 ≈5.3
60-69 ≈-1 ≈4.6
Al Wazzan Arabian, Females 20-25 Maxillary 3.13±1.74 n.a n.a n.a n.a n.a n.a
(2004) African, East and males 26-35 central 2.80±1.70
Asian 36-45 incisors 2.42±1.67
46-55 1.85±1.68
56-60 0.93±1.37
20-25 Maxillary 1.67±1.50 n.a n.a n.a n.a n.a n.a
26-35 lateral 1.63±1.50
36-45 incisors 1.47±1.29
46-55 1.08±1.15
56-60 0.57±0.94
20-25 Maxillary 0.55±1.00 n.a n.a n.a n.a n.a n.a
26-35 canines 0.54±0.84
36-45 0.51±0.90
46-55 0.51±0.99
56-60 0.29±0.76
20-25 Mandibular 0.75±1.07 n.a n.a n.a n.a n.a n.a
26-35 central 0.92±1.36
36-45 incisors 1.04±1.38
46-55 1.20±1.10
56-60 1.34±1.23
20-25 Mandibular 0.71±1.01 n.a n.a n.a n.a n.a n.a
26-35 lateral 0.95±1.28
36-45 incisors 1.00±1.26
46-55 1.12±1.00
56-60 1.32±1.49

75
 20-25 Mandibular 0.65±1.04 n.a n.a n.a n.a n.a n.a
26-35 canines 0.79±1.24
36-45 0.81±1.22
46-55 0.89±0.93
56-60 1.07±1.42
Van der 20-25 Maxillary 5.5±2.2 n.a 20.3±2.7 16.0±2.7 n.a n.a n.a
Geld et al. Caucasian n.a 35-40 central 3.8±2.8 23.3±2.3 18.0±1.9
(2008a) 50-55 incisors 2.0±2.6 24.0±2.6 18.3±2.6
20-25 Maxillary 4.0±2.1 n.a n.a n.a n.a n.a n.a
35-40 lateral 2.7±1.9
50-55 incisors 1.1±1.5

20-25 Maxillary 2.1±1.2 n.a n.a n.a n.a n.a n.a

35-40 canines 0.7±1.4
50-55 0.7±1.3
20-25 Mandibular 0.5±1.0 n.a n.a n.a n.a n.a n.a
35-40 central 0.7±1.2
50-55 incisors 1.5±1.5
20-25 Mandibular 0.3±0.9 n.a n.a n.a n.a n.a n.a
35-40 lateral 0.7±1.2
50-55 incisors 1.7±1.6
20-25 Mandibular 0.3±1.0 n.a n.a n.a n.a n.a n.a
35-40 canines 0.8±1.3
50-55 1.4±1.6
Desai et al. n.a Females 15-19 Maxillary n.a 8.76±1.9 21.58±3.16 16.84±2.94 7.87±1.94 6.26±1.81 n.a
(2009) and males 20-29 central 9.02±2.12 21.7±2.87 16.83±2.53 8.28±1.84 6.72±1.89
30-39 incisors 9.29±2.28 22.25±1.92 17.06±2.16 8.38±1.59 6.61±1.74
40-49 7.62±2.27 22.02±3.47 17.74±2.83 6.51±1.67 5.61±1.71
50+ 7.15±2.55 22.69±3.12 18.3±2.78 6.25±2.15 5.39±2.09
Chetan et n.a Females 15-20 n.a n.a n.a 19.12±1.81 15.28±2.13 7.64±0.76 6.20±0.91 n.a
al. (2012) 21-30 19.84±1.46 15.64±1.66 8.16±1.07 6.24±1.16
30-41 20.24±1.45 16.60±1.85 7.72±1.37 5.64±1.32
41-50 20.36±1.38 16.52±1.71 6.48±0.82 5.44±1.00
Males 15-20 n.a n.a n.a 20.64±2.33 16.32±2.36 7.64±1.04 5.88±1.13 n.a
21-30 21.32±1.97 17.12±1.79 8.28±1.67 6.12±1.51
30-41 21.60±2.20 17.76±2.11 7.68±1.75 5.72±1.40
41-50 22.96±1.99 19.36±1.47 6.56±1.50 5.60±1.41

76
Singh et al. n.a Females 15-25 Maxillary 0.88±2.00 9.01±1.33 19.61±2.02 12.97±2.21 8.03±1.11 6.65±1.24 0.77±1.45
(2012) 30-40 incisors 0.39±1.10 8.84±1.44 20.63±2.08 14.41±2.25 7.88±1.20 6.29±1.11 0.30±0.70
45-55 0.33±1.06 8.49±1.64 21.32±2.79 15.42±2.65 7.86±1.44 6.41±1.75 0.39±0.97
Females 15-25 Mandibular n.a 1.67±1.49 n.a n.a n.a n.a n.a
30-40 incisors 2.02±1.58
45-55 1.83±1.06
Males 15-25 Maxillary 0.26±1.08 8.44±2.21 21.64±2.67 14.91±2.75 8.28±1.53 6.55±1.48 0.31±0.68
30-40 incisors 0.28±0.91 7.47±1.91 21.19±2.63 15.69±2.77 7.53±1.32 6.17±1.50 0.13±0.54
45-55 0.06±0.25 6.92±2.54 22.73±2.65 17.53±2.66 7.19±1.60 5.83±1.54 0.18±0.53
Males 15-25 Mandibular n.a 1.93±1.44 n.a n.a n.a n.a n.a
30-40 incisors 2.65±1.64
45-55 2.24±1.93
Gibelli et Caucasian Females 21-34 n.a n.a n.a n.a n.a Upper: n.a n.a
al. and males 10.5±1.5
(2015) Lower:16.
45-65 4±4.2

Upper:
9.0±1.6
Lower:10.
8±1.7
Drummond n.a Females 19-24 Maxillary n.a 8.90±1.17 21.44±2.40 n.a n.a n.a 0.48±1.99
and Capelli 25-34 central 9.20±1.25 21.32±1.91 0.11±1.79
(2016) 35-44 incisors 8.15±1.53 21.58±2.32 -0.90±2.10
45-60 8.09±1.86 21.93±2.45 -0.99±2.28
Males 19-24 Maxillary n.a 8.53±1.53 21.60±2.02 n.a n.a n.a -1.40±1.75
25-34 central 7.88±1.59 22.60±2.22 -2.42±2.01
35-44 incisors 6.52±1.56 23.33±1.91 -3.49±1.75
45-60 6.07±1.66 23.85±2.88 -3.98±1.93

Table 4.21: Reported perioral measurements in different age groups.

77
 Author (year) Gender Population Age Tooth length (mm) Tooth width (mm) Overjet Overbite
groups (mm) (mm)
(years) Maxillary Maxillary Maxillary Maxillary Maxillary Maxillary (Mean±SD) (Mean±SD)
central lateral canines central lateral canines
incisors incisors (Mean±SD incisors incisors (Mean±SD
(Mean±SD (Mean±SD ) (Mean±SD (Mean±SD )
) ) ) )
Females Caucasian n.a n.a n.a 8.54±0.41 6.21±0.18 7.35±0.59 n.a n.a
Lavelle Males 8.79±0.45 6.32±0.56 7.53±0.38
(1972)
Females Mongolian 18- 28 8.57±0.59 6.85±0.62 7.94±0.54
Males 8.67±0.42 6.99±0.77 8.07±0.66

Females African 9.21±0.44 7.48±0.38 8.21±0.52

Males 9.33±0.59 7.61±0.63 8.32±0.62

Gillen et al. Females Caucasian R:9.90 R:8.28 R:9.48 R:9.05 R:6.79 R:8.04 n.a n.a
(1994) L:9.82 L:8.57 L:9.36 L:9.18 L:6.90 L:7.99

African R:9.15 R:7.96 R:8.97 R:9.19 R:7.21 R:8.03

Americans L:9.37 L:7.82 L:9.05 L:9.18 L:7.46 L:8.11
18-35
R:10.48 R:8.70 R:10.68 R:9.15 R:7.37 R:8.34
Males Caucasian L:10.69 L:8.99 L:10.81 L:9.24 L:7.31 L:8.41

African R:10.98 R:9.55 R:10.34 R:9.66 R:7.72 R:8.93

Americans L:10.84 L:9.27 L:10.88 L:9.65 L:7.90 L:8.76

Owens et al. Females Caucasian n.a n.a n.a R:8.4 n.a n.a 2.3 3.6
(2002b) and Hispanic R:9.0 3.0 3.4
males African R:9.1 2.7 3.0
American 18-41 R:8.8 2.7 2.8
Chinese R:8.4 2.2 2.7
Japanese R:9.1 2.2 2.5
Korean

Table 4.22: Reported values about intraoral parameters in different populations and age groups.

78
4.8 Ideal human face, overview of literature

There are some guidelines described by the different authors, which come into use during
comprehensive aesthetic analysis.

4.8.1 Enface view.

The existing guidelines for the ideal human face from enface view can be concluded in the
following order (Figure 4.1, Figure 4.2, Figure 4.3) (Farkas et al. 1984, Powel and Humpreys
1984, Wilkinson et al. 2003, Fradeani 2004, Sarver and Jacobson, 2007).

• Left and right side of face should be symmetrical.

• Horizontal and vertical proportions of the face should be roughly equal.

• Upper lip height should be equal to 1/3 of lower face height.

• Nose length should be approximately equal to air length.

• Mouth width should be approximately equal to 1.5X nose width.

• Face width should be approximately equal to 4X nose width.

• Medial interlimbus distance should be approximately equal to mouth width.

• Intergonial distance should be approximately equal to the distance between the outer
points of the left and right eye fissures.

• Face width should be larger than the intergonial distance; that is, the human face
should ideally be trapezoidal.

79
Figure 4.1: Horizontal proportions
A≈ B≈ C
D (Upper lip height) ≈1/3 C
Facial grid modified from: http://hifisnap.com/photos/13/how-to-draw-human face/a7d6175d d8135 da ae775f99412 460dfc-jpg
Figure 4.2: Vertical proportions Figure 4.3: Relation between horizontal and
vertical proportions
A≈ B≈ C≈D≈E; G≈H
A (Nose length) ≈ B (air length); C (nose width) ≈
D (right eye fissure width) ≈ E (Interocular
distance) ≈ F (left eye fissure width); G (mouth
width) ≈ 1,5C; H (Face width) ≈ 4C, I (Interlimbus
distance) ≈ G, J (Intergonial distance) ≈ K
(Distance between the outer points of the left and
right eye fissure)
80
4.8.2 Profile view

Guidelines helpful during profile analysis are mentioned below (Figure 4.4, Figure 4.5,
Figure 4.6, Figure 4.7, Figure 4.8).

If the nasofacial angle is 42°, the ratio between the n-sn line and the perpendicular line to
it, which drawn through the nasal tip nose should be 2:1, approximately (Baum 1982)
(Figure 4.4)

If the nasofacial angle is 36°, the ratio between the n-sn line and the perpendicular line

to it, drawn through the nasal tip should be approximately 2.8:1 (Powel and Humpreys
1984) (Figure 4.5).

If the nasofacial angle is 36°, the ratio between the n-al line and the perpendicular line to
it drawn through the nasal tip nose should be approximately 0.55-0.60 (Goode 1984)
(Figure 4.6).

The ratio between the nasal tip projection and the upper lip length should be
approximately 1:1 (Simon 1982) (Figure 4.7).

The line drawn along the posterior rand of the ear should be parallel to the line drawn
along the nasal dorsum (Krugmann 1981) (Figure 4.8)

Facial soft tissue profile, excluding the nose, should be slightly convex (see table 4.4)

Nasolabial angle should be slightly obtuse, although this varies in females and males (see
table 4.8)

The upper lip position should be more anterior than the lower lip position, although its
anteroposterior position relative to other facial parameters varies distinctively across
populations and genders (see table 4.23).

81
4.8.2 Profile view

Guidelines helpful during profile analysis are mentioned below (Figure 4.4, Figure 4.5, Figure
4.6, Figure 4.7, Figure 4.8).

• If the nasofacial angle is 42°, the ratio between the n-sn line and the perpendicular line
to it, which drawn through the nasal tip nose should be 2:1, approximately (Baum
1982) (Figure 4.4)

• If the nasofacial angle is 36°, the ratio between the n-sn line and the perpendicular line

to it, drawn through the nasal tip should be approximately 2.8:1 (Powel and Humpreys
1984) (Figure 4.5).

• If the nasofacial angle is 36°, the ratio between the n-al line and the perpendicular line
to it drawn through the nasal tip nose should be approximately 0.55-0.60 (Goode
1984) (Figure 4.6).

• The ratio between the nasal tip projection and the upper lip length should be
approximately 1:1 (Simon 1982) (Figure 4.7).

• The line drawn along the posterior rand of the ear should be parallel to the line drawn
along the nasal dorsum (Krugmann 1981) (Figure 4.8)

• Facial soft tissue profile, excluding the nose, should be slightly convex (see table 4.4)

• Nasolabial angle should be slightly obtuse, although this varies in females and males
(see table 4.8)

• The upper lip position should be more anterior than the lower lip position, although its
anteroposterior position relative to other facial parameters varies distinctively across
populations and genders (see table 4.23).

82
Figure 4.4 (Baum 1982): Figure 4.5 (Powell and Figure 4.6 (Goode Figure 4.7 (Simons Figure 4.8 (Krugman 1981):
if NFa ≈42° and AB⟂n- Humphreys 1984): if 1984): if NFa ≈36° and 1982): if AB (lower Line A (nasal dorsum) II line B
sn, n-sn/AB≈2/1 NFa ≈36° and AB⟂n-sn, AB⟂n-ala, AB/n-ala≈ nasal contour) ≈BC (the posterior auricular plane
n-sn/AB≈2,8/1 0,55-0.60 length of the upper lip),
AB≈BC g-sn-pg’ – slightly convex
C- slightly obtuse nasolabial
angle
Facial grid modified from: http://drawingpencilarts.com/face-profile-drawing/

83
4.8.3 Smile analysis

Miniesthetic- relevant analyses include smile analysis; Figure 4.9 represents the guidelines for
the ideal smile (Dong et al. 1998; Morley and Eubank, 2001; Fradeani 2004; Maulik and
Nanda, 2007; Kirtley 2008; Desai et al. 2009; Camara 2010; Passia et al. 2010; Al-Johany et
al. 2011), which can be summarized by the following points:

• The upper lip line should be straight or upward.

• The cervical line, papillary line, contact points line, incisal line, and lower lip line
should be convex and parallel to each other.

• The incisal line should not be in contact with the lower lip line.

• The buccal corridor should be average, but this has no significant impact on smile
attractiveness.

• The smile width should be medium.

• Gingival exposure should be 0-1 mm during smile (average smile line).

• The ratio of the height of the upper lip vermillion border to the total vermillion height
should be 2/5; the height of the lower lip vermillion border to total vermillion height
should be 3/5.

• Tooth exposure at rest depends strictly on age and gender.

Figure 4.9: A – upward upper lip line; B - convex cervical line; C – convex papillary
line; D – convex contact points line; E - convex incisal line; F – convex lower lip line,

Dentolabial grid was modified from Fradeani (2004).

84
4.8.4 Dental analysis and tooth arrangement

The relationship between the parameters to be considered when describing the ideal tooth
composition are depicted in Figure 4.10. These parameters are in the following order
(Lombardi 1973; Chiche and Pinault, 1994; Snow 1999; Kirtley 2008; Gurel 2003; Fradeani
2004;Chu 2007; Bhuvaneswaran 2010):

• The dental midline should be correlated with the facial midline.

• Maxillary central incisors should show vertical symmetry.

• The length of the connector band should be decreased distally along the arch. The
ideal ratio of the contact area of the anterior teeth should be 50: 40: 30, for the contact
area between the maxillary central incisors, maxillary central and lateral incisors, and
maxillary lateral incisors and canines, respectively.

• Incisal embrasures should increase from anterior to posterior, and the incisal
embrasure between the maxillary central incisor should be perfectly triangular.

• The maxillary teeth should show apical distoinclination, incisal mesioinclination, and
tilt slightly palatal. The inclination of the maxillary central incisors should be least
noticeable. The prominence of tooth axis inclination should increase from anterior to
posterior

• Gingival zenith should be slightly distal from the tooth axis.

• Interdental papilla between the maxillary central incisors should be the longest and
perfectly triangular, and its height should decrease progressively from anterior to
posterior.

• Overjet and overbite should be 2-4 mm.

• The maxillary lateral incisors should be positioned between the line drawn between
the apical point of the maxillary central incisors and maxillary canines and the line
drawn through the incisal edge of the maxillary central incisor and canines.

• Ideal tooth proportions for the maxillary canines should be w/l= 0.75- 0.80.

85
 • The interdental contact area between the maxillary central incisors should occupy of
50% of the length of maxillary incisors.

• There are different concepts for ideal tooth-to-tooth proportions, which are depicted in
Figure 4.10.

Figure 4.10: A- the line drawn through the most apical point of the maxillary central
incisor and canine; B- the line drawn through the incisal edge of the maxillary central
incisor and canine; C, D, E- interdental contact area, ΔF, ΔG, ΔH- incisal embrasures; I, J,
K, L, M, N- axis of the teeth; O-length of maxillary central incisor, P, Q, R, - width of
teeth,
Tooth proportion/O≈0,75-0.80
Tooth to tooth proportions: Golden proportions: P/Q/R≈ 1.618/1/0.618 (Lombardi 1973)
Golden percentage (P+Q+R) X2=100%, P≈25%, Q≈15%, R≈10% (Snow 1999)
Chu’s concept: Q≈P-2, R≈P-1 (Chu 2007)

4.9. Summary of results

4.9.1 Average facial and dental parameters in various populations and genders, based on
the results tables

Racial groups have been classified based on recommendations from the National Institutes of
Health (2015). In this classification, the racial groups and respective subgroups have been
sorted in the following order:

Dental grid was modified from Fradeani (2004).

• White. A person having origins in any of the original peoples of Europe, the Middle
East, or North Africa.

86
 • Asian. A person having origins in any of the original peoples of the Far East,
Southeast Asia, or the Indian subcontinent including, Cambodia, China, India, Japan,
Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

• African American. A person having origins in any of the black racial groups of
Africa. Terms such as "Haitian" can be used in addition to "African American."

• American Indian or Alaska Native. A person having origins in any of the original
peoples of North and South America (including Central America), and who maintains
tribal affiliation or community attachment.

• Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, Cuban, South or

Central American, or other Spanish culture or origin, regardless of race. The term,
"Spanish origin," can be used in addition to "Hispanic or Latino".

• Native Hawaiian or another Pacific Islander. A person having origins in any of the
original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Asian-American populations have been investigated separately, because they are not clearly
classified above. North American Caucasian has been categorized within the White group. No
results have been found in papers regarding Native Hawaiian or other Pacific Islander groups,
thus this group has been excluded from the summary table. The mean average of the
parameters in the different populations/subgroups has been extracted from the identified
studies and the results have been summarized based on the aforementioned classification. No
data fit within the summary table due to deviations in reference pointes/lines regarding the
face height and chin prominence among African-Americans. Table 4.23 demonstrates the
mean average range for each racial group in either gender.

4.9.2 Parameters for performing a comprehensive aesthetic analysis

The description and measurement of the parameters regarding macro-, micro-, and
miniesthetic have been collected from all the included articles. Table 4.24 summarizes all of
the parameters, to be ascertained during a comprehensive aesthetic rehabilitation.
Additionally, the reference points/lines, the determining factors through the analysis of the
appropriate parameters, and the pleasing outcomes for each parameter are described in this
table.

87
Parameters Reference Conclusion
lines/poin Mean range in different racial groups
ts White Asian African Asian Hispanic American
American American or Latino Indian or
Alaska
Native
Facial na’-me’ F:124.0-124.9 F:122.03-126.4 n.a n.a n.a n.a 1. No marked difference found
Macroesthet height M:132-137.7 M:132.73-135.9 between the racial groups
ic: (mm)
Facial 2. Males have greater facial
parameters height than females.
Facial zg’-zg’ 128.8-138.7 139.2-142.7 130.5- 127.5-144.1 n.a 125.9 1. The Asians have the widest
width 139.0 face.
(mm) 2. The face width of African
Americans is greater than the
White population, with no
marked difference
3. There is great variation for
the average face width of Asian
Americans.
Lower sn-me’/sn- F: 63,0- 71.1 F: 63.13-72.64 66.8-67.5 54.3-66.8 n.a 57.8 1. No marked difference found
face gn M:64.8-81.1 M: 72.4-78.3 between the racial groups
height 2.Males have lower face height
(mm) than the females.
Interca en- en 31.8-33.3 36.7-37.1 31.4-35.8 34.3-36.9 n.a 31.2 1.The Asian and Asian
nthal (Thais 26.6) American have the greatest
distanc intercanthal distance.
e (mm) 2.Thais are exception. They
have the smallest intercanthal
distance.
Eye en- ex 29.4-31.3 28.9-29.4 32.1-32.9 27.3 n.a 30.6 1.The African Americans and
fissure Indian Americans have wider,
width and the Asian and Asian
(mm) Americans have less wide eye
fissures than other populations.
Ear sa-sba 59.6-62.7 59.2-61.4 57.2-60.5 67.6 n.a 58.6 1. African Americans have
length shorter ear length than White
(mm) and Asian populations.

88
 Soft n’-sn- F:163.8- 163.3-169.5 161.6 n.a 163.2 n.a 1. African Americans have the
tissue pg’/g-sn- 169.05 most and White populations
facial pg’ M:163.8- have least convex profile
convex 170.60
ity
excludi
ng
nose
(°)
Macroesthet Mouth ch-ch F:50.2-55.2 47.8-47.9 53.6- 54.6 47.1-50.5 n.a 51.1 1.African Americans and
ic: width M: 46.9-54.5 Indian Americans have wider
Oral (mm) and Asians have less wide
parameters mouths than other populations.
2. There is great variation for
the average face width of Asian
Americans.
Upper sn’- stms F:17.40- 22.4 23.40-24.24 F:24.6- n.a n.a F:18.6 1. African Americans have the
lip M:18.78- 26.34 longest upper lip.
length 24.13 M:26.1- 2.Asians have greater lip length
(mm) 27.72 than White populations.
3. Males have longer upper lip
than females
Lower (stmi- n.a n.a n.a n.a n.a n.a Because of the use of the
lip me’) or alternate reference points, no
length (stmi- comparison was performed.
(mm) sm’)
Upper F:1.1-2.8 F:1.2-1.5 n.a n.a n.a n.a 1. No marked difference was
lip - M:0.9-3.0 M: 1.1-1.2 found between the racial
volume groups.
(cm 3)
Lower F:1.4-2.7 F:1.3 n.a n.a n.a n.a
lip - M:1.3-2.9 M:1.4-1.6
volume
(cm3)

89
 Upper F:8.7-12.58 F:12.3-13.8 n.a n.a n.a F:8.3 1. Asian populations show
lip - M:10.8-15.22 M:13.58-15.11 greater lip thickness than the
thickne White population.
ss
(mm)

Lower F:10.2-13.6 F:13.03-14.4 n.a n.a n.a n.a

lip M:11.3-13.1 M:14.80-16.1
thickne -
ss
(mm)
Upper Ls- to pr- -7.5- -6.37 -1.9- -1. 0.02-0.55 n.a -4.1 n.a 1. African Americans show the
lip to pg’ greatest and the NAC
E-line population show the least
(mm) protruded lip position.
2. African Americans have
Lower Li- to pr- -5.2- -3.98 -2.6- 0.8 2.9 n.a -2.6 n.a positive anteroposterior
lip to pg’ position of the lips.
E-line 3. Lip position of Asians is
(mm) more anterior than that of
Whites and Hispanics.
4. The difference between
Hispanics and Whites regarding
the anteroposterior lip position
is not marked.
Macroesthet Nasal n’-prn 50.6- 55.2 36.8-52.6 48.0-51.8 n.a n.a 45.6 1. NAC have greater nasal
ic: Nasal bridge bridge height than other
parameters length populations, with significant
(mm) difference.
2.The variation regarding the
average amount of nasal bridge
length in Asians is significant.
Nasal n-sn F: 46.5- 54.48 F:52.44-58.23 F: 49.3 n.a n.a n.a 1. Asians have more nasal
height M: 45.6- 56.92 M:54.19-60.33 M:52.4 height than the other
(mm) populations.
2. Males have more nasal
height than females.

90
 Nasal al-al F: 31.4-37.5 F:34.75-37.48 F: 38.0- F:35.5-36.0 n.a 31.2 1. African Americans have the
width M: 33.3-39.0 M:36.12-42.88 40.1 M:40.7-41.2 widest nose.
(mm) M:44.1- 2. Asian and Asian Americans
43.5 have wider noses than Whites.
3. Males have wider nose than
females.
Nasal sn-prn F:11.05-20.1 F:16.3-19.7 F:20.4 n.a n.a n.a 1. No marked difference have
tip M:11.6-21.5 M:18.24-21.1 M:23.1 been found.
projecti
on
(mm)
Nasal Nasolabial F: 95.7-119.2 F:90.36-100.05 90.0 92.1 105.1 92.1 1. Caucasians and Hispanics
tip angle M: 91.11- M:90.1-100.99 show greater nasolabial angles
rotatio (Cm- Sn- 110.8 than Asians and African
n (°) tangent of Americans
the outer
edge of
the Ls)
Macroesthet Chin pg’/TVL F: -6.4- -2.6 F: -11.1- -2.9 n.a n.a n.a n.a 1. The chin protrusion of
ics: chin promin M: -6.5- +3.8 M: -9- -5.78 Asians is less than that of
parameters ence Whites.
(mm)

Mentoc g-pg’/c- 82.50- 104.86 99.88 80.60- n.a n.a n.a 1. Because of the distinctive
ervical me’ 126.8 variation in the mean
angle mentocervical angle, no
(°) comparison could be
performed.

Labio li-sm-Pg’ F: 108.75- 141.3 104.77 n.a n.a n.a 1. Asians have greater
mental 132.2 138.9 labiomental angles than the
angle M;129.26- other populations.
(°) 130.19
Miniesthetic Gingiv - 79 50-75 81 n.a 67 n.a 1. Gingival display is greatest
. al soft in African Americans.
tissue
display
(% of

91
 the
particip
ants)
Maxill - 1.82-4.09 1.86-2.88 1.57-2.78 n.a n.a n.a 1. The visibility of the
ary maxillary central incisors is
central greater in the White population
incisor than others.
exposu
re at
rest
Microestheti Maxill - F:9.39-9.90 B.g 11.93 F:9.15- n.a n.a n.a 1. No marked difference was
c ary M:10.19-11.69 9.37 found between the different
central M:10.84- racial groups
incisor 10.98 2. Males have longer maxillary
length central incisors than females.
Maxill - F:8.06±9.18 8.57-9.1 F:9.1-9.21 n.a n.a 9.0 1. African Americans have the
ary M:8.59±9.33 M:9.33- widest maxillary incisors.
central 9.66 2. Maxillary incisor width of
incisor Hispanics and Asians is greater
s width than that of Caucasians.
(mm) 3. Males have wider maxillary
incisors than females
Overjet - 2.3 2.2-2.7 2.7 n.a n.a 3.0 1. No marked difference was
found between the different
racial groups.
2.Hispanics have more overjet
than other racial groups.
Overbite - 3.6 2.5-2.8 3.0 n.a n.a 3.4 1. White populations have the
most and Asians have the least
overbite.
2. The difference between the
Hispanics and White
population is not marked.
Table 4.23: Mean average amount of facial and dental parameters in different populations and genders, basing on the results tables.

92
Parameter Reference Appropriate function in the aesthetic rehabilitation Pleasing aesthetic outcomes
lines/points
Facial height na’- me’ To determine the vertical dimension Lower face height should be approximately equal to ½ of
(mm) the facial height
Macroest Facial width zg- zg To determine the vertical dimension, indirectly The facial index varies depending on the facial shape (see
hetic: (mm) through the facial index. §1.4.3).
Facial Lower face sn-me’/sn-gn To determine the vertical dimension Interocclusal space should be 2-4 mm at rest.
paramete height (mm)
rs Interpupillary Hl- Hr To determine the mouth width Should be approximately equal to the mouth width
distance
Intercanthal en- en To determine the nose width Should be approximately equal to the eye fissure width
distance/Intero and nose width
cular distance
(mm)
Eye fissure en- ex To determine the nose width Should be approximately equal to the intercanthal distance
width (mm) and nose width
Ear length sa-sba To determine the nose length Should be approximately equal to the nose length
(mm)
Skeletal n-A-pg To determine the prominence of the maxilla and/or Should be slightly convex
convexity (°) mandibula
Soft tissue n’-sn-pg’/g-sn-pg’ To determine the prominence of the maxilla and/or Should be slightly convex
facial mandibula
convexity
excluding
nose (°)
Total soft n’-pr-pg’ To determine the prominence of the nose and/or its Should be convex
tissue relation to the chin and lips
convexity (°)
Facial midline g’ (or n’)-prn-stms- To determine the facial symmetry Should be straight and perpendicular the esthetic plane
pg’ To determine the maxillary interincisal midline (horizon)
Interpupillary Hl-Hr To determine the occlusal plane from frontal view. Should be parallel to the esthetic plane (horizon)
line
Ala tragus al- tragus To determine the occlusal plane from profile -
line/Campers
line
Posterior To determine nasal bridge inclination Nasal bridge inclination should be parallel to posterior
auricular plane auricular plane form profile

93
 form profile
Macroest Upper lip to Ls- to pr- pg’ line To determine the anteroposterior upper lip position Should be „- “, except for African Americans.
hetic: E-line
Oral
paramete Lower lip to Li- to pr-pg’ line To determine the anteroposterior lower lip position Should be „- “, except for African Americans.
rs E-line

Macroest Nasal bridge n’ -prn To determine the ideal nasal proportions for the There are no factors to determine the nasal bridge length
hetic: length cosmetic correction, based on the relationship directly. Additional nasal parameters and their pleasing
Nose between these parameters. relation to each other determine the pleasing nasal length,
paramete indirectly
rs Nasal height n’ –sn Should be approximately equal to half the distance of
facial height (na`-me`).
Nasofacial g- n’-prn Should be 36°- 40°, ideally.
angle
Nasal width al’-al Should be approximately equal to the intercanthal distance.
Nasolabial Cm- Sn- tangent of To determine the rotation of the nasal tip Should be obtuse ideally (depends significantly on gender
angle the outer edge of the To determine the relation between the nasal tip and race.)
Ls rotation and the prominence of the upper lip.
Macroest Chin pg’ to TVL To determine the mandibular prominence during This parameter varies depending on the racial groups.
hetic: prominence orthognatic surgery.
Chin Cervicomental SM-Th-N To determine the “sagging” in the cervicomental Should be slightly obtuse, 105°- 120° depending on the
paramete angle area. gender.
rs. Mentocervical g-pg’/c-me’ Could be slightly acute, right, or obtuse angle.
angle
Labiomental li-sm-Pg’ To determine the labiomental fold during the Should be rarely 130° in Class I subjects.
angle cosmetic procerdures.
Miniesth Mouth width ch-ch To determine of the tooth visibility during smile. Six anterior maxillary teeth, maxillary premolars, and in
etic. (mm) some cases, the first maxillary molars should be visible
Upper lip sn’- stms To determine of the gingival exposure during smile 1 mm gingival margin should be exposed during smile
length (mm)
To determine of the tooth exposure at rest and The pleasing tooth exposure varies depending on the upper
during smile lip length, which depends strictly on gender and age.
Lower lip (stmi- me’) To determine the upper lip length in relation to the Relation of upper lip to lower lip should be 1:2
length or lower lip or
(stmi- sm’) Relation of upper lip to lower lip should be 1:1

94
Upper lip line The inferior border of To determine the smile type, regarding the position The corner points of the mouth should be level with the
upper lip during of the corner of the mouth during smile (upward, central point of the lower line or higher than it, ideally
smile straight, downward). (straight and high, respectively)
To determine gingival band exposure and visible 1 mm maxillary gingival band should be visible, ideally
part of the maxillary incisors during smile (high, (average smile line).
average, low smile line).
Lower lip line The superior border To determine of the incisal line during the tooth Should be convex, that is incisal line should be parallel to
of lower lip during arrangement. the lower lip line.
smile There should be no contact between the maxillary anterior
To determine the length of the maxillary anterior teeth and lower lip line.
teeth during smile.
Upper Upper (ls- stms) - Relation between upper vermillion height and total
vermillion vermillion height should be 2:5.
height

Lower Lower (stmi-li) - Relation between lower vermillion height and total
vermillion vermillion height should be 3:5.
height

Interlabial gap (stms- stmi) To determine the vertical dimension. Could be 1-5 mm, approximately
To determine of the tooth exposure at rest.

Upper lip - To determine the pleasing lip volume

volume (cm 3) -

Lower lip - To determine the pleasing lip volume

volume (cm3)
Upper lip - To determine the appropriate anteroposterior
thickness inclination of the maxillary incisors to create
pleasing anteroposterior lip position
Lower lip - To determine the appropriate anteroposterior
thickness inclination of the mandibular incisors to create a
pleasing anteroposterior lip position
Cervical line The line joined To determine the relationship between the gingival Should be symmetrical and convex.
through the gingival zenith and the maxillary anterior teeth.

95
 zenith points of the
maxillary anterior
teeth.
Papillary line The line joined To determine the relationship between the height of Should be symmetrical and convex.
through the tips of the the papillae of the maxillary anterior teeth. The height of the papillae between the maxillary incisors
papillae between the should be equal to half the height of the teeth.
maxillary anterior
teeth.
Contact point The line joined To determine the relationship between contact Should be symmetrical and convex.
line and through the proximal points of the maxillary anterior teeth. Should be parallel to the papillary line.
contact area. contact points of the The ideal ratio for the contact area should be 50:40:30,
maxillary anterior from maxillary central incisors to maxillary canines.
teeth.
Incisal line The line joined To determine the relationship between the tooth Should be symmetrical and convex.
through the incisal length of the maxillary anterior teeth. Should be parallel to the lower lip line.
edge of the maxillary
anterior teeth.
Buccal The lateral negative To determine the smile fullness. Should be normal (According to the classification of
corridor space between the Fradeani (2004) and Calamia et al. (2011).
maxillary posterior
teeth and the corner
of the mouth during
smile.
Miniesth Dental midline The interincisal line To determine the symmetry of the tooth Should coincide with the facial midline.
etic of the maxillary composition.
incisors. Should be perpendicular to esthetic plane (horizon).

Tooth axis The line joined To determine the mesiodistal and labiolingual Maxillary teeth should show apical distoinclination and
through the apical inclination of the teeth. incisal mesioinclination.
and incisal midpoints
of tooth. The inclinations of the maxillary central incisors are less
prominent and show mirror imaging to each other.
Tooth to tooth - These parameters should be based on the anatomic length
proportions and width in various populations and genders. (see Table
Tooth - 4.23)
proportions

96
 Interincisal Angle between the To determine the ideal gingival course. Should be the smallest and symmetrical between the
angles incisal part of maxillary incisors.
adjacent teeth. Should be higher and wider from maxillary central incisors
to distal.
Overjet To determine the coverage of the maxillary incisors Should be 2-4 mm.
over the mandibular antagonists along the
horizontal axis.
Overbite To determine the coverage of the maxillary incisors Should be 2-4 mm.
over the mandibular antagonists along the vertical
axis.
Gingival The line drawn across To determine the maxillary gingival margin The gingival margin outline of the maxillary central
margin outline the coronal edge of location and symmetry. incisors at left and right should show mirror imaging.
the gingival tissue in The gingival margin outline of the maxillary central
the maxillae. incisors and canines should be at the same level and the
gingival margin of the maxillary lateral incisors should be
lower that its.
Gingival The most apical point To determine the maxillary gingival margin Should show mirror imaging in the maxillary central
zenith of the gingival location and symmetry. incisors.
margin Should be located distally to the tooth axis, ideally.

Tooth shape - - Should correlate with subject personality, temperament

and/or gender (see §1.6.2.1).
Tooth texture - - Each tooth should have characteristic macro- and
microtexture (see §1.6.1 and 1.6.2.1).
Tooth color - - The maxillary incisors could be brighter and the maxillary
canines could be more chromatic for the natural
appearance.

Table 4.24: Key parameters for performing comprehensive aesthetic analysis.

97
5. Discussion

Systematic reviews aim to collect, analyze, and summarize the results of available
literature, in this case regarding the correlation among dental aspects related to facial and
dental aesthetics. The results show that a clear correlation exists between facial and dental
aesthetics, but the workflow could vary depending on the case.

5.1 Materials and methods

5.1.1 Systematic review

The process begins with a systematic search of the literature. Several databases are
available for searching. The lists of identified articles should be matched and combined
with each other; additional papers identified by hand-searching can then supplement the
list. For this dissertation, the PubMed (MEDLINE- National Library of Medicine) was
searched without any date restrictions. Google Scholar, Library of the Medical Center -
University of Freiburg, and the bibliographies of identified articles were then used for
hand-searching. Language limitation was applied; that is, only papers in English or
German were selected in the first screening. To avoid influence of the abnormalities on
the results, papers concerned with measurements in subjects with facial and/or dental
deformities or defects have been eliminated. To obtain the result for the natural average
value of various parameters, studies including subjects with prosthodontic or conservative
restorations in the visible area, a history of plastic or orthognathic surgery, or additional
cosmetic rehabilitations were excluded as well. Regarding the age restrictions, only
studies with the subjects 13 years of age or older were included. There was not enough
similarity between the data of the included studies to allow for statistical meta-analysis of
the sampled data.

5.1.2. The PICO format

The PICO format is a concept designed to develop a focused, researchable question. The
PICO question should be formulated based on the population (P), intervention (I),
comparison (C), and outcomes (O) principle. After performing the appropriate systematic
review, the PICO question should be answered. In this dissertation, the population (P) was
human subjects age 13 and older and the intervention (I) is aesthetic analysis.

98
The results of the measurements have been compared (C) among multiple populations, age
groups, and genders. The typical characteristics for each group, as well as the description of
the ideal human face and guidelines for comprehensive aesthetic analysis are described (O) in
this study.

5.2 Results

The comprehensive consideration of the inclusion and exclusion criteria make the results of
this review more reliable. Outcomes of the papers examined in this review could be
summarized in 2 points.

• 1. Regarding the average face, the values for average facial and dental parameters
deviate across populations, age groups, and genders (see §4.9.1 and §5.2.1).

• 2. Regarding the ideal human face, the ideal human face could be described
mathematically based on the golden rules/proportions and neoclassical canons (see
§4.9.2 and §5.2.2). But arguments about the validity, incidence in nature, and the
theoretical possibility of an ideal human face remain current topics in the literature.

5.2.1 Comparison across populations and age groups

5.2.1.1 Comparison between different populations

Variation in facial appearance is a theme which has been investigated by many authors. In
most of these studies, a comparison has been performed between the Caucasian/North
American Caucasian and other populations, and the facial features of the Asian and African
American population was determined in relation to Caucasian/North American Caucasian
populations.

Asian vs. North American Caucasian/Caucasian populations

The results of the literature showed considerable differences among the various racial groups
and populations regarding the average aesthetic parameters. Le et. al (2002) examined the
difference between the Asian and North American Caucasian (NAC) populations. In
summary, features typical of the Asian population include a significantly smaller mouth and
wider nose, shorter eye fissure, and greater interocular distance than the NAC populations.

99
Asian cohorts also showed smaller lower face heights relative to forehead height. These
results are consistent with the those of Dawei et al. (1997) and Teck et al. (2000), which
showed that Chinese women have a narrower mouth, wider nose, smaller palpebral fissure,
and wider intercanthal distance relative to NAC women.

Hwang et al. (2002) noticed another considerable difference between Korean and European-
American adults in their study. The Korean populations had more protruded lips and less
protruded chins than the EA populations. The angle of nasal inclination of the Korean adults
was less. The results of a study by Farkas et al. (2005) confirmed those of the previous studies
regarding the differences between Asian and NAC populations. They also demonstrated that
Caucasian males and Asians have wider faces, while Caucasian and Asian females have wider
chins. According to Owens et al. (2002a), Koreans have a significantly less convex profile
than the other populations. They have more acute interlabial and nasolabial angles than
Caucasians. The anteroposterior of their lips are more protruded than for Caucasians.
Regarding micro- and miniesthetics, it has been reported that the central incisor width of the
Japanese population was less than that of Caucasians, while Korean populations showed the
widest central incisors. The Japanese had the least gingival exposure at rest and during
smiling. Vig and Brundo in (1978) found no significant difference regarding tooth visibility at
rest among the Asian, African American, and Caucasian populations.

African Americans vs. North American Caucasian/Caucasian populations

Porter and Olson (2001) compared African American and NAC women. They reported that
the African American females had longer foreheads and lower face height, and shorter noses
and ear length than the NAC females, while the interocular distance, eye fissure, nasal base,
mouth, and bizygomatic distance (face width) were wider. The nasal bridge and ear
inclination were greater. Owens et al. (2002a) reported that the African Americans had the
most convex soft tissue profile, the most acute interlabial and smaller nasolabial angle, and
the most anterior position of the lips, than in any of the other populations. Regarding intraoral
parameters, it has been reported that African Americans had the greatest gingival exposure.
The width of the central incisors is similar to that of Koreans and greater than other
populations (although the difference is not significant). Apart from the aforementioned
differences in previous studies, Farkas et al. (2005) reported that although both the African
and Asian populations had wider noses than NAC, this difference was more distinctive in the

100
Africans, because Africans had similar intergonial and bizygomatic distances relative to
NAC.

Connor and Moshiri (1985) demonstrated a significantly more acute nasolabial angle in the
African American populations than the NAC due to the more protruded maxillae among
African Americans. They found longer upper lips in the African Americans, as well. Freitas et
al. (2010) compared several parameters between white and black Brazilians. They showed
that the African Americans have more strongly protruding maxillae and lips, longer upper lips
and a smaller nasolabial angle than the white population. Unlike these parameters, lip
thickness in both populations was nearly equal. The authors reported that the black population
had more inclined maxillary and mandibular incisors, likely to compensate for the maxillary
protrusion. While it has been confirmed in the literature that the African American population
has wider incisors than Caucasian population, differences regarding the tooth length between
the populations are not clearly defined.

5.2.1.2 Comparison among age groups, age related soft- tissue and dental changes

Literature describing the average values of facial and dental parameters show that aging plays
an important role in facial appearance. Two points could be mentioned to explain these age-
related soft tissue changes: the reduction in muscle tone and the increasing collagen:elastin
ratio. The age-related changes in the middle and lower parts of the face are more relevant for
dentists. However, more remarkable changes occur in the perioral region, which should be
taken into consideration to achieve satisfactory results during esthetic rehabilitation.
Depending on the perioral changes and tooth abrasion with aging, the following factors vary
in between young and old subjects: lip shape and surface, length, thickness, gingival exposure
during smile, wideness of buccal corridor and smile, and tooth exposure at rest and during
smiling.

Penna et al. (2015) classified the changing of the lip shape and lip surface during aging:

Regarding the shape: 1) Short concave upper lip with 2–3 mm of upper incisors visible and
prominent everted vermilion; 2) Moderately elongated and straighter upper lip with upper
incisors at the lower border of the upper lip and mild degree of vermilion inversion; 3)
Strongly elongated upper lip which forms a convex curve around the frontal teeth row. Upper
incisors are not visible and vermilion is inverted.

101
Regarding the surface: A) Distinct philtral columns, Cupid’s bow and white roll without static
radial wrinkles, minor dynamic radial wrinkles; B) Flattened philtral columns and Cupid’s
bow, indistinct white roll, onset of static radial wrinkles, strong dynamic radial wrinkles; C)
Invisible philtral columns, Cupid’s bow and white roll, considerable static radial wrinkles.

According Desai et al. (2009) the lip exposure of the maxillary incisors decreases 1.5-2 mm
during aging. The decrease in lip thickness is 1.5 mm from 15-year-old to 50-year-old (and
greater) subjects. In older subjects, the transversal smile width is increased and the vertical
smile width is decreased relative to young subjects. Remarkably, no high smile line has been
identified in the 50+ age group, while the 15-19y age groups did not show a low smile line.
Van der Geld et al. (2008a) reported similar outcomes; namely, that the maxillary tooth
exposure at rest and during smiling, starting with the upper lip length, can vary significantly
between the 20-25 and 50-55 age groups. They showed that the height of the lip line decrease
2mm during the spontaneous smile and 4 mm at rest position during aging processes. An
interesting outcome of this paper is that the decrease of the smile line at rest is greater than for
the spontaneous smile. The results of the Drummond and Capelli (2016) supported previous
investigations. However, a curious finding of this study was that the increasing upper lip
length and decreasing smile line in male subjects was more noticeable than for female
subjects. Not only extraoral, but also intraoral parameters are affected during aging process.
The changing features of the dental parameters through aging are the tooth surface, tooth
length (tooth proportions), and incisal line. The tooth micro- and macrotextures are reduced or
disappear with aging (Fradeani 2004; Erdemir et al. 2016). In young patients, the incisal
margin is straight and tilted buccolingually. However, in older patients, the incisal margin is
slightly convex and tooth length is decreased due to abrasion (Magne et al. 2003). The
abrasion of the maxillary incisors causes a flat or reversed incisal line, which is the typical
feature of the aging smile (Fradeani 2004; Magne et al. 2003).

Age-related changes in the perioral area have been investigated by multiple teams. Changes in
parameters resulting from perioral aging could be summarized by the following points: an
increase in upper lip length; a decrease in the smile index caused by the increasing smile
intervermillion distance and decreasing intercommissural distance; a decrease in the smile
line caused by the increasing upper lip length; a decrease in the visibility of the maxillary
incisors at rest and during smiling caused by the increasing upper lip length; a decrease in
tooth length due to abrasion; an increase in mandibular incisor visibility at rest and during

102
smiling caused the increasing upper lip length and sagging of the lower lip; disappearance of
the tooth texture; decreased tooth length; and a flat or reversed incisal line caused by a
decrease in maxillary incisor length.

5.2.2 Validity of the ideal human face in nature

Mathematic of the ideal human face is based on the neoclassical canons, golden proportions,
and golden percentage rules. There are several canonical guidelines that have been used to
describe and draw the beautiful face. Farkas et al. (1985) revised these canons and examined
their validity among North American Caucasian faces. Nine formulas of the neoclassical
canons have been described. (The relevant canons for esthetic dentistry have been described
in §3.4.1. According to this study, there are some deviations between the neoclassical canons
and the average face of North American Caucasian subjects. The features of the average face
in NAC subjects are in the following order: the nose is shorter than the ear; the intercanthal
distance is greater than the eye width; the intercanthal distance is smaller than the nose width;
the bizygomatic distance (face width) is greater than 4X the interalar distance (nose width);
and the mouth width is greater than 1.5X the interalar distance.

The profile inclination (nasal bridge, face, and lower face inclination) were the only
parameters in the average NAC face correlating with the neoclassical canons. The
neoclassical canons describe the mathematically ideal face, but these certainly do not suggest
the esthetically pleasant face. Many studies report that faces with deviation of different
parameters from neoclassical canons are more aesthetically pleasing. For example, according
to Skiles and Randal (1983), the inclination of the nasal bridge and ear are more esthetic, if
they are not ideally parallel. Torsello et al. (2010) examined the facial proportions and
validity of the neoclassical canons in 50 Italian models. According to results, the features of
the average beautiful face are in the following order: middle face height was smaller than the
lower and upper face, ear length was greater than nose length and, in 72% of the subjects, the
nasal bridge inclination was not correlated with ear inclination. Additionally, facial growth
led to age-related changes between the facial proportions. Because of alterations in mouth
width, face width, and eye fissure length, the inequalities between the nose and face, nose and
mouth, mouth and face, and interocular and eye fissure length measurements increase with
age (Farkas et al. 1985). The validity of the neoclassical canons varies across diverse
populations. Dawei et al. (1997) exhibited in their study that the correlation between the
neoclassical canons and facial proportions for Chinese populations was 21.8-51.5%, while

103
for NAC populations, the correlation was 20.4- 40.8 %. Porter and Olson (2001) have
examined the facial proportions of African American women, and found that facial features in
this population did not correlate with the neoclassical canons. Le et al. (2002) examined in
their study the validity of the neoclassical canons in Asian and NAC populations. Their
results suggested that the orbital canon (en-en ≈ ex-ex) was invalid in 98-100% of the Asian
(en-en > ex-ex) and 20% of the NAC (en-en < ex-ex) cohort. Regarding the orbitonasal
canon (en-en ≈ al-al), 76.7% of the Thai and Vietnamese population had a wider nose than the
intercanthal distance. These values were 43.8% for the Chinese cohort and 45% for NAC. The
frequency of variation for the nasoral canon (ch-ch ≈ 1.5X al-al) was 96.7-100% for the Asian
and 18.3% for the NAC population (ch-ch < 1.5X al-al). The nasofacial canon (al-al ≈ 0.25X
zy-zy) varied in 83.3-90% of the Asian (al-al > 0.25X zy-zy) and 50 % of the NAC
population (al-al< 0.25 zy-zy). Summarizing these studies, the neoclassical canons were valid
in only 1.1%-21.7% of the Asian and in 16.7%-36.7% of the NAC population.

Another commonly discussed approach to describe the beautiful face is using the Golden
proportions of the face. According to this theory, the beautiful face proportions should
correlate with the divine proportions. The commonly assumed rules based on the golden
proportions from the frontal view are as follows (Jefferson 2004; Atiyeh and Hayek, 2008;
Zhang et al. 2016): bizygomatic distance (face width)/height of the head ≈ 1/1.618; menton-
nose side/nose side-hairline ≈ 1/1.618; menton-corner of the mouth /lateral canthus of the
eyes-corner of the mouth ≈ 1/1.618; nose width/mouth width ≈ 1/1.618; nose width/distance
between the lateral point of the right and left eyes (ex-ex) ≈ 1/1.618²; nose width/distance
between the right and left face sides ≈ 1/1.618³.

In contrast to the aforementioned authors, Holland (2008), Schmid et al. (2008), and Peron et
al. (2012) supported the opinion that the beautiful face should not absolutely fit golden ratios.
Marquardt created beauty masks for females and males at rest and during smiling through the
use of pentagons and decagons, which were based on the phi ratios in their proportionality.
Moreover, Marquardt presented that beauty is not strictly dependent on the phi ratios, but
rather on variables such as the race, gender, and age. He categorized the 4 main periods of
human age (infants, children, adults, old age), 9 main racial groups (Europeans (which
include Middle Eastern and Mediterranean subsets), Eastern Indians, Asians, American
Indians, Africans, Melanesians, Micronesians, Polynesians, Australian Aborigines).

104
His description of inevitable deviations from the beauty masks and description of typical
characteristics for each age, gender, and racial group lead to increased individualization in
beauty analysis. He refused the notion that the Caucasian face is the ideal human beauty,
instead proposing that the beautiful Caucasian face is not more closely related to his beauty
mask than beautiful subjects from other racial groups. Subjects closely matching the beauty
mask were considered beautiful independent of their race. Marquardt mentioned that some
subjects in each group fit closely to the beauty mask, while other subjects show significant
deviation from the mask. But the majority of the subjects fall somewhere between these two
groups. The ability of the Marquardt beauty mask to describe the beautiful face is a
controversial topic in the literature. While some authors find the mask helpful to create
beautiful faces, other authors suggested that the mask is unsuitable for this mission. Bashour
(2006) and Kim (2007) claimed that the mask was a useful facility during facial beauty
analysis. On the contrary, Holland (2008) exhibited in his study two mean adverse opinions to
this approach. At first, the mask does not fit the aesthetic perceptions of all racial groups,
especially sub-Saharan Africans and East Asians. Secondly, the faces of white female subjects
closely matching the mask have masculinized features. But this appearance does not fulfill the
expectations and preferences of the whole population, especially because of the lacking
femininity.

Lombardi (1973) and Levin (1978) used “golden proportions” to describe the ideal
relationship between the maxillary teeth. The golden proportion is the proportion between two
parts, such that the larger part is approximately 1.61803 times larger than the smaller.
According to this rule, the width ratio between maxillary central incisors and lateral incisors
should ideally be 1.618:1, and the ratio between the width of the maxillary lateral incisors and
canines should be 1:0.618. Thus, from the frontal view, the apparent width of the maxillary
central incisor is 60% wider than the maxillary lateral incisor, which is in turn 60% wider
than the apparent width of the maxillary canines (Lombardi 1973; Levin 1978). On the other
hand, Preston (1993) demonstrated that the golden proportion appears only rarely in the
natural dentition. According to the results of the study, the golden proportion was found
between the central and lateral maxillary incisors at a frequency of 17% and never observed
between the lateral incisors and canines (Figure 4.10). Wolfart et al. (2004) determined the
golden range for the relationship between the width of the maxillary lateral and central
incisors. They found that a 56-68% ratio between the maxillary lateral and the central incisors
is most attractive according to dentists, while medical students and patients estimate a 50-

105
-74% ratio between the maxillary lateral and central incisors as the most attractive. In another
concept from Snow (1999) (the “golden percentage” concept), the anterior segment of the
maxilla, which consists of the six maxillary anterior teeth, creates an area which sums to
100%. The apparent width from the frontal view of each anterior tooth comprises this anterior
segment. The ratio for the maxillary central and lateral incisors and canines are
25%:15%:10%, respectively, per left and right side (Figure 4.10). In a further study, the
authors conclude that the golden proportions and the golden percentage are not central factors
playing a decisive role in dental aesthetics (Ong et al. 2006). To describe the optimal tooth-to-
tooth relationship, Chu (2007) developed another concept, according to which the pleasing
tooth composition is as follows: the maxillary lateral incisors should be 2mm and the
maxillary canine should be 1mm narrower than the maxillary central incisors (Figure 4.10).

5.3 Facial parameters necessary for facilitating collaboration between

dentists and plastic surgeons in comprehensive aesthetic rehabilitation

Pleasing facial aesthetics arise through harmony between the pleasing parameters of the face.
All such parameters interact with each other and influence the choice and arrangement of
prosthetic reconstructions directly or indirectly. Parameters which must be considered when
planning prosthetic rehabilitation absolutely include those of the lower face and some of the
parameters of the middle face. In particular, the nasolabial angle, lip thickness, lip length, lip
prominence, and mouth width should be evaluated and optimized to create pleasing aesthetic
results during the prosthetic rehabilitation. The aforementioned factors play an important role
in determining prospective tooth length and vertical position, prospective anteroposterior
tooth position, and inclination for creating pleasing teeth and gingival exposure, and a
beautiful smile.

Nasolabial angle depends on several factors: anteroposterior position of the maxillae and
maxillary incisors, lip prominence, lip thickness, and the vertical position and rotation of the
nasal tip. In cases of obtuse or flat nasolabial angles, plastic surgeons should evaluate all of
the aforementioned factors to determine which, if any, deviate from normal and should be
corrected - for example, nasal tip rotation and/or lip thickness. The mean value of the
nasolabial angle was determined to be 90-95° in men and 100-105° in women (Rohrich and
Bell, 1992). Brown and Guyuron (2013) defined the ideal nasolabial angle in their study.
They concluded that the aesthetically ideal female nasolabial angle is 96.8°- 100.2° and the

106
ideal male nasolabial angle is 93.9°- 97.3°. In rhinoplasty, the ideal nasolabial angle varies
between 90° and 120°. The most pleasant nasolabial angle is 100.9°- 108.9° for females and
90.7°- 103.3º for male subjects (Sinno et al. 2014).

Lip parameters: The reference line for the anteroposterior lip position is the E-Line (Esthetic
line), drawn from the tip of the nose to the tip of the chin. It varies depending on lip
protrusion, lip thickness, maxillary protrusion, prominence of the nasal tip, chin protrusion, or
any combination of these parameters. The E-Line is helpful for arranging the anteroposterior
position and inclination of the teeth, but is not the sole determining factor. During aesthetic
rehabilitation, the pleasantness of the lip prominence should be determined first, and any
corrections necessary for creating an aesthetic appearance should be performed. The
corrections could be performed through plastic surgical procedures, but the appropriate
anteroposterior tooth position is necessary to obtain a pleasant lip protrusion. Through the
analysis of the portraits of popular actresses in 1957, it has been determined that the lower lip
is roughly two and the upper lip is four millimeters posterior to the E-Line in a pleasant facial
profile (Ricketts 1957). Based on this study, variations in lip position could be classified as
either anterior and posterior. Owens et al. (2002a) compared the relationship between lip
position and the E-line in various racial groups. African Americans show the most anterior lip
position. The average lip-to-E-line distances are +0.3 (lips located anterior to the E-line) and
+2.9 (lips located anterior to the E-line) in the upper and lower lips, respectively. Conversely,
Caucasians have the greatest degree of lip retroposition. The upper lip position is on average
7.5 mm, and the lower lip position is on average 5.2 mm posterior to the E-line (Owens et al.
2002b). Matoula and Pancherz (2006) showed that the mean distance of the upper lip to the E-
line is 3.27 mm (lips located posterior to the E-line), and the average distance between the
lower lip and E-line is -2.55 mm (lips located posterior to the E-line) in attractive female
patients. Evaluating for aesthetic preferences in different races, Nomura et al. (2009)
concluded that the preferred mean distance from the lip position to the E-line is -2.86 mm for
both male and female subjects. According to this study, all patient groups with lip positions
posterior to the E-line are preferred by the observer groups. Hispanic American and Japanese
observers preferred less prominent lip profiles. During treatment planning, the race and
gender of the patient should be taken into consideration. The differences among racial groups
are described in §4.9.1. Subject perioral aging is the one of the considerable factors in
achieving satisfactory results during the esthetic rehabilitation.

107
Based on the classification of Penna et al. (2015) (§5.2.1.1) the treatment options can be
summarized in the following order.

Group 1- rejuvenation not necessary; Group 2 - tailor structural and volume augmentation to
increased length—discuss shortening procedure; Group 3 - Lip lift- Careful with isolated
augmentation.

Group A- rejuvenation not necessary; Group B- Evaluate resurfacing with laser or peeling,
add definition to white roll and philtrum with fillers or fat; Group C- Deeper resurfacing,
filler/fat for vertical rhytides and restoration of lip structure more.

For the ideal treatment planning, plastic surgeons should evaluate all of the lip parameters and
use combinations treatment options, especially in Class 2 and 3 with B and C. Plastic
surgeons use some reference measurement during lip correction or rejuvenation procedures.
For example, according to Conconi, the upper lip vermillion height is 2/5 and lower lip
vermillion height 3/5 of the total vermillion height. While the upper lip vermillion height
varies between 9 and 12 mm, the lower lip vermillion height ranged from 16 to 18mm. The
difference between the genders are observable in the results tables. It is clear from the results
that the nasolabial angle is more obtuse in males than in females, the latter having a shorter
upper lip and increased tooth and gingival margin visibility at rest and during smiling.

5.4. Proposed guidelines for the interdisciplinary treatment planning

During the analysis, it should not be forgotten, that all of the abovementioned results are a
summary of the literature and they are valid in most but not all cases. The individual
parameters for example: the form and proportions of the face, proportions, height and mass of
the body are the considerable factors, that can be indirectly helpful during the final treatment
planning. The dental aesthetics should not be imagined separately, but as a part of the whole
facial aesthetic, and should be integrated in the whole human beauty. Based on the
aforementioned facts, a mutual collaboration between the plastic surgeons and the dentists is
not only recommended but also necessary in order to achieve the best aesthetic results. Figure
5.1 (5.1.1; 5.1.2; 5.1.3) describes the proposed workflow of the comprehensive aesthetic
rehabilitation, which can be helpful as guidelines during the interdisciplinary rehabilitation.
The description of the mutual workflow of different cases shows that the main steps of the
treatment planning is almost identical. The interdisciplinary treatment planning begins with
the diagnostic Wax-up+ Mock-up which define the prospective incisal edge position, the

108
thecourse of the gingival margin line, tooth length, tooth display at rest, in addition to tooth
and gingival display during smile. Mock-up is also the base of the following steps like the
temporalization (if necessary), orthodontic treatment (if necessary) and surgical crown
lengthening or shortening which are the initial steps of the interdisciplinary treatment. The
orthognathic surgical procedures and soft tissue corrections are performed depending on case,
additionally. The treatment ends with the definitive prosthodontic rehabilitation, if required.
The workflow could be performed as digital or analog. Because of some lacks in the digital
workflow, such as only 2D information, absence of the simulation of the patients’ mimics
during analysis, the analog workflow remains the more preferred way under the available
circumstance in modern digital dentistry. But the digital workflow facilitates the
communication between the plastic surgeons, dentists and dental technician, and leads to
time- saving during the treatment planning. Because of these advantages, there is an absolute
necessity for the innovations in the digital dentistry. For example: to perform the digital
workflow, the development of the digital planning program would be valuable, because it
facilitates the performing the facial and dental manipulation together (as one step), it gives us
3D information of the individual characteristics, and allows the simulation of the patient
mimics. Collaboration between the plastic surgeons and dentist could be supported through
this kind of program. Because of all facial and dental manipulations could be performed
through one program and at the same time, the timespan to create the rational planning would
be reduced.

109
 Patient with request of eshetic
Plastic surgeon Dentist
rehabilitation

1. Interview, communication with patient

• get information about the patient's name and age
• get information about the patient's requests and expectations
• get information about the patient’s psychosocial, emotional, social
status
• set up the patient's awareness

2. Medical history

General medical anamnesis Dental Anamnesis

3. Collecting data

Extraoral
Radiograph Intraoral
Image capture Dental
• facial photographs Periodontal
• lip Functional
Video capture Prosthodontic
• during speech, Impression for casts
• during smiling, Image capture: intraoral
• during the
pronunciation "s",
"m", "e", "f" sounds

4. Possible cases

Insufficient or no Excessive gingiva

exposure during Prominent lip Insufficient lip
exposure of the projection projection
maxillary central smile (gummy
smile) (Figure 5.1.3) (Figure 5.1.3)
incisors at rest.
(Figure 5.1.1) (Figure 5.1.2)

Figure 5.1: Proposed workflow for the comprehensive esthetic rehabilitation.

110
 Patient with insufficient or no
Plastic surgeon exposure of the maxillary central Dentist
incisors at rest

5. Analysis

Tooth exposure at rest and during smiling

Phonetic analysis
Relation between the smile line and lower lip
line
Gingival exposure during smile Tooth length and width & tooth
Negative space proportions
Interlabial gap at rest Shape and length of root
Upper and lower lips length & upper/lower Vertical dimension
lip proportions Overjet & overbite
Height of the maxillae
Lower face height and horizontal face
proportions

6. Diagnosis (Cause of the case)

Long upper Short Combination

lip maxillary of these
teeth factors

7. Treatment planning

Definition of the incisal edge position, course of the gingival margin line, tooth
length, tooth display at rest, tooth+ gingival display during smile
(Diagnostic Wax-up (digital or analog) –> Mock-up –> Temporaries according to the
Mock-up (if necessary)

Aesthetic analysis with Mock-up or temporaries (digital or analog) –> Planning of the
necessary corrections and the procedures

8. Plastic, surgical and orthodontic treatment

Orthodontic treatment

Surgical crown lengthening

Lip shortening
procedures

9. Definitive prosthodontic treatment (if necessary)

Figure 5.1.1: Proposed workflow for the comprehensive aesthetic rehabilitation: Patient with
insufficient or no exposure of the maxillary central incisors at rest.

111
 Patient with excessive gingiva
Plastic surgeon exposure during smile (gummy smile) Dentist

5. Analysis

Tooth exposure at rest and during smiling

Phonetic analysis
Relation between the smile line and lower lip
line Tooth length and width & tooth
Negative space proportions
Interlabial gap at rest Periodontal support of the teeth
Upper and lower lips length & upper/lower lip Shape and length of root
proportions Vertical dimension
Gingival exposure at rest Overjet & overbite
Mobility of the upper lip
Lower face height and horizontal face
proportions
Height of the maxillae

6. Diagnosis (Cause of the case)

Excessive
maxillary Altered Combination
Hyperactive Short
growth
Dentoalveolar
passive of several
upper lip upper lip extrusion
(maxillary eruption factors
hypertrophy)

7. Treatment planning

Definition of the incisal edge position, course of the gingival margin line, tooth
length, tooth display at rest, tooth+ gingival display during smile
(Diagnostic Wax-up (digital or analog) –> Mock-up –> Temporaries according to the
Mock-up (if necessary

Aesthetic analysis with Mock-up or temporaries (digital or analog) –> Planning of the
necessary corrections and the procedures

8. Plastic, surgical and orthodontic treatment

Orthodontic
Orthognatic treatment
surgery
Botox
Lip
lengthening Surgical crown
lengthening

9. Definitive prosthodontic treatment (if necessary)

Figure 5.1.2: Proposed workflow for the comprehensive aesthetic rehabilitation: Patient with
excessive gingiva exposure during smile (gummy smile).

112
 Patient with prominent or with
Plastic surgeon Dentist
insufficient lip projection

n
5. Analysis

Tooth exposure at rest and during smiling

Phonetic analysis
Relation between the smile line and lower lip line
Interlabial gap at rest
Anteropsoterior lip postion: Relation with E- Line, B-Line,
S-Line, TVL line (if another facial and nasal parameters Tooth length and width & tooth
are in aveage range) proportions
Nasolabial angle (if nasal tip rotation is in average range) Periodontal support of the teeth
Upper and lower lips length & upper/lower lip proportions Shape and length of root
Lips thickess Overjet and Overbite
Lips volume
Height of the upper and lower vermillion border& its
relation to each other
Anteroposterior position of the maxillae and mandibular
(chin analysis)
Profile convexity

6. Diagnosis (Cause of the case)

Maxillomandibular Dental Combination

Thick or thin protrusion or protrusion or of several
lips retrusion retrusion factors

7. Treatment planning

Definition of the incisal edge position, course of the gingival margin line, tooth length,
tooth display at rest, tooth+ gingival display during smile
(Diagnostic Wax-up (digital or analog) –> Mock-up –> Temporaries according to the
Mock-up (if necessary)

Aesthetic analysis with Mock-up or temporaries (digital or analog) –> Planning of the
necessary corrections and the procedures

8. Plastic- surgical and orthodontic treatment

Appropriate lip procedures Orthognatic surgery Orthodontic retrusion

(lip shortening or or protrusion
lengthening, lip (If necessary, apical or
augmentation, or coronal positioned
combination of its) flap)

9. Definitive prosthodontic treatment (if necessary)

Figure 5.1.3: Proposed workflow for the comprehensive aesthetic rehabilitation: Patient with
prominent or with insufficient lip projection.

113
6. Conclusion

It can be concluded from this study that no strict guidelines exist for creating an aesthetic
appearance, and that the mathematical standardization of aesthetics should be avoided. First,
it has been established that subjects with small asymmetries have a more natural appearance,
which is esthetically preferred by contemporary clinicians and society. Next, each population,
age group, and gender has its own expectations and preferences regarding the concept of
beauty. Finally, facial appearance should correlate with the anatomical individuality and body
proportions of each subject. Therefore, the described guidelines, related existing deviations,
and the special features of the beautiful face across various populations – which are described
in this study – are only guiding factors for dentists and plastic surgeons during design of an
esthetically pleasant face, taking into consideration each patient’s own requests. Additionally,
the proposed comprehensive aesthetic treatment workflow can be used as a guideline to foster
mutual collaboration between plastic surgeons and dentists.

114
7. Summary

Aim of the study: The aim of this systematic review is to demonstrate the ideal human face,
average values of facial parameters in various populations, as well as the interaction between
plastic surgery and aesthetic dentistry.

Materials and methods: This systematic review was performed according to the Preferred
Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. An
electronic search for suitable articles for this systematic review was performed in the PubMed
database (MEDLINE - National Library of Medicine). The articles were not limited with
respect to publication date. Determined search terminologies for the systematic review are in
the following order: “Aesthetic”, “Esthetics”, “Dentistry”, “Guidelines”, “Analysis”,
“Beauty”, “Face”, “Lip”, and “Nose”. Hand-searching was performed in Google Scholar,
Library of the Medical Center - University of Freiburg, and in the bibliographies of identified
articles. Inclusion and exclusion criteria are determined. Papers remaining after the review of
abstracts were included in the full-text analysis. Initial full-text analyses were performed for
potential exclusion of articles for which irrelevance could not be determined from title and
abstract alone. During a second full-text analysis, the data was extracted from studies which
met the inclusion criteria, but don’t fall within the scope with this review.

Results: The description of the ideal human face has been found from the literature.
Nevertheless, the results revealed that, each population owns distinctive facial parameters,
which create the specific face appearance for this population. Consequently, characteristic
aesthetical features of each group vary from the above described ideal human face. That is,
the founded ideal human face can be used as a guide for plastic surgeons and dentists, but
should not be the only aim during the aesthetic rehabilitation.

Conclusion: It can be concluded from this study that no strict guidelines exist for creating an
aesthetic appearance, and that the mathematical standardization of aesthetics should be
avoided. The described guidelines, related existing deviations, and the special features of the
beautiful face across various populations – which are described in this study – are only
guiding factors for dentists and plastic surgeons during design of an esthetically pleasant face,
taking into consideration each patient’s own requests.

115
8. Zusammenfassung

Ziel der Studie: Das Ziel dieser systematischen Übersichtsarbeit besteht darin, das ideale
menschliche Gesicht, die Durchschnittswerte von Gesichtsparametern in verschiedenen
Populationen sowie die Zusammenarbeit zwischen plastischer Chirurgie und ästhetischer
Zahnmedizin zu demonstrieren.

Materialien und Methoden: Diese systematische Übersichtsarbeit wurde gemäß den

Richtlinien für „Preferred Reporting Items for Systematic Reviews and Meta-Analyses
(PRISMA)“ durchgeführt. Eine elektronische Suche nach geeigneten Studien für diese
systematische Übersichtsarbeit wurde in der PubMed-Datenbank (MEDLINE - National
Library of Medicine) durchgeführt. Entschlossene Suchterminologien für die systematische
Übersichtsarbeit sind in der folgenden Reihenfolge: "Ästhetik", "Zahnmedizin", "Richtlinien",
"Analyse", "Schönheit", "Gesicht", "Lippe" und "Nase". Handsuche wurde in Google Scholar,
Bibliothek des Medizinischen Zentrums - Universität Freiburg, und in den
Literaturverzeichnissen der identifizierten Studien durchgeführt. Ein- und Ausschlusskriterien
wurden festgelegt. Nach der Überprüfung der Abstracts verbleibende Studien wurden in die
Volltextanalyse einbezogen. In der Volltextanalyse wurden die Daten aus Studien extrahiert,
die die Einschlusskriterien erfüllten aber für diese systematische Übersichtarbeit irrelevant
sind.

Ergebnisse: Die Beschreibung des idealen menschlichen Gesichts in der Literatur wurde
erfunden. Dennoch zeigten die Ergebnisse der Übersichtsarbeit, dass jede Population,
Altersgruppe und jedes Geschlecht für jeden Parameter unterschiedliche Mittelwerte
aufweisen. Das heißt, dass ideale menschliche Gesicht als Leitfaden für plastische Chirurgen
und Zahnärzte dienen kann, sollte aber nicht das einzige Ziel bei der ästhetischen
Rehabilitation sein.

Schlussfolgerung: Es kann zusammengefasst werden, dass es keine strenge Richtlinien gibt,

um ein ideales ästhetischen Aussehen herzustellen und „Ästhetik“ nicht mathematisch zu
standardisieren ist. Die beschriebenen Richtlinien, Mittelwerte jeden Parameters für ein
schönes Gesicht in verschiedenen Populationen, die in dieser Studie beschrieben wurden, sind
nur die Faktoren, die die Zahnärzten und plastischen Chirurgen führen können, um eine
ästhetisch angenehmes Gesicht unter Berücksichtigung von Patientenwünsche zu erzeugen.

116
9. Bibliography

Ackerman, M. B.; Ackerman J. L. (2002): Smile analysis and design in the digital era. J Clin
Orthod 36(4),221-236.

Ahmad, I. (2004): Digital and conventional dental photography: a practical clinical manual.
Chicago, Quintessence.

Ahmad, I. (2005): Anterior dental aesthetics: Dental perspective. Br Dent J 199(3),135-141

Al Wazzan, K. A. (2004): The visible portion of anterior teeth at rest. J Contemp Dent Pract
5(1),53-62.

Al-Habahbeh, R., Al-Shammout,R., Al-Jabrah, O., Al-Omari, F. (2009): The effect of gender
on tooth and gingival display in the anterior region at rest and during smiling. Eur J Esthet
Dent 4(4),382-395.

Al-Jasser, N. M. (2000): Cephalometric evaluation of craniofacial variation in normal Saudi

population according to Steiner analysis. Saudi Med J 21(8),746-750.

Al-Jasser, N. M. (2003): Facial esthetics in a selected Saudi population. Saudi Med J

24(9),1000-1005.

Al-Jasser, N. M. (2005): Cephalometric evaluation for Saudi population using the Downs and
Steiner analysis. J Contemp Dent Pract 6(2),52-63.

Al-Johany, S. S., Alqahtani, A.S., Alqahtani, F.Y., Alzahrani, A.H. (2011): Evaluation of
different esthetic smile criteria. Int J Prosthodont 24(1),64-70.

Alcalde, R. E., Jinno, T., Orsini, M. G., Sasaki, A., Sugiyama, R. M., Matsumura; T., (2000):
Soft tissue cephalometric norms in Japanese adults. Am J Orthod Dentofacial Orthop.
118(1),84-89.

Anderson, K. M., Behrents, R. G., McKinney, T., Bushgang, P. H. (2005): Tooth shape
preferences in an esthetic smile. Am J Orthod Dentofacial Orthop 128(4),458-465

Anic-Milosevic, S., Lapter-Varga, M., Slaj, M. (2008): Analysis of the soft tissue facial
profile by means of angular measurements. Eur J Orthod 30(2),135-140.

117
Anic-Milosevic, S., Mestrovic, S., Prlic, A., Slaj, M. (2010): Proportions in the upper lip-
lower lip-chin area of the lower face as determined by photogrammetric method. J
Craniomaxillofac Surg 38(2),90-95.

Anic-Milosevic, S., Anic-Milosevic, S., Lapter-Varga, M., Dumancic, J., Slaj, M. (2011):
Analysis of the soft tissue profile in Croatians with normal occlusions and well-balanced
faces. Eur J Orthod 33(3),305-310.

Armijo, B. S., Brown, M., Guyuron, B.(2012): Defining the ideal nasolabial angle. Plast
Reconstr Surg 129(3),759-764.

Arnett, G. W., Jelic, J. S., Kim, J., Cummings, D.,V., Beress, A., Worley, C. M., Chung, B.,
Bergman, B. (1999): Soft tissue cephalometric analysis: diagnosis and treatment planning of
dentofacial deformity. Am J Orthod Dentofacial Orthop. 116(3),239-253.

Ash, M. M.; Nelson. J. S. (2003). Wheeler's dental anatomy, physiology, and occlusion,
Elsevier Health Sciences, Philadelphia.

Atiyeh, B. S.; Hayek, S. N. (2008): Numeric expression of aesthetics and beauty. Aesthetic
Plast Surg 32(2),209-216.

Att, W.; Girard, M. (2014): Digital workflow in reconstructive dentistry. In: J. L. Ferencz, N.
R. F. A. Silva and J. M. Navarro High-strength ceramics: Interdisciplinary
perspectives.Quintessence, Chicago, 261-277.

Basciftci, F. A., Uysal, T., Buyukerkmen, A., Demir, A. (2003): Determination of Holdaway
soft tissue norms in Anatolian Turkish adults. Am J Orthod Dentofacial Orthop. 123(4),395-
400

Bashour, M. (2006): An objective system for measuring facial attractiveness. Plast Reconstr
Surg 118(3),757-774;

Batwa, W., Hunt, N. P., Petrie, A., Gill, D. (2011): Effect of occlusal plane on smile
attractiveness. Angle Orthod 82(2),218- 223

Baum, S. (1982): Introduction. Ear Nose Throat J 61,426-428.

Bengel, W. (2006). Mastering digital dental photography. Quintessence, London.

118
Bhayana, G., Atreja, S. H., Atreja, G., Juneja, A., Kumar, A. (2015): Virtual articulators in
prosthodontics: a future oriented technology. Am J Oral Medicine Rad 2(4),217- 220.

Bhuvaneswaran, M. (2010): Principles of smile design. J Conserv Dent. 13(4),225-232.

Bidra, A. S. (2011): Three dimensional esthetic analysis in treatment planning for implant
supported fixed prosthesis in the edentulous maxilla: review of the esthetics literature. J
Esthet Restor Dent. 23(4),219-236

Bisson, M.; Grobbelaar A. (2004): The esthetic properties of lips: a comparison of models and
nonmodels. Angle Orthod 74(2),162-166.

Boehler, W.; Marbs A (2002). 3D scanning instruments. Proceedings of the CIPA WG 6

International Workshop on Scanning for Cultural Heritage Recording, Thessaloniki, Ziti.

Borman, H., Ozgur., F., Gursu, G. (1999): Evaluation of soft-tissue morphology of the face in
1,050 young adults. Ann Plast Surg 42(3),280-288.

Brand, R. W.; Isselhard D. E. (2013). Anatomy of Orofacial Structures: A Comprehensive

Approach, Elsevier Health Sciences, Saint Louis.

Brown, M.; Guyuron, B (2013): Redefining the ideal nasolabial angle: Part 2. Expert analysis.
Plast Reconstr Surg 132(2),221-225.

Burstone, C. J. (1967): Lip posture and its significance in treatment planning. Am J Orthod
53(4),262-284.

Calamia, J. R., Levine, J. B., Lipp, M., Cisneros G., Wolff, M. S. (2011): Smile design and
treatment planning with the help of a comprehensive esthetic evaluation form. Dent Clin
North Am 55(2),187-209

Calamia, J. R.; Wolff M. S. (2015): The Components of Smile Design: New York University
Smile Evaluation Form Revisited, Update 2015. Dent Clin North Am 59(3),529-546.

Calcada, D., Correia, A., Araujo, F. (2014): Anthropometric analysis of anterior maxillary
teeth with digital photography - a study in a Portuguese sample. Int J Esthet Dent 9(3),370-
380.

119
Câmara, C. A. (2010): Esthetics in Orthodontics: six horizontal smile lines. Dental Press J
Orthod 15(1),118-131

Cao, Z., Yin.Q., Tang, X., Sun, J, (2010). Face recognition with learning-based descriptor.
23rd IEEE Conference on computer vision and pattern recognition, Institute of Electrical and
Electronics Engineers (IEEE), San-Francisco.

Chetan, P., Tandon, P., Singh, G. K., Nagar, A., Prasad, V., Chugh, V. K. (2012): Dynamics
of a smile in different age groups. Angle Orthod 83(1),90-96

Chiche, G.; Pinault, A. (1994): Artistic and scientific principles applied to esthetic dentistry.
In: G. Chiche and A. Pinault Esthetics of anterior fixed prosthodontics, Quintessence,
Chicago 13- 32.

Chiu, C. S.; Clark R. K. (1992): The facial soft tissue profile of the southern Chinese:
prosthodontic considerations. J Prosthet Dent 68(5),839-850.

Choe, K. S., Sclafani, A. P., Litner, J. A., Yu, G., Romo, T. (2004): The Korean American
woman's face: anthropometric measurements and quantitative analysis of facial aesthetics.
Arch Facial Plast Surg 6(4),244-252.

Choi, B., Baek, S. H., Yang, W. S., Kim, S. (2000): Assessment of the relationships among
posture, maxillomandibular denture complex, and soft-tissue profile of aesthetic adult Korean
women. J Craniofac Surg 11(6),586-594.

Choi, J. Y., Lee, S. H., Baek, S. H. (2013): Effect of various facial angles and measurements
on the ideal position of the nasal tip in the Asian patient population. JAMA Facial Plast Surg
15(6),417-421.

Chu, S. J. (2007): Clinical steps to predictable color management in aesthetic restorative

dentistry. Dent Clin North Am 51(2),473-485.

Cintra, O., Coachman, C., Da Silva, L. C., Santos, T. (2012): Standartized digital photography
for virtual orthognatic surgical planning. Selected Reading Oral Maxillofac Surg 20(3),2-18.

Clark, J. R., Hutchinson, I., Sandy, J. R. (2001): Functional occlusion: II. The role of
articulators in orthodontics. J Orthod 28(2),173-177.

120
Clinical photgraphy guidelines (2014). Academy of Laser Dentistry’s Annual Conference.
Scottsdale.

Condon, M., Bready, M., Quinn, F., O´Connel, B. C., Houston, F. J., O´sulivan, M. (2011):
Maxillary anterior tooth dimensions and proportions in an Irish young adult population. J
Oral Rehabil 38(7),501-508

Connor, A. M.; Moshiri. F(1985): Orthognathic surgery norms for American black patients.
Am J Orthod 87(2),119-134.

Crumley, R. L.; Lanser. M (1988): Quantitative analysis of nasal tip projection. Laryng.
98(2),202-208

D'Apuzzo, N. (2006). Overview of 3D surface digitization technologies in Europe. Three-

Dimensional Image Capture and Applications VII, San Jose, SPIE- International Society for
Optics and Photonics.

Da Silveira, A. C., Daw, J. L., Kusnoto, B., Evans, C., Cohen, M. (2003): Craniofacial
applications of three-dimensional laser surface scanning. J Craniofac Surg. 14(4),449-456

Daniels, C.; Richmond, S. (2014): The development of the index of complexity, outcome and
need (ICON). J Orthod 27(2),149-162.

Dawei, W., Guozheng, Q., Mingli, Z., Farkas, L. G. (1997): Differences in horizontal,
neoclassical facial canons in Chinese (Han) and North American Caucasian populations.
Aesthetic Plast Surg 21(4),265-269.

Demirel, K. (2016): Soft tissue considerations in the management of diastemas. In: E. Yildiz,
T. Yucel, U. Erdemir and D. G. Cakan Esthetic and functional management of
diastema.Springer, Switzerland, 121-129.

Desai, S., Upadhyay, M., Nanda, R. (2009): Dynamic smile analysis: changes with age. Am J
Orthod Dentofacial Orthop 136(3),310.e311-310.

Desai, V., D. Bumb (2013): Digital dental photography: a contemporary revolution. Int J Clin
Pediatr Dent 6(3),193-196.

Dong, J.-K., Jin, T., Cho, H., Oh, S. (1998): The esthetics of the smile: a review of some
recent studies. Int J Prosthodont 12(1),9-19

121
Dong, Y., Zhao, Y., Bai, S., Wu, G., Wang, B. (2010): Three-dimensional anthropometric
analysis of the Chinese nose. J Plast Reconstr Aesthet Surg 63(11),1832-1839

Douglass, C. W., C. G. Sheets (2000): Patients' expectations for oral health care in 21st
century. J Am Dent Assoc. 131(Supplement 1),3-7.

Drummond, S., J. Capelli Jr (2016): Incisor display during speech and smile: Age and gender
correlations. The Angle Orthodontist 86 (4), 631-637

Eli, L., Bar-Tat, Y., Kostovetzki, I. (2001): At first glance: social meanings of dental
appearance. J Public Health Dent. 61(3),150-154

Eliakim-Ikechukwu, C., Ekpo, A., Etika, M., Ihentuge, C. (2013): Facial aesthetic angles of
the Ibo and Yoruba ethnic groups of Nigeria. IOSR J Pharm Biol Sci. 5, 14-17

Mesembe, O., Erbay, E. F.; Caniklioğlu, C. M. (2002): Soft tissue profile in Anatolian
Turkish adults: Part II. Comparison of different soft tissue analyses in the evaluation of
beauty. Am J Orthod Dentofacial Orthop. 121(1),65-72

Erbay, E. F., Caniklioğlu, C. M., Erbay, S. K. (2002): Soft tissue profile in Anatolian Turkish
adults: Part I. Evaluation of horizontal lip position using different soft tissue analyses. Am J
Orthod Dentofacial Orthop 121(1),57-64.

Erdemir, U., Yucel, T., Yildiz, E., Cakan, D. G., Sayinsu, K. (2016): Dental analysis. In: E.
Yildiz, T. Yucel, U. Erdemir and D. G. Cakan Esthetic and functional management of
diastema.Springer, Switzerland, 101-120.

Fanous, N. (1987): Aging lips. Esthetic analysis and correction. Facial Plast Surg 4(3),179-
183.

Farkas, L. G., Hreczko, T. A., Kolar, J. C., Munro, L. R. (1985): Vertical and horizontal
proportions of the face in young adult North American Caucasians: revision of neoclassical
canons. Plast Reconstr Surg 75(3),328-337.

Farkas, L. G., Katic, M. J., Forrest, C. R. (2005): International anthropometric study of facial
morphology in various ethnic groups/races. J Craniofac Surg 16(4),615-646

122
Farkas, L. G., Katic, M. J., Forrest, C. R. (2007): Comparison of craniofacial measurements
of young adult African-American and North American white males and females. Ann Plast
Surg 59(6),692-698

Farkas, L. G., Katic, M. J., Hreczko, T. A., Deutsch, K., Munro, L. R. (1984): Anthropometric
proportions in the upper lip-lower lip-chin area of the lower face in young white adults. Am J
Orthod 86(1),52-60

Fernandez-Riveiro, P., Smyth-Chamosa, E., Suarez-Quintanilla, D., Suarez-Cunquerio, M.

(2003): Angular photogrmmetric analysis of the soft tissue facial profile. Eur J Orthod
25(4),393-399.

Fernandez-Riveiro, P., Suarez-Quintanilla, D., Smyth-Chamosa, E., Suarez-Cunquerio, M.

(2002): Linear photogrammetric analysis of the soft tissue facial profile. Am J Orthod
Dentofacial Orthop 122(1),59-66.

Ferrario, V. F., Sforza, C., Serrao, G. (2000): A three-dimensional quantitative analysis of

lips in normal young adults. Cleft Palat E Craniofac J 37(1),48-54

Ferring, V., H. Pancherz (2008): Divine proportions in the growing face. Am J Orthod
Dentofacial Orthop 134(4),472-479.

Fortes, H. N., Guimaraes, T. C., Belo, I. M., da Matta, E. N. (2014): Photometric analysis of
esthetically pleasant and unpleasant facial profile. Dental Press J Orthod 19(2),66-75.

Fradeani, M. (2004). Esthetic analysis: a systematic approach to prosthetic treatment,

Quintessence, Chicago.

Freitas, L. M. A. d., Freitas, K. M. S. d. et al., Pinzan A., Janson G., Freitas M. R. d. (2010):
A comparison of skeletal, dentoalveolar and soft tissue characteristics in white and black
Brazilian subjects. J. Appl. Oral Sci. 18(2),135-142

Galloway, T., Renner, G. (2012): Facial Buttress System. In: T. Galloway and G. Renner
Midface Trauma.Springer, Berlin, 25.

Gateno, J., Xia, J. J., Teichgraber, J. F. (2011): New 3-dimensional cephalometric analysis for
orthognathic surgery. J Oral Maxillofac Surg 69(3),606-622.

123
Gibelli, D., Codari, M., Rosati, R., Dolci, C., Tartaglia, G. M., Cattaneo, C., Sforza, C.
(2015): A Quantitative Analysis of Lip Aesthetics: The Influence of Gender and Aging.
Aesthetic Plast Surg 39(5),771-776.

Gillen, R. J., Schwartz, R. J., Hilton, T. J., Evans, D. B. (1994): An analysis of selected
normative tooth proportions. Int J Prosthodont 31(10), 1543-1554.

Gode, S., Tiris, F. S., Akyildiz, S., Apaydin, F. (2011): Photogrammetric analysis of soft
tissue facial profile in Turkish rhinoplasty population. Aesthetic Plast Surg 35(6),1016-1021.

Goode, R. L. (1984): Personal communications,Proprotions of the aesthetic face. Thiem-

Stratton, New York.

Grammer, K., Thornhill, R. (1994): Human (Homo sapiens) facial attractiveness and sexual
selection: the role of symmetry and averageness. J Comp Psychol 108(3), 233-242.

Gurel, G. (2003). The Science and Art of Porcelain Laminate Veneers. Quintessence,
Chicago.

Guyer, P. (2008): 18th century german aesthetics. In: Stanford Encyclopedia of Philosophy.

Hajeer, M. Y., Millett, D. T., Ayoub, A. F., Siebert, J. P. (2004): Current Products and
Practices: Applications of 3D imaging in orthodontics: Part I. J Orthod 31(1),62-70

Hasanreisoglu, U., Berksun, S., Aras, K., Arslan. (2005): An analysis of maxillary anterior
teeth: facial and dental proportions. J Prosthet Dent 94(6),530-538.

He, Z. J., Jian, X. C., Wu, X.S, Gao, X., Zhou, S. H., Zhong, X. H. (2009): Anthropometric
measurement and analysis of the external nasal soft tissue in 119 young Han Chinese adults. J
Craniofac Surg 20(5),1347-1351.

Hess, L. A. (2006): Countinuing education; Determining the correct certical and horizontal
incisal edge position. Clinical Materials 129(6),775-784.

Hochman, M. N., Chu, S. J. (2012): Maxillary anterior papilla display during smiling: a
clinical study of the interdental smile line. Int J Periodontics Restorative Dent 32(4),375-383.

Holland, E. (2008): Marquardt’s Phi Mask: pitfalls of relying on fashion models and the
golden ratio to describe a beautiful face. Aesthetic Plast Surg 32(2),200-208

124
Hu, X., Lin, Y., Heberer, S., Nelson, K. (2012): Analysis of soft tissue display in Chinese
subjects during an enjoyment smile. Quintessence Int 43(2),105-110.

Hu, X., Lin, Y., Heberer, S., Nelson, K. (2013): Analysis of soft tissue display during
enjoyment smiling: part 1--Caucasians. Int J Periodontics Restorative Dent 33(1),e9-15.

Hulsey, C. M. (1970): An esthetic evaluation of lip-teeth relationships present in the smile.

Am J Orthod 57(2),132-144.

Husein, O. F., Sepehr, A., Garg, R., Sina-Khadiv, M., Gattu, S., Watzmann, J., Wu, E. C.,
Shieh, M., Heitmann, G. M., Galle, S. E. (2010): Anthropometric and aesthetic analysis of the
Indian American woman's face. J Plast Reconstr Aesthet Surg 63(11),1825-1831.

Hwang, H.-S., Kim, W.-S., McNamara, J., James, A. (2002): Ethnic differences in the soft
tissue profile of Korean and European-American adults with normal occlusions and well-
balanced faces. Angle Orthod 72(1),72-80

Iglesias-Linares, A., Yanez- Vico, R., Moreno- Manteca, B., Moreno-Fernandez, A. M.,
Mendoza-Mendoza, A., Solano-Reina, E. (2011): Common standards in facial esthetics:
craniofacial analysis of most attractive black and white subjects according to People magazine
during previous 10 years. J Oral Maxillofac Surg 69(6),e216-224.

Jahangiri, L., (2002): Relationship between tooth shade value and skin color: an observational
study. J Prosthet Dent 87(2),149-152

Jahanshahi, M., Golalipour, M. J. Heidari, K. (2008): The effect of ethnicity on facial

anthropometry in Northern Iran. Singapore Med J 49(11),940-943.

Jain, S. K., Anand, C. Ghosh, S. K. (2004): Photometric facial analysis-a baseline study. J
Anat Soc India 53(2),11-13.

Janghu, D., Dua, Vinay S., Mangla, R., Khanna, M. (2015): Smile esthetics. Indian J Oral Sci
6(3),101-107.

Janson, G., Branco, N. C., Fernandes, T. M. F., Sathler, R., Garib, D., Lauris, J. R. P. (2011):
Influence of orthodontic treatment, midline position, buccal corridor and smile arc on smile
attractiveness: A systematic review. Angle Orthod 81(1),153-161.

125
Jayaratne, Y. S. N., Deutsch, C. K., McGrath, C. P., Zwahlen, R. A. (2013): A 3D
anthropometric analysis of the orolabial region in Chinese young adults. Br J Oral Maxillofac
Surg. 51(8),908-912.

Jefferson, Y. (2004): Facial beauty-establishing a universal standard. Int J Orth 15(1),9-26

Joiner, A. (2004): Tooth colour: a review of the literature. J Dent 32(Suppl 1),3-12

Joseph, L. H.; Vasconez, H. C. (2015): Midfacial fractures. In: P. J. Taub, P. K. Patel, S. R.

Buchman and N. M. Cohen Ferraro's Fundamentals of Maxillofacial Surgery Springer, Berlin,
185.

Joshi, P. R., Bhat, G. S., Dixit, S. (2008): Selection of articulator for general dental practice.
Kathmandu Univ Med J 6(1),112-116.

Kalha, A. S., Latif, A., Govardhan, S. N. (2008): Soft-tissue cephalometric norms in a South
Indian ethnic population. Am J Orthod Dentofacial Orthop. 133(6),876-881.

Kapoor, T. J.; Singh, G. (2015): Diagnostic aids: case history and clinical examination. In: G.
Singh Textbook of orthodontics.Jaypee Brothers Medical Publishers, New Delhi.

Karrer, M. (2002): Das Schöne, das Gesicht und die Zähne: Blicke in die Ästhetik. Dtsch
Zahnärztl Z 57(9),515-525.

Kesmas, S., Swasdison, S., Yodsanga, S., Sessirisombat, S., Jansisyanont, P. (2010): Esthetic
alveolar ridge preservation with calcium phosphate and collagen membrane: preliminary
report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 110(5), e24-36.

Kim, M. S., Angela B., Andrew J. W., Gregory P. R., Elisabeth K. B., Melissa A. C.,
Karen M. B. –E., Mia K. M. (2011): A pilot study on using eye tracking to understand
assessment of surgical outcomes from clinical photography. J Digit Imaging 24(5),778-786.

Kim, S. Y., Bayome, M., Park, J. H., Kook, Y. A., Kang, J. H., Kim, K. H., Moon, H. B.
(2015): Evaluation of the facial dimensions of young adult women with a preferred facial
appearance. Korean J Orthod 45(5),253-260.

Kim, S. H., Whang, E., Choi, H. G., Shin, D. H., Uhm, K. I., Chung, H., Song, W. C., Koh,
K. S. (2010): Analysis of the midface, focusing on the nose: an anthropometric study in
young Koreans. J Craniofac Surg 21(6),1941-1944.

126
Kim, Y.H. (2007): Easy facial analysis using the facial golden mask. J Craniofac Surg.
18(3),643-649

Kirtley, G. E. (2008): The art of a beautiful smile. J Cosmet Dent 24(3),122-131.

Komori, M., Kawamura, S., Ishihara, S. (2009): Averageness or symmetry: which is more
important for facial attractiveness? Acta Psychol 131(2),136-142.

Kowner, R. (1996): Facial asymmetry and attractiveness judgement in developmental

perspective. J Exp Psychol Hum Percept Perform 22(3), 662-675

Koralakunte, P. R.; Aljanakh, M. (2014): The role of virtual articulator in prosthetic and
restorative dentistry. J Clin Diagn Res 8(7),25-28.

Krugman, M. E. (1981): Photoanalysis of the rhinoplasty patient. Ear Nose Throat J

60(7),328-330

Ku, J. E., Yang, H. S., Yun, K. D. (2012): A morphometric analysis of maxillary central
incisor on the basis of facial appearance in Korea. J Adv Prosthodont 4(1),13-17.

Kurth, J. R.; Kokich, V. G. (2001): Open gingival embrasures after orthodontic treatment in
adults: prevalence and etiology. Am J Orthod Dentofacial Orthop 120(2),116-123

Langlois, J. H., Roggman, L. A., Musselman, L (1994): What is average and what is not
average about attractive faces?. Psychological science 5(4), 214-220

Lauren, M. (2014): A new 4-dimensional imaging system for jaw tracking. Int J Comput Dent
17(1),75-82

Lauren, M.; McIntyr, F. (2013): 4D clinical imaging for dynamic CAD. Int J Dent 2013 (1-5).

Lavelle, C. L. B. (1972): Maxillary and mandibular tooth size in different racial groups and in
different occlusal categories. Am J Orthod 61(1),29-37.

Le, T. T., Farkas, L. G. Ngim, R. C., Levin, L. S., Forrest, C. R. (2002): Proportionality in
Asian and North American Caucasian faces using neoclassical facial canons as criteria.
Aesthetic Plast Surg 26(1),64-69.

Lee, S. P., Lee, S. J., Hayashi, K., Park, Y. S. (2012): A three-dimensional analysis of the
perceived proportions of maxillary anterior teeth. Acta Odontol Scand 70(5),432-440.

127
Levin, E. I. (1978): Dental esthetics and the golden proportion. J Prosthet Dent 40(3),244-252

Lew, K. K., Ho, K. K., Keng, S. B., Ho, K. H. (1992): Soft-tissue cephalometric norms in
Chinese adults with esthetic facial profiles. J Oral Maxillofac Surg 50(11),1184-1189;

Li, K. Z., Byun, S. H., Kim, S. M., Lee, J. H. (2014): Anthropometric nasal analysis of Han
Chinese young adults. J Craniomaxillofac Surg 42(2),153-158.

Liang, L.-Z., He, Y. W., Tang, Y. L., Wu, J. L., Cao, X. P., Xiao, G. Z., Mao, Z. Y. (2013):
Analysis of dynamic smile and upper lip curvature in young Chinese. Int J Oral Sci 5(1),49-
53.

Lindhe, J., Karring, T., Araújo, M. (2015): Anatomy of the periodontal tissues. In: J. Lindhe
and N. P. Lang Clinical periodontology and implant dentistry.John Wiley & Sons, Oxford, 3-
48.

Lindhe, J., Wennström, L. J., Berglundh, T. (2015): The mucosa at teeth and implants. In: J.
Lindhe and N. P. Lang Clinical periodontology and implant dentistry.John Wiley & Sons,
Oxford, 83- 96.

Lombardi, R. E. (1973): The principles of visual perception and their clinical application to
denture esthetics. J Prosthet Dent 29(4),358-382.

Magne, P., Gallucci, G. O., Belser, U. C. (2003): Anatomic crown width/length ratios of
unworn and worn maxillary teeth in white subjects. J Prosthet Dent 89(5),453-461.

Malkoç, S., Demir, A., Uysal, T., Canbuldu, N. (2009): Angular photogrammetric analysis of
the soft tissue facial profile of Turkish adults. Eur J Orthod. 31(2),174-179.

Matoula, S.; Pancherz, H. (2006): Skeletofacial morphology of attractive and nonattractive

faces. Angle Orthod 76(2),204-210

Maulik, C.; Nanda, R. (2007): Dynamic smile analysis in young adults. Am J Orthod
Dentofacial Orthop 132(3),307-315.

Mehl, C., Harder, S., Wolfart, S., Vollrath, O., Trinkler, A., Wenz, H. J., Kern, M. (2014):
Perception of dental esthetics in different cultures. Int J Prosthodont 27(6),523-529.

Metiu, D. (2014): The Golden Ratio- From the oldest to the newest arts. Cinematographic Art
& Documentation 9(13),52-56

128
Millar, B. J.; Wilson, N. (2014). Principles and practice of esthetic dentistry: essentials of
esthetic dentistry. Elsevier health sciences, London.

Miller, E. L., Bodden, W. R., Jamison, H. C., (1979): A study of the relationship of the dental
midline to the facial median line. J Prosthet Dent 41(6),657-660

Miloro, M., Borba, A. M., Ribeiro-Junior, O., Naclério-Homem, M. G., Jungner, M. (2014):
Is there consistency in cephalometric landmark identification amongst oral and maxillofacial
surgeons? Int J Oral Maxillofac Surg 43(4),445-453

Miron, H., Calderon, S., Allon, D. (2012): Upper lip changes and gingival exposure on
smiling: Vertical dimension analysis. Am J Orthod Dentofacial Orthop. 141(1),87-93.

Mommaerts, M. Y., B. Moerenhout (2011): Ideal proportions in full face front view,
contemporary versus antique. J Craniomaxillofac Surg. 39(2),107-110

Moore, T., Southard, K. A., Casko, J. S., Qian, F., Southard, T. E. (2005): Buccal corridors
and smile esthetics. Am J Orthod Dentofacial Orthop 127(2),208- 213.

Morley, J.; Eubank, J. (2001): Macroesthetic elements of smile design. J Am Dent Assoc
132(1),39-45

Moshkelgosha, V., Fathinejad, S., Pakizeh, Z., Shamsa, M., Golkari, A. (2015): Photographic
Facial Soft Tissue Analysis by Means of Linear and Angular Measurements in an Adolescent
Persian Population. Open Dent J 9, 346-356.

Naini, F. B. (2011): Facial symmetry and asymmetry. In: F. B. Naini Facial aesthetics:
concepts and clinical diagnosis.Wiley-Blackwell, Oxford, 257-298.

Nandini, S., Prashanth, C. S., Somiah, S. K., Reddy, S. R. (2011): An evaluation of nasolabial
angle and the relative inclinations of the nose and upper lip. J Contemp Dent Pract 12(3),152-
157.

Nesi, F., Nishimori, L. E., Silva, C. D. O., Marson, F. C., Sabio, S., Correa, G. de O. (2014):
Semi- adjustable articulators. J Surg Clin Dent 1(1),14-21.

Netter, F. H. (2014): Head and neck. In: F. H. Netter Atlas of Human Anatomy.Elsevier
Health Sciences, Phyladelphia, 1-152.

129
Nomura, M., Motegi, E., Hatch, J. P., Gakunga, P. T., Ng'ang'a, P. M., Rugh, J.
D., Yamaguchi, H. (2009): Esthetic preferences of European American, Hispanic American,
Japanese, and African judges for soft-tissue profiles. Am J Orthod Dentofacial Orthop
135(4),87-95.

Noroozi, H., Hosseinzadeh, N. T., Saeeda, R. (2001): The dental arch form revisited. Angle
Orthod 71(5),386-389.

Ochi, K.; Ohashi, T. (2002): The effects of an external nasal dilator and nasal dimensions in
Asians. Otolaryngol Head Neck Surg 126(2),160-163

Odioso, L. L., Gibb, R. D., Gerlach, R. W. (2000): Impact of demographic, behavioral, and
dental care utilization parameters on tooth color and personal satisfaction. Compend Contin
Educ Dent 21(29),35-41.

Ofodile, F. A.; Bokhari, F.(1995): The African-American Nose: Part I I. Ann Plast Surg
34(2),123-129

Ong, E., Brown, R. A., Richmond, S. (2006): Peer assessment of dental attractiveness. Am J
Orthod Dentofacial Orthop 130(2),163-169.

Oshagh, M., Moghadam, T., Dashlibrun, Y. N. (2010): Evaluation of the effect of buccal
corridor size on smile attractiveness. Eur J Esthet Dent 5(4),370-380.

Owens, E. G., Goodacre, C. J., Loh, P. L., Hanke, G., Okamura, M., Jo, K. H., Munoz, C. A.,
Naylor, W. P. (2002a): A multicenter interracial study of facial appearance. Part 1: A
comparison of extraoral parameters. Int J Prosthodont 15(3),273-282.

Owens, E. G., Goodacre, C. J., Loh, P. L., Hanke, G., Okamura, M., Jo, K. H., Munoz, C. A.,
Naylor, W. P. (2002b): A multicenter interracial study of facial appearance. Part 2: A
comparison of intraoral parameters. Int J Prosthodont 15(3),283-288

Paolucci, B., Calamita, M., Coachman, C., Gürel, G., Shayder, A., Hallawell, P. (2012):
Visagism: The art of dental composition. Quintessence Dent Technol 35, 187-200.

Passia, N., Blatz, M., Strub, J. R. (2010): Is the smile line a valid parameter for esthetic
evaluation? A systematic literature review. Eur J Esthet Dent 6(3),314-327

130
Patil, S. B., Gresnigt, M. M., Mahesh, K., Dilbaghi, A., Cune, M. S. (2011): The average
Indian female nose. Aesthetic Plast Surg 35(6),1036-1042.

Peck, S., Peck, L., Kataja, M. (1992): Some vertical lineaments of lip position. Am J Orthod
Dentofacial Orthop. 101(6),519-524

Penna, V., Fricke, A., Iblher, N., Eisenhardt, S. U., Stark, G. B. (2015): The attractive lip: A
photomorphometric analysis. J Plast Reconstr Aesthet Surg 68(7),920-929.

Philips, E. (1999): The classification of smile patterns. J Can Dent Assoc 65(5),252-254.

Porter, J. P.; Olson, K. L. (2001): Anthropometric facial analysis of the African American
woman. Arch Facial Plast Surg 3(3),191-197

Powell, N., B. Humphreys (1984). Proportions of the aesthetic face, Thieme medical pub.

Prendergast, P. M. (2013): Anatomy of the face and neck. In: M. A. Shiffman and A. D.
Guiseppe Cosmetic Surgery.Springer, Berlin-Heidelberg, 29- 45.

Preston, J. D. (1993): The golden proportion revisited. J Esthet Restor Dent 5(6),247-251

Rhee, S. C., Dhong, E. S., Yoon, E. S. (2009): Photogrammetric facial analysis of attractive
Korean entertainers. Aesthetic Plast Surg 33(2),167-174.

Rhee, S. C., Kang, S. R., Park, H. S. (2004): Balanced angular profile analysis. Plast Reconstr
Surg 114(2),535-544.

Ricketts, R. M. (1957): Planning treatment on the basis of the facial pattern and an estimate of
its growth. Angle Orthod 27(1),14-37.

Rohrich, R. J.; Bell, W. H. (1992): Management of nasal deformities: An update. In: W. H.

Bell Modern Practice in Orthognatic and Reconstructive Surgery.Saunders, Philadelphia, 262-
283.

Rohrich, R. J.; Pessa W. H. (2007): The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 119(7),2219- 2227.

Rosati, R., Codari, M., Maffessanti, F., Dolci, C., Ferrario, V. F., Sforza, C. (2014): The labial
aging process: a surface analysis-based three-dimensional evaluation. Aesthetic Plast Surg
38(1),236-241.

131
Rosenstiel, S. F., Rashid, R. G. (2002): Public Preferences for Anterior Tooth Variations: A
Web Based Study. J Esthet Restor Dent 14(2),97-106

Rosenstiel, S. F., Ward, D. H., Rashid, R. G. (2000): Dentists' preferences of anterior tooth
proportion—a Web based study. J Prosthodont 9(3),123-136.

Roumanas, E. D. (2009): The social solution—Denture esthetics, phonetics, and function. J

Prosthodont 18(2),112-115

Rubin, L. R. (1974): The anatomy of a smile: its importance in the treatment of facial
paralysis. J Plast Reconstr Surg 53(4),384-387.

Sabri, R. (2005): The eight components of a balanced smile. J Clin Orthod 39(3),155-167.

Sarver, D., Jacobson, R. S. (2007): The aesthetic dentofacial analysis. Clin Plast Surg.
34(3),369-394

Sarver, D. M. (2001): The importance of incisor positioning in the esthetic smile: the smile
arc. Am J Orthod Dentofacial Orthop 120(2),98-111

Sarver, D. M. (2004): Principles of cosmetic dentistry in orthodontics: Part 1. Shape and

proportionality of anterior teeth. Am J Orthod Dentofacial Orthop 126(6),749-753

Sarver, D. M., Ackerman, M. B. (2003): Dynamic smile visualization and quantification: Part
2. Smile analysis and treatment strategies. Am J Orthod Dentofacial Orthop 124(2),116-127

Sawyer, A. R., et al. (2009): 3D stereophotogrammetry quantitative lip analysis. Aesthetic

Plast Surg 33(4),497-504.

Schabel, B. J., Baccetti, T., Franchi, L., McNamara, J. A. (2010): Clinical photography vs
digital video clips for the assessment of smile esthetics. Angle Orthod 80(4),678-684

Scheid, R. C. (2007). Woelfel's dental anatomy. Lippincott Williams & Wilkins, Philadelphia.

Scheideman, G. B., Bell, W. H., Legan, H. L., Finn, R. A., Reisch, J. S. (1980):
Cephalometric analysis of dentofacial normals. Am J Orthod 78(4),404-420.

Schmidhuber, J. (2009): Simple algorithmic theory of subjective beauty, novelty, surprise,

interestingness, attention, curiosity, creativity, art, science, music, jokes. J SICE 48(1),21-31.

132
Schwarz, A. M. (1961): Roentgenostatics: a practical evaluation of the X-ray headplate. Am J
Orthod 47(8),561-585

Sforza, C., Laino, A., D'Alessio, R., Grandi, G., Binelli, M., Ferrario, V. F. (2009): Soft-tissue
facial characteristics of attractive Italian women as compared to normal women. Angle
Orthod 79(1),17-23.

Sharma, A. A., Park, J. H. (2010): Esthetic considerations in interdental papilla: remediation

and regeneration. J Esthet Restor Dent 22(1),18-28

Shindoi, J. M., Matsumoto, Y., Sato, Y., Ono, T., Harada, K. (2013): Soft tissue
cephalometric norms for orthognathic and cosmetic surgery. J Oral Maxillofac Surg.
71(1),e24-e30

Simons, R. L. (1982): Nasal tip projection, ptosis and supratip thickening. Ear Nose & Throat
J 61(8),452-455

Singh, B., Ahluwalia, R., Verma, D., Grewal, S. B., Goel, R., Kumar, P. S. (2012): Perioral
age-related changes in smile dynamics along the vertical plane: a videographic cross-sectional
study. Angle Orthod 83 (3) 468-475

Sinno, H. H., Markarian, M. K., Ibrahim, A. M., Lin, S. J. (2014): The Ideal Nasolabial Angle
in Rhinoplasty: A Preference Analysis of the General Population. Plast Reconstr Surg
134(2),201-210.

Skiles, M. S.; Randall, P. (1983): The Aesthetics of Ear Placement: An Experimental Study.
Plast Reconstr Surg 72(2),133-138

Snow, S. R. (1999): Esthetic smile analysis of maxillary anterior tooth width: the golden
percentage. J Esthet Restor Dent 11(4),177-184.

Sommerville, J. M., Sperry, T. P., BeGole, E. A. (1988): Morphology of the submental and
neck region. Int J Adult Orthodon Orthognath Surg 3(2),97-106.

Sondell, K., Soderfeldt, B., Palmqvist, S. (2002): Dentist-patient communication and patient
satisfaction in prosthetic dentistry. Int J Prosthodont. 15(1 ),28-37.

Steele, D. G.; Bramblett, C. A. (1988): The Skull. In: D. G. Steele and C. A. Bramblett The
Anatomy and Biology of the Human Skeleton.Texas A&M University Press, Texas 20-70.

133
Sterrett, J. D., Oliver, T., Robinson, F., Fortson, W., Knaak, B., Russell, C. M. (1999):
Width/length ratios of normal clinical crowns of the maxillary anterior dentition in man. J
Clin Periodontol 26(3),153-157

Sunilkumar, L. N., Jadhav, K. S., Nazirkar, G., Singh, S., Nagmode, P. S., Ali, F. M. (2013):
Assessment of Facial Golden Proportions among North Maharashtri-an Population. J Int Oral
Health 5(3),48-54.

Tarvade, S. M.; Agrawal, G. (2015): Smile analysis: A review Part I. Int J Contemp Dent Med
Rev 2015, 1-4

Teck, S. R. S., Smith, J. D., Chan, A. S. Y. (2000): Comparison of the aesthetic facial
proportions of southern Chinese and white women. Arch Facial Plast Surg 2(2),113-120

Thiagarajan, B., Narashiman, S., Arjunan, K. (2013): Fracture zygoma and its management
our experience. Otolaryngol Onl J 3(1.5),17-33.

Tjan, A. H. L., Miller, G. D., The, J. G. P. (1984): Some esthetic factors in a smile. J Prosthet
Dent 51(1),24-28

Toma, A. M., Zhurov, A., Playle, R., Ong, E., Richmond, S. (2009): Reproducibility of facial
soft tissue landmarks on 3D laser scanned facial images. Orthod Craniofac Res 12(1),33-42

Torsello, F., Graci, M., Grande, N. M., Deli, R. (2010): Relationships between facial features
in the perception of profile attractiveness. Prog Orthod 11(2),92-97.

Torsello, F., Mirigliani, L., D’Alessio, R., Deli, R. (2010): Do the neoclassical canons still
describe the beauty of faces? An anthropometric study on 50 Caucasian models. Prog Orthod
11(1),13-19.

Tucker, L. M. (2008): Guidelines for treatment planning the ideal soft tissue framework. In:
M. Cohen Interdisciplinary treatment planning: principles, design,
implementation.Quintessence, Chicago, 165- 189.

Tuncel, U., Turan, A., Kostakoglu, N. (2013): Digital anthropometric shape analysis of 110
rhinoplasty patients in the Black Sea Region in Turkey. J Craniomaxillofac Surg 41(2),98-
102.

134
Türp.C, J., Alt K. W. (1998): Anatomy and morphologie of human teeth. In: K. W. Alt, F. W.
Rösing and M. Teschler-Nicola Dental anthropology: Fundamentals, limits and
prospects.Springer, Vienna, 71- 94.

Uysal, T., Yagci, A, Basciftci, F.A., Sisman, Y. (2009): Standards of soft tissue Arnett
analysis for surgical planning in Turkish adults. The European Journal of Orthodontics
31(4),449

Uzun, A., Akbas, H., Bilgic, S., Emirzeoglu, M., Bostanci, O., Sahin, B., Bek, Y. (2006): The
average values of the nasal anthropometric measurements in 108 young Turkish males. Auris
Nasus Larynx 33(1),31-35

Van der Geld, P., Oosterveld, P., Berge, S. J., Kuijpers-Jagtman, A. M. (2008a): Age-related
changes of the dental aesthetic zone at rest and during spontaneous smiling and speech. Eur J
Orthod 30(4),366-373

Van der Geld, P., Oosterveld, P., Berge, S. J., Kuijpers-Jagtman, A. M. (2008b): Tooth
display and lip position during spontaneous and posed smiling in adults. Acta Odontol Scand
66 (4),207- 213

Vig, R. G., Brundo, G. C. (1978): The kinetics of anterior tooth display. J Prosthet Dent
39(5), 502-504.

Wilkinson, C. M., Motwani, M., Chiang, E. (2003): The relationship between the soft tissues
and the skeletal detail of the mouth. J Forensic Sci. 48(4),728-732

Witkowski, S. (2012): Virtuelle artikulation. Quintessenz Zahntech 38(8),902-917.

Wolfart, S., Bindl, A., Schmidlin, P. R., Luthy, H., Mormann, W. H. (2004): Inability to relate
tooth forms to face shape and gender. Eur J Oral Sci 112(6),471-476

Wolfart, S. (2014): Implantatprothetik: Ein patientenorientiertes Konzept, Quintessence,

Deutschland

Wong, N. K., Kassim, A. A., Foong, K. W. (2005): Analysis of esthetic smiles by using
computer vision techniques. Am J Orthod Dentofacial Orthop 128(3),404-411.

135
Wong, W. W., Davis, D. G., Camp, M. C., Gupta, S. C. (2010): Contribution of lip
proportions to facial aesthetics in different ethnicities: a three-dimensional analysis. Aesthet
Surg J. 63(12),2032-2039

Xu, Y., Jiang, Z., Xiao, X., Fu, J., Su, Q. (2010). Measurement and classification of shanghai
female face shape based on 3D image feature. 3rd International Congress on Image and
Signal Processing (CISP), Yantai, Institute of Electrical and Electronics Engineers (IEEE).

Xufeng, L., Jie, Y., Yong, Y. (1999): Curvature feature based method for human face
classification and recognition. Infrared Laser Eng 4, 2707-2714.

Zhang, D., Chen, F., Xu, Y. (2016): A new hypothesis on facial beauty perception. In:
Computer Models for Facial Beauty Analysis.Springer, 143-163.

Zhang, Y. L., Le, D., Hu, W. J., Zhang, H., Liang, L. Z., Chung, K. H., Cao, Z. Q. (2015):
Assessment of dynamic smile and gingival contour in young Chinese people. Int Dent J
65(4),182-187.

Zimmermann, M., A. Mehl (2014): Virtual smile design systems: a current review. Int J
Comput Dent 18(4),303-317.

Zuhr, O., M. Hürzeler (2012): Plastic-esthetic Periodontal and Implant Surgery: A

Microsurgical Approach. Quintessence, London

Zylinski, C. G., Nanda, R. S., Kapila, S. (1992): Analysis of soft tissue facial profile in white
males. Am J Orthod Dentofacial Orthop 101(6),514-518.

136
10. Acknowledgements

I would like to register my deepest gratitude to the Ministry of Education in Azerbaijan for
granting me a most generous postgraduate scholarship.

I am thankful to the University Hospital of Freiburg for providing a productive academic and
clinical postgraduate program.

My gratitude goes to my supervisors, Prof. Wael Att and Prof. Olga Polydorou. Their
meticulous feedback, acute observation and constructive comments were invaluable guidance
to my study and to this thesis.

I am grateful to my parents, Mehriban Seyidaliyeva and Bahram Seyidaliyev for I could not
have reached this stage in life without them being there for me. I would like to express my
appreciation to my brother for their moral support and good wishes.

My family have been my main support through it all. I would like to dedicate this thesis to my
family.

137
 Diese Seite enthält persönliche Daten und ist daher nicht Teil der Online-Publikation.

. 138