Professional Documents
Culture Documents
Esthetics
Esthetics , which is derived from the Greek word for "perception",
deals with beauty and the beautiful.
It has two dimensions: Objective
Subjective.
The first stage raises the upper lip to the nasolabial fold by
contraction of the levator muscles originating in the fold and
inserting at the upper lip. The medial muscle bundles raise the lip
at the anterior teeth and the lateral muscle groups raise the lip at
the posterior teeth. The lip then meets resistance at the nasolabial
fold because of cheek fat.
The second stage involved further raising superiorly of the lip and the
fold by three muscle groups:
(1) The levator labii superior muscles of the upper lip, originating at
the infraorbital region,
(2) The zygomaticus major muscles
(3) Superior fibers of the buccinator.
The low smile displays <75% of the maxillary incisors in the full
smile and may be found in about 20% of a population,
Tjan &Miller
SMILE STYLE
There are three styles
The cuspid smile is characterized by the action of all the elevators of
the upper lip, raising it like a window shade to expose the teeth
and gingival scaffold.
.
The complex smile is characterized by the action of the
elevators of the upper lip and the depressors of the lower lip
acting simultaneously, raising the upper lip like a window shade
and lowering the lower lip like a window.
The Mona Lisa smile is characterized by the action of the
zygomaticus major muscles, drawing the outer commissures
outward and upward, followed by a gradual elevation of the
upper lip. Patients with complex smiles tend to display more
teeth and gingiva than patients with Mona Lisa smiles.
Dynamic smile visualization and quantification:
In the contemporary orthodontic paradigm, we examine patients in
both resting and dynamic relationships in 3 spatial dimensions
and then attempt to harmonize the discrepancy between their
anatomic and physiologic lip–tooth–jaw relationships and their
esthetic and functional desires.
In the art of treating the smile, we are faced with a 2-fold task.
First, in problem-oriented treatment planning, the orthodontist must
establish a diagnosis that identifies and quantifies which elements
of the smile need correction, improvement,and identifying the
positive elements of the smile that should be maintained.
Second, a visualized treatment strategy must be created to address
the patient’s chief concerns. Computer imaging technology has
greatly facilitated recognition of the effect of our orthodontic
treatment plans on facial appearance.
The contemporary orthodontist no longer evaluates patients in terms
of only the profile, but also frontally and vertically, to complete
the 3 spatial dimensions,and statically and dynamically. Sarver
philosophy mandates that the orthodontist now add a fourth
dimension: Time.
The first is that of soft tissue repose and animation assessed at the
patient’s examination and includes how the lips animate on
smile, gingival display, crown length, and other attributes of the
smile.
These clips are taken before and after treatment and help to assess
the changes in smile characteristics bought about by orthodontic
treatment. The patient’s head is placed in a cephalometric holder
and asked to say, “Chelsea eats cheesecake in the Chesapeake”
and then to smile.
The video clip is reviewed and the frame that represents the patient’
natural unstrained social smile is selected.
Smile Analysis
The flaw in traditional smile analysis has been that many of the
vertical and anteroposterior calculations related to anterior tooth
display are made from the tracing of the lateral cephalogram,
which is taken in repose. As a result, incisor position has been
determined from a static rather than a dynamic record.
COMMISSURE HEIGHT
The height of the Commissure is measured from a line constructed
from the alar bases through subspinale and then from the
commisures perpendicular to this line
Short philtrum
V-Y cheiloplasty
Excessive overjet
Orthodontics
The social smile is chosen to undergo examination in 4 dimensions
Frontal. Sagittal, oblique and time related.
FRONTAL DIMENSION
Smile index
It describes the area framed by the vermillion border during the
social smile.
It is determined by dividing the inter commissural width by the
interlabial gap during smile.
A small smile index would imply a gummy smile.
Vertical parameters
Incisal display
Less than 75% of the central incisor crown display is
considered inadequate.
Gingival display
Relationship between the incisal margins of the upper
incisors and the lower lip and the gingival margin with the upper
lip.
The vertical aspects of smile anatomy are the degree of maxillary
anterior tooth display (Morley ratio), upper lip drape, and gingival
display
In a youthful smile, 75-100% of the maxillary central incisors
should be positioned below an imaginary line drawn between
the commissures . Both skeletal and dental relationships
contribute to these smile components.
EXCESSIVE UPPER INCISOR SHOW AT REST AND ON
SMILE
Short philtrum
V-Y cheiloplasty
Vertical maxillary excess
Maxillary impaction via Le Fort I osteotomy
Long incisor crown height
Crown height reduction
Hypermobile smile
Cartilage or spacer technique
Kamer technique
Botulinium toxin injection
Detorqued incisors
Orthodontic incisor torque
Excessive incisal show treatment differs in adults and
adolescents
In adolescents with moderately excessive incisordisplay
(4-5mm) treatment often is not indicated.
When excessive gingival display (6-8mm) intrusion by
orthodontic intrusion arches or extra orally through J hook
headgear can be considered.
When greater than 8mm, the clinician can consider waiting till
growth ceases for surgical correction the vertical maxillary
excess.
The two characteristic of the smile that are best viewed in this
view is
Overjet
Incisor angulations .
In both absolute and proportional terms the lower lip grew more
than the upper lip.
Genecov in his study from the Bolton Brush sample found that
males between the ages of 7-17 had a greater increase in lip
length than females in the same period.
LIP THICKNESS DURING GROWTH AND MATURITY
It was observed in Subtelny’s study that that upper lip attained a
greater thickness in the vermillion region than over point A. This
increase in thickness at the vermillion border was approximately
equal to the increase in length of the lip. In both males and
females the lip increased in thickness from ages 1-14. After the
age of 14 the lips continued to become thicker in males but not in
females.
Similarly in the lower lip the gain in thickness was greater at
vermillion border than at Pogonion or point B .Lip thickness
increase for males from ages 1-18 was around 7mm while for
females it was around 6mm.
Mamandras in his study of lip thickness found that the female lip
thickened till the age of 14 after which it remained the same till
the age of 18 beyond which it showed thinning. males attained
maximum lip thickness by age of 16 after which they too showed
thinning. Horizontal thickness of both sexes completed by age 15.
Nanda et al in his study slightly differed from Mamandras. He
found that lip thickness increased uniformly from age 7-18,
females attained full lip thickness by age 13 with slight thinning
staring then. in males however the thickness continued till the age
of 18.
The differential in the two sexes with respect to lip thickness implies
that the treatment result of extraction therapy of the facial profile
will be more noticeable female than male patients. Because
female lips do not thicken with age , any extraction plan for
females with straight to convex profiles should be cautiously
considered. Lip fullness in relation to the nose which will
continue to grow should also be noted.
The differences between chin, lip and nose growth must also be
considered when planning the final esthetic goals.
Facial harmony in orthodontics is determined by the
morphological relationships and proportions of the nose lips
and chin. Because balance between these structures can be
altered by both growth and orthodontics it is clinically
important for the orthodontist to understand the changes that
occurs not only with treatment but also the amount and
direction of growth expected in the facial structures.
LIPLINE
SMILE ARC
UPPER LIP CURVATURE
LATERAL NEGATIVE SPACE
SMILE SYMMETRY
FRONTAL OCCLUSAL PLANE
DENTAL COMPONENTS
GINGIVAL COMPONENTS
ROY SABRI
JCO- 2005
LIP LINE
The lip line is the amount of vertical tooth exposure in smiling.
The lip line is optimal when the upper lip reaches the gingival
margin, displaying the total cervicoincisal length of the
maxillary central incisors, along with the interproximal
gingiva.
The starting point of a smile is the lip line at rest, with an
average maxillary incisor display of 1 .91 mm in men and
nearly twice that amount. 3.40mm, in women.
Tjan, Miller performed a semi-quantitative study of smile-line
variations; their data suggest evidence of sexual dimorphism of
smile lines in the vertical dimension. Full face photographs of
smiling men and women were analyzed with the intention of
identifying features of lip position for help in designing esthetic
dental restorations.
One part of the study divided the smiles into three categories:
A "low smile" displaying less than 75% of the clinical crown height
of the maxillary anterior teeth,
An "average smile" revealing 75% to 100% of the maxillary anterior
crown height,
A "high smile" exposing a band of contiguous maxillary gingiva.
Among these three categories, there was a sex difference in smile-
line frequency:
In general ,males show less upper incisor and more lower incisor
at rest,where as females show more upper incisor and less lower
incisor at rest.
Vig and Brundo reported a gradual decrease in maxillary incisor
exposure for each increase in age group from under 30 to over
60.
Age changes in vertical tooth display during normal
conversation, demonstrated by female patients ages 25 and 65.
In rest position , young woman shows only maxillary incisors,
whereas older woman shows only mandibular incisors.
However, for the women, the upper lip and chin soft-tissue
decreased in thickness, and the lower lip showed a small
increase in thickness. Taken together with the minor
mandibular skeletal changes, the women did not have an effect
of straightening the profile.
Both sexes had increased upper lip length that reduced the incisor
exposure by 1.0mm
In adolescents, a short upper lip relative to commissure height
could be considered normal because of the lip lengthening that
continues even after vertical skeletal growth is complete.
The ideal dosage might be 2.5 U per side at the LLS, 2.5 U per
side at the LLS/ZM sites, and 1.25 U per side at the OO sites.
Vertical Maxillary Height
When upper lip length and mobility are normal, a gingival smile
with excessive incisor display at rest can be attributed to
vertical maxillary excess.
This kind of skeletal gingival smile is generally associated with
excessive lower facial height.
Conversely, a low lip line with no incisor display at rest is
“skeletal” when associated with inadequate lower facial height
due to a vertically deficient maxilla .
The best reference for impacting or lengthening the maxilla is the
incisor display at rest, taking upper lip length and any incisor
attrition into account.
The full smile does not make a good reference, partly because of
the individual variation in lip mobility.
Incisor Inclination
Proclined maxillary incisors, whether in a Class II, division I
malocclusion or in a Class III compensation, tend to reduce the
incisor display at rest and in smiling .
Maxillary incisor inclination affects not only the lip line, but the
smile arc as well, when the curvature of the incisal edges does
not coincide with the border of the lower lip in smiling.
The patient’s archform—and particularly the configuration of the
anterior segment—will greatly influence the degree of
curvature of the smile arc. The broader the archform, the less
curvature of the anterior segment and the greater the likelihood
of a flat smile arc.
The Correlation of Smile Line with the Vertical
Cephalometric Parameters of Anterior Facial Height
Journal of Dentistry, Tehran University of Medical Sciences
Hosseinzade-Nik et al. 2005
More vertical growth in the posterior maxilla than in the anterior
maxilla could result in a changed relationship between the
occlusal plane and the curvature of the lower lip upon smile.
Growth in the brachyfacial pattern (low mandibular plane angle
and a tendency for parallelism of the sella-nasion line, palatal
plane and occlusal plane) may lead to a flat smile arc.
Patients with this skeletal pattern might, theoretically have a
tendency for the anterior maxilla to lack the clockwise tilt
needed for an ideal smile arc, in some cases, it might even
exhibit a counterclockwise tilt that results in a flat smile arc.
Upper Lip Curvature
The upper lip curvature is assessed from the central position
to the corner of the mouth in smiling.
Upward -when the corner of the mouth is higher than the central
position
Straight - when the corner of the mouth and the central position
are at the same level,
Downward-when the corner of the mouth is lower than the central
positionl.