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LIPS A GATEWAY TO ESTHETICS

CONTENT
Introduction
Aim and Purpose Facial analysis

A) Frontal view
B) Lateral view
LIPS DENTOLABIAL RELATIONSHIP SUMMARY
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Introduction:
The term esthetic is derived from greek word meaning

esthesia meaning sensibility or capacity for sensation In contrast to Anesthesia which means loss of sensation or capacity for sensation. Esthetic is an adjective term which denotes a pleasant sensation .

 Lips are components of macroesthetic elements of

smile design.

The location and shape of smile line , the extend of

exposure of facial surfaces of upper teeth and gingiva , buccal corridor and outline form of vermillion border of lips are some of the factors which contributes to pleasant smile.

A disharmony can be injurious to the attractiveness of

smile

AIM & OBJECTIVE

Draw the functional inter-relationship existing between the lips

& teeth.
PURPOSE OF PRESENTATION :

To highlight measurable components in evaluation of the smile. To highlight relationship of peri-oral soft tissue & teeth to attractive smile. To lay diagnostic parameters for prosthodontist in planning treatment procedure

FACIAL ANALYSIS
The facial features have an important influence on the

perception of an individuals personality.

Analysis of these features is made using horizontal

and vertical reference lines, to determine the size and proportion of face from chin to hairline and also the relationship of the patients face and dentition in space.

Facial analysis is checked at conversational distance

FRONTAL VIEW
The first horizontal line from the top is the Ophriac line , the second horizontal line below it is the Interpupillary line, the third horizontal line is the Commissure line. A vertical line is the facial midline and is Identified as straight or Curved( right or left)

 This horizontal reference line should normally be

parallel to the incisal and occlusal plane of the patients teeth

SYMMETRY AND DIVERSITY

In most subjects in whom asymmetry is found, the

dimensional difference between the left and the right sides of the face is less than 3%

Original appearance Mirrored image against left (a) and Right (b) side
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HORIZONTAL DISHARMONY
In cases where interpupillary line and the

commissural line are not alligned parallel to horizontal plane, the horizon is taken as the ideal reference plane.

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 In an asymmetrical smile with large differential

elevation of upper lip may be due to a deficiency of muscular tonus on one side of the face.
Myofunctional excercises have been recommended to

help overcome this deficiency and restore smile symmetry

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FACIAL PROPORTIONS
The face is divided horizontally into three portions

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The lower third of the face represents the area that receives the most attention, since it is dominated by the presence of lips and teeth The distance from bottom of the nose to the lower edge of upper lip therefore should be approximately half the length between the lower lip and the bottom of the chin. Ideal ratio 33:66 The lower third of the face plays a significant role in determining the overall esthetic appearance

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 This third portion is slightly wider than the upper two

portions in a youthful patient with no occlusal wear and normal vertical dimension.
However this portion may eventually shrink with age

and severe wear

Divided into 1)within normal limits 2) excessive lover facial height 3)deficient lower facial height
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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

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LATERAL VIEW
Normal profile:

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Convex profile

Concave profile

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E-LINE or Ricketts E-plane

In normal profile , the upper lip is about 4mm and the lower lip is about 2mm posterior to the E-Line.
The lip position considered to be normal is one that

lies posterior to the E-Line

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 Inconspicuous maxillary central incisors can therefore be considered a natural and useful compensation for balancing the esthetic appearance of a patient with a convex profile

Greater dental dominance can be pleasing in a concave profile, particularly if the patient has thick lips.

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NASOLABIAL ANGLE
The size of this angle is affected by inclination of

base of the nose and by the position of the upper lip. Nasolabial angles in females- 100-105degrees In males 90-95degrees

In convex profile <90degree In concave profile

=90degree

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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

Nasolabial angles , E-Lines can change significantly

following restorative-prosthetic treatment

Care must be taken not to make changes to the

dental position that would interfere with the muscular areas composed of tongue ( internally) and lips and cheeks (externally)

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LIPS
The upper and lower lips meet laterally at the labial

commissure.

The contour of lips identifies the limit within which

the prosthetic rehabilitation must be finalized and helps to arrange the correct dental position

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SHAPE OF LIPS
Straight lips Convex lips

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 Concave lips

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 Enclosed between the upper and lower vermilion

borders of lip during the smile is the Smile space /Smile zone which contains the dental arches with its various smile lines, buccal corridor and the inter incisal and inter occlusal dark spaces.

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SMILE ZONE
The inferior border of the upper lip & the superior border

of the lower lip forms an outline of the space that is revealed while smiling & is called smile zone.
There are six basic smile-zone shape:

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 The maxillary incisors should fill 75% to100% of

this space to create youthful look

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SIZE OF THE LIPS

Thick and narrow lips: associated with extroversion

Medium and average lips:

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 Thin and wide lips : associated with introversion

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 The labial philtrum measurement , as a rule 2-3mm

LABIAL PHILTRUM

shorter than the height of labial commissure, which is also measured from base of the nose .

PROSTHETIC APPLICATION: In young subjects, labial philtrum is much shorter,

this means that the maxillary incisors are much more visible in young people.

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 The average lip length at rest , as measured from subnasale

to the most inferior portion of upper lip at the midline, is about 23mm in males and 20mm in females.

Lip length should be roughly equal to the commissure height. A short lip length relative to commissure height results in

unesthetic , reverse resting upper lip line.

A short upper lip is not always associated with high lip line

Eight components of balanced smile-Roy Sabri Journal of clinical orthodontics march2005 vol.3
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MORPHOLOGIC CHANGES
A patients profile inevitably varies throughout the

course of his or her life including lips which are subjected to inevitable flattening process with age.

Prosthetic application: This is generally the reason why a wish for more

prominent lips, regardless of physiologic aging

Especially in females, a certain prominence of upper

lip compared to lower lip nowadays is considered particularly attractive

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 According to Rufenacht, a correlation can be found

between tooth shape , teeth arrangment and lip shape. Upper and lower lips with average volume.

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Upper and lower lips with full volume

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Upper and lower thin lips

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Dentolabial Analysis :
1) Tooth-Lower lip position
2)Lip line 3)Midline- Relationship of central incisors to philtrum

4)Midline-canting to right or left

5)Teeth exposure during physiologic rest position 6)Smile line(maxillary incisal edge relation to superior

border of lower lip) 7) Number of teeth exposed in a full smile 8) Buccal corridor
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DENTOLABIAL ANALYSIS-LIP MOVEMENT

The lips should move consistently in a horizontal plane

and therefore be parallel to the interpupillary line During smiling ,maxillary teeth may be more visible while in many phases of speech mandibular teeth may be more exposed.

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Stages of smile:
Smile is a generalized term , it requires to be specified in

order to understand its features.

STAGE 1 :Pre smile-lip posture: Lips are in rest position,

vermillion border of upper and lower lip in passive contact.

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 STAGE 2:Silent smile( closed mouth smile): Initiation

of smile reflex, lips are still in apposition, teeth are not visible. The muscles of facial expressions begin to contract . This changes the shape of lip seal.

Eg. As in formal meeting someone

STAGE 3 : Open smile( passive smile): lips slightly

parted, slight labial surface of anterior teeth exposed.

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STAGE 4: Active smile: Lips

expose teeth,gingiva and mucosa of varying extend.Smile folds appear on both sides at the angle of mouth to compliment smile

STAGE 5: Laughter :Lip expose teeth,gingiva,labial and buccal mucosa to a much greater extend,intense smile lines , smile folds appear in cheek around the corner of mouth.

Esthetic considerations of smile- DR. E.G.R Solomon

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 It is important to differentiate between a posed and a

spontaneous smile A Posed smile-is voluntary , static , reproducible and need

not elicited or accompanied by emotions

A spontaneous smile- is involuntary, induced by joy or

mirth, dynamic but not sustained

A spontaneous smile results in more lip elevation

Since a posed is fairly reproducible , rehearsed can therefore be used as a reference position .
The importance of incisal positioning in the esthetic smile: the smile arc
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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

Many subjects limit the width of their smile to hide

incongruous restorations, discolored teeth etc.

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TOOTH EXPOSURE AT REST

Exposure of maxillary teeth varies from 1-5mm,

depending on the height of the lips and the patients age and sex On average maxillary incisors are exposed 1) more in women 2) much more in young patients than middle aged.

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PROSTHETIC CONSIDERATION
A determination of what portion of the maxillary

incisors is visible with the lips at rest constitutes one of the key parameters for evaluating whether any alternation to tooth length is needed.

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 In the smiles of young subjects with normal occlusion

,those displaying the first molars are considered esthetically pleasing.

Goldstein describes the youthful smile in which the

front teeth are longer and create a line that comes a little down in the middle of the smile, travelling superiorly to the corners.

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 By standardizing maximum and minimum lip

parameters based on muscular and phonetic positions ,one can quantify esthetic ratios and relationships of tooth reveal M POSITION- by having the patient say the letter M repetitively and then allow lip to part gently, one can assess minimum tooth reveal E POSITION- when patients says the letter E in uninhibited and exaggerated way, one can ascertain the maximum extension of lips- cheese

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 To create a harmonious smile, incisal margins in all

cases should maintain parallel alignment with the lower lip( if the commissure line is parallel to the horizontal line)

Contacting lips

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Non-contacting lips

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 Covering lips

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 There is a physiologic reason for making the incisal plane

contact the lower lip.

The lip can accommadate to any incisal edge positions to

form f and v sounds

But the facial muscles becomes fatigued if the lower lip

requires abnormal lip activity to squeeze the sound into a flat band If a patients complains about a tired face when talking a lot or if facial fatigue occurs , it is probable that there is a mismatch between lips and the teeth.
Dawson Tmj to smile design

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 For an attractive smile, contact should preferably be

present between the incisal edges of upper teeth and vermilion border of lower lip
Absence of parallelism of between smile line and lower

lip together with no contact of incisal edges with lower lips creates a negative space , an undesirable feature as it distracts the obeservers attention.

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Smile line/Smile arcLip

Incisal Curve and Lower

The smile arc is defined as the relationship of the

incisal edges of maxillary incisors and canines to the curvature of lower lip in the posed smile.

Females shows more curvature of smile line in

comparision to men after orientation of the smile line, one can design its curve or shape

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 Convex incisal curve: The incisal plane when

observed from the front , has a convex curve that follows the natural concavity of lower lip during smiling.

Class 1 patients slightly evident Class 3 patients flatten out considerably Class 2 patients noticeably convex

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RADIATING SMILE
The convexity of incisal curvature with ideal tooth

proportions produces a radiating symmetry.

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FLAT OR REVERSE INCISAL CURVE

Abrasion of incisal edges- flat or reverse incisal

curvature , decrease in incisal length, negative anterior space.

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HORIZONTAL SYMMETRY
An inevitable sense of aged smile.

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PROSTHETIC CONSIDERATIONS
The lightness of the smile, governed by the progression of

the interincisal angles , is reinforced by the parallelism found between the lines that joins all the anterior interdental points of contact, the incisal curvature , and that of the lower lip.

Convex smile line accentuates the quality of smile and therefore it is a positive smile line.

A convex smile line and parallelism of smile line to lower lip are two desirable qualities of smile which gives pleasantness to smile.
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 Concave smile line gives an unpleasant , harsh,

distracted character to smile and therefore it is a negative smile line.

Straight smile line can have a positive or negative

effect depending on its harmony with lip curvature and to the presence or absence of buccal corridor

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 The curvature of lower lip is not always homogeneous.

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 The ability of the lips (upper and lower)to adapt to

new situations.

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INCISAL PROFILE
Position of incisal edge anteroposterior direction

Prosthetic rehabilitation should involve modifying the incisal profile so as to allow the anterior teeth to remain inside the vermillion border of lower lip.
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Prosthetic considerations- if teeth are inclined too far forward. 1)feeling of excessive tooth length

2)closing of lips more difficult

3)upper lip to prominent and sometimes can alter actual morphology of lower lip
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LIP LINE
The lip line is the amount of vertical tooth exoposure in

smiling

The first step in this analysis is to evaluate the exposure

of anterior teeth during smiling with an maxillary incisal display in males 1.91mm in men and nearly twice in females 3.40mm low , average, and high.

Tjan and coworkers identified three types of smile lines : Female lip lines are an average 1.5mm higher than male lip

lines with more gingival exposure

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LOW LIP LINE:

The motility of upper lip exposes- <75% of anterior

teeth.

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AVERAGE LIP LINE:

Labial movement reveals 75% to 100% of anterior

teeth as well as interproximal papillae.

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 A pleasing smile( optimal lip line) can be defined as one

that exposes the entire cervicoincisal length of maxillary teeth completely , along with approximately with the interproximal gingivae.

Gingival exposure that does not exceed 2 to3 mm is

considered esthetic

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HIGH LIP LINE

Complete exposure of anterior teeth , a gingival band

of varying height is also exposed.

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 Gingival and mucosal smile imparts attractiveness to

smile.
Failure to expose the upper anterior teeth gives a

negative smile, which lacks expression

Exposure of only the upper anterior teeth produces a

static smile

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 When the upper anterior teeth interdental papilla and

certain extend of gingiva and mucosa are exposed , a dynamic , pleasant and attractive smile is produced.
In an attractive smile, gingiva and mucosa of posterior

teeth are exposed to compliment the anterior gingiva mucosa exposure- a common noticeable feature in a beautiful smile.
Esthetic consideration of smile: Dr. E.G.R Solomon
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PROSTHETIC CONSIDERATIONS
High smile line- lack of harmony in the gingival levels 1)preprosthetic surgery 2)orthodontic treatment
Exposure of gingival margin during smiling-obliges the dentist to hide the restorative margin inside the gingival sulcus.

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GUMMY SMILE
A gummy smile is characterized by gingival exposure in excess of 3-4 mm.

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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

Among the various treatment options that can be

considered with the patient, the orthognathic and orthodontic treatments are often especially suitable particularly when healthy teeth are involved.

If patient requires prosthetic rehabilitation, the

restorative therapy often will have to be combined with orthodontic or surgical crown lengthening procedures, with dual aims of re-establishing ideal tooth length and reducing amount of visible gingiva.

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 If a gingival smile is caused by a hypermobile lip, it would be

mistake to correct it with aggressive incisal intrusion or maxillary impaction surgery , because that would result in minimal or no incisal display at rest and thus make patient look older. Excessive lip elevation should be therefore recognized as a limiting factor
If a low lip line is due to hypomobile lip, extensive extrusion

or cosmetic lengthening of tooth would result in an overbite with excessive incisal display at rest.
Eight components of balanced smile-Roy Sabri Journal of clinical orthodontics march2005 vol.3

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 When upper lip length and mobility are normal, a

gingival smile with excessive incisal display at rest can be attributed to vertical maxillary excess associated with usually with excessive lower facial height conversely a low lip line with no incisal display at rest is skeletal when associated with inadequate lower facial height due to vertically deficient maxilla
The best reference for impacting or lengthening the

maxilla is the incisal display at rest, taking upper lip length and any incisal attrition in account.
Eight components of balanced smile-Roy Sabri Journal of clinical orthodontics march2005 vol.3

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Gingiva and Upper lip curvature:

tissues of maxillary anterior teeth should be located along the horizontal line extending from canine to canine.

The gingival contours should be symmetric and the marginal gingival

Ideally, the lateral incisors reach slightly short of that line The gingival zenith point is located

distal to the long axis of maxillary Central and cuspids, along the long axis of lateral incisor

Smile design-DCNA 51(2007) ,Nicholas C. Davis

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SMILE WIDTH
Lip movement when smiling generally exposes the

anterior teeth, along with the premolars and in many cases, the maxillary first molars as well.

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 In the posterior segments, uprighting the posterior teeth

and slight uprighting of cuspids , the smile can be made to appear wider that more completely fills the buccal corridor This inclines should not exceed a perfectly vertical orientation
This makes the teeth appear bigger , producing more

reflective surfaces for a broader smile, which is in high demand today

Smile design-DCNA 51(2007) ,Nicholas C. Davis

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 In a broad smile amount of reveal of the maxillary

posterior teeth also becomes an esthetic considerations

In patients who have narrow arch form and wide lip

extensions, tooth reveal behind the canine can be in shadow or disappear completely . This condition has been called Deficient Vestibular Reveal and may have negative esthetic influence in some patients.

JADA, Vol. 132, january 2001-macroesthetic elements of smile design

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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

If the patient exposes gingival margins of maxillary

molars when smiling, exposure of metal margin will be unattractive and disagreeable to the patient. In these cases, differentiated tooth preparation of buccal margin can be performed, involving a greater tooth reduction (shoulder, chamfer).

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BUCCAL CORRIDOR
The buccal corridor is space seen on either side of

mouth during smiling, between the buccal walls of maxillary teeth and the corners of mouth. Depending on its width, the buccal corridor can be classified as normal, wide, or absent.

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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

Positioning prosthetic restorations too buccally in

posterior areas can fill whole of labial corridor, altering natural and harmonious progression of the smile. Clinician should carefully evaluate width of corridor, varying, if necessary, the axial inclinations of tooth preparations. This ensures enough space to create restorations with appropriate contour.
Patients with narrow arches and wider smile have

broader buccal corridor area

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 Buccal corridor is a positive component which gives

dynamism and enhances the character of smile

When the smile line changes from convex or straight to a

concave smile line, there is reduction in size of buccal corridor. Pronounced buccal corridor is invariably seen when there is convex or straight smile line.
Gingival and mucosal smile with large buccal corridor is

esthetic
Esthetic consideration of smile: Dr. E.G.R Solomon

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 From a frontal view, Axial inclination of the anterior teeth tends to incline mesially

toward the midline and become more pronounced from the central incisors to the canines.

This inclination is least noticeable with the centrals and becomes

more pronounced with the laterals and even more so with the canines.

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The axial inclination of the posterior teeth from the frontal view exhibits the same mesial inclination toward the midline as the cuspid. There is a direct relationship between the pleasing effect that these smiles can generate and the equilibrium in the balance of lines of tooth inclination.
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INTERINCISAL LINE
Reference : maxillary

MIDLINE
Reference : center of

inter-incisal line.

upper lip or labial philtrum.

A variation between facial and dental midline that is limited to within 4mm is not noticeable either to patients or to general dental practitioners.
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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

Incorrect axial inclination can be immediately

recognized by any observer as an unesthetic feature and is less pleasing than a lateral alteration of maxillary interincisal line in relation to facial midline.

Optimizing axial inclination to re-establish vertical

alignment of dental midline is mandatory in restorative prosthetic treatment, even though this action can involve further mediolateral alteration of maxillary interincisal line with respect to facial midline.
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 Canting ( a dental midline that is not parallel to facial

midline) has been shown to be even more discernable to patients and is considered more of a handicap than dental midline that are not coincidental but are atleast parallel

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OCCLUSAL PLANE vs COMMISSURAL LINE

Occlusal plane is established by joining the incisal

surfaces of anterior teeth with occlusal surfaces of posterior teeth.

The incisal plane is anterior portion of occlusal plane.

When viewed from the front, it should be parallel to horizontal reference lines, such as interpupillary line and commissural line, to maintain a natural facial harmony.

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PROSTHETIC CONSIDERATIONS AND APPLICATIONS

A slight deviation from horizontal plane is considered

acceptable and does not necessarily require correction.

A marked lack of parallelism between occlusal plane,

the commissural line and interpupillary line needs a multidisciplinary treatment.

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Conclusion:
The following points are important in harmonizing smile: Esthetic restorations that show the entire cervicoincisal length of maxillary anterior teeth with only the inter dental papilla
Smile line should be parallel with lower lip curvature Maxillary first molars should be considered as a part of

esthetic zone Dental midline should coincide with facial midline or they should be parallel to avoid canting
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References :
Esthetic analysis: Mauro Fradeani
Tmj to smile design : Dawson Esthetic consideration of smile: Dr. E.G.R Solomon JADA, Vol. 132, january 2001-macroesthetic elements of

smile design

Smile design-DCNA 51(2007) ,Nicholas C. Davis Eight components of balanced smile-Roy Sabri Journal of clinical orthodontics march2005 vol.3

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