THE SMILE LINE AND ITS

IMPORTANCE IN
TREATMENT PLANNING

K. KOHILA
 INTRODUCTOIN
IT ALL BEGINS WITH THE SMILE

An attractive,well balanced smile can be a

valuable personal asset.

A pleasing smile is important in personal

communication and to facial beauty. One‘s
dental and facial appearance is important not
only in the role that attractiveness plays to
others but also in ones self concept.
INTRODUCTION
Enhancement of facial beauty is one of
the primary elective goals of patients
seeking dental care.
The goal of orthodontic treatment should
be attainment of the best possible esthetic
result, dentally and facially.
 DEFINITION
Webster’s dictionary

A pleased or amused expression of the

face, formed by curling of the mouth upward

Advanced learners dictionary – A.S.Hornby

Pleased,happy, amused or other

expression of the face with a parting of the
lips and loosening of the face muscles
 REVIEW OF LITERATURE
Robert Mack,

Fort lauderdale- JPD 1996

The incisal edges of the maxillary
anterior teeth should be in curvilinear
harmony with the arc of the lower lip in
a full but unforced smile
All teeth lie within the circumference of
the lower lip and make gentle contact
with mucosal tissue
Frush & Fisher JPD-1958

There should be harmony between the

curvature of the incisal edges of the maxillary
anterior teeth and the curvature of the upper
border of the lower lip

Arnett & Bergman AJO-1993

Ideal smile exposes three quarters of the

crown height to 2mm of gingiva, females more
than males
 ANATOMY OF THE
SMILE
Ackerman & Ackerman JCO-2002
Components of the smile
VERTICAL ASPECTS OF SMILE
ANATOMY

•Maxillary anterior tooth display[Morley

ratio]

•Upper lip drape

•Gingival display
 Morley ratio

In a youthful smile, 75-100% of the maxillary

central incisors should be positioned below an
imaginary line drawn between the commissures
 Soft tissue determinants of
the display zone

·Lip thickness

·Intercommissure width

·Interlabial gap

·Gingival architecture
GENESIS OF A FULL SMILE

Rubin et al -1989 plast reconst surgery

Stage -0

Stage -I
Stage -II
I stage

• upper lip raises to

the nasolabial fold

•Further elevation is
stopped by the cheek
fat
II stage
Further raising by 3 muscle
groups

• levator labii superior

muscle
• Zyg.major muscle
• Sup fibers of
buccinator
Squinting during smile
 SMILE
CLASSIFICATION

Anthony H.Tjan 1984- JPD

High smile

Average smile

Low smile
 HIGH SMILE

Reveals the total cervicoincisal length

of the maxillary anterior teeth & a
continuous band of gingiva
 AVERAGE SMILE

Reveals 75% to 100% of the maxillary

anterior teeth and the interproximal
gingiva
 LOW SMILE

Displays less than 75% of the

anterior teeth
Ackerman & Ackerman JCO-2002

•Social smile / posed smile

•Enjoyment smile / unposed smile

Each type involves a different anatomic

presentation of the elements of the
display zone
 Social smile
-Stage I smile
•Voluntary
•unstrained
•static facial expression
 ENJOYMENT SMILE
-stage II smile
•Involuntary
•Dynamic
•Natural -expresses authentic human emotion
 SMILE STYLE
Rubin 1974 -plast reconst surgery

Cuspid smile or Commissure smile

Complex smile or Full denture smile
Mona Lisa smile
Depends on the direction of elevation &
depression of the lips and the prominent
muscle groups involved
 CUSPID SMILE

Elevators of the upper lip raises it like a

window shade to expose the teeth &
gingival scaffold
 COMPLEX SMILE
Elevators of the upper lip and the depressors
of the lower lip acts simultaneously, raising the
upper lip like a window shade & lowering the
lower lip like a window
 MONA LISA SMILE
Zygomaticus major muscle draws the outer
commissures outward & upward followed by a
gradual elevation of the upper lip
 CHARACTERISTICS OF TYPICAL
SMILE
•Total cervicoincisal length
•Only interproximal gingiva
•Incisal curvature parallels the lower lip
curvature & touches the lower lip
•Six anteriors , I & II PM are displayed
•midline
 GINGIVAL SMILE LINE
Definition
The smile at its fullest exposes the gingiva
superior to the maxillary anterior teeth
Other names
Gummy smile
High lip line
Short upper lip
Full denture smile
 Etiology
•Short philtrum
•Vertical maxillary excess
•Excessive curtain on smile
•More superiorly positioned upper lip
•Decreased upper lip length
•Increased interlabial gap at rest
•Increased overjet
•Increased overbite
GINGIVAL SMILE LINE & LIP ELEVATION

Rubin 1989- plast Recont surgery

The persons with gingival smile lines have

significantly more efficient lip elevation

musculature than those with average lip lines

Key anatomical determinant in the genesis

of the gingival smile line

SMILE LINE / LIP LINE

SMILE ARC

BUCCAL CORRIDORS
 SMILE LINE /LIP
LINE
High smile line
Medium smile line
Low smile line
Reverse smile line
 HIGH SMILE LINE / GINGIVAL
SMILE LINE
Exposes a lot of gum tissue above the front
teeth
 MEDIUM SMILE LINE
Shows upto but doesn't include the upper
gum line of the front teeth
•Central incisors are longer & wider than the
lateral incisors
•Cuspids are more pointed & same length as
the centrals
•Tissue fills in the space
between the teeth nicely
& frames their beautiful
 LOW SMILE
LINE
Doesn't reveal the gingiva at all, the tooth
wear can eventually make the person appear
as if he/she has no front teeth
 REVERSE SMILE LINE

The cuspids are lower than the central

incisors
 SMILE ARC

Smile arc is defined as the relationship of

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

Types

Consonant/ideal smile arc

Nonconsonant /flat smile arc
CONSONANT /IDEAL SMILE
ARC
YOUTHFUL SMILE

Maxillary incisal edge curvature is

parallel to the curvature of lower lip
upon smile
NONCONSONANT / FLAT SMILE

ARC
Maxillary incisal curvature is flatter than
the curvature of the lower lip on smile
 NEGATIVE SPACE [BUCCAL
CORRIDOR]
Full smile
The teeth should fill the corners of the
smile & this is commonly referred to as full
smile
 GENDER DIFFERENCE IN
SMILE
Male - Low smile line
TYPE
Female – High smile line

Females have more maxillary & less

mandibular tooth exposure than
males at all ages
 Robert G. Vig ,Brundo 1978-JPD

Women displayed almost twice as much

anterior teeth with the lips at rest as in men

Men displayed more mandibular incisor

than the women , namely 1.23mm compared
to 0.49mm
Peck,Peck, kataja 1992-AJO
Vertical lineaments of lip position

The upper lip smile line or lip position on

smiling was 1.5mm more superior in the
females than in the males

High smile line –Female lineament

Low smile line -Male lineament

UPPER LIP LENGTH
Greater in males than in females

INTERLABIAL GAP
Greater in females
AGE DIFFERENCE IN SMILE
TYPES
Lip coverage of the maxillary incisors
increases with age
High smile is common among younger
age group

With age gradual lowering of the midpoint of

the lips exposes the mandibular incisors
more & covers the maxillary incisors to a
greater degree
 Vig, Brundo 1978 JPD

Decrease in maxillary incisor exposure &increase in

mandibular incisor exposure with age
 Bjorn, Zaccharisson 1998 JCO

Change in lip position

• effect of gravity on upper & lower
lip positions
• sagging of perioral soft tissue
natural flattening
stretching & decreasing
elasticity of skin
Display of maxillary incisors –indicates youth

mandibular incisors- indicates age

SMILE LINE IN VARIOUS

MALOCCLUSIONS
 Flat smile arc
•Brachyfacial growth pattern

lack of tendency of the anterior maxilla

to tilt clockwise rotation

•Vertical maxillary deficiency

•Thumb sucking habit

reduction in anterior vertical

dentoalveolar development
Gingival smile line
• Vertical maxillary excess

Karin Willmar 1974

• Class II malocclusion

Vig, Brundo 1978-JPD

resistance to usual pattern of
increased lip coverage with age
 CLINICAL
IMPLICATIONS FOR
SMILE TYPES
 Low & average smile types
Deep bite correction
intrusion of anteriors
extrusion of posteriors

Overintrusion of anteriors
upper incisors tend to hide behind the lip
which worsens with age
MAXILLARY INCISOR
INTRUSION ?
Maxillary incisors should be moved in the
vertical direction that improves their
relationship to the resting lip position

sometimes extrusion is necessary

In most orthodontic patients,

expect those with gummy smile ,
active intrusion of maxillary
incisors is undesirable
CORRECTION OF
DEEP BITE ? ?
•Intrusion of mandibular incisors

•Growing patient with short lower

face extrusion of posterior teeth
 High smile type
Active maxillary incisor intrusion
should be the goal in these patients

Intrusion base arches

utility arches

Combination of orthodontic
periodontal
surgical therapy
 DIAGNOSIS

Assessment of the patient’s smile

is very critical because this is an

important focal pint of how a

person interacts with the society

 DIAGNOSTIC AIDS

Clinical examination
Photographs
Study models
Cephalogram
Smile analysis
 CLINICAL
EXAMINATION
1. Upper lip line
refers to the upper lip line at
maximum smile
2. Upper lip length

measured independently in a
relaxed position when the mandible is
in occlusal rest position

Upper lip

Normal length 19-22mm

Short upper lip

18mm or less

increased interlabial gap

increased incisor exposure[normal

lower face height]

3.UPPER TOOTH TO LIP
RELATIONSHIP

•Rest position

•Maximum smile
 Upper tooth to lip
relationship
1 to 5mm

Disharmony
• / anatomic upper lip length
• / maxillary skeletal length
•Thick upper lips
•The angle of view
Angle of view

•Patient’s height

•Observer’s height

•The distance from the facial surface of

the upper lip to the incisive edge

increased lip thickness reveals less

relative tooth exposure
 4.INTERLABIAL GAP

Interlabial gap is the vertical midline

opening between the relaxed upper &
lower lips with the mandible in rest
position

Normal –1 to 5mm
Factors affecting interlabial
gap
Gender
Lip length
Vertical dentoskeletal height
 Increased interlabial gap

•Anatomic short upper lip

•Vertical maxillary excess

•Mandibular protrusion with open

 Decreased interlabial gap

•Vertical maxillary deficiency

•Anatomically long upper lip

•Mandibular retrusion with deep bite

 PHOTOGRAPHS
Frontal
at rest
frontal dynamic
close up image of the posed smile

Each patient should be coached & asked

to achieve the same lip position at least
twice in succession before a photograph
is taken
 STUDY MODELS

•Tooth size discrepancy

•Clinical crown height

•Overbite

•Overjet

•Static occlusal relationship

 LATERAL
CEPHALOGRAPH
•Sella Nasion to Mandibular plane

•Sella Nasion to Palatal plane

•Anterior maxillary height

 SMILE ANALYSIS
Ackerman & Ackerman JCO 2002

Drawbacks of conventional photography

1. Difficult to standardize photograph
camera angle
distance to the patient
head position
discrepancy between intraoral &
extraoral technique
2. Impossible to repeat the social smile
exactly

In children this is due to relatively

late maturation of the social smile
 STANDARDISED DIGITAL
VIDEOGRAPHY

Allows the clinician to capture a

patient’s speech, oral & pharyngeal

function & smile at the same time

Procedure
Chelsea eats cheesecake on the Chesapeake

30 frames /sec
5 sec clip –150 frames
Downloaded to Apple Final Cut pro
for compression & conversion into an
Apple Quick Time viewer file
 SMILE ANALYSIS

From the Quick Time video clip, the

frame that best represents the social
smile is selected, captured with a
program called screen snapz, & saved as a
JPEG file

This image is then opened in a program

Smile mesh, which measures 15
attributes of the smile
SMILE MESH
•Maxillary incisor display

•Upper lip drape

•Buccal corridor ratio

•Maxillary midline offset

•Interlabial gap

•Intercommissure width in frontal plane

Diagnosis

1. Extra oral photo gallery

captured social smile
full facial portrait at rest
three quarter smiling view
profile view
2. Cant of the maxillary occlusal plane to
FHP on the lateral ceph
3. Vertical & anteroposterior skeletal
& dental development

4. Panoramic & supplemental intraoral

radiographs

5. Study models

static occlusal relationship

tooth size discrepancies

Problem list

•Inadequate maxillary incisor display

•Unfavorable Morley ratio
•Excess gingival show
•Flat or reverse smile arc
•Asymmetric cant of maxillary
transverse occlusal plane
•Obliterated buccal corridors
 FACTORS

INFLUENCING SMILE

LINE
SOFT TISSUE

DENTAL

SKELETAL
 Soft tissue factors

1. Philtrum height

From subspinale to the most inferior

portion of the upper lip

The absolute linear measurement is

not important, but its relationship to
the upper incisor & commissure should
be assessed
Age difference in philtrum height

Adolescent
philtrum height is shorter than the
commissure height due to differential
in vertical lip growth
Adults
A short philtrum in an adult results in
an unesthetic reverse resting maxillary
lip line
 2. COMMISSURE HEIGHT
Adults
2to 3mm greater than the philtrum

height
Adolescence
several mm greater than philtrum
Drooping of the commissures height
due to aging & facial jowling
corrected by Rhytidectomy [face lift]
3. Lip incompetence /Interlabial gap

Lip incompetence is the amount of

lnterlabial gap at rest

more common in adolescence than in

adults due to differential lip growth

 Lip incompetence in adults

•Short philtrum
•Vertical maxillary excess
•Excessive overjet

Matthews 1978-JPD
interlabial gap was highly related to
gummy smile
 Dental factors
1. Incisor show
At rest
On smile

The amount of maxillary incisor that

shows at rest is a critical esthetic
parameter because one of the inevitable
characteristics of aging is diminished
upper incisor show
Excessive incisor show at rest

•Short upper lip philtrum height

•Vertical maxillary excess

•Excessive crown height

•Detorqued maxillary incisors

 Inadequate incisor show at rest

•Excessive upper lip philtrum height

•Vertical maxillary deficiency

•Inadequate crown height

•Flared maxillary incisors

 Inadequate incisor show on smile

• Long philtrum height [rare]

• Vertical maxillary deficiency
• Inadequate curtain on smile
• Excessively long incisal crown height
• Flared maxillary incisors
• Diminished vertical dentoalveolar
development 2º to a thumb /digit
sucking habit
• High Frenal attachment
limits lip mobility & decrease the
incisor show on smile
• Hypomobility of the smile
seen in cases of trauma or neural
deficit
2. Crown length

Vertical height of maxillary central

incisors in adults is normally between
9 & 12mm, with an average of

10.6mm in males

9.5mm in females
Factors influencing crown height

• Age of the patient

A child with incomplete permanent

incisor eruption has a short clinical
crown height & the primary incisors are
only 4-5mm in height

Therefore improvement of the gummy

smile in young children is the rule
• Gingival architecture
short clinical crown may be due to
excessive gingival encroachment
In adults the gingival margin is
positioned about 1mm coronal to the
CEJ
Thick & fibrotic gingiva tends to
migrate slowly than the thin gingiva
 SKELETAL FACTORS

Vertical skeletal development

Vertical maxillary excess

Vertical maxillary deficiency

 VERTICAL MAXILLARY EXCESS

Excessive gingival display

Long lower facial height

Open bite

Excessive interlabial gap

Convex profile
 VERTICAL MAXILLARY DEFICIENCY

Insufficient incisor show at rest

Inadequate upper incisor display on smile

Short lower facial height

Low mandibular plane angle

Short chin height

Vertical lip redundancy

 ACHIEVING AN

ESTHETIC AND

FUNCTIONAL SMILE
 It must be understood that there is no
universal ‘ideal’ smile

The most important esthetic goal in

orthodontics is to achieve a balanced
smile which can best be described as an
appropriate positioning of the teeth&
gingival scaffold within the dynamic
display zone
 Treatment solutions for
improvement of short philtrum

Esthetic lip surgery

V-Y cheiloplasty

Le Fort I osteotomy

Rhinoplasty
V-Y cheiloplasty +Rhinoplasty

The v-y procedure itself may gain

philtrum length, but when combined with

rhinoplasty, the amount of tissue available

for lip lengthening appears to increase

dramatically
Treatment of excessive incisor show at
rest

Adolescents & adults who have excessive

incisor show at rest have different

treatment considerations
Adolescents
Incisor show
4-5mm –Observation
self correction by growth of lips
6-8mm – Intrusion of maxillary
incisors

> 8MM- Surgical correction

Adults
•VME -maxillary impaction LeFortI
osteotomy

•Short philtrum – V-Y cheiloplasty

•Excess crown length – Reduction in crown

length

•Detorqued maxillary incisors- Uprighting

through torque or advancement or both
 Inadequate incisor show at rest

•VMD -Maxillary downgraft LeFort I

osteotomy

•Long philtrum –Direct/Indirect lip lift

•Inadequate crown length- cosmetic dental

correction

•Flared maxillary incisors –Orthodontic torque

or retraction or both
 TREATMENT OF
HYPERMOBILE SMILE
SMILE IMMOBILIZATION
1. Spacer approach –Ellenbogen & Swara
Cartilage or silicone is laid over the
alveolar process between the septum & the
maxillary gingival mucosa.
Decreased lip elevation – spacer
-partial transection
of the
2. Kamer 1979 Smile surgery
A horizontal strip of mucosa is excised
from the superior upper lip.
An inferiorly based mucosal flap is
developed from the opposing alveolar
mucosa & is sutured to the inferior border
of the excised labial mucosa
lowers the height of gingivolabial sulcus
simpler than spacer tech with same
esthetic results
 BRACKET POSITIONING

Straight incisal curve

to achieve canine guidance

gingivally placed lower incisor brackets

Parallelism of the incisal curve & the inner
contour of the lower lip in smiling may
seem difficult to produce.

This appearance can readily be achieved if

the maxillary central incisors are
symmetrically positioned 0.5 –1mm longer
than the lateral incisors
 INTERDISCIPLINARY CARE

Smile enhancement involves the team work of

Orthodontist

Oral & Maxillofacial surgeon

Periodontist

Prosthodontist
The various procedures, that requires the
team effort are the following

Simple gingivectomy

Surgical crown lengthening

Cosmetic contouring

Veneering

Crowns & Laminates

 CONCLUSIO
N
A smile is a curve that sets everything straight

In our modern competitive society, a pleasing

appearance often means the difference
between success and failure in both our
professional and personal lives.

A charming smile can open doors and knock

down barriers that stand between us and a
fuller, richer life
Dale Carnegie, once remarked, one of the
most important ways to win friends and
influence people is to smile

It is important for orthodontists to make

every effort to develop a harmonious balance
that will produce the most attractive smile
possible for each patient being treated..
STAGE -I
•upper lip raises to the nasolabial
fold- contraction of the levator
muscles

Medial muscle bundle

lateral muscle bundle

•Cheek fat resists further elevation

 Stage-II

Further elevation -3 muscle groups

•Levator labii superior muscle
•zygomaticus major muscle
•superior fibers of the buccinator

Squinting during final stage of smiling

-contraction of the periocular
musculature to support maximum upper
lip elevation through the fold
 AGE,GENDER & RACE DIFFERENTIAL
Vig, Brundel 1978-JPD
AGE
Amount of upper incisor show at rest
decreases with age, while the amount of
lower incisor show increases
RACE
Whites exhibit more upper incisor
show at rest than do Blacks & Asians
Blacks & Asians exhibit more lower
incisor show than whites
GENDER
males show less upper incisor & more
lower incisor at rest
Females show more upper incisor &
less lower incisor at rest
The amount of upper incisor show in
females is significantly more than in
males