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1. THE SMILE LINE AND ITS
IMPORTANCE IN
TREATMENT PLANNING

2. 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.

3. 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.
INTRODUCTION

4. 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

5. 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

6. 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

7. ANATOMY OF THE
SMILE
Ackerman & Ackerman JCO-2002

8. Components of the smile

9. VERTICAL ASPECTS OF SMILE
ANATOMY
•Maxillary anterior tooth display[Morley
ratio]
•Upper lip drape
•Gingival display

10. Morley ratio
In a youthful smile, 75-100% of the maxillary
central incisors should be positioned below an
imaginary line drawn between the commissures

11. Soft tissue determinants of
the display zone
·Lip thickness
·Intercommissure width
·Interlabial gap
·Gingival architecture

12. GENESIS OF A FULL SMILE
Rubin et al -1989 plast reconst surgery
Stage -0
Stage -I
Stage -II

14. I stage
• upper lip raises to
the nasolabial fold
•Further elevation is
stopped by the cheek
fat

15. II stage
Further raising by 3 muscle
groups
• levator labii superior
muscle
• Zyg.major muscle
• Sup fibers of
buccinator
Squinting during smile

16. SMILE
CLASSIFICATION
Anthony H.Tjan 1984- JPD
High smile
Average smile
Low smile

17. HIGH SMILE
Reveals the total cervicoincisal length
of the maxillary anterior teeth & a
continuous band of gingiva

18. AVERAGE SMILE
Reveals 75% to 100% of the maxillary
anterior teeth and the interproximal
gingiva

19. LOW SMILE
Displays less than 75% of the
anterior teeth

20. 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

21. Social smile
•Voluntary
•unstrained
•static facial expression
-Stage I smile

22. ENJOYMENT SMILE
•Involuntary
•Dynamic
•Natural -expresses authentic human emotion
-stage II smile

23. 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

24. CUSPID SMILE
Elevators of the upper lip raises it like a
window shade to expose the teeth &
gingival scaffold

25. 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

26. MONA LISA SMILE
Zygomaticus major muscle draws the outer
commissures outward & upward followed by a
gradual elevation of the upper lip

27. 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

28. 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

29. 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

30. 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

31. SMILE LINE / LIP LINE
SMILE ARC
BUCCAL CORRIDORS

32. SMILE LINE /LIP LINE
High smile line
Medium smile line
Low smile line
Reverse smile line

33. HIGH SMILE LINE / GINGIVAL
SMILE LINE
Exposes a lot of gum tissue above the front
teeth

34. 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

35. 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

36. REVERSE SMILE LINE
The cuspids are lower than the central
incisors

37. 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

38. CONSONANT /IDEAL SMILE
ARC
Maxillary incisal edge curvature is
parallel to the curvature of lower lip
upon smile
YOUTHFUL SMILE

39. NONCONSONANT / FLAT SMILE
ARC
Maxillary incisal curvature is flatter than
the curvature of the lower lip on smile

40. NEGATIVE SPACE [BUCCAL
CORRIDOR]
Full smile
The teeth should fill the corners of the
smile & this is commonly referred to as full
smile

42. GENDER DIFFERENCE IN SMILE
TYPE
Male - Low smile line
Female – High smile line
Females have more maxillary & less
mandibular tooth exposure than
males at all ages

43. 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

44. 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

45. UPPER LIP LENGTH
Greater in males than in females
INTERLABIAL GAP
Greater in females

46. AGE DIFFERENCE IN SMILE
TYPESLip 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

47. Vig, Brundo 1978 JPD
Decrease in maxillary incisor exposure &increase in
mandibular incisor exposure with age

48. 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

49. Display of maxillary incisors –indicates youth
mandibular incisors- indicates age

50. SMILE LINE IN VARIOUS
MALOCCLUSIONS

51. Flat smile arc
•Brachyfacial growth pattern
lack of tendency of the anterior maxilla
to tilt clockwise rotation
•Thumb sucking habit
reduction in anterior vertical
dentoalveolar development
•Vertical maxillary deficiency

52. 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

53. CLINICAL IMPLICATIONS
FOR SMILE TYPES

54. 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

55. MAXILLARY INCISOR
INTRUSION ?

56. 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

57. CORRECTION OF
DEEP BITE ? ?

58. •Intrusion of mandibular incisors
•Growing patient with short lower
face extrusion of posterior teeth

59. 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

60. 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

61. DIAGNOSTIC AIDS
Clinical examination
Photographs
Study models
Cephalogram
Smile analysis

62. CLINICAL
EXAMINATION
1. Upper lip line
refers to the upper lip line at
maximum smile

63. 2. Upper lip length
measured independently in a
relaxed position when the mandible is
in occlusal rest position
Upper lip
Normal length 19-22mm

64. Short upper lip
18mm or less
increased interlabial gap
increased incisor exposure[normal
lower face height]

65. 3.UPPER TOOTH TO LIP
RELATIONSHIP
•Rest position
•Maximum smile

66. Upper tooth to lip
relationship1 to 5mm
Disharmony
• / anatomic upper lip length
• / maxillary skeletal length
•Thick upper lips
•The angle of view

67. 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

68. 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

69. Factors affecting interlabial
gap
Gender
Lip length
Vertical dentoskeletal height

70. Increased interlabial gap
•Anatomic short upper lip
•Vertical maxillary excess
•Mandibular protrusion with open

71. Decreased interlabial gap
•Vertical maxillary deficiency
•Anatomically long upper lip
•Mandibular retrusion with deep bite

72. 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

73. STUDY MODELS
•Tooth size discrepancy
•Clinical crown height
•Overbite
•Overjet
•Static occlusal relationship

74. LATERAL
CEPHALOGRAPH
•Sella Nasion to Mandibular plane
•Sella Nasion to Palatal plane
•Anterior maxillary height

75. 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

76. 2.Impossible to repeat the social smile
exactly
In children this is due to relatively
late maturation of the social smile

77. STANDARDISED DIGITAL
VIDEOGRAPHY
Allows the clinician to capture a
patient’s speech, oral & pharyngeal
function & smile at the same time

78. Procedure

79. 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

80. 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

81. SMILE MESH

82. •Maxillary incisor display
•Upper lip drape
•Buccal corridor ratio
•Maxillary midline offset
•Interlabial gap
•Intercommissure width in frontal plane

83. 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

84. 3.Vertical & anteroposterior skeletal
& dental development
4.Panoramic & supplemental intraoral
radiographs
5.Study models
static occlusal relationship
tooth size discrepancies

85. 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

86. FACTORS
INFLUENCING
SMILE LINE

87. SOFT TISSUE
DENTAL
SKELETAL

88. 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

90. 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

91. 2.COMMISSURE HEIGHT
Adults
2to 3mm greater than the philtrum
height
Adolescence
several mm greater than philtrum
heightDrooping of the commissures
due to aging & facial jowling
corrected by Rhytidectomy [face lift]

93. 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

94. Lip incompetence in adults
•Short philtrum
•Vertical maxillary excess
•Excessive overjet
Matthews 1978-JPD
interlabial gap was highly related to
gummy smile

95. 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

96. Excessive incisor show at rest
•Short upper lip philtrum height
•Vertical maxillary excess
•Excessive crown height
•Detorqued maxillary incisors

97. Inadequate incisor show at rest
•Excessive upper lip philtrum height
•Vertical maxillary deficiency
•Inadequate crown height
•Flared maxillary incisors

98. 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

99. • High Frenal attachment
limits lip mobility & decrease the
incisor show on smile
• Hypomobility of the smile
seen in cases of trauma or neural
deficit

100. 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

101. 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

102. • 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

103. SKELETAL FACTORS
Vertical skeletal development
Vertical maxillary excess
Vertical maxillary deficiency

104. VERTICAL MAXILLARY EXCESS
Excessive gingival display
Long lower facial height
Open bite
Excessive interlabial gap
Convex profile

105. 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

106. ACHIEVING AN
ESTHETIC AND
FUNCTIONAL SMILE

107. 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

108. Treatment solutions for
improvement of short philtrum
Esthetic lip surgery
V-Y cheiloplasty
Le Fort I osteotomy
Rhinoplasty

109. 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

111. Treatment of excessive incisor show at
rest
Adolescents & adults who have excessive
incisor show at rest have different
treatment considerations

112. Adolescents
Incisor show
4-5mm –Observation
self correction by growth of lips
6-8mm – Intrusion of maxillary
incisors
> 8MM- Surgical correction

113. 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

114. 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

115. 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

116. 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

117. BRACKET POSITIONING
Straight incisal curve
to achieve canine guidance
gingivally placed lower incisor brackets

118. 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

119. INTERDISCIPLINARY CARE
Smile enhancement involves the team work of
Orthodontist
Oral & Maxillofacial surgeon
Periodontist
Prosthodontist

120. The various procedures, that requires the
team effort are the following
Simple gingivectomy
Surgical crown lengthening
Cosmetic contouring
Veneering
Crowns & Laminates

121. CONCLUSIO
NA 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

122. 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..

124. 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

125. 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

126. 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

127. 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