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30.10.

2018 Smile: A review

J Pharm Bioallied Sci. 2015 Apr; 7(Suppl 1): S271–S275. PMCID: PMC4439690
doi: [10.4103/0975-7406.155951: 10.4103/0975-7406.155951] PMID: 26015730

Smile: A review
W. S. Manjula, M. R. Sukumar, S. Kishorekumar, K. Gnanashanmugam, and K. Mahalakshmi
Department of Orthodontics, Sree Balaji Dental College and Hospital, Bharath University, Chennai, Tamil Nadu, India
Address for correspondence: Dr. W. S. Manjula, E-mail: drmjula@gmail.com

Received 2014 Oct 31; Revised 2014 Oct 31; Accepted 2014 Nov 9.

Copyright : © Journal of Pharmacy and Bioallied Sciences

This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
“Beauty is in the mind of the beholder, each mind perceives a different beauty” famously said by writer
Margeret Wolfe Hungerford. A beautiful smile is a gateway to the world. The aim of this article was to
identify the criteria for designing the perfect smile. It was determined, smile design is a multifactorial
process and various steps are involved in designing a radiant smile.

KEY WORDS: Arc, buccal corridor, smile

Dale carnegie said that one of the most important way to win friends and influence friends and people is to
smile.[1] An attractive, well-balanced smile can be a personal asset.[2] When a person senses happiness,
pleasure, humor or greetings, a smile develops. Webster defines the smile as “a change of facial expression
involving a brightening of the eyes, an upward curving of the corners of the mouth with no sound and less
muscular distortion of the features than in a laugh that may express amusement, pleasure, tender affection,
approval, restrained mirth, irony, derision or any of various other emotions.”

The success of smile design is determined by the patient's soft-tissue limitations and the extent to which
orthodontics or multidisciplinary treatment can satisfy the patient's and orthodontist's esthetic goals.
Classical cultures of Greece and Rome based their standards of beauty on set rules of proportions and
compositions.

Divine Proportion
The Greek art and literature gave importance on divine proportion or the golden ratio which is often
associated with esthetics and harmony in many fields like architecture, sculpture, music, human face etc., [
Figure 1]. Phythagoras, a Greek sculptor, used the golden ratio so often in his work that the number 1.618
(golden ratio) was given the name phi.[3]

Lombardi was a pioneer in use of golden proportion in dentistry. He described the use of a “repeated ratio”
in the maxillary anterior teeth which implies that an optimized dentofacial composition of the width of
lateral to central incisor width and the canine to lateral incisor are repeated in proportion.

Levin devised a grid to evaluate and develop harmonious proportions of teeth. The Golden proportion for
each tooth was 62% of the adjacent teeth.[4] The golden percentage was calculated by dividing the width
of each central incisor, lateral incisor, and canine by the total width of all six maxillary anterior teeth and
multiplying the resulting value by 100.[5,6]

Anatomy of the Smile

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Smile emanates from the facial movements and is the clear manifestation of the facial structures. The
perioral musculature can be classified into three groups:

Group I muscles: Buccinator, orbicularis oris, levator anguli oris, depressor anguli oris, risorius,
zygomaticus major
Group II muscles: Levator labii superioris, levator labii superioris alaeque nasi, zygomaticus minor
Group III muscles: Depressor labii inferioris, mentalis, platysma.

Group I muscles insert into the modiolus, Group II muscles inserted into the upper-lip, and Group III
muscles insert into lower-lip.

The upper and lower lips frame the display zone of the smile [Figure 2]. Within this framework, the
components of the smile are the teeth and the gingival scaffold. The main effectors of the smile are the
zygomaticus major muscles which insert into the modiolus of the orbicularis oris at each corner of the
mouth.

The soft-tissue determinants of the display zone are lip thickness, interlabial gap, intercommissure width,
smile index (width/height), gingival architecture.[7]

Muscular Basis of Smile


Rubin et al. have identified the nasolabial fold as the keystone of the smiling mechanism. They stated that
a smile is formed in two stages. In the first stage, the levator muscles contract and raise the upper lip to
nasolabial fold. In the second stage, the levator labii superioris, zygomaticus major, and buccinator
muscles raise the lips even more superiorly. The final stage if often characterized by appearance of
squinting. It represents the contraction of the periocular musculature to support maximum upper-lip
elevation through the fold.

Classification of Smile
Many authors have classified smile into different types, e.g. Ackerman et al. classified smile into two basic
types: The social smile/posed smile which is reproducible, voluntary. The lips part due to moderate
muscular contraction of the lip elevator muscles, and the teeth and sometimes, the gingival scaffold are
displayed; the enjoyment smile/unposed smile/Duchenne smile, is an involuntary smile and is elicited by
laughter or great pleasure and results from maximal contraction of the elevator and depressor muscles
causing full expansion of the lips, gingival show, and maximum anterior tooth display [Figure 3].[7,8]

Tjan[2] classified smile into high smile where complete length of incisors is exhibited along with some
amount of gingival display [Figure 4]. In average smile, 75–100%of upper incisors and inter dental papilla
is displayed [Figure 5].

In low smile line, <75% of the maxillary incisors in the full smile is displayed [Figure 6].

Rubin[9] classified three styles of smile depending on the direction of elevation and depression of the lips
and the predominant muscle groups involved. He stated that in Commissure smile, the zygomaticus major
muscles pull the upper-lip like a Cupid's bow. This is referred as the Mona Lisa smile. In the canine smile,
the upper-lip is elevated uniformly like a diamond without the corners of the mouth turning upward. In the
complex smile/full denture smile, the upper-lip moves superiorly as in the canine smile, but the lower-lip
also moves inferiorly.

Records in the Treatment of Smile


Orthodontic records fall into three separate categories which provide the information and documentation
required in the treatment planning regimen. They are: (1) Static records (2) dynamic records,[3] direct
biometric measurement static records include photographs, radiographs, and study casts. Digital
photography captures the facial images like frontal at rest, frontal smile, oblique facial smile (for
evaluation of occlusal plane, palatal cant, overjet etc.), close-up oblique smile (for assessment of crown
height, gingival architecture), and profile smile.

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The dynamic recordings of smile and speech are accomplished through the use of digital videography
where it is taken in frontal and oblique dimension. Digital video and computer technology captures around
30 frames/s. Ackerman et al. developed Smile mesh, computer software to analyze photographs of posed
smiles and test the reproducibility and reliability of the smile. Three smile images of the patient are taken
and the software measures 15 attributes of the smile such as the upper lip drape, maxillary incisor display,
interlabial gap, buccal corridor ratio, maxillary midline offset, and intercommissure width in the frontal
plane [Figure 7].[7,10]

Direct Biometric Measurement


Direct measurement[11] permits the clinician to quantify resting and dynamic lip – tooth relationships. The
measurements such as philtrum height, commissure height, interlabial gap, amount of incisor show at rest,
amount of incisor display on smile, crown height, gingival display, smile arc are done.

The philtrum height is measured in millimeters from subspinale (the base of the nose at the midline) to the
most inferior portion of the upper lip on the vermilion tip beneath the philtral columns. Commissure height
is measured from a line constructed from the alar bases through subspinale and then from the commissures
perpendicular to this line. The differential lip growth exhibits as the difference in height in phlitrum and
commissural height in adolescents. The interlabial gap is measured as the distance in millimeters between
the upper and lower lips when lip incompetence is present.

Crown height is the vertical height of the maxillary central incisors; crown height is normally between 9
and 12 mm in adults (10.6 mm in men and 9.6 mm in women).

The amount of gingival display on smile and the incisor display, along with crown height, helps the
deciding how much tooth movement is required to improve the smile index. A gummy smile is often more
esthetic than a smile with less tooth display.

The smile arc from the frontal view is the relationship of the curvature of the incisal edges of the maxillary
incisors and canines to the curvature of the lower lip in the posed social smile. In an ideal smile arc or in
consonant smile, the curvature of the maxillary incisal edge is parallel to the curvature of the lower lip
upon smile; in a nonconsonant or flat smile, the maxillary incisal curvature is flatter than the curvature of
the lower lip on smile.

Smile Analysis
Smile analysis is traditionally performed in the frontal, oblique, sagittal dimension, and with time.

Ackerman and Ackerman developed a ratio called the smile index (inter commissural width/interlabial
gap), to visualize and quantify the frontal smile. The ratio is used for comparing smiles among patients.
The lower the smile index, the less youthful the smile appears.

In the oblique view, the contour of the maxillary occlusal plane is noted. The maxillary occlusal plane
should be in consonant with the curvature of the lower lip on smile. In sagittal dimension, overjet and
incisor angulations are best visualized. Orthodontic correction of overjet involves macro-elements, such as
jaw patterns and soft-tissue elements like nasal projection.

According to time, orthodontic patients can be categorized as a preadolescent, adolescent, and adult. The
growth, maturation, and aging of the perioral soft-tissues have a profound effect on the appearance of both
resting and smiling presentations. Orthodontic cephalometric research indicates that on average, profiles
flatten over time.[12]

Components of Smile
Hulsey concluded that a key component present in an esthetic smile was a consonance between the arcs
formed between the incisal edges of the maxillary anterior teeth and the curvature of the lower lip.

Various components of a balanced smile are lip line, buccal corridor, smile arc, upper-lip curvature, smile
symmetry, frontal occlusal plane, dental components, gingival components

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The lip line is the amount of vertical tooth exposure in smiling, that is, the height of the upper-lip relative
to the maxillary central incisors.[13,14] It depends on various factors.

In general, female lip lines are an average 1.5 mm higher than male lip lines[15] and with aging, there is a
gradual decrease in exposure of the maxillary incisors at rest and to a much lesser degree, in smiling. The
upper lip length at rest is about 23 mm in males and 20 mm in females.[12] When the upper-lip is elevated,
it displays about 80% of its original length. If a gingival smile is caused by a hypermobile lip, intrusion or
impaction surgery would decrease the amount of gingival display and makes the patient look older. When
upper-lip length and mobility are normal, a gingival smile with excessive incisor display at rest can be
attributed to vertical maxillary excess which is often associated with excessive lower facial height.

The average vertical crown height of the maxillary central incisor is 10.6 mm in males and 9.8 mm in
females[15] and a short crown may be due to attrition or excessive gingival encroachment. When all other
factors are equal, the incisor exposure at rest determines the vertical position of the incisal edge. Therefore,
a deep bite should be corrected by maxillary incisor intrusion in a patient with excessive incisor display at
rest and with posterior extrusion and/or lower incisor intrusion in a patient with a normal lip line at rest.
An open bite case should be corrected by maxillary incisor extrusion if there is inadequate incisor display
at rest, but with the posterior intrusion and/or lower incisor extrusion if the lip line is normal at rest.

Incisor inclination also plays a role in the lip line. Ricketts noted that the upper-lip thickened as the upper
incisor was retracted and gave a rule of thumb of 1 mm increase in thickness of the lip for every 3 mm of
retraction of the tips of the incisors.

The buccal corridor is the space created between the buccal surface of the posterior teeth and the lip
corners when the patient smiles.[14] Orthodontists refer to buccal corridors as “negative" spaces. It is
measured from the mesial line angle of the maxillary first premolars to the interior portion of the
commissure of the lips. The negative space is affected by the smile, the maxillary arch width, the facial
muscles, the position of the buccal surfaces of the posterior maxillary teeth, etc.[12,16] Moore et al. stated
that when the buccal corridor is of 28% as medium-narrow, 15% as medium, 10% as medium-broad, and
2% as broad smile fullness.

The smile arc is the relationship between a hypothetical curve drawn along the edges of the maxillary
anterior teeth and the inner contour of the lower lip in the posed smile.[14,16,17] The curvature of the
incisal edges appears to be more pronounced for women than for men and tends to flatten with age.[7] The
archform and the maxillary anterior occlusal plane influence the degree of curvature of the smile arc. The
smile arc can be unintentionally flattened during orthodontic treatment by any or all of the following three
techniques such as over intrusion of maxillary incisors, improper bracket positioning, and the cant of the
occlusal plane. Other factors that can affect the smile arc are attrition due to shortening of the central
incisors, habits such as thumb sucking, excessive posterior vertical growth, and the lower-lip musculature.

The upper-lip curvature is assessed from the central position to the corner of the mouth in smiling. Upward
and straight lip curvatures are considered more esthetic than downward lip curvatures.[9]

Smile symmetry is the relative positioning of the corners of the mouth in the vertical plane which can be
assessed by the parallelism of the commissural and pupillary lines.[18] Myofunctional appliances are
recommended when there is a large differential elevation of the upper-lip due to a deficiency of muscular
tonus on one side of the face.

The frontal occlusal plane is represented by a line running from the tip of the right canine to the tip of the
left canine. A transverse cant can be caused by differential eruption of the maxillary anterior teeth or a
skeletal asymmetry of the mandible[12] which can be diagnosed by asking the patient to bite on a tongue
blade or a mouth mirror in the premolar area during the clinical examination.

Dental components of the smile include the size, shape, color, and alignment, crown angulations of the
teeth, the midline and arch symmetry. Factors that can disturb the continuity of the dental composition
include midline diastema and lack of inter proximal contacts.

The gingival components of the smile are the color, contour, texture, and height of the gingiva.
Inflammation, blunted papillae, open gingival embrasures (black triangle), and uneven gingival margins
detract from the esthetic quality of the smile. The space created by a missing papilla above the central
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incisor contact point, referred to as a “black triangle,” may be caused by root divergence, triangular teeth,
or advanced periodontal disease. Orthodontic root paralleling and flattening of the mesial surfaces of the
central incisors, followed by space closure, will lengthen this contact area and move it apically toward the
papilla.[13]

Conclusion
In our modern competitive society, a charming smile can open doors and knock down barriers that stand
between us and a fuller, richer life. It must be understood that there is no universal “ideal” smile. The most
important esthetic goal in orthodontics is to achieve a “balanced” smile. The components of the smile
should be considered not as rigid boundaries but as artistic guidelines to help the orthodontist to treat
individual patients. 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.

Footnotes
Source of Support: Nil

Conflict of Interest: None declared.

References
1. Carnegie D. United States: Simon and Schuster; 1936. How to Win Friends and Influence People.

2. Tjan AHL, Miller GD. The JGP. Some esthetic factors in a smile. J Pros Dent. 1984;51:24–28. []

3. Ahmad I. Anterior dental aesthetics: Historical perspective. Br Dent J. 2005;198:737–42.


[PubMed: 15980831]

4. Murthy BV, Ramani N. Evaluation of natural smile: Golden proportion, RED or Golden percentage. J
Conserv Dent. 2008;11:16–21. [PMCID: PMC2813089] [PubMed: 20142879]

5. Ali Fayyad M, Jamani KD, Agrabawi J. Geometric and mathematical proportions and their relations to
maxillary anterior teeth. J Contemp Dent Pract. 2006;7:62–70. [PubMed: 17091141]

6. Ricketts RM. The biologic significance of the divine proportion and Fibonacci series. Am J Orthod.
1982;81:351–70. [PubMed: 6960724]

7. Ackerman MB, Ackerman JL. Smile analysis and design in the digital era. J Clin Orthod. 2002;36:221–
36. [PubMed: 12025359]

8. Ritter DE, Gandini LG, Jr, Pinto Ados S, Ravelli DB, Locks A. Analysis of the smile photograph. World
J Orthod. 2006;7:279–85. [PubMed: 17009478]

9. Rubin LR, Mishriki Y, Lee G. Anatomy of the nasolabial fold: The keystone of the smiling mchanism.
Plast Reconst Surgery. 1989;83:1–8. []

10. Schabel BJ, Baccetti T, Franchi L, McNamara JA. Clinical photography vs digital video clips for the
assessment of smile esthetics. Angle Orthod. 2010;80:490–6. [PubMed: 20482353]

11. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 1. Evolution of the
concept and dynamic records for smile capture. Am J Orthod Dentofacial Orthop. 2003;124:4–12.
[PubMed: 12867893]

12. Sarver DM, Ackerman MB. Dynamic smile visualization and quantification: Part 2. Smile analysis and
treatment strategies. Am J Orthod Dentofacial Orthop. 2003;124:116–27. [PubMed: 12923505]

13. Sabri R. The eight components of a balanced smile. J Clin Orthod. 2005;39:155–67.
[PubMed: 15888949]

14. Mackley RJ. An evaluation of smiles before and after orthodontic treatment. Angle Orthod.
1993;63:183–9. [PubMed: 8214786]

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15. Peck S, Peck L, Kataja M. Some vertical lineaments of lip position. Am J Orthod Dentofacial Orthop.
1992;101:519–24. [PubMed: 1598892]

16. Sarver DM. The importance of incisor positioning in the esthetic smile: The smile arc. Am J Orthod
Dentofacial Orthop. 2001;120:98–111. [PubMed: 11500650]

17. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53:262–84.
[PubMed: 5227460]

18. Janzen EK. A balanced smile – a most important treatment objective. Am J Orthod. 1977;72:359–72.
[PubMed: 269665]

Figures and Tables

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Figure 1

Sunflower, e.g., of the golden proportion

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Figure 2

Smile components

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Figure 3

Social smile enjoyment smile

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Figure 4

High smile

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Figure 5

Average smile

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Figure 6

Low smile

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Figure 7

Smile mesh

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