Journal Pre-proof

Mechanics to Enhance Facial and Smile Esthetics

Andre Wilson Machado DDS, MS, PhD

PII: S1073-8746(20)30023-2
DOI: https://doi.org/10.1053/j.sodo.2020.06.008
Reference: YSODO 607

To appear in: Seminars in Orthodontics

Please cite this article as: Andre Wilson Machado DDS, MS, PhD , Mechanics to Enhance Facial and
Smile Esthetics, Seminars in Orthodontics (2020), doi: https://doi.org/10.1053/j.sodo.2020.06.008

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2020 Elsevier Inc. All rights reserved.

 Mechanics to Enhance Facial and Smile Esthetics

Andre Wilson Machado, DDS, MS, PhD

Professor of Orthodontics, From the Department of Orthodontics, Faculty of Dentistry,

Federal University of Bahia, Salvador, Bahia – Brazil

Address:

Faculdade de Odontologia, Universidade Federal da Bahia (UFBA), Rua Araújo Pinho,

n. 62. 7 andar. CEP 40110-150, Salvador, Bahia – Brazil.

E-mail: [email protected]
ABSTRACT

The parameters for achievement of treatment success sometimes differ between

patients and orthodontists, while patients focus on esthetics, orthodontists usually

emphasize occlusal criteria. Although smile esthetics is an extensive topic, clinicians

must understand the main principles of an ideal smile in order to use the appropriate

orthodontic mechanics to enhance facial and smile esthetics. The objectives of this

paper are: 1) to review the two main principles of a beautiful and youthful smile to

guide the clinician to visualize the main esthetic goals of orthodontic treatment, and 2)

to present two clinical situations where appropriate orthodontic mechanics were used

to obtain optimal facial and smile esthetics results.

INTRODUCTION

Although obtaining a functional occlusion is a mandatory goal of any orthodontic

treatment, laypeople usually seek treatment for esthetic purposes.1,2 Thus, the

expectations from orthodontic treatment are no longer restricted to occlusal criteria;

patients seek a beautiful and harmonious smile and, more recently, facial youth.3-5 In

other words, the parameters for achievement of treatment success sometimes differ

between patients and orthodontists. While patients generally focus on esthetics,

orthodontists concentrate on occlusal criteria. A study conducted by Schabel et al6, for

example, revealed no strong relationship between well-finished orthodontic cases from

an occlusal standpoint and smile esthetics. Thus, while planning each case, the

orthodontist must carefully attend to not only the occlusal criteria but also the patient’s

expectations to obtain complete success, including both facial and smile esthetics.

This aspect is of vital importance because, sometimes, the orthodontic mechanical

approach improves the occlusal criteria but might depreciate smile esthetics and/or

facial esthetics. The most common clinical example is the correction of a deep bite by

means of upper incisor intrusion. The level of overbite may be corrected but, often,

along with deterioration of esthetics.1

With this thought in mind, the main principles of an ideal smile must be understood

in order to incorporate this information into the orthodontic diagnosis and treatment

plan. Since “smile esthetics” is an extensive topic and also a subjective issue, just

what are the most important parameters that should guide the clinician during the

orthodontic diagnosis and treatment planning stages? In other words, how can

orthodontic mechanics enhance facial and smile esthetics?

The objective of this paper is twofold: first, to review the two main principles of a

beautiful and youthful smile to guide the clinician to visualize the main esthetic goals of

orthodontic treatment and, second, to present two clinical situations where the ideal

mechanical approach was used to obtain optimal smile esthetics results.

Main Principles of an Ideal Smile

Smile analysis is a broad subject that involves several characteristics such as: 1)

Incisal design; 2) Maxillary central incisor ratios and symmetry; 3) Proportions among

maxillary anterior teeth; 4) Presence of spacing in the maxillary anterior teeth; 5)

Gingival design; 6) Gingiva exposure on smiling; 7) Buccal corridors; 8) Midline and

tooth angulation (occlusal cant); 9) Detailing: Tooth color and anatomical shape, and

10) Lip volume.1

 Among all these characteristics, there is a consensus that the noblest area of the

smile is the maxillary anterior teeth (canine to canine or first premolar to first

premolar), the so-called “esthetic zone”. In addition, central incisors are known as key

elements and characterize the terminology "focus on centrals". In summary, central

incisors must be highlighted as the true protagonists of the smile.1

Recognizing the sovereign role of the upper central incisors, what would be the

most important characteristics to be achieved? Due to space limitations, we will

discuss the two main characteristics to achieve a great “focus on centrals”: 1) Incisal

design1,7-9 and 2) Maxillary central incisor proportions and symmetry.1,2,10,11

#1: Incisal Design

The incisal design is the most important characteristic in a smile analysis and

corresponds to the design formed by the incisal edges of the teeth in the esthetic

zone.1 It is also described in the literature as incisal curvature12 and smile arc13. The

ideal incisal design forms a gentle curve that gently follows the contour of the lower lip

and is classified as: convex, curved, and consonant, among others (Fig. 1).12,13

In fact, it is not mandatory that the incisal edges of the teeth in the esthetic zone

follow the contour of the lower lip, this anatomical area is simply a reference guide. On

the other hand, the incisal edges in the esthetic zone must form a gentle and upward

curve bilaterally. In addition, it is mandatory that the incisal edges of the central

incisors be parallel to the ground or the inter-pupillary line (Fig. 1).1

To assist the clinician in visualizing the incisal design, it is suggested to mark a

point on the incisal edge of all teeth in the esthetic zone, in the intraoral or close-up
smile photos, and connect the dots. Thus, it becomes easier to visualize possible

problems in the incisal design and/or presence of an occlusal cant. When the incisal

design does not go up bilaterally, is classified as straight or reverse, and these types

are not attractive as the ideal arrangement (Fig. 2).1,12,13

Interestingly, a comparison between the most attractive design (convex) and the

most unattractive (reverse) raises the following question: why are they complete

opposites from an esthetic standpoint? First, in terms of beauty, the curved contour of

incisal edges in the esthetic zone is considered as the most important factor of dental

esthetics.14 Second, in terms of joviality, the more curved the incisal design, and the

greater the focus on the centrals, the younger the smile looks; whereas, the more

straight, the more aged it looks.1 Additionally, according to the literature, the older

someone is, the less maxillary incisor exposure and the more mandibular incisor

exposure there will be, both at smiling, at rest or while speaking.15,16

With these thoughts in mind, the identification of these characteristics is the

starting point of any esthetic planning of the smile and, among the teeth in the esthetic

zone, the central incisors are the most important. So, in order to proceed during

treatment planning, the following question must be answered: At the end of the

treatment, where would we like to place the incisal edges of the teeth in the esthetic

zone, especially the central incisors?

To answer this question, we need to understand that vertical alterations in the

upper centrals imply the alteration of three characteristics: 1) the central-to-lateral

incisal step, 2) the gingival design among the teeth in the esthetic zone, and 3) the

amount of gingival exposure in the central incisor area. Among these aspects, the

central-to-lateral step is the most important.7 For a long time, the specialty used an
esthetic parameter without scientific evidence: “the ideal step between central and

lateral incisors is 0.5 mm”. Due to this gap in the literature, several different vertical

positions of the upper central incisors were tested and slightly extruded centrals were

found to be more attractive than intruded centrals.7-9 The results of these studies

indicated that the central-to-lateral ideal incisal step should be 1- 2 mm for female and

male patients (Fig. 3.) 7-9

And what is the impact of this information on the execution of orthodontic

mechanical planning? All intrusion or extrusion movements are able to change this

characteristic and implementation starts from the initial bonding phase for fixed

orthodontic appliances or with the virtual planning stage for aligners. With this concept

in mind, from the initial stages of orthodontic treatment, depending on the vertical

position of the upper centrals, we can already define an attractive and youthful, or

unattractive and aged, smile.

For instance, during bracket placement, small differences in the position of the

upper central incisors can have a great impact on smile esthetics. A variety of bracket

prescription recommendations suggest that upper central bracket positions (X) should

be identical to the canine (X)17 or slightly above the position of the canines (X + 0.25;

X + 0.5; X + 1.0)18-19. Interestingly, if we use the same bracket height for centrals and

canines and consider that they have the same anatomical crown length, after proper

aligning and leveling phases, their incisal edges might be even. According to the

results shown previously8-9, if we don't accomplish an ideal incisal design (a gentle and

upward curve bilaterally), the smile could be perceived as unattractive. Therefore, it is

mandatory to incorporate smile characteristics into orthodontic diagnosis and, then use

this information to properly position maxillary anterior brackets: upper central incisors

should appear more extruded than intruded in order to guarantee an ideal incisal
design and proper central-to-lateral incisal step. In other words, we must avoid routine

intrusion of the upper central incisors for the reasons described previously.

#2: Proportion and symmetry between central incisors

After establishing the ideal vertical position of the upper central incisors, we need

to adjust the width-to-length (W/L) proportions and symmetry.

Treatment must be conducted to obtain central incisor W/L proportions between

75 and 80%, since it is considered more attractive (Fig. 4).20 In most clinical

presentations of adult patients, the W/L ratio is altered due to incisal wear inherent to

aging of the dentition and, thus, the proportion tends to increase (> 85%). Interestingly,

when this type of wear occurs, the negative esthetic impact also affects the incisal

design as it decreases the central-to-lateral incisal step (Fig. 4B). The correction of this

characteristic commonly involves multidisciplinary treatment by means of crown

lengthening for upper centrals with incisal restorations and/or gingivectomy.1

After correcting the proportions, maximum symmetry between central incisors

must be achieved. The concept that reinforces the importance of this guideline is

based on the clinical assumption that, the closer to the midline, the greater the need

for symmetry and, the further away, slight asymmetries are clinically acceptable. 14 In

order to test this hypothesis, the esthetic impact of incisal edge asymmetries was

evaluated in the upper incisors.2,10,11 The results confirmed the need for maximum

symmetry between centrals, since a slight 0.5 mm incisal edge asymmetry was

detected by orthodontists and laypeople. However, small asymmetries (1.0 mm)

between upper laterals may not be detected2,11, while even greater asymmetries may

not be detected at the canines and premolars. In other words, the incisal edges of the
centrals are the most important area and, thus, maximum symmetry is a vital

characteristic.

CASE ILLUSTRATIONS

Case #1

The first clinical example is very instructive. A 34-year-old female patient

presented to our office with the chief-complaint that she was unhappy with her smile

and that the appearance of her teeth was aging her.

She had a Class I malocclusion with a slight anterior open bite tendency (Fig.

5). As discussed before, by assessing her smile, it is easy to recognize a reverse

incisal design but the overall appearance of her teeth was very attractive, such as:

tooth color, adequate tooth anatomy, centrals W/L proportion of 81%, and good

symmetry (Fig. 6).

The objective was to modify the incisal design by selectively extruding the

maxillary incisors. Orthodontic treatment was basically aligning and leveling the

maxillary arch with fixed appliances and the key aspect was to customize the vertical

position of the brackets in the esthetic zone (Fig. 7). This bonding customization can

be predicted by moving the upper incisors to the final positions using templates on the

computer (Fig. 7A). The difference between the initial position and final position can be

measured and the amount of tooth extrusion assessed. In this case, both upper

laterals were extruded 0.5 mm, the right central 2.5 mm, and the left central 2.0 mm.

Those numbers were transferred to the brackets and a customized bonding procedure

was performed (Fig. 7B). From the mechanical standpoint, by using continuous
arches, it was expected that the extrusion force in the anterior incisors would result in

upper incisor retroclination. In this situation, that side effect was not considered a

problem due to the initial overjet and initial incisor torque.

Final intraoral photographs show maintenance of the Class I occlusion and

open bite correction (Fig. 8). The smile photo displays a beautiful and youthful result,

achieving the ideal incisal design with the ideal central-to-lateral incisal step which

guarantees a great focus on centrals (Fig. 9).

Case #2

In contrast to the previous case, this patient displayed both smile problems

previously described: incisal design deviation with severe occlusal canting and altered

W/L proportion of the upper centrals.

A 20 year-old male patient presented with the chief-complaint that he was very

unsatisfied with his smile and facial appearance. In addition, the patient refused

orthognathic surgery as an option.

Pretreatment intraoral photographs showed a slight Class III malocclusion on

the right side and severe canting of the occlusal plane (Fig. 10). Esthetically, he

exhibited an unattractive smile with a severe cant in the esthetic zone, straight incisal

design, altered upper central W/L proportions (right central was 91% and left central

was 88%) and an asymmetric gummy smile (Figs. 11 and 12).

The treatment goal was to correct the incisal cant and, then, to adjust the ideal

tooth proportions in the esthetic zone with gingivectomy. This option consisted of

aligning and leveling the maxillary arch with continuous arches and, then, intruding the
maxillary right side by means of skeletal anchorage (i.e.: on the buccal side, one mini-

plate and, on the palatal side, one mini-implant) (Fig. 13). The purpose of applying two

forces was to prevent any side effects, such as buccal or palatal dental inclination.

After creating an open bite on the right side, the lower dentition was extruded and

slightly distalized with intermaxillary elastics using the mini-plate as anchorage. After

correcting the occlusal cant, the smile esthetics improved, as evident during the frontal

smile analysis (Fig. 14). After finishing orthodontic treatment, the patient was referred

for gingivectomy to re-establish ideal W/L proportions in the esthetic zone.

Post-treatment photos showed that the occlusion was highly optimized with

Class I canines and molars, and overjet and overjet within normal limits. Esthetically,

the two main principles of smile esthetics were fulfilled: incisal design slightly moving

upward bilaterally and central incisor W/L proportions of 77% and highly symmetrical

(Figs. 15 and 16).

CONCLUSION

In order to allow orthodontic mechanics to enhance facial and smile esthetics,

clinicians must carefully focus on two important aspects: 1) incisal design where incisal

edges of all teeth in the esthetic zone must form a gentle and upward curve bilaterally

and; 2) upper central incisor width-to-length (W/L) proportions need to be between 75-

80%, and upper centrals must be symmetrical.

REFERENCES

1. Machado AW. 10 commandments of smile esthetics. Dental Press J Orthod.

2014;21:127-142.
2. Machado AW, Moon W, Gandini LG Jr. Influence of maxillary incisor edge
asymmetries on the perception of smile esthetics among orthodontists and
laypersons. Am J Orthod Dentofacial Orthop 2013;143:658-64.
3. Correa BD, Vieira Bittencourt MA, Machado AW. Influence of
maxillary canine gingival margin asymmetries on the perception of smile
esthetics among orthodontists and laypersons. Am J Orthod Dentofacial
Orthop 2014;145:55-63.
4. Van der Geld P, Oosterveld P, Van Heck G, Kuijpers-Jagtman AM.
Smile attractiveness. Self-perception and influence on personality. Angle
Orthod 2007;77:759-765.
5. Machado AW, Carvalho T, Araújo TM, Gandini Junior LG. The role of
orthodontics as an auxiliary tool to lip augmentation. An Bras Dermatol
2011;86:773-777.
6. Schabel BJ, McNamara JA, Baccetti T, Franchi L, Jamieson SA. The
relationship between posttreatment smile esthetics and the ABO Objective
Grading System. Angle Orthod 2008;78:579–584.
7. Machado AW, McComb R, Moon W, Gandini Jr LG. Influence of the vertical
position of maxillary central incisors on the perception of smile esthetics
among orthodontists and laypersons. J Esthetic Rest Dent. 2013;25:392–401.
8. Menezes EBC, Bittencourt MAV, Machado AW. Do different vertical positions
of maxillary central incisors influence smile esthetics perception? Dental Press
J Orthod. 2017;22:95-105.
9. Simões D, Brito GM, Cangussu MCT, Machado AW. Does the vertical position
of maxillary central incisors in men influence smile esthetics perception? Am J
Orthod Dentofacial Orthop 2019;156:485-492.
10. Sobral MC, Crusoé-Rebello IM, Machado AW. Does the presence of maxillary
central incisor edge asymmetry influence the perception of dentofacial
esthetics in video analysis? Angle Orthod. 2019;89:775-780.
 11. Betrine JR, Figueiredo BA, Machado AW. Does the presence of unilateral
maxillary incisor edge asymmetries influence the perception of smile
esthetics? J Esthetic Rest Dent. 2017;29:291-297.
12. Tjan AH, Miller GD, The JG. Some esthetic factors in a smile. J Prosthet Dent.
1984;51:24-82.
13. Sarver DM. The importance of incisor positioning in the esthetic smile: the
smile arc. Am J Orthod Dentofacial Orthop. 2001;120:98-111.
14. Chiche G, Pinault A. Esthetics of anterior fixed prosthodontics. Chicago:
Quintessence; 1994.
15. Vig RG, Brundo GC. The kinetics of anterior tooth display. J Prosthet Dent.
1978;39:502-504.
16. Drummond S, Capelli J Jr. Incisor display during speech and smile: Age and
gender correlations. Angle Orthod. 2016;86:631-637.
17. 3M Unitek. MBT versatile+ appliance bracket placement guide. REF 12-100-
102, 1999.
18. Voudouris J. Excellence and efficiency: Interactive twin self-ligation. Toronto:
Interactive Self-Ligation and Dentofacial Orthopedic Publications, 2003.
19. Kalange J. Ideal appliance placement with APC brackets and indirect bonding.
J Clin Orthod. 1999;33:516–526.
20. Witt M, Flores-Mir C. Laypeople's preferences regarding frontal dentofacial
esthetics: tooth-related factors. J Am Dent Assoc. 2011;142:635-645.

FIGURE LEGENDS
Figure 1. Two characteristics of the ideal incisal design: 1) incisal edges must form a

gentle and upward curve bilaterally (dotted yellow line); 2) incisal edges of the central

incisors must be parallel to the ground (dark blue line).

Figure 2. Different types of incisal design: A) convex or curved; B) planar or straight;

and C) inverted or reverse.

Figure 3. Ideal central-to-lateral incisal step.

Figure 4. Different width-to-length proportion of central incisors: A) ideal, between 75

and 85%; B) long teeth with ratio < 75%; and C) short or squared teeth with ratio >

85%.

Figure 5. Initial intra-oral photos. Note the reverse incisal design (black line).
Figure 6. Initial close-up smile photo.

Figure 7. A) Digital illustration showing final incisor positioning; B) alignment and

leveling outcomes with alteration in the bonding protocol following the ideal incisal

design.

Figure 8. Final intra-oral photos. Note the curved incisal design (black line).
Figure 9. Final close-up smile photo.

Figure 10. Initial intra-oral photos. Note the straight incisal design and severe canting

of the occlusal plane (black line).

Figure 11. Initial close-up smile photo.
Figure 12. Illustration of the severe occlusal canting. White line displays the inter-

pupillary line.
Figure 13. Dentoalveolar intrusion of the right side: on the buccal side (A), there is one

mini-plate, and on the palatal side (B), there is one mini-implant.

Figure 14. Illustration of the result on smile esthetics after correction of the severe

occlusal canting. White line displays the inter-pupillary line; red line shows the initial

central incisor incisal edges, and; green line shows the final central incisor incisal

edges.

Figure 15. Final intra-oral photos. Note the curved incisal design (black line).
Figure 16. Final close-up smile photo.