Evaluation of the Smile

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J Oral Maxillofac Surg68:547-554, 2010

Evaluation of the Smile: Facial andDental Considerations

Antoine J. Panossian, DMD, MD,* and Michael S. Block, DMD†

Purpose: The purpose of this article is to establish an evidence-based evaluation of the esthetic regionof the mouth, by reviewing normal values for the face, the smile line, and the teeth.

Materials and Methods: A Medline search was performed to find evidence-based data on acceptednormal ranges of facial and dental proportions. The information found was organized following asequence of physical examinations, which then was used to develop a decision tree for diagnosis andtreatment planning.

Conclusions: By following this evaluation algorithm, clinicians will be able to document a standard setof data that will reveal skeletal and dental dysmorphia, which can then follow a well-organized sequenceof treatment to re-establish facial and dental harmony.© 2010 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 68:547-554, 2010
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he esthetic zone is important for successful dentalnd facial reconstruction. The clinician should be ableo incorporate facial and dental evaluation, in a con-ise format, to identify and then direct the patient foreconstruction. This article will provide cliniciansith the background for an evaluation that leads toiagnosis and effective treatment planning.Proper evaluation of the esthetic zone requires ex-

mination of soft and hard tissues of the face. Forroper diagnosis, the physical examination should beonsistent and repetitive. The evaluation begins withhe facial soft tissues and skeleton, followed by anntraoral evaluation of the teeth and their relation tohe lips. To provide an evidence-based recommenda-ion, a review of the literature was performed thatncluded reports on the accepted normal values foracial thirds, including the vertical lengths of theower third of the face. The literature review con-rmed that the ideal length and proportions of theaxillary incisors and the relationship of these teeth

o the relaxed and animated lip, including the dental

*Senior Resident, Department of Oral and Maxillofacial Surgery,

SU School of Dentistry, New Orleans, LA.

†Clinical Professor, Department Oral and Maxillofacial Surgery,

SU School of Dentistry, New Orleans, LA, and Private Practice,

etairie, LA.

Address correspondence and reprint requests to Dr Block: De-

artment Oral and Maxillofacial Surgery, LSU School of Dentistry,

1 Florida Avenue, New Orleans, LA 70119-2799; e-mail: drblock@

drnola.com

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6803-0009$36.00/0

poi:10.1016/j.joms.2009.09.021

547

elationships to the lower lip, are based on the eth-icity and appearance of the patient and is subjective

n nature.Examination of the facial skeleton indicates the

resence of maxillary or mandibular dysmorphia, in-luding the horizontal and vertical skeletal deformi-ies. The lips in regard to length and fullness aremportant to consider when determining the idealosition of the teeth. Evaluation of the size and loca-ion of the maxillary teeth will determine whether theeeth need crown lengthening or need to be bodilyoved because of skeletal dysmorphia.A traditional physical evaluation of a patient startsith the top of the head and follows a well-structured

equence that works its way inferiorly. A “top toottom” routine will ensure a complete examination.s the result of this evaluation, recommendations for

reatment can be based on objective criteria. Fromhis examination, an algorithm for diagnosis and treat-ent planning is developed (Figs 1, 2).Although facial beauty is a subjective concept, as

linicians we must have some objective means to aidn diagnosis and treatment. Sarver1 stated that “anynalysis based on cephalometric or facial ‘normative’alues has one inherent weakness, and that is thateauty is not the norm.” While this is true, an objec-ive method must be available for the clinicians as

starting point. Fishman proposed a non-numericraphic approach to evaluate facial esthetics.2 Byeveloping centrographic images, the face is divided

nto 4 triangles. These images are then superimposed,nd balance and harmony are evaluated. Marquardteveloped a set of facial masks that can be superim-
osed to evaluate facial balance and harmony. By
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548 EVALUATION OF THE SMILE

uperimposing the images, theoretically one can as-ess deviation from the ideal.3

aterials and Methods

An online literature search based on the terms “es-

IGURE 1. A, Diagnostic flowsheet for evaluation of tooth form., Diagnostic flowsheet for evaluation of the facial thirds.

anossian and Block. Evaluation of the Smile. J Oral Maxillo-ac Surg 2010.

hetic evaluation of the face” and “esthetic evaluation f

f teeth” revealed 160 articles in the English-languageiterature that concerned various subtopics of theseerms. These articles were reviewed, and papers thatontained evidence-based analyses or case series withocumented consistent conclusions were used to de-elop a set of relative normal values for the clinician.he facial evaluation was divided into thirds. Thesthetic appearance and position of the teeth wereivided into sections relating to size, position relativeo the lips, and exposure of the gingiva with the lipselaxed and upon smiling.

As part of the clinical examination, tooth display isssessed at rest and during a smile. The patient issked to open the mouth slightly and to relax the lips.he length of the central incisor that is displayed isocumented in millimeters for both the right and leftooth. The midline of the dentition is also documentedn relation to the facial midline.

If a patient has excessive tooth show at rest, thelinician will need to differentiate between a short lipength, anterior vertical skeletal excess of the maxilla,nd the length of the tooth.

esults

FACIAL/SKELETAL EVALUATION OF THE PATIENT

An objective evaluation begins by dividing the facento vertical thirds. These thirds are based on horizon-al lines drawn at the hairline, the nasal base, andenton. The thirds should be equal in length. If one

hird is longer than normal or shorter than normal,hen a skeletal or soft tissue deformity exists, contrib-ting to the appearance of the patient. In general, thepper and middle third do not contribute significantlyo the esthetic zone of the maxilla and mandible buto contribute to facial harmony. If the thirds are equal,his establishes balance and harmony.1,4 However, these of divine proportions must be considered for eachatient because individual beauty is specific to multi-le facial attributes.5

UPPER THIRD OF THE FACE

If the upper third of the face is long, then theatient has either a high hairline or a low brow. Softissue reasons for increased length in the upper thirdnclude brow ptosis or hair loss.6

MIDDLE THIRD OF THE FACE

The middle third of the face encompasses the eyes,alar eminence, submalar region, and the nose. This

s further anatomically subdivided into posterior, an-erior, or total maxillary regions. If the patient has anpen bite deformity, then posterior vertical maxillaryxcess may contribute to a long middle third of the
ace. Posterior maxillary skeletal excess can also be

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PANOSSIAN AND BLOCK 549

ombined with anterior maxillary hypoplasia contrib-ting to an anterior open bite deformity. Posterior andnterior vertical maxillary skeletal excess will result inxcessive tooth exposure at rest and excessive gingi-al show on smile. These discrepancies will be evi-ent when a combined examination with the lowerhird is completed.7 Nasal obstruction is commonlyound in these patients and can be incorporated intohe final treatment plan.

If a skeletal discrepancy is suspected, a lateral cepha-ometric evaluation will determine whether the skeletalimensions are outside of the normal range, confirminghe clinical diagnosis. Cephalometric radiographic anal-sis was introduced by Broadbent in 1931.8 There areultiple cephalometric analyses including those byowns,9,10 Ricketts,11-14 Steiner,15-17 and Tweed.18-20

egardless of which analysis is used, it is merely a meanso obtain an objective measurement, which should beombined with clinical evaluation. Lateral cephalomet-ic facial tracings can be used to predict facial profileesulting from surgical correction of dentofacial defor-ities.21

The patient with anterior maxillary hyperplasia willresent with excessive tooth show at rest and exces-

IGURE 2. A, Patient with central incisor laying against the lowstablished after fabrication of new temporaries with esthetic toothstablished the need to move the facial gingival margin coronally onhe gingival margin discrepancy. E, The final restoration with dent

anossian and Block. Evaluation of the Smile. J Oral Maxillofac

ive gingival show at smile. The lateral cephalogram a

easurements will usually include an excessive ante-ior facial height, with increased maxillary and man-ibular plane angles related to sella-nasion. The pa-ient with anterior vertical maxillary hypoplasia willresent with deficient incisor show at rest and uponmile.5,7,22

LOWER THIRD OF THE FACE

The lower third of the face extends from the sub-asale, which is the base of the nose, to the menton,hich is the most inferior point on the mandibular

ymphysis. The lower third, defined from the nasalase to the menton, can be further divided into thirds

ncluding the length of the lip (one third) and theength of the lip to chin (two thirds). The commis-ures of the lips are one third from the base of theose to the chin.1,23 Deviations from the normal dis-ances in the lower facial height may involve one orore of three components.When evaluating the upper third of the lower facial

hird, the lip length and lip volume should be docu-ented. Lip length is measured from the subnasale to

pper lip stomion, which is the wet line. For maleatients, the lip length should measure 22 � 2 mm,

with excessive show at rest. B, Diagnosis of dental origin wastions (prosthetics by Dr Marco Brindis). C, The esthetic temporariest central incisor. D, Orthodontic tooth extrusion was used to correctbilitation, including crowns on teeth and implants.

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Lip thickness can be measured on cephalometricadiographs with the lips relaxed. Lip thickness in-reases during childhood and adolescence, reaching aaximum thickness at the conclusion of the adoles-

ent growth spurt. The thickness of the lips decreasesn the late teens.25,26 There are significant differencesn lip volume depending on the ethnicity of the pa-ient. Following strict criteria with measurementsust take into account the differences between race

nd ethnicity.27,28

Volume deficiency will appear as a short lip. It ismportant to consider age-related changes in lip thick-ess and length when determining if lip morphology

s abnormal and needs to be treated.28,29 As a patientrows through childhood, there are significant varia-ions in soft tissue changes that are patient-specific.28,30

verage soft tissue anterior-posterior thickness of thepper lip, lower lip, and chin is approximately 11 to4 mm. A 1:1:1 relationship exists among these 3tructures.31 If there is a variance in the thickness ofhese areas, the general balance of the lower third willppear abnormal and less esthetic.

The lower two thirds of the lower facial third iseasured from the lower lip stomion (top surface of

he lower lip) to soft tissue menton or chin. Acceptedeasures for male patients is 51 � 3 mm and for

emale patients 48 � 3 mm.32 If the lower facial thirdength is long, the underlying skeletal abnormality

ay be excessive bony chin length.33 Excessive ver-ical growth of the maxilla causes the mandible tootate which increases vertical facial height. It is thusossible to have an increased lower facial height with

deal upper and lower lip measurements. This, how-ver, will affect the tooth–lip relationships.Vig and Brundo34 demonstrated the average maxil-

ary incisor exposure at rest in males is 1.91 mm and.40 mm in females. Younger individuals display more

ncisor show than older individuals. Vig and Brundourther demonstrated that race and ethnicity plays aole in amount of maxillary incisor show. Caucasianshow an average of 2.43 mm, African Americans show.57 mm, and Asians show an average of 1.86 mm

ncisor display at rest.34

ooth Display and Angulation

Evaluation of the clinical crown is performed andncludes the angulation of the incisor. The long axis ofhe maxillary incisor should be 22 degrees to theasion–point A (NA) line. The incisor edge should bemm anterior to the NA line, which is evaluated on

he lateral cephalogram. When the patient standsith a natural head position, the angle of the incisors

hould be close to perpendicular to the natural headosition in a relatively protrusive position that has
een shown to be more esthetic than a retroclined d
ncisor.7,35 The incisor edge should support the lipsut not be excessively positioned either anteriorly orosteriorly. The edge of the central incisor should belightly posterior to the base of the columella. Theosition of the lower incisor should be at 20 degreeso the nasion–point B (NB) line with the labial face ofhe incisor 4 mm anterior to that line.16,36 The upperncisors to maxillary plane are angled 110 degrees, theower incisors to mandibular plane are angled 90egrees, and the interincisal angle is 135 � 5 de-rees.7

The length of the central maxillary incisor mea-ured from the facial gingival margin to the incisordge should be 10.5 to 11.0 mm, according to normalalues and dental esthetic concepts.37-39

The width of the central incisor is ideally 8.0 to 8.5m. These proportions are accepted dimensions for

he ideal esthetic maxillary central incisor.37-39

The length and width of the maxillary incisors andanines have been reported to follow the “goldenroportion,” which provides specific proportions ofidths for the anterior maxillary teeth. However, in a

tudy involving 157 dental students, the apparentesiodistal widths did not follow any proportions, yet

till were deemed to be esthetic. It was determinedhat each individual unique aspect must be consid-red without rigid criteria or dental proportions. Theules of proportions should be used as general guide-ines but do not have evidence-based data to supportheir use otherwise.22 The incisor edges should fol-ow the arc of the lower lip. There are different typesf lower lip arcs that contribute to the esthetics of theatient and need to be considered.29,40

In the clinical examination of the patient, a ruler issed to measure the length of the central incisor. Ifhe crown’s length and width are normal, the positionf the tooth within the alveolar bone is then assessed

n relation to the lips at rest and on smile.If the exposed tooth length is deficient, the clini-

ian needs to establish whether the crown lengthrom the cement–enamel junction (CEJ) is normal orhether the crown length from the CEJ is short. Peri-

pical radiographs are useful to confirm the length ofhe crown of tooth to be evaluated. If the crown lengths determined to be normal but the exposed crownength is deficient, then it is most likely that gingivalyperplasia is present, which decreases the length ofhe exposed crown. If the crown’s length from theementoenamel junction is short, the subsequent re-torative workup must take this into consideration.

The length of the incisors is determined by measur-ng the incisal edge to the facial gingival margin as thelinical crown length. The anatomic crown length ishe distance from the incisor edge to the CEJ. The
ifference in measurements will determine how

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uch gingiva can be removed without exposure ofhe root surfaces.

The gingival shape is different on the mesial com-ared with the distal surface of the incisors. Theesial aspect is less vertical compared with the distal

spect of the facial gingival margin as it approacheshe papilla. The facial gingival margin can be at theeight of the central incisor when excessive gingivalhow is present, creating a more esthetic smile.

Altered passive eruption is present when a greatermount of the anatomic crown is covered with gin-iva. The location of the osseous crest in relation tohe CEJ of the tooth will determine which procedureeeds to be performed to achieve esthetic crown

engthening. The proposed gingival esthetic contours mapped on the attached gingiva, and the gingiva isemoved. If the width of keratinized gingiva is small,he band of keratinized gingiva is apically reposi-ioned. The amount of bone removal is dependent onhe establishment of 3 mm of sulcus, which repre-ents the biologic width. If the root surface is ex-osed, appropriate restorations are necessary for es-hetic coverage.38,39

The clinical examination with the lips relaxed andouth slightly opened includes measuring the amount

f incisor edge exposure from the upper lip. Patientsan have the amount of tooth exposed at rest andpon spontaneous smiling documented with videolips, which have been determined to be as predict-ble as a relaxed lip posture, resulting in establish-ent of the measures with predictability from which

o treat.41 If there is inadequate exposure of the tooths per Vig and Brundo,34 the clinician needs to differ-ntiate between a short tooth or a normal-sized toothhat is associated with vertical anterior maxillary de-ciency. The patient may also have excessive lip

ength, which can be an etiology for the inadequateooth exposure.

EXCESSIVE GINGIVAL SHOW WITH SMILE

There are 4 main reasons for excessive gingivalhow on animation: vertical maxillary excess, shortpper lip, gingival hyperplasia, or short crowns. Ver-ical maxillary excess is diagnosed with the aid ofateral cephalometrics and a long lower facial third. Ahort upper lip is diagnosed by direct measurement ofip length in the presence of otherwise normal facialhird lengths.

Gingival hyperplasia is diagnosed when there is aormal crown length in the presence of a deep softissue pocket or bone coverage coronal to the CEJ ofhe tooth. Short clinical crowns may be caused by ahort anatomic crown or gingival hyperplasia, whichs differentiated with the clinical evaluation and peri-
pical radiographs. i
iscussion

The patient with a long upper facial third mayesire shortening the distance from the hairline to therow. The correction of brow ptosis is repositioninghe brow or hairline by performing a brow lift. Theorrection of a high hairline may require hair trans-lantation. Skeletal excess of the frontal bone is rarend is associated with craniofacial deformities.

Vertical maxillary skeletal deformities are treatedith maxillary repositioning using Le Fort level os-

eotomies to reposition the maxilla to correct thekeletal position.

If the middle third is long, the clinician shouldonsider vertical maxillary excess as a diagnosis. Inhe patient who has a long lower face, in the presencef excessive tooth display with gingival show, thexcessive skeletal vertical distance is treated by supe-ior repositioning of the maxilla. These patients mayave nasal obstruction, which will require correctionor stability of the surgical repositioning of the max-lla. Masking the diagnosis of vertical maxillary excess

ith attempted intrusion of the teeth, lip tethering,rown lengthening with crown, and bridge restora-ions are alternatives, but each has associated disad-antages.If a patient has a deficient upper lip length, increas-

ng lip volume by injecting fillers into the body of theip will increase the total length from subnasale to theottom aspect of the lip, up to 2 mm.42,43 If the upper

ip is excessive in length, lip shortening may be con-idered.44

If the lower facial third length is long, the underly-ng skeletal abnormality may be excessive bony chinength. This can be corrected by osseous surgery. Ifhe lower facial third is deficient, augmentation of thehin may be necessary.The patient with excessive display at rest will

equire careful evaluation and establishment of ahorough facial diagnosis. If the central incisorooth is 11.0 mm in length, which is normal, withxcessive show at rest, then it is possible that akeletal component of anterior vertical maxillaryxcess is present or that the lip length is deficient.xcessive show of the incisor will need to bereated either by restorative management with newestorations or superior repositioning of the toothy surgery or by orthodontics or both. The finaletermination of plans to be presented to the pa-ient may require opinions from surgeons, restor-tive dentists, and orthodontists.

If the tooth is normal in length but is deficient inhow with the lips at rest, a diagnosis of verticalaxillary deficiency is included. Inferior reposition-

ng of the maxilla can be performed to correct the

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osition of the maxilla to a more esthetic locationaking into consideration facial proportions, lip thick-ess, length of the incisors, and display at rest.Gingival hyperplasia can be corrected with crown

engthening. If the anatomic crown is short, restor-tive treatment may be indicated using crowns oreneers to lengthen the anatomic crown. When ex-essive gingival display is caused by a short upper lip,ip augmentation with injectables can increase lipength up to 2 mm.

For example, a patient presented with excessiveooth display (Fig 2). Her current incisal edges con-acted the lower lip. Upon smile she showed 1 mm ofingiva. Her right central incisor was 10.5 mm inength and was appropriate to the lower lip. Her leftentral incisor was 12.0 mm long and touched theower lip when the lips are at rest. Diagnostic models

ere used to document the tooth proportions andone levels. A new temporary bridge was fabricatedhat set the incisor edge and thus defined the idealocation of the facial gingival margin. From here thereatment plan included orthodontic extrusion to re-et the facial gingival margin to its necessary position.er facial thirds were normal and her lip length wasormal, thus her diagnosis was dental in origin andequired dentoalveolar procedures only.

As another example, a patient presented with ex-essive gingival show (Fig 3). The teeth were shortnd measured 8.5 mm. She needed crown lengthen-ng to address the gingival show. Her facial thirds

ere normal, her lip length was normal, and theength of her crown from incisor edge to the CEJ was1.0.Another patient (Fig 4) presented with excessive

ingival show with 9.0-mm tall central incisors. Herncisor show at rest was 7 mm. Her cephalometricnalyses indicated total (anterior and posterior) verti-al maxillary excess. Her treatment plan includedaxillary superior repositioning with Le Fort level

IGURE 3. Patient with short clinical crowns with adequate incisorhow at rest. Treatment included implant placement on the sites ofhe maxillary right and left lateral incisors, with crown lengtheningo correct the length of the central incisors.

Aanossian and Block. Evaluation of the Smile. J Oral Maxillofacurg 2010.

steotomies 4 mm, resulting in 3 mm of incisor showt rest in this young woman. In addition, crownengthening would be performed to lengthen the cen-ral incisors to the ideal 10.5-mm length. She had aombined deformity involving skeletal and dental ab-ormalities.The above-mentioned patients represent common

roblems involving the esthetic appearance of theatient’s face and smile. The clinician must includekeletal analysis and dental measures (Table 1) andnalyses in the examinations to provide the patientith a thorough diagnosis and a treatment plan that

ddresses that patient’s specific problems.Proper evaluation of the esthetic zone is crucial for

uccessful treatment outcomes. For centuries, schol-rs have tried to objectify beauty and ideal features.

IGURE 4. A, Patient with vertical maxillary excess in the anteriornd posterior maxilla, combined with short clinical crowns. B, Atest patient shows 7 to 8 mm of central incisor. Treatment for thisatient included superior maxillary repositioning of 5 mm com-ined with crown lengthening.

anossian and Block. Evaluation of the Smile. J Oral Maxillofacurg 2010.

lthough there exist no such entities, we have been

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ble to create various tools to guide us in finding theorrect balance and harmony of facial features, in turnulfilling some of our patients’ needs and wants. Byollowing our simple protocol, one can ensure a com-lete evaluation that will lead to the correct diagnosis.e emphasize that this protocol is a simple and effi-

ient way to home in on the proper diagnosis, which,hen made, gives the practitioner the ability to treat

he patient or refer that patient to the proper sourceor treatment. The length and volume of the lip,hich, if deficient, can contribute to excessive tooth

how. If the clinical crown length is short (�10.5m), the restorative dentist should perform a diag-ostic mockup of the planned restoration, taking intoonsideration the ideal location of the incisor edge.his will provide the clinical information necessary toelp diagnose a dental or skeletal problem. However,efore the mockup, the dentist should expose a ra-iograph, which is then used to determine whetherhe short clinical crown is caused by gingival over-rowth or altered passive eruption.

eferences1. Sarver DM: Esthetic Orthodontics and Orthognathic Surgery. St

Louis, Mosby, 1998, p 32. Fishman LS: Individualized evaluation of facial form. Am J

Orthod 111:510, 19973. Marquardt SR: Archetype theory. Marquardt Beauty Analysis.

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4. Koury ME, Epker BN: Maxillofacial esthetics: Anthropometricsof the maxillofacial region. J Oral Maxillofac Surg 50:806, 1992

5. Baker BW, Woods MG: The role of the divine proportion in theesthetic improvement of patients undergoing combined orth-odontic/orthognathic surgical treatment. Int J Adult OrthodonOrthognath Surg 16:108, 2001

6. Arteaga DM, Taylor CO: Esthetic evaluation and treatment of

Table 1. EVALUATION FORM

acial third lengthUpper third _____________________________________Middle third _____________________________________Lower third _____________________________________Length of upper lip (subnasale to upper lip stomian) ___Length of lip to chin ______________________________Upper lip thickness _______________________________Lower lip thickness _______________________________

ooth displayCentral incisor at rest ____________________________Central incisor smile ____________________________Midline upper dentition __________________________Length of central incisor (R) ______________________Width of central incisor (R) _______________________Length of central incisor (L) _______________________Width of central incisor (L) _______________________

anossian and Block. Evaluation of the Smile. J Oral Maxillofacurg 2010.

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Documents

Evaluation of the Smile