Principles of Smile Design
Principles of Smile Design
PMCID: PMC3010027
doi: 10.4103/0972-0707.73387: 10.4103/0972-0707.73387 PMID: 21217950
Department of Conservative Dentistry, SRM Dental College and Hospital, SRM University, Chennai, India
Address for correspondence: Dr. Mohan Bhuvaneswaran, ’Chaitanyam’, AH-147, III st, Shanthi Colony, Anna Nagar,
Chennai - 40, India. E-mail: [email protected]
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
An organized and systematic approach is required to evaluate, diagnose and resolve esthetic problems
predictably. It is of prime importance that the final result is not dependent only on the looks alone. Our ultimate
goal as clinicians is to achieve pleasing composition in the smile by creating an arrangement of various esthetic
elements. This article reviews the various principles that govern the art of smile designing. The literature search
was done using PubMed search and Medline. This article will provide a basic knowledge to the reader to bring
out a functional stable smile.
Keywords: Elements of smile designing, esthetic smile, smile designing, smile proportions
INTRODUCTION
Smile, a person’s ability to express a range of emotions with the structure and movement of the teeth and lips,
can often determine how well a person can function in society. Of course, the importance given to a beautiful
smile is not new. The search for beauty can be traced to the earliest civilizations; both the Phoenicians (app 800
BC) and Etruscians (app 900 BC) carefully carved animal tusks to simulate the shape, form and hue of natural
teeth. It was not until the 18th century that dentistry was recognized as a separate discipline and its various
branches were established. Pierre Fauchard (1678–1761) of France, the leader of the movement, together with
several colleagues modernized and promoted dentistry and also advocated esthetic practices.[1] This article
reviews the various principles that govern the art of smile designing. The literature search was done using pub
med search and medline.
Facial composition
Facial beauty is based on standard esthetic principles that involve proper alignment, symmetry and proportion
of face. Analyzing, evaluating and treatment planning for facial esthetics often involve a multidisciplinary
approach which could include orthodontics, orthognathic surgery, periodontal therapy, cosmetic dentistry and
plastic surgery. Thus, esthetic approach to patient care produces the best dental and facial beauty.[4]
But in our clinical practice, unless and otherwise there is an obvious discrepancy in the face, we restrict our
smile makeover to the dental composition only. There are two facial features which do play a major role in the
smile design:
2. lips.
The interpupillary line should be perpendicular to the midline of the face and parallel to the occlusal plane. Lips
are important since they create the boundaries of smile design. If we come across major discrepancies in the
above-mentioned two factors, then we have to seriously consider the correction of the facial composition, before
we venture into the correction of the dental composition.[5]
In classical terms, the horizontal and vertical dimensions for an ideal face are as follows:
1. Horizontal:
The distance between the eyebrow and chin should be equal to the width of the face [Figure 1].
2. Vertical:
The facial height is divided into three equal parts from the fore head to the eyebrow line, from the
eyebrow line to the base of the nose and from the base of the nose to the base of the chin.
The full face is divided into two parts, eyes being the midline.
The lower part of the face from the base of the nose to the chin is divided into two parts, the upper
lip forms one-third of it and the lower lip and the chin two-thirds of it [Figure 2].
The basic shape of the face when viewed from the frontal aspect can be one of the following:
1. Square
2. Tapering
3. Square tapering
4. Ovoid
1. Straight
2. Convex
3. Concave
These factors play a role in determining the tooth size, shape and the lateral profile; in short, the tooth
morphology is dependent on the facial morphology.[6,7]
1. Tooth components
a. Dental midline
b. Incisal lengths
c. Tooth dimensions
d. Zenith points
e. Axial inclinations
g. Incisal embrasure
a. Gingival health
c. Interdental embrasure
d. Smile line
The role of each of the above-mentioned factors in smile designing is given below.
The philtrum of the lip is one of the most accurate of these anatomical guide posts. It is always in the center of
the face except in surgical, accident or cleft cases. The center of the philtrum is the center of the cupids bow and
it should match the papilla between the centrals. If these two structures match and the midline is incorrect, then
the problem is usually incisal inclination. If the papilla and philturm do not match, then the problem is a true
midline deviation. A midline that does not bisect the papilla is more noticeable than the one that does not bisect
the philturm.
1. location and
2. alignment.
Midline should be
a. parallel to the long axis of the face: the line angle that forms the contact between the centrals should be
parallel to the long axis of the face;
b. perpendicular to the incisal plane: the line angle that forms the contact between the centrals should be
perpendicular to the incisal plane and
c. over the papilla: the midline should drop straight down from the papilla.
A face bow transfer or even a reference stick aligned parallel to the interpupillary plane provides useful
information in laboratory communication regarding midline inclination and the possible presence of a canted
incisal plane.[10]
Maxillary and mandibular midlines do not coincide in 75% of cases. Therefore, it is not advisable to use the
mandibular midline as a reference point for establishing the maxillary midline. Mismatch between maxillary
and mandibular midline does not affect esthetics since mandibular teeth are not usually visible while smiling.
Incisal lengths (incisal edge positions) Maxillary incisal edge position is the most important determinant in
smile creation because once set, it serves as a reference point to decide the proper tooth proportion and gingival
levels. The parameters used to help establish the maxillary incisal edge position are:
2. phonetics and
3. patient input
Degree of tooth display: When the mouth is relaxed and slightly open, 3.5 mm of the incisal third of the
maxillary central incisor should be visible in a young individual. As age increases, the decline in the muscle
tonus results in less tooth display.
Phonetics: Phonetics is a major determinant of the tooth length. In order to determine proper lip, tongue and
incisal support and tooth position, it is necessary that the patient sits either erect or stands during the phonetic
exercises.[11,12] The various phonetics used are as follows:
M sound: After pronunciation, the lips return to their normal rest position, allowing evaluation of the
amount of the tooth display in rest position.
E sound: The maxillary incisal edge position should be positioned halfway between the upper and lower
lip during the “E” sound.
F and V sounds: Fricative sounds are produced by the interaction of the maxillary incisal edge with the
inner edge of the lower lips’ vermilion border. Thus, fricative sounds help to determine the labiolingual
position and length of the maxillary teeth.
S sound: During pronunciation, the mandibular central incisors are positioned 1 mm behind and 1 mm
below the maxillary incisal edge.
Patient input: Intraoral cosmetic preview and provisional restorations help to confirm proper placement of the
final incisal edge position. The patient desires must be met as best as possible, provided they do not interfere
with the parameters previously discussed.
Correct incisal edge position is crucial because it is related to the pitch of the anterior teeth, labial contours, lip
support, anterior guidance, lingual contours and tooth display. The pitch of each anterior tooth is determined by
the combination of correct lip support and the lingual labial position of the incisal edge. This location influences
anterior guidance and the labial and lingual contours. In short, all these factors play a dominant role in both
esthetics and function.
Tooth dimensions Correct dental proportion is related to facial morphology and is essential in creating an
esthetically pleasing smile. Central dominance dictates that the centrals must be the dominant teeth in the smile
and they must display pleasing proportions. They are the key to the smile. The proportions of the centrals must
be esthetically and mathematically correct. The width to length ratio of the centrals should be approximately 4:5
(0.8–1.0); a range for their width of 75–80% of their length is most acceptable. The shape and location of the
centrals influences or determines the appearance and placement of the laterals and canines. Various guidelines
for establishing correct proportions in an esthetically pleasing smile are
The important point to be noted here is that it is not the actual size, but instead the perceived size, that these
proportions are based on when viewed from the facial aspect (in short, it is the distance between proximal line
angles of the teeth).
1. Golden proportion (Lombardi): When viewed from the facial, the width of each anterior tooth is 60% of
the width of the adjacent tooth (mathematical ratio being 1.6:1:0.6) [Figure 3]. It is difficult to apply as
patients have different arch form, lip anatomy and facial proportions. Strict adherence to golden
proportion calculations limits creativity and this may lead to cosmetic failure.[13]
2. Recurring esthetic dental proportion (Ward): The successive width proportion when viewed from the
facial aspect should remain constant as we move posteriorly form midline. This offers great flexibility to
match tooth properties with facial proportions [Figure 4].
3. M proportions (Methot): This method compares the tooth width with the facial width using a software.
The whole analysis is done in the computer and hence involves more of mathematics rather than artistic
analysis.
4. Chu’s esthetic gauges: Dr. Chu’s research supports Levin’s RED concept and refutes the golden
proportion. A series of gauges are available to make intraoral analysis easier. The gauges allow for
fast, simple analysis and diagnosis of tooth width problems, tooth length problems and gingival
length discrepancies;
color coding predefines desired tooth proportions, quicker and easier to read than any other
instrument;
used as a reference guide between clinician and lab technician, hence reduces the incidences of
miscommunications errors.
These principles are used as a guide rather than a rigid mathematical formula. Most authors recommend creating
harmony and balance by eye via proper adjustment and evaluation of provisionals rather than any formula.[14]
The factors guiding individual tooth dimensions are as follows.
Maxillary central incisor: Centrals are the focal point of an esthetic smile and create the central dominance as
described earlier. Approximate length of the central should be 10–11 mm and the width is calculated
accordingly so that the ratio falls between 75 and 80%
Maxillary lateral incisor: These are the playful part of the smile. They provide individuality, are never
symmetrical and influence gender characterization.
Maxillary canine: They play a critical point in creating a pleasing smile as they are
the junction between the anterior and posterior dental segments; hence, only the mesial half of the canine
is visible from the frontal view when the patient smiles;
support the frontal muscles – the size and characteristic of the buccal corridor is determined by the size,
shape and position of the canine and
canine depicts the personality characterization (masculine: vigorous and aggressive; feminine: delicate
and soft).
central incisor is wider than the lateral by 2–3 mm and canine by 1–1.5 mm;
Maxillary bicuspids: They play a very important role for arch design. They should fill the buccal corridor.[15]
Buccal corridor refers to dark space (negative space) visible during smile formation between the corners of the
mouth and the buccal surfaces of the maxillary teeth [Figure 5a and b]. Its appearance is influenced by
4. the prominence of the canines particularly at the distal facial line angle and
5. any discrepancy between the value of the premolars and the six anterior teeth.
Arch form has a direct influence on the buccal corridor.[16] The ideal arch is broad and conforms to a U shape.
A narrow arch is generally unattractive. The unattractive, negative space should be kept to a minimum. This
problem can be solved or minimized by restoring the premolars. The buccal corridor should not be completely
eliminated because a hint of negative space imparts to the smile a suggestion of depth.
Ultimately, there is no formula for anterior esthetics; instead, the final esthetics is a combination of
Zenith points Zenith points are the most apical position of the cervical tooth margin where the gingiva is most
scalloped. It is located slightly distal to the vertical line drawn down the center of the tooth. The lateral is an
exception as its zenith point may be centrally located[17] [Figure 6]. Establishing the proper location of zenith
points is a critical step in alteration of mesial and distal dimensions,
2. provide the illusion of bodily movement and reduce exaggerated triangular form and
Tooth inclinations Axial inclination compares the vertical alignment of maxillary teeth, visible in the smile line,
to central vertical midline. From the central to the canine, there should be natural, progressive increase in the
mesial inclination of each subsequent anterior tooth. It should be least noticeable with the centrals and more
pronounced with the laterals and slightly more so with the canines. If the incisal plane is canted, the axial
inclination of the anterior teeth and the midline itself, if it is at right angle to the incisal plane, will be
correspondingly incorrect.[15]
The evaluation of axial inclination can be done on a photograph of the anterior teeth in a frontal view. A line is
sketched on each tooth from the middle of the incisal edge through the midline of the tooth at its gingival
interface. Axial inclination can also refer to the degree of tipping in any plane of reference. The guide for
labiolingual inclination is as follows:
2. Maxillary lateral incisor – cervical is tucked in, incisal edge inclined slightly labially
3. Maxillary canine – cervical area positioned labially, cusp tip lingually angulated
It follows the 50:40:30 rule in reference to the maxillary central incisor [Figure 7].
The increasing ICA helps to create the illusion of longer teeth by wider and also extend apically to
eliminate black triangles.
As a general rule, the ICP moves apically, the further posterior one moves from the midline [
Figure 8].
Incisal embrasures The incisal embrasures should display a natural, progressive increase in size or depth from
the central to the canine. This is a function of the anatomy of these teeth and as a result, the contact point moves
apically as we proceed from central to canine [Figure 9]. The contact points in their apical progression should
mimic the smile line.[16] Failure to provide adequate depth and variation to the incisal embrasure will
2. make the contact areas too long and impart to the dentition a box like appearance. The individuality of the
incisors will be lost if their incisal embrasures are not properly developed.
Also, if the incisal embrasures are too deep, it will tend to make the teeth look unnaturally pointed. As a rule, a
tooth distal to incisal corner is more rounded than its mesio incisal corner.
Sex, age and personality Minor differences in the length, shape and positioning of the maxillary teeth allow for
dramatic characterization.[18]
Youthful teeth: unworn incisal edge, defined incisal embrasure, low chroma and high value
Aged teeth: shorter; so less smile display, minimal incisal embrasure, high chroma and low value
Aggressive, hostile angry: pointed long “fangy” cusp form Passive, soft: blunt, rounded, short cusp form
Symmetry and balance Symmetry is the harmonious arrangement of several elements with respect to each
other. Symmetrical length and width is most crucial for the centrals. It becomes less absolute as we move
further away from the midline
Dynamic symmetry: two objects very similar but not identical. Playing with perfect imperfection in the
laterals and canines allows for a more vital, dynamic, unique and natural smile.[16]
Balance is observed as the eyes move distally from the midline, so that both the right and left sides of the smile
are well balanced.
1. pale pink in color, stippled, firm and it should exhibit a matte surface;
3. located interdentally – 5 mm above the intercrestal bone papilla should be pointed and should fill the
gingival embrasure right up to the contact area.
Gingival level and harmony Establishing the correct gingival levels for each individual tooth is the key in the
creation of harmonious smile. The cervical gingival height (position or level) of the centrals should be
symmetrical. It can also match that of the canines. It is acceptable for the laterals to display the same gingival
level. However, the resultant smile may be too uniform and it is preferable to exhibit a rise and fall in the soft
tissue by having the gingival contour over the laterals located toward the incisal compared to the tissue level of
the centrals and canines [Figure 10]. The gingival margin of the lateral incisor is 0.5–2.0 mm below that of the
central incisors. The least desirable gingival placement over the laterals is for it to be apical to that of the
centrals and or the canines.[16]
The gingival shape on the mandibular incisors and the maxillary laterals should exhibit a symmetrical half oval
or half circular shape. The maxillary centrals and canines should exhibit a gingival shape that is more elliptical.
Thus, as mentioned earlier, the gingival zenith is located distal to the long axis of the maxillary centrals and
canines and coincides along the long axis of the maxillary lateral incisors.[17,20]
Interdental embrasure (cervical embrasure) The darkness of the oral cavity should not be visible in the
interproximal triangle between the gingiva and the contact area. If the most apical point of the restoration is 5
mm or less from the crest of the bone, then black triangles will be avoided. At times, this will require long
contact area that will be extended toward the cervical. This will encourage the formation of a healthy, pointed
papilla instead of the blunted tissue form that often accomplishes a black triangle[21] [Figure 11]. Conversely,
an improperly developed cervical embrasure that involves overextended, bulky restorations will result in an
improper emergence profile and swollen and inflamed gingival tissues.[22]
Smile line Smile line refers to an imaginary line along the incisal edges of the maxillary anterior teeth which
should mimic the curvature of the superior border of the lower lip while smiling. Another frame of reference for
the smile line suggests that the centrals should appear slightly longer or, at least, not any shorter than the
canines along the incisal plane. This approach is particularly useful in cases of lip symmetry or extreme lip
curvature during smile formation [Figure 12]. Reverse smile line or inverse smile line occurs when the centrals
appear shorter than the canines along the incisal plane.
Lip line should not be confused with the smile line. It refers to the position of the inferior border of the upper lip
during smile formation and thereby determines the display of tooth or gingiva at this hard and soft tissue
interface. Under ideal conditions, the gingival margin and the lip line should be congruent or there can be a 1–2
mm display of the gingival tissue. Showing 3–4 mm or more of the gingiva (gummy smile) often requires
cosmetic periodontal recontouring to achieve an ideal result.[23]
Finally, the individual tooth morphology has to mimic nature, once all the above-mentioned factors are fulfilled.
[7] Also, the appropriate shade selection has to be done to bring out all the hard work of our smile design. Shade
selection must be customized for each individual. It should be natural and polychromatic. The body of the tooth
can be fairly uniform in color but the gingival third should be noticeably richer in chroma. The chroma should
also increase from central to the canine, canine having a higher chroma.[24]
CONCLUSION
It is vivid from the above discussion that the smile we create should be esthetically appealing and functionally
sound too. It is our duty to carefully diagnose, analyze and deliver the best to our patients, taking into account
all of the discussed factors. The smile designing done by us has to be as conservative as possible unlike the past.
Our aim has to be less reduction of tooth structure and greater esthetics and durability. This simply means that
cosmetic dentistry has to be a multispecialty branch, wherein all treatments like orthodontics, periodontics,
surgical procedures have to be performed whenever deemed necessary.
Footnotes
Source of Support: Nil
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Figure 1
Figure 2
Figure 3
Figure 4
Figure 5
Figure 6
Open in a separate window
Zenith points and its relation to midline
Figures
(7) ICAs – 50:40:30 rule, (8) ICPs – moves appically as we move from central to canine, (9) Incisal embrasure –
increase in size and depth from central to canine
Figures
(10) Ideal gingival level – centrals and canines same level and laterals cervical to them, (11) Interdental embrasure –
showing black triangle, (12) Smile line that follows the superior border of the lower lip
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