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10.5005/jp-journals-10021-1052
ORIGINAL ARTICLE
Esthetic and Smile Characteristics at Rest and during Smiling
ABSTRACT
Objective: This study was conducted to evaluate the role of smile in overall facial esthetics.
Materials and methods: The sample comprised of photographs taken in natural head position of 100 normal Himachali subjects (50 males,
50 females) and they were divided in 3 age groups: Group I consisiting of 39 subjects aged (15-20) years, Group II consisiting of 35 subjects
aged (21-24) years, Group III consisiting of 26 subjects aged (25-29) years. The various parameters were analyzed using the clever ruler
software: Upper lip length during rest and smiling, lower lip length during rest and smiling, smile index, buccal corridor, upper lip thickness,
lower lip thickness, interlabial gap, incisal display, widest visible maxillary display and intercommissural width. Student t-test and using one-
way analysis of variance (ANOVA) were used to compare the mean of different groups.
Results: The results showed changes in the maxillary incisal display, interlabial gap and smile index were highly significant from Group I to
Group III. There was a decrease of 2.2 mm in maxillary incisal display and 2.0 mm in interlabial gap whereas smile index showed an
increase of 0.7 mm with the increasing age.
Conclusion: It has been concluded from the study that with the increasing age, the smile gets wider transversely and narrow vertically.
Keywords: Smile, Esthetics, Facial profile, Gingival display, Buccal corridor.
How to cite this article: Sachdeva K, Singla A, Mahajan V, Jaj HS, Negi A. Esthetic and Smile Characteristics at Rest and during Smiling.
J Ind Orthod Soc 2012;46(1):17-25.
smiling, lower lip length at rest and during smiling, upper lip 2. No previous orthodontic treatment or maxillofacial surgery
thickness, lower lip thickness, maxillary incisal display, 3. Complète permanent dentition
interlabial gap at smile, smile index, buccal corridors, widest 4. Voluntary involvement in the study
visible maxillary display and intercommissural width and sexual 5. No active periodontal disease
dimorphism with respect to smile. 6. No craniofacial anomalies or other pathologies
The aims and objectives of the study were:
1. To check the sexual dimorphism with respect to smile in
Himachali population.
2. To check the age-related changes with smile in Himachali
population.
Figs 1A and B: Group I—15-20 years: (A) At rest, (B) During smiling Figs 3A and B: Group III—25-29 years: (A) At rest, (B) During smiling
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Total 100
7. No severe malocclusion
8. No deleterious habit causing malocclusion (tongue thrusting,
thumb-sucking, etc.).
The exclusion criteria included:
1. Missing teeth that could have been visible on smile
2. Prosthodontic work on teeth visible in smile
3. Excessive dental attrition Fig. 4: (1) Upper lip length (rest)—from subnasale to stomion
superius; (2) Lower lip length (rest)—from stomion inferious to menton
4. Lip irregularities (incompetent, potentially incompetent,
short lips, etc.).
5. Inability to determine natural head position.
The subjects were photographed with posed smiles. The
photographs taken for each subject will follow the described
standardized parameters:
1. Nikon D-40 digital camera.
2. Distance between the camera and the subject was taken as
3.5 ft.
3. The camera was mounted on a tripod stand with the lens
positioned parallel to the true perpendicular of the face in
natural head position.
4. The camera was raised to the level of subject’s lower facial
third.
5. The same illumination was used for photography of each
individual.
Fig. 5: (1) Outer commissure width—distance from outer most corner
Each file was opened in Microsoft Office Picture Manager of the mouth from one side to the other, (2) Inner commissure width—
and adjusted by using the millimeter ruler in the frame. The distance from inner most corner of the mouth from one side to the
following procedure was used to adjust each picture. First, the other, (3) Upper lip length (smiling)—from subnasale to stomion
superius, (4) Visible maxillary widest display—teeth displayed from first
picture was magnified to 51% to get 1 inch = 97 pixels. Then, molar to first molar, (5) Upper lip thickness—vertical distance from the
the clever ruler function was chosen and adjusted, so as to get most superior point of the cupid's bow to the most inferior portion of the
1:1 ratio. To check the accuracy of these steps, the 10 mm area tubercle of the upper lip, (6) Interlabial gap—the position of the upper
and lower lips as measured from the midpoint of the lips when a patient
on the ruler was measured again. If done correctly, this
is relaxed and smiling, (7) Incisal display—stomion superius to maxillary
measurement would read 10 mm and thus direct measurements incisor edge (if the central incisors were not at the same levels, 2
could be recorded. The various parameters were studied using measurements were taken and the average used for that subject, (8)
clever ruler software are: (1) Upper lip length at rest and during Lower lip thickness—lower lip inside to vermilion—cutaneous junction,
(9) Lower lip length (smiling)—from stomion inferious to menton
smiling—subnasale to stomion superius; (2) lower lip length at
rest and during smiling—from stomion inferious to menton;
(3) upper lip thickness—vertical distance from the most superior (8) inner intercommissural width; (9) visible maxillary dental
point of the cupid’s bow to the most inferior portion of the width (Figs 4 and 5).
tubercle of the upper lip; (4) lower lip thickness—lower lip Smile index was developed by Ackermann and
inside to vermilion—cutaneous junction; (5) maxillary incisor Ackermann10 and determined by dividing the outer inter-
display—stomion superius to maxillary incisor edge (if the commissural width by the interlabial gap height during smile.
central incisors were not at the same levels, two measurements Vertical lip thickness was the vertical distance from the most
were taken and the average used for that subject; (6) interlabial superior point of the peak of the lip to the most inferior portion
gap at smile—the position of the upper and lower lips as of the tubercle of the upper lip.
measured from the midpoint of the lips when a patient is relaxed Frush and Fisher15 defined buccal corridors as the spaces
and smiling; (7) outer intercommissural width—distance from between the buccal surfaces of the posterior teeth and the corners
outer most corner of the mouth from one side to the other; of the mouth when smiling.
RESULTS rest and during smiling, upper lip thickness and lower lip
The mean, standard deviation and p-value were calculated for thickness (Table 4, Graphs 2 and 3).
each parameter. Overall means for the various perioral
DISCUSSION
measurements were calculated.
There were highly significant age-related differences in One of the primary aims of an orthodontic treatment is to attain
lower lip length during smiling, interlabial gap, incisal display, and preserve facial attractiveness.16 Facial attractiveness and
outer commissure width and smile index. Upper lip length during smile attractiveness appear strongly connected to each other.
smiling and widest visible maxillary display was also found to Furthermore, attractiveness is suggested to influence personality
be significant (Table 2, Graph 1). development and social interaction.4 The smile also influences
Multiple comparisons among subgroups were done via the a person’s perceived attractiveness and is the cornerstone of
HSD (Honestly significant difference test) (Table 3). The data social interaction.17 In most arenas, attractiveness was found
demonstrated a significant difference between Group I and to be equally important for men and women. The smile is
Group III in certain parameters: Lower lip length during smiling, rightfully deemed a valuable means of nonverbal social
incisal display, smile index, interlabial gap. communication and sound criteria of facial attractiveness.18
Statistically significant sex-related differences were found Smile analysis and smile design have become key elements of
in upper lip length at rest and during smiling, lower lip length at orthodontic diagnosis and treatment planning over the last
Table 2: Mean values of parameters according to age (one-way analysis of variance ANOVA)
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Dependent variable (mm) Age group (I) Age group (J) Mean difference (I-J) p-value
Upper lip length at rest Tukey HSD 15-20 21-24 1.11257 0.117
25-29 0.38000 0.804
21-24 15-20 –1.11257 0.117
25-29 –0.73257 0.464
25-29 15-20 –0.38000 0.804
21-24 0.73257 0.464
Lower lip length at rest Tukey HSD 15-20 21-24 –1.88190 0.132
25-29 –2.07333 0.126
21-24 15-20 1.88190 0.132
25-29 –0.19143 0.983
25-29 15-20 2.07333 0.126
21-24 0.19143 0.983
Upper lip length during smiling Tukey HSD 15-20 21-24 0.90952 0.303
25-29 –0.90333 0.368
21-24 15-20 –0.90952 0.303
25-29 –1.81286* 0.024*
25-29 15-20 0.90333 0.368
21-24 1.81286* 0.024*
Lower lip length during smiling Tukey HSD 15-20 21-24 –2.83562* 0.004**
25-29 –3.84333* <0.001**
21-24 15-20 2.83562* 0.004**
25-29 –1.00771 0.540
25-29 15-20 3.84333* <0.001**
21-24 1.00771 0.540
Contd...
Contd...
Dependent variable (mm) Age group (I) Age group (J) Mean difference (I-J) p-value
decade.19-21 Perception of facial attractiveness varies from of muscles as person ages which leads to the decrease in lip
person to person and is influenced by their personal experience volume, loss of lip architecture and lip lengthening. These
and social environment. So the aim of our study was to evaluate changes highlight the importance of having age-related norms
the various parameters of the smile. The significant parameters as references, so that more objective and specific treatment can
of smile are as follows: be rendered to older patients. This is in accordance with the
study conducted by Ravindra Nanda et al.7
Upper Lip Length The present study shows upper lip length at rest was
21.7 mm for males and 19.4 mm for females. Mean value was
Upper lip length at rest indicated a decrease of 19.0 mm statistically higher in males as compared to females. The values
(Group I) to 18.6 mm (Group III) though it was statistically for upper lip length from our study were in close proximity
nonsignificant. Upper lip length during smiling is increased from with the study conducted by Farkas et al22 who found the upper
13.4 mm (Group I) to 14.3 mm (Group III) indicating atrophy lip length in the range of 21.8 mm for males and 19.6 mm for
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Graph 2: Mean values of parameters in male patients Graph 3: Mean values of parameters in female patients
females. Wolford et al23 also found the upper lip length in the lengths at rest was 40.6 mm for males and 37.8 mm for females
range of 22 mm for males and 20 mm for females which is also and during smiling were 40.1 mm for males and 37.7 mm for
similar to the results of our study. females. Mean value was statistically higher in males as compared
to females. This in accordance with the study conducted by the
Lower Lip Length Scheideman et al24 who reported increased lower face height in
Lower lip length during smiling is increased from 36.9 mm (Group male subjects. This is mainly because of increased lower lip
I) to 40.8 mm (Group III). The present study shows lower lip length. This significant difference in facial heights between men
and women might be significant in treatment planning because by the Shyam Desai and Ravindra Nanda7 who found an increased
these differences can be indications to increase or decrease facial of smile index from 5.6 mm to 6.7 mm which indicates, that as
height. Similar results were found by the study conducted by person ages smile gets narrow vertically and wider transversely.
Kalha et al25 and Arnett and Bergman.26 Similar results were found by Ackermann et al.10 The present
study shows statistically nonsignificant difference in smile index
Upper Lip Thickness 1.9 mm for males and 2.1 mm for females.
Upper lip thickness indicated an increase of 7.6 mm (Group I)
to 8.7 mm (Group III) though it was statistically nonsignificant. Buccal Corridor
This is in accordance with the study conducted by Ravindra Buccal corridor is decreased with age from 7.2 mm (Group I)
Nanda et al7 who found an increase in upper lip thickness from to 6.7 mm (Group III). The present study shows statistically
7.87 mm to 8.28 mm. nonsignificant difference in bucca1 corridor 6.7 mm for males
The present study shows upper lip thickness at rest was and 6.4 mm for females. The impact of buccal corridors on
14.1 mm for males and 12.6 mm for females. This is in smile esthetics has no effect on the esthetic evaluations of smiles.
accordance with the study conducted by Kalha et al25 and Arnett The results of our study, which looked at differences between
and Bergman.26 buccal corridor spaces, indicated no statistically significant
difference in either sex and age groups. This is in accordance
Lower Lip Thickness with the study conducted by Martin AJ et al.30 Thus, we can
Mean value of lower lip thickness was 9.79 mm (Group I) to assume that buccal corridor space plays only a minimal role in
9.7 mm (Group III) though it was statistically nonsignificant. esthetic evaluation of a smile and the perceived difference could
The present study shows lower lip thickness was 10.4 for males be due to other factors, such as smile arc, tooth arrangement,
and 9.1 mm for females. This is in accordance with the study tooth shade, gingival architecture, gingival display, lip thickness.
conducted by Kalha et al25 and Arnett and Bergman26 who also Our study indicates that incisal dispay decreases with time,
reported higher lower lip thickness for males than females. therefore treatment should be age-specific. It also helps to
broaden our knowledge and understanding of how the perioral
Incisal Display soft tissues change with age and helps clinicians to optimize
The data in Table 2 show that there is a decrease in the upper dentofacial esthetics while satisfying other treatment goals.
incisal display from 8.6 mm (Group I) to 6.4 mm (Group III). CONCLUSION
This is evidence that, as one ages, the upper lip displays less
maxillary incisors on smile. This is in accordance with the study Standardized photographs were taken with posed smiles. Means,
conducted by Husely27 and Tjan et al.1 Similar results were standard deviations and statistical significances were calculated
obtained by Vig and Brundo28 who noted a decrease in maxillary for all values. These results show:
incisor exposure of about 3.41 mm from less than 29 years to 1. A significant decrease of 2.2 mm in maxillary incisal display
over 60 years of age. Dong et al29 examined both maxillary and 2.0 mm in interlabial gap was found at smile with
incisor display at rest and smile. They described decreases in increasing age.
maxillary incisor display of about 2.5 mm at rest and 2 mm at 2. The smile index significantly increased, indicating that the
smile between the 20 to 29 year and the 60 to 69 year age groups. smile gets narrower vertically and wider transversely as a
The present study shows no statistically significant person ages.
difference in upper incisal display 7.8 mm for males and 3. Outer commissure width and lower lip length during smiling
also increases with age.
7.6 mm for females.
4. It was found that Himachali males had larger upper lip length
Interlabial Gap and lower lip length both at rest and during smiling than
Himachali females. Upper lip and lower lip thickness was
Interlabial gap is decreased with age from 9.3 mm (Group I) to
also found to be more in Himachali males when compared
7.3 mm (Group III) causing an increase in the smile index
to Himachali females.
between the same age groups as shown in Table 2. This data
5. Longitudinal studies with larger samples should be carried
provide the evidence as the person ages the smile gets wider
out in future as this type of study can give better applicable
transversely and narrower vertically. This is in accordance with
values clinically.
study conducted by Shyam Desai and Ravindra Nanda7 who
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