An esthetic evaluation of lip-teeth

relationships present in the smile

Charles M. Hulsey, D.D.S.
Tachibawa, Japan

A paramount objective of modern orthodontic therapy is the improve-

ment of facial esthetics. Extensive study and measurement of facial features
have resulted in various norms which may be used by the orthodontist to eval-
uate soft-tissue form and relationships and to direct his therapy by serving
as guidelines.
The majority of these appraisals have been limited to the lateral or profile
view of the face. The development of roentgenographic cephalometric tech-
niques and the importance of the anteroposterior dimension in malocclusions
have focused attention on the lateral aspect at the expense of the frontal. In-
formation is needed concerning soft-tissue and dental relationships from a fron-
tal view to provide a wider basis for assessing facial esthetics.
The smile is one of the most effective means by which people convey their
emotions, and, from a social standpoint, it is viewed frontally more often than
in profile. Webster1 defines the smile as “a change of facial expression in-
volving 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 lips provide a handsome frame around the oral stoma, complementing
the teeth with their symmetrical curvatures and contrasting color. The main
effecters of the smile are the zygomaticus major muscles which insert into the
modiolis of the orbicularis oris at each corner of the mouth. They raise the cor-
ners of the mouth upward and outward and curve the lips into a smile.2
Two questions have arisen: (1) Are the smiles of orthodontically treated
patients as attractive as those of persons with “normal occlusion”? (2) What

A dissertation presented to the Graduate Committee of Washington University School

of Dentistry in partial fulfillment of the requirements for the degree of Master of
Science, June, 1967.
From the United States Air Force Hospital, Tachikawa, Japan, Box 7067, APO
San Francisco, Calif. 96323.

132
y~~~5~ Lip-teeth relationships in sma7e 133

relationship between the lips and teeth, if any exists, should the orthodontist
consider in positioning the anterior teeth during orthodontic treatment?
The purpose of the present study was to determine whether some measurable
components exist which might permit an objective evaluation of the smile. If
there should appear to be some relationship of perioral soft tissue and teeth
common to attractive smiles, an additional diagnostic parameter would be avail-
able to the orthodontist in planning treatment procedures.

Review of the literature

Prior to Angle, orthodontists followed the premise of correction only for

esthetic reasons. Dr. Angle popularized the belief that placing the teeth in
“normal occlusion” would yield the ideal esthetic result. However, orthodontists
soon noted that facial features of patients with corrected occlusion may not
necessarily be beautiful.3
Orthodontic treatment should not try to change a patient’s inherited racial
characteristics; instead, the effort should be to establish harmony and balance
between the dentition and the surrounding soft tissue. Harmony refers to the
pleasing and attractive interrelationship existing between the dentition and the
surrounding soft tissue.
In a 1964 publication, Stallard4 recommended relating the anterior teeth to
the lips when positioning these teeth during orthodontic treatment. He was
concerned not only with esthetics but with the functional interrelationship exist-
ing between the lips and teeth. He said:
Lip and tooth-edge relations are important for three reasons: (1) Lip forces in-
fluence tooth alignment and stability. (2) The lower lip feeds food chunks
between the opposing incisors; hence, it is well to place the tooth edges where
the lower lip can use them easily. (3) The lip closure should be easy and graceful.
The ease with which lips work with the teeth and the grace with which they rest
over them reveal good arch form and position.

Stallard has considered the smile in tooth positioning, stressing that the
line of the upper incisor edges should be parallel to the lip borders and that the
upper teeth should “hang down evenly in the open smile.”
The smile is considered by prosthodontists in tooth positioning.” Frush and
Fisher69 7 have directed attention toward the “smiling line,” the harmony be-
tween the curvatures of the incisal edges of the upper anterior teeth and the
upper border of the lower lip. They have pointed out that natural teeth do not
have their incisal edges on a flat plane. Instead, there is a curve upward from
central incisors to canines, so that the incisal edges of the upper anterior teeth
form a pleasing arc that coincides with the curvature of the upper border of
the lower lip during a smile.
The “smiling line” is a part of the dynesthetic interpretation of the dento-
genie concept of denture esthetics which Frush and Fisher originated. This con-
cept is concerned with the interpretation of three vital factors: personality, sex,
and the age of the patient. The consideration of these factors by orthodontists
could lead to a more individualized interpretation of facial esthetics in treat-
ment.?
134 Iiulsey Amer. J. Orthodont.
Febmary 1970

In the dentogenic concept, the placement of the central incisor controls the
midline, the lip support, the labioversion of the teeth, and the composition of
the “smiling line.” The lateral incisor is the “personality tooth” and is sub-
ordinated to the central incisor. Sex emphasis comes from its rotation and thr
shape of its incisal edge. Canine position is \-cry important to the conecpt of
the “smiling linr.” This tooth supports t,he anterior arch at its widest part ant1
also controls the size of the bnccal corriclor, the space between the buccal SI~I*-
faces OSthe teeth and the corner of’ the lips when the patient smiles. The canine
should be carefully position4 to tlominate the lateral incisor and to completcl
the desired upward curvature of the “smiling line.““, 7
The causal relationship existing between perioral soft tissue and tooth posi-
tion is controversial. Brodi@ has tlirrctcd attention to the effect of the muscu-
latwe on the teeth and their surrounding bone structure. Hc has stated that
the musculature surrounding the dentition has a definite effect on the positions
the teeth may occupy. Hovell” also has emphasized the effect of t,he soft tissues
and the musculature, stressing how they guide teeth into occlusion. He has
suggested that atypical swallowing habits and abnormal lip posture may possibl>*
influence tooth st,ability.
Ballardl” has dcfinctl incompetent lip morphology as “the failure of the lips
to produce an anterior sral when the mandible is in its endogenous postural
position and the muscles of facial expression are similarly in a resting posi-
tion.” He believed that the position of the dental arches is the result of soft,
tissues and their muscular activity. Sclare I1 has discussed various lip postures
and has contrasted them with the types of malocclusion existing. Patients with
flaccid lower lips had upper teeth which protruded, whereas in patients with
taut lower lips the lower anterior teeth were in linguoversion. She has concluded
that the pressure of the lower lip on the incisal third of the upper incisors main-
tains their correct relationship with the lower incisors.

lower lip relations

Nicoll” has studied the relationship of the lower lip line to the upper in-
cisors. In this study the lateral cephalometric film was used for the measure-
ments. In “normal occlusion,” Class I malocclusion, and treated orthodont,ic
cases, the lower lip rose above the incisal edge of the upper central incisors to
the same height. In Angle’s Class II, Division 2 malocclusion, however, the lower
lip coverage of the upper central incisors was greater than in the previous
groups.
Jackson,‘” in the conclusion of his detailed study, has offered a different
view. He found that an ideal incisor relationship is compatible with both com-
petent and incompetent lips. He concluded that growth and eruptive pathways
determine incisor relationships and that lip posture and function are only
secondary factors. Jackson has re-evaluated competent and incompetent lip pos-
tures and has reclassified them into a more workable system by relating the lip
position to the upper central incisor when the subject was sitting upright with
the mandible in the physiologic rest position.
The orthodontist can alter facial appearance by moving teeth. Subtelny,14
iFtkt%z”z’ Lip-teeth relatiowhips in smile 135

in his study on soft tissue, noted that as the denture becomes more upright the
lips were bound to become more retruded relative to the facial profile. He has
stated : “This strong interrelationship between the lips and the dental structures
is obviously important to the orthodontist.” RickettP also noted a change in ap-
pearance resulting from tooth movement, finding that the upper lip thickened
as the upper incisor was retracted. He 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.
A review of the literature has revealed that (1) the prosthodontist is aware
of the smile and its components and considers these factors when he positions
teeth in dentures, (2) the functional interrelationships between the teeth and
the lips may be an important factor in facial beauty, (3) the influence of soft
tissue on the position of the teeth is a debated subject, (4) it has been estab-
lished that orthodontic therapy can effect a change in perioral soft-tissue mor-
phology.
In the present study an objective evaluation of the validity of the “smile
line” concept was made. Stallard’s thoughts of beauty being interrelated with
the function of the lips and teeth were considered by comparing smiles of
subjects with “normal occlusion” with the smiles of orthodontically treated
subjects. The most functional relationships existed in the mouths of the subjects
with “normal occlusion,” although these may not be the most beautiful relation-
ships. None of the aforementioned studies has attempted a frontal evaluation
of the lip-teeth interrelationships from the standpoint of esthetics. A study of the
components of the smile has not been attempted before.
In this study, standardized photographs of smiling subjects were compared
and analyzed on the basis of the following features : (1) the curvature of the up-
per lip, (2) the height of the upper lip relative to the upper anterior teeth, (3)
the relationship between the incisal edges of the upper anterior teeth and the
upper border of the lower lip, (4) the width of the buccal corridor space, and
(5) the symmetry of the smile. An analysis of these components of the smile
may lead to a better understanding of the composition of an attractive smile.

Methods and materials

The present study involved forty persons. Criteria for selection of the subjects
were that they (1) be Caucasian, (2) be in the age range of 15 to 25 years,
(3) have no gross developmental aberrations of the head and face, and (4) have
a full complement of teeth in “normal occlusion.” Twenty of the subjects com-
prised an untreated (‘normal occlusion” group, and the remaining twenty sub-
jects had undergone orthodontic treatment. There were ten male and ten female
subjects in each group.
A standardized, oriented frontal photograph of each subject’s face was taken
to obtain quantitative data. By means of a cephalostat, the subject’s head was
positioned so that the Frankfort horizontal plane was parallel to the floor and
the midsagittal plane of the head was aligned with the center of the camera
lens. The camera was positioned and adjusted so as to obtain a sharp image
of the face from tip of nose to tip of chin. In this position, the focal plane was
465 mm. from the soft tissue, with the camera lens focused on the lips. The
136 Hdsey Amer. J. Orthodont.
February 1970

subject was asked to smile, and the film was exposed during the smile. Numerous
exposures of each subject were taken, but little difference was found to exist bc-
tween the resulting smiles. Black and while film was exposed $$ s second at f/l 6,
using room illumination. The resulting 35 mm. negatives were enlarged to near
life size (3 by 5 inches).
The photographs wese masked so that only a rectangular area of propor-
Conate size and shape surrounding each smile was exposed. A panel of ten men
and ten women of varied vocations and of the same age range as the subjects
were given a standard set of instructions telling them to ra,tc each photograph
as to the attractiveness of the individual smile, Each panel member made his
evaluation in private, without any knowledge of the subject’s identity or treat-
ment history. The member was instructed to rate the smiles by placing cnch
photograph in one of five categories : (1) poor, (2) fair, (3) good, (4) vcr>r
good, and (5) excellent. The categories were displayed on a 24 by 30 inch white
card positioned in front of the panel member and each photograph was placed
beneath its rated category, with no more than eight photographs permitted in
any one category. The scores obtained for each subject were averaged, and a mean
rating for each smile was determined from the smile-rating technique. The chi-
square test was used to determine whether the smiles of the subjects with normal
occlusions differed significantly from the smiles of the orthotlontically treated
subjects. By means of the complex analysis of variance, the smiles were com-
pared for (1) effect of sex, (2) effect of orthodontic treatment, and (3) sex and
orthodontic treatment interaction.
The smiles were measured to determine the ratio of the arc of curvature of
the upper incisor teeth to the arc of curvature of the upper border of the lower
lip. Since the lower lip curvature was observed not to be consistently corrcspon
dent with the curvature of the incisal edges of the upper teeth from canine to
canine as Frush and Fisher stated, (of the twenty “normal occlusions”, the
upper canines of sixteen subjects were below the lower lip line), the relationship
was limited to the zone from upper lateral incisor to upper lateral incisor. 11;
order t,o facilitate this and other aspects of the study, certain landmarks were
established (Fig. I) :
1. Point C. The midmost, ineisalmost point between the incisal edges of the upper
central incisors.
2. Points RL and LL. Points on the incisal edges of the upper right and left lateral
incisors where the long axis of each tooth intersects the incisal edge.

Point CLou------\ ,-Point C

Point RL Point LL
Point RC Point LCh

Point RCus Point LCus

Point RLab Point LLab
Point CLab

Fig. 1. Landmarks used to evaluate the lip-tooth relationships of the smile.

 Lip-teeth relutionships ilt smile 137

3. Points RCh and LCh. The innermost corners of the lips.

4. Point CLab. The midmost point on the upper curvature of the lower lip, directly
inferior to point C.
5. Points ECUS and LCus. Points on the most lateral surfaces of the upper canines.
6. Points RLab and LLab. Points on the upper curvature of the lower lip, directly
inferior to points RL and LL.
7. Point CLow. The most inferior point on the inferior curvature of the upper lip.
A straightedge was aligned through points RL and LL by laying it on the
photographs. The perpendicular distance from the straightedge to point
C was measured. The straightedge was aligned through points RLab and
LLab. The perpendicular distance from the straightedge to point CLab was
then measured. The perpendicular measurements represent the depth of the
arcs of curvature for the lower lip and the upper incisor teeth. The measure-
ments establish a smile line ratio:
Length of perpendicular for the arc of the upper incisors
Length of perpendicular for the arc of the lower lip
The ratio epxresses the corresponding harmony between the arcs, with a ratio
of 1:O defined as perfect harmony because the arcs would then have equal
depth. The smile line ratios were correlated with the smile scores of the smiles
by means of a scatter plot diagram in order to see if a significant correlation
existed between the two.
The effect of the buccal corridor width was studied by establishing a ratio:
Distance between upper canines, points RCus and LCus
Distance between the corners of the smile, points RCh and LCh
The distance between the most lateral points of the canines, points RCus and
LCus, was measured and recorded. The distance between RCh and LCh was then
measured and a ratio was established. The ratios and the mean smile score for
each smile were plotted on a scatter plot diagram in order to see whether a
significant correlation existed.
The effect of the curvature of the upper lip was studied for each smile.
A straightedge was aligned through points RCh and LCh, and point CLow was
observed to determine whether or not the point was inferior or superior to the
line established. The curvature was expressed as positive if the corners of the
smile were superior to the center of the upper lip, as straight if the upper lip
was straight with point CLow on the line of the rule, and as negative if the cor-
ners of the smiles were below t.he center of the upper lip. The curvature was
compared with the smile scores by determining the number of persons in each
group and the median rating of each group.
The effect of the upper lip height was assessed by means of a scale relating
the upper lip height to the length of the upper central incisor’s clinical
crown:
-2. The upper lip height is two thirds of the upper central incisor’s height superior
to or short of the gingival margin of the upper central incisor.
-1. The upper lip height is one third of the upper central incisor’s height superior
to or short of the gingival margin of the upper central incisor.
00. The height of the upper lip is at the same level as the gingival margin of the
upper central incisor.
 Amer. J. Orthodont.
138 Hubey February1970

+l. The upper lip height is one third of the upper central incisor’s height inferior
to or below the gingival margin of the upper central incisor (estimate).
+2. The height of the upper lip is two thirds of the upper central incisor’s height
inferior to the gingival margin of the upper central incisor (estimate).

The upper lip heights were assessed for each smile, and they were compared with
the mean rated scores of each smile by grouping the number of smiles in each
respective upper lip height group. A median of the scores of the smiles in each
upper lip height group was found.
A ratio of measure of smile symmetry was used. The ratio of symmetry is as
follows :
Distance from RCh to CLow + Distance from RCh to CLab
Distance from IXh to CLow t Distance from LCh to CLab
CLow was interpreted as the most inferior point on the inferior border of the
upper lip, and CLab was interpreted as the most inferior point on the upper
border of the lower lip. CLab was not related to point C in this test, as it has been
previously. This ratio was compared with the mean smile scores by construction
of a scatter plot diagram.

Results

The total data collected included (1) the mean smile scores, (2) the smile
line ratios, (3) the smile symmetry ratios, (4) the buccal corridor ratios, (5)
the upper lip heights, and (6) the upper lip curvatures.
Because of the wide spread of the ratings for each smile, from poor to excel-
lent, the rating technique was examined to see whether the panel members
could duplicate their previous ratings. Five panel members, selected at random,
repeated the rating test at least 2 weeks after they had previously judged the
smiles. The difference in rank, from poor to excellent, for each of the smiles
resulting from the first and second judgments by the selected panel member were
then compared by a rank-order coefficient of correlation. The resulting coeffi-
cient of correlation was +0.9405, indicating that the raters could repeat their pre-
vious choices fairly consistently and that the wide spread was due to differences
in opinion among the raters.
A standard estimate of error was determined for the smile line ratios, the
smile symmetry ratios, and the buccal corridor ratios. The estimates were, in
order, 0.201, 0.008, and 0.013. The margin of error was considered within ac-
ceptable limits.
The mean smile scores of the orthodontically treated subjects were found to
be significantly lower than the mean smile scores of the “normal occlusion”
subjects at the 0.05 level of significance. The chi-square test and analysis of vari-
ance technique were used. There was no significant difference between the ortho-
dontically treated males and females or between the “normal occlusion” males
and females. Interaction between sex and orthodontic treatment was not found to
be present.
The smile line ratios recorded were plotted with the smile scores to determine
whether or not a correlation existed. Since the researcher was interested in the
absolute difference of the smile ratio of each smile from 1.0 or perfect harmony,
Volume 57 Lip-teeth relationships in smile 139
Number 2

the ratios were recorded as the absolute difference from 1.0 and replotted. As
the smile scores were not normally distributed, a coefficient of correlation would
be invalid, so a chi-square test was used. A significant difference at the 0.05 level
was found to exist between the smile scores with a smile line ratio of 1.00 to 1.25,
which would be at or near perfect harmony, and the smile scores with a larger
smile ratio. It may be concluded that, when the smile scores increased, it was
generally seen that the smile line ratios became closer to 1.00 or perfect har-
mony between the arcs of curvature of the lower lip and the incisal edges of the
upper incisor teeth.
Observation of the pattern of the scatter plot diagram showed that the buccal
corridor ratio was not related to the smile scores.
’ A scatter plot diagram of the mean smile scores and the smile symmetry
ratios was constructed to determine their relationship. A look at the scatter
plot diagram quickly revealed that no asymmetrical smiles have high mean
smile scores. The smile symmetry ratio stresses the importance of a 1.0 or per-
fect symmetry of each side of the lips with the other in order to have a good
smile.
The effect of the upper lip curvature is expressed in Fig. 2. The group in
which the upper lip curved upward contained the most subjects and the group
with a straight upper lip contained the fewest subjects. Smiles with the upper
lip curving downward were not quite as attractive, according to the mean smile
scores.
The effect of upper lip height is expressed in Fig. 3. It may be noted that
neither the smiles with excessively short upper lips nor those with excessively
long upper lips faired well in the ratings.

26'

+ 0

2.87 4.175 2.73

4.8 4.65 3.65

1.2 3.5 1.3

Fig. 2. Histogram of upper lip curvatures and their occurrences.

140 Hdsey deter. J. Orthodont.
February1970

Five smiles are displayed in Fig. 4: (1) the smile with the highest smile
score; (2) the smile with the lowest smile score; (3) the highest-rated smile
with an upper lip height of +l; (4) the highest-rated smile with an upper lip
height of -1; and (5) the highest-rat.ed smile with a curved-down upper lip.

Discussion

The present study revealed that the mean rated smile scores of the ortho-
dontically treated subjects were significantly poorer than the mean rated smile
scores of the subjects with “normal occlusion.” Other information gained about
the smiles may be broken down into five basic categories: (1) the smile line
ratio, (2) the smile symmetry ratio, (3) the buccal corridor ra6io, (4) the upper
lip height, and (5) the upper lip curvature.
There is a significant difference at t.he 0.05 level between the mean smile
scores of those subjects with a smile line ratio of 1.0 to 1.25 and the mean smile
scores of those subjects with a less harmonious smile ratio. This indicates that
the harmony between the arcs of curvature of the incisal edges of the upper
incisor teeth and the upper border of the lower lip is an important fcaburc
of an attractive smile. The smile line ratio can be altered by the orthodontist in
treatment, as he may move t,he anterior teeth into a position of harmony with
the curvature of the lower lip, and an awareness of this ratio may enable him
to give his patients a more attractive smile.
In this study, none of the subjects with asymmetrical smiles was judged by
the panel members to have a very attractive smile, and none of these asymmetri-
cal smiles and a high mean smile score. The question may arise as to whether or
not ort.hodontic treatment can affect the symmetry of the smile. The orthodontist
aligns the midline of the dentition with the midline of the face. Ilowerer,
aligning the midline of the dentition with the center of the smile might allow
him more precision in his judgment. In sane persons, smile symmetry may be
lacking because of a deficiency of muscular tonus on one side of the face. Rogers”c

15
*cl.
Of
sub- 10
,ects

m Lip Heiqhts

rIledran
score?. 2.27 2.87 3.55 2.90 1.45

high
scores 2.55 3.65 4.80 4.25 3.10

10-M
Score.3 2.00 1.35 1.30 1.30 1.20

Fig. 3. Histogram indicating the number of subjects for each upper lip height.
 Volume 57
Number 2 Lip-teeth reiixtionships ir, smile 141

Pig. 4. Photographs of subjects’ smiles.

142 Hulsey

myofunctional exercises might help the patient to overcome his deficiency and
to restore symmetry to his smile.
The mean smile scores were found to bc completely independent, of the bucd
corridor ratio when a scatter plot diagram was observed. It would appear that
the buccal corridor ratio has little effect upon t,hc attractiveness of the smile.
From this finding, expansion of the dental arches during orthodontic treatment
would not affect the attractiveness of the smile in most cases.
The majority of the subjects had an upper lip height of 0, that is, the upper
lip was at the height of t,he gingiral margin of the upper central incisor. The
median smile scores of the 0 group were considerably better than the median
smile scores of any other group. The -2 and the +2 groups had very low median
smile scores of 2.27 and 1.15, respectively. It. appeared that the height of the LIP-
per lip in relation to the gingiral margin of the upper incisor teeth was an
important factor affecting the judgment of the panel members as to the attrac-
tiveness of the smile. Few research studies have investigat,ctl whether or not
orthodontic treatment can actually change the vertical relationship existing be-
tween the upper lip and the upper incisor teeth. This could be important, for
if orthodontic treatment conlti change the vertical relationship between a short
upper lip and the gingival margin of the upper central incisors to a 0 rating, the
smile would be expected to be more attractive. On the other hand, if orthodontic
treatment could change the relationship cxist,ing between the long upper lip
and the upper incisor teeth, a more esthetic smile would be the result. Further
investigation of these arcas would seem of value.
The upper lip curvatnrc was found to be upward in twenty-six of the forty
subjects in the study. Only four subjects had a straight upper lip, whereas in ten
subjects the upper lip curved downward. The median smile scores of the down-
ward-curving upper lips were lower than the others. Little is known as to whether
or not the upper lip curvature is subject to alteration b’y orthodontic therapy
at the present time. It appears that good smiles can be found with either a
curved-up upper lip, a straight upper lip, or a curved-down upper lip, so this
factor could be considered a constant. In these situations, the orthodontist would
concentrate his efforts on factors which may be within his control.
This study examined some information about t,hc smile and established some
measurable components from which further evaluation may be continued. It re-
vealed that the smiles of orthodontically treated subjects were not as attractive
to the panel as the smiles of persons wih “normal occlusion.”
Preorthodontic and postorthodontic subjects were not compared in the study.
However, postorthodontic smiles might represent a dramatic improvement when
compared with preorthodontic smiles. This study suggested that positioning
the anterior teeth in harmony with the upper border of the lower lip and careful
attention t.o the midline relationships which exist between the denture and the
surrounding soft tissue may enable the orthodontist to give his patients a more
attractive smile.
Summary

This study was initiated in an attempt to obtain some information about two
questions: (I) Are the smiles of orthodontically treated patients as attractive
Volume 57 Lip-teeth relationships in smile 143
Number 2

as those of persons with “normal occlusion”? (2) What relationship between the
lips and teeth, if any exists, should the orthodontist consider in positioning the
anterior teeth during orthodontic treatment?
Forty subjects, twenty with orthodontically treated occlusions and twenty
with “normal occlusions,” were evaluated. There were ten male and ten female
subjects in each group. Standardized black and white photographs of their
smiles, with the areas surrounding the smiles masked out, were evaluated by
a panel of ten men and ten women. No photographs of the smiles of patients prior
to orthodontic t,herapy were used.
Five basic components of each smile were studied: (1) the smile line ratio,
that is, the congruency of the arc of curvature of the upper border of the lower
lip and the arc of curvature of the incisal edges of the upper anterior teeth;
(2) the smile symmetry ratio, whether or not the lips on each side of the smile
midline were symmetrical with each other; (3) the buccal corridor ratio, the
ratio of the width between the canine teeth to the width of the smile; (4) the
height of the upper lip, determined by the relationship of the upper lip to the
gingival margin of the upper centra.1 incisor; and (5) the curvature of the upper
lip, whether or not the corners of the smile were above, even with, or below the
midline of the upper lip.
The following observations were made:
1. As a result of the panel members’ evaluations, orthodontically treated
subjects had significantly poorer smile scores than the subjects with “normal
occlusion.”
2. The smile line ratio appeared to be of importance to an attractive smile,
and the most attractive smile displayed a smile line ratio of 1.00 to 1.25 or near
perfect harmony between the ares of curvature of the incisal edges of the upper
incisors and the upper border of the lower lip.
3. The smile symmetry ratio was revealed in this study to be important to a
good smile, since no smiles that were asymmetrical had high smile scores.
4. The buccal corridor ratio appeared to be of no significance to an attractive
smile.
5. The height of the upper lip to the upper central incisor influenced the
rating of the smile, the most attractive smiles having the upper lip at the height
of the gingival margin of the upper central incisor.
6. In the subjects studied, the upper lip curvature was most desirable when
the corners of the smile were above the midline of the upper lip. However, those
smiles in which the corners of the smile were below the midline of the upper
lip were attractive if they possessed the most desirable relationships of each of
the other components.
Further evaluation of these and other components of the smile should lead
to the development of a “smile index,” so that the orthodontist may be better
able to give the patient an “ideal smile” which would be an expression of the
optimum in facial esthetics for that individual.

REFERENCES
1. Grove, Philip B. (editor) : Webster’s third new international dictionary of the English
language, ed. 14, Springfield, Mass., 3961, G. and C. Merriam Company, Publishers, Vol.
II, p. 2151.
 Amer. J. Orthodont.
144 Hulsey February 1970

2. McKenzie, R. T.: Human facial types-Facial expression, Dental Cosmos 77: 639-650,
1935.
3. Reidel, R. A.: Esthetics and its relation to orthodontic therapy, Angle Orthodontist
20: 168-178, 1950.
4. Stallard, H.: Survival of the periodontium during and after orthodontic treatment, AX.
J. ORTHODONTICS 50: 584-592, 1964.
5. Krajicek, J. a.: Simulation of na.tural appearance, J. Pros. Dent. 12: 28-33, 1962.
6. Frush, J. P., and Fisher, K. D. : How dentogenics interprets the personality factor, J.
Pros. Dent. 6: 441-449, 1965.
7. Frush, J. P., and Fisher, R. D.: The dynesthetic interpretation of the dentogenic con-
cept, J. Pros. Dent. 8: 558-581, 1958.
8. Brodie, A. G.: Anatomy and physiology of head and neck musculature, AX J. ORTHO-
DONTICS 36: 831. 844,1952.
9. Hove& J. H.: Recent advances in orthodontics, Brit. D. J. 98: 114-122, 1955.
10. Ballard, C. F.: A symposium on Class II, Division 1 malocclusion, D. Practitioner 7: 269.
286, 1957.
11. Ware, Rachel: The trapped lower lip, Brit. D. J. 102: 398-403, 1957.
12. Nicol, W. A.: The relationship of the lip line to the incisor teeth, D. Practitioner 5:
12-17, 1955.
13. Jackson, D.: Lip positions and incisor relationships, Brit. D. J. 112: 147.155, 1962.
14. Subtelny, J. D.: The soft tissue profile, growth and treatment changes, Angle Ortho-
dontist 31: 105122, 1961.
15. Ricketts, R. M.: A cephalometric synthesis, BM. J. ORTHOWNTWS 46: 647.673, 1960.
16. Rogers, A. P.: Exercises for development of the muscles of the face with :L view to in-
creasing their functional activity, Dental Cosmos 60: 857-876, 1918.
17. Laeey, 0. L.: Statistical methods in experimentation, ed. 6, New York, 1964, The Mac-
millan Company.
18. McNemar, Quinn: Psychological statistics, ed. 3, New York, 1962, John Wiley & Sons, Inc.