DYNAMIC SMILE VISUALISATION AND QUANTIFICATION

David.M.Sarver ,Mark .B.Ackerman AJO 2003

PART - I
Evolution of the concept and dynamic records of smile capture :
Esthetics mainly defined in terms of profile enhancement Angle 1899 once ideal tooth-jaw positions were achieved , then soft tissues would fall in line.

Recent focus multifactorial nature of smile , combined with a shift towards patient driven esthetic diagnosis and treatment planning

In contemporary orthodontics ,patients are examined in 3 spatial dimensions (static and dynamic ) attempt to harmonise lip tooth jaw relationships (anatomic &physiologic ) and esthetic and functional desires

To treat smile :
1. Identify the positive elements of smile to be maintained or protected during our treatment 2. Visualized treatment strategy to address patients chief concerns

EVALUATE SMILE
3 spatial dimensions in profile frontal - statically & dynamically oblique 2 dynamic factors to be considered: 1. Soft tissue repose and animation 2. Facial changes with aging Disadvantages of cephalometric evaluation : 1. Scammons growth curve 2. Stable dento-skeletal relationships.

RECORDS FOR TREATMENT OF SMILE :

1. STATIC RECORDS :

Photographs frontal rest ,smile - profile rest , smile - oblique smile - smile close-ups (frontal ,oblique)

Radiographs
Study models

Profile -smile

Close-up frontal

Close-up oblique

2. Dynamic records

Digital videography :
records tooth display during speech & smile 30 frames /sec.- in standardized fashion Chelsea eats cheese cake on Chesapeake video clip is taken (5 sec )

---the smile that best represents patients unstrained social smile selected.

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3 smile styles :
1. Commisure smile 2. Cuspid smile 3. Complex smile 3. DIRECT MEASUREMENT AS A BIOMETRIC TOOL Allows quantification of resting & dynamic lip tooth relationships. ADVANTAGES:

1. Information translated to meaningful treatment plan

2. Visualize time related changes & repeatability

STATIC 1. Commisure height 2. Philtrum height 3. Inter labial gap 4. Incisor show at rest DYNAMIC 1. Crown height

2. Gingival display
3. Smile arc 4. Incisor show at smile

PHILTRUM HEIGHT :
sub spinale to vermilion border -relation to max. incisor & commissure height is more important - In adolescence , philtrum height is shorter than commissure height COMMISURE HEIGHT :

Construct line from alar bases thru subspinale & from the commisures perpendicular to this line
GINGIVAL DISPLAY :

Relation with incisor show at rest is important .

It is BETTER to treat gummy smile less aggressively more esthetic than a smile with less tooth display

SMILE ARC :
From frontal view :

curvature of incisal edges of incisors & canines to curvature of lower lip in posed social smile
Ideal smile arc /consonant Flat smile / nonconsonant Reverse smile arc

Case illustration:

Excessive gingival display due to

Short philtrum height

Excessive curtain on smile Short max. incisor crown height Mild vertical max. excess

PART II :
SMILE ANALYSIS AND TREATMENT STRATEGIES

3 dimensions 1. Frontal

2. Oblique
3. Sagittal 4 th dimension TIME

FRONTAL DIMENSION:
Vertical and transverse characteristics Smile index : ACKERMAN AND ACKERMAN

Area framed by vermilion border during social smile

Intercommissure width ----------------------------- at social smile Inter labial gap -enables comparison of smiles

Vertical characteristics of the smile :

1. Incisor display 2. Gingival display 3. Smile arc 4. Relation between gingival margins & u.lip -gingival margins of canines should coincide with upper lip & lateral incisors slightly inferior. -gingival margins should coincide with upper lip in the social smile. - age factor.

Transverse characteristics of smile

1. Arch formuse of broad square arch forms in collapsed arch improves transverse smile dimensions -denture smile -flattening of smile arc

2. Buccal corridorFrom mesial line angle of I p.m. to interior portion of commissure intercommissure width ---------------------------inter premolar width

3. Transverse cant of maxillary occ. plane Differential eruption Skeletal mandibular asymmetry Asymmetric smile curtain Only frontal smile visualization allows visualization of any dental /skeletal asymmetry transversely. Frontal full face /close up smile mandatory.

OBLIQUE DIMENSIONS

Characterizes smile as not obtainable with frontal view / ceph. Analysis

Explains palatal plane cant antero posteriorly Visualize occlusal plane in reln. to lower lip. Smile arc in oblique view: Curvature of max. incisal edges, canines, premolars and molars to the curvature of lower lip on posed smile. Consonant /parallel Nonconsonant /flat

Occlusal cant

Oblique- smile arc

SAGITTAL DIMENSIONS

1.Overjet
In cl.II / cl.III patients , frontal smile appears esthetic. Oblique & sagittal views shows underlying skeletal pattern & dental compensation

SAGITTAL MAXILLARY POSITION influences smile in frontal view ( transverse smile dimensions )

Transverse smile dimension is a function of both arch width and A-P position of max. & mnd. arches

2. INCISOR PROCLINATION: Flaring of incisors decreased incisor show

THE FOURTH DIMENSION TIME 1. Growth 2. Maturation 3. Aging

Preadolescent Adolescent

Adult

Effects of maturation & aging on soft tissues

Profiles flattens over time

Rate of philtrum lengthening is greater than that of commisures

Flattening of M characteristic of vermilion border of upperlip Decrease in turgor Decreased incisor display at rest Decreased gingival display on smile

TREATMENT PLANNING
Identify problems and plan correction

Identify &quantify positive esthetic arrangement

Example :

Consonant smile arc

Treatment strategy : 1. Maintain vertical incisor position 2. Extrude max. canines to level 3. Finish with periodontal crown lengthening

ALTERING SMILE ARC : strategies to be used.

Treating occlusal plane:

1. Preadolescents growth modification appliance

2. Adolescents &adults surgical modification

Bracket placement
Difference in incisal edge-bracket slot distance between max. central and lateral incisors should be 1-1.5mm to preserve / create consonant smile arcs. Cosmetic porcelain laminates /composite bonding Enamel odontoplasty