Lips Gateway to Esthetics

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CONTENT

Introduction

Aim and Purpose

Facial analysis

A) Frontal view

B) Lateral view

LIPS

DENTOLABIAL RELATIONSHIP

SUMMARY

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Introduction: The term esthetic is derived from greek word meaning

esthesia meaning sensibility or capacity for sensation

In contrast to Anesthesia which means loss of sensationor capacity for sensation.

Esthetic is an adjective term which denotes a pleasantsensation .

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Lips are components of macroesthetic elements ofsmile design.

The location and shape of smile line , the extend ofexposure of facial surfaces of upper teeth and gingiva ,buccal corridor and outline form of vermillion border oflips are some of the factors which contributes to

pleasant smile.

A disharmony can be injurious to the attractiveness ofsmile

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AIM & OBJECTIVE Draw the functional inter-relationship existing between the lips

& teeth.

PURPOSE OF PRESENTATION :

To highlight measurable components in evaluation of the smile.

To highlight relationship of peri-oral soft tissue & teeth to

attractive smile.

To lay diagnostic parameters for prosthodontist in planningtreatment procedure

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FACIAL ANALYSIS

The facial features have an important influence on the

perception of an individuals personality.

Analysis of these features is made using horizontaland vertical reference lines, to determine the size and

proportion of face from chin to hairline and also therelationship of the patients face and dentition inspace.

Facial analysis is checked at conversational distance 7


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FRONTAL VIEW

The first horizontal line from the top is the Ophriacline , the second horizontal line below it is theInterpupillary line, the third horizontal line is theCommissure line.

A vertical line

is the facial midline and is

Identified as straight or

Curved( right or left)

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This horizontal reference line should normally beparallel to the incisal and occlusal plane of the patientsteeth

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SYMMETRY AND DIVERSITY In most subjects in whom asymmetry is found, the

dimensional difference between the left and the rightsides of the face is less than 3%

Original appearance Mirrored image against left (a) and Right (b) side

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HORIZONTAL DISHARMONY

In cases where interpupillary line and thecommissural line are not alligned parallel to horizontalplane, the horizon is taken as the ideal referenceplane.

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In an asymmetrical smile with large differentialelevation of upper lip may be due to a deficiency ofmuscular tonus on one side of the face.

Myofunctional excercises have been recommended tohelp overcome this deficiency and restore smile

symmetry

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FACIAL PROPORTIONS

The face is divided horizontally into three portions

.

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The lower third of the face represents the areathat receives the most attention, since it isdominated by the presence of lips and teeth

The distance from bottom of the nose to the lower

edge of upper lip therefore should be approximatelyhalf the length between the lower lip and thebottom of the chin. Ideal ratio 33:66

The lower third of the face plays a significant rolein determining the overall esthetic appearance

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This third portion is slightly wider than the upper twoportions in a youthful patient with no occlusal wearand normal vertical dimension.

However this portion may eventually shrink with ageand severe wear

Divided into 1)within normal limits 2) excessive lover facial height

3)deficient lower facial height

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PROSTHETIC CONSIDERATIONS

AND APPLICATIONS

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Convex profile Concave profile

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E-LINE or RickettsE-plane

In normal profile , the upper lip is about 4mm andthe lower lip is about 2mm posterior to the E-Line.

The lip position considered to be normal is one that

lies posterior to the E-Line

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NASOLABIAL ANGLE The size of this angle is affected by inclination of

base of the nose and by the position of the upperlip.

Nasolabial angles in females- 100-105degrees

In males 90-95degrees

In convex profile


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AND APPLICATIONS

Nasolabial angles , E-Lines can change significantlyfollowing restorative-prosthetic treatment

Care must be taken not to make changes to thedental position that would interfere with themuscular areas composed of tongue ( internally) and

lips and cheeks (externally)

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LIPS

The upper and lower lips meet laterally at the labial

commissure.

The contour of lips identifies the limit within whichthe prosthetic rehabilitation must be finalized and

helps to arrange the correct dental position

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SHAPE OF LIPSStraight lips Convex lips

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Concave lips

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Enclosed between the upper and lower vermilionborders of lip during the smile is the Smile space/Smile zonewhich contains the dental arches with its

various smile lines, buccal corridor and the interincisal and inter occlusal dark spaces.

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SMILE ZONE

The inferior border of the upper lip & the superior borderof the lower lip forms an outline of the space that is

revealed while smiling & is called smile zone.

There are six basic smile-zone shape:

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The maxillary incisors should fill 75% to100% ofthis space to create youthful look

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SIZE OF THE LIPS

Thick and narrow lips: associated with extroversion

Medium and average lips:

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LABIAL PHILTRUM The labial philtrum measurement , as a rule 2-3mm

shorter than the height of labial commissure, which isalso measured from base of the nose .

PROSTHETIC APPLICATION:

In young subjects, labial philtrum is much shorter,this means that the maxillary incisors are much morevisible in young people.

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MORPHOLOGIC CHANGES A patients profile inevitably varies throughout the

course of his or her life including lips which aresubjected to inevitable flattening process with age.

Prosthetic application:

This is generally the reason why a wish for moreprominent lips, regardless of physiologic aging

Especially in females, a certain prominence of upperlip compared to lower lip nowadays is consideredparticularly attractive

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Upper and lower lips with full volume

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Upper and lower thin lips

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Dentolabial Analysis : 1) Tooth-Lower lip position

2)Lip line

3)Midline- Relationship of central incisors to philtrum 4)Midline-canting to right or left

5)Teeth exposure during physiologic rest position

6)Smile line(maxillary incisal edge relation to superior

border of lower lip)7) Number of teeth exposed in a full smile

8) Buccal corridor

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DENTOLABIAL ANALYSIS-LIPMOVEMENT

The lips should move consistently in a horizontal plane

and therefore be parallel to the interpupillary line During smiling ,maxillary teeth may be more visible

while in many phases of speech mandibular teeth maybe more exposed.

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Stages of smile: Smile is a generalized term , it requires to be specified in

order to understand its features.

STAGE 1 :Pre smile-lip posture: Lips are in rest position,vermillion border of upper and lower lip in passive contact.

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STAGE 2:Silent smile( closed mouth smile): Initiationof smile reflex, lips are still in apposition, teethare not visible. The muscles of facial expressions

begin to contract . This changes the shape of lip seal.

Eg. As in formal meeting someone

STAGE 3 : Open smile( passive smile): lips slightlyparted, slight labial surface of anterior teethexposed.

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STAGE 4: Active smile: Lipsexpose teeth,gingiva and mucosaof varying extend.Smile foldsappear on both sides at the angleof mouth to compliment smile

STAGE 5: Laughter:Lipexpose teeth,gingiva,labialand buccal mucosa to a muchgreater extend,intense smilelines , smile folds appear incheek around the corner ofmouth.

Esthetic considerations of smile- DR. E.G.R Solomon 42


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It is important to differentiate between a posed and aspontaneous smile-

A Posed smile-is voluntary , static , reproducible and neednot elicited or accompanied by emotions

A spontaneous smile- is involuntary, induced by joy ormirth, dynamic but not sustained

A spontaneous smile results in more lip elevation

Since a posed is fairly reproducible , rehearsed can therefore beused as a reference position .

The importance of incisal positioning in the esthetic smile: the smile arc

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AND APPLICATIONS Many subjects limit the width of their smile to hide

incongruous restorations, discolored teeth etc.

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TOOTH EXPOSURE AT REST

Exposure of maxillary teeth varies from 1-5mm,depending on the height of the lips and the patientsage and sex

On average maxillary incisors are exposed 1) more inwomen 2) much more in young patients than middleaged.

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PROSTHETIC CONSIDERATION

A determination of what portion of the maxillaryincisors is visible with the lips at rest constitutes oneof the key parameters for evaluating whether anyalternation to tooth length is needed.

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In the smiles of young subjects with normal occlusion,those displaying the first molars are consideredesthetically pleasing.

Goldstein describes the youthful smile in which thefront teeth are longer and create a line that comes alittle down in the middle of the smile, travellingsuperiorly to the corners.

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By standardizing maximum and minimum lipparameters based on muscular and phonetic positions,one can quantify esthetic ratios and relationships oftooth reveal

M POSITION- by having the patient say the letter Mrepetitively and then allow lip to part gently, one canassess minimum tooth reveal

E POSITION-when patients says the letter E in

uninhibited and exaggerated way, one can ascertainthe maximum extension of lips- cheese

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To create a harmonious smile, incisal margins in allcases should maintain parallel alignment with the lowerlip( if the commissure line is parallel to the horizontalline)

Contacting lips

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Non-contacting lips

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Covering lips

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For an attractive smile, contact should preferably bepresent between the incisal edges of upper teeth andvermilion border of lower lip

Absence of parallelism of between smile line and lowerlip together with no contact of incisal edges withlower lips creates a negative space , an undesirablefeature as it distracts the obeserversattention.

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Smile line/Smile arc- Incisal Curve and Lower

Lip The smile arc is defined as the relationship of the

incisal edges of maxillary incisors and canines to thecurvature of lower lip in the posed smile.

Females shows more curvature of smile line incomparision to men

after orientation of the smile line, one can design its

curve or shape

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Convex incisal curve: The incisal plane when

observed from the front , has a convex curvethat follows the natural concavity of lower lipduring smiling.

Class 1 patients slightly evident

Class 3 patients flatten out considerably

Class 2 patients noticeably convex

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RADIATING SMILE The convexity of incisal curvature with ideal tooth

proportions produces a radiating symmetry.

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HORIZONTAL SYMMETRY

An inevitable sense of aged smile.

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The lightness of the smile, governed by the progression ofthe interincisal angles , is reinforced by the parallelismfound between the lines that joins all the anteriorinterdental points of contact, the incisal curvature , and

that of the lower lip.

Convex smile line accentuates the quality of smile andtherefore it is a positive smile line.

A convex smile line and parallelism of smile line to lower lipare two desirable qualities of smile which gives pleasantnessto smile.

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Concave smile line gives an unpleasant , harsh,distracted character to smile and therefore it is a

negative smile line.

Straight smile line can have a positive or negative

effect depending on its harmony with lip curvatureand to the presence or absence of buccal corridor

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The curvature of lower lip is not always homogeneous.

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Prosthetic considerations- ifteeth are inclined too farforward.

1)feeling of excessive toothlength

2)closing of lips moredifficult

3)upper lip to prominent andsometimes can alter actualmorphology of lower lip


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LIP LINE The lip line is the amount of vertical tooth exoposure in

smiling

The first step in this analysis is to evaluate the exposure

of anterior teeth during smiling with an maxillary incisaldisplay in males 1.91mm in men and nearly twice in females3.40mm

Tjan and coworkers identified three types of smile lines :

low , average, and high. Female lip lines are an average 1.5mm higher than male lip

lines with more gingival exposure

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AVERAGE LIP LINE:

Labial movement reveals 75% to 100% of anteriorteeth as well as interproximal papillae.

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A pleasing smile( optimal lip line) can be defined as onethat exposes the entire cervicoincisal length ofmaxillary teeth completely , along with approximately

with the interproximal gingivae.

Gingival exposure that does not exceed 2 to3 mm isconsidered esthetic

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HIGH LIP LINE

Complete exposure of anterior teeth , a gingival bandof varying height is also exposed.

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Gingival and mucosal smile imparts attractiveness tosmile.

Failure to expose the upper anterior teeth gives anegative smile, which lacks expression

Exposure of only the upper anterior teeth produces astatic smile

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When the upper anterior teeth interdental papilla andcertain extend of gingiva and mucosa are exposed , adynamic , pleasant and attractive smile is produced.

In an attractive smile, gingiva and mucosa of posteriorteeth are exposed to compliment the anterior gingivamucosa exposure- a common noticeable feature in abeautiful smile.

Esthetic consideration of smile: Dr. E.G.R Solomon

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GUMMY SMILEA gummy smile is characterized by gingival exposure inexcess of 3-4 mm.

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AND APPLICATIONS Among the various treatment options that can be

considered with the patient, the orthognathic andorthodontic treatments are often especially suitable

particularly when healthy teeth are involved.

If patient requires prosthetic rehabilitation, therestorative therapy often will have to be combined

with orthodontic or surgical crown lengtheningprocedures, with dual aims of re-establishing idealtooth length and reducing amount of visible gingiva.

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If a gingival smile is caused by a hypermobile lip, it would bemistake to correct it with aggressive incisal intrusion or

maxillary impaction surgery , because that would result inminimal or no incisal display at rest and thus make patientlook older. Excessive lip elevation should be thereforerecognized as a limiting factor

If a low lip line is due to hypomobile lip, extensive extrusionor cosmetic lengthening of tooth would result in anoverbite with excessive incisal display at rest.

Eight components of balanced smile-Roy Sabri Journal of clinical orthodonticsmarch2005 vol.3

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When upper lip length and mobility are normal, agingival smile with excessive incisal display at rest can beattributed to vertical maxillary excess associated withusually with excessive lower facial height conversely a lowlip line with no incisal display at rest is skeletal whenassociated with inadequate lower facial height due tovertically deficient maxilla

The best reference for impacting or lengthening the

maxilla is the incisal display at rest, taking upper liplength and any incisal attrition in account.

Eight components of balanced smile-Roy Sabri Journal of clinical orthodontics

march2005 vol.3 78


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Gingiva and Upper lip curvature: The gingival contours should be symmetric and the marginal gingival

tissues of maxillary anterior teeth should be located along thehorizontal line extending from canine to canine.

Ideally, the lateral incisors reach slightly short of that line

The gingival zenith point is located

distal to the long axis of maxillary

Central and cuspids, along the longaxis of lateral incisor

Smile design-DCNA 51(2007) ,Nicholas C. Davis79


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SMILE WIDTH Lip movement when smiling generally exposes the

anterior teeth, along with the premolars and in many

cases, the maxillary first molars as well.

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In the posterior segments, uprighting the posterior teethand slight uprighting of cuspids , the smile can be made

to appear wider that more completely fills the buccalcorridor

This inclines should not exceed a perfectly verticalorientation

This makes the teeth appear bigger , producing morereflective surfaces for a broader smile, which is in high

demand today

Smile design-DCNA 51(2007) ,Nicholas C. Davis

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In a broad smile amount of reveal of the maxillaryposterior teeth also becomes an estheticconsiderations

In patients who have narrow arch form and wide lipextensions, tooth reveal behind the canine can bein shadow or disappear completely . This conditionhas been called Deficient Vestibular Reveal and mayhave negative esthetic influence in some patients.

JADA, Vol. 132, january 2001-macroesthetic elements of smile design

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PRO THETIC CON IDER TION


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PROSTHETIC CONSIDERATIONSAND APPLICATIONS If the patient exposes gingival margins of maxillary

molars when smiling, exposure of metal margin will beunattractive and disagreeable to the patient.

In these cases, differentiated tooth preparation ofbuccal margin can be performed, involving a greatertooth reduction (shoulder, chamfer).

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AND APPLICATIONS Positioning prosthetic restorations too buccally in

posterior areas can fill whole of labial corridor,altering natural and harmonious progression of the

smile. Clinician should carefully evaluate width of corridor,

varying, if necessary, the axial inclinations of toothpreparations. This ensures enough space to create

restorations with appropriate contour.

Patients with narrow arches and wider smile havebroader buccal corridor area

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Buccal corridor is a positive component which givesdynamism and enhances the character of smile

When the smile line changes from convex or straight to aconcave smile line, there is reduction in size of buccal

corridor. Pronounced buccal corridor is invariably seen when there is

convex or straight smile line.

Gingival and mucosal smile with large buccal corridor isesthetic


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From a frontal view,


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F m f ,

Axial inclination of the anterior teeth tends to incline mesiallytoward the midline and become more pronounced from the central

incisors to the canines.

This inclination is least noticeable with the centrals and becomesmore pronounced with the laterals and even more so with thecanines.

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The axial inclination of the posterior teeth fromthe frontal view exhibits the same mesialinclination toward the midline as the cuspid.

There is a direct relationship between the

pleasing effect that these smiles can generate andthe equilibrium in the balance of lines of toothinclination.


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INTERINCISALLINE

Reference : maxillaryinter-incisal line.

MIDLINE

Reference : center ofupper lip or labialphiltrum.

A variation between facial and dental midline that islimited to within 4mm is not noticeable either to

patients or to general dental practitioners.

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AND APPLICATIONS Incorrect axial inclination can be immediately

recognized by any observer as an unesthetic featureand is less pleasing than a lateral alteration of

maxillary interincisal line in relation to facial midline.

Optimizing axial inclination to re-establish verticalalignment of dental midline is mandatory in

restorative prosthetic treatment, even though thisaction can involve further mediolateral alteration ofmaxillary interincisal line with respect to facialmidline.

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Canting ( a dental midline that is not parallel to facialmidline) has been shown to be even more discernableto patients and is considered more of a handicap than

dental midline that are not coincidental but are atleastparallel

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OCCLUSAL PLANE vs

COMMISSURAL LINE Occlusal plane is established by joining the incisal

surfaces of anterior teeth with occlusal surfaces of

posterior teeth.

The incisal plane is anterior portion of occlusal plane.When viewed from the front, it should be parallel to

horizontal reference lines, such as interpupillary lineand commissural line, to maintain a natural facialharmony.

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AND APPLICATIONS A slight deviation from horizontal plane is considered

acceptable and does not necessarily requirecorrection.

A marked lack of parallelism between occlusal plane,

the commissural line and interpupillary line needs amultidisciplinary treatment.

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Conclusion:The following points are important in harmonizingsmile:

Esthetic restorations that show the entirecervicoincisal length of maxillary anterior teeth withonly the inter dental papilla

Smile line should be parallel with lower lip curvature

Maxillary first molars should be considered as a part of

esthetic zone

Dental midline should coincide with facial midline orthey should be parallel to avoid canting

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References : Esthetic analysis: Mauro Fradeani

Tmj to smile design : Dawson


JADA, Vol. 132, january 2001-macroesthetic elements ofsmile design

Smile design-DCNA 51(2007) ,Nicholas C. Davis Eight components of balanced smile-Roy Sabri Journal of

clinical orthodontics march2005 vol.3

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