Professional Documents
Culture Documents
Guilherme Jansona; Nuria Castello Brancob; Thais Maria Freire Fernandesb; Renata Sathlerb;
Daniela Garibc; Jose Roberto Pereira Laurisd
ABSTRACT
Objective: To assess the scientific evidence of the influence of some variables on smile
attractiveness: orthodontic treatment, midline position, axial midline angulation, buccal corridor,
and smile arc.
Materials and Methods: Literature was searched through PubMed, Web of Science, Embase, and
All EBM Reviews. The inclusion criteria consisted of studies written in English; published in the
past three decades; concerning the influence of orthodontic treatment, midline position, axial
midline angulation, buccal corridor, and smile arc on smile esthetics; and judged by a minimum of
10 raters. Quality features evaluated were adequate description of samples, absence of
confounding factors, and description of methods used to evaluate the smiles and statistical
analyses.
Results: Initially, 203 articles were retrieved. Of these, 20 abstracts met the initial inclusion criteria
and were selected. Thirteen articles were classified as high quality, seven as average, and none as
low quality.
Conclusion: Four-premolar extraction or nonextraction treatment protocols seem to have no
predictable effect on overall smile esthetics, meaning that if well indicated, extraction in
orthodontics does not necessarily have a deleterious effect on facial esthetics. The selected
articles recommend that a small dental midline deviation of 2.2 mm can be considered acceptable
by both orthodontists and laypeople, whereas an axial midline angulation of 10u (2 mm measured
from the midline papilla and the incisal edges of the incisors) is already very apparent, and
considering studies dealing with real smiles, buccal corridor sizes and smile arc alone do not seem
to affect smile attractiveness. (Angle Orthod. 2011;81:153161.)
KEY WORDS: Orthodontics; Esthetics
a
Professor and Head, Department of Orthodontics, Bauru
Dental School, University of Sao Paulo, Brazil.
b
Orthodontic Graduate Student, Department of Orthodontics,
Bauru Dental School, University of Sao Paulo, Brazil.
c
Assistant Professor, Department of Orthodontics, Bauru
Dental School, University of Sao Paulo, Brazil.
d
Associate Professor, Department of Community Health,
Bauru Dental School, University of Sao Paulo, Brazil.
Corresponding author: Dr Guilherme Janson, Department of
Orthodontics, Bauru Dental School, University of Sao Paulo,
Alameda Octavio Pinheiro Brisolla 9-75 Bauru-SP-17012-901,
Brazil
(e-mail: jansong@travelnet.com.br)
INTRODUCTION
For a long time, orthodontic treatment was primarily
based on occlusal relationship results.1 Currently,
modern orthodontics also requires a harmonious
balance between soft tissues and occlusion. The
influence of smile attractiveness components is important because it allows the professional to identify
the hierarchy of esthetic preference.2 Therefore,
knowledge of the influence of orthodontic treatment
on smile attractiveness is very important, and recently,
some smile components such as midline position, axial
midline angulation, buccal corridor, and smile arc have
received greater attention.120
DOI: 10.2319/040710-195.1
153
154
155
Table 1. Search Terms and Number of Articles Processed in Each Selection Phase
Key Words
Results
Selected
% of Total Selected
Abstracts
168
16
80
59
45
63
40
10
Database
PubMed
Web of Science
Embase
Hand search
Total
a
203
100a
21
Year of
Publication
2009
2009
2008
2008
2008
2008
2007
2007
2007
2006
2006
2006
2005
2005
2003
2003
1999
1999
1998
1995
Orthodontic
Treatment
Midline
Position
Axial Midline
Angulation
Buccal
Corridor
Smile
Arc
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
156
Year of
Publication
Subjects
Ioi et al.15
2009
Rodrigues et al.11
2009
Gul-e-Erum and
Fida4
2008
McNamara et al.17
2008
Shyagali et al.12
2008
Ker et al.7
2008
Martin et al.16
2007
Parekh et al.2
2007
Pinho et al.10
2007
Gracco et al.14
2006
Isiksal et al.1
2006
Parekh et al.19
2006
Moore et al.18
2005
Roden-Johnson
et al.20
2005
Occlusion/Smile Description
6 BC variations: extra broad (0% BC),
broad (5% BCs), medium broad
(10% BCs), medium (15% BCs),
medium narrow (20% BCs), and
narrow (25% BCs)
Ideal control smile, dental midline
deviation of 3 mm in relation to the
patients philtrum; reverse smile arc
BCs: narrow, medium narrow, medium,
medium broad, and broad; SA:
consonant, nonconsonant, and flat
smile; midline: dental to facial midline
deviation 2 mm right and left, 1 mm
right and left, and no deviation; axial
midline angulation: no angle, 2.5u
right and left, 5u right and left
No significant skeletal asymmetry or
anterior or posterior crossbite; no
known missing or malformed teeth
causing a tooth size discrepancy; and
visible erupting or erupted maxillary
permanent canines and first premolars
No deviation, maxillary dental midline
deviation of 2 and 4 mm either to
the right or left
BC variations: range of values
019 mm; SA: at maxillary canine
04 mm and at maxillary second
molar 010 mm; midline: maxillary
midline to face 04.4 mm and
maxillary to mandibular midline
02.9 mm
Smiles that filled 84%, 88%, 92%, 96%,
and 100% of the oral aperture; PM2PM2 that filled 84%, 88%, 92%, and
96% of the oral aperture; smiles with
asymmetrical BCs that filled 88%, 90%,
94%, and 96% of the oral aperture
3 BC variations (none, ideal, excessive)
combined with 3 SA variations (flat,
ideal, excessive)
No deviation, maxillary dental midline
deviation of 1, 2, 3 and 4 mm
Minimal, moderate, and evident BCs
Evaluated Area
Mouth area
Mouth area/face
Face
Mouth area
Mouth area
Mouth area
Mouth area
Mouth area
Lower third
Mouth area
Face
Mouth area
157
Table 3. Continued
Article
Year of
Publication
Subjects
Occlusion/Smile Description
Evaluated Area
Mouth area
Face
2003
Thomas et al.13
2003
Johnston et al.6
1999
Kokich et al.9
1999
Beyer and
Lindauer3
1998
Johnson and
Smith5
1995
Face
Mouth area
Face
Mouth area
158
Year of
Publication
Type of Raters
Ioi et al.15
2009
Rodrigues et al.11
2009
Laypeople (20)
Gul-e-Erum and
Fida4
2008
McNamara et al.17
2008
Shyagali et al.12
2008
Ker et al.7
2008
Laypeople (243)
Martin et al.16
2007
Parekh et al.2
2007
Pinho et al.10
2007
Gracco et al.14
2006
Isiksal et al.1
2006
Parekh et al.19
2006
Moore et al.18
2005
Laypeople (30)
Roden-Johnson
et al.20
Kim and Gianelly8
2005
2003
Authors Conclusion
Both the orthodontists and dental students
preferred broader smiles to medium or
narrow smiles.
Variations from beauty norms of a smile do not
necessarily result in reduced attractiveness.
A broad and a flat smile in the male are
preferred; a medium-broad and a flat/
consonant smile in the female are preferred;
midline deviation was considered
unattractive in the male subjects by only
orthodontic residents, while in the female
subjects, it was considered unattractive by all
groups, except operative residents; all
groups perceived axial incisal angulation as
unesthetic at a 5u change.
No correlation was found between the size or
ratio value of the buccal corridors distal to the
most posterior teeth visible on smile. No
correlation was found between smile arc and
smile esthetics.
Discrepancies of 2 mm or more are likely to be
noticed by both orthodontic and laypeople.
The ideal buccal corridor size was 16%, and the
acceptability range was 8% to 22%; raters
preferred a consonant smile but accepted a
smile with minimal curvature as well;
maxillary to mandibular midline deviation was
acceptable until it exceeded 2.1 mm, and
one-third of the respondents accepted the
maxillary to face maximal deviation of
2.9 mm.
Large BCs are considered less attractive than
those with small BCs.
Large BCs and flat smile arcs are rated as less
acceptable.
Midline shifts were perceived at 1 mm by
orthodontists and 3 mm by prosthodontists;
laypersons did not notice midline shifts.
A minimal buccal corridor was considered more
attractive.
Treatment modality alone has no predictable
effect on the overall esthetic assessment of a
smile; a transverse characteristics of the
smile appeared to be of little significance to
an attractive smile.
Large BCs and flat smile arcs are considered
less attractive.
Large BCs are considered less attractive than
those with small BCs.
BCs does not influence smile esthetics.
There is no predictable relationship between
extraction and nonextraction treatment and
the esthetics of the smile.
159
Table 4. Continued
Article
Year of
Publication
Type of Raters
Authors Conclusion
Thomas et al.13
2003
Johnston et al.6
1999
Kokich et al.9
1999
1998
1995
Sample
Description
Confounding Factors
Considered
15
Ioi et al.
Rodrigues et al.11
Gul-e-Erum and Fida4
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
McNamara et al.17
Shyagali et al.12
Ker et al.7
Martin et al.16
Parekh et al.2
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Pinho et al.10
Gracco et al.14
Isiksal et al.1
Parekh et al.19
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Moore et al.18
Roden-Johnson et al.20
Kim e Gianelly8
Thomas et al. 13
Johnston et al.6
Kokich et al.9
Beyer and Lindauer3
Johnson and Smith5
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Validity Method
Statistical Analysis
Inadequate (BCs)
Adequate (SA, ML)
Inadequate (BCs)
Adequate (SA; ML; AMLA)
Adequate (BCs, SA)
Adequate (ML)
Adequate (BCs, SA; ML)
Inadequate (BCs)
Inadequate (BCs)
Inadequate (SA)
Adequate (ML)
Adequate (BCs)
Adequate (OT)
Inadequate (BCs)
Inadequate (SA)
Inadequate (BCs)
Adequate (BCs)
Adequate (OT)
Adequate (AMLA)
Adequate (ML)
Adequate (ML, AMLA)
Adequate (ML)
Adequate (OT)
Adequate
Adequate
Inadequate
Adequate
Inadequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
Adequate
SA indicates smile arc; BC, buccal corridor; ML, midline; OT, orthodontic treatment; AMLA, axial midline angulation.
Angle Orthodontist, Vol 81, No 1, 2011
160
all articles, the smile arc interfered in smile esthetics.2,4,7,19 When natural smiles were on trial, results
showed that the smile arc did not interfere in smile
attractiveness.17 The tendency was to favor those
articles that dealt with actual subjects and accept their
conclusion that the smile arc alone is not able to
influence the smile esthetics.
Finally, smile attractiveness is a set of features that
must be considered in orthodontic treatment planning
with the understanding that every aspect of the set is
important in the final score of smile beauty.
CONCLUSIONS
N Nonextraction and four-premolar extraction treatment protocols seem to have no predictable effect
on the overall esthetic assessment of the smile. This
means that the simple fact of extracting teeth or not
does not necessarily have a detrimental facial
esthetic effect.
N A limit of 2.2 mm can be considered acceptable for
midline deviation. Concerning the axial midline
angulation, 10u (2 mm measured from the midline
papilla and the incisal edges of the incisors) is
already very apparent.
N Based on studies with actual subjects, neither buccal
corridor sizes nor smile arc alone seem to affect
smile attractiveness.
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