BDJOpen www.nature.

com/bdjopen

ARTICLE OPEN

Analysis of different characteristics of smile

1 2
Mehwish Khan , Syed Murtaza Raza Kazmi , Farhan Raza Khan2 and Imran Samejo1

INTRODUCTION: Analysis of smile is imperative in the diagnosis and treatment planning phases of aesthetic dentistry.
AIM: To evaluate the components of smile among students of a dental institution.
METHODS: Frontal view digital photographs with posed smile of 157 dental students were assessed using Adobe Photoshop7.0.
Smile characteristics evaluated included; smile line, smile arc, smile design, upper lip curvature, labiodental relationship and
number of teeth displayed. Data were analyzed using SPSS version 23.0. Pearson chi-square test was used to determine the gender
based differences for various parameters.
RESULTS: Average smile line (43.3%), consonant smile arcs (45.2%), cuspid smiles (45.9%), upward lip curvature (43.9%), maxillary
anterior teeth not covered by lower lip (60.5%) and teeth displayed up to first premolars (35.7%). Gender based differences were
not statistically significant except for smile arc (p value = 0.02) and number of teeth displayed (p value < 0.001). There was a
significant relationship between lip curvature and smile pattern (p value < 0.001) and lip curvature and smile arc (p value = 0.01)
revealing that upward lip curvature was associated with commissure type smiles and consonant smile arcs.
CONCLUSIONS: The smile characteristics should be considered before beginning the aesthetic treatment of the patient to obtain
adequate results in oral rehabilitation.
1234567890();,:

BDJ Open (2020)6:6 ; https://doi.org/10.1038/s41405-020-0032-x

INTRODUCTION private-sector dental institution, which can further be applied as a

Dento-facial aesthetics has an important role in dental practice of guide in the fabrication of anterior aesthetic restorations.
the contemporary era, reflected by increasing demands for more
cosmetic and aesthetic procedures by the patients.1,2 The
perception of beauty varies according to individual preferences MATERIALS AND METHODS
and influenced by the ethnic or cultural background.2 In order to This cross-sectional study was conducted from December 2017 to
achieve an optimum aesthetic result in oral rehabilitation, the May 2018 at a private dental institute in Karachi, Pakistan. The
crucial steps involving proper pretreatment workup, diagnosis and study was approved by the Institutional review board (AUG-2017-
treatment planning cannot be overlooked.3 PRT05) and written informed consent was obtained from the
Smile is a facial expression that usually indicates pleasure, participants. Sample size was calculated using WHO calculator
friendliness and gratitude.2 Analysis of smile is imperative in the “Sample size determination in health studies”. A convenience
diagnosis and treatment planning phases of prosthodontics and consecutive sampling technique was employed to select total
aesthetic dentistry. According to neurological control, smile can 170 subjects (76 males and 94 females) for the study. Of these 170,
broadly be divided into involuntary (spontaneous) and voluntary four did not give consent to participate in the study and nine were
(posed) smile. An involuntary smile is related to emotion, whereas excluded on account of history of orthodontic treatment. Final
the posed (social) smile is intentional and usually not related with sample size comprised of 157 (67 males and 90 females) dental
emotion.4–6 There are a number of parameters that constitute the students who had healthy natural dentition without any signs of
natural smile of an individual. These include smile line, smile arc, active caries in anterior teeth. In addition to history of orthodontic
smile design, upper lip curvature, labiodental relationship, teeth treatment, subjects with congenital defects, facial asymmetry,
display, buccal corridor, and position of incisal edge. In maxillofacial trauma, crowding, or severe tooth wear were also
addition, dental-facial midline, symmetry, gingival display and excluded.
gingival zenith position also play an important role in the Standardised posed smile photographs were taken of 157 sub-
aesthetic appraisal of smile. All these factors must be taken into jects seated in natural head position using a Nikon camera (D5300
account while designing a smile makeover. Furthermore, the with 105-mm lens (ISO 500, f 1/5.6, exposure time 1/200), fixed in
norms for these smile characteristics may differ in different position with a tripod. Each image was assessed using Adobe
populations thus the ethnicity should also be taken into account Photoshop version 7.0.
as a variable. Following characteristics of smile were evaluated:
Although, there are abundant data regarding the factors
contributing to the smile in the western populations but there is ● Smile line or lip line: extent of vertical tooth display in smiling
an insufficient data regarding these aesthetic norms among or elevation of the upper lip in relation to the maxillary
South Asian population. The present study was conducted to incisors.7 Three types have been described, high, average and
evaluate the components of posed smiles in dental students of a low2 (Fig. 1a–c). High smile that shows the maxillary anterior

1
Sindh Institute of Oral Health Sciences, Jinnah Sindh Medical University, Karachi, Pakistan and 2Aga Khan University & Hospital, Karachi, Pakistan
Correspondence: Mehwish Khan ([email protected])

Received: 16 December 2019 Revised: 18 February 2020 Accepted: 25 February 2020

© The Author(s) 2020

 Analysis of different characteristics of smile
M Khan et al.
2

Fig. 1 Basic characteristics of smile. (a) High Smile line, (b) Average Smile line, (c) Low Smile line, (d) Consonant Smile arc, (e) Straight Smile
arc, (f ) Reverse Smile arc, (g) Commissure Smile type, (h) Cuspid Smile type, (i) Complex Smile type.

teeth along with a significant amount of gingiva, average of maxillary anterior teeth (Fig. 2h), “not touching” the teeth
smile showing maxillary anterior teeth with only interproximal (Fig. 2i) or “covering” the anterior teeth (Fig. 2j)2
gingiva, and low smile that shows less than two-third of the ● Number of teeth displayed: Smiles were categorised as
maxillary anterior teeth. displaying teeth up to the canines (Fig. 2a), first premolars
● Smile arc: is the relationship between the curvature of the (Fig. 2b), second premolars (Fig. 2c), or the first molars
maxillary anterior teeth and upper border of the lower lip.6,8,9 (Fig. 2d). A tooth was counted when more than half of its
It was defined in the study by drawing a line along the surface was visible.
maxillary central incisal edges to the cusp tips of maxillary ● In addition, relationship of upper lip curvature with smile arc
canines, which was related to another line drawn across the and different types of smile design was also investigated.
superior border of the lower lip. In subjects whose maxillary
teeth were covered by lower lip, smile arc was designated as Statistical Package of Social Sciences (SPSS) version 23.0 was used
"not available". Three categories described: “parallel to the for data analysis. Frequency distribution of the parameters of smile
teeth” (when the two lines follow the same curvature) also were determined. Pearson Chi-square test was used to determine
called as a consonant smile (Fig. 1d). Whereas, if the two are the gender based differences. Spearman’s correlation coefficient was
not parallel, it is called a non-consonant smile.6 A non- employed to assess the correlation among parameters of smile in
consonant smile can either be “straight” (with flatter curvature the two genders. Level of significance was kept at 0.05.
of the teeth in relation to the lower lip) (Fig. 1e), or “reverse”
(when maxillary teeth form a reverse curve in relation to lower
lip) (Fig. 1f).3 RESULTS
● Smile design or smile type: three basic patterns have been Mean age of males (n = 67) and females (n = 90) were 22.8 ± 1.6
identified.10 The commissure smile (Fig. 1g) is the typical and 22.5 ± 4 years, respectively (Tables 1–3).
pattern that can be imagined as a Cupid bow. In this pattern, Average smile line was frequently observed among the
the maxillary first molars lie few millimetres above the incisal subjects, followed by low smile line. Most common smile type
edges of the central incisors. In the cuspid smile type observed was cuspid, followed by commissure and then complex
(Fig. 1h), the shape of the lips can be demonstrated as a smile type. Upward lip curvature was observed in most individuals
diamond, the rise of the upper lip resembles a window followed by equal distribution of downward and straight lip
shade. In this design, the position of the maxillary molars is curvatures. No statistically significant gender based difference was
inferior to or at the level of the central incisors. In the observed for smile line, smile type, and upper lip curvature. In
complex smile (Fig. 1i), the shape of the lips is visualised as addition, most participants had their maxillary anterior teeth not
two parallel chevrons, displaying all the upper and lower covered by the lower lip during smile without any statistically
teeth. The upper lip moves superiorly with the lower lip significant differences between the genders.
moving inferiorly during smile.10 For smile arcs, consonant smile arcs were more common
● Upper lip curvature; a straight line was drawn through the followed by flat or straight arc. A statistically significant difference
midpoint of the inferior border of the upper lip and its between males and females was observed (p value = 0.02)
relationship with the corners of mouth evaluated.1,11 Three indicating that a consonant smile is common in females and a
categories identified (Fig. 2e-g); upward (the corners of the flat smile in males. Teeth displayed up to first premolars among
mouth lie above the horizontal line), straight (the corners of majority of subjects. With few participants having their first molars
the mouth at or within 1 mm of the line), and downward visible during smile. Statistically significant gender differences
(the corners of the mouth lie below the horizontal line). observed in this group (p value < 0.001) with males having
● Labiodental relationship of the lower lip and maxillary broader smile displaying teeth up to first molars while females
anterior teeth: was identified by evaluating the distance are more likely to display teeth up to first premolars.
between the superior border of the lower lip and inferior Significant association between upper lip curvature and smile
border of the maxillary anterior teeth. The relationship may design was found (p value < 0.001). Commissure smiles were
be divided into lower lip “slightly touching” the lower border associated with the upward lip curvature whereas, straight lip

BDJ Open (2020)6:6

 Analysis of different characteristics of smile
M Khan et al.
3

Fig. 2 Additional characteristics of smile. (a) Teeth displayed up to canine, (b) Teeth displayed up to first premolars, (c) Teeth displayed up to
second premolars, (d) Teeth displayed up to first molars, (e) Upward Upper lip curvature, (f ) Straight Upper lip curvature, (g) Downward Upper
lip curvature, (h) Lower lip slightly touching the maxillary anterior teeth, (i) Not-touching labiodental relationship, (j) Maxillary anterior teeth
covered by lower lip.

Table 1. Smile characteristics of participants (n = 157). Table 3. Assessment of relationship of upper lip curvature with smile
arc and smile type.
Smile parameters Categories Frequency (%)
Upper lip curvature p value
Smile line Low 61 (38.9%)
Average 68 (43.3%) Smile arc Upward Downward Straight 0.01*
High 28 (17.8%) Consonant 36 18 17
Smile arc Consonant 71 (45.2%) Straight 15 22 22
Straight 59 (37.6%) Reverse 06 02 03
Reverse 11 (7.0%) Not available 12 02 02
Not available 16 (10.2%) Smile type Upward Downward Straight 0.000*
Smile type Commissure 56 (35.7%) Commissure 47 06 03
Cuspid 72 (45.9%) Cuspid 22 15 35
Complex 29 (18.5%) Complex 00 23 06
Upper lip curvature Upward 69 (43.9%) *Statistically significant p value with chi-square test.
Downward 44 (28.0%)
Straight 44 (28.0%)
curvatures were associated with cuspid and downward with
Labiodental relationship Slightly touching 46 (29.3%) gummy smiles. A significant relationship of lip curvature and smile
Not touching 95 (60.5%) arc (p value = 0.01) was also observed, which indicates that more
Covered by lower lip 16 (10.2%) subjects with upward lip curvature were found to have a
Teeth displayed Canine 32 (20.4%) consonant smile arc.
First premolar 56 (35.7%)
Second premolar 50 (31.8%) DISCUSSION
First molar 19 (12.1%) A detailed examination of the smile characteristics is an essential
part of treatment planning in restorative dentistry especially when
anterior dentition is involved and the patient has high aesthetic
demands. The present study has explored common features of a
Table 2. Association of smile parameters with gender. posed smile among a sample of Pakistani students. Posed smile
was employed in the present study mainly because it’s readily
Smile parameter p value reproducible. The common findings were: average smile line,
consonant smile arcs, cuspid-type smile, an upward lip curvature,
Smile line 0.791 with a not-touching relationship of maxillary anterior teeth with
Smile arc 0.02* lower lip and teeth displayed up to first premolars.
Smile type 0.412 Consideration of smile line has a clinical application in
Upper lip curvature 0.396 treatment of the patients, great care should be taken to avoid
excessive display of gingiva during restoration of anterior teeth in
Labiodental relationship 0.589
patients with high smile lines. Average smile line was observed to
Teeth displayed <0.001* be the most frequent among participants in the present study.
*Statistically significant p value with chi-square test. Other studies such as Tjan et al.2 and Nold et al.3 have also
reported similar findings. Tjan and Miller2 also reported that high

BDJ Open (2020)6:6

 Analysis of different characteristics of smile
M Khan et al.
4
smile line were least common in their study, this too is in (all Caucasians) showed teeth up to the first premolar on posed
agreement with the present study. Contrary to this, Nold et al.3 smile. Both these studies showed no gender based differences for
revealed low smile line to be least common among their study extent of teeth visible during smile. And, the present study
participants. Furthermore, aforementioned studies showed statis- suggests that males have wider smiles, exposing more teeth than
tically significant differences between male and female partici- females. Greater smile width among males requires consideration
pants for the position of smile line. However, no such difference during treatment planning of anterior restorations.
has been observed in the present study. Clinically, it is known that A correlation between pattern of smile design and upper lip
low smile lines are more tolerant to inadequacies in the anterior curvature was observed in the present study. Most participants
restorations and hence it is easier for the dentist to satisfy these with upward lip curvature had a commissure smile type whereas
patients with the restorative dentistry work.12 subjects with cuspid smiles showed predominantly straight lip
The term smile arc has different definitions in literature of curvatures. Downward upper lip curvature was primarily seen in
Prosthodontics, Orthodontics and Cosmetic dentistry.9 In the individuals with gummy smiles. A similar association was reported
present study, smile arc has been defined as described by Sarver.9 by Liang et al.15 where straight or upward upper lip curvatures
A consonant smile arc is considered to be more attractive than a were seen predominantly with commissural smiles, and down-
non-consonant smile.6 Consonant smile arc was most commonly ward upper lip curvature among subjects with cuspid type and
observed among the participants of this study whereas reverse gummy smiles.
smile arc was least frequent. These findings are in agreement with This study also proposes a relationship between consonant smile
Tjan and Miller,2 Nold et al.,3 and Desai et al.13 Statistically arcs and upward lip curvature, which suggests that curvature of the
significant difference existed regarding smile arc between the two upper lip may affect the position of smile arc. More research is
genders, this was also testified by Nold et al.3 On the other hand, needed to confirm if such an association among different
Maulik and Nanda14 reported that straight smile arc was the most characteristics of smile can be established. One limitation of the
common finding observed in 49% of their participants followed by present study lies in its lack of generalizability. As this study was
consonant and reverse smile arc in 40% and 10% subjects, conducted in only one dental school located in the largest city of the
respectively. Their methodology involved capturing spontaneous country but it limits the generalizability of the results to the whole
smiles by making video of orthodontically treated and untreated population. In addition, there was no information on occlusion,
subjects. This may be the reason of different results from our study cephalometric/ anthropometric measurements of maxilla and
which involved posed smile of otherwise healthy subjects. mandible. A large sample size comprising of ethnically diverse
A large proportion of the subjects had cuspid smile in the group of subjects are warranted with inclusion of some other
present study, whereas previous studies10,15,16 have reported the components contributing to smile such as occlusal plane, symmetry,
commissure smile pattern as the most common. Liang et al. in lip length, lip thickness and smile width and gingival zenith etc.
their study on Chinese subjects reported that more female
subjects were found to have commissure smile pattern while
complex smile being primarily a male feature.15 The recent study CONCLUSIONS
did not show any gender based differences regarding the smile Within the limitations of the study, it can be concluded that the
pattern. These differences may be attributed to the difference in findings in the studied sample were presence of average smile line,
population studied. consonant smile arcs, cuspid-type smile, an upward lip curvature,
According to Hulsey;8 an upward lip curvature was the most with a non-touching relationship of maxillary anterior teeth with
prevalent feature in subjects of his study, which is similar to the lower lip and teeth displayed up to first premolars. These findings
present study. Contrary to this, Liang et al.15 showed large number can be incorporated in smile analysis of individuals belonging to
of individuals with straight lip curvatures, followed by downward the South Asian population before beginning the aesthetic
and upward. These contradictory results stem out to demographic treatment. Moreover, each case must be assessed individually
variation. Dong et al.11 reported that straight to upward lip along with the consideration of the expectations and preferences
curvatures are considered more appealing than downwards. It has of the patient to obtain adequate results in oral rehabilitation.
been documented that curvature of the upper lip cannot be
altered by orthodontic treatment, thus attaining an ideal smile in a
patient with downward lip curvature is limited.7 ADDITIONAL INFORMATION
Majority of the participants in the present study, had a non- Competing interests: The authors declare no competing interests.
touching labiodental relationship followed by relatively few
participants with covering and slightly touching relationships Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims
in published maps and institutional affiliations.
(with no gender based difference statistically); these results are
similar to that reported by Nold et al.3 This is contradictory to the
findings of Tjan et al.2. They have observed a higher percentage of REFERENCES
touching labiodental relationship in their studies. Moreover,
1. Al-Johany, S. S., Alqahtani, A. S., Alqahtani, F. Y. & Alzahrani, A. H. Evaluation of
significant differences in males and females were also recorded. different esthetic smile criteria. Int J. Prosthodont. 24, 64–70 (2011).
Desai et al.13 reported that with increasing age, people usually 2. Tjan, A. H., Miller, G. D. & The, J. G. Some esthetic factors in a smile. J. Prosthet.
cover their maxillary incisal edges with their lower lip during smile. Dent. 51, 24–28 (1984).
Dong et al.11 concluded that greater aesthetic scores were 3. Nold, S. L., Horvath, S. D., Stampf, S. & Blatz, M. B. Analysis of select facial and
obtained for patients whose lower lips slightly touched or did dental esthetic parameters. Int J. Periodont. Restor. Dent. 34, 623–629 (2014).
not touch the maxillary anterior teeth than those whose teeth 4. Gill, D. S., Naini, F. B. & Tredwin, C. J. Smile aesthetics. Dent. Updat. 34, 152–154
were covered by lower lip. Moreover, everted lower lip is usually (2007). 7-8.
seen with excessive proclination of incisors, while upright and 5. Rigsbee, O. H. III, Sperry, T. P. & BeGole, E. A. The influence of facial animation on
smile characteristics. Int. J. Adult Orthodon. Orthognath. Surg. 3, 233–239 (1988).
retroclined incisors are partially covered by the lower lip.7
6. Sarver, D. M. & Ackerman, M. B. Dynamic smile visualization and quantification:
Data of the present study suggest that individuals usually display Part 2. Smile analysis and treatment strategies. Am. J. Orthod. Dentofac. Orthop.
six maxillary anterior teeth along with the first premolars during 124, 116–27. (2003).
posed smile. Dong et al and Maulik and Nanda observed teeth 7. Sabri, R. The eight components of a balanced smile. J. Clin. Orthod. 39, 155–167
display upto second premolars during smile.11,14 Similar to our (2005). quiz 4.
study, teeth display upto first premolar was also reported by Tjan 8. Hulsey, C. M. An esthetic evaluation of lip-teeth relationships present in the smile.
et al.2 However, Nold et al.3 showed that only 24% participants Am. J. Orthod. 57, 132–144 (1970).

BDJ Open (2020)6:6

 Analysis of different characteristics of smile
M Khan et al.
5
9. Sarver, D. M. The importance of incisor positioning in the esthetic smile: the smile Open Access This article is licensed under a Creative Commons
arc. Am. J. Orthod. Dentofac. Orthop. 120, 98–111 (2001). Attribution 4.0 International License, which permits use, sharing,
10. Rubin, L. R. The anatomy of a smile: its importance in the treatment of facial adaptation, distribution and reproduction in any medium or format, as long as you give
paralysis. Plast. Reconstr. Surg. 53, 384–387 (1974). appropriate credit to the original author(s) and the source, provide a link to the Creative
11. Dong, J. K., Jin, T. H., Cho, H. W. & Oh, S. C. The esthetics of the smile: a review of Commons license, and indicate if changes were made. The images or other third party
some recent studies. Int J. Prosthodont. 12, 9–19 (1999). material in this article are included in the article’s Creative Commons license, unless
12. Mehta, S. B., Banerji, S. & Aulakh, R. Patient assessment: preparing for a pre- indicated otherwise in a credit line to the material. If material is not included in the
dictable aesthetic outcome. Dent. Updat. 42, 78–86 (2015). article’s Creative Commons license and your intended use is not permitted by statutory
13. Desai, S., Upadhyay, M. & Nanda, R. Dynamic smile analysis: changes with age. regulation or exceeds the permitted use, you will need to obtain permission directly
Am. J. Orthod. Dentofac. Orthop. 136, 310. e1–310.e10 (2009). from the copyright holder. To view a copy of this license, visit http://creativecommons.
14. Maulik, C. & Nanda, R. Dynamic smile analysis in young adults. Am. J. Orthod. org/licenses/by/4.0/.
Dentofac. Orthop. 132, 307–315 (2007).
15. Liang, L.-Z., Hu, W.-J., Zhang, Y.-L. & Chung, K.-H. Analysis of dynamic smile and
upper lip curvature in young Chinese. Int J. Oral. Sci. 5, 49 (2013). © The Author(s) 2020
16. Patterns, I. S. The classification of smile patterns. J. Can. Dent. Assoc. 65, 252–254
(1999).

BDJ Open (2020)6:6