375 Maxillary Anterior Papilla Display During Smiling: A Clinical Study of the Interdental Smile Line Mark N. Hochman, DOS* The smile has become the objec- Stephen J. Chu, DMD, MSD, CDT* tive endpoint evaluation by which Dennis P. Tarnow, DOS*** practitioners define esthetic treat- ment outcomes. Esthetics embrac- es and encompasses all specialties The purpose of this research was to quantify the visual display (presence) or of dentistry; therefore, proper di- lack of display (absence) of interdental papillae during maximum smiling in a agnosis of a patient's esthetic smile patient population aged 10 to 89 years. Four hundred twenty digital single-lens line before any treatment is under- reflex photographs of patients were taken and examined for the visual display taken is critical for success. of interdental papillae between the maxillary anterior teeth during maximum Previous studies on the smile smiling. Three digital photographs were taken per patient from the frontal, right line have focused on the visual frontal-lateral, and left frontal-lateral views. The data set of photographs was amount and location of midfacial examined by two examiners for the presence or absence of the visual display tooth and gingival display relative of papillae. The visual display of interdental papillae during maximum smiling to the upper lip.1~4 Tjan et al set occurred in 380 of the 420 patients examined in this study, equivalent to a 91% smile guideline standards in the occurrence rate. Eighty-seven percent of all patients categorized as having a profession in the mid-1980s.2 Their low gingival smile line (n = 303) were found to display the interdental papillae research classified smiles into three upon smiling. Differences were noted for individual age groups according to the decade of life as well as a trend toward decreasing papillary display with basic categories (high, average, increasing age. The importance of interdental papillae display during dynamic and low) according to the exposure smiling should not be left undiagnosed since it is visible in over 91% of older of the midfacial cervical margin of patients and in 87% of patients with a low gingival smile line, representing a the clinical crown relative to the ver- common and important esthetic element that needs to be assessed during smile milion border of the upper lip. The analysis of the patient. (Int J Periodontics Restorative Dent 2012;32:375-383.) majority of these patients (69%) fell within the category of the average *Clinical Associate Professor, Department of Orthodontics and Department of smile line, with 75% to 100% tooth Periodontology, New York University College of Dentistry, New York, New York. **Clinical Associate Professor and Director of Esthetic Dentistry, Columbia University exposure (Fig 1). A total of 11% of College of Dental Medicine, New York, New York. subjects were found to reveal the ***Clinical Professor and Director of Implant Education, Columbia University College of entire clinical crown with a contigu- ~- Dental Medicine, New York, New York. ous band of gingiva, hence catego- Correspondence to: Mark N. Hochman, 150 East 58th Street, Suite 3200, New York, NY rized as a high smile line (Fig 2). 10155; fax: 815-572-9374; email: [email protected]. The low smile line category, found Volume 32, Number 4, 2012 376 Fig 1 Average smile line where 75% to Fig 2 High smile line where 100% tooth Fig 3 Low smile line where 75% tooth 100% tooth exposure is displayed. exposure plus some of the midfacial gingiva exposure or less is displayed. is displayed. in 20% of patients, represented a using videography.3 The amount of approach to the comprehensive smile displaying less than 75% of midfacial tooth display could have analysis of tooth form and its sur- the clinical crown (Fig 3). been underestimated by previous rounding gingival structures. This A limited patient population studies since posed or static pho- biometric approach uses determi- between 20 to 30 years of age from tographs have been shown to limit nants that are identified and can both sexes was used in one such the display of maxillary anterior be measured objectively, allowing study.2 Additionally, each subject teeth during smiling. Of importance the clinician to more easily identify was analyzed from a single frontal was the finding of a correlation tooth and gingival abnormalities full-face posed photograph per- between natural aging and the re- for the dentate patient. The clinical spective. Gender differences were lationship between the soft tissue endpoint of treatment enables indi- found for women versus men, who and dentition by Dickens et al.6 It vidual patient analysis to be quanti- demonstrated greater tooth dis- was found that increased age re- fied in relation to normative values play during smiling, respectively.2-5 sults in a significant reduction of the that have been reported and con- Of note, differentiation of smile cat- exposed clinical crown to the bor- firmed by different research groups egories was primarily based on the der of the upper lip during smiling using various methods.10'12 Several relative position of the vermilion of age groups evaluated between groups have established that ob- border of the upper lip to the total the ages of 7 and 40 years; how- jective measurements of width-to- clinical crown length. The relative ever, only subjects younger than 40 length ratio of teeth or proportion position of the upper lip to the in- were evaluated in this study.6 result in a mean 80% of patients terdental papillae was not assessed Chu et al7'8 and Stappert et being judged to have pleasing independently for these groups.2'4 al9 recently published a series of dimensions for maxillary ante- More recently, Van Der Geld studies in an attempt to more ob- rior teeth.13'15 In addition, recently et al demonstrated that patients jectively diagnosis and treat the published data demonstrate that reveal more tooth display during needs of the esthetic-restorative the interdental papilla proportion spontaneous versus posed smiling patient. They took a "biometric" (clinical tooth length to interdental The International Journal of Periodontics & Restorative Dentistry 377 Fig 4 Height of the interdental papillae measured from the gingi- val zenith indsally is roughly 40% of the length of the clinical crown. papilla length) can be measured papillary gingival tissues. It is be- objectively in patients with estheti- lieved that the visual display (pres- cally pleasing smiles. This papilla ence) or lack of display (absence) of proportion of tooth length/papilla interdental papillae during smiling length (Fig 4) was found to be, is a critical component to the diag- on average, 40% of the length of nosis and treatment of the esthetic- the tooth from the gingival zenith restorative patient requiring either (highest point of the midfacial gin- interdisciplinary reconstructive or gival margin) to the incisal edge.8 conformative dental care. The authors have defined the The purposes of this study term interdental smile line (ISL) as were to determine the following: the position of the maxillary vermil- the overall percentage of patients ion border relative to the interdental aged 10 to 89 years who display papillae. Two basic categories are the interdental papillae of the max- defined: high interdental smile line illary anterior teeth during smiling (HISL) and low interdental smile line to establish a normative value; any (LISL). ISL analysis is differentiated differences between age groups from traditional smile line analysis, with respect to the display of the which relates the postural position interdental papillae during smiling, of the vermilion border of the up- thereby evaluating the effects of per lip to the clinical crown length aging on the amount of interdental of the maxillary anterior teeth. The papillary display; and if gender dif- ISL exclusively assesses the relative ferences affect the presence or ab- position of the labial tissues to the sence of interdental papillae during relative position of the interdental smiling. Volume 32, Number 4, 2012 378 Figs 5a to 5c Digital single-lens reflex smile photographs were taken from the (a) right frontal-lateral, (b) frontal, and (c) left-frontal lateral perspectives to assess the presence vs absence of interdental papillae. Note that from the frontal perspective, it is not immediately apparent whether the interdental papillae are displayed. Method and materials analyzed, and carefully evaluated Definition of terms by visual examination for the pres- Inclusion criteria were complete ence or absence of display of in- Gingival smile line maxillary and mandibular arches terdental papillae and midfacial A high gingival smile line (HGSL) up to and including the first molar. gingiva. Images were digitally en- displays the midfacial tissues of all A total of 420 male and female pa- larged to provide greater visual ac- maxillary anterior teeth upon smil- tients were randomly selected, with curacy. The vermilion border of the ing (Fig 6), whereas a low gingival ages ranging from their teens to upper lip was evaluated relative to smile line (LGSL) does not (Fig 7). 80s. Groupings of each age were di- the display or absence of the inter- CB-GSL does not display the midfa- vided into cohorts ranging from the dental papilla and midfacial gingiva cial gingiva of the maxillary central second to the ninth decade of life. of the maxillary teeth. incisors but reveals the midfacial Two independent examiners evalu- Two basic categories were de- gingival tissues of the maxillary ated digital photographic records fined: HISL and LISL. A third variant lateral incisors and/or those distal providing a right frontal-lateral, category, referred to as Cupid's bow upon smiling (Fig 8). frontal, and left frontal-lateral smile smile line, was defined as when the view of each patient (Figs 5a to upper lip displayed the interden- Interdental smile line 5c).