Journal of International Oral Health

: 2019  |  Volume : 11  |  Issue : 4  |  Page : 221--227

Smile enhancement with anatomic diagnostic wax-up and comprehensive esthetic smile designing

Shivani Kohli, Ang Yee 
 Department of Prosthodontics, Faculty of Dentistry, MAHSA University, Selangor, Malaysia

Correspondence Address:
Dr. Shivani Kohli
Department of Prosthodontics, MAHSA University, Jenjarum 42610, Selangor.


Esthetic smile design is a conceptual tool that can reinforce diagnosis, improve communication, and enhance certainty of the treatment. Analysis of the facial and gingival features in relation to the teeth can be achieved by evaluating facial, dento-labial, and dentogingival parameters, which are crucial steps in smile designing. Following this, diagnostic wax-up, which is an imperative tool, was carried out on maxillary anterior teeth to satisfy the smile design and to establish an anterior guidance. Diagnostic wax-up allowed the dentist to effectively communicate with the patient concerning the final esthetic outcome with improved smile line. Esthetic pre-evaluative provisional prepared from the diagnostic wax-up permits the dentist and the patient to appraise the appearance of the future restorations during smile and function. Hence, the aim of this case report was to highlight smile enhancement with the aid of anatomic diagnostic wax-up following principles of esthetic smile designing.

How to cite this article:
Kohli S, Yee A. Smile enhancement with anatomic diagnostic wax-up and comprehensive esthetic smile designing.J Int Oral Health 2019;11:221-227

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Kohli S, Yee A. Smile enhancement with anatomic diagnostic wax-up and comprehensive esthetic smile designing. J Int Oral Health [serial online] 2019 [cited 2019 Nov 13 ];11:221-227
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Novel expertise has heightened our capacity to examine our patients more precisely due to accessibility to innovative concepts of esthetics and function.[1] Nowadays, patients are becoming even more conscious of their teeth and, for many, esthetics has become one of the key motive for pursuing dental treatment.[2],[3] The societal appeal of young adult may perhaps be affected by their dentofacial appearance.[4],[5],[6],[7],[8]

“Smile line” is a universally used parameter to assess and classify a person’s smile. It is a curve that passes through the incisal margins of the maxillary central incisors and canines making an arc. The smile arc is convex when the incisal edge of the maxillary central incisors appears below the canine cusps and concave when the cuspal tips of the canine are more occlusal than the incisal edge of the maxillary central incisors, and when they lie in a straight line, the smile arc is considered to be straight.[9]

According to recent prototype, nothing is more imperative than facial esthetics in dentistry,[10] and attaining acceptable esthetics and harmony among the orofacial structures is the prime objective of dental treatment.[11],[12],[13],[14] Studies in the past have found that the symmetry of the smile is positively associated with a “good smile,” and asymmetrical smiles were not given higher smile scores.[15] An asymmetric smile can be due to various factors, e.g. disparity in tooth size, tooth shape, or uneven papillary height.[16] The diagnostic information must direct the treatment phases, integrating all of the patient’s needs, personality, function, and biologic concerns into an esthetic treatment plan.[17],[18],[19]

The objective of esthetic treatment is to achieve an improved appearance that gives a vivacious and realistic look to the patient. This article focuses on significance of diagnostic wax-up and historically acknowledged smile design concepts with various smile parameters.

 Case Presentation

A 51-year-old female patient reported to the dental clinic. She had lost both her maxillary central incisors and left lateral incisor 10 years ago in an accident. Since then she was wearing acrylic removable partial denture. She complained of unesthetic appearance and altered speech with her existing denture. Her prime concern was to seek the best treatment to restore her smile and speech with a fixed replacement alternative [Figure 1]. There was no tenderness on percussion on the abutment teeth and all the interferences that prevented complete range of anterior guidance functional pathways were removed. Further radiographic investigations were conducted, wherein orthopantomograph [Figure 2] revealed no evidence of pathologic lesions and bone loss around the abutment teeth. Intraoral periapical radiograph [Figure 3] showed satisfactory crown-to-root ratio with absence of periapical radiolucencies with respect to 13, 12, and 23.{Figure 1}, {Figure 2}, {Figure 3}

Different treatment options were given to patient including dental-implant-supported crowns and bridge and fixed bridge (including all ceramic and porcelain fused to metal bridge) to replace the upper anterior edentulous region using 12, 13, and 23 as abutments. Due to the acceptable esthetics, durability, and cost concern, patient agreed for porcelain fused to ceramic bridge. Tooth-supported fixed partial dentures have an expected survival rate of 85% at 15 years; hence, prognosis was excellent.[20]

The final treatment plan was to fabricate a fixed partial denture replacing missing teeth using maxillary right lateral incisor, and right and left canine as abutments. Diagnostic impressions and models were made to be mounted on a semi-adjustable articulator.

Diagrammatic view of the future bridge was designed according to the smile analysis and discussed with the patient before proceeding to the next phase. Smile design involves the evaluation of elements in a specific sequence: (1) facial analysis (overall facial equilibrium), (2) dentofacial analysis (relating dental midline to the face), (3) dento-labial analysis (relating the teeth to the lips), (4) dentogingival analysis (relating teeth to the gingiva), and (5) dental analysis (the intratooth and intertooth relationships, i.e., shape and position of the tooth).[20],[21]

 Facial and Dentofacial Analysis

Smile analysis begins with facial analysis at the macro esthetic level, which includes examining patient’s facial form and balance and then proceeding toward individual teeth. Any unbalance will result in unesthetic smile. Following this, oral-facial analysis was conducted to determine the maxilla-mandibular relationship.[22],[23]

Ideally, the dental and facial midlines should coincide, but rarely it happens. In one of the study, Kokich concluded that a discrepancy of up to 4mm will normally not be perceived as unesthetic as long as the dental and facial midlines are parallel to each other.[15]

 Dento-labial Analysis

It was conducted to assess the relationship of the lips to the teeth, i.e. visibility of teeth both at rest and function. Regarding the incisal edge position, minimum exposure of incisal edge by 2mm at rest position is required for esthetic results.[24] Gull wing pattern, wherein the incisal edges of the maxillary anterior teeth follow the curvature of the lower lip, is considered to be very esthetic [Figure 4].[25],[26]{Figure 4}

A negative space that appears between the buccal surface of the posterior teeth and the corner of the lip when the person smiles, giving depth and natural aspect to the smile, is called as buccal corridor space.[27] A wide smile with a negligible buccal corridor is believed to be most appealing.[9]

 Dentogingival Analysis

It comprises of esthetic gingival relationship: gingival line (relation of free gingival margins of the maxillary teeth) and positioning of tip of the papilla, gingival contour, scalloping, and gingival color. Arranging lateral incisor 1mm incisal to the central incisor is generally perceived as esthetic. The distance between the gingival scallop to the tip of the papilla should be between 4 and 5mm [Figure 2].[1]

 Dental Analysis

Intertooth relationship: After measuring esthetic outcomes on many patients in the University of California–Los Angeles, the dentists have determined the esthetic zone for the central incisor to be between 10.5 and 12mm. The width-to-length esthetic relationship has been discussed in the previous studies to be 70%–80%.[1]

Intratooth relationship: Golden proportion has been considered as a mathematical tool for assessing proportion among anterior teeth though it is considered debatable in developing esthetically pleasing smiles.[28] Henceforth, golden percentage was used for intratooth analysis for this patient with value of 22% for centrals, 15.5% for laterals, and 12.5% for canines as these values are mostly applicable to natural dentition [Figure 5].[29]{Figure 5}

Following the smile analysis, diagnostic wax-up was conducted on maxillary anterior teeth to satisfy the smile design and to establish an anterior guidance that disoccluded posterior teeth in all eccentric movements [Figure 6]. Putty index was prepared on the diagnostic wax-up to replicate it into the provisional restoration. Tooth preparations were conducted on 12, 13, and 23 for porcelain fused to metal bridge following correct principles. The provisional restoration was fabricated and left in the patient’s mouth for 2 weeks to assess esthetics, phonetics, and function in reference to anterior guidance [Figure 7].{Figure 6}, {Figure 7}

At the subsequent appointment, the patient was verified for comfort and esthetics. It was evaluated that the established functional pathways were in harmony with the envelope of function. Maxillary alginate impressions were made along with provisional restorations and mounted after face bow transfer [Figure 8]. The anterior guidance was customized with the autopolymerizing acrylic resin to transfer exact details of anterior guidance to the dental technician [Figure 9]. With this guidance, as discussed by Dawson,[17] the technician could mimic the functional movements of the jaw and recreate a perfect functional and comfortable incisor guidance for the patient. Final restorations were prepared following the planned smile design and anterior guidance. They were evaluated and cemented with RelyX cement [Figure 10] and [Figure 11].{Figure 8}, {Figure 9}, {Figure 10}, {Figure 11}

 Posttreatment: Dental Esthetics Evaluation

Optimum facial esthetics is one of the imperative goals of prosthodontic treatment. In this case, the facial form and balance were improved along with the labial support. The dento-labial esthetics was improved by achieving the 3mm display of maxillary central incisors at rest. Smile line followed the gull wing pattern according to the curvature of lower lip [Figure 12]. Pertaining to the dentogingival analysis, the lips and the gingiva frames the teeth. The ratio of tooth to gingival tissue was synchronized to prevent an overdominance of any element. An esthetic gingival relationship that constitutes gingival line and scalloping was achieved considerably. In normal dentition, the contour of the gingiva to the tip of the papilla is between 4 and 5mm. However, in this case it was less than 4mm as the longer pontic was needed to cover the edentulous region [Figure 13].{Figure 12}, {Figure 13}

As length of the teeth also affects esthetics, acceptable width-to-length relationship, which is best between 70% and 80%, was achieved.[1] Golden percentage was used to accomplish an ideal interdental proportion by redistributing the available spaces among maxillary anterior teeth during designing of a six-unit anterior bridge. Thus, with the aid of anatomic wax-up, the esthetics and function as desired by the patient was achieved.

 Follow-up and Evaluation

The patient was called for follow-up appointments at a regular time interval. The soft-tissue response at 6 months was exceptional with good papilla support and expected emergence profile. After almost 2 years, there have been no clinical problems and the patient was very pleased with the results. She felt very comfortable with the fit and was maintaining good oral hygiene [Figure 14].{Figure 14}

Patient’s consent was taken to use any photographs for records or publication.


An attractive smile can be an enormous asset to one’s personality. The facial, gingival, and dental components can be manipulated to design a beautiful smile.[30] The color, shape, proportion, and position of the teeth can be worked with to create a pleasing smile.[25] The gingival architecture can also be altered. An appropriate white and pink esthetic balance is the solution in smile designing.[31]

The goal of an esthetic rehabilitation is to develop a stable masticatory system, where the teeth, supporting structures, and joints all function in harmony (Dawson[32]).[33]

Amendment of dental esthetic inconsistencies desires cautious evaluation, planning, and multidisciplinary approach. Anatomic wax-up is one of the most vital tools when planning to alter the patient’s smile. It allows the clinician to visualize the alterations needed to achieve a pleasant smile and assist them in treatment planning.[34] Recreation of the lost anterior guidance was achieved because of the acceptable performance with interims, which was transferred to the laboratory. Hence, the permanent restorations were fabricated precisely.[35] Therefore, acquaintance of smile design, together with latest technologies, allows the dentist to diagnose, plan, create, and deliver esthetic smile to the patient.[36],[37]


Dentists require adequate information for meticulous decision-making to formulate treatment that is acceptable as per the desires of the patient. Henceforth, esthetic principles must be incorporated to provide data that can aid the dentist to create a beautiful smile for our patients.

Informed consent

Patient’s consent was taken for crown and bridge treatment and to use any photographs for record keeping, educational, publication, or research purpose.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Davis NC Smile design. Dent Clin North Am 2007;51:299-318.
2Alberton SB, Alberton V, de Carvalho RV Providing a harmonious smile with laminate veneers for a patient with peg-shaped lateral incisors. J Conserv Dent 2017;20:210-3.
3Marzola R, Derbabian K, Donovan TE, Arcidiacono A The science of communicating the art of esthetic dentistry. Part I: Patient-dentist-patient communication. J Esthet Dent 2000;12:131-8.
4Miro AJ, Shalman A, Morales R, Giannuzzi NJ Esthetic smile design: Limited orthodontic therapy to position teeth for minimally invasive veneer preparation. Dent Clin North Am 2015;59:675-87.
5McNamara L, McNamara JA Jr, Ackerman MB, Baccetti T Hard- and soft-tissue contributions to the esthetics of the posed smile in growing patients seeking orthodontic treatment. Am J Orthod Dentofacial Orthop 2008;133:491-9.
6Soares PV, Spini PH, CarvalhoVF, Souza PG, Gonzaga RC, Tolentino AB, et al. Esthetic rehabilitation with laminated ceramic veneers reinforced by lithium disilicate. Quintessence Int 2014;45:129-33.
7Witt M, Flores-Mir C Laypeople’s preferences regarding frontal dentofacial esthetics: Tooth-related factors. J Am Dent Assoc 2011;142:635-45.
8Feraru M, Musella V, Bichacho N Individualizing a smile makeover: Current strategies for predictable results. J Cosm Dent 2016;32:109-14.
9Ritter DE, Gandini LG Jr, Pinto Ados S, Ravelli DB, Locks A Analysis of the smile photograph. World J Orthod 2006;7:279-85.
10Uribe F, Nanda R Individualized orthodontic diagnosis. In: Nanda R, editor.Biomechanics and Esthetic Strategies in Clinical Orthodontics. 1st ed. Philadelphia, PA: Elsevier, Saunders; 2005. p. 38-73.
11Proffit WR Malocclusion and dentofacial deformity in contemporary society. In: Proffit WR, editor. Contemporary Orthodontics. 4th ed. St. Louis, MO: Mosby, Elsevier; 2007. p. 3-23.
12Ittipuriphat I, Leevailoj C Anterior space management: Interdisciplinary concepts. J Esthet Restor Dent 2013;25:16-30.
13Proffit WR The soft tissue paradigm in orthodontic diagnosis and treatment planning: A new view for a new century. J Esthet Dent 2000;12:46-9.
14Sarver DM, Proffit WR Special consideration in diagnosis and treatment planning. In: Graber IM, Vandersdal R, editors.Orthodontics: Current Principles and Techniques. 4th ed. St Louis, MO: Mosby, Elsevier; 2005. p. 3-70.
15Kokich VO, Kokich VG, Kiyak HA Perceptions of dental professionals and laypersons to altered dental esthetics: Asymmetric and symmetric situations. Am J Orthod Dentofacial Orthop 2006;130:141-51.
16Gill DS, Naini FB, Tredwin CJ Smile aesthetics. Dent Update 2007;34:152-8.
17Dawson PE Functional Occlusion: From TMJ to Smile Design. St Louis, MO: Mosby; 2007.
18Montero J, Gómez Polo C, Rosel E, Barrios R, Albaladejo A, López-Valverde A The role of personality traits in self-rated oral health and preferences for different types of flawed smiles. J Oral Rehabil 2016;43:39-50.
19Kois JC Diagnostically driven interdisciplinary treatment planning. Seattle Study Club J 2002;6:28-34.
20Radz G Ceramics: Porcelain-fused-to-metal restorations. In: Freedman G, editor.Contemporary Esthetic Dentistry. St. Louis, MO: Mosby; 2012; p. 510.
21McLaren EA, Rifkin R Macroesthetics: Facial and dentofacial analysis. J Calif Dent Assoc 2002;30:839-46.
22Pedrosa VO, França FM, Flório FM, Basting RT Study of the morpho-dimensional relationship between the maxillary central incisors and the face. Braz Oral Res 2011;25:210-6.
23Ward HD Proportional smile design using: The recurring esthetic dental proportion to correlate the widths and lengths of the maxillary anterior teeth with the size of the face. Dent Clin North Am 2015;59:623-38.
24Arnett GW, Bergman RT Facial keys to orthodontic diagnosis and treatment planning. Part II. Am J Orthod Dentofacial Orthop 1993;103:395-411.
25Bhuvaneswaran M Principles of smile design. J Conserv Dent 2010;13:225-32.
26Modi R, Kohli S, Bhatia S Anterior esthetic restoration of a patient using modified ovate pontic design: A case report. Ann Dent Spec 2014;2:158-62.
27Moore T, Southard KA, Casko JS, Qian F, Southard TE Buccal corridors and smile esthetics. Am J Orthod Dentofacial Orthop 2005;127:208-13; quiz 261.
28Snow SR Esthetic smile analysis of maxillary anterior tooth width: The golden percentage. J Esthet Dent 1999;11:177-84.
29Murthy BV, Ramani N Evaluation of natural smile: Golden proportion, RED or golden percentage. J Conserv Dent 2008;11:16-21.
30Paris JC, Ortet S, Larmy A, Brouillet JL, Faucher AJ Smile esthetics: A methodology for success in a complex case. Eur J Esthet Dent 2011;6:50-74.
31Bitter RN The periodontal factor in esthetic smile design–altering gingival display. Gen Dent 2007;55:616-22.
32Dawson PE Determining the determinants of occlusion. Int J Periodontics Restorative Dent 1983;3:8-21.
33Kohli S, Bhatia S The quest for perpetual smile. Br Biomed Bull 2014:2:316-21.
34Gürel G Discovering the artist inside: A three-step approach to predictable aesthetic smile designs, part 2. Dent Today 2013;32:128-31.
35Alpert RL A method to record optimum anterior guidance for restorative dental treatment. J Prosthet Dent 1996;76:546-9.
36Havens DC, McNamara JA Jr, Sigler LM, Baccetti T The role of the posed smile in overall facial esthetics. Angle Orthod 2010;80:322-8.
37McLaren EA, Cao PT Smile analysis and esthetic design: “In the Zone”. Inside Dent 2009;5:46-8.