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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 4  |  Page : 221-227

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

Department of Prosthodontics, Faculty of Dentistry, MAHSA University, Selangor, Malaysia

Date of Web Publication14-Aug-2019

Correspondence Address:
Dr. Shivani Kohli
Department of Prosthodontics, MAHSA University, Jenjarum 42610, Selangor.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_191_17

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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.

Keywords: Diagnostic Wax-Up, Esthetics, Smile, 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;11:221-7

How to cite this URL:
Kohli S, Yee A. Smile enhancement with anatomic diagnostic wax-up and comprehensive esthetic smile designing. J Int Oral Health [serial online] 2019 [cited 2021 May 14];11:221-7. Available from:

  Introduction Top

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 Top

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: Preoperative view with removable partial denture and without denture

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Figure 2: Orthopantomograph

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Figure 3: Intraoral periapical 12, 13 (left), and 23 (right)

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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 Top

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 Top

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: Pretreatment dentofacial and dentogingival analysis

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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 Top

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 Top

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: Pretreatment dental analysis

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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: Diagnostic wax-up

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Figure 7: Provisional restoration

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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: Face-bow transfer

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Figure 9: Customized incisal guidance table

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Figure 10: Post-cementation: Intraoral frontal view

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Figure 11: Post-cementation: Intraoral occlusal view

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  Posttreatment: Dental Esthetics Evaluation Top

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: Post-cementation: Dento-labial analysis

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Figure 13: Post-cementation: Dentogingival analysis

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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 Top

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: Preoperative and postoperative extra-oral view

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

  Discussion Top

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]

  Conclusion Top

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.

  References Top

Davis NC Smile design. Dent Clin North Am 2007;51:299-318.  Back to cited text no. 1
Alberton 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.  Back to cited text no. 2
Marzola 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.  Back to cited text no. 3
Miro 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.  Back to cited text no. 4
McNamara 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.  Back to cited text no. 5
Soares 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.  Back to cited text no. 6
Witt M, Flores-Mir C Laypeople’s preferences regarding frontal dentofacial esthetics: Tooth-related factors. J Am Dent Assoc 2011;142:635-45.  Back to cited text no. 7
Feraru M, Musella V, Bichacho N Individualizing a smile makeover: Current strategies for predictable results. J Cosm Dent 2016;32:109-14.  Back to cited text no. 8
Ritter DE, Gandini LG Jr, Pinto Ados S, Ravelli DB, Locks A Analysis of the smile photograph. World J Orthod 2006;7:279-85.  Back to cited text no. 9
Uribe 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.  Back to cited text no. 10
Proffit 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.  Back to cited text no. 11
Ittipuriphat I, Leevailoj C Anterior space management: Interdisciplinary concepts. J Esthet Restor Dent 2013;25:16-30.  Back to cited text no. 12
Proffit 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.  Back to cited text no. 13
Sarver 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.  Back to cited text no. 14
Kokich 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.  Back to cited text no. 15
Gill DS, Naini FB, Tredwin CJ Smile aesthetics. Dent Update 2007;34:152-8.  Back to cited text no. 16
Dawson PE Functional Occlusion: From TMJ to Smile Design. St Louis, MO: Mosby; 2007.  Back to cited text no. 17
Montero 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.  Back to cited text no. 18
Kois JC Diagnostically driven interdisciplinary treatment planning. Seattle Study Club J 2002;6:28-34.  Back to cited text no. 19
Radz G Ceramics: Porcelain-fused-to-metal restorations. In: Freedman G, editor.Contemporary Esthetic Dentistry. St. Louis, MO: Mosby; 2012; p. 510.  Back to cited text no. 20
McLaren EA, Rifkin R Macroesthetics: Facial and dentofacial analysis. J Calif Dent Assoc 2002;30:839-46.  Back to cited text no. 21
Pedrosa 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.  Back to cited text no. 22
Ward 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.  Back to cited text no. 23
Arnett GW, Bergman RT Facial keys to orthodontic diagnosis and treatment planning. Part II. Am J Orthod Dentofacial Orthop 1993;103:395-411.  Back to cited text no. 24
Bhuvaneswaran M Principles of smile design. J Conserv Dent 2010;13:225-32.  Back to cited text no. 25
Modi 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.  Back to cited text no. 26
Moore 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.  Back to cited text no. 27
Snow SR Esthetic smile analysis of maxillary anterior tooth width: The golden percentage. J Esthet Dent 1999;11:177-84.  Back to cited text no. 28
Murthy BV, Ramani N Evaluation of natural smile: Golden proportion, RED or golden percentage. J Conserv Dent 2008;11:16-21.  Back to cited text no. 29
Paris 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.  Back to cited text no. 30
Bitter RN The periodontal factor in esthetic smile design–altering gingival display. Gen Dent 2007;55:616-22.  Back to cited text no. 31
Dawson PE Determining the determinants of occlusion. Int J Periodontics Restorative Dent 1983;3:8-21.  Back to cited text no. 32
Kohli S, Bhatia S The quest for perpetual smile. Br Biomed Bull 2014:2:316-21.  Back to cited text no. 33
Gürel G Discovering the artist inside: A three-step approach to predictable aesthetic smile designs, part 2. Dent Today 2013;32:128-31.  Back to cited text no. 34
Alpert RL A method to record optimum anterior guidance for restorative dental treatment. J Prosthet Dent 1996;76:546-9.  Back to cited text no. 35
Havens DC, McNamara JA Jr, Sigler LM, Baccetti T The role of the posed smile in overall facial esthetics. Angle Orthod 2010;80:322-8.  Back to cited text no. 36
McLaren EA, Cao PT Smile analysis and esthetic design: “In the Zone”. Inside Dent 2009;5:46-8.  Back to cited text no. 37


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]

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