Esthetic Influence of Negative Space in the Buccal Corridor during Smiling

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1 Originl Article Esthetic Influence of Negtive Spce in the Buccl Corridor during Smiling Dltro Enes Ritter ; Luiz Gonzg Gndini Jr b ; Ary dos Sntos Pinto c ; Arno Locks d ABSTRACT The purpose of this study ws to mesure nd verify the esthetic influence of the bilterl spces between mxillry teeth nd lip corners, clled negtive spce (NS), during smile. The smple ws comprised of 60 smile photogrphs obtined from 60 individuls (30 men nd 30 women) ged 18 to 25 yers old. Two orthodontists nd two ly people evluted these pictures regrding esthetics by visul nlogue scle. In ech picture, the right nd left NS were mesured in millimeters nd in proportion to the smile width (SW). Dt were nlyzed for sttisticl significnce (P.05). The men NS of the smple ws mm, nd the NS proportion in reltion to the SW ws %, for both sides of the rch. No significnt symmetries were observed between the right nd left sides. The NS ws significntly lrger in men thn in women when mesured in millimeters (P.028) ( mm in men vs mm in women), but the NS proportion to the SW ws similr ( % in men vs % in women). When the 12 individuls with the smllest NS in proportion to SW were compred with the 12 individuls with the lrgest NS in proportion to SW, there ws no sttisticl difference regrding the esthetic evlution (P.11). It ws concluded tht the NS did not influence the esthetic evlution of smile photogrphs in the smple in this study, for both orthodontists nd ly people. (Angle Orthod 2006;76: ) KEY WORDS: Esthetic; Negtive spce; Smile INTRODUCTION The fce is the most importnt individul fctor determining the physicl ppernce of people; the mouth nd teeth re considered fundmentl in fcil esthetics. 1,2 Therefore, it is essentil to control the esthetic effects cused by orthodontic tretment, which is only possible by knowing the principles tht mnge the blnce between teeth nd soft tissues during smile. 3,4 Consequently, more thorough studies re re Orthodontic Associte Professor, Federl University of Snt Ctrin, Florinópolis, Brzil. b Orthodontic Assistnt Professor, UNESP, Arrqur, São Pulo, Brzil. c Orthodontic Assistnt Professor, UNESP, Arrqur, São Pulo, Brzil d Orthodontic Professor nd Chir, Federl University of Snt Ctrin, Florinópolis, Brzil. Corresponding uthor: Dltro Enes Ritter, Ru Nereu Rmos , Snt Ctrin , Brzil (e-mil: dltroritter@hotmil.com) Accepted: Mrch Submitted: Februry by The EH Angle Eduction nd Reserch Foundtion, Inc. quired on the detils tht cn influence the esthetic blnce between teeth nd soft tissues. During smile, bilterl spces pper between the buccl surfce of the most visible mxillry posterior teeth nd the lip commisure, clled negtive spces (NSs), blck spces, or buccl corridor. 5 9 The purpose of this study ws to verify the influence of the NS on the smile esthetics, ie, whether individuls with lrger or smller NS hve ltered esthetics becuse of this fctor. This study lso mesured the NS during smile in millimeters nd in percentge in reltion to the smile width (SW), ssessing ny differences between sexes, ssessing presence of symmetries, nd estblishing pttern for dignosis nd clinicl evlution of devitions of this mesurement from normlity. MATERIALS AND METHODS Sixty photogrphs obtined from 60 subjects (30 men nd 30 women) were used in this study. All subjects presented complete permnent dentition with the possible exception of third molrs. The smple ws selected mong dentl students t the Federl University of Snt Ctrin, Florinópolis, Brzil, nd included white individuls ged 18 to 25 yers, with 198

2 ESTHETIC INFLUENCE OF NEGATIVE SPACE DURING SMILE 199 FIGURE 1. Method used to mesure the smile width nd right nd left negtive spces in millimeters nd in percentge. good dentl lignment in both rches, blnce between the fcil thirds, nd spontneous lip sel. All individuls hd not been treted orthodonticlly nd signed n informed consent form pproved by the university ethics committee. Frontl view photogrphs were tken of the lower fcil third, including the nose tip nd chin. The individuls were photogrphed t forced smile becuse it is more esily reproduced, seted with the cephlostt positioned t 90 cm from the cmer nd in nturl hed position. 10,13 16 A metllic millimeter ruler (Kws Mnufcturer, Tokyo, Jpn) ws positioned close to the lip commisure s scle. Pictures were tken in the sme closed environment under the sme light conditions with CoolPix 950 digitl cmer (Nikon, Jpn) t 2000 pixels of resolution. After the photogrphs were completed the SW, right nd left negtive spces (RNS nd LNS, respectively), nd the proportion of NS to the totl SW were mesured, following the methods of Hulsey 7 nd Johnson nd Smith. 9 A line ws projected between the lip commisures (right nd left cheilion points), nd the mximum width of the mouth during smile ws mesured in millimeters. The distnce between the most buccl lterl points of the mxillry teeth, perpendiculr to the SW lined up to the right nd left lip commisures, ws mesured, representing the RNS nd LNS (Figure 1). On the bsis of the SW nd RNS nd LNS mesurements in millimeters, the percentge of RNS nd LNS in reltion to the SW during smile ws derived. The progrm UTHSCSA (University of Texs Helth Science Center t Sn Antonio) ImgeTool for Windows version 1.21 (Copyright ) ws used for mesurement of the digitized photogrphs. An lbum ws ssembled with the 60 blck-ndwhite smile printed photogrphs, showing only the mouth re, including the lips, teeth, nd introrl visible structures, to void interference from other fcil structures, such s the nose nd chin. FIGURE 2. Exmple of demrction of the visul nlog scle used for evlution by the exminers. The esthetic evlution ws crried out by two orthodontists nd two ly people (clled exminers) by nlysis of ll photogrphs, using the visul nlog scle (VAS) 1,17 supplied below ech photogrph. The VAS vries progressively in vlues from estheticlly very poor, poor, neutrl, good, to very good. Ech exminer ws sked to mrk on the VAS point on which the smile ws closest to the correspondent vlue of the VAS, s observed in Figure 2. After ech exminer completed the esthetic evlutions, the points mrked on the VAS were converted into grdes from 0 to 10, 0 being the minimum esthetic vlue nd 10 the mximum esthetic vlue. Two weeks fter the first evlution of the lbum, ech exminer received second lbum with the sme photogrphs in different rrngement. The men of the two evlutions ws used s finl esthetic grde for ech photogrph. After the exminers evluted estheticlly the 60 photogrphs, the 12 photogrphs with the smllest NS (group G1) were sttisticlly compred with the 12 photogrphs with the lrgest NS (group G2). Figure 3 shows exmples of the photogrphs used in the study. Thus, it ws observed whether the smile photogrphs with the lrgest NS presented sttisticlly different esthetic grdes thn the photogrphs with the smllest NS. To verify whether there ws sttisticl difference in the NS between sexes nd between the right nd left sides, the smple ws divided in reltion to the mens nd stndrd devitions. To verify the clibrtion of the investigtor conducting the mesurements, SW nd NS mesurements were chieved in millimeters on 10 photogrphs of the smple t two distinct periods with 15-dy intervl. As observed in Tble 1, the investigtor presented good clibrtion for chieving the mesurements ddressed in this study becuse sttisticlly similr mens nd vrinces were chieved for ech mesurement t the two periods of mesurements.

3 200 RITTER, GANDINI, PINTO, LOCKS TABLE 2. Frequency, Men, nd SD of the SW, RNS, nd LNS Mesurements in Two Moments for the Photogrph Repetbility Test Mesurements (mm) Moment Frequency Men SD P FIGURE 3. Exmples of the pictures used in the study. Pictures 3A nd 3C hve smller NS in millimeters nd in proportion to SW (group G1), nd pictures 3B nd 3D hve lrger NS (group G2), s described below. Picture 3A-Group G1 3B-Group G2 3C-GroupG1 3D-Group G2 Gender Mle Mle Femle Femle SW mm RNS mm % LNS mm % TABLE 1. Frequency, Men, nd SD of the Exminer Clibrtion, in Two Moments Mesurements (mm) Moment Frequency Men SD P SW NS b RNS NS LNS NS SW indictes smile width; RNS, right negtive spce; nd LNS, left negtive spce. b NS indictes not significnt (P.05). SW NS b RNS NS LNS NS SW indictes smile width; RNS, right negtive spce; nd LNS, left negtive spce. b NS indictes not significnt (P.05). TABLE 3. Negtive Spce Frequency, Men, nd SD in Millimeters, by Sex nd Side in Totl Smple Fctors Frequency Men SD P Sides Right NS Left Sex Women * Men Totl smple NS indictes not significnt (P.05). * significnt (P.05). To verify the reproducibility of the smile photogrphs, ie, whether the forced smile my be repeted with the sme expression by the sme individul t nother period nd thus be used s method for comprison, two series of photogrphs were tken on different dys (30-dy intervl) of 10 individuls of the smple. The SW nd the bilterl NS were mesured in millimeters nd re shown in Tble 2, which reveled tht the individuls included in the smple repeted the sme dimensions of forced smile on the first nd second photogrphs. To investigte the differences between sexes nd symmetry regrding the NS during forced smile, the two-wy prmetric nlysis of vrince nd the Tukey test were pplied to check ny possible significnt differences. Investigtion of the esthetics of forced smile ws performed by the three-wy (side, sex, nd exminer) prmetric nlysis of vrince nd the Tukey test to detect ny possible significnt differences. FIGURE 4. Men of negtive spce in millimeters nd by sex nd side (*P.05). The region of rejection of the hypotheses inherent to ech type of sttisticl nlysis ws constructed t the 0.05 level. RESULTS Tble 3 shows the NS frequency, mens, nd stndrd devitions in millimeters ccording to sex, right nd left sides, nd for the totl smple. The men vlues of the NS in millimeters ccording to sex nd right nd left sides re shown in Figure 4. Tble 4 shows the NS frequency, mens, nd stn-

4 ESTHETIC INFLUENCE OF NEGATIVE SPACE DURING SMILE TABLE 4. Negtive Spce Frequency, Men, nd SD in Percentge, by Sex nd Side Fctor Frequency Men SD P Side Right NS Left Sex Women NS Men Totl smple NS indictes not significnt (P.05). 201 FIGURE 6. Men esthetic scores ttributed by ech exminer for groups G1 nd G2 together, nd men esthetic scores ttributed to groups G1 nd G2 by ll exminers together (*P.05). FIGURE 5. Men of negtive spce in percentge in reltion to the smile width, by sex nd side. TABLE 6. Esthetic Score s Men, SD, nd Sttisticl Groups (S.Gr.) for Groups G1 nd G2 Attributed by Ech Exminer Exminer Group Men SD S. Gr. 1 G A G A 2 G A G A 3 G A G A 4 G A G A TABLE 5. Frequency, Men, SD, nd Sttisticl Groups (S. Gr.) for Esthetic Evlutions by Moment, Exminer, nd Group Fctors Fctors Frequency Men SD S. Gr. P Moment A.157 NS A Exminer O B.001*** O A O C O B Group A.110 NS A NS indictes not significnt (P.05). *** significnt (P.001). drd devitions in percentge ccording to sex, right nd left sides, nd for the totl smple. The men vlues of the NS in percentge ccording to sex nd right nd left sides re shown in Figure 5. The frequencies, mens, stndrd devitions, nd sttistic groups for the esthetic evlutions ccording to the fctors exminer nd group, re exhibited in Tble 5. The men vlues of the esthetic evlutions (grdes) ssigned by ech exminer to groups G1 nd G2 nd men of the evlutions of ll four exminers re shown in Figure 6. FIGURE 7. Esthetic mens ttributed by ech exminer for groups 1 nd 2. Tble 6 shows the esthetic men scores nd stndrd devitions ssigned by ech exminer for groups G1 nd G2, s nlyzed by the Tukey test. Figure 7 shows the esthetic mens ssigned by ech exminer individully for groups G1 nd G2. DISCUSSION The men NS during forced smile for the totl smple ws mm for ech side (Tble 3). In proportion to SW, the men vlue ws % for ech side (Tble 4). Considering both sides of the dentl rch, this study found vlue of 19.20% for the proportion of NS to SW, lrger thn the 9% for cses treted with extrction of premolrs nd 8% for cses

5 202 RITTER, GANDINI, PINTO, LOCKS treted without extrctions found by Johnson nd Smith, 9 with no quntittive or esthetic difference between groups. The lrge difference between the results of this study nd the findings of Johnson nd Smith cn be ttributed to the type of smile nlyzed, nmely, forced smile in the present study becuse of the esier reproduction nd nturl smile in the study of Johnson nd Smith, 9 which is more difficult to reproduce. 4,18,19 Rigsbee et l 11 found proportions of 40% for NS in n orthodonticlly treted group, nd 42% for nonorthodonticlly treted group, with no sttisticl difference between these groups. However, these uthors mesured the NS by Hulsey s 7 method considering the distnce between the mxillry cnines s the lterl limit of the mxillry rch. Using Hulsey s 7 method, Johnson nd Smith 9 did not find ny difference in the proportion of intercnine distnce SW between cses treted without (29%) or with (28%) extrction of premolrs. Becuse of the different methodologies used, comprison of the results of this study with those of of Rigsbee et l 11 nd Johnson nd Smith 9 is limited. Another fctor tht my hve influenced the results, cusing this difference between studies, is the light conditions under which the photogrphs re tken. Becuse teeth re positioned more posteriorly in the buccl corridor, light becomes reduced, which cuses grdul drkening nd consequently less observtion of these posterior teeth. 4 The less-illuminted the photogrph, the lrger will be the NS becuse less teeth will be observed, thus reducing the rch width, wheres the SW is the sme. Therefore, there my hve been differences in the stndrdiztion of light conditions between studies, impiring comprison between them. According to the literture, n estheticlly plesing smile usully shows symmetry nd proportion between teeth, gingiv, nd lips. 3,15,20,21 The position of the mouth corners or lip commisures lso ffects the smile symmetry, nd there must be regressive proportion of the teeth exposure creted by curvture of the dentolveolr rch. 8 There re no specific studies on symmetries relted to the NS. Tble 3 nd Figure 4 show tht the mens of the right (6.52 mm 1.97) nd left (6.84 mm 2) sides of the NS did not show significnt differences (P.05). The men NS proportion to SW ws % for the right side nd % for the left side (Figure 5; Tble 4), with no sttisticl difference between these vlues. These results show presence of symmetry between the right nd left sides regrding the NS in the present study. Few studies in the literture hve investigted whether there is ny difference in the NS between mles nd femles. Tble 3 shows tht the resultnt men NS, on ech side, ws mm for the women nd mm for the men. This ws evidence tht there ws sttisticlly lrger NS in millimeters for the men compred with the women (P.05). On the other hnd, the proportion of NS to SW on ech side ws % for the men nd % for the women (Figure 5; Tble 4), which ws not sttisticlly significnt (P.05). This demonstrted tht the men in this study presented sttisticlly lrger NS thn the women, yet this difference ws not significnt in terms of percentge. This indictes proportionlity of the NS to SW size between sexes, with men showing lrger NS dimensions. Tble 3 shows the men NS in millimeters for the right nd left sides, for both sexes, s shown in Figure 4. The sttisticl nlysis revels tht the possible interction between side nd sex ws not significnt (P.05). The interction between the right nd left sides nd sex ws lso investigted for the NS mesurements in percentge to SW, nd the mens nd stndrd devitions shown in Tble 4 nd Figure 5 lso revel no sttisticlly significnt interction of the fctors side nd sex (P.05). Therefore, in smples of this study, there ws evidence demonstrting tht for both men nd women, the men NS ws sttisticlly similr for the right nd left sides. Similrly, for both right nd left sides, the men presented the lrgest NS in millimeters, yet equl in percentge to the SW s in the women. Tble 5 shows the frequency, mens, stndrd devitions, nd sttistic groups for the esthetic evlutions of the photogrphs of groups G1 nd G2, ccording to exminer nd group. The Tukey test reveled tht exminer O2 (ly individul) ssigned the highest esthetic score (6.887 group A); exminers O1 (ly individul) nd O4 (orthodontist) ssigned the sme men scores (5.498 nd 5.579, respectively group B); nd exminer O3 (orthodontist) ssigned the lowest esthetic score (4.446 group D). A P.05 vlue ws ssocited to the exminer fctor, which ws evidence tht exminers did not ssign equl esthetic scores, regrdless of the group fctor. Despite this difference between the criteri nd prmeters dopted by the exminers for the esthetic evlution, the exminers showed constncy in their evlutions t periods 1 nd 2, reveling tht ll exminers kept their own criteri for esthetic evlution t different moments (Tble 5). The men vlues of the esthetic evlutions ssigned to the photogrphs in group G1 (smller NS) nd group G2 (lrger NS) by exminers re shown on Tble 5 (Figure 6). The Tukey test pplied for the group fctor evidenced tht groups G1 nd G2 belonged to the sme sttistic group. Thus, there ws no sttisticl difference in the esthetic evlutions be-

6 ESTHETIC INFLUENCE OF NEGATIVE SPACE DURING SMILE tween the groups with lrger nd smller NS, mening tht, in this smple, the NS cnnot be considered fctor tht influenced the esthetic evlutions, regrdless of the exminer fctor. Some uthors gree tht the size of NS is not estheticlly criticl, provided it is within the typicl limits of individul differences. 5,6,9 However, these uthors did not provide informtion regrding the extent of this limit, therefore impiring dequte evlution. On the other hnd, other uthors believe tht it is importnt to chieve dequte NS nd minimize the blck spces t the mouth corners. 11,19,22 Rufencht 8 recommends dequte restortion of the lterl NS, llowing smile chrcteriztion in conformity with the individul personlity, yet lso did not specify the dequte size or proportion of the NS. Some studies lso demonstrted tht broder smiles, showing more posterior teeth, re considered more plesnt thn smile tht shows less posterior teeth. 15,23 25 In this study, however, the NS proportion did not influence the esthetic evlutions, regrdless of the exminer fctor. Tble 6 exhibits the mens nd stndrd devitions ssigned to groups G1 nd G2, ccording to the judgment of ech exminer (Figure 7). The Tukey test reveled tht ech exminer ssigned equl men esthetic scores for groups G1 (smllest NS) nd G2 (lrgest NS), mening tht ll exminers considered groups G1 nd G2 sttisticlly identicl regrding the proportion of NS to SW, confirming the lck of influence of the NS on the esthetic evlution of this smple. Therefore, this study reveled tht both orthodontists nd ly people did not consider the NS significnt fctor influencing their esthetic evlutions in this smple. CONCLUSIONS The men NS for ech side ws 6.68 mm ( 1.99). In proportion to the distnce between the lip commisures, the men NS for ech side ws 9.60% ( 2.56). There ws symmetry of the NS between the right nd left sides. The men showed sttisticlly lrger NS thn the women, yet the percentge difference ws not significnt. The NS did not influence the esthetic evlutions of the smile photogrphs. Orthodontists nd ly people did not consider the NS s n importnt fctor influencing their esthetic evlutions. More studies on lip-teeth reltionship re required to help understnd the NS influence on smile esthetics. REFERENCES Shw WC, Rees G, Chrles CR. The influence of dentofcil ppernce on the socil ttrctiveness of young dults. Am J Orthod. 1985;87: Peck S, Peck L. Selected spects of the rt nd science of fcil esthetics. Semin Orthod. 1995;1: Peck H, Peck S. A concept of fcil esthetics. Angle Orthod. 1970;40: Grber LW, Lucker GW. Dentl esthetic self-evlution nd stisfction. Am J Orthod. 1980;77: Ackermn M, Ackermn J. Smile nlysis nd design in the digitl er. J Clin Orthod. 2002;36: Frush JO, Fisher RD. The dynesthetic interprettion of the dentogenic concept. J Prosthet Dent. 1958;8: Hulsey CM. An esthetic evlution of lip-teeth reltionships present in the smile. Am J Orthod. 1970;57: Rufencht CR. Fundmentls of Esthetics. 2nd ed. Crol Strem, Ill: Quintessence Publishing; 1990, Johnson DK, Smith RJ. Smile esthetics fter orthodontic tretment with nd without extrction of four first premolrs. Am J Orthod Dentofcil Orthop. 1995;108: Showfety KJ, Vig PS, Mtheson S. A simple method for tking nturl-hed-position cephlogrms. Am J Orthod. 1983;83: Rigsbee OH, Sperry TP, Begole EA. The influence of fcil nimtion on smile chrcteristics. Int J Adult Orthodont Orthognth Surg. 1988;4: Moskowitz ME, Nyyr A. Determinnts of dentl esthetics: rtionl for smile nlysis nd tretment. Compend Contin Educ Dent. 1995;16: Ackermn JL, Ackermn LB, Bresinger CM, Lndis JR. A morphometric nlysis of the posed smile. Clin Orthod Res. 1998;1: Arnett GW, Bergmn RT. Fcil keys to orthodontic dignosis nd tretment plnning. Prt I. Am J Orthod Dentofcil Orthop. 1993;103: Mrgolis MJ. Esthetics considertions in orthodontic tretment of dults. Dent Clin N Am. 1997;41: Cooke MS, Wei SHY. The reproducibility of nturl hed position: methodologicl study. Am J Orthod Dentofcil Orthop. 1988;93: Kokich VO, Kiyk HA, Shpirfo PA. Compring the perception of dentist nd ly people to ltered dentl esthetics. J Esthet Dent. 1999;11: Eckmn P, Dvidson RJ, Friesen WV. The Duchenne smile: emotionl expression nd brin physiology. J Pers Soc Psychol. 1990;58: Srver DM. The importnce of incisor positioning in the esthetic smile: the smile rc. Am J Orthod Dentofcil Orthop. 2001;120: Allen EP. Use of mucogingivl surgicl procedures to enhnce esthetics. Dent Clin North Am. 1988;32: Jerrold L, Lowenstein LJ. The midline: dignosis nd tretment. Am J Orthod Dentofcil Orthop. 1990;97: Dierkes JM. The beuty of the fce: n orthodontic perspective. J Am Dent Assoc. 1987;89: Dong JK, et l. The esthetics of the smile: review of some recent studies. Int J Prosthod. 1999;12: Snow SR. Esthetic smile nlysis of mxillry nterior tooth width: the golden percentge. J Esthet Dent. 1999;11: Morley J, Eubnk J. Mcroesthetic elements of smile design. J Am Dent Assoc. 2001;132:39 45.

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