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REVIEW

Clinical effectiveness of orthodontic treatment on

smile esthetics: a systematic review
This article was published in the following Dove Press journal:
Clinical, Cosmetic and Investigational Dentistry

Terpsithea Christou 1 Objectives: The aim of this systematic review is to identify how different types of
Anna Betlej 1 orthodontic interventions affect the esthetics of the smile, any time after orthodontic
Najd Aswad 1 treatment.
Dorothy Ogdon 2 Materials and methods: A systematic search of the literature was carried out using 5
Chung How Kau 1 electronic databases (PubMed, Embase, The Cochrane Library, Scopus, Dentistry and Oral
Sciences Source) that included articles until October 2017. Randomized and non-randomized
1
School of Dentistry, Department of
controlled clinical trials, case–control observational studies, and cohort and cross-sectional
Orthodontics, University of Alabama at
Birmingham (UAB), Birmingham, AL, studies with validated data collection and/or follow-up periods reporting on orthodontic
USA; 2School of Dentistry, University of interventions that changed the smile any time after orthodontic treatment were part of the
Alabama at Birmingham (UAB),
Birmingham, AL, USA study protocol. Only studies that were published in the English language and those that had
human patients of any age and gender who underwent orthodontic treatment were included.
Results: A total of 814 articles were found and 9 of them were included (7 cohort and 2
cross-sectional studies). Among the selected articles, 8 stated the type of orthodontic inter-
vention used during treatment and 1 did not specify the intervention. Eight articles were
judged of moderate risk and 1 had high risk of bias.
Conclusion: Orthodontic treatment affects the esthetics of the smile in three dimensions.
There was slight evidence that extractions do not affect the smile width and buccal corridors
area. Evidence on palatal expansion was controversial. The remaining existing data evidence
that investigated smile esthetics after orthodontic treatment was uncertain. Therefore, more
validated, evidence-based studies are needed.
Keywords: smile esthetics, smile design, orthodontics, biomechanics, interventions

Introduction
Improving the appearance of the smile is one of the main reasons patients seek
orthodontic treatment. Understanding the components of an esthetically attractive
smile is essential to achieving patient satisfaction as well as successful treatment
results. In the 20th century, Edward Angle addressed this problem through an
emphasis on achieving optimal occlusion, which was thought to coincide with
appealing smile esthetics.1 This approach remains a central idea in orthodontics,
and orthodontists and other dental practitioners have focused research efforts on
Correspondence: Terpsithea Christou developing and providing guidelines for achieving optimal occlusion through
School of Dentistry, Department of
Orthodontics, University of Alabama at orthodontic treatment. In the past, diagnosis was based on cephalometric analysis
Birmingham (UAB), 1919 7th Avenue combined with photographs of a patient’s profile. Analysis and intentional design of
South SDB 305, Birmingham, AL 35294,
USA the smile were generally underemphasized during treatment planning. As the field
Tel +1 205 934 4547 and available technologies have continued to evolve, a gradual shift toward an
Fax +1 205 975 7580
Email tetich@uab.edu increased emphasis on dental esthetics in treatment planning has occurred, and now

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an esthetically pleasing smile is a key desired outcome of Table 1 Summarized criteria that were applied for this current
orthodontic treatment. Moore et al2 noted that the specific review
components of the smile that are valued for esthetics have Inclusion criteria Exclusion criteria
changed in the last 50 years. Correctly identifying the
Randomized and non- Patients with craniofacial discre-
factors that contribute to the creation of an esthetically randomized clinical trials study- pancies, cleft lip and/or palate, or
pleasing smile by contemporary standards is critical to ing the effect of orthodontic any syndrome affecting the face
supporting professionals who aim to include intentional treatment on smile esthetics
smile design in orthodontic treatment planning. The ortho- Studies written in English Orthognathic cases or Invisalign
cases
dontic and dental literature include a range of information
Patients who underwent ortho- Studies investigating perception
on both soft and hard tissue structures that are components
dontic treatment with any type of laypeople or specialists about
of an esthetic smile. In this article, we have categorized of orthodontic appliance or smile esthetics
information from previous literature searches in three orthodontic treatment method
major divisions of the balanced smile. These divisions Observational studies Studies investigating smile
are the lip line, smile line, and dental components. The esthetics from the lateral aspect
rather than the frontal aspect
first division we describe is the lip line. This includes lip
Editorials
thickness, upper lip length, height of smile (overall or
Letters
posteriorly), gingival display at smiling, inter-labial gap, Case reports
and upper lip curvature/shape. The second division we
describe, the smile line, includes smile arc, buccal corri-
dors, cant of occlusal plane, upper incisor inclination, last component known to contribute to the creation of
posterior tooth visible, smile width/index ratio, smile sym- a balanced smile. Our aim in writing this review was to
metry, vertical maxillary height, and facial/dental midline. gather information on smile design related to orthodontic
The third division includes micro-esthetics of dental com- treatment only. Because the focus of our question was
ponents of the smile, upper incisor ratio/size/symmetry, solely outcomes following orthodontic treatment alone,
upper incisor inclination, upper incisor angulation, upper studies that reported data concerning treatment strategies
incisor vertical position, tooth color, and incisal that included implants or treatment systems that are not
embrasures.3–8 To date, not many studies in the literature considered conventional orthodontic methods (such as the
have been systematically reviewed in such a manner. Invisalign system) were not included. Studies that included
The aim of this systematic review was to identify data on outcomes of orthognathic surgery were also
studies that report the biomechanical effects of orthodontic excluded because orthognathic surgery in conjunction
treatment on the esthetics of the smile and determine how with orthodontic treatment may alter smile outcomes in
the smile is affected in the three planes of space: vertical, ways that are not similar to the effects on smile appearance
transverse, and sagittal. following orthodontic treatment alone.
Studies to be considered for review were identified by
Materials and methods thorough searches of electronic databases as well as hand-
This carefully designed systematic review was created and searching reference lists and consultations with experts in
the results reported according to guidance provided by the the field of orthodontics. Our group developed a search
Preferred Reporting Items for Systematic Reviews and strategy for use in PubMed that was adapted for use in
Meta-Analysis (PRISMA) guidelines and the Cochrane Embase, The Cochrane Library, Scopus, and Dentistry and
Handbook for Systematic Reviews of Interventions.9–12 Oral Sciences Source. The initial search was developed in
The protocol and research question of this narrative review June 2017, and the final search update for this project in
was created based on the Problem, Intervention, each selected database was carried out on October 9th,
Comparison, Outcome (PICO) format.13 2017. The searches were not limited by date. The search
The eligibility criteria for study inclusion were pre- strategies used in PubMed are reported in Table 2. The
determined and are summarized in Table 1. A study was initial development of search strategies and database selec-
considered eligible when it reported the outcomes of at tion for this review were completed in collaboration with
least one orthodontic intervention known to affect the Dorothy Ogdon, Assistant Professor and Reference
appearance of the smile or at least one treatment Librarian. Once database searching was complete,

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Table 2 Search strategies from selected databases

Database Key words Search Result Result

strategy with without
duplicates duplicates
PubMed 1) “Smiling”[Mesh] OR “Orthodontics”[Mesh]; 2) smile AND orthodontic A- 1 and 2 97 69
AND esthetic; 3) Randomized Controlled Trial OR RCT OR Clinical Trial and 3.
OR clinical trial OR Review; 4) smile AND orthodontic AND aesthetic; 5) B- 1 and 4 and
smile AND orthodontic AND improvement; 6) smile AND orthodontic 3.
AND enhancement; 7) smile AND orthodontic AND attractive. C- 1 and 5
and 3.
D- 1 and 6
and 3.
E- 1 and 7 and
3.
Embase 1) smile; 2) orthodontics; 3) aesthetic; 4) esthetic; 5) improvement; 6) A- 1 and 2 391 144
enhancement; 7) attractive. and 3.
B- 1 and 2 and
4.
C- 1 and 2
and 5.
D- 1 and 2
and 6.
E- 1 and 2 and
7.
The Cochrane 1) smile; 2) orthodontics; 3) esthetic; 4) aesthetic; 5) improvement; 6) A- 1 and 2 50 32
Library enhancement; 7) attractive. and 3.
B- 1 and 2 and
4.
C- 1 and 2
and 5.
D- 1 and 2
and 6.
E- 1 and 2 and
7.
Scopus 1) smile AND orthodontics AND esthetic; 2) clinical trial OR randomized A- 1 and 2. 272 96
trial OR randomized controlled trial; 3) smile AND orthodontics AND B- 3 and 2.
aesthetic; 4) smile AND orthodontics AND improvement; 5) smile AND C- 4 and 2.
orthodontics AND enhancement; 6) smile AND orthodontics AND D- 5 and 2.
attractive. E- 6 and 2.
Dentistry and 1) orthodontics; 2) smile; 3) orthodontic; 4) esthetic; 5) randomized A- 1 and 2 4 2
Oral Sciences controlled trial OR clinical trial; 6) aesthetic; 7) improvement; 8) and 3 and 4
Source enhancement; 9) attractive. and 5.
B- 1 and 2 and
3 and 6 and 5.
C- 1 and 2
and 3 and 7
and 5.
D- 1 and 2
and 3 and 8
and 5.
E- 1 and 2 and
3 and 9 and 5.

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deduplication was carried out using tools available through inclination; 3, incisor angulation; 4, incisor vertical position;
EndNote citation management software. Following dedu- 5, tooth color; 6, incisal embrasures). Examples of the forms
plication, three investigators independently evaluated the are provided in Tables 3 and 4. In the case of unreported or
titles and abstracts of retrieved studies for relevance based unclear information referring to the included studies, the
on the eligibility criteria reported in Table 1. Following authors were contacted via email for clarification.To assess
title and abstract screening, the remaining articles were the quality of the studies selected for inclusion, the authors
further reviewed for relevance to the research topic. Any reviewed each selected study independently, and any dis-
disagreements on whether a study met the inclusion cri- agreements were resolved through group consensus. There
teria were resolved by discussion amongst all three are many validated methods available in the literature that can
investigators. be used to assess the overall quality and risk of bias in
To facilitate detailed investigation of the effects of ortho- individual studies.10,11 For the purposes of this review, if
dontic treatment on smile esthetics, data for different types of randomized controlled trials were identified for inclusion,
orthodontic interventions (eg, extractions, self-ligating brack- the Cochrane Collaboration’s risk of bias tool was used to
ets, rapid palatal expander, biteplane, intrusion arch) were assess risk of bias;10 the Newcastle-Ottawa scale was used11
categorized according to the primary focus of correction. The to assess the risk of bias in non-randomized studies. The
categories included as possible options for the primary focus Newcastle-Ottawa scale was designed to be used to assess
of correction are: vertical correction (eg, with a biteplane or risk of bias in case–control and cohort studies and includes
intrusion arch), transverse correction (eg, with a rapid palatal criteria referring to the selection, comparability, and expo-
expander), or sagittal correction (eg, with extractions). sures of the study or criteria referring to the selection, com-
Changes in the smile as the primary outcome following parability, and outcome measures, respectively. For the cross-
orthodontic treatment were based on measurement results sectional studies, a modified version of this scale was used to
on variables that constitute a balanced smile. The variables assess risk of bias. Regardless of which scale was used to
included in this article were summarized according to smile evaluate a study, the criteria for rating the bias of publication
line, lip line, and micro-esthetics (Table 4). were organized into 8 parameters. A star system was used to
To facilitate efficient collection of data on both types of assign a rating; each parameter was awarded 1 star or
orthodontic interventions, the primary focus of correction, a maximum 2 stars for comparability questions. Studies that
and measurement results, original data extraction and col- received 8, 7, or 6 stars using this rating system were con-
lection forms were developed and used by two reviewers sidered to have moderate risk of bias, whereas studies that
to independently collect data from each study selected for received 5 or fewer stars were considered to have a high risk
inclusion. Two reviewers extracted and recorded data from of bias. Studies that received the maximum allowed amount
studies selected for inclusion; the third reviewer checked of 9 stars were considered to have a low risk of bias.
information reported on the data extraction forms and Due to a wide variability in reported outcomes across
refined reported information as needed. studies selected for inclusion the information from
The first form was used to collect the following informa- selected studies could not be compared statistically, and
tion: 1) author and year of publication; 2) study design; 3) the group was not able to perform a meta-analysis.
participants (sample size, ages before treatment, sex); 4)
intervention; 5) method (tools used for data acquisition); 6)
author’s conclusion; and 7) risk of bias. The second form Results
was used to collect information on esthetic elements of the Study characteristics
smile, including: 1) author and year of publication; 2) ortho- After the initial search, 814 articles were retrieved. Further
dontic treatment; and 3) parameters, divided into the subsec- searches returned 343 articles after duplicate articles were
tions a) smile line parameters (1, buccal corridors; 2, smile removed. An additional 8 articles were identified by con-
arc; 3, occlusal cant; 4, smile width/index; 5, last tooth tacting authors for relevant studies and by handsearching.
visible; 6, maxillary height; 7, smile symmetry; 8, facial/ Titles and abstracts were reviewed for 351 articles and 17
dental midline), b) lip line parameters (1, upper lip length/ articles were retrieved for full text assessment. After
thickness; 2, height of smile; 3, gingival/incisor display; 4, detailed assessment of the quality, 8 articles complied
interlabial gap; 5, lip curve/shape), and c) micro-esthetic with the eligibility criteria and therefore were included
parameters of the smile (1, upper incisor ratio; 2, incisor for final study in this review.21–18 Figure 1 shows a flow

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 Table 3 Characteristics of included studies
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Author (year) Study Participants Intervention Method Authors’ conclusion Risk of

design bias
Akyalcin et al (2017)14 Cohort 53 subjects Extractions At T1=pre treatment, T2=4 years+2 months, 1. Premolar extractions did not have any adverse effects on Moderate
(19 males, 34 T3=17 years+8 months, study model analysis; the transverse dimension of the maxillary dentition
females); smile analysis on digital pictures 2. Buccal corridor ratios were not negatively affected by
28 extraction, extraction treatment as compared to non-extraction
25 non-extraction treatment
3. Long-term changes in buccal corridor ratios were com-
parable in both groups
Shook et al (2016)15 Cohort 84 patients: Self-ligating At T1=pre treatment and T2=post treatment. Post-treatment arch width increase is likely to be seen Moderate
- Conventional brackets Treatment time duration: self-ligating: in patients treated by either conventional or Damon

Clinical, Cosmetic and Investigational Dentistry 2019:11

brackets N=45, mean=21.8–23.95 months and conventional: self-ligating brackets.
(male 22, female 23); mean=22.85–26.43 months; It is highly unlikely that there is any significant difference
- Damon self-ligating photographs and digital model measurements; in buccal corridor width between patients treated with
N=39, (male 19, pre-treatment cephalograms were digitized to either system
female 20); mean determine the vertical facial pattern
age=15.13 years
Mah et al (2013)16 Cohort 46 subjects (18 Extractions Cephalograms; 1. The change in the curvature of the smiling was found to Moderate
males, 28 females); digital study models be related more significantly to the magnitude of difference
mean age 16.6±4.2 pre and post orthodontic treatment in the inclination between the pre-treatment anterior
years; Class II occlusal plane and the functional occlusal plane than to the
Division 1 change in the inclination of the maxillary incisors
2. The change in the maxillary intercanine width did not
influence the curvature significantly
Carvalho et al Cohort 27 subjects (15 RME palatal 81 extraoral photographs of maximum smile RME was beneficial for the smile esthetics and resulted in an Moderate
(2012)17 females, 12 males); expander before expansion and 3–6 months after fixation increase of the transverse smile dimension and exposure of
mean age 10 years+3 of the expanding screw maxillary central and lateral incisors. However, lip thickness
months and buccal corridors remained unchanged
Tauheed et al (2012)18 Cohort 57 subjects (45 males, Extractions Study model analysis; Golden proportions were improved after orthodontic High
12 females); digital pictures analysis pre and post orthodon- treatment.
31 non-extraction, tic treatment There was a significant difference between the post-treat-
26 extraction; age ment micro-esthetic values between non-extraction and
12–30 years extraction groups. The non-extraction group was found to
be closer to these proposed norms

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(Continued)

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Table 3 (Continued).

Author (year) Study Participants Intervention Method Authors’ conclusion Risk of

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design bias

Yang et al (2008)19 Cross- 92 subjects (19 Extractions Cephalometric analysis; Extraction and non-extraction treatment did not affect Moderate
sectional males, 73 females); study models analysis; the buccal corridor area
36 non-extraction, digital pictures analysis
56 extraction
Maulik and Nanda Cross- 230 subjects; RME palatal Videos taken while smiling 1. The orthodontically treated group demonstrated Moderate
(2007)20 sectional 73 non-orthodontic expansion significantly more parallel smile arcs compared with the
treatment (tx); untreated group
70 orthodontic tx 2. The RME group showed significantly less buccal cor-
with RME; ridor on smiling
87 orthodontic tx 3. The RME group had significantly fewer posterior
without RME; age maxillary teeth visible on smile compared to the non-
14–35 years expanded group
4. The coincidence of high posterior smile height and
reverse smile arc is statistically significant
Lindauer et al (2005)21 Cohort 20 subjects: Bite plate Cephalometric analysis; About half of the patients in both the intrusion arch and Moderate
-10 intrusion arch and study models analysis; the bite plate groups experienced flattening of the smile
-10 bite plate intrusion arch pictures analysis at T1=pre treatment and arc during the overbite correction phase of treatment
T2=post overbite procedure correction: Bite
plate mean duration=3.7±1.2 months and
intrusion arch duration =4.6±1.5 months
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Table 4

Author (year) Orthodontic Smile line parameter

treatment
Buccal Smile Occlusal Smile Last Maxillary
corridors arc cant width/index tooth height
visible
Akyalcin et al (2017)14 X X X
Shook et al (2016)15 X X X
Mah et al (2013)16 X X
Carvalho et al (2012)17 X X X X
Tauheed et al (2012)18 X
Yang et al (2008)19 X X
Maulik and Nanda (2007)20 X X X X
Lindauer et al (2005)21 X X X

Author (year) Orthodontic treatment Smile symmetry Facial/dental midline

Akyalcin et al (2017)14 X
Shook et al (2016)15 X
Mah et al (2013)16 X
Carvalho et al (2012)17 X
Tauheed et al (2012)18 X
Yang et al (2008)19 X
Maulik and Nanda (2007)20 X
Lindauer et al (2005)21 X

Author (year) Orthodontic Lip line parameter

treatment
Upper lip Height of Gingival/ Inter- Vertical Lip
length/ smile incisor labial maxillary curve/
thickness display gap height shape

Akyalcin et al (2017)14 X
Shook et al (2016)15 X
Mah et al (2013)16 X
Carvalho et al (2012)17 X X X
Tauheed et al (2012)18 X
Yang et al (2008)19 X
Maulik and Nanda (2007)20 X
Lindauer et al (2005)21 X

Author (year) Orthodontic Micro-esthetic parameter of smile

treatment
Upper inci- Incisor Incisor Incisor Tooth Incisal
sor ratio inclination angulation vertical color embrasures
position
Akyalcin et al (2017)14 X
Shook et al (2016)15 X
Mah et al (2013)16 X
Carvalho et al (2012)17 X
Tauheed et al (2012)18 X X
Yang et al (2008)19 X
Maulik and Nanda (2007)20 X
Lindauer et al (2005)21 X X

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Identification
Records identified through Additional records identified
database searching through other sources
(n=814) (n=8)

Records after duplicates removed

(n=343+8)
Screening

Records screened Records excluded

(n=351) (n=334)

Full-text articles assessed Full-text articles excluded,

Eligibility

for eligibility with reasons

(n=17) (n=8)

Studies included in
quantitative synthesis
Included

(n=8)

Figure 1 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram showing a graphical representation of the flow of citations reviewed
in the course of this current review.
Note: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009) Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement.
PLoS Med 6(7): e1000097. 2009 Moher et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License. 37

chart of this study, according to the PRISMA statement, their study design when compared to study controls for the
with the number of articles found at the initial retrieval, factor that was being investigated. All studies in this
screening, and final selection for this review. Tables 3 and review used orthodontics and assessed how the mechanics
4 summarize the characteristics of the included studies. No of orthodontic intervention influenced the appearance of
randomized controlled trials or case–control studies were the smile and its parameters. All 8 studies described the
found to be eligible for this review. The study designs for treatment protocol and orthodontic intervention.
8 publications that met the inclusion criteria were 2 cross-
sectional studies and 6 cohort studies. After evaluation of
the quality of the studies, 8 of the studies were judged to Outcomes
have moderate risk of bias and 1 was judged to have high The study parameters for the systematic review are
risk of bias. None of the studies were considered to have present in three broad categories: vertical, transverse,
low risk of bias. Most of the studies failed to show follow- or sagittal foci of correction representing changes to
up outcomes or failed to adequately explain the analysis of the smile in the respective dimensions of space.

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The studies selected for inclusion in this review are sum- On the contrary, Carvalho et al17 showed that buccal corri-
marized as follows: dors remain unchanged after rapid palatal expansion. The
authors evaluated 27 patients in 3 different time frames: T1,
1. One article described an orthodontic treatment to before expansion; T2, 3 months after expansion; and T3, 6
correct a vertical problem. months after expansion. Buccal corridors were shown to
2. Five articles described correction of a transverse decrease on the right side and remain unchanged on the left
discrepancy. side. In the conclusion it was claimed that buccal corridors
3. Two articles addressed sagittal problems. did not show any clinically significant difference before and
4. Five studies that described the correction of after treatment. They stated that rapid palatal expansion
a transverse discrepancy reported outcomes on the does not affect buccal corridors when compared before
use of rapid palatal expanders, self-ligating brack- and after orthodontic expansion.
ets, and extractions. Another study in this category15 evaluated how self-
5. Finally, two studies that described corrections of sagit- ligating brackets affect the smile and its parameters compared
tal problems reported outcomes on the use of extrac- to conventional brackets. The results showed that there is not
tions to correct Class II malocclusion or crowding. significant difference for the smile esthetic outcome whether
Damon self-ligating or conventional brackets are used. Both
increase the arch width and decrease buccal corridors. The
Smile esthetics after orthodontic
authors concluded that it is highly unlikely to have any sig-
intervention with primary focus on nificant difference in buccal corridor widths between patients
correcting vertical orthodontic problems treated with Damon self-ligating or conventional brackets.
Lindauer et al21 investigated how intrusion arch vs bite plate Akyalcin et al38 compared long term changes (up to 17
can correct a deep overbite and explained the different years) between extraction vs non-extraction groups before and
mechanics that there are used in each case. They found after orthodontic treatment. This study included 53 patients, 28
that both accomplish satisfying correction of the overbite, had premolar extractions and 25 had non-extraction treatment.
but both are likely to cause some degree of flattening of the The authors concluded that extractions do not affect the trans-
smile arc during treatment. The intrusion arch, however, will verse maxillary arch width or the buccal corridors.
decrease the maxillary incisor exposure due to the intruding Furthermore, long term results (at 4 and 17 years post treat-
mechanism and can lead to significant flattening of the smile ment) showed similar outcomes between the 2 study groups.
arc. The authors suggested that the flat smile arc could be Another study by Yang et al19 evaluated differences of buccal
corrected to some degree using flat continuous arch wires in corridor areas in extraction vs non-extraction orthodontic
the later stages of orthodontic treatment. This action will treatment. The authors referenced literature that suggests buc-
bring the maxillary incisors closer to their initial vertical cal corridors are controlled by the vertical skeletal pattern of
position and therefore create a more parallel smile arc. the face, the amount of upper incisor exposure, and the sum of
the tooth material. The results supported the fact that the more
Smile esthetics after orthodontic hyper-divergent vertical skeletal pattern present in a patient,
the less buccal corridor exposure was present. In addition, the
intervention with primary focus on narrower the inter-molar distance, the larger buccal corridors.
correcting transverse orthodontic Finally, there was no statistically significant correlation
problems between extractions and buccal corridors area exposure.
In this group, 2 studies assessed how the smile changes after
rapid maxillary expansion (RME). Maulik and Nanda20
evaluated the smile of 230 subjects divided into 3 groups:
Smile esthetics after orthodontic
a) non-treated; b) orthodontically treated without RME; and intervention with primary focus on
c) orthodontically treated with RME. It was found that the correcting sagittal orthodontic problems
orthodontically treated group appeared to have more paral- Mah et al16 investigated how orthodontic correction of 46
lel smile arcs with the lower lip, compared to the untreated Class II Division I cases who were treated with maxillary
group. The authors also showed that rapid palatal expansion first premolar extractions will affect the patients’ smile arc
decreases the exposure of buccal corridors after treatment. in regard to the lower lip. The authors examined their

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results based on differences in the occlusal plane, maxil- asked to rate patients’ smiles.25 The result showed either
lary incisor inclination, and inter-canine distance, before very week relationships or no correlation between the ABO
and after treatment. This study showed that extraction of Objective Grading System factors and smile esthetics.
upper premolars to correct a maxillary sagittal discrepancy There have also been proposals38,19 that extraction treat-
results in deepening of smile line curvature. This occurs ment have no effect on the smile width and buccal corridors.
due to clockwise rotation of the anterior occlusal plane and In addition, Yang et al19 suggested that the initial facial
reduction of proclination of maxillary incisors. However, pattern, maxillary inter-molar distance, and sum of teeth
the authors did not find any clinically significant difference material are the factors that will determine the buccal corri-
of the smile arc due to an increase of the inter-canine dor exposure, not the extraction component. It is worth
distance during Class II Division I correction. underlying that the authors of these 2 studies used different
In another study, Tauheed et al18 evaluated a total of 53 definitions of buccal corridors. In the first study, buccal
patients and attempted to assess whether the ratio of the teeth corridors refer to the linear definition of the term which is
affects smile attractiveness. They concluded that it was very described as the space between the corners of the lips at
challenging to achieve ideal teeth ratios in every case and that smiling and the last visible posterior teeth. In the second
orthodontic treatment improves micro-esthetics such as max- study, buccal corridors are defined as the area distal to the
illary central incisor crown width–height ratio, connectors lateral incisors up to the corners of the mouth. A meta-
between maxillary anterior sextant, gingival zenith level of analysis26 that was published in 2015 investigating the
the maxillary lateral incisor, and golden percentage22 of the effectiveness of tooth extraction and non-extraction treat-
anterior teeth, regardless of whether extractions were per- ment on smile esthetics could not conclude that an extrac-
formed or not. However, these micro-esthetic parameters tion treatment will affect the esthetics of the smile.
showed greater deviation from the golden proportion ratio Therefore, their conclusions are in agreement with our
values in extraction cases compared to non-extraction ones. findings in this review. In addition, Meyer et al27 conducted
a retrospective study and evaluated arch width and buccal
Discussion corridor changes before and after orthodontic treatment.
This review aimed to identify studies that report the effects The final sample size in that study consisted of 57 patients
of orthodontic treatment alone on the esthetics of the smile (30 had 4 premolar extractions and 27 had no premolar
at any time following the completion of therapy and extractions). Among other intra-oral measurements (inter-
determine which components of smile attractiveness have canine and inter-molar maxillary distance), Meyer et al also
been systematically evaluated in previous clinical studies. measured buccal corridors between the extraction and non-
This current review highlights the fact that different extraction groups. They did not find any significant differ-
orthodontic interventions appear to correlate significantly ences before and after orthodontic treatment for these two
with the smile esthetic result. Orthodontic treatment may groups. These results are in agreement with Akyalcin et -
influence one or more parameters that affect smile esthetics. al’s38 and Yang et al’s19 studies as well.
Extraction biomechanics seem to be of the most important Tauheed et al18 focused on the proportions of the smile
concern for researchers regarding their influence on smile and found that teeth ratios after extraction treatment of
esthetics.38–18 Palatal expanders also have been connected maxillary premolars will deviate more from the golden
to have an effect on the smile,20,17 followed by self-ligating proportion ratios than in non-extraction cases. Hence, to
brackets15 and intrusion devices.21 them, it is of great importance to preserve the micro-
Even though similar studies have been done, these have esthetics in the finishing stages when extraction mechanics
been from information on smile esthetics from the layper- are used in orthodontic treatment. Mah et al,16 on the other
son's point of view.23,24 A study by Akyalcin et al14 used hand, focused on the smile arc changes after maxillary
a sample size of 462 patients who were, according to ABO premolar extractions. According to Sarver,3 a harmonious
clinical examination, successfully treated. Subjects were smile should have the smiling line curvature created by the
rated by 30 panel members for their smile attractiveness. incisal edges of the upper teeth or else the smile arc to be
The results showed a harmonious smile arc and less gingi- parallel with the lower lip. Mah et al highlighted the fact
val display to be key factors for an attractive smile. that the smile arc can be affected by three factors: the
A similar study used records of 48 orthodontically treated difference between the inclination of the anterior occlusal
patients. Twenty-five orthodontists and 20 laypeople were plane and functional occlusal plane, the maxillary incisor

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inclination, and the inter-canine width. According to the Carvalho et al’s study was a cohort. They used a smaller
results of his Class II Division I study group, the smile arc sample size of 27 people but evaluated results in three
is expected to increase after space closure in maxillary different time frames: T1, before expansion; T2, 3 months
premolar extraction cases. According to this study, it is after expansion; and T3, 6 months after expansion. The
important that cephalometric data are incorporated in the mean age of this group was 10 years and 3 months. In
treatment plan to improve or maintain the curvature of the addition, only for this study do we have information on the
smile arc. Mah et al’s findings are referring to the increase patient’s initial severity of the transverse dimension. All
of the smile arc after clockwise rotation of the anterior patients included in Carvalho et al’s study presented with
occlusal plane, in accordance with previous studies by initial unilateral or bilateral cross-bite. As we can notice,
Ackerman and Ackerman8 and by Lombardi.2828 Several these 2 studies used different research design and inclusion
authors have mentioned that the effect of maxillary incisor criteria, and this is one of the limitations when it comes to
inclination is in regard to the smile arc.8,28,29 Their studies comparing their results. Therefore, it is of great impor-
show that over-proclination of the maxillary incisors will tance that more studies become available and more evi-
have a negative effect on the smile esthetic due to flatten- dence exists in relation to the effect of the palatal expander
ing of the smile arc. This concept is found to be in agree- on the smile and more specifically on buccal corridors.
ment with Mah et al’s study. On the contrary, Mah et al did A systematic review published in 2011 evaluated the buc-
not find a significant change of the smile arc due to an cal corridors and smile. Two articles concluded no correla-
increase of the inter-canine distance, whereas Sarver and tion between buccal corridors and smile attractiveness.
Ackerman30 suggested that the smile arc is also expected Eight articles concluded that less attractive smiles will
to flatten after an increase of the inter-canine distance. result from large buccal corridors.31
Maulik and Nanda20 studied the connection between Further investigation into the effect of intrusion devices
expansion of the upper arch using a palatal expander and on the smile and its parameters is required. In this study,
buccal corridor/smile esthetics. The authors used the per- only 1 study was found to qualify for this review. Both the
centage of represented buccal corridors in the total smile intrusion arch and bite plane cause some degree of flatten-
width as an indicator of a narrow smile. This description ing of the smile arc, with the first leading to more severe
was initially introduced by Moore et al in their article results due to the possible significant intrusion of the max-
“Buccal corridors and smile esthetics”2 In this study, illary incisors as a consequence of the biomechanical effect
Moore et al defined ranges of buccal corridors as follows: of the intrusion arch.21 Due to lack of information from
28% of buccal corridors would represent a medium- other studies it is difficult to have a clear judgment regard-
narrow smile, 15% a narrow smile, 10% a medium-broad ing the exact side effects on the smile of intrusion arch, bite
smile, and 2% a broad smile fullness. Maulik and Nanda plate, and a variety of other intrusion devices that are used
found buccal corridor results to be significantly different in orthodontics on a daily basis. Studies3,8,32 agree that
between the expanded (9.6%) and non-expanded (11%) maxillary incisor intrusion might possibly cause flattening
groups. The group that underwent orthodontic treatment on the smile arc with negative effect on the final orthodontic
with a palatal expander showed significantly less buccal outcome. Therefore, these devices seem to have
corridors on smiling. Carvalho et al17 also tested how a significant impact on smile and further studies are needed
palatal expanders affect the smile esthetics. The authors to provide evidence-based data.
found that expanders seemed to increase the smile width Finally, the analysis of the use of different bracket
and exposure of the maxillary central and lateral incisors systems on smile esthetics found only 1 eligible study.
but lip thickness remain unchanged. These researchers did Following the introduction of self-ligating brackets, sup-
not find a statistically significant decrease for buccal cor- porters of this system claimed that improved smile
ridors. They used the linear definition of buccal corridor esthetics can be achieved. Furthermore, statements have
for their measurements. Results for the buccal corridors in been made that self-ligating brackets can increase the
the last 2 studies contradict each other. Comparing these smile width and decrease the buccal corridors and produce
two studies, Maulik and Nanda’s study was a cross- fuller, broader smiles. This concept was not proven
sectional study with a sample size of 230 subjects and because the authors15 tested the hypothesis of whether
used videos to evaluate their results. The age of the parti- the Damon self-ligating bracket system had a different
cipants was between 14 and 35 years. On the other hand, effect on buccal corridors compared to traditional brackets

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