Esthetics: Patients\' Perceptions of Dental Attractiveness

CLINICAL RESEARCH Esthetics: Patients’ Perceptions of Dental Attractiveness WilliamJ. Dunn, DDS, * David F. Murchison, DDS, f andJames C. Broome, DDS$ Purpose: The importance of dentofacial attractiveness to the psychosocial well-being of an individual has been well established. Very little information is available regarding dental patient perceptions of a pleasing esthetic image. The purpose of this study was t o identify factors distinctive t o attractive smiles versus unattractive smiles, as perceived by patients. Materials and Methods: Standardized format photographs (5 x 7 in, matte finish, at f-32 and 1:2 magnification) of eight male and eight female smiles, framing only lips and teeth, were viewed by 297 subjects. The smiles exhibited differences in symmetry, tooth shade, number of teeth displayed, and height of maxillary lip line, and included both restored and unrestored teeth. Respondents ranked the photographs in order from most t o least appealing appearance. Respondents viewed each series of photographs in a similar lighting and time period. A questionnaire identified the respondent’s age, sex, race, education, income, and home town. Twenty-five demographic groups were established from the information in the questionnaire. Data were analyzed using stepwise discriminant analysis to determine the combination of smile characteristics that best predicted the ranking. Results: The same female smile was chosen as the most attractive by 24 of the 25 demographic groups. This smile is characterized by natural teeth having light shade, high lip line, a large display of teeth, and radiating symmetry. Two female smiles typified by darker shade and asymmetry were rated by all groups as being least attractive. Two male smiles were judged equal as the most pleasing esthetically. Respondents favored those smiles characterized by light shade, a moderate display of teeth, moderate lip line, and a symmetrical arrangement of teeth. One male smile characterized by darker shade was rated as least attractive. Conclusions: In all cases, tooth shade was the most important factor, followed in sequence by unrestored natural teeth and number of teeth displayed. No correlation was found to exist between specific demographic groups and smile variables. Jfrosthod 7996:5:166-171. Copyright o 1996 by the American College of Prosthodontists. INDEX WORDS: esthetic dentistry, smiles, dental morphology, patient expectations

OCIETY PL4CES great emphasis on physical

S

attractiveness, and a major component of facial attractiveness is the smile. An attractive smile is an asset that can greatly affect certain aspects of a person’s lifestyle. This could place a dccided disadvantage socially and professionally on those individuals with unattractive smiles. The public is inundated

*Major, US AirFurce, Dental Corps, HoirrardL4irForce Bnre, Panama. ?Lieutenant Colonel, US Air Force, Dental Corps, Depuy Dzreclvr, ildvanced Educational ProLyamin General D e n t i s t y z y e a r , 81sl Den101 Squadronl SGD,KeeslrrAir Fmce Base, MS. $Lieutenant Colorid, US Air Force, Dental Corps, Direclur, Akianced EducatiunalProgravn in General Dentistv, 60th Medical Groul, Travis Air Farce Base, CA. Accepted 1I4q28,1996. Prmiom!y presented as an abstract at tlrt. 72nd General Session ofthe lntemational Associalion ofDenta1Research, Senttle, W, March 1994. Cmespoiz&nce to: Lt Col Dacid F. hiurchison, 81.rt MDGIDS, 606 Fisher Sl, Kee.tkAFB, MS 39.534-2567. CoDright 01996ky the American CollegeoJProssthodontists 1059-94lx’l~6l0~03-0003~~.00l0

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daily with advertising portraying images of white teeth in perfect alignment and symmetry. Considerable research has beer1 conducted on the technical aspects of esthetic restorative materials and procedures, but very little information exists regarding patients’ perceptions of dental attractiveness.’ The importance of dentofacial attractiveness to the psychosocial well-being of an individual has been well documented.‘-6 Research by Shaw4 and others has shown that dentofacial appearance had a very strong influence on young adults and their preference for friends. A number of studies have documcnted the effects of dental attractiveness on interpersonal relationships.i-’OIn comparison with less attractive persons, those judged more attractive generally are regarded as more popular,”-’+ are more desired as dating partners,l5>Ib are attributed to have more socially desirable characteristic^,^>" and are perceived as having greater intelligence and educational p~tential.~~Angle stated that “the mouth

Journal nfPrasthodontics, Vol5,N o 3 (Sepmbw), 1996pp 166-171

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September 1996, Volume 5, iliumber 3

is a most potent factor in making or marring the beauty and character of the face.”IgNearly a century later, this statement still holds true. Studies of eye movemerit show that, in a face-to-face situation, the eyes primarily scan the other person’s eyes and the area of the mouth, with little time spent in observation of other feature^.^ As far back as 1914, dentists tried to harmonize the face with teeth. Williams20claimed that the most pleasing appearance is one in which the inverted outline form of a person’s face and the outline form of the individual’s maxillary central incisor are identical. This became the basis for the Trubyte system of denture teeth; this classification is still being taught in some dental srhools.*’ Another addition to Williams’ idea of esthetics was an attempt by Frush and Fisherz2to harmonize the teeth with a patient’s sex, personality, and age. In 1980, Brisman‘j compared the esthetic concepts of dentists and patients. One thousand four hundred twenty-one dental patients, dental students, and dentists from the New York City area evaluated drawings and photographs of maxillary antenor teeth of varying shape, symmetry, and proportion, and ranked them according to their preferences. According to Brisman’s study, patients prefer a tooth arrangement in which incisal edges of maxillary anterior teeth are almost in the same plane or horizontal symmetry. Dentists preferred a greater amount of radiating symmetry by raising the incisal edge of the maxillary lateral incisor off the plane created by the central incisors. Patients also rejected the horizontal asymmetry for which dentists often strive in an attempt to avoid an artificial look. Cephalometrics has become a quick and simple method of analyzing the dentition. In an attempt to establish quantifiable esthetic standards, some orthodontists relied heavily on cephalometric data alone. It was found that additional factors are necessary to define the attractive smile.24 Regarding dental patient perception of personal esthetic image, the literature suggests that most people think that their ?miles can be improved e ~ t h e t i c a l l y .Goldstein ’ ~ ~ ~ ~ ~ reported ~ that, in a group of beauty pageant contestants, 80% thought that their smiles could be impr~ved.~’ Women also tended to be harsher judges on attractiveness?6 Studies have repeatedly shown that the preferences of dentists and patients differ ~ignificantly.~~,~’-~* The purpose of this investigation was to identify and draw conclusions about what the general population considers

distinctive factors that contribute to an attractive smile.

Materials and Methods Photographs of eight male and eight female smiles were selected for study from a group of more than 100 smiles. Both restored and unrestored teeth were included. The photographs depicted smiles with varying tooth shades, number of teeth displayed, height of maxillary lip line, smile symmetry, and natural versus restored teeth. The term “tooth shade” in this study refers predominantly to the value (relative brightness) of the teeth. AU photographs were made under the same conditions by the same photographer, camera, and film (frontal view, 1.2 magnification with an Olympus OM-1 camera [Olympus Optical Co, Ltd, Tokyo,Japan] with 105-mm rotatingpoint flash at f-32 and Ektachrome 100 HC film [Eastman Kodak Co, Rochester, Nu]. Photographs sized at 5 X 7 in were produced via internegatives and mounted on 6 X %in 18% gray cards. Respondents to the surveywere chosen at random from the military community of Keesler Air Force Base and from the Biloxi/Gulfport, MS, metropolitan area. Keesler Air Force Base is a large facility whose population represents diverse regional, cultural, and educational backgrounds. A booth was set up outside the base exchange and at the civilian shopping mall where avaried sample of male and female respondents were asked to rank the photographs for overall appearance and attractiveness. Respondents were allowed to move and organize the photographs until they achieved a definite rank order. Following this, the respondents completed a questionnaire identifjing their age, sex, race, educational level, income level, and geographic regional area (Fig 1). The rank ordering of the smiles was transformed into a score for each smile. Within each demographic subgroup, and for the overall analysis, the scores for each smile were averaged. A panel of dentists rated each smile photograph for specific characteristics of shade, natural versus restored teeth, width of teeth displayed, smile symmetry, and height of lip line. These factors were the independent variables used for the statistical analyses of the rankings. Stepwise discriminant analysis was used to predict characteristics that alone, or in combination: best predicted smile attractiveness. Male and female smiles were studied separately, and, within each sex, an overall analysis was performed. Separate models for age, sex, race, educational level, income, and geographic origin of the respondents were thenconstructed and analyzed.

Results The average ranking of the men’s and women’s smiles are depicted in the photographs (Fig 2) in order from top to bottom,with most attractive at the

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Dental Attractiueness a Dunn et a1

RESPONDENT INFORMATION

AGE: MALE / FEMALE: (circle one)

RACE: (circle one) Caucasian

African-American Hispanic Asian I Pacific islander American Indian

HIGHEST LEVEL OF EDUCATION YOU HAVE COMPLETED: (circle onc) Jr. High High School College (yrs.) Post graduate (yrs.)

1234

1234

ANNUAL INCOME: (total combined income if married, or sponsor’s income if you are a dependent) $0 - 10,000 $10,000- 25,000 $25,000- 40,000 $40,000- 55,000 $55,000--YOUR HOMETOWN: (area where? you were raised)

Northeast Southeast Midwest South Southwest Northwest West Outside USA not applicable

Thank you for your participation in !his survey. Figure 1. Respondent questionnaire. top and least attractive at the bottom. Twenty-five demographic groups were established from the information in the questionnaire. The same female smile was chosen as most attractive by 24 of the 25 demographic groups. This smile was identified as natural teeth with light shade, a high lip line, large display of teeth, and radiating symmetry. Two female smiles identified by darker shade of teeth and asymmetry were rated by all groups as being least attractive. Two male smiles were judged equal as the most pleasing esthetically. These smiles were characterized by light shade, a moderate display of teeth, moderate lip line, and a symmetrical arrangement of teeth. One male smile

characterized by darker shade was rated the least attractive. After stepwise discriminant analysis, the cumulative proportion of total dispersion (Table 1) was used as the “predictive index,” or percent predictability of attractiveness attributable to individual or combined smile variables. Approximately 77% of the perceived attractiveness of men’s smiles can be explained by shade alone. The combination of shade and natural teeth accounted for a predictive index of 91%. The three factors of shade, natural teeth, and width of display accounted for a predictive index of almost 98% of men’s smiles. For women, the values were 61%, 90%, and 97%, respectively.

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Women's Smiles

Men's Smiles

2.20

3.62

3.06

3.62

4.06

3.75

4.18

4.25

El I

4.04

4.23

5.00

5.12

6.44

5.56

6.79

1 6.02

Figure 2. Average ranking of smile photographs.

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Dental Attractiveness

Table 1. Results of Stepwise Discriminant Analysis of Smile Variables Cumulative Proportions cf Total Dirfimsion Variable

Men

Women

Shade Shade + natural teeth Shade + natural teeth + display Shade + natural teeth display + symmetry Shade + natural teeth + display + symmetry + lip line

0.771 0.907 0.977

0.612 0.903 0.972

Dunn et a1

counted for by the first three predictor variables, the improvement in the separation by adding the remaining two is still statistically significant. No correlation was found to exist between demographic groups and smile variables.

Discussion

It can be assumed that patients will continue to seek “the ideal” in dental esthetics, especially in this age 0.998 0.995 of media hype and preoccupation with attractiveness. Manufacturers will in turn flood the market 1.000 1.000 with cosmetic products attempting to accomplish this. However, multiple factors determine the attracAfiproximate tiveness of a smile; dentists must be cognizant of No. of F Statistic Variable Variables these factors when restoring smiles. Entered Included Men Women This study investigated the characteristics of a smile that alone, or in combination, best predict the Shade 1 122.158 70.646 2 8 1.934 Natural teeth 60.854 subjective perception of attractiveness. Within all Display 3 58.583 47.167 groups, tooth shade was the most important variable Symmetry 4 49.996 41.408 in predicting dental attractiveness. Approximately 5 43.361 Lip line 36.701 77% of the perceived attractiveness of men’s smiles could be explained by shade alone. The combination of shade and unrestored (natural-looking) teeth In all cases, tooth shade was the most important accounted for a predictive index of 90%. The three factor in predicting attractiveness, followed in sefactors of shade, unrestored natural teeth, and width quence by natural-looking (unrestored) teeth and of tooth display accounted for a predictive index of number of teeth displayed (Fig 3). For each variable, more than 97% of men’s smiles. For women, the the approximate F statistic is reported in Table 1. 97%, respectively, The values were 61%, 90%, and This approximate F is a transformation of the Wilk’s variables of symmetry and height of lip line contribA statistic testing the null hypothesis of equality of uted the least to predicting perceived attractiveness. group means for the variables in the discriminant B r i ~ m a n *studied ~ patients’ concepts of symmetry function at each step. The highly significant values of and found that dental patients preferred symmetrithe Fs ( p < .001 in all cases) indicate that each cal arrangements of teeth over asymmetry or radiatvariable improves the separation of the attractiveing symmetry, but did not compare these variables ness rankings as it is added. Although more than 97% with any other smile characteristic. Brisman also did of the variation among the rankings has been acnot include tooth shade in his study, the variable that the present study concluded was most important. 100 an I Preferences of the different demographic groups included in this study were quite uniform. The same female smile was selected as most attractive by 24 of % 40 B 30 the 25 demographic groups. Two smiles were rated b 20 10 by all groups as least attractive. It has been postu0 Shade Shade + Shade + lated that there may be unique cultural preferences Natural Natural Teeth Teeth + that identify the attractive smile; however, in this Display study, no correlations existed between specific demoCombinationsof Characteristics graphic groups and smile variables. Figure 3. Predictors of an attractive smile. Only the A person’s ability to recognize a beautiful smile is results of all respondents rating male (U)and female (0) innate, and, ultimately, the perception of attractivesmiles are shown, because no significant correlations were ness is an individual preference. This research identideterminrd to exist between specific demographic groups fied certain variables that people consider in their and smile variables. *Percent predictability of attractiveness attributable to individual or combinrd smile variables. assessment. It has been assumed that the shade of

+

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Septeinber 1996, Volurm5, Number3

one’s teeth might be an important factor in dental attractiveness. The present study confirms that, for the general population, tooth shade is indeed the most important variable of the attractiveness of a smile.

Conclusions I. Tooth shade was the most important variable evaluated in predicting dental attractiveness. It was followed in sequence by a natural (unrestored) tooth appearance and number of teeth displayed. 2. The variables of symmetry and height of lip line were found to contribute the least in predicting perceived attractiveness in this study. 3. Multivariant analysis yielded a finding that no significant correlation existed between demographic groups and the smile variables stuhed.

References 1. Neumann LM, Christenscn C, Cavanaugh C:: Dental esthetic satisfiction i n adults.JAm Dent Assac 1989;118565-570 2. Baldwin DC:: Appcarance and aesthetics in oral health. Community Dent Oral Epidemiol 1980;8:244-256 3. Jenny J:Visibility and prestige of occupations and the importance of dental treatment.,J Can Dent Assoc 1986;52:987-989 4. Shaw WC, Rees G, Dawe M, et al: The influence of dentofarial appearance on the social attractiveness of young adults. Am J Orthod Dentofacial Orthop 1985;87:21-26 5. Graber LW, Lurker GW: Dental esthrtic self-evaluation and satisfaction. AmJ Ortho 1980;77:163-173 6. Levinson N A Psychologic facets of esthetic dcntal health care: a develupmental perspective. J Prosthrt Drnt 1990;64:486-491 7. Cavior N, Dokecki PR: Physical attrartiveness, perceived attitude similarity, and academic achievement as contributors to interpersonal attraction among adolescents. Dev Psychol 1973;9:4454 8. Kleck RE, Richardson SA, Ronald L: Physical cues and interpersonal attraction in children. Child Dev 1974;45:305310 9. Miller AG: Role of physical attractiveness in impression formation. Psychol Sci 1970;19:241-234 10. Cross JF, Cross J: .4ge, sex, race and the perception of facial beauty. Dev Psychol 1971;5:433-439

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11. Byrne I), London 0, Reeves K The effects of physical attracti\,enrss, SCX, and attitude similarity on interpersonal attraction. J Prrs Soc Psychol 1968;36:259-271 12. Kleck RE, Rubenstein C: Physical attractiveness, perceived attitude similarity, and interpersonal attraction in an oppositesex encounter.JPer-sSocPsychol 1975;31:107-114 13. Perrin FSC: Physical attractivencss and repulsiveness. J Exp Psychol 1921;4:203-217 1.1.. Walster E, Aronsori V, Abraham D, et al: Importance of physical attractiveness in dating behavior. J Pcrs Soc Psychol 1966;4:503-516 15. Brislin RIV. Lewis S A Dating and physical attractivencss: a replication. Psychol Rep 1968;22:976 16. Huston TL: Ambiguity of acceptance, social dcsirability, and dating choice.J Exp Soc Psychol I973;9:32-42 17. Dion KK, Berscheid E, Walster E: What is beautiful is good.J Pers Soc Psychol 1972;24:285-290 18. Clrffore M, Salster E: The effect of physical attractiveness on tcachcr expectations. SK Educ 1973;46248-258 19. Angle EH: Malocclusion of the Tccth (cd 7) Philadelphia, PA, SS White Dcntal Manufacturing, 1907 20. WilliamsJL: The ternperaniental selection of artificial teeth, a fidlacy. Dental Digest IYl4;20:6.%75 21. Pound E: Applying harmony in selecting and arranging- teeth. Drnt Clin North Am 1962;6241-258 22. FrushJP, Fisher RD:How dentogenics interprets the pcrsonaliq factor.,JProsthet Dent 1956;6:44149 23. Brisman AS: Esthetics: a comparison of dentists’ and paticnrs’ concepts.,J Am Dent Assoc 1980;300:345-352 24. i\mett GW, Bergman R T Facial keys to orthodonticdiagnosis and treatment plaruiirtg. Part I. Am J Orthod Dcntofacial Orthop 1993;103:299-312 25. Coldstcin RE: Change Your Smile (ed 2). Chicago, IL, Quintessence Publishing Co, 1984 26. Goldstein RE, Lancaster JS: Survey of patient attitudes toward current esthetic procedures. J Prosthet Dent 3981;52: 775-780 27. Sherer JL: Cosmetic drntistry: putting patients first. AGD Impact 1992;20:9-I5 28. Hcymann 110: The artistry of conservative esthetic dentistr).. J Am Dent ASSK 1987;(specialissue): 14E-23E 29. Bass NM: The aesthetic analysis of the face. Eur J Orthod 1991;13:343-350 30. Lamontagne P: The evolution of drntal esthetics.J Dentaire du Quebec 1990;27:365-371 31. Beder OE:Estheticcanenigma.JProsthet Dent 1971;25:588591 32. Albino JE, ’ledesco LA, Conny DJ: Patient perceptions of dental-facial esthetics: shared concerns in orthodontics and prosthodontics. J Prosthet Dent 1984;52:9-13