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Perception of Dental Students and Laypersons to Altered Dentofacial Aesthetics

Article in Journal of International Society of Preventive and Community Dentistry · November 2019
DOI: 10.4103/jispcd.JISPCD_340_19

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Original Article

Perception of Dental Students and Laypersons to Altered Dentofacial

Aesthetics
Khalid Aldhorae1, Basema Alqadasi2, Zainab M. Altawili3, Ali Assiry4, Anas Shamalah3, Salah addin Al-Haidari5

1
Department of Aims and Objectives: The aims of the study were to comprehensively assess

Abstract
Orthodontics, College the perception of altered dentofacial aesthetics between dental students and
of Dentistry, Thamar laypersons and to identify the threshold where different variables such gender
University, Thamar, Yemen,
and clinical training impair dentofacial attractiveness. Materials and Methods:
2
Orthodontic Department,
Hospital of Stomatology, Ten photographs were digitally manipulated involving three facial, two smile,
Xi’an Jiaotong University, four dental, and one gingival components. Fifty images were randomized and
Xi’an, Shaanxi, People’s rated according to attractiveness by two groups dental students which subdivided
Republic of China, into preclinical students and clinical students, and laypersons. The participants
3
College of dentistry evaluated the original and manipulated images using a visual analog scale. The
University of Science responses were then analyzed using Mann–Whitney U test. Results: The results
and Technology, Sana’a,
showed threshold levels of noticeable differences between varying levels of
Yemen, 4Department of
Preventive Dental Sciences, discrepancy. The overall perception of aesthetics was high among dental clinical
Najran University, Najran, students with the highest perception toward facial profile and the lowest toward
Kingdom of Saudi gingival margin height. Of the respondents, no differences were found in the
Arabia, 5Department of perception between male and female participants. Dental students perceived
Orthodontics, College aesthetic components more accurately than laypersons. Conclusion: Dental
of Dentistry, Sana’a students group had a better perception of dentofacial aesthetics than included
University, Sana’a, Yemen laypersons. Unlike gender, clinical training has a substantial positive effect on the
assessment of beauty. Dental students sub divided into dental preclinical students
Received : 15-08-19.
and dental clinical students (clinical training is a variable of all subgroups).
Accepted : 03-10-19.
Published : 11-11-19.
Keywords: Aesthetics, dental students, dentofacial, laypersons, perception

Introduction display, buccal corridors, smile arc, diastema, midline

position, and facial symmetrical alterations.[4]
P eople pay more attention to their beauty and they
are more concerned about their appearance than
their health.[1] The face is reported to be a determinant
Dentofacial aesthetics is more objective when perceived
by dental specialists, orthodontists more specifically.
factor for the perception of aesthetics, especially the Perception of beauty by dental students, on the contrary,
mouth and eyes, which are the most important areas the may reflect varying degrees of fluctuation owing to the
people focus on during social interactions.[2,3] With the level of their dental education gained from different
advent of time, it has been noticed that the definition of aspects of dentistry. Perception of dentofacial aesthetics
beauty keeps changing constantly. Additionally, dental by laypersons depends on their society’s beliefs and norms,
and facial beauty is influenced by geographic, ethnic, which differ among societies for dental and orthodontic
cultural, and demographic factors. Perception of smile
depends not only on concerns associated with teeth but Address for correspondence: Prof. Khalid Aldhorae,
Head of Orthodontic Department, College of Dentistry,
also on the nearby soft tissues, which include gingival Thamar University, Thamar, Yemen.
E-mail: drdurai2008@gmail.com
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows
Access this article online others to remix, tweak, and build upon the work non-commercially, as long as
Quick Response Code: appropriate credit is given and the new creations are licensed under the identical terms.
Website: www.jispcd.org For reprints contact: reprints@medknow.com

How to cite this article: Aldhorae K, Alqadasi B, Altawili ZM,

Assiry A, Shamalah A, Al-Haidari S. Perception of dental students
DOI: 10.4103/jispcd.JISPCD_340_19
and laypersons to altered dentofacial aesthetics. J Int Soc Prevent
Communit Dent 0;0:0.

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Aldhorae: Perception to altered dentofacial aesthetics

treatment decisions, it is essential to understand the Photo manipulation

threshold of what community considers acceptable in Three standard photographs of facial aesthetics and
terms of abnormal dentofacial aesthetic features.[5] seven standard photographs of posed smile of young
To the best of our knowledge, no study has been man were digitally modified using Adobe Photoshop
conducted so far that compare how different dental (version CS 3, Adobe Systems, San Jose, California).
students and laypersons perceive dentofacial aesthetics. Each standard photograph along with four modified
Therefore, the aims of this study were to assess analogues represented one group for specific esthetic
the perception of dentists, dental students, dental trait (facial or smile, [Figures 1–10]).
technicians, and laypersons on 10 dentofacial aesthetic A total of 35 photographs displayed anterior teeth
components, and whether such a perception is affected and 15 photographs displayed the facial aesthetics.
by gender or clinical training. The colored photographs of dental aesthetics did
not display the nose, chin, and cheeks in an attempt
Materials and Methods to avoid their confounding influence on the smile.
This is a prospective cross-sectional observational The photographs were grouped into 10 sets. Every
study conducted at the College of Dentistry, Thamar
University, Thamar, Yemen, from December 2018
to March 2019. Two groups of university students
were included in this study: Dental students whose
subdivided into: preclinical students and clinical
students, and laypersons
1. Dental students group (group 1: n = 533, 309 males
and 224 females), which are further divided into the
following two subgroups:
a. Clinical subgroup: n = 202, 129 males and 73
females
b. Preclinical subgroup: n = 331, 179 males and 149
females
2. Laypersons group (group 2: n = 213, 131 males and
82 females)
Figure 2: Manipulation of facial soft tissue profile: (A) Straight
When we deal with subgroups as a one group when facial profile (Class I), (B) slightly convex facial soft tissue profile
compared the dental students with laypersons, however, (mild Class II), (C) moderately convex facial soft tissue profile
we compare both subgroups to show the main group of (moderate Class II), (D) severely convex facial soft tissue profile
dental students (severe Class II), (E) concave facial soft tissue profile (Class III)

Figure 1: Chin manipulation of male with a pleasant face: (A) The Figure 3: Manipulation of facial vertical proportions: (A) Severely
midsagittal plane coincident with soft tissue pogonion point of the reduced lower anterior facial height (short face), (B) slightly
chin, (B) 2 mm shift of soft tissue pogonion to the left, (C) 4 mm reduced lower anterior facial height, (C) average vertical facial
shift of soft tissue pogonion to the left, (D) 6 mm shift of soft tissue proportions, (D) slightly increased lower anterior facial height, (E)
pogonion to the left, (E) 8 mm shift of soft tissue pogonion to the left severely increased lower anterior facial height (long face)

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Aldhorae: Perception to altered dentofacial aesthetics

Figure 4: Manipulation of a women photograph with pleasant smile: (A) Normal smile line, (B) 1 mm higher upper lip positions, (C) 2 mm
higher upper lip position, (D) 3 mm higher upper lip position, (E) 4 mm higher upper lip position

[Figure 7], clinical crown width [Figure 8], and occlusal

plane canting [Figure 9]), and one gingival component
(clinical crown height [Figure 10]).
Data collection
The manipulated photos were presented in the form of
Power Point software version 16.0.4266.1003 (USA,
NY, Microsoft Corporation, Microsoft Office 2016).
There were 10 slides, each slide represented a group
of five numbered photographs for a given aesthetic
component as aforementioned [Figures 1–10]. The
following question was asked as a heading for each
of these slides: “Which of the following images is
the most beautiful from your point of view?” The
participants answered in a predesigned answer sheet
Figure 5: Manipulation of buccal corridor: (A) Obliterated buccal that included inquiry about participant’s gender,
corridor (2%), (B) narrow buccal corridor (10%), (C) normal participant’s profession, and level of study.
buccal corridor (15%), (D) wide buccal corridor (22%), (E) very
wide buccal corridor (28%) Ethical considerations
A consent form was signed by the participant in the
study, those who refused to participate were not
set included five images, one with ideal aesthetics
included, and the ethical approval was given by the
and the others obtained by gradual alterations of the
ethics committee of the College of Dentistry, Thamar
original photograph for each variable. A visual analog
University, Yemen.
scale was set from 1 to 5 to score these images, where
5 was the most pleasant and 1 was the least pleasant Statistical analysis
one. An overall aesthetic score was calculated by Data were handled and analyzed using the standard
adding the individual component scores together package for social sciences, the Statistical Package
and multiplying it by two to be presented of 100 for the Social Sciences (SPSS) software, version 21
[Table 1]. The photographs within each group were (IBM, Armonk, New York). Qualitative variables were
arranged randomly and differently in different groups. statistically described using frequencies and proportions,
The manipulation involved three facial components and by mean values with interquartile range (IQR) for
(facial symmetry [Figure 1], facial soft tissue profile quantitative variables. Individual (of 5) and overall
[Figure 2], and facial vertical proportion [Figure 3]), (of 100) aesthetic scores were checked for normal
two smile components (smile line [Figure 4] and buccal distribution using Kolmogorov–Smirnov test. Between
corridor [Figure 5]), four dental (maxillary midline group comparisons, based on gender and, clinical
deviation [Figure 6], maxillary midline diastema training, were done using Mann-Whitney U test.

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Aldhorae: Perception to altered dentofacial aesthetics

Figure 6: Manipulation of maxillary dental midline: (A) No midline deviation, (B) 1 mm midline deviation, (C) 2 mm midline deviation, (D)
3 mm midline deviation, (E) 4 mm midline deviation

Figure 7: Manipulation of maxillary midline diastema: (A)

No maxillary midline diastema, (B) 0.5 mm maxillary midline
diastema, (C) 1 mm maxillary midline diastema, (D) 1.5 mm
maxillary midline diastema, (E) 2 mm maxillary midline diastema
Figure 8: Manipulation of clinical crown width of maxillary
right lateral incisor: (A) Normal clinical crown width, (B) 1 mm
Stepwise multiple linear regression analysis for the mesiodistal reduction of clinical crown width, (C) 2 mm mesiodistal
reduction of clinical crown width, (D) 3 mm mesiodistal reduction
significant independent determinants of perception
of clinical crown width, (E) 4 mm mesiodistal reduction of clinical
of individual overall aesthetics was conducted where crown width
gender and clinical training were entered into the
equation as independent variables. A P value of 0.05 were females. The total response rate of the participants
was considered as significant. was 95.11%, 331 (36.2%) were students at preclinical
level in dentistry, 202 (22.1%) were students at clinical
Results level in dentistry, and 213 (23.2%) were Laypersons
The total number of participants was 746; of the group (art, financial banking, and trading) as shown
respondents, 534 (58.4%) were males and 381 (41.6%) in Table 2.

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Aldhorae: Perception to altered dentofacial aesthetics

Table 1: Scoring system of the perception of overall,

facial, smile, dental, and gingival components
Variable Score
Overall 100
Facial
components
Q1 No facial asymmetry 5
2 mm facial asymmetry 4
4 mm facial asymmetry 3
6 mm facial asymmetry 2
8 mm facial asymmetry 1
Q2 Straight soft tissue profile 5
Slightly convex soft tissue 4
profile
Moderately convex soft tissue 3
profile
Figure 9: Manipulation of occlusal plane canting of maxillary arch:
(A) No occlusal plane canting, (B) 1 mm occlusal plane canting, (C)
Severely convex soft tissue 2
2 mm occlusal plane canting, (D) 3 mm occlusal plane canting, (E) profile
4 mm occlusal plane canting Concave soft tissue profile 1
Q3 Average facial vertical 5
proportions
Slightly reduced anterior 4
lower facial height
Short face 2
Slightly increased anterior 3
lower facial height
Long face 1
Smile
components
Q4 Normal gingival display 5
1 mm increased gingival 4
display
2 mm increased gingival 3
display
3 mm increased gingival 2
display
4 mm increased gingival 1
Figure 10: Manipulation of crown height by manipulation of
gingival margin height of maxillary right central incisor: (A) 0 mm display
gingival margin height, (B) 0.5 mm increase in gingival margin Q5 Narrow buccal corridor 4
height, (C) 1 mm increase in gingival margin height, (D) 1.5 mm (10%)
increase in gingival margin height, (E) 2 mm increase in gingival Normal buccal corridor 5
margin height
(15%)
Wide buccal corridor (22%) 3
The overall perception of aesthetics was high
Obliterated buccal corridor 2
among dental students, especially students at
(2%)
clinical levels. (30.16 ± 3.66) with the highest
Very wide buccal corridor 1
perception found toward facial profile (3.62 ± 1.07)
(28%)
followed by gingival display and midline deviation
Dental
(3.61 ± 1.64 and 3.61 ± 0.93, respectively), and The
components
gingival height of clinical crown. Facial asymmetry
Q6 No maxillary midline 5
was perceived as aesthetically acceptable by more
deviation
than 35% of dental students (median [IQR] = 3
1 mm maxillary midline 4
[3–4]). Gingival display and clinical crown height
deviation

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Aldhorae: Perception to altered dentofacial aesthetics

Table 1: Continued Table 2: Descriptive data of the participants in the present

Variable Score study
2 mm maxillary midline 3 Group Male Female Total
deviation Preclinical 180 (19.7%) 151 (16.5%) 331 (36.2%)
3 mm maxillary midline 2 Clinical 129 (14.1%) 73 (8%) 202 (22.1%)
deviation Layperson 132 (17.69%) 81 (10.85%) 213 (28.55%)
4 mm maxillary midline 1 Total 441 (59.11%) 305 (40.88%) 746 (100%)
deviation
Q7 No maxillary midline 5
diastema males and females, P > 0.05 [Table 2]. However, males
0.5 mm maxillary midline 4 significantly perceived facial height, buccal corridor,
diastema midline deviation, and gingival marginal height more
1 mm maxillary midline 3 accurately than females; whereas females perceived
diastema vertical facial proportion, frontal occlusal canting,
1.5 mm maxillary midline 2 maxillary midline shift, gingival display, midline
diastema diastema, and facial symmetry more accurately
2 mm maxillary midline 1 than males [Table 3]. The effect of dental students
diastema participants’ clinical training on the dentofacial
Q8 Normal clinical crown width 5 esthetic perception was presented [Table 4]. Students in
1 mm reduction of clinical 4 clinical levels generally perceived aesthetic components
crown width (30.92 ± 4.64) more accurately than those in preclinical
2 mm reduction of clinical 3 levels (30.46 ± 92). Those significant differences include
crown width facial symmetry, soft tissue facial profile, gingival
3 mm reduction of clinical 2 display, maxillary midline deviation, and gingival
crown width marginal height of clinical crown.
4 mm reduction of clinical 1 Multiple linear regression confirmed the bivariate
crown width analysis, clinical training and gender were the
Q9 No frontal occlusal canting 5 independent determinants of aesthetic perception by
1 mm frontal occlusal canting 4 dental students; however, the fractions by which these
2 mm frontal occlusal canting 3 two variables contributed to the explanation of the
3 mm frontal occlusal canting 2 variability of aesthetic perception were minimal ranging
4 mm frontal occlusal canting 1 from 1.9% (facial height) to 77% (overall aesthetics) as
Gingival components shown in Table 6.
Q10 Symmetric gingival margin 5
height Discussion
0.5 mm asymmetric gingival 4 Aesthetics has become more important factor
margin height than health and function nowadays. Perception of
1 mm asymmetric gingival 3 dentofacial aesthetics varies between the people
margin height depending on their age, gender, socioeconomic status,
1.5 mm asymmetric gingival 2 level of education, and occupation; therefore, trying
margin height to screen the dentofacial aesthetic perception is a
2 mm asymmetric gingival 1 challenge for a given group of population, and the
margin height result comparison rarely presents similarities.
To achieve reliability of the presentation; PowerPoint
were perceived by more than half of the sample
was presented properly to all participants, it was
[Table 3].
presented by the same operates to every group in
Table 4 showed that less than one-third of the dental class rooms, all the classrooms that present study was
students perceived gingival height (median [IQR] = conducted checked for light and data show performance
1 [1–1]). Overall, dental students perceived aesthetic to guarantee that the proper presentation of PowerPoint
components more accurately than laypersons (P < slides were achieved for all participants. PowerPoint
0.05 and P < 0.01, respectively) [Tables 4 and 5]. No was presented to every group in their classrooms. And
difference was found in aesthetic perception between it was not presented to the whole participants at once.

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Aldhorae: Perception to altered dentofacial aesthetics

Table 3: Mean and median scores of the participants’ perception of different aesthetic components for the whole sample
and by gender
Aesthetic components All sample (n = 746) Males (n = 441) Females (n = 305) P value
Mean (SD) Median(IQR) Mean (SD) Median (IQR) Mean (SD) Median (IQR)
Overall 30.69 (4.13) 31 (28 – 33) 30.65 (4.29) 31 (28 – 33) 30.75 (3.88) 31 (28 – 33) 0.759
Facial components
Q1 (Facial symmetry) 3.35 (1.04) 3 (3 – 4) 3.29 (1.04) 3 (3–4) 3.44 (1.02) 3 (3 – 4) 0.057
Q2 (Facial profile) 3.64 (1.05) 4 (3 – 4) 3.61 (1.06) 4 (3–4) 3.69 (1.04) 4 (3 – 4) 0.304
Q3 (Facial height) 3.54 (0.91) 4 (3 – 4) 3.66 (0.95) 4 (3–4) 3.37 (0.82) 3 (3 – 4) <0.001*
Smile components
Q4 (Gingival display) 3.58 (1.61) 4 (2 – 5) 3.45 (1.63) 4 (2–5) 3.77 (1.55) 5 (2 – 5) 0.009*
Q5 (Buccal corridors) 2.47 (1.47) 3 (1 – 4) 2.80 (1.46) 3 (1–4) 2.65 (1.45) 2 (1 – 4) 0.161
Dental components
Q6 (Midline deviation) 3.62 (1.71) 4 (3 – 4) 3.63 (2.08) 4 (3–4) 3.62 (0.95) 4 (3 – 4) 0.961
Q7 (Midline diastema) 2.38 (0.91) 2 (2 – 2) 2.36 (0.91) 2 (2–2) 2.42 (0.92) 2 (2 – 2) 0.350
Q8 (Clinical crown width) 3.24 (1.33) 4 (2 – 4) 3.18 (1.30) 4 (2–4) 3.31 (1.37) 3 (2 – 4) 0.186
Q9 (Occlusal canting) 3.09 (1.42) 3 (2 – 4) 3.15 (1.45) 3 (2–5) 3.01 (1.36) 3 (2 – 4) 0.182
Gingival components
Q10 (Gingival marginal 1.51 (0.94) 1 (1 – 2) 1.53 (0.97) 1 (1–2) 1.48 (0.88) 1 (1 – 2) 0.448
height)
SD = standard deviation. *Significance at 5%

Table 4: Mean and median scores of dental students’ perception of different aesthetic components by clinical training
Aesthetic components Preclinical students (n = 331) Clinical students (n = 202) P value
Mean (SD) Median (IQR) Mean (SD) Median (IQR)
Overall 30.16 (3.66) 30 (28–33) 30.92 (4.64) 31 (28–34) 0.048*
Facial components
Q1 (Facial symmetry) 3.33 (1.00) 3 (3–4) 3.26 (0.93) 3 (3–3) 0.413
Q2 (Facial profile) 3.62 (1.07) 4 (3–4) 3.73 (0.84) 4 (3–4) 0.188
Q3 (Facial height) 3.48 (0.84) 4 (3–4) 3.47 (0.84) 3 (3–4) 0.894
Smile components
Q4 (Gingival display) 3.61 (1.64) 4 (2–5) 3.78 (1.70) 5 (2–5) 0.257
Q5 (Buccal corridors) 2.68 (1.89) 3 (1–4) 2.63 (1.52) 2 (1–4) 0.737
Dental components
Q6 (Midline deviation) 3.61 (0.93) 4 (3–4) 3.92 (2.74) 4 (4–4) 0.121
Q7 (Midline diastema) 2.30 (0.79) 2 (2–2) 2.28 (0.95) 2 (2–2) 0.802
Q8 (Clinical crown width) 3.19 (1.32) 4 (2–4) 3.39 (1.29) 4 (3–4) 0.086
Q9 (Occlusal canting) 3.04 (1.41) 3 (2–4) 3.11 (1.52) 3 (2–5) 0.596
Gingival components
Q10 (Gingival marginal 1.31 (0.72) 1 (1–1) 1.36 (0.82) 1 (1–1) 0.475
height)
SD = standard deviation. *Significance at 5%

These classrooms were large enough to accommodate systematic errors or biases that could to lead an observer
50-60 students who have clear vision onto the screen to take the first image as a model and compare to the
irrespective of their locations in the classroom. In manipulated one. No instructions were given to the
addition, the screen was large enough, which could be raters to avoid focusing their attention at any specific
seen clearly from different angles in the classrooms. area, such as smile, midline, teeth, or any other dental
The 10 sets of images had been subjected to digital parameters, as they were asked about facial expression
manipulation including slight modifications to beauty. To assess the internal consistency reliability,
investigate the effects of dental education level of 50 randomly selected participants were invited to fill
clinical training The original and manipulated images a second copy of the questionnaire two weeks later;
were organized in five different sequences to avoid Cronbach’s alpha results for both were 0.95, which

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Aldhorae: Perception to altered dentofacial aesthetics

Table 5: Mean and median scores of dental students’ perception and laypersons’ perception of different aesthetic
components
Aesthetic components Dental (preclinical) students (n = 331) Layperson students (n = 213) P value
Mean (SD) Median (IQR) Mean (SD) Median (IQR)
Overall 30.16 (3.66) 30 (28–33) 31.30 (4.21) 31 (29–34) 0.001*
Facial components
Q1 (Facial symmetry) 3.33 (1.00) 3 (3–4) 3.47 (1.16) 3 (3–5) 0.148
Q2 (Facial profile) 3.62 (1.07) 4 (3–4) 3.59 (1.20) 4 (3–4) 0.767
Q3 (Facial height) 3.48 (0.84) 4 (3–4) 3.70 (1.06) 4 (3–5) 0.011*
Smile components
Q4 (gingival display) 3.61 (1.64) 4 (2–5) 3.36 (1.43) 3 (2–4) 0.061
Q5 (Buccal corridors) 2.68 (1.89) 3 (1–4) 2.92 (1.49) 3 (2–4) 0.100
Dental components
Q6 (Midline deviation) 3.61 (0.93) 4 (3–4) 3.37 (1.29) 4 (2–4) 0.019*
Q7 (Midline diastema) 2.30 (0.79) 2 (2–2) 2.61 (1.01) 2 (2–3) <0.001*
Q8 (Clinical crown width) 3.19 (1.32) 4 (2–4) 3.17 (1.38) 4 (2–4) 0.867
Q9 (Occlusal canting) 3.04 (1.41) 3 (2–4) 3.15 (1.34) 3 (2–4) 0.360
Gingival components
Q10 (Gingival marginal 1.31 (0.72) 1 (1–1) 1.95 (1.61) 2 (1–2) <0.001*
height)
SD = standard deviation. *Significance at 5%

indicated a perfect agreement. This was the first study is similar to the findings of a study by McAvinchey
that provided published information about 10 aesthetic et al.[22] Facial profile is essential and is the fundamental
components assessed in general and among dental standardized soft tissue parameter used in orthodontic
students and laypersons in particular; a previous practice.[11] Assessment of soft tissue facial profile
study conducted in Saudi Arabia indicated those 10 revealed that approximately 74.48% of the participating
measures between dental students.[5] The use of the dental students consider slightly convex and straight
image rating method had been reliable and validated profiles as aesthetically normal, with no sex differences.
and applicable for recent study.[6] The respondents This is in line with a previous study that found that
(a response rate of 95.11%) who participated in this the preferred soft tissue profile was slight convex and
study were distributed by gender, studying sector, and straight facial profile.[12] Furthermore, Yin et al.[12] and
clinical training of only dental students, and were Macías et al.[11] found that females preferred slight
sufficient for proper statistical analysis to provide convex facial profile, whereas males preferred slight
valid results. The overall perception of aesthetics concave facial profile.[11,12]
was high among dental students (30.45 ± 4.07).
Gingival display is a sensitive factor in smile perception
Students in clinical levels generally perceived aesthetic
by dental students and dentists but less critical with
components (30.92 ± 4.64) more accurately than those
laypersons, nonetheless all consider gummy smile
in preclinical levels (30.46 ± 92). This was less than
as unpleasant.[13] Literature showed the tolerable
that found by Al-Saleh et al.[7] and Omar and Tai.[8] The
appearance of gingival display while smiling was
highest perception was toward facial profile, gingival
1–2 mm.[8,14] May et al.[15] found 3 mm was appealing.
display, and maxillary midline deviation as more than
Wang et al.[16] found that laypersons preferred average
33% of dental students perceived the standards of
or low smile line over high smile line “gummy smile,”
these three components.
which confirms what we found in this study, that is, the
Perception of facial asymmetry is important to least favored smile by laypersons (14.55%) was 4-mm
clinicians in assessment and treatment and to patient gingival display [Table 6]. Furthermore, in this study
themselves as a part of normal required aesthetics. regarding perception of gingival display, a significant
More than two-third of the dental students perceived difference was observed between both dental students
2 mm or 4 mm facial asymmetry, McAvinchey et al.[22] and dentists; preclinical dental students considered
found that dental students considered 5.13 + 2.06 mm gummy smile as attractive unlike clinical students,
of facial asymmetry as normal. This study found no dentists, and laypersons. In this study, maxillary
sex difference in the precision of facial asymmetry, this midline deviation was not significantly different among

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Aldhorae: Perception to altered dentofacial aesthetics

Table 6: Independent determinants of perception of dental students, dentists, dental technicians, and laypersons of
different aesthetic components and overall aesthetics as shown by stepwise multiple linear regression analyses
Determinants Independents* B 95% CI of B Adjusted R2 P value
Overall No variables were entered into the equation
Facial components
Q1 (Facial symmetry) No variables were entered into the equation.
Q2 (Facial profile) College –0.105 (–0.175, –0.036) 0.009 0.003*
Q3 (Facial height) Gender –0.263 (–0.384, –0.143) 0.019 <0.001*
Smile components
Q4 (gingival display) No variables were entered into the equation.
Q5 (Buccal corridors) Gender –0.195 (–0.385, –0.006) 0.003 0.044*
Dental components
Q6 (Midline deviation) No variables were entered into the equation.
Q7 (Midline diastema) No variables were entered into the equation.
Q8 (Clinical crown width) College –0.088 (–0.175, 0) 0.003 0.049*
Q9 (Occlusal canting) No variables were entered into the equation.
Gingival components
Q10 (Gingival marginal College 0.283 (0.220, 0.346) 0.077 <0.001*
height)
*Independent variables: Gender and college. *Significance at 5%

gender; however, it was significantly different between According to literature, whether the person was
dental students and laypersons. More than 44% of the attractive or not, facial symmetry increases the
participating laypersons accepted the appearance of beauty perception.[6,10,17,24] More than two-third of
maxillary midline shift of 2 mm or more. This supports the dental students in this study perceived a facial
what Chang et al.[17] found, that is, laypersons tolerate symmetry of 2 mm as normal; Alhammadi et al.[5]
smile with more than 2 mm midline shift. In addition, found that dental students considered 4.21 ± 1.13 mm
orthodontists and laypersons had the same perception of facial asymmetry as normal. We found that there
of midline deviations.[18] This is contradictory to this was no gender difference in the perception of facial
study that revealed significant difference between asymmetry; this is similar to the findings of a study by
laypersons and dental students. However, dental Alhammadi et al.[5] and McAvinchey et al.[22] However,
students and laypersons considered a 4-mm discrepancy there was a significant difference between dental
between the dental and facial midlines as unattractive students, especially preclinical level students, and
facial feature. dentists with dental technicians, as dental students
perceived 6 mm and more asymmetry as aesthetically
Regarding perception of vertical changes, this study unpleasant.
revealed that significant difference was found between
dental students and laypersons; dental students were The clinical crown width of lateral incisor was modified
more aware of vertical changes, which was in agreement while keeping the gingival level to be consistent with
with the findings of a study by Romani et al.[19] The facial resulting change. Change in length and width decreases
vertical changes were less decisive to laypersons but the perception of aesthetic smile.[6,16,25,26] Dentists
were critical to dental students. In addition, statistical and laypersons considered a decrease in length and
difference regarding gender was found in a recent study, width will automatically decrease the attractiveness
males (38.38%) preferred slightly increased lower facial of smile.[23,24] No significance in gender was found in
height, this is in disagreement with, Johnston et al.[20] this study. This is similar with the findings of a study
who found that slight decrease in lower facial height by Daou et al.[25] and Kim and Kim,[14] which showed
third was more appealing third was more appealing. that gender was not a significant factor. However, a
However, we found that slightly reduced, slightly significant difference was found among dental students
increased, or average lower facial height were considered as clinical dental students were more sensitive to height/
as pleasant faces. This is similar to the findings of a width ratio change.
study by Abu Arqoub and Al-Khateeb[21] on a group of Frontal occlusal canting was difficult to determine for
non-dental students and laypersons. all groups; all groups had high perception threshold.

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Aldhorae: Perception to altered dentofacial aesthetics

This is in agreement with the findings of a study by variables in aesthetic perception by study sample. This
Alhammadi et al.,[5] where highest perception threshold study included studying sector, and clinical training
was noticed in the determination of frontal occlusal of only dental students, and were sufficient for proper
canting between clinical and preclinical dental students. statistical analysis to provide valid results. However,
This is contradictory to the findings of a study by their roles were very little as revealed by the stepwise
Padwa et al.[26] who found that the perception of frontal linear regression analyses; these variables explained just
occlusal canting depends on the degree of inclination up to 8.9% of the variability of the overall perception of
rather than the observers’ levels of experience. This aesthetics. This means that up to 91% of the variability
study showed no significant difference between dental was explained by other factors not included in our study.
students and laypersons. This emphasizes the role of other factors, such as cultural
All groups had high perception threshold toward norms and ethnicity, in determining the aesthetics.
buccal corridor in this study The difficulty to perceive Hence, large-scale studies are highly recommended
buccal corridor was reported in several studies.[5,17,23,26] where the role of other factors must be considered.”
Pithon et al.[27] found that females were sensitive to the
buccal corridor change; wider buccal corridor was more Conclusion
pleasant. This is consistent with our study findings, The overall perception of dentofacial aesthetics was
which revealed significant difference among gender. high among dental students, with the highest perception
However, narrow and obliterated buccal corridor was observed toward facial profile and the lowest toward
found to be more pleasant by females. Laypersons gingival marginal height. Clinical dental students level
and dentists perceived buccal corridor similarly.[23] in generally perceived aesthetic components more
Agree with our study that found buccal corridor was accurately than did this by clinical training with no
no significant difference between dental students and differences in overall aesthetic perception between
laypersons. males and females.
Midline diastema appearance was not pleased by Ethical considerations
different geographical population.[5,7,28,29] Midline All the procedures have been performed as per the
diastema of 0.5 mm was considered the threshold for ethical guidelines laid down by the Declaration of
dental students, dentists, and laypersons. This is less than Helsinki and have been approved by the review board of
the findings of a study by Kokich et al.[29] who reported ethics committee of the College of Dentistry, Thamar
that 2 mm maxillary midline diastema was considered
University, Thamar, Yemen (approval number: EA-12,
as the threshold for general dentists and laypersons.
dated: November 7, 2018).
Pinho[28] reported that increase in midline diastema
increases unpleasantness. Midline diastema was not Data availability
significant among gender, this is similar to the findings The data set used in this study is available on request
of a study by Pinho.[28] However, a significant difference from the corresponding author (e-mail: drdurai2008@
was found between dental students and laypersons. gmail.com) at the Orthodontic Department, College of
Midline diastema perception are differ between several Dentistry, Thamar University, Thamar, Yemen.
studies. In this study, the lowest perception was toward
Acknowledgement
gingival marginal height, as less than 25% of the dental
students perceived the standards of these elements. We would like to thank the officials and other staff
Which was in agreement with a study that excepted members at the University of Science and Technology
by dental and pharmacy students.[8] No significant for their help during the period of this project work.
difference among gender was found. In agreement with Declaration of patient consent
previous studies.[7,17] A significant difference was found The authors certify that they have obtained all
between dental students and dentists with technicians appropriate patient consent forms. In the form the
and dental students with laypersons. Pinho[28] reported patient(s) has/have given his/her/their consent for his/
a significant difference between orthodontists and her/their images and other clinical information to be
laypersons, as orthodontists were sensitive to gingival reported in the journal. The patients understand that
position and crown length. their names and initials will not be published and
Stepwise linear regression analyses were used to due efforts will be made to conceal their identity, but
strengthen the role in the explanation between study anonymity cannot be guaranteed.

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Aldhorae: Perception to altered dentofacial aesthetics

Financial support and sponsorship 15. May J, Bussen PV, Steinbacher DM. Smile Aesthetics. Aesthetic
Orthognathic Surgery and Rhinoplasty 2019;253-87.
Nil.
16. Wang C, Hu WJ, Liang LZ, Zhang YL, Chung KH. Esthetics
Conflicts of interest and smile-related characteristics assessed by laypersons. J
Esthet Restor Dent 2018;30:136-45.
There are no conflicts of interest.
17. Chang CA, Fields HW Jr., Beck FM, Springer NC,
Firestone AR, Rosenstiel S, et al. Smile esthetics from patients’
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