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Evaluation of the attractiveness of different gingival zeniths in smile esthetics

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DOI: 10.1590/2177-6709.23.5.047-057.oar

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 original article

Evaluation of the attractiveness of different gingival

zeniths in smile esthetics
Suzy Nomura1, Karina Maria Salvatore Freitas2, Paula Patrícia Cotrin da Silva3, Fabricio Pinelli Valarelli2, Rodrigo Hermont
Cançado2, Marcos Roberto de Freitas4, Renata Cristina Gobbi de Oliveira2, Ricardo Cesar Gobbi de Oliveira2

DOI: https://doi.org/10.1590/2177-6709.23.5.047-057.oar

Objective: To evaluate the smile attractiveness of different gingival zeniths by general dentists, orthodontists and layper-
sons and the esthetic perception in the symmetric and asymmetric changes in gingival zeniths.

Methods: Posed photographs of five patients were taken and digitally manipulated in Keynote software, in the gingival zenith
region, in increments of 0.5 to 1mm in maxillary central and lateral incisors, symmetrically and asymmetrically, in nine differ-
ent ways for each patient. The photos were then uploaded to a website, where evaluators (general dentists, orthodontists and
laypersons) could observe and vote according to their esthetic perception, scoring from 1 to 10, 1 being the least attractive and
10 the more attractive. Kruskal-Wallis and Mann-Whitney tests were used for comparison.

Results: Asymmetric gingival zeniths were less attractive than symmetrical gingival zeniths; gingival zenith differences
greater than 1mm were perceptible in the smile attractiveness, both by laypersons, general dentists and orthodontists.
When comparing maxillary central incisors with maxillary lateral incisors, the aesthetic change performed in the central
incisors are more perceptible than those performed in lateral incisors, both symmetrical and asymmetrical. In a general
way, orthodontists and general dentists are more critical in the evaluation and perception of gingival zenith changes, with
the laypersons perceiving this change only from 1mm of maxillary right central incisor asymmetrical change.

Conclusions: Asymmetric gingival zeniths are less attractive than symmetrical ones. Gingival zenith differences
greater than 1mm are perceptible in the smile attractiveness. Orthodontists and general dentists are more critical in
evaluating smile esthetics.

Keywords: Smile. Gingival zenith. Esthetics. Attractiveness.

1
Private Practice (São Paulo/SP, Brazil). How to cite: Nomura S, Freitas KMS, Silva PPC, Valarelli FP, Cançado RH,
2
Centro Universitário Ingá, Departamento de Ortodontia (Maringá/PR, Brazil). Freitas MR, Oliveira RCG, Oliveira RCG. Evaluation of the attractiveness of
3
Universidade de São Paulo, Faculdade de Odontologia de Bauru, Programa de different gingival zeniths in smile esthetics. Dental Press J Orthod. 2018 Sept-
Pós-graduação em Odontologia (Bauru/SP, Brazil). -Oct;23(5):47-57. DOI: https://doi.org/10.1590/2177-6709.23.5.047-057.oar
4
Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento
de Ortodontia, Odontopediatria e Saúde Coletiva (Bauru/SP, Brazil). Submitted: October 15, 2017 - Revised and accepted: February 05, 2018

» The authors report no commercial, proprietary or financial interest in the products » Patients displayed in this article previously approved the use of their facial and in-
or companies described in this article. traoral photographs.

Contact address: Karina Freitas

Rua Jamil Gebara, 1-25, apt. 111 – Bauru/SP, Brasil – CEP: 17.017-150
E-mail: kmsf@uol.com.br

© 2018 Dental Press Journal of Orthodontics 47 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
original article Evaluation of the attractiveness of different gingival zeniths in smile esthetics

INTRODUCTION val esthetic is as important to laypersons as to den-

Dentofacial aesthetics have a great importance tists and orthodontists? Different gingival zeniths
in social attractiveness of the individual, and in this are perceivable for general dentists, orthodontists
context the maxillary incisors play a fundamental and laypersons?
role. Patients who have a normal and aligned rela- In order to answer these questions, the aim of this
tionship of the incisors have generally been classi- study was to evaluate the smile attractiveness of dif-
fied as more friendly, popular, intelligent and with ferent gingival zeniths by general dentists, orthodon-
greater chances of getting a job than individuals tists and laypersons, besides to evaluate the esthetic
who present disharmony in these teeth. 1,2 The per- perception of symmetric and asymmetric changes in
ception of dental aesthetics, however, varies signifi- the gingival zenith and to compare these differences
cantly among patients and professionals from dif- among central and lateral maxillary incisors.
ferent areas, despite substantial efforts to establish
common treatment parameters. 3 Esthetic Dentistry MATERIAL AND METHODS
is, more and more, arousing interest and playing an The study has been approved by research ethics
important role in the dentists clinical routine, as committee of Centro Universitário Ingá (UNINGÁ)
well as in patients’ lives, especially nowadays where under protocol number 23950913.6.0000.5220.
media promotes the beauty in wonderful faces and All participants in the study signed a free and in-
perfect smiles, and they are all related with good formed consent form.
health and mental/physical well-being. 4 The inte- The sample size calculation has been based on an al-
gration among various specialties became basic and pha significance level of 5% (0.05) and a beta of 20%
necessary in today’s dentistry to perform a complete (0.20) to achieve a 80% power of the test to detect a
dental treatment. minimum difference of 1 (±1.36) for the 0 to 10 scores
Some aesthetic parameters for evaluation of the smile (using a attractiveness scale in which 0 = hardly attrac-
aesthetics by laypersons are already established. They tive; 5 = attractive, and 10 = very attractive).8 Thus, the
are: 0-2mm diastema, 0-3mm midline discrepancy, sample size calculation showed the need for at least 30
5-16mm buccal corridors, 1.5-4mm gingival exposure, individuals in each group.
0-4° occlusal canting and 2-5mm overbite.5 However, The sample was selected from 5 patients, males
the aesthetic parameters for evaluation of smile attrac- and females, with attractive smiles, using the follow-
tiveness with different gingival zeniths are not well ing criteria: complete dentition including second
known, mainly among laypersons. Besides that, in an molars, no dental anomalies (shape and number),
evaluation of what would be less aesthetic between no anterior diastemas and no active periodontal dis-
asymmetries of the incisal edges or asymmetries of the ease, Class I malocclusion and matching midlines.
gingival margins, laypersons and dental professionals The smile’s picture was obtained from several pho-
considered the latter less attractive.6 tographic records of posed smiles, so the most at-
According to Miller7 a well-grounded eye is ca- tractive could be selected.9-11 The photos were taken
pable to detect something that is unbalanced, out of by the same operator with a digital Nikon D7000
harmony and out of symmetry. camera, macrolens 105mm and R1C1 twin flash
The gingival zenith is the most apical point of the mounted on a tripod.
gingival tissue and is located distal to the longitu- The smile pictures were obtained with the pa-
dinal axis of maxillary centrals and canines. In the tient seated in front of the operator, 60 cm away
maxillary lateral incisors and all mandibular incisors, from the camera lens. The researcher and patient
they should coincide with longitudinal dental axis.4 chairs were adjusted to keep the camera lens in the
Any change of these positions could generate aes- same height of patient lips, adjusting the tripod. Pa-
thetic disharmony, and depending on the size of this tients were trained to keep the natural head position,
disharmony, be noticed even by laypersons. in a upright posture, focusing an imaginary point in
General dentists and orthodontists are more se- the same height of their eyes, resulting in a horizon-
vere when judging their patients’ smiles? The gingi- tal vision axis.12

© 2018 Dental Press Journal of Orthodontics 48 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
Nomura S, Freitas KMS, Silva PPC, Valarelli FP, Cançado RH, Freitas MR, Oliveira RCG, Oliveira RCG original article

Patients were instructed to give a pleasant posed size proportion of the dental structures and their soft
smile as natural as possible, with their teeth in the tissue, when seen at the same distance.
maximum intercuspation position. Several frames All photos were converted from color to black
were obtained from the same patient to choose a and white to reduce the confounding factors.13
more pleasant picture to be included in the sample. To the different gingival zenith evaluation, five
For standardization, all the photographs were ob- patients with attractive smile and well balanced facial
tained in manual mode, colored, with fine qual- proportions were selected to use their initial images
ity, ISO 100, diaphragm aperture of 22 and shutter as ideal (Fig 2). The original photograph (ideal smile)
speed of 125. was then manipulated, by using a image processing
Each photo was digitally manipulated in Keynote software (Keynote) with different levels of gingival
software (Apple, USA) to be evaluated by laypersons, zeniths alterations (Fig 3).
general dentists and orthodontists, then they were The gingival zenith alterations were:
uploaded to a specifically designed website, in which 1) Ideal: ideal zenith, adjustments with incre-
evaluators could choose the smile attractiveness in ments smaller than 0.5mm in the initial photos, ap-
different gingival zenith positions. This digitally proaching to the smile considered ideal.
manipulation was also made to reduce distracting 2) Right maxillary lateral incisor (U2R): asym-
factors or number of variables, as explained: photos metrically altered zenith with an 0.5-mm increase in
were cropped to correct small head alterations and the right maxillary lateral incisor.
to diminish the examination area, remaining visible 3) Maxillary lateral incisors (U2) ½ = symmetri-
only maxillary and mandibular incisors with their cally altered zenith with 0.5-mm increase in maxil-
adjacent soft tissue, including lips. Height and width lary lateral incisors.
standardization was also made in the selected pic- 4) Right maxillary central incisor (U1R) ½ =
tures, to cut them all in the same size proportion. asymmetrically altered zenith with 0.5-mm addition
To the edited images, a magnification was made to in the upper right central incisor.
keep the proportions of teeth and gingivae, using 5) Maxillary central incisors (U1) ½ = symmetri-
the patient real incisor height measured in the dental cally altered zenith with 0.5-mm enlargement in the
casts (Fig 1). This way, all photos could reach a real upper central incisors.
6) Right maxillary lateral incisor (U2R) 1 =
asymmetrically altered zenith with 1-mm increase in
right maxillary lateral incisor.
7) Maxillary lateral incisors (U2) 1 = symmetri-
cally altered zenith with 1-mm increase in maxillary
lateral incisors.
8) Right maxillary central incisor (U2R) 1 =
asymmetrically altered zenith with 1-mm increase in
right upper central incisor.
9) Maxillary central incisors (U1) 1 = symmetri-
cally altered zenith with 1-mm increase in maxillary
central incisors.
After photographs digital manipulation, a print
screen was taken, then the image was converted to
black and white. The black and white space was de-
fined as standard, using the same percentages to the
following settings: saturation, brightness, sharpness
and contrast, for each subject group (Fig 4).
Three groups of raters were used in this study: laypeo-
Figure 1 - Dental cast. ple, general dentists and orthodontists. In this research,

© 2018 Dental Press Journal of Orthodontics 49 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
original article Evaluation of the attractiveness of different gingival zeniths in smile esthetics

layperson was defined as a subject with no formal educa-

tion in dentistry or dental hygiene, however, but study-
ing or already finished high school, with minimal age of
17 years and maximum age of 75 years. General dentists
should be graduated in Dentistry and could have or not a
specialization in any Dentistry area, except Orthodontics.
Orthodontists raters were considered as a general dentist
that already had finished their specialization, master de-
gree or PhD in Orthodontics.10 Each rater received the
Figure 2 - Ideal smile. links to access the internet website where they could ac-
cess and evaluate the photos.
Laypersons group comprised 71 subjects with
mean age of 30.78 years, general dentists group
comprised 30 subjects (20 female and 10 male) with
mean age of 38. 4 years; and orthodontists group
comprised 56 subjects (22 female and 34 male) with
mean age of 38 years.
The smile attractiveness evaluation was made
through website visualization. When accessing the web
address www.digitalorthosmile.com (Fig 5), the evaluator
went through the following phases sequence to per-
A form the analysis of the different gingival zeniths: Free
and Informed Consent Form (questionnaire elaborated
in a simplified way, specifically for dentists, laypersons
and orthodontists); simple instructions to facilitate the
access and understanding of the research participants;
and the photos gallery called Dental Aesthetic Gallery.
Before starting the research, the evaluators visualized all
9 pictures of each patient. Then, they rated their prefer-
ences in this group and they went on to the next one
until the end of the voting in the 5 patients in the sam-
B
ple (Fig 6). It was stipulated that 5 smiles photographs
Figure 3 - A) Keynote mask; B) Maxillary right central incisor with increase of
1mm performed with Keynote mask. would be a sufficient number to generate a reliability of
results, and even 45 (5 x 9) being a large number, they
were evaluated in groups of 9, allowing the evaluators
to give the note that they considered more applicable.
The raters could stay as long as necessary to evalu-
ate the images, and could come back in the web site
at any time to better judge any smile, with the pos-
sibility of enlarging the image for better verification
one by one. Once completed and sent the final an-
swers, they could not re-open the questionnaire to
change the scores. After finalizing the votes, some
orientations were given to the evaluators and the data
were collected.
All data were stored in an database accessible via
Figure 4 - Final manipulated black and white photo. internet only by the researchers.

© 2018 Dental Press Journal of Orthodontics 50 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
Nomura S, Freitas KMS, Silva PPC, Valarelli FP, Cançado RH, Freitas MR, Oliveira RCG, Oliveira RCG original article

Statistical analysis orthodontists. To compare each smile change between

Intra-examiner error was performed to verify the the younger and older groups, Mann-Whitney non-
rater’s response reproducibility. It was calculated using parametric test was used.
a new survey with new answers by 20 examiners, one
month later. Weighted Kappa test was used.14 To de- RESULTS
termine the gender ratio, the three sample groups were Comparing the ages between laypersons, gen-
compared to each other, using Chi-Square test. To de- eral dentists and orthodontists (Table 1), results in-
termine the age compatibility between the sample dicated a significant difference between laypersons
groups, the Variance Analysis (ANOVA) and Tukey’s group and general dentists and orthodontists groups.
test were used. The non-parametric Kruskal-Wallis Laypersons were younger, with mean age of 30.78
test was used to compare the smile changes among all years, while general dentists had a mean age of 38.4
groups and separately between laypersons, dentists and years and orthodontists had a mean age of 38 years.

Figure 5 - Website print screens.

© 2018 Dental Press Journal of Orthodontics 51 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
original article Evaluation of the attractiveness of different gingival zeniths in smile esthetics

© 2018 Dental Press Journal of Orthodontics 52 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
Nomura S, Freitas KMS, Silva PPC, Valarelli FP, Cançado RH, Freitas MR, Oliveira RCG, Oliveira RCG original article

Figure 6 - Altered gingival zeniths: A) patient 1,

E B) patient 2, C) patient 3, D) patient 4, E) patient 5.

Table 1 - Age comparison among laypersons, dentists and orthodontists (One-way ANOVA test and Tukey’s test).

Laypersons Dentists Orthodontists

Variable (n=71) (n=30) (n=56) p
Mean (S.D.) Mean (S.D.) Mean (S.D.)
Age (years) 30.78 (12.11)A 38.40 (8.75)B 38.00 (10.43)B 0.000*

*Statistically significant for p<0.05

Smile changes comparison among all groups and central incisor changes were statistically significant;
separately between each other (Table 2) has been to orthodontists, the 0.5-mm asymmetrical changes
statistically significant, with some relevant results in the right maxillary central incisor were statisti-
to be considered: to laypersons, the right maxillary cally significant, however, there were no significant

© 2018 Dental Press Journal of Orthodontics 53 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
original article Evaluation of the attractiveness of different gingival zeniths in smile esthetics

differences in 0.5-mm maxillary central incisors that for the 1-mm increase in the gingival margins
symmetrical changes. In all three groups, right max- all they had statistically significant differences.
illary central incisor had the major significant statis- When comparing each smile change between lay-
tically difference. Among all groups, it was observed persons, general dentists and orthodontists (Table 3), it

Table 2 - Smile changes comparison among different gingival zeniths for all evaluators and for the 3 groups of evaluators separately (Non-parametric Kruskal-Wallis test).

IDEAL U2R ½ U2 ½ U1R ½ U1 ½ U2R 1 U2 1 U1R 1 U1 1

Median Median Median Median Median Median Median Median Median
p
(Mean) (Mean) (Mean) (Mean) (Mean) (Mean) (Mean) (Mean) (Mean)
I.R. (s.d.) I.R. (s.d.) I.R. (s.d.) I.R. (s.d.) I.R. (s.d.) I.R. (s.d.) I.R. (s.d.) I.R. (s.d.) I.R. (s.d.)
7.00 (6.61) 6.00 (6.39) 7.00 (6.48) 6.00 (5.90) 6.00 (6.28) 6.00 (6.11) 6.00 (6.02) 5.00 (4.95) 6.00 (5.89)
All (n=785) 1.90(3.00) 1.91 (3.00) 3.00 (1.90) 2.00 (2.00) 3.00 (2.05) 3.00 (2.24) 2.00 (1.96) 2.00 (2.19) 4.00 (2.25) 0.000*
A AC A B AC BC BC D B
7.00 (6.49) 7.00 (6.44) 7.00 (6.46) 6.00 (6.09) 6.00 (6.29) 7.00 (6.60) 6.00 (6.26) 5.00 (5.39) 6.00 (6.25)
Laypersons 3.00 (2.09) 3.00 (2.11) 3.00 (2.07) 3.00 (2.05) 3.00 (2.14) 3.00 (2.03) 3.00 (2.04) 3.00 (2.13) 3.00 (2.28) 0.000*
A A A A A A A B A
7.00 (6.60) 6.00 (6.26) 7.00 (6.39) 5.00 (5.52) 6.00 (5.85) 6.00 (5.63) 6.00 (5.78) 4.00 (4.37) 5.00 (4.93)
Dentists 3.00 (1.60) 2.00 (1.53) 1.00 (1.57) 3.00 (1.81) 2.00 (1.87) 3.00 (1.72) 2.00 (1.70) 3.00 (1.94) 3.00 (2.06) 0.000*
A ACD AC BCDF BCD BDF BCD E EF
7.00 (6.76) 6.00 (6.40) 7.00 (6.54) 6.00 (5.87) 7.00 (6.50) 6.00 (5.76) 6.00 (5.85) 5.00 (4.71) 6.00 (5.95)
Orthodon-
3.00 (1.78) 3.00 (1.83) 3.00 (1.84) 3.00 (2.00) 3.00 (2.00) 3.00 (2.60) 3.00 (1.96) 3.00 (2.27) 4.00 (2.18) 0.000*
tists
A ABD A BC A C CD E BC

*Statistically significant for p<0.05. Different letters in a row indicate the presence of statistically significant difference.

Table 3 - Comparison of each gingival zenith change among laypersons, dentists and orthodontists (Non-parametric Kruskal-Wallis test).

Laypeople (n=71) Dentists (n=30) Orthodontists (n=56)

ZENITH CHANGES Median (Mean) Median (Mean) Median (Mean) P
I.R. (S.D.) I.R. (S.D.) I.R. (S.D.)
7.00 (6.49) 7.00 (6.60) 7.00 (6.76)
IDEAL 0.31
3.00 (2.09) 3.00 (1.60) 3.00 (1.78)
7.00 (6.44) 6.00 (6.26) 6.00 (6.40)
U2R ½ 0.505
3.00 (2.11) 2.00 (1.53) 3.00 (1.83)
7.00 (6.46) 7.00 (6.39) 7.00 (6.54)
U2 ½ 0.705
3.00 (2.07) 1.00 (1.57) 3.00 (1.84)
6.00 (6.09) 5.00 (5.52) 6.00 (5.87)
U1R ½ 3.00 (2.05) 3.00 (1.81) 3.00 (2.00) 0.004*
A B AB
6.00 (6.29) 6.00(5.85) 7.00 (6.50)
U1 ½ 3.00 (2.14) 2.00(1.87) 3.00 (2.00) 0.003*
A B A
7.00 (6.60) 6.00 (5.63) 6.00 (5.76)
U2R 1 3.00 (2.03) 3.00 (1.72) 3.00 (2.60) 0.000*
A B B
6.00 (6.26) 6.00 (5.78) 6.00 (5.85)
U2 1 3.00 (2.04) 2.00 (1.70) 3.00 (1.96) 0.008*
A B B
5.00 (5.39) 4.00 (4.37) 5.00 (4.71)
U1R 1 3.00 (2.13) 3.00 (1.94) 3.00 (2.27) 0.000*
A B B
6.00 (6.25) 5.00 (4.93) 6.00 (5.95)
U1 1 3.00 (2.28) 3.00 (2.06) 4.00 (2.18) 0.000*
A B A

*Statistically significant for p<0.05. Different letters in a row indicate the presence of statistically significant difference.

© 2018 Dental Press Journal of Orthodontics 54 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
Nomura S, Freitas KMS, Silva PPC, Valarelli FP, Cançado RH, Freitas MR, Oliveira RCG, Oliveira RCG original article

Table 4 - Comparison of each smile change between younger and older groups (Mann-Whitney non-parametric test).

Younger (n=530) Older (n=225)

ZENITH CHANGES Median (Mean) Median (Mean) p
I.R. (s.d.) I.R. (s.d.)
7.00 (6.64) 7.00 (6.55)
IDEAL 0.761
3.00 (1.84) 3.00 (2.02)
7.00 (6.39) 6.00 (6.39)
U2R ½ 0.851
3.00 (1.90) 3.00 (1.94)
7.00 (6.48) 7.00 (6.47)
U2 0.5 0.921
3.00 (1.88) 3.00 (1.96)
6.00 (5.91) 6.00 (5.87)
U1R 0.5 0.676
3.00 (1.99) 3.00 (2.02)
6.00 (6.41) 7.00 (6.00)
U1 0.5 0.003*
3.00 (2.01) 3.00 (2.12)
6.00 (6.16) 6.00 (6.02)
U2R 1 0.571
3.00 (2.30) 3.00 (2.10)
6.00 (6.11) 6.00 (5.83)
U2 1 0.044*
3.00 (1.95) 3.00 (1.99)
5.00 (5.06) 5.00 (4.72)
U1R 1 0.038*
3.00 (2.15) 3.00 (2.24)
6.00 (6.14) 6.00 (5.36)
U1 1 0.000*
3.00 (2.19) 4.00 (2.30)

*Statistically significant for p<0.05. Different letters in a row indicate the presence of statistically significant difference.

was statistically significant for the 0.5-mm maxillary requires a qualified professional who know how to
right central incisor change. Laypersons and general den- use this program for the digital images manipulation,
tists had a smaller statistical difference in the 0.5mm and to achieve a manipulated image as natural as possible.
1.00mm maxillary central incisors symmetrical changes. Due to this difficulty and so to the practicality that
In a comparison performed dividing each group Keynote software offers, with simple resources that
in two parts (Table 4) — a younger part (from 17 to enables the own researcher to operate it and make
40 years old) and an older part (from 41 to 75 years the wanted digital images manipulation, in the pres-
old) — smile changes in the right maxillary central in- ent study Keynote was chosen, because the digital
cisors, right maxillary lateral incisor, right maxillary images manipulations showed as high quality as
central incisor were statically significant, with the older those performed with Adobe Photoshop and in some
group always giving lower scores than the younger one, cases even better one. The maxillary incisors trans-
and this, as seen before, corroborate the fact that dentists fer and the ruler calibration have made the images of
and orthodontists groups had the older evaluators, and this study very similar to the patients’ teeth real size.
the laypersons group had the younger subjects. Canine is a tooth that has a prominent buccal bossa
and the photograph can suffer some distortions in this
DISCUSSION area. Due to this it was decided not to make any digital
In this research methodology, the authors have manipulation because it would be closer to the real one
pursued a manner to handle images that, when the and less perceptible to the evaluators than the digital
photos were digitally manipulated and so observed manipulated photo. There was also a concern to stan-
by the evaluators, these changes were as least per- dardize as much as possible the smile image attain-
ceptible as possible, giving to the observer a natural ment. The photos were taken only by a researcher at
esthetic smile visual sensation. In the vast majority the same distance from the camera lens to the patients’
of researches in which digital images are manipu- lips, under the same lighting conditions.
lated, arguably the program of choice is Adobe Pho- In the age comparison between the three groups
toshop.13,15-21 Adobe Photoshop is an image editing (Table 1), laypersons were the youngest and general
program that has been marketed for many years be- dentists and orthodontists had their ages statistically
cause it has advanced features, but nevertheless often similar. Pithon et al17 showed that younger layper-

© 2018 Dental Press Journal of Orthodontics 55 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
original article Evaluation of the attractiveness of different gingival zeniths in smile esthetics

sons are more critical to the dental aesthetic than pared to their corresponding lateral incisors, show-
older ones, but even though they were the group ing a greater visual impact to the laypersons, dentists
with younger subjects, they were still less critical and orthodontists’ eyes. Machado et al19 affirm that
than dentists and orthodontists when evaluating the maxillary central incisors are the key to a pleasant
smiles. When comparing the older and the younger smile and its symmetry is of utmost importance for
groups (Table 4), the older groups gave lower scores the smile aesthetics.
than the younger one, confirming the fact that gen- Based in these results, laypersons, general den-
eral dentists and orthodontists were the older sub- tists and orthodontists had a greater perception of
jects and laypersons were the youngest. A similar 1-mm changes in the gingival margin and when
result was found in a study22 of the perception of asymmetrical, these results are different to those
smile attractiveness and its aesthetics standards vari- found in other studies, 13,24 in which laypersons
ations, in which younger evaluators were more criti- perceived this difference in the gingival margin
cal when judging smiles with diastema. Sriphadung- just from 2-mm changes.
porn and Chamnannidiadha23 also concluded that Therefore, if 1-mm changes in the gingival mar-
age impacts smile perception. However, to Kokich et gins are perceptible and uncomfortable to the layper-
al13 the professional evaluators’ years of experience sons’ aesthetic perception, orthodontists must take
and laypersons evaluators’ age did not influence the a great care when finalizing their orthodontic cases
aesthetic perception. because the patients’ esthetic demands are increasing.
In the comparison of smile changes among all It also has been observed that when comparing
groups and separately between the three groups (Ta- maxillary central incisors with their correspondent
ble 2), laypersons had significant perception of 1-mm lateral incisors, always the same changes performed
asymmetric changes in the maxillary right central in- in central incisors were much more perceptible to
cisor, but in other studies these asymmetric changes evaluators than those performed on lateral incisors.
were noted from 2-mm asymmetry.13,24 This is simi- Therefore, dentists and orthodontists must preserve
lar to other study25 in which dental students were the and seek for the maximum maxillary central incisors
evaluators and these asymmetries were noted from aesthetics of their patients, because they are the most
2-mm changes. This findings suggests that any ther- visible teeth in people’s eyes.
apeutic attempt (orthodontic, aesthetic or surgical)
to correct gingival margins asymmetries between 0.5 CONCLUSIONS
and 1,5mm may be an overreacted measure of dental Asymmetric gingival zeniths are less attractive
professionals rather than an aesthetic appeal, since it than symmetrical gingival zeniths; gingival zeniths
seems not to be so relevant to laypersons.24 changes greater than 1mm are perceptible in the
Some authors13,26 demonstrated that dental and gin- smile attractiveness, both by laypersons as general
gival asymmetries have a negative impact on patient at- dentists and orthodontists. When comparing maxil-
tractiveness. The results of the present study shows that lary central incisors with maxillary lateral incisors,
gingival asymmetries are always less attractive than the the aesthetic changes performed in the central inci-
symmetric changes, that is, when small changes oc- sors are more perceptible than those performed in
curs the evaluators show differences in their judgments, lateral incisors, both symmetrical as asymmetrical.
where symmetric changes are more difficult to identify. In a general way, orthodontists and general den-
In another study, Kokich et al16 compared the dentists tists are more critical in the evaluation and percep-
and laypersons perception to symmetrical dental chang- tion of gingival zenith changes, with the laypersons
es, and noted that when the symmetrical gingival mar- perceiving this change only from 1mm of maxillary
gin change was evaluated, none of the three groups (or- right central incisor asymmetrical change. However,
thodontists, general dentists and laypersons) could dis- orthodontists’ perception is similar with the layper-
tinguish between levels of gingival margin discrepancy. sons when the gingival zenith changes are performed
It was also noticed that maxillary central incisors symmetrically in the maxillary central incisors.
always had a greater aesthetic relevance when com-

© 2018 Dental Press Journal of Orthodontics 56 Dental Press J Orthod. 2018 Sept-Oct;23(5):47-57
 Nomura S, Freitas KMS, Silva PPC, Valarelli FP, Cançado RH, Freitas MR, Oliveira RCG, Oliveira RCG original article

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17. Pithon MM, Santos AM, Andrade ACV, Santos EM, Couto FS, Coqueiro RS.
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