Perception of Saudi dentists and lay people to altered smile esthetics

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1 The Sui Dentl Journl (2013) 25, King Su University The Sui Dentl Journl ORIGINAL ARTICLE Pereption of Sui entists n ly people to ltere smile esthetis Neel Tli, *, Smr AlOmr, Asm AlMihn Deprtment of Peitris Dentistry n Orthoontis, College of Dentistry, King Su University, Riyh, Sui Ari Dentist, Riyh, Sui Ari Reeive 8 Ferury 2012; revise 3 Septemer 2012; epte 25 Septemer 2012 Aville online 7 Novemer 2012 KEYWORDS Sui entists; Smile esthetis; Pereption; Ly people Astrt Aim: To evlute n ompre the pereptions of Sui entists n ly people to ltere smile fetures. Methos: Thirty-six igitl smile photogrphs with ltere fetures were use. Altere fetures inlue the following: rown length, with, gingivl level of the lterl inisors, gingivl isply, miline istem, n upper miline shift. The photogrphs were presente to smple of 30 entists n 30 ly people with equl gener istriution. Eh prtiipnt rte eh piture with visul nlogue sle, whih rnge from 0 (very unttrtive) to 100 (very ttrtive). Results: Dentists were more ritil thn ly people when evluting symmetril rown length isrepnies. Compre to ly people, Sui entists gve lower rtings to rown length isrepny of >2 mm (P < 0.001), rown with isrepny of P2 mm(p < 0.05), hnge in gingiv to lip istne of P2 mm(p < 0.01), n miline evition of >1 mm (P < 0.01). There ws no signifint ifferene etween entists n ly people towrs ltertions in the gingivl level of the lterl inisors or towrs spe etween the entrl inisors. No signifint sex ifferene ws seen ross the groups. Conlusion: In this smple, Sui entists gve signifintly lower ttrtiveness sores to rown length n rown with isrepnies, miline evitions, n hnges in gingiv to lip istne ompre to Sui ly people. ª 2012 King Su University. Proution n hosting y Elsevier B.V. All rights reserve. 1. Introution * Corresponing uthor. Aress: Deprtment of Peitri Dentistry n Orthoontis, College of Dentistry, King Su University, P.O. Box 60169, Riyh 11545, Sui Ari. Tel.: E-mil ress: nftli@yhoo.om (N. Tli). Peer review uner responsiility of King Su University. Proution n hosting y Elsevier Fil ttrtiveness is efine y the smile of n iniviul, whih is vlule metho for influening people. Smile nlysis is n integrl prt of the overll fil nlysis rrie out y entists, orthoontists, n mxillofil surgeons. An iniviul smile is efine s the ynmi n stti reltionship of the entition n supporting strutures to the fil soft tissues. A smile nlysis inlues the mount of the inisors n gingiv show upon smiling, the smile r (prllelism ª 2012 King Su University. Proution n hosting y Elsevier B.V. All rights reserve.

2 14 N. Tli et l. etween the mxillry inisl eges n the lower lip), tooth proportions, gingivl height n ontours, reltionship etween the entl miline n fil miline, n tooth she n olor. Normlly upon smiling, the entire upper inisor is seen. Some isply of the gingiv is onsiere eptle. A isply of the upper inisors of <75% is onsiere uneptle (Kokih et l., 1999). Mxillry tooth with proportions provie n exmple of the golen proportion. The with of the lterl inisor shoul e roun 62% of the with of the entrl inisor. The mxillry entl miline shoul oinie with the soft tissue fil miline (Johnston et l., 1999). However, it n e iffiult to ssess the reltionship of the entl miline to the fil miline. One ommon metho for this ssessment is to use entl floss through the fil miline. Another metho is to ssess the reltionship of the entl miline to the philtrum of the upper lip. A miline isrepny of <2 mm etween the mxillry entl miline n the fil miline is onsiere to e eptle (Beyer n Linuer, 1998; Crsh et l., 2003). However, ny mxillry inisl nt (unprllel reltionship etween the mxillry inisors) is esily pereive y entl professionls n ly people (Kokih et l., 1999). Professionl n oservnt iniviuls re le to etet fetures tht re out of lne or hrmony (Miller, 1989). For orthoonti tretment eisions, it is essentil to unerstn the threshol of wht ommunity onsiers eptle in terms of norml smile fetures. The pereptions of estheti entl ltertions y ly people n professionls hve een evlute (Kokih et l., 1999; Flores et l., 2004; LV et l., 2005; Moore et l., 2005). Asymmetri ltertions mke teeth unttrtive to entists n ly people like (Kokih et l., 2006). The pereption of fil n entl esthetis hs een evlute with the visul nlogue sle (VAS), whih is onsiere to e n esy n relile metho (Tli n Al-Shkhs, 2008). The im of this stuy ws to evlute n ompre the pereptions of Sui entists n ly people to ltere smile fetures. 2. Mteril n methos 2.1. Smple Two juging groups (30 Sui entists n 30 Sui nonentists) were ske to prtiipte in this stuy. The nonentist group represente Sui ly people. The seletion of the juges ws rnom. The ly people group h ifferent kgrouns, with n ge rnge of yers. The entl group inlue generl prtitioners, with n ge rnge of yers. The mle to femle rtio ws equl in oth groups. A onsent form ws signe y the prtiipnts in the stuy, n ethil pprovl ws given y the College of Dentistry Reserh Center Vriles n mesurements Thirty-six igitl photogrphs were use in this stuy. The photogrphs showe the smile lone, exluing other fil strutures, to minimize ny istrting vriles. The smile fetures in the photogrphs were igitlly ltere y Aoe Photoshop softwre (Aoe Systems In., Sn Jose, CA). The ltertions were intentionlly rete to resemle smile estheti isrepny. The photogrphs were groupe into six sets, eh representing n ltere smile feture, with ltertion inrements rnging from 0.5 to 1 mm. The ltere fetures were s follows: (1) rown length (CL), (2) level of the gingivl mrgins of the lterl inisors, (3) gingiv show, (4) rown with, (5) mxillry miline shift, n (6) miline istem. The ltertions re esrie in etil in Setions through The sets were rrnge in orer, ut the inrementl hnges were not sequene. During the survey, the photogrphs were oe y the uthors with seril numers from 1 to 36. Photogrphs isplying the inrementl hnges were rrnge n isplye rnomly Crown length (Fig. 1) The CL of the mxillry entrl inisors ws inrese y 0.5 mm. The inisl ege ws use s referene point for the highest point of the gingivl mrgin Level of the gingivl mrgins of the lterl inisors (Fig. 2) The vertil position of the gingiv of the mxillry lterl inisors ws inrese y 1 mm reltive to the jent entrl inisor Gingiv show (Fig. 3) The gingiv to lip mrgin level (gingivl show) ws inrese y 1 mm, to rete gummy smile. Altertions were se on the reltionship of the upper lip with the gingivl mrgin of the mxillry inisors Crown with (Fig. 4) Symmetril rown with ltertions were me to the mxillry lterl inisors. The inisl ege ws kept t the sme level. The ltertion ws limite to the mesio-istl with of the lterl inisors, whih ws erese y 1 mm Miline shift (Fig. 5) A mxillry entl miline shift ws me, while the lower miline n the lip upi ow were fixe n use s referene. A 1-mm inrement ws use to shift the mxillry miline to the right of the ptient Miline istem (Fig. 6) A miline istem ws introue etween the mxillry entrl inisors y 0.5-mm inrement mesure from the interproximl ontt point of the entrl inisors Visul nlogue sle An evlution form ontining the VAS uner the photogrphs ws istriute to oth juging groups n use to rte the smile esthetis. The VAS ws 100 mm in length. The left en of the sle ws lelle s very unttrtive n ws represente y the numer zero. The right en of the sle ws lelle very ttrtive n ws represente y the numer 100. Eh juge ws ske to ple mrk long the VAS to rte his/her pereption of entl esthetis. Eh mrk on the VAS ws mesure with liper n reore.

3 Pereption of Sui entists n ly people to ltere smile esthetis mm 1 mm e 1.5 mm f 2 mm 2.5 mm 3 mm Figure 1 Photogrphs showing ltertion to the rown length of the entrl inisors. The ltertion ws me to the mxillry entrl inisors, using the inisl ege s referene point to the highest point of the gingivl mrgin. () Centrl inisor rown length ltertion y 0.5 mm inrement; () 1 mm inrement; () 1.5 mm inrement; () 2 mm inrement; (e) 2.5 mm n (f) 3 mm inrement Sttistil nlysis The t were nlyse y Stuent s t-test to ientify ny sttistilly signifint ifferenes in the pereption of entists n ly people to ltere smile esthetis. The onfiene level ws set t P < One-wy nlysis of vrine (ANOVA) ws use to investigte possile ssoition etween sex n the pereption towrs smile isrepnies. 3. Results A omprison of the pereptions of Sui entists n ly people to ltere smile esthetis showe tht entists were more ritil thn ly people when evluting symmetri CL isrepnies. There ws no signifint ifferene etween entists n ly people when the CL isrepny ws <2 mm. However, entists gve lower VAS rtings thn ly people to CL isrepnies of >2 mm (P < 0.001) (Tle 1; Fig. 7). Rtings y entists were lower thn those y ly people when ssessing ltertions of the lterl inisor gingivl mrgins. However, this ifferene ws not sttistilly signifint (Tle 2; Fig. 8). The pereptions of entists n ly people to gingiv show were not signifintly ifferent t the 0-mm level. However, entists gve lower rtings thn ly people when the gingiv to lip mrgin ws >1 mm (P < 0.01) (Tle 3; Fig. 9). Dentists gve lower rtings thn ly people when the rown with isrepny ws P2 mm(p < 0.05) (Tle 4; Fig. 10). Sui entists gve lower rtings thn ly people to miline evition >1 mm (P < 0.01) (Tle 5; Fig. 11). A smll mount of spe etween the mxillry entrl inisors ws rte s unttrtive y oth entists n ly people, with no signifint ifferene etween the two groups (Tle 6; Fig. 12). No signifint sex ifferene ws seen ross the groups. However, femles tene to give slightly higher rtings for most of the isrepnies. 4. Disussion In this stuy, the threshol for CL isrepny y Sui entists n ly people ws P2 mm, whih is onsiere to e low threshol. These finings re omprle to those of Kokih et l. (1999), who evlute the pereptions of entl professionls n ly people to ilterl CL ltertions. In tht stuy, the threshol for unttrtiveness ws 1.0 mm for orthoontists, 1.5 mm for generl entists, n 2.0 mm for ly people. The length of the mxillry inisors shoul e greter thn their mesio-istl with. Therefore, inisors shoul exhiit retngulr shpe in the gingivl-inisor imension rther thn squre shpe. This golen proportion oul e hieve y orthoonti intrusion followe y omposite uil-ups,

4 16 N. Tli et l. 0 mm 1 mm e 2 mm 3 mm f 4 mm 5 mm Figure 2 Photogrphs showing ltertion to the vertil height of the ginigivl mrgins of the mxillry lterl inisors in reltion to the gingivl height of the entrl inisors. () no ltertion; () 1 mm ltertion; () 2 mm; () 3 mm; (e) 4 mm n (f) 5 mm. veneers, or even porelin rowns. In some ses, estheti gingivetomy my e onsiere s tretment option (Kokih, 1996; Kokih n Sper, 1997). Previous stuies hve reporte prevlene rtes of smll (peg-shpe) lterl inisors rnging from 0.37% to 4% in ifferent regions of Sui Ari (Al Emrn, 1990; Slem, 1989). In the present stuy, Sui entists gve lower rtings thn ly people when the rown with isrepny ws P1mm (P < 0.05). This threshol is omprle to the threshol foun y previous stuy, whih reporte tht generl entists were le to etet lterl inisor rown with nrrowing of 3 mm, wheres ly people i not notie hnge until the lterl inisor with ws nrrowe y 2 mm. Therefore, entists pper to e more sensitive to smller peg-shpe lterl inisors. To hve norml estheti smile, the lterl inisor with shoul e two-thirs the with of the entrl inisor, or it shoul follow the golen proportion of of the with of the entrl inisor. If ptient hs smll peg-shpe lterl inisor, omposite uil-up or ermi veneers my e use to meet the golen proportion of n estheti smile. In this stuy, the rtings y Sui entists were slightly lower when ssessing lterl inisor gingivl level ltertions s ompre to Sui ly people. However, this ifferene ws not sttistilly signifint. This fining is in greement with previous stuy tht showe tht symmetril gingivl ltertions were not etete y orthoontists, entists, or ly people (Kokih et l., 1999). Normlly, the entire upper inisor is seen upon smiling. A gingivl isply of 1 2 mm is onsiere eptle (Chihe n Pinult, 1994). Sui entists n ly people pereive hnge in ttrtiveness when the gingiv to lip istne ws P1 mm. This fining is in isgreement with previous stuy tht showe inrese gingiv to lip istne ws not notiele y Amerin entists n ly people until it ws t lest 4 mm (Kokih et l., 1999). Sui entists n ly people pper to hve lower threshol to exessive gingiv show upon smiling. The rting of Sui entists n ly people ws omprle to tht of Amerin orthoontists, who rte 2 mm of gingivl show s exessive. The prevlene rtes of miline istem n miline isrepny in Suis were previously reporte to e 32.8% n 30.7%, respetively (Al-Blkhi n Zhrni, 1994). A smll mount of spe etween the mxillry entrl inisors ws rte s unttrtive y oth Sui entists n ly people. However, there ws no signifint ifferene in the rtings of Sui entists n ly people to spe etween the entrl inisors. Sui entists gve lower sores thn ly people to miline evition of >1 mm (P < 0.01). These finings re omprle to the threshol reporte y Amerin entists n ly people (Kokih et l., 1999). However, Sui entists were more sensitive to miline evitions. Orthoontists shoul only ept mxillry miline evition if the evition is vertil without ny nt (ngultion) in the mxillry nterior teeth. No signifint sex ifferene ws seen ross the groups

5 Pereption of Sui entists n ly people to ltere smile esthetis 17 e f Figure 3 Photogrphs showing ltertion of the gingiv to lip reltion (Gingivl show). Altertions were se on the reltion of the upper lip with the gingivl mrgin of the mxillry inisors. () No hnge; () 1 mm inrese in gingivl show; () 2 mm; () 3 mm; (e) 4 mm n (f) 5 mm. Figure 4 Photogrphs showing ltertions to mxillry lterl inisors rown with. The mesio-istl with of the mxillry lterl inisors ws erese y n inrement of 1 mm. () 1 mm erese in the with of the mxillry lterl inisors; () 2 mm; () 3 mm n () 4 mm. in the pereption of symmetril smile ltertions. This oservtion onfirms tht esthetis is viewe y n iniviul regrless of his or her gener. The finings of the present stuy my e utilize y entists n orthoontists when mking tretment eisions, prtiulrly eisions influene y the threshols of Sui ly people to ltere smile fetures. Future stuies re neee to exmine the pereptions of orthoontists to ltere smile esthetis n of Sui entists, ly people, n orthoontists to symmetri ltertions.

6 18 N. Tli et l. e f Figure 5 Photogrphs showing ltertions to mxillry entl miline in reltion to the philtrum of the lip. The ltertions were one with 1 mm inrement. () No miline evition; () 1 mm miline evition to the left; () 2 mm evition; () 3 mm evition; (e) 4 mm evition n (f) 5 mm evition. e f Figure 6 Photogrphs showing ltertion of miline istem. The ltertions were one y n inrement of 0.5 mm. () No ltertion; () 0.5 mm miline istem; () 1 mm istem; () 1.5 mm istem; (e) 2 mm istem n (f) 2.5 mm istem.

7 Pereption of Sui entists n ly people to ltere smile esthetis 19 Tle 1 Mens n stnr evitions of VAS rting y entists n ly people to rown length isrepny. (CL: Crown length in mm). Vrile Dentists Ly people t-test p-vlue CL ± ± NS CL ± ± NS CL ± ± NS CL ± ± NS CL ± ± *** CL ± ± *** CL ± ± ** NS: Not signifint. * p < ** p < *** p < Figure 8 Line grph showing the men rting of the gingivl mrgin level isrepny y entist n ly people. (GM: Gingivl mrgin in mm). Tle 3 Mens n stnr evitions of the rting y entists n ly people to the gingivl to lip mrgin isrepny. (GL: Gingivl to lip mrgin in mm). Dentists Ly people t-test p-vlue GL ± ± NS GL 1 52 ± ± ** GL ± ± * GL 3 45 ± ± * GL ± ± ** GL ± ± ** NS: Not signifint. * p < ** p < *** p < Figure 7 Line grph showing the men rting of the rown length isrepny y entist n ly people. (CL: Crown length in mm). Tle 2 Mens n stnr evitions of rting y entists n ly people to ltere gingivl mrgin level isrepny. (GM: Gingivl mrgin in mm). Dentists Ly people t-test p-vlue GM ± ± NS GM ± ± NS GM 2 56 ± ± NS GM ± ± NS GM ± ± NS GM ± ± NS NS: Not signifint. 5. Conlusions The smple of Sui entists exmine in this stuy ws more ritil thn ly people when evluting symmetri CL isrepnies. However, ly people signifintly pereive CL isrepnies of >2 mm. Figure 9 Line grph showing the men rting of the gingivl to lip mrgin isrepny y entist n ly people. (GL: Gingivl to lip mrgin in mm). The smple of Sui entists gve signifintly lower VAS rtings thn ly people when the rown with isrepny ws P2 mm.

8 20 N. Tli et l. Tle 4 Mens n stnr evitions of rting y entists n ly people to rown with isrepny. (CW: Crown with in mm). Dentists Ly people t-test p-vlue CW ± ± NS CW 1 44 ± ± NS CW 2 43 ± ± * CW ± ± ** CW ± ± * NS: Not signifint. * p < ** p < *** p < The VAS rtings of Sui entists were slightly lower thn Figure 11 Line grph showing the men rting of the miline shift isrepny y entist n ly people. (MS: Miline shift in mm). Tle 6 Mens n stnr evitions of rting y entists n ly people to miline istem isrepny. (MD: Miline istem in mm). Dentists Ly people t-test p-vlue MD 0 54 ± ± NS MD ± ± NS MD 1 38 ± ± NS MD ± ± NS MD ± ± NS MD ± ± NS NS: Not signifint. Figure 10 Line grph showing the men rting of the rown with isrepny y entist n ly people. (CW: Crown with in mm). Tle 5 Mens n stnr evitions of rting y entists n ly people to miline shift isrepny. (MS: Miline shift in mm). Dentists Ly people t-test p-vlue MS ± ± NS MS ± ± ** MS 2 42 ± ± NS MS ± ± ** MS ± ± NS MS ± ± ** NS: Not signifint. * p < ** p < *** p < Figure 12 Line grph showing the men rting of the miline istem isrepny y entist n ly people. (MD: Miline istem in mm). those of ly people when ssessing lterl inisor gingivl/ inisl level ltertions. When the gingiv to lip mrgin isrepny ws >1 mm, entists gve signifintly lower VAS rtings thn ly people. A smll mount of spe etween the mxillry entrl inisors ws rte s unttrtive y oth entists n ly people, with no signifint ifferene etween the groups. Compre to Sui ly people, Sui entists gve signifintly lower VAS rtings to miline evitions of >1 mm. Femles tene to give slightly higher rtings for most of the isrepnies. Conflit of interest The uthors hve no onflit of interest to elre.

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