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The effect of gender on tooth and gingival

display in the anterior region at rest and during
smiling

Article in European journal of esthetic dentistry : official journal of the European Academy of Esthetic Dentistry,
The · December 2009
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 CLINICAL RESEARCH pyrig
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The Effect of Gender on Tooth ss e n c e
fo r

and Gingival Display in the Anterior

Region at Rest and During Smiling
Riyad Al-Habahbeh, BDS, MSc
Senior Specialist in Restorative Dentistry, Head of Department of Dentistry,
Marka Medical Center, Prince Aysha Bint al-Hussien Medical Complex,
Marka, Amman, Jordan

Raghda Al-Shammout, BDS, JBOrth

Assistant Specialist in Orthodontics, Division of Orthodontics, Department of Dentistry,
Al-Hussein Hospital, King Hussein Medical Center, Amman, Jordan

Dr Osama Al-Jabrah, BDS, MSc, JBPD

Specialist in Prosthetic Dentistry, Division of Prosthodontics, Department of Dentistry,
Marka Medical Center, Prince Aysha Bint al-Hussien Medical Complex,
Marka, Amman, Jordan

Dr Farooq Al-Omari, BDS, MSc, MORTH RCSEd

Specialist in Orthodontics, Division of Orthodontics, Department of Dentistry,
Marka Medical Center, Prince Aysha Bint al-Hussien Medical Complex,
Marka, Amman, Jordan

Correspondence to: Dr Riyad Al-Habahbeh

PO Box: 36227 Al-Hashmi Janobi, Amman, Jordan, Tel: 00962 6 5053802; e-mail: riyad_habahbeh@yahoo.com

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Abstract
The aim of the present study was to inves-
tigate the effect of gender on the degree of
maxillary and mandibular anterior teeth
and associated gingival display when the
lips are at rest and during smiling.
A total of 247 subjects (144 females
[58.3%]; 103 males [41.7%]) were included
in the study. All of the subjects had all nat-
ural anterior teeth present with no caries,
extreme occlusal wear, restorations, extru-
sion, obvious deformities, or tooth mobility.
Subjects with a history of congenital anom-
alies, lip trauma, or facial surgery were ex-
cluded. Crown length, displayed portions
of anterior teeth, and associated gingivae
at rest and during smiling were measured
using a Fowler electronic digital caliper,
which had a resolution of 0.01 mm. The vis-
ible portions of the maxillary anterior teeth
were measured vertically from the lower
border of the upper lip to the incisal edge
of the incisors, or cusp tip for the canines.
The visible portions of the mandibular an-
terior teeth were measured vertically from
the upper border of the lower lip to the in-
cisal edges of the incisors, or cusp tip for
the canines at the midpoint of the tooth. The
measurements were taken by two inde-
pendent clinicians and they were repeated
three times and the mean value was calcu-
lated for further analysis. SPSS (V 11) soft-
ware was used to analyse the data. Statis-
tical analyses were performed by Student
t test and ANOVA. The significance level
was set at 5%.
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At rest, males displayed significantly
ss e n c e
fo r
more buccal length for maxillary lateral in-
cisors (1.85 ± 1.27 vs 1.43 ± 1.37; P < 0.01),
maxillary canines (0.94 ± 0.91 vs 0.35 ±
0.67; P < 0.0001), mandibular central inci-
sors (1.09 ± 1.17 vs 0.82 ± 1.32; P < 0.01),
mandibular lateral incisors (0.98 ± 1.07 vs
0.79 ± 1.22; P < 0.05), and mandibular ca-
nines (0.87 ± 1.23 vs 0.57 ± 0.98; P < 0.05)
than females. However, no gender differ-
ences in the display of buccal length of the
maxillary central incisor were recorded at
rest and during smiling. During smiling, no
gender differences in the display of buccal
length of the anterior teeth were recorded.
Gingival display during smiling presented
significant differences between gender
groups in the maxillary anterior region, with
females displaying more gingivae of cen-
tral incisors (1.85 ± 1.38 vs 1.73 ± 1.07; P <
0.05), lateral incisors (2.05 ± 0.93 vs 1.94
± 1.23; P < 0.0001), and canines (2.37 ±
1.24 versus 2.02 ± 1.49; P < 0.05). How-
ever, no gender differences were observed
in the gingival display of the mandibular
anterior region. Females displayed 29% vs
25% of maxillary central incisor crown
length compared to males at rest. Howev-
er, during smiling, 87% of maxillary anteri-
or teeth were displayed in females com-
pared to less than 80% in males.
Males displayed more of the maxillary
lateral, canine, and mandibular anterior
teeth than females at rest. During smiling,
no gender differences in anterior tooth dis-
play were recorded, however, females dis-
played more maxillary gingivae than males.
(Eur J Esthet Dent 2009;4:382–395.)
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Introduction
Driven by increased interest within den-
tistry and greater patient awareness out-
side the profession, facial esthetics and the
desire of patients to improve their appear-
ance have grown in importance.1,2 Interest
in the overall facial appearance has in-
creased in contemporary prosthodontic
3-5
treatment, rather than concentrating on
one aspect such as a smile analysis.6-8
The degree of anterior tooth display with
the lips at rest and during smiling is an im-
portant esthetic factor in determining the
outcome of fixed and removable prostho-
dontic care, implant dentistry, operative
dentistry, anterior esthetic procedures, and
9,10
orthognathic surgery.
The dentofacial composition encom-
passes both the frontal and sagittal planes
in two muscular positions, static and dy-
11
namic. The amount of tooth exposure at
rest is predominantly a muscle-determined
position, however, a smile is determined by
the dynamic muscular position of the lips.1
The static position is determined when the
lips are slightly parted and the teeth are out
of occlusion with the peri-oral muscles rel-
atively relaxed. In this position, four factors
influence tooth exposure: lip length, age,
race, and sex (LARS).12,13 It has been report-
ed that individuals with shorter upper lips
display more maxillary central incisor sur-
face than people with longer upper lips,
and those with longer upper lips show
12
more mandibular central incisors.
Age influences the amount of tooth vis-
ibility. The amount of maxillary teeth dis-
played is inversely proportional to in-
creasing age, whereas the amount of
mandibular teeth displayed is directly pro-
14
portional to increasing age. Therefore, a
young person will display more maxillary
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than mandibular teeth, whereas an ss e n c e
fo r
individual will show more mandibular
rather than maxillary teeth.12
The result of aging is reduced tonicity of
the orofacial muscles and laxness of tegu-
mental relief in the lower third of the face,
resulting in formation of the labial, nasolabi-
al, and mental grooves and ridges. The
loss of elasticity of the upper lip, with in-
creasing tooth support by the gingival two-
thirds of the maxillary incisors, accounts for
less maxillary and more mandibular incisor
teeth display.15
A decreasing amount of maxillary, and
an increasing amount of mandibular tooth
visibility is seen when comparing Cau-
casians to Asians to blacks. Racial differ-
ences in the amount of displayed maxillary
central incisors were also reported, with
white Americans showing more tooth sur-
face than blacks.16 Males generally have
longer upper lips, displaying nearly half the
amount of their maxillary teeth at rest com-
pared to females. Before the amount of
tooth exposure at rest is prescribed for the
proposed prostheses, each patient should
be assessed according to the LARS factor,
eg, an increased maxillary tooth exposure
is indicated for young females, and the op-
posite for elderly males.11
The dynamic position is the second con-
stituent of dentofacial composition, typical-
ly represented by a smile.12,13 The extent of
tooth exposure during smiling depends on
skeletal make-up, degree of contraction of
the facial muscles, shape and size of the
dental elements, and shape and size of the
lips, which vary from extremely thin to full
and thick.11 Individuals with thin and taught
lips should be provided with teeth which
confer delicacy and fragility. Conversely,
patients with thick lips require teeth which
display dominance and boldness.1

Tjan and Miller divided the smile into three
types according to the smile line: a high
smile line completely revealing the maxil-
lary incisors and a continuous band of the
gingiva; an average smile line, revealing
75 to 100% of the maxillary incisors; and a
low smile line, revealing less than 75% of
the maxillary incisors.4 It has been found
that low smile lines are a predominantly
male characteristic (2:1 M:F) and a high
smile line is a predominantly female char-
7
acteristic.
The extent of tooth display at rest and dur-
ing smiling is mainly determined by the up-
per and lower lip positions and their move-
17
ments during function. In some studies,
female subjects have been shown to display
significantly more gingival tissue than
males,7,17,18 while the “gummy smile” has
been reported as a female characteristic.7
Decisions about restorative margin
placement are, however, directly related,
among other parameters, to the amount of
gingival display at different functional lip
positions, such as during speech, exagger-
ated smile, and the rest position of the
mandible.19
Increased esthetic demands in fixed and
removable prosthetic restorations have fo-
cused mainly on the maxillary anterior
teeth at rest10 and during smiling.20
Thus, it is of clinical interest to investigate
the degree of tooth display in the maxillary
and mandibular anterior region at rest and
smiling as sufficient data are lacking at
present. The identification of any possible
correlations between tooth and gingival
display, gender, and age is of interest as
they could be used as guidelines for es-
thetic considerations in prosthetic restora-
tions of teeth.11 Research on the effect of
age on anterior tooth display is in prepara-
tion.
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The aim of the present study was to inves-
ss e n c e
fo r
tigate the effect of gender on the buccal
length of the maxillary and mandibular an-
terior teeth and associated gingival display
at rest and during smiling among Jordani-
ans.
Materials and methods
The sample for the present study was se-
lected from a general population of sub-
jects who attended two dental practices. A
total of 247 participants were selected and
accepted to participate in the study. There
were 144 (58.3%) females and 103 (41.7%)
males from Jordan, aged between 18 and
67 years with a mean age of 34.3 (±10.76).
Inclusion/exclusion criteria
The selected subjects had not undergone
orthodontic or surgical treatment (ie, gingi-
val surgery or extraction of teeth). They had
maxillary and mandibular natural anterior
teeth present without caries, extreme oc-
clusal wear, restorations, extrusion, obvi-
ous deformities, or tooth mobility. Subjects
with a history of congenital anomalies, lip
trauma, or facial surgery were excluded.
Measurements
Measurements were performed using a
Fowler electronic digital caliper (Kevelaer,
Germany) to the nearest tenth of a millime-
ter for specific measured dimensions in
each patient. The caliper had two edges,
external and internal (Fig 1); the internal
edges were used in the measurements to
avoid lip distortion. The visible portion of
anterior teeth at rest is shown in (Fig 2). For
measurements of patients at a rest position,
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the visible portions of anterior teeth ss e n c e
fo r
measured vertically from the lower border
of the upper lip to the incisal edge of the in-
cisors (the cusp tip for the canines) at the
midpoint of the tooth at the rest position
(when the lips and the lower jaw were in the
rest position) for the maxillary teeth. For the
mandibular teeth, measurements were
made from the upper border of the lower
lip to the incisal edge of the incisors (the
cusp tip for the canines) at the midpoint of
Fig 1 Fowler electronic digital caliper used in the the tooth at the rest position. Figure 3
measurements. shows a measurement of the displayed
buccal length of an anterior tooth at rest
with the internal edges of the caliper.
The visible portion of anterior teeth (and
associated gingivae) during smiling is
shown in Figure 4. For measurements of pa-
tients during maximum smiling, the portion
of anterior teeth (maxillary and mandibular)
and the displayed gingivae were measured
by:
I measuring the displayed clinical crown
length (distance between incisal edges
of the central and lateral incisors [cusp
a
tip for the canines] and the most vertical,
superior point at the gingival margin of
the maxillary anterior teeth [the most ver-
tical, inferior point at the gingival margin
for the mandibular anterior teeth])
I measuring the displayed teeth and gin-
givae from the incisal edges of the max-
illary central and lateral incisors (cusp tip
for canines) to the inferior border of the
upper lip, and from the incisal edges of
the mandibular central and lateral inci-
sors (cusp tip for canines) to the superi-
or border of the lower lip
b
I the displayed gingival portion was cal-
Fig 2 The displayed buccal length of anterior teeth at
culated by subtracting the amount of the
rest: (a) female and (b) male.
displayed teeth and associated gingi-
vae from the amount of the displayed
clinical crown length.

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ss e n c e fo r

a b

Fig 3 Measuring the displayed buccal length of anterior teeth with the caliper at rest: (a) female and (b) male.
The digital caliper measured the buccal length of anterior teeth vertically from the lower border of the upper lip
and the upper border of the lower lip to the incisal edge of the incisors (to the cusp tip for the canines) at the mid-
point of the tooth at the rest position for the maxillary and mandibular anterior teeth, respectively.

a b

Fig 4 The displayed buccal length of anterior teeth (and associated gingivae) during smiling: (a) female and
(b) male.

a b

Fig 5 Measuring the displayed buccal length of anterior teeth (and associated gingivae) with the caliper dur-
ing smiling: (a) female and (b) male. The digital caliper measured the buccal length of anterior teeth (and asso-
ciated gingivae) vertically from the lower border of the upper lip and the upper border of the lower lip to the in-
cisal edge of the incisors (to the cusp tip for the canines) at the midpoint of the tooth during smiling for the maxillary
and mandibular anterior teeth, respectively.

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Figure 5 shows a measurement of the dis-
played buccal length of an anterior tooth
and associated gingivae during smiling
with the external edges of the caliper. The
measurement was considered to be zero
if the tooth could not be seen regardless of
how short it was. Measurements were per-
formed on the opposing anterior teeth on
the right side, repeated three times, and
the mean value and standard deviation
were calculated for further analysis.
The measuring gauge had a resolution
of 0.01 mm and the measured dimensions
were recorded to this degree of accuracy.
The measurements were taken by two in-
dependent clinicians (155 subjects from
one clinician and 92 from the other).
Inter-examiner variability and bias in
measurements were assessed by re-
measuring the clinical crown lengths of
the maxillary left central incisors from 25
(10.0%) randomly selected participants, by
each examiner. Cronbach’s test and Stu-
dent t test were performed for inter-exam-
iner reliability evaluation.
Statistical analysis
Statistical Package for Social Sciences,
Version 11 (SPSS-V11, Chicago, IL, USA)
software was used for the analyses. All
recorded data were analyzed by Student t
test and analysis of variance (ANOVA).
Bonferroni multiple comparisons post
hoc tests in ANOVA were performed to re-
veal statistically significant differences in
mean values of the parameters evaluated
(clinical crown length, amount of teeth dis-
played, and gingival display at rest and
during smiling). The significance level was
set at 5%.
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Results ss e n c e
fo r
Cronbach’s internal consistency coefficient
was 0.862. A paired Student t test revealed
no statistically significant deviation of
measurements between the examiners at
a 5% significant level (mean difference
0.04 ± 0.63 mm; P value = 0.784). As there
was a strong Cronbach’s coefficient and
small mean difference between the two
examiner’s measurements, it was as-
sumed that the other measurements
would be reliable.
Age and sex distribution of the partici-
pants are shown in Table 1. Mean values
of crown length of maxillary and mandibu-
lar anterior teeth are shown in Table 2. The
average crown lengths were slightly high-
er for males than those for females.
The most significant differences in the
buccal length of tooth display with lips at
rest were between the sexes. Males dis-
played more of the maxillary lateral incisor,
canine, and mandibular anterior teeth than
the females (P < 0.05). The differences for
maxillary canines had the highest signifi-
cance (P < 0.0001). On the other hand, no
statistically significant gender differences in
the display of maxillary central incisors
were recorded, although females showed
more of the maxillary central incisor than
males, with average visible amounts of 3.02
± 1.96 mm and 2.63 ± 1.15 mm, respective-
ly (Table 3).
The mean buccal length of tooth sur-
face and associated gingival display dur-
ing smiling are shown in Table 4. Females
displayed more maxillary anterior teeth
than males. However, males displayed
slightly more mandibular anterior teeth
and associated gingivae than females, but
no significant differences were recorded.
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Table 1 Age and sex distribution of the participants. ss e n c e fo r
Male Female Total

Age (years) Number Percentage Number Percentage Number Percentage

≤20 9 8.7 15 10.4 24 9.7

21–30 24 23.3 31 21.5 55 22.3

31–40 34 33.0 42 29.2 76 30.8

41–50 22 21.4 28 19.4 50 20.2

51–60 11 10.7 19 13.2 30 12.2

>60 3 2.9 9 6.3 12 4.8

Total 103 144 247

Table 2 Mean values of crown length (mm).

Maxillary anterior teeth Mandibular anterior teeth

Sex Number Central Lateral Canine Central Lateral Canine
(%) incisor incisor incisor incisor

Male 103 10.73 ± 9.26 ± 10.57 ± 9.12 ± 9.33 ± 11.22 ±

(41.70%) 2.02 1.22 1.09 1.17 0.65 1.04

Female 144 10.47 ± 8.95 ± 9.89 ± 8.91 ± 9.23 ± 10.94 ±

(58.30%) 2.34 1.35 0.87 0.88 0.74 0.76

Total 247 10.58 ± 9.08 ± 10.17 ± 9.00 ± 9.27 ± 11.06 ±

2.21 1.33 0.99 1.00 0.70 0.88

± = standard deviation

Table 3 Mean values of buccal length display of the anterior teeth of male and
female participants at rest.
Maxillary anterior teeth Mandibular anterior teeth
Sex Number Central Lateral Canine Central Lateral Canine
incisor incisor incisor incisor

Male 103 2.63 ± 1.87 ± 0.94 ± 1.09 ± 0.98 ± 0.87 ±

(41.70%) 1.15 1.27 0.91 1.17 1.07 1.23

Female 144 3.02 ± 1.43 ± 0.35 ± 0.82 ± 0.79 ± 0.57 ±

(58.30%) 1.96 1.37 0.67 1.32 1.22 0.98

Studen t test 1.32 3.97 6.82 4.13 3.67 3.18

P value 0.13 0.0084 0.00003 0.0016 0.017 0.041

Significance level NS <0.01 <0.0001 <0.01 <0.05 <0.05

± = standard deviation; NS = not significant

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Table 4 Mean values of buccal length of the anterior teeth (and gingival portion)
ss e n c e fo r
display of male and female participants during smiling.
Maxillary anterior teeth Mandibular anterior teeth
Sex Number Central Lateral Canine Central Lateral Canine
incisor incisor incisor incisor

Male 103 8.72 ± 7.27 ± 8.31 ± 2.79 ± 2.73 ± 2.86 ±

(41.70%) 1.27 1.62 1.83 1.42 0.95 1.12

Female 144 9.14 ± 7.74 ± 8.57 ± 2.25 ± 2.18 ± 2.31 ±

(58.30%) 1.45 0.87 1.10 1.36 1.07 1.32

Studen t test 0.87 1.73 1.94 1.67 1.59 1.55

P value 0.45 0.095 0.063 0.16 0.22 0.31

Significance level NS NS NS NS NS NS

± = standard deviation; NS = not significant

Table 5 Percentages of buccal length display in relation to clinical crown length

in male and female participants at rest and during smiling
Maxillary anterior teeth Mandibular anterior teeth

Central incisor Lateral incisor Canine Central incisor Lateral incisor Canine

M F M F M F M F M F M F

At rest 24.5 28.8 20.0 16.0 8.9 3.5 12.0 9.2 10.5 8.5 7.8 5.2

During 77.0 87.3 78.5 86.5 78.6 86.7 30.6 25.3 29.3 23.6 25.5 21.1
smiling

Significance ** ** ** ** ** ** * * * * * *
level

M: male, F: female, * statistically significant P <0.05, ** statistically significant P <0.001.

Table 6 Mean values of gingival display associated with anterior teeth of male
and female participants during smiling (in mm).
Maxillary anterior teeth Mandibular anterior teeth
Sex Number Central Lateral Canine Central Lateral Canine
incisor incisor incisor incisor

Male 103 1.73 ± 1.94 ± 2.02 ± 0.26 ± 0.21 ± 0.08 ±

1.07 1.23 1.49 0.11 0.09 0.03

Female 144 1.85 ± 2.05 ± 2.37 ± 0.18 ± 0.13 ± 0.05 ±

1.38 0.93 1.24 0.07 0.10 0.04

Studen t test 5.24 6.87 3.34 0.23 0.35 1.07

P value 0.012 0.0001 0.037 0.66 0.78 0.96

Significance level <0.05 =0.0001 <0.05 NS NS NS

± = standard deviation; NS = not significant

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Table 7 Number and percentages of participants displaying gingivae associated
ss e n c e fo r
with anterior teeth during smiling.
Maxillary anterior teeth Mandibular anterior teeth

Central incisor Lateral incisor Canine Central incisor Lateral incisor Canine

n % n % n % n % n % n %

Male 103 19 18.5 40 38.8 20 19.4 32 31.1 33 32.0 28 27.2

Female 144 58 40.3 71 49.3 56 38.9 32 22.2 29 20.1 22 15.3

Total 247 77 31.2 111 44.9 76 30.8 64 25.9 62 25.1 50 20.2

Table 5 shows percentages of buccal
length display in relation to clinical crown
length in male and female participants at
rest and during smiling. Males displayed
more of the buccal length of anterior teeth
at rest except for the maxillary central inci-
sors. Females displayed an average of
29% of crown length compared to 25% for
males. However, during smiling, 87% of
maxillary anterior teeth were displayed in
females compared to less than 80% in
males (P < 0.001; post hoc ANOVA). The
opposite was true for mandibular tooth dis-
play, but did not exceed 25% in females
and 31% in males (P < 0.05; post hoc
ANOVA).
Female subjects displayed more gingi-
val tissues associated with maxillary ante-
rior teeth, and the differences between sex-
es were statistically significant (P < 0.05).
However, no statistically significant differ-
ences in the display of the gingivae asso-
ciated with the mandibular teeth were
recorded (Table 6).
Table 7 shows the number and percent-
ages of subjects displaying gingiva asso-
ciated with anterior teeth during smiling.
Gingivae associated with maxillary central
incisors and canines were displayed al-
most equally in approximately 31% of sub-
jects. In addition, 45% of subjects displayed
gingivae associated with maxillary lateral
incisors. However, gingival display associ-
ated with mandibular anterior teeth was
recorded in approximately 25% of subjects
for the incisors and in only 20% for the ca-
nines.
Discussion
The present study was conducted to inves-
tigate the effect of gender on the amount of
tooth and gingival display in the anterior re-
gion at rest and during maximum smiling.
The sample was representative of the Jor-
danian population of dental patients who
attended two dental practices for a period
of 6 months.
Variations in tooth display have been re-
ported between subjects of different gen-
der and age.11 The amount of the display of
anterior teeth and associated gingiva has
been generally overlooked by restorative
dentists as an element of esthetic assess-
ment.12 The amount of tooth exposure at

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rest, which is predominantly a muscle-de-
termined position, is known as the static
position, whereas the dynamic position is
11,18
typically characterized by the smile.
The mean amount of maxillary central
incisor display in males at rest was 2.63 ±
1.15 mm and in females was 3.02 ± 1.96
mm. In Vig and Brundo, the measure-
ments were 1.91 mm and 3.40, respective-
12
ly, while Connor and Moshiri reported the
visible amount of maxillary central incisor
to be 1.82 ± 2.80 mm for males and 4.09
± 2.27 mm for females.16 In addition, it has
been reported in a survey conducted in
adolescents that females displayed slight-
ly more maxillary incisor clinical crown
length compared with males, with lips at
7
rest during maximum smile. These find-
ings were in agreement with the present
study, although some variations may to
some extent be explained by differences in
measuring techniques and differences be-
tween the populations studied.
The present study showed no gender
differences in the display of the maxillary
central incisor at rest; contrary to previous
studies.12,16 However, males displayed sig-
nificantly more of the maxillary lateral inci-
sor (P < 0.01), canine (P < 0.0001),
mandibular central incisor (P < 0.01), later-
al incisor, and canine (P < 0.05) compared
to females (Table 3).
The study demonstrated that prominent
maxillary lateral incisor, canine,
mandibular anterior teeth are associated
with males when the lips are at rest, while
prominent maxillary central incisors are
associated with females. It has been re-
ported that females display twice as much
maxillary tooth compared with males, with
lips gently parted in repose.12
The present study showed no statistical-
ly significant gender differences in anteri-
392
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
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ess c e n
or tooth display during maximum tsmiling,
ot
n
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en
although females displayed more of the
buccal length of maxillary anterior teeth
than males. However, male subjects dis-
played more of the buccal length of the
mandibular anterior teeth compared to fe-
males (Table 4). These results were in
agreement with a previous study.12
Some studies7,18 that investigated anteri-
or tooth visibility have revealed significant
differences in smile type between males
and females, with females presenting most
frequently with a high or average lip line,
thus displaying greater amounts of tooth
crown length. Another study reported that
upper-lip length was found to decrease by
an average of approximately 28% relative
to lip height at rest.21
In the present study, it was shown that
28.8% of the buccal length of maxillary
central incisors were displayed in females
at rest compared to 24.5% in males. How-
ever, males were shown to display more of
the buccal length of maxillary lateral inci-
sors and canines and the mandibular an-
terior teeth. In addition, during maximum
smiling, it was shown that females dis-
played an average of 87% of the buccal
length of maxillary anterior teeth compared
to an average of 78% for males . However,
the opposite was true for the mandibular
anterior teeth (Table 5). Kapagiannidis et
al,20 reported that the mean amount of tooth
and display for maxillary central incisors and
canines was 78% and 83% in males, and
87% and 85% in females, respectively.
Gingival display during smiling present-
ed significant differences between gender
groups in the maxillary anterior region, with
females displaying a mean of 0.12 mm and
0.35 mm more gingivae compared with
males in incisor and canine areas, respec-
tively. The greatest statistically significant

difference was reported in the maxillary
lateral incisor (P = 0.0001).
A considerable gender difference as-
sociated with the frequency of a high
smile line (approximately a 2 to 1 ratio for
females over males) has been reported in
previous studies.7,17 This predominance of
high smile lines for females is supported
by the findings in the present study as
well, especially for canines. The most im-
portant finding from the present study
though was that with both genders, max-
illary canine gingival display was more
prominent when compared with incisors.
For the mandibular teeth, however, no
statistically significant gender differences
in the amount of gingival display were re-
ported, although males were shown to dis-
play more gingivae compared with fe-
males (Table 6). These results were in
agreement with a previous study7 which
found that a lip elevation of 5.2 mm during
smiling resulted from a 23% decrease in
the initial lip length of 22.3 mm. In addition,
there were more than 2 mm of exposed
gingivae above the maxillary central inci-
sor , which resulted from a more extensive
upper-lip length elevation rather than a
short upper lip.22
The present study reported that during
maximum smiling more females (42.8%)
were shown to display maxillary gingivae
compared to males (25.6%). However,
30.1% of males displayed mandibular gin-
givae compared to only 19.2% of females
(Table 7).
Recording gingival recession in com-
bination with gingival display would pro-
vide substantial information in determin-
ing the extent to which this factor may or
may not affect the amount of gingival dis-
play. An important outcome from this
study was that 45% of subjects had gin-
AL-HABAHBEH ET ALopyrig
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display in the maxillary lateralt einci-
ot n
n
gival ss e n c e
fo r
sor region.
This important finding reveals the ne-
cessity for increased esthetic awareness in
restoring maxillary incisors and especially
the placement and waxing of their associ-
ated gingiva in removable prostheses.23
However, more than 55% of subjects that
participated in the present study did not
display gingiva associated with the anteri-
or region during maximum smiling. Ac-
cordingly, the routine sub-gingival place-
ment of esthetic crowns could be an
unnecessary over-treatment that might
compromise periodontal health.24,25
For complete denture patients, a guide-
line was suggested to adjust the vertical
length of the maxillary occlusion rim in the
anterior region by extending it approxi-
mately 2 mm below the relaxed lip to es-
tablish the lip length-incisal edge relation-
ship and accordingly a visible amount of
the anterior teeth.26 However, female pa-
tients may reasonably be expected to
show 4 to 5 mm of tooth beneath the rest-
ing lip, especially if the patient had a class
II division 1 profile or short upper lip.27 Al-
so, the visible amount of anterior teeth can
be one of the helpful guidelines for deter-
mining the appropriate vertical dimension
of occlusion.28,29
It has been shown that the maxillary
central incisor is a superior reference to the
rest of the anterior teeth in regard to the
amount of visible tooth surface. In addition,
maxillary central incisors are the most
dominant anterior teeth in the dental arch
because they can be seen in their full
size.30 The maxillary right central incisor
was therefore used as a parameter to as-
sess racial and gender differences.31 Ac-
cordingly, some variations were obvious
concerning tooth and gingival display of
393
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 4 • NUMBER 4 • WINTER 2009
 CLINICAL RESEARCH
the contralateral side that were not record-
ed in the present study, as only the right
side display was measured.
Esthetic considerations could become a
major concern for patients seeking
32
prosthodontic services in the future.
ditionally, prosthodontists have been
taught to evaluate facial esthetics to re-
store overall harmony to the face.33 Clini-
cians are encouraged to create or restore
a pleasant facial appearance by develop-
ing a balanced and pleasant smile.
Prosthodontists, and many patients alike,
often focus on key frontal esthetic param-
eters, and certain esthetic canons estab-
lish a relationship between eyes and
teeth.36,37
Gender differences regarding the buc-
cal crown length display of anterior teeth
and associated gingivae at rest and in
maximum smiling positions should be
considered on an individual basis when
restoring teeth, as the results of the pres-
ent study demonstrate many variations be-
tween males and females, particularly in a
rest position. However, the esthetic appear-
ance of tooth display during smiling may
be generalized over both sexes as no sta-
tistically significant gender differences
were recorded.
Conclusion
From the results of the present study, the
following conclusions can be drawn.
I Males displayed significantly more
buccal length of the maxillary lateral in-
cisors and canines, and mandibular
anterior teeth at rest compared to fe-
male participants (P < 0.05). However,
during smiling, no statistically signifi-
cant gender differences were recorded,
394
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VOLUME 4 • NUMBER 4 • WINTER 2009
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although females displayed more of
ss e n c e
fo r
their maxillary and less of their mandi-
bular anterior teeth.
I Females displayed more of their maxil-
lary central incisor compared to males,
Tra- at rest and during maximum smiling,
but the differences between both gen-
ders were not statistically significant.
I At rest, 28.8% of the buccal length of
maxillary central incisors were dis-
played in females compared to 24.5%
34,35
in males. However, males were shown
to display more of the buccal length of
maxillary lateral incisors, canines, and
the mandibular anterior teeth.
I During maximum smiling, females dis-
played an average of 87% of the buccal
length of maxillary anterior teeth com-
pared to males (an average of 78%).
However, males displayed slightly more
of the buccal length of mandibular an-
terior teeth than females.
I Gingival display during smiling present-
ed significant differences between gen-
der groups in the maxillary anterior re-
gion, with females displaying more
gingivae compared to males (P < 0.05).
For the mandibular teeth, however, the
amount of gingival display presented
only slight differences between gender
groups. Although not statistically signif-
icant, males were shown to display
more gingivae in the mandibular ante-
rior region compared to females.
I During smiling, approximately 45% of
subjects displayed gingivae associated
with maxillary lateral incisors and 31% of
subjects displayed gingivae in the re-
gion of maxillary central incisor and ca-
nine teeth. However, gingivae associat-
ed with the mandibular anterior region
were only displayed in approximately
25% or less of participants.

References
1. Rufenacht CR. Fundamentals
of aesthetics. London: Quintes-
sence Publishing, 1990:18.
2. Qualtrough AJ, Burke FJ. A
look at dental esthetics. Quin-
tessence Int 1994;25:7–14.
3. Landa LS. Practical guidelines
for complete denture esthetics.
Dent Clin North Am 1977;21:
285–298.
4. Tjan AHL, Miller GD, The JG.
Some esthetic factors in a
smile. J Prosthet Dent
1984;51:24–28.
5. Behrend DA. An improved
esthetic control system. Int J
Prosthodont 1988;1:80–86.
6. Aboucaya WA. A classification
of smiles. Quintessence Int
1975;10:1–2.
7. Peck S, Peck L, Kataja M. The
gingival smile line. Angle
Orthod 1992;62:91-100.
8. Mackley RJ. An evaluation of
smiles before and after ortho-
dontic treatment. Angle Orthod
1993;63:183–189.
9. Zachrisson BU. Esthetic factors
involved in anterior tooth dis-
play and the smile: vertical
dimension. J Clin Orthod
1998;35:432–445.
10. Al Wazzan KA. The visible por-
tion of anterior teeth at rest. J
Contemp Dent Pract
2004;1:53–62.
11. Ahmad I. Anterior dental aes-
thetics: Dentofacial perspec-
tive. Br Dent J 2005;199:81–88.
12. Vig RG, Brundo GC. The kinet-
ics of anterior tooth display. J
Prosthet Dent
1978;39:502–504.
13. Ahmad I. Geometric consider-
ations in anterior dental aes-
thetics: restorative principles.
Pract Periodont Aesthet Dent
1998;10:813–822.
14. Geron S, Atalia W. Influence of
sex on the perception of oral
and smile esthetics with differ-
ent gingival display and incisal
plane inclination. Angle Orthod
2005;75:778–784.
View publication stats
AL-HABAHBEH ET ALopyrig
15. Mohindra NK, Bulman JS. The
effect of increasing vertical
dimension of occlusion on
facial aesthetics. Br Dent J
2002;192:164–168.
16. Connor AM, Moshiri F. Orthog-
nathic surgery norms for
American black patients. Am J
Orthod 1985;87:119–134.
17. Ackerman MB, Ackerman J.
Smile analysis and design in
the digital era. J Clin Orthod
2002;36:221–236.
18. Owens EG, Goodacre CJ, Loh
PL et al. A multicenter interra-
cial study of facial appearance.
Part 2: A comparison of intrao-
ral parameters. Int J Prostho-
dont 2002;15:283–288.
19. Nohl FSA, Steele JG, Wassell
RW. Crowns and other extra-
coronal restorations: Aesthetic
control. Br Dent J
2002;192:443–450.
20. Kapagiannidis D, Kontonasaki
E, Bikos P, Koidis P. Teeth and
gingival display in the premo-
lar area during smiling in rela-
tion to gender and age. J Oral
Rehabil 2005;32:830–837
21. Tarantili VV, Halazonetis DJ,
Spyropoulosc MN. The spon-
taneous smile in dynamic
motion. Am J Orthod Dentofa-
cial Orthop 2005;128:8–15.
22. Peck S, Peck L. Facial realities
and oral esthetics. In: McNa-
mara JA Jr (ed). Esthetics and
the treatment of facial form, Vol
28, Craniofacial Growth Series.
Ann Arbor: University of Michi-
gan, 1993:77–113.
23. Donovan TE, Derbabian K,
Kaneko L, Wright R. Esthetic
considerations in removable
prosthodontics. J Esthet Restor
Dent 2001;13:241–253.
24. Schätzle M, Lang NP, Ånerud
Å, Boysen H, Bürgin W, Löe H.
The influence of margins of
restorations on the periodontal
tissues over 26 years. J Clin
Periodontol 2000;27:57–64.
25. Ahmad I. Anterior dental aes-
thetics: Gingival perspective.
Br Dent J 2005;199:195–202.
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
No C
ht
t fo
rP
by N
ub
Q ui
lica
tio
te n ot
n
ss e n c e fo r
26. Zarp GA, Bolender CL, Carls-
son GE. Boucher’s prostho-
dontic treatment for edentu-
lous patients (ed 11). St. Louis,
Missouri: Mosby,
1997:191–244.
27. McCord JF, Grant AA. Regis-
tration: Stage I-Creating and
outlining the form of the upper
denture. Br Dent J
2000;188:529–536.
28. Mack MR. Vertical dimension:
A dynamic concept based on
facial form and oropharyngeal
function. J Prosthet Dent
1991;66:478–485.
29. McCord JF, Grant AA. Regis-
tration: Stage II-Intermaxillary
relations. Br Dent J
2000;188:601–606.
30. Hasanreisoglu U, Berksun S,
Aras K, Arslan I. An analysis of
maxillary anterior teeth: Facial
and dental proportions. J Pros-
thet Dent 2005;94:530–538.
31. Ballard ML. Asymmetry in
tooth size: A factor in the etiol-
ogy, diagnosis and treatment
of malocclusion. Angle Orthod
1944;14:67–71.
32. Albino JE, Tedesco LA, Conny
DJ. Patient perceptions of
dentofacial esthetics: Shared
concerns in orthodontics and
prosthodontics. J Prosthet Dent
1984;52:9–13.
33. Di Biase DD. Class II maloc-
clusion: Making the face fit.
Dent Update 1991;6:429–435.
34. Janzen EK. A balanced smile—
A most important treatment
objective. Am J Orthod
1977;72:359–372.
35. Matthews TG. The anatomy of
a smile. J Prosthet Dent
1978;39:128–134.
36. Brisman AS. Esthetics: A com-
parison of dentists’ and
patients’ concepts. J Am Dent
Assoc 1980;100:345–352.
37. Farrow AL, Zarrinia KKA.
Bimaxillary protrusion in black
Americans—An esthetic evalu-
ation and the treatment con-
siderations. Am J Orthod
Dentofac Orthop
1993;104:240–250.
395
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