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The assessment of dentofacial esthetics in

restorative dentistry: A review of the
literature
Cornelia Frese, Hans Joerg Staehle and Diana
Wolff
JADA 2012;143(5):461-466
10.14219/jada.archive.2012.0205

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CLINICAL PRACTICE

The assessment of dentofacial esthetics

in restorative dentistry
A review of the literature
Cornelia Frese, Dr Med Dent; Hans Joerg Staehle, Dr Med, Dr Med Dent;
Diana Wolff, Dr Med Dent

n classical music, there are only a few

I compositions that have reached the

highest rank along with Symphony
No. 9, “Ode to Joy,” by Ludwig van
Beethoven, which he completed in 1824.
With this composition, Beethoven led
AB STRACT
Background. The authors conducted a literature review
to determine how dentofacial esthetics can be evaluated in
restorative dentistry and which quantifiable clinical param-
music to previously unknown heights, and eters can be used for this assessment of dentofacial
since then only imitation, not improve- esthetics.
ment, has been possible. In math and arts, Types of Studies Reviewed. The authors selected 35
the ideal proportion is the golden propor- studies that focused on assessment strategies for dental pro-
tion, which has the proportion of 1.6103 to fessionals. The primary inclusion criteria were intraoral
1, in which the shorter part is 62 percent and extraoral esthetic assessment methods and indexes or
of the longer part of a line.1 This ratio cre- rating scales evaluating esthetics in restorative dentistry.
ates an esthetically pleasing rectangle. Results. The studies’ protocols and assessment methods
were heterogeneous. The authors grouped the studies into
Kant described esthetic judgment as being
six categories according to topic: golden proportion, soft-
based on feelings of pleasure or dis-
tissue measurement, smile and smile line assessment, oro-
pleasure.2 Even today, Beethoven’s sym-
facial indexes and scales, incisor proportion and angulation,
phony and the principle of the golden pro-
and facial esthetics. These categories included various
portion are models of perfection for
esthetic parameters, including the smile line, lip line,
thinkers and artists all over the world.
incisal offset, location of dental and facial midline, incisor
In dentistry, the golden proportion was angulations and width to height ratios of the maxillary
first described in detail by Levin.3 He pro- anterior teeth, gingival contour, and root coverage and
posed that the golden proportion existed papilla height. These parameters should be considered
in dentistry—for example, in the propor- when providing dental treatment in the anterior area, as
tion of the width between the central and they allow for quantification and objective judgment.
the lateral incisor and that between the Clinical Implications. The findings of this review
lateral incisor and the canine, as well as might increase interest in a comprehensive dental esthetic
within the dimensions of a smiling face. index that allows for objective quantification and intrastudy
Well-formed anterior teeth and an attrac- and interstudy comparison of dental treatment outcomes.
tive smile have positive effects on a Key Words. Dentofacial esthetics; assessment; restora-
patient’s self-esteem and psychosocial tive dentistry; literature review.
well-being.4-6 In restorative dentistry, JADA 2012;143(5):461-466.
esthetic knowledge is based mainly on an
Dr. Frese is a senior dentist, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany; and a
senior dentist, Department of Conservative Dentistry, School of Dental Medicine, University Hospital Heidelberg, Germany. Address reprint requests to Dr.
Frese at Department of Conservative Dentistry, School of Dental Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg,
Germany, e-mail cornelia.frese@med.uni-heidelberg.de.
Dr. Staehle is the head, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.
Dr. Wolff is a senior dentist, Department of Conservative Dentistry, School of Dental Medicine, Ruprecht Karls University, Heidelberg, Germany.

JADA 143(5) http://jada.ada.org May 2012 461

Copyright © 2012 American Dental Association. All rights reserved.
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CLINICAL PRACTICE
accumulation of experts’ references in textbooks
and literature that describe parameters com-
monly accepted in the Western world.7-19 Little,
however, has been reported regarding what pro-
fessionals’ esthetic perceptions and discrimina-
tions are based on and whether their subjective
perceptions can be assigned to objective esthetic
items that allow for quantification.20
In general, esthetic ratings can be subjective
or objective. An example of a subjective method
of rating esthetics is a questionnaire that solic-
its patients’ opinions. Objective measurements
include ratings or indexes used by dental profes-
sionals to quantify a status.21 The most com-
monly accepted clinical rating criteria in
restorative dentistry are Ryge and Snyder’s cri-
teria,22 today known as the modified U.S. Public
Health Service (USPHS) criteria or FDI World
Dental Federation clinical criteria.23-25 Although
the criteria quantify the esthetic parameters
“surface luster,” “surface staining,” “color match
and translucency” and “esthetic anatomical
form,” they provide insufficient detail for the
purposes of treatment planning or outcome
assessment of restorations of anterior teeth.
One crucial aspect that is not represented in the
modified USPHS criteria is the smile assess-
ment, which is influenced by the teeth, the lip
framework and the gingival scaffold.26 The
shape and size of the lips outline the esthetic
zone, forming a frame that displays the teeth
and various amounts of gingiva.27
We surveyed the literature to identify meth-
ods of esthetic assessment of anterior maxillary
teeth and facial esthetics used in restorative
dentistry. Our goal in conducting this review
was to classify the different methods and
extract quantifiable clinical parameters that
might aid the development of a standardized
and comprehensive esthetic evaluation index to
be used for diagnosis, treatment planning and
outcome assessment.
METHODS
Search strategy. We searched the Cochrane
Library and MEDLINE (PubMed, National
Library of Medicine) from Jan. 1, 1975, to Dec.
31, 2010, by using Medical Subject Headings
(MeSH) and free text terms. The search strategy
included the combination of the following MeSH
terms: “dental” and “aesthetic,” “dental” and
“aesthetic” and “index,” “dental” and “aesthetic”
and “measurement,” “dental” and “aesthetic”
and “assessment,” “dental” and “aesthetics” and
“needs assessment” and “adolescent,” “dental”
and “aesthetics” and “needs assessment” and
“child.” We included and manually searched ref-
462 JADA 143(5) http://jada.ada.org May 2012
Copyright © 2012 American Dental Association. All rights reserved.
erence articles found in full-text manuscripts.
Selection criteria. We selected studies
according to the inclusion and exclusion criteria
listed in the box. Our focus was on including
studies that had extraoral and intraoral esthetic
assessment methods and indexes and rating
scales evaluating esthetics in restorative
dentistry.
Review methods and categories. As much
as possible, we adapted the review method from
the Preferred Reporting Items for Systematic
Reviews and Meta-Analyses statement’s item
checklist and flowchart (Figure).28 We evaluated
the abstracts of all reports identified by means
of our database search according to the inclusion
and exclusion criteria. For articles that met the
inclusion criteria, we obtained the full-text ver-
sions. After reading the articles, we sorted and
grouped them into six categories according to
their esthetic assessment topic: golden propor-
tion, soft-tissue measurement, smile and smile
line assessment, orofacial indexes and scales,
incisor proportion and angulation, and facial
esthetics. Owing to the heterogeneity of the
study protocols and methods we used, statistical
data collection and analysis were not applicable.
RESULTS
The golden proportion. Levin3 described the
naturalness of the golden proportion and recom-
mended that this principle be applied to the
arrangement of the anterior esthetic region. Be-
cause tooth dimensions vary greatly by sex and
race, Mahshid and colleagues,29 Preston30 and
Gillen and colleagues31 could not agree that the
golden proportion applied to the relationship of
maxillary anterior teeth. Nikgoo and col-
leagues32 found the golden proportion between
the maxillary central incisor and the lateral
incisor in 50.3 percent of people with an attrac-
tive smile. In a Web-based study, Rosenstiel and
colleagues33 interviewed dentists regarding
computer-manipulated images of width to
height ratios of the anterior maxillary teeth and
found that the golden proportion was inferior
when normal or short teeth were evaluated.
Only when assessing long teeth did dentists
prefer them for fulfilling the golden proportion.
Soft-tissue measurement. Kerner and col-
leagues34,35 found that an image analysis system
was reliable for assessing root coverage. In com-
bination with a five-point ordinal scale, they
recommended the use of this image analysis
ABBREVIATION KEY. MeSH: Medical Subject Head-
ings. USPHS: U.S. Public Health Service. VAS:
Visual analog scale.
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CLINICAL PRACTICE

system for comparing before and after treat- BOX

ment outcomes. Cairo and colleagues36 found
that a five-item root coverage esthetic score
Final inclusion and exclusion
with a 10-point scale might be a useful method criteria.
for assessing root coverage outcome. To measure INCLUSION CRITERIA
soft tissue around implant-supported single d Original articles written in English
crowns, Fürhauser and colleagues37 introduced dExtraoral esthetic assessment methods for restorative
the seven-item pink esthetic score that had a dentistry
maximum score of 14 points. Cardaropoli and dIntraoral esthetic assessment methods for restorative
dentistry
colleagues’38 papilla preservation index can be
used to assess the interproximal papilla level of d Scales and indexes evaluating esthetics in restorative
dentistry
natural teeth by means of a four-point scoring dFacial anthropometrics
system. Weinländer and colleagues39 suggested EXCLUSION CRITERIA
using gingivamorphometry on standardized dTooth whitening and bleaching methods
photographs and found that pixel counts were dOrthodontic scales and indexes (Dental Aesthetic
Index; Index of Orthodontic Treatment Need; Treat-
an accurate means of measuring dentogingival ment Priority Index; Index of Complexity, Outcome
parameters. Regarding the gingival contour and Treatment Need; American Board of Orthodontics
from the axis orbital plane orientation of the objective grading system)
27
head, Charruel and colleagues found that the d Orthodontic malocclusion

zenith of the canine was as high as or slightly d Quality of life questionnaires (Oral Health Impact
Profile, Quality of Life Questionnaire, Dental Impact
higher than that of the central incisor, whereas on Daily Living, Geriatric Oral Health Assessment Index)
the zenith of the lateral incisor was below or on dAssessment by laypeople
the gingival line. Current methods can provide dHead radiographs
practitioners with three-dimensional informa- dHead profiles
tion obtained by means of laser scanners,
computer-aided design/
computer-aided manu-
Abstracts identified through Abstracts identified through
facturing cameras or database research other sources
the projection moiré (n = 135) (n = 13)

method.40
Smile and smile
line assessment. Abstracts remaining after removal of duplicates
Ackerman and Ack- (n = 134)
41
erman introduced
the smile index, Abstracts excluded
Abstracts screened
which assesses and (n = 134)
(n = 92)

quantifies a smile’s
appearance. This
Full-text articles excluded
index involves the Full-text articles assessed for eligibility
(n = 7)
(n = 42)
ratio between the
intercommissure
width and the inter- Studies included in the quantitative synthesis
(n = 35)
labial distance in a
smile typically used
as a social smile. In a Figure. Flow of information through the different phases of the review in accordance with the Pre-
youthful and harmo- ferred Reporting Items for Systematic Reviews and Meta-Analyses28 statement.
nious smile, 70 to 100
percent of the maxillary incisors should be vis- clinical photographs and video panels, Schabel
ible and exposed by the upper lip.41-44 Sarver and and colleagues47 showed that q-sort assessment
Ackerman45 suggested analyzing smiles in four is more reliable than is using a visual analog
dimensions (frontal, sagittal, oblique and time) scale (VAS). They also compared the subjective
to enhance the possibility of esthetic measure- q-sort assessment with an objective software
ment. Several investigators have described the program (SmileMesh, TDG Computing,
parallelism of the maxillary incisal edge curva- Philadelphia) assessment and found that the
ture and the lower lip line as an ideal relation- objective assessment tool was not able to predict
ship for harmonious smiles.4,26,42,43,46 To quantify an attractive or an unattractive smile. Van der
smile tooth exposure and lip position by rating Geld and colleagues44,48 found that use of the

JADA 143(5) http://jada.ada.org May 2012 463

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CLINICAL PRACTICE
digital video graphic method was reliable for
smile and smile line assessment in clinical prac-
tice. When this method is used in combination
with a three-grade scale, a visual semiquantita-
tive estimation can be achieved.
Orofacial indexes and scales. The orofa-
cial esthetic scale developed by Larsson and
colleagues49,50 in 2010 is an eight-item self-
reporting instrument used to assess the esthetic
impact of treatment on patients’ facial appear-
ance. This quantitative assessment involves the
use of a numeric scale that ranges from 0 (very
unsatisfied) to 10 (very satisfied). The authors
found that this scale was a suitable tool for
assessing esthetics in clinical and research facil-
ities. Peerlings and colleagues51 developed a
photographic scale to measure facial esthetics
and found that it was sufficient for clinical prac-
tice. Using a reference photograph assigned the
number 100, they judged a picture or a face as
being higher (more esthetic) or lower (less
esthetic) on the scale. Regarding single-tooth
restorations, Meijer and colleagues21 developed
the nine-item Implant Crown Aesthetic Index in
which they used a six-point rating scale that
ranged from 0 (excellent) to 5 (poor esthetics) to
obtain a quantitative rating. Modi and col-
leagues52 developed the illustrated index of
tooth appearance to quantify the esthetics of
natural teeth. Their index includes 10 cat-
egories represented by clinical images of maxil-
lary anterior teeth. The images help score
patients’ teeth or in placing patients’ clinical
photographs into one of the categories.
Incisor proportion and angulation. Using
computer-manipulated photographs of maxil-
lary anterior teeth, Wolfart and colleagues19 and
Brunzel and colleagues5 found that tooth ar-
rangements including central incisors with ideal
tooth axes were rated more attractive on a VAS
and a six-point rating scale than were incisors
with deviant tooth axes. Minor changes (≤ 10
degrees) in angulations of one or both lateral
incisors did not influence the esthetic appear-
ance negatively, whereas mesial or distal angu-
lation (> 10 degrees) of one or both central inci-
sors received the least attractive ratings. Re-
garding the proportions of maxillary anterior
teeth, Wolfart and colleagues1 reported that
most dentists chose central incisors with a
width to height ratio of 75 to 80 percent as the
most attractive. These investigators concluded
that the width to height ratio of the maxillary
central incisors is more important than is the
relationship between central and lateral inci-
sors. In 2009, Rosenstiel and colleagues20 found
that restorative treatment of the anterior maxil-
464 JADA 143(5) http://jada.ada.org May 2012
Copyright © 2012 American Dental Association. All rights reserved.
lary teeth often resulted in reduced width to
height ratios with less lateral incisor offset.
Sarver and Ackerman45 recommended that the
ideal offset between central and lateral incisors
be 1.0 to 1.5 millimeters.
Facial esthetics. On the basis of their re-
view regarding ideal and beautiful facial fea-
tures, Hönn and Göz53 concluded that there is
universal cognition of facial beauty. They found
that symmetry and averageness were some of
the most important factors in facial attractive-
ness. The concept of beauty, however, can be
influenced by sex-specific characteristics and
fashion trends. The most reliable parameter
used to assess facial and dental symmetry is the
facial and dental midline. After examining 500
participants with natural dentitions, Miller and
colleagues54 found that for reconstructions of
fully edentulous jaws the most reliable orienta-
tion for the maxillary midline was the exact
facial midline directed by the philtrum. The
facial midline should be placed precisely in the
midsagittal plane. Faure and colleagues55
showed the negative impact of angulation or a
shift of the facial midline when they modified
facial symmetries and interocular distances on
36 standardized photographs. Student volun-
teers assessed facial esthetics by using a ratio
scale and a reference photograph. The investiga-
tors found that the modifications had a negative
effect on the perceived facial esthetics.
DISCUSSION
In the words of Kant2:
It is chiefly in those estimates that are called aes-
thetic, and which relate to the beautiful and sublime,
whether of nature or of art, that one meets with the
above difficulty about a principle (be it subjective or
objective). And yet the critical search for a principle of
judgement in their case is the most important item in
a critique of this faculty.
The critical search for a judgment of treat-
ment outcomes in dentistry is limited by the dif-
ferent perspectives of patient and practitioner
(subjective and objective). The practitioner
needs to be aware of esthetic principles and
should have the expertise to identify and meet
the patient’s needs. Although both perspectives
deserve attention, we focused on objectivity.
We summarized the findings of 35 original
studies focusing on the esthetic assessment of
facial and dental parameters to identify princi-
ples and methods of esthetic quantification and
measurement, as well as to assemble quantifi-
able esthetic parameters. Owing to the hetero-
geneity of the study protocols and methods, we
were not able to collect and analyze data statis-
 Downloaded from jada.ada.org on October 14, 2014
tically. However, we attempted to illustrate the
key aspects of the complex nature of patients’
faces and teeth by categorizing the studies we
reviewed.
The different aspects of dentofacial esthetics
in combination with the subjective and objective
principles of judgment entail diverse assess-
ment methods. In most of the studies, the tools
for dental and facial esthetic assessment were
standardized, computer-manipulated photo-
graphs rated by dental professionals or inde-
pendent judges.1,4,5,19-21,33,35,37,39,42,43,47,51,52,55,56 Investi-
gators in a few studies examined patients
clinically to determine quantifiable param-
eters.29,32,36,49,50,54 We noted several approaches
that involve digital tools such as the SmileMesh
program,41,47,56 an image analysis system34,35 and
computer vision techniques with three-
dimensional scans of cast models.46 Three
studies used only maxillary cast models for
assessment,27,30,31 and in one investigation, the
investigators mounted cast models in an articu-
lator.27 It is our opinion that the use of standard-
ized photographs that are evaluated by dental
professionals might be an effective and reliable
method for assessing dentofacial esthetics.
We noticed a similar heterogeneity with
regard to the grading and quantification of the
methods described in the studies. Most investi-
gators used numeric ranking scales or scoring
systems to quantify the results, but the number
of points in the scales and systems varied
widely. Among the studies we reviewed, two
used scales ranging from one to 10,49,50 one used
a scale ranging from one to six,19 three used
scales ranging from one to five,4,21,34 three used
scales ranging from one to four,34,38,44 four used
three-grade scoring systems,26,42-44 one used a
0-3-6 point scoring system,36 and one used a 0-1-2
point scoring system.37 Furthermore, investiga-
tors used a VAS,1,5,32,55,56 a ratio scale,55 a best-
worst ranking order33,52 and the nine-grade
q-sort technique47,56 for obtaining measurements
of esthetic parameters. In some studies, investi-
gators measured specific parameters (for ex-
ample, width to height ratios or dimensions of a
social smile) to calculate ratios.29-32,41,45 The most
reasonable rating scale should be restricted to a
maximum of five to seven rating points; other-
wise, judgment can become too complicated in
clinical practice. In judging esthetics, the use of
scales with an odd amount of numbers seems to
be beneficial because they allow practitioners to
choose a middle score that represents an aver-
age outcome or standard. The extremes on
scales that have odd amounts of numbers rarely
are chosen, whereas the average category is
Copyright © 2012 American Dental Association. All rights reserved.
CLINICAL PRACTICE
chosen most often. This symbolizes a gaussian
distribution in a representative cohort.
Through our review, we found that the fol-
lowing parameters are sufficiently and reason-
ably quantifiable: smile line, lip line, incisal
offset, location of dental and facial midline,
incisor angulations and width to height ratios of
the maxillary anterior teeth, gingival contour,
and root coverage and papilla height.
CONCLUSION
Despite all the differences in assessment and
measurement strategies that we noted in the
studies we reviewed, we consistently found
agreement regarding esthetic judgment (“the
beautiful and sublime”). When the seven quan-
tifiable parameters we found through our
review are assessed by means of a structured
index that contains a five- to seven-point rating
scale, the index score becomes more valuable
than that from a single-item assessment. With
such an index, practitioners do not have to
chose between several items but can perform a
comprehensive assessment in daily practice.
Further studies are needed to establish and
validate a common dental esthetic index and to
verify whether practitioners’ assessment agrees
with patients’ subjective perception of the treat-
ment outcome. Although esthetic feelings and
sensations are influenced by sex, race, region-
alism and people’s self-perceptions, the seven
specified parameters we identified are accepted
widely in the West. If these guidelines are used
in careful agreement with the patient’s needs
and expectations, both the dentist and the
patient may achieve a satisfying esthetical
rehabilitation. ■
Disclosure. None of the authors reported any disclosures.
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