RESEARCH AND EDUCATION

Comparison of gingival display in smile attractiveness among

restorative dentists, orthodontists, prosthodontists,
periodontists, and laypeople
Célia Regina Maio Pinzan-Vercelino, DDS, MSc, PhD,a Ana Carla Souza Costa, DDS, MSc,b
Meire Coelho Ferreira, DDS, MSc, PhD,c Fausto Silva Bramante, DDS, MSc, PhD,d
Melissa Proença Nogueira Fialho, DDS, MSc,e and Júlio de Araújo Gurgel, DDS, MSc, PhDf

Smile analysis has been ABSTRACT

routinely used to establish
Statement of problem. Multidisciplinary treatment needs a common goal, and dentists should
diagnosis, prognosis, and understand the esthetic perception of laypeople and the other specialists involved. Such
treatment plan to achieve information is sparse.
esthetic goals.1-4 Periodontal
Purpose. The purpose of this cross-sectional study was to compare the influence of gingival display
and tooth factors such as po-
on perceived smile esthetics among restorative dentists, orthodontists, prosthodontists,
sition, shape, size, proportion, periodontists, and laypeople.
symmetry, and parallelism
should be considered during Material and methods. Photographs of the smiles of 2 volunteers (1 female and 1 male) were
manipulated on a computer to produce gingival exposure of 1, 3, and 5 mm and central incisor
treatment planning to create
coverage of 3 and 5 mm. The images were evaluated by using a 100-mm visual analog scale by 155
ideal smiles.5-13 However, the raters divided into 5 groups (restorative dentists, orthodontists, prosthodontists, periodontists, and
perception of esthetics is sub- laypeople).
jective, individual, and influ-
Results. The dental specialists, mainly orthodontists and periodontists, were more sensitive about
enced by the judgments of alterations in gingival display than the laypeople. For the female smile, higher mean scores were
those with whom the patient attributed to 1 mm of gingival exposure by all groups of raters. For the male smile, 3 mm of central
interacts.2,14,15 Furthermore, incisor coverage received higher mean scores, except for the laypeople, who considered gingival
esthetic parameters are often display of 1 mm to be more attractive. For both smiles, 5 mm of gingival display was judged to be
associated with aspects to the least attractive.
which some attention is Conclusions. Considering the differences in opinion between dental specialists and laypeople and
called.7,16 New treatment op- the acceptable variations in gingival display, the preferences of patients should be considered in
tions frequently call attention the diagnosis and treatment decision-making process. (J Prosthet Dent 2019;-:---)
to situations that had previ-
ously been imperceptible to most individuals. Consid- parameters. As the concept of beauty is ever changing in
ering gingival display, the use of botulinum toxin as a society,18,19 adequate parameters based on scientific ev-
17
treatment option may have altered the perception of idence must be established to overcome the subjectivity
laypeople with regard to previously established of smile analysis.

a
Professor, Department of Orthodontics, University Ceuma (UniCeuma), São Luís, Brazil.
b
Doctoral student, University Ceuma (UniCeuma), São Luís, Brazil.
c
Professor, Department of Epidemiology, University Ceuma (UniCeuma), São Luís, Brazil.
d
Professor, Department of Orthodontics, Pontificia Universidad Católica Madre y Maestra (PUCMM), Santiago de los Caballeros, Dominican Republic.
e
Professor, Department of Denstistry, University Ceuma (UniCeuma), São Luís, Brazil.
f
Professor, Department of Orthodontics, University Ceuma (UniCeuma), São Luís, Brazil; Professor, Department of Orthodontics, State University of São Paulo (UNESP),
Marília, Brazil.

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Clinical Implications
The different dental specialists, mainly orthodontists
and periodontists, were more critical of variations in
gingival display than the laypeople. Dentists should
pay attention to patient concerns to avoid treating
small discrepancies in gingival display that may not
be recognized by patients.
The patient or the dentist may suggest the need for
smile correction. Dentists should understand the esthetic
perception of laypeople with regard to gingival display so
that they do not unnecessarily treat small discrepancies
that often go unrecognized by patients.7,20-22 As treat-
ment frequently involves a multidisciplinary team,23
different specialists should have an understanding
among themselves regarding smile esthetics; this un-
derstanding would facilitate communication and assist in
determining a common treatment objective.24
Studies that compared the opinions of orthodontists,
general dentists, and laypeople have been published25-28;
however, the authors are unaware of a study that has
compared the sensitivity of different dental specialties to
gingival display. Therefore, this study aimed to compare
the influence of the gingival display of a male and a fe-
male individual on perceived smile esthetics among
restorative dentists, orthodontists, prosthodontists, peri-
odontists, and laypeople. The null hypothesis was that no
difference would be found among the different specialists
and laypeople regarding gingival display in the attrac-
tiveness of male and female smiles.
MATERIAL AND METHODS
This cross-sectional study received approval from the
local human research ethics committee (protocol num-
ber: 205.703), and written informed consents were ob-
tained from the volunteers, who were photographed, and
from the raters. A pilot study was conducted to deter-
mine an appropriate sample size to compare the means
of the scores on the visual analog scale (VAS). The
sample size was calculated considering a 95% confidence
level, a standard deviation of 29.70, and the minimum
difference to be detected between groups of 15 mm in the
mean score given for the attractiveness of each smile. A
minimum of 31 raters were determined for each group,
totaling 155 individuals.
Five groups evaluated the images: restorative dentists,
orthodontists, prosthodontists, periodontists, and
laypeople (Table 1). The inclusion criteria for the spe-
cialists included them having finished their specializa-
tions at least 2 years previously and being registered at
the Regional Council of Dentistry. The registries were
confirmed with the council. The following inclusion
THE JOURNAL OF PROSTHETIC DENTISTRY
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Table 1. Demographic data
Sex
Age, Mean ±SD Years as Specialists,
Groups n Male Female (min-max) Mean ±SD (min-max)
Restorative 31 8 23 35.48 ±5.55 6.12 ±4.16 (2-19)
dentists (28-50)
Orthodontists 31 14 17 37.25 ±7.99 6.80 ±5.60 (2-20)
(27-63)
Prosthodontists 31 11 20 39.38 ±9.66 7.09 ±4.90 (2-19)
(27-61)
Periodontists 31 15 16 36.45 ±6.96 8.64 ±6.91 (2-33)
(24-58)
Laypeople 31 14 17 34.75 ±7.32 d
(25-54)
criteria were established for the laypeople: having a col-
lege education but no dental background; not having
orthodontic treatment in the previous 5 years; not being
associated with artistic activities; and not having any
direct contact with dentists, including spouse or sons of
dentists, and oral hygiene technicians. The laypeople
were enrolled in a shopping mall.
The smiles of 2 volunteers (1 female and 1 male) were
photographed, and the images were manipulated by
using a computer software program (Photoshop CS5;
Adobe Systems).20,27-38 They were sized to provide im-
ages with measurements similar to those measured on an
actual patient; the maxillary right central incisor of the
volunteers was used as references.39 Most of the nose,
chin, and cheeks were removed to reduce the number of
variables in the images.14,24-26,28,40 The gingival display
was altered by progressively moving the upper lip up-
ward or downward. The buccal gingival margin of the
maxillary central incisors was used as the reference point
for the measurements. The upper lip was positioned
above this point at 1, 3, and 5 mm and below this point
at 3 and 5 mm. The following images were created
(Figs. 1, 2): A, 3 mm of gingival exposure; B, 1 mm of
gingival exposure; C, 5 mm of central incisor coverage; D,
5 mm of gingival exposure; and E, 3 mm of central incisor
coverage. Negative gingival display values indicated that
the lip rested above the gingival margin while smiling,
whereas positive values indicated that the lip rested
below the gingival margin.41 The final images were
presented in a standardized color and format with a
resolution of 300 dots per inch (dpi).
The images were printed, mounted in an album,
and presented to the raters by the same researcher
(C.R.M.P.-V.), who controlled the observation time at 20
seconds. The raters viewed only 1 image at a time, and
comparisons between photographs were not permitted.42
To control the tendency for the evaluator to give a low
score to a smile because the next one might be perceived
as better, one composition of all images was shown for 20
seconds before the evaluation to calibrate them.24
Each rater was given a brief explanation of the study
and was asked to evaluate the attractiveness of the smile
Pinzan-Vercelino et al
- 2019 3

in the images by using the VAS.24,26,28,29,31,32,39,43,44 The

VAS consisted of an unmarked 100-mm horizontal line
with “unattractive” printed at one end and “very
attractive” printed at the other. The raters placed a ver-
tical mark on the point of the scale that represented their
esthetic perceptions of each smile. The scores were
measured by using digital calipers (Digimatic Caliper 200
mm/.0005; Mitutoyo).
To evaluate intrarater agreement, 1 photograph of the
female smile and 1 of the male smile were duplicated,
printed, and mounted in the album with the other pho-
tographs. The scores for these duplicates were analyzed by
using the intraclass correlation coefficient (ICC).
To analyze measurement reproducibility, all scales of
38 raters were remeasured after an interval of 4 weeks. A
paired t test was applied with the purpose of evaluating
the significance of the differences between the 2 mea-
surements, thus demonstrating
P the systematic error. The
Dahlberg formula (Se2= d2/2n) was used to evaluate the
casual error.
The data were submitted to the Shapiro-Wilk test to
evaluate their distribution. As normality was not
demonstrated, the intergroup comparison was performed
by using the Kruskal-Wallis and Mann-Whitney tests,
and the Friedman and Wilcoxon tests were applied to the
intragroup comparison. For the intergroup and intra-
group comparisons, the level of significance was adjusted
by using the Bonferroni correction (a=.005).

RESULTS
The esthetic perceptions of the raters using the VAS scale
showed high reproducibility (ICC=0.983).28 No system-
atic error was detected (t test: P=.392), and the causal
error was acceptable (Dahlberg=0.098).
In the intergroup evaluation for the female smile,
significant differences among the groups of raters were
found for the smiles with 1, 3, and 5 mm of gingival
exposure (A, B, and D, respectively) and 5 mm of incisor
coverage (C). For the male smile, significant differences
among groups were found for the smiles with 3 mm and
5 mm of gingival exposure (A and D, respectively) and 5
mm of central incisor coverage (C) (Table 2).
For the female smile, higher mean scores were
attributed to 1 mm of gingival exposure (B) by all groups
of raters. The lowest mean scores were found for 5 mm of
gingival exposure (D). For the male smile, 3 mm of
central incisor coverage (E) received the highest mean
scores, except for the laypeople, who considered gingival
exposure of 1 mm (B) more attractive. The lowest mean
scores were found for 5 mm of gingival display (D) for all
groups of raters (Table 2). For all female and male smiles,
Figure 1. Female smile. A, 3 mm of gingival exposure. B, 1 mm of
the laypeople attributed higher scores to the variations of
gingival exposure. C, 5 mm of central incisor coverage. D, 5 mm of
gingival exposure. E, 3 mm of central incisor coverage.
gingival display than the different dental specialists
(Table 2).

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For female smiles, the periodontists, followed by the

orthodontists, were the specialists who most frequently
diverged from the opinions of the laypeople. No statis-
tically significant difference was found among the spe-
cialists regarding gingival display (Table 3). For the male
smile, the orthodontists, followed by the periodontists,
diverged more frequently from the opinion of the
laypeople. The specialists in restorative dentistry, pros-
thetics, and periodontics attributed similar scores to the
variations in the gingival display of the male smile. Or-
thodontists diverged only from the prosthodontists in the
evaluation of the smile with 5 mm of gingival coverage
(C) by attributing lower scores (Tables 2 and 3).
In the intragroup comparisons, for the female smile,
the orthodontists, followed by the laypeople, prostho-
dontists, and periodontists, diverged more frequently
regarding the variations in gingival display (Table 4).
Only restorative dentists showed similar values for all
the smiles. The periodontists and prosthodontists
showed similar judgments. Except for restorative den-
tists, most of the statistically significant differences were
found in the comparison with 5 mm of gingival expo-
sure (D), demonstrating that more accentuated gingival
exposure (5 mm) diminishes the attractiveness of the
smile.
For the male smile, the orthodontists were the most
critical raters. The restorative dentists, prosthodontists,
and periodontists gave similar evaluations (Table 4). The
lowest scores were attributed to 5 mm of gingival expo-
sure (D). The highest scores were attributed to smiles
with 1 mm of gingival exposure and 3 mm of central
incisor coverage (Table 2), with no statistically significant
differences between these conditions in any intragroup
evaluation (Table 4).

DISCUSSION
Many treatments are performed by multidisciplinary
teams23; therefore, it is necessary to know the parameters
that are accepted by the different dental specialists, who
are the care providers.25,26 It is also necessary to know
the parameters that are accepted by laypeople, the pa-
tients.20 Studies have proposed the establishment of
thresholds for gingival display20,25,26; however, this
investigation focused on comparing opinions among
restorative dentists, orthodontists, prosthodontists, peri-
odontists, and laypeople. The results of the present study
supported rejection of the null hypothesis because dental
specialists, mainly orthodontists and periodontists, were
more sensitive about alterations in gingival display than
laypeople.
To prevent the impact of confounding factors, a
Figure 2. Male smile. A, 3 mm of gingival exposure. B, 1 mm of gingival
single-factor (gingival display) study was designed by
exposure. C, 5 mm of central incisor coverage. D, 5 mm of gingival
exposure. E, 3 mm of central incisor coverage.
using a series of artificial smiles that were digitally altered
from 1 female smile and 1 male smile.41 Two individuals

THE JOURNAL OF PROSTHETIC DENTISTRY Pinzan-Vercelino et al

- 2019 5

Table 2. Descriptive statistics (mean ±standard deviation) and intergroup and intragroup comparisons for male and female smiles
Images Restorative Dentists Orthodontists Prosthodontists Periodontists Laypeople Pa
Female smile
A 51.05 ±28.76 55.80 ±20.08 48.72 ±21.30 40.77 ±21.33 65.34 ±15.15 <.001
B 53.39 ±22.45 63.41 ±22.10 58.29 ±18.53 53.58 ±22.56 67.56 ±18.15 .025
C 38.54 ±21.84 37.51 ±23.10 46.27 ±25.17 38.97 ±20.79 58.45 ±17.83 .001
D 29.42 ±27.52 21.96 ±16.81 30.15 ±24.77 25.38 ±22.38 41.45 ±20.91 .008
E 53.09 ±20.71 46.46 ±26.69 55.45 ±22.45 49.20 ±19.50 60.79 ±16.52 .075
Pb <.001 <.001 <.001 <.001 <.001
Male smile
A 39.14 ±29.21 28.71 ±22.10 34.19 ±23.20 34.94 ±23.07 59.65 ±19.73 <.001
B 55.80 ±24.14 52.32 ±24.42 52.79 ±26.79 51.30 ±25.42 65.63 ±20.21 .115
C 39.29 ±21.88 26.61 ±21.60 43.05 ±26.79 36.14 ±20.22 51.80 ±19.15 <.001
D 24.44 ±23.12 18.04 ±22.46 28.43 ±25.64 24.51 ±23.44 38.07 ±21.48 .002
E 56.21 ±20.71 54.10 ±27.27 55.69 ±20.95 53.29 ±20.45 57.12 ±21.27 .929
Pb <.001 <.001 <.001 <.001 <.001

Images of smiles with various degrees of maxillary incisor exposure, in 2-mm increments: A, −3 mm; B, −1 mm; C, +5 mm; D, −5 mm; E, +3 mm. Negative gingival display values indicate that
lip rests above gingival margin while smiling, whereas positive values indicate that lip rests below gingival margin. aIntergroup comparison (Kruskal-Wallis test). bIntragroup comparison
(Friedman test).

Table 3. Pairwise comparisons among the groups of raters: restorative dentists, orthodontists, prosthodontists, periodontists, and laypeople
(Mann-Whitney test)
P
Female Smile Male Smile
Comparisons A B C D E A B C D E
Restorative dentists Orthodontists *** *** *** *** *** *** *** *** *** ***
Restorative dentists Prosthodontists *** *** *** *** *** *** *** *** *** ***
Restorative dentists Periodontists *** *** *** *** *** *** *** *** *** ***
Restorative dentists Laypeople *** *** ** *** *** *** *** *** *** ***
Orthodontists Prosthodontists *** *** *** *** *** *** *** * *** ***
Orthodontists Periodontists *** *** *** *** *** *** *** *** *** ***
Orthodontists Laypeople *** *** ** ** *** ** *** ** ** ***
Prosthodontists Periodontists *** *** *** *** *** *** *** *** *** ***
Prosthodontists Laypeople * *** *** *** *** ** *** *** *** ***
Periodontists Laypeople ** * * * *** ** *** * *** ***

Images of the smiles with various degrees of maxillary incisor exposure, in 2-mm increments: A, −3 mm; B, −1 mm; C, +5 mm; D, −5 mm; E, +3 mm. Significant at P<.005 (Bonferroni
correction for multiple comparisons). *P<.005; **P<.001; ***P>.005.

with excessive gingival display were selected to allow
digital alterations of the gingival display. The images
were based on a cropped face that displayed only the
mouth and teeth, increasing the focus on local alter-
ation8,14,24-26,29,38,40 because raters tend to focus on the
eyes and mouth.15 Furthermore, the methodology used
in the present investigation did not enable an analysis of
the full face because changes in gingival display were
performed by progressively moving the upper lip upward
and downward, which would become unnatural on the
images of the full face.
To reduce bias in the results of the laypeople group,
orthodontic patients in active treatment or treated in the
previous 5 years, people with a dental background, and
people with direct contact with dentists (spouse or sons
of dentists and oral hygiene technicians) were not
included. Orthodontic treatment could make them more
analytical with regard to gingival display and could
influence their judgments because perception has a
psychological basis.45 Individuals who were orthodonti-
cally treated for more than 5 years ago were included
because it was considered that sufficient time had passed
between treatment and judgment. This criterion may be
considered a limitation of this study; however, Witt and
Bartsch46 investigated the information retention of or-
thodontic patients and reported that approximately 70%
of information transmitted could not be remembered 10
days later.
The different dental specialists were more critical of
the variations in gingival display than the laypeople. This
finding indicates that the goals of the practitioners may
not be in harmony with the goals of the patients.25 Al
Taki et al27 also found that laypeople were less able to
discriminate among levels of discrepancies than ortho-
dontists and dentists when gingival display was evalu-
ated. This outcome may be related to the fact that dental

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6 Volume - Issue -

Table 4. Pairwise comparisons of variations in gingival display within each group of raters: restorative dentists, orthodontists, prosthodontists,
periodontists, and laypeople (Wilcoxon test)
Group A×B A×C A×D A×E B×C B×D B×E C×D C×E D×E
Female smile
Restorative dentists *** *** *** *** *** *** *** *** *** ***
Orthodontists *** *** ** *** * ** *** *** *** *
Prosthodontists *** *** *** *** *** ** *** *** *** *
Periodontists *** *** *** *** *** ** *** *** *** *
Laypeople *** *** ** *** *** ** *** *** *** *
Male smile
Restorative dentists *** *** *** *** *** ** *** *** *** **
Orthodontists * *** *** * * ** *** *** ** **
Prosthodontists *** *** *** *** *** * *** *** *** **
Periodontists *** *** *** *** *** ** *** *** *** **
Laypeople *** *** * *** *** ** *** *** *** ***

Images of smiles with various degrees of maxillary incisor exposure, in 2-mm increments: A, −3 mm; B, −1 mm; C, +5 mm; D, −5 mm; E, +3 mm. Significant at P<.005 (Bonferroni correction
for multiple comparisons). *P<.005; **P<.001; ***P>.005.

specialists receive specific training during their education,
making them more sensitive to alterations.41 This result
highlights the importance of effective communication
between dental specialists and their patients when
planning treatment.9,25,28,31,39
In the intergroup comparisons, the orthodontists and
periodontists were generally the most critical raters.
Probably, periodontists were critical because in their
specialty, the periodontal tissues are constantly evalu-
ated. Orthodontists are likely more critical because of the
specialist training required to observe and evaluate fea-
tures that do not seem to influence the other specialties
tested or the public. Furthermore, the orthodontists
routinely use facial analysis, including smile analysis, in
their diagnosis and treatment-planning decisions.1,3,4
Previous studies have also reported that orthodontists
identified smaller levels of deviation than general den-
tists.24-26,28,39
For the female smile, all groups of raters attributed
higher mean scores to the smile with 1 mm of gingival
exposure. For the male smile, 3 mm of central incisor
coverage received the highest mean scores from the
dental specialists, whereas the laypeople judged the
smile with 1 mm of gingival exposure to be the most
attractive. The perception of esthetics may depend on the
development of a form concept.18 According to this
concept, when a facial pattern is seen more frequently, it
is more often perceived as more correct.18 Miron et al10
found that higher smile patterns are more common
among women and that lower smile patterns are more
common among men. This tendency was confirmed in
the present investigation and in previous studies.8,11,30
For both the male and female smiles, all groups of
raters considered 5 mm of gingival exposure to be the
least esthetically pleasing one. Previous studies have also
demonstrated that an increase in gingival exposure di-
minishes the attractiveness of the smile.21,25-27,34 After
5 mm of gingival exposure, the images with 5 mm of
central incisor coverage received the lowest scores, indi-
cating that excessive underexposure of the teeth when
smiling is also perceived as unattractive.16,30,34 Excessive
overlapping and underlapping of maxillary gingiva and
teeth were not only judged as being unattractive but were
correlated with the personality characteristics of neurot-
icism and self-esteem16 and resulted in less observer
sympathy.30
The male smile with 5 mm of central incisor coverage
showed a statistically significant difference between the
orthodontists and prosthodontists. This finding may be
related to the fact that orthodontists see younger patients
more frequently than prosthodontists.43 Younger pa-
tients exhibit a higher smile line than adult
patients because lip coverage of the maxillary central
incisors tends to increase with age, thereby diminishing
gingival exposure.12,19,35 This result may also be related
to the form concept.18
In the intragroup comparisons for the female smile, 1
and 3 mm of gingival exposure and 3 mm of central
incisor coverage received the highest scores, with no
statistically significant differences in these conditions. For
the male smile, 1 mm of gingival exposure and 3 mm of
central incisor coverage received the highest scores.
Large esthetic ranges are usually described when gingival
display is evaluated.20,22,25,41
Limitations of this study include that there were more
female than male raters. Some studies have reported that
the sex of the rater affects the evaluation of smile es-
thetics,14,21,30,36 while other investigations showed no
influence.9,33,37,38,43 Future studies should consider the
sex variable. Furthermore, in the present study, the dis-
tance of the buccal gingival margin of the maxillary
central incisors to the upper lip was evaluated in in-
crements of 2 mm instead of 1 mm; because there was no
assessment of 2 or 4 mm, these discrepancies could not

THE JOURNAL OF PROSTHETIC DENTISTRY Pinzan-Vercelino et al

- 2019
be assessed. Also, because computer-manipulated im-
ages from only 1 male and 1 female model were evalu-
ated, the dependence on the sex of the image could not
be investigated conclusively. Therefore, the results
should be viewed as tendencies to be confirmed in future
studies with more smiles from each sex.
In this investigation, static photographs were evalu-
ated. Capturing the smile by using a video camera may
improve the viewing of anatomic and physiological
changes compared with static images produced by a
digital camera.4,35 Further investigations evaluating dy-
namic smile representations should be conducted.
The findings of this study may guide dental practices
in the decision-making process of diagnosis and treat-
ment planning. However, these conclusions were drawn
based on mean values, and it is therefore difficult to
apply this information to all patients.26 As the amount of
acceptable gingival display varies widely, the preferences
of the patients should be considered in decisions
regarding treatment planning.9,19 Gingival display is not
always unpleasing in the eye of the public.21
CONCLUSIONS
Based on the findings of this observational study, the
following conclusions were drawn:
1. The restorative dentists, orthodontists, prostho-
dontists, and periodontists were more sensitive to
alterations in gingival display than laypeople. The
orthodontists and periodontists were often the most
critical raters.
2. Dental specialists should pay attention to patient
concerns during the first appointment.
3. The preferences of the patient should be considered
during treatment planning.
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Corresponding author:
42. Witt M, Flores-Mir C. Laypeople’s preferences regarding frontal dentofacial
esthetics: Tooth-related factors. J Am Dent Assoc 2011;142:635-45. Dr Célia Regina Maio Pinzan-Vercelino
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Perceptions of aesthetics in three age groups. J World Fed Orthod 2015;4: University Ceuma, Rua Josué Montello
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its implication for workers in dental organizations: a review of literature. Copyright © 2019 by the Editorial Council for The Journal of Prosthetic Dentistry.
Anthropologist 2014;17:501-7. https://doi.org/10.1016/j.prosdent.2019.03.023

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