RESEARCH

An analysis of the aesthetic proportions of anterior

maxillary teeth in a UK population
Rahul Kalia1

Key points
Golden Proportion, Preston’s Proportion, Recurrent
Esthetic Dental Proportion and Golden Percentage
are the main aesthetic proportions proposed for use
in dentistry.
There is limited prevalence of all these aesthetic A modified version of Golden Percentage has a
proportions among maxillary anterior teeth in the UK high prevalence and is better proposed for use as
sample. a geometric component of aesthetic smile design
principles.

Abstract
Introduction Many aesthetic proportions have been proposed for use in dentistry: Golden Proportion, Preston’s Proportion,
Recurrent Esthetic Dental (RED) Proportion and Golden Percentage. Although there have been studies to consider these
proportions in other countries, there have been no studies in the UK to evaluate their prevalence and value.
Methods The maxillary anterior teeth of 509 students from University of Birmingham’s School of Dentistry were photographed
in a standardised manner and the aesthetic proportions statistically analysed using an unpaired one-sample t-test.
Results Golden Proportion existed in a very limited number of the sample. RED did not exist in the sample. The sample’s
average ratio was similar to Preston’s Proportion; however, there was too wide a distribution for the proportion to be of
relevant use. The vast majority of the sample conformed to modified Golden Percentage values; 22.5% for central incisors,
15% for lateral incisors and 12.5% for canines.
Conclusion Golden Proportion, Preston’s Proportion and RED Proportion have limited value in aesthetic dentistry as they do
not accurately or broadly represent natural, aesthetic smiles. However, slightly modified Golden Percentage values are vastly
more representative and are recommended as a more relevant geometric component to smile design principles in the UK.

Introduction ratio in anterior maxillary teeth for use in Preston’s Proportion

Social media, advertising and celebrities
are just some factors which have increased
demand for cosmetic dental procedures.
Consequently, aesthetic considerations have
become a growing concern in dental treatment
planning. This trend has been supported by the
application of mathematical proportions which
aim to aid the planning of a natural-looking,
aesthetic smile.1
denture aesthetics. Levin3 developed its use in
1978 to produce the most aesthetic smile. The
visible width of the maxillary lateral incisor
should be 62% of the width of the maxillary
central incisor when viewed facially (a ratio
of 1.618). The visible width of the maxillary
canine should be 62% of the width of the
maxillary lateral incisor (a ratio of 0.618).
Fig. 1 Golden Proportion
Preston4 conducted a study in 1993 which
concluded that the Golden Proportion was
largely absent in natural aesthetic smiles. Only
17% of central incisors and no canines were in
Golden Proportion to the lateral incisor. This
led to his revised proportion: the maxillary
lateral incisor should be 66% of the central
incisor width and canines should be 84% of

Golden Proportion
The Golden Proportion (Fig. 1) is an aesthetic 0.618 1.0 1.618 A B= C=
A x 0.62 B x 0.62
ratio of 0.618 (62%) reflecting a relationship
between larger and smaller objects. In 1973,
Lombardi2 proposed the use of this repeated

1
Ark-G Dental & Cosmetic Centre, 10–12 Crayford High
Street, Crayford, DA1 4HG, UK.
Correspondence to: Rahul Kalia
Email: rahul.kalia@hotmail.co.uk

Refereed Paper.
Accepted 13 January 2020
https://doi.org/10.1038/s41415-020-1329-9

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 RESEARCH

the width of the lateral incisors when viewed

Fig. 2 Preston’s Proportion
from the frontal aspect (Fig. 2).

Golden Percentage 0.84 1.0 1.515 A B= C=

In 1999, Snow 5 applied proportions differently: A x 0.66 B x 0.84

each tooth in the anterior segment of the

maxillary dentition should occupy a given
percentage of the whole maxillary intercanine
distance from a frontal view. The visible width
of each maxillary central incisor should be 25%
of the maxillary intercanine distance, lateral
incisors should be 15% and canines should
display 10% for the most aesthetic smile. This
is termed the Golden Percentage (Fig. 3).

Recurrent Esthetic Dental (RED) Fig. 3 Golden Percentage

Proportion 100%
Rosenstiel, Ward and Rashid6 were the first to
appreciate that the exact proportional value 10% 15% 25% 25% 15% 10%
may differ between patients according to their
face shape, skeletal structure and general body
type. They accepted natural variation and the
unlikelihood of proportional smile designs
to follow strict mathematical rules. RED
proportion (Fig. 4) recommends the use of a
constant proportion to be used in the reduction
of the visible width of teeth as one moves
distally from the central incisor to the canine.
The exact value of the proportion can differ
between patients depending on the heights of
the maxillary anterior teeth. A smaller RED Fig. 4 RED Proportion
proportion is advocated in patients with more
of an ectomorph body shape, and a larger C= B= A A B= C=
RED proportion to suit those with more of an Bxχ Axχ Axχ Bxχ
endomorph body shape.
Table 2 summarises the aesthetic proportion
values.
Del Monte et  al.7 identify the face as the
most important anatomical location for
attractiveness. The dental appearance is
the second most important aspect of facial
attractiveness, after the eyes. Despite this,
limited evidence on smile aesthetics is available.
While there have been a number of different
ideal proportions which have been proposed Proportion only. Consequently, this study aims each year with a macro lens and ring flash by
to reflect the most aesthetic smile, there has to evaluate the occurrence of a wider range of one individual. Standardised camera settings
been very limited research into the prevalence, aesthetic proportions in a UK sample. were as follows:
relevance and application   of   these – • ISO – 100/200 (lowest possible setting)
particularly within the United Kingdom (UK). Method • Shutter speed – 1/200 second
Attempts have been made to assess • Aperture – F:22–32
occurrence of some proposed proportional As part of their second year undergraduate • Flash – set to give appropriate exposure at
values in Turkey,8 Malaysia,9 Iran,10,11 Ireland,12 training in tooth anatomy, 509 dental students aperture setting.
Jordan,13 America,4 Bangladesh14 and India.15,17 consented to have their maxillary anterior
The findings of these studies are summarised teeth photographed as part of a tooth drawing Images were cropped using Photoshop
in Table 1. No comparable studies have been exercise16 at University of Birmingham’s School Elements and manipulated digitally, where
conducted in the UK. Most previous studies of Dentistry between 2008 and 2017. Digital required, to optimise horizontal plane and
have evaluated the incidence of Golden Single Lens Reflex (DSLR) cameras were used exposure.

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Table 1 A table to summarise studies around the world investigating the prevalence of aesthetic smile proportions

Country of Proportions
Author(s) Methodology Sample Results
study investigated
Golden Proportion existed in 14–25% of sample.
Standardised frontal
RED Proportion not present as a consistent value
photographs (same camera 56 Asian dental
Golden Proportion, from central incisor to canine.
Murthy and Ramani settings and technique). students (20 male,
India Golden Percentage, Golden Percentage present (22% central incisor:
(2008)15 Analysis using Adobe 36 female; 20–25
RED Proportion 15% lateral incisor: 13% canine), but not as exact
Photoshop 7.0 by one years old)
values proposed by Snow (25% central incisor: 15%
investigator.
lateral incisor: 10% canine).
Dental casts taken. Digital
Golden Proportion does not exist within the
calliper used to record
Al-Marzok, Majeed population. The study found narrower central
perceived widths of teeth. 49 dental students
and Ibrahim Malaysia Golden Proportion incisors and wider canines compared to lateral
Measurements repeated by (18–23 years old)
(2013)9 incisors, as opposed to a constant reduction in
three researchers to increase
width like the Golden Proportion suggests.
reliability.
Standardised frontal 11.1% with Golden Proportion in central
photographs. Analysis incisor:lateral incisor width ratio. Under 5% with
Mahshid et al. Golden Proportion using image-measurement 157 dental students Golden Proportion in lateral incisor:canine width
Iran
(2004)11 (in aesthetic smiles) program (Dimaxis). Repeated (82 male, 75 female) ratio.
to increase reliability and Mean lateral:central incisor width ratio – 67%.
validity. Mean canine:lateral incisor width ratio – 84%.
17% with Golden Proportion in central
incisor:lateral incisor width ratio.
Standardised frontal
Golden Proportion, 100 dental students 4% with Golden Proportion in canine:lateral incisor
Aziz and Hossain photographs. Analysis using
Bangladesh Golden Percentage, (50 male, 50 female; width ratio.
(2017)14 Statistical Package for Social
RED Proportion 18–35 years old) Golden Percentage in 7% of central incisors, 66%
Science Software version 20.
of lateral incisors and 21% of canines.
4% had RED Proportion.
Dental casts recorded. Golden Proportion existed in central incisor:lateral
Images captured of casts 109 dental students incisor width ratio – 65%. Golden Proportion does
Condon et al.
Ireland Golden Proportion from frontal view. Widths (49 male, 69 female; not exist in lateral incisor:canine width ratio – 89%.
(2011)12
measured using Adobe 18–25 years old) Results more in accordance with Preston’s
Photoshop 6.0. Proportion of 66% and 84%, respectively.
100 dental students Golden Proportion does not exist within the
Standardised frontal
Hasanreisoglu et al. (50 male, 50 female; sample.
Turkey Golden Proportion photographs. Analysis using
(2005)8 mean age of 22 The occurrence of any other continuous proportion
Adobe Photoshop.
years old) was not detected.
‘Small’ teeth (proposed 80%).
Central incisor:lateral incisor width ratio – 73%.
Lateral incisor:canine width ratio – 76%.
‘Medium’ teeth (proposed 76%).
Frontal photograph captured Central incisor:lateral incisor width ratio – 72%.
90 participants. (45
with same camera settings Lateral incisor:canine width ratio – 83%.
Shetty et al. (2011)17 India RED Proportion male, 45 female;
and technique. Analysis using ‘Tall’ teeth (proposed 62%).
18–35 years old)
Adobe Photoshop. Central incisor:lateral incisor width ratio – 71%.
Lateral incisor:canine width ratio – 75%.
RED Proportion does not exist within the sample.
There is an absence of any recurring proportion
within the perceived width ratios.

Inclusion/exclusion criteria
Inclusion criteria:
• Complete maxillary anterior dentition
(upper right canine to upper left canine).
Exclusion criteria:
• Congenital or acquired dental defects (eg
hypodontia, peg laterals, diastemata)
• Presence of anterior direct or indirect
restorations of significant size.
Five hundred and nine students met these
criteria. A limitation in this study was not
being able to distinguish those who had
received orthodontic treatment from their
photos. Ethnicity and gender of participants
were not recorded in this study. Future studies
would benefit from analysing whether these
factors have a practical implication on smile
design principles.
The maximum width and length proportions
of the six anterior teeth were measured using
Microsoft PowerPoint by inserting boxes
around the teeth and recording their lengths
and widths. The perceived widths of teeth were
recorded from the most mesial aspect of a tooth
to the most distal aspect of the same tooth, as
viewed in the anterior image. All recordings
were measured by one investigator, and
recorded and analysed using Microsoft Excel.
Golden Proportion and Preston’s Proportion
were assessed by recording the maxillary
central incisor:lateral incisor width ratio
(CEN:LAT) and maxillary canine:lateral
incisor width ratio (CAN:LAT). Consistent
with methods in previous research,4,11 the
percentage of participants who fall within 1%
of Golden Proportion and Preston’s Proportion
were calculated. In addition, the average
proportion among the data of CEN:LAT and
CAN:LAT was calculated and compared to the
exact Golden and Preston’s Proportion values
using a one-sample t-test.
The Golden Percentage was assessed by
recording the intercanine distance by adding

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the perceived widths of all six maxillary

Fig. 5 Line graphs to show the distribution of the sample’s average proportion of CAN:LAT
anterior teeth. The width of each tooth was and CEN:LAT (blue) compared to Preston’s Proportion (red) and Golden Proportion (green)
divided by the intercanine distance and
percentage calculated. Following this, the same CAN:LAT and CEN:LAT (blue) Preston’s Proportion Golden Proportion (green)
statistical analysis as Golden and Preston’s CAN:LAT sample distribution
Proportion was conducted. 120
RED Proportion was assessed by comparing
the difference between LAT:CEN and 100

No. of students from sample

CAN:LAT. Participants were considered
80
as conforming to RED Proportion if the
difference between these two ratios was less 60
than 1%.
40

Results 20

Golden Proportion 0
Fewer than 10% of the sample’s CEN:LAT 0.5 0.6 0.7 0.8 0.9 1.0 1.1 1.2
were in Golden Proportion. This dropped to CAN:LAT ratio

1.4% for the sample’s CAN:LAT. The average CEN:LAT sample distribution
proportion of CEN:LAT was 1.511  ±  0.013 90

(95% confidence interval [CI]), lower than the 80

Golden Proportion of 1.618, thus suggesting
No. of students from sample

70
narrower central incisors were more common. 60
These findings support most literature, except
50
Condon et al.12 who found Golden Proportion
40
to exist in the CEN:LAT.
30
The average proportion of CAN:LAT was
0.826 ± 0.012 (95% CI), higher than the Golden 20

proportion of 0.618, thus suggesting wider 10

canines were more common. Both results 0
were statistically significant, thus suggesting 1.3 1.3 1.5 1.6 1.7 1.8 1.9 2.0

this sample, on average, did not conform to CEN:LAT ratio

the Golden Proportion.
These findings are consistent with
Al-Marzok, Majeed and Ibrahim,13 who also Table 2 A table to summarise the proposed ideal values of the aesthetic proportions
found narrower central incisors and wider
Mathematical proportion Ratio/tooth Proposed ideal value
canines compared to lateral incisors, as
opposed to a constant reduction in width like Golden Proportion CEN:LAT 1.618
the Golden Proportion suggests. Golden Proportion CAN:LAT 0.618

Preston’s Proportion LAT:CEN 66%

Preston’s Proportion
The average data from this sample are more Preston’s Proportion CAN:LAT 84%
in accordance with Preston’s Proportion. Golden Percentage CEN 25%
The average LAT:CEN width ratio was
Golden Percentage LAT 15%
66.7% ± 0.52% (95% CI), similar to Preston’s4
suggestion of 66%. The average CAN:LAT Golden Percentage CAN 10%
width ratio was 82.6%  ±  1.18% (95% CI),
RED Proportion LAT:CEN and CAN:LAT Can vary, but must be equal
similar to Preston’s suggestion of 84%. The
LAT:CEN average was statistically significant
while the CAN:LAT average was not. Table 3 A table to compare the prevalence of this sample conforming to the Golden
The large variance among the sample Percentage values and the modified Golden Percentage values suggested by this study
explains why only around 16% of the sample’s
Tooth Golden Percentage value ±1% Modified Golden Percentage value ±1%
LAT:CEN width ratio and 6.5% of the sample’s
CAN:LAT width ratio conformed to Preston’s CEN 8.8% 71.3%
Proportion. The limited prevalence of this LAT 71.5% 71.5%
proportion suggests it is of limited value and
CAN 12.6% 61.5%
relevance.

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The average percentage of intercanine

distance covered by central incisors
was 22.6%  ±  1.0%, lateral incisors was
15.1% ± 1.0% and canines was 12.3% ± 1.2%.
These findings are very similar to Murthy and
Ramani (2008), who found mean results of
21.9–22.3% for central incisors, 15.3–15.5%
for lateral incisors and 12.0–12.6% for canines
among 56 Asian dental students. A number
Fig. 6 The dentition which conformed closest to Golden Proportion (courtesy of Louis Mackenzie) of other studies have concluded similar
figures.14,18,19,20
Table 3 shows how a much larger percentage
of this study’s sample conformed to modified
Golden Percentage values of 22.5% for
CEN, 15% for LAT and 12.5% for CAN.
This is indicative of a narrow distribution
around these values, unlike the distribution
compared to Preston’s Proportion. There
was also a considerably higher prevalence
of these values than the values proposed
Fig. 7 The dentition which conformed closest to Preston’s Proportion (courtesy of Louis Mackenzie) by Murthy and Ramani15 – 22%, 15.5% and
12.5%. Overall, this suggests that the modified
Golden Percentage values proposed have the
highest prevalence and most relevance.

Fig. 8 The dentition which conformed closest to Golden Percentage (courtesy of Louis Mackenzie)
Fig. 9 The dentition which conformed closest to RED Proportion (courtesy of Louis Mackenzie)
The findings of the LAT:CEN are very similar
to values in previous research by Mashid et al.11
(67%) and Condon et al.12 (65%). The CAN:LAT
ratio of this study was slightly lower than their
averages of 84% and 89%, respectively.
In summary, the data support previous
research that Preston’s Proportion is more
representative of the average proportion found
among the width ratios of natural anterior
maxillary teeth than Golden Proportion.
Figure 5 shows how the sample is distributed
far more closely to Preston’s Proportion as
opposed to Golden Proportion. However,
the wide distribution of the sample around
these values indicate the small prevalence
of the proportion, thus suggesting Preston’s
Proportion is of limited use.
Golden Percentage
Under 9% of the sample’s central incisors and
under 13% of the sample’s canines conformed
to Golden Percentage values. In contrast,
many lateral incisors (71.5%) conformed to
Golden Percentage.
RED Proportion
No participant had an exact recurrent
proportion in width between CEN:LAT:CAN.
Only 21 participants (4.1%) of the sample had
CEN:LAT and LAT:CAN width ratios within
1% of each other. This suggests the sample
did not conform to RED Proportion. The
large average difference between CEN:LAT
width ratio and LAT:CAN width ratio of
18.4% ± 1.32% (95% CI) with a large standard
deviation of 15.2% further supports the
absence of a recurrent ratio.
This is consistent with the literature,
which has also failed to find a consistent
or similar ratio between CEN:LAT width
ratio and LAT:CAN width ratio among their
samples.12,15,16
The dentitions from the sample which
conformed closest to each of the aesthetic
proportions are shown in Figures 6, 7, 8 and 9.
Discussion
A low prevalence was found of all
mathematical proportions investigated, thus
highlighting the limited clinical relevance
of prior aesthetic proportions. Despite the
average ratios of this study’s sample being
similar to Preston’s Proportion, a limited
percentage of the sample conformed to the
proportion due to such a wide distribution.
The sample’s lateral incisors did conform

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 RESEARCH
to the recommended value of Golden
Percentage. However, this finding was not
consistent for central incisors and canines.
The overall sample conformed far more to
modified Golden Percentage values – 22.5%
for central incisors, 15% for lateral incisors
and 12.5% for canines (Fig. 10). Consequently,
these values are recommended instead of
previous mathematical proportions for use
in design principles of natural-looking,
aesthetic smiles.
However, the proportion of the maxillary
incisors and canines is only one aspect
of dental aesthetics and following simply
mathematical computations may not always
produce a result that satisfies the patient.
Aesthetics is a branch of psychology,
converting a physical entity by the brain
into a psychological – usually pleasurable
– experience in the mind. Dental aesthetics
has been analysed in the literature using three
general principles: geometric, psychological
and perceptual theories, some dating as far
back as 3,000 BC in Ancient Egypt.
The seminal landmark of geometric
theories for quantifying beauty (or aesthetics)
is credited to Pythagorus (530  BC), who
first proposed the Golden Proportion and
its reciprocal, the Golden Ratio. The first
person to apply the Golden Proportion in
dentistry was Lombardi in 1973, spurning the
evolution of dental aesthetics that burgeoned
in the 1980s. This was particularly fervent in
America, resulting in spurious application
of the Golden Proportion for ostensible
‘cosmetic makeovers’ for beautification.
Furthermore, the Golden Proportion is
endorsed by eminent authors3,21,22,23 that is still
used in many institutions for teaching dental
students to this day. It wasn’t until the 1990s
and 2000s that the concept of the Golden
Proportion was questioned and refuted by
several authors, who proposed alternative
mathematical calculations such as RED or
Golden Coefficients for creating pleasing
anterior dental aesthetics.6,24,25
A sub-category of geometric theories is
the so-called ‘correlation hypotheses’, linking
the size of facial features, such as width of
the nose or inter-zygomatic distance to the
width of maxillary anterior teeth. Most of
these theories, based purely on mathematical
and correlation concepts, have subsequently
been disproved.8,13,26 Furthermore, it is worth
pointing out that the difference between
various geometric theories relating to tooth
width is often as small as 0.5  mm, which
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Fig. 10 Modified Golden Percentage
100%
12.5% 15% 22.5%
is barely perceptible at a social distance of
viewing.
The psychological theories explore a
link between an individual’s psychological
make-up, tainted by education, society, social
mores, persona, etc, to the apparent shape
and size of the maxillary anterior teeth.27,28,29
However, these concepts are highly subjective,
belonging to the realm of psychology, which is
perhaps beyond the scope of many practising
clinicians.
Lastly, perceptual theories have recently
become vogue, aiming to address dental
aesthetics by the way we ‘see’ or perceive a
beautiful smile.30,31,32,33 Therefore, to discuss
dental aesthetics and make recommendations
on a single item such as tooth proportion is
perhaps too simplistic and possibly naive.
Conclusion
Despite the wide acceptance of Golden
Proportion when mathematical proportions
are applied in aesthetic dentistry, the
overwhelming literature refutes its use as
the most relevant, aesthetic proportion. This
study identifies modified Golden Percentage
values – 22.5% for central incisors, 15% for
lateral incisors and 12.5% for canines – of
greatest use in smile design principles.
However, it is important to note that
geometric proportions are only one aspect for
deciphering anterior dental aesthetics. Other
factors require consideration before finalising
an aesthetic prescription. These include the
patient’s personality, wishes, psychological
make-up, education, morality, religion, plus
their ethnic and socio-economic background,
which all impact on whether an aesthetic
dental restitution is greeted with enthusiasm
or rejection.
22.5% 15% 12.5%
Acknowledgements:
The author would like to thank all participants
and Mr Louis Mackenzie for taking and providing
all photographs, as well as his continued support
throughout the research.
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