ORIGINAL ARTICLE

Optimal gingival display on smiling based

on different facial vertical patterns in
Iranians
Mohammad Moslem Imani,a Ehsan Mohamadi Nezhad,b Amin Golshah,a and Roya Safari-Faramanic
Kermanshah, Iran

Introduction: This study aimed to determine the optimal gingival display on smiling on the basis of different facial
vertical patterns in Iranians from the perspective of laypeople, maxillofacial surgeons, and orthodontists.
Methods: Photographs were obtained from short-faced, normal-faced, and long-faced males and females
(1 male and 1 female from each group) aged 18-30 years. The original photographs were then modified to
have 6, 4, 2, 0,
2,
4, and
6 mm gingival display. Three groups of raters (n 5 40), including laypeople,
orthodontists, and maxillofacial surgeons, were requested to score each photograph regarding smile
attractiveness using a 5-point Likert scale. Data were analyzed using analysis of variance and the Kruskal-
Wallis test. Results: Regarding the photographs of the normal-faced female model, all 3 rater groups gave
the highest score to a 2 gingival display. In the normal-faced male model, all 3 rater groups gave the highest
and lowest scores to 0 and 6 mm gingival display, respectively. In the long-faced female model, all 3 rater
groups gave the same score to 0, 4, and 6 gingival display. In the long-faced male model, the 3 rater groups
gave the same score to 0, 2, 4, and 6 gingival display. In the short-faced female model, all 3 rater groups
gave the highest score to 0 gingival display. In the short-faced male model, the 3 rater groups gave the same
score to all values of gingival display except
4 mm. Conclusions: The laypeople, maxillofacial surgeons,
and orthodontists all gave the highest score to the photograph of a short-faced Iranian female model with
0 gingival display. (Am J Orthod Dentofacial Orthop 2023;163:766-76)

F
acial attractiveness is important in social success
and greatly influences smile attractiveness.1 Accord-
ing to the literature, people with beautiful smiles,
are smarter, more attractive, and better accepted by
others.2 Esthetic concerns are a great motivation for pa-
tients to seek dental treatment,3 and smile attractiveness
is a major priority for patients seeking orthodontic treat-
ment.4 According to the literature, 80% of patients
seeking orthodontic treatment for themselves or their
a
Department of Orthodontics, School of Dentistry, Kermanshah University of
Medical Sciences, Kermanshah, Iran.
b smiling is among the important factors affecting smile es-
Student Research Committee, School of Dentistry, Kermanshah University of
Medical Sciences, Kermanshah, Iran.
c
Social Development and Health Promotion Research center, Kermanshah Uni-
versity of Medical Sciences, Kermanshah, Iran.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This work was supported by the Kermanshah University of Medical Science, Ker-
manshah, Iran.
Address correspondence to: Amin Golshah, Department of Orthodontic, School
of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran;
e-mail, amin.golshah@gmail.com.
Submitted, October 2021; revised and accepted, June 2022.
0889-5406/$36.00
Ó 2022 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2022.06.025
children aim to improve facial esthetics.5 Therefore, ortho-
dontists should first identify the motives of orthodontic
patients to create a beautiful smile that meets patient
expectations.6 Because of the increased demand for an
attractive appearance, esthetic considerations are now
critical in treatment plans.4 Considering the subjectivity
of esthetics, assessing the factors that define an esthetic
smile is difficult.6
Factors affecting smile esthetics include the smile arc,
tooth display, gingival display, buccal corridor display,
midline alignment, tooth ratios, gingival health, tooth co-
lor, and occlusal plane canting.7 Gingival display when
thetics.8 Van der Geld et al9 found that the amount of
gingival display was a fundamental factor influencing
the satisfaction of patients with their smile esthetics.
Increased gingival display when smiling is referred to as
gummy smile.10
In an ideal smile, the crown of maxillary central incisors
and 1 mm of the gingiva should be revealed. In addition,
according to some authors, up to 3 mm of gingival display
can still be considered in the range of acceptable smile es-
thetics.11 Moreover, evidence shows a difference in the

766
Imani et al
amount of gingival display when smiling between males
and females, and females may have greater gingival display
than males when smiling.8-11
A beautiful smile requires a balance between the
different soft-tissue and hard-tissue parameters of the
face.12 Different vertical dimensions create different
facial characteristics.13 Smile esthetics is influenced by
facial patterns. Different esthetic perceptions have
been reported for the buccal corridor among long, short,
and normal-faced subjects.13 Thus, evaluation of the
features of smile esthetics in different facial patterns
may bring about more reliable data. A previous study
showed that facial type affects the perception of facial
beauty and smile attractiveness; thus, it should not be
assessed separately from the smile and vice versa.14
Demir and Baysal15 evaluated the smile properties of pa-
tients with increased vertical facial height and reported
greater upper lip elevation, shorter upper lip, and
increased interlabial gap both at rest and when smiling
in the vertical group. Such variations affect the smile
features, especially concerning gingival display. Careful
consideration of such variations in patients with
different vertical facial heights can greatly enhance cor-
rect diagnosis and treatment planning.
The esthetic perception highly depends on educa-
tional level, culture, and social environment.16 Thus,
variations may exist in the opinion of patients, ortho-
dontists, and maxillofacial surgeons concerning the re-
sults of orthodontic treatment.17,18
To the best of our knowledge, this is the first study
to evaluate the optimal gingival display on smiling in
subjects with different facial vertical patterns. Consid-
ering the significance of smile esthetics in orthodontic
treatment, this study aimed to determine the optimal
gingival display on smiling on the basis of different
facial vertical patterns in Iranians from the perspective
of laypeople, maxillofacial surgeons, and orthodon-
tists.
MATERIAL AND METHODS
The protocol of this study was approved by the ethics
committee of the Medical Sciences Ethics Committee at
Kermanshah University (IR.KUMS.REC.1398.201). In this
cross-sectional study, the minimum sample size was
calculated to be 40 people per group, according to a pre-
vious study by Helm et al,19 assuming a 5 0.05, b 5 0.2,
mean score of 3.86 for
2 mm gingival display, mean
score of 2.93 for
4 mm gingival display, a variance
of 1.67, power of 90%, and significance level of 0.05.
In this study, short-faced, normal-faced, and long-
faced males and females (1 male and 1 female from
each group) were selected according to the hard-tissue
American Journal of Orthodontics and Dentofacial Orthopedics
767
(Jarabak, Sn-GoGn, Frankfort-mandibular plane angle
[FMA])20 and soft-tissue (Legan-Burstone, vertical
height ratio, G-Sn/Sn-Me’)21,22 cephalometric analyses
of their lateral cephalograms. Facial types were deter-
mined according to the FMA, the Jarabak index, and
the middle facial one-third to lower facial one-third ratio
on the basis of the results of lateral cephalometric anal-
ysis (FMA 5 15; Jarabak index 5 75; and G-Sn/Sn-
Me 5 55/45 for the short-faced patients and FMA 5
35, Jarabak index 5 55 and G-Sn/Sn-Me 5 45/55 for
the long-faced patients).23 The inclusion criteria for
the candidates were as follows: ideally aligned teeth,
aged 18-30 years,24 Class I skeletal, molar and canine
relationship, absence of maxillary diastema,25 not hav-
ing dental prosthetic restorations,24 no clinical evidence
of periodontal disease or caries when smiling,26 absence
of facial asymmetry,24 absence of pathologic lesions or
deformities in the maxillofacial region,24 and no history
of orthodontic treatment or facial surgery. After select-
ing suitable candidates, they were briefed about the
study, and written informed consent was obtained
before photography.
After final confirmation by 2 experienced orthodon-
tists (M.M.I. and A.G.), all 6 models underwent frontal
intraoral photography and frontal-view extraoral
photography with a posed smile. All photographs were
taken indoors under artificial fluorescent lighting by a
digital camera (5Dw R; Canon, Tokyo, Japan) with Sigma
EM-140 DG Macro Ring Flash, which was used in auto-
matic mode with a macro lens (EF 100mm f/2.8 Canon),
without optical zoom, from 150 cm distance.
The patients were instructed about the natural head
position and seated on a chair. The chair height was
adjusted to match the patient’s eyes with the camera.
The eyes had to be open, and the patients were asked
to look straight into their eyes in a mirror.15
Next, Adobe Photoshop CC software program
(version 19; San Jose, Calif) was used to modify each
original photograph to create 7 photographs with 6, 4,
2, 0,
2,
4, and
6 mm gingival display.21
The intraoral photograph of the teeth was superim-
posed on the extraoral photograph of the lip frame,
and then different gingival displays were created by
moving the intraoral photograph upward and down-
ward, as described by Tosun and Kaya.27
For the measurement of gingival display, the photo-
graphs were calibrated. For this purpose, the ratio of the
physical incisogingival length of the right central incisor
in millimeters to its length in the original intraoral
photograph in pixels was calculated.27
Considering the possible magnification when printing
the photographs, all final images were cropped such that
they all measured 15 3 10 cm and were printed on
June 2023  Vol 163  Issue 6
768
photographic paper with similar dimensions (15 3 10 cm
or 6 3 4 in).28 A total of 42 photographs with different
gingival displays were created as such (Figs, A-F),
randomly placed in a photograph album (one photograph
on each page), and administered among 3 groups of raters
including 40 lay people, 40 oral and maxillofacial sur-
geons, and 40 orthodontists. The raters were also provided
with a checklist and were asked to rate the attractiveness of
each smile image separately using a 5-point visual analog
scale (VAS).29 A score of 1 indicated minimum smile
attractiveness, whereas a score of 5 indicated maximum
smile attractiveness. The checklist included a thorough
explanation regarding the observation of photographs
and instructions on how to score the smiles on the basis
of their level of attractiveness. Moreover, it should be
mentioned that only the researcher was aware of the order
of images in each photograph album. The raters were re-
quested not to go back for the comparison of photo-
graphs. All raters scored the photographs in 1 session
(3-4 minutes) in a well-lit room.
The inclusion criteria for the laypeople were aged
18-35 years, Iranian ethnicity, no psychological condi-
tion, and no visual impairment. The laypeople were
selected among those sitting in the waiting area at a
local airport who had not received orthodontic treat-
ment. The selection was performed by convenience
sampling. An equal number of males and females
were recruited to achieve a more representative sample.
Oral and maxillofacial surgeons and orthodontists were
all university faculty members and had a minimum of 5
years of clinical experience. Subjects were selected by
snowball sampling. Snowball sampling is a nonprob-
ability sampling technique in which the recruited par-
ticipants introduce future participants to recruit in
the study among their social network. In this study,
we asked the selected surgeons and orthodontists to
introduce their colleagues to the approach and invited
them to participate.
Ten raters were randomly selected from each group
and were requested to rate the images again after a 2-
week interval to calculate the intrarater reliability. The
intraclass correlation coefficient was then calculated
and interpreted according to Cicchetti’s classifica-
tion.30
Statistical analysis
Data analysis was conducted using Stata (version
14.2; StataCorp, College Station, Tex). The mean values
and standard deviations of the groups were compared
using a 1-way analysis of variance, and the Bonferroni
test performed pairwise comparisons. P \0.05 was
considered statistically significant.
June 2023  Vol 163  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Imani et al
RESULTS
Table I presents the intraclass correlation coefficient
values for the intrarater reliability of the raters. The
lowest total intraclass correlation coefficient was 0.966
and 0.822 for intrarater reliability, respectively, which
were considered excellent according to Cicchetti’s classi-
fication.30 No significant difference was found regarding
the opinion of male and female raters about smile
attractiveness (P .0.05). The opinion of raters with a
university education and those with a high-school
diploma or lower level of education was not significantly
different regarding smile attractiveness (P .0.05).
Table II presents the mean score of each photograph
allocated by the 3 rater groups. Table III presents pair-
wise comparisons of the rater groups regarding the
attractiveness of different values of gingival display.
Table IV presents pairwise comparisons of gingival
display values on the basis of different skeletal patterns
from the perspective of each rater group using the Bon-
ferroni test.
Normal-face female model
A significant difference existed in the opinion of the 3
rater groups for all values of gingival display except for 2
mm (Table III). All 3 rater groups gave a maximum score
of 2 mm gingival display. Photographs with
6,
4, and

2 mm gingival display were more attractive to
laypeople than the other 2 rater groups. The photo-
graphs with 0 and 2 mm gingival display were more
attractive to surgeons than the other rater groups. The
photographs with 4 and 6 mm gingival display were
more popular among orthodontists. The laypeople
gave the maximum score to the photograph with a 2
mm gingival display and the minimum score to a 6
mm gingival display. Orthodontists gave the maximum
score to the photograph with a 2 mm gingival display
and the minimum score to the photograph with a
6
mm gingival display (Table II).
Normal-face male model
No significant difference existed between the opinion
of the 3 rater groups for the photographs with a
6,
4,
4, and 6 mm gingival display, but significant differences
were found for other values (Table III). All 3 rater groups
gave the maximum score of 0 mm gingival display. The
photographs with a
6 and
2 mm gingival display ac-
quired higher scores among laypeople than the other 2
rater groups. The photograph with a
4 gingival display
acquired the same score from the laypeople and sur-
geons. The photograph with a 0 mm gingival display ac-
quired a higher score in the group of surgeons than the
other 2 groups. The photographs with a 2, 4, and 6 mm
Imani et al 769

Fig. Final photographs: A, Female model with a normal skeletal pattern; B, Male model with a normal
skeletal pattern; C, Female long-faced model; D, Male long-faced model; E, Female short-faced model;
and F, male short-faced model.

American Journal of Orthodontics and Dentofacial Orthopedics June 2023  Vol 163  Issue 6
770 Imani et al

Table I. Intraclass correlation coefficients (ICC) for intrarater reliability of the raters
Normal skeletal pattern Long-faced Short-faced

Female Male Female Male Female Male

Gingival display Raters ICC P value ICC P value ICC P value ICC P value ICC P value ICC P value

6 Laypeople 0.883 \0.001 0.882 \0.001 0.800 0.002 0.948 \0.001 0.940 \0.001 0.943 \0.001
Maxillofacial surgeons 1.000 \0.001 0.899 \0.001 0.947 \0.001 1.000 \0.001 0.840 0.001 0.930 \0.001
Orthodontists 0.800 \0.001 0.800 0.017 0.963 \0.001 0.816 0.001 0.870 \0.001 1.000 \0.001
Total 0.948 \0.001 0.884 \0.001 0.941 \0.001 0.942 \0.001 0.923 \0.001 0.946 \0.001

4 Laypeople 1.000 \0.001 0.968 \0.001 0.938 \0.001 0.892 \0.001 1.000 \0.001 0.800 0.002
Maxillofacial surgeons 0.910 \0.001 0.918 \0.001 0.917 \0.001 0.844 0.001 0.967 \0.001 1.000 \0.001
Orthodontists 0.962 \0.001 0.800 0.002 1.000 \0.001 1.000 \0.001 0.862 \0.001 1.000 \0.001
Total 0.956 \0.001 0.910 \0.001 0.947 \0.001 0.908 \0.001 0.966 \0.001 0.898 \0.001

2 Laypeople 0.941 \0.001 0.861 \0.001 0.816 0.001 0.965 \0.001 0.930 \0.001 0.959 \0.001
Maxillofacial surgeons 0.930 \0.001 0.957 \0.001 0.944 \0.001 0.912 \0.001 0.899 \0.001 1.000 \0.001
Orthodontists 0.800 0.002 0.870 \0.001 0.911 \0.001 0.914 \0.001 0.756 0.008 0.818 0.001
Total 0.920 \0.001 0.916 \0.001 0.901 \0.001 0.921 \0.001 0.924 \0.001 0.945 \0.001
0 Laypeople 0.900 \0.001 0.896 \0.001 0.891 \0.001 0.888 \0.001 0.837 0.001 0.939 \0.001
Maxillofacial surgeons 0.947 \0.001 0.775 0.003 0.899 \0.001 0.897 \0.001 0.778 0.002 1.000 \0.001
Orthodontists 0.859 \0.001 0.814 0.001 0.806 \0.001 0.968 \0.001 0.832 0.001 0.966 \0.001
Total 0.903 \0.001 0.889 \0.001 0.877 \0.001 0.937 \0.001 0.822 \0.001 0.959 \0.001
2 Laypeople 0.920 \0.001 0.934 \0.001 0.953 \0.001 0.824 0.001 0.930 \0.001 0.828 0.001
Maxillofacial surgeons 0.956 \0.001 0.815 0.001 0.828 0.001 0.917 \0.001 0.877 \0.001 1.000 \0.001
Orthodontists 0.959 0.002 0.945 \0.001 0.944 \0.001 0.899 \0.001 0.947 \0.001 1.000 \0.001
Total 0.947 \0.001 0.925 \0.001 0.917 \0.001 0.894 \0.001 0.931 \0.001 0.948 \0.001
4 Laypeople 0.752 0.004 0.947 \0.001 1.000 \0.001 0.959 \0.001 0.887 \0.001 0.952 \0.001
Maxillofacial surgeons 0.847 0.001 0.917 \0.001 0.929 \0.001 0.898 \0.001 0.775 0.003 0.859 \0.001
Orthodontists 0.761 0.003 1.000 \0.001 0.816 0.001 1.000 \0.001 0.892 \0.001 0.882 \0.001
Total 0.929 \0.001 0.963 \0.001 0.948 \0.001 0.938 \0.001 0.873 \0.001 0.907 \0.001
6 Laypeople 0.954 \0.001 0.933 \0.001 0.938 \0.001 1.000 \0.001 0.875 \0.001 0.836 0.001
Maxillofacial surgeons 0.934 \0.001 0.862 0.074 0.940 \0.001 0.899 \0.001 0.878 \0.001 0.873 \0.001
Orthodontists 0.796 0.002 0.875 \0.001 0.800 0.030 0.815 0.001 0.933 \0.001 1.000 \0.001
Total 0.934 \0.001 0.910 \0.001 0.922 \0.001 0.897 \0.001 0.902 \0.001 0.881 \0.001

gingival display acquired higher scores in the group of
orthodontists.
Laypeople gave the maximum score of 0 and the min-
imum score of 6 mm gingival display. Surgeons gave the
maximum and minimum scores of 0 and 6 mm gingival
display, respectively. Orthodontists gave the maximum
and minimum scores of 0 and
6 mm gingival display,
respectively (Table II).
Long-faced female model
No significant difference existed between the opinion
of the 3 rater groups for the photographs with 0, 14,
and 16 mm gingival display, but significant differences
were found for other values (Table III). Laypeople gave
the highest score to
2 mm gingival display, whereas
surgeons and orthodontists gave the highest score to
0 gingival display. The photographs with
6,
4, and

2 mm gingival display acquired a higher score among
the laypeople than the other 2 rater groups. The photo-
graphs with 0, 2, 4, and 6 mm gingival display acquired a
higher score in the orthodontist’s group than in the other
2 rater groups. Laypeople gave the maximum and min-
imum scores to
2 and 6 mm gingival display, respec-
tively. The surgeons and the orthodontists gave the
maximum and minimum scores of 0 and 6 mm gingival
display, respectively (Table II).
Long-faced male model
No significant difference existed between the opinion
of the 3 rater groups for the photographs with 0, 2, 4,
and 6 mm gingival display, but significant differences
were found for other values (Table II). Laypeople gave
the highest score to
2 mm gingival display, whereas
surgeons and orthodontists gave the highest score of
0 mm. The photographs with
6,
4, and
2 mm
gingival display acquired a higher score among the
laypeople than the other 2 rater groups. The photograph
with a 0 mm gingival display acquired a higher score
among surgeons. The photograph with a 2 mm gingival
display acquired an equal score among surgeons and
laypeople. In addition, the photograph with a 4 mm
gingival display acquired the same score among all

June 2023  Vol 163  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Imani et al 771

Table II. Mean score of each photograph allocated by the 3 rater groups
Gingival display Laypeople Surgeons Orthodontists Total Fy P value*
Normal skeletal pattern
Female

6 2.20 6 1.01 1.92 6 0.73 1.52 6 0.55 1.88 6 0.83 7.37 0.001

4 2.92 6 1.14 2.82 6 0.93 2.37 6 0.98 2.71 6 1.04 3.29 0.0406

2 3.65 6 1.12 3.15 6 0.80 2.92 6 0.91 3.24 6 0.99 6.02 0.0032
0 3.60 6 1.19 3.72 6 0.98 3.15 6 1.13 3.48 6 1.13 3.26 0.0420
2 3.85 6 1.23 4.00 6 0.93 3.97 6 1.00 3.94 6 1.05 0.23 0.7958
4 2.65 6 1.07 3.02 6 1.07 3.35 6 1.05 3.00 6 1.09 4.31 0.0156
6 1.57 6 1.05 1.85 6 0.80 2.6 6 0.93 2.00 6 1.02 12.85 \0.0001
F 34.54 45.56 34.72
P value \0.0001 \0.0001 \0.0001
Male

6 1.56 6 0.96 1.52 6 0.60 1.32 6 0.47 1.47 6 0.71 1.30 0.2766

4 2.17 6 1.10 2.17 6 0.84 1.82 6 0.78 2.05 6 0.93 1.92 0.1506

2 3.37 6 1.33 3.02 6 1.05 2.70 6 0.91 3.03 6 1.13 3.68 0.0281
0 3.67 6 1.26 4.22 6 0.66 4.20 6 0.72 4.03 6 0.95 4.51 0.0130
2 2.82 6 0.81 3.32 6 0.82 3.57 6 0.90 3.24 6 0.90 8.09 0.0005
4 2.77 6 1.64 2.5 6 0.96 2.72 6 1.10 2.66 6 1.26 0.53 0.5891
6 1.37 6 0.89 1.17 6 0.38 1.45 6 0.81 1.33 6 0.73 1.50 0.2274
F 28.05 79.89 75.71
P value \0.0001 \0.0001 \0.0001
Long-faced
Female

6 3.00 6 1.10 2.07 6 0.76 2.12 6 0.96 2.40 6 1.04 11.82 \0.0001

4 3.27 6 1.10 2.75 6 0.74 2.47 6 0.81 2.83 6 0.95 8.10 0.0005

2 4.17 6 0.81 3.50 6 0.90 3.12 6 0.88 3.60 6 0.96 15.03 \0.0001
0 3.65 6 1.14 3.67 6 1.02 3.87 6 3.94 3.73 6 1.03 0.56 0.5706
2 2.87 6 1.21 3.07 6 1.16 3.57 6 1.23 3.17 6 1.23 3.57 0.0314
4 1.82 6 0.95 2.10 6 0.90 2.20 6 0.94 2.04 6 0.93 1.73 0.1811
6 1.50 6 0.84 1.85 6 0.83 1.92 6 0.94 1.75 6 0.88 2.68 0.0728
F 52.08 30.25 34.98
P value \0.0001 \0.0001 \0.0001
Male

6 2.62 6 1.19 1.70 6 0.72 1.62 6 0.58 1.98 6 0.98 16.28 \0.0001

4 2.92 6 1.14 2.47 6 0.87 2.17 6 0.87 2.52 6 1.01 6.03 0.0032

2 3.87 6 1.04 3.07 6 0.86 2.87 6 0.96 3.27 6 1.04 12.19 \0.0001
0 3.30 6 1.11 3.70 6 1.01 3.27 6 1.26 3.42 6 1.14 1.77 0.1756
2 3.40 6 1.00 3.40 6 1.12 3.17 6 0.95 3.32 6 1.03 0.63 0.5334
4 2.40 6 0.87 2.42 6 0.95 2.42 6 0.98 2.41 6 0.93 0.01 0.9906
6 1.42 6 0.87 1.40 6 0.54 1.67 6 0.94 1.50 6 0.77 1.54 0.2181
F 37.17 48.72 27.44
P value \0.0001 \0.0001 \0.0001
Short-faced
Female

6 2.42 6 1.15 2.00 6 0.60 1.77 6 0.73 2.06 6 0.89 5.88 0.0037

4 2.97 6 1.09 2.92 6 0.97 2.42 6 0.84 2.77 6 1.00 3.88 0.0233

2 3.52 6 1.19 3.72 6 0.96 3.22 6 1.02 3.49 6 1.07 2.23 0.1121
0 4.30 6 0.91 4.07 6 0.91 4.37 6 0.74 4.25 6 0.86 1.32 0.2716
2 3.42 6 1.21 3.22 6 1.27 3.82 6 1.23 3.49 6 1.25 2.42 0.0934
4 2.20 6 1.01 2.57 6 1.15 2.97 6 1.09 2.58 6 1.12 5.05 0.0079
6 1.72 6 1.01 1.80 6 0.85 2.20 6 1.09 1.90 6 1.00 2.66 0.0743
F 39.89 37.51 48.36
P value \0.0001 \0.0001 \0.0001
Male

6 1.60 6 0.81 1.42 6 0.59 1.27 6 0.55 1.43 6 0.67 2.41 0.0941

4 2.05 6 1.03 1.80 6 0.64 1.50 6 0.68 1.78 6 0.83 4.65 0.0114

2 3.07 6 1.24 3.12 6 0.91 2.75 6 0.90 3.00 6 1.03 1.56 0.2152
0 3.95 6 1.13 3.95 6 0.84 3.92 6 0.88 3.94 6 0.95 0.01 0.9911

American Journal of Orthodontics and Dentofacial Orthopedics June 2023  Vol 163  Issue 6
772 Imani et al

Table II. Continued

Gingival display Laypeople Surgeons Orthodontists Total Fy P value*

2 4.12 6 0.96 3.77 6 0.92 4.12 6 0.91 4.00 6 0.94 1.88 0.1574
4 2.40 6 1.25 2.57 6 0.98 2.72 6 1.01 2.56 6 1.09 0.89 0.4140
6 1.75 6 0.80 1.6 6 0.63 1.85 6 0.92 1.73 6 0.79 1.00 0.3715
F 66.65 82.14 99.56
P value \0.0001 \0.0001 \0.0001

y
One-way analysis of variance; *P \0.05 was considered statistically significant.

Table III. Pairwise comparisons of the rater groups regarding the attractiveness of different values of gingival display
Normal skeletal pattern Long-faced Short-faced

Female Male Female Male Female Male

Gingival LP vs LP vs O vs LP vs LP vs O vs LP vs LP vs O vs LP vs LP vs O vs LP vs LP vs O vs LP vs LP vs O vs
display S O S S O S S O S S O S S O S S O S

6 0.368 0.001 0.077 1.000 0.410 0.629 0.000 0.000 1.000 0.000 0.000 1.000 0.088 0.003 0.735 0.72 0.091 0.940

4 1.000 0.053 0.153 1.000 0.276 0.276 0.032 0.000 0.528 0.122 0.002 0.510 1.000 0.039 0.071 0.507 0.009 0.298

2 0.063 0.003 0.884 0.486 0.023 0.582 0.002 0.000 0.167 0.001 0.000 1.000 1.000 0.632 0.114 1.000 0.485 0.321
0 1.000 0.174 0.051 0.027 0.037 1.000 1.000 1.000 1.000 0.353 1.000 0.290 0.733 1.000 0.364 1.000 1.000 1.000
2 1.000 1.000 1.000 0.029 0.000 0.571 1.000 0.033 0.199 1.000 0.997 0.997 1.000 0.458 0.098 0.288 1.000 0.288
4 0.356 0.012 0.527 1.000 1.000 1.000 0.57 0.224 1.000 1.000 1.000 1.000 0.380 0.006 0.311 1.000 0.557 1.000
6 0.574 0.000 0.000 0.677 1.000 0.290 0.23 0.096 1.000 1.000 0.454 0.345 1.000 0.102 0.220 1.000 1.000 0.489

Note. Pairwise comparisons were carried out using the Bonferroni test. P \0.05 was considered statistically significant.
LP, laypeople; S, surgeons; O, orthodontists.

raters. The photograph with a 6 mm gingival display ac-
quired a higher score among orthodontists than the
other 2 rater groups.
Laypeople gave the maximum and minimum scores
to
2 and 6 mm gingival display, respectively. The sur-
geons gave the maximum and minimum scores of 0 and
6 mm gingival display, respectively, whereas the ortho-
dontists gave the maximum and minimum scores of
0 and
6 mm, respectively (Table II).
Short-faced female model
No significant difference existed between the opinion
of the 3 rater groups for the photographs with
2, 0, 2,
and 6 gingival display, but significant differences were
found for other values (Table II). All 3 rater groups
gave the highest score to the photograph with a 0 mm
gingival display. The photographs with
6 and
4
mm gingival display acquired a higher score among
laypeople than the other 2 rater groups. The photograph
with a
2 mm gingival display acquired a higher score
among the surgeons, whereas photographs with 0, 2,
4, and 6 mm gingival display acquired a higher score
among orthodontists than the other 2 rater groups.
Laypeople and surgeons gave the maximum and
minimum scores of 0 and 6 mm gingival display,
respectively, whereas the orthodontists gave the
maximum and minimum scores of 0 and
6 mm,
respectively (Table II).
Short-faced male model
No significant difference existed between the opinion
of the 3 rater groups for all photographs except for a
4
mm gingival display (Table II). Laypeople and orthodon-
tists gave a higher score to the photograph with a 2 mm
gingival display, whereas surgeons gave a higher score to
the photograph with a 0 mm gingival display. The pho-
tographs with
6 and
4 mm gingival display acquired
a higher score among laypeople than the other 2 rater
groups. The photograph with a 0 mm gingival display
acquired an equal score in all 3 rater groups. The photo-
graph with a
2 mm gingival display acquired a higher
score among surgeons than the other 2 groups. Photo-
graphs with a 2 mm gingival display acquired equal
scores among laypeople and orthodontists. In addition,
the photographs with 4 and 6 mm gingival display ac-
quired a higher score among orthodontists than the
other 2 rater groups.
Laypeople gave the maximum and minimum scores
to 2 and
6 mm gingival display, respectively. The sur-
geons gave the maximum and minimum scores of 0 and

June 2023  Vol 163  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
 American Journal of Orthodontics and Dentofacial Orthopedics

Imani et al
Table IV. Pairwise comparisons of gingival display values based on different skeletal patterns from the perspective of each rater group (with least significant
difference adjustment)
Normal skeletal pattern Long-faced Short-faced

Female Male Female Male Female Male

Gingival display LP S O LP S O LP S O LP S O LP S O LP S O

6 and
4 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.002 0.125 0.023 \0.001 \0.001 \0.001 \0.001 0.215 0.001 \0.001 \0.001

6 and
2 0.169 0.365 \0.001 0.643 \0.001 \0.001 0.041 \0.001 \0.001 0.534 0.160 0.606 \0.001 0.133 0.018 0.056 \0.001 \0.001

6 and 0 \0.001 \0.001 0.317 0.092 0.146 \0.001 \0.001 \0.001 0.004 0.001 \0.001 0.037 0.254 0.012 \0.001 0.001 \0.001 \0.001

6 and 2 \0.001 \0.001 \0.001 0.001 \0.001 \0.001 0.116 \0.001 0.033 \0.001 \0.001 \0.001 0.006 \0.001 \0.001 \0.001 \0.001 \0.001

6 and 4 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.001 \0.001 0.001 0.021 0.895

6 and 6 \0.001 0.010 0.002 0.036 0.037 0.907 0.036 0.195 \0.001 0.002 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001

4 and
2 \0.001 0.001 0.323 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.009 \0.001 \0.001 \0.001 \0.001 \0.001 0.076 0.160 0.029

4 and 0 \0.001 \0.001 0.047 \0.001 \0.001 \0.001 0.005 0.096 0.014 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.295 0.255 0.002

4 and 2 0.200 0.117 \0.001 \0.001 \0.001 \0.001 \0.001 0.891 0.696 0.012 0.812 0.193 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001

4 and 4 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.018 0.691 0.067 0.013 \0.001 \0.001 \0.001

4 and 6 0.800 \0.001 0.253 0.264 \0.001 \0.001 \0.001 \0.001 \0.001 0.063 \0.001 \0.001 \0.001 0.046 \0.001 \0.001 \0.001 \0.001

2 and 0 \0.001 \0.001 \0.001 0.005 \0.001 \0.001 \0.001 \0.001 \0.001 0.006 0.074 0.070 0.003 \0.001 \0.001 0.002 0.001 0.037

2 and 2 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.004 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.305 \0.001 \0.001 \0.001

2 and 4 0.037 \0.001 \0.001 \0.001 \0.001 \0.001 0.001 0.413 \0.001 \0.001 \0.001 \0.001 0.060 0.283 \0.001 \0.001 \0.001 \0.001

2 and 6 \0.001 0.536 0.042 0.026 0.194 \0.001 \0.001 0.001 0.110 0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001
0 and 2 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.221 0.338 \0.001 0.003 0.018 0.001 0.253 0.025 \0.001 \0.001 \0.001
0 and 4 0.004 0.660 \0.001 \0.001 \0.001 0.050 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001
0 and 6 \0.001 \0.001 0.113 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001
2 and 4 \0.001 \0.001 \0.001 0.109 \0.001 0.418 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001
June 2023  Vol 163  Issue 6

2 and 6 0.338 \0.001 \0.001 \0.001 \0.001 \0.001 0.482 \0.001 \0.001 0.311 \0.001 \0.001 \0.001 \0.001 \0.001 0.280 0.227 0.103
4 and 6 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 \0.001 0.078 0.032 \0.001 0.044 0.800 \0.001 \0.001 0.002 \0.001 0.001 \0.001

Note. Pairwise comparisons were carried out using the Bonferroni test. P \0.05 was considered statistically significant.
LP, laypeople; S, surgeons; O, orthodontists.

773
774

6 mm gingival display, respectively, whereas the ortho-
dontists gave the maximum and minimum scores of 2
and
6 mm, respectively (Table II).
DISCUSSION
Many Iranian adults seek orthodontic treatment in
different parts of the world. Thus, it is important to
find their cephalometric norms.31 Evidence shows the
presence of some differences in these norms. For
example, Iranians have a more convex profile.31 Iranian
laypeople also prefer a profile slightly more convex than
the Caucasian norms, especially for women.32 This study
determined the optimal gingival display of a smiling
view on the basis of different facial vertical patterns
from the perspective of laypeople, maxillofacial sur-
geons, and orthodontists. A 5-point VAS as a Likert-
based scale was used in the present study. Psychosocial
exposures often exhibit extensive variations over time
and are usually evaluated by multi-item Likert indexes
(5-point) or a 10-point single VAS. In general, no
conclusive evidence exists supporting the statistical su-
periority of either VAS or Likert-based scales over each
other.33 A previous study indicated that the response
behavior of VAS and Likert scales was the same.34 Both
Likert scales and VAS have shown strong comparable
correlations with physiological markers.35,36 However,
researchers who prefer Likert scales claim that they are
easier to use by the administration and the respondent.34
Normal-faced subjects
Regarding the photographs of normal-faced males
and females, a 2 mm gingival display in the female
model and 0 mm in the male model acquired the highest
score from all rater groups. Najafi et al37 evaluated the
effect of buccal corridor size and gingival-tooth display
on smile attractiveness according to the opinion of 2
groups of university students. Complete maxillary cen-
tral incisor display with a 0 mm gingival display acquired
the maximum score among 9 smile images from dental
students. This result was in line with our findings
regarding 0 mm gingival display in our male model
with a normal skeletal pattern, which acquired the
maximum score from all 3 rater groups. However, med-
ical students gave a maximum score to the photograph
with a 2 mm gingival display, which was in line with
our findings in our female model with a normal skeletal
pattern. Sriphadungporn and Chamnannidiadha,38 in
their study in Bangkok, compared the opinion of raters
from 2 age groups of 15-29 years and 36-52 years using
a VAS. They gave the maximum score to smiles with 2
and 0 mm gingival display, which agreed with the
opinion of all 3 rater groups in our study. De Lima
June 2023  Vol 163  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Imani et al
et al21 evaluated the effect of facial patterns on smile
attractiveness and different levels of gingival display
from the perspective of dentists and laypeople. In normal
facial profiles, they found a significant difference be-
tween the opinion of laypeople and dentists in 4, 5,
and 6 mm gingival display, such that laypeople gave
the same score to different levels of gingival display,
which was different from our findings. Dentists gave a
higher score to 2, 3, and 4 mm gingival display, which
was close to our findings.
Long-faced subjects
In long-faced male and female models in our study,
laypeople and orthodontists gave the same score to
long-faced male and female models, whereas the opinion
of surgeons was different regarding long-faced males
and females, and they preferred greater tooth display.
In the study by Sriphadungporn and Chamnanni-
diadha,38 the younger rater group gave the maximum
score to 0 and 2 mm gingival display. This result was
only in line with the opinion of our surgeons regarding
the long-faced female model in our study with a 0 mm
gingival display. In contrast, the younger rater group in
their study gave the minimum score of
4 and 6 mm
gingival display, whereas, in our study, a
6 mm gingival
display was the least attractive according to the opinion
of all rater groups. Another study39 conducted in Tehran
evaluated the opinion of medical and dental students
regarding the effect of gingival display on smile attrac-
tiveness. Both rater groups gave the maximum score of
2 mm gingival display, which was different from our find-
ings. De Lima et al21 evaluated the effect of gingival
display in different facial patterns on smile attractiveness
according to the opinion of dentists and laypeople. They
reported a significant difference in 0, 4, 5, and 6 mm
gingival display such that dentists gave the maximum
score to 0 mm gingival display, which was the same as
the opinion of surgeons and orthodontists in our study.
In contrast, laypeople in their study gave the same score
to all photographs, which was different from the opinion
of laypeople in our study.
Short-faced subjects
Regarding the short-faced male model in our study,
Laypeople and orthodontists gave the maximum and min-
imum scores of 2 and
6 mm gingival display, respec-
tively. The surgeons gave the maximum and minimum
scores to 0 and
6 mm gingival display, respectively.
Thus, the opinion of laypeople and orthodontists were
the same regarding the most and the least attractive smile
of our short-faced male model. In addition, the opinion of
all 3 rater groups was the same regarding the least
Imani et al
attractive smile of our short-faced male model (
6 mm).
In total, regarding short-faced subjects, it appears that
smaller gingival display in short-faced females and greater
gingival display in short-faced males were more attractive
among the rater groups. Our results in this respect were in
agreement with those of Sriphadungporn and Chamnan-
nidiadha38 and Najafi et al.37
These results indicated that 0-2 mm of gingival
display in normal-faced models was the most attractive
to all raters;
2 mm of gingival display was the most
attractive for the long-faced, and 0-2 mm of gingival
display was the most attractive for the short-faced model
according to the opinion of all raters. Laypeople believed
that maximum gingival display was less attractive for
normal-faced males and females, female short-faced
models, and male long-faced models, whereas ortho-
dontists believed that minimum gingival display was
less attractive for the abovementioned models. However,
all raters believed that minimum gingival display was the
least attractive for long-faced and short-faced males.
Evaluation of only 1 male and 1 female model with
each of the 3 facial patterns was a limitation of this
study. In addition, other facial components may affect
the judgment of raters regarding smile attractiveness.
Future studies are required to assess the effect of lip
length on smile attractiveness in males and females.
Furthermore, the optimal gingival display should be
evaluated with different facial skeletal patterns in a
larger sample size.
CONCLUSIONS
Significant differences existed in the opinion of the
rater groups regarding the most and the least attractive
smile concerning gingival display in our male and female
models with normal skeletal facial patterns; 0-2 mm of
gingival display in normal-faced models was the most
attractive to all raters. Laypeople believed that maximum
gingival display was less attractive for normal-faced
males and females, whereas orthodontists believed that
minimum gingival display was less attractive for this
group. For the female model with a normal skeletal
pattern, the most attractive gingival display was 12,
and the least attractive was
6.
A significant difference existed in the opinion of the 3
rater groups regarding the most and the least attractive
smile concerning gingival display in our long-faced male
and female models. The laypeople preferred a
2 mm
gingival display in male and female models. The sur-
geons and orthodontists preferred a 0 mm gingival
display for female and male models. However,
2 mm
gingival display was the most attractive to all raters for
the long-faced model. Laypeople believed that
American Journal of Orthodontics and Dentofacial Orthopedics
775
maximum gingival display was less attractive for male
long-faced models, whereas orthodontists believed
that minimum gingival display was less attractive for
this group. All raters believed that minimum gingival
display was the least attractive for long-faced males.
No significant difference existed in the opinion of the
3 rater groups regarding the most and the least attractive
smile concerning gingival display in our short-faced male
and female models, and smaller gingival display in fe-
males and greater gingival display in males were
preferred. In addition, according to the opinion of all
raters, 0-2 mm of gingival display was the most attractive
for the short-faced model. The laypeople, maxillofacial
surgeons, and orthodontists all gave the highest score
to the photograph of a short-faced female model with
0 gingival display. Laypeople believed that maximum
gingival display was less attractive for a female short-
faced model, whereas orthodontists believed that mini-
mum gingival display was less attractive for this group.
However, all raters believed that minimum gingival
display was the least attractive for short-faced males.
AUTHOR CREDIT STATEMENT
Mohammad Moslem Imani contributed to conceptu-
alization, methodology, validation, and supervision; Eh-
san Mohamadi Nezhad contributed to investigation,
data curation, and validation; Amin Golshah contributed
to conceptualization, original draft preparation, meth-
odology supervision, and manuscript review and editing;
Roya Safari-Faramani contributed to manuscript review
and editing and formal analysis.
REFERENCES
1. Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofa-
cial appearance on the social attractiveness of young adults. Am J
Orthod 1985;87:21-6.
2. Rodr
ıguez-Mart
ınez A, Vicente-Hern
andez A, Bravo-Gonz
alez LA.
Effect of posterior gingival smile on the perception of smile es-
thetics. Med Oral Patol Oral Cir Bucal 2014;19:e82-7.
3. Giddon DB. Orthodontic applications of psychological and percep-
tual studies of facial esthetics. Semin Orthod 1995;1:82-93.
4. Kiyak HA. Does orthodontic treatment affect patients’ quality of
life? J Dent Educ 2008;72:886-94.
5. Sarver DM. The importance of incisor positioning in the esthetic
smile: the smile arc. Am J Orthod Dentofacial Orthop 2001;120:
98-111.
6. Sharma PK, Sharma P. Dental smile esthetics: the assessment and
creation of the ideal smile. Semin Orthod 2012;18:193-201.
7. Abu Alhaija ES, Al-Shamsi NO, Al-Khateeb S. Perceptions of Jorda-
nian laypersons and dental professionals to altered smile aes-
thetics. Eur J Orthod 2011;33:450-6.
8. Ker AJ, Chan R, Fields HW, Beck M, Rosenstiel S. Esthetics and
smile characteristics from the layperson’s perspective: a
computer-based survey study. J Am Dent Assoc 2008;139:
1318-27.
June 2023  Vol 163  Issue 6
776
9. Van der Geld P, Oosterveld P, Van Heck G, Kuijpers-Jagtman AM.
Smile attractiveness. Self-perception and influence on personality.
Angle Orthod 2007;77:759-65.
10. Geron S, Atalia W. Influence of sex on the perception of oral and
smile esthetics with different gingival display and incisal plane
inclination. Angle Orthod 2005;75:778-84.
11. Suzuki L, Machado AW, Bittencourt MA. An evaluation of the in-
fluence of gingival display level in the smile esthetics. Dent Press J
Orthod 2011;16:37-9.
12. Krajicek DD. Simulation of natural appearance. J Prosthet Dent
1962;12:28-33.
13. Nimbalkar S, Oh YY, Mok RY, Tioh JY, Yew KJ, Patil PG. Smile
attractiveness related to buccal corridor space in 3 different facial
types: a perception of 3 ethnic groups of Malaysians. J Prosthet
Dent 2018;120:252-6.
14. Batwa W. The influence of the smile on the perceived facial type
esthetics. BioMed Res Int 2018;2018:3562916.
15. Demir R, Baysal A. Three-dimensional evaluation of smile charac-
teristics in subjects with increased vertical facial dimensions. Am J
Orthod Dentofacial Orthop 2020;157:773-82.
16. Krishnan V, Daniel ST, Lazar D, Asok A. Characterization of posed
smile by using visual analog scale, smile arc, buccal corridor mea-
sures, and modified smile index. Am J Orthod Dentofacial Orthop
2008;133:515-23.
17. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception of
dentists and lay people to altered dental esthetics. J Esthet Dent
1999;11:311-24.
18. Roden-Johnson D, Gallerano R, English J. The effects of buccal
corridor spaces and arch form on smile esthetics. Am J Orthod Den-
tofacial Orthop 2005;127:343-50.
19. Helm S, Kreiborg S, Solow B. Psychosocial implications of maloc-
clusion: a 15-year follow-up study in 30-year-old Danes. Am J Or-
thod 1985;87:110-8.
20. Ahmed M, Shaikh A, Fida M. Diagnostic performance of various
cephalometric parameters for the assessment of vertical growth
pattern. Dental Press J Orthod 2016;21:41-9.
21. Lima APB, Conti ACCF, Filho LC, Cardoso MA, Almeida-Pedrin RR.
Influence of facial pattern in smile attractiveness regarding
gingival exposure assessed by dentists and laypersons. Am J Or-
thod Dentofacial Orthop 2019;155:224-33.
22. Imani MM, Hosseini SA, Arab S, Delavarian M. Characterization of
soft tissue cephalometric norms of Kurdish population of Iran. J
Res Med Dent Sci 2018;6:335-42.
23. Siddiqui N, Tandon P, Singh A, Haryani J. Dynamic smile evalua-
tion in different skeletal patterns. Angle Orthod 2016;86:1019-25.
24. Berlin NF, Berssenbr€ ugge P, Runte C, Wermker K, Jung S,
Kleinheinz J, et al. Quantification of facial asymmetry by 2D anal-
ysis - a comparison of recent approaches. J Craniomaxillofac Surg
2014;42:265-71.
June 2023  Vol 163  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Imani et al
25. Jayalakshmi NS, Ravindra S, Nagaraj KR, Rupesh PL,
Harshavardhan MP. Acceptable deviation between facial and
dental midlines in dentate population. J Indian Prosthodont Soc
2013;13:473-7.
26. Hassan DA, Ghaib NH. The reliability of bisecting interpupillary
perpendicular line, facial and dental laterality and coincidence in
adult normal occlusion Iraqi sample (a photographic, cross sectional
study). J Baghdad Coll Dent 2012;24(special issue 1):94-8.
27. Tosun H, Kaya B. Effect of maxillary incisors, lower lip, and
gingival display relationship on smile attractiveness. Am J Orthod
Dentofacial Orthop 2020;157:340-7.
28. Golshah A, Serenjianeh AM, Imani MM. Smile attractiveness of
Persian women after orthodontic treatment. Am J Orthod Dento-
facial Orthop 2020;158:75-83.
29. Al Taki A, Khalesi M, Shagmani M, Yahia I, Al Kaddah F. Percep-
tions of altered smile esthetics: a comparative evaluation in ortho-
dontists, dentists, and laypersons. Int J Dent 2016;2016:7815274.
30. Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating
normed and standardized assessment instruments in psychology.
Psychol Assess 1994;6:284-90.
31. Taki AA, Oguz F, Abuhijleh E. Facial soft tissue values in Persian
adults with normal occlusion and well-balanced faces. Angle Or-
thod 2009;79:491-4.
32. Imani MM, Sanei E, Niaki EA, Shahroudi AS. Esthetic preferences
of orthodontists, oral surgeons, and laypersons for Persian facial
profiles. Am J Orthod Dentofacial Orthop 2018;154:412-20.
33. Holmes S, Dickerson J. The quality of life: design and evaluation of
a self-assessment instrument for use with cancer patients. Int J
Nurs Stud 1987;24:15-24.
34. Hasson D, Arnetz BB. Validation and findings comparing VAS vs.
Likert scales for psychosocial measurements. Int Electron J Health
Educ 2005;8:178-92.
35. Arnetz BB. Techno-stress: a prospective psychophysiological study
of the impact of a controlled stress-reduction program in advanced
telecommunication systems design work. J Occup Environ Med
1996;38:53-65.
36. Grant S, Aitchison T, Henderson E, Christie J, Zare S, McMurray J,
et al. A comparison of the reproducibility and the sensitivity to
change of visual analogue scales, Borg scales, and Likert scales
in normal subjects during submaximal exercise. Chest 1999;116:
1208-17.
37. Najafi HZ, Oshagh M, Azizi M. Esthetic effect of the buccal corridor
size and amount of tooth-gingival display on smile attractiveness
in two student population. J Dent Med 2015;28:57-67.
38. Sriphadungporn C, Chamnannidiadha N. Perception of smile es-
thetics by laypeople of different ages. Prog Orthod 2017;18:8.
39. Chou JC, Thompson GA, Aggarwal HA, Bosio JA, Irelan JP. Effect
of occlusal vertical dimension on lip positions at smile. J Prosthet
Dent 2014;112:533-9.