Eur J Oral Sci 2004; 112: 471–476 Copyright
Eur J Oral Sci 2004

Printed in UK. All rights reserved European Journal of

Oral Sciences

Stefan Wolfart1, Holger Menzel2,

Inability to relate tooth forms to face Matthias Kern1
1
Department of Prosthodontics, Propaedeutics
shape and gender and Dental Materials, School of Dentistry,
University Hospital Schleswig-Holstein,
Campus Kiel, Kiel, Germany; 2Private Praxis,
Herrsching, Germany
Wolfart S, Menzel H, Kern M. Inability to relate tooth forms to face shape and gender.
Eur J Oral Sci 2004; 112: 471–476.
Eur J Oral Sci, 2004

This study aimed to examine whether there exists a gender-dependent correlation

between the inverted face shape and that of the upper central incisor as the literature
often suggests. Standardized portraits and anterior tooth photographs of 204 dental
students were made. Standardized enlargements of facial outlines and of the upper
right incisor outlines were traced. They were classified into three different shapes:
tapered, ovoid and square-shaped. Ten dentists determined twice – with an intervening
interval of 3 wk – the gender of the students on the basis of the anterior tooth pho- Dr Stefan Wolfart, Department of
Prosthodontics, Propaedeutics and Dental
tographs. Tooth and face shapes could be classified as tapered (25% and 27%, Materials, School of Dentistry, Christian-
respectively), ovoid (39% and 41%, respectively) or square-shaped (36% and 32%, Albrechts University, Arnold-Heller-Str. 16,
respectively). A significant correlation could be shown between face shape and gender, D-24105 Kiel, Germany
but not between tooth shape and gender. The dentists were correct about the gender of
Telefax: + 49–431–5972860
the subjects in 47 to 59% of all cases. The reproducibility of their judgments varied E-mail: swolfart@proth.uni-kiel.de
between 54% and 77%. The theory that the tooth shape should correspond to the
inverted facial shape could therefore not be confirmed. In addition it could be shown Key words: assessment; central incisor; face
shape; gender; tooth shape
that the participants were not capable of determining a subject’s gender from intraoral
photographs alone. Accepted for publication August 2004

Esthetic dentistry is becoming an increasingly important
issue for dentists and their patients (1–3). For an
attractive smile, the position (4), form and color of the
upper central incisors are the most essential factors (1). It
has already been shown that in the absence of other
information, personal judgments about strangers are
influenced by their dental appearance (5).
When parts of the upper anterior teeth have to be
restored, clues gained from the natural dentition can
be of help in achieving an individual and attractive
restoration (1, 6). However, if all teeth are missing and
no photographs or casting models document the ori-
ginal dentition, other criteria have to be used. These
criteria are not only useful for complete dentures but
also for any complex anterior restoration. Treatment
planning concerning position, form and color of the
teeth must be determined independently of the specific
restoration (7). In this context, the upper central inci-
sors are the most relevant teeth of the human dentition
and therefore the most important in terms of the
esthetic outcome (1, 6).
As for the selection of a tooth shape, Williams (8)
suggested, 90 yr ago (in 1914) that a correlation exis-
ted between the upside-down facial shape and the
shape of the upper central incisors (the so-called Ôlaw
of harmonyÕ). The dental outlines of the upper incisor
were classified into three categories: tapered, ovoid and
square-shaped. More recently, Bell (9) studied
photographs of dental casts, X-rays of central incisors
and photographs of faces. Three dentists made
subjective attempts at categorizing face and tooth
forms. Mavroskoufis & Ritchie (10) made compar-
isons by projecting the tooth form onto the tracings
of the actual face form. Not one of these investigators
reported a correlation that would have supported
the original concept of Williams (8). However,
other authors were indeed able to confirm his theory
(11–13).
Furthermore, it was proposed as Ôdentogenic theoryÕ
that a relationship existed between, on the one hand,
the gender of a person and, on the other, his or her
face or tooth shape (14). The authors believed that
roundness, smoothness and softness, as feminine
characteristics, should be reflected in dentures for
women, just as the masculine vigor and boldness
should be reflected in dentures for men. According to
this theory, femininity is characterized by oval tooth
shape and rounded tooth edges, while masculinity is
expressed by square teeth. Making use of this theory,
other authors were able to confirm a correlation
between tooth shape and gender, but not between tooth
shape and face form (13, 15). None of these studies,
however, used standardized methods for the classifi-
cation of tooth shape. Nevertheless, the Ôdentogenic
theoryÕ has, for decades, formed part of dentists’ well-
established working hypotheses and has been taught in
dental schools and transmitted to generations of den-
tists through standard textbooks (16–18). Hence, it is
not surprising that in one survey, 96% of the partici-
pating dentists stated that square-shaped teeth appear
to be more masculine than ovoid teeth, while a survey
of patients did not confirm this result. In this study,
472 Wolfart et al.

only two photographs (upper front teeth and lips) – one
showing square-shaped teeth, the other ovoid tooth
forms – were used (19). To the best of our knowledge, no
well-designed study has been undertaken in which par-
ticipants attempted to determine the gender of a person
on the basis of the tooth form. Therefore, the null
hypothesis of this study was that there is no gender-
dependent correlation between face and tooth shape. The
secondary hypothesis was that dental practitioners and
postgraduate students are not able to identify a subject’s
gender merely by intraoral photographs of anterior
teeth.
Material and methods
Photographs
Photographs were taken of 204 dental students (mean age
23.7 ± 2.7 yr; 102 males, 102 females). All students were
Caucasian with a healthy dentition, i.e. without missing
teeth or any type of front teeth restorations. Students with
severe tooth wear were excluded from the study. Two
standardized photographs were taken of each student:
portrait (closed lips) and the anterior teeth without lips (see
examples in Fig. 1). For each photograph, standardized
distances (portrait, 100 cm, teeth, 12 cm) were used, and the
resulting magnifications were calculated (portrait, 1 : 10;
teeth, 1 : 1.2). The height of the camera (Pentax Z1-P, SMC
Pentax FA Makro 2.8/100 mm; Pentax, Tokyo, Japan) was
adjusted individually according to the position of the stu-
dents’ eyes. Slides were used for the evaluation of tooth and
face shape. They were projected using a slide-projector
(Novomat 515 AF-M; Braun, Frankfurt am Main,
Germany) with an integrated screen and a standardized
enlargement (5.5 : 1). On the projector screen, the facial
outlines and dental outlines of the upper right incisor were
traced and copied on translucent foil (Fig. 2). They were
coded for anonymity.
Pre-evaluation
Pre-evaluation was performed in order to define three cat-
egories (tapered, ovoid, square) for both tooth and face
shapes. Different commercially available tooth sets of den-
ture teeth (Vitapan; Vita, Bad Säckingen, Germany) were
used for this pre-evaluation of our method. These tooth sets
are classified by the manufacturer as tapered (T36–T99),
ovoid (O13–O99), square (X12–X199) or square-tapered
(Z51–Z97). Standardized photographs (magnification 1 : 2)
of these sets were made, and the dental outlines of the upper
right incisors were traced and copied on translucent foil. In
order to be able to determine the tooth shape, the outline
sketch was analyzed as described in detail in Fig. 2. The
tooth form quotient, TQ ¼ TA/TB, was calculated and
used to classify the tooth form into the three categories
mentioned: tapered, ovoid and square (Fig. 3).
To assess the interpersonal and intrapersonal reliability,
pre-evaluation was repeated once by the same participant
and then again by another person.
Evaluation of tooth and face shape
In the photographs of the main study, the shape of the
right upper incisor was determined in the same way as in
the pre-evaluation. The correlation between TQ and the
different form categories was defined in accordance with
the results of the pre-evaluation. For the evaluation of the
face shape, the outline sketch of the portraits was turned
upside-down (Fig. 2). The quotient for face shape, FQ ¼
FA/FB, was calculated and used in an analogous manner
to that of the tooth shape (Fig. 3).
To assess the reliability of the instrument, the measuring
was repeated for 10 randomly selected subjects.
Evaluation of tooth shape by participants
For the evaluation of tooth shape, two different groups
of participants were chosen: five dental practitioners

A B

C D

Fig. 1. Examples of photographs used in this study. The gender of only 12 males and 5 females was determined correctly by over
90% of the participants (sample A, male; and B, female) in a total of 204 intraoral photographs. In contrast, sample C (male) and D
(female) were determined incorrectly by more than 90% of the participants.
 Tooth forms, face shape and gender 473

Tangent distal
X Tangent mesial
Tangent right
X 1/5 of XS
Tangent left

FA
1/5 of XS

TA
4/5 of XS

4/5 of XS O1 S2
S
FB
S1 S1 O2
O1
S
TB
S2 Ou
Outlin O2
e tli
ne
Median
Median

Fig. 2. In the panel on the left (the tooth), the outline of the upper right incisor was traced and coded for anonymity. In the next step,
the median of the tooth was drawn in the sketch. (X) was the most apical point of intersection between the median and the outline.
Mesial and distal tangents were constructed to the outline – parallel to the median. We dropped two perpendiculars on the median
starting from the most apical (O1) and most incisal (O2) point of intersection between the outline and the tangent. They define two
points of intersection (S1 and S2). The line S1S2 was bisected (S). By taking the width of the tooth through (S) the widest stretch
across the tooth was defined (TB). Dividing the line SX into five parts, the line TA could be constructed parallel to TB on 4/5 of the
length of XS. In the panel on the right, for the evaluation of the face shape, the outline sketch was turned upside down. The lines FB
(the widest stretch across the face) and FA (a defined parallel stretch to line FB) were constructed in an analogous manner to the lines
TA and TB.

(vocational experience at least 10 yr); and five postgraduate

students (vocational experience 1–2 yr). All participants
were unpaid volunteers. The survey was performed in a
classroom at the dental hospital. Appointments were
made, and participants were interviewed individually. Two-
hundred and four black-and-white prints (size 9 · 13 cm)
of the intraoral anterior tooth photographs were shown to
the participants in a random order. The participants were
asked to determine the gender of the subject on the basis of
the tooth form. No further information was given. At this
first survey, the participants were not allowed to make any
notes, and no information about the planned second survey
was given. After 3 wk a second, identical, survey was
carried out with the same participants and using the same
prints (but in a different order). The participants were not
informed that they were given the same prints as during the
first survey.
Statistical analysis
For statistical analysis of the pre-evaluation, the Concor-
dance-Correlation coefficient (20) was used to assess
interpersonal and intrapersonal reliability. The correlations
between tooth form and face shape, on the one hand, and
between both tooth form and face shape and gender, on
the other hand, were analyzed by using the Spearman
correlation analysis – cappa-coefficients were added. For
these procedures, tooth form quotient and face shape
quotient were correlated to gender. Gender was coded with
a value of 1 for women and a value of 2 for men. The
Student’s t-test was used to verify the reliability of random
error concerning the evaluation of tooth and face shape.
Binomial-test and cappa-coefficients were used for the
participants’ attempts at determining the gender. All
hypothesis testing was conducted at a 95% level of
confidence.

tapered ovoid square Results

TB FB
TQ TQ
Pre-evaluation
FQ ≤ 0.61 0.61 < TQ > 0.70 FQ ≥ 0.70
FQ Mean values and standard deviation of the tooth form
TB FB TB FB
quotients (TQ) were 0.60 ± 0.03 (tapered), 0.66 ± 0.02
(ovoid), 0.76 ± 0.05 (square) and 0.76 ± 0.03
TA FA TA FA (square-tapered). The Concordance-Correlation coeffi-
TA FA
cient showed a high consistency for interpersonal (0.92)
and intrapersonal (0.93) repetition.
Fig. 3. Classification of tooth and face shape. The quotient
(TQ and FQ) of the lengths TA/TB and FA/FB was calculated.
These results determined the classification of the face
Tooth and face shape were classified as tapered if FQ or and tooth shape for the main evaluation. Tooth forms
TQ £ 0.61, as ovoid if FQ or TQ were between 0.62 and 0.69, ÔsquareÕ and Ôsquare-taperedÕ were pooled. Both face and
and as square-shaped if FQ or TQ ‡ 0.70. tooth shapes were classified as shown in Fig. 3.
474 Wolfart et al.

100% weak (r ¼ 0.18) it was statistically significant (P £ 0.01).

However, no significant correlation was found
80%
(P > 0.05) between tooth shape and face shape. Only in
Distribution of shapes

P ≤ 0.01
P > 0.5
60% No conformity
35% of all cases did the tooth and the face shapes
square conform (Fig. 4).
ovoid
40% The random error for the re-evaluation of 10 tooth
tapering
and face shapes was, at most, ± 2.5% for each of the
20%
lines TA, TB, FA and FB. No statistically significant
0%
differences were found between the first evaluation and
the re-evaluation (P ¼ 0.28). In addition, this random
en

en

en
l

l
en

en

en
Al

Al

Al
M

M
error did not influence the classification of either tooth
om

om

om
W

W
Tooth shape Face shape Conformity of or face shapes.
tooth and face shape

Fig. 4. Distribution of tooth and face shape. No significant

correlation was found between tooth shape quotient (TQ) and
Evaluation of tooth form by participants
gender (P > 0.05, Spearman-correlation), but a significant The participants analyzed the 204 photographs
correlation was found between face shape quotient (FQ) and (Table 1). They were asked to determine the gender on
gender (P £ 0.01, r ¼ 0.18, Spearman-correlation). Only in
35% of all cases did the tooth shape conform to the face shape; the basis of the tooth form. The successful guesses
no statistically significant correlation was found (P > 0.05, accounted for 47% to 63% of cases in the first survey.
Spearman-correlation). The binomial test showed that three out of the 10 den-
tists did not quote randomly (P £ 0.05). Independently
of whether the decision of the dentists was correct or
incorrect, it was analyzed whether his or her judgment in
the first survey was the same as that of the second survey.
Tooth and face shapes
The dentists’ ÔcoherenceÕ ratio lay in a range between
Tooth shape was classified in 25% of cases as tapered, 54% and 77%. For eight out of the 10 dentists this
in 39% of cases as ovoid and in 36% of cases as coherence was statistically significant (P £ 0.05, binomial
square-shaped (Fig. 4). No significant correlation was test).
found between tooth form quotient (TQ) and gender The gender of only 12 males and 5 females was
(P > 0.05). Tapered faces were more common in female determined correctly by > 90% of the participants who
subjects (34%) than in male subjects (21%), whereas evaluated the 204 intraoral photographs. Fig. 1A,B
square-shaped faces were less common in female subjects shows two examples. In contrast, Fig. 1C,D shows two
(26%) than in male subjects (38%). Although the corre- photographs in which gender was determined incorrectly
lation between face shape quotient (FQ) and gender was by > 90% of the participants.

Table 1
Gender assignment based on the assessment of intraoral photographs of the anterior teeth

Accordance between judgment

First survey (n ¼ 204) Second survey (n ¼ 204) of first and second survey
Dentist* Hit rate (%) Cappa P-value Hit rate (%) Cappa P-value Accord.à Cappa P-value

Pr_1 56 0.13 NS 61 0.20 £ 0.01 70 0.40 £ 0.01

Pr_2 59 0.19 £ 0.01 63 0.26 £ 0.01 64 0.27 £ 0.01
Pr_3 58 0.17 £ 0.05 58 0.17 £ 0.05 74 0.46 £ 0.01
Pr_4 57 0.15 £ 0.05 53 0.05 NS 68 0.35 £ 0.01
Pr_5 53 0.07 NS 51 0.02 NS 58 0.17 £ 0.05
Mean 1–5 57 56 67
(SD) (2) (3) (6)
Gr_1 56 0.12 NS 51 0.20 NS 54 0.07 NS
Gr_2 47 ) 0.07 NS 56 0.13 NS 75 0.49 £ 0.01
Gr_3 55 0.11 NS 56 0.12 NS 54 0.09 NS
Gr_4 55 0.10 NS 57 0.15 £ 0.05 67 0.35 £ 0.01
Gr_5 56 0.12 NS 60 0.20 £ 0.01 77 0.53 £ 0.01
Mean 1–5 54 57 65
(SD) (4) (5) (11)
Mean all 55 57 66
(SD) (4) (4) (8)

*Pr, dental practitioners; Gr, postgraduate students.

Significance levels of the hit rates of each participants based on the binomial test.
àAccord., accordance.

Discussion
In previous studies, the investigators (9, 10, 21) subject-
ively classified face and tooth shapes using different
categories based on the classification of Williams (8).
However, when different participants attempted to clas-
sify teeth, they achieved, in only 65% of all cases, the
same results (21). In 15% of the cases the participants
were not able to assign the teeth to any of the given
categories. To obtain more objective results, a computer-
based system was employed which linked both facial and
dental outlines to different geometrical forms (22).
Unfortunately, this method was neither tested for
validity and reproducibility, nor was it ever used in a
clinical study. The method used in the present study was
developed from this system. Regarding the test instru-
ments, validity and reproducibility were demonstrated
with high Concordance-Correlation coefficients (pre-
evaluation).
Participants were asked twice to determine the sub-
jects’ gender from intraoral tooth photographs. Black-
and-white prints were used to eliminate the influence of
different tooth or gingival colors. In addition, other
gender-specific variables, such as lips, skin and beard,
were eliminated. Incidentally, the study of Brisman (19)
disregarded such important details of presentation
because lips can indeed be seen on his photographs.
In his observation, participants were requested to state
whether square-shaped teeth appear to be more mascu-
line than ovoid teeth.
Certainly, judging a dentition from canine to canine
for the purposes of determining the gender automatically
involves more than just the tooth shape. Other factors,
such as size, position, angulation and proportion of the
teeth, also potentially influence our judgments. These
additional factors could have been eliminated if the
participant had taken only the upper central incisor into
consideration. We decided, however, to work, in the
current study, with all anterior teeth because rather than
being focused on a single tooth, clinicians are confronted
with all teeth in their daily routine.
No significant correlation was found between tooth
shape and gender (Fig. 4), which confirms the outcome
of other studies (9, 10). The Ôdentogenic theoryÕ (14),
which claims that the female tooth form is more often
ovoid and the male tooth form more often square-
shaped, could therefore not be confirmed.
Moreover, no significant correlation was found
between tooth shape and face shape (Fig. 4). Therefore,
the present study does not confirm the Ôlaw of harmonyÕ
(8). We found an agreement between tooth and face
shape in only 35% of cases. This confirms the results of a
previous study (15).
In the current study, the accuracy of the decisions that
participants made as regards gender was 55 ± 4% in the
first survey. These results are similar to the outcome of
another study (23), in which the gender was correctly
determined in 53% of all cases. In both studies the hit
rates were thus
50%, i.e. the same hit rates that one
would expect if the participants answered at random. In
accordance with this, the cappa-coefficient (Table 1)
Tooth forms, face shape and gender 475
showed, at most, only a low (0.2) consistency (24). On
the other hand, reproducibility between the first and the
second survey was 66 ± 8.2%. The cappa-coefficient
varied between low (0.1) and moderate (0.5) consistency.
These results suggest that some of the dentists (with the
higher cappa-coefficients) used certain criteria to influ-
ence their decision, whereas others guessed. They seemed
to have in mind a picture of a typically female or a
typically male dentition. This picture may, of course, not
be realistic, but it helps the clinicians to arrive at a
reproducible decision. The factors governing such deci-
sions could be the length, the position, or the proportion
of the teeth, or even the oral hygiene of the subject.
A correlation between some of these factors and gender
has been shown previously; women have smaller teeth
than men (25) and they do have a better oral hygiene
(26, 27). Moreover, many dentists are also influenced by
certain doctrines and theories (14) that have still wide
currency in dental schools and which are often trans-
mitted through standard textbooks (16–18). This may
explain why some of the very pronounced and typical
intraoral photographs were correctly, or incorrectly,
identified with a very high percentage (Fig. 1).
We therefore conclude that this study confirms neither
the theory that the tooth shape corresponds to the
inverted facial shape, nor the theory that the female
tooth shape is more often ovoid and the male tooth
shape more often square. In addition, participants were
not able to determine the gender of a person from
strictly intraoral photographs. Therefore, the rules
concerning the selection of anterior teeth should be
reconsidered. Neither the inverted facial shape nor the
gender should be used as guidelines for anterior tooth
selection in complete dentures or complex anterior res-
torations, because it could lead to unsatisfactory results.
Instead, the opinions and desires of the patients should
be taken into account to ensure optimal dental aes-
thetics for each individual.
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