ORIGINAL ARTICLE

Impact of variations in maxillary lateral

incisor dimensions on smile esthetics
Alireza Haerian,a Elaheh Rafiei,a Neda Joshan,a Rojin Eghbali,b and Pooya Fadaei Tehranib
Yazd, Iran

Introduction: Dentofacial esthetics has become an increasingly important topic in recent years among ortho-
dontic patients, so it is suggested that the esthetic perspectives of clinicians and patients be considered
when planning orthodontic treatment. The maxillary lateral incisors play a key role in smile esthetics. The pur-
pose of this study was to investigate the effect of dimensional changes of the maxillary lateral incisors on smile
esthetics as perceived by orthodontists, general dentists, and laypersons. Methods: This was a descriptive
cross-sectional study. A photograph showing an attractive smile was selected. The dimensions of the
maxillary lateral incisors were edited with photograph editing software to represent variations in width, crown
length, gingival height, and mesial angulation. Groups of orthodontists, general dentists, and laypersons
(n 5 16 per group) evaluated the smile attractiveness of the images using the Likert scale according to smile
esthetics criteria. Statistical analysis was performed using SPSS software (version 25) and Kruskal-Wallis
statistical test. The significance level was set at 0.05. Results: There was no significant difference between
mean scores of lateral incisor golden proportion changes, vertical crown length changes, gingival height
changes, and mesial angulation changes (P .0.05). All groups found 1 mm more incisally positioned gingival
height of lateral incisor than the central incisor and 1 mm more apically positioned incisal edge of lateral incisor
than the central incisor to be the most attractive. In the group of orthodontic specialists, the 20 mesial angulation
and in the other 2 groups the 10 and 15 mesial angulation had the highest score. Conclusions: Partial devi-
ations from the ideal esthetic proportions were not detected by laypersons, general dentists, or orthodontists and
are acceptable and even attractive from the point of view of patients. Some adherence to these ratios will be
acceptable in dental treatments. (Am J Orthod Dentofacial Orthop 2021;-:---)

T
he maxillary lateral incisor plays an important role
in smile esthetics. Numerous studies have shown
that the shape, size, angle, and position of the
maxillary lateral incisor can affect smile esthetics.1-4
Designing a beautiful smile is a complex process that
requires a multidisciplinary approach. Recently, the
popularity of designing an attractive natural smile, as
an architectural blueprint used in cosmetic dentistry,
has increased for achieving optimal esthetic results.5,6
Orthodontic patients also evaluate the outcome of their
a
Department of Orthodontics, Faculty of Dentistry, Shahid Sadoughi University
of Medical Sciences, Yazd, Iran.
b
Dental Students Research Center, Faculty of Dentistry, Shahid Sadoughi Univer-
sity of Medical Sciences, Yazd, Iran.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
This study was supported and approved by the Vice Chancellor for Research at
Shahid Sadoughi University of Medical Science, Yazd, Iran.
Address correspondence to: Pooya Fadaei Tehrani, Department of Orthodontics,
Dental Students Research Center, School of Dentistry, Shahid Sadoughi Univer-
sity of Medical Sciences, Yazd, Iran; e-mail, pooya.fadaei@yahoo.com.
Submitted, April 2020; revised and accepted, June 2020.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2020.06.047
treatment on the basis of their smile and improving over-
all facial appearance. Although orthodontic treatment
was previously planned on the basis of occlusal relation-
ships, more attention is now being paid to the promotion
of dentofacial features for ideal facial esthetic.7
Patients' perception of smile esthetics is subjective, so
a lateral incisor may be ideal for a group of patients and
may not be attractive for others. The effects of factors
such as gender and ethnicity on the patient's perception
of smile esthetics have been previously investigated.8
In addition, factors such as culture also influence one's
understanding of esthetics. As a result, the perception
of esthetics varies considerably among patients. There-
fore, in addition to the geometric and objective assess-
ment of patients' smiles, a scientific understanding of
smile satisfaction from the viewpoint of the professionals
involved in the esthetics field is also essential.9
To have a proper occlusion, the teeth must be of a
suitable size. About 5% of the population have some de-
gree of mismatch, the most common cause being the
width or anomaly of the maxillary lateral tooth.10
Studies have shown that the shape, size, angle, and
position of the lateral incisor may affect the esthetic of

1
2 Haerian et al
a smile.3,11 In addition, it has been shown that the lateral
incisor relationship with the central incisor and canine
also play an important role in smile esthetics.12
One of the most important aspects of dental and den-
tofacial esthetics is the appearance of anterior teeth in
the vertical dimension. Therefore, dental and gingival
manifestations and asymmetries should be carefully
examined. The perception of dentofacial esthetics by
laypersons and health care professionals such as ortho-
dontists or general dentists should be taken into account
when planning an orthodontic treatment plan.9 Studies
have shown the effect of gingiva on the perception of
smile esthetics, and it has also been shown that ortho-
dontists are more sensitive to gingival changes than lay-
persons. However, the gingival margin height difference
between the central and lateral incisors is not considered
unattractive by laypersons and dental professionals.13,14
In contrast, it has been suggested that the maxillary cen-
tral incisors and canines must be placed almost at the
same level, and the incisal edge of the lateral teeth
should be 0.5-1.5 mm more gingivally positioned.13,15,16
However, the esthetics effect of changes in the vertical
position of the maxillary lateral incisor is still unclear.2
In addition, the relationship between the lateral tooth
and the central and canine teeth, called golden propor-
tion, plays an important role in the smile design.11,12,17
According to the golden ratio formula, the apparent
width of each tooth is 0.618 of its mesially positioned
tooth widths.18,19 This principle is ideally used to deter-
mine the width of the teeth as they relate to each other.
This ratio can only be used after determining the incisal
plane, gingival plane, and central incisor's length.20-22
The lateral incisor angulation is also a key component
in smile esthetics. Dental prosthetics reference books
suggest that lateral incisor mesial angulation gives a
more feminine look to the patient.23 This may explain
why a significant number of women and men have a
more favorable view toward a 5 mesial angulation of
maxillary lateral incisor.11
To provide more concrete guidelines on the percep-
tion of smile esthetics, a large number of studies have
been conducted using digital image manipulation.24-28
Features such as smile arch; optimal gingival value;
ideal buccal corridor; impact of maxillary anterior
diastema; effect of midline and longitudinal axis
deviation; and importance of size, ratio, and symmetry
of maxillary incisors are better described using this
technique.29
This study aimed to investigate the effect of changes
in the vertical and horizontal dimensions and the angu-
lation of maxillary lateral incisors on smile esthetics from
the point of view of orthodontists, general dentists, and
laypersons.
- 2021  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
MATERIAL AND METHODS
This cross-sectional study was approved by the Ethics
in Research Committee under control no. IR.S-
SU.REC.1398.018. First, a smile photograph with the
following characteristics, which are the inclusion criteria
for determining an ideal smile, was taken from a volun-
teer: (1) appropriate width to length ratio of the teeth in
the cosmetic area; (2) convex and consonant smile arc;
(3) 1 mm gingival display during a smile; (4) average
width of buccal corridors; (5) same gingival height of
central incisor and canine; (6) lateral incisor gingival
height is 0.5 mm more incisal than the central incisors
and canines; and (7) 1 mm step between the incisal
edge of the central and lateral incisors.
Photographs were taken while the patient was stand-
ing in natural head position, and the line between his pu-
pils was parallel to the horizon. The camera was mounted
on a stand about 90 cm (36 in) from the person so that the
camera was parallel to the horizon and was positioned
equal to the height of the person's face. The candidate
was instructed how to smile before taking a photograph.
The repetition of the posed smile has been demonstrated
by Ackerman et al.30 Informed consent was obtained from
the volunteer to use their photograph in the research.
The image was edited using Photoshop software
(Adobe, San Jose, Calif). First, image retouching was
done to adjust the color, brightness, and contrast and re-
move any stains and discoloration of the lips and skin.
The size of the image was then adjusted so that each
millimeter measured on it was clinically equivalent to
1 mm (1:1 ratio). Then the nose and chin area was crop-
ped in the photograph to obtain a close-up image of the
smile so that the upper border of the image was the base
of the nose and the lower border was above the chin.
Then, with the same Photoshop program, the following
changes were made to the lateral incisor on standard
photography:
1. Change of lateral to central incisor width according
to golden proportion at values of 5% (from 52% to
72%) (G1) (Fig 1).
2. Change of lateral incisor height relative to the cen-
tral incisor at the values of 0.5 mm (in the range of
0 to 2 mm) (G2) (Fig 2).
3. Change of lateral incisor gingival height relative to
the central incisor at the values of 0.5 mm (in the
range of 0 to 2 mm) (G3) (Fig 3).
4. Mesial angulation of lateral incisor with respect to
the longitudinal axis of lateral incisor at the values
of 5 (in the range of 5 to 25 ) (G4) (Fig 4).
As a result, 4 groups, each consisting of 5 smile
images, were prepared. Each image was printed on
Haerian et al 3

Fig 1. Lateral incisor width changes relative to the central incisor according to the golden ratio rule.
W, Percentage of transverse changes.

Fig 2. Lateral incisor height changes relative to the central incisor at the values of 0.5 mm. TH, Change
in lateral tooth height.

American Journal of Orthodontics and Dentofacial Orthopedics - 2021  Vol -  Issue -

4 Haerian et al

Fig 3. Lateral incisor gingival height changes relative to the central incisor at the values of 0.5 mm.
GH, Change in lateral tooth gingival height.

A4 matte (3.5-in) paper. For each image, a separate Statistical analysis

identification code was written behind the image for
the time the results were collected. The images were
evaluated by a group of raters, including orthodon-
tists, general dentists, and laypersons. Sixteen subjects
in each group examined 5 sets of photographs and
rated each photograph from the most attractive to
the least attractive, with scores ranging from 5 to
1.2 Each evaluator was given brief information about
the study before rating.
Responses on a Likert-type scale ranged from 1 to 5
were used to evaluate: 1, very unattractive; 2, unattrac-
tive; 3, neither unattractive nor attractive (neutral); 4,
attractive; 5, very attractive.
Each evaluator was interviewed individually and
given 10 seconds to evaluate each photograph. Thirty
seconds of additional time was also given for evaluating
each set. Thus, it took 80 seconds for each set and
320 seconds for all 4 sets. The evaluator could not see
the code inserted behind the photograph.
The intrarater agreement method was used to eval-
uate the reliability of the study. After 2 weeks, 25% of
each group of assessors were asked to reevaluate the
photographs. The kappa coefficient was used to assess
the degree of agreement between the evaluators.31
Statistical analyses were performed using SPSS sta-
tistical software (version 25.0, SPSS, Chicago, Ill).
Kolmogorov-Smirnov test results showed that the
attractiveness score in 4 study groups (lateral incisor
width-to-height ratio changes, lateral incisor height
changes, lateral incisor gingival height changes, and
lateral incisor mesial angulation changes) did not
follow the normal distribution from the point of view
of laypersons, general dentists and orthodontists
(P \0.05). Therefore, Kruskal-Wallis nonparametric
test was used for data analysis. The level of significance
was set at 5%.
RESULTS
Kappa coefficient results for evaluators’ agreement
were between 0.806 and 0.876, indicating a good agree-
ment level. The results of the Kruskal-Wallis test showed
that there was no significant difference between the lay-
persons, general dentists, and orthodontists in the 4
study groups (P 5 0.906) (Table I).
According to the results of the Kruskal-Wallis test,
there was no significant difference between the 4 groups
of lateral incisor changes (P 5 0.995) (Table II).

- 2021  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics

Haerian et al 5

Fig 4. Changes of mesial angulation of lateral incisor relative to its longitudinal axis at the values of 5 .
MA, Mesial angle of the lateral incisor.

In the gingival height changes group, all evaluators

gave the highest score to a difference of 1 mm. This Table I. Comparison of the average smile attractive-
means that for all evaluators, 1 mm more incisal position ness score between evaluators in study groups
of lateral incisor gingival height relative to central incisor Groups Evaluators Mean Standard deviation P
is more attractive. In addition, in the incisal height G1 M1 3.00 1.44 0.906
changes group, all evaluators gave the highest score to M2 3.00 1.42
a difference of 1 mm, which means that 1 mm more M3 2.91 1.43
apical position of lateral incisor incisal edge relative to G2 M1 2.95 1.42 0.967
M2 3.00 1.42
central incisor is more attractive. M3 3.00 1.42
In the width-to-height ratio changes group, layper- G3 M1 3.00 1.42 0.975
sons and general dentists gave the highest score of M2 3.02 1.43
67%, and orthodontists gave the highest score of 62% M3 2.97 1.42
and 67%. In the angulation changes group, laypersons G4 M1 3.00 1.42 0.994
M2 2.97 1.44
gave the highest score of 10 and 15 and general den- M3 2.99 1.41
tists and orthodontists to 15 and 20 , respectively.
G1, Change of lateral to central incisor width; G2, change of lateral
incisor height relative to the central incisor; G3, change of lateral
DISCUSSION incisor gingival height relative to the central incisor; G4, mesial
Numerous researchers have measured and reported angulation of lateral incisor with respect to the longitudinal axis
of lateral incisor; M1, laypersons; M2, general dentists; M3, ortho-
the ideal proportions of anterior teeth for an esthetic dontists.
smile.5,18,32 However, few have addressed the role of
maxillary lateral incisor in smile esthetics. This study
was designed to investigate this role. for achieving their therapeutic goals. Proper dialogue
The patient's perception of esthetics is personal. The between the dentist and the patient is important in iden-
lateral incisor may be important for one group of pa- tifying the patient's perception of the ideal smile.8
tients, whereas not having much importance for others. Various studies have shown that with a slight change
It is essential for dentists to be aware of patients' needs in ideal proportions, smile esthetic is reduced.12 These

American Journal of Orthodontics and Dentofacial Orthopedics - 2021  Vol -  Issue -

6 Haerian et al

anterior guidance. The golden ratio is just one compo-

Table II. Comparison of mean smile attractiveness
nent of the smile design. This ratio is valuable in assess-
score between lateral incisor changes groups in 3
ing smiles and also having a pattern for veneers.1
groups of evaluators
Another factor for the smile esthetics that researchers
Evaluators Groups Mean SD P have noticed is the lateral incisor height. In the present
M1 G1 3.00 1.44 0.995 study, all evaluating groups selected the height of
G2 2.95 1.42 1 mm as the most attractive. The findings of different
G3 3.00 1.42
studies in this area are different. In the study from Al
G4 3.00 1.42
M2 G1 3.00 1.42 0.997 Taki et al,1 orthodontists and general dentists considered
G2 3.00 1.42 the 1 mm, and laypersons 0.5 mm, height difference be-
G3 3.02 1.43 tween the lateral and central incisor the most attractive.
G4 2.97 1.44 Kokich et al18 also showed that laypersons were less ac-
M3 G1 2.91 1.43 0.980
curate about lateral incisor height than dentists. Pani
G2 3.00 1.42
G3 2.97 1.42 et al17 considered a 2 mm difference as ideal. To evaluate
G4 2.99 1.41 this index, in the second group of the present study, the
M1, Laypersons; M2, general dentists; M3, orthodontists; G1, lateral incisor height was changed from 0.5 mm to 2 mm
change of lateral to central incisor width; G2, change of lateral relative to the central incisor. The results showed that
incisor height relative to the central incisor; G3, change of lateral this range of changes was not detectable for the study
incisor gingival height relative to the central incisor; G4, mesial evaluators. Therefore, different ideals for this index
angulation of lateral incisor with respect to the longitudinal axis
have been mentioned in various studies and cannot be
of lateral incisor.
definitively commented.
The ideal position of the lateral incisor gingiva has
changes are usually reviewed from the perspective of lay- been described as 1 mm more incisal than the central
persons, dentists, and professionals. The 3 groups incisor and canine.34-38 In the study by Eichholz,39 the
participating in this study included laypersons, general majority of participants considered the relationship of
dentists, and orthodontists. Dentists and orthodontists the lateral incisor gingiva to be 1 mm more incisal
are used in these studies because of their more accurate than the central incisor. Allen40 states that the lateral
assessment, and laypersons are enrolled because they are incisor gingival height can be the same as the central
the main recipients of dental treatments. incisor. Townsend41 states that the lateral incisor gingiva
The golden ratio law states that the smaller case size can be 2 mm more incisal relative to the central incisor.
should be 62% of the bigger one (in the frontal view). Proffit10 has mentioned a difference of 2 mm or more as
Lombardi et al33 suggest that the ideal width for the not attractive. To evaluate this index, in the third group
lateral incisor is 62% of the central incisor. In this study, of the present study, the lateral incisor gingival height
the lateral incisor width was changed at values of 5% was changed in relation to the central incisor in values
from 52% to 72% and presented to the evaluators. Ac- of 0.5 mm (range from 0 to 2 mm). In this group, there
cording to the results of this study, laypersons, dentists, was no significant difference in the score of attractive-
and orthodontists did not differentiate between the es- ness between laypersons, general dentists, and ortho-
thetics of smiles in these images. Bukhary et al2 reported dontists, and this range of changes was not detectable
the best esthetics for the lateral incisor when the golden for the participants in this study. In the present study,
ratio was 62%. Among laypersons, only a small group the highest score was a 1 mm difference in the gingival
considered this ratio the most beautiful, which is consis- height change group. This ratio falls between the ideal
tent with the results of the present study. Ker et al14 results reported in the studies mentioned above.
examined 243 laypersons by changing the lateral incisor Different populations appear to have an acceptable
width incrementally by 0.18 mm. Their study identified range of 0-2 mm, which is in line with Proffit's view.10
the 72% ratio as the most attractive. They also found ra- The lateral incisor angulation is an important part of
tios of 53% and 76% acceptable. In the present study, in an attractive smile. To investigate this, in the fourth
the golden ratio change group, the highest score was for group of the present study, mesial angulation of the
the 67% ratio. This ratio falls between the ideal results lateral incisor was changed relative to its longitudinal
reported in the studies above. It seems that different axis at 5 (from 5 to 25 ). The results showed that
populations consider ratios between 62% and 72% this range of changes was not detectable for this study's
acceptable. It should be noted that these exact ratios evaluators. In the present study, the highest score was
rarely occur naturally in humans. Sometimes the ortho- from 10 to 20 . Brunzel et al11 evaluated the effect of
dontist needs a wider lateral incisor for creating good different angulations of incisors on smile esthetic, and

- 2021  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics

Haerian et al
in their study, symmetrical teeth with ideal axes as well
as minimal angulation changes in 1 or both lateral inci-
sors were the most attractive images. Although in the
study of Pani et al,17 the majority of participants consid-
ered the lateral incisor parallel to the central incisor to be
the most beautiful image and up to a 5 mesial shift,
which is inconsistent with the results of the present
study.
Overall, various studies have suggested different pat-
terns for smile esthetics. Because the modifications
made in this study were symmetrical rather than 1-sided,
the symmetry in the smile appears to affect the percep-
tion of the smile's esthetics; it has made the evaluators
find the smiles attractive and do not consider deviations
from ideal ratios very important. This result is consistent
with the findings of Brunzel et al11 and Brisman et al42
on the greater attractiveness of a smile with symmetrical
teeth.
The present study, by examining the indexes of the
width, length, position of the maxillary lateral incisor
gingiva and the angulation of this tooth, showed that
smile esthetics was not as sensitive as in previous studies.
Of course, many factors contribute to these differences.
These factors include the population under study and
the images used. The studies that have been described
have each been conducted in different countries,
showing that people of different countries may have
different views in the field of smile esthetics. The images
used in the studies also had different standards.
Choosing the original image and how it is changed can
greatly influence the results.
CONCLUSIONS
The present study showed that all evaluator groups
selected approximately similar images as the ideal smile.
However, the differences in attitudes and sensitivity be-
tween dentists and laypersons indicate the effect of ed-
ucation on judging the attractiveness of a smile. In
addition, small deviations from ideal proportions remain
hidden from the eyes of laypersons, general dentists, and
orthodontists, and considering even some of these pro-
portions will have a good effect on dental treatments.
AUTHOR CREDIT STATEMENT
Alireza Haerian contributed to conceptualization,
project administration, and manuscript review and edit-
ing; Elaheh Rafiei contributed to conceptualization,
methodology, and manuscript review and editing;
Neda Joshan contributed to resources. Rojin Eghbali
contributed to investigation and original draft prepara-
tion; Pooya Fadaei Tehrani contributed to original draft
preparation and manuscript review and editing.
American Journal of Orthodontics and Dentofacial Orthopedics
7
ACKNOWLEDGMENTS
This report was based on a thesis submitted to the
School of Dentistry, Shahid Sadoughi University of Med-
ical Sciences, in partial fulfillment of the requirements
for the Doctor of Dental Surgery degree (no. 985).
REFERENCES
1. Al Taki A, Hamdan AM, Mustafa Z, Hassan M, Abu-Alhuda S. Smile
esthetics: impact of variations in the vertical and horizontal dimen-
sions of the maxillary lateral incisors. Eur J Dent 2017;11:514-20.
2. Bukhary SM, Gill DS, Tredwin CJ, Moles DR. The influence of
varying maxillary lateral incisor dimensions on perceived smile
aesthetics. Br Dent J 2007;203:687-93.
3. King KL, Evans CA, Viana G, Begole E, Obrez A. Preferences for ver-
tical position of the maxillary lateral incisors. World J Orthod 2008;
9:147-54.
4. Alsulaimani FF, Batwa W. Incisors’ proportions in smile esthetics.
J Orthod Sci 2013;2:109-12.
5. Rosenstiel SF, Ward DH, Rashid RG. Dentists’ preferences of ante-
rior tooth proportion—a web-based study. J Prosthodont 2000;9:
123-36.
6. Soh J, Chew MT, Chan YH. Perceptions of dental esthetics of Asian
orthodontists and laypersons. Am J Orthod Dentofacial Orthop
2006;130:170-6.
7. 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.
8. Al-Habahbeh R, Al-Shammout R, Al-Jabrah O, Al-Omari F. The ef-
fect of gender on tooth and gingival display in the anterior region
at rest and during smiling. Eur J Esthet Dent 2009;4:382-95.
9. Cotrim ER, Vasconcelos J

Haddad AC, Reis SA. Perception
unior AV,
of adults’ smile esthetics among orthodontists, clinicians and
laypeople. Dent Press J Orthod 2015;20:40-4.
10. Proffit W, Fields HJI. Sarver DMContemporary Orthodontics. 4th
ed. St. Louis: Mosby; 2007. p. 167-8.
11. Brunzel S, Kern M, Freitag S, Wolfart S. Aesthetic effect of minor
changes in incisor angulation: an internet evaluation. J Oral Reha-
bil 2006;33:430-5.
12. Nikgoo A, Alavi K, Alavi K, Mirfazaelian A. Assessment of the
golden ratio in pleasing smiles. World J Orthod 2009;10:224-8.
13. Raj V. Esthetic paradigms in the interdisciplinary management of
maxillary anterior dentition-a review. J Esthet Restor Dent 2013;
25:295-304.
14. 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.
15. Eslami N, Omidkhoda M, Shafaee H, Mozhdehifard M. Comparison
of esthetics perception and satisfaction of facial profile among
male adolescents and adults with different profiles. J Orthod Sci
2016;5:47-51.
16. Machado RM, Assad Duarte ME, Jardim da Motta AF, Mucha JN,
Motta AT. Variations between maxillary central and lateral incisal
edges and smile attractiveness. Am J Orthod Dentofacial Orthop
2016;150:425-35.
17. Pani SC, Fernandez RA, Kudsi RI, et al. The impact of lateral incisor
dimensions on smile perception– A study of patients’ tolerance for
deviation from the ideal. Period Prosthodont 2016;2:10.
18. 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.
- 2021  Vol -  Issue -
8 Haerian et al
19. Kovich V. Esthetics and anterior tooth position: an orthodontic
perspective. Part I: Crown length. J Esthet Dent 1993;5:19-23.
20. Johnston CD, Burden DJ, Stevenson MR. The influence of dental to
facial midline discrepancies on dental attractiveness ratings. Eur J
Orthod 1999;21:517-22.
21. Shaw WC, Lewis HG, Robertson NR. Perception of malocclusion. Br
Dent J 1975;138:211-6.
22. Machado AW, Moon W, Gandini LG Jr. Influence of maxillary
incisor edge asymmetries on the perception of smile esthetics
among orthodontists and laypersons. Am J Ortod Dentofacial
Orthop 2013;143:658-64.
23. Zarb GA, Hobkirk J, Eckert S, Jacob R. Prosthodontic Treatment for
Edentulous Patients. In: e-Book: Complete Dentures and Implant-
Supported Prostheses. 13th ed. St. Louis, MO: Elsevier Health
Sciences; 2013. p. 110-25.
24. Musskopf ML, Rocha JMD, R€osing CK. Perception of smile
esthetics varies between patients and dental professionals when
recession defects are present. Braz Dent J 2013;24:385-90.
25. Pinho S, Ciriaco C, Faber J, Lenza MA. Impact of dental asymme-
tries on the perception of smile esthetics. Am J Orthod Dentofacial
Orthop 2007;132:748-53.
26. Zhang YF, Xiao L, Li J, Peng YR, Zhao Z. Young people’s esthetic
perception of dental midline deviation. Angle Orthod 2010;80:
515-20.
27. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental profes-
sionals and laypersons to altered dental esthetics: asymmetric
and symmetric situations. Am J Orthod Dentofacial Orthop
2006;130:141-51.
28. Talic N, AlOmar S, AlMaidhan A. Perception of Saudi dentists and
lay people to altered smile esthetics. Saudi Dent J 2013;25:13-21.
29. Menezes EBC, Bittencourt MAV, Machado AW. Do different verti-
cal positions of maxillary central incisors influence smile esthetics
perception? Dent Press J Orthod 2017;22:95-105.
- 2021  Vol -  Issue - American Journal of Orthodontics and Dentofacial Orthopedics
30. Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A morpho-
metric analysis of the posed smile. Clin Orthod Res 1998;1:2-11.
31. Naini FB, Donaldson AN, McDonald F, Cobourne MT. Assessing
the influence of chin prominence on perceived attractiveness in
the orthognathic patient, clinician and layperson. Int J Oral
Maxillofac Surg 2012;41:839-46.
32. Wolfart S, Thormann H, Freitag S, Kern M. Assessment of dental
appearance following changes in incisor proportions. Eur J Oral
Sci 2005;113:159-65.
33. Lombardi RE. The principles of visual perception and their clinical
application to denture esthetics. J Prosthet Dent 1973;29:358-82.
34. Sarver DM, Ackerman MB. Dynamic smile visualization and quan-
tification: part 2. Smile analysis and treatment strategies. Am J
Orthod Dentofacial Orthop 2003;124:116-27.
35. Shillingburg H, Sather D, Wilson E Jr, Cain J, Mitchel D, Blanco L.
Fundamentals of Fixed Prosthodontics. 4th ed., 119. Chicago:
Quintessence Publishing; 2012. p. 299-345.
36. Kokich VG, Nappen DL, Shapiro PA. Gingival contour and clinical
crown length: their effect on the esthetic appearance of maxillary
anterior teeth. Am J Orthod 1984;86:89-94.
37. Kokich VG. Esthetics and vertical tooth position: orthodontic
possibilities. Compend Contin Educ Dent 1997;18:1225-31: quiz
1232.
38. Allen EP. Use of mucogingival surgical procedures to enhance
esthetics. Dent Clin North Am 1988;32:307-30.
39. Eichholz A. Esthetic smile preferences of sental professionals.
Kansas City: University of Missouri; 2017.
40. Allen EP. Surgical crown lengthening for function and esthetics.
Dent Clin North Am 1993;37:163-79.
41. Townsend CL. Resective surgery: an esthetic application. Quintes-
sence Int 1993;24:535-42.
42. Brisman AS. Esthetics: a comparison of dentists’ and patients’
concepts. J Am Dent Assoc 1980;100:345-52.