Efficacy of The Gender on The Width Length

Ratio Of Maxillary Anterior Teeth In The

Kuwaiti Population and The Influence of Thi
on The Attracti!ene Gingi!al "#ile$
Experi#ental "tudy

%ahd El &a#ad
'(" "indh Medical )ollege
Pa*itan

+,--
Introduction
There is considerable empirical evidence to suggest that individuals use facial
appearance as a guide to infer a variety of characteristics about a person,
including personality, integrity, social and intellectual competence, and mental
health ( Eagly AH 1991). The impact of appearance on perceptions of personal
characteristics is not limited to initial meetings; such perceptions may have a
lasting effect ( Berscheid E 1981). Moreover, individuals rated as attractive tend
to earn more, have more successful life outcomes, and have greater self-worth
than less-attractive individuals ( Dion K et al 1972, Loh ES 1993).
Facial attractiveness plays a key role in social interaction. t influences mating
success, kinship opportunities, personality evaluations, performance, and
employment prospects ( Dion K et al 1972, Bull R and Rumsey N.1988, Flanary
C 1992). Attractiveness is suggested to influence personality development and
social interaction. Attractive children and adults are judged and treated more
positively than unattractive children and adults, even by those who know them.
Attractive children and adults also exhibited more positive behaviors and traits.
Facial attractiveness correlated with extraversion and self-confidence/self-
esteem ( Langlois J et al 2000).
Empirical evidence for this relationship is given by a meta-analysis of facial-
attractiveness studies ( Langlois J et al 2000). n most domains, attractiveness
was found to be equally important for men and women. Other studies showed
correlations between self-reported attractiveness and personality traits such as
dominance, emotional stability, and self-esteem ( Feingold A 1992) or with
inhibition, health anxiety, and self-esteem ( . Greitemeyer T and Brodbeck F
2000).
The mouth is the center of communication in the face, the smile plays an
important role in facial expression and appearance. One important component
of facial appearance is the appearance of the mouth and teeth. The significance
of the mouth is emphasized by its importance in social interactions; the mouth is
scanned by interlocutors in face-to-face situations ( Miller AC 1970).This has
been demonstrated in studies with photographs, where higher intellectual and
social abilities were attributed to individuals with esthetic smiles. They were also
judged to be more attractive than the same individuals on photographs with
modified lower-level esthetic smiles ( Eli et al 2001 , Newton JT et al 2003).
Good dental appearance is thought to be a requirement of prestigious
occupations among some professional groups ( Jenny J and Proshek J.1986).
Established norms for dental and facial appearance do not vary widely among
industrialized nations, and extreme deviations are viewed as unacceptable
( Cons NC et al 1983). t is unsurprising, therefore, that poor dentofacial
appearance produces negative perceptions of personal characteristics ( Shaw
WC 1981, Shaw WC and Humphreys S 1982, Shaw WC et al 1985, Kerosuo H
et al 1995).

One of the most important aspects of dental and facial esthetics is the vertical
anterior tooth display. Esthetic judgment is made by viewing the patient from the
front in dynamic states like conversation, facial expressions, and smiling
( Zachrisson BU.1998). Tjan and Miller in a study of the full smiles of 454
students, aged 2030 years, divided the smile line into three types: a high smile
line, average smile, and low smile ( Tjan AH and Miller GD 1984).
A high smile line, revealing the complete maxillary incisors and a continuous
band of the gingiva; an average smile, revealing 75100% of the maxillary
incisors; and a low smile, revealing less than 75% of the maxillary incisors ( Tjan
AH and Miller GD 1984). The high smile line, defined as gingival smile line or
gummy smile, commonly provokes strong concern from clinicians. Orthodontists
and surgeons are conditioned to see a gingival smile as esthetically undesirable
( Janzen EK 1977). This lead to the postulation of various treatment alternatives
for the gingival smile that include various combinations of orthodontics
periodontal and surgical therapy, depending on the diagnosis of the gingival
smile.
But do gingival smile is really a disease that need treatment? A really good
answer to this question is what Peck and Peck have said that we tend to forget
that facial esthetics is a subject that interests all people everywhere, and the
ultimate source of esthetic values should be the people and not just ourselves
( Peck S and Peck H. 1970). This issue is exactly what this study is trying
to exlore is to deter!ine whether the esthetic "alues in a sa!le o#
$ra%ic dental students is the sa!e or di##erent #ro! the esthetic "alues
%een ostulated long ago in the literature and i# there are any e##ect o# the
gender in this di##erence i# it exist.
$i! o# the study
The aim of this study is to evaluate the influence of the lip positions related to
the incisor teeth on smile esthetics as assessed by Arabic dental students .
Re!iew of Literature

The golden proportion or phi is 1.618. Throughout history, this ratio for the length-width of
rectangles has been considered the most pleasing to the eye. The golden section - a precise
way of dividing a line, music or anything else - goes back to least as far as around 500 BC,
when Pythagoras proved that the Golden Section was the basis for the proportions of the
human figure and that the human body was built with each part in a definite Golden
Proportion to all the other parts.

S&'( S. ). 1999 investigated the golden percentage of the esthetic smile analysis of the
maxillary antrior tooth width, has revealed repeatable, objective principles that can be
systematically applied to evaluate and improve dental esthetics in predictable ways.
Symmetry across the midline, anterior or central dominance, and regressive proportion are
three composition elements required to create unity and esthetics in a smile. The Golden
Proportion has been suggested as one possible mathematic analysis tool for assessing
dominance and proportion- in the frontal view of the arrangement of maxillary teeth. t has
proven to be controversial in developing esthetically beautiful smiles and cumbersome for
evaluating symmetry. The clinical significance of the study is that its considered a bilateral
analysis of apparent individual tooth width as apercentage of the total apparent width of the
anterior segment and propses the concept of the golden percentage as amore useful
application in diagnosing and develping symmetry dominance and proportion for esthetically
pleasing smiles.

*inoo *. et al +00, evaluated golden proportion in ndividuals with an esthetic smile
aimming to investigate the existence of the golden proportion between the widths of the
maxillary anterior teeth in individuals with an esthetic smile. The study was conducted with
157 dental students (75 women and 82 men), with ages ranging from 18 to 30 years.
Students whose natural smile did not develop any visual tension with regard to the study's
and their own criteria were selected as having esthetic smile. An image measurement
program was used to measure the apparent mesiodistal widths of six maxillary anterior teeth
on the scanned photographs of these subjects. The existence of the golden proportion was
investigated in the width ratios of maxillary anterior teeth.The golden proportion was not
found to exist between perceived maxillary anterior teeth widths of individuals with an
esthetic smile.
The study Concluded that the golden proportion is not a common factor in esthetic smiles.

-#uk H et al +00., analaysed the maxillary anterior teeth facial and dental proportions.
Aimming at analyzing the clinical crown dimensions of maxillary anterior teeth to determine
whether consistent relationships exist between tooth width and several facial measurements
in a subset of the Turkish population. Where Full-face and anterior tooth images of 100
Turkish dental students viewed from the front and engaged in maximum smiling were
recorded with digital photography under standardized conditions. Gypsum casts of the
maxillary arches of the subjects were also made. The dimensions of the anterior teeth, the
occurrence of the golden ratio, the difference between the actual and perceived sizes, and
the relationship between the anterior teeth and several facial measurements by gender were
analyzed using the information obtained from both the computer images and the casts. One-
sample, 2-sample, and paired t tests, and repeated-measures analysis of variance and
Duncan multiple-range tests were performed to analyze the data (alpha=.05).


The dimensions of the central incisors (P<.05) and canines (P<.01) varied by gender. The
existence of the so-called "golden proportion" for the maxillary anterior teeth as a whole was
not found. Significant differences emerged when the mean ratios between various perceived
widths were compared with their ideal golden ratios (P<.01). Proportional relationships
between the bizygomatic width and the width of the central incisor, and the intercanine
distance and the interalar width in women were observed. The study concluded that The
maxillary central incisor and canine dimensions of men were greater than those of women in
the Turkish population studied, with the canines showing the greatest gender variation.
Neither a golden proportion nor any other recurrent proportion for all anterior teeth was
determined. Bizygomatic width and interalar width may serve as references for establishing
the ideal width of the maxillary anterior teeth, particularly in women.



Van Der Geld P. et al 2007, examined the smile effectiveness on self preception and
influence on personality, with the objective to investigate self-perception of smile
attractiveness and to determine the role of smile line and other aspects correlated with smile
attractiveness and their influence on personality traits. Participants judged their smile
attractiveness with a patient-specific questionnaire. The questionnaire contained a
spontaneous smiling photograph of the participant. Objective smile-line height was measured
using a digital videographic method for smile analysis. Personality was assessed with the
Dutch Personality ndex. The study results was as follow, the size of teeth, visibility of teeth,
and upper lip position were critical factors in self-perception of smile attractiveness (social
dimension). Color of teeth and gingival display were critical factors in satisfaction with smile
appearance (individual dimension). Participants, smiling with teeth entirely displayed and
some gingival display (two to four millimeters), perceived their smile line as most esthetic.
Smiles with disproportional gingival display were judged negatively and correlated with the
personality characteristics of neuroticism and self-esteem. Visibility and position of teeth
correlated with dominance. The results of this research underpin the psychosocial
importance and the dental significance of an attractive smile.

n (ard /. H. +007 study that aimed to determine whether North American dentists prefer
smile designs created using the recurring esthetic dental (RED) proportion, other
mathematically defined tooth proportion relationships, or naturally occurring tooth-to-tooth
width proportions previously reported to occur in the North American population. Where
Three hundred and one North American dentists were surveyed to determine their
preferences of imaged smiles exhibiting different anterior tooth width proportions and the
primary proportion influencing their decision. The study concluded that Smiles created using
the principles of the RED proportion were preferred by a majority of dentists surveyed. The
majority of dentists reported that overall balance was the primary factor affecting their
selection.


Parnia 0 et al +010 studied the Proportions of maxillary anterior teeth relative to each other
and to golden standard in tabriz dental faculty students aimed to evaluate the occurrence of
golden standard values and golden proportion in the anterior teeth. Where the Photographs
of 100 dentistry students (50 males and 50 females) were taken under standard conditions.
The visible widths and lengths of maxillary right and left incisors were calculated and the
ratios were compared with golden standard. Data was analyzed using SPSS 14 software.
Review of the results of the means showed statistically significant differences between the
width ratio of right lateral teeth to the central teeth width with golden proportion (P<0.001).
Likewise, the difference was significant for the left side, too (P<0.001). Test results of mean
differences showed that the mean difference between proportion of right laterals to centrals
with golden proportion was significant (P<0.001). The difference was significant for the left
side, too (P<0.001). As a result, there is no golden proportion among maxillary incisors. The
review of results of mean differences for single samples showed that the mean differences
between the proportion of width-to-length of left and right central teeth was statistically
significant by golden standard (P<0.001). Therefore, considering the width-to-length
proportion of maxillary central teeth, no golden standard exists. The study concluded that the
evaluation of the width-to-width and width-to-length proportions of maxillary incisors no golden
proportions and standards were detected, respectively.

1ondon *. 2t al +011 did a study named the Maxillary anterior tooth dimensions and
proportions in an rish young adult population that was undertaken in a young rish population
to determine the dimensions and ratios of the six maxillary anterior teeth. One hundred and
nine rish subjects (age 18-25 inclusive) had irreversible hydrocolloid impressions made of
their maxillary dentition poured in type V stone. Clinical crown dimensions were measured
with a digital calliper. The stone casts were digitally photographed in a standardised manner
enabling calculation of various ratios between the maxillary anterior teeth. Sexual dimorphism
existed for various tooth dimensions; most notably canine teeth were in the region of 08 mm
longer and 06 mm wider in males. Central and lateral incisors were found to be 05 mm wider
in males. t is, therefore, recommended that dimensional tooth guidelines should be given for
each of the sexes and not on a population basis. With regard to tooth proportion ratios, no
significant differences were found between genders or the left and right sides for any of the
measurements or ratios measured. The digitally recorded tooth proportions were similar for
both sexes, and the Golden Proportion guidelines could only be applied to the lateral
incisor/central incisor widths (0618). dentified width proportions for the canine/central incisor
were 058 and for canine/lateral incisor 089.

PI&I &. P. et al +01+ did an analysis of the golden proportion and with/heigth ratios of
maxillary anterior dentition in patients with lateral incisor agenesis. With the purpose to to
assess the presence of the golden proportion (GP) in the facial view tooth-to-tooth width
proportion of the six maxillary anterior teeth and to evaluate the width/height (W/H) ratios of
the incisors of patients with maxillary lateral incisor (L) agenesis treated either with implants
or orthodontically. Forty-eight patients with L agenesis were divided into four experimental
groups: unilateral recontouring group (N = 10), bilateral recontouring group (BRG, N = 18),
unilateral implant group (UG, N = 10), bilateral implant group (N = 10), and a control group
(CG, N = 25) of patients without agenesis. GP ratios were determined on patients' dental
casts placed over Levin's grids, whereas W/H ratios were measured directly on the casts and
a millimeter ruler to determine these distances. Statistical analysis was performed with
ShapiroWilk, KruskalWallis, MannWhitney, Friedman, and Wilcoxon tests (p < 0.05). The
incidence of GP in the tooth-to-tooth width proportions was significantly different between
groups and more commonly found between centrals and laterals than between laterals and
canines. The results demonstrated that the GP was not found to be present in the majority of
the cases treated with maxillary agenesis, regardless of the method of treatment. The mean
W/H ratios of the laterals ranged between 0.75 and 0.90. Although the GP may be a useful
diagnostic guide, it was not observed in the majority of esthetic outcomes of patients treated
with maxillary L agenesis in this study.


n +01+ Peixoto et al did a study about the Photographic analysis of esthetic dental
proportions. The aim of this study was to analyze smiles considered to be harmonious, by
observing the patterns of proportion between the width and length of the central incisor and its
shape. Methods A total of 85 people with harmonious smiles were used for the sample,
divided by sex and age. Two photographs were produced for each patient: smile and
occlusion, using a lip retractor. The photographs were scanned and transferred to the
software application Corel Draw 10, where the esthetic dental factors were measured. Results
t was shown that harmonious smiles usually have a height/width ratio of between 65% and
85% and a predominance of the triangular shape, followed by the square shape. Conclusion
Despite differences in tooth size and shape, they have, both individually and in conjunction, a
certain proportion, as does the face and more specifically, the mouth.

n +01+ also 3i42un 5u et al did as study about morphometric analysis of maxillary central
incisor on the basis of facial appearance of Korean to identify a more esthetic width-to-length
ratio by analyzing maxillary central incisor of Korean adult population. A total of 40 men and
40 women were included in this study. The NON-MEDA group included 40 non-celebrities,
who were healthy and 25 to 39 years old, with normal dentofacial appearance. The MEDA
group consisted of 40 celebrities selected only on the basis of their soft-tissue facial
appearance. The facial photographs of 40 celebrities were collected from the nternet
websites. The width and length of the maxillary central incisor were measured using Adobe
Photoshop 7.0, a software for analysis, measurement and edition of photographs. Data
were analyzed statistically using the ndependent t-test at 5% statistical significance level.
The mean ratio for the MEDA group was 0.77, whereas that of the NON-MEDA group was
0.88. The difference between the two groups was statistically significant. No significant
gender differences were found in the width-to-length ratio in MEDA group. n NON-MEDA
group, however, there were significant differences between female and male. The study
concluded that After analyzing maxillary anterior teeth of Korean adults, our results were in
accordance with the general Western standards of esthetics. A dentist restoring the natural
look and beauty of teeth will have to consider those standards.
Al-Marzok et al +016 evaluated the maxillary anterior teeth and their relation to the golden
proportion in malaysian with the purpose to evaluate whether consistent relationships exist
between tooth width and height of the clinical crown dimensions; and to investigate the
occurrence of the golden proportion of the maxillary anterior teeth. Dental casts of the
maxillary arches were made in this cross-sectional study from MAHSA University College
students who met the inclusion criteria. The 49 participants represented the Malaysian
population main ethnics. The dimensions of the anterior teeth and the perceived width of
anterior teeth viewed from front were measured using a digital caliper. Comparison of the
perceived width ratio of lateral to central incisor and canine to lateral incisor with the golden
proportion of 0.618 revealed there were a significant statistical difference (p < 0.05). The
statistical difference was significant for the width-to-height ratio of central incisors to the
golden standard of 80%. There was no significant difference in the comparison among ethnic
groups for the golden proportion and the golden standard. The golden proportion was not
found to exist between the perceived widths of maxillary anterior teeth. No golden standard
were detected for the width-to-height proportions of maxillary incisors. Specific population
characteristics and perception of beauty must be considered. However, ethnicity has no
association with the proportions of maxillary anterior teeth.


7ishnu ) +016 did a review named it: Esthetic Paradigms in the nterdisciplinary
Management of Maxillary Anterior Dentition where he reviewed some commonly used esthetic
proportions and paradigms in dentistry. Establishing optimal anterior esthetics frequently
entails restorative, orthodontic, and periodontal treatment. Several guidelines have been
purported to facilitate an esthetic outcome during the rehabilitation of the maxillary anterior
teeth. The golden proportion, recurring esthetic dental proportion, tooth width : height ratios,
vertical positioning of the maxillary lateral incisor, and the apparent contact dimension are
examples of some such guidelines. Evaluation of these esthetic paradigms including their
validity, esthetic significance, perception by laypeople, and the range of tolerance to
alterations are very important considerations.This review presents a comprehensive analysis
of some selected esthetic dental paradigms and recommendations for their application in the
interdisciplinary management of anterior dental esthetics.
8in 3a!ayet &. et al +01, compared Crown Width/Length Ratio of Six Maxillary Anterior
Teeth between Different Facial Groups in Bangladeshi Population Measurements were done
in 70 male and 70 female Bangladeshi adults. Facial index was used to determine the broad,
average, and narrow facial type. Crown width/length ratio of six maxillary anterior teeth was
measured from the study models. Percentage of each facial type was determined. There were
no patients with broad facial type. 55.71% of subjects represented narrow face and 44.28%
represented average face. For male, 57.14% were narrow face and 42.85% were average
face. For female, 54.28% were narrow face and 45.71% were average face. n male group,
the mean crown width/length ratio and standard deviation of the central incisors, lateral incisor
and canine in narrow face group were 0.921 mm 0.078 mm, 0.878 mm 0.172 mm and
0.896 mm 0.097 mm respectively. For average face group, the ratio was 0.914 mm 0.087
mm, 0.865 mm 0.112 mm and 0.885 mm 0.073 mm. n female group, the narrow face
showed the ratio of 0.965 mm + 0.107 mm, 0.898 mm 0.138 mm and 0.912 mm 0.087
mm. The average face group ratio was 0.989 mm 0.166 mm, 0.898mm 0.092 mm and
0.910 mm 0.087 mm respectively. There was no significant difference in the mean crown
width/length ratios of maxillary anterior teeth between narrow and average facial groups (p
&gt; .05). Conclusion: Crown width/length ratio of six maxillary anterior teeth obtained from
this study can serve as a guideline for selection of appropriate tooth size and shape of
anterior teeth for Bangladeshi population.

*aterials and *ethods
Study /esign9
A cross-sectional analytic interview study comparing participants perceptions of
the esthetic value of their smile by color photographs with the standards of
esthetic values in dental literature in the light of the effect of gender as a
confounder on this variables.
Participants:
From the Kuwait University Faculty of dentistry student population, 50
participants would be chose randomly from the students of the 2
nd
academic
year cohort, which is the last preclinical year in the faculty, where the students
still don't have a review of the fundamentals of the clinical values of esthetic
and so as not affect their choice of most attractive smile, students to participate
in the study would be chosen according their students D numbers randomly,
where each fifth number of the students would be taken from the administrative
data file .The chosen students would be assigned to 2 groups according to
gender, so as to be 25 males and 25 females.
S!ile $ssess!ent9
Participants would be told that the investigator is researching "the way we look
at our smile.Each participant as asked their perceptions of their own smile after
digital modifcations of their smile to choose which is the most attractive smile,
of 3 photographs with one exposing 3 mm of gingiva , other with the lip at
dentoginigival junction, and the last with lip covering 3 mm of the gingiva.
For assessing smile attractiveness, a participant specific questionnaire was
developed. Where the 3 colored digitally modified photos would be on the left of
the questionnaire and on the right of each photo a 3 check box labeled with bad
smile, moderate smile, good smile so as the participant choose which is the best
photograph he would represent the most attractive in his opinion.
Statistical $nalysis9
-sing SPSS 17 statistical analysis co!uter rogra!: the statistical data
analysis o# the study would done: to co!are %etween the articiants
choice o# the good looking s!ile in the light o# the e##ect o# gender as a
con#ounder.
)e#erences
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