CLINICAL RESEARCH

Prevalence of alterations in the characteristics of smile

symmetry in an adult population from southern Europe
Emilio Jimnez-Castellanos, PhD, DMD,a Ana Orozco-Varo, PhD, DMD,b Gema Arroyo-Cruz, PhD, DMD,c and
Alejandro Iglesias-Linares, PhD, DMDd
Attempts to analyze and
ABSTRACT
determine characteristics of an
Statement of problem. Deviation from the facial midline and inclination of the dental midline or
ideal smile have been reocclusal plane has been described as extremely inuential in the laypersons perceptions of the
ported,1-3 together with the
overall esthetics of the smile.
negative inuence of alterPurpose. The purpose of this study was to determine the prevalence of deviation from the facial
ations on overall life quality4,5
midline and inclination of the dental midline or occlusal plane in a selected sample.
or the effect of an attractive
Material and methods. White participants from a European population (N=158; 93 women, 65
smile on personal satisfaction
men) who met specic inclusion criteria were selected for the present study. Standardized 1:1 scale
6,7
and individual personality.
frontal photographs were made, and 3 variables of all participants were measured: midline deviWhen it comes to quantitative
ation, midline inclination, and inclination of the occlusal plane. Software was used to measure
and qualitative characteristics
midline deviation and inclination, taking the bipupillary line and the facial midline as references.
of the smile, sex is generally
Tests for normality of the sample were explored and descriptive statistics (means SD) were
calculated. The chi-square test was used to evaluate differences in midline deviation, midline
considered to be an inuencing
8
inclination, and occlusion plane (a=.05)
factor. Patient awareness and
developments in dental techResults. Frequencies of midline deviation (>2 mm), midline inclination (>3.5 degrees), and occlusal
niques have contributed to an
plane inclination (>2 degrees) were 31.64% (mean 2.71.23 mm), 10.75% (mean 7.9 degrees 3.57),
and 25.9% (mean 9.07 degrees 3.16), respectively. No statistically signicant differences (P>.05)
increased demand for dental
were
found between sex and any of the esthetic smile values.
treatment and a greater
esthetic concern among paConclusions. The incidence of alterations with at least 1 altered parameter that affected smile
esthetics was 51.9% in a population from southern Europe. (J Prosthet Dent 2016;115:736-740)
tients about specic features of
9-11
their smile.
Kokich et al,12 in 1999, studied patient perceptions of
inclination and the inclination of the occlusal plane on
and concerns about specic features of the smile and
the perceptions of a Spanish population sample deterestablished well-dened quantitative and qualitative
mined that a midline deviation of more than 2 mm from
limits of acceptability for modications as perceived by
the dental midline, a dental midline inclination of 3.5
laypersons and professionals. Since then, various studies
degrees, and an incisal plane inclination of 2 degrees
have analyzed the inuence of specic esthetic smile
constituted the respective visual perception thresholds of
changes on the perceptions of laypersons.13-18
a poor esthetic appearance.19 This agrees with other
Findings from a previous study carried out by our
data from different populations obtained with measuregroup of the inuence of midline deviation and
ments from frontal photographs.15,16,20-24

Dentistry Department, University of Seville, Seville, Spain.

Associate Professor, Dentistry Department, University of Seville, Seville, Spain.
c
Associate Professor, Dentistry Department, University of Seville, Seville, Spain.
d
Associate Professor, Department Stomatology IV, Complutense University of Madrid, Madrid, Spain.
b

736

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737

Clinical Implications
Facial analysis is needed in rehabilitation treatment,
under esthetic conditions due to the high prevalence
of deviation and inclination of the dental midline
and the inclination of the occlusal plane.

Various studies have stated that midline deviation

ranges from 4% to 54% in Saudi Arabian teenagers,25,26
students,27 and the general population of the United
States,28 sportsmen from Brazil,29 Brazilian students,30
Portuguese students,31 and Indian young people.32
Although numerous studies have underlined the highly
unesthetic impact of midline inclination on the overall
perception of smile attractiveness among the general
population33-36 and of midline or occlusal plane inclination,37 few have commented on how common these alterations are in the population.38 Kattadiyil et al39 stated
that their prevalence in some populations was 23.8% and
that perception was largely determined by sight angle.
The incidence of these types of smile characteristics in
specic populations is therefore of considerable interest.
The main objective of the present study was to determine
the prevalence of these alterations in a selected population of Spanish origin, as compared with other populations described in the literature, in order to improve
treatment planning.
MATERIAL AND METHODS
The nal sample included 159 white individuals drawn
from a Spanish population, who visited a dentists ofce
for different reasons between January and December
2013. The individuals were consecutively invited to
participate in the study provided they fullled the
following selection criteria: adults only; had at least 6
anterior maxillary teeth present; no previous orthodontic
or restorative treatment in the anterior area; no craniofacial deformities; no alterations to the morphology of the
6 anterior maxillary teeth; no history of orthognathic
surgery; no muscle tone alterations to the facial musculature; and they were white and of Spanish origin.
All individuals who met these criteria participated in
the present study. Exclusion criteria were determined
by subsequent analysis of the recorded photographs.
Those whose records failed to meet the required standard (1:1 scale; appropriate quality of the captured
image; the line bisecting the intercanthal line coincided
with the nasion and nasal tip) were eliminated from
analysis.
The same camera (Easy Share model Z7590; Kodak)
was used to obtain standardized extraoral photographs
of all participants. Participants were photographed
in a standing position and against the same white
Jimnez-Castellanos et al

Figure 1. Representative image with selected landmarks and traced

lines. C, canthus landmark; Co, commissural point; Co-Co0 , intercommissural line; Ic-Ic0 , intercanthal line; Na, nasion; Na-Ph, facial midline; NT,
nasal tip; Ph, philtrum.

background. As previously described in other studies,30,31

a cheek retractor was used for all photographic projections. All photographs were captured in 1:1 scale with
the cameras scaling device. The accuracy of the described
method was assessed by measuring previously scaled
pictures and adding a scale bar to the picture obtained.
Having previously aligned all photographs with the
bipupillary line and the line bisecting the inner intercanthal distance and after assessing whether all records
met the quality criteria indicated, a photogrammetric
study was performed. The following landmarks were
identied on all photographs: Na, nasion; Ph, philtrum;
C, canthus landmark; NT, nasal tip; Co: commissural
point. Connection lines and angles were as follows:
Na-Ph, facial midline; Ic-Ic0 , intercanthal line; Co-Co0 ,
intercommissural line was traced, and linear and angular
parameters were measured on all the photographs (Power Point 2010 software; Microsoft; golden ratio 1:1;
Windows 2000) (Fig. 1) following a modied method
taken from methods and measurements published previously.17,30-32
To assess the precision of the method, 20 pictures
were selected at random to evaluate whether the selected
midline coincided with the main reference points of the
facial midline.40
To establish the diagnostic agreement of the method
of measurement, 20 pictures were chosen at random
from among those taken of the 159 participants. Linear
and angular parameters of these 20 pictures were
measured again, rst by the same examiner (E. J-C.)
and then by a second examiner (A.O.V.). Intraclass
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Table 1. Frequencies and distribution of asymmetric characteristics found

Characteristic

Frequency (%)

No. of Women (%)

No. of Men (%)

Mean (SD)

Total midline deviation

57 (36.1%)

36 (63.2%)

21 (36.8%)

2.56 (1.29)

Midline deviation (>2 mm)

50 (31.64%)

33 (66%)

17 (34%)

2.78 (1.23)

Total midline inclination

20 (12.7%)

14 (70%)

6 (30%)

7.06 (3.87)

P
.512

Midline inclination (>3.5 )

17 (10.75%)

12 (70.6%)

5 (29.4%)

7.90 (3.57)

.401

Occlusal plane inclination (<2 )

41 (25.9%)

26 (63.4%)

15 (36.6%)

9.07 (3.16)

.587

Alteration of at least 1 characteristic MD and/or MI and/or OPI

82 (51.9%)

49 (59.8%)

33 (40.2%)

.991

MD, midline deviation; MI, midline inclination; OPI, occlusal plane inclination.

correlation coefcients were determined to assess both

intraexaminer and interexaminer reliability. In all cases,
the intraexaminer and interexaminer correlation was
more than 0.75, which is considered excellent.41
Statistical analysis was descriptive, with calculations
of means, standard deviations, and frequencies. The
normality of the sample was tested, and a nonparametric
test was used to analyze associations between sex and
dened linear and angular parameters (corrected chisquare test results; a=.05). All data were compiled and
analyzed by means of software (SPSS Statistics v22; IBM
Corp).
RESULTS
The sample consisted of 158 participants (65 men
[41.1%] and 93 women [58.9%]), ranging from 13 to 78
years of age (mean: 43.14 14.72 years of age). Table 1
shows the frequencies for parameters associated with
facial midline asymmetry, with deviation from the
midline being considered more than 2 mm, midline
inclination greater than 3.5 degrees, and occlusion plane
inclination greater than 2 degrees. Deviation from the
midline was found in 36.1% (n=57) of the sample (mean
deviation 2.56 1.29 mm) and, in terms of sex, was more
common among women than men (36.8% males [n=21];
63.2% in women [n=36]). Seven participants, however,
showed a midline deviation of less than 2 mm and 50 of
more than 2 mm.
The frequency of midline inclination was 12.7% (30%
men [n=6] and 70% women [n=14]) with a mean deviation of 7.06 (3.87) degrees. Seventeen of the 20 participants had a midline deviation of more than 3.5
degrees (10.75% of the total sample), with an average
inclination of 7.90 (3.57) degrees.
An inclination of the occlusal plane was observed in
25.9% (n=41) of participants (15 men [36.6%] and 26
women [63.4%]), with an average of 9.07 (+3.16) degrees
of inclination. The inclination exceeded 2 degrees in all
participants. Thirty-three men and 49 women, 51.9% of
the sample, showed alterations of at least 1 of the characteristics of the symmetrical smile. No statistically signicant differences were observed for any of the study
variables associated with total prevalence (P<.05)
(Table 1).
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DISCUSSION
A modied version of a previously published photogrammetric methods and standardized photograph captions at 1:1 scale were used.30-32 However, in addition to
measuring midline deviation, other essential parameters
of the smile were included, such as midline inclination
and inclination of the occlusal plane.
Other studies, including that of Kattadiyil et al,39
analyzed the inuence of the angle of vision on the
occlusal plane in the perception of an esthetic smile and
concluded that the frontal view was best for professional
and other nondental evaluators. This supports the choice
of a frontal photograph for assessing this parameter in
the present study.
One of the main controversies concerns the reference
plane to be used to make photogrammetric measurements. The appropriateness of the line bisecting the
intercanthal line has been discussed at length in the
literature,30,31 although no full consensus has been
reached on the ideal reference line or plane. Many
investigators,32,40 have proposed and validated the
reference line adopted in this study. Bidra et al40 studied
and determined which facial anatomic landmarks lay
closest to the real facial midline and the midline of the
mouth and concluded that the line midway between the
oral commissures, the natural dental midline, the nasion,
the philtrum, and the tip of the nose were the best points
for tracing the real facial midline. In the present study, a
randomized selection of photographic records was used
to test whether the landmarks cited by Bidra et al40 were
those that best matched the facial midline used by our
group, although here only deviations of more than 2 mm
were taken into account, which makes this limitation of
secondary importance.
As in previous studies, which used sample sizes
ranging between 80 and 200 participants,29-32,38 a
representative sample size (n=158) was used to dene
the frequency of relevant smile characteristics in this
specic population. The frequency of deviation from the
facial midline (36.1%) in our specic population was
similar to those found by Sheats et al27 (39%) and Miller
et al28 (30%) for other subgroups and more frequent
than those described in studies by Murshid et al25
(24%), Alamoudi et al26 (10%), and Souza et al29
Jimnez-Castellanos et al

June 2016

(4%). The last study, however, was carried out in a

subpopulation of 84 athletes, who might have an untypical appearance.
Different ndings have been observed for the specic
impact of midline deviation on perceptions of the smile,
as rated by the general population. Kokich et al12,13
highlighted the fact that a 4-mm deviation from the
midline was not perceived as changing overall facial esthetics, although those studies limited the area of study
to the perioral cavity so that the remainder of the face
played no part in the general perception. Compared to
these ndings, other studies17 have concluded that the
threshold for detecting a midline deviation among both
dental professionals and nonprofessionals is 2 mm. A
deviation of less than 2 mm is not noticed by observers,
which is consistent with numerous studies that have
used the whole face to evaluate perceptions of the
characteristics of smile esthetics and their inuence when
altered.15,16,18-24 These studies concluded that the general population was able to detect a midline deviation of
more than 2 mm and regarded it as unesthetic. On the
basis of this assumption, a distinction was made in the
present study between a midline deviation of any
magnitude (36.1%) and one that was more than 2 mm
(31.64%). Studies such as those by Jayalakshmi et al32
have likewise found frequencies of approximately 50%
and 37%, respectively. (50% midline deviation of any
magnitude and 37% more than 2 mm).
Sex is usually considered to be an inuencing factor in
the quantitative and qualitative characteristics of the
smile.8 However, although differences between the sexes
were observed (women more commonly had midline
deviations than men), these differences were not statistically signicant. This nding agrees with results
described by other investigators.30,31 However, Alamoudi
et al26 and Jayalakshmi et al32 did nd statistically signicant differences, and midline deviation was more
frequent among women than men.
Midline inclination has been described as having a
much stronger negative impact than midline deviation
on the perception of an esthetic smile,33-37 although
surprisingly, the prevalence of midline inclination in
the population has not previously been described. Our
results showed that midline inclinations accounted for
just 12.7% of the sample. Furthermore, if we consider
the threshold to be 3.5 degrees, which is where
different authors report that the general population
starts to perceive it as unesthetic, the frequency in
the present sample was even lower (10.7%). No statistically signicant differences by sex were found
(P>.05).
The frequency of occlusal plane inclination in other
populations was found to be around 24%,38 which is
similar to the ndings of a study of a population from
southern Europe (25.9%). No differences by sex were
Jimnez-Castellanos et al

739

found (P>.05). However, the inclinations recorded in this

study were greater than 2 degrees, which, according to
some authors, is the point at which it is perceived as
esthetically unacceptable to the layperson.37
This study reports useful information about some of
the main characteristics of the smile that are considered
by both the layperson and the professional in determining whether a smile is esthetic. Many factors can
be considered in an analysis of what constitutes the
esthetic smile, including the correct proportions, color,
symmetry, gingival margins, buccal corridors, incisal
edges, and lip-to-teeth relationship; balancing them all
is an important concept in prosthodontics.42 Although
any alteration in any of the variables cited is important,
many authors have focused on the esthetic impact of
midline deviations and inclinations and inclination
of the occlusal plane. Judging by the results of the authors cited, those variables are considered to be easily
detectable by the general population,12-14,19 which is
why we set out to establish how prevalent they were
in a specic population. Nevertheless, the consideration of whether a smile is esthetic or a face generally
attractive depends on various anatomic24 and psychological factors.43,44 Identifying an attractive face induces
the activation of the medial orbitofrontal cortex, a region
involved in representing associations between stimulus
and reward, which is highly activated by smiling facial
expressions.
One report concluded that teenagers rated the
perceived positive skills of other teenagers with attractive
smiles as 10% higher than those with less attractive
smiles.45 In the same vein, other personality trait factors,
such as calmness, warmth, low anxiety, and extroversion,
correlated strongly with a beautiful smile.7 Future studies
should perhaps study in greater depth the combination
of psychological evaluations and the way these factors
affect specic esthetic variations in the perception of an
esthetic smile. This might give clinicians a better understanding of the key factors to be considered for all aspects
of successful dental rehabilitation.
CONCLUSIONS
The prevalence of esthetic smile alterations, with at least
1 altered parameter, in a white population from southern
Europe was 51.9%, and women were affected more than
men (59.8% and 40.2%, respectively), although signicant differences related to sex (P>.05) were not found.
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Corresponding author:
Dr Emilio Jimnez-Castellanos
Dentistry Department, College of Dentistry
Sevilla University
Street Avicena s.n. 41009 Sevilla
SPAIN
Email: ejcb@us.es
Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

Jimnez-Castellanos et al