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Canine substitution for missing maxillary lateral

incisors: The influence of canine morphology,
size, and shade on perceptions of smile
attractiveness
Elaine Brough,a Ana Nora Donaldson,b and Farhad B. Nainic
London, United Kingdom

Introduction: This study was conducted to determine whether variations in the morphology, size, or shade of
maxillary canines would influence perceptions of smile attractiveness in patients with canines substituted for
missing maxillary lateral incisors. Methods: A smiling photograph of a hypodontia patient who had had
orthodontic space closure with maxillary canines replacing the lateral incisors was digitally modified to create
a bilaterally symmetrical image. Four groups of images were created, digitally altering canine gingival height,
crown tip height, canine width, and canine shade. Three groups of judges (40 orthodontists, 40 dentists, and
40 laypeople) ranked the images for smile attractiveness, also scoring the most and the least attractive of each
of the 4 groups, and the most and least attractive of all images. Results: Canine gingival height was the most
attractive 0.5 mm below the gingival margin of the maxillary central incisor and progressively less attractive
with increasing gingival height. Increasing canine width, increased canine tip height, and pointed canines
were perceived to be unattractive. Brighter than normal shades of canines were preferred to darker shades.
Narrow canine crowns were most frequently ranked as the most attractive overall, 1.5 mm narrower was
preferred by the orthodontists and dentists, and 3.0 mm narrower was preferred by the laypeople. All 3 groups
ranked the darkest image, 20 times darker than the original, most frequently as the least attractive image over-
all. There was good general agreement between orthodontists, dentists, and laypeople for all 4 parameters of
smile attractiveness, although laypeople demonstrated greater intragroup variations. Conclusions: The
morphology, size, and shade of the maxillary canine in patients having orthodontic space closure and lateral
incisor substitution can have a marked effect on perceived smile attractiveness. (Am J Orthod Dentofacial
Orthop 2010;138:705.e1-705.e9)

I
t has been reported that hypodontia (excluding third
molars) affects between 3% and 6% of the general
population. The maxillary lateral incisor is the sec-
ond most affected tooth with an incidence of 1% to 2%
in Caucasians1 and accounts for 20% of all missing
teeth.2 The absence of the maxillary lateral incisors af-
fects the proportions of the maxillary labial segment and
ultimately the esthetics of the smile. An unattractive
smile can affect a persons appearance, personality,
a
Specialist registrar, St Georges Hospital, London, United Kingdom.
b
Reader in Biostatistics, Kings College London Dental Institute, Department of
Biostatistics, Kings College London, United Kingdom.
c
Consultant orthodontist/honorary senior lecturer, St Georges Hospital and
Kingston Hospital, London, United Kingdom.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Farhad B. Naini, St Georges Hospital and Medical School,
Blackshaw Rd, London SW17 0QT, United Kingdom; e-mail, Farhad.Naini@
yahoo.co.uk.
Submitted, January 2010; revised and accepted, April 2010.
0889-5406/$36.00
Copyright 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.04.027
and psychological well-being.3 It might also provoke
an unfavorable response from others in society.4,5
The management of patients with missing maxillary
lateral incisors can be challenging, commonly involving
1 of 3 possible treatment approaches: accepting the
space, creating enough space for replacement with pros-
thetic units (denture, bridge, or implant) for the missing
lateral incisor, or closing the space orthodontically with
the maxillary canine substituting for the missing lateral
incisor and camouflaging the canine to mimic the ap-
pearance of a lateral incisor. The difficulty with the ca-
nine substitution method is achieving an acceptable
esthetic outcome, because of the inherent size, shape,
and shade differences between the maxillary canine
and lateral incisors.6
The advantages of space closure with canine substitu-
tion are the avoidance of long-term maintenance of the
prosthetic replacement of the lateral incisor with a denture,
bridge, or implant, which can have future retreatment re-
quirements and cost implications. Patients who had space
closure were found to be periodontally more healthy than
those with prostheses7; there was no significant difference
705.e1
705.e2 Brough, Donaldson, and Naini
in occlusal function and prevalence of temporomandibular
dysfunction.7,8 However, this treatment approach requires
careful consideration of the differences in the morphology
between the lateral incisor and the canine, and whether the
patient is ultimately suitable for space closure and the
result will be acceptable and esthetic.
The lateral incisor has incisiform morphology: ie,
a smaller, flat-faced tooth compared with the caniniform
and conical shaped canine. The canine has a broader
neck and, because the tooth is thicker and contains
more dentin, is often darker. The gingival margin of
the canine is usually higher than that of the lateral inci-
sor, and canines tend to have a prominent tip. If these
differences are not compensated for, the esthetic out-
come will be compromised.9-11
Several techniques can be used to mask the differ-
ences between the 2 tooth types. The canine bracket
can be inverted to increase palatal root torque, which
might reduce the eminence of the canine. The bracket
can be positioned more gingivally to extrude the canine
and its gingival margin; the canine tip can then be re-
duced.12 Since the canine is wider than the lateral inci-
sor, its width can be reduced mesiodistally with
interdental enamel reduction. Finally, because the ca-
nine is often naturally darker than the adjacent lateral
incisor, the tooth can be bleached after orthodontic
treatment.
Previously, authors have investigated perceived
smile attractiveness in hypodontia patients (Table
I).2,13-16 However, the influence of the morphology of
the maxillary canine on the perceived attractiveness of
the smile has not been investigated.
The principal aims of this study were to (1) quanti-
tatively score smile attractiveness in a hypodontia pa-
tient, managed with space closure and maxillary
canines substituted for the missing lateral incisors,
with incremental alteration of the following parameters
of the maxillary canine: crown width, crown height and
tip morphology, gingival margin height, and shade; and
(2) compare the perceptions of smile attractiveness
between orthodontists, dentists, and laypeople.
MATERIAL AND METHODS
One hundred twenty observers were recruited as
participants for the study. They were orthodontists, den-
tists, and laypeople.
Each group had 40 observers. The orthodontists
comprised final year and higher orthodontic trainees,
specialist practitioners, and hospital consultants and in-
cluded 12 men and 28 women (18 white and 22 non-
white; mean age, 33.9 6 7.8 years; range, 26-65
years). The dentists were all qualified practitioners
American Journal of Orthodontics and Dentofacial Orthopedics
December 2010
and included 16 men and 24 women (26 white and 14
nonwhite; mean age, 34.3 6 11.2 years; range, 23-57
years). The lay group comprised people from various
nonclinical backgrounds and included 11 men and 29
women (33 white and 7 nonwhite; mean age, 36.6 6
11.7 years; range, 20-63 years). Each observer was
asked to rank a series of images in the order of attrac-
tiveness of the smiling mouth, displaying the maxillary
second premolar to second premolar. The original
photograph was of a smiling mouth showing only the
maxillary dentition of a hypodontia patient who had
been treated by space closure and canine substitution.
A photograph of a patients smile was selected that
exhibited good dental alignment, having had maxillary
canines substituted for missing lateral incisors. The
photograph showed the maxillary teeth, lips, and sur-
rounding skin, but the nose and chin were cropped out
to reduce the confounding variables. A bilaterally sym-
metrical image was digitally created (Photoshop CS2
software, Adobe Systems, San Jose, Calif). The photo-
graph was then digitally altered to create 31 images di-
vided into 4 groups. In each group of images, 1 variable
was incrementally altered; the variables were canine
width (6 images), canine crown height and tip morphol-
ogy (9 images), canine gingival margin height (6 im-
ages), and canine shade (10 images). A duplicate of 1
image was included in each group of images to assess
intraexaminer reliability (Fig 1).
The images were printed on color photographic
paper in size 6 3 4 in, and each image had a unique
identifier number on the reverse side of the image.
The images were laid out on a table in their 4 groups
in random order.
All observers in the study were given the same
verbal instructions by the same examiner (E.B.). The
observers were asked to study 1 group of photos at
a time and then to rank them for attractiveness, from
most to least attractive.
Once they had ranked the 4 groups of images and
were happy with their decisions, the 4 most attractive
images they selected were grouped together, and the 4
least attractive images were grouped together sepa-
rately. They were then asked to pick the most attractive
image from the 4 attractive images and the least attrac-
tive image from the 4 least attractive images.
Statistical analysis
The data were analyzed by using descriptive, mixed
logistic regression analysis. Data analysis was per-
formed with a statistical package (version 9, Stata,
StataCorp, College Station, Tex).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
Table I. Previous studies of the management of patients with hypodontia of the maxillary lateral incisor and smile
attractiveness
Topic Authors
13
Influence of various dimensions of Bukhary et al
maxillary lateral incisors to smile
attractiveness
Bilateral aplasia of maxillary lateral Zimmer and
incisors and orthodontic space Seifi-Shirvandeh14
closure
Missing maxillary lateral incisors; Armbruster
esthetic impact, comparing dental et al15,16
specialists and laypeoples
opinions
Lateral incisor agenesis Robertson
and Mohlin2
PPM, Push-and-pull mechanics; TMD, temporomandibular dysfunction.
Preference scores per image were computed overall
and for each observer and professional group. Average
ranks for each parameter were investigated along with
differences in ranks given by each group.
Mixed logistic regressions were used to assess what
influenced the choice for the most and the least attrac-
tive images. The independent variables were sex, age,
ethnicity, amount of alteration, and professional status
(group) of the observer.
RESULTS
Each of the 4 groups of images was analyzed individ-
ually. The data were analyzed for image preference related
to the person, the observer group, and the overall total.
In the overall data of canine width alterations (Table II),
the image that was favored by most observers was
image 5; 50% of the observers found it the most attrac-
tive, followed by images 1 and 6. The least attractive
image was image 4, 71.67% of the observers finding it
the least attractive.
Brough, Donaldson, and Naini 705.e3
Sample Results
41 hypodontia and 46 nonhypodontia Digitally altered width and height of
patients, 30 dentists maxillary laterals: 67% then 72%
lateral to central ratio preferred.
Images of maxillary laterals
1-1.5 mm shorter than the centrals
were perceived as attractive;
significantly shorter or longer teeth
were unattractive.
25 patients (15 female, 10 male), Class III elastics are an essential part
bilateral maxillary lateral incisor of PPM that have minor dental and
aplasia treated by PPM (for space skeletal effects. Orthodontic space
closure) closure for bilateral maxillary
lateral incisor aplasia by PPM is
a valid alternative to prosthetic
replacements.
140 dentists, 43 orthodontists, 29 Laypeople ranked canine substitution
dental specialists, 40 laypeople highest. Orthodontists preferred no
teeth missing .canine substitution
.bridges .implants. Restorative
dentists would restore the missing
tooth, but they did not necessarily
rank the restored option image as
attractive.
50 patients; 30 had space closure, 20 Space closure patients were more
had space opening and restorative satisfied with treatment outcome
replacement than space opening patients. No
difference in TMD symptoms.
Space opening: poorer periodontal
condition, greater plaque
accumulation, and gingivitis.
There were no significant differences in participant
preferences (most or least attractive) related to age,
sex, or ethnicity.
In the data for group-specific differences, there were
significant differences in the preferences for attractive-
ness of the photographs comparing the orthodontists
and the laypeople, and the dentists and the laypeople
(there were no significant differences between the
orthodontists and dentists).
By using multivariate logistic regression, both the
orthodontist and the dentists were statistically signifi-
cantly more likely to pick image 5 as attractive (ranked
1 or 2). Orthodontists and dentists were 12.5 and 7.7
(P 5 0.001) times more likely, respectively, to pick image
5 as attractive; 92.5% of the orthodontists, 85% of the den-
tists, and 58% of the laypeople ranked image 5 as 1 or 2.
The least attractive image was number 4. It was
almost unanimously ranked as the least attractive image
by all groups; 72% of all observers found image 4 the
least attractive. Both orthodontists and dentists were
more likely than laypeople to rank this image least
705.e4 Brough, Donaldson, and Naini American Journal of Orthodontics and Dentofacial Orthopedics
December 2010

Fig 1. A, Canine width images; B, canine crown height and tip morphology images; C, canine gingi-
val height images; D, Canine shade images.

attractive; 95% of the orthodontists and 85% of the either by the dentists or the orthodontists and only by
dentists ranked it least attractive, but only 35% of 5% of the laypeople.
the laypeople agreed with this. No observer chose it as All 3 groups were in general agreement about
the most attractive. It was never chosen in second place, which images were attractive and unattractive, in terms
American Journal of Orthodontics and Dentofacial Orthopedics Brough, Donaldson, and Naini 705.e5
Volume 138, Number 6

Table II. Overall and group-specific ranks for variations in canine width for each group
Orthodontists Dentists Laypeople

Image Alteration Mean score SD Mean SD Rank Mean SD Rank Mean SD Rank

1 (D.D.) Original image 2.46 1.20 2.08 0.86 2 2.33 0.83 2 2.98 1.59 2
2 (V.E.) 1.5 mm wider 4.12 1.20 4.23 0.95 4 4.10 1.24 4 4.03 1.39 5
3 (L.B.) 1.5 mm wider 3.98 1.30 4.35 0.86 5 4.20 0.99 5 3.38 1.69 4
(copy of image 2)
4 (M.D.) 3.0 mm wider 5.47 1.00 5.93 0.35 6 5.83 0.45 6 4.65 1.29 6
5 (R.S.) 1.5 mm narrower 1.94 1.31 1.48 0.64 1 1.58 0.87 1 2.78 1.73 1
6 (Y.D.) 3.0 mm narrower 3.04 1.45 2.95 1.06 3 2.98 1.37 3 3.20 1.84 3

of width of the canine. However, the spread of the
data and therefore the variations in opinions of the lay-
people were greater than those of the orthodontists and
dentists.
In the overall data of canine tip alterations (Table III),
the image that was favored by most observers was image
1; 35.8% of them found it the most attractive, followed by
images 3, 4, and 2. The least attractive image was image 9;
57.5% of the observers found it the least attractive image.
There were no significant differences in observer
preferences related to age, sex, or ethnicity.
In the multivariate logistic regression, the orthodon-
tists and dentists were more likely than laypeople to find
image 1 attractive and rank it either as 1 or 2. The odds
of this were 7.14 times greater for orthodontists than
laypeople (P 5 0.000) and 4 times greater for dentists
than laypeople (P 5 0.01).
Age (P 5 0.97), sex (P 5 0.20), and ethnicity
(P 5 0.99) had no significant effect on attractiveness
rank. Both orthodontists and dentists were more likely
than laypeople to rank image 1 as most attractive. Ortho-
dontists were 3.71 times more likely than laypeople
(P 5 0.02) and dentists were 1.85 times more likely
than laypeople (P 5 0.26) to prefer image 1.
The image found least attractive more often was
image 9; 57.5% of all observers found image 9 the most
unattractive. It was chosen by 82.5% of the orthodontists,
51.2% of the dentists, and 40% of the laypeople. No
orthodontist or layperson observer chose it as the most
attractive.
Orthodontists were significantly more likely than
dentists (P 5 0.003) and laypeople (P 5 0.0000) to
pick image 9 as the least attractive.
In the overall data of canine shade (Table IV), the
image that was favored by most observers was image
3 (10 times brighter); 23.33% found it to be the most at-
tractive, followed by image 2 (5 times brighter), image 4
(15 times brighter), and image 1 (original image). The
least attractive image was image 10 (20 times darker),
the darkest image; 78.33% of the observers found it
the least attractive image. No participant scored image
10 as the most attractive.
There were no significant differences in observer
preferences related to age, sex, or ethnicity.
When we analyzed the data for group-specific dif-
ferences with multivariate logistic regression analysis,
the orthodontists and the dentists were more likely
than the laypeople to pick image 3 as the most attractive
(1.74 and 1.4 times, respectively); however, this was not
significant.
Image 3 (10 times brighter) was preferred and
ranked number 1 by both the orthodontists and the lay-
people, whereas image 2 (5 times brighter) was ranked
first by the dentists. Both the orthodontists and the den-
tists favored the more natural shades, compared with the
laypeople, who ranked the brighter shades (15 and 20
times brighter) more attractive than the natural shades.
There was overall agreement between the 3 groups
that image 10 was the least attractive. In all 3 groups,
the 3 darkest shades were the least attractive, and the re-
lationship between darker shades and reduced attrac-
tiveness correlated.
Image 10 was ranked least attractive by 87.5% of the
orthodontists, 80% of the dentists, and 67.5% of the
laypeople. Although all groups agreed about the least
attractive image, the orthodontists (P 5 0.013) were
statistically more likely than the laypeople to pick
image 10. The difference between orthodontists and
laypeople was significant, whereas that between dentists
and laypeople was not.
Age (P 5 0.15) and sex (P 5 0.89) had no signifi-
cant effect on the preference ranks, but ethnicity did
(P 5 0.03).
In the overall data for canine gingival height (Table V),
the image that was favored by most of the observers was
image 1; 30% found it the most attractive, followed by
images 3, 2, and 4. Image 6 was ranked as the least
attractive image by 78.3% of the observers.
There were no significant differences in observer
preferences related to age, ethnicity, or sex.
705.e6 Brough, Donaldson, and Naini American Journal of Orthodontics and Dentofacial Orthopedics
December 2010

Table III. Overall and group-specific ranks for variations in canine height and tip morphology for each group
Orthodontists Dentists Laypeople

Image Altered canine tip Mean score SD Mean SD Rank Mean SD Rank Mean SD Rank

1 (J.K.) Original image 2.76 1.98 1.88 1.2 1 2.69 2.08 1 3.68 2.13 3
2 (X.O.) Increased 0.5 mm 3.66 2.3 2.45 1.38 2 3.56 1.94 4 4.93 2.67 5
3 (B.A.) Increased 0.5 mm 3.28 1.84 3.18 1.28 3 3.13 1.88 2 3.54 2.25 1
(copy of image 2)
4 (G.G.) Reduced 0.5 mm 3.55 2.03 3.28 1.34 4 3.33 1.9 3 4.02 2.6 4
5 (H.I.) Increased 1.0 mm 4.73 1.98 5.30 1.11 5 5.28 1.82 5 3.66 2.34 2
6 (E.A.) Reduced 0.5 mm and pointed 6.69 1.65 7.20 1.04 7 6.59 1.77 7 6.29 1.9 8
7 (S.A.) Increased 1.5 mm 5.72 1.75 5.48 1.36 6 5.82 1.7 6 5.85 2.13 6
8 (L.C.) Increased 0.5 mm and pointed 6.88 1.81 7.48 0.99 8 7.10 1.79 8 6.1 2.18 7
9 (A.Z.) Increased 1.0 mm and pointed 7.73 2.07 8.78 0.53 9 7.49 2.35 9 6.93 2.32 9

Table IV. Overall and group-specific ranks for variations in canine shade for each group
Orthodontists Dentists Laypeople

Image Alteration Mean score SD Mean SD Rank Mean SD Rank Mean SD Rank

1 (C.C.) Original 3.77 1.83 3.60 1.46 4 3.28 1.68 2 4.43 2.12 5
2 (E.B.) 5 times brighter 3.53 2.32 2.95 2.16 2 3.25 2.16 1 4.38 2.43 4
3 (H.J.) 10 times brighter 3.17 2.12 2.73 1.71 1 3.35 2.39 3 3.43 2.18 1
4 (G.H.) 15 times brighter 3.72 2.28 3.20 1.57 3 4.38 2.6 4 3.58 2.44 2
5 (F.C.) 20 times brighter 4.75 2.40 4.95 2.17 6 5.33 2.07 6 3.98 2.76 3
6 (D.E.) 5 times darker 5.06 1.88 4.68 1.75 7 4.98 1.95 5 5.53 1.88 6
7 (J.L.) 10 times darker 6.33 1.97 6.98 1.48 5 6.18 1.78 7 5.85 2.40 7
8 (K.B.) 10 times darker 7.06 1.83 7.38 0.98 8 6.68 1.95 8 7.13 2.28 8
(copy of image 7)
9 (B.B.) 15 times darker 8.18 1.92 8.80 0.85 9 8.33 2.14 9 7.43 2.23 9
10 (S.B.) 20 times darker 9.44 1.44 9.75 0.74 10 9.28 1.92 10 9.3 1.38 10

When we analyzed the data for group-specific dif-
ferences, there was an indication of a difference in the
preferences for attractiveness of the set of photographs
comparing the groups (P 5 0.07).
Dentists were more likely than orthodontists to give
the best ranks (1 and 2) to image 1 (P 5 0.03), and both
dentists and laypeople were slightly more inclined than
orthodontists to give the highest rank to image 1; these
differences were not statistically significant. Orthodon-
tists preferred image 3.
All groups ranked image 6 as least attractive. Eth-
nicity (P 5 0.06) had an effect on the worst rank. Age
(P 5 0.12) and sex (P 5 0.23) had no significant effect.
In the multivariate logistic regression, the orthodon-
tists and dentists were more likely than laypeople to
give the worst rank to image 6. Orthodontists were
statistically significantly more likely than the laypeople
to find image 6 unattractive (P 5 0.000).
The observers were also asked to pick the image that
they found the overall least attractive from the 4 images
chosen as least attractive in the previous section.
Figure 2 demonstrates the frequency of the images
ranked least attractive.
The image chosen as the overall least attractive im-
age was the darkest shade of the canine (SB, 20 times
darker); this was chosen by all 3 groups. This was
followed by image MD (canine, 3.0 mm wider), the
widest canine image; then image AZ (canine tip in-
creased by 1.5 mm and pointed), the longest crown tip.
Image SB was also chosen most frequently as the
least attractive by the laypeople, followed in order of
frequency by images MD and ZJ.
Agreement within the groups varied. The greatest in-
tragroup agreement was found in the orthodontists, with
5 images chosen as least attractive. This was followed by
the dentists with 8 images chosen as the least attractive.
Ten images were chosen by the laypeople as least attrac-
tive, demonstrating the lowest intragroup agreement.
The participants were also asked to pick the image
that they found the most attractive overall from the 4 im-
ages chosen as most attractive in the previous section.
Figure 3 demonstrates the frequency of the images
ranked most attractive.
The image chosen most frequently by the orthodon-
tists as most attractive was image RS (1.5 mm nar-
rower), with images CC (original image) and DD
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
Table V. Overall and group-specific ranks for variations in gingival margin height
Image Alteration Mean score
1 (O.P.) Original (0.5 mm below margin of U1) 2.57
2 (W.B.) 0.5 mm lower than image 1 2.74
3 (C.B.) Copy of image 2 2.68
4 (K.A.) 0.5 mm higher than image 1 3.00
5 (P.C.) 1.0 mm higher than image 1 4.51
6 (Z.J.) 1.5 mm higher than image 1 5.50
(original image) chosen equally second most frequently
as the most attractive image.
The image most frequently chosen by the dentists as
the most attractive overall image was image RS
(narrower by 1.5 mm), followed by image CC (original
image), the same as those chosen by the orthodontist
group. Images KA (gingival margin 0.5 mm higher),
DD (original image), and BA (0.5 mm increased crown
tip height) were equally selected as the most attractive
by the dentist group.
Different images were chosen as the most attractive
by the laypeople. Image YD (3.0 mm narrower, the
narrowest image from the group) was chosen most
frequently as the most attractive. The second most
commonly selected was image HI (1 mm increased
crown tip height), followed by image FC (20 times
brighter).
There was less agreement between groups and
within groups when selecting the most attractive image
compared with the least attractive image, as shown in
Figure 3. The most attractive image overall was unani-
mously image RS by both the dentists (29%) and the or-
thodontists (25%). This differed from the laypeople
(14%), who picked image YD as the most attractive, al-
though there was little agreement on which image was
the most attractive. There were 13 different images cho-
sen as the most attractive by the orthodontist group, 17
different images chosen by the laypeople, and 16 differ-
ent images by the dentists.
The reliability of the rank was tested for each set of
photographs by placing a duplicate image in the set.
The reliability was set at 1 or less, which meant that
the observer placed the duplicate images side by side
(eg, duplicate images were ranked 3 and 4). The results
demonstrated good agreement for all tests (canine
width: difference, 0.14, P 5 0.38, agreement level,
good; canine shade: difference, 0.67, P 5 0.00,
agreement level, statistically poor but clinically accept-
able [\1]; canine gingival height: difference, 0.06,
P 5 0.72, agreement level, good; canine tip height: dif-
ference, 0.27, P 5 0.27, agreement level, good). The
levels of agreement for all parameters were clinically
Brough, Donaldson, and Naini 705.e7
Rank total Rank by Rank by Rank by
SD (all groups) orthodontists dentists laypeople
1.36 1 3 1 1
1.31 3 2 3 4
1.41 2 1 4 2
1.32 4 4 2 3
1.24 5 5 5 5
1.16 6 6 6 6
good; however, for shade, there was statistically rela-
tively poor agreement (P 5 0.00), although the images
were ranked 7 and 8 by the observers (ie, next to each
other).
DISCUSSION
From the results of this study, there were general
preferences related to the morphology of the canine in
the position of the lateral incisor. Orthodontists
preferred narrow rather than wide teeth, natural shades,
gingival margins just below the adjacent central incisor,
and rounded tips. These opinions were shared by
dentists, although they tended to favor a less narrow
or average size tooth, finding the images of the narrow-
est teeth unattractive. They also preferred teeth 1 shade
darker than did the orthodontists. Laypeople shared the
same overall preference trends, but they preferred
narrower (3.0 mm narrower) and slighter brighter
canines than did the orthodontists and the dentists;
they demonstrated a greater range of opinions and less
overall agreement within the group.
When we analyzed the data of each specific mor-
phologic feature, starting with canine width, there was
an overall preference and general trend for narrower
canines in the position of the lateral incisor. The photo-
graphs ranked most attractive were with the canines
slightly narrower than the original image, followed by
the original image. All 3 groups chose narrow canines
most frequently as the most attractive overall, with
3.0-mm narrower canines chosen by laypeople and
1.5-mm narrower chosen by orthodontists and dentists.
This supports previous research by Bukhary et al13 in
which a 67% ratio of lateral incisor width to central
incisor width was perceived as the most attractive by
orthodontists and dentists, although laypeople preferred
a lower ratio. Wider teeth were found to be less attrac-
tive. Increasing the width of the canine had an inversely
proportional relationship to perceived attractiveness.
In terms of gingival margin height, the image ranked
most attractive had the gingival margin of the tooth in the
lateral incisor position as 0.5 mm below the level of the
adjacent central incisor. When the gingival margin was
705.e8 Brough, Donaldson, and Naini
Fig 2. Frequency of the images chosen as least attractive by orthodontists, dentists, and laypeople.
Fig 3. Frequency of the images chosen as most attractive by orthodontists, dentists, and laypeople.
only slightly lower than this, it was also ranked high;
conversely, images with high gingival levels were per-
ceived as unattractive. The degree and magnitude of
the height of the gingival margin had an inverse relation-
ship on perceived attractiveness. The group-specific data
varied. Orthodontists preferred canine gingival margin
height at 1 mm below the level of the central incisor,
whereas both the laypeople and dentists preferred it
0.5 mm below. It appears from the data that small
gingival height discrepancies have a minimal effect on
attractiveness, but gingival height increases greater
than 1.0 mm were perceived as relatively unattractive;
this was verified by all 3 groups.
The shade of the tooth in the lateral incisor position
had a significant impact on the perceived attractiveness
of the smile. Generally, brighter shades were found
American Journal of Orthodontics and Dentofacial Orthopedics
December 2010
more attractive than darker shades by all groups. The
images showing canines slightly brighter than the orig-
inal image were ranked as most attractive, followed by
the original shades. Orthodontists preferred brighter
than original teeth, dentists preferred slightly darker
shades compared with the orthodontists, and laypeople
found slightly brighter shades attractive. Darker than
original shades were perceived as unattractive by all 3
groups, and the darkest shade of all the images was
most frequently ranked as the most unattractive (image
SB, 20 times darker than original).
Related to crown height and tip morphology alter-
ations, all 3 groups agreed. They found increased crown
tip heights greater than 1.5 mm unattractive, and, when
the tip of the canine was pointed, this was also perceived
as unattractive. The image with the canine tip height 1.0 mm
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 6
increased and pointed was ranked the least attractive
in this section. Orthodontists and dentists disliked
the pointed tips and ranked them most unattractive.
The laypeople also disliked canines with pointed tips,
but they ranked the 1.5 mm increased crown height
with a rounded tip as the least attractive image.
For crown height, group-specific preferences were
found in the data. The original image was preferred by
dentists, slightly shorter canines were preferred by or-
thodontists, and a slightly increased canine crown
height was preferred by laypeople.
CONCLUSIONS
In hypodontia patients with missing maxillary lat-
eral incisors, having undergone space closure with ca-
nine substitution, the following conclusions were made.
1. The morphology of the maxillary canine is noticed
by orthodontists, dentists, and laypeople, and this
might have a detrimental effect on perceived smile
attractiveness.
2. Dark canines were ranked least attractive by all groups.
3. Wide canines were perceived as unattractive.
4. Narrower canines were found most attractive over-
all most frequently by all 3 groups.
5. Canine gingival height greater than 0.5 mm above
the gingival margin level of the adjacent central in-
cisor was perceived as unattractive.
6. Natural shades were preferred by dentists and
slighter brighter shades by orthodontists, whereas
bright shades were preferred by laypeople; all
groups found brighter canines more attractive
than darker canines, and there was a correlation be-
tween darker canines and unattractive smiles.
7. Orthodontists and dentists disliked a greater than
1.0-mm increase in canine tip height and pointed
tips, and scored them unattractive; laypeople liked
a 1.0-mm increase in canine tip height, but greater
than 1.5 mm and pointed tips were perceived as
unattractive.
8. Pointed canine tips were found highly unattractive
by all groups.
Orthodontists, dentists, and laypeople noticed the
morphology of the canine in orthodontic camouflage
cases. The feature with the most detrimental effect on
smile attractiveness was a canine with a dark shade;
all 3 groups agreed. Small changes in any featureie,
gingival margin variations 6 0.5 mm, width changes
6 0.5 mm, and tip height changes 6 0.5 mmwere
Brough, Donaldson, and Naini 705.e9
generally acceptable and tolerated. However, the farther
any parameter varied from the average, the more unat-
tractive the perceived appearance of the smile. The ex-
ception to this was reduction of the width of the canine;
1.5-mm reductions were scored highly by orthodontists
and dentists, and 3.0-mm reductions were scored highly
by laypeople.
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