Journal of Oral Rehabilitation 2006 33; 489–495

Subjective and objective perception of upper incisors

S . W O L F A R T * , A . C . Q U A A S †, S . F R E I T A G ‡, P . K R O P P §, W . - D . G E R B E R § &
M . K E R N * *Department of Prosthodontics, Propaedeutics and Dental Materials, School of Dentistry, Christian-Albrechts
† ‡
University at Kiel, Department of Prosthodontics, School of Dentistry, Albert-Ludwig University, Freiburg, Institute of Medical
§
Informatics and Statistics, Christian-Albrechts University at Kiel and Institute of Medical Psychology, Christian-Albrechts University at
Kiel, Germany

SUMMARY The purpose of this study was to evaluate
the subjective judgment (SJ) of patients on their
own dental appearance and to correlate the results
with objective measurements (OM) of their
dentition concerning the appearance of the upper
incisors. Seventy-five participants (30 men and
45 women) with normal well-being were included
in the study. In a questionnaire they judged the
appearance of their upper incisors. Furthermore,
OM were evaluated by the investigator with regard
to the following points: (i) absolute length of the
upper central incisors, (ii) their length exposed
during laughing, (iii) width-to-length ratio of cen-
tral incisors and (iv) the proportion between the
width of the lateral and central incisors. The
subjective results were registered on visual-ana-
logue scales. For the objective results standardized
photographs were taken. No gender dependent
differences could be found for the objectively
measured parameters (median): OM1, 10Æ7 mm;
OM2, 8Æ1 mm; OM3, 0Æ81; OM4, 0Æ79. However,
significant correlations between subjective and
objective results (SJ1/OM1, SJ2/OM2, SJ3/OM3)
could be shown for men, but not for women. The
maximum of the calculated regression-curves for
men reflect ‘golden standard values’ well known
from the literature. The degree of satisfaction con-
cerning appearance of anterior incisors in accord-
ance with golden standard values is higher for men
than for women.
KEYWORDS: upper incisors, aesthetics, golden propor-
tion, central incisor, survey, gender
Accepted for publication 10 September 2005

authors have presented guidelines regarding anterior

Introduction
Restoring teeth successfully within the aesthetical zone
results in a clearly positive effect on patient’s self-
esteem and quality of life (1). A successful therapy
depends largely on good interaction between the
clinician and his or her patient, especially in situations
of complex restorations (2–6). The wishes and needs
of patients have to be considered in the same way
as aesthetic guidelines known from the scientific
literature.
Dental appearance is influenced by a variety of
different factors. These factors determine a harmoni-
ously balanced smile which arises as a result of the
ideal interaction of dental and gingival beauty cri-
teria. In order to achieve excellent aesthetics several
aesthetics which include recommendations for the
optimal anterior tooth proportions and tooth lengths
(3–8). There are golden standard values concerning
the optimal length (10–12 mm) (2, 3) and the width-
to-length ratio of the upper central incisors [66–80%
(9) or 75–85% (10), respectively]. Other studies
(11, 12) proposed that dental aesthetic is ideal if the
widths of laterals-to-centrals are in golden proportion
when the patient is viewed head-on. This ratio is
approximately 1Æ61803:1, i.e. the smaller term is
about 62% of the larger term. Elsewhere these
tooth-to-tooth proportions showed the best results
concerning attractive appearance within a range of
56–68% (10). A further beauty criterion is the fact
that both the upper anterior teeth and approximately

ª 2006 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2005.01581.x

490 S . W O L F A R T et al.
1 mm of the gingiva are visible when smiling. When
>3 mm of gingiva are exposed most of the patients
find the resulting smile less attractive (13).
In studies evaluating golden standard values partic-
ipants judged the appearance of various dentitions
from digitally manipulated photos (10) or from sket-
ches (9), but never they analysed their own dentition.
Several studies showed that the above mentioned
aesthetical guidelines differed from the anatomic
average values in men (14, 15) and some authors
have reservations about ‘magic numbers’ (14, 16).
With regard to these arguments the question arises
whether patients are sensitive to these values when
they judge their own dental appearance and whether
the results of this self-assessment are in accordance
with golden standard values known from the special-
ized literature. This might be an important evidence
for the question whether golden standard values are
the useful elements that should be used when clini-
cians interact with their patients.
It is of further interest to seek an answer to the
question whether there are any gender related differ-
ences in the self assessment. For it was shown previ-
ously that dental appearance is more important for
women than for men (17), and women also appeared to
be more oriented to and less satisfied with their
outward appearance than men (18).
The purpose of this study was to evaluate whether
participants’ SJ of their own dental appearance with
respect to different standard aesthetic parameters cor-
relate with OM of the patients’ dentitions. Further-
more, the results were compared with golden standard
values and anatomic average values, respectively,
otherwise known from the scientific literature.
Material and methods
Participants
Eighty participants (33 men and 47 women) were
selected. They were all patients at the dental hospital
facility in Kiel (Christian-Albrechts University at Kiel,
Germany). The participants were unpaid volunteers
and took part in the survey during a routine check-
up visit. To ensure a heterogeneous group of partic-
ipants representative of restorative dentistry they
were selected from four different subgroups (20
participants in each group): group A participants
had a complete and healthy dentition. They had
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 489–495
neither crowns, fixed partial dentures (FPDs), fillings
or periodontal problems on their upper anterior teeth.
Group B participants had aesthetical problems with
their upper anterior teeth, especially because of
insufficient fillings, an irregular tooth position or
periodontal problems, but they had no prosthodontic
restorations on their upper anterior teeth. Group C
participants had crowns or FPDs on at least one of
their upper anterior teeth. Group D participants had
removable partial dentures replacing at least the
upper anterior teeth.
Participants were interviewed individually.
Throughout the survey the investigator’s interest in
a specific dental feature was not revealed. The survey
was performed after the routine check-up visit in a
class room at the dental hospital. For help the
participants could use a mirror to check their dental
appearance.
Well-being
To ensure that the participants did not differ notably
from the general population in well-being, a long-
established and highly reliable test was used, which
contains 28 items (Befindlichkeitsbogen; Beltz Test,
Germany) (19, 20). Only participants with normal well-
being were accepted for the study.
Objective measurements
For OM two standardized frontal photographs (Dental
Eye III*) were taken perpendicularly to the axes of each
participant’s upper anterior teeth: (i) lips and teeth
during strong smiling, (ii) anterior teeth without lips.
Additionally, a tape measure was photographed with
the same magnification. All photographs were taken
with standardized adjustments (magnification 1:1Æ8)
and were digitized with 1200 dpi (Perfection 3200
Photo,†). The analysis of the photographs was per-
formed with Adobe Photoshop (‡) to measure four
parameters of the upper anterior teeth (Fig. 1): length
of the upper central incisors (OM1), length of the upper
central incisors exposed during laughing (OM2), width-
to-length ratio of the upper central incisors (OM3) and
proportion between the widths of lateral and central
*Yashica, Tokyo, Japan.
†
Epson, Tokyo, Japan.
‡
Adobe, San Jose, CA, USA.

e Statistical tests for gender-dependent differences in
Lip-lin
OM1
W1 W2
OM2
OM4 = w2/w1
OM3 = w1/OM1
Fig. 1. For objective measurements (OM) the following parame-
ters were measured: OM1, length of the upper central incisors;
OM2, length of the upper central incisors exposed during
laughing; OM3, width-to-length ratio of central incisors; OM4,
proportion between the widths of central and lateral incisors.
incisors (OM4). The real length of the different lines
could be calculated using the tape measure. In all cases,
a value for the right side (teeth: 13–11) and left side
(teeth: 21–23) was calculated, as the mean of both
values was used for evaluation.
Subjective measurements
To determine their SJ the participants were asked to
answer four questions (SJ1–SJ4) concerning different
standard aesthetic parameters of their own teeth. The
answers were registered on visual-analogue scales
(VAS) with a length of 100 mm and the endpoints
‘don’t like it at all’ and ‘very nice’. These results were
later transformed to numbers from 0 (‘don’t like it at
all’) to 100 (‘very nice’). The following questions were
asked in German and were translated for this publica-
tion into English:
(SJ1): Do you like the absolute length of your upper
anterior teeth?
(SJ2): Do you like the length of your teeth exposed
during laughing?
(SJ3): Do you like the proportions of your upper
anterior teeth?
(SJ4): Do you like the harmony of the widths of your
upper anterior teeth?
During this main evaluation the participants were
not allowed to take any notes, and no information
about the planned second survey was given. Approxi-
mately after 1 year the SJ test was repeated with the
same questions (SJ1–SJ4) and 18 randomly chosen
participants (20% of all participants, 10 males and 8
females) were asked to answer them. Only patients
with no changes in their dental status – as compared
with the main evaluation – were included.
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 489–495
PERCEPTION OF UPPER INCISORS 491
Statistical analysis
results were performed by using the Wilcoxon-rank
sum test. As appropriate, linear or non-linear regres-
sion models were used to evaluate the relationship
between subjective and objective measurements.
Model fitting was analyzed by using coefficients of
determination and F-tests. To determine the reliability
of the subjective measurements (SJ1–SJ4), Pearson’s
correlation coefficient between the main evaluation
and the second survey was calculated, and a paired t-
test of equivalence with a 10% range of agreement
(21) was performed. For all tests the level of signi-
ficance was set to 5%.
Results
Participants
Of the original 80 participants 75 participants (94%)
showed a normal well being [mean age 47 year
standard deviation (17); range 19–79 year; 44 males
and 31 females]. They fell into the following profes-
sional categories: 19 pensioners, three housewives,
14 students, 30 employees and nine academics.
The other five participants showed a depressive well-
being (three men and two women) and were excluded
from the study.
Objective and subjective measurements
The median values of objective and subjective results
were analysed for men and women and are shown in
Table 1. Gender dependent differences (P > 0Æ05) could
be shown for none of the groups (OM1–OM4 and SJ1–
SJ4).
Regression models were fitted to evaluate the corre-
lation between OM (OM1–OM4) and SJ (SJ1–SJ4)
(Figs 2–5). A significant relationship between objective
and subjective results (Figs 2–4) could be shown for men
(r2 between 0Æ26 and 0Æ35, P £ 0Æ05), but not for women
(P > 0Æ05). The maxima of the calculated regression
curves indicate the objective values which were assessed
as most attractive by the participants; they are marked by
shadowed boxes in the figures. The maximum is around
12 mm as far as the length of the upper central incisors is
concerned (Fig. 2). As regards the central incisors during
laughing, the results demonstrate that the higher the
492 S . W O L F A R T et al.

Table 1. Median of objective measurements (OM) and subjective judgements (SJ) (n ¼ 75)

OM* SJ‡
Anatomic
Variable Men Women average values† Men Women

Absolute length of upper 10Æ8 mm (9Æ9, 11Æ7) 10Æ6 mm (9Æ9, 11Æ3) 10Æ1–11Æ7 mm 69 (45, 92) 62 (30, 97)
central incisor (OM1 & SJ1)
Length of central incisor exposed 7Æ5 mm (5Æ5, 8Æ3) 8Æ4 mm (6Æ4, 10Æ1) 75–100% of full 69 (46, 94) 66 (35, 98)
during laughing (OM2 & SJ2) length of upper
anterior teeth
Width-to-length ratio of upper 0Æ82 (0Æ76, 0Æ86) 0Æ81 (0Æ73, 0Æ86) 0Æ78–0Æ87 77 (52, 99) 72 (46, 98)
central incisor (OM3 & SJ3)
Proportion between width of lateral 0Æ82 (0Æ70, 0Æ91) 0Æ79 (0Æ69, 0Æ90) 0Æ78–0Æ85 68 (44, 96) 68 (44, 93)
and central incisor (OM4 & SJ4)

*On standardized photographs aesthetic parameters were measured.

†
Anatomic average values known from the literature (14, 15, 23).
‡
Visual-analogue scales (0, don’t like it at all; 100, very nice). Median and 25th and 75th percentile (in brackets) are shown. For none of
the groups a gender dependent difference could be shown (P > 0Æ05, Wilcoxon-rank sum test).

Men Women
100 100

80 80 Fig. 2. Regression analyses to eval-

VAS (units on scale)

uate the relationship between objec-

60 60 tive measurement (OM) (y-axis) and
subjective judgement (SJ) (x-axis)
40 40
concerning OM1/SJ1. The shadowed
box in the figure marked the maxima
20 20
r 2 = 0·26 of the calculated regression curve
Observations
P = 0·017 P = n.s. and indicates the objective values
0 0 Regression-curve
6 8 10 12 14 16 6 8 10 12 14 16 which were assessed as most
Absolute length of upper central incisors (mm) attractive.

Men Women
100 100

80
VAS (units on scale)

80

60 60

40 40

Fig. 3. Regression analyses to eval-

20 20
r 2 = 0·28 uate the relationship between objec-
Observations
P = 0·003 P = n.s.
0 Regression (linear) tive measurement (OM) (y-axis) and
0
4 6 8 10 12 4 6 8 10 12 subjective judgement (SJ) (x-axis)
Length of upper central incisors exposed during laughing (mm) concerning OM2/SJ2.

visible part of the teeth was, the better was the quoting
Reproducibility of subjective judgment
(Fig. 3). The maximum width-to-length ratio of the
upper central incisors was around 0Æ75 (Fig. 4). The Concerning the 18 randomly chosen participants, the
maximum proportion of the widths lateral-to-central SJ of the main evaluation and of the second survey
incisors was around 0Æ65 (Fig. 5). were statistically equivalent (P £ 0Æ05, 10% range of

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 489–495

 PERCEPTION OF UPPER INCISORS 493

Men Women
100 100

80 80

VAS (units on scale)

Fig. 4. Regression analyses to eval-
uate the relationship between objec- 60 60
tive measurement (OM) (y-axis) and
subjective judgement (SJ) (x-axis) 40 40
concerning OM3/SJ3. The shadowed
box in the figure marked the maxima 20 20
r 2 = 0·35 Observations
of the calculated regression curve
P = 0·003 P = n.s. Regression-curve
and indicates the objective values 0 0
which were assessed as most 0·5 0·6 0·7 0·8 0·9 1·0 1·1 1·2 0·5 0·6 0·7 0·8 0·9 1·0 1·1 1·2

attractive. Width-to-length proportion of upper central incisors

Men Women
100 100

80 80
VAS (units on scale)

Fig. 5. Regression analyses to eval-

uate the relationship between objec- 60 60
tive measurement (OM) (y-axis) and
subjective judgement (SJ) (x-axis) 40 40
concerning OM4/SJ4. The shadowed
box in the figure marked the maxima 20 20
of the calculated regression curve r 2 = 0·18 Observations
P = 0·069 P = n.s
and indicates the objective values Regression-curve
0 0
which were assessed as most 0·5 0·6 0·7 0·8 0·9
0·5 0·6 0·7 0·8 0·9
attractive. Proportion between width of lateral and central incisors

agreement) with Pearson’s correlation coefficients Evaluating the OM Table 1 shows that there was no
ranging from 0Æ81 to 0Æ97 for all questions. Therefore, gender related difference for any of the parameters
it can be concluded that the participants’ SJ about the (OM1–OM4) and that the median values reflected
appearance of upper incisors are consistent. anatomic average values known from the literature:
studies analyzed the anatomical crown form of unre-
stored upper central incisors and found mean width-to-
Discussion
length ratios of 87% for worn and 78% for unworn
Many authors agree that the upper central incisors in central incisors (14) or 85–86% for ‘normal Caucasian
particular are the key determinants in evaluating subjects’ (15). The mean length of a central incisor was
anterior dental aesthetics (3, 4, 11, 22). This can be 11Æ7 mm (14). In natural dentitions, the mean width of
taken as implying that these teeth probably play the the anatomic crowns of upper central incisors is 9Æ1 mm
subconscious key role in people’s judgements concern- and for upper lateral incisors it is 7Æ1 mm (14). Based on
ing dental aesthetics. Thus, the questions SJ1–SJ4 were these values mean tooth-to-tooth proportion of laterals-
all linked to the length or proportion of the upper to-centrals of 78% can be calculated. Previous studies
incisors and were correlated to OM concerning the showed that an average smile (69% of all participants)
central incisor. Moreover, we assumed we would exhibits approximately 75–100% of the full length of
obtain reproducible and stable results when asking the maxillary anterior teeth (23). It can be concluded
questions on this key region for dental appearance. that the OM in the present study did not differ notably
That this was really the case was shown by the fact that from the general population and was not gender
the answers were reproducible in a second survey, related. Furthermore, men and women did not differ
which demonstrated consistency in the aesthetic ratings significantly in their perception concerning their SJ
of participants concerning these questions. (Table 1, SJ1–SJ4).

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 489–495

494 S . W O L F A R T et al.
On this basis, it was expected that the results of the
regression analysis were not gender related. However, a
significant correlation (OM1/SJ1, OM2/SJ2, OM3/SJ3)
or at least a trend (OM4/SJ4) between objective and
subjective results could only be shown for men, but not
for women. The maxima of the regression curves,
which indicate the most attractive values, corresponded
to golden standard values known from the literature,
which were already explained in the introductory
section. Nevertheless, it has to be considered that the
coefficients of determination lie in a range from 0Æ26 to
0Æ35, meaning that only about one-third of the vari-
ation in the data can be explained by the regression
models.
Why were the latter results dependent upon gender?
Two arguments seem to be important: first, the
perception of men and women may be different –
men seem to be more rational and women more
intuitive and emotional. These general differences
between men and women were previously discussed
in psychological publications (24) and might have
influenced the answers and self-assessment concerning
the questions SJ1–SJ4. Secondly, women are perhaps
more influenced by the overall aesthetic appearance of
their teeth and their smile than men. If they are not
satisfied with this general view, they cannot judge
‘objectively’ a single factor, for example the absolute
length of the upper incisors. This finding is supported
by the results of psychological studies, which showed
that women appeared to be more oriented to and less
satisfied with their outward appearances and that they
had higher body awareness and symptom perception
compared with men (18, 25). To summarize, it can be
assumed that women might be more influenced by
emotions and that they have more critical judgement
concerning beauty criteria. The complexity of dental
appearance often can not be determined or analyzed
using single parameters. This meets the criticism of
some authors, who were more cautious about the
application of ‘magic numbers’ (14), because they often
neglect differences between patients, which are com-
pletely individual (16).
In the interaction between patients and clinicians
isolated values such as the length of the upper anterior
teeth have to be used with caution as regards the
aesthetical judgment of dental appearance, because for
example the length interacts with the proportion of the
tooth, the tooth-to-tooth proportions and the incisal
line (5, 6). Only when the clinician understands these
ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 489–495
relations is he able to ask the right and useful questions
in the dialogue with the patient and lead him or her to
the best possible aesthetic result.
Given the limitations of this study the following can
be summarized. (i) The OM of this study reflect
anatomic average values known from the scientific
literature and concerning these results no gender
dependent difference could be found. (ii) For men a
statistically significant correlation between OM and SJ
could be shown. However, this does not apply to
women. Therefore, when using these single values in
the interaction between clinicians and patients, the
influence of all other aesthetic relevant factors, known
from various guidelines on aesthetics has to be taken
into account.
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Correspondence: Dr Stefan Wolfart, Department of Prosthodontics,
Propaedeutics and Dental Materials, School of Dentistry, Christian-
Albrechts University, Arnold-Heller-Str. 16, D-24105 Kiel, Germany.
E-mail: swolfart@proth.uni-kiel.de