ORIGINAL ARTICLE

Perceptions of dental esthetics of Asian

orthodontists and laypersons
Jen Soh,a Ming Tak Chew,b and Yiong Huak Chanc
Singapore

Introduction: The aim of the study was to determine the impact of anterior dental crowding, overjet, overbite,
dental spacing, and type of malocclusion on dental esthetic perceptions of Asian orthodontists. Methods:
Twenty-one Asian orthodontists (10 men, 11 women) and 158 adult laypersons (38 men, 120 women) rated
the attractiveness of 50 pairs of black-and-white intraoral photographic prints of various types of
malocclusions. Each pair included a frontal and a right buccal view of the dentition at maximum
intercuspation. Raters used a visual analogue scale (VAS), with “least attractive” (0 mm) and “most attractive”
(100 mm) as the 2 extremes, to score the dental esthetics of the photographs. A principal investigator
objectively measured the dental traits from study models. Linear regression analysis was performed with VAS
scores as the dependent variable and anterior dental crowding, overjet, and overbite measurements as the
independent variables. Independent sample t tests were used to determine the effect of dental spacing on
the VAS scores. The Kruskal-Wallis test was used to determine the effect of type of malocclusion (Class I,
Class II Division 1, Class II Division 2, Class III) on VAS scores. Results: Increased overjet (⬎6 mm) and
severe maxillary dental crowding (⬎8 mm) were found to be significantly correlated with laypersons’ VAS
scores (P ⬍.05). Reverse overjet was found to be significantly correlated with orthodontists’ VAS scores
(P ⬍.05). No significant correlation was found between overbite, dental spacing, and VAS scores. Class III
malocclusions were significantly perceived to be the most unesthetic by orthodontists. Conclusions: Overjet
was the major occlusal trait that influenced the perceptions of dental esthetics of both laypersons and
orthodontists. (Am J Orthod Dentofacial Orthop 2006;130:170-6)

A
primary goal in orthodontic treatment is to
improve dental esthetics. The long-term bene-
fits of orthodontic treatment on dental health,
function, and occlusal stability remain controversial.1-5
However, the desire to improve dental appearance as the
key motivational drive for adolescents and adults to seek
orthodontic treatment has been well documented.6-10
The importance of dental esthetics has been empha-
sized with the development of occlusal indexes that
assess this aspect of the malocclusion to justify the need
for orthodontic treatment.11,12 The establishment of
good dental esthetics is the first step toward a pleasing
smile that orthodontic patients expect from treatment.
A pleasing dental appearance often means straight teeth
in most laypersons’ opinions, and their perceived ben-
efits derive from orthodontic treatment.13-15 From a
a
Assistant professor, Faculty of Dentistry, National University of Singa-
pore, Singapore.
b
Consultant, National Dental Centre, Department of Orthodontics, Singapore.
c
Head biostatistician, Clinical Trials & Epidemiology Research Unit, Singa-
pore.
Reprint requests to: Dr Jen Soh, Faculty of Dentistry, National University
Hospital, 5 Lower Kent Ridge Road, Main Building, Singapore 119 074;
e-mail, pndsj@nus.edu.sg.
Submitted, October 2004; revised and accepted, May 2005.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.05.048
170
professional standpoint, good dental alignment is only
1 aspect of achieving good dental esthetics. Other
anterior occlusal traits for consideration include overjet
(OJ), overbite (OB), and dental midline relationships.
Occlusal traits have been shown to affect the
awareness of malocclusion with implications on orth-
odontic treatment uptake.16,17 The perception of dental
esthetics primarily focuses on the anterior region of the
dentition. Previous studies have shown that the aware-
ness of anterior occlusal traits rather than posterior
traits was associated with the perception of malocclu-
sion and satisfaction with dental appearance.18-21 These
studies also found that the major concerns among adults
were anterior dental crowding (DC), rotations, and
increased or reverse OJ. The availability of orthodontic
treatment was found to influence the awareness of
malocclusion in young adults.17 Ingervall et al19 found
that the awareness of malocclusion was associated with
educational background and increasing age in Swedish
men. Gosney7 noted that dental crowding, rotation, and
spacing were occlusal traits of concern expressed by
adolescents receiving orthodontic treatment and their
parents. OJ alone was not a significant factor associated
with treatment uptake. Females were found to express
greater concern and dissatisfaction with dental appear-
ance than males.6,16,22,23
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 2
The visual analogue scale (VAS) has been widely
applied in various fields of dental research.24-26 In orth-
odontics, the VAS had been used as a measuring tool in
studies about dentofacial esthetic assessment,27-29 priori-
tization of treatment need,30 and pain associated with
orthodontic tooth movement.31 Recent studies have used
the aesthetic component (AC) of the index of orthodontic
treatment need11 as the measuring tool to determine dental
esthetics.14,15,32-34 Hunt et al33 concluded that the current
use of the AC cutoff score to establish treatment need
does not reflect society’s dental esthetic expectations in
an adult cohort. Grzywacz34 also found that profes-
sional rating based on the current criteria of the AC
scale did not improve the precision and reliability of
matching the esthetic requirements of professionals and
12-year-olds. Thus, these studies suggest a difference in
dental esthetic acceptability between professionals and
laypersons. Frequency of dental attendance and sex
were found to contribute to the results from laypersons.
Although these patient factors could partially explain
the variation in responses, the question remains as to
why such perceptual differences existed. Could the
variations in the assessment of dental esthetics be due
to different visual emphasis given to anterior occlusal
traits by laypersons and orthodontists? Which occlusal
features significantly influence laypersons’ perceptions
of dental esthetics? Can the variations in dental esthet-
ics be explained from the perspective of occlusal
features of malocclusions?
The aim of this study was to identify the anterior
occlusal traits that impact the perceptions of dental
esthetics by Asian laypersons and orthodontists.
MATERIAL AND METHODS
Fifty pairs of intraoral photographs of dentitions
representing various malocclusions of Chinese subjects
were used. Each pair contained a frontal view and a
right buccal view at maximum intercuspation. The
photographs were scanned with Nikon Coolscan III
film scanner (1350 pixels per inch, 3669 ⫻ 2273 pixels;
Nikon, Tokyo, Japan) followed by conversion from
color to grayscale images by using Adobe Photoshop
(version 7.0, San Jose, Calif). The images were then
imported into PowerPoint software (Microsoft, Red-
mond, Wash) to create the questionnaires. Grayscale
photographic images were used to eliminate the effect
of tooth and gingival tissue color that might influence
the ratings of dental esthetics. A total of 158 Asian
laypersons with tertiary or higher educational back-
grounds and 21 orthodontists of Chinese ethnic back-
grounds participated in the study (Table I). The partic-
ipants were instructed to score the 50 pairs of
photographs on a VAS of 100 mm with “least attrac-
Soh, Chew, and Chan 171
Table I. Occlusal trait categorizations
Category of occlusal trait measurements (mm)
Occlusal Very
trait Reversed Reduced Normal Increased increased
OJ ⬍0 0-⬍2 2-3 ⬎3-6 ⬎6
Open bite Reduced Normal Increased
OB ⬍0 0-⬍2 2 ⬎2
Ideal Mild Moderate Severe
DC 0 1-4 5-8 ⬎8
tive” (0 mm) and “most attractive” (100 mm) as the 2
extremes. No time limit was imposed during the ses-
sions. Laypersons and orthodontists rated the photo-
graphs in separate sessions with no principal investiga-
tors present. Markings on the VAS were measured by
an independent assessor using a metal ruler up to an
accuracy of 1 mm.
Study models of the 50 pairs of photographs were
used for the measurement of OJ, OB, and DC to the
nearest 0.5 mm by using a vernier caliper by the
principal investigator (J.S.). The most proclined or
retroclined central incisor was used to determine the
amount of OJ. The greatest overlap or interincisal gap
between the maxillary and mandibular central and
lateral incisors was used to determine the amount of OB
or open bite. The contact point displacements from
canine to canine of both arches were summed to
determine the severity of the DC in each arch. Anterior
dental spacing (DS) was identified as present or absent
from the study models. The type of malocclusion was
classified as incisor Class I, Class II Division 1, Class II
Division 2, or Class III from the study models. The OJ,
OB, and DC measurements were categorized as shown
in Table I.
Statistical analysis
The raw VAS scores from both laypersons and
orthodontists were standardized to an equal rating
platform as follows: individual raw VAS score minus
mean raw score divided by SD of raw VAS score.
This standardized VAS score quantified the number
of standard deviations of each raw score from the mean.
Multiple linear regression analysis was performed
separately on the standardized VAS scores of the
laypersons and the orthodontists as dependent variables
with OJ, OB, and DC as independent variables and
statistical significance set at P ⬍.05.
Kruskal-Wallis 1-way analyses of variance (ANOVA)
172 Soh, Chew, and Chan American Journal of Orthodontics and Dentofacial Orthopedics
August 2006

Table II. Characteristics of study sample There was no difference in the raw VAS scores
Orthodontists Laypersons
given to malocclusions with or without DS by orth-
(n ⫽ 21) (n ⫽ 158) odontists and laypersons (P ⬎.05).

Sex DISCUSSION
Male 10 (47.6%) 38 (24.1%)
Female 11 (52.4%) 120 (75.9%)
We preferred to use the VAS scale instead of the
Ethnicity 10-photograph ordinal scale of AC grading11 for these
Chinese 21 (100%) 106 (67.1%) reasons: (1) the disparity in the level of acceptability
Malay — 32 (20.2%) associated with perceived dental esthetics between
Indian — 20 (12.7%) laypersons and professionals using AC assessment as
Mean age ⫾ SD (yrs) 34.5 ⫾ 5.1 24.4 ⫾ 4.0
Years in clinical practice
reported recently,33,34 (2) the likelihood that partici-
1-5 11 (52.4%) — pants would attempt to match the 50 photographs with
⬎5 10 (47.6%) — the AC photographs instead of rating the photographs
per se without bias, (3) the 50 photographs comprised a
range of malocclusions with various degrees of in-
creased or decreased OJ and OB, instead of increasing
by rank were performed for the malocclusion types and OJs and OBs in the AC photographs, and (4) the
the standardized VAS scores. introduction of the right buccal view for the assess-
Independent sample t tests were used to determine ment. We introduced the right buccal view of the
whether there was a difference in raw VAS scores of dentition to show proclination or retroclination of the
malocclusions with and without DS, with statistical incisors in Class II Division 1 and Class II Division 2
significance set at P ⬍.05. malocclusions, respectively, as well as reverse OJ
associated with Class III malocclusions. The influence
of OJ on dental esthetic assessment requires this view
RESULTS to be included.
Table II shows the characteristics of the sample. The Scoring of dental midlines was not included in this
mean age of the orthodontists was 34.5 years (SD, ⫾ 5.1 study because this dental trait could not be readily
years), with almost equal numbers of male (47.6%) and determined from the photographs, and the margin of
female (52.4%) clinicians. Eleven orthodontists (52.4%) error during assessment would probably be substantial.
had 1 to 5 years of clinical experience. The other half of Moreover, malocclusions with deep or complete OB
the clinician sample had more than 5 years of clinical would make the assessment of the mandibular dental
practice. The mean age of the laypersons was 24.4 years midline difficult, if not impossible. The literature also
(SD, ⫾ 4.0 years), with 38 men (24.1%) and 120 suggests that a dental midline discrepancy is not a
women (75.9%). The ethnic groups of the laypersons major concern of laypersons. Laypersons were less
included Chinese (67.1%), Malay (20.2%), and Indian sensitive to mild dental midline discrepancies.35 In
(12.7%). addition, the assessment of dental midline relationships
would be more meaningful when related to facial
The standardized VAS scores of the orthodontists
midline discrepancies, but this was not an aim of our
were significantly associated with reverse OJ (P ⬍.05)
study.36 Thus, the assessment of dental midline rela-
as shown in Table III. The standardized VAS scores of
tionships alone would not enhance our results.
the laypersons were significantly related to OJ greater
The raw VAS scores were mathematically con-
than 6 mm and severe maxillary crowding greater than verted to standardized scores to facilitate meaningful
8 mm (P ⬍.05), as shown in Table IV. OB was not analysis of the data because the participants had differ-
significantly related to the standardized VAS scores for ent ranges of raw VAS scores for the attractive and
either orthodontists or laypersons. Mild to moderate unattractive extremes. Thus, there was a need to stan-
maxillary and mandibular DC were also nonsignificant dardize the raw VAS scores by taking the mean raw
occlusal traits. scores as the central reference to overcome this limita-
There was a significant difference between stan- tion because of the participants’ subjective and variable
dardized VAS scores of orthodontists and type of usage of the VAS scale.
malocclusion (Table V) for the Class III malocclusions Our results show that orthodontists and laypersons
(Table VI). There was no difference in the standardized have visual-emphasis differences to anterior occlusal
VAS scores of laypersons for the various malocclu- traits in their perceptions of dental esthetics. Asian
sions. orthodontists emphasized reverse OJ and Class III
American Journal of Orthodontics and Dentofacial Orthopedics Soh, Chew, and Chan 173
Volume 130, Number 2

Table III. Relationship of OJ, OB, and DC with orthodontists’ standardized VAS scores
Unstandardized coefficients 95% CI for B

Anterior occlusal trait B SE Significance Lower bound Upper bound

Constant .101 .474 .833 ⫺.860 1.062

OJ
Reverse vs normal ⫺.886 .327 .010 ⫺1.549 ⫺.224
Reduced vs normal .137 .583 .816 ⫺1.046 1.319
Increased vs normal .477 .286 .104 ⫺.104 1.058
Very increased vs normal ⫺.390 .342 .261 ⫺1.083 .303
OB
Anterior open bite vs normal ⫺.036 .433 .934 ⫺.915 .843
Reduced vs normal .206 .426 .633 ⫺.659 1.070
Increased vs normal .006 .335 .986 ⫺.673 .685
DC
Maxillary
Mild vs ideal .243 .473 .611 ⫺.716 1.202
Moderate vs ideal .045 .398 .910 ⫺.761 .852
Severe vs ideal ⫺.513 .400 .208 ⫺1.325 .298
Mandibular
Mild vs ideal .337 .322 .302 ⫺.317 .991
Moderate vs ideal .311 .317 .334 ⫺.333 .954
Severe vs ideal .001 .348 .998 ⫺.704 .706

Multiple linear regression analysis with laypersons’ standardized VAS scores as dependent variable and OJ, OB, and DC as independent variables,
P ⬍.05.
B, regression estimate.

Table IV. Relationship of OJ, OB, and DC with laypersons’ standardized VAS scores
Unstandardized coefficients 95% CI for B

Anterior occlusal trait B SE Significance Lower bound Upper bound

Constant .535 .405 195 ⫺.286 1.357

OJ
Reverse vs normal ⫺.498 .279 .083 ⫺1.065 .068
Reduced vs normal ⫺.015 .499 .977 ⫺1.026 .997
Increased vs normal ⫺.062 .245 .801 ⫺.559 .435
Very increased vs normal ⫺.681 .292 .026 ⫺1.273 ⫺.088
OB
Anterior open bite vs normal .303 .371 .419 ⫺.449 1.055
Reduced vs normal .365 .365 .324 ⫺.375 1.104
Increased vs normal ⫺.017 .286 .953 ⫺.598 .563
DC
Maxillary
Mild vs ideal ⫺.230 .404 .574 ⫺1.050 .590
Moderate vs ideal ⫺.197 .340 .565 ⫺.887 .492
Severe vs ideal ⫺.696 .342 .049 ⫺1.390 ⫺.002
Mandibular
Mild vs ideal .237 .276 .396 ⫺.322 .796
Moderate vs ideal .209 .271 .446 ⫺.341 .760
Severe vs ideal ⫺.046 .297 .879 ⫺.649 .557

Multiple linear regression analysis with laypersons’ standardized VAS scores as dependent variable and OJ, OB, and DC as independent variables,
P ⬍.05.
B, regression estimate.

malocclusions in their perception of dental esthetics. OJ greater than 6 mm when assessing dental esthetics.
The greater the reverse OJ, the lower their dental The greater the increased OJ, the lower their dental
esthetic ratings reflected by the VAS scores. This was esthetic ratings. Thus, the threshold of dental esthetic
in contrast to Asian laypersons who emphasized severe acceptability among Asian laypersons might be gov-
174 Soh, Chew, and Chan American Journal of Orthodontics and Dentofacial Orthopedics
August 2006

Table V. Type of malocclusion and standardized VAS scores of orthodontists and laypersons
Orthodontists (n ⫽ 21) Laypersons (n ⫽ 158)

Type of malocclusion Number of cases Mean SD P value Mean SD P value

Class I 14 .129 .747 .008 .112 .655 .96

Class II Div 1 21 .194 .914 ⫺.069 .670
Class II Div 2 4 .350 .655 ⫺.070 .548
Class III 11 ⫺.660 .470 .009 .643

Kruskal-Wallis 1-way ANOVA by rank, P ⬍.05.

Div, Division.

Table VI.
Pair-wise comparison of orthodontists stan-
dardized VAS scores between different types of
malocclusion
Pair-wise comparison
Class I and Class II Div 1
Class I and Class II Div 2
Class I and Class III
Class II Div 1 and Class II Div 2
Class II Div 1 and Class III
Class II Div 2 and Class III
Mann-Whitney U test, P ⬍.025.
Div, Division.
erned by the amount of increased OJ at 6 mm. This
finding shows that the perception of dental esthetics
from an occlusal viewpoint varies between dental
professionals and laypersons. Thus, it is important to
establish which occlusal traits patients perceive to
contribute to poor dental esthetics during orthodontic
consultation to avoid vague generalizations and misin-
terpretations of their esthetic concerns. These findings
might show that laypersons with severely increased OJs
are less satisfied with dental esthetics and perhaps
would seek orthodontic consultation in the future,
whereas patients with Class III malocclusions with
reverse OJs would be perceived as esthetically less
acceptable by orthodontists who would readily advise
treatment to improve the dental appearance. It would be
of future interest to explore their impact of anterior
occlusal traits on perceived dental esthetics by orth-
odontic patients, especially those with severe Class II
Division 1 and Class III incisors.
Severe maxillary DC was found to be significantly
correlated with laypersons’ dental esthetic ratings.
However, its impact appeared to be marginal as re-
flected by the P value. These results suggest that
perhaps OJ was the major anterior occlusal trait of
visual impact when laypersons or orthodontists as-
sessed dental esthetics. With a severe positive or
negative OJ, other anterior occlusal traits might not
have a significant effect on the dental esthetic ratings of
this study sample. Perhaps DC would be significant to
dental esthetics in a patient with a Class I malocclusion
and normal OJ. A limitation to the assessment of DC
P value
was the lack of occlusal photographs of the maxillary
and mandibular arches. This could have accounted for
.654 mandibular DC not being statistically significant be-
.505 cause mandibular incisor crowding could not be clearly
.002
.915 assessed from the photographs, except for the Class III
.004 malocclusions with reverse OJ and mandibular incisor
.010 crowding. Mandibular incisor crowding might be a
genuine concern to orthodontic patients but not neces-
sarily to laypersons. Moreover, severe maxillary ante-
rior DC would be more obvious than mandibular
incisor crowding, both at maximum intercuspation and
on smiling in normal social situations. Thus, maxillary
DC was found to be a significant trait rather than
mandibular DC in the perception of dental esthetics by
the laypersons in this study.
A consideration in the design of this study was to
avoid the use of too many photographic views of the
dentition to minimize fatigue during assessment; only 2
views were used. Grayscale photographic prints were
used to eliminate the effects of tooth and gingival color
during assessment. We knew that tooth morphology
(eg, shape and size) could also influence the perception
of dental esthetics, but this was not investigated. It
might be more appropriate to use well-aligned denti-
tions with various degrees of OJ and OB instead of
crowded dentitions to assess tooth morphology of the
anterior occlusion from photographic prints.
Previous studies found that the perception of dental
esthetics is a complex process influenced by various
factors such as self-awareness of malocclusion, age, sex,
education, cultural, and ethnic backgrounds.20,37-40 We
did not study these factors because of the disparity of the
sample size among the ethnic groups and between the
sexes. However, it was evident that certain occlusal
traits and the type of malocclusion were significant
occlusal factors that had influenced the perception of
dental esthetics by Asian orthodontists and laypersons.
Our primary objective was to identify the anterior
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 2
occlusal traits that have significant impact on perceived
dental esthetics. Full-face smiling views of the various
malocclusions were not used. A recent study concluded
that dental views rather than full-face views were more
appropriate for the perception of dental esthetics from
the visible anterior occlusion.40 A separate study would
be necessary to determine the interrelationship between
perceived dental and facial esthetic ratings.
CONCLUSIONS
There was a difference in the perceptions of dental
esthetics of Asian orthodontists and laypersons. Orth-
odontists perceived Class III malocclusions with re-
verse OJ to be less esthetically pleasing. Malocclusions
with OJ greater than 6 mm and severe maxillary DC
greater than 8 mm were perceived to have poorer dental
esthetics by laypersons. OB and DS were nonsignifi-
cant occlusal traits in the assessment of dental esthetics
by both orthodontists and laypersons.
SUPPLEMENTARY DATA
Supplementary data associated with this article can
be found, in the online version (mosby.com/AJODO),
at doi:10.1016/j.ajodo.2005.05.048.
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