The Effect of Esthetic CrownLengthening on Perceptions ofa Patients Attractiveness, Friendliness,Trustworthiness, Intelligence, andSelf-ConfidenceSam Malkinson,* Thomas C. Waldrop,* John C. Gunsolley,* Sharon K. Lanning,*and Robert Sabatini*

Background: Smile esthetics have been shown to play a major role in the perception of whether a per-son is attractive, and whether they are perceived as friendly, trustworthy, intelligent, and self-confident. Aproposed major determinant of the esthetics of a smile is the amount of gingival display, which can beexcessive in cases of altered passive eruption. The aim of this study is to see whether altering the amountof gingival display of patients would affect dental professionals and laypersons perceptions of the afore-mentioned social parameters.

Methods: Patients were identified as having altered passive eruption and excessive gingival display.Smiling control photographs were taken and then digitally altered so as to lengthen the teeth andthus reduce the amount of gingival display. These became the test photographs. The control andtest photographs were shown in random order. The control group of evaluators consisted of senior dentalstudents, and the test group of evaluators comprised students who had no formal dental training. Groupswere asked to rate, on a visual analog scale, each pictures attractiveness, friendliness, trustworthiness,intelligence, and self-confidence.

Results: The test pictures with less gingival display were consistently and statistically significantlyrated higher for all five social parameters than were their control counterparts (P

Research has shown that agreement on attrac-tiveness ratings is consistent even amongdifferent cultures, suggesting a core human

perception of what constitutes beauty.1,2 Within theface, the mouth carries nearly a third of the impor-tance in the hierarchy of factors that determinewhether a person is judged to be attractive.3 Fordentists, esthetics are one of the pillars of the clinicaltreatment delivered, along with form and function.Some characteristics of an esthetic smile include: 1)dental midline is straight; 2) smile line follows theconvexity of the lower lip; 3) central incisors aresymmetric; 4) gingival margins of the central in-cisors are symmetric; 5) incisal embrasures gradu-ally deepen from central incisors to canines; 6) teethare straight or mesially inclined; and 7) width-to-length ratio of the central incisors is 75% to 80%.4

There are also other factors influencing the estheticsof a smile, including incisor show and gingival dis-play.5-10 Additionally, the background knowledgeof the observer who is perceiving the smile, that is,whether said observer is a dental professional ora layperson, also has an effect.6,7 Research hasdemonstrated that a patients smile can influencehis or her perceived beauty.5,9 Relationships havebeen identified among personality traits of emotio-nal stability, self-esteem, and dominance, and theperceived attractiveness of a persons smile.10 Astudy by Shaw et al. highlighted that people withfaces that had high background attractivenesswere judged to be of a higher social class and ofa higher level of sexual attraction.11 Other studieshave pointed to the fact that people of attractivefacial appearance were thought more desirable asdating partners, more successful in their careers,and were recommended for lighter sentences bya mock jury.12-16 Finally, Berscheid et al. found thatmost Americans believe that dental appearance isvery important in social interactions.17

Studies have implied that the attractiveness ofan individual may influence personality developmentand social interaction.18 Attractive individuals havebeen shown to be judged more positively, whereasunattractive individuals have been assigned morenegative characteristics.12,18 Further studies haveshown that appearance is related to a persons lead-ership status, and that core traits such as friendliness,sincerity, openness to experience, agreeableness, con-scientiousness, intelligence, honesty, and extraversionare related to leadership.19-21

A proposed major esthetic problem in dentistry iswhat is termed excessive gingival display, betterknown by laypeople as a gummy smile. Theprevalence of excessive gingival display has beenestimated at 10% of the population between theage of 20 and 30 years, and it is seen more in

women than in men.22,23 Possible etiologic factors forthis clinical presentation include gingival enlarge-ment/overgrowth, altered passive eruption, shortclinical crowns, vertical maxillary excess, or a shortupper lip, or combinations of these conditions.24-26

A wide variety of therapeutic approaches may beconsidered, depending on the diagnosis. Thesemay vary from simple procedures such as gingi-vectomy, to more complex procedures includingmucoperiosteal flaps, osseous resective surgery,27

and orthognathic surgery.Eruption involves two phases, active and passive.

Active eruption ceases when the teeth come intocontact with the opposing dentition. The additionalstep involved in the normal eruption pattern ofteeth involves passive eruption, which is the migra-tion of the epithelial attachment apically to exposethe anatomic crown of the tooth. A delay or failureof this to occur can result in the appearance ofshort clinical crowns and excessive gingival display.A 12.1% incidence of altered passive eruption wasreported in a study of 1,025 patients with a meanage of 24.2 6.2 years.28

Because of the potentially significant impact onesthetics of the gummy smile due to altered passiveeruption, the ability of dental professionals to treatit, and the broader social context, the aims of thisresearch are twofold: 1) to see if there is any differ-ence in peoples perceptions of social parameterssuch as attractiveness, friendliness, trustworthiness,intelligence, and self-confidence, when looking atsimulated before- and after-treatment photographsof gummy smiles; and 2) to see if there is any dif-ference in this perception between senior dentalstudents and laypersons.

MATERIALS AND METHODS

Preparation of Survey ItemsFollowing an exemption from approval by the In-stitutional Review Board of Virginia CommonwealthUniversity (VCU), a survey was constructed usingpreoperative facial frontal smiling photographs of 10individuals, simulated patients cropped to excludefacial features not pertaining to the mouth, so as notto introduce unnecessary confounding variables.6 Nooral or written consent was therefore required. Thepreoperative photographs were the control photo-graphs. These patients were identified from thestudents and support staff of the School of Dentistry.In each case, the patient in question was diagnosed ashaving altered passive eruption in the anterior maxilla.The patient sample of individuals consisted of threemales and seven females (aged 22 to 28 years). Onemale and two females were African American. Theremaining patients, two males and five females, werewhite. In this study, all future references to patients

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refer to those individuals who had pictures taken oftheir mouths, and all references to evaluators referto the control and test groups of students who werefilling out the survey questionnaires regarding theaforementioned pictures.

Survey ConstructionThe patients control photographs (Fig. 1A) weredigitally altered using a photo-editing program toproduce a projected version of what the patient wouldlook like after an esthetic crown-lengthening surgery(Fig. 1B). The modifications were thus limited tovarying the heights of the zeniths of the gingivalmargins and the flatness of the gingival margins.These photographs were the test photographs. Thus,a total of 20 photographs were a part of the survey.29

An electronic survey was constructed using thepatients photographs, which were placed in randomorder as per a sequence generated by a computerprogram on a website.30 These pictures were placedin this random order in an electronic presentation.

This presentation was shown to groups of evaluatorsin lecture halls by being projected onto a big screen.

Explanations were delivered verbally at the beginningof the study, and the investigator remained withthe evaluators to ensure they had no questions onhow to complete the study. The evaluators filled outpaper questionnaires, starting with their sex, age,race/ethnicity, and whether they were a senior dentalstudent or a student who had completed no formaleducation in dentistry. For each individual photo-graph, there were five statements proposed ona page of the questionnaire. The statements were:1) This person is attractive. 2) This person isfriendly. 3) This person is trustworthy. 4) This per-son is intelligent. 5) This person is self-confident.

Evaluators indicated their level of agreement ordisagreement with each statement via a visual ana-log scale (VAS).31 This consisted of a horizontal linewith gradations, exactly 100 mm in length. On theleft side of this line was the word Disagree, and onthe right side was the word Agree. Evaluators wereinstructed to place an X on this line, which allowedthe researcher to assign a numerical value to theevaluators responses. The answer recorded wasa value between 0 and 100.

Identification of EvaluatorsThe survey was administered to two groups of eval-uators. The first group was senior dental students.This comprised the control group, which had receivedformal training in recognition of excessive gingivaldisplay and in the diagnosis of altered passive eru-ption. The second group, the test group of laypeople,consisted of members of what is known at VCU asD0.5 students, who are students that have beenprovisionally accepted to dental school but have notbegun their formal dental training any further thanbasic science courses, and additionally a group offirst-year medical students, whose curriculum doesnot include lectures regarding dental esthetics.Evaluators were identified by means of mass e-mailsand announcements made over the School of Den-tistrys intercom system, and the study was con-ducted from December 2011 to January 2012.

Statistical MethodsThe responses of the evaluators were measured witha standard metric ruler, and the level of agreementwas measured as an integer between 1 and 100.The measurement was performed from the start ofthe dotted line of the VAS until the point at which thecenter of the marked X crossed the dotted line. Thesevalues were recorded into a database on a spread-sheet. Because each evaluator assessed each pa-tient before and after the digital editing of the images,each evaluator rated 20 images. This resulted in

Figure 1.A)Control image.B) Projected test image of patient after esthetic crown-lengthening.

Adobe Photoshop CS5, Adobe, San Jose, CA. Microsoft PowerPoint, Microsoft, Redmond, WA. Microsoft Excel, Microsoft.

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a repeated measures design for two factors, thepatient and the evaluator.

The distributions of the outcome variables wereevaluated. Although the distributions did not as-sume a normal distribution when evaluated with theShapiro-Wilk W test, the distributions were nearlynormally distributed when assessed visually. Be-cause there was a large number of evaluations (n =1,540), parametric methods were used due to as-sumptions about the distribution of mean responsesunder the central limit theorem.

Distribution of scores for the social parameters.See Figure 2.

To analyze the effect of editing the images, po-tential covariates of race and sex of both the patientsand the evaluators, and age of the evaluators,analysis of variance (ANOVA) was used. The ANOVAmodel included two random effects (one for thepatients and one for the evaluators), along withthe fixed effects previously described. To evaluatethe relationship among the five outcome variables,Pearson correlation coefficients were calculatedusing a statistical software package.i The level ofsignificance was set at P

Effect of Patient Race and Sex on EvaluatorsPerceptions of Attractiveness, Friendliness,Trustworthiness, Intelligence, andSelf-ConfidenceAnalyses were carried out on the race and sex of thepatient in the pictures to see if they had any effecton the outcomes. Regarding the race of the patients,a statistically significant effect was found for theparameters trustworthiness and self-confidence, withevaluators ranking African Americans more trust-worthy than whites (64.4 3.6 versus 59.0 3.3)and more self-confident than whites (71.3 4.0 versus 63.7 3.4). Regarding the sex of thepatients, a statistically significant effect was foundfor the parameters of trustworthiness and in-telligence, with evaluators rating females moretrustworthy than males (65.3 3.3 versus 58.1 3.6) and more intelligent than males (68.0 3.4 versus 61.0 3.8).

Effect of Evaluator Race, Sex, and Age onEvaluators Perceptions of Attractiveness,Friendliness, Trustworthiness, Intelligence,and Self-ConfidenceAnalyses were also carried out on the race, sex, andage of the evaluators from both groups doing theevaluations, to see if they had any effect on theoutcomes. Of all these factors, only age had a bor-derline statistically significant effect, and it was onlyfor the parameter of attractiveness (P = 0.0263).

Correlation Between Social ParametersThe correlation between how the evaluators per-ceived the patients attractiveness, friendliness,trustworthiness, intelligence, and self-confidence isshown in Table 4. All of the parameters showedstatistically significant positive correlations witheach other (P 65% of postorthodontic patientsdemonstrate non-ideal width-to-length ratios, and>60% demonstrate asymmetries of the gingivalmargins.33 The current study includes some of theseparameters, but also first asked the evaluators howattractive the smile was. The results indicated thatattractiveness was positively correlated with the

Table 1.

Demographics of Dental and Non-DentalEvaluators

Group Race Sex n

Mean Age

(years) SD

Dental Asian F 5 27.0 1.9AA F 2 27.0 1.4White F 12 25.9 1.1

M 24 28.3 4.5

Non-dental Asian F 12 25.1 5.7M 6 22.2 0.4

White F 7 25.0 1.9M 9 25.3 2.9

AA = African American.

Table 2.

Differences in Least Square Mean Scores for Social Parameters Between Control andTest Patient Pictures, for Both Control and Test Groups of Evaluators

Attractive Friendly Trustworthy Intelligent Self-Confident

Evaluator Patient n Mean SE Mean SE Mean SE Mean SE Mean SE

Control(dental)

Control 430 49.5 4.1 62.4 3.7 58.3 3.5 60.1 3.6 63.3 3.6

Test 430 58.4 4.1 66.5 3.7 61.6 3.5 65.0 3.6 70.0 3.6

Test(non-dental)

Control 340 53.7 4.2 67.6 3.8 61.8 3.7 65.0 3.9 65.7 3.8

Test 340 59.7 4.2 70.8 3.8 65.0 3.7 67.8 3.9 71.0 3.8

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other social parameters. That those correlationstended to be lower than the correlations among theother four social parameters is not surprising, be-cause under the given circumstances, attractivenessis the least nebulous concept. This is because anevaluator can identify for him- or herself things abouta persons smile that are attractive or not. If thecorrelation coefficients between attractiveness andthe other social parameters had all approacheda value of 1, then it might have been interpreted thatmeasuring attractiveness and friendliness, trust-worthiness, intelligence, and self-confidence wereall measuring the same thing. The implicationfrom the results of the current study is that theperceived improvement in ratings of friendliness,trustworthiness, intelligence, and self-confidencefollowing esthetic crown lengthening of the teeth is

because of the perceived improvement in attrac-tiveness.

Simulated esthetic crown lengthening on the pa-tients in the current study led to higher ratings of allfive social parameters. The gingival digital alterationswere performed in such a manner that nothing otherthan the heights of the gingival zeniths were altered,and this was done to isolate the effect of estheticcrown lengthening. This was performed in contrast tothe experimental protocol of another similar study byIoi et al.,34 which instead digitally treated patientsby moving their entire dental unit apically withoutchanging the ratio of the height to the width, as isdone in the current study. They did, however, findvery similar results in terms of higher ratings for at-tractiveness for the digitally altered pictures. Anotherinteresting difference worth discussing that relates

Table 3.

Differences in Least Square Mean Scores for Social Parameters Between Test and ControlGroups, for Both Before and After Pictures

Attractive Friendly Trustworthy Intelligent Self-Confident

Picture Evaluator n Mean SE Mean SE Mean SE Mean SE Mean SE

Control (before) Control 430 49.5 4.1 62.4 3.7 58.3 3.5 60.1 3.6 63.3 3.6

Test 340 53.7 4.2 67.6 3.8 61.8 3.7 65.0 3.9 65.7 3.8

Test (after) Control 430 58.4 4.1 66.5 3.7 61.6 3.5 65.0 3.6 70.0 3.6

Test 340 59.7 4.2 70.8 3.8 65.0 3.7 67.8 3.9 71.0 3.8

Table 4.

Pearson Correlations Between Social Parameters

Pairwise Correlations

Variable By Variable Correlation Lower 95% Upper 95%

Attractive Friendly 0.56 0.52 0.60

Attractive Trustworthy 0.59 0.56 0.63

Attractive Intelligent 0.63 0.60 0.66

Attractive Self-confident 0.59 0.55 0.62

Friendly Trustworthy 0.78 0.76 0.80

Friendly Intelligent 0.63 0.60 0.66

Friendly Self-confident 0.67 0.65 0.70

Trustworthy Intelligent 0.73 0.71 0.76

Trustworthy Self-confident 0.59 0.56 0.62

Intelligent Self-confident 0.64 0.61 0.67

All correlations are statistically significant at P

to this study is the evaluator population. The Ioi et al.study34 was performed in Japan, and the two groupswho rated the pictures were dental students andpracticing orthodontists, neither of whom could beconsidered laypeople. It has been previously estab-lished that dental professionals can pick up on es-thetic parameters of a patients smile.35 It was forthis reason that the control group of evaluators in thecurrent study was chosen to be senior dental stu-dents, for whom the training and didactic educationis still fresh. The test group was chosen to be stu-dents with no formal dental training. Despite thisgroups lack of formal training, they were able toperceive differences in attractiveness, friendliness,trustworthiness, intelligence, and self-confidence justas well as the senior dental students. This findingmay well be the most significant of the study, be-cause the subtext reveals that any person can makesubjective decisions about whether they find an in-dividual attractive based on their smile, and whetherthis affects how friendly, trustworthy, intelligent, andself-confident they perceive the individual to be.

Finally, the statistical analyses revealed that therace and sex of the patient being evaluated affectedthe results. Different studies by Furnham36 andSteiger et al.37 found that despite there being nostatistically significant difference in actual IQ valuesbetween men and women, women perceived theirIQ to be lower than mens. In the current study,although the evaluators were not self-assessing,women were rated as appearing to have higher in-telligence than men. Regarding trustworthiness, theresults of this study correlate with results obtainedin another study, which also found that attractivewomen were likely to be rated more trustworthy thanmen.38 The results also indicate that African Amer-icans were rated more trustworthy than whites, de-spite that in another study there was no significantdifference between the two on how trustworthy theywere rated.39 In terms of self-confidence, the resultsmay contradict an assertion made that AfricanAmericans were significantly less self-confident,40

inasmuch as those pictures of African Americanswere rated higher for self-confidence than picturesof whites. Interestingly, in the current study, neitherpatient sex nor patient race has any effect onwhether the pictures are perceived as more orless attractive, despite conflicting evidence in theliterature.41,42 Further, and again in conflict withpublished results, neither the sex nor the race of theevaluator doing the evaluation affects the outcomeof the ratings.43

CONCLUSIONS

It should be clear that a gummy smile can havean adverse effect on the perception of a patients

attractiveness, friendliness, trustworthiness, in-telligence, and self-confidence. For any dental pro-fessional, an assessment of the amount of gingivaldisplay is appropriate, as is an investigation intothe etiology of any diagnosed excessive gingivaldisplay. Although the treatment rationale for thisissue is at present more esthetic than it is biologic,the available body of evidence shows that the socialparameters associated with an attractive smile areindispensable for healthy interpersonal interaction.

ACKNOWLEDGMENTS

This work was supported by a research grant fromthe Alexander Fellowship, VCU. Dr. Sam Malkinsonwould like to thank his Research Committee of Drs.Waldrop, Gunsolley, Lanning, and Sabatini, and alsoFaye Miles and Shelby Haynes, administrative assis-tants, all of the Department of Periodontics, VCU.Thanks also to Dr. Michael Healy, Associate Dean,Admissions and International Affairs, VCU Schoolof Dentistry, and Chris Ray, medical student, VCUSchool of Medicine, for their support with logistics.The authors report no conflicts of interest related tothis study.

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Correspondence: Dr. Thomas C. Waldrop, VirginiaCommonwealth University School of Dentistry Depart-ment of Periodontics, 521 N. 11th St., P.O. Box 980556,Richmond, VA 23298. Fax: 804/828-0657; e-mail:tcwaldro@vcu.edu.

Submitted June 28, 2012; accepted for publicationSeptember 29, 2012.

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