ORIGINAL ARTICLE

Peer assessment of dental attractiveness

Egle Ong,a Rebecca A Brown,b and Stephen Richmondc
Cardiff, Wales, United Kingdom
Introduction: The objectives of the study were to determine the relative importance of various dental
features that contribute to overall dental attractiveness and to test the validity of the concepts of golden
proportion and golden percentage as applied to the human dentition. Methods: Sixty 30-year-old subjects
(29 men, 31 women) were selected from the 20-year longitudinal Cardiff Survey. Color photographs of the
subjects dentitions were taken with the lips retracted so that their teeth and gums were clearly exposed.
Twelve nondentists, aged 32 to 33 years, equally divided according to sex, rated the subjects dental
appearances on a 5-point Likert attractiveness scale. The maxillary anterior teeth were measured, and
relevant ratios were calculated and compared with the golden proportion. Factor analyses and linear
regression were used to investigate the hierarchy of dental features, and variance components analysis was
used to estimate interrater agreement. Results and conclusions: Overall dental attractiveness did not
depend on any particular feature of the dentition. A hierarchy of various features was established, with crown
shape ranked highest, and tooth and gum color ranked lowest. The golden proportion and the golden
percentage were not decisive factors in determining dental attractiveness. (Am J Orthod Dentofacial Orthop
2006;130:163-9)

hysical attractiveness influences a perons life in

various ways and to a considerable extent.1-3
Moreover, facial appearance has been suggested
to be a slightly more powerful predictor of overall
attractiveness than the body.4
Recently, it was reported that all facial features are
similarly important in making ones face attractive (in
children and adults alike) as judged by laypeople in
their early 30s.5 The importance of ones dental appearance in overall facial attractiveness when impressions
are formed should not be overestimated. Nevertheless,
there is evidence that people with impaired dental
appearance are highly likely to be perceived substantially differently from those having healthy-looking
dentitions.6-13
The evidence about the long-term effects of various
factors that can affect overall dental attractiveness is
somewhat scarce. However, it was suggested that
malocclusion might adversely affect body image and
self-concept not only in adolescence but also in adulthood.14 Factors that might affect overall dental appearFrom the Department of Dental Health and Biological Sciences, School of
Dentistry, Wales College of Medicine, Biology, Life and Health Sciences,
Cardiff, Wales, United Kingdom.
a
Visiting scholar.
b
Medical statistician.
c
Professor.
Reprint requests to: Stephen Richmond, Department of Dental Health and
Biological Sciences, School of Dentistry, Wales College of Medicine, Biology,
Life and Health Sciences, Heath Park, Cardiff CF14 4XY, Wales, United
Kingdom; e-mail, richmonds@cardiff.ac.uk.
Submitted, September 2004; revised and accepted, February 2005.
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.02.018

ance could be classified as related to single teeth (size,

color, shape), adjacent teeth (proportions and alignment), and periodontium (gingival color, contour, and
texture).15,16 The area of most esthetic importance is
likely to be the maxillary anterior teeth because of their
high visibility in an average open smile.17
Some dental esthetic factors can be evaluated by
subjective judgmentie, attractiveness of tooth shape18
or color.19 In addition, the esthetic value of other features,
such as crown proportions or symmetry across the midline, can be objectively assessed with specific measures,
such as the golden proportion20,21 or its modification, the
golden percentage.22
The width-to-height ratio of the maxillary central
incisors has been suggested to be significant in terms
of overall dental appearance because these teeth
normally dominate in a persons smile.20 For the
golden proportion, the width-to-height ratio of a
maxillary central incisor crown would be equal to
0.62. The golden proportion takes into consideration
the relative widths of the maxillary anterior teeth and
assumes that in an attractive dentition the ratio of the
apparent widths of the central incisor to the lateral
incisor is 1.62:1; similarly, the apparent width of the
lateral incisor is in the golden proportion to the width
of the canineie, 1:0.62.21 The golden percentage is
a modification of the golden proportion rule, and it
was proposed as a simple and objective tool to assess
such dental esthetic measures as anterior dominance,
symmetry across the midline, and regressive proportion.22
In spite of much literature about esthetic dentistry,
163

164 Ong, Brown, and Richmond

it is still not possible to definitively state which features

make dental appearance attractive. Few studies have
attempted to estimate the potential of various dental
characteristics or determine a hierarchy of factors
contributing to an attractive dentition,19 and none took
all esthetic dental features into account while assessing
their significance in overall dental attractiveness when
impressions are formed.
The aim of this study was to investigate various
factors that contribute to overall dental attractiveness.
The objectives were (1) to determine the relative
importance of various dental features (alignment; tooth
color, shape, size, and crown proportions; dentition
proportions; gum color and contour) and their contribution to overall dental attractiveness and (2) to test the
validity of the golden proportion (and the golden
percentage) as applied to the human dentition.
SUBJECTS AND METHODS

In this study, we used data from the longitudinal

Cardiff Survey, which began in 1981.23
Sixty white subjects (31 women, 29 men), aged 30,
who represented a broad range of dental attractiveness,
were selected from the sample of 331 (by using the
average tooth attractiveness score obtained from a
panel of 6 judges and derived from a 10-cm visual
analog scale). Color photographs of the anterior dentitions were taken with the subjects lips retracted so that
their teeth and gums were clearly visible.
A questionnaire was devised with a 5-point attractiveness scale for various features of teeth and gums
(tooth alignment, color, shape, size, teeth crown proportions, dentition proportions, gum color and contour)
(Table I). In addition, the raters were asked to evaluate
the overall attractiveness of each dentition. Supplementary definitions were added regarding the proportions of
the teeth and the dentition to aid the rater. Sixty
photographs were randomly organized into a folder
with 1 questionnaire and photograph per page (to
reduce the ordering effect).
Twelve white nondentists, aged 32 to 33 years,
equally divided according to sex, were invited to rate
these dental photographs. The raters were asked to
complete the questionnaires at home and return them
within 3 days. Each rater was paid 20.
The golden-proportion rule was applied to the
maxillary central incisors. Incisal-gingival heights and
mesiodistal widths of the clinical crowns were measured as seen from the front view by using digital
photographic images and the cursor functions in PowerPoint 97 (Microsoft, Redmond, Wash). Width-toheight ratios were computed for both right and left

American Journal of Orthodontics and Dentofacial Orthopedics

August 2006

maxillary central incisors (1 dentition was excluded

because of a missing maxillary right central incisor).
The principle of the golden percentage was used to
assess the arrangement of the 6 maxillary anterior teeth
while suggesting that, in the ideal case scenario (when
the teeth are in the golden proportion), their relative
widths should approximate the following percentages:
10% (right canine), 15% (right lateral incisor), 25%
(right central incisor), 25% (left central incisor), 15%
(left lateral incisor), and 10% (left canine).22
For the latter purpose, a subsample of 50 subjects
was selected (dentitions with clearly visible gaps between the maxillary front teeth were excluded). The
apparent widths of the 6 maxillary anterior teeth (right
canine to left canine) were measured by using digital
photographic images and the cursor functions in Microsoft PowerPoint 97. The mesiodistal widths of these
teeth were added together, and the total width of the
maxillary front segment accounted for 100%. In that
way, the relative width of each tooth was calculated and
assigned a respective percentage for each dentition.
Statistical analysis

Factor and linear regression analyses were used to

investigate individual dental features. Factor analysis
aimed to identify any underlying factors of combined
dental features that contribute to overall dental attractiveness. Regression analysis was used to determine
how well each dental feature predicted the overall
attractiveness score. Dental attractiveness scores were
averaged over raters for these statistical analyses.
As well as providing attractiveness scores, the raters
designated each subjects dentition as attractive or unattractive. A consensus was obtained for all 12 raters for
each subject. If there was a tie, the subject was assigned to
the unattractive group.
Interrater reliability was assessed as the ratio of subject
variance to the sum of subject, rater, and error variance
determined from the variance components analysis.24
Unless otherwise stated, a P value of .05 was
considered statistically significant.
RESULTS

The results of the factor analysis are shown in Table II.

Only 1 factor was extracted with similar weightings for all
features. This suggests that each dental feature contributed
approximately equally to overall dental attractiveness.
This was true for the entire sample as well as for men and
women, and the attractive and unattractive dentitions (as
classified by the raters) separately.
According to the linear regression analysis results
(Table III), in both the entire sample and in the groups
for sex and attractiveness, the dental feature most

Ong, Brown, and Richmond 165

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 2

Table I.

Five-point dental attractiveness rating scale

Neither attractive
nor unattractive

Very unattractive
Overall dentition
Teeth
Alignment
Color
Shape
Size
Tooth-crown proportions*
Dentition proportions
Gums
Color
Contour

Very attractive

1
1
1
1
1
1

2
2
2
2
2
2

3
3
3
3
3
3

4
4
4
4
4
4

5
5
5
5
5
5

1
1

2
2

3
3

4
4

5
5

Women

Men

*Defined as width-to-length ratio of crown.

Defined as width-to-length ratio of entire dentition.

Table II.

Factor loadings and communalities for factor analysis of dental features

Entire sample

Dental feature

Factor
loading

Alignment
Tooth color
Shape
Size
Crown proportions
Dentition proportions
Gum color
Gum contour
Variance explained

.136
.116
.145
.143
.144
.140
.128
.140
83.7%

Com
.825
.602
.940
.914
.926
.874
.730
.884

Attractive
Factor
loading
.157
.108
.169
.151
.165
.160
.153
.158
66.2%

Unattractive

Com
.690
.325
.801
.638
.766
.723
.658
.699

Factor
loading
.140
.103
.158
.155
.155
.147
.130
.151
75.8%

Com
.722
.394
.914
.890
.890
.796
.622
.839

Factor
loading
.135
.121
.144
.145
.145
.138
.126
.139
83.4%

Com
.808
.649
.924
.931
.937
.846
.708
.864

Factor
loading
.137
.111
.148
.142
.144
.142
.129
.143
82.7%

Com
.821
.541
.954
.884
.904
.887
.724
.898

Com, Communality.

Table III.

Results of linear regression for each dental feature with overall attractiveness score
R2 values from univariate linear regressions

Dental feature
Alignment
Tooth color
Shape
Size
Crown proportions
Dentition proportions
Gum color
Gum contour

Entire sample

Attractive

Unattractive

Women

Men

.831
.632
.864
.814
.837
.820
.605
.740

.698
.388
.764
.555
.674
.628
.402
.458

.725
.462
.773
.707
.716
.668
.484
.630

.796
.685
.857
.820
.822
.785
.577
.706

.853
.561
.864
.778
.834
.839
.599
.766

P .01.

strongly associated with overall attractiveness was

tooth shape. The dental features least associated with
overall score were color of teeth and gums.
As can be seen from Table IV, generally, the scores
for all dental features as well as overall dental attrac-

tiveness were significantly higher in the attractive

dentition group.
The overall dental attractiveness score in women
was significantly higher than in men. Similarly, tooth
size, crown proportions, and dentition proportions were

166 Ong, Brown, and Richmond

Table IV.

American Journal of Orthodontics and Dentofacial Orthopedics

August 2006

Mean scores (standard deviations) for various dental features by dentition attractiveness and sex

Attractiveness
Attractive (n 16)
Unattractive (n 44)
P
Sex
Female (n 31)
Male (n 29)
P

Overall

Alignment

Tooth color

Shape

Size

Teeth crown
proportions

Dentition
proportions

Gum
color

Gum
contour

3.5 (.43)
2.1 (.60)
.000

3.5 (.38)
2.4 (.66)
.000

3.5 (.35)
2.6 (.63)
.000

3.5 (.30)
2.5 (.59)
.000

3.4 (.31)
2.5 (.53)
.000

3.3 (.26)
2.5 (.48)
.000

3.4 (.42)
2.3 (.57)
.000

3.3 (.44)
2.6 (.54)
.000

3.3 (.37)
2.5 (.52)
.000

2.7 (.86)
2.3 (.77)
.045

2.8 (.76)
2.4 (.75)
.054

2.9 (.71)
2.7 (.66)
.276

2.9 (.67)
2.6 (.69)
.069

2.9 (.62)
2.5 (.57)
.013

2.9 (.56)
2.5 (.55)
.018

2.8 (.71)
2.3 (.68)
.012

3.0 (.60)
2.7 (.58)
.098

2.8 (.56)
2.6 (.63)
.073

rated significantly more attractive in the female subjects.

The average maxillary central incisor ratio was
found to be just above 0.8 (Table V) and therefore was
generally higher than the golden proportion (0.62) for
our sample.
The mean ratios for the central incisors did not
differ significantly between the men and the women.
Interestingly, the central incisors width-to-height ratio
was significantly greater in the unattractive group (for
the left central incisor only).
Table VI shows the results of the golden percentage
analysis, suggesting that, in this sample, average dentition was more or less symmetrical across the midline,
with the maxillary central incisors occupying just above
46% (slightly less than the golden 50%). Interestingly,
a similar pattern remained when studied in separate sex
and dental-attractiveness groups; generally, differences
between the relative widths of the teeth were not
statistically significant (except that men had wider right
canines than the women, and attractive dentitions had
wider right lateral incisors than unattractive dentitions).
From variance components analysis, the following
results were obtained for interrater reliability, with 2
as the variance for each component:
R 2SUBJECTS
2SUBJECTS 2RATERS 2ERROR

0.669
0.669 0.182 0.403

0.53

The interrater agreement of 0.53 could be regarded

as moderate for assessing a persons dental attractiveness.
DISCUSSION

The need for a very detailed, almost histologic

approach to dental aesthetics was highlighted in the
early 1970s,20 and attempts since then have been
made to address what makes a smile attractive.

Table V.

Mean ratios (standard deviations) for maxillary right and left central incisors (entire sample and
groups by dentition attractiveness and sex)

Entire sample (n 59)

Attractiveness
Attractive (n 16)
Unattractive (n 43)
P
Sex
Female (n 31)
Male (n 28)
P

Right central
incisor

Left central
incisor

.83 (.09)

.82 (.09)

.80 (.10)
.84 (.08)
.061

.78 (.10)
.83 (.08)
.046

.82 (.08)
.84 (.10)
.526

.81 (.10)
.82 (.08)
.907

Several studies attempted to evaluate the significance of various dental features in terms of overall
dental attractiveness, most of them considering only 1
feature or a few features.18,25 Dunn et al19 assessed the
importance of several dental features: symmetry, tooth
shade, number of teeth displayed, height of maxillary
lip line, and number of natural-looking teeth. Nevertheless, other elements, such as gingival appearance,
tooth shape, and tooth proportions, were not evaluated.
It was suggested that the cumulative visual impact of
the anterior dentition often transcends the sum of the
individual parts.26
In this study, we investigated dental esthetics and
considered as many dental factors as possible. Both
subjective and objective measures were used and their
importance assessed in overall dental attractiveness.
Although all dental features investigated contributed similarly to overall dental attractiveness, a hierarchy of features was established. Interestingly, tooth
shape was most strongly associated with overall attractiveness, whereas the color of teeth and gums had the
weakest association with the overall score (although
still statistically significant). Only very minor changes
in the ranking order occurred when the sex of a subject
or the attractiveness of a dentition was considered.

Ong, Brown, and Richmond 167

American Journal of Orthodontics and Dentofacial Orthopedics

Volume 130, Number 2

Table VI. Mean values (standard deviation) of golden percentage calculations (entire sample and groups by dentition
attractiveness and sex)
Golden %
10 %

Entire sample (n 50)

Attractiveness
Attractive (n 16)
Unattractive (n 34)
P
Sex
Female (n 28)
Male (n 22)
P

15 %
Right

25 %

25 %

15 %

10 %

Left

Canine

Lateral incisor

Central incisor

Central incisor

Lateral incisor

Canine

13.2 (2.1)

14.4 (1.7)

23.2 (1.4)

23.1 (1.2)

13.9 (1.9)

12.3 (1.7)

13.0 (1.8)
13.3 (2.2)
.634

15.1 (1.1)
14.1 (1.9)
.022

22.8 (1.1)
23.3 (1.4)
.193

22.8 (1.2)
23.3 (1.2)
.139

14.6 (1.3)
13.6 (2.1)
.085

11.9 (1.4)
12.5 (1.9)
.247

12.5 (2.0)
14.0 (1.9)
.012

14.6 (1.7)
14.1 (1.7)
.314

23.3 (1.4)
23.1 (1.4)
.606

23.2 (1.1)
23.0 (1.2)
.488

14.3 (1.3)
13.5 (2.4)
.141

12.2 (1.6)
12.4 (2.0)
.604

It was not unexpected that the gingival features

color and contourwere less significant than most
tooth characteristics (except color). A possible explanation for this is that the gums are normally less visible
than the teeth during daily interaction and thus less
noticeable to laypeople than to dental professionals,
who observe gingival structures daily. Also, our subjects did not have major gingival problems. The finding
that tooth color was least associated (apart from the
gingival characteristics) with overall dental attractiveness was somewhat unexpected and is in contrast to the
findings of another relevant study in which it was
concluded that tooth shade was the most important
variable in predicting dental attractiveness.19 However,
a comparison of those results and our findings should
be made with care because the methods, and the dental
features studied, differed considerably.
Furthermore, it was recently reported that tooth
whiteness was not associated with increased overall
facial attractiveness as perceived by other people.27 In
this context, the esthetic value of tooth color and its
perception is still a poorly researched area. Nevertheless, from the present evidence, it seems safe to suggest
that the stereotypical the whiter the teeth, the more
attractive they look might not be completely true.
Interestingly, the shape of the teeth stood out as a
feature most strongly associated with overall dental
attractiveness, both generally and in the sex and dentition-attractiveness groups. It is beyond the scope of
this article to determine what tooth shape was preferred by the panel, but it seems worthwhile for
future investigation.
The findings regarding the proportions of the dominant teeth in ones smile are in line with earlier
findings by other researchers. The golden proportion
(the ratio of 0.62) is not generally found in the central

incisors of the general population.28,29 Also, the golden

proportion was not considered exceptionally attractive
in an experimental setting.18,25 The average maxillary
central incisor width-to-height ratio in this study was
just over 0.8 and did not differ significantly between
men and women. The proportion was slightly less in the
attractive group; however, the difference was significant for the maxillary left central incisors but not for the
right.
The golden proportion principle for the esthetic
evaluation of the maxillary front teeth was strongly
advocated by Levin.21 However, others suggested that
the regressive proportion of 0.62 was too strong for
dental use,20 and, moreover, that it rarely occurs in a
natural dentition.30 It was stated that the exact proportions are not as important as the concepts of
symmetry and a logical approach to esthetic restoration of the maxillary anterior teeth.31 Furthermore,
the application of a greater regressive proportion was
suggested.32,33
The principle of the golden percentage was used for
evaluation of the width of each maxillary front tooth for
its contribution to symmetry, dominance, and proportion of the entire anterior segment. Our findings are
mainly in line with previously reported relevant data.
Generally, the maxillary central incisors were found to
be the dominant element of the average dentition while
occupying slightly less than the suggested golden 50%
of the total width of the anterior segment. 22
The proportions of the maxillary central incisor
crowns and the relative maxillary front teeth widths
remained rather constant in the sex and dentitionattractiveness groups. Therefore, it can be concluded
that in this sample the golden proportion was not the
decisive factor when assessing dental attractiveness. In
addition, the relative widths of the maxillary anterior

168 Ong, Brown, and Richmond

teeth and the crown proportions of the maxillary central

incisors could not be used as specific measures to
distinguish womens dentitions from mens.
It is plausible that, as long as the maxillary central
incisors are a dominant element of the dentition, the
maxillary front teeth are just about symmetrical across
the midline and their relative widths decrease gradually
and proportionally as seen from the front, the dentition
can be considered attractive even if the relative width
proportions deviate from the golden percentage.
It is known that the perception of dental esthetics
varies significantly among people of different ages and
occupations, and depends on the level of education.18,34
In addition, various environmental factors eg, lighting conditions have been reported to influence the
perception of tooth color35 and, most probably, other
dental features. Therefore, because of these factors and
because esthetic evaluation always has a lesser or a
greater amount of subjectivity, a certain amount of
perception variability is expected2,5 Interrater agreement for dental attractiveness in this study was moderate. Nevertheless, it could differ considerably if the
panel included judges with different demographic characteristics.
CONCLUSIONS

1. Overall dental attractiveness did not depend on any

particular feature of the dentition; nevertheless, a
hierarchy of various features was established, with
crown shape ranked the highest, and tooth and gum
color ranked the lowest.
2. The golden proportion and the golden percentage
were not decisive factors in determining dental
attractiveness.
We thank Professor Bill Shaw, the principal investigator for the longitudinal Cardiff Study, and Anne
Kingdon for maintaining contact with the subjects and
organizing the recall program and database. We acknowledge funding from the NHS Research and Development Program.

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