RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10063-0155 |
Layman’s Perception of the Gingival Component of Smile Esthetics: A Web-based Study
1–5Department of Periodontics, GSL Dental College & Hospital, Rajamahendravaram, Andhra Pradesh, India
Corresponding Author: Ashok Kodangala P, Department of Periodontics, GSL Dental College & Hospital, Rajamahendravaram, Andhra Pradesh, India, Phone: +91 7049754198, e-mail: drashokkp@gmail.com
Received: 23 March 2024; Accepted: 17 April 2024; Published on: 17 May 2024
ABSTRACT
Introduction: Esthetic demands can frequently bring significant challenges to practitioners. It necessitates a thorough clinical examination and documentation as well as clear communication between the patient and clinician, which is crucial for understanding treatment outcomes and expectations. Complete smile analysis is a vital component of diagnosis and treatment for effective esthetic outcomes. The purpose of this study was to assess the layman’s perceptions of the gingival component of smile esthetics utilizing the existence of a black triangle between the maxillary anterior teeth and the presence of gingival pigmentation.
Objectives: To assess the layman’s perception on the gingival component of smile esthetics based on gingival pigmentation and interdental papillae.
Materials and methods: A cross-sectional survey was conducted among laypersons using a self-explanatory questionnaire.
Results: About 76.1% of the respondents chose the smile without the pigmentation as more attractive. In the pictures involving the black triangles, as the dimensions of the black triangle increased, the scores decreased correspondingly.
Conclusion: This study showed that most of the subjects felt dark gums were unattractive and the visual display of the interdental papillae is an important smile feature that is preferred in the overwhelming majority of patients receiving treatment.
How to cite this article: Kodangala P A, Ravinuthala V, Thirumalasetty SSMK, et al. Layman’s Perception of the Gingival Component of Smile Esthetics: A Web-based Study. CODS J Dent 2023;15(2):42–47.
Source of support: Nil
Conflict of interest: None
Keywords: Esthetics, Gummy smile, Smile
INTRODUCTION
Numerous extraoral and oral elements influence how a person’s face looks. Due to a greater understanding of esthetics and beauty, the demand for esthetic dentistry among clinicians and dentists has grown significantly in recent years.1
People with prominent smile lines often have cosmetic concerns since so much of the gingiva is exposed when speaking and smiling. Mental health problems may result from this, particularly in those whose confidence and self-esteem are greatly impacted by their appearance. As a large portion of the gingiva is visible when speaking and smiling, cosmetic issues are also prevalent, particularly in patients with a high smile line. Psychosocial issues may arise from this, particularly for those whose appearance has a significant impact on their confidence and self-worth.2
In esthetically significant zones, achieving “white” and “pink” esthetics is the ultimate goal of contemporary restorative dentistry. Either the natural dentition or the restoration of dental hard tissues with the proper materials are referred to as “white esthetics.” The soft tissues that envelop an area, such as the gingiva and interdental papilla, are referred to as “pink esthetics” because they have the power to enhance or detract from the appearance. Patients, restorative dentists, and periodontists are all very concerned about the existence or lack of the interproximal papilla. Loss of papilla may cause lateral food impaction, cosmetic inadequacies (referred to as “black triangle disease”), and phonetic issues (space allows passage for air or saliva). Periodontal disease often causes papilla loss because of gingival inflammation, loss of attachment, and interproximal bone height resorption. The interdental papilla receives very little blood supply; therefore, the doctor mostly leaves it alone. To reduce papillae loss, it is crucial to maintain the integrity of interdental papillae during all dental operations. One of the toughest and least predictable issues is reconstructing the missing interdental papilla.3
Gingiva color varies throughout individuals; this is thought to be related to cutaneous pigmentation. Light brown to dark brown to black are the different shades. Skin tones, textures, and hues vary between races and geographical regions. The quantity and size of the vasculature, the thickness of the gingival epithelium, the level of keratinization, and the pigments contained therein all have a major impact on the gingival color.3
Melanin exhibits the highest incidence rate among the primary pigments that contribute to the normal color of the gingiva, along with carotene, decreased hemoglobin, and oxyhemoglobin. The excessive amount of melanin in the basal and suprabasal cell layers of the epithelium results in gingival hyperpigmentation according to Dummett (1979).
The word “melanin” was first used in 1840 by the Swedish chemist Berzelius to refer to a black pigment he had extracted from ocular membranes. Melanin derives from the Greek word “melanos,” which meaning “dark.”4
This study was designed to analyze the esthetic concerns of patients based on gingival pigmentation and black triangles. A questionnaire survey featuring a few images was created for people to provide their feedback on them.
MATERIALS AND METHODS
The study had 243 people participating in total. The survey was created with Google Forms. The subjects were sent the link to an online survey that had been created. People with minimum education qualification of high school education, above the age of 18, were included in the study. Individuals without education and medical, dental, and paramedical professionals and students were excluded from this study.
A set of two questions was prepared using Google Forms. There are a total of two components to the questionnaire—part one was to determine the participant’s demographic data which includes email ID, age, gender, and education; part two consisted of questions along with pictures and visual analog scale (VAS) pages. The photo album used for evaluation consisted of two photo sets based on two variables—gingival pigmentation and black triangle. One set consisted of two photos with and without gingival pigmentation (Figs 1 and 2). Another set consisted of six different photographs. One randomly selected smile was chosen. The photograph was edited and made into six photographs to test reliability. Between the maxillary central incisors, black triangles of various sizes were created. Six photos were generated as a consequence, including the reference image with no black triangles and the others with black triangles that increased in size to 0.5 mm (0.5, 1, 1.5, 2, and 2.5 mm) (Fig. 3). The pictures were altered to create a symmetrical appearance, and the ruler’s position was changed to reflect the patient’s teeth’s true size. Adobe Photoshop CS6 was used to digitally change the smiling features in the pictures. The link was forwarded to subjects of different colleges in Andhra Pradesh. The participants were instructed to use a VAS (Fig. 4) to rank the individual smile images’ attractiveness on a scale of least to most appealing.
Fig. 1: Gingiva without pigmentation
Fig. 2: Gingiva with pigmentation
Fig. 3: First image without black triangle and five other images showing increased dimension of black triangles
Fig. 4: Visual analog scale
RESULTS
A total of 243 respondents were identified as laypersons since none them identified their occupation as related to the medical or dental healthcare profession.
Gender: About 60.5% of the respondents were male and 39.5% were female.
Fig. 5: Medical or dental healthcare profession of male and female
When it came to concern about the color of the gingiva, 76.1% of the subjects thought that dark gums were unattractive. In the case of the presence or absence of the black triangle, smiles with the absence of the black triangles were chosen as attractive ones (Fig. 5) compared to other smile photographs with black triangles at different sizes.
For question 2; for picture 1, 33.3% of the respondents opted for the score 10 on VAS (Fig. 4) as the highest response which indicates the smile is highly attractive. For picture 2, 26.3% of the respondents opted for the score 9 on VAS as the highest response. For picture 3, 24.6% of the respondents opted for the score 7 on VAS as the highest response. For picture 4, 22.7% of the respondents opted the score 6 on VAS as the highest response. For picture 5, 22% of the respondents opted the score 6 on VAS as the highest response. For picture 6, 19.8% of the respondents opted the score 6 on VAS as the highest response (Fig. 3 and Table 1).
| Percentage | ||||||
|---|---|---|---|---|---|---|
| Score | Picture 1 | Picture 2 | Picture 3 | Picture 4 | Picture 5 | Picture 6 |
| 10 | 33.3 | 10.6 | 7.2 | 5.5 | 7.2 | 6.8 |
| 9 | 12.5 | 26.3 | 15.3 | 13.9 | 11.9 | 9.3 |
| 8 | 15.4 | 16.1 | 24.6 | 17.6 | 12.7 | 11.8 |
| 7 | 7.9 | 16.38 | 16.9 | 22.7 | 14 | 14.8 |
| 6 | 5.8 | 8.5 | 12.3 | 12.2 | 22 | 19.8 |
| 5 | 10.8 | 8.9 | 12.5 | 13.4 | 16.9 | 19 |
| 4 | 2.1 | 3 | 3 | 6.3 | 5.9 | 6.3 |
| 3 | 2.1 | 2.1 | 3.8 | 4.2 | 3.8 | 3.8 |
| 2 | 2.5 | 5.5 | 1.7 | 0.8 | 2.19 | 2.5 |
| 1 | 7.5 | 3 | 2.5 | 3.4 | 3.4 | 5.9 |
Bold values represent the highest percentage of responses given by the subjects for the respective picture on the visual analog scale (VAS)
DISCUSSION
The emphasis on facial esthetics as a measure of social status has grown recently. One crucial component of facial esthetics is the grin. In order to attain a stunning and youthful smile, many dentists are now including facial esthetics in their treatment plans. Still, beauty is, as they say, completely subjective. More so than the dentist’s opinion, the patient’s desire for smile esthetics is influenced by their own experiences and social context.1
Several factors, such as tooth visibility, proportions, and the health of the gingival tissues, affect oral esthetics. A proper fusion between having healthy teeth and periodontal tissues is crucial for success in esthetics, which is primarily expressed by an attractive smile. There is a prevalent demand for esthetic therapy for gingival hyperpigmentation. Gingival melanin depigmentation has been treated with a variety of techniques, with varying degrees of success, including chemicals, gingivectomy, gingivectomy with free gingival autografting, acellular dermal matrix allografts, electrosurgery, cryosurgery, abrasion with diamond bur, and various types of lasers.2
In the present study, a total of 243 individuals filled out the questionnaire, out of which, 182 were males and 61 were females. Among them, 76.1% believed a smile without gingival pigmentation is attractive, whereas remaining subjects (i.e., 23.9%) believed a smile with gingival pigmentation is attractive (Figs 1 and 2).
An interdental papilla is a crucial element of an attractive smile, and its absence can lead to a gingival black triangle (GBT). In addition to making space for food and plaque accumulation, these spaces may additionally impact phonation. The presence or absence of the interproximal papilla is of great concern to periodontists, restorative dentists, and patients. Loss of papillae can cause phonetic issues (space permits air or saliva to pass through) and lateral food impaction in addition to cosmetic defects (also known as “black triangle disease”). Due to interproximal bone height resorption, gingival inflammation, and attachment loss, periodontal disease frequently results in the loss of papilla. As the soft tissues typically constrict throughout the healing phase, periodontal surgical therapy can also result in missing papillae. Factors like availability of underlying osseous support, periodontal biotype, tooth morphology, and contact points will influence the presence of interdental papilla. There are several reasons that interdental papillae may be absent or lost, including diseases related to plaque, traumatizing oral hygiene practices, abnormal tooth form, improper restoration contouring, spacing between teeth, and tooth loss.3
The cone-shaped pad of gingiva that occupies the space between neighboring teeth apical to the contact area is known as the papilla of the central incisors. The presence of the papilla between the maxillary central incisors has a significant positive influence on the esthetics of the smile, particularly in the perception of young adults (15–44 years of age).5
In the current study, the subjects found the picture with no black triangle to be more appealing while the picture with 2.5 mm black triangle was the least appealing. The remaining pictures with increasing black triangle sizes (0.5, 1, 1.5, and 2) (Fig. 3) received scores of 9, 8, 7, and 6, respectively. This shows that as the dimensions of the black triangle increased, the scores decreased correspondingly.
Kokich et al. were among the first to assess the subjective assessment of several smiling characteristics such as midfacial gingival display, midline deviation, diastema, incisal angulation, and gingival embrasure. In this study, orthodontists considered an ideal smile with a normal gingival embrasure to be much more appealing than one with a 2 mm open gingival embrasure. On the other hand, general dentists and laypeople needed a greater divergence (3 mm) in order to consider the smile less attractive, which is consistent with the findings of this study.5
Similar to the current study, Sriphadungporn et al. found that photos without a black triangle were evaluated as the most appealing. In contrast, images with a black triangle were rated as the least appealing.6 Pithon et al. observed that younger people are more likely than older people to see black spaces in maxillary anterior crenations and the bigger the black spaces, the less appealing they judge the smile, which is similar to the findings of the current study.7
Study participants thought that gingiva without pigmentation was more beautiful than gingiva with pigmentation. Roshna and Nandakumar conducted surveys of different populations’ personal beliefs and discovered that pink gums were the ideal color, which was similar to our results.8
Alomari et al. conducted a study on both dental professionals and laypeople and discovered that the ideal smile and that with black triangles between the upper incisors were evaluated as the greatest and least appealing smiles, respectively. Orthodontists, prosthodontists, and general dentists rated the presence of black triangles in the smile as the least appealing, whilst periodontists and laypeople rated pigmented gingiva as the least attractive smile, respectively. Dental specialists scored the changed smiling photos lower than laypeople.9
In the Sharma et al. study, general dentists and orthodontists found a reduction in interdental papilla between maxillary central incisors by 1 mm to be attractive, whereas laypeople found a decrease in interdental papilla between maxillary central incisors by 2 mm to be attractive. For orthodontists, the least attractive image was a reduction in interdental papilla between all maxillary anteriors by 3 mm which does not coincide with the results of the present study, and all the study groups found image patchy pigmentation to be most attractive. Image with pigmentation in bands was considered unpleasant by laypeople, while images having generalized pigmentation was deemed unattractive by general dentists and orthodontists similar to the present study.10
The lack of awareness of gingival pigmentation, potential therapies, and the significance of interdental papillae among the subjects may be the reason for their lack of concern. Considering the statistics above, more people need to be educated on gingival esthetics.
Limitations of the Study
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Sample size and composition: The study had a sample size of 243 respondents, which may not represent a diverse range of individuals. Additionally, the demographic composition skewed toward a higher proportion of males (60.5%) compared to females (39.5%), which could affect the generalizability of the findings. Moreover, the study might not have included participants from different cultural or socioeconomic backgrounds, limiting the generalizability of the results. Additionally, the participants were from Andhra Pradesh, which may not represent the perceptions of individuals from other regions.
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Online survey methodology: Conducting the survey online via Google Forms may have limited the accessibility of the study to individuals who have internet access and are proficient in using online platforms. This method might exclude individuals who are not technologically savvy or do not have access to the internet, potentially skewing the sample toward a more digitally literate population.
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Limited scope of variables: The study focused primarily on the perception of gingival pigmentation and the presence of black triangles in smile esthetics. However, other factors such as tooth color, alignment, and overall facial features can also influence smile attractiveness. Failing to account for these variables could limit the comprehensiveness of the study’s findings.
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Subjectivity of assessment: The assessment of smile esthetics was based on subjective perceptions of attractiveness, which can vary widely among individuals. While VASs were used to quantify these perceptions, personal biases and preferences may still have influenced participants’ ratings, leading to potential inconsistencies in the data.
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Cross-sectional design: The study employed a cross-sectional survey design, which captures data at a single point in time. This design does not allow for the assessment of changes in perceptions over time or causal relationships between variables. Longitudinal or experimental designs could provide more robust evidence regarding the factors influencing smile esthetics.
Addressing these limitations in future research endeavors could enhance the validity and reliability of findings in understanding laypersons’ perceptions of smile esthetics.
Future research could build upon the findings of this study to further explore various aspects of smile esthetics and gingival health. Several potential paths for further investigation include:
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Cultural and geographical variations: Investigate how cultural backgrounds and geographical locations influence perceptions of smile esthetics and gingival health. Comparing responses from different regions and cultural groups could provide valuable insights into the diversity of esthetic preferences.
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Longitudinal studies: Conduct longitudinal studies to track changes in individuals’ perceptions of smile esthetics over time. Understanding how perceptions evolve with age, life experiences, and exposure to different cultural norms could inform more tailored treatment approaches.
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Inclusion of clinical data: Integrate clinical data, such as periodontal measurements and intraoral photographs, to correlate subjective perceptions with objective measures of gingival health and esthetics. This could help validate the relationship between visual assessments and clinical outcomes.
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Patient education and awareness: Develop interventions to improve patient education and awareness regarding gingival health and its impact on smile esthetics. Assess the effectiveness of educational programs in empowering individuals to make informed decisions about their oral health and treatment options.
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Interdisciplinary collaboration: Foster interdisciplinary collaboration between dentists, periodontists, orthodontists, psychologists, and sociologists to gain a comprehensive understanding of smile esthetics. Integrating perspectives from multiple disciplines could lead to more holistic approaches to smile enhancement and patient care.
By addressing these avenues for future research, scholars can deepen our understanding of smile esthetics and gingival health, ultimately improving clinical practices and patient outcomes in esthetic dentistry.
CONCLUSION
According to this web-based perception research, most of the subjects felt that dark gums were unattractive. The visual display of the interdental papillae is an important smile feature that is preferred in most patients receiving treatment. This anatomical structure’s preservation and/or recreation, whether biologically or restoratively, should be given special attention. Due to the variation in esthetic perception by each person, participation between periodontists and patients in decision-making and treatment planning is crucial to generating successful results.
QUESTIONNAIRE
1. Which smile do you think is more attractive?
(a) 
(b) 
(c) Both (a) and (b)
2. Score the attractiveness of each separately using a VAS.
REFERENCES
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