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Comparison between orthodontist, general dentist, and layperson in the perception of pink esthetics on smile: A cross-sectional study
*Corresponding author: Panchali Batra, Department of Orthodontics, Jamia Millia Islamia University, New Delhi, India. panchali.batra@gmail.com
-
Received: ,
Accepted: ,
How to cite this article: Sharma N, Kannan S, Arora N, Singh AK, Malhotra A, Batra P. Comparison between orthodontist, general dentist, and layperson in the perception of pink esthetics on smile: A cross-sectional study. APOS Trends Orthod 2022;12:176-86.
Abstract
Objectives:
Smile designing has become an essential part of dental training and a beautiful smile not only adds to the esthetics of the face but also conveys emotions and augments the self-esteem of an individual. A beautiful smile is achieved by well-balanced pink and white esthetics. This study was designed to evaluate the difference in perceptions of orthodontists, general dentists, and laypersons to alterations in gingival characteristics on smile.
Material and Methods:
Smile images were modified intentionally to obtain the desired variations in gingival features such as color and contour of free gingival margins, inflammation, pigmentation, gingival margins with or without recession, zenith, and interdental papilla. A total of 51 images were rated by orthodontists, general dentists, and laypersons using Q sort methodology.
Results:
Variations in the position of free gingival margin with recession was most negatively ranked gingival factor by orthodontists, general dentists, and laypersons followed by variations in the position of interdental papilla. Position of free gingival margin without a recession, color changes due to pigmentation, and inflammation were moderately ranked. Control images and altered gingival zenith images were most positively ranked. Bilateral changes were perceived more readily compared to unilateral in factors such as a black triangle, zenith position, pigmentation, inflammation, and recession.
Conclusion:
Orthodontists seem to be less tolerant in their evaluations in comparison to general dentists and laypersons. The findings of this study point toward a crucial fact that smile designing should focus on parameters that are perceived readily by the public in general.
Keywords
Smile perception
Gingival alterations
q sort
Laypersons
General dentists
Orthodontists
Pink aesthetics
INTRODUCTION
The mouth and eyes work in conjunction for effective communication. A beautiful smile not only adds to the esthetics of the face but also conveys emotions and participates in the self-esteem of an individual.[1,2] This is the reason that smile designing has become an essential part of dental training and needs the expertise of an orthodontist, periodontist, prosthodontist, endodontist, and at times maxillofacial or plastic surgeons. Both hard- and soft-tissue factors must be taken into consideration while designing a beautiful smile.[3-9] Esthetic preferences to a particular component of a smile may vary and be influenced not only by ethnological and racial differences but also by factors such as age, sex, education status, economic status, and geographical location.[10-12]
Many studies have evaluated how alterations in hard-tissue factors affect smile esthetics and whether there is a difference in the perception of orthodontists, general dentists, and laypersons to these alterations;[13-17] However, very few studies have focused on the gingival factors and the impact of altered gingival esthetics.[18-21] To the best of our knowledge, only one study has evaluated the impact of various gingival characteristics alterations on smile esthetics as perceived by laypersons,[9] but the perception of general dentists and orthodontists to these altered gingival characteristics still needs to be evaluated. It is important to know the difference in perception among the three groups, and how the level of training can influence the perception. While designing a pleasing smile, a balance should be struck, keeping in mind the perceptions of orthodontists, general dentists, and laypersons. The purpose of this study was to evaluate the difference in perceptions of orthodontists, general dentists, and laypersons to alterations in gingival characteristics and to evaluate the extent to which the three groups of evaluators overlook these changes. We also aimed to rank the gingival characteristics that are most negatively and most positively marked by the three groups of evaluators.
MATERIAL AND METHODS
Institutional ethical clearance (MRDC/IEC/2017/01) was obtained from the university before commencing the survey and written informed consent was taken from all the evaluators. The study was conducted over 5 months, and various dental colleges/hospitals of the region were visited for the collection of data.
Model selection and image manipulation
A close-up frontal smile of a 25-year-old female with no history of orthodontic or restorative treatment was selected for the study [Figure 1]. The smiling photograph was chosen as it was pleasing, fulfilled to a large extent, the previously mentioned characteristics of a balanced smile,[22] and the gingival factors to be evaluated were visible during her social smile. The smile photograph was cropped in Adobe PhotoshopCS2 so that only the lips, the tip of the nose, and the mentolabial sulcus were visible to reduce any distractions. The photograph was then compressed so that the measurements made clinically and on printed photographs were similar, taking maxillary central incisor as the reference point. The smile image was then modified intentionally to obtain the desired variations in gingival features [Supplemental File, Factors 1-7]. Forty-nine modifications were produced and two photographs of an original smile [Figure 1] were added to check for the reproducibility of the results. Thus, a total of 51 images were produced [Figures 2-8]. These final images which were digital files were then professionally printed in the size of 3.5 × 5 inches.
- (ct) Control image.
- Variations in the position of free gingival margin without recession. (a) Unilateral reduction of Free Gingival Margin of canine up to the level of lateral incisor, (b) Unilateral reduction of Free Gingival Margin of canine below the level of lateral incisor, (c) Unilateral increase in the Free Gingival Margin level of canine from the central incisor, (d) Unilateral increase in the Free Gingival Margin level of the central incisor by 1 mm from canine, (e) Unilateral increase in the Free Gingival Margin level of the central incisor by 2 mm from canine, (f) Unilateral reduction of Free Gingival Margin of the central incisor up to the level of lateral incisor, (g) Unilateral reduction of Free Gingival Margin of the central incisor below the level of lateral incisor, (h) Unilateral increase in the Free Gingival Margin of lateral incisor above the level of canine and central incisor, (i) Unilateral reduction of Free Gingival Margin of lateral incisor by 2 mm below the level of canine.
- Variations in the positions of interdental papilla. (a) Reduction in interdental papilla between maxillary central incisors by 1 mm, (b) Reduction in interdental papilla between maxillary central incisors by 2 mm, (c) Reduction in interdental papilla between maxillary central incisors by 3 mm, (d) Reduction in interdental papilla between all maxillary anteriors by 1 mm, (e) Reduction in interdental papilla between all maxillary anteriors by 2 mm, (f) Reduction in interdental papilla between all maxillary anteriors by 3 mm.
- Variations in the zenith position. (a) Bilateral mesial shift of canine zenith, (b) Bilateral mesial shift of the central incisor zenith, (c) Bilateral distal shift of lateral incisor zenith, (d) Bilateral mesial shift of lateral incisor zenith, (e) Unilateral mesial shift of canine zenith, (f) Unilateral mesial shift of the central incisor zenith, (g) Unilateral mesial shift of lateral incisor zenith, (h) Unilateral distal shift of lateral incisor zenith.
- Color changes due to varying degrees of gingival inflammation. (a) Papillary gingivitis, (b) Marginal gingivitis, (c) Generalized gingivitis.
- Color changes due to varying degrees of gingival pigmentation. (a) Patchy pigmentation, (b) Pigmentation in bands, (c) Generalized pigmentation.
- Variations in the positions of free gingival margin with recession. (a) Unilateral recession of canine by 1 mm, (b) Unilateral recession of canine by 2 mm, (c) Unilateral recession of canine by 3 mm, (d) Bilateral recession of canine by 2 mm, (e) Bilateral recession of canine by 3 mm, (f) Bilateral recession of central incisor by 2 mm, (g) Bilateral recession of central incisor by 3 mm, (h) Unilateral recession of central incisor by 1 mm, (i) Unilateral recession of central incisor by 2 mm, (j) Unilateral recession of central incisor by 3 mm, (k) Recession in all maxillary anteriors by 1 mm, (l) Recession in all maxillary anteriors by 2 mm, (m) Recession in all maxillary anteriors by 3 mm, (n) Bilateral recession in lateral incisor by 3 mm, (o) Unilateral recession in lateral incisor by 2 mm, (p) Unilateral recession in lateral incisor by 3 mm.
- Varying contours of the gingiva. (a) Bilaterally accentuated gingival contour, (b) Bilaterally denuded gingival contour, (c) Unilaterally accentuated gingival contour, (d) Unilaterally denuded gingival contour.
Selecting the evaluators
A total of 150 evaluators performed the study (70 men and 80 women). The evaluators consisted of 50 orthodontists, 50 general dentists, and 50 laypersons. A sample size of 50 each was taken because, by a Q Sort method, participants’ viewpoints can be shown effectively even with a smaller participant group.[23] The laypersons consisted of patients visiting the dental OPD of the institute and students enrolled in various courses in the university. The evaluators had at least intermediate-level qualifications and a complete or an incomplete college degree. It was assured that none of the evaluators in this group had any previous dental affiliation to reduce bias. The general dentists and orthodontists were faculty members visiting various dental colleges of the region and with a minimum of 5 years of experience. General dentists were graduates in dentistry who had not pursued their postgraduation in any specialty of dentistry. The participants’ ages were between 22 and 50 years. Basic information such as ethnicity, education, and socioeconomic status of the evaluator was also gathered.
Q-sort protocol
All the evaluators were briefed about the survey without unveiling the changes that had been done in the images and were asked to evaluate the photographs using a forced Q-sort technique whereby the evaluators are forced to put a defined number of photographs in each column.[23] An 11-point scale where ranking values ranged from –5 to +5, where –5 denoted the least attractive photograph and +5 denoted the highly attractive photograph was used [Figure 9]. The methodology as described previously was used.[9] The average time taken by evaluators to complete the survey was approximately 20 minutes.
- Example of the Q sort configuration used.
Statistical tests and analysis
Descriptive analysis was presented in terms of the frequency distribution of traits such as mean-mode and standard deviation calculation to analyze the most-liked image by a maximum number of subjects (Mode), ordering of characteristics in the increasing order of their attractiveness appeal (Mean). Standard deviation was used to understand variance in responses. An independent sample t-test was used for intergroup comparison [Table 1] to compare all factors with the control group (Factor 8) and to compare each of the consecutive factors in the ranking table. To analyze whether there is a statistically significant difference in mean responses across factors by three groups (orthodontists, general dentists, and laypersons), Kruskal–Wallis test was performed. All statistical tests were done at a 5% level of significance. The data was analyzed using statistical software SPSS 25.0 (Statistical Package for the Social Sciences).
| Factors | Name | Mean | Standar d Deviatio n | Ranking According to Mean | P-value (comparing all factors with control image) | P-value (consecutive factor comparison) |
|---|---|---|---|---|---|---|
| ct | Control images | 2.2 | 1.72 | 1 | 1 | 0.72 (Factor 8~Factor 3) |
| 3 | Variations in the zenith position | 2.13 | 1.78 | 2 | 0.72 | 0.00** (Factor 3 ≠ Factor 7) |
| 7 | Varying contours of gingival | 1.16 | 1.59 | 3 | 0.00** | 0.64 (Factor 7~Factor1) |
| 1 | Variations in the position of free gingival margin without recession | 1.07 | 1.81 | 4 | 0.00** | 0.00** (Factor 1 ≠ Factor 5) |
| 5 | Color changes due to varying degrees of gingival pigmentation | -0.19 | 2.26 | 5 | 0.00** | 0.09 (Factor 5~Factor 4) |
| 4 | Color Changes due to varying degrees of gingival inflammation | –0.6 | 1.93 | 6 | 0.00** | 0.00** (Factor 4 ≠ Factor 2) |
| 2 | Variations in the position of interdental papilla | –1.26 | 2.05 | 7 | 0.00** | 0.055 (Factor 2~Factor 6) |
| 6 | Variations in the position of free gingival margin with recession | –1.71 | 2.01 | 8 | 0.00** |
Mean response ranking based on statistical significance: 8~3 > 7~1 > 5~4 > 2~6. A~B denotes that there is no significant difference statistically between mean response of factors A and B A ≠ B denotes that there is a significant difference between mean response of factors A & B ** in P<0.01, hence, highly statistically significant at 1% level of significance
RESULTS
Table 1 refers to the ranking of the seven factors and the control group or the intergroup comparison. The factors were rated in decreasing order of attractiveness as follows: Control images, variations in the zenith position, varying contours of the gingiva, variations in the position of free gingival margin without recession, color changes due to varying degrees of gingival pigmentation, color changes due to varying degrees of gingival inflammation, variations in the position of interdental papilla, and variations in the position of free gingival margin with recession. P-values to compare all factors with the control group [Figure 1] and to compare each of the consecutive factors in the ranking table is also presented in Table 1. A highly statistically significant difference was found in the means of all factors when compared with the control group except for Factor 3 (variations in the zenith position) which means, Factor 3 was rated as highly as the control image.
Table 2 describes the most attractive and least attractive variations in a group or the intragroup rating. Factor 1 was variations in the position of free gingival margin without recession [Figure 2]. Laypersons considered a unilateral increase in the Free Gingival Margin of the central incisor by 1 mm from the canine (2D) to be most attractive. General dentists and orthodontists both considered image unilateral reduction of Free Gingival Margin of canine up to the level of the lateral incisor (2A) to be most attractive. The image with unilateral reduction of Free Gingival Margin of the central incisor below the level of the lateral incisor (2G) was rated least attractive by orthodontists, general dentists, and laypersons.
| Factor | Laypersons | General dentists | Orthodontists | P-value | |||
|---|---|---|---|---|---|---|---|
| Most attractive | Least attractive | Most attractive | Least attractive | Most attractive | Least attractive | ||
| ct | Control (ct) 2.26 ± 1.6 |
Control (ct) 2.30 ± 1.91 |
Control (ct) 2.05 ± 1.64 |
0.50 | |||
| 3 | Figure 4h 2.94 ± 1.68 |
Figure 4b 1.32 ± 1.58 |
Figure 4g 2.56 ± 1.85 |
Figure 4b 1.2 ± 1.76 |
Figure 4h 3.12 ± 1.67 |
Figure 4b 1.54 ± 1.69 |
0.59 |
| 7 | Figure 8a 1.82 ± 1.6 |
Figure 8d 0.96 ± 1.94 |
Figure 8a 1.7 ± 1.98 |
Figure 8b 0.68 ± 1.28 |
Figure 8b 1.46 ± 1.39 |
Figure 8c 0.64 ± 1.19 |
0.08 |
| 1 | Figure 2d 2.08 ± 1.78 |
Figure 2g –0.26 ± 1.44 |
Figure 2a 2.12 ± 1.79 |
Figure 2g 0.22 ± 1.3 |
Figure 2a 2.8 ± 1.63 |
Figure 2g –0.64 ± 1.38 |
0.28 |
| 5 | Figure 6a –0.46 ± 1.91 |
Figure 6b –1.56 ± 2.24 |
Figure 6a –0.02 ± 1.96 |
Figure 6c –0.94 ± 2.12 |
Figure 6a 1.74 ± 1.74 |
Figure 6c 0.4 ± 2.26 |
0.00** |
| 4 | Figure 5b –0.19 ± 2.15 |
Figure 5a –1.16 ± 1.76 |
Figure 5b –0.46 ± 2.14 |
Figure 5a –0.8 ± 1.68 |
Figure 5b 0.34 ± 2.12 |
Figure 5c –0.46 ± 1.58 |
0.00** |
| 2 | Figure 3b 0.12 ± 2.04 |
Figure 3e –2.62 ± 1.83 |
Figure 3a 0.48 ± 1.39 |
Figure 3e –2.58 ± 1.93 |
Figure 3a 0.14 ± 1.26 |
Figure 3f –2.58 ± 1.7 |
0.85 |
| 6 | Figure 7a 1.2 ± 2.02 |
Figure 7m –2.58 ± 1.82 |
Figure 7a 1.62 ± 1.85 |
Figure 7m –3.26 ± 2.02 |
Figure 7a 1.46 ± 2.14 |
Figure 7m –4.3 ± 1.26 |
0.00** |
The second factor was variation in the position of the interdental papilla [Figure 3]. Laypersons considered a reduction in interdental papilla between maxillary central incisors by 2 mm (3B) to be attractive whereas general dentists and orthodontists considered a reduction in interdental papilla between maxillary central incisors by 1 mm (3A) to be attractive. Furthermore, for laypersons and general dentists’ reduction in interdental papilla between all maxillary anteriors by 2 mm (3E) was ranked least attractive, and for orthodontists, the least attractive image was a reduction in interdental papilla between all maxillary anteriors by 3 mm (3F). The third factor was the variations in the zenith position [Figure 4]. Laypersons and orthodontists considered image (4H) unilateral distal shift of lateral incisor zenith to be most attractive whereas general dentists considered image (4G) unilateral mesial shift of lateral incisor zenith to be attractive. Orthodontists, general dentists, and laypersons considered image (4B) bilateral mesial shift of the central incisor zenith to be least attractive. The fourth factor was color changes due to varying degrees of gingival inflammation [Figure 5]. Orthodontists, general dentists, and laypersons considered image (5B) marginal gingivitis to be most attractive. Furthermore, laypersons and general dentists considered image (5A) papillary gingivitis to be least attractive whereas orthodontists considered image (5C) generalized gingivitis to be least attractive.
The fifth factor was color changes due to varying degrees of gingival pigmentation [Figure 6]. Orthodontists, general dentists, and laypersons considered image (6A) patchy pigmentation to be most attractive. Laypersons considered image (6B) pigmentation in bands to be unattractive and general dentists and orthodontists considered image (6C) generalized pigmentation to be unattractive. The sixth factor was variations in the position of free gingival margin with recession [Figure 7]. Orthodontists, general dentists, and laypersons all considered image (7A) unilateral recession of canine by 1 mm to be most attractive and image (7M) recession in all maxillary anterior by 3 mm to be least attractive. The seventh factor was varying contours of the gingiva [Figure 8]. Laypersons and general dentists considered image (8A) bilaterally accentuated gingival contour to be most attractive whereas orthodontists considered image (8B) bilaterally denuded gingival contour to be most attractive. Furthermore, general dentists considered image (8B) bilaterally denuded gingival contour to be least attractive, orthodontists considered image unilaterally accentuated gingival contour (8C) to be least attractive, and laypersons considered image (8D) unilaterally denuded gingival contour to be least attractive. The last factor was the control group [Figure 1] and both control photographs were rated positively by all three groups. Kruskal–Wallis test was performed to understand if the response distribution was same across the three groups. Based on P-values in Table 2, no statistically significant difference in mean response was found across three groups for Factors 8 (control image), 3 (Variations in the zenith position), 7 (Varying contours of gingiva), 1 (Variations in the position of free gingival margin without recession), and 2 (Variations in the positions of interdental papilla). However, a statistically significant difference in mean response was found across three groups for Factor 4 (Color changes due to varying degrees of gingival inflammation), 5 (Color changes due to varying degrees of gingival pigmentation), and 6 (Variations in the positions of free gingival margin with the recession), which could be attributed mainly due to the orthodontist group.
DISCUSSION
This study aimed to evaluate the difference in perception of a trained eye versus an untrained eye and whether the level of training made any difference in the perceptions. It is important to evaluate this as it would enable the smile architects to design smiles keeping in mind the threshold levels of acceptance of various groups.
The two most commonly used ranking methodologies to analyze and compare the esthetic perceptions are the VAS and Q-sort.[24-27] Both methods have merits and demerits of their own. In VAS participants rank individual photographs and they cannot return to the previous photograph and change the rank order if they wish to, whereas, in Q-methodology, all the photographs are present in front of the participant.[25] The Q sort has been presented with slightly increased values than VAS according to some studies.[24,25] Hence, Q sort was used in this study. The first thing that was analyzed in this study was, which altered gingival characteristic was most and least noticeable by orthodontists, general dentists, and laypersons [Table 1]. The results indicate that change in color either due to inflammation or pigmentation or due to black triangles was perceived most negatively by all the three groups as in the study conducted by Batra et al.[9] Although in our study, a gingival recession was ranked most negatively, possibly due to more trained subjects evaluating the images.
The second aim was to assess the extent to which alterations within each factor can go unnoticed. For variations in the free gingival margin without recession, changes in the central area were more readily perceived by all three groups. The bilateral presence of the black triangle was easily detectable in comparison to the black triangle present unilaterally. The results also point towards the fact that the level of training also influences the perceptions as orthodontists could detect even minor changes. The previous studies have shown that the black triangle was noticeable at 3 mm by dentists and laypersons and at 2 mm by orthodontists, periodontists, and prosthodontists.[13,28] A study done by Gehrke et al. contradicts this result as according to them, black triangles of even 1 mm were detectable by laypersons.[19]
In the zenith group, unilateral changes went unnoticed by all the three groups in comparison to bilateral. The changes in the position of the zenith in lateral incisors and canines were unnoticed in comparison to alterations in the central incisors. This could be because of the distal positioning of canines and thus their reduced visibility as compared to the central incisors.
For those factors that affected the color such as inflammation and pigmentation of the gingiva, it was found that the color changes that were perceived readily like localized change in color due to inflammation or generalized pigmentation ranked more unesthetic. Variations in the position of free gingival margin with recession were found to be least attractive and most negatively ranked by all the three evaluators. The results indicate that unilateral or bilateral recession of gingiva is noticed only when it reaches 3 mm and canines because they are distally positioned that their recession goes unnoticed by all three evaluator groups. Similar results were found by Musskopf et al.[20] who claimed that a generalized recession is more unesthetic in comparison to a localized recession. The other studies which show similar results are by Gehrke et al.,[19] Kokich et al.,[13], and Batra et al.[9] Thus, recession in interdental papilla or free gingival margin was more negatively perceived when it was generalized as compared to localized changes.
Coming over to the last factor, varying contours of the gingiva, the results showed that for laypersons and general dentists, both accentuated gingival contours bilaterally (8A) were found to be most attractive and for orthodontists, denuded gingival contour bilaterally (8B) was found to be most attractive. The results show that the changes done bilaterally remain unnoticed to trained as well as an untrained eye in comparison to changes done unilaterally.
This study has reinforced the importance of pink esthetics in smile design. The gingival factors were found to be as important as dental factors in perceiving the esthetics of a smile by different specialties and laypersons, as were found in the study done by Kau et al.[29,30] The main challenges faced in the study were that there were 51 images, and it was difficult for the evaluators to judge each photograph individually, especially by laypersons. Cross-checking at the end of each Q sort was very important before the evaluator left to ensure that the desired number of photos were placed in each column. Another important observation was that orthodontists took less time and were more confident while doing Q-sort. Orthodontists seem to be less tolerant in their evaluations in comparison to general dentists and laypersons. These differences in perception should be kept in mind while formulating a treatment plan and designing a balanced smile.
CONCLUSION
In the present study, the three groups rated the gingival recession as the least attractive factor followed by a black triangle and changes in color due to inflammation and pigmentation. Alterations in gingival scalloping and changes in location of free gingival margin without recession were ranked moderately. Gingival zenith and control group images were most positively ranked. Bilateral changes were perceived more readily compared to unilateral in factors such as a black triangle, zenith position, pigmentation, inflammation, and recession. Modifications on distal teeth like canines went unnoticed due to their reduced visibility. The findings of this study point towards the crucial fact that smile design should focus on factors that are perceived readily by the public in general.
Acknowledgments
I would like to acknowledge Mrs. Khyati Sharma [B.Sc (Statistics Hons.) and Masters in Statistics] for doing all the statistical analysis of the study as without her sincere efforts and dedication this study would not have been possible.
Declaration of patient consent
Patient’s consent not required as there are no patients in this study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
SUPPLEMENT
Various Modifications Done on Ideal Smile
1. Variations in the position of free gingival margin without a recession
| Nomenclature | Unilateral |
|---|---|
| Figure 2a | Unilateral reduction of Free Gingival Margin of canine up to the level of lateral incisor |
| Figure 2b | Unilateral reduction of Free Gingival Margin of canine below the level of lateral incisor |
| Figure 2c | Unilateral increase in the Free Gingival Margin level of canine from the central incisor |
| Figure 2d | Unilateral increase in the Free Gingival Margin level of the central incisor by 1 mm from canine |
| Figure 2e | Unilateral increase in the Free Gingival Margin level of the central incisor by 2 mm from canine |
| Figure 2f | Unilateral reduction of Free Gingival Margin of the central incisor up to the level of lateral incisor |
| Figure 2g | Unilateral reduction of Free Gingival Margin of the central incisor below the level of lateral incisor |
| Figure 2h | Unilateral increase in the Free Gingival Margin of lateral incisor above the level of canine and central incisor |
| Figure 2i | Unilateral reduction of Free Gingival Margin of lateral incisor by 2 mm below the level of canine |
2. Variations in the positions of interdental papilla
| Nomenclature | |
|---|---|
| Figure 3a | Reduction in interdental papilla between maxillary central incisors by 1 mm |
| Figure 3b | Reduction in interdental papilla between maxillary central incisors by 2 mm |
| Figure 3c | Reduction in interdental papilla between maxillary central incisors by 3 mm. |
| Figure 3d | Reduction in interdental papilla between all maxillary anteriors by 1 mm |
| Figure 3e | Reduction in interdental papilla between all maxillary anteriors by 2 mm |
| Figure 3f | Reduction in interdental papilla between all maxillary anteriors by 3 mm |
3. Variations in the zenith position
| Nomenclature | Unilateral | Bilateral | Nomenclature |
|---|---|---|---|
| Figure 4e | Unilateral mesial shift of canine zenith | Bilateral mesial shift of canine zenith | Figure 4a |
| Figure 4f | Unilateral mesial shift of the central incisor zenith | Bilateral mesial shift of the central incisor zenith | Figure 4b |
| Figure 4g | Unilateral mesial shift of lateral incisor zenith | Bilateral distal shift of lateral incisor zenith | Figure 4c |
| Figure 4h | Unilateral distal shift of lateral incisor zenith | Bilateral mesial shift of lateral incisor zenith | Figure 4d |
4. Color changes due to varying degrees of gingival inflammation
| Nomenclature | |
|---|---|
| Figure 5a | Papillary gingivitis |
| Figure 5b | Marginal gingivitis |
| Figure 5c | Generalized gingivitis |
5. Color changes due to varying degrees of gingival pigmentation
| Nomenclature | |
|---|---|
| Figure 6a | Patchy pigmentation |
| Figure 6b | Pigmentation in bands |
| Figure 6c | Generalized pigmentation |
6. Variations in the positions of free gingival margin with a recession
| Nomenclature | Unilateral | Bilateral | Nomenclature |
|---|---|---|---|
| Figure 7a | Unilateral recession of canine by 1 mm | Bilateral recession of canine by 2 mm | Figure 7d |
| Figure 7b | Unilateral recession of canine by 2 mm | Bilateral recession of canine by 3 mm | Figure 7e |
| Figure 7c | Unilateral recession of canine by 3 mm | Bilateral recession of central incisor by 2 mm | Figure 7f |
| Figure 7h | Unilateral recession of central incisor by 1 mm | Bilateral recession of central incisor by 3 mm | Figure 7g |
| Figure 7i | Unilateral recession of central incisor by 2 mm | Bilateral recession in lateral incisor by 3 mm | Figure 7n |
| Figure 7j | Unilateral recession of central incisor by 3 mm | Recession in all maxillary anteriors by 1 mm | Figure 7k |
| Figure 7o | Unilateral recession in lateral incisor by 2 mm | Recession in all maxillary anteriors by 2 mm | Figure 7l |
| Figure 7p | Unilateral recession in lateral incisor by 3 mm | Recession in all maxillary anteriors by 3 mm | Figure 7m |
7. Varying contours of gingiva
| Nomenclature | Unilateral | Bilateral | Nomenclature |
|---|---|---|---|
| Figure 8c | Accentuated gingival contour | Accentuated gingival contour | Figure 8a |
| Figure 8d | Denuded gingival contour | Denuded gingival contour | Figure 8b |
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