J Gandhara Med Dent Sci

October - December 2025

PERCEPTION OF ORTHODONTIC MICRO ESTHETIC PARAMETERS AND THEIR SOCIAL

ACCEPTABILITY THRESHOLD: A CROSS-SECTIONAL STUDY

1 2 3 4 5

Syeda Multazam Ahmad , Nabila Anwar , Hazrat Asad ur Rehman Hoti , Jawad Shah , Farheen Sajid ,

Anum Waseem , Aneela Baseer

ABSTRACT

OBJECTIVES

This study aimed to evaluate orthodontic patients’ perception of micro

esthetic parameters in the maxillary central incisors.

METHODOLOGY

A cross-sectional observational study was conducted at Rehmat Memorial

Hospital, Abbottabad, using non-probability consecutive sampling on 120

participants aged 16-40 years who had no prior orthodontic treatment or

professional exposure to dental esthetics. A female patient with clinically

ideal micro esthetic features was photographed under standardized

conditions. The image was digitally altered to modify individual micro

esthetic parameters-width-to-height ratio (60% and 100%), gingival zenith

position (1 mm mesial and distal shift), interproximal contact point (1.5 mm

apical shift), and axial inclination (5° mesial and distal tilt)-while keeping

other features constant. Participants rated the attractiveness of the original

and altered images using a 10-point Visual Analog Scale in randomized

order. Data were analyzed using one -way ANOVA and stratiﬁed by gender.

RESULTS

The mean age of participants was 28.99 ± 6.96 years, with 56.7% females.

The highest attractiveness scores were given to unaltered images across all

parameters: width-to-height ratio (mean 8.92), gingival zenith (8.45), axial

inclination (8.00), and contact point (8.06). Altered images received

signiﬁcantly lower ratings (p < 0.001). Male participants generally showed

higher tolerance for esthetic variations than females.

CONCLUSION

Minor alterations in micro esthetic features of maxillary central incisors

signiﬁcantly impact perceived dental attractiveness. Maintaining natural

tooth proportions, gingival contours, and contact points is critical in esthetic

treatment planning. Gender diﬀerences suggest varying esthetic sensitivities

that should be considered clinically.

KEYWORDS: Esthetics, Dental; Orthodontics; Central Incisor; Gingiva;

Cross-Sectional Studies

How to cite this article

Ahmad SM, Anwar N, Hoti HAUR,

Shah J, Sajid F, Waseem A, etal.

Perception of Orthodontic Micro

Esthetic Parameters and Their Social

Acceptability Threshold: A Cross-

Sectional Study. J Gandhara Med Dent

Sci. 2025;12(4):48-52. https://doi.org/10

Date of Submission: 24-06-2025

Date Revised: 20-09-2025

Date Acceptance: 20-09-2025

Professor and Head of Department

Orthodontics, Rehmat Memorial

Postgraduate Dental Hospital,

Abbottabad

FCPS Trainee, Department of ,

Orthodontics, Rehmat Memorial Post

graduate Dental Hospital, Abbottabad

Senior Lecturer

Department of

Orthodontics, Rehmat Memorial Post

graduate Dental Hospital, Abbottabad

FCPS Trainee, Department of

Orthodontics, Rehmat Memorial Post

graduate Dental Hospital, Abbottabad

General Dentist, Department of

Orthodontics, Rehmat Memorial Post

graduate Dental Hospital, Abbottabad

Trainee, Department of Orthodontics,

Rehmat Memorial Post graduate Dental

Hospital, Abbottabad

Correspondence

Syeda Multazam Ahmad, FCPS Trainee,

Department of Orthodontics, Rehmat

Memorial Post graduate Dental Hospital,

Abbottabad

+92-346-4323001

multazam.ahmad683@gmail.com

INTRODUCTION

Orthodontic treatment has evolved beyond its

traditional aim of correcting malocclusions and

improving oral function.

In contemporary practice,

esthetic considerations have become of paramount

importance, with patients increasingly seeking

orthodontic interventions to improve facial and dental

appearance.

Normal occlusion not only contributes to

functional eﬃciency but also plays a critical role in

facial harmony and attractiveness.

The success of

orthodontic treatment is not solely determined by

clinical outcomes but also by patient satisfaction, which

is closely linked to their perceptions and expectations.

Subjective assessments of patients, their dental and

facial esthetics, can signiﬁcantly inﬂuence their

motivation for seeking treatment and their compliance

throughout the orthodontic process. Esthetic

evaluation in orthodontics encompasses three

hierarchical levels: macro-esthetics, mini-esthetics, and

micro-esthetics.

6,7

Macro-esthetics involves the

assessment of facial proportions and proﬁle harmony.

Mini-esthetics focuses on the smile framework,

including lip posture, smile arc, and buccal corridors.

Micro-esthetics pertains to the intricate details of dental

anatomy, such as tooth size, shape, color, gingival

contours, and the relationships between adjacent teeth.

These micro-esthetic elements are crucial for achieving

a natural and pleasing smile, as they inﬂuence the

perception of dental attractiveness at a detailed level.

ORIGINAL ARTICLE

.37762/jgmds.12-4.748

J Gandhara Med Dent Sci

October - December 2025

Key components of micro-esthetics include the width-

to-height ratio of anterior teeth, the presence and shape

of interdental papillae, the contour and symmetry of

gingival margins, and the alignment of contact points

and embrasures.

The golden proportion, which refers

to the ideal ratio between the widths of anterior teeth, is

often used as a guideline for achieving esthetic balance.

Additionally, the gingival zenith position-the highest

point of the gingival margin-plays a vital role in the

perception of tooth symmetry and overall smile

esthetics.

Several studies have investigated the impact

of orthodontic treatment on esthetic outcomes. Tauheed

et al.

evaluated macro-, mini-, and micro-esthetic

parameters in orthodontically treated patients, ﬁnding

significant improvements post-treatment, particularly in

micro-esthetic aspects such as the golden ratio and

connectors of anterior teeth. A systematic review and

meta-analysis by Alam et al.

reported that orthodontic

interventions lead to statistically signiﬁcant

enhancements in micro-esthetic parameters,

emphasizing the importance of these subtle details in

overall smile attractiveness. Despite the recognized

importance of micro-esthetics in orthodontic outcomes,

there is a paucity of research on patients’ perceptions of

these parameters. Most existing studies have

concentrated on clinical assessments or professional

evaluations, with limited exploration of how patients

perceive and value micro-esthetic elements. This gap in

the literature warrants the need for research that centers

on patients’ subjective experiences and expectations

regarding micro-esthetic features. The objective of this

study was to determine the perception about micro-

esthetic parameters by orthodontic patients

METHODOLOGY

A cross-sectional observational study was conducted in

the Department of Orthodontics at Rehmat Memorial

Hospital, Abbottabad, using a non-probability

consecutive sampling technique. Written informed

consent was obtained from all participants for their

voluntary participation in the study, and they were

assured of the conﬁdentiality of their information.

Ethical approval was obtained prior to the initiation of

the study (RmDTH/EC/4089, dated 30/3/2023). The

sample size was calculated as 120 participants,

assuming a power of 80%, a signiﬁcance level of 0.05,

an assumed eﬀect size (δ) of 0.33, and a standard

deviation of 0.643 for the gingival zenith perception

diﬀerence between normal and altered images. The

inclusion criteria for the study were individuals with no

prior history of orthodontic treatment and no

professional exposure to dental or facial esthetics,

including both genders, aged between 16 and 40 years,

and of Pakistani nationality. The exclusion criteria were

participants with visual impairments that could aﬀect

esthetic judgment, individuals with professional

backgrounds in dentistry ﬁelds, those who had

undergone previous orthodontic treatment, and mentally

disabled patients. A female patient with clinically and

photographically veriﬁed regular micro-esthetic

features was selected for this study. The subject

possessed ideal characteristics in all key areas of smile

aesthetics, including tooth proportions, gingival

margins, incisal edge contours, interproximal contact

point positioning, and axial inclination of the anterior

teeth, aligning with established aesthetic norms. A high-

resolution frontal photograph of the subject’s smile was

taken under controlled conditions, including consistent

lighting, a neutral background, a steady head position,

and a natural smile expression. Using Adobe

Photoshop, the original photograph was digitally

modified to create several versions of the image, each

altering a speciﬁc micro-esthetic parameter. To ensure

that the changes were isolated, only one parameter was

adjusted at a time while keeping all other features of the

smile intact. The speciﬁc changes made were as

follows: The tooth proportion (width-to-height ratio)

was adjusted by reducing the clinical crown height of

the maxillary central incisors to achieve a ratio of 60%,

while maintaining the original width, using the

Transform (Scale - vertical only) tool. For another

version, the crown height was increased to simulate a

width-to-height ratio of 100%, creating a more square-

shaped appearance. The gingival margin height and

contour were altered by shifting the gingival zenith of

each central incisor 1 mm distally, creating a more

pronounced distal position, and in another version, the

zenith was shifted 1 mm mesially to simulate an

unfavorable mesial shift. The interproximal contact

point position was modiﬁed by shifting the contact

point between the central incisors downward by about

1.5 mm, creating visible black triangles, which were

then reﬁned using the Clone Stamp tool. Finally, the

axial inclination of the anterior teeth was changed by

tilting the crowns of the central incisors by 5 degrees

mesially and distally using the Free Transform (Distort)

tool. Patients aged 15 years and older who attended the

orthodontic clinic were invited to participate in the

perception survey. Patients with visual impairments or

those with prior professional training in dental

aesthetics were excluded from the study. Each

participant was shown the original, unaltered image

(control) along with a set of images, each corresponding

to a single modiﬁed micro-esthetic parameter. The

order in which the images were presented was

randomized to avoid any order eﬀects. Participants

were asked to rate the aesthetic appeal of each image

using a 10-point Visual Analog Scale (VAS), where 0

represented "extremely unattractive" and 10 represented

Perception of Orthodontic Micro Esthetic Parameters

J Gandhara Med Dent Sci

October - December 2025

"extremely attractive." Each participant marked their

response independently for each image. The scores

were then measured in millimeters from the left

endpoint (0 cm) to the mark the participant made, and

the data were recorded for further analysis. Intra- and

inter-observer reliability were assessed by repeating

ratings on 20% of the images after a one-week interval,

yielding intraclass correlation coeﬃcients (ICCs)

greater than 0.85, indicating excellent reliability.

Statistical analysis was performed through R software

4.3.1. Mean and SD were computed for normally

distributed numeric data, and median with IQR for

skewed data. A one-way ANOVA was performed to

compare the perception of normal versus altered mini-

esthetic parameters. Stratiﬁcation was performed by

gender. p < 0.05 was considered the signiﬁcance level.

RESULTS

The majority (n = 76, 63.3%) were aged 26–40 years,

while a smaller proportion (n = 44, 36.7%) were aged

16–25 years. The mean age was 4.98±1.61 years. There

were slightly more female participants (n = 68, 56.7%)

than male participants (n = 52, 43.3%). The mean

perception score was highest for the unaltered wide-to-

height ratio (8.92, SD = 0.84), followed by the 60%

ratio (6.13 ± 1.65) and the 100% ratio (5.54 ± 1.47),

with the diﬀerences being highly statistically signiﬁcant

(ANOVA, p < 0.001). Similarly, the unaltered zenith

received the highest mean score (8.45 ± 0.87), while the

zenith distal (5.18 ± 1.50) and zenith mesial inclination

(4.89 ± 1.61) had signiﬁcantly lower scores, with the

diﬀerences again showing statistical signiﬁcance

(ANOVA, p < 0.001). For axial inclination, the

unaltered axial inclination had the highest mean score

(8.0±1.01), while the axial distal (5.42±1.25) and axial

mesial inclination (5.26±1.29) were rated lower, with

signiﬁcant diﬀerences observed (ANOVA, p < 0.001).

Lastly, the contact point down had a mean score of 5.1

± 1.37, which was signiﬁcantly lower than the unaltered

contact point (8.06 ± 0.98), with the diﬀerence being

highly statistically signiﬁcant (t-test, p < 0.001). Table

2 shows that males generally rated micro-esthetic

parameters of the maxillary central incisor higher than

females. The unaltered wide-to-height ratio received the

highest scores for both genders (males: 9.02 ± 0.8;

females: 8.82 ± 0.84), with signiﬁcant diﬀerences in all

conditions (ANOVA, p < 0.001). Males also rated the

100% wide-to-height ratio, unaltered zenith, and axial

distal inclination higher, with statistical signiﬁcance

(ANOVA, p < 0.001). However, the diﬀerence in

unaltered axial inclination was not signiﬁcant. Both

genders rated the altered contact point signiﬁcantly

lower compared to the unaltered one (t-test, p < 0.001).

Table 1: Perception of Orthodontic Patients about the Micro-

Esthetic Parameters of Maxillary Central Incisors

Micro-esthetics of the Central

incisor

Mean (SD) p value

Wide to height ratio (100%) 5.54 (1.47) ANOVA,

p<0.001

Wide to height ratio (60%) 6.13 (1.65)

Unaltered wide-to-height ratio 8.92 (0.84)

Unaltered zenith 8.45 (0.87) ANOVA,

p<0.001

Zenith distal 5.18 (1.50)

Zenith mesial inclination 4.89 (1.61)

Axial distal inclination 5.42 (1.25) ANOVA,

p<0.001

Axial mesial inclination 5.26 (1.29)

Unaltered axial inclination 8.00 (1.01)

Contact point down 5.10 (1.37) t-test,

p<0.001

Unaltered contact point 8.06 (0.98)

Table 2: Perception of Orthodontic Patients about Micro-Esthetic

Parameters of Maxillary Central Incisors Stratiﬁed by Gender

Variable Male

mean(SD)

Female

mean(SD)

P-Value

Wide to height

ratio (100%)

5.64 (1.47) 5.44 (1.47) ANOVA,

p<0.001

Wide to height

ratio (60%)

6.23 (1.65) 6.03 (1.65)

Unaltered wide-to-

height ratio

9.02 (0.84) 8.82 (0.84)

Unaltered zenith 8.55 (0.87) 8.35 (0.87) ANOVA

p<0.001

Zenith distal 5.28 (1.50) 5.08 (1.50)

Zenith mesial

inclination

4.99 (1.61) 4.79 (1.61)

Axial distal

inclination

5.52 (1.25) 5.32 (1.25) ANOVA

p<0.001

Axial mesial

inclination

5.36 (1.29) 5.16 (1.29)

Unaltered axial

inclination

8.10 (1.01) 7.90 (1.01)

Contact point

down

5.20 (1.37) 5.00 (1.37) t-test,

p<0.001

Unaltered contact

point

8.16 (0.98) 7.96 (0.98)

DISCUSSION

The results of this study highlight the signiﬁcant impact

that minor alterations to micro-esthetic parameters of

the maxillary central incisors can have on aesthetic

perception. The original, unaltered images consistently

received the highest ratings for attractiveness across all

the micro-esthetic parameters assessed. Specifically, the

wide-to-height ratio, gingival zenith, axial inclination,

and interproximal contact points all showed statistically

significant diﬀerences in aesthetic appeal when altered.

The results suggest that even slight modiﬁcations in key

aspects of a smile, such as tooth proportions, gingival

margins, axial inclination, and interproximal contact

points, can have a considerable impact on its perceived

attractiveness. The width-to-height ratio is integral to

the smile’s overall harmony, and deviations from this

ratio typically result in lower ratings of attractiveness.

This is likely because signiﬁcant departures from

Perception of Orthodontic Micro Esthetic Parameters

J Gandhara Med Dent Sci

October - December 2025

natural proportions are typically viewed as less

appealing.12 Additionally, the gingival zenith, which is

crucial for maintaining the aesthetic balance of the

gingival contour, loses its appeal when shifted distally

or mesially.

Changes in axial inclination and

interproximal contact points also led to noticeable

declines in attractiveness, with the latter notably

contributing to the formation of visible black triangles,

which are generally regarded as undesirable.

The

perception of micro esthetic parameters showed

apparent diﬀerences between genders. Male

participants consistently gave higher ratings to several

features, including the unaltered width-to-height ratio,

the 100% width-to-height ratio, the natural gingival

zenith position, and distal axial inclination. These

differences were statistically signiﬁcant across multiple

variables (p < 0.001). This indicates that male patients

may have a greater tolerance for minor deviations from

ideal esthetic norms, while female patients may be

more critical of subtle variations in anterior dental

morphology. These diﬀerences could be inﬂuenced by

psychosocial factors, varying esthetic expectations, or

differences in visual perception.

Alomari et al.

conducted a comprehensive study comparing how

different dental professionals and laypersons perceive

altered gingival characteristics. Using digitally

modified photographs, they surveyed 120 orthodontists,

45 periodontists, 49 prosthodontists, 130 general

dentists, and 172 laypersons. They found that black

triangles between the upper incisors were consistently

rated as the least attractive feature, especially by

orthodontists, prosthodontists, and general dentists,

while laypersons were more sensitive to pigmented

gingiva and periodontists to inﬂamed gingiva.

Interestingly, dental professionals gave signiﬁcantly

lower aesthetic ratings than laypersons, reﬂecting a

higher sensitivity to microaesthetic discrepancies. Yang

et al.

evaluated the inﬂuence of changes in the

mesiodistal angulation of the maxillary central incisors

on smile attractiveness. Their study included 52

orthodontists and 61 laypersons who rated digitally

altered images. Increased angulation was perceived as

less attractive, conﬁrming the importance of correct

axial inclination in dental esthetics. Romsics et al.

performed a cross-sectional multi-site study involving

861 dental students across all ﬁve grades of dental

school in Hungary. The study assessed students’

perceptions of dentofacial mini- and microesthetics

through questionnaires and image evaluations. Findings

indicated that students’ perceptions evolved with their

academic progression, with signiﬁcant associations

observed between the year of study and the perception

of maxillary midline shifts and the visibility of dental

arches.

LIMITATIONS

The use of high-resolution digital images and precise

modification of speciﬁc micro-esthetic features enabled

a controlled evaluation of each parameter. Randomized

image presentation reduced response bias, and the

sample size allowed for meaningful statistical analysis.

However, some limitations exist. The cross-sectional

design captures only a single time point, limiting

insights into changes over time. The age range (16-40

years) and focus on orthodontic patients may aﬀect

generalizability. Moreover, esthetic perception is

subjective and inﬂuenced by cultural and personal

factors not controlled for in this study.

CONCLUSIONS

This study found that small changes in microesthetic

features of the maxillary central incisors, such as the

width-to-height ratio, gingival zenith position, axial

inclination, and interproximal contact points, can

significantly aﬀect perceived dental attractiveness.

Natural, unaltered images were rated most favorably,

while deviations often reduced esthetic appeal, mainly

when they resulted in visible black triangles or

disproportionate tooth dimensions. Male participants

showed greater tolerance for minor esthetic variations

compared to females, suggesting gender-based

diﬀerences in perception.

CONFLICT OF INTEREST: None

FUNDING SOURCES: None

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AUTHORS CONTRIBUTION

The authors accept responsibility for all aspects of the work

and will ensure that any concerns regarding the accuracy or

integrity of any part are properly investigated and resolved.

Syeda Multazam Ahmad - Concept & Design; Data

Acquisition; Data Analysis/Interpretation; Drafting

Manuscript; Critical Revision; Supervision; Final Approval

Nabila Anwar - Concept & Design; Data

Analysis/Interpretation; Drafting Manuscript; Critical

Revision; Supervision; Final Approval

Hazrat Asad ur Rehman Hoti - Concept & Design; Data

Acquisition; Drafting Manuscript; Critical Revision; Final

Approval

Jawad Shah - Concept & Design; Data Analysis/Interpretation;

Drafting Manuscript; Critical Revision; Final Approval

Farheen Sajid - Concept & Design; Data

Analysis/Interpretation; Drafting Manuscript; Final Approval

Anum Waseem - Concept & Design; Data Acquisition;

Drafting Manuscript; Final Approval

Aneela Baseer - Concept & Design; Data Acquisition; Drafting

Manuscript; Final Approval

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Perception of Orthodontic Micro Esthetic Parameters