Smiles around the world
Ilyaas Rehman explores what makes the ‘ideal’ smile in different parts of the world and how this diversity, and versatile dentistry, can help meet patients’ expectations
Across the globe, a smile is universally understood as an expression of happiness. However, are all smiles universally accepted? It is ironic that, linguistically, an ‘artificial smile’ denotes a person who forcedly wears the smile despite having no feeling of joy. However, the smiles that the world drools over are those that are, technically, most artificial!
So, how did we come to our subjective obsession with ‘perfect’ smiles? This article aims to explore what drives the need for ‘perfection’, and the factors involved in achieving the ‘ideal’ smile around the world today.
If the British Academy of Cosmetic Dentistry had existed a few thousand years ago, much of its emphasis would have surrounded extractions, dentures, or the filing of teeth to improve smile aesthetics. The discovery by archaeologist Hermann Junker of two teeth connected by gold in an Egyptian tomb1 sparked much interest in the dental world – has the practice of dentistry with a cosmetic ethos existed for much longer than we thought? Is the craving for pearly whites not only a thing of the recent past?
Gone are the days of veneers mimicking piano keys or crowns bright enough to join the constellations
It is no surprise that cosmetic dentistry represents the second largest non-surgical beauty industry, after makeup. A study by the American Academy of Cosmetic Dentistry (AACD) gives compelling evidence as to why this is: 96 per cent of adults believe an attractive smile makes a person more appealing to members of the opposite sex and three-quarters of adults feel an unattractive smile can impede a person’s career.2 A further study concluded that having an ideal dentition makes a person up to 4.8 times more likely to enter a relationship.3 But exactly what is it that makes the smile attractive?
Several factors will influence the smile image, of which some are given higher preference. The tooth shade is undoubtedly one of the biggest factors (Fig 1): this can be further broken down into the hue, value and chroma as per the Munsell colour system. Teeth are also judged by their spacing or crowding; presence of overbites and overjets; presence of occlusal canting and the dental midline relative to facial planes.
There are also several aspects of the smile that are not tooth-related, which heavily influence the smile aesthetics, for example excessive gingival display gives the classic ‘gummy smile’ (Fig 2). More recently, the buccal corridor has gained significance as this area of ‘blackness’ can create an illusion of missing teeth, almost negating the brilliance of the white dentition. Furthermore, the size, shape and symmetry of the lips are crucial in creating the perfect framework for the smile: the classic ‘cupid’s bow’ is often associated with beauty (Fig 3).
It would seem therefore, that if we use these factors to attempt to create an ideal smile, everyone’s needs are met. However, this is where the objectivity of ideals, such as Andrew’s six keys in orthodontics, clash with the subjectivity of cultural norms. The ancient practice of Ohaguro in Asian countries such as Japan, Philippines, Laos and more is a testament to this: for centuries, women would drink an iron-based black dye infused with cinnamon and other spices to achieve an intensely black tooth colour4 (Fig 4). This would then signify wealth and sexual maturity. More recently, a craze among Japanese women to request crooked ‘fang-like’ canines surfaced.5 The practice, known as the ‘yaeba’ look, is thought to be an attractive feature among young females. The clash of cultural ideals continues in the controversial practice of dental mutilation. Though it may occur around the globe, it predominates in communities of the Western Cape, South Africa. The deliberate extraction of incisors in youth to create the ‘passion gap’ is believed to be of significance when entering adulthood.6 It is becoming obvious now that the Western ideals of beauty may not be shared worldwide. Nor is it a case of us and them – can you remember the nation’s disagreement over the ‘London look’?
We too have come a long way in the Western hemisphere. Gone are the days of veneers mimicking piano keys or crowns bright enough to join the constellations. A much greater preference is given, in most cases, to subtle, undetectable dental work. Introduction of new composite resin materials with nano-hybrid technology, improved bonding systems, stronger aesthetic ceramics such as lithium disilicate, resin pigments and 3D scanning technology have all played their role in bringing us to breathtakingly natural outcomes of restorative dentistry today. So how do we want our smiles to look?
The AACD posed the question back in 20042: “What is the first thing you notice in a person’s smile?” to which the consensus was: straight, white, clean, and sincere! The desire for this type of smile cannot merely be attributed to vanity. Research has shown that 70 per cent of people who are unhappy with their teeth say it has negatively affected their lives and a further study shows 78 per cent of women and 63 per cent of men reported that their teeth negatively impacted their mental health.7
It comes as no surprise then, that 75 per cent of orthodontists in the UK report an increase in adults requesting treatment.8 More recently, lip augmentation has become a popular add-on to complete the smile package. Loss of volume with age causes lips to become flat and thin; injectable dermal fillers are used to restore the youthful appearance (Fig 5). This practice is almost the opposite in other parts of the world, such as East Asia, where lip reduction surgery is more common9.
Tooth whitening, however, has experienced a spike of interest across the seas. Several new products, such as the popular activated charcoal toothpaste, have attracted support from a wide audience who are looking for a more DIY approach to perfection. Is our profession willing to condone this approach?
The art of dentistry today allows patients to achieve their dream smile with a minimalistic, conservative approach. In fact, in the UK, it has become frowned upon to adopt a treatment plan involving destructive crown and veneer preparations when the same result can be obtained without unnecessary removal of tooth tissue. Experienced clinicians are now able, in some cases, to transform patients’ lives in a few hours without the use of local anaesthetic. Contemporary techniques and materials allow the dentists to recreate teeth to the fine details of tertiary anatomy, such as developmental grooves and line angles that reflect light correctly.
In closing, the world in its diversity will never conform to one set of ideals. Despite this, part of the beauty of dentistry lies in its versatility, allowing it to achieve a wide range of outcomes. Though these may not objectively satisfy what we tell ourselves is ideal, the ultimate satisfaction to be gained as a dentist is ethically meeting a patients’ expectations. The joyous smile they leave you with will not be artificial (or will it?)
About the author
Ilyaas Rehman is a final-year dental student from the University of Glasgow with a keen interest in academia and restorative dentistry.
1. Forshaw, RJ. (2009). The practice of dentistry in ancient Egypt. British Dental Journal, 481-486.
2. AACD (2004). Can a new smile make you appear more successful and intelligent?
3. Yoann Lopez, JLM. (2013). Influence of teeth on the smile and physical attractiveness. A new internet basing method. Open Journal of Stomatology.
4. DHWTY. (2016, March 17). The Allure of Blackened Teeth: A Traditional Japanese Sign of Beauty. (Retrieved from Ancient Origins).
5. Nelson, S. C. (2013, February 01). Yaeba: Japanese ‘Double Tooth’ Trend (From Huffington Post).
6. AG, M. (1998). Dental mutilation in southern African history and prehistory with special reference to the ‘Cape Flats Smile’. Journal of South African Dental Association, 179-183.
7. Dentistry.co.uk. (2012, June 25). Bad teeth can have mental impact (From Dentistry.co.uk).
8. Miyanger, V. (J2016, July 25). Adults seeking more orthodontic treatment. (From Dentistry.co.uk).
9. Scott, E. (2017, April 18). Lip reduction is the next big surgery trend. (From the Metro newspaper).