RESEARCH AND EDUCATION

Layperson’s preference regarding orientation of the transverse

occlusal plane and commissure line from the frontal perspective
Bruno Pereira Silva, DMD, PhD,a Emilio Jiménez-Castellanos, MD, DDS, PhD,b Sivan Finkel, DMD,c
Inmaculada Redondo Macias, DMD,d and Stephen J. Chu, DMD, MSD, CDTe

The transverse occlusal plane ABSTRACT

(TOP) when viewed from a Statement of problem. Facial asymmetries in features such as lip commissure and interpupillary
frontal perspective should be plane canting have been described as common conditions affecting smile esthetics. When pre-
parallel to the facial horizontal sented with these asymmetries, the clinician must choose the reference line with which to orient
reference lines such as the the transverse occlusal plane of the planned dental restorations.
interpupillary line (IL) and the Purpose. The purpose of the online survey described in this study was to determine lay preferences
commissure line (CL) to regarding the transverse occlusal plane orientation in faces that display a cant of the commissure
maintain facial harmony.1-5 line viewed from the frontal perspective.
Song et al6 found that 54.7%
Material and methods. From a digitally created symmetrical facial model with the transverse
of 1282 participants presented occlusal plane and commissure line parallel to the interpupillary line (horizontal) and a model
angulations under 1 degree constructed in a previous study (control), a new facial model was created with 3 degrees of cant of
between IL and CL. However, the commissure line. Three digital tooth mountings were designed with different transverse
these authors found no refer- occlusal plane orientations: parallel to the interpupillary line (A), parallel to the commissure line (B),
ences studying the impact a and the mean angulation plane formed between the interpupillary and commissure line (C),
“canted” commissural line resulting in a total of 4 images. All images, including the control, were organized into 6 pairs and
evaluated by 247 selected laypersons through an online Web site survey. Each participant was
can have on a smile’s inte-
asked to choose the more attractive face from each of the 6 pairs of images.
gration relative to the overall
face. Results. The control image was preferred by 72.9% to 74.5% of the participants compared with the
other 3 images, all of which represented a commissure line cant. Among the 3 pairs which represent
Lack of parallelism among
a commissure line cant, 59.1% to 61.1% preferred a transverse plane of occlusion cant (B and C)
the TOP, CL, and IL can be compared with a plane of occlusion parallel to the interpupillary, line and 61.1% preferred a plane
attributed to different causes. of occlusion parallel to the commissure line (B) compared with the mean angulation plane (C).
The presence of an elevated
Conclusions. Laypeople prefer faces with a commissure line and transverse occlusal plane parallel
labial commissure at rest or
to the horizontal plane or horizon. When faces present a commissure line cant, laypeople prefer a
alar base on one side is often transverse occlusal plane with a similar and coincident cant. (J Prosthet Dent 2016;-:---)
an indication of vertical skel-
etal asymmetry. Conditions
for each patient should be individually diagnosed; Restorative treatment alone can also be a solu-
sometimes orthognathic surgery combined with tion depending on a particular situation and the
orthodontic treatment is necessary to treat these patient’s individual needs.6 Assessment of dentofacial
discrepancies.5,7,8 asymmetries and other discrepancies that can affect the

a
Clinical Professor, Department of Periodontology of School of Dentistry, University of Seville, Seville, Spain.
b
Professor of Prosthodontics, School of Dentistry, University of Seville, Seville, Spain.
c
Clinical Instructor, Advanced Aesthetic Dentistry, New York University College of Dentistry, New York, NY.
d
Private practice, Amsterdam, The Netherlands.
e
Clinical Associate Professor, Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, NY.

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Clinical Implications
Laypeople prefer some degree of transverse
occlusal plane inclination in patients who present a
lip commissure line cant. The acceptable degree of
canting should be assessed on an individual patient
basis.

horizontal reference lines should be considered initially

as a part of the esthetic diagnosis.9,10
Using image analysis, Ferrario et al11 concluded that
the angulation of the TOP in healthy dental students can
reach a mean of between 2.15 and 2.90 degrees. Figure 1. Control image.
Jiménez-Castellanos et al12 observed some inclination
of the TOP in 25.9% of a southern Europe population.
The inclination exceeded 2 degrees in all participants.
Silva et al13 studied the esthetic impact of different
facial and dental discrepancies and concluded that 3
degrees of occlusal plane cant would be detected by the
majority of laypeople. The results of other studies have
shown that deviations in cant are not noticeable unless
they exceed between 2 and 4 degrees.10,14,15
Asymmetry, even among esthetically pleasing faces, is
a typical finding.16 Some variations of facial asymmetry
are not considered an esthetic liability, despite the
absence of objective criteria scientifically defined as
differentiating normal and abnormal asymmetries.13
Therefore, the purpose of this online survey was to
determine lay preferences regarding TOP orientation in Figure 2. New facial model created with 3 degrees of canting of
faces which possess a cant of the commissural line or plane. commissure plane.
All images, including the control image, were orga-
MATERIAL AND METHODS
nized into 6 pairs so that each different image could be
A cohort of 247 laypeople (126 women and 121 men) were directly compared, 2 forced choices. Participants were
selected from a pool of patients who visited 3 different asked, “Which face is more attractive?” A single answer
dental practices between January and July 2013 to perform was accepted for each pair of images viewed, thereby
an online internet-based survey. The survey was performed allowing direct comparisons between the 4 images: pair
using survey software (SurveyGizmo; Widgix, LLC). Inclu- 1: control and A; pair 2: Control and B; pair 3: Control
sion criteria were included in the survey questions; partici- and C; pair 4: A and B; pair 5: A and C; pair 6: B and C.
pants were more than 18 years of age, and their occupation These paired arrangements of the 4 different images
could not be related to any dental health care profession. allowed direct comparison to measure and establish
Ethnicity and educational background were also noted. subjective lay preferences. All 6 pairs of images were
Beginning with a symmetric (control) face model shown to each participant through the online Web site
(Fig. 1) wherein the TOP, CL, and IL were all parallel, a survey, with the software randomizing the order in which
new face model was created with 3 degrees of CL cant each participant viewed each pair.
(Fig. 2).13 Three digital dentition “mountings” were then Once all the questionnaires were completed, the data
designed with different transverse occlusal line or were collected in a spreadsheet table (Excel 2010;
transverse plane orientations: parallel to the IL/plane Microsoft Corp) and statistical analysis was performed
(Fig. 3), parallel to the adjusted CL/plane (Fig. 4), and the with software (IBM SPSS Statistics v22; IBM Corp). The
mean between the angle of the interpupillary plane and chi-squared test (Pearson and/or Fisher exact test) was
commissure plane equivalent to 1.5 degrees (Fig. 5C), performed to determine that participant sex was not a
resulting in a total of 4 images. Image manipulation factor (P<.05). Ethnicity and educational background data
software (Photoshop [Adobe Systems] CS3 Extended for were not statistically analyzed, since some subgroups
Macintosh [Apple Inc]) was used for all image editing. presented too low an n value for evaluation.

THE JOURNAL OF PROSTHETIC DENTISTRY Silva et al

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Figure 3. Transverse occlusal plane parallel to interpupillary plane (A). Figure 4. Transverse occlusal plane parallel to commissure plane (B).

100
90 25.5 27.1 25.5
(A) (B) (C) 41.3
80 (C)
59.1

Preference (%)
61.1
70 (B) (C)
60
50
40 74.50 72.90 74.50
Control Control Control 58.70
30 (B)
40.90 38.90
20 (A) (A)
10
0
1 2 3 4 5 6
Pair
Figure 6. Results for pair 1. Control and A; pair 2: control and B; pair 3:
control and C; pair 4: A and B; pair 5: A and C; pair 6: B and C.
Figure 5. Transverse occlusal plane mean between angle of interpupil-
lary plane and commissure plane equivalent to 1.5 degrees (C).
TOP parallel to the CL, 58.7% of the respondents
preferred the TOP completely parallel to the CL (Table 1).
RESULTS
DISCUSSION
A total of 247 observers fulfilled the inclusion criteria: 121
men (49%) and 126 women (51%). Sixty-nine percent of Previous studies have focused on the layperson’s
the participants were Hispanic residents of Europe. perception of the cant of the occlusal plane using images
Forty-five percent of participants had a bachelor’s degree, from the lower third of the face or from observing the
10% had a postgraduate degree, and the remaining labial frame created by the lips alone.10,14,15,17,18 How-
participants had a high school education or less. Partic- ever, the authors were unable to find studies that
ipant ages ranged between 18 to 58 years of age, with an researched the esthetic impact of the cant of the CL.
average 25.9 years of age. When a lack of parallelism between occlusal plane, CL,
Between 72.9% and 74.5% of the participants and IL is present, different treatment options should be
preferred the control image (parallel CL) compared with considered. Orthognathic surgery combined with ortho-
any of the 3 images with a commissure cant (Fig. 6). When dontics can be one treatment option to solve the lack of
the CL was canted, the participants preferred a TOP also parallelism between the horizontal reference lines, although
canted, coincident with the commissures. The TOP par- restorative dental treatment may provide a less invasive
allel to the CL was preferred by 59.1% compared with solution that may adequately address the patient’s needs.5-8
40.9% who preferred a TOP completely parallel with the The IL (or the horizontal plane) is conventionally and
IL (horizontal). The occlusal plane orientation at a mean commonly used as the reference line to establish the
or average between the angle of IL and CL was preferred occlusal plane in the frontal perspective.1-5 However,
by 58.7% compared with 41.3% who preferred a TOP the authors are unaware of any publications regarding
completely parallel with the IL. When the mean between the establishment of the TOP in patients who present
the angle of IL and CL angulation was compared with the with commissural line or plane canting.

Silva et al THE JOURNAL OF PROSTHETIC DENTISTRY

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Table 1. Results of 6 paired arrangements of 4 different images (Control,
A, B, and C)
Pair % Control %A %B
1 74.5 25.5
2 72.9 27.1
3 74.5
4 40.9 59.1
5 38.9
6 58.7
The digitally designed face used in this study pre-
sented a CL angulation of 3 degrees. This angulation was
chosen based on a previous study where the author,
using the same digital facial model, came to the conclu-
sion that 3 degrees of the TOP was noticeable by the
majority of laypeople.13 Padwa et al10 came to similar
conclusions that laypeople can identify occlusal plane
angulations greater than 3 degrees, 70% of the time. A
female model was used in this study. However, some
studies have concluded that observers are more critical of
female models.14 The participants of this study were all
laypeople whose occupations were not related to dental
care in an effort to maintain the “layperson” quality and
limit bias.
This current study demonstrates that laypeople prefer
symmetrical faces with the CL parallel to the IL and TOP.
The control image was preferred by over 70% of partic-
ipants compared with all other images. Other studies
have also demonstrated that people tend to feel attracted
to symmetrical faces or smiles.8,13,16-18
The current study shows that when there is a lack of
parallelism between the IL and CL, the majority of
laypeople prefer a TOP canted in the same direction as
the commissures. However, each situation should still be
evaluated individually and the degree of cant determined
for each individual patient, since approximately 4 of 10
(40%) people prefer a TOP completely parallel with the
IL.
When developing a facially driven smile design for a
patient with lack of parallelism between the commis-
sure and ILs, clinicians must decide which horizontal
reference line in a transverse plane should be followed
to align the restorative occlusal plane. It appears that
the direction of the commissure cant should be
considered and followed in some clinical situations,
rather than the IL or the true horizontal. This phe-
nomenon is understandable given that the esthetic
outcome is our ultimate goal and there should be har-
mony with the smile and face. However, when dis-
crepancies exist between the 2 major reference lines (IL
and TOP) an acceptable treatment option is to follow
the frame given by the CL.
THE JOURNAL OF PROSTHETIC DENTISTRY
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CONCLUSIONS
%C Based on the findings of this online survey, the following
conclusions were drawn:
1. Laypeople prefer symmetrical faces with the CL
25.5
parallel to the IL and OP in a transverse plane.
2. When a lack of parallelism exists between the IL and
61.1
41.3
the CL, most laypeople prefer a TOP with a cant
coincident with the CL.
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Corresponding author:
Dr Bruno Pereira da Silva
Universidad de Sevilla
Periodontology, School of Dentistry
Calle Avicena
España, Sevilla 41009
SPAIN
Email: brunopereira.doc@gmail.com
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
Silva et al