- Almost half of the participants were completely satisfied with their dental appearance and tooth colour. - Satisfaction differed between age groups and dental status - half of younger/middle-aged patients with natural teeth were completely satisfied, while half of older patients were moderately satisfied. - Those with composite restorations were mostly moderately satisfied with appearance, while over 70% of older patients were dissatisfied with their tooth colour.

1. Original article
Influences of age and maxillary anterior teeth status on
patient’s satisfaction with dental appearance and tooth colour
Vlatka Lajnert1
, Daniela K. Pavicˇic´1
, Renata Grzˇic´1
, Zoran Kovacˇ1
,Dana Pahor2
, Davor Kuis˘3
,
Suncˇana Simonic´-Kocijan1
, Robert Antonic´1
and Danko Bakarcˇic´4
1
Department of Prosthodontics, Dental School, Faculty of Medicine, University of Rijeka, Rijeka, Croatia; 2
Department of Social Medicine,
Faculty of Medicine, University of Rijeka, Rijeka, Croatia; 3
Department of Oral Medicine and Periodontology, Dental School, Faculty of
Medicine, University of Rijeka, Rijeka, Croatia; 4
Department of Paediatric dentistry, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
doi: 10.1111/j.1741-2358.2011.00543.x
Influences of age and maxillary anterior teeth status on patient’s satisfaction with dental appearance
and tooth colour
Objectives: To study the impact of age, gender, tooth colour and maxillary anterior teeth status on
patient’s satisfaction with their dental appearance.
Material and methods: A total of 259 Caucasian subjects participated in the study (119 men, mean age
56 years; 140 women, mean age 61 years) divided into three age groups (young 35 age; middle aged 35–
54 age; old ‡55 age). Their maxillary anterior teeth status was classified into three groups: (1) natural teeth
(NTG) group; (2) composite filling group (CFG) and (3) porcelain-fused-to-metal fixed prosthodontic
restoration group (FPDG). The participants judged appearance and tooth colour using a scale with three
categories: completely dissatisfied, moderately dissatisfied and completely satisfied.
Results: Almost half of the participants were completely satisfied with their dental appearance and tooth
colour. Half of the ‘young’ and ‘middle-aged’ participants with natural maxillary anterior teeth were
completely satisfied and half of the ‘old’ participants were moderately satisfied with their dental appearance
and tooth colour. The majority of participants with composite restorations (45–51%) were moderately
satisfied with their dental appearance, one-third of ‘young’ and ‘middle-aged’ participants were moderately
satisfied or dissatisfied with their tooth colour and more than 70% of older participants were dissatisfied
with their tooth colour (p 0.05).
Conclusions: Satisfaction with the appearance of the maxillary anterior teeth differed both between
individuals of different age and different dental status.
Keywords: gender, patient satisfaction, aesthetics.
Accepted 6 April 2011
Introduction
In modern society, because of the decrease in caries
prevalence1,2
, restorative dentistry has shifted from
functional to aesthetic dentistry3,4
.
Assessment of dental appearance, one of the
most important aspects of dental aesthetics, often
refers to the six maxillary anterior teeth as the most
visible ones during communication, speech, func-
tioning and smiling5,6
. Rating is influenced by a
variety of different factors determining a harmo-
nious interaction of dental and gingival beauty,
tooth colour, size and shape of teeth as well as the
visibility of the teeth and soft tissue gums at rest
and when smiling7,8
.
The patient’s attitude towards dental appearance
proved to be very important and should be
acknowledged in dental treatment decisions9,10
.
Previous studies have indicated associations be-
tween patient’s dental appearance and quality of
life and general well-being6,11–13
. Using socio-
demographic characteristics of the individuals, age
has been shown to be one of the most important
influences on a patient’s dental perception14–16
. It
has already been shown that concerns about dental
appearance have been greatest in middle-aged
e674 Ó 2011 The Gerodontology Society and John Wiley Sons A/S, Gerodontology 2012; 29: e674–e679

2. subjects and of decreasing priority in older sub-
jects14,15
. It is often supposed that the elderly no
longer have great expectations of their dental
appearance, because of the loss of some or all their
natural teeth, darker colour or discolouration of
their teeth, periodontal diseases and numer-
ous dental restorations, which influence overall
appearance of their maxillary anterior teeth. In a
study of over 3300 participants in the UK, Alkhatib
et al.14,17
reported that 12.1% patients in the age
group 55+ years were dissatisfied with their dental
appearance, which was in accordance with their
previous results. In their study, tooth colour
accounted for half of the reasons for a patients’
dissatisfaction, proving it to be one of the most
important factors in dental appearance assess-
ment14,17
.
The aim of this study was to investigate the im-
pact of ageing and different maxillary anterior teeth
status on patient’s satisfaction with dental appear-
ance and tooth colour.
It was hypothesised that older patients would
demonstrate a lower level of satisfaction, because of
changed appearance, darker colour of their
remaining maxillary anterior teeth and the possible
existence of various restorations, and that, patients
with restorations would be less satisfied than those
having their own intact teeth.
Materials and methods
A total of 259 Caucasian subjects participated in the
study (119 men, mean age 56 years; 140 women,
mean age 61 years). All the participants included in
the study gave written informed consent to the
survey procedures, which were approved by the
Ethical Committee of the School of Dental Medi-
cine.
For the six maxillary anterior teeth, the inclusion
criteria were as follows: Angle class I individuals
with all six anterior teeth present in the upper jaw;
while exclusion criteria were as follows: evidence
of gingival inflammation or gingival hyperplasia,
attachment loss, observable gingival recession,
history of any traumatic injury, observable occlusal
wear, dental malocclusion, history of orthodontic
or bleaching treatment, visible tooth staining, car-
ies and composite fillings on the facial surfaces of
the teeth or ceramic crowns older than 2 years.
Patients from 15 to 75 years were grouped in
three different groups. The first group comprised
patients with natural teeth (NTG); the second
group comprised patients with composite filling
(CFG) and the third group comprised patients with
at least one or more porcelain-fused-to-metal fixed
prosthodontic restoration (crown) (FPDG) on their
upper anterior teeth. For the purposes of the study,
patients were also divided into three age groups:
young 35 age; middle-aged 35–54 age; old ‡55
age.
Patients were then asked to complete a ques-
tionnaire and assess their satisfaction with the
dental appearance and colour of their maxillary
anterior teeth using a three-point scale with pos-
sible answers ‘dissatisfied’, ‘moderately satisfied’, or
‘completely satisfied’.
The data were analysed using SPSS 10.0 statistical
software (SPSS Inc., Chicago, IL, USA). The v2
test
was used to compare the rates of patients’ satis-
faction with their dental appearance and tooth
colour between different age and maxillary anterior
teeth status groups (p 0.05).
Results
A total of 259 patients participated in this study. Of
these, 119 (46%) were men and 140 (54%) were
women. At the time of investigation, the patients
were aged between 15 and 75 years, 116 (45%) of
them were in the younger age group, 86 (33%) in
the middle-aged group and 57 (22%) in the older
age group.
One hundred and forty-six (56%) patients had
their natural maxillary anterior teeth, 45 (17%)
had composite fillings and 68 (27%) had porcelain-
fused-to-metal crowns or fixed partial dentures on
their upper anterior teeth (FPDG). The distribution
of the maxillary anterior teeth status in the three
different age groups is shown in Table 1. Two-
thirds of the younger (76%) and half of the middle-
Table 1 Distribution of maxillary anterior teeth status in different age groups.
Age groups Natural
Composite
restorations
Porcelain-fused-to-metal
restorations Total v2
df p-value
Maxillary anterior teeth status
15–34 89 17 10 116 51.208 4 0.000
35–54 42 17 27 86
55+ 15 11 31 57
Ó 2011 The Gerodontology Society and John Wiley Sons A/S, Gerodontology 2012; 29: e674–e679
Maxillary anterior teeth status on patient’s satisfaction e675

3. aged patients (48%) had their own teeth, while
55% of older patients had porcelain-fused-to-metal
crowns or fixed partial dentures on their upper
anterior teeth. There was a significant difference in
anterior dental status between different age groups
(p 0.05) (Table 1).
The number of patients dissatisfied, moderately
or completely satisfied with dental appearance and
tooth colour in different age and maxillary anterior
teeth status groups is shown in Table 2. The overall
rating of satisfaction was high; almost half of the
patients (43%) were completely satisfied with their
dental appearance and tooth colour. However, a
significant difference was observed for both the
dental appearance and the tooth colour between
different maxillary anterior teeth status groups as
well as between different age groups (p 0.05)
(Table 2). The majority of individuals with NTG
and porcelain-fused-to-metal restorations (FPDG)
were completely satisfied, while those with com-
posite restorations (CFG) were just moderately
satisfied with their dental appearance and tooth
colour (p 0.05) (Table 2). Almost half of the
younger patients were moderately satisfied with
their dental appearance, while half of the middle-
aged and older patients were completely satisfied
(p 0.05) (Table 2). The majority of younger and
middle-aged patients were completely satisfied
with their dental appearance, but the majority of
older individuals were just moderately satisfied
(p 0.05) (Table 2).
The distribution of ratings of satisfaction with
own dental appearance and tooth colour in differ-
ent maxillary anterior teeth status groups depen-
dent on age are illustrated in Figs 1 and 2.
In the NTG, the majority of the young (48%) and
middle-aged individuals (50%) were completely
satisfied, while the majority of the older age group
(48–60%) were moderately satisfied with their
dental appearance and tooth colour, with signifi-
cant difference between age groups regarding their
satisfaction with dental appearance (v2
= 9.535;
df = 4; p = 0.049) (Figs 1 and 2).
In patients with direct anterior composite resto-
rations (CFG), the majority of patients of all ages
(45–51%) were moderately satisfied with their
dental appearance (p 0.05) and 37% of young
and 30% of middle-aged patients were moderately
satisfied or dissatisfied with their tooth colour,
respectively (p 0.05) (Figs 1 and 2). At the same
time, more than 70% of older patients were dis-
satisfied with their tooth colour (p 0.05) (Fig. 2).
In the FPDG, approximately 45% of middle-aged
and 51% of older patients were completely satisfied
with their dental appearance and tooth colour,
respectively (Figs 1 and 2). In the younger age
group, 70% of them were moderately satisfied with
their dental appearance and 60% with their tooth
colour. Significant difference was found between
age groups regarding their satisfaction with dental
appearance (v2
= 10.521; df = 4; p = 0.033) and
tooth colour (v2
= 12.602; df = 4; p = 0.013).
Table 2 Satisfaction with dental appearance and tooth colour dependant on maxillary anterior teeth status and age of
the patients.
Dissatisfied Moderately satisfied Completely satisfied Total v2
value df p-value
Maxillary anterior teeth status
Dental appearance
NTG 18 57 71 146 15.47 4 0.004
CFG 11 22 9 45
FPDG 15 24 29 68
Tooth colour
NTG 14 60 72 146 25.98 4 0.000
CFG 19 14 12 45
FPDG 12 26 30 68
Age groups
Dental appearance
16–34 13 55 48 116 10.34 4 0.035
34–54 23 26 37 86
55+ 11 22 24 57
Tooth colour
16–34 16 47 53 116 3.03 4 0.553
34–54 19 29 38 86
55+ 10 24 23 57
NTG, natural teeth group; CFG, composite filling group; FPDG, fixed partial denture group (porcelain fused to metal).
Ó 2011 The Gerodontology Society and John Wiley Sons A/S, Gerodontology 2012; 29: e674–e679
e676 V. Lajnert et al.

4. Discussion
Patient’s satisfaction has become an increasingly
important factor in aesthetic treatment. In this
study, we investigated satisfaction with dental
appearance and tooth colour in relation to age and
maxillary anterior teeth status. Our hypothesis was
that older patients would demonstrate lower level
of satisfaction and those older patients with resto-
rations would be less satisfied than those having
their own teeth.
It has already been shown that concerns about
dental appearance are greatest in middle-aged
individuals and of decreasing priority in older
individuals18
. In Valittu’s study, which included
subjects with a wide age range, the importance of
dental appearance was less in older patients than in
younger patients19
. We expected that in older
individuals, their interest in dental appearance
would be diminished, together with the lower
socio-economic status of older patients and their
lower incomes (they are not able any more to
afford very expensive aesthetic restorations).
The overall rating of satisfaction in this study was
high; although some of the patients were not at all
satisfied with their dental appearance, a high level
of satisfaction with dental appearance and tooth
colour was found, with almost half of the patients
(43%) completely satisfied. With regard to the
older population in this study (55 years of age and
older), approximately 80% were completely or
moderately satisfied with dental appearance and
tooth colour, which is in agreement with the out-
come of Meng’s study, where 75% of older people
also appeared to be very satisfied and satisfied with
their dental appearance15
, as well as Alkhatib’s
study in the UK population, where 80.3% of the
55+ were satisfied with their dental appearance and
71.1% were satisfied with their tooth colour14
.
Newton has explained the existence of a high level
0
10
20
30
40
50
60
70
80
Dissatisfied Moderately
satisfied
Completely
satisfied
Dissatisfied Moderately
satisfied
Completely
satisfied
Dissatisfied Moderately
satisfied
Completely
satisfied
Natural maxillary anterior teeth Composite fillings on maxillary
anterior teeth
Ceramic crowns on maxillary
anterior teeth
Dental appearance
Percentage
15-34
35-54
55+
Figure 1 Satisfaction with dental appearance in patients with natural maxillary anterior teeth, composite fillings of
ceramic crowns on maxillary anterior teeth depending on their age.
0
10
20
30
40
50
60
70
80
Dissatisfied Moderately
satisfied
Completely
satisfied
Dissatisfied Moderately
satisfied
Completely
satisfied
Dissatisfied Moderately
satisfied
Completely
satisfied
Natural maxillary anterior teeth Composite fillings on maxillary
anterior teeth
Ceramic crowns on maxillary
anterior teeth
Tooth colour
Percentage
15-34
35-54
55+
Figure 2 Satisfaction with tooth colour in patients with natural maxillary anterior teeth, composite fillings of ceramic
crowns on maxillary anterior teeth depending on their age.
Ó 2011 The Gerodontology Society and John Wiley Sons A/S, Gerodontology 2012; 29: e674–e679
Maxillary anterior teeth status on patient’s satisfaction e677

5. of patient interest in dental appearance up to old
age with its connection with social interactions20
.
Furthermore, in the industrialised countries, the
proportion of the elderly in society grows sub-
stantially and the characteristics of this group are of
major interest for the community today.
In contrast with the significant age difference in
patient’s satisfaction with the dental appearance,
where most of the younger were just moderately
satisfied (probably due to the higher level of aes-
thetic expectation associated with the large media
influence) and the other age groups were either
moderately or completely satisfied (these results
are in accordance with Alkhatib’s17
), the signifi-
cant difference in satisfaction with tooth colour
between younger and older age groups was not
found (p 0.05) (Table 2). This finding is similar
to Odioso’s results, which showed very little dif-
ference in satisfaction with own tooth colour
between young and older age groups in the last
decades21
.
So far, our findings were similar to those from
Alkhatib’s study, but they have failed to include
dental status as one of the most important factors
influencing the patient’s attitudes toward their
dental appearance and tooth colour. Therefore, we
divided our study group into the three most fre-
quent maxillary anterior teeth status subgroups –
all natural anterior teeth group, composite filling
group (having at least one composite filling on the
maxillary anterior tooth) and the porcelain-fused-
to-metal restoration group. We examined the level
of patient’s satisfaction with dental appearance and
tooth colour separately for each group.
In the young and middle-aged NTG, the majority
of individuals were completely satisfied with their
dental appearance and tooth colour. This was ex-
pected because of their awareness of oral health
maintenance. On the contrary, the majority of
older NTG individuals were only moderately satis-
fied with their dental appearance and tooth colour,
probably because their remaining natural teeth
might exhibit colour changes and therefore teeth
appear darker. Although the exclusion criteria in
the present study included visible tooth wear
comprising dentine, older natural teeth also
exhibited tooth wear in enamel, which also might
decrease dental appearance satisfaction.
In the CFG, the majority of patients of all ages
were moderately satisfied with their dental
appearance, and one-third of young and middle-
aged patients were moderately satisfied or dissat-
isfied with their tooth colour, respectively. More
than 70% of older patients were dissatisfied with
their tooth colour. This group of patients showed
the lowest level of satisfaction with both dental
appearance and tooth colour, probably due to the
material characteristics of the restorations. Com-
posite filling is the most common restoration in
maxillary anterior teeth, because of its low price
in comparison to prosthetic restoration. Although
it can be completed in a single treatment session
with no added laboratory cost, this material is
presently limited by several restrictions – inability
to completely replicate natural teeth in colour,
low wear resistance, surface porosity and poly-
merisation-induced shrinkage, which certainly
influence the patient’s level of satisfaction22
.
Therefore, these materials need to improve their
performance.
In the FPDG, approximately half of the middle-
aged and older patients were completely satisfied
with their dental appearance and tooth colour. In
the younger age group, the majority of them were
moderately satisfied with their dental appearance
and their tooth colour. These results were surpris-
ing because we expected older patients to be
dissatisfied with prosthetic restorations, because of
the awareness that they have lost some of their
maxillary anterior teeth. It seems that the younger
patients in the FPDG were dissatisfied for the
mentioned reasons, and the older patients were
completely satisfied, because the prosthodontic
restorations achieved their aesthetic goal in terms
of dental appearance and tooth colour more than
composite ones. Another reason for their satisfac-
tion could also be the fact that they compare their
restored anterior maxillary teeth status with the
status prior to prosthodontic treatment.
The results of the present study have shown that
ageing is not the main factor determining the level
of a patient’s satisfaction, but that dental status
plays an important role, as well.
Conclusion
Aesthetic attitudes towards the maxillary anterior
teeth appearance and colour differed both between
different age groups and different maxillary
anterior teeth status groups. This must be
acknowledged in treatment planning and should be
considered along with the function of the future
restoration.
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Correspondence to:
Vlatka Lajnert, University of Rijeka, Dental School,
Kresimirova 40, 51000 Rijeka, Croatia.
Tel.: 00 385 91 216 00 99
Fax: 00 385 51 217 183
E-mail: vlatkamikic@yahoo.com
Ó 2011 The Gerodontology Society and John Wiley Sons A/S, Gerodontology 2012; 29: e674–e679
Maxillary anterior teeth status on patient’s satisfaction e679