We congratulate Batra et al for addressing a relevant topic: the impact of gingival alterations on smile esthetics (Batra P, Daing A, Azam I, Miglani R, Bhardwaj A. Impact of altered gingival characteristics on smile esthetics: Laypersons’ perspectives by Q sort methodology. Am J Orthod Dentofacial Orthop 2018; 154:82-90). The authors used a reliable method (Q sort) and concluded that asymmetric gingival alterations and optical color changes have the greatest negative impacts on laypersons’ perceptions.

An important issue about this research is the control smile used as a starting point to the manipulation and the creation of the discrepancies that the study objectives targeted. The article states “The student’s smile was selected because it was considered highly attractive according to the objective principles of the ideal smile described in the literature.” However, an important feature well described in the literature cited was not found in the control smile: “The incisal edge line follows the form of the lower lip— while the line joining the tops of the free gingival margins form the upper lip.” To match this description, in a frontal view photograph the incisal edges of the lateral incisors should be positioned vertically above the incisal edges of the central incisors, and the incisal edge of the canine should be positioned above the lateral incisor’s edge. The described positioning was not followed, since the canine’s incisal edge was on the same level of the central incisors. This characteristic has great importance, and several authors have highlighted its role in smile esthetics.

Moreover, the quality of this image is questionable for 2 reasons: the volunteer was not properly positioned; thus, the smile was not an exact frontal view. Additionally, the photographic resolution is poor, and 1 sign of this statement is that the reader cannot see the buccal corridor. We would like the authors to specify the digital camera used to photograph the volunteer.

Another comment to this research is the image manipulation process to create the alterations. Other authors have run their researches using full-resolution images, which illustrate the possibility of making the alterations close to reality. This has great importance to give the evaluators a more realistic scenario and might have influenced the results of the research. We will be glad to hear the authors’ comments about those topics.