From Clinical Findings to Treatment Willingness: Self-Perception of Smile Aesthetics Among Dental Students—A Cross-Sectional Study

Background: Objective smile characteristics do not necessarily determine how individuals perceive their own dental appearance or whether perceived concerns translate into treatment willingness. This study investigated the relationship between clinical findings, self-perception, and treatment attitude across ten smile characteristics in final-year dental students. Methods: This cross-sectional study included 116 students who underwent standardized clinical and photographic assessment and independently evaluated the same smile characteristics and their willingness to receive treatment. Clinical–perceptual agreement was examined using Cohen’s κ and Gwet’s AC1. Multivariable logistic regression assessed whether cumulative self-perceived concerns were associated with overall smile dissatisfaction. Results: Sixty-eight participants (58.6%) reported at least one concern. Clinical–perceptual correspondence was feature-dependent. Agreement was high for position/alignment (93.1%; κ = 0.852; AC1 = 0.871) but considerably lower for central-incisor proportion (64.7%; κ = 0.167; AC1 = 0.446); notably, 41 of 48 participants outside the prespecified 77–83% interval reported no concern about tooth size. Treatment willingness was high for concerns about shade and alignment but low for concerns about tooth size and shape. Each additional self-perceived concern was associated with higher odds of overall smile dissatisfaction (adjusted OR = 6.48; 95% CI, 3.13–13.41; p < 0.001). Conclusions: Clinical deviation, self-perceived concern, and treatment willingness were not interchangeable constructs. Their relationship was strongly feature-dependent, supporting smile assessment that integrates clinical findings with the individual’s perception and treatment preferences.