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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden 1 2 3
Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion
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Aliza Jesani a,b, Andrew T. DiBiase b, Martyn T. Cobourne c,*, Timothy Newton d a
King’s College London Dental Institute, London, UK Department of Orthodontics, East Kent Hospitals University NHS Foundation Trust, London, UK c Department of Orthodontics and Craniofacial Development, King’s College London Dental Institute, London, UK d Q2 Social & Behavioral Sciences, King’s College London Dental Institute, London, UK b
article info
abstract
Article history:
Objectives: Whereas the psychosocial benefits of orthognathic treatment for the individual
Received 5 February 2014
patient are established, there is little data relating to social perceptions in relation to
Received in revised form
changes in facial appearance as a result of combined orthodontic and orthognathic treat-
28 April 2014
ment. This study aimed to investigate the social impact of combined orthodontic–orthog-
Accepted 4 May 2014
nathic surgical correction for class III malocclusion in Caucasian subjects.
Available online xxx
Methods: This cross-sectional study compared perceptions of facial appearance prior to and
Keywords:
shown photographs of four Caucasian subjects (2 male and 2 female) pre- and post-
after orthognathic correction of class III malocclusion. Eighty undergraduate students were Orthognathic surgery
orthognathic class III correction. Observers were asked to rate these subjects in relation
Social impact
to four different outcomes: (i) social competence (SC); (ii) intellectual ability (IA); (iii)
Orthodontics
psychological adjustment (PA); (iv) attractiveness. A mixed-model analysis of variance
Caucasians
(ANOVA) was calculated to determine the effect of each variable. Results: Statistically significant differences were found in ratings of the same face before and after treatment. After treatment, faces were rated as more psychologically adjusted, more sociable, more likely to be successful and more attractive; with the mean psychological adjustment rating being associated with the most change (before treatment = 8.06 [SD 2.30]; after treatment = 6.64 [SD 2.03], t = 2.04, p < 0.001). Conclusions: After combined orthodontic–orthognathic correction of class III malocclusion in Caucasians, individuals are rated by young adults as being better adjusted both psychologically and socially, more likely to be successful and more attractive. # 2014 Elsevier Ltd. All rights reserved.
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1.
Introduction
There is good evidence that in the absence of any previous acquaintance and without any prior knowledge of an
individual’s personality or behavioural traits, people will make subconscious and subjective judgments of one another.1,2 A key factor in this decision-making process is a person’s appearance, which has been presented as one of the four key determinants of interpersonal attraction.3 The face is
* Corresponding author at: Department of Orthodontics and Craniofacial Development, Floor 22, Guy’s Tower, King’s College London Dental Institute, London SE1 9RT, UK. Tel.: +44 02071888028; fax: +44 02071881674. E-mail address: [email protected] (M.T. Cobourne). http://dx.doi.org/10.1016/j.jdent.2014.05.002 0300-5712/# 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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thought to be one of the main features in determining physical attractiveness4,5 and in particular; the mouth, smile and eyes have been specifically identified as key components.6,7 Faces play a very important role in providing implicit impressions and spontaneous inferences including social category, identity, emotion, psychological and physical traits, as well as the inter-dependence of attributes.8 The appearance of an individual can influence our behaviour towards them, in relation to whom we offer to help, choose to date and employ.9 It has also been shown to have an impact on decisions such as criminal justice10,11 and congressional elections.12 Numerous studies have looked at the influence of facial appearance on social perceptions. Evidence appears to support the notion of a ‘beautiful is good’ stereotype and suggests that facial appearance is used as a guide to infer a variety of characteristics, including attractiveness, personality, sociability, intellectual competence, mental health and personal achievement.13,14 It has been postulated that the attractiveness effect is in fact, driven by the perception that ‘ugly is bad’.15 There has been previous research investigating social judgments made as a result of anomalies in dental appearance. Faces displaying a normal incisor relationship as opposed to faces with missing lateral incisors, a crowded dentition, prominent incisors or a unilateral cleft lip gain the most favourable ratings in relation to perceived friendliness, social class, intelligence and popularity.14 Whilst in young adults, faces with incisor crowding and a median diastema can be considered significantly less intelligent, sexually attractive or beautiful and judged to belong to a lower social class.16 The presence of dental decay can also have an effect on people’s perceptions. Individuals with a non-carious and intact dentition are rated more favourably with respect to social, professional and aesthetic traits,17 with the position of the caries rather than the extent being regarded as most important.18,19 Caries present in central incisors was rated lower than that in just the lateral incisors; whilst caries in all four teeth was not rated significantly worse than that in only the central incisors. More recently, four attributes of athletic, social, leadership and academic abilities in relation to the nonideal and ideal smile have been investigated by manipulating photographs. In all areas but academic performance, the ideal aesthetic smile was rated higher.20 Collectively, all these studies have shown that facial appearance has an effect on social perception irrespective of social, ethnic and economic background. The area of orthodontic treatment that has the most impact on facial appearance is orthognathic surgery. A nine-year national review carried out between 1997 and 2006 indicated that on average, over 900 mandibular orthognathic procedures were carried out annually in England.21 Orthognathic treatment outcome can improve self-reported quality of life.22–26 Considerable research has demonstrated the benefits of combined orthognathic–orthodontic treatment on the psychological well being of the patient, as viewed by the patient him or herself27–29; but to date, there has been no research investigating the effects of orthognathic treatment on perceived social benefits, and in particular, whether social perception is altered following such treatment? The aim of this study was to ascertain the influence of orthognathic treatment in the management of class III
malocclusion on subjective ratings of personal characteristics, specifically in the following areas: social competence (SC), intellectual ability (IA), psychological adjustment (PA), and attractiveness in an adult patient. The null hypothesis tested was that orthognathic treatment for class III malocclusion in Caucasian patients has no influence on the appraisal individuals make about an adult’s personal characteristics.
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Materials and methods
Ethical approval for this study was obtained from the King’s College London Biomedical Sciences, Dentistry, Medicine, Natural and Mathematical Sciences Research Ethics Subcommittee (BDM RESC). Reference number: BDM/11/12-28. This cross-sectional analytical questionnaire vignette study compared participants’ perceptions of the personal characteristics of various faces prior to and after orthognathic treatment. The explicit interest of the investigator was concealed during the whole procedure by simply informing participants that the investigator was researching ‘the way we look at other people’. Each participant was given one of two questionnaire packs, which contained four vignettes along with four corresponding questionnaires. The participant was asked their perceptions in the form of ten questions.
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2.1.
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Participants
On the basis of the effect sizes reported previously, the present study was designed to have 80% power to detect standardised mean differences of 0.5, which required seventy-two observers in the observation group.18,19 Eighty participants were drawn from undergraduate students studying the BSc in Biomedical Sciences at King’s College London University. This course covers all aspects of biomedical science including biochemistry, genetics, cell biology, physiology, pharmacology, cell and tissue structure and function, statistics and issues related to the practice of science, including ethics and communication. The range of ages among the students was between 18 to 25 and the male:female ratio was approximately 3:2. The average age of those undergoing orthognathic treatment in a recent nineyear national survey was found to be 24 years.21 It was therefore felt that the opinions of those falling in a corresponding peer group of similar age would be ideal for this study. Individuals with severely impaired vision were excluded.
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2.2.
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Vignettes
Four patients who had previously undergone combined orthodontic and orthognathic treatment at East Kent Hospital University Foundation NHS Trust for the treatment of a class III malocclusion were used in the study. There were two male patients and two female. The cases differed in their pretreatment orthodontic characteristics and were chosen to provide variation in pre-treatment attractiveness, as judged by the research team.
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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A vignette was made of each patient using extra-oral photographs pre- and post-orthognathic treatment. Each subject provided written consent for the use of his or her facial images for research purposes. Those chosen for the study were also free from oral pathology, ensuring that only the affects of facial appearance were investigated. Four standardised full-face colour photographs were used for each subject to show: frontal (at rest and smiling); full profile and
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three-quarter profile views. In total, two Caucasian male and two Caucasian female subjects of similar age were used. The vignette packs were subdivided into Type A (Fig. 1) and Type B (Fig. 2), with each containing one of the following sets of photographs arranged such that no one observer was required to comment on the ‘same face’: [Type A vignette pack: Male 1 Before, Male 2 After, Female 1 Before, Female 2 After; Type B vignette pack: Male 1 After, Male 2 Before, Female 1 After,
Fig. 1 – Vignette type A. Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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Fig. 2 – Vignette type B.
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Female 2 Before]. The researchers felt it was important that observers did not see the same picture before and after surgery in order to blind them to the independent variable and thus avoid demand characteristics. Subjects chosen all had combined maxillary retrognathia and mandibular prognathism requiring bimaxillary surgery for definitive correction.
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2.3.
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A structured questionnaire was utilised to inquire about the four categories of personal characteristics associated with
Measures
physical appearance: social competence (SC), intellectual ability (IA), psychological adjustment (PA) and attractiveness (Appendix 1). The questionnaire was drawn from previous studies in this area.13,18,19,30 The first three questions related to sociability, the next three success, the next three related to psychological adjustment, and a final single question asked about perceived attractiveness. Scores were additive, derived for all four scales following the standard procedure adopted in previous studies by summing the individual item scores. Where items had three responses (‘Yes’ ‘No’ and ‘Don’t know’), responses of Yes were scored as a value of 1, and responses of ‘No’ or ‘Don’t know’ were given a value of 2. Scores on scales
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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Table 1 – Analysis of variance: sociability. Effect
F (sig)
Gender of photo
t = 0.97 ns
Before/after
t = 6.42 p < 0.001 F = 18.31 p < 0.001
Face
Groups defined by effect
Mean (SD)
Female Male Before
6.40 (2.18) 6.63 (1.97) 7.21 (2.06)
After Male 1
5.82 (1.86) 7.18 (1.89)+
Male 2 Female 1 Female 2
Effect
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were scored such that higher scores indicated more negative attributes.
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2.4.
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The mean values of all variables were calculated for each face. A mixed model analysis of variance (ANOVA) was calculated to determine the effect of each variable.
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3.
Results
Table 1 shows the results for ratings of sociability and suggests differences in ratings for different faces, as might be expected. In particular, Male 1 and Female 1 were seen as being less sociable. However, there were no differences in ratings across males and females. All faces were rated as significantly more sociable after orthognathic treatment. Similarly, Table 2 suggests differences in ratings of possible success for different faces; in particular, Male 1 was seen as being less successful. Again, there were no differences in ratings across male and female faces, and all faces were rated as significantly more likely to be successful after orthognathic treatment. The same pattern held for ratings of psychological adjustment and attractiveness (Tables 3 and 4, respectively).
Table 2 – Analysis of variance: success. F (sig)
Gender of photo
t = 3.34 p = 0.001
Before/after
t = 3.76 p < 0.001
Face
F = 19.67 p < 0.001
Gender of photo
t = 12.05 ns
Before/after
t = 2.04 p < 0.001
Face
F = 21.13 p < 0.001
Groups defined by effect
Mean (SD)
Male
6.93 (1.89)
Female Before
7.66 (1.99) 7.70 (1.87)
After Male 1
6.89 (2.00) 8.61 (1.69)+
Male 2 Female 1 Female 2
6.70 (1.80)= 7.14 (1.90)= 6.73 (1.88)=
+, = Similar postscripts indicate homogenous subsets (higher scores indicate lower ratings of likely success).
Groups defined by effect
Mean (SD)
Male Female Before
7.61 (2.34) 7.09 (2.18) 8.06 (2.30)
After Male 1
6.64 (2.03) 7.20 (2.28)!
Male 2 Female 1 Female 2
6.98 (2.08)+! 8.86 (2.24)= 6.35 (1.69)+
+, =, ! Similar postscripts indicate homogenous subsets. Lower scores indicate greater positive psychological adjustment.
Table 4 – One way analysis of variance: attractiveness. Effect
Statistical method
Effect
F (sig)
6.08 (1.91)= 7.38 (2.15)+ 5.43 (1.75)=
+, = Similar postscripts indicate homogenous subsets (high scores indicate lower sociability).
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Table 3 – One way analysis of variance: psychological adjustment.
F (sig)
Gender of photo
t = 1.52 ns
Before/after
t = 5.83 p < 0.001
Face
F = 15.14 p < 0.001
Groups defined by effect
Mean (SD)
Male Female Before
2.74 (0.96) 3.00 (0.97) 3.17 (0.93)
After Male 1
2.57 (0.92) 3.20 (0.89)=
Male 2 Female 1 Female 2
2.80 (0.99)! 3.14 (0.94)= 2.34 (0.80)+
+, =,! Similar postscripts indicate homogenous subsets. Scores range from 1 = very attractive to 5 = very unattractive.
The magnitude of the effect size for the comparison of photographs before and after surgery was calculated using the formula proposed for Cohen’s d. The following effect sizes were found: sociability d = 0.71; psychological adjustment d = 0.66; attractiveness d = 0.65 and success d = 0.43. With the exception of the variable perceived success, these represent medium effect sizes, suggesting that the change represents a moderately significant effect.
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Discussion
All four patients were perceived to be more psychologically adjusted, sociable, successful and attractive following orthognathic treatment. There was evidence of variation between the individual faces but not for gender of face. This data suggests that the facial change following combined orthodontic and surgical treatment of class III malocclusion contributes to the judgement of the personality of an individual. The findings support previous research that suggests poor dental and facial appearance exerts a negative influence on the appraisal of social perception.14,16–19 The effect sizes were, with the exception of the judgement of ‘success’, in the range of 0.6 to 0.7 – a medium effect size. There are no available data on what would constitute a clinically significant difference in these ratings, but this equates to a 60% to 70% difference in the individual’s perception
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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of the trait. We can hypothesise that in social interactions, such as a job interview or dating a 60% difference in perceived sociability would have an impact on the interaction. There are strengths and weaknesses within the methodological approach adopted for this study. The experimental design is essentially a controlled design with separate participants rating the before and after images of each patient. Random allocation of participants to the different levels of the independent variables is designed to mitigate the influence of confounding variables. It remains a possibility that the differences observed may be related to differences between observers who saw the two different groups of vignettes. However this is unlikely given that participants were randomly assigned to each set, and the inclusion of both before- and after- surgery photos in each set of photos. The use of real-life images adds to the external validity of the study, however previous studies have utilised digitally modified faces or a silhouette of a standard face whilst varying a factor related to facial appearance.13,17,18,30,31 This of course, allows for increased standardisation of the treatment being assessed and a reduction of bias due to fewer confounding factors, but does not fully reflect a real-life situation. The photographs used in this study were the exact photographs, un-modified taken before and after orthognathic treatment, demonstrating a true representation of an individual undergoing surgical correction of a class III discrepancy. It therefore incorporated a number of other factors that would not be present in mock-up or silhouette images, such as facial changes one would expect with growth and maturational changes of the patient. As a result of using the true photographs, it was not possible to eliminate the influence of additional confounding variables or background influences relating to aesthetic components that one could manipulate or standardise in an ‘artificial’ set up of digitally manipulated photographs. Although all patients selected had a class III malocclusion the severity of dental and skeletal discrepancies differed between the individuals. In addition, the female subjects had varying amounts of makeup application in their ‘before’ and ‘after’ photographs, whilst the presence of a tattoo on the neck of one of the subjects (male 2) both before and after treatment, could also have introduced some bias. In the case of the tattoo, this could have been removed with computer software for the purposes of the investigation; however, we wished to avoid image manipulation and a decision was therefore made to leave it. Indeed, it should be remembered that for the undergraduate students who participated in this study, the presence of a tattoo is relatively commonplace within their society not necessarily associated with negative connotations. The inability to control for changes pre- and post in individual photographs may have introduced alternative sources of variation in social perceptions. However the choice of photographs does enhance the external validity of the research. Furthermore, photographs of only four individuals were used in the present study, and this is probably not sufficient to give a range of change pre- and post-treatment. This study has demonstrated that the principle that social judgments change following treatment, but larger studies with a greater range of faces are required to demonstrate the full range of the effect. The sample chosen to rate these images was composed of undergraduate Biomedical science students. These individuals
were of different ethnic backgrounds, gender and were all in the process of further education. This was not considered to be a fair representation of the general population, but it was felt that this particular age group would fall into the peer group of the chosen orthognathic patients and their opinions were considered valid. Demographic information was not requested from the student sample group, so it was not possible to assess the potential difference-specific age, gender and ethnicity that may have contributed to personality judgments. It has been commonly assumed that an individual’s cultural and ethnic background has an influence on judgments made of other people. However a recent meta-analysis showed that even diverse cultural and ethnic groups agreed about who was and was not attractive.1 A recent review of previous studies; however, concluded that the perception of facial beauty does appear to be influenced by our cultural environment and our relative exposure to various facetypes.32 Within the sample used, a Western-cultural background was prevalent and therefore this relationship may have not been exhibited. The sample size was based on the ability to detect a moderate effect size as predicted from previous studies. The actual effect sizes found here are in three of the four cases greater than anticipated suggesting that there was adequate power in the study. The results both support previous research within the field of social perception and attractiveness and extend this to consideration of the impact of orthognathic treatment on social perceptions. It has been shown that level of attractiveness has an implication on behaviour towards an individual. As a result of expected social characteristics it has been postulated that good-looking people may develop desirable qualities in response to other’s expectations .33 From the limited sample group in this study, it appears that following the alteration of facial appearance achieved in the correction of class III malocclusion, all areas of social perception concurrently improved, including overall attractiveness. These results are important because they highlight the indirect benefits this type of treatment can provide to an individual in relation to their social situation. This study did not explore the relationship between change in the individuals’ own perception of themselves and the social perceptions made by others, this could be investigated in future studies.
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Conclusions
After combined orthodontic–orthognathic correction of class III malocclusion in Caucasians, individuals are rated by young adults as being better adjusted both psychologically and socially, more likely to be successful and more attractive.
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Acknowledgements
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The authors are grateful to Padhraig Fleming, Nick Goodger and Jeremy McKenzie who between them treated some of the patients in this study. We are also grateful to the undergraduate students at King’s College London who were involved in evaluating the vignettes.
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Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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Appendix 1. Questionnaire used for each case in the study Please look at the photograph attached to this questionnaire and complete the following questions concerning the person it shows. 1) This person works for a large bank. How popular do you think this person is with their colleagues? (Please circle only one answer) Very popular 1
Quite popular 2
Neither popular or unpopular 3
Quite unpopular 4
Very unpopular 5
Quite unfriendly 4
Very unfriendly 5
2) How friendly does this person appear to you? (Please circle only one answer) Very friendly 1
Quite friendly 2
Neither friendly or unfriendly 3
3) Do you think this person has a good social life? (Please circle only one answer) Yes
No
I Don’t Know
4) How successful do you think this person was at school? (Please circle only one answer) Very successful 1
Quite successful 2
Neither successful or unsuccessful 3
Quite unsuccessful 4
Very unsuccessful 5
Quite unintelligent 4
Very unintelligent 5
5) How intelligent does this person appear to you? (Please circle only one answer) Very intelligent 1
Quite intelligent 2
Neither intelligent or unintelligent 3
6) Do you think this person went to university? (Please circle only one answer) Yes
No
I don’t know
7) Do you think this person is extroverted or introverted? (Please circle only one answer) Very extroverted 1
Quite extroverted 2
Neither extroverted nor Introverted 3
Quite introverted 4
Very introverted 5
8) Does this person appear to be a happy person? (Please circle only one answer) Very happy 1
Quite happy 2
Neither happy or unhappy 3
Quite unhappy 4
Very unhappy 5
9) How self-confident does this person appear to you? (Please circle only one answer) Very self-confident 1
Quite self-confident 2
Neither self-confident nor not self-confident 3
Not self-confident 4
Not at all self-confident 5
10) How would you rate this person? (Please circle only one answer) Very attractive 1
Quite attractive 2
Neither attractive nor un-attractive 3
Not attractive 4
Very unattractive 5
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE
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references
1. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M, Smoot M. Maxims or myths of beauty? A meta-analytic and theoretical review. Psychol Bull 2000;126: 390–423. 2. Uleman JS, Adil Saribay S, Gonzalez CM. Spontaneous inferences, implicit impressions, and implicit theories. Ann Rev Psychol 2008;59:329–60. 3. Crisp R, TR N. Essential social psychology. London: SAGE Publications Ltd.; 2010. 4. Riggio RF, Widaman KF, Tucker JS, Salinas C. Beauty is more than skin deep: components of attractiveness. Basic Appl Soc Psychol 1991;12:423–9. 5. Synnott A. Truth and goodness, mirrors and masks. Part 1: a sociology of beauty and the face. Br J Sociol 1989;40:607–36. 6. Goldstein RE. Study of need for esthetics in dentistry. J Prosthet Dent 1969;21:589–98. 7. Kerns LL, Silveira AM, Kerns DG, Regenitter FJ. Esthetic preference of the frontal and profile views of the same smile. J Esthet Dentist 1997;9:76–95.
8. Zebrowitz LA. Final faces find favour. Soc Cognit 2006;24: 657–701. 9. Zebrowitz LA. Reading faces: window to the soul? Boulder Colarado. Westview Press; 1997. 10. Blair IV, Judd CM, Chapleau KM. The influence of Afrocentric facial features in criminal sentencing. Psychol Sci 2004;15:674–9. 11. Eberhardt JL, Davies PG, Purdie-Vaughns VJ, Johnson SL. Looking deathworthy: perceived stereotypicality of Black defendants predicts capital-sentencing outcomes. Psychol Sci 2006;17:383–6. 12. Todorov A, Mandisodza AN, Goren A, Hall CC. Inferences of competence from faces predict election outcomes. Science 2005;308:1623–6. 13. Newton JT, Prabhu N, Robinson PG. The impact of dental appearance on the appraisal of personal characteristics. Int J Prosthodont 2003;16:429–34. 14. Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthodont 1985;87: 21–6. 15. Griffin AM, Langlois JH. Stereotype directionality and attractiveness stereotyping: is beauty good or is ugly bad? Soc Cognit 2006;24:187–206.
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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16. Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthodont 1995;17:505–12. 17. Eli I, Bar-Tai Y, Kostovestski I. At first glance: social meanings of dental appearance. J Public Health Dent 2000;61:150–4. 18. Kershaw S, Newton JT, Williams DM. The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and ‘whitened’ teeth. Br Dent J 2008;204:E9. [discussion 256–257]. 19. Somani A, Newton JT, Dunne S, Gilbert D. The impact of visible dental decay on social judgements: comparison of the effects of location and extent of lesion. Int Dent J 2010;60:169–74. 20. Henson ST, Lindauer SJ, Gardner WG, Shroff B, Tufekci E, Best AM. Influence of dental esthetics on social perceptions of adolescents judged by peers. Am J Orthodont Dentofac Orthoped 2011;140:389–95. 21. Cunningham SJ, Moles DR. A national review of mandibular orthognathic surgery activity in the National Health Service in England over a nine year period. Part 2. Patient factors. Br J Oral Maxillofac Surg 2009;47:274–8. 22. Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following orthognathic surgery. Br J Oral Maxillofac Surg 1996;34:210–3. 23. Flanary CM, Barnwell GM, VanSickels JE, Littlefield JH, Rugh AL. Impact of orthognathic surgery on normal and abnormal personality dimensions: a 2-year follow-up study of 61 patients. Am J Orthodont Dentofac Orthoped 1990;98: 313–22.
24. Kiyak HA, McNeill RW, West RA, Hohl T, Heaton PJ. Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthodont 1986;89:383–92. 25. Lee S, McGrath C, Samman N. Impact of orthognathic surgery on quality of life. J Oral Maxillofac Surg 2008;66:1194–9. 26. Murphy C, Kearns G, Sleeman D, Cronin M, Allen PF. The clinical relevance of orthognathic surgery on quality of life. Int J Oral Maxillofac Surg 2011;40:926–30. 27. Hatch JP, Rugh JD, Bays RA, Van Sickels JE, Keeling SD, Clark GM. Psychological function in orthognathic surgical patients before and after bilateral sagittal split osteotomy with rigid and wire fixation. Am J Orthodont Dentofac Orthoped 1999;115:536–43. 28. Jacobson A. Psychological aspects of dentofacial esthetics and orthognathic surgery. Angle Orthodont 1984;54:18–35. 29. Kovalenko A, Slabkovskaya A, Drobysheva N, Persin L, Drobyshev A, Maddalone M. The association between the psychological status and the severity of facial deformity in orthognathic patients. Angle Orthodont 2012;82:396–402. 30. Jeremiah HG, Bister D, Newton JT. Social perceptions of adults wearing orthodontic appliances: a cross-sectional study. Eur J Orthod 2011;33:476–82. 31. Naini FB, Donaldson AN, McDonald F, Cobourne MT. The influence of combined orthodontic–orthognathic surgical treatment on perceptions of attractiveness: a longitudinal study. Eur J Orthod 2013;35:590–8. 32. Collins M. The eye of the beholder: face recognition and perception. Semin Orthodont 2012;18:229–34. 33. Feingold A. Good looking people are not what we think. Psychol Bull 1992;111:304–41.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.intl.elsevierhealth.com/journals/jden 1 2 3
Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion
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Q1
Aliza Jesani a,b, Andrew T. DiBiase b, Martyn T. Cobourne c,*, Timothy Newton d a
King’s College London Dental Institute, London, UK Department of Orthodontics, East Kent Hospitals University NHS Foundation Trust, London, UK c Department of Orthodontics and Craniofacial Development, King’s College London Dental Institute, London, UK d Q2 Social & Behavioral Sciences, King’s College London Dental Institute, London, UK b
article info
abstract
Article history:
Objectives: Whereas the psychosocial benefits of orthognathic treatment for the individual
Received 5 February 2014
patient are established, there is little data relating to social perceptions in relation to
Received in revised form
changes in facial appearance as a result of combined orthodontic and orthognathic treat-
28 April 2014
ment. This study aimed to investigate the social impact of combined orthodontic–orthog-
Accepted 4 May 2014
nathic surgical correction for class III malocclusion in Caucasian subjects.
Available online xxx
Methods: This cross-sectional study compared perceptions of facial appearance prior to and
Keywords:
shown photographs of four Caucasian subjects (2 male and 2 female) pre- and post-
after orthognathic correction of class III malocclusion. Eighty undergraduate students were Orthognathic surgery
orthognathic class III correction. Observers were asked to rate these subjects in relation
Social impact
to four different outcomes: (i) social competence (SC); (ii) intellectual ability (IA); (iii)
Orthodontics
psychological adjustment (PA); (iv) attractiveness. A mixed-model analysis of variance
Caucasians
(ANOVA) was calculated to determine the effect of each variable. Results: Statistically significant differences were found in ratings of the same face before and after treatment. After treatment, faces were rated as more psychologically adjusted, more sociable, more likely to be successful and more attractive; with the mean psychological adjustment rating being associated with the most change (before treatment = 8.06 [SD 2.30]; after treatment = 6.64 [SD 2.03], t = 2.04, p < 0.001). Conclusions: After combined orthodontic–orthognathic correction of class III malocclusion in Caucasians, individuals are rated by young adults as being better adjusted both psychologically and socially, more likely to be successful and more attractive. # 2014 Elsevier Ltd. All rights reserved.
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1.
Introduction
There is good evidence that in the absence of any previous acquaintance and without any prior knowledge of an
individual’s personality or behavioural traits, people will make subconscious and subjective judgments of one another.1,2 A key factor in this decision-making process is a person’s appearance, which has been presented as one of the four key determinants of interpersonal attraction.3 The face is
* Corresponding author at: Department of Orthodontics and Craniofacial Development, Floor 22, Guy’s Tower, King’s College London Dental Institute, London SE1 9RT, UK. Tel.: +44 02071888028; fax: +44 02071881674. E-mail address: [email protected] (M.T. Cobourne). http://dx.doi.org/10.1016/j.jdent.2014.05.002 0300-5712/# 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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thought to be one of the main features in determining physical attractiveness4,5 and in particular; the mouth, smile and eyes have been specifically identified as key components.6,7 Faces play a very important role in providing implicit impressions and spontaneous inferences including social category, identity, emotion, psychological and physical traits, as well as the inter-dependence of attributes.8 The appearance of an individual can influence our behaviour towards them, in relation to whom we offer to help, choose to date and employ.9 It has also been shown to have an impact on decisions such as criminal justice10,11 and congressional elections.12 Numerous studies have looked at the influence of facial appearance on social perceptions. Evidence appears to support the notion of a ‘beautiful is good’ stereotype and suggests that facial appearance is used as a guide to infer a variety of characteristics, including attractiveness, personality, sociability, intellectual competence, mental health and personal achievement.13,14 It has been postulated that the attractiveness effect is in fact, driven by the perception that ‘ugly is bad’.15 There has been previous research investigating social judgments made as a result of anomalies in dental appearance. Faces displaying a normal incisor relationship as opposed to faces with missing lateral incisors, a crowded dentition, prominent incisors or a unilateral cleft lip gain the most favourable ratings in relation to perceived friendliness, social class, intelligence and popularity.14 Whilst in young adults, faces with incisor crowding and a median diastema can be considered significantly less intelligent, sexually attractive or beautiful and judged to belong to a lower social class.16 The presence of dental decay can also have an effect on people’s perceptions. Individuals with a non-carious and intact dentition are rated more favourably with respect to social, professional and aesthetic traits,17 with the position of the caries rather than the extent being regarded as most important.18,19 Caries present in central incisors was rated lower than that in just the lateral incisors; whilst caries in all four teeth was not rated significantly worse than that in only the central incisors. More recently, four attributes of athletic, social, leadership and academic abilities in relation to the nonideal and ideal smile have been investigated by manipulating photographs. In all areas but academic performance, the ideal aesthetic smile was rated higher.20 Collectively, all these studies have shown that facial appearance has an effect on social perception irrespective of social, ethnic and economic background. The area of orthodontic treatment that has the most impact on facial appearance is orthognathic surgery. A nine-year national review carried out between 1997 and 2006 indicated that on average, over 900 mandibular orthognathic procedures were carried out annually in England.21 Orthognathic treatment outcome can improve self-reported quality of life.22–26 Considerable research has demonstrated the benefits of combined orthognathic–orthodontic treatment on the psychological well being of the patient, as viewed by the patient him or herself27–29; but to date, there has been no research investigating the effects of orthognathic treatment on perceived social benefits, and in particular, whether social perception is altered following such treatment? The aim of this study was to ascertain the influence of orthognathic treatment in the management of class III
malocclusion on subjective ratings of personal characteristics, specifically in the following areas: social competence (SC), intellectual ability (IA), psychological adjustment (PA), and attractiveness in an adult patient. The null hypothesis tested was that orthognathic treatment for class III malocclusion in Caucasian patients has no influence on the appraisal individuals make about an adult’s personal characteristics.
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Materials and methods
Ethical approval for this study was obtained from the King’s College London Biomedical Sciences, Dentistry, Medicine, Natural and Mathematical Sciences Research Ethics Subcommittee (BDM RESC). Reference number: BDM/11/12-28. This cross-sectional analytical questionnaire vignette study compared participants’ perceptions of the personal characteristics of various faces prior to and after orthognathic treatment. The explicit interest of the investigator was concealed during the whole procedure by simply informing participants that the investigator was researching ‘the way we look at other people’. Each participant was given one of two questionnaire packs, which contained four vignettes along with four corresponding questionnaires. The participant was asked their perceptions in the form of ten questions.
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2.1.
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Participants
On the basis of the effect sizes reported previously, the present study was designed to have 80% power to detect standardised mean differences of 0.5, which required seventy-two observers in the observation group.18,19 Eighty participants were drawn from undergraduate students studying the BSc in Biomedical Sciences at King’s College London University. This course covers all aspects of biomedical science including biochemistry, genetics, cell biology, physiology, pharmacology, cell and tissue structure and function, statistics and issues related to the practice of science, including ethics and communication. The range of ages among the students was between 18 to 25 and the male:female ratio was approximately 3:2. The average age of those undergoing orthognathic treatment in a recent nineyear national survey was found to be 24 years.21 It was therefore felt that the opinions of those falling in a corresponding peer group of similar age would be ideal for this study. Individuals with severely impaired vision were excluded.
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2.2.
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Vignettes
Four patients who had previously undergone combined orthodontic and orthognathic treatment at East Kent Hospital University Foundation NHS Trust for the treatment of a class III malocclusion were used in the study. There were two male patients and two female. The cases differed in their pretreatment orthodontic characteristics and were chosen to provide variation in pre-treatment attractiveness, as judged by the research team.
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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A vignette was made of each patient using extra-oral photographs pre- and post-orthognathic treatment. Each subject provided written consent for the use of his or her facial images for research purposes. Those chosen for the study were also free from oral pathology, ensuring that only the affects of facial appearance were investigated. Four standardised full-face colour photographs were used for each subject to show: frontal (at rest and smiling); full profile and
3
three-quarter profile views. In total, two Caucasian male and two Caucasian female subjects of similar age were used. The vignette packs were subdivided into Type A (Fig. 1) and Type B (Fig. 2), with each containing one of the following sets of photographs arranged such that no one observer was required to comment on the ‘same face’: [Type A vignette pack: Male 1 Before, Male 2 After, Female 1 Before, Female 2 After; Type B vignette pack: Male 1 After, Male 2 Before, Female 1 After,
Fig. 1 – Vignette type A. Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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Fig. 2 – Vignette type B.
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Female 2 Before]. The researchers felt it was important that observers did not see the same picture before and after surgery in order to blind them to the independent variable and thus avoid demand characteristics. Subjects chosen all had combined maxillary retrognathia and mandibular prognathism requiring bimaxillary surgery for definitive correction.
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2.3.
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A structured questionnaire was utilised to inquire about the four categories of personal characteristics associated with
Measures
physical appearance: social competence (SC), intellectual ability (IA), psychological adjustment (PA) and attractiveness (Appendix 1). The questionnaire was drawn from previous studies in this area.13,18,19,30 The first three questions related to sociability, the next three success, the next three related to psychological adjustment, and a final single question asked about perceived attractiveness. Scores were additive, derived for all four scales following the standard procedure adopted in previous studies by summing the individual item scores. Where items had three responses (‘Yes’ ‘No’ and ‘Don’t know’), responses of Yes were scored as a value of 1, and responses of ‘No’ or ‘Don’t know’ were given a value of 2. Scores on scales
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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Table 1 – Analysis of variance: sociability. Effect
F (sig)
Gender of photo
t = 0.97 ns
Before/after
t = 6.42 p < 0.001 F = 18.31 p < 0.001
Face
Groups defined by effect
Mean (SD)
Female Male Before
6.40 (2.18) 6.63 (1.97) 7.21 (2.06)
After Male 1
5.82 (1.86) 7.18 (1.89)+
Male 2 Female 1 Female 2
Effect
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were scored such that higher scores indicated more negative attributes.
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2.4.
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The mean values of all variables were calculated for each face. A mixed model analysis of variance (ANOVA) was calculated to determine the effect of each variable.
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3.
Results
Table 1 shows the results for ratings of sociability and suggests differences in ratings for different faces, as might be expected. In particular, Male 1 and Female 1 were seen as being less sociable. However, there were no differences in ratings across males and females. All faces were rated as significantly more sociable after orthognathic treatment. Similarly, Table 2 suggests differences in ratings of possible success for different faces; in particular, Male 1 was seen as being less successful. Again, there were no differences in ratings across male and female faces, and all faces were rated as significantly more likely to be successful after orthognathic treatment. The same pattern held for ratings of psychological adjustment and attractiveness (Tables 3 and 4, respectively).
Table 2 – Analysis of variance: success. F (sig)
Gender of photo
t = 3.34 p = 0.001
Before/after
t = 3.76 p < 0.001
Face
F = 19.67 p < 0.001
Gender of photo
t = 12.05 ns
Before/after
t = 2.04 p < 0.001
Face
F = 21.13 p < 0.001
Groups defined by effect
Mean (SD)
Male
6.93 (1.89)
Female Before
7.66 (1.99) 7.70 (1.87)
After Male 1
6.89 (2.00) 8.61 (1.69)+
Male 2 Female 1 Female 2
6.70 (1.80)= 7.14 (1.90)= 6.73 (1.88)=
+, = Similar postscripts indicate homogenous subsets (higher scores indicate lower ratings of likely success).
Groups defined by effect
Mean (SD)
Male Female Before
7.61 (2.34) 7.09 (2.18) 8.06 (2.30)
After Male 1
6.64 (2.03) 7.20 (2.28)!
Male 2 Female 1 Female 2
6.98 (2.08)+! 8.86 (2.24)= 6.35 (1.69)+
+, =, ! Similar postscripts indicate homogenous subsets. Lower scores indicate greater positive psychological adjustment.
Table 4 – One way analysis of variance: attractiveness. Effect
Statistical method
Effect
F (sig)
6.08 (1.91)= 7.38 (2.15)+ 5.43 (1.75)=
+, = Similar postscripts indicate homogenous subsets (high scores indicate lower sociability).
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Table 3 – One way analysis of variance: psychological adjustment.
F (sig)
Gender of photo
t = 1.52 ns
Before/after
t = 5.83 p < 0.001
Face
F = 15.14 p < 0.001
Groups defined by effect
Mean (SD)
Male Female Before
2.74 (0.96) 3.00 (0.97) 3.17 (0.93)
After Male 1
2.57 (0.92) 3.20 (0.89)=
Male 2 Female 1 Female 2
2.80 (0.99)! 3.14 (0.94)= 2.34 (0.80)+
+, =,! Similar postscripts indicate homogenous subsets. Scores range from 1 = very attractive to 5 = very unattractive.
The magnitude of the effect size for the comparison of photographs before and after surgery was calculated using the formula proposed for Cohen’s d. The following effect sizes were found: sociability d = 0.71; psychological adjustment d = 0.66; attractiveness d = 0.65 and success d = 0.43. With the exception of the variable perceived success, these represent medium effect sizes, suggesting that the change represents a moderately significant effect.
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Discussion
All four patients were perceived to be more psychologically adjusted, sociable, successful and attractive following orthognathic treatment. There was evidence of variation between the individual faces but not for gender of face. This data suggests that the facial change following combined orthodontic and surgical treatment of class III malocclusion contributes to the judgement of the personality of an individual. The findings support previous research that suggests poor dental and facial appearance exerts a negative influence on the appraisal of social perception.14,16–19 The effect sizes were, with the exception of the judgement of ‘success’, in the range of 0.6 to 0.7 – a medium effect size. There are no available data on what would constitute a clinically significant difference in these ratings, but this equates to a 60% to 70% difference in the individual’s perception
Please cite this article in press as: Jesani A, et al. Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusion. Journal of Dentistry (2014), http://dx.doi.org/10.1016/j.jdent.2014.05.002
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of the trait. We can hypothesise that in social interactions, such as a job interview or dating a 60% difference in perceived sociability would have an impact on the interaction. There are strengths and weaknesses within the methodological approach adopted for this study. The experimental design is essentially a controlled design with separate participants rating the before and after images of each patient. Random allocation of participants to the different levels of the independent variables is designed to mitigate the influence of confounding variables. It remains a possibility that the differences observed may be related to differences between observers who saw the two different groups of vignettes. However this is unlikely given that participants were randomly assigned to each set, and the inclusion of both before- and after- surgery photos in each set of photos. The use of real-life images adds to the external validity of the study, however previous studies have utilised digitally modified faces or a silhouette of a standard face whilst varying a factor related to facial appearance.13,17,18,30,31 This of course, allows for increased standardisation of the treatment being assessed and a reduction of bias due to fewer confounding factors, but does not fully reflect a real-life situation. The photographs used in this study were the exact photographs, un-modified taken before and after orthognathic treatment, demonstrating a true representation of an individual undergoing surgical correction of a class III discrepancy. It therefore incorporated a number of other factors that would not be present in mock-up or silhouette images, such as facial changes one would expect with growth and maturational changes of the patient. As a result of using the true photographs, it was not possible to eliminate the influence of additional confounding variables or background influences relating to aesthetic components that one could manipulate or standardise in an ‘artificial’ set up of digitally manipulated photographs. Although all patients selected had a class III malocclusion the severity of dental and skeletal discrepancies differed between the individuals. In addition, the female subjects had varying amounts of makeup application in their ‘before’ and ‘after’ photographs, whilst the presence of a tattoo on the neck of one of the subjects (male 2) both before and after treatment, could also have introduced some bias. In the case of the tattoo, this could have been removed with computer software for the purposes of the investigation; however, we wished to avoid image manipulation and a decision was therefore made to leave it. Indeed, it should be remembered that for the undergraduate students who participated in this study, the presence of a tattoo is relatively commonplace within their society not necessarily associated with negative connotations. The inability to control for changes pre- and post in individual photographs may have introduced alternative sources of variation in social perceptions. However the choice of photographs does enhance the external validity of the research. Furthermore, photographs of only four individuals were used in the present study, and this is probably not sufficient to give a range of change pre- and post-treatment. This study has demonstrated that the principle that social judgments change following treatment, but larger studies with a greater range of faces are required to demonstrate the full range of the effect. The sample chosen to rate these images was composed of undergraduate Biomedical science students. These individuals
were of different ethnic backgrounds, gender and were all in the process of further education. This was not considered to be a fair representation of the general population, but it was felt that this particular age group would fall into the peer group of the chosen orthognathic patients and their opinions were considered valid. Demographic information was not requested from the student sample group, so it was not possible to assess the potential difference-specific age, gender and ethnicity that may have contributed to personality judgments. It has been commonly assumed that an individual’s cultural and ethnic background has an influence on judgments made of other people. However a recent meta-analysis showed that even diverse cultural and ethnic groups agreed about who was and was not attractive.1 A recent review of previous studies; however, concluded that the perception of facial beauty does appear to be influenced by our cultural environment and our relative exposure to various facetypes.32 Within the sample used, a Western-cultural background was prevalent and therefore this relationship may have not been exhibited. The sample size was based on the ability to detect a moderate effect size as predicted from previous studies. The actual effect sizes found here are in three of the four cases greater than anticipated suggesting that there was adequate power in the study. The results both support previous research within the field of social perception and attractiveness and extend this to consideration of the impact of orthognathic treatment on social perceptions. It has been shown that level of attractiveness has an implication on behaviour towards an individual. As a result of expected social characteristics it has been postulated that good-looking people may develop desirable qualities in response to other’s expectations .33 From the limited sample group in this study, it appears that following the alteration of facial appearance achieved in the correction of class III malocclusion, all areas of social perception concurrently improved, including overall attractiveness. These results are important because they highlight the indirect benefits this type of treatment can provide to an individual in relation to their social situation. This study did not explore the relationship between change in the individuals’ own perception of themselves and the social perceptions made by others, this could be investigated in future studies.
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Conclusions
After combined orthodontic–orthognathic correction of class III malocclusion in Caucasians, individuals are rated by young adults as being better adjusted both psychologically and socially, more likely to be successful and more attractive.
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Acknowledgements
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The authors are grateful to Padhraig Fleming, Nick Goodger and Jeremy McKenzie who between them treated some of the patients in this study. We are also grateful to the undergraduate students at King’s College London who were involved in evaluating the vignettes.
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Appendix 1. Questionnaire used for each case in the study Please look at the photograph attached to this questionnaire and complete the following questions concerning the person it shows. 1) This person works for a large bank. How popular do you think this person is with their colleagues? (Please circle only one answer) Very popular 1
Quite popular 2
Neither popular or unpopular 3
Quite unpopular 4
Very unpopular 5
Quite unfriendly 4
Very unfriendly 5
2) How friendly does this person appear to you? (Please circle only one answer) Very friendly 1
Quite friendly 2
Neither friendly or unfriendly 3
3) Do you think this person has a good social life? (Please circle only one answer) Yes
No
I Don’t Know
4) How successful do you think this person was at school? (Please circle only one answer) Very successful 1
Quite successful 2
Neither successful or unsuccessful 3
Quite unsuccessful 4
Very unsuccessful 5
Quite unintelligent 4
Very unintelligent 5
5) How intelligent does this person appear to you? (Please circle only one answer) Very intelligent 1
Quite intelligent 2
Neither intelligent or unintelligent 3
6) Do you think this person went to university? (Please circle only one answer) Yes
No
I don’t know
7) Do you think this person is extroverted or introverted? (Please circle only one answer) Very extroverted 1
Quite extroverted 2
Neither extroverted nor Introverted 3
Quite introverted 4
Very introverted 5
8) Does this person appear to be a happy person? (Please circle only one answer) Very happy 1
Quite happy 2
Neither happy or unhappy 3
Quite unhappy 4
Very unhappy 5
9) How self-confident does this person appear to you? (Please circle only one answer) Very self-confident 1
Quite self-confident 2
Neither self-confident nor not self-confident 3
Not self-confident 4
Not at all self-confident 5
10) How would you rate this person? (Please circle only one answer) Very attractive 1
Quite attractive 2
Neither attractive nor un-attractive 3
Not attractive 4
Very unattractive 5
THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE
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references
1. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M, Smoot M. Maxims or myths of beauty? A meta-analytic and theoretical review. Psychol Bull 2000;126: 390–423. 2. Uleman JS, Adil Saribay S, Gonzalez CM. Spontaneous inferences, implicit impressions, and implicit theories. Ann Rev Psychol 2008;59:329–60. 3. Crisp R, TR N. Essential social psychology. London: SAGE Publications Ltd.; 2010. 4. Riggio RF, Widaman KF, Tucker JS, Salinas C. Beauty is more than skin deep: components of attractiveness. Basic Appl Soc Psychol 1991;12:423–9. 5. Synnott A. Truth and goodness, mirrors and masks. Part 1: a sociology of beauty and the face. Br J Sociol 1989;40:607–36. 6. Goldstein RE. Study of need for esthetics in dentistry. J Prosthet Dent 1969;21:589–98. 7. Kerns LL, Silveira AM, Kerns DG, Regenitter FJ. Esthetic preference of the frontal and profile views of the same smile. J Esthet Dentist 1997;9:76–95.
8. Zebrowitz LA. Final faces find favour. Soc Cognit 2006;24: 657–701. 9. Zebrowitz LA. Reading faces: window to the soul? Boulder Colarado. Westview Press; 1997. 10. Blair IV, Judd CM, Chapleau KM. The influence of Afrocentric facial features in criminal sentencing. Psychol Sci 2004;15:674–9. 11. Eberhardt JL, Davies PG, Purdie-Vaughns VJ, Johnson SL. Looking deathworthy: perceived stereotypicality of Black defendants predicts capital-sentencing outcomes. Psychol Sci 2006;17:383–6. 12. Todorov A, Mandisodza AN, Goren A, Hall CC. Inferences of competence from faces predict election outcomes. Science 2005;308:1623–6. 13. Newton JT, Prabhu N, Robinson PG. The impact of dental appearance on the appraisal of personal characteristics. Int J Prosthodont 2003;16:429–34. 14. Shaw WC, Rees G, Dawe M, Charles CR. The influence of dentofacial appearance on the social attractiveness of young adults. Am J Orthodont 1985;87: 21–6. 15. Griffin AM, Langlois JH. Stereotype directionality and attractiveness stereotyping: is beauty good or is ugly bad? Soc Cognit 2006;24:187–206.
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16. Kerosuo H, Hausen H, Laine T, Shaw WC. The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthodont 1995;17:505–12. 17. Eli I, Bar-Tai Y, Kostovestski I. At first glance: social meanings of dental appearance. J Public Health Dent 2000;61:150–4. 18. Kershaw S, Newton JT, Williams DM. The influence of tooth colour on the perceptions of personal characteristics among female dental patients: comparisons of unmodified, decayed and ‘whitened’ teeth. Br Dent J 2008;204:E9. [discussion 256–257]. 19. Somani A, Newton JT, Dunne S, Gilbert D. The impact of visible dental decay on social judgements: comparison of the effects of location and extent of lesion. Int Dent J 2010;60:169–74. 20. Henson ST, Lindauer SJ, Gardner WG, Shroff B, Tufekci E, Best AM. Influence of dental esthetics on social perceptions of adolescents judged by peers. Am J Orthodont Dentofac Orthoped 2011;140:389–95. 21. Cunningham SJ, Moles DR. A national review of mandibular orthognathic surgery activity in the National Health Service in England over a nine year period. Part 2. Patient factors. Br J Oral Maxillofac Surg 2009;47:274–8. 22. Cunningham SJ, Hunt NP, Feinmann C. Perceptions of outcome following orthognathic surgery. Br J Oral Maxillofac Surg 1996;34:210–3. 23. Flanary CM, Barnwell GM, VanSickels JE, Littlefield JH, Rugh AL. Impact of orthognathic surgery on normal and abnormal personality dimensions: a 2-year follow-up study of 61 patients. Am J Orthodont Dentofac Orthoped 1990;98: 313–22.
24. Kiyak HA, McNeill RW, West RA, Hohl T, Heaton PJ. Personality characteristics as predictors and sequelae of surgical and conventional orthodontics. Am J Orthodont 1986;89:383–92. 25. Lee S, McGrath C, Samman N. Impact of orthognathic surgery on quality of life. J Oral Maxillofac Surg 2008;66:1194–9. 26. Murphy C, Kearns G, Sleeman D, Cronin M, Allen PF. The clinical relevance of orthognathic surgery on quality of life. Int J Oral Maxillofac Surg 2011;40:926–30. 27. Hatch JP, Rugh JD, Bays RA, Van Sickels JE, Keeling SD, Clark GM. Psychological function in orthognathic surgical patients before and after bilateral sagittal split osteotomy with rigid and wire fixation. Am J Orthodont Dentofac Orthoped 1999;115:536–43. 28. Jacobson A. Psychological aspects of dentofacial esthetics and orthognathic surgery. Angle Orthodont 1984;54:18–35. 29. Kovalenko A, Slabkovskaya A, Drobysheva N, Persin L, Drobyshev A, Maddalone M. The association between the psychological status and the severity of facial deformity in orthognathic patients. Angle Orthodont 2012;82:396–402. 30. Jeremiah HG, Bister D, Newton JT. Social perceptions of adults wearing orthodontic appliances: a cross-sectional study. Eur J Orthod 2011;33:476–82. 31. Naini FB, Donaldson AN, McDonald F, Cobourne MT. The influence of combined orthodontic–orthognathic surgical treatment on perceptions of attractiveness: a longitudinal study. Eur J Orthod 2013;35:590–8. 32. Collins M. The eye of the beholder: face recognition and perception. Semin Orthodont 2012;18:229–34. 33. Feingold A. Good looking people are not what we think. Psychol Bull 1992;111:304–41.
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