Accepted Manuscript Perception of oral and maxillofacial surgeons, orthodontists and laypersons in relation to the harmony of the smile Andrezza Lauria , DDS, MsC Danillo Costa Rodrigues , DDS Raquel Correia de Medeiros , DDS, MsC Roger William Fernandes Moreira , DDS, MsC, PhD PII:
S1010-5182(14)00166-8
DOI:
10.1016/j.jcms.2014.05.010
Reference:
YJCMS 1817
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 29 December 2013 Revised Date:
30 March 2014
Accepted Date: 8 May 2014
Please cite this article as: Lauria A, Rodrigues DC, de Medeiros RC, Fernandes Moreira RW, Perception of oral and maxillofacial surgeons, orthodontists and laypersons in relation to the harmony of the smile, Journal of Cranio-Maxillo-Facial Surgery (2014), doi: 10.1016/j.jcms.2014.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Perception of oral and maxillofacial surgeons, orthodontists
Andrezza Lauria, DDS, MsC1 Danillo Costa Rodrigues, DDS2 Raquel Correia de Medeiros, DDS, MsC3
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and laypersons in relation to the harmony of the smile
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Roger William Fernandes Moreira, DDS, MsC, PhD4
1. DDS, MsC, PhD Student in Oral and Maxillofacial Surgery, School of Dentistry of Piracicaba, Sate University of Campinas (UNICAMP), Brazil. 2. DDS, MsC Student in Oral and Maxillofacial Surgery, School of Dentistry of Piracicaba, State University of Campinas (UNICAMP), Brazil.
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3. DDS, MsC, PhD Student in Oral and Maxillofacial Surgery, School of Dentistry of Piracicaba, Sate University of Campinas (UNICAMP), Brazil.
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4. DDS, MsC, PhD, Associate professor in Oral and Maxillofacial Surgery Piracicaba Dental School, State University of Campinas (UNICAMP), Brazil.
Address correspondence to authors:
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School of Dentistry of Piracicaba, CP 52, State University of Campinas-UNICAMP 13.414-903, Piracicaba, SP, Brazil.
E-mail and telephone correspondence to Andrezza Lauria: E-mail: [email protected] Telephone: +55 19 2106-5708
ACCEPTED MANUSCRIPT
Perception of oral and maxillofacial surgeons, orthodontists and laypersons in relation to the harmony of the smile
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Abstract:
Objective: Harmony is one of the main objectives in surgical and orthodontic treatment and this harmony
must be present in the smile, as well as in the face. The aim of the present study was to assess the perceptions
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of professionals and laypersons in relation to the harmony of the smile of patients with or without vertical maxillary alterations.
Materials and Methods: Sixty observers (oral and maxillofacial surgeons, orthodontists and laypersons)
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reported the degree of harmony of six smiles using an objective questionnaire and the participants indicated if there was a need for corrective surgery or not. The classification of observers was recorded on a Likert scale from 1 to 5. Mixed regression was used to determine differences between the three groups. Results: Statistically significant differences were found only for the harmony of the smile between the oral and maxillofacial surgeons and laypersons, with laypersons being more critical when assessing the smile. There was
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no statistical difference between the other groups for the harmony of the smile or the indication of corrective surgery. The patterns of greater or lesser harmony determined by observers during the smile were similar to those found in the literature as the ideal standard in relation to vertical maxillary positioning.
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Conclusions: Laypersons had a tendency to be more critical in relation to facial harmony than surgeons, although no statistical differences were found in the other groups in relation to the harmony of the smile or
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indication for the corrective surgery. In addition, the patterns of greater or lesser harmony of the smile determined by the participants were similar to those found in the literature as the ideal standard in relation to vertical maxillary positioning. Overall, the present study demonstrates that adequate interaction between surgeons, orthodontists and laypersons is essential in order to achieve facial harmony with orthodontic and/or surgical treatment.
Clinical Relevance: Opinion of specialists and laypersons about the smile in relation to the vertical positioning of the maxilla.
Keywords: smile; harmony; perception; maxilla; vertical excess; vertical deficiency
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Introduction:
The lower third of the face, which extends from the base of the nose to the soft tissue of the chin, is
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extremely important for the diagnosis and treatment planning of dentofacial deformities since the need for surgical and/or orthodontic correction is often dependent on the appearance of this region (Arnett &
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McLaughlin, 2004).
In dentofacial deformities involving the jaw, there are abnormalities in the three facial planes (vertical, transverse and antero-posterior) that can modify the harmony of the face of the individual, even
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when seen in isolation. Vertical maxillary deficiency may cause a feeling of edentulism in the patient whereas vertical maxillary excess involves a convex profile with excessive exposure of the gum tissue and the resting lip and smile (Obwegeser, 2007).
A general assessment of facial balance and symmetry must be performed to assess the aesthetics of
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the face, including a detailed analysis of specific aesthetic relationships (Epker et al., 1978) such as the smile. The harmony of the face affects social status and is important in interpersonal connections, stimulating a positive effect for the individual (Matoula S & Pancherz H, 2006). The smile is clearly a significant signal of
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reliability and is important in facial appearance features such as attractiveness (Grammer et al., 2003). Many
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positive qualities are associated with being physically attractive (Schmidt et al., 2012).
Taking into consideration the importance of the smile adds additional information when treatment
planning vertical maxillary problems (Arnett & McLaughlin, 2004). Several criteria for the assessment of its placement are used. One of these involves the exposure of the upper central incisors and gum tissue in the smile. Ideally, the exposure of the central incisors in a spontaneous smile should stay in the range of three quarters of the length of the crown of the central incisors (approximately 8 mm) and up to 2 mm of gum tissue (Arnett & McLaughlin, 2004; Proffit et al., 2005; Reyneke, 2003). Women tend to have greater exposure of the central incisors due to a shorter lip length than men (Arnett & McLaughlin, 2004).
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Aesthetic corrections require knowledge of the factors that affect attractiveness and the extent of the modifications required (Khosravanifard et al., 2012). The three-dimensional nature of dento-osseous aspects of deformities is of great importance to the treatment plan and satisfactory esthetic and functional results
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(Epker et al., 1978).
A combination of orthodontic and surgical treatment aims to bring a more harmonious relationship to the face, which should be based on the opinion of the surgeon or orthodontist, as well as the patient's goals. In
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the patient´s view, surgery usually produces an improvement in body self-image, particularly in terms of facial attractiveness (Lovius et al., 1990). In a study of the perceptions of clinicians and orthodontists regarding the need for orthognathic surgery based on facial appearance, Juggins et al. (2005) found that orthodontists and
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oral and maxillofacial surgeons do not always share the same clinical goals. The surgeons had a greater tendency to indicate surgical treatment than orthodontists, whereas patients have a minor complaint in relation to the changes in their facial appearance.
The aim of the present study was to determine the perceptions of professionals and laypersons
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regarding the harmony of the smile of patients with and without vertical maxillary abnormalities, and the indication for surgical treatment to correct it.
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Materials and Methods:
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The present study determined the perceptions of 20 oral and maxillofacial surgeons, 20 orthodontists and 20 laypersons in relation to the harmony of the smile through an objective questionnaire, in which the observers reported the degree of harmony of the smiles exposed and indicated corrective surgery.
The Research Ethics Committee of the School of Dentistry of Piracicaba – Unicamp, Piracicaba, São
Paulo, Brazil, approved the present study under protocol number 034-2013.
Images:
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Six (06) smiles from the frontal view of Caucasian females, between 20 and 30 years of age, were selected. These women had no prior orthodontic treatment. The smiles were selected according to the exposure of the central incisors and gum tissue, showing the presence of vertical maxillary excess, proper vertical positioning and vertical maxillary deficiency (Figure 01 – A to E). The smiles were photographed using a
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Canon EOS T2i camera, with a dual circular flash, at a distance of 15 cm from the object in natural light. The photographs were later included in the questionnaire for the examiners to assess the smiles.
maxillary positioning and F – Smile with vertical maxillary deficiency
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Questionnaire and Observers:
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Figure 1 (A to F): A and B – Smiles with vertical maxillary excess; C, D and E – Smiles with proper vertical
Smiles were exposed on the frontal view, where the observer selected its degree of harmony (extremely harmonious, harmonious, neither harmonious nor disharmonious, disharmonious and extremely disharmonious) and if they would consider it necessary to perform corrective surgical procedures if it was their
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smile (yes or no). The questionnaire was sent by e-mail and shown on the computer screen to 60 individuals, selected according to the following criteria:
- 40 dentists (20 oral and maxillofacial surgeons and 20 orthodontists), all involved in the
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management of patients with dentofacial deformities;
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- 20 laypersons, with no history of orthosurgical treatment or cosmetic surgery in the facial area.
The age, sex and profession of all observers were recorded.
Statistical analysis:
The classification of observers was recorded on a Likert scale from 1 to 5. Mixed regression was used to assess differences between the three groups (oral and maxillofacial surgeons, orthodontists and laypersons), along with the effects of age, sex and the criteria of harmony of the observers. The regression models were adjusted to include all the variables that had a significance lower than P=.25 in univariate models.
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Given the low value of the relevance of the test, the reference to a significant interaction was set at 5%. Mixed regression uses a multi-level approach to take into account the effect of grouping by the observer. The model was validated using a logarithmic transformation for the assessment scale to determine the effect of deviation
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from normality.
Results:
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Table 1 displays the demographic data for the characterization of the sample.
To determine the result of the mixed regression in the attractiveness of the images, it is possible to
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see (Table 2) the factors arising from separate analyses. There were no statistically significant differences for the age or sex of the evaluators in relation to the assignment of scores for the smile (p>0.05). However, there were differences for the effect of the group of lay observers compared to surgeons (p0.05) were observed for the factors under study in the analysis of indication for surgery (Table 3).
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Table 4 displays the mean scores obtained for each image, ordered from the most harmonious to the most disharmonious smile. From image 1 to image 5, there is a reduction in the mean while image 6 is higher
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than the mean of the scores (Table 4). The highest mean belongs to smile number 6 and the lowest mean to smile number 4.
Discussion:
The face is a particular source of concern for many individuals since it is the focus in social interactions and the source of non-verbal and verbal communication (Bell et al., 1985). Beauty, which is often associated with harmony, can be expressed in a number of specific characteristics, assessed according to objective and
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subjective criteria by professionals and individuals in general. As stated by Springer et al. (2012), individual perceptions of one’s own facial attractiveness do not generally correlate with other people’s perceptions and are usually better than the opinions expressed by others.
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The balance and proportions of facial structures are more important than numeric values when facial aesthetics are assessed (Reyneke, 2003). Several analyses of soft tissue from the maxillofacial complex are held in front view, profile and ¾ to determine the harmony of the face. Faces and smiles considered extremely
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beautiful and attractive exhibit certain characteristics of facial harmony: proportion between facial width and height; proper exposure of the incisors in the smile; non-forced lip closure and projection of the chin in relation to the profile, determining the balance with the forehead, cheeks, paranasal area and neck (Arnett &
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McLaughlin, 2004; Bell et al., 1985; Reyneke, 2003). Anic-Milosevic et al. (2010) made seven vertical measurements (height of lower face, height of the lower third of the face, upper lip height, lower lip height, chin length, lower and upper vermilion heights) in the lower third of the face in a sample with 110 subjects and found proportional relationships that could contribute as a template for a satisfactory and balanced soft tissue
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profile.
Facial appearance is among the biggest concerns for patients and their perception about what is aesthetically inappropriate should be taken into account by professionals during planning (Reyneke, 2003).
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Scientific studies comparing the views of experts and patients or laypersons in relation to different aspects of facial harmony (Naini et al., 2012a, 2012b, and 2012c) have shown that most patients and laypersons are more
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critical than professionals when assessing facial harmony. This is similar to the results of the present study, in which laypersons were more critical than oral and maxillofacial surgeons regarding the harmony of the smile, although the difference was not statistically significant when compared to orthodontists.
The smile is a part of facial expression. When the smile is observed in isolation, it can often seem
extremely disharmonious. However, the individual can exhibit a more favorable set and minimize the facial appearance. The harmony, covering the whole face, sometimes causes the professional to modify a more unfavorable opinion into a more favorable opinion.
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Several factors may dictate the harmony or disharmony of a smile, including: gum exposure; length; thickness and tone of the upper and lower lips; buccal corridor (broad or narrow); symmetry of the smile; dental crowding; morphology of the teeth and their exposure or lack of exposure (Miloro et al., 2004; Fonseca et al., 2009). The gummy smile is one of the major problems of facial aesthetics and the aim of the present
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study was to show images of smiles with different vertical jaw positions to observe the vision of each
professional and layperson in relation to the harmony of the smile and the corrective surgery indication.
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As shown above, facial harmony is observed in the smile, the variability of gum exposure, vertical jaw abnormalities, the length of the upper lip, the crowns of upper incisors, the presence of gum hypertrophy and the magnitude of lip elevation in the smile (Arnett & McLaughlin, 2004; Fonseca et al., 2009). Oral and
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maxillofacial surgeons and orthodontists in the present study probably assessed these items during the assessment of the images. In relation to the individual responses of laypersons, it seems that they paid particular attention to dental alignment and leveling, as well as dental proportion and symmetry, since they considered extreme cases of higher and lower gum exposure as harmonious.
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In a study by Naini et al. (2012c) about the opinion of surgeons, orthodontists and laypersons on the convexity of the lower third, it was notable that the more evident the convexity of the lower third, the higher the observation of disharmony and the indication for surgery by observers. Although we cannot directly
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compare the results of Naini with those of the present study due to the different subjects appraised, this finding is different to the findings of the present study, in which there was no difference between the smile
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and the indication for surgery. In the present study, the evaluators’ age and sex did not significantly affect the scores of the smiles and the indication for surgery, which also differs from the study by Naini.
Treatment should not be planned only by the assessment of the smile. Open communication between
the orthodontist, patient and surgeon is of extreme importance in the determination of the diagnosis, treatment possibilities and goals to be reached (Reyneke, 2003). Usually, the factor that influences the desire for surgery is related to the facial change extension, as shown by Naini et al. (2012b) who reported that 6 mm protrusions or 10 mm retrusions of the chin were indications for surgery by experts and laypersons. In the present study, there was no statistical difference between the three groups regarding the indication for
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corrective surgery. This may be explained by the fact that there are treatments that do not necessarily involve orthognathic surgery and can, in principle, solve or mask the problem. These treatments include increased clinical crown, the application of botulinum toxin on the lips, phonoaudiological treatment, aesthetic restorations and isolated orthodontic treatment. Another factor to be considered is the low number of
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observers in the study.
It is worth mentioning that the purpose of the research was not to investigate the relationship
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between the degree of deformity (measured in mm) and greater or lower indications for surgical procedures, as in other studies (Bell et al., 1985; Naini et al., 2012a, 2012b). The present study aimed to find the opinion of
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observers in respect to this association, without specifically determining a value for it.
In the literature, surgeons typically have a greater tendency to indicate orthognathic surgery for patients with dentofacial deformities than orthodontists (Juggins et al., 2005; Bell et al., 1985), which was not the case when comparing the groups in the present study. This result may suggest an improvement in the interaction between specialties, with regard to the patient's interests, and knowledge exchange among the
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specialties to achieve facial harmony satisfaction for all involved (professional and patient).
The most attractive smile according to the observers was the smile that exposed all of the upper central incisors and a small strip of gum (smile 4). The least attractive smile had no gum tissue exposure and a partial view of the upper central incisors (smile 6). These results are similar to those found in the literature for
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the ideal standard of incisive exposure while smiling (Arnett & McLaughlin, 2004; Obwegeser, 2007; Epker et al., 1978; Reyneke, 2003; Miloro et al., 2004; Fonseca et al., 2009) taking into account an assessment of the
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vertical maxillary positioning.
Conclusions
Laypersons had a tendency to be more critical in relation to facial harmony than surgeons, although no statistical differences were found between the other groups in relation to the harmony of the smile and the indication for corrective surgery. In addition, the patterns of greater or lesser harmony in the smile
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determined by the observers were similar to those found in the literature for the ideal standard in relation to vertical maxillary positioning. It is clear that adequate interaction between surgeons, orthodontists and patients is essential to determine the objectives to be achieved for a more effective treatment and the best
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aesthetic result for the patient.
THE AUTHORS CONFIRM THAT THERE ARE NO CONFLITS OF INTEREST IN THE PRESENT STUDY
Arnett GW & Mclaughlin RP. Facial and dental planning for orthodontists and oral surgeons. Edinburgh, Mosby, 2004.
2.
Obwegeser JA. Maxillary and Midface deformities: Characteristics and treatment strategies. Clin Plastic Surg 34: 519 33, 2007.
Epker BN, Fish LC, Paulus J. The surgical-orthodontic correction of maxillary deficiency. Oral surgery
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3.
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1.
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Grammer K, Fink B, Moller A, Thornhill, R. Darwinian aesthetics: sexual selection and the biology of beauty. Biol Rev Camb Philos Soc 78(3): 385 407, 2003.
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Schmidt K, Levenstein R, Ambadar Z. Intensity of smiling and attractiveness as facial signals of trustworthiness in women. Percept Motor Skills 114(3): 964 78, 2012.
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Proffit WR, White Jr RP, Sarvier DM. Contemporary treatment of dentofacial deformity. Edinburgh, Mosby, 2005.
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Reyneke JP. Essentials of Orthognathic Surgery. Chicago, Quintessence, 2003.
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Khosravanifard B, Rakhshan V, Raeesi E. Factor’s influencing attractiveness of soft tissue profile. Surg Oral Med Oral Pathol Oral Radiol Aug 2; In Press, 2012.
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Lovius BB, Jones RB, Pospisil OA, Reid D, Slade PD, Wynne TH. The specific psychosocial effects of
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orthognathic surgery. J Craniomaxillofac Surg 18(8): 339 42, 1990.
Juggins KJ, Nixon F, Cunningham SJ. Patient- and clinician-perceived need for orthognathic surgery.
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Am J Orthod Dentofacial Orthop 128(6): 697 702, 2005.
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Bell R, Kiyak HA, Joondeph DR, McNeill RW, Wallen TR. Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. Am J Orthod 88: 323 32, 1985.
Springer IN, Wiltfang J, Kowalski JT, Russo PA, Schulze M, Becker S, Wolfart S. Mirror, mirror on the
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wall…: self-perception of facial beauty versus judgement by others. J Craniomaxillofac Surg 40(8): 773
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6, 2012.
Anic-Milosevic S, Mestrovic S, Prlić A, Slaj M. Proportions in the upper lip-lower lip-chin area of the
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lower face as determined by photogrammetric method. J Craniomaxillofac Surg 38(2): 90 5, 2010.
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Naini FB, Donaldson ANA, McDonald F, Cobourne MT. Assessing the Influence of Asymmetry Affecting the Mandible and Chin Point on Perceived Attractiveness in the Orthognathic Patient, Clinician, and Layperson. J Oral Maxillofac Surg 70: 192 206, 2012a.
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Naini FB, Donaldson ANA, McDonald F, Cobourne MT. Assessing the influence of chin prominence on perceived attractiveness in the orthognathic patient, clinician and layperson. Int J Oral Maxillofac Surg 41(7): 839 46, 2012b.
Naini FB, Donaldson ANA, McDonald F, Cobourne MT. Assessing the influence of lower facial profile
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convexity on perceived attractiveness in the orthognathic patient, clinician, and layperson. Oral Surg
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Miloro M, Ghali E, Larsen P, Waite PD. Peterson´s Principles of oral and maxillofacial surgery – v II. ed
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2. Hamilton/London, BC Decker, 2004.
Fonseca RJ, Marciani R, Turvey TA. Oral and Maxillofacial Surgery – v III. Philadelphia, WB. Saunders,
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2009.
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Tables
Table 1. Demographic data of the sample. Observers
Number
Average Age
95% C.L.
age group
male)
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(years)
Gender (%
20
30.95
32.79 – 29.11
24.00 – 38.00
23.33
Layperson
20
34.45
40.32 – 28.58
23.00 – 64.00
18.33
Orthodontist
20
28.89
30.37 – 27.42
23.00 – 37.00
8.33
Table 2. Multivariate regression for attractiveness of images. Coef. 0.004651 0.03706
-0.00193 -0.06674
95% C.I. 0.01123 0.1409
0.15630 0.03807 -0.1182
0.03684 -0.08560 -0.2498
0.27580 0.16170 0.01337
Coef. -0.01953 -0.4398
-0.05222 -0.05220
95% C.I. 0.01316 0.01316
-0.3968 -0.2434 0.1534
-1.0440 -0.9159 -0.5430
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Description Age Gender Groups OMF Surgeon vs. Layperson OMF Surgeon vs. Orthodontist Layperson vs. Orthodontist
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OMF Surgeon
P Value 0.1651 0.4828 0.1651 0.0105 0.5451 0.0781
Description
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Table 3. Multivariate regression for corrective surgery.
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Age Gender Groups OMF Surgeon vs. Layperson OMF Surgeon vs. Orthodontist Layperson vs. Orthodontist
0.2505 0.4291 0.8498
P Value 0.2407 0.1223 0.4745 0.2286 0.4768 0.6650
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Table 4. Mean scores for each image presented in the questionnaire. Image 1 2 3 4 5 6
Number 60 60 60 60 60 60
Mean 3.750 3.683 2.883 2.033 2.450 4.217
Std Error 0.118 0.110 0.114 0.089 0.129 0.126
95% C.L. 3.986 3.514 3.904 3.463 3.112 2.655 2.211 1.856 2.708 2.192 4.469 3.965
Median 4.000 4.000 3.000 2.000 2.000 4.000
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ACCEPTED MANUSCRIPT
S1010-5182(14)00166-8
DOI:
10.1016/j.jcms.2014.05.010
Reference:
YJCMS 1817
To appear in:
Journal of Cranio-Maxillo-Facial Surgery
Received Date: 29 December 2013 Revised Date:
30 March 2014
Accepted Date: 8 May 2014
Please cite this article as: Lauria A, Rodrigues DC, de Medeiros RC, Fernandes Moreira RW, Perception of oral and maxillofacial surgeons, orthodontists and laypersons in relation to the harmony of the smile, Journal of Cranio-Maxillo-Facial Surgery (2014), doi: 10.1016/j.jcms.2014.05.010. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Perception of oral and maxillofacial surgeons, orthodontists
Andrezza Lauria, DDS, MsC1 Danillo Costa Rodrigues, DDS2 Raquel Correia de Medeiros, DDS, MsC3
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and laypersons in relation to the harmony of the smile
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Roger William Fernandes Moreira, DDS, MsC, PhD4
1. DDS, MsC, PhD Student in Oral and Maxillofacial Surgery, School of Dentistry of Piracicaba, Sate University of Campinas (UNICAMP), Brazil. 2. DDS, MsC Student in Oral and Maxillofacial Surgery, School of Dentistry of Piracicaba, State University of Campinas (UNICAMP), Brazil.
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3. DDS, MsC, PhD Student in Oral and Maxillofacial Surgery, School of Dentistry of Piracicaba, Sate University of Campinas (UNICAMP), Brazil.
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4. DDS, MsC, PhD, Associate professor in Oral and Maxillofacial Surgery Piracicaba Dental School, State University of Campinas (UNICAMP), Brazil.
Address correspondence to authors:
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School of Dentistry of Piracicaba, CP 52, State University of Campinas-UNICAMP 13.414-903, Piracicaba, SP, Brazil.
E-mail and telephone correspondence to Andrezza Lauria: E-mail: [email protected] Telephone: +55 19 2106-5708
ACCEPTED MANUSCRIPT
Perception of oral and maxillofacial surgeons, orthodontists and laypersons in relation to the harmony of the smile
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Abstract:
Objective: Harmony is one of the main objectives in surgical and orthodontic treatment and this harmony
must be present in the smile, as well as in the face. The aim of the present study was to assess the perceptions
SC
of professionals and laypersons in relation to the harmony of the smile of patients with or without vertical maxillary alterations.
Materials and Methods: Sixty observers (oral and maxillofacial surgeons, orthodontists and laypersons)
M AN U
reported the degree of harmony of six smiles using an objective questionnaire and the participants indicated if there was a need for corrective surgery or not. The classification of observers was recorded on a Likert scale from 1 to 5. Mixed regression was used to determine differences between the three groups. Results: Statistically significant differences were found only for the harmony of the smile between the oral and maxillofacial surgeons and laypersons, with laypersons being more critical when assessing the smile. There was
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no statistical difference between the other groups for the harmony of the smile or the indication of corrective surgery. The patterns of greater or lesser harmony determined by observers during the smile were similar to those found in the literature as the ideal standard in relation to vertical maxillary positioning.
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Conclusions: Laypersons had a tendency to be more critical in relation to facial harmony than surgeons, although no statistical differences were found in the other groups in relation to the harmony of the smile or
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indication for the corrective surgery. In addition, the patterns of greater or lesser harmony of the smile determined by the participants were similar to those found in the literature as the ideal standard in relation to vertical maxillary positioning. Overall, the present study demonstrates that adequate interaction between surgeons, orthodontists and laypersons is essential in order to achieve facial harmony with orthodontic and/or surgical treatment.
Clinical Relevance: Opinion of specialists and laypersons about the smile in relation to the vertical positioning of the maxilla.
Keywords: smile; harmony; perception; maxilla; vertical excess; vertical deficiency
1
ACCEPTED MANUSCRIPT
Introduction:
The lower third of the face, which extends from the base of the nose to the soft tissue of the chin, is
RI PT
extremely important for the diagnosis and treatment planning of dentofacial deformities since the need for surgical and/or orthodontic correction is often dependent on the appearance of this region (Arnett &
SC
McLaughlin, 2004).
In dentofacial deformities involving the jaw, there are abnormalities in the three facial planes (vertical, transverse and antero-posterior) that can modify the harmony of the face of the individual, even
M AN U
when seen in isolation. Vertical maxillary deficiency may cause a feeling of edentulism in the patient whereas vertical maxillary excess involves a convex profile with excessive exposure of the gum tissue and the resting lip and smile (Obwegeser, 2007).
A general assessment of facial balance and symmetry must be performed to assess the aesthetics of
TE D
the face, including a detailed analysis of specific aesthetic relationships (Epker et al., 1978) such as the smile. The harmony of the face affects social status and is important in interpersonal connections, stimulating a positive effect for the individual (Matoula S & Pancherz H, 2006). The smile is clearly a significant signal of
EP
reliability and is important in facial appearance features such as attractiveness (Grammer et al., 2003). Many
AC C
positive qualities are associated with being physically attractive (Schmidt et al., 2012).
Taking into consideration the importance of the smile adds additional information when treatment
planning vertical maxillary problems (Arnett & McLaughlin, 2004). Several criteria for the assessment of its placement are used. One of these involves the exposure of the upper central incisors and gum tissue in the smile. Ideally, the exposure of the central incisors in a spontaneous smile should stay in the range of three quarters of the length of the crown of the central incisors (approximately 8 mm) and up to 2 mm of gum tissue (Arnett & McLaughlin, 2004; Proffit et al., 2005; Reyneke, 2003). Women tend to have greater exposure of the central incisors due to a shorter lip length than men (Arnett & McLaughlin, 2004).
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Aesthetic corrections require knowledge of the factors that affect attractiveness and the extent of the modifications required (Khosravanifard et al., 2012). The three-dimensional nature of dento-osseous aspects of deformities is of great importance to the treatment plan and satisfactory esthetic and functional results
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(Epker et al., 1978).
A combination of orthodontic and surgical treatment aims to bring a more harmonious relationship to the face, which should be based on the opinion of the surgeon or orthodontist, as well as the patient's goals. In
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the patient´s view, surgery usually produces an improvement in body self-image, particularly in terms of facial attractiveness (Lovius et al., 1990). In a study of the perceptions of clinicians and orthodontists regarding the need for orthognathic surgery based on facial appearance, Juggins et al. (2005) found that orthodontists and
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oral and maxillofacial surgeons do not always share the same clinical goals. The surgeons had a greater tendency to indicate surgical treatment than orthodontists, whereas patients have a minor complaint in relation to the changes in their facial appearance.
The aim of the present study was to determine the perceptions of professionals and laypersons
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regarding the harmony of the smile of patients with and without vertical maxillary abnormalities, and the indication for surgical treatment to correct it.
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Materials and Methods:
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The present study determined the perceptions of 20 oral and maxillofacial surgeons, 20 orthodontists and 20 laypersons in relation to the harmony of the smile through an objective questionnaire, in which the observers reported the degree of harmony of the smiles exposed and indicated corrective surgery.
The Research Ethics Committee of the School of Dentistry of Piracicaba – Unicamp, Piracicaba, São
Paulo, Brazil, approved the present study under protocol number 034-2013.
Images:
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Six (06) smiles from the frontal view of Caucasian females, between 20 and 30 years of age, were selected. These women had no prior orthodontic treatment. The smiles were selected according to the exposure of the central incisors and gum tissue, showing the presence of vertical maxillary excess, proper vertical positioning and vertical maxillary deficiency (Figure 01 – A to E). The smiles were photographed using a
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Canon EOS T2i camera, with a dual circular flash, at a distance of 15 cm from the object in natural light. The photographs were later included in the questionnaire for the examiners to assess the smiles.
maxillary positioning and F – Smile with vertical maxillary deficiency
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Questionnaire and Observers:
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Figure 1 (A to F): A and B – Smiles with vertical maxillary excess; C, D and E – Smiles with proper vertical
Smiles were exposed on the frontal view, where the observer selected its degree of harmony (extremely harmonious, harmonious, neither harmonious nor disharmonious, disharmonious and extremely disharmonious) and if they would consider it necessary to perform corrective surgical procedures if it was their
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smile (yes or no). The questionnaire was sent by e-mail and shown on the computer screen to 60 individuals, selected according to the following criteria:
- 40 dentists (20 oral and maxillofacial surgeons and 20 orthodontists), all involved in the
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management of patients with dentofacial deformities;
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- 20 laypersons, with no history of orthosurgical treatment or cosmetic surgery in the facial area.
The age, sex and profession of all observers were recorded.
Statistical analysis:
The classification of observers was recorded on a Likert scale from 1 to 5. Mixed regression was used to assess differences between the three groups (oral and maxillofacial surgeons, orthodontists and laypersons), along with the effects of age, sex and the criteria of harmony of the observers. The regression models were adjusted to include all the variables that had a significance lower than P=.25 in univariate models.
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Given the low value of the relevance of the test, the reference to a significant interaction was set at 5%. Mixed regression uses a multi-level approach to take into account the effect of grouping by the observer. The model was validated using a logarithmic transformation for the assessment scale to determine the effect of deviation
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from normality.
Results:
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Table 1 displays the demographic data for the characterization of the sample.
To determine the result of the mixed regression in the attractiveness of the images, it is possible to
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see (Table 2) the factors arising from separate analyses. There were no statistically significant differences for the age or sex of the evaluators in relation to the assignment of scores for the smile (p>0.05). However, there were differences for the effect of the group of lay observers compared to surgeons (p0.05) were observed for the factors under study in the analysis of indication for surgery (Table 3).
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Table 4 displays the mean scores obtained for each image, ordered from the most harmonious to the most disharmonious smile. From image 1 to image 5, there is a reduction in the mean while image 6 is higher
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than the mean of the scores (Table 4). The highest mean belongs to smile number 6 and the lowest mean to smile number 4.
Discussion:
The face is a particular source of concern for many individuals since it is the focus in social interactions and the source of non-verbal and verbal communication (Bell et al., 1985). Beauty, which is often associated with harmony, can be expressed in a number of specific characteristics, assessed according to objective and
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subjective criteria by professionals and individuals in general. As stated by Springer et al. (2012), individual perceptions of one’s own facial attractiveness do not generally correlate with other people’s perceptions and are usually better than the opinions expressed by others.
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The balance and proportions of facial structures are more important than numeric values when facial aesthetics are assessed (Reyneke, 2003). Several analyses of soft tissue from the maxillofacial complex are held in front view, profile and ¾ to determine the harmony of the face. Faces and smiles considered extremely
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beautiful and attractive exhibit certain characteristics of facial harmony: proportion between facial width and height; proper exposure of the incisors in the smile; non-forced lip closure and projection of the chin in relation to the profile, determining the balance with the forehead, cheeks, paranasal area and neck (Arnett &
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McLaughlin, 2004; Bell et al., 1985; Reyneke, 2003). Anic-Milosevic et al. (2010) made seven vertical measurements (height of lower face, height of the lower third of the face, upper lip height, lower lip height, chin length, lower and upper vermilion heights) in the lower third of the face in a sample with 110 subjects and found proportional relationships that could contribute as a template for a satisfactory and balanced soft tissue
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profile.
Facial appearance is among the biggest concerns for patients and their perception about what is aesthetically inappropriate should be taken into account by professionals during planning (Reyneke, 2003).
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Scientific studies comparing the views of experts and patients or laypersons in relation to different aspects of facial harmony (Naini et al., 2012a, 2012b, and 2012c) have shown that most patients and laypersons are more
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critical than professionals when assessing facial harmony. This is similar to the results of the present study, in which laypersons were more critical than oral and maxillofacial surgeons regarding the harmony of the smile, although the difference was not statistically significant when compared to orthodontists.
The smile is a part of facial expression. When the smile is observed in isolation, it can often seem
extremely disharmonious. However, the individual can exhibit a more favorable set and minimize the facial appearance. The harmony, covering the whole face, sometimes causes the professional to modify a more unfavorable opinion into a more favorable opinion.
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Several factors may dictate the harmony or disharmony of a smile, including: gum exposure; length; thickness and tone of the upper and lower lips; buccal corridor (broad or narrow); symmetry of the smile; dental crowding; morphology of the teeth and their exposure or lack of exposure (Miloro et al., 2004; Fonseca et al., 2009). The gummy smile is one of the major problems of facial aesthetics and the aim of the present
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study was to show images of smiles with different vertical jaw positions to observe the vision of each
professional and layperson in relation to the harmony of the smile and the corrective surgery indication.
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As shown above, facial harmony is observed in the smile, the variability of gum exposure, vertical jaw abnormalities, the length of the upper lip, the crowns of upper incisors, the presence of gum hypertrophy and the magnitude of lip elevation in the smile (Arnett & McLaughlin, 2004; Fonseca et al., 2009). Oral and
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maxillofacial surgeons and orthodontists in the present study probably assessed these items during the assessment of the images. In relation to the individual responses of laypersons, it seems that they paid particular attention to dental alignment and leveling, as well as dental proportion and symmetry, since they considered extreme cases of higher and lower gum exposure as harmonious.
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In a study by Naini et al. (2012c) about the opinion of surgeons, orthodontists and laypersons on the convexity of the lower third, it was notable that the more evident the convexity of the lower third, the higher the observation of disharmony and the indication for surgery by observers. Although we cannot directly
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compare the results of Naini with those of the present study due to the different subjects appraised, this finding is different to the findings of the present study, in which there was no difference between the smile
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and the indication for surgery. In the present study, the evaluators’ age and sex did not significantly affect the scores of the smiles and the indication for surgery, which also differs from the study by Naini.
Treatment should not be planned only by the assessment of the smile. Open communication between
the orthodontist, patient and surgeon is of extreme importance in the determination of the diagnosis, treatment possibilities and goals to be reached (Reyneke, 2003). Usually, the factor that influences the desire for surgery is related to the facial change extension, as shown by Naini et al. (2012b) who reported that 6 mm protrusions or 10 mm retrusions of the chin were indications for surgery by experts and laypersons. In the present study, there was no statistical difference between the three groups regarding the indication for
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corrective surgery. This may be explained by the fact that there are treatments that do not necessarily involve orthognathic surgery and can, in principle, solve or mask the problem. These treatments include increased clinical crown, the application of botulinum toxin on the lips, phonoaudiological treatment, aesthetic restorations and isolated orthodontic treatment. Another factor to be considered is the low number of
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observers in the study.
It is worth mentioning that the purpose of the research was not to investigate the relationship
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between the degree of deformity (measured in mm) and greater or lower indications for surgical procedures, as in other studies (Bell et al., 1985; Naini et al., 2012a, 2012b). The present study aimed to find the opinion of
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observers in respect to this association, without specifically determining a value for it.
In the literature, surgeons typically have a greater tendency to indicate orthognathic surgery for patients with dentofacial deformities than orthodontists (Juggins et al., 2005; Bell et al., 1985), which was not the case when comparing the groups in the present study. This result may suggest an improvement in the interaction between specialties, with regard to the patient's interests, and knowledge exchange among the
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specialties to achieve facial harmony satisfaction for all involved (professional and patient).
The most attractive smile according to the observers was the smile that exposed all of the upper central incisors and a small strip of gum (smile 4). The least attractive smile had no gum tissue exposure and a partial view of the upper central incisors (smile 6). These results are similar to those found in the literature for
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the ideal standard of incisive exposure while smiling (Arnett & McLaughlin, 2004; Obwegeser, 2007; Epker et al., 1978; Reyneke, 2003; Miloro et al., 2004; Fonseca et al., 2009) taking into account an assessment of the
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vertical maxillary positioning.
Conclusions
Laypersons had a tendency to be more critical in relation to facial harmony than surgeons, although no statistical differences were found between the other groups in relation to the harmony of the smile and the indication for corrective surgery. In addition, the patterns of greater or lesser harmony in the smile
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determined by the observers were similar to those found in the literature for the ideal standard in relation to vertical maxillary positioning. It is clear that adequate interaction between surgeons, orthodontists and patients is essential to determine the objectives to be achieved for a more effective treatment and the best
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aesthetic result for the patient.
THE AUTHORS CONFIRM THAT THERE ARE NO CONFLITS OF INTEREST IN THE PRESENT STUDY
Arnett GW & Mclaughlin RP. Facial and dental planning for orthodontists and oral surgeons. Edinburgh, Mosby, 2004.
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Epker BN, Fish LC, Paulus J. The surgical-orthodontic correction of maxillary deficiency. Oral surgery
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Tables
Table 1. Demographic data of the sample. Observers
Number
Average Age
95% C.L.
age group
male)
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(years)
Gender (%
20
30.95
32.79 – 29.11
24.00 – 38.00
23.33
Layperson
20
34.45
40.32 – 28.58
23.00 – 64.00
18.33
Orthodontist
20
28.89
30.37 – 27.42
23.00 – 37.00
8.33
Table 2. Multivariate regression for attractiveness of images. Coef. 0.004651 0.03706
-0.00193 -0.06674
95% C.I. 0.01123 0.1409
0.15630 0.03807 -0.1182
0.03684 -0.08560 -0.2498
0.27580 0.16170 0.01337
Coef. -0.01953 -0.4398
-0.05222 -0.05220
95% C.I. 0.01316 0.01316
-0.3968 -0.2434 0.1534
-1.0440 -0.9159 -0.5430
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Description Age Gender Groups OMF Surgeon vs. Layperson OMF Surgeon vs. Orthodontist Layperson vs. Orthodontist
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OMF Surgeon
P Value 0.1651 0.4828 0.1651 0.0105 0.5451 0.0781
Description
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Table 3. Multivariate regression for corrective surgery.
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Age Gender Groups OMF Surgeon vs. Layperson OMF Surgeon vs. Orthodontist Layperson vs. Orthodontist
0.2505 0.4291 0.8498
P Value 0.2407 0.1223 0.4745 0.2286 0.4768 0.6650
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Table 4. Mean scores for each image presented in the questionnaire. Image 1 2 3 4 5 6
Number 60 60 60 60 60 60
Mean 3.750 3.683 2.883 2.033 2.450 4.217
Std Error 0.118 0.110 0.114 0.089 0.129 0.126
95% C.L. 3.986 3.514 3.904 3.463 3.112 2.655 2.211 1.856 2.708 2.192 4.469 3.965
Median 4.000 4.000 3.000 2.000 2.000 4.000
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