Smile attractiveness of patients treated for congenitally missing maxillary lateral incisors as rated by dentists, laypersons, and the patients themselves Luciana Manzotti De-Marchi, DDS, MSc,a Núbia Inocencya Pavesi Pini, DDS, MSc,b Adilson Luis Ramos, DDS, PhD,c and Renata Corrêa Pascotto, DDS, PhDd School of Dentistry, State University of Maringá, Maringá, Paraná, Brazil; State University of Campinas, Piracicaba, São Paulo, Brazil Statement of problem. Esthetic judgments can help dental professionals better understand how attentive people are to their own smiles and those of others. Purpose. The purpose of this study was to evaluate the smile attractiveness of patients treated for maxillary lateral incisor agenesis compared with that of individuals with a complete dentition. Material and methods. Photographs were made of the smiles of patients with maxillary lateral incisor agenesis who were treated with space closure and teeth recontouring (n¼26) or space opening and implants (n¼20) and of a control group with a complete dentition (n¼22). Both laypersons and dentists assessed smile attractiveness by using a visual analog scale. Patients and controls also assessed the level of satisfaction with their own smile. Assessments were performed twice, and the reliability of the method was determined with Cronbach a and intraclass correlation. Multifactorial and 1-way ANOVA were used to analyze smile attractiveness and participant satisfaction, followed by the Bonferroni post hoc test (a¼.05). Results. Attractiveness ratings by dentists and laypersons did not differ significantly among the study groups (P¼.64). The ratings of male dentists and female laypersons differed significantly from those of other evaluators (P¼.01). Patients with space closure and teeth recontouring were significantly more satisfied than controls (P¼.002). No significant differences were found between the patients with implants and controls or between the patients with implants and those with space closure and teeth recontouring. Conclusions. The smiles of patients with maxillary lateral incisor agenesis were judged to be as attractive as those of the controls. Male dentists were the most critical raters, closely followed by female laypersons. All participants had high levels of satisfaction with their own smile; patients treated with space closure and teeth recontouring were the most satisfied. (J Prosthet Dent 2014;-:---)
Clinical Implications Treatments of patients with congenital unilateral or bilateral maxillary lateral incisor agenesis can produce esthetics comparable with the esthetics of individuals with complete dentitions who have never undergone any type of orthodontic treatment; a slight advantage was observed for patients treated with space closure and teeth recontouring.
Dental agenesis in the anterosuperior region can compromise the balance and the symmetry of the smile, negatively a
affecting self-esteem.1-4 Maxillary lateral incisor agenesis (MLIA) can be treated either by space closure and
teeth recontouring (SCR) or space opening/maintenance for the placement of implant-supported prostheses
Graduate student, School of Dentistry, State University of Maringá. Auxiliary Professor, Department of Dentistry, University Center of Maringá. c Graduate student, School of Dentistry (Restorative Dentistry), Piracicaba Dental School, State University of Campinas. d Associate Clinical Professor, School of Dentistry, State University of Maringá. b
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Volume (SOI).5-8 In SCR procedures, canine mesialization to the agenesis area requires conversion of the premolar into a canine and the canine into a lateral incisor. As these teeth differ in anatomy, color, and gingival height, the esthetic result may be compromised if the anatomy of the converted teeth is not created well.9-11 However, highly satisfactory results can be achieved in these patients if procedures are carefully planned and performed with an interdisciplinary approach.5,6,10,12-14 Dental implants placed in the anterosuperior region have also shown satisfactory esthetic results with positive patient self-evaluation.15,16 A pleasant and attractive smile can significantly boost an individual’s self-confidence and acceptance by society by improving interpersonal relationships.17,18 Recent studies have sought to analyze the esthetic perception of the smile by both laypersons and dentists.19-23 Furthermore, attention to patient satisfaction with treatment outcomes has increased.2,16,24-26 Studies of esthetic perception and judgment can help dental professionals to better understand how attentive to detail people are with regard to their own smiles and those of others, to prioritize patient needs, and to avoid professional bias.3,4,17,24,26 The objective of this study was to assess smile attractiveness in patients with unilateral or bilateral MLIA and the patients’ level of satisfaction with their own smile compared with individuals having a complete dentition. The null hypothesis was that patients with MLIA would have smiles rated as attractive and would be as satisfied as control individuals with a complete dentition.
MATERIAL AND METHODS Photographs were made of the smiles of patients with MLIA and of controls with complete dentitions. Smile attractiveness of the participants was assessed from the photographs by 20 laypersons and 20 dentists. The level of satisfaction with their own
smile was also assessed in patients and controls. The design of this retrospective, comparative study was approved by the Ethics Committee on Human Research of the State University of Maringá, Paraná, Brazil (protocol No. 010800093000-08). The records of the public dental clinic at the Department of Dentistry, State University of Maringá, were searched for patients with congenital unilateral or bilateral MLIA treated either with SCR or with SOI and whose treatment had been completed at least 6 months previously. A total of 60 records met these selection criteria. The patients were individually contacted by phone, and 46 agreed to participate in the study. Patients with MLIA were allocated to 2 groups: SCR, patients who had been orthodontically treated with space closure involving the mesial movement of canines and recontouring of the maxillary anterior teeth with composite resin (n¼26), and SOI, patients orthodontically treated with lateral incisor space opening/maintenance and placement of implants in the agenesis area (n¼20). A control group (CG) composed of 22 volunteers was selected according to the following inclusion criteria: no prior orthodontic or orthopedic treatment, the presence of all teeth (except for third molars), no skeletal abnormalities, and good dental alignment. All participants were fully informed of the purpose of the study and signed a written informed consent.
Photographic procedures All participants were individually scheduled to visit a dental office specially prepared for photography with darkened windows and standard lighting. Participants were instructed to come to their appointments shaven and without makeup. Photographs were made with a posed smile and included the lower third of the face from the subnasal point to the mentum.21 A digital camera fixed to a tripod and equipped with a macro 60-mm objective lens (Nikon D50; Nikon Corp) and a ring flash (EM-140DG; Sigma Corp)
The Journal of Prosthetic Dentistry
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was used. All photographs were made from a distance of 1 meter, with individuals positioned at the same height as the photographer. Participants were instructed to keep a natural head position, with the eyes focused on an imaginary point at eye level. Several photographs were made of each patient.19 Photographs judged as having unforced, natural smiles were selected by the authors.20 All photographs were made by the same author (L.M.M.), who is an experienced dental photographer. The selected photographs were then transferred to editing software (Photoshop CS2; Adobe Systems Software Ltd), which was used to crop the photographs to show only the lower third of the face.19,21,23,27,28 No attempt was made to manipulate images in any way. All images were adjusted to the same size (1710 cm).23 Two videos containing the 68 photographs were prepared (ProShow; Photodex Corp). For the first assessment, photographs were arranged in chronologic order as made, regardless of the participant group assignment. For the second assessment, the same photographs used in the first video were placed in alphabetical order according to patient name. Examples of photographs are shown in Figures 1 and 2.
Smile attractiveness rating Two groups of people, who were known to the authors and who live and work locally, were invited to rate the attractiveness of the smiles. One group consisted of 20 laypersons (10 men and 10 women) with no formal dental education but with college degrees. The second group included general dentists (10 men and 10 women) with at least 4 years of clinical practice. Ratings were obtained on 2 separate occasions 1 month apart. All raters were invited to an auditorium specially prepared for the assessments. Raters sat approximately 5 meters away from the screen and received a notepad containing 68 visual analog scales (VAS).19 The scales ranged from ‘least
De-Marchi et al
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2014
3 between the extreme left of the VAS and the mark made by the rater or participant was always measured with the same ruler and by the same operator (L.M.M.).
Statistical analyses
1 Patient with unilateral maxillary lateral incisor agenesis treated with space opening and implant. Her own score was 55 for satisfaction with her own smile. Female laypersons scored her with 51, male laypersons with 56, female dentists with 58, and male dentists with 38 for smile attractiveness.
2 Patient with bilateral maxillary lateral incisor agenesis treated with space closure and teeth recontouring. His own score was 99 for satisfaction with his own smile. Female laypersons scored him with 59, male laypersons with 51, female dentists with 66, and male dentists with 49 for smile attractiveness. attractive’ on the extreme left to ‘most attractive’ on the extreme right of a 100-mm line.24 Each horizontal line had a number corresponding to the photographs being shown, and raters were instructed to assess each smile by marking their perception of dental esthetics on the scale. The video of the photographs was projected on the screen, and the consecutive photographs were each shown for 5 seconds, a time judged sufficient for raters to have a first impression of the smile. After each photograph, a blank screen showing the word ‘answer’ appeared for 5 seconds; raters then marked their
De-Marchi et al
answers on the VAS. All raters were blinded to the patient treatments. All 68 individuals participating in the study, both patients and volunteers, also rated their level of satisfaction with their own smile on 2 different occasions without any visual cues. The VAS scales of the participants were different from those used by the raters, ranging from ‘completely dissatisfied’ on the extreme left to ‘completely satisfied’ on the extreme right. The first self-assessment was conducted just after their photographs were made, and the second self-assessment was performed 1 month later. The distance (in millimeters)
The Fisher post hoc exact conditional test for 2 proportions was used to calculate the power achieved by the study based on the definitive sample size (SAS 9.3; SAS Institute Inc). The Fisher exact test was also used to determine any significant differences among the test groups regarding sex and unilateral or bilateral agenesis. The Mann-Whitney test was used to compare groups regarding posttreatment time. The Shapiro-Wilk normality test and the t test for independent samples were used to analyze differences in the age of the raters. To determine the reliability of the method, internal consistency, and interrater reliability, Cronbach a and intraclass correlation coefficient (ICC) statistics were used to compare the results obtained in the first and second assessments. The distribution of the results obtained in millimeters was analyzed with the Kolmogorov-Smirnov normality test. Multifactorial ANOVA was used to verify the effects of smile attractiveness scores obtained in the photographic assessments among raters (laypersons and dentists), groups (SCR, SOI, and CG), and sex (men and women). Oneway ANOVA was used to compare the level of satisfaction of patients (SCR and SOI) and controls (CG) with their own smiles, and the Student t test was used to compare patient satisfaction according to sex. The Bonferroni correction for multiple comparisons was used as a post hoc test. All statistical analyses (except the Fisher exact conditional test) were carried out with statistical software (Statistica 9.0; StatSoft Inc) with the level of significance set at 5%.
RESULTS The Fisher exact conditional test for 2 proportions found that the study
4
Volume achieved a computed power of .941 for the experimental groups (SCR, SOI, and CG) and .99 for raters (laypersons and dentists). Participant age ranged from 14.10 to 41.10 years in patients treated with SCR, 19.02 to 45.08 years in patients treated with SOI, and 19.07 to 26.12 years in the CG. No statistically significant differences in sex (P¼.48), type of agenesis (P¼.37), or posttreatment time (P¼.89) were found among the study groups (Table I). The ages of the dentists and laypersons were not significantly different (P¼.08) (Table II). The Cronbach a and ICC indicated a high level of consistency between the first and the second assessments: .96 for the laypersons, .97 for dentists, and .90 for self-raters. Consequently, the ratings obtained in the first assessment were included in the analyses. Multifactorial ANOVA found no statistically significant differences (df¼2; F¼6.41; P¼.64) in the smile attractiveness ratings of laypersons and dentists within any of the groups studied (Table III). However, when the analysis was performed taking sex into consideration, significant differences were observed (df¼1; F¼22.08; P
Clinical Implications Treatments of patients with congenital unilateral or bilateral maxillary lateral incisor agenesis can produce esthetics comparable with the esthetics of individuals with complete dentitions who have never undergone any type of orthodontic treatment; a slight advantage was observed for patients treated with space closure and teeth recontouring.
Dental agenesis in the anterosuperior region can compromise the balance and the symmetry of the smile, negatively a
affecting self-esteem.1-4 Maxillary lateral incisor agenesis (MLIA) can be treated either by space closure and
teeth recontouring (SCR) or space opening/maintenance for the placement of implant-supported prostheses
Graduate student, School of Dentistry, State University of Maringá. Auxiliary Professor, Department of Dentistry, University Center of Maringá. c Graduate student, School of Dentistry (Restorative Dentistry), Piracicaba Dental School, State University of Campinas. d Associate Clinical Professor, School of Dentistry, State University of Maringá. b
De-Marchi et al
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Volume (SOI).5-8 In SCR procedures, canine mesialization to the agenesis area requires conversion of the premolar into a canine and the canine into a lateral incisor. As these teeth differ in anatomy, color, and gingival height, the esthetic result may be compromised if the anatomy of the converted teeth is not created well.9-11 However, highly satisfactory results can be achieved in these patients if procedures are carefully planned and performed with an interdisciplinary approach.5,6,10,12-14 Dental implants placed in the anterosuperior region have also shown satisfactory esthetic results with positive patient self-evaluation.15,16 A pleasant and attractive smile can significantly boost an individual’s self-confidence and acceptance by society by improving interpersonal relationships.17,18 Recent studies have sought to analyze the esthetic perception of the smile by both laypersons and dentists.19-23 Furthermore, attention to patient satisfaction with treatment outcomes has increased.2,16,24-26 Studies of esthetic perception and judgment can help dental professionals to better understand how attentive to detail people are with regard to their own smiles and those of others, to prioritize patient needs, and to avoid professional bias.3,4,17,24,26 The objective of this study was to assess smile attractiveness in patients with unilateral or bilateral MLIA and the patients’ level of satisfaction with their own smile compared with individuals having a complete dentition. The null hypothesis was that patients with MLIA would have smiles rated as attractive and would be as satisfied as control individuals with a complete dentition.
MATERIAL AND METHODS Photographs were made of the smiles of patients with MLIA and of controls with complete dentitions. Smile attractiveness of the participants was assessed from the photographs by 20 laypersons and 20 dentists. The level of satisfaction with their own
smile was also assessed in patients and controls. The design of this retrospective, comparative study was approved by the Ethics Committee on Human Research of the State University of Maringá, Paraná, Brazil (protocol No. 010800093000-08). The records of the public dental clinic at the Department of Dentistry, State University of Maringá, were searched for patients with congenital unilateral or bilateral MLIA treated either with SCR or with SOI and whose treatment had been completed at least 6 months previously. A total of 60 records met these selection criteria. The patients were individually contacted by phone, and 46 agreed to participate in the study. Patients with MLIA were allocated to 2 groups: SCR, patients who had been orthodontically treated with space closure involving the mesial movement of canines and recontouring of the maxillary anterior teeth with composite resin (n¼26), and SOI, patients orthodontically treated with lateral incisor space opening/maintenance and placement of implants in the agenesis area (n¼20). A control group (CG) composed of 22 volunteers was selected according to the following inclusion criteria: no prior orthodontic or orthopedic treatment, the presence of all teeth (except for third molars), no skeletal abnormalities, and good dental alignment. All participants were fully informed of the purpose of the study and signed a written informed consent.
Photographic procedures All participants were individually scheduled to visit a dental office specially prepared for photography with darkened windows and standard lighting. Participants were instructed to come to their appointments shaven and without makeup. Photographs were made with a posed smile and included the lower third of the face from the subnasal point to the mentum.21 A digital camera fixed to a tripod and equipped with a macro 60-mm objective lens (Nikon D50; Nikon Corp) and a ring flash (EM-140DG; Sigma Corp)
The Journal of Prosthetic Dentistry
-
Issue
-
was used. All photographs were made from a distance of 1 meter, with individuals positioned at the same height as the photographer. Participants were instructed to keep a natural head position, with the eyes focused on an imaginary point at eye level. Several photographs were made of each patient.19 Photographs judged as having unforced, natural smiles were selected by the authors.20 All photographs were made by the same author (L.M.M.), who is an experienced dental photographer. The selected photographs were then transferred to editing software (Photoshop CS2; Adobe Systems Software Ltd), which was used to crop the photographs to show only the lower third of the face.19,21,23,27,28 No attempt was made to manipulate images in any way. All images were adjusted to the same size (1710 cm).23 Two videos containing the 68 photographs were prepared (ProShow; Photodex Corp). For the first assessment, photographs were arranged in chronologic order as made, regardless of the participant group assignment. For the second assessment, the same photographs used in the first video were placed in alphabetical order according to patient name. Examples of photographs are shown in Figures 1 and 2.
Smile attractiveness rating Two groups of people, who were known to the authors and who live and work locally, were invited to rate the attractiveness of the smiles. One group consisted of 20 laypersons (10 men and 10 women) with no formal dental education but with college degrees. The second group included general dentists (10 men and 10 women) with at least 4 years of clinical practice. Ratings were obtained on 2 separate occasions 1 month apart. All raters were invited to an auditorium specially prepared for the assessments. Raters sat approximately 5 meters away from the screen and received a notepad containing 68 visual analog scales (VAS).19 The scales ranged from ‘least
De-Marchi et al
-
2014
3 between the extreme left of the VAS and the mark made by the rater or participant was always measured with the same ruler and by the same operator (L.M.M.).
Statistical analyses
1 Patient with unilateral maxillary lateral incisor agenesis treated with space opening and implant. Her own score was 55 for satisfaction with her own smile. Female laypersons scored her with 51, male laypersons with 56, female dentists with 58, and male dentists with 38 for smile attractiveness.
2 Patient with bilateral maxillary lateral incisor agenesis treated with space closure and teeth recontouring. His own score was 99 for satisfaction with his own smile. Female laypersons scored him with 59, male laypersons with 51, female dentists with 66, and male dentists with 49 for smile attractiveness. attractive’ on the extreme left to ‘most attractive’ on the extreme right of a 100-mm line.24 Each horizontal line had a number corresponding to the photographs being shown, and raters were instructed to assess each smile by marking their perception of dental esthetics on the scale. The video of the photographs was projected on the screen, and the consecutive photographs were each shown for 5 seconds, a time judged sufficient for raters to have a first impression of the smile. After each photograph, a blank screen showing the word ‘answer’ appeared for 5 seconds; raters then marked their
De-Marchi et al
answers on the VAS. All raters were blinded to the patient treatments. All 68 individuals participating in the study, both patients and volunteers, also rated their level of satisfaction with their own smile on 2 different occasions without any visual cues. The VAS scales of the participants were different from those used by the raters, ranging from ‘completely dissatisfied’ on the extreme left to ‘completely satisfied’ on the extreme right. The first self-assessment was conducted just after their photographs were made, and the second self-assessment was performed 1 month later. The distance (in millimeters)
The Fisher post hoc exact conditional test for 2 proportions was used to calculate the power achieved by the study based on the definitive sample size (SAS 9.3; SAS Institute Inc). The Fisher exact test was also used to determine any significant differences among the test groups regarding sex and unilateral or bilateral agenesis. The Mann-Whitney test was used to compare groups regarding posttreatment time. The Shapiro-Wilk normality test and the t test for independent samples were used to analyze differences in the age of the raters. To determine the reliability of the method, internal consistency, and interrater reliability, Cronbach a and intraclass correlation coefficient (ICC) statistics were used to compare the results obtained in the first and second assessments. The distribution of the results obtained in millimeters was analyzed with the Kolmogorov-Smirnov normality test. Multifactorial ANOVA was used to verify the effects of smile attractiveness scores obtained in the photographic assessments among raters (laypersons and dentists), groups (SCR, SOI, and CG), and sex (men and women). Oneway ANOVA was used to compare the level of satisfaction of patients (SCR and SOI) and controls (CG) with their own smiles, and the Student t test was used to compare patient satisfaction according to sex. The Bonferroni correction for multiple comparisons was used as a post hoc test. All statistical analyses (except the Fisher exact conditional test) were carried out with statistical software (Statistica 9.0; StatSoft Inc) with the level of significance set at 5%.
RESULTS The Fisher exact conditional test for 2 proportions found that the study
4
Volume achieved a computed power of .941 for the experimental groups (SCR, SOI, and CG) and .99 for raters (laypersons and dentists). Participant age ranged from 14.10 to 41.10 years in patients treated with SCR, 19.02 to 45.08 years in patients treated with SOI, and 19.07 to 26.12 years in the CG. No statistically significant differences in sex (P¼.48), type of agenesis (P¼.37), or posttreatment time (P¼.89) were found among the study groups (Table I). The ages of the dentists and laypersons were not significantly different (P¼.08) (Table II). The Cronbach a and ICC indicated a high level of consistency between the first and the second assessments: .96 for the laypersons, .97 for dentists, and .90 for self-raters. Consequently, the ratings obtained in the first assessment were included in the analyses. Multifactorial ANOVA found no statistically significant differences (df¼2; F¼6.41; P¼.64) in the smile attractiveness ratings of laypersons and dentists within any of the groups studied (Table III). However, when the analysis was performed taking sex into consideration, significant differences were observed (df¼1; F¼22.08; P
