Introduction
Appreciation of the soft-tissue profile is important in orthodontic diagnosis and treatment. However, are the patients themselves aware of their profile appearance? We aimed to evaluate if age influences self-perception of the soft-tissue profile in children.
Methods
The study population for this prospective cross-sectional investigation consisted of 3 groups of 60 patients, classified according to age (<12 years; 12-15 years; >15 years). Each subject’s right-sided facial profile was photographed to obtain a silhouette. Facial profile silhouette templates were created to represent the local population. Each subject’s photograph was inserted into the corresponding template, and the subjects were asked to identify themselves. Facial profile self-recognition was recorded as a binary variable (yes or no). Other recorded variables included age, sex, and sexual maturity rating (using Tanner staging). Chi-square tests were used to analyze facial profile self-recognition between different subgroups, and stepwise multiple regression was used to predict the probabilities of facial profile self-recognition, with age, sexual maturity rating, and other recorded variables as independent variables.
Results
Eighty percent of subjects aged >15 years recognized their own profile, compared with only 55% and 50% of subjects aged 12-15 years and <12 years, respectively. Subjects aged >15 years were significantly more likely to recognize their profile than younger subjects ( P = 0.001). Similarly, subjects with the most advanced sexual maturity rating (stage V) were significantly more likely to recognize their profile (85% self-recognition) than those in groups I-IV ( P <0.001). Girls were more likely to recognize their profiles than boys ( P = 0.028). When using multiple regression analysis, sexual maturity rating appears to be the only significant predictor for facial profile self-recognition ( R 2 = 0.25; P <0.001).
Conclusions
Facial profile self-recognition seems to improve with age and sexual maturity (sexual maturity rating stage V). Because orthodontic treatment planning takes possible soft-tissue changes into account, it is important to evaluate the degree of self-perception of the patients to adapt our goals and treatment discussions.
Highlights
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Approximately half of the children aged <15 years do not recognize their own profile.
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Facial profile self-recognition is more predominant in older and more sexually mature children.
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Girls may be more likely to recognize their own profiles than boys.
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Being aware of these patterns can help orthodontists convey information age appropriately.
Soft-tissue esthetics is of major concern in orthodontic treatment planning. Orthodontists tend to focus on findings from the soft-tissue profile examination, which constitutes part of their diagnostic workup, using these findings for treatment planning. This approach is evident when looking at the number of recent meta-analyses that focus on profile changes after treatment, such as comparing treatment with or without extractions, comparing space closure with en masse retraction vs 2-step retraction, comparing outcomes with orthodontic camouflage vs orthognathic surgery in Class II malocclusion, or looking at the treatment of dentoalveolar protrusion using maximum anchorage.
After the taking of initial orthodontic records, the effect of the soft-tissue profile on treatment choice and the effect that orthodontic treatment can have on the soft-tissue profile is discussed with patients and their families before the beginning of treatment. Depending on the objectives of treatment, the soft-tissue profile can be improved or worsened. Thus, it is important to inform the patient about the potential changes on their soft-tissue profile, based on the best available evidence. However, the relevance this may have for the patient is not always clear, and this may also be age-dependent, differing between adolescent and younger patients. Although using objective outcomes to quantify soft-tissue profile characteristics may help the treatment planning process, patients’ perceptions may differ. In our search for perfection, our definition of normality may be influenced by what we consider ideal, which may not be consistent with the patient’s perception of normal. Studies have pointed out that laypersons are less critical when evaluating soft-tissue profiles than orthodontists.
Fleming et al ask a pertinent question: “Are dental researchers asking the right questions?”. It has been shown that most outcomes used in orthodontic research do not reflect patient perspectives. Another relevant question may be, to what extent do we as orthodontists essentially ignore the perception of the patient and their family on their profile and its influence on the motivation for orthodontic treatment? Interestingly, Øland et al found that in a group of patients undergoing orthognathic surgery, the preoperative facial profile type did not have any influence on the motives to seek and undertake treatment.
When considering the soft-tissue profile, one question that arises is, how much are patients aware of their own profile? Johnston et al asked a group of adult laypersons and potential orthognathic patients whether they had seen their profile, and approximately two thirds stated that they had. It was also found that Class III orthognathic surgical patients, women, and older subjects were more likely to have seen their profile. It has also been claimed that laypersons are not generally aware of their facial profiles unless exposed to photographs. A small number of studies have investigated self-perception of the soft-tissue profile, using methods in which the participant is asked to choose a profile from constructed images that most resembles their own, and found that the self-perception of the profile is generally poor. Only 1 study using the participants’ own profile photographs to evaluate self-perception found that self-perception is rather accurate. It is important to detect early enough any misperception a patient could have of their own profile. Orthodontists, together with patients, need to align their perceptions of the patient’s profile to ensure good communication and avoid misunderstandings.
Logically, it is more likely that adult patients are conscious of the appearance of their profile, whereas children and teenagers, who constitute the majority of our orthodontic population, may be less so. To guarantee a good age-appropriate communication between the practitioner and the patient, practitioners need to know whether the patient understands what the soft-tissue profile is and if they are aware of their own profile. The present study aimed to evaluate if age influences self-perception of the soft-tissue profile in children.
Material and methods
The present prospective cross-sectional study was given authorization after a written request to the local ethics committee (CCER_Req-2017-00963). Before participation, written informed consent was obtained from each patient and their parent or legal guardian if aged <18 years.
All subjects were recruited from the Department of Pediatrics at the University Hospitals of Geneva from April 2018 to September 2019, including patients coming to different outpatient clinics or the adolescent medicine clinic.
The participants were divided into 3 groups according to their age, with the intent of having 3 equally sized groups. The 3 age groups were as follows: <12 years, 12-15 years, and >15 years. The separation between these 3 age groups was suggested by an experienced pediatrician (M.C.) based on pubertal development. It was decided to divide patients on the basis of age because this information is easily available to every clinical orthodontist. To calculate the desired sample size, we conducted an initial pilot study on 35 students within the dental school, and 89% of this group demonstrated soft-tissue profile self-recognition. Based on these results, and the findings from a study by Tufekci et al looking at profile perception, the sample size for the present study was calculated to be able to find a 21% difference (based on the difference between groups in the aforementioned study) in profile recognition between the different age groups, with the oldest age group presenting 89% recognition (as per our pilot study), with an alpha P value of 0.05, and a power of 80%. The calculated required sample size was 59 patients per group, and we thus decided to include a total of 60 patients per group.
To recruit an appropriate number of patients within each age group, we previously reviewed the lists of pediatric consultations to identify patients with ages matching the desired study groups. Then patient recruitment was carried out in the waiting area. While waiting for their appointment with the pediatrician, all patients were asked by a single orthodontist (V.V.) if they were willing to participate in the study, with sufficient explanations being given. Inclusion criteria were patients aged from 9 to 20 years, without any apparent craniofacial abnormalities or deformities. Once the required number of patients were included for 1 group, no more patients were approached within that age range, and recruitment was continued for the remaining groups.
Each individual’s soft-tissue profile was photographed with a Nikon Digital SLR Camera D70 (Nikon Photo Products, Tokyo, Japan) set up with a 105-mm objective at 2 m from the subject. Pictures were taken with the patient at rest and in a way that only the silhouette was visible. Any details of the face were imperceptible because only the shadow of the profile was photographed with a small aperture opening and light coming from behind the participant. The picture was then modified with PowerPoint (Microsoft, Redmond, Wash) by cropping so that details of the hair could not be seen and transforming it to full black and white ( Fig 1 ), similar to what has been used in previous studies. All photographs were taken by the same orthodontist (V.V.) under the same conditions.
Different templates were generated to standardize the process of recognition by selecting various profile photographs from the pool of orthodontic patients of our University clinic. Efforts were made to include different profile types and patients of different ethnic backgrounds to represent the diversity of the local population. These template profile pictures were then darkened with the same process on PowerPoint. The generation of templates was as follows: two templates were produced with 9 photographs each, for each of the age groups (<12 years, 12-15 years, or >15 years), 1 for female patients and 1 for male patients, making a total of 6 templates. The placement of the photographs in the templates was standardized with 2 rows of 5 profile silhouettes, leaving the ninth position empty (second from the right on the bottom row). This position was left blank to incorporate the profile silhouette of the study subject. An example of a template is shown in Figure 2 . Once the study silhouette was added to the corresponding template (according to age group and sex), the individual was asked to identify themselves within the template containing 10 silhouette profiles.
Besides profile recognition, other variables recorded for each participant were sex, age, the reason for the pediatric consultation, history of previous or active orthodontic treatment, and sexual maturity rating (Tanner staging). The included sample was diverse concerning the reason for consultation. Five main categories appeared: eating disorders, chronic diseases, psychosocial issues, psychiatric issues, and somatic complaints.
The sexual maturity rating, which is an objective classification system used to evaluate the development and sequence of secondary sex characteristics of children during puberty, comprising 5 stages with stage I corresponding to no signs of sexual maturity and stage V corresponding to completed sexual development, was evaluated by 2 pediatricians (M.C. and C.S.). The 2 pediatricians had been previously calibrated to each other in the use of this rating. Finally, the participants were also asked, in the form of an open-ended question, which part of the profile they look at to help them recognize their profile.
Statistical analysis
Statistical analysis was performed using SPSS (version 25; SPSS, Chicago, Ill). Initially, chi-square tests were performed to compare the percentage of facial profile self-recognition on the basis of age group, sexual maturity rating, sex, the reason for pediatric consultation, and history of previous or active orthodontic treatment. To compare the proportions of recognition between each group, we performed chi-square tests. Subsequently, stepwise multiple linear regression analysis was performed to evaluate the influence of the studied variables on facial profile self-recognition.
Results
A total of 180 subjects took part in the study, from an initial 182 subjects approached. Two subjects refused to participate. The included subjects were aged from 9 to 20 years, with 117 female and 63 male subjects. Three equally sized groups of 60 subjects, who had been defined a priori , were formed on the basis of age: <12 years, 12-15 years, and >15 years, respectively. Baseline data concerning the 3 age groups are presented in Table I .
