This study evaluated the perception of facial esthetics of patients with different profiles as assessed by orthodontists, lay people, and patients.
The sample comprised 120 patients (81 females, 39 males; mean age, 26.3 years) selected from private practices at the onset of orthodontic treatment. The patients were divided into 3 groups of 40 according to the type of facial profile. The groups were composed of straight, concave, and convex profiles, on the basis of the facial convexity angle (G.Sn.Pog’) measured on the initial cephalometric tracings. Patients analyzed only their frontal (smiling and at rest) and profile facial photographs and evaluated the pleasantness of these images on a 5-point Likert scale. A group of 30 orthodontists and 30 lay people also evaluated the patients’ facial pleasantness, using the same scale. Factorial analysis of variance (convexity and sex) was used to evaluate the differences between the convexities, and analysis of variance mixed model (type of evaluator and sex) to compare the 3 categories of evaluators, using the aligned rank transform technique. The correlation between the convexity angle and facial pleasantness was assessed by the Spearman correlation coefficient.
Patients and lay people assigned higher pleasantness scores than orthodontists, with statistically significant differences for all evaluations, except for the frontal analysis of the convex group. The correlation coefficients regarding profile convexity and facial pleasantness were negative, indicating a tendency that more convex or concave facial profiles received lower pleasantness scores; however, this correlation was only significant in the evaluation of profile photographs by orthodontists.
Patients with different profiles were scored with acceptable faces by lay people and patients themselves. Orthodontists’ perceptions were different; they attributed lower pleasantness scores. Discrepant profiles affect facial esthetics in the profile view when judged by orthodontists.
Perceptions of facial esthetics were evaluated in facial photographs.
Profile convexity did not affect the esthetic perceptions of patients or lay people.
Orthodontists assessed facial esthetics more critically, especially in profile.
Discrepant profiles did not influence frontal view evaluation.
The concept of beauty is wide and individual; therefore, the assessment of beauty is extremely subjective. Esthetics play a substantial role in peoples’ lives, and facial appearance has a deep influence on personal attractiveness and self-esteem. The human face is considered the most important individual factor concerning attractiveness.
The criteria to determine the esthetics as acceptable or unacceptable varies according to social and cultural values, and this standard has changed across history. It is important to understand that the perception of dentofacial esthetics should consider the esthetic parameters of the patients and the society in which they belong. , This appreciation of beauty is also influenced by individual factors, such as sex, ethnicity, education, and the influence of marketing and media. , The satisfaction with the face goes beyond the rules. Psychological and ethnic factors influence the perception of patients and should be assessed during orthodontic planning. Comparison between the esthetic perception and facial satisfaction between males and females, as well as adolescents and adults may also be different and should be considered.
The improvement in facial esthetics and smile should be the primary goal of treatment. , Considering the face is important during orthodontic treatment planning because it affects patient satisfaction with the treatment outcomes. , The expectation of improving facial esthetics is an encouraging factor and one of the main reasons leading people to search for treatment.
On the basis of these concepts of beauty, the isolated correction of malocclusion should not be considered successful if the facial esthetics is not satisfactory at treatment completion. The appearance of teeth and smile are components of facial attractiveness, and the soft-tissue contour is also important, constituting an important step in the orthodontic diagnosis and treatment planning. Therefore, the assessment of facial esthetics should be part of the routine of orthodontists, not only in the diagnosis but also during and after orthodontic treatment, considering that most patients search for orthodontic treatment for esthetic purposes, regardless of their functional condition.
This humanized and individualized view of orthodontic treatment concerning the results and defined goals evidences a new scenery in orthodontics. The highly technical standpoint of professionals may lead to treatment failure. Understanding the standpoint of patients in relation to the results achieved may improve the standpoint of professionals because the facial outcomes greatly influence patient satisfaction. ,
The current status of dental research challenges to understand the patients’ perception of their appearance, suggesting that the professional should get closer to the patient’s expectations during treatment planning. Significant differences concerning the perception of the facial profile and dental appearance between patients and orthodontists have been reported.
Regarding the perception of facial esthetics, few studies have evaluated the self-perception of patients with different profile analyzing their own images (not manipulated) and comparing with orthodontists’ and lay people’s assessments. This study aimed to investigate to what extent patients seeking orthodontic treatment perceive deviations from the norm of balanced facial profile comparing to the perception of orthodontists and lay people.
Material and methods
The Research Ethics Committee of the University of North Paraná, Londrina, Paraná, Brazil, under protocol number 2.359.615, approved this study.
The sample calculation was based on the study of McKeta et al. To compare straight, convex, and concave profiles—considering an average standard deviation of 0.669, at a significance level of 5% and power of 80%—we determined that a total of 38 subjects should be included in each group. For comparison between lay people and orthodontists, the same criteria were applied, and each group of examiners should be composed of 30 subjects.
A total of 120 white patients were selected for this study, 81 females and 39 males, aged 15-55 years, with a mean age of 26.3 years. The patients were selected from private practices at the onset of orthodontic treatment, from October 2017 to June 2018. The following inclusion criteria were adopted: aged 15-55 years, complete orthodontic records with photographs on white background without lipstick or beard, permanent dentition without fixed appliances at the onset of orthodontic treatment, and no previous orthodontic treatment.
To classify the facial profile of patients as straight, concave, or convex, a single evaluator (G.H.V.) performed the cephalometric tracings of patients as follows: identified 3 reference points (glabella, subnasale, and soft-tissue pogonion), traced a line joining these points—thus obtaining the facial convexity angle (G.Sn.Pog’)—and measured the supplementary angle. This tracing was obtained on the software Radiocef Studio 2 (version 2.0; Radio Memory Ltda, Belo Horizonte, Brazil). Convexity angle values between 8° and 16° indicated a straight profile, with 12° the reference of ideal value; angle values above 16° characterized a convex profile, and values below 8° the concave profile, on the basis of the analysis of Jacobson. The mean values of the convexity angle for the group of the convex profile was 19.6° (range, 17°-28°) and for the concave profile group was 5° (range, −3° to 7°).
The patients were divided into 3 groups according to the type of facial profile, as shown in Figures 1-6 . The groups were composed of 40 patients each. The straight profile group included 25 females and 15 males , with a mean age of 24.7 years. The convex profile group comprised 28 females and 12 males , with a mean age of 26.2 years. The concave profile group was composed of 28 females and 12 males, with a mean age of 28.1 years.
After the selection of all patients, a photograph album was organized. All photographs were printed on the same size, texture, and paper as the original photograph available on the initial orthodontic record. The distribution of photographs in the album was randomly arranged, and each album page contained the 3 photographs of the same patient, the first smiling, followed by the frontal photograph at rest, and finally the facial profile photograph.
In the appointment before starting the treatment and after information about the study objectives and consent to participate, the patients pointed the reasons that led them to search for orthodontic treatment and analyzed their own facial photographs to evaluate the pleasantness of their smile, frontal and profile views of their faces. This evaluation was performed on a Likert scale comprising 5 options about the pleasantness of the face and facial profile. The 5 responses were presented in increasing order of pleasantness: 1 = very unpleasant , 2 = unpleasant , 3 = acceptable , 4 = pleasant , and 5 = very pleasant .
A group of 30 orthodontists (15 males and 15 females, mean age of 37.2 years) and 30 lay people (15 males and 15 females, mean age of 35.4 years) also analyzed the photograph album of all 120 patients, using the same scale and criteria of pleasantness. Both groups, evaluators and patients, comprised individuals of a single ethnic group (white). The process of assessment of the photographs was conducted without the interference of the researcher, and a limit of 30 seconds per page to analyze the photographs was established.
To evaluate the study reliability, we assessed the method error after 30 days by reevaluation of the facial convexity angle of 40 out of the 120 patients in the sample. The evaluation of photographs of 40 patients was also repeated. All 30 lay subjects and 30 orthodontists reevaluated 40 out of the 120 patients and assigned the scores again for the photographs smiling, frontal, and profile, to assess the method reproducibility.
The data did not present a normal distribution according to the Shapiro-Wilk test. The 3 groups of patients regarding profile convexity did not preset an equal proportion of sex, and this could influence the results of the statistical analysis. In order to correct this effect in the analysis, we opted to perform a factorial analysis, including the sex effect, so the aligned rank transform technique was used. Factorial analysis of variance (convexity and sex) was used to evaluate the differences between the convexities, and analysis of variance mixed model (type of evaluator and sex) to compare the 3 categories of evaluators.
The correlation between the facial convexity angle and facial pleasantness was assessed by the Spearman correlation coefficient. In this case, the angle value is considered as the absolute difference between the value obtained for each patient and the value of 12°, which is the central point of the straight profile, on the basis of the facial convexity angle. All tests were applied at a significance level of 5%. All statistical procedures were performed using SPSS statistical software (version 25; IBM Corp, Armonk, NY).
The intraexaminer error for patients, lay people, and orthodontists was evaluated by the weighted kappa, and the results were interpreted using the classification proposed by Landis and Koch. The kappa ranged from 0.77 to 0.83, 0.75 to 0.76, and 0.62 to 0.71 for patients, lay people, and orthodontists, respectively. The agreement was considered substantial and almost perfect for the patients, and substantial for lay people and orthodontists. The intraexaminer systematic error of the facial convexity angle was analyzed by the paired t test ( P = 0.096; not significant). The casual error was determined by the Dahlberg formula, revealing an error of 0.39.
Regarding the reasons given by the patients who sought orthodontic treatment, 59.2% reported the presence of teeth crowding, 19.2% protruding teeth, and 7.2% difficulty in chewing, among other reasons.
As shown in Table I , no statistically significant differences were found in the comparison of pleasantness scores assigned by the patients for the 3 types of profile, although the patients with straight profile assigned slightly greater pleasantness scores than patients with concave or convex profiles. Regardless of the profile type, the sex of the patients did not significantly affect any of the comparisons; except when patients evaluated their frontal image, which was statistically significant ( P = 0.016), and the scores attributed to the female patients were slightly higher than those attributed to the males.
|Photograph||Profile||Mean||Median||First quartile||Third quartile||P|
|Frontal at rest||Straight||3.3||3.0||3.0||4.0|
When the lay people evaluated the photographs of the 120 patients, no statistically significant difference was found between scores assigned for pleasantness among the 3 types of facial profiles, both in frontal and profile photographs, as shown in Table II .
|Photograph||Profile||Mean||Median||First quartile||Third quartile||P|
|Frontal at rest||Straight||3.4||3.0||3.0||4.0|