Patient- and clinician-perceived need for orthognathic surgery

INTRODUCTION: To better understand why patients believe they need orthognathic treatment, a study was undertaken to examine perceived need for treatment by patients and clinicians. This questionnaire-based study was undertaken at The John Radcliffe Hospital, Oxford, United Kingdom. SUBJECTS AND METHODS: Forty patients were recruited from combined orthodontic-surgical clinics. They were asked to rate their perceived need for treatment based on facial appearance, dental appearance, function, and overall need. Twenty orthodontists and 20 maxillofacial surgeons were asked to rate perceived need for treatment based on the same parameters, using study models and clinical photographs. Ratings were marked on visual analog scales. RESULTS: Significant differences were found between patients and clinicians in perceived need for treatment based on facial appearance (orthodontists compared with patients, P = .023; surgeons compared with patients, P = .001). In addition, maxillofacial surgeons rated a significantly greater overall need for treatment than patients (P = .027), and they rated treatment need based on facial appearance (P = .005) and function (P < .001) significantly higher than orthodontists. CONCLUSIONS: Clinicians rated greater need for orthognathic treatment based on facial appearance than did patients. Surgeons also rated greater overall need for treatment than patients. In addition, surgeons rated treatment need based on facial appearance and function significantly higher than orthodontists, but large variations existed in both clinician groups.     

Professional perceptions of the benefits of orthodontic treatment

The aim of this study was to assess general dental practitioners' and orthodontists' perceptions of the benefits of orthodontic treatment. A specially designed questionnaire was sent to a random sample of 150 general dental practitioners (GDPs) and all orthodontists in Northern Ireland (excluding hospital practitioners) with a postgraduate qualification (n = 29). There was a 93 per cent response rate by the general dental practitioners and all but one specialist practitioner returned the questionnaire. The questionnaire comprised 14 visual analogue scales (VAS) whereby participants were asked to rate the importance of various possible dental health and psychosocial benefits of orthodontic treatment. In addition to the VAS, the influence of dentist variables such as number of years since qualification, orthodontic cases completed, referral rates and attendance at postgraduate lectures were examined. When ratings on the 14 dental health and psychosocial scales were examined overall, GDPs rated an improvement in self-esteem while orthodontists considered an improvement in physical attractiveness as the most important benefit of orthodontic treatment. Even though psychosocial variables received the highest ratings, examination of the mean ratings (and 95 per cent confidence intervals) revealed that some dental health factors were also rated highly by both groups. While the results do indicate an encouraging awareness of the psychosocial benefits of orthodontic treatment, they also suggest that both GDPs and orthodontists have an unrealistic expectation of the dental health gain likely to result from orthodontic treatment.     

Facial-profile attractiveness changes in adult patients treated with the Herbst appliance

Aim

The goal of this study was to compare facial profile attractiveness changes of adult patients treated with the Herbst appliance assessed by orthodontists and laypeople.

Materials and methods

The patient sample comprised 28 adult Herbst patients. Facial profile photographs of the patients were randomly divided into two evaluation sets (before T0, after treatment T1). Ten members of the Angle Society of Europe (orthodontists) and 10 dental students in their third semester (laymen) rated both sets of photographs using Visual Analog Scales (VAS) with an interval of 1 day between the ratings.

Results

On average, both orthodontists and students found an improvement in facial profile attractiveness through Herbst appliance treatment (VAS T1–T0?=?0.3?±?1.9 cm). However, the interindividual perception of profile attractiveness varied greatly in the two rater groups. For both time periods (T0, T1), lower VAS ratings were given by students than by orthodontists.

Conclusion

Herbst therapy in adult patients generally improves facial profile attractiveness. Students rated facial profiles more critically than orthodontists.     

正畸医生与正畸患者对面部美学的评价及其差别

目的 通过Q分类法来调查正畸医生与正畸患者对面部美学的评价及其差别,同时调查男性与女性对面部美学的评价及其差别。 方法 将96例正畸完成后的患者（男、女各48例）临床照片由20名经验丰富的正畸医生（男7名,女13名）和25例正畸患者（男13例,女12例）用Q分类法进行评价。Kappa检验和McNemar检验用来评估正畸医生和正畸患者之间,以及男女之间对面部美学评价是否一致和其差别。 结果 在对男性面部美观调查中,正畸医师与正畸患者的评价具有较高的一致性,男性与女性的评价具有较高的一致性。在对女性面部美观调查中,正畸医师与正畸患者的评价的一致性较差,男性与女性评价的一致性也较差。 结论 正畸医师与正畸患者对面部美观的评价基本一致;男性与女性对面部美学的评价基本不一致。     

Panel perception of facial attractiveness

The full-face and profile photographic transparencies of 60 subjects (30 male, 30 female) divided equally among Angles Class I, Class II Division 1, and Class III malocclusions, taken before and after orthodontic treatment, were randomly distributed in projector carousels and shown to four panels consisting of orthodontists, dental students, art students, and the parents of children undergoing orthodontic treatment. The faces were rated according to the method of Lundstrom et al. (1987). Full-face views generally were rated more attractive than profile views and Class II and Class III malocclusion subjects were rated lower than Class I malocclusion subjects. While the art student and parent panels were less critical in their appraisal of facial attractiveness, they were less sensitive to the changes brought about by orthodontic treatment than the orthodontist and dental student panels, although all could appreciate an improvement in the Class II Division 1 group.     

The B.S.S.O. M.Orth. Prize of the Royal College of Surgeons of England 1998

Abstract

Aim: To determine the relationship between treatment need assessment scores of orthodontists, general practitioners, and pediatric dentists.

Study design: Observational.

Sample: Ten general dental practitioners, 18 orthodontists and 15 pediatric dentists reviewed 137 dental casts and recorded their opinion on whether orthodontic treatment was needed.

Results: We found a high level of agreement between pediatric dentists, orthodontists and general practitioners (Kappa range 0.86–0.95). Between the groups, the amount of agreement was lower.

Conclusions: Orthodontists, general dental practitioners, and pediatric dentists in this sample exhibit high levels of agreement on orthodontic treatment need.     

Rating of facial attractiveness

Epidemiologic investigations of orthodontic treatment should include both objective clinical measures and elements of perceptual assessment in the definition of malocclusion and skeletal disproportion. The effect of dental training and the view of the face presented as a stimulus on judgments of facial attractiveness were evaluated using a method recommended by Howells & Shaw (1) for epidemiologic surveys. Three views (two full face and one profile) of 18 orthodontic patients were presented as stimuli to three panels of judges with different levels of dental training (16 orthodontic residents, 17 dental students, and 71 undergraduate students). Ratings for facial attractiveness were obtained using a visual analog scale. The visual analog scores given the series of 54 slides by each judge were then ranked to create a "location-free" outcome measure. Both the ratings and the rankings of these ratings differed significantly among the three views for 80% of the patients. However, no view was consistently rated or ranked as most attractive across all patients. The ordering of the views from least to most attractive for a given patient appears to be highly dependent on the patient being presented as stimulus. Future studies should consider showing multiple views of a subject simultaneously if the intent is to obtain an overall treatment need score that incorporates assessment of facial attractiveness. The patients were consistently rated as more attractive by the orthodontic residents than by either dental or undergraduate students. When the ranks were analyzed, there were significant differences between the panels but the consistent pattern of differences between the panels disappeared.(ABSTRACT TRUNCATED AT 250 WORDS)     

The Role of the Posed Smile in Overall Facial Esthetics

Objective:To evaluate the role of the posed smile in overall facial esthetics, as determined by laypersons and orthodontists.Materials and Methods:Twenty orthodontists and 20 lay evaluators were asked to perform six Q-sorts on different photographs of 48 white female subjects. The six Q-sorts consisted of three different photographs for each of two time points (pre- and posttreatment), as follows: (1) smile-only, (2) face without the smile, and (3) face with the smile. The evaluators determined a split-line for attractive and unattractive images at the end of each Q-sort. The proportions of attractive patients were compared across Q-sorts using a Wilcoxon signed-rank test for paired data. The evaluators also ranked nine facial/dental characteristics at the completion of the six Q-sorts.Results:Evaluators found the pretreatment face without the smile to be significantly more attractive than the face with the smile or the smile-only photographs. Dissimilar results were seen posttreatment; there was not a significant difference between the three posttreatment photographs. The two panels agreed on the proportion of “attractive” subjects but differed on the attractiveness level of each individual subject.Conclusions:The presence of a malocclusion has a negative impact on facial attractiveness. Orthodontic correction of a malocclusion affects overall facial esthetics positively. Laypeople and orthodontists agree on what is attractive. Overall facial harmony is the most important characteristic used in deciding facial attractiveness.     

The use of anthropometric proportion indices in the measurement of facial attractiveness

This study used anthropometric data in the form of Farkas' proportion indices in order to quantify facial attractiveness, and to relate measured change through surgery, to clinical judgement. Standardized photographs of 15 orthognathic patients were used in album form and rated by 10 experienced clinicians: album 1 for facial attractiveness (before surgery) and album 2 for improvement in facial attractiveness (before and after surgery). Twenty-five proportion indices were selected and linear measurements recorded from the pre- and post-surgical photographs. The corresponding change in indices and in clinicians' scores were compared. The clinicians' assessment of the degree of improvement in facial appearance achieved through surgery, related closely to the scores produced by the change in proportion indices (r = 0.698, P = 0.004). Clinical assessment demonstrated a clear inverse relationship between initial attractiveness rating and the degree of improvement achieved through orthognathic surgery (r = -0.781, P = 0.001). The results showed good repeatability in terms of clinical assessment, photography and digitization. The method would appear to have potential for further development, possibly into a 'facial attractiveness index' for the objectives of quantification of improvement achieved through treatment.     

Consistency of orthodontic treatment decisions relative to diagnostic records

The purpose of this study was to evaluate how incremental information obtained from different types of diagnostic records contributes to the determination of orthodontic treatment decisions. Pretreatment records of 57 orthodontic patients were assessed by five orthodontists who were part-time faculty members and also in private practice. This sample consisted of dental school orthodontic patients who had Class II malocclusions and included patients at three different dental developmental stages. The following diagnostic records were used: study models (S), facial photographs (F), a panoramic radiograph (P), a lateral cephalogram (C), and its tracing (T). Five combinations of diagnostic records were presented to the orthodontists in the following sequence: (1) S; (2) S + F; (3) S + F + P; (4) S + F + P + C; and (5) S + F + P + C + T. The simultaneous interpretation of all diagnostic records (S + F + P + C + T) was used as the "diagnostic standard." There was a diagnostic standard for each of the patients and for each of the orthodontists. The diagnostic standard was achieved: (1) S = 54.9%, (2) S + F = 54.2%, (3) S + F + P = 60.9%, and (4) S + F + P + C = 59.9%. Thus, in a majority of cases (55%), study models alone provided adequate information for treatment planning, and incremental addition of information from other types of diagnostic records made small differences.     

Examiner Differences in the Assessment of Different Malocclusions

BACKGROUND: In the current discussion about ensuring treatment quality and reducing costs in the health sector, indication systems with which to determine the need for a treatment and the success of therapy are increasingly being used in orthodontics. These indication systems require the objective evaluation of malocclusions. Our objective was to determine the examiner reliability in the assessment of various malocclusions. MATERIALS AND METHODS: In 180 adults (64 male, 116 female, aged 20-49) from the population-based Study of Health in Pomerania (SHIP), malocclusions were recorded clinically and on models by calibrated examiners. An experienced orthodontist conducted the clinical examination. Another orthodontically-experienced examiner analyzed the models. To compare the model examiners, two examiners with varying degrees of orthodontic experience evaluated 60 of the 180 models as well (29 male, 31 female). One of the model examiners repeated the assessment of 60 models at a later time (intra-individual comparison). RESULTS AND CONCLUSIONS: Reliability amongst the examiners depended on which malocclusions were judged: crowding and contact point displacement showed little agreement, while cross bite, edge-to-edge bite, deep bite and enlarged overjet revealed greater agreement. Comparison between the clinical examination and model analysis (kappa median 0.57) revealed the greatest differences between the examiners. Comparison of the three model examiners also showed differences. The contrast to the orthodontically least experienced examiner was greater (kappa median 0.61 and 0.62) than the divergence between the two orthodontically more experienced examiners (kappa median 0.70). The intra-individual examiner comparison revealed the smallest differences (kappa median 0.82).     

Evaluation of the aesthetic component of the Index of Orthodontic Treatment Need by Swedish orthodontists

The aim of the present study was to evaluate if the majority of orthodontists in Sweden agree with the ranking of the photographs in the aesthetic component (AC) of the Index of Orthodontic Treatment Need (IOTN), and its treatment need classification. Ten separate colour photographs (originals from the AC) and two questionnaires were sent to 272 orthodontists in Sweden. Eighty-one per cent (219) returned one or both questionnaires. One hundred and ninety-four orthodontists answered the AC 'grading of dental attractiveness' and 217 the AC 'need for orthodontic treatment' (nine of the integrated questions had to be excluded because more than one alternative had been chosen). The aesthetic ranking by the orthodontists was compared with the original AC and the deviation was estimated.The results showed that the grading of photographs 2-9 varied greatly among the orthodontists, but the agreement was almost complete for photographs 1 and 10. The establishment of treatment need for each photograph had good agreement with the original index for photographs 1, 2, and 8-10, while the majority of the orthodontists considered that photographs 5 and 7 should be treated and that photograph 6 showed a borderline case. The participating Swedish orthodontists' aesthetic ranking of the photographs was: 1, 2, 3, 4, 6, 5, 7, 9, 8, and 10. Regarding treatment need, no need for treatment was set for photographs 1-4, borderline for photograph 6 and a need for treatment for photographs 5, 7-10. Further studies are needed to evaluate if laymen in Sweden make the same judgements as Swedish orthodontists.     

The relationship between posttreatment smile esthetics and the ABO Objective Grading System

OBJECTIVE: To evaluate the correlations between the components of the Objective Grading System developed by the American Board of Orthodontics (ABO) and smile esthetics. MATERIALS AND METHODS: The clinical photographs of 48 orthodontically treated patients were rated by a panel of 25 experienced orthodontists (15 men and 10 women) and 20 parents of orthodontic patients (eight men and 12 women). One of the investigators, a director of the ABO, scored the posttreatment dental casts and panoramic radiographs of all patients according to the guidelines of the Objective Grading System. The relationship between the occlusal outcome and perceived smile attractiveness of the subjects were evaluated by a Pearson product-moment correlation. Logistic regression was used to determine whether the individual component or total combined scores of the ABO Grading System could predict whether a smile would be considered "attractive" or "unattractive" by the panel of raters. RESULTS: Extremely weak relationships were found among all factors of the ABO Objective Grading System and perceived smile attractiveness (r values ranging from -0.11 to 0.14; P > .05). As derived from logistic regression equations, neither total scores nor individual components of the ABO Grading system could predict attractive or unattractive smiles. CONCLUSIONS: This study suggests that additional criteria might be incorporated into the assessment of overall orthodontic treatment outcomes, including variables evaluating the smile.     

Evaluation of the peer assessment rating (PAR) index as an index of orthodontic treatment need.

The need for orthodontic treatment has an objective component based on occlusal traits and a subjective component based on the esthetic impact of the occlusion. An occlusal index that measures the objective deviation from normal or ideal occlusion might be sufficient to mirror the subjective opinion of orthodontists about treatment need. The objective of this study was to determine whether the American (US) and United Kingdom (UK) weightings of the peer assessment rating (PAR) index are valid instruments with which to determine treatment need. Fifteen orthodontists rated the need for orthodontic treatment of 170 casts. Their collective decision was compared with the PAR value for the cast determined by a calibrated examiner. A range of suggested treatment cutoff points from the literature was used to generate receiver operating characteristic (ROC) curves and optimized cutoff points. The cutoff points were 17 for both the US PAR and the UK PAR, and sensitivity, specificity, and kappa were 92%, 86%, and 0.77 for the US PAR and 92%, 89%, and 0.80 for the UK PAR. The area under the ROC curve was 97% for the US PAR and the UK PAR. Both the US PAR and the UK PAR scores were excellent predictors of orthodontic treatment need as determined by a panel of orthodontists. An occlusal index used to measure deviation from normal or ideal occlusion might perform as well as indexes of treatment need in predicting orthodontists' evaluations of treatment need.     

Perceptions of dentofacial morphology by laypersons, general dentists, and orthodontists.

Line drawings of facial profiles and color photographs of dentitions were evaluated subjectively by 1,150 parents, 72 general practictioners of dentistry, and 54 orthodontists with regard to the normality and abnormality in dentofacial morphology and the need for orthodontic treatment. A significant difference was found between the evaluations of the parents and the professional groups in ten of the 11 facial profiles and in seven of the 11 photographs of dentitions. In general, the parents considered more of the examples acceptable and not requiring orthodontic treatment than did the professional groups. The dentists and orthodontists deviated significantly in their ratings onjy in their judgement of "ugly duckling" example (picture 22, higher abnormal rating by the dentists) and the profile example 10 (higher abnormal rating by orthodontists). number of orthondontists may have associated the conditions in picture 10 with a Class II, Division 2 malocclusion and, as such, scored it abnormal.     

Facial attractiveness: A longitudinal study

BACKGROUND: The aim of the study was to investigate various factors that might affect facial attractiveness from ages 11 to 31 years. METHODS: Sixty subjects were selected from a sample participating in the longitudinal Cardiff Survey. Three-quarter-view facial photographs were taken of the subjects smiling and not smiling. Photos were taken in 1981, when the subjects were aged 11 years, and in 2001, when they were aged 31. Twelve judges used a 9-point Likert scale to evaluate overall facial attractiveness and the attractiveness of various facial features. The judges were also asked to estimate the adults' ages. Univariate and multivariate statistical tests and the generalizability theory were used. RESULTS AND CONCLUSIONS: Overall facial attractiveness does not depend on any single feature; smiling and youthful facial appearance make women look more attractive; facial attractiveness tends to decrease over time from ages 11 to 31; people tend to retain their relative levels of attractiveness throughout their life spans; orthodontic treatment improves dental appearance, but it does not necessarily make a person more attractive in the long term. Nevertheless, the positive effect of orthodontic treatment could still be observed, especially in men with lower levels of facial attractiveness in childhood.     

Upper canine inclination influences the aesthetics of a smile

This current study investigated which angle of canine inclination (angle between canine tooth axis (CA‐line) and the line between the lateral canthus and the ipsilateral labial angle (EM‐line)) is perceived to be most attractive in a smile. The second objective was to determine whether laymen and dental experts share the same opinion. A Q‐sort assessment was performed with 48 posed smile photographs to obtain two models of neutral facial attractiveness. Two sets of images (1 male model set, 1 female model set), each containing seven images with incrementally altered canine and posterior teeth inclinations, were generated. The images were ranked for attractiveness by three groups (61 laymen, 59 orthodontists, 60 dentists). The images with 0° inclination, that is CA‐line (maxillary canine axis) parallel to EM‐line (the line formed by the lateral canthus and the ipsilateral corner of the mouth) (male model set: 54·4%; female model set: 38·9%), or ?5° (inward) inclination (male model set: 20%; female model set: 29·4%) were perceived to be most attractive within each set. Images showing inward canine inclinations were regarded to be more attractive than those with outward inclinations. Dental experts and laymen were in accordance with the aesthetics. Smiles were perceived to be most attractive when the upper canine tooth axis was parallel to the EM‐line. In reconstructive or orthodontic therapy, it is thus important to incline canines more inwardly than outwardly.     

Inter-examiner variability in orthodontic treatment decisions for Danish children with 'borderline' treatment need

This study explored the variation between examiners in the orthodontic treatment need assessments of fifth-grade children with a borderline orthodontic treatment need. Each of three groups of children with borderline treatment need (n = 18, 19, and 19, respectively) were examined by one of three groups of orthodontists (33 in each group), whereby each of 56 children had 33 orthodontic treatment need assessments based on a clinical examination. This treatment need determination exercise was subsequently repeated with treatment need determined based on study casts and extraoral photographs. The proportion of positive treatment decisions based on the clinical examination was 49.3, 49.6, and 52.5 per cent, respectively, and 45.7, 46.3, and 50.5 per cent, based on the model assessments. There was a considerable disagreement between examiners in the treatment need assessments, whether assessments were based on a clinical examination or on a model-based case presentation. The average percentage agreement between two orthodontists for the treatment need based on clinical examination was 69, 66, and 61, respectively, corresponding to mean kappa values of 0.38, 0.32, and 0.22. When the model-based assessments were considered, the average percentage agreement between two orthodontists was 62, 58, and 69, respectively, corresponding to mean kappa values of 0.25, 0.16, and 0.37. Linear regression analysis of the orthodontists' treatment propensity as a function of their gender, place of education, years of orthodontic treatment experience, type of workplace, and place of work showed that only the orthodontic experience was influential for the model-based treatment propensity [β = 0.34 per cent/year (95 per cent confidence interval = 0.01-0.66)].     

A comparison of the reliability and validity of 3 occlusal indexes of orthodontic treatment need.

Several occlusal indexes are currently used to ascertain eligibility for orthodontic treatment. A comparison of 3 indexes of orthodontic treatment need was made with the consensus opinion of a panel of 15 experienced orthodontists. Sets of study casts (170) representing the full spectrum of malocclusions were selected. An examiner, calibrated in the Dental Aesthetic Index, the Handicapping Labiolingual Deviation with the California Modification, and the Index of Orthodontic Treatment Need, scored the casts. The panel of orthodontists individually rated the same casts for their degree of orthodontic treatment need. The mean rating of the panel on the need for treatment was used as the gold standard for evaluating the validity of the indexes. Intrarater and interrater reliability was high (kappa > 0.8). Overall accuracy of the indexes, as reflected in area under receiver-operating characteristic curves, was also high: Dental Aesthetic Index, 95%; Handicapping Labiolingual Deviation with the California Modification, 94%; and Index of Orthodontic Treatment Need, 98%. Cutoff points for the indexes that resulted in the closest agreement with the gold standard differed from the published cutoff points for the indexes. The indexes appear to be valid measures of treatment need as perceived by orthodontists. The published cutoff points for the indexes were more conservative in assigning patients for treatment than a panel of orthodontists. However, adjusting the cutoff points moved all 3 indexes into close agreement with the experts.     

Influence of orthodontic appliances on visual attention to smiling faces by eye-tracking evaluation

The influence of wearing orthodontic appliances on visual attention to smiling faces is not well understood. The purpose of this study was to investigate how laypeople viewed a frontal posed smiling face with orthodontic appliances compared with orthodontists. Frontal posed smiling facial photographs of 10 female models without an appliance or wearing clear tray, ceramic, or metal appliances were taken, and areas of interest (AOIs) for the eyes, nose, and mouth were determined. Visual attention from 43 laypeople and 42 orthodontists was evaluated for each image using an eye-tracking system. Total fixation time for each AOI was calculated and analyzed by three-way repeated measures analysis of variance and Tukey–Kramer multiple comparison tests (P < 0.05). The layperson group spent significantly more time looking at the mouth with ceramic and metal brackets than without brackets, similar to the orthodontist group (P < 0.001 and 0.001, respectively). Though the orthodontist group spent significantly more time looking at the mouth with metal brackets than the mouth with ceramic brackets (P < 0.040), no significant difference was noted in the layperson group. Under all appliance conditions, the layperson group spent significantly more and less time looking at the eyes and mouth than the orthodontist group, respectively (P < 0.001 and 0.001, respectively). These findings suggest that it may help patients who will start orthodontic treatment to understand an individual’s interest in the appearance of the orthodontic appliance, and orthodontists to counsel patients at the orthodontic appliance selection stage during the diagnosis.