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PERCEPTIONS OF FACIAL ATTRACTIVENESS: OUTCOMES OF ORTHOGNATHIC SURGERY by BRITTANY REID CHUNG HOW KAU, COMMITTEE CHAIR AMJAD JAVED NATHANIEL LAWSON NADA SOUCCAR A THESIS Submitted to the graduate faculty of The University of Alabama at Birmingham, in partial fulfillment of the requirements for the degree of Master of Science BIRMINGHAM, ALABAMA 2015 PERCEPTIONS OF FACIAL ATTRACTIVENESS: OUTCOMES OF ORTHOGNATHIC SURGERY BRITTANY REID DEPARTMENT OF ORTHODONTICS ABSTRACT Perceptions of physical attractiveness contribute to generalized assumptions that can create significant bias in social decision-making. Because these biases exist, patients often seek ways to improve facial harmony and overall appearance. Orthodontics and orthognathic surgery are treatment modalities that may be considered as a means to achieve facial balance. Orthodontists and oral surgeons must have an understanding of facial beauty and how to properly carry out techniques in order to preserve or improve facial balance. More importantly, the treatment goals of the patient and clinician(s) must coincide. The objectives of this study were to evaluate perceptions of orthognathic surgery outcomes, evaluate whether panels of observers with different levels of orthodontic experience assess facial attractiveness similarly, and to determine what soft tissue features influence assessment of facial attractiveness. In a three-part questionnaire, laypersons, dental students, orthodontic residents, orthodontists, oral surgery residents, and oral surgeons were asked to rate facial attractiveness of surgical and non-surgical patients, select a preference for surgical “before-and-after” photographs, and rank facial features that contribute to facial attractiveness. Although assessors perceived postsurgical patients as less attractive than non-surgical patients, a far greater percentage of assessors preferred the post-surgical face to the pre-surgical face. The association between attractiveness rating and treatment modality (surgical vs. non-surgical) did not vary by the assessor’s background. There seems to be no consensus on a hierarchy of ii facial features that contribute to facial attractiveness; however, based on the overall average rank, raters perceived the eyes and nose as contributing most to facial attractiveness, and the nasolabial angle, labiomental sulcus, and chin-neck contour contributing the least. Keywords: orthognathic surgery, facial attractiveness iii ACKNOWLEDGMENTS I would like to acknowledge Drs. Chung How Kau, Amjad Javed, and Nathaniel Lawson for their willingness to serve as members of my committee. I appreciate the thoughtful counsel provided by each of these members throughout this project. I would like to express the deepest appreciation to my faculty mentor, Dr. Nada Souccar. Without her guidance, patience, and encouragement, this thesis would not have been possible. The unending support she has provided me during residency has been invaluable. Sincere gratitude is extended to those who agreed to participate in this study, to Kelli Eberhardt for providing countless hours of data entry, and to Dr. Russell Griffin who so graciously assisted me in the organization, analysis, and interpretation of the data. I would also like to express gratitude to my family who has supported me throughout my education, and to my loving husband Kaleb for his unwavering love and encouragement. Most importantly, I am thankful for our Almighty God as the source of all knowledge and the provider of many blessings. iv TABLE OF CONTENTS Page ABSTRACT ........................................................................................................................ ii ACKNOWLEDGMENTS ................................................................................................. iv LIST OF TABLES ............................................................................................................. vi LIST OF FIGURES .......................................................................................................... vii CHAPTER 1 INTRODUCTION ............................................................................................................1 2 LITERATURE REVIEW .................................................................................................3 3 AIMS AND HYPOTHESES ..........................................................................................23 4 MATERIALS AND METHODS ....................................................................................24 5 RESULTS .......................................................................................................................32 6 DISCUSSION .................................................................................................................47 7 CONCLUSIONS.............................................................................................................56 LIST OF REFERENCES ...................................................................................................57 APPENDIX: IRB APPROVAL .........................................................................................60 v LIST OF TABLES Table Page 1 Surgical patients for assessment ..................................................................................37 2 Non-surgical patients for assessment ...........................................................................38 3 Basic demographics of raters participating in study ....................................................39 4 Characteristics of dental raters participating in the study as given in N(%) ................40 5 Basic demographics of layperson raters participating in study ...................................41 6 Comparison of mean attractiveness ratings by type of rater and stratified by age and gender of rating subject ................................................................................................42 7 Comparison of attractiveness preference before and after orthognathic surgery stratified by age and gender of rating subject ..............................................................43 8 Comparison of mean rankings of facial features’ contribution to facial attractiveness by type of rater .............................................................................................................44 9 Rankings of facial features’ contribution to facial attractiveness by type of rater ......44 10 Intraclass correlation coefficients and 95% confidence intervals for facial feature rankings and attractiveness ratings ..............................................................................45 11 Kappa agreement statistic for choice of whether the pre-surgery or post-surgery face was more attractive...............................................................................................46 vi LIST OF FIGURES Figure Page 1 The Visual Analog Scale (VAS) ..................................................................................25 2 Composite of extraoral photographs ............................................................................27 3 Extraoral photographs for comparison.........................................................................28 4 List of facial features to be ranked by the assessors ....................................................29 5 Pre-treatment and post-treatment composites of surgical patients ..............................30 vii 1 CHAPTER 1 INTRODUCTION Human attraction has inherently become a major focus of our culture. Although there are many components that lead to one person’s attraction to another, modern society places emphasis on physical attraction. Physical attraction is a multifaceted concept and can be defined differently depending on cultural norms and individual subjective preferences.1 Perceptions of physical attractiveness contribute to generalized assumptions that can create significant bias in social decision-making. Because these biases exist, patients often seek ways to improve facial harmony and overall appearance. Orthodontics and orthognathic surgery are treatment modalities that may be considered as a means to achieve facial balance in some of these patients.2, 3 Clinicians have a duty to present all pertinent information, including risks and benefits of each treatment option, to a patient so that they may make an informed decision about what treatment is best for them. When presented with the option of orthognathic surgery, most patients will rely on both the orthodontist and oral surgeon to collect enough information to adequately diagnose a case before treatment options are presented.4, 5 This team of clinicians must have an understanding of facial beauty, know how to evaluate facial form, and know how to properly carry out techniques in order to preserve or improve facial balance.4, 5 It is critical for the clinician to assess whether or not the patient’s goals are reasonable and obtainable. It is equally important for the clinician to have a general level of agreement with the patient, the patient’s family and 2 peers, and the general public about what an esthetic outcome would be. Once the case has been appropriately diagnosed, the orthodontist and oral surgeon must formulate a treatment plan and should be confident that an invasive procedure is worth the risk if orthognathic surgery is proposed as an option. This is particularly important in “borderline” cases in which it is less obvious that orthognathic surgery is necessary to correct an esthetic problem.6 It is assumed that if a proper diagnosis is made, and techniques are carried out without fault, then the outcome of a surgical procedure will be a success. But, what if the clinicians planning the case and the patient have a different perception of what is attractive, and the goals of treatment are inadvertently different from the start? Or, what if the clinicians’ and patient’s general perceptions of facial attractiveness are similar, but translation and execution of these treatment objectives fall short? Is the orthodontic and surgical team routinely producing a face that is more acceptable when perceived by the lay public? Can a post-surgical patient expect to be perceived as equally attractive as their non-surgical peers? The primary objective of this study is to evaluate perceptions of orthognathic surgery outcomes. Is the “post-surgical face” perceived as attractive? How does the “post-surgical face” compare in attractiveness to the average (non-surgical) face? The secondary objectives of this study are (1) to evaluate whether panels of observers with different levels of orthodontic experience assess facial attractiveness similarly and (2) to determine what soft tissue features influence assessment of facial attractiveness. The results of this study would provide clinicians with more information that would assist patients in treatment decisions. 3 CHAPTER 2 LITERATURE REVIEW Historical perspective Prehistory-Ancient Egypt: Evolution of the Idealized Facial Form Artistic renderings from the Stone Age contain little representation of human form. This finding is likely due to the fact that prehistoric man was so consumed with survival tactics that he had little time to express esthetic awareness. When the human form was presented in Paleolithic art, it is described as “vague, grotesque, and distorted.”1 This representation of the human form is likely not because humans during this period were grossly unattractive. Instead, this finding reflects the culture during that time period – conscious considerations of esthetics were simply not a priority.1 Concepts of beauty and attractiveness first became a focus of cultural art during the time of the ancient Egyptians (2600-2000 BC).7 The statues created of Egyptian royalty often were idealized versions of the individual and showed only vague resemblance to the subject. These renderings depicted well-balanced facial features, harmonious proportions, and symmetry. Individuals of lower social stature were often depicted more realistically.1, 8 The Greeks and Romans: Expanding the Concept of Aesthetics The ancient Greeks expanded on the concept of “aesthetics” to encompass human emotion in addition to physical beauty.1, 9 Although they took a more philosophical 4 approach, Greek philosophers still urged that “beautiful creations” followed certain geometrical laws.7 It was during this period that sculptures of the human form adhered to certain geometric rules or canons that stressed “ideal bodily proportions and harmonious anatomic relationships in human representation.”1 Ancient Greek mathematicians and artists can also be credited with first describing the concept of the golden proportion.1, 6, 9 This geometrical concept suggests that if a line is divided into two parts, the longer part divided by the smaller part is also equal to the whole length divided by the longer part. This ratio is seen in certain design elements in ancient history as well as naturally occurring phenomenon, including the human face. The concept suggests the emphasis on the proportion of vertical or horizontal parts to the whole as being esthetically pleasing.1, 6, 9 Greek philosophers adhered to the importance of balance in beautiful things. According to Plato, “The qualities of measure and proportion invariably constitute beauty and excellence.”6 It was during the Golden Age of Greece that principles, or canons, for ideal facial form were established.6, 8 The Romans also expressed vast interest in the human form through art and sculpture. They appreciated the idealized human form, but adopted a more realistic interpretation of their subjects in sculpture.1, 7, 8 The Romans are historically known for depicting a harmonious facial form.1, 10 After the collapse of the Roman Empire, the focus shifted from outward physical beauty to a more introspective spiritual beauty.1, 7 This suppression in the focus on physical beauty continued until the Renaissance. The Renaissance: Reemergence of Realistic Esthetics Artists of the Renaissance like Leonardo Da Vinci (1452-1519) and Michelangelo (1475-1564) had a strong influence on the reemergence of esthetics in cultural art. 5 Michelangelo’s work captured a realistic representation of the human form.1 His sculpture David epitomizes the esthetic ideal of the Italians during his time.1 Da Vinci further defined ideal proportion by intense study of the human form and applied these canons to his artwork. His studies consisted of measurements on live humans and focused on sizes and proportions of the forehead, nose, mouth, and chin relative to the whole head.9, 10 According to Da Vinci, the well-balanced face has a distance from the chin to the nostrils, from nostrils to eyebrows, and from eyebrows to hairline that are equal in length. Furthermore, the ears are equal in length to the nose and the upper lip is equivalent in length to the one-third of the lower facial height.9, 10 His findings suggest that there is natural variability in human form and a range of acceptability.9, 11 Therefore, it is important that less stress be placed on strict adherence to absolute numeric values that are considered “normal” and more of a focus on balanced proportions that may be considered acceptable for that particular person. The Present: Assessing Facial Balance There is no question that humans have been interested in the concept of beauty and attractiveness for centuries. Individuals have attempted to describe and create objective guidelines for what is considered beautiful for generations.5 Beauty is defined as a characteristic that provides a perceptual experience of pleasure or satisfaction. To describe something as beautiful often involves an interpretation of some entity as being in balance and harmony with nature, which may lead to feelings of attraction and emotional well-being.12 Attractiveness is defined as the perception of the physical traits of an individual human person as pleasing or beautiful.13 These terms, by definition, are 6 subjective. If our definitions of beauty and attractiveness are somewhat abstract, then how do we as clinicians define what is a beautiful face? Arnett best describes this quandary: “A person’s ability to recognize a beautiful face is innate, but translating this into defined treatment goals is problematic.”5 Peck describes several concepts that contribute to facial beauty1: Facial equilibrium – the correspondence in size, form, and arrangement of facial features on the opposite sides of the median sagittal plane. Symmetry and balance are critical components of the “attractive” human face. • Facial harmony – the orderly and pleasing arrangement of the facial parts in profile • Profile “flow” – regularity and evenness are preferred over irregularities or acute curves • Facial proportion – comparative relation of facial elements in profile Planning an improvement in facial form first requires objective standards or guidelines of an ideal form that can be used for comparison. Clinicians must consider symmetry and balance, facial harmony, and facial proportions while in the diagnosis of a case. Although anecdotal in nature, the classical canons first described by the ancient Greeks and utilized by artists of the Renaissance are still considered loose guidelines that aid in assessment of the facial form today.8 The eleven neoclassical canons as described by Bashour8 include the following: 1. The head can be divided into two equal halves with a horizontal line passing through the eyes. 2. The face can be divided into equal thirds. 7 3. The head can be divided into equal fourths. 4. The length of the ear equals the length of the nose. 5. The distance between the eyes equals the width of the nose. 6. The distance between the eyes equals to the width of each eye. 7. The width of the mouth equals one and one-half width of the nose. 8. The width of the nose equals one-fourth the width of the face. 9. The nose inclination equals the ear inclination. 10. The lower face height can be divided into equal thirds. 11. The lower face height can be divided into equal quarters. Farkas challenged the validity of these canons by using soft tissue anthropometry to measure and compare more than 100 dimensions and proportions in hundreds of people. He used these measurements to define standards of soft tissue components of the head and face.10, 14 Farkas found that the canons and the golden proportion described previously were only present in a highly selective group of people, not in the majority of the population.14 Because these observations are not evidence-based, they should only be considered as a “rough working guide” to analyzing the human face.8 More recent methods to assess facial form have transitioned from anthropometric systems utilized in the eighteenth and nineteenth centuries to cephalometric analysis.8, 15 In 1931, Broadbent introduced cephalometric radiography to measure hard and soft tissues of the head and face.16 As interest in facial esthetics increased, multiple hard and soft tissue cephalometric analyses and norms were developed to evaluate the position of the nose, lips, and chin, among other facial features.16-19 Although cephalometric analysis aids in the diagnosis of a case, it is not adequate to solely treat a case based on 8 cephalometric norms. In addition to cephalometric measurements, Arnett stresses the importance of the clinical exam in order to “reverse negative traits and maintain positive traits” when treating a patient with orthodontics or orthognathic surgery.5 Arnett utilizes a clinical exam that assesses the dental occlusion and describes nineteen facial components in three planes of space.4 He urges that without an organized and comprehensive assessment, a clinician’s ability to adequately diagnose and treat a case is limited. 4, 5 Social aspect of attractiveness It is evident that physical attractiveness is a characteristic that may contribute to how one person may interact with other individuals. Multiple studies have demonstrated that people formulate assumptions based on physical appearance, and then use these assumptions to judge that person in regards to intelligence level, employability, and relationships, among other traits. Alley and Hildebrant suggest that the face is the most important contributor to physical attractiveness, and subsequently has a major influence on social interactions and an individual’s development.20 Several authors describe a “beauty-is-good” stereotype in which individuals with attractive faces are perceived as being more competent and more likeable than their less attractive peers, and this level of facial attractiveness promotes positive expectations and impressions with a resultant gain in interpersonal advantages.20, 21 In a study by Clifford and Walster, fifth-grade teachers were provided with questionnaires and facial photographs of twelve fifth-grade boys and girls who were preselected based on level of attractiveness (attractive or unattractive) and asked to 9 speculate on the child’s Intelligence Quotient (IQ), the child’s social relationships with their peers, and parental attitudes towards school. The teachers were also asked to predict what level of education the child would achieve in the future. The authors found that attractive children were perceived by their teachers as having higher intelligence levels and better social skills than unattractive children. The teachers also reported that they expected the attractive children to achieve a higher level of education and to have parents that were more invested in their child’s academic performance than their less attractive peers.22 In a similar double-blind study by Ross and Salvia, teachers were given photographs of attractive and unattractive children with similar report cards that described a poor academic performance. The authors found that attractive children were rated more favorably that unattractive children in regards to future academic and social development. The teachers also reported lower expectations for academic success for the unattractive children.23 Algozzine further investigated the effect of attractiveness on student interactions. In this study, teachers were instructed to give a report on the number of positive, negative, and neutral interactions that each child in the classroom had with the teacher and their classmates. The teachers were then asked to give each child an attractiveness rating. The results indicated that attractive children had more positive interactions with their teachers and peers than did unattractive children.24 Rosen and Underwood examined the relationship between facial attractiveness, aggression, and popularity. Teachers were asked to provide attractiveness ratings of students from facial photographs and report on level of physical aggression and social acceptance. These authors found that for the students with low facial attractiveness 10 scores, physical aggression had a negative effect on popularity level. On the other hand, highly aggressive students that were perceived as attractive had higher popularity scores.25 Additional studies have shown that the influence of physical attractiveness carries into the workplace and relationships later in life as well. In accordance with the “beautyis-good” stereotype, most studies suggest that physical attractiveness is advantageous in social scenarios. Some studies, however, have shown that physical attractiveness may actually act as a hindrance in certain situations. In a study by Johnson et al., participants were asked to rate employment suitability of potential job applicants who had previously been selected according to their physical attractiveness. Their results indicate that physical attractiveness benefits both men and women applying for a variety of jobs, in regards to their perceived level of employment suitability. However, high levels of attractiveness may be detrimental for women applying for more masculine-type jobs for which physical appearance was considered to be unimportant.26 In a study by Agthe et al., participants were given photographs of four individuals that had been previously selected according to attractiveness level (one attractive male, one unattractive male, one attractive female, and one unattractive female) and job applications for each candidate. Each application was fabricated so that each candidate was similar in regards to job qualifications. The participants were then asked to select one applicant that would be most suitable for a specified job. The results indicate that attractiveness is a hindrance when the person being evaluated is of the same sex as the evaluator. It was suggested that the negative response of a same-sex evaluator may be in an attempt to avoid a perceived self-threat from the same-sex individual that was regarded as highly attractive.27 11 Taken together, these studies suggest that stereotyping in regards to facial attractiveness begins during childhood and continues throughout adolescence and adulthood, where attractiveness plays a pivotal role in the interactions and subsequent relationships that a person will develop with other individuals. It is suggested that attractive people may have higher levels of self-esteem and thus feel more comfortable in social settings, thus resulting in more positive interactions and social gains than those who do not exhibit the same level of self-confidence.21, 27 It is concluded that, in general, attractive individuals are perceived as being more intelligent, more sociable and wellliked by their peers, and more apt to obtain a high level of success in future endeavors. It is important to note, however, that although attractiveness does contribute greatly to the perception of an individual’s abilities, it is not the only contributing factor. It is apparent that facial attractiveness may have an impact on an individual’s quality of life. Because of the social implications that degree of facial attractiveness can have, some patients will consider invasive procedures, including orthognathic surgery, to improve their facial appearance. Orthognathic surgery Patients often seek orthodontic or orthognathic treatment as a means to improve facial harmony and overall appearance.2, 3, 28 Orthognathic surgery is used to correct conditions of the jaw and face related to skeletal disharmonies, abnormal growth, sleep apnea, and TMJ disorders that cannot be treated with orthodontics alone.29, 30 A surgical approach may improve function, and aid in both the stability and esthetic value of treatment. 12 Skeletal Patterns The classification and analysis of facial skeletal patterns is complex and involves comparisons in three planes of space.31, 32 The ideal facial skeleton can be described as orthognathic in which components of the hard and soft tissue skeleton are harmonious with each other. Patients that exhibit orthognathism are often classified as a skeletal Class I. The maxilla and mandible are positioned in such a way that neither jaw projects significantly more than the other, and the maxillomandibular complex is in a wellbalanced position relative to the anterior cranial base. Prognathism can be used to describe a patient with one jaw more protrusive than the other (mandibular prognathism, for example), or both jaws protrusive relative to the cranial base (bimaxillary protrusion).31 In a similar manner, retrognathism can be used to describe a patient with one jaw more retrusive than the other (mandibular retrognathism, for example), or both jaws retrusive relative to the cranial base (bimaxillary retrusion).31 An ideal jaw relationship also requires that neither jaw is deficient or excessive in vertical and transverse dimensions. Patients with a Class II skeletal pattern may exhibit maxillary excess, mandibular retrognathia, or both. A skeletal Class II pattern may also result from vertical maxillary excess and the resultant downward and backward (clockwise) rotation of the mandible. Patients with a Class III skeletal pattern may exhibit maxillary deficiency, mandibular prognathism, or both. A skeletal Class III pattern may also result from vertical maxillary deficiency and the resultant upward and forward (counterclockwise) rotation of the mandible. These skeletal discrepancies often result in less than ideal soft tissue drape 13 and/or dental malocclusions.5, 31Skeletal asymmetries may also exacerbate these problems. Skeletal Discrepancies: To Correct or Camouflage? Orthognathic surgery is an approach to treat skeletal malocclusions that cannot satisfactorily be treated with growth modification or “camouflage” treatment. Growth modification is reserved for the adolescent patient who is actively growing, and utilizes different fixed or removable appliances that can affect the final jaw position. Headgear, for example, can be used to restrict growth of the maxilla and allow the growing mandible to “catch up.” Functional appliances, as described by Proffit, can also be used to “posture the mandible, [and the resultant] stretch of the muscles and soft tissues are transmitted to the dental and skeletal structures, thus moving teeth and modifying growth” in Class II patients.32 Although skeletal changes are seen, the majority of the correction with growth modification is dentoalveolar in nature.31, 32 Johnston argues that functional appliances do not change the inherent growth pattern, but rather “make clever use of the normal pattern.”33 He further argues that “favorable mandibular growth produces maxillary dentoalveolar compensations that prevent the excess mandibular growth from having any marked effect on the malocclusion. Functional appliances may avoid this mesial movement of the maxillary dentition by dissociating mandibular displacement from the condylar growth that normally accompanies it.”33 By posturing the mandibular anteriorly, and maintaining this advanced position long enough for remodeling at the condyle and glenoid fossa, functional appliances such as the Twin Block and Herbst are able to correct skeletal Class II discrepancies.32, 33 14 According to Proffit, differential jaw growth, even in the most favorable of circumstances, may not be sufficient to correct the skeletal discrepancy, and additional dental compensations are often necessary.32 Camouflage treatment utilizes dental extractions to put the remaining teeth in a position that compensates for, and essentially masks, the skeletal malocclusion.32 In a Class II patient with mandibular retrognathia, maxillary first premolars may be extracted to retract the maxillary anterior teeth. Extractions would be avoided in the deficient mandibular arch, and the lower incisors would be proclined to further reduce the overjet.32 In a Class III patient, lower first premolars may be extracted to retract lower incisors while the maxillary anteriors are proclined to create positive overjet. Depending on the amount of crowding, inclination of the incisors, or other factors, it may be prudent to extract premolars in both arches to create a more functional occlusion or produce more favorable esthetics.32 Proffit asserts the camouflage treatment results in less favorable outcome for patients that exhibit a dolichocephalic facial pattern, moderate to severe anteroposterior jaw discrepancies, severe crowding, or skeletal discrepancies.32 When growth modification cannot be achieved or camouflage would result in a poor outcome, a surgical approach may be considered a viable option for a patient. The American Association of Oral and Maxillofacial Surgeons (AAOMS)34 asserts that orthognathic surgery should be considered as medically appropriate in the following circumstances: A. Anteroposterior discrepancies (established norm = 2 mm) a. Maxillary/Mandibular incisor relationship: i. Horizontal overjet of +5 mm or more 15 ii. Horizontal overjet of zero to a negative value b. Maxillary/Mandibular anteroposterior molar relationship discrepancy of 4 mm or more (established norm = 0 to 1 mm) c. These values represent two or more standard deviations from published norms B. Vertical discrepancies a. Presence of a vertical facial skeletal deformity which is two or more standard deviations from published norms for accepted skeletal landmarks b. Open Bite i. No vertical overlap of anterior teeth ii. Unilateral or bilateral posterior open bite greater than 2 mm c. Deep overbite with impingement or irritation of buccal or lingual soft tissues of the opposing arch d. Supraeruption of a dentoalveolar segment due to lack of occlusion C. Transverse discrepancies a. Presence of a transverse skeletal discrepancy which is two or more standard deviations from published norms b. Total bilateral maxillary palatal cusp to mandibular fossa discrepancy of 4 mm or greater, or a unilateral discrepancy of 3 mm or greater, given normal axial inclination of the posterior teeth D. Asymmetries a. Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry 16 Orthognathic Surgery: A Brief Overview Rudimentary surgical techniques to correct mandibular prognathism originated in the early 1900s.32 These techniques were refined during the first half of the century, and the sagittal split ramus osteotomy was first introduced in 1957. This method, commonly referred to now as the bilateral sagittal split osteotomy (BSSO), was introduced as a means to treat mandibular retrognathism or prognathism by lengthening or reducing the mandible, respectively.32, 35 BSSO is the most commonly performed orthognathic surgical technique, and involves sagittal cuts through the mandibular ramus via an intraoral approach to correct mandibular discrepancies.32, 35 Other techniques, such as the inverted “L” osteotomy or intraoral vertical ramus osteotomy (IVRO) may be used to address more extensive mandibular setbacks.35 Genioplasty to move the chin relative to the body of the mandible is often utilized in single or two-jaw surgical procedures, or can be performed alone as an adjunct to camouflage treatment.32 It was not until the 1960s that surgeons successfully developed a technique to reposition the maxilla. The LeFort I osteotomy involves cuts that extend from the nasal septum and along the apices of the maxillary teeth. The pterygoid plates are spared by making a cut through the pterygomaxillary junction 32, 36 This technique allows for the maxilla to be repositioned vertically, anterior-posteriorly, and transversely.36 Because this technique allows for repositioning of the maxilla in all three planes of space, the Lefort I procedure is routinely used to correct Class II and Class III malocclusions, mid-face deficiencies, vertical maxillary excess, and dentoskeletal asymmetries.36 With the advent of internal rigid fixation in the 1990s, techniques to reposition one or both jaws, as well 17 as the chin, had been refined such that even patients with severe dentofacial deformities could be treated successfully with stable and predictable results.32 Orthognathic Surgery: Successful Outcomes Treatment success is dependent on several factors. For orthognathic surgery to “succeed,” a proper diagnosis must be made, a thorough treatment plan must be devised, and techniques must be executed flawlessly to ensure a stable and predictable result.5, 32 When presented with the option of orthognathic surgery, most patients will rely on the both the orthodontist and oral surgeon to collect enough information to adequately diagnose a case before treatment options are presented.4, 5 This team of clinicians must have an understanding of facial beauty, know how to evaluate facial form, and know how to properly carry out techniques in order to preserve or improve facial balance.4, 5 A critical step in this process is for the clinician to gain insight on why the patient is seeking treatment. The clinician must understand the patient’s motive for seeking care, and must decide if the patient’s goals are reasonable and obtainable. If this step is overlooked, treatment may be considered a failure before treatment is initiated.5 It is equally important for the clinician to have a general level of agreement with the patient, the patient’s family and peers, and the general public about what an esthetic outcome would be. Once the case has been appropriately diagnosed, the orthodontist and oral surgeon must formulate a treatment plan and should be confident that an invasive procedure is worth the risk if orthognathic surgery is proposed as an option. This is particularly important in “borderline” cases in which it is less obvious that orthognathic surgery is necessary to correct an esthetic problem.6 18 In a study by Jacobson in 1984, fifty patients who had undergone orthognathic surgery to correct different skeletal anomalies were surveyed about their reactions and attitudes before, during, and after surgery. The results indicate that the single most important reason for having orthognathic surgery was to improve facial appearance. Eighty-eight percent of patients responded positively when asked if they would recommend surgery to a friend. The patients who would not recommend surgery stated that they responded negatively because they were either inadequately informed about the procedure or has results that did not meet their expectations.37 A more recent study suggests similar satisfaction ratings. When patients that were treated with a bimaxillary osteotomy to correct a Class III skeletal pattern were surveyed about their perception in improvement after surgery, 77.9% were satisfied with post-operative outcomes and 73% reported that they would recommend treatment to other patients. Additionally, 67.5% reported an increase in self-confidence as a result of improved facial appearance and chewing function, and postoperative satisfaction correlated positively with opinions of family and friends.38 In a study by Trovik et al., patients were followed 10-14 years after BSSO for mandibular advancement. Participants rated their perceived treatment outcome on items concerning oral function and appearance and were asked to rate their overall satisfaction (very satisfied, relatively satisfied, and not satisfied) with orthognathic treatment. Most responders were only reasonably satisfied with the treatment. Whether peers noticed a change in appearance after treatment was a significant factor affecting both treatment satisfaction and reporting a good quality of life. These findings are consistent with other studies that suggest that self-perception is not the only thing that matters, and a patient’s 19 satisfaction with treatment can be positively influenced by how other individuals perceive them after treatment. 38, 39 These findings suggest that perceptual assessment may be equally important as clinical findings in determining successful outcomes of surgical treatment. Levels of agreement between raters Some studies suggest that there is a significant amount of agreement when judging facial beauty within and between populations.1 In general, people of different races, professions, sexes, and age groups tend to agree on levels of facial attractiveness.20 Some studies show that laypersons, orthodontists, and oral surgeons generally agree on preferences of facial attractiveness.2, 40 In a study by Juggins et al., 40 patients, 20 orthodontists, and 20 oral surgeons were asked to rate the patients’ perceived need for orthognathic surgery based on facial appearance, dental appearance, function, and overall need using clinical photographs and models. Both orthodontists and oral surgeons rated a greater need for surgery based on facial appearance than did the patients. Oral surgeons rated treatment need based on facial appearance significantly higher than did orthodontists.41 In a study by Knight and Keith, dental clinicians and non-dental laypersons were asked to rank students based on facial attractiveness level by arranging their photographs in a pile accordingly. The primary objective of the study was to see if dental experts and non-dental laypersons could agree upon an order of levels of facial attractiveness. The results show that there was total agreement between the most attractive and most unattractive faces. In other words, both clinicians and laypersons agreed on the “ideal” 20 faces. There were, however, differences in rankings between clinicians and laypersons in the intermediate levels of attractiveness.42 In a study by Maple et al., photographs of three men and three women were altered incrementally to change anteroposterior and vertical dimensions. Orthodontists, oral surgeons, and laypersons were then asked to rate facial attractiveness on a visual analog scale (VAS). The results of this study indicate that laypersons and clinicians tended to agree on facial attractiveness.40 These authors concluded that it is critical for clinicians to be able to predict patient satisfaction. In a similar study by Vargo et al., “experts” (orthodontists and oral surgeons) and “naïve” raters were asked to rate facial attractiveness of facial photographs and give a recommendation on treatment need and compare these assessments to patient motivations. These authors found that both groups of clinicians the laypersons had a significant level of agreement when assessing facial attractiveness. Furthermore, the laypersons’ profile attractiveness rating and the patient’s expected change in self-consciousness were the strongest predictors for a patient’s motivation to pursue orthognathic surgery. These results suggest that patients are strongly influenced by the reactions of their peers, and their motivations for seeking orthognathic surgery cannot always be objectively defined.2 Soh and Wong found significant levels of agreement between orthodontists and oral surgeons when rating Chinese facial profile attractiveness. Normal and bimaxillary protrusive Chinese males and females were judged as being highly attractive by orthodontists and oral surgeons, and Chinese males and females with protrusive mandibles judged as least attractive. Orthodontists and oral surgeons had differing perceptions on the most attractive male profile. Orthodontists preferred flatter profile and 21 oral surgeons preferred more protrusive profile. Furthermore, the gender of the dental professionals and number of years in clinical practice had an effect on profile rankings.43 In a series of studies et al., clinicians, laypersons, and pre-surgical patients were asked to assess facial images in which certain facial elements (chin height, chin prominence, lower facial profile convexity) had been altered incrementally. In regards to chin height, surgical correction was desired with chin height greater than 50-58% and less than 20%-23% of lower anterior facial height (LAFH). Patients and clinicians were found to be more critical than laypeople, but there were no significant differences found between clinicians and patients.44 In regards to chin prominence, surgery was desired for chin protrusions greater than 6 mm and retrusions greater than 10 mm, and the greater the retrusion or prominence of the chin, the lower the attractiveness rating and the greater the desire for surgical correction. There were, however, no significant differences between assessors when rating chin prominence.45 In regards to lower facial profile convexity, a straight profile was perceived as most attractive and greater degrees of convexity or concavity were deemed as progressively less attractive. In this study, the results indicate that patients are the most critical, and clinicians are more critical than laypeople.46 As modern society places strong emphasis on physical attractiveness, mass media has been shown to play a role in the layperson’s perception of attractiveness. Some authors suggest that because dental professionals have a more academic and less emotional perception of facial beauty, their preferences of facial attractiveness may differ from those of the general population.1, 28 If this is true, are orthodontists and oral surgeons routinely producing a face that is esthetically pleasing to lay persons? Clinicians have a 22 duty to assess every treatment outcome and decide what factors lead to the success or failure of that case. In the case of a poor outcome, what factors can be identified as contributing to that failure? Was it poor diagnosis? Poor case set-up? Poor execution of surgical technique? Was the patient given a less-than-ideal result? Was the case executed well, but the patient had unrealistic expectations on the final outcome? It is assumed that if a proper diagnosis is made, and techniques are carried out without fault, then the outcome of a surgical procedure will be a success. But, what if the clinicians planning the case and the patient have a different perception of what is attractive, and the goals of treatment are inadvertently different from the start? These are all questions that must be considered and addressed to ensure that a patient’s experience with orthognathic surgery is nothing but positive. An improved understanding of treatment outcomes may lead to better communication between clinicians and patients, and will undoubtedly benefit the patient. 23 CHAPTER 3 AIMS AND HYPOTHESES Aims The aims of this study are: (1) to evaluate whether panels of observers with different levels of orthodontic experience assess facial attractiveness similarly, and (2) to determine what soft tissue features influence assessment of facial attractiveness. Hypotheses The null hypotheses of this study are: (1) There is no difference in perceptions of facial attractiveness of the “average” face when compared to the “post-surgical” face when observers rate 2-dimensional (2D) photographs on a visual analog scale, and (2) There is no difference in perceptions of facial attractiveness among raters with different levels of dental education 24 CHAPTER 4 MATERIALS AND METHODS Case selection Cases for presentation were selected from the University of Alabama at Birmingham School of Dentistry Orthodontic Clinic patient database. All cases for presentation were selected retrospectively by the PI and co-investigator. All ages and ethnic groups were considered for inclusion in both groups. Patients with cleft lip/palate and severe craniofacial abnormalities were excluded from both groups. The patients’ rationales for pursuing treatment included improving facial esthetics and/or improving function. This study was approved by the University of Alabama at Birmingham’s Institutional Review Board. Surgical faces Using the management software (Dolphin Management and Imaging Systems, Chatsworth, CA), a report was created of all patients who had undergone orthognathic surgery by using surgical search terms (surgery, jaw surgery, orthognathic surgery, 2-jaw surgery, LeFort osteotomy, LeFort I, segmental osteotomy, 3-piece maxilla, 2-piece maxilla, maxillary advancement, BSSO, and mandibular advancement). Thirty consecutive surgical cases (14 males, 16 females) were selected (Table 1). All skeletal malocclusions (anterior open bite, Class II, Class III, etc.) were considered for inclusion. 25 All orthognathic surgery procedures (maxillary advancement, mandibular advancement, two-jaw surgery, etc.) were also considered for inclusion. Extraoral pretreatment photographs and photographs from the debond appointment were included for assessment. Non-surgical faces Using the Dolphin Management software, a report was created of all patients who had been treated with orthodontics and debonded from 2011-2013. Sixty consecutive patients were selected for initial assessment. Extraoral photographs from the debond appointment were included for assessment. The investigators rated attractiveness of each patient using a visual analog scale (VAS). The VAS was graded from 0 (very unattractive) to 10 (very attractive) (Fig. 1). Very unattractive____|____|____|____|____|____|____|____|____|____Very attractive 0 1 2 3 4 5 6 7 8 9 10 Figure 1. The Visual Analog Scale (VAS) Facial attractiveness ratings from the investigators were compared. If the investigators disagreed on a rating by more than two points, the patient was excluded. Facial attractiveness ratings were then averaged for each patient. Thirty “average” patients (9 males, 21 females) were selected for presentation (Table 2). An attempt was made to match non-surgical patients in gender and age to the surgical patients previously selected. Once patients were selected for each group, facial photographs were cropped and arranged in a composite: profile, frontal, frontal smiling. All photographs were cropped 26 in the same manner. An attempt was made to crop out as many distracting features (hair, clothing, etc.) as possible. Participants The participants (ages 19-65) for this study consisted of four groups with various levels of dental education: laypersons, dental students, orthodontic residents, orthodontic faculty members, oral surgery residents, and oral surgery faculty members. All dental students, residents, faculty members were studying or teaching at the University of Alabama at Birmingham School of Dentistry. The laypersons were patrons of the same school. The following assumptions were made about each group: laypersons have no orthodontic or orthognathic experience, dental students have very limited, if any, orthodontic or orthognathic experience; residents have “some” orthodontic/orthognathic experience; and orthodontists and oral surgeons have the most orthodontic/orthognathic experience of all groups. (The terms participants, assessors, and raters will be used interchangeably from this point forward.) Ethical approval and informed consent for this study were obtained from the Institutional Review Board of the University of Alabama at Birmingham and participants of this study, respectively. Each participant was assigned a unique code at the time consent was given in order to collect and to analyze the data anonymously. Assessing Images Photographs were arranged in two separate PowerPoint presentations. The first presentation included both surgical and non-surgical patients. The second presentation 27 included surgical patients only. Assessors were asked to create a ranked list of facial features that they perceive as contributing to facial attractiveness between presentations. Section 1: Comparing Surgical and Non-surgical Faces All 60 (surgical and non-surgical) patients were included for assessment. Patients were grouped according to age and gender (under 40 females, over 40 females, under 40 males, over 40 males), but surgical and non-surgical patients were intermixed within these groupings. The order of presentation of the patient composites within each grouping was assigned using a random numbers table. A patient’s composite (Fig. 2) was presented to the assessors, and the assessor was asked to rate the patient’s facial attractiveness on the VAS (Fig. 1). Assessors were given eight seconds to rate each patient. Patient composites were presented individually for four or five patients, then frontal smiling photographs from all patients from that set were presented together (Fig. 3). The assessors were then asked to select the most attractive and most unattractive patient from that set. Assessors were given ten seconds to make this selection. Assessors were asked to rate and compare all sixty patients in this manner before proceeding with the next section. Figure 2. Composite of extraoral photographs 28 Figure 3. Extraoral photographs for comparison Section 2: Ranking Facial Features that Contribute to Facial Attractiveness After assessing facial attractiveness of all 60 patients, participants were asked to complete a questionnaire that contained a list of 12 facial features: vertical proportions, horizontal proportions, lower face height, chin, nasolabial angle, nose, lips, labiomental sulcus, chin-neck contour, skin complexion, eyes, and “other” (Fig. 4). They were asked to rank these facial features from 1 (contributing the most to facial attractiveness) to 12 (contributing the least to facial attractiveness). If the participant did not know the meaning of an item on the list, they were asked to cross it off the list before ranking and not include that item in the ranked list. Participants were also asked to add “other” items 29 to the list prior to ranking each item. Multiple “other” items could be added to the list. The final ranking could include more or less than 12 items. Facial Feature Rank Vertical proportions Horizontal proportions Lower face height Chin Nasolabial angle Nose Lips Labiomental sulcus Chin-neck contour Skin complexion Eyes "Other" Figure 4. List of facial features to be ranked by the assessors Section 3: Selecting a Preference of Pre-treatment and Post-treatment Surgical Faces All thirty surgical patients were included for assessment. Patients were grouped according to age and gender (under 40 females, over 40 females, under 40 males, over 40 males). The order of presentation of the patient composites within each grouping was assigned using a random numbers table. A patient’s pre-treatment composite and post-treatment composite (Fig. 5) were presented to the assessors. Each pre-treatment composite was randomly assigned letter A or B, then the post-treatment composite was assigned the other letter such that the pretreatment composite did not always precede the post-treatment composite. Assessors 30 were asked to select a preference for the composite that they found was more attractive. If they did not have a preference, they were given the option to select “no preference.” Figure 5. Pre-treatment and post-treatment composites of surgical patients Statistical Analysis Descriptive statistics using frequency and percent as well as mean and standard deviation were computed for categorical and continuous variables, respectively, for each of the six groups of assessors. The association between both facial feature rankings and attractiveness ratings and rater group was estimated using an analysis of variance (ANOVA) and repeated measures ANOVA, respectively. For each ANOVA model in which the overall F-test was significant, pairwise comparisons using Tukey’s range test was used to determine which groups differed while accounting for multiple comparisons. 31 For attractiveness ratings, models were stratified by the age and gender of the rated subject (four strata total). To determine the reliability of rankings and ratings, an intraclass correlation coefficient and 95% confidence limits were computed for each ranking or rating overall and stratified by rater group. A chi-square test was used to examine whether the pre- or post-surgery image was more attractive was differential by rater group. A kappa statistic was calculated to determine whether agreement varied overall and by rater group. 32 CHAPTER 5 RESULTS Cases for Assessment The demographics for the patients included for assessment are given in Tables 1 and 2. The patients are grouped by age and gender. The skeletal classification prior to bonding was noted for each patient. A general surgical procedure and the surgery date were noted for each surgical patient based on information input into the patient’s treatment card. The bond date was denoted at the start of comprehensive treatment when one arch of appliances was placed and the age at bonding was calculated for each patient. The final records were obtained at the debond date when all fixed appliances were removed. Participants The participants (181 total) included 101 (56.4%) males and 78 (43.6%) females. Two participants (both dental students) did not provide their gender. This group included 42 laypersons (19 male, 23 female), 100 dental students (54 male, 46 female), 15 orthodontic residents (7 male, 8 female), 10 orthodontic faculty members (all male), 9 oral surgery residents (8 male, 1 female), and 5 oral surgery faculty members (all male). The basic demographics of the raters that participated in the study are included in Table 3. Table 4 shows the demographics of each rater group with dental experience. 33 Orthodontists and oral surgeons reported an average of 23.7 years and 22.4 years, respectively, of experience in their field. Two oral surgery residents and two oral surgeons noted additional training in plastic and/or reconstructive surgery (Table 4). Table 5 shows the demographics of the layperson participants. The majority of layperson raters (52.4%) had at least some college education, and 21.4% had a doctoral or professional degree (Table 5). Comparing Surgical and Non-Surgical Faces Table 6 shows the comparison of mean attractiveness ratings by type of rater estimated from a repeated measures ANOVA. These data are stratified by age and gender of the subject who was being rated. Mean attractiveness ratings were 0.55 points lower for surgical patients compared to non-surgical patients. This finding was significant for all groups of patients when categorized by age and gender (p < 0.0001 for all groups) such that surgical patients, on average, were rated 0.50-0.65 points lower than the nonsurgical patients. The p-value for the three-way interaction between the type of rater, type of patient (surgical vs non-surgical), and age-gender assignment of the patient was not significant (Table 6). Selecting a Preference of Pre-treatment and Post-treatment Surgical Faces Table 7 shows the comparison of attractiveness preference before and after surgery. These data are stratified by age and gender of the subject who was being rated. The raters most often chose the post-surgical face as more attractive than the pre-surgical face. This finding was statistically significant. 34 Ranking Facial Features The comparison of mean rankings of facial features’ contribution to facial attractiveness is shown in Table 8. These data are stratified by rater category. Significantly different mean values (p < .05) between rater groups were found for the following characteristics: vertical proportions, horizontal proportions, lower face height, labiomental sulcus, skin complexion, and eyes. Pairwise comparisons using Tukey’s range test was used to determine which groups differed while accounting for multiple comparisons. For vertical proportions, significantly different mean values were found between the orthodontic resident versus layperson groups. Although significantly different mean values were found between rater groups for horizontal proportions and lower face height, there were no significant pairwise comparisons when further analyzed with the Tukey range test. Significantly different mean values were found between dental students versus laypersons when ranking labiomental sulcus, but the standard deviation for the layperson group was considerably high, thus indicating a lot of variation in responses. Mean values that were significantly different for skin complexion were found between dental students versus laypersons, orthodontic residents versus laypersons, and orthodontists versus laypersons. There was also a difference in mean values for eyes between dental students versus orthodontic residents and orthodontic residents versus laypersons that was significant. The rankings of facial features’ contribution to facial attractiveness is shown in Table 9. These data are stratified by rater category. Means for each facial feature were used to create a ranked list within each rater group. If two features averaged the same rank, the median was used as a tiebreaker to assign the final rank. Based on the overall 35 average rank, raters perceived the eyes, nose, and vertical proportions as contributing most to facial attractiveness and the nasolabial angle, labiomental sulcus, and chin-neck contour contributing the least. Dental students, oral surgery residents, orthodontists, and laypersons all ranked eyes as the top facial feature contributing to facial attractiveness. Orthodontic residents and oral surgeons ranked vertical and horizontal proportions as the most important features (Table 9). All groups ranked the nose at the top one-third of their lists. Of the rank list generated for the laypersons, 33.3% of laypersons did not rank vertical proportions, horizontal proportions, or lower facial height. Similarly, 83.3% of laypersons did not rank nasolabial angle, and 95.2% did not rank the labiomental sulcus. Reliability and Agreement Levels Six orthodontic residents and seven laypersons were surveyed a second time at least two weeks after the initial assessment to minimize recall bias. Table 10 shows the intraclass correlation coefficients and 95% confidence intervals for facial feature rankings and attractiveness ratings. Overall, there is moderate reliability of facial feature rankings and facial attractiveness ratings. Orthodontic residents were more reliable with facial feature rankings when compared with attractiveness ratings. Laypersons were more reliable with attractiveness ratings when compared with facial feature rankings (Table 10). Table 11 shows the Kappa agreement statistic for choice of whether the presurgery or post-surgery face was more attractive. Overall, the Kappa statistic was low (0.48). Agreement was equally low for both the orthodontic resident group (0.53) and layperson group (0.44) who took the assessment the second time. The agreement was 36 especially poor when “no preference” for the pre- or post-surgical image was selected at the first assessment (Table 11). 37 Table 1. Surgical patients for assessment Skeletal Surgical Bond Age at Surgical Final Pt. Gender Classification Other Procedure Date Bonding Date Records 1 F III M axilla 10/01/10 15 y 10 m 06/01/11 03/01/12 2 F II M andible 10/01/09 12 y 9 m 03/01/12 08/01/12 3 F II AOB, CR M ax/M and, G 01/01/12 22 y 5 m 02/01/13 07/01/13 4 F II M ax/M and 01/01/03 16 y 1 m 12/01/04 06/01/05 5 F II M ax/M and, G 09/01/09 16 y 0 m 06/01/12 11/01/13 6 F II M andible 07/01/10 13 y 7 m 07/01/12 08/01/13 7 F I AOB M axilla, G 10/01/06 19 y 6 m 03/01/07 06/01/07 8 F II M andible 10/01/10 14 y 2 m 12/01/11 08/01/12 9 F II M andible 11/01/08 16 y 0 m 08/01/11 02/01/12 10 F II M andible 06/01/09 16 y 2 m 09/01/11 03/01/12 11 F III A M ax/M and 02/01/12 17 y 0 m 09/01/13 06/01/14 12 F II M andible 09/01/03 52 y 1 m 04/01/05 08/01/05 13 F III M axilla 09/01/11 56 y 10 m 02/01/13 09/01/13 14 F II A M ax/M and 06/01/11 50 y 6 m 11/01/12 01/01/12 15 F II M andible, G 04/01/08 53 y 3 m 10/01/09 04/01/10 16 F II M ax/M and, G 08/01/12 65 y 11 m 09/01/13 04/01/14 17 M III AOB M ax/M and 02/01/07 19 y 9 m 05/01/07 03/01/08 18 M III M ax/M and 03/01/05 18 y 2 m 06/01/06 04/01/07 19 M II AOB M axilla 08/01/10 16 y 1 m 01/01/13 06/01/13 20 M III AOB, A M ax/M and, G 12/01/10 19 y 10 m 06/01/11 10/01/12 21 M III AOB M ax/M and, G 08/01/07 17 y 9 m 05/01/09 02/01/10 22 M III AOB M axilla 08/01/11 18 y 1 m 07/01/12 03/01/13 23 M II AOB M axilla 07/01/08 18 y 3 m 07/01/09 08/01/09 24 M II M andible 01/01/05 14 y 7 m 07/01/07 03/01/08 25 M II A M ax/M and 07/01/11 19 y 1 m 08/01/12 03/01/14 26 M II M ax/M and 11/01/12 13 y 5 m 12/01/13 04/01/14 27 M III M ax/M and, G 04/01/08 26 y 5 m 12/01/08 06/01/09 28 M II OSA M ax/M and 03/01/13 39 y 4 m 11/01/13 04/01/14 29 M III M axilla 11/01/10 43 y 2 m 05/01/11 12/01/11 30 M II M ax/M and, G 03/01/10 37 y 6 m 03/01/11 01/01/12 * A = Asymmetry, AOB = Anterior Open Bite, CR = Condylar Replacement, G = Genioplasty, OSA = Obstructive Sleep Apnea 38 Table 2. Non-surgical patients for assessment Pt. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Skeletal Gender Classification F II F I F III F II F II F II F I F I F I F II F I F I F II F II F II F II F II F I F I F II F II M II M II M I M II M III M II M II M I M I Bond Date 10/01/11 09/01/11 08/01/11 05/01/11 10/01/11 08/01/11 08/01/11 10/01/11 10/01/09 10/01/11 09/01/11 04/01/12 09/01/11 07/01/10 04/01/10 08/01/11 07/01/12 08/01/12 05/01/12 09/01/11 03/01/10 05/01/11 08/01/11 09/01/11 02/01/12 06/01/10 10/01/09 10/01/11 09/01/11 05/01/12 Age at Bonding 12 y 9 m 12 y 0 m 11 y 9 m 13 y 2 m 27 y 9 m 16 y 10 m 12 y 3 m 16 y 1 m 14 y 5 m 14 y 5 m 13 y 1 m 13 y 6 m 13 y 7 m 12 y 10 m 11 y 10 m 13 y 3 m 40 y 11 m 60 y 2 m 55 y 10 m 40 y 0 m 40 y 8 m 15 y 5 m 14 y 7 m 13 y 9 m 14 y 7 m 13 y 1 m 17 y 5 m 13 y 4 m 12 y 6 m 41 y 11 m Final Records 09/01/13 10/01/13 03/01/13 10/01/13 06/01/12 11/01/13 01/01/14 04/01/13 08/01/12 11/01/13 05/01/13 01/01/14 02/01/13 04/01/13 02/01/13 12/01/13 01/01/14 02/01/14 11/01/12 07/01/13 08/01/13 08/01/13 04/01/13 02/01/13 09/01/13 08/01/12 12/01/12 03/01/13 02/01/14 06/01/13 39 Table 3. Basic demographics of raters participating in study N (%) Gender M ale Female 101 (56.4) 78 (43.6) Race Caucasian African-American Asian-Indian Spanish/Hispanic Asian American Indian/Alaskan Native Other 139 (76.8) 12 (6.6) 4 (2.2) 7 (3.9) 16 (8.8) 1 (0.6) 2 (1.1) Age (years) ≤18 19-25 26-29 30-35 36-39 40-45 46-49 50-55 56-59 60-65 ≥66 0 (0.0) 97 (53.6) 26 (14.4) 18 (9.9) 3 (1.7) 10 (5.5) 1 (0.6) 13 (7.2) 7 (3.9) 4 (2.2) 2 (1.1) Job title Dental student Orthodontic resident Oral surgery resident Orthodontist Oral surgeon Layperson 100 (55.3) 15 (8.3) 9 (5.0) 10 (5.5) 5 (2.8) 42 (23.2) 40 Table 4. Characteristics of dental raters participating in the study as given in N(%) Dental Orthodontic Oral surgery Orthodontist Oral surgeon student resident resident (n=10) (n=5) (n=100) (n=15) (n=9) Gender M ale 53 (54.1) 7 (46.7) 8 (88.9) 10 (100.0) 4 (80.0) Female 45 (45.9) 8 (53.3) 1 (11.1) 0 (0.0) 1 (20.0) Race Caucasian African-American Asian-Indian Spanish/Hispanic Asian American Indian/Alaskan Native Other 71 (71.0) 8 (8.0) 3 (3.0) 3 (3.0) 12 (12.0) 1 (1.0) 2 (2.0) 10 (66.7) 1 (6.7) 1 (6.7) 2 (13.3) 1 (6.7) 0 (0.0) 0 (0.0) 7 (77.8) 2 (22.2) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 7 (70.0) 0 (0.0) 0 (0.0) 2 (20.0) 1 (10.0) 0 (0.0) 0 (0.0) 2 (40.0) 1 (20.0) 0 (0.0) 0 (0.0) 2 (40.0) 0 (0.0) 0 (0.0) Age (years) ≤18 19-25 26-29 30-35 36-39 40-45 46-49 50-55 56-59 60-65 ≥66 0 (0.0) 92 (92.0) 4 (4.0) 3 (3.0) 1 (1.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 10 (66.7) 3 (20.0) 1 (6.7) 1 (6.7) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (44.0) 4 (44.0) 0 (0.0) 1 (11.1) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 4 (40.0) 0 (0.0) 1 (10.0) 3 (30.0) 0 (0.0) 2 (20.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (20.0) 0 (0.0) 0 (0.0) 1 (20.0) 1 (20.0) 0 (0.0) 2 (40.0) 0 (0.0) - - - 23.7±11.8 22.4±13.5 2 (22.2) 0 (0.0) 2 (40.0) Education level (year in dental school or residency for respective group) 1 60 (60.0) 4 (28.6) 2 (22.2) 2 40 (4.0) 6 (42.9) 2 (22.2) 3 0 4 (28.6) 2 (22.2) 4 0 1 (11.1) 5 2 (22.2) 6 M ean years practicing - - Has additional training in plastic or reconstructive surgery (%) 0 (0.0) 0 (0.0) 41 Table 5. Basic demographics of layperson raters participating in study N (%) Gender M ale 19 (45.2) Female 23 (54.8) Race Caucasian 42 (100.0) Age (years) ≤18 19-25 26-29 30-35 36-39 40-45 46-49 50-55 56-59 60-65 ≥66 0 (0.0) 5 (11.9) 8 (19.1) 7 (16.7) 1 (2.4) 4 (9.5) 0 (0.0) 11 (26.2) 4 (9.5) 2 (4.8) 0 (0.0) Current education level Less than high school High school College M aster’s degree Doctor or professional degree Other 0 (0.0) 4 (9.5) 22 (52.4) 6 (14.3) 9 (21.4) 1 (2.4) 4.82± 1.79 5.04± 1.71 N on-s urgical 4.25± 2.03 N on-s urgical 4.71± 1.72 N on-s urgical 0.9180 5.67± 1.32 5.56± 1.12 5.14± 1.29 5.05± 1.11 4.98± 1.06 4.64± 0.93 5.60± 1.18 5.08± 1.41 5.38± 1.22 5.04± 1.21 res ident O ral s urgery * S = surgical, NS = non-s urgical, B = beta, R C = rater category * Estim ated from a rep eated m easures A N O VA , s ignificant at p < .05 p = 0.0600 6.20± 1.26 5.40± 1.54 Patient age/gender interaction 5.49± 1.24 4.97± 1.58 Surgical 5.58± 1.29 4.79± 1.32 5.25± 1.26 4.43± 1.15 5.66± 1.29 4.81± 1.63 5.57± 1.28 4.81± 1.42 N on-s urgical O VER 40 M A LE 4.28± 1.66 Surgical U N D ER 40 M A LE 3.83± 1.86 Surgical O VER 40 F EM A LE 4.40± 1.74 Surgical U N D ER 40 F EM A LE 4.31± 1.74 N on-s urgical res ident Surgical O VER A LL M ean ranking O rthodontic D ental student 6.10± 0.99 4.97± 0.85 5.56± 1.05 4.70± 1.21 5.34± 1.24 4.58± 1.30 5.46± 1.15 4.95± 1.60 5.50± 1.14 4.79± 1.34 6.40± 1.52 6.53± 1.19 5.85± 1.39 5.22± 1.64 4.84± 1.28 4.96± 1.40 5.61± 2.00 5.20± 1.83 5.58± 1.75 5.30± 1.67 O rthodontist O ral s urgeon 5.78± 1.68 5.00± 1.68 4.69± 1.75 4.18± 1.70 4.59± 1.79 3.93± 1.64 5.13± 1.64 4.48± 1.81 4.95± 1.72 4.32± 1.75 Lay p ers on B eta -0.5473 -0.4967 -0.5105 -0.6463 -0.5586 (S v N S) Table 6. C omp arison of m ean attractiveness ratings by ty p e of rater and stratified by age and gender of rating subject < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 p -value B 0.5938 0.1537 0.4421 0.7396 0.0600 p -value RC 42 43 Table 7. Comparison of attractiveness preference before and after orthognathic surgery stratified by age and gender of rating subject Dental student Choice (%) OVERALL Pre-surgery Post-surgery Neither Orthodontic Oral surgery Orthodontist resident resident Oral surgeon Layperson p-value 16.5 64.8 18.7 10.4 72.7 16.9 14.8 63.3 21.9 6.7 70 23.3 9.3 71.3 19.3 15.8 65.4 18.8 <0.0001 UNDER 40 FEM ALE Pre-surgery 18.6 Post-surgery 63.7 Neither 17.7 10.9 74.6 14.6 21.2 58.6 20.2 4.6 72.7 22.7 7.3 70.9 21.8 15.4 69.1 15.6 0.0009 OVER 40 FEM ALE Pre-surgery 16 Post-surgery 65.6 Neither 18.5 11.5 68.5 20 12.1 66.7 21.2 10.9 64.6 24.6 16.4 65.5 18.2 18 61.9 20.1 0.5018 UNDER 40 M ALE Pre-surgery 14.6 Post-surgery 64 Neither 21.4 5.3 78.7 16 11.1 64.4 24.4 2 76 22 4 72 24 11 64.3 24.8 0.0793 6.7 70 23.3 0 93.3 6.7 17.5 0 15.9 0.4588 OVER 40 M ALE Pre-surgery 14.3 13.3 7.4 Post-surgery 67.3 71.1 66.7 Neither 18.3 15.6 25.9 * Estimated from a chi-square test, significant at p < .05 44 Table 8. Comparison of mean rankings of facial features’ contribution to facial attractiveness by type of rater Dental student Vertical proportions Orthodontic Oral surgery Orthodontist Oral surgeon Layperson resident resident p-value 5.60±2.92 3.60±3.29 4.44±2.74 5.60±4.09 2.80±1.48 6.68±2.67 0.0086 Horizontal proportions 6.05±2.90 4.80±3.63 6.11±2.15 8.10±3.48 4.20±3.56 7.32±2.40 0.0160 Lower face height 8.04±3.02 6.27±2.79 6.78±3.15 5.70±3.80 6.40±2.19 7.86±2.07 0.0479 Chin 5.76±2.32 6.53±2.59 6.44±2.46 6.20±1.69 8.40±2.30 5.44±1.79 0.0671 Nasolabial angle 8.57±2.46 8.67±2.82 10.33±1.00 7.60±2.12 7.60±2.07 8.86±1.77 0.1921 Nose 4.10±2.22 4.93±2.28 3.22±1.64 4.50±1.90 4.20±2.2 3.98±1.71 0.4793 Lips 5.08±2.38 6.67±2.79 4.00±2.60 5.30±3.09 5.20±2.39 5.28±2.60 0.1969 Labiomental sulcus 9.82±1.98 9.40±2.10 9.67±1.80 7.90±2.73 9.60±1.14 5.00±5.67 0.0050 Chin-neck contour 6.67±2.90 7.27±2.91 6.44±2.96 8.30±2.95 9.00±2.35 6.21±2.12 0.1262 Skin complexion 5.79±3.42 7.73±3.28 6.22±2.49 7.20±3.43 4.20±2.77 3.60±2.57 0.0001 Eyes 3.01±2.74 6.07±3.61 3.00±2.65 * Estimated from an ANOVA, significant at p < .05 3.30±3.23 4.40±3.97 3.29±2.70 0.0099 Table 9. Rankings of facial features’ contribution to facial attractiveness by type of rater Dental student Orthodontic Oral surgery Orthodontist resident resident Oral surgeon Layperson Overall Average Rank Vertical proportions #4 #1 #4 #4 #1 #8 3.67 Horizontal proportions #7 #2 #5 #10 #2 #9 5.83 Lower face height #9 #5 #9 #5 #7 #10 7.5 Chin #5 #6 #7 #6 #9 #6 6.5 Nasolabial angle #10 #10 #11 #8 #8 #11 9.67 Nose #2 #3 #2 #2 #4 #3 2.83 Lips #3 #7 #3 #3 #6 #5 4.5 Labiomental sulcus #11 #11 #10 #9 #11 #4 9.33 Chin-neck contour #8 #8 #8 #11 #10 #7 8.67 Skin complexion #6 #9 #6 #7 #3 #2 5.5 Eyes #1 #4 #1 #1 #5 #1 2.17 45 Table 10. Intraclass correlation coefficients and 95% confidence intervals for facial feature rankings and attractiveness ratings ICC LCB UCB OVERALL Facial feature rankings 0.67 0.56 0.76 Attractiveness ratings Overall <40 years of age female >40 years of age female <40 years of age male >40 years of age male 0.68 0.7 0.58 0.68 0.7 0.64 0.64 0.45 0.61 0.53 0.72 0.75 0.68 0.74 0.81 ORTHODONTIC RESIDENTS Facial feature rankings 0.71 0.57 0.81 Attractiveness ratings Overall <40 years of age female >40 years of age female <40 years of age male >40 years of age male 0.59 0.6 0.48 0.58 0.71 0.52 0.49 0.26 0.45 0.45 0.65 0.69 0.65 0.69 0.86 LAYPERSONS Facial feature rankings 0.6 0.41 0.74 Attractiveness ratings Overall <40 years of age female >40 years of age female <40 years of age male >40 years of age male 0.75 0.79 0.66 0.74 0.69 0.71 0.73 0.51 0.65 0.44 0.79 0.84 0.77 0.81 0.84 46 Table 11. Kappa agreement statistic for choice of whether the pre-surgery or post-surgery face was more attractive A OVERALL First rating A B C Column total Kappa (95% CI) 141 (36.3) 23 (5.9) 24 (6.2) 188 (48.3) 0.48 (0.41-0.55) ORTHODONTIC RESIDENTS First rating A 68 (38.0) B 12 (6.7) C 12 (6.7) Column total 92 (51.4) Kappa (95% CI) 0.53 (0.42-0.63) LAYPERSONS First rating A B C Column total Kappa (95% CI) 72 (34.8) 11 (5.2) 12 (5.7) 96 (45.7) 0.44 (0.34-0.53) Second rating B C Row total 20 (5.1) 114 (29.3) 18 (4.6) 152 (39.1) 16 (4.1) 22 (5.7) 11 (2.8) 49 (12.6) 177 (45.5) 159 (40.9) 53 (13.6) 8 (4.5) 53 (29.6) 10 (5.6) 71 (39.7) 3 (1.7) 6 (3.4) 7 (3.9) 16 (8.9) 79 (44.1) 71 (39.7) 29 (16.2) 12 (5.7) 61 (29.1) 8 (3.8) 81 (38.6) 13 (6.2) 16 (7.6) 4 (1.9) 33 (15.7) 98 (46.7) 88 (41.9) 24 (11.4) 47 CHAPTER 6 DISCUSSION The aims of this study were to evaluate whether panels of observers with different levels of orthodontic experience assess facial attractiveness similarly, and to determine what soft tissue features influence assessment of facial attractiveness. More specifically, the investigators aimed to determine if post-surgical outcomes are favorable. Previous studies have contradictory results on levels of agreement between assessors of different backgrounds. Several studies show differences in agreement on facial attractiveness between clinicians and non-dental assessors.41, 42, 44, 46 In a two-part study by Ng et al, orthodontists, art students, and laypersons rated pre- and post-surgical frontal and lateral photographs of 10 patients (5 male, 5 female) who had undergone BSSO for mandibular advancement. In the first part of the study, assessors were given pre- and post-operative photographs that were randomly assigned A or B, and were asked to score overall facial attractiveness on a VAS. In the second part of the study, the investigators were given the same photographs, but the pre- and post-operative photographs were matched and the operative status was disclosed to the assessors.47 This study design is similar to our study, except that all of the patients had undergone orthognathic surgery. Contrary to the findings in our study, Ng et al found that ratings of facial attractiveness varies among groups of raters with different backgrounds, and significant differences were found between orthodontists and art students.47 48 Several studies have demonstrated a general level of agreement among laypersons, orthodontists, and oral and maxillofacial surgeons concerning facial apperance.20, 40, 48 Similar to these studies, our findings suggest that the rater category (layperson, orthodontist, oral surgeon, etc.) has no bearing on facial attractiveness ratings. In our study, all groups of raters rated surgical patients, on average, 0.55 points lower than non-surgical patients. These findings were true for all patient subjects in each age/gender category such that, on average, patients who had undergone orthognathic surgery were perceived as being less attractive than those who were treated with orthodontics alone. Although the mean ratings for surgical patients were lower than those for non-surgical patients, raters most often chose the post-surgery image when pre- and post-surgery images of the patient were presented in a “before and after” format. In fact, on average, if the assessors did not prefer the post-surgical face, they selected “no preference” (neither option) over selecting the pre-surgical face. This is similar to the findings in the second part of the study by Ng et al in that attractiveness scores were significantly higher for post-operative photographs when they were paired with the preoperative photographs.47 When assessors are asked to compare faces, there are several confounding variables (hairstyle, facial hair, skin color/complexion, etc.) that are not influenced by the treatment modality that make it difficult to compare different patients. It is evident that rating facial attractiveness is very subjective, especially when comparing individuals to one another. In our study; however, when assessors were asked to rate the same face, there was a very strong level of agreement such that the vast majority preferred the postsurgical face. Taken together, our findings suggest that a “before and after” format 49 (photos from the same patient) may be the more reliable way to assess perceived outcomes of orthognathic surgery. In order to ethically recommend an invasive procedure to a patient, it is critical to know if the benefits outweigh the risks. In order to recommend orthognathic surgery to a patient, we must be confident that this treatment modality is consistently providing a favorable outcome. In a study by Phillips et al, orthodontists, oral surgeons, and first-year dental students were asked to rate pre- and post-treatment photographs of 13 orthodontic camouflage and 13 orthognathic surgery patients on a VAS.49 The results suggest that the dental students were most critical, whereas orthodontists and oral surgeons tended to give higher attractiveness scores overall. There was no significant change noted in the mean facial attractiveness scores for the orthodontic camouflage group, whereas the orthognathic surgery group mean scores showed significant improvement in facial attractiveness. Furthermore, even through the orthognathic surgery group showed vast improvement in facial attractiveness after treatment, this group was still considered significantly less attractive than the orthodontic camouflage group.49 These findings are similar to our study in that, although patients who had undergone orthognathic surgery had a favorable outcome (post-surgical face preferred over pre-surgical face), mean attractiveness scores were rated lower for the surgical patients than the non-surgical patients. It is well understood that facial attractiveness is a multifactorial concept. Although some people may have individual facial features that are exceptionally attractive, it is usually the combination of multiple parts working in tandem to create an overall attractive appearance. In an effort to better understand how individuals perceive 50 facial attractiveness, assessors were asked to rank facial features in order of importance relating to overall attractiveness. Previous studies have found that lower facial height, tooth alignment, and overall facial harmony contribute to facial attractiveness, but there is no consensus in the literature that suggests a hierarchy of facial features that define facial attractiveness.3, 50 The facial features selected for the questionnaire for this study are commonly assessed during a clinical examination, but are not meant to be a comprehensive list of all features that contribute to facial attractiveness. An “other” category was included to allow for assessors to contribute additional facial features that they felt were important. Our results indicate differences between groups when ranking facial features that contribute to facial attractiveness. Although there was no consensus across all groups on a hierarchy of facial features that contribute to facial attractiveness, there were several commonalities between lists. A significant difference was found between orthodontic residents and laypersons when ranking skin complexion and eyes, whereas laypersons perceived these features as more important contributors to facial attractiveness than orthodontic residents. Orthodontic residents and oral surgeons ranked vertical and horizontal proportions as the top two items on their lists. Oral surgery residents and orthodontists ranked eyes, nose, and lips as their top three items. Laypersons also ranked eyes and nose in their top three. Taken together, these findings only weakly support a previous study that suggests that clinicians may have a more “academic” and laypersons a more “emotional” approach to assessing facial features.28 Overall, our findings do suggest that oral surgeons and oral surgery residents tend to rank facial features most similarly to all other groups. 51 A limitation to the rank list provided to assessors was that the list included various terms (nasolabial angle, for example) that are not common knowledge without some level of dental education. Several of the laypersons did not rank items with which they were unfamiliar. For example, 33.3% of laypersons did not rank vertical proportions, horizontal proportions, or lower facial height. Similarly, 83.3% of laypersons did not rank nasolabial angle, and 95.2% did not rank the labiomental sulcus. It is possible that the ranks lists provided by the laypersons may not accurately reflect a true understanding of each term. The rank list provided also had a section where the assessors could write in “other” facial features that were not included on the list. Some of these items included teeth, smile, hairstyle, symmetry, facial hair, and eyebrows, among others, but there were too few repeat answers to report rank lists of these items. An argument against using the VAS is that, because individuals are not equally calibrated, it is a subjective method to collect data. Numerous studies suggest that the VAS can provide a quick, simple, and reliable way to assess facial attractiveness.40, 49, 51 Phillips et al defend the VAS as a good instrument to rate continuous variables: “The rating scores can detect differences in overall perceptions of facial attractiveness between panels [of assessors] and … [can] indicate the direction of change as well as the extent of change.”49 Intrarater reliability for our study using the VAS to rate facial attractiveness was good (ICC = 0.67). These findings are consistent with those of Maple et al (ICC = 0.71).40 Some critics argue that facial attractiveness cannot be assessed with 2D photographs alone. Most clinicians would agree that the best way to assess a patient is at the clinical exam.4, 5 This method for rating facial attractiveness simply was not feasible 52 for this study. Although 2D photographs provide a static representation of a dynamic form, they have been consistently used in orthodontic treatment planning for decades. Three-dimensional (3D) technology is advancing such that more sophisticated methods of treatment planning are being utilized, but the clinical exam accompanied with 2D photographs continues to be the norm for treatment planning both surgical and nonsurgical cases. Phillips et al reported that, when assessing facial photographs, there is not a single view consistently favored as the most attractive. They did suggest that showing multiple views of a subject simultaneously is the most appropriate method of presenting 2D facial photographs for assessment.52 This supports the presentation of frontal and profile views of each subject in this study. Although the use of 2D photographs for this study is reasonable, the lack of standardization of the facial photographs used in this study may have resulted in less reliable ratings of these particular photographs. Because several different clinicians took the photographs, there were invariably items that were not well controlled. It was evident in some photographs that the lighting was less than ideal, and, even though an attempt was made to crop out distracting features, this was not always possible. (Cropping out facial hair or hairstyles that covered portions of the face was not possible without grossly distorting the photograph.) There were also two surgical patients included in the study that did not have pre-treatment photographs available. The first set of progress photos (with fixed appliances on) was used for these patients instead. Another potential limitation of the study was the inevitable selection bias that accompanies a convenience sample. For example, all laypersons were Caucasian and the majority of the other rater groups was also only marginally diversified for ethnicity. Also, 53 all of the orthodontist assessors were male, and only two of the oral surgeons were female. A more diversified sample for assessors would be ideal, but the sample may not necessarily misrepresent the population. In fact, the demographics of the dental professional do parallel those reported by the American Dental Association (ADA) and American Dental Education Association (ADEA). In this study, the majority of all participants was male, but not by a large margin. There was about a 60/40 split males:females for dental professionals. This suggests a trend towards a slight increase in female dentists similar to that reported by the ADA in 2011.53 In this demographic update, there were 77.8% professionally active male dentists and 22.2% professionally active female dentists in the United States in 2009. Among new professionally active dentists in 2009, 62.1% were male and 37.9% were female.53 In this study, the percentages of male and female participants in the dental student and orthodontic resident groups were more evenly split between males and females, with slight female predominance in the orthodontic resident group. This finding represents a drastic increase in females entering the dental profession since the 1980s where female dentists comprised only 3% of the dental profession. In this study, 88.9% of oral surgery residents, 80% of oral surgeons, 100% of orthodontists were male. The demographics of this study suggest that these specialties are still predominantly male. The majority of dental professional participants (non-laypersons) were Caucasian (70.8%). Asian or Asian-Indians (2.9%), Spanish/Hispanics (0.7%), African-Americans (8.7%), American Indian/Alaskan Native or Other (2.2%) comprised the remainder of the participant pool. These percentages loosely correspond with demographics reported by 54 the ADEA in 2010, where the racial demographics were 65% Caucasian, 5% Asian, 16% Hispanic, 12% African-American, 1% American-Indian/Alaskan Native or Other.54 Our findings suggest that there is a level of agreement between groups of different backgrounds and that orthognathic surgery in this sample did provide favorable outcomes. Future studies may also consider asking the patients whose photographs were used in this study to assess facial attractiveness of the same set of patients, including themselves. Previous studies suggest that patients who pursue treatment are more critical than laypersons and clinicians.46 It would also be valuable to attempt to assess the clinical characteristics of the patients that had the most favorable outcomes in the hopes of being able to translate these outcomes to future treatment planning attempts. In other words, was there a trend of reliable facial attractiveness ratings associated with specific surgical procedures? If so, what additional steps can we take that may aid in creating a more objective method to plan and execute orthognathic surgery cases? Our findings suggest that outcomes of orthognathic surgery were favorable in our patient sample, but clinicians should still be selective in evaluating cases for treatment. This is especially true for those patients in which surgical movements may be small. Patients must understand what esthetic changes may or may not occur as a result of surgery. Communication is critical between the patient and clinicians for the treatment outcome to be successful. Even if the surgery is a technical success in that the jaws are positioned in a favorable position to allow the teeth to fit together ideally and for the face to be balanced, it may still be a failure if the treatment outcomes are different than the pre-treatment expectations of the patient. Thorough communication will undoubtedly 55 assist patients in making appropriate treatment decisions, thus resulting in more favorable outcomes. 56 CHAPTER 7 CONCLUSIONS On average, assessors of different backgrounds (laypersons, dental students, orthodontic residents, orthodontists, oral surgery residents, and oral surgeons) tend to rate the facial attractiveness of post-surgical patients as slightly less attractive than patients treated with orthodontics alone. 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