Jan Rustemeyer1* and Aynur Sari-Rieger2
1 Professor and Chair, Department of Oral and Maxillofacial Surgery, Plasic Operations, Klinikum Bremen-Mitte, Medical School of the University of Göttingen, Bremen, Germany
2 Consultant, Department of Oral and Maxillofacial Surgery, Plasic Operations, Klinikum Bremen-Mitte, Medical School of the University of Göttingen, Bremen, Germany
Department of Oral and Maxillofacial Surgery Plastic Operations
28177 Bremen, Germany
Tel: 0049 421 497 2451
Fax: 0049 421 497 2452
Background: Controversy exists as to whether laypersons, professionals, and patients agree in their perceptions of facial attractiveness following orthodontic surgery.
Materials and Methods: Each panel consisted of six males and six females who rated sets of pre- and postsurgical lateral photographs of 20 female and 20 male patients using a five-point scale. Patients rated their own set of photographs.
Results: Ratings of patients and panels revealed no significant correlations. Male orthodontists judging boys, female maxillofacial surgeons judging boys, and male laypersons judging boys and girls agreed more over the same adolescent than did the other raters. In the orthodontists’ group, female orthodontists’ scores were significantly lower than scores given by male colleagues. Older maxillofacial surgeons gave significantly lower scores than did their younger counterparts.
Conclusion: The results of this study suggest that laypersons’ assessments are more like those of orthodontists’ and maxillofacial surgeons’ panels than those of the patients’ group. Hence, findings in the laypersons’ panel cannot be transferred without concerns for patients. Information gathered from this study might support the cooperation of the medical staff and might assist in treatment planning.
Keywords: Orthognathic surgery, Esthetics, Photogrammetry, Panel study, Facial convexity, Facial attractiveness
Since todays orthognathic surgery patients focus their expectations mostly on the postsurgical facial outcome, quality-of-life benefits are generally high if these patients perceive aesthetic improvement in facial features after surgery.1,2 However, the question arises as to whether the general public as the consumer of orthodontic services appreciates facial change brought about by orthognathic surgery in the same way as orthodontists or surgeons, since patients motives for treatment are not necessarily related to objectively determined needs.
What laypersons perceive as a beautiful, attractive, or satisfying outcome may not agree with that of professionals whose judgment is based on experience and training.3,4 Several investigators have sought to answer this question by comparing ratings of facial attractiveness given by panels of experts that include orthodontists and surgeons and panels of laypersons. However, panel composition and assessment of data have been inconsistent and vary from study to study. On the one hand, some results suggest that preferences of facial attractiveness by laypersons, orthodontists, and surgeons are generally in agreement.5,6 On the other hand, laypersons might be expected to give lower improvement scores after surgery than do professionals and should be less critical in their evaluation of profiles displaying dysgnathia as well as normal reference profiles.7 Expert raters should provide more reliable ratings on certain morphologic features, but laypersons profile attractiveness ratings should be the best predictors of patients motivation for surgery.3,4 Hence, controversy remains in the literature as to whether laypersons, professionals, and patients agree in their perceptions of facial attractiveness. However, this information is urgently needed to counsel patients who seek orthognathic surgery and especially to communicate with patients on their treatment expectations. Therefore, the objective of this study was to compare the pre- to postsurgical changes of patients soft tissue profiles after surgical correction of prognathism and maxillary hypoplasia as perceived by maxillofacial surgeons, orthodontists, laypersons, and patients themselves.
Materials And Methods
Ethical approval of the study protocol:
Approval for the study was given by the ethics committee of the state medical association (Study No. 401). All the patients signed release forms permitting the use of their data and photographs for scientific purposes.
Records from orthognathic surgery patients assembled in 2012 and 2013 were searched and pre- and post-treatment files from 40 patients were randomly selected after stratification for gender, type of dysgnathia, surgical treatment, and certain exclusion criteria to avoid any bias. These criteria were patient findings that exceeded routine orthognathic surgery, such as those with an anterior open bite greater than 1 cm, facial asymmetry with occlusal cants in the frontal plane, midline deviations and mandibular border asymmetry, matured cleft lip and palate, severe congenital facial or post-traumatic deformity, and obese patients (BMI > 30 kg/m2). Hence, the study sample included files of 20 females (mean age 21.8 SD deviation 5.5 years) and 20 males (mean age 22.5 4.9 years), who underwent bimaxillary osteotomy for correction of prognathism and maxillary hypoplasia.
Booklets and raters:
Profile images were printed on glossy photo paper to an image size of 4 5 cm. Thirty-six survey booklets were made, each including the 40 sets of pre- and postsurgical patient profile photographs. Three sets of photos were shown per page. Six randomly selected sets (three female and three male profile sets) were duplicated and rated twice to test reproducibility. A rating scale was printed beneath each set of photos in the booklet to evaluate the differences in facial pre- and postsurgical aesthetics on a five-point scale on which means − 2 = markedly worsened, − 1 = worsened, 0 = no change, +1 = improved, and +2 = markedly improved (Figure. 01). Raters were contacted by phone to determine their readiness for participation in the study. Each booklet included a questionnaire to provide gender, age, and profession. To obtain anonymity and avoid the possibility of tracing the booklets, no further personal data were sampled. Each rater was requested to read the given instructions before proceeding with the study. Raters were asked to evaluate the aesthetic change between pre- and postsurgical photographs in the most objective way, without being influenced by factors such as make-up, eye color, and hair style. The final booklet consisted of 18 pages containing 46 pre- and postsurgical patient profile photographs and was sent to the raters together with a self-addressed envelope for a cost-free return.
Fig. 1: Original set of lateral photographs (left side = presurgical; right side = postsurgical) with a rating scale as it was printed in the booklet.
The rating panels consisted of 12 orthodontists (six females, mean age 45.5 7.6 years; six males, mean age 44.8 8.9 years), 12 maxillofacial surgeons (six females, mean age 41.3 4.7 years; six males, mean age 51.8 10.4 years), and 12 laypersons (six females, mean age 37.3 15.1 years; six males, mean age 37.7 13.6 years). The laypersons were recruited from incidental contacts and had a relatively high socioeconomic background, but none of them was trained in dentistry or surgery. The data were collected and analyzed after all booklets were completed and returned. In addition, each orthognathic surgery patient rated his or her set of photographs given in the booklet with the same rating scale as did the panel members at the follow-up appointment 6 months post surgery.
Data were subjected to statistical analysis using the SPSS statistical software package, version 20.0 (IBM, SPSS, Chicago, IL). Normal distribution of datasets was confirmed using the Kolmogorov-Smirnov test. In statistically evaluating the reproducibility of the ratings on the five-point scale, the random error for a rater was calculated as, where SD is the standard deviation of the differences in the ratings of the duplicated photographs. The reliability of the final score was expressed as the intraclass correlation coefficient (ICC), as described by Kiekens et al.8 Variance of the random effects, Vb , was the between-subject variance, which reflected the variability of the five-point score between patients. The within-subject variance, Vw, reflected the variability of the panel members over the same patient. The ICC was then calculated as Vb /[Vb + Vw], which can be interpreted as the mean correlation of randomly selected pairs of single panel members. The ICC was 1 when all panel members agreed on all patients. If the panel members substantially disagreed on the same patient, the within-subject variance was large compared with the between-subjects variance and the ICC was close to 0. When the five-point score was based on the average five-point scores of N randomly selected raters, the ICC for pairs of panels was ICC(N ) = N ICC(1)/[1+( N − 1) ICC(1)]. To assess significant differences between ratings of the panels, a two-way analysis of variance (ANOVA) was performed on the mean ratings. To assess the effect of age on ratings, age was dichotomized at the median age of the panel members and the patients. A median age of the panel members above 44 years was categorized as old; a median age below 44 as young; a median age of patients above 20 was categorized as old, and a median age below 20 as young. The paired t test was used to evaluate the intraclass effect of gender and age on all groups. Results were considered significant if the P value was less than 0.05 and highly significant if the P value was less than 0.01. All statistics were finally checked by biostatisticians at our institution.
Random error and intraclass correlation coefficient (ICC):
The mean of the differences of scores between the original and duplicate photographs varied from −0.17 to 0.67 among each panel group. Statistical evaluation of the reproducibility of the ratings on the five-point scale revealed random errors for the measurements from 0.26 to 0.91 (mean 0.46 0.19) for orthodontists, from 0.26 to 0.67 (0.39 0.21) for maxillofacial surgeons, and from 0.26 to 0.76 (0.46 0.17) for laypersons. No significant differences could be obtained between the random errors of the three panel groups, female and male raters, and old and young raters. The ICCs for the three panels, each consisting of one randomly selected rater, are displayed in Table. 01. Generally, the ICC was higher in male raters among all panels, except the ICCs of female maxillofacial surgeons judging boys and female orthodontists judging girls. Since Vw was much smaller for male orthodontists judging boys, female maxillofacial surgeons judging boys, and male laypersons judging boys and girls, these panel raters agreed more over the same adolescent than did the other raters. Female orthodontists evaluating boys produced the lowest ICC and a remarkably high Vw. For the total number of 12 raters per panel, the ICCs were 0.95 for orthodontists, 0.95 for maxillofacial surgeons, and 0.97 for laypersons.
Variance among groups rating profile changes of girls and boys.
Vb = between-subject variance; Vw = within-subject variance; ICC = intraclass correlation coefficient.
Comparison between groups and effect of gender and age:
Highly significant correlations with r ranging from 0.610 to 0.811 were obtained between the overall ratings of all panels. Ratings of patients and panels revealed no significant correlations. However, no significant differences in rating were obtained between panel groups and patients group by two-way ANOVA (Table. 02). In the orthodontists group exclusively, female orthodontists scores were significantly lower than scores given by male colleagues. Older maxillofacial surgeons gave significantly lower scores than did their younger counterparts. With respect to gender and age, no effect on scoring could be found in the ratings by laypersons or patients.
Table. 02 Ratings of photographic profiles of patients (girls and boys) given by orthodontists, maxillofacial surgeons, laypersons, and patients themselves.
|Mean ± SD||t test||ANOVA|
|Orthodontists||Female||0.75 ± 0.95|
|Male||1.01 ± 0.85||0.002†||0.288a|
|Old||1.08 ± 0.84|
|Young||0.85 ± 0.96||0.864|
|Maxillofacial surgeons||Female||0.93 ± 0.89|
|Male||0.85 ± 0.80||0.307|
|Old||0.77 ± 0.87|
|Young||0.98 ± 0.82||0.006†|
|Laypersons||Female||0.79 ± 1.03|
|Male||0.75 ± 0.95||0.581|
|Old||0.87 ± 0.92|
|Young||0.72 ± 1.02||0.126|
|Patients||Female||0.75 ± 1.18|
|Male||1.20 ± 0.93||0.199||0.392b|
|Old||1.04 ± 1.06|
|Young||0.94 ± 1.09||0.771|
SD = standard deviation; atested for orthodontists’, laypersons, and maxillofacial surgeons’ panels (mean ratings of three groups); btested for panels and patients’ group (mean ratings of four groups); †highly significant at the level P < 0.01 (two-tailed).
In this study, the ICCs fulfilled the requirement for an ICC to be equal to or above 0.80 for a panel size to be large enough to obtain reliable results in evaluating profile changes in adolescent faces by using photographs and a five-point scale.8 The best agreement of panel members ratings of pre- to postoperative profile changes was obtained for male orthodontists judging boys, female maxillofacial surgeons judging boys, and male laypersons judging girls and boys. In contrast, the lowest agreement was found among female orthodontists judging boys. No significant differences in overall ratings were obtained between panels on the one hand and between the panels and patient group on the other hand. In accordance with the findings of other study groups,4,6,9 these results revealed that the ratings of pre- to postoperative changes towards higher facial attractiveness by orthodontists, maxillofacial surgeons, laypersons, and patients are generally in agreement, although significant correlations between ratings could be obtained only for the panels. In the recent literature, the influence of gender and age of panel members on their ratings is still disputable, and it varies among studies. Some studies indicated that the gender of panel members was not decisive for their ratings.10 Other studies, however, indicated that female panel members are less critical than males 11 and female laypersons rate female faces as more attractive than do male laypersons.12 In our study a significant effect of raters ages on rating scores was shown in the maxillofacial surgeon panel,in which older practitioners gave significantly lower scores than did the younger ones. With respect to gender, in the orthodontists group, female orthodontists rated facial changes significantly lower than did their male colleagues, suggesting that female orthodontists are more critical than male orthodontists. However, no impact of gender on scoring could be found in the laypersons panel.
Although there is no difference in the overall ratings between groups, the results of this study suggest that laypersons assessments are more like those of orthodontists and maxillofacial surgeons panels than those of the patients group. Hence, findings in the laypersons panel cannot be transferred without concerns for patients. However, information gleaned from this study might elicit support from board members and medical staff insofar as assisting in treatment planning and recommendations to patients.
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Rustemeyer J, Sari-Rieger A. Pre- to Postsurgical Profile Changes Following Orthognathic Surgery and Their Perception in Professional and Patient Panels. J Oral Sci Health. 2014;1(2):1-6.
Competing interests: The authors declare that no competing interests exist.