PROCENA ESTETIKE OSMEHA I RAZLIČITIH TIPOVA PROFILA LICA ASSESSMENT OF SMILE ESTHETICS AND VARIOUS TYPES OF FACE PROFILES

Uvod: Nesavršen osmeh i profil lica nešto su zbog čega se pacijenti najčešće obraćaju ortodontima. Cilj sprovedenog istraživanja je utvrditi da li postoji razlika u proceni estetike osmeha i profila od strane različitih ispitivanih grupa. Materijal i metod: U okviru sprovedenog istraživanja,15 ortodonta, 15 studenata završne godine stomatologije i 15 osoba van stomatološke struke ocenjivalo je osmeh 21 osobe (8 osoba muškog i 13 osoba ženskog pola) starosti od 18 do 30 godina.Od ispitanika je zahtevano da ponuđene osmehe ocene brojevima od 1 do 9 i da za svaki osmeh zaokruže jedan od ponuđenih faktora koji u najvećoj meri narušava estetiku osmeha. Ortodonti i osobe van stomatološke struke takođe su ocenjivali pravilan, bimaksilarno retrognat i bimaksilarno prognat profil iste osobe, muškog i ženskog pola,ocenama od 1 do 3, pri čemu je ocenom 3 označavan najlepši profil. Rezultati: Iako ne postoji statistički značajna razlika u prosečnoj oceni estetike osmeha od strane svih ispitivanih grupa, osobe van stomatološke struke dale su najnižu prosečnu ocenu. Sve ispitivane grupe su, pored nepravilnosti pojedinih zuba, navele različite faktore koji narušavaju estetiku osmeha. Ortodonti i osobe van stomatološke struke, kao najlošiji navode bimaksilarno prognat profil. Zaključak: Zbog razlika u proceni estetike osmeha i profila lica od strane ortodonta i pacijenata, potrebno je napraviti estetski protokol za dijagnozu i plan terapije, pri čemu treba uzeti u obzir i studije koje se bave procenom estetike osmeha i lica od strane pacijenata.


Introduction
The beauty of a smile influences the beauty of one's face to a great extent.
Imperfect smile is one of the main reasons why patients turn to orthodontists 1 . Perception of beauty is individual and depends on age, gender, race, education, experience, environment and media 2 .
There is a growing tendency to define a perfect smile both mathematically and geometrically. A great number of papers deal with this topic 3,4 . The question of the beauty of a face, facial profile and the analysis of a smile represent an integral part of everyday work of every orthodontist. This analysis includes the evaluation of tooth size and color, the visibility of the gingiva, teeth proportionality, the relation between facial and dental midline as well as the presence of buccal corridors. The course of an orthodontic treatment is determined based on this analysis.
Within the process of planning an orthodontic treatment, it is important to know how the patient perceives the problem. Having in mind that education and experience are the key factors which influence the estimation of beauty, it is possible that an orthodontist and a patient do not perceive things in the same manner and therefore have different expectations in terms of a therapy. To what degree the expert knowledge of orthodontists influences the evaluation of beauty could be clarified by the comparison of beauty assessment of orthodontists and final-year students at the Faculty of Dentistry. There are not a lot of papers on this topic in modern literature.
The aim of this research is to determine whether or not there are any differences in the evaluation of a smile and facial aesthetics between orthodontist, dental students and people who do not have expertise in this field (laypeople).

Subjects and methods
The sample comprised 21 smiles of white people (8 males and 13 females) 18 to 30 years of age. All the people who participated in the study were informed about the type of the research in detail and have signed the document of consent.
People who were undergoing any orthodontic treatment, people with dentofacial deformity, as well as those with prosthetic works were not included in this study.
Standardized frontal and ophthalmic photographs were used for the smile analysis. All the photographs were taken by Panasonic camera DMC 27 in front of the standardized white background.
The respondents were asked to assess the photographs with numbers from 1 to 9. Marks 1-3 represented aesthetically unacceptable smile, 4-6 aesthetically acceptable smile, while 7-9 a beautiful smile. The respondents also circled one of the given answers to the reasons which mostly impair the aesthetics of a smile.
The photographs were evaluated by 15 orthodontists, 15 final-year dental students and 15 laypeople. Collected data were further statistically analyzed. Mean values were determined for each study group. In order to determine the existence of differences among the studied groups, the received results were analyzed by means of Bonferroni test. Results which referred to the main factors which impair a smile were also described.
Within the second part of the research, 15 orthodontists and 15 laypeople evaluated the beauty of balanced, bimaxillary retrognathic (BMR) and bimaxillary prognathic (BMP) male and female facial profile with the numbers from 1 to 3.
Standardized photographs of ideal male and female facial profile were taken and developed. Regular profile was determined according to an aesthetic Z line. This line reaches the most prominent point of the chin and the most prominent lip and in ideal profile cuts through the tip of the nose. The photographs were then processed in photo shop and we got bimaxillary retrognathic and bimaxillary prognathic profile of each ( Figure 2).

Results
The obtained results suggested that there was no statistically significant difference in the evaluation of the aesthetics of the given smiles made by orthodontists, students of dentistry and laypeople (Table 1).
Bonferroni test showed that there was no statistically significant difference between the orthodontists and laypeople (p=0.89), orthodontists and students (p=0.58) students and laypeople (p=0.60) in terms of their evaluation of the aesthetics of a smile with the numbers from 1 to 9.
As far as finding the concrete reasons which impair the given smiles, the results showed that there were differences among the examined groups (Graph. 1, 2 and 3).
Orthodontists as well as laypeople assessed bimaxillary prognathic profile as aesthetically most unacceptable. Unlike orthodontists, laypeople were not able to make difference between regular and bimaxillary retrognathic profiles and considered them both approximately attractive (Graph. 4).

Discussion
In the conducted study, marks used for the evaluation of smile aesthetics in all the groups is close to number 5 which means that the majority of given smiles is marked as aesthetically acceptable. There is no statistically significant difference in the evaluation of the aesthetics of a smile between the groups, however the group consisting of laypeople gave the lowest average mark. This means that people who do not have expertise in dentistry, and who are most often our patients, are harsher in the assessment of the aesthetics of a smile.
Each group of respondents saw smiles from their perspective and stressed out various imperfections as main causes that impair the aesthetics of a smile.
From a standpoint of an orthodontist, crowding, asymmetry and irregular position of teeth are the main causes that impair the aesthetics of a smile, while laypeople apart from irregular teeth position stress out the visibility of the gingiva and teeth color. Besides the irregular teeth position, students also identify teeth color and shape as the key factors which impair the aesthetics of a smile.
Based on the obtained results we can conclude that beauty is a matter of a subjective assessment and should keep in mind that because of the differences in the aesthetic perception of orthodontists and patients there is a need for an aesthetic protocol for making the diagnosis and a plan of treatment, taking into consideration studies which deal with the aesthetic perception of a smile and face by patients as well.
The results also show that orthodontic knowledge changes the perception of smile aesthetics in comparison with the students of dentistry who are more similar to laypeople in terms of stating the facts that impair smile aesthetics.
It is necessary to inform the patient about what it is possible to achieve in detail before the treatment as well as ask the patient what the main aesthetic problem is and at the same time the reason why he or she wants to undergo an orthodontic treatment.
There are not a lot of papers on the aesthetics of a smile from the viewpoint of different groups of people in the literature. Cotrim R et al 2 . and Rodrigues C de D et al. 5 came to the conclusion that the assessment of vidljivost gingive pri osmehu poželjni i estetski privlačni faktori, što se ne poklapa sa našim rezultatima, s obzirom na to da ispitivane osobe van stomatološke struke navode vidljivost gingive kao jedan od tri glavna faktora koji remete estetiku osmeha. Ova činjenica još jedan je u nizu dokaza da ortodonti i osobe koje su van stomatološke struke različito gledaju na estetiku osmeha.
the aesthetics of a smile by laypeople is not in accordance with orthodontic norms, which is similar to the results of our study to a certain extent.
Van der Geld et al. 6 point out that the visibility of the whole incisor crown and moderate visibility of the gingiva while smiling are aesthetically desirable which does not coincide with our results, since laypeople in our study state that the visibility of the gingiva is one of the main factors that impair the aesthetics of a smile. This fact is yet another proof that orthodontists and laypeople perceive the aesthetics of a smile differently.
The difference in the assessment of the facial profile aesthetics is evident between the mentioned groups. Laypeople cannot see the difference between a balanced and retrognathic profile. These results coincide with the results of Falkensammer F et al. 7 who stress out that orthodontists and maxillofacial surgeons perceive the beauty differently from laypeople. On the other hand Manevska I. et al. 8 define a concave profile as aesthetically least acceptable which does not concur with the results of our study.

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The most severe assessments of the aesthetics of a smile were those done by laypeople even though there was no statistically significant difference between the groups. • Orthodontists state that besides irregularity of certain teeth, crowding and asymmetry impair the aesthetics of a smile to a great extent. Dental students are closer to laypeople in their evaluation and claim that shape and teeth color represent important factors which undermine the aesthetics of a smile.
• Because of the differences in the aesthetic assessment of orthodontists and patients, it is necessary to establish an aesthetic protocol for making the diagnosis and treatment plan while taking into account studies on aesthetic assessment of a smile and face by patients. • Orthodontists and laypeople identify the bimaxillary prognathic profile as least acceptable which is an important piece of information having in mind that orthodontic treatment can influence the change in the profile of a patient.