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ORIGINAL ARTICLE
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Assessment of BSSO surgery need in adult male and female using photos and silhouette


1 Department of Orthodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, SS Nagar, Mysuru, Karnataka, India
2 Department of Public Health, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, SS Nagar, Mysuru, Karnataka, India

Date of Submission20-Nov-2021
Date of Decision05-Mar-2022
Date of Acceptance26-Apr-2022

Correspondence Address:
S Suma,
Department of Orthodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, SS Nagar, Mysuru, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_901_21

  Abstract 


The orthognathic surgery plays an important role in achieving a pleasant-sounding dental, skeletal, and soft tissue which in turn helps an individual with jaw divergences to have function efficiency, aesthetic harmony, and structural balance. Pre-treatment profile photographs of the subjects were taken and morphed forward and backward, in 2 mm steps, until severely prognathic or retrognathic, respectively, to get class III and class II skeletal relation was acquired and the images were labeled from 1 to 5. The morphed profile photos were then camouflaged using Adobe Photoshop CS (v. 5.1) to generate silhouette images. The images were evaluated by three groups of assessors which includes orthodontists, oral surgeons, and laypersons. There was a statistically significant difference between oral surgeons, orthodontists, and laypersons in scoring class II (P < 0.001) for scoring adult females but no significance in rating adult males. There was a statistically significant difference between oral surgeons, orthodontists, and laypersons in scoring class III (P < 0.001) for scoring adult males and females. No difference was observed between scores when evaluated differently with the use of silhouettes or photos.

Keywords: BSSO, profile photo, orthognathic surgery, silhouettes



How to cite this URL:
Suma S, Prakash N, Chandrashekar B R, Raghunath N, Pradeep S. Assessment of BSSO surgery need in adult male and female using photos and silhouette. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2022 Dec 7]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=346454




  Introduction Top


In our day-to-day social interactions and activities, facial aesthetics play an important factor. In orthodontic treatment planning profile, balance and attractiveness are the most deciding factors. In routine orthodontic treatment planning, treatment options mainly include non-extraction, extraction, and orthognathic surgery, in all, we consider profile balance. Orthodontic treatment aims to achieve efficiency, structural balance, and aesthetic harmony. But in a few cases achieving the goal becomes difficult only by orthodontic treatment, so those cases are treated through orthognathic surgeries.

The orthognathic surgery plays a significant role in achieving a pleasant-sounding dental, skeletal, and soft tissue which in turn helps an individual with jaw divergences to have function efficiency, aesthetic harmony, and structural balance. An individual who requires orthognathic surgery needs to be evaluated in detail for effective treatment by both orthodontists and oral surgeons. Apart from this, patient and the peer group expectations and knowledge regarding this becomes very crucial. Among different types of malocclusions, the study reports that 5% of all class II, 33% of all class III, and 25% of long face patients were latent candidates for orthognathic surgery.[1]

Attractive individuals are looked upon as more prevalent and having a finer personality. The perception regarding attractiveness and beauty is a complex issue, and it is forevermore predictable that what is measured to be more beautiful and attractive to a layperson may not agree with the perception of specialists based on their knowledge and training.[2] The valuation of a person's appearance as professed by them and the conceivable enhancement with orthognathic surgery are vital deliberations during treatment planning for dentofacial problems. Hence, it is imperative to distinguish both the specialists' and the patient's views on the facial acceptance before the orthognathic surgery.

The previous pieces of research have concluded that different perception levels for facial acceptance exist between patients, peers, and dental professionals.[3] In most of the studies, facial attractiveness is evaluated using profile images or silhouettes. The use of profile images or silhouettes allows the investigator to facade puzzling factors such as gender, race, beauty, and facial blemishes. The morphed profile photos or silhouettes are most frequently rated using a visual analog scale.[4].

The aim and objective of the present study was to assess the apparent level at which orthodontists, oral surgeons, and patients endorse Bilateral sagittal split osteotomy (BSSO) surgery using progressively camouflaged mandibles in adult male and female photos and silhouettes. The other objective of the study was also to evaluate if orthodontists, oral surgeons, and patients recommend surgery at varied grades of prognathia and retrognathia and to determine the superiority between photos and silhouettes in assessing mandibular orthognathic surgery.


  Material and Method Top


Ethical approval was attained from the institutional ethical committee and consent was obtained from the patients both for their clinical information and to use photographs and radiographs for research and further presentations. A sample of skeletal and dental class I subject (one male and one female) with balanced profile assigned to the study who visited the department of orthodontics and dentofacial orthopedics for the treatment on a random basis. The subjects selected were aged between 18 and 25 years.

Pre-treatment profile photographs of the subjects were taken and morphed backward (at B point and Pogonion), in 2 mm steps, until severely prognathic class III skeletal relation was acquired and the images were labeled from 1 to 5 [Figure 1] and [Figure 2]. The original image was gradually morphed to get retrognathic profile to a severely retrognathic profile with 2 mm incremental advancement [Figure 3] and [Figure 4]. The morphed profile photos [Figure 1], [Figure 2], [Figure 3], [Figure 4] were then camouflaged using Adobe Photoshop CS (v. 5.1) to generate silhouette images [Figure 1]a, [Figure 2]a, [Figure 3]a, and [Figure 4]a, respectively. Each image was labeled from 1to 5 for both profile photos and silhouettes both retrognathic or prognathic mandibles in ascending order.
Figure 1: Modified profile photos of adult male showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most prognathic mandible morphed forward into class III. (a) Modified profile silhouette of an adult female showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most prognathic mandible morphed forward into class III

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Figure 2: Modified profile photos of adult female showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most prognathic mandible morphed forward into class III. (a) Modified profile silhouette of an adult female showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most prognathic mandible morphed forward into class III

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Figure 3: Modified profile photos of adult male showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most retrognathic mandible morphed forward into class III. (a) Modified profile silhouette of an adult male showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most retrognathic mandible morphed forward into class III

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Figure 4: Modified profile photos of adult female showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most retrognathic mandible morphed forward into class III (a) Modified profile silhouette of an adult female showing the morphed mandible in 2 mm steps. Score 0 is the normal position and score 5 is the most retrognathic mandible morphed forward into class III

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The images were evaluated by three sets of evaluators which included orthodontists, oral surgeons, and laypersons. Each group contained 30 evaluators with 15 males and 15 females. The age group of the evaluators ranged from 31 to 58 years and all were selected as a part of a convenient sample. All the evaluators scored the mandibular position level at which they would recommend surgical setback or advancement for each customary image. Apart from rating the profile photos and silhouettes, the evaluator was asked to mention the age and gender of all and the years of experience of orthodontists and oral surgeons in the administered questionnaires.


  Results Top


The comparison of different evaluation scores concerning mandibular setback and advancement for adult males and females are enumerated in [Table 1], [Table 2], [Table 3]. After evaluating the values of modified silhouettes and photos, the recommended score for BSSO setback in adult males group by the orthodontists is score 5, oral surgeons is score 5, and most of the laypersons recommended a score of 5. Only two persons recommended scores 3 and 4. No difference was observed between scores when evaluated differently with the use of silhouettes or photos. After evaluating the values of modified silhouettes and photos, the recommended score for BSSO setback in adult female group by the orthodontists is score 5, oral surgeons is score 5 whereas the scoring of laypersons differed—16 evaluators scored 5, 10 evaluators scored 4, and 4 evaluators scored 3. No difference was observed between scores when evaluated differently with the use of silhouettes or photos.
Table 1: Comparison of different evaluation scores with regard to mandibular setback in adult male and female

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Table 2: Comparison of different evaluation scores with regard to mandibular advancement in adult male and female

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Table 3: Comparison of different evaluation scores with regard to the selection of photos or silhouettes between different groups of evaluators

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After observing modified silhouettes and photos, the recommended score for BSSO advancement in adult males group by the orthodontists is score 5, among oral surgeons, the scoring differed a little—28 evaluators scored 5 whereas 2 scored 4, and regarding laypersons, 20 evaluators scored 4 and 10 scored 5. No difference was observed between scores when evaluated differently with the use of silhouettes or photos. After viewing modified silhouettes and photos, the recommended score for BSSO advancement in the adult females group among orthodontists—24 evaluators scored 5, 4 have scored 4, and 2 have scored 3, among oral surgeons—21 evaluators scored 5, 5 have scored 4, and 4 have 3, and regarding laypersons—13 evaluators scored 5 and 17 scored 4. No difference was observed between scores when evaluated differently with the use of silhouettes or photos.

The study results suggest a statistically significant difference exists while rating class II profile with the P < 0.001 between orthodontists, oral surgeons, and laypersons for scoring adult females but no significance in rating adult males. The study results reveal a statistically significant difference between oral surgeons, orthodontists, and laypersons in scoring class III (P < 0.001) for both adult males and females.

The evaluators' demographic information was documented via the questionnaire and is described in [Table 4]. In all groups, it included 15 male and 15 female evaluators. All evaluators were less than 60 years of age. All the specialists who participated in the study, that is, both orthodontists and oral surgeons had an experience ranging between 16 and 30 years. But two oral surgeons had an experience of more than 30 years.
Table 4: Gender distribution of evaluators in the study

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  Discussion Top


The correction of skeletal classes II and III malocclusions often requires orthognathic surgery as an improved treatment option to achieve more reliable, stable, and aesthetic harmony. It will become very significant to know if oral surgeons and orthodontists recommend the BSSO surgery at the same level of skeletal discrepancy. In addition to the specialist recommendation, we need to understand the layperson's expectation and recommendations for the selection of BSSO surgery.

Orthodontists, oral surgeons, and laypersons appraised both class II and class III profile divergence at a statistically different level for mandibular positions. This outcome agrees with the existing works.[5],[6],[7] The orthodontists and oral surgeons recommend mandibular surgery for skeletal class III discrepancy at the same level, but laypersons recommend a lesser prognathism than both the specialists for the adult male. This suggests that both orthodontists and oral surgeons consent to more skeletal class III discrepancy in their range of profile suitability than laypersons. Whereas in the adult female, both oral surgeons and laypersons recommend surgery at a lesser degree of skeletal class III discrepancy. These findings agree with the previous study results.[7],[8] It has been understood from the previous literature that the specialists censoriously evaluate profile aesthetics. One would imagine that the untrained eyes of laypersons would be less critical. Though the present study found the contrary result that the laypersons were seeming to be more critical in evaluating aesthetic enhancements than the specialists, the same findings are obtained in an earlier study where specialists inclined to give higher assessment scores than laypersons.[9]

In the case of skeletal class II discrepancy where it requires mandibular advancement, all the evaluators rated at a statistically different mandibular position. When it is compared between orthodontists, oral surgeons, and laypersons, both surgeons and laypersons recommended BSSO for a lesser degree of discrepancy with statistically significant differences for both adult males and females. These findings agree with the findings of previous studies.[6],[7],[8]

The study revealed no statistically significant differences between photos and silhouettes for class II and class III profiles (P = 0.320) during evaluation. These results are not in contract with the previous study.[10] These results are not in agreement with the previous study which was exclusively done on African-American male and female individuals. They state that the use of photos will likely induce a bias during evaluation as more defining features may mislead the surveyor to recommend a BSSO surgery at a slighter level.


  Conclusions Top


The conclusions obtained from the present study give valuable inputs to clinicians in treatment planning and educating the affected regarding BSSO surgery. The evaluations of profile silhouettes and photos by orthodontists, oral surgeons, and laypersons for skeletal discrepancies of class II and class III adult male and female patients recommended BSSO surgery at different levels. Both oral surgeons and laypersons recommended BSSO for advancement and setback of mandible at a lesser retrognathism and prognathism than orthodontists. The results of the study conclude no statistically significant difference exists while assessing the superiority of photos and silhouettes for rating BSSO surgical recommendation in both skeletal class II and class III adult male and female profiles.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Proffit WR, Jackson TH, Turvey TA. Changes in the pattern of patients receiving surgical-orthodontic treatment. Am J Orthod Dentofacial Orthop 2013;143:793-8.  Back to cited text no. 1
    
2.
Chew MT, Sandham A, Soh J, Wong HB. Outcome of orthognathic surgery in Chinese patients. A subjective and objective evaluation. Angle Orthod 2007;77:845-50.  Back to cited text no. 2
    
3.
Dunlevy HA, White RP Jr, Turvey TA. Professional and lay judgment of facial aesthetic changes following orthognathic surgery. Int J Adult Orthodon Orthognath Surg 1987;2:151-8.  Back to cited text no. 3
    
4.
Tsang S, McFadden L, Wiltshire W, Pershad N, Baker A. Profile changes in orthodontic patients treated with mandibular advancement surgery. Am J Orthod Dentofacial Orthop 2009;135:66-72.  Back to cited text no. 4
    
5.
Juggins KJ, Nixon F, Cunningham SJ. Patient and clinician perceived need for orthognathic surgery. Am J Orthod Dentofacial Orthop 2005;128:697-702.  Back to cited text no. 5
    
6.
Bell R, Kiyak HA, Joohdeph DR, McNeill RW, Wallen TR. Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. Am J Orthod 1985;88:323-32.  Back to cited text no. 6
    
7.
Moretz, Jessicah L. “Photos and Silhouettes in Evaluating the Need for BSSO Surgery in Adult Females.” (2013).  Back to cited text no. 7
    
8.
Almeda M, Bittencourt M. Anteroposterior position of the mandible and perceived need for orthognathic surgery. J Oral Maxillofac Surg 2009;67:73-82.  Back to cited text no. 8
    
9.
Ng D, De Silva RK, Smit R, De Silva H, Farella M. Facial attractiveness of skeletal Class II patients before and after mandibular advancement surgery as perceived by people with different backgrounds. Eur J Orthod 2013;35:515-20.  Back to cited text no. 9
    
10.
Hockley A, Weinstein M, Borislow A, Braitmas L. Photos vs silhouettes for evaluation of African-American profile aesthetics. Am J Orthod Dentofacial Orthop 2012;141:161-8.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
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