|SYMPOSIUM 2014 , TANDLEGEFORENINGEN|

Pernilla Larsson Gran

Odont Dr, PhD,

Specialist in Prostodontics,

Senior consultant

Centre of Oral Rehabilitation

Östergötland and Malmö University

SWEDEN

HOW DO WE MEASURE OROFACIAL ESTHETICS?

HOW DO WE MEASURE OROFACIAL ESTHETICS?

WE SMILE – EVERYWHERE

|EKMAN & FREISEN (1971 ) CONSTANTS ACROSS CULTURES IN FACE AN D EMOTIONS|

”Duchenne smile”

“…the zygomatic major can be

willed into action, but that only the

“sweet emotions of the soul” force

the orbicularis oculi to contract. “Its

inertia, in smiling,”

WE SMILE – TOGETHER

Abel and Kruger (2010)

Smile Intensity in Photographs Predicts Longevity

WE SMILE – AND SURVIVE

|DENTAL IMPLANTS FOR L IFE |

E M E L I E - W I T H O U T A S M I L E

C E M E N T A N D R O O T D Y S P L A S I A

|DENTAL IMPLANTS FOR L IFE |

E M E L I E - W I T H O U T O C C L U S I O N

|DENTAL IMPLANTS FOR L IFE |

O R A L H A B I L I TAT I O N

|DENTAL IMPLANTS FOR L IFE |

E M E L I E S M I L E S

|DENTAL IMPLANTS FOR L IFE |

|HOMUNCULUS |

Penfield & Rasmussen: The Cerebral Cortex of Man:

A Clinical study of Localization of Function. Macmillan 1950.

”A state in which we neither suffer pain nor are hindered in

the functions of daily life.” Galen 200 eKr

Biostatic/analytic perspective:

”identical with the abscence of disease” The goal is survival and reproduction. Boorse

Holistic perspective:

”A is completely healthy if, and only if, A has the ability, given standard

circumstances, to reach all his or her vital goals.”Nordenfeldt

HEALTH

QUALITY OF LIFE- QoL

How good is

your life for

you?

Dr David Locker

”Quality of life seems to be influenced by the extent to which we feel

capable of participating in activities that meet our needs and

expectations.

These activities, in turn, are influenced by our environment, economic

status, responsibilities, biological constitution and, of course, time.”

MacEntee 2007

Q U A L I T Y O F L I F E

Allison, Locker, and Feine

“Quality of life: a dynamic construct”

Social Science & Medicine 1997.

By Jonathan Miller

|AUNT MÄRTA 99 ÅR|

W H AT I S O R A L H E A LT H R E L AT E D Q U A L I T Y O F L I F E ?

Märta 99 yrs

SOCIAL IMPACT

ESTHETICS

ORAL FUNCTION

IMPAIRED QUALITY OF LIFE

|AUNT MÄRTA 99 YEARS|

D E N TA L I M P L A N T S F O R Q U A L I T Y O F L I F E

|AUNT MÄRTA 100 ÅR|

M Ä RTA S M I L E S

|SCIENT IF IC DOCUMENTAT ION |

D I M E N S I O N S O F O R A L H E A LT H R E L AT E D Q U A L I T Y O F L I F E

John et al J Dent Res 2004

”Esthetics is one dimension of oral health related quality of life”

OHIP

N= 2050; age 16-79 yrs

Dimensional structure explored by factor analysis

Psychosocial impact

Orofacial pain

Oral functions

Appearance

E S T H E T I C S

”a set of principles concerned with the nature and appreciation of beauty” the Oxford English Dictionary

Nature of beauty:

Objective and subjective perspective

Eco: Aesthetics has historically been

connected to thoughts what is good

and right.

D E N TA L A N D O R O FA C I A L E S T H E T I C S

Esthetic Dentistry

“an appearance showing harmony between natural and

reconstructed parts of the dentition” Belser 2004

Dental Aesthetics

”the science of copying or harmonizing our work with nature and

rendering our art inconspicuous” Pilkington 1936

D E N TA L A N D O R O FA C I A L E S T H E T I C S

Aesthetically successful restorations were positively

correlated with patient´s self-esteem and QoL. Davis et al 1998

An attractive smile is important from a psychosocial viewpoint.

Dentofacial aesthetics is important for personal success. van der Geld et al 2007

Aesthetic perception differ between clinical experts and

patients. Öwall et al 2005, Kokich et al 2006

H E A LT H Y T E E T H – F O C U S S H I F T T O WA R D S E S T H E T I C S

Web

Development

Theobald et al

2006

Samordnitsky et al

2008

|ESTHET ICS |

White teeth more important than

prevention…

Larsson P et al 2010

• 4 out of 5 dissatisfied with tooth color

• Only 10 % satisfied with facial

appearance

”Munhälsa i Sverige”

1500 subjects

H E A LT H Y T E E T H – F O C U S S H I F T T O WA R D S E S T H E T I C S

Survey Swedish dental nurse association

2013

|ESTHET ICS |

A G A P B E T W E E N PAT I E N T S A N D P R O F F E S S I O N

Larsson P et al. (2010)

Deep interviews with

patients Focusgroup with dental

proffessionals

A G A P B E T W E E N PAT I E N T S A N D P R O F F E S S I O N

V I O C H PAT I E N T E R N A S E R O L I K A P Å E S T E T I K

”Både små och stora tänder i en rad är störande” ”Bleker alla på TV sina tänder? Vita är fräscht.” ”Det är inte okej i Sverige med gluggar ju” ”Min haka är för liten” ”Stora, utstående, gulbruna tänder är värst”

”Mjukvävnaden runt en krona

är avgörande för estetiken”

”Ocklusionsplanet vill man ska

vara rakt och snyggt”

”Mittlinjen och smileline är

viktigt för intrycket”

”Snyggt när man karaktäriserar

proslinet med rotfärg och

transpa”

Larsson P et al. Development of Orofacial Esthetic Scale

(2010)

C O M M U N I C AT E

LISTEN, UNDERSTAND, MEET AND GUIDE

Proffessional

Realistic

Natural

My daughters test Kelleher 2012

|PSYCHOMETRICS |

I S O H R Q O L A N D E S T H E T I C S M E A S U R A B L E ?

?

|PSYCHOMETRICS |

I S E S T H E T I C S M E A S U R A B L E ?

The theory and technique of psychological

measurement – such as of knowledge, abilities,

attitudes, and behaviors – primarily by

questionnnaires and tests.

Streiner and Norman

PSYCHOMETRICS

|PSYCHOMETRICS |

IS ESTHETICS MEASURABLE?

• Screening of psychosocial aspects, population surveys,

outcome-measures in clinical trials, cost-benefitanalyser

• Psychometric properties

• Problems with ad-hoc scales

• Often both esthetics and psychosocial impact in the same

scale. What is what?

Q O L , F U N C T I O N , E S T H E T I C S

Why do we give our patients oral rehabilitation?

Three different concepts capturing

patients´ experience

Three PROM´s

Can be used separately or in combination

|DENTAL IMPLANTS FOR L IFE |

R E B E C K A - W I T H O U T A S M I L E

|DENTAL IMPLANTS FOR L IFE |

O R A L H A B I L I TAT I O N

|DENTAL IMPLANTS FOR L IFE |

R E B E C K A S M I L E S

Kokich software manipulation with permission

Kokich VO, Kokich VG, Kiyak HA.

Perception of dental professionals and laypersons to altered dental

esthetics: Asymmetric and symmetric situations.

Am J Orthod Dentofacial Orthop 2006

Objective and

professional

measures

Experts

Clinical criteria

Professional assessment

Reproducibility

Golden Standard

Detailed

Patient-reported

outcome

measures (PROM)

Subjective

Self-reported

Perceptions

Soft values

Impact on OHRQoL

Brief

Ritter DE et al. 2006 Analysis of the smile photograph, Review

“Optimal facial esthetics is one of the objectives in orthodontic treatment

and an important issue in modern society.”

Review and discuss criterion adopted by dental literature to analyze the

smile, such as:

dental midline, smile line, dental exposure, negative space,

dental proportion, and symmetry.

O B J E C T I V E & P R O F F E S S I O N A L

Magne and Belser

Oxford Press

O B J E C T I V E & P R O F F E S S I O N A L

Magne and Belser

Systematic review of parameters and methods for the

professional assessment of aesthetics in dental

implant research

Benic GI, Wolleb K, Sancho-Puchades M, Hämmerle CHF.

J Clin Periodontol 2012

• Mucosa aesthetics

• Reconstruction aesthetics

• Mucosa and reconstruction aesthetics

O B J E C T I V E & P R O F F E S S I O N A L

Jemt (1997) Papilla Index

Furhauser et al (2005) Pink Esthetic Score

Mesial, distal papilla, soft tissue level,

coulor, contour, alveolar process deficiency

O B J E C T I V E & P R O F F E S S I O N A L S E S T H E T I C

M E A S U R E S

Meijer et al (2005) Implant Crown Esthetic Index

Belser et al (2009) Pink and White Esthetic Score (PES/WES)

Dueled et al (2009) Esthetic Outcome Objective Score

Papillas, level of facial mucosa, mucosa texture and color,

tooth form, colour, surface texture, translucency, characterization

O B J E C T I V E & P R O F F E S S I O N A L S E S T H E T I C

M E A S U R E S

|ESTHET ICS |

A G A P B E T W E E N PAT I E N T S A N D P R O F F E S S I O N

Patient-reported outcome measures (PROM)

orthodontits dentists lay people

Gingiva-to-lip distance 2 3 4

Occlusal plane asymmetry 1 1 3

Maxillary midline deviation 4 - -

Kockich 1999

Development of OES

Larsson, John, Bondemark,

Nilner, List 2009-2010

Development of OES

Larsson, John, Bondemark,

Nilner, List 2009-2010

Component Matrixa

.855 .299

.732 .611

.887 .096

.913 -.209

.928 -.175

.776 .042

.803 -.356

.940 -.192

Utseende

Prof il

Mun

Tandrad

Form

Färg

Tandkött

Overall - Upplevelse

1 2

Component

Extraction Method: Principal Component Analysis.

2 components extracted.a.

Total Variance Explained

5.880 73.501 73.501 5.880 73.501 73.501

.712 8.899 82.400 .712 8.899 82.400

.497 6.211 88.611

.356 4.453 93.064

.226 2.825 95.889

.176 2.200 98.089

.089 1.110 99.199

.064 .801 100.000

Component

1

2

3

4

5

6

7

8

Total % of Variance Cumulativ e % Total % of Variance Cumulativ e %

Initial Eigenvalues Extraction Sums of Squared Loadings

Extraction Method: Principal Component Analysis.

Exploratorisk faktoranalys

factor

Latent root criterion (eller eigenvalue over 1)

The first factor accounted for 73,5% of the variance

variables

Expolratory factor analysis

Unidimensionality for the OES

5. Measurement model (dimensionality) Exploratory factor analysis (n=119)

Aesthetically

compromised

Functionally

disabled

OAS Item Patients

I

Ctrl

III

Patients

II

Ctrl

IV

I vs III I vs

II

II vs

IV

Mean SD Mean SD Mean SD Mean SD P P P

Face 4.8±2.3 7.1±2.2 6.6±2.2 6.8±2.3 <0.001 0.005 0.599

Profile 5.6±2.1 6.7±2.6 6.6±2.0 6.5±2.7 0.057 0.046 0.866

Mouth 4.3±2.4 7.0±2.7 5.8±2.2 6.7±2.4 <0.001 0.016 0.178

Tooth alignment 3.2±2.4 6.2±2.7 6.3±2.4 6.2±2.5 <0.001 <0.001 0.747

Tooth shape 4.1±2.3 6.4±2.6 6.7±2.3 6.5±2.5 0.010 <0.001 0.586

Tooth color 4.3±2.4 5.6±2.2 6.6±2.4 5.1±2.1 0.052 0.001 0.431

Gingiva 5.0±2.5 6.9±2.5 7.0±1.8 6.7±2.4 0.006 0.001 0.803

Overal impression 4.1±2.6 6.7±2.5 6.8±2.0 7.1±2.1 <0.001 <0.001 0.653

Summary score 31.4±

12.3

45.9±

15.2

45.7±

10.7

45.5±

14.2

<0.001 <0.001 0.967

Summary score and discriminative validity of the Orofacial Esthetic Scale

(OES).

Aesthetically

compromised

Functionally

disabled

OAS Item Patients

I

Ctrl

III

Patients

II

Ctrl

IV

I vs III I vs

II

II vs

IV

Mean SD Mean SD Mean SD Mean SD P P P

Face 4.8±2.3 7.1±2.2 6.6±2.2 6.8±2.3 <0.001 0.005 0.599

Profile 5.6±2.1 6.7±2.6 6.6±2.0 6.5±2.7 0.057 0.046 0.866

Mouth 4.3±2.4 7.0±2.7 5.8±2.2 6.7±2.4 <0.001 0.016 0.178

Tooth alignment 3.2±2.4 6.2±2.7 6.3±2.4 6.2±2.5 <0.001 <0.001 0.747

Tooth shape 4.1±2.3 6.4±2.6 6.7±2.3 6.5±2.5 0.010 <0.001 0.586

Tooth color 4.3±2.4 5.6±2.2 6.6±2.4 5.1±2.1 0.052 0.001 0.431

Gingiva 5.0±2.5 6.9±2.5 7.0±1.8 6.7±2.4 0.006 0.001 0.803

Overal impression 4.1±2.6 6.7±2.5 6.8±2.0 7.1±2.1 <0.001 <0.001 0.653

Summary score 31.4±

12.3

45.9±

15.2

45.7±

10.7

45.5±

14.2

<0.001 <0.001 0.967

Summary score and discriminative validity of the Orofacial Esthetic Scale

(OES).

Aesthetically

compromised

Functionally

disabled

OAS Item Patients

I

Ctrl

III

Patients

II

Ctrl

IV

I vs III I vs

II

II vs

IV

Mean SD Mean SD Mean SD Mean SD P P P

Face 4.8±2.3 7.1±2.2 6.6±2.2 6.8±2.3 <0.001 0.005 0.599

Profile 5.6±2.1 6.7±2.6 6.6±2.0 6.5±2.7 0.057 0.046 0.866

Mouth 4.3±2.4 7.0±2.7 5.8±2.2 6.7±2.4 <0.001 0.016 0.178

Tooth alignment 3.2±2.4 6.2±2.7 6.3±2.4 6.2±2.5 <0.001 <0.001 0.747

Tooth shape 4.1±2.3 6.4±2.6 6.7±2.3 6.5±2.5 0.010 <0.001 0.586

Tooth color 4.3±2.4 5.6±2.2 6.6±2.4 5.1±2.1 0.052 0.001 0.431

Gingiva 5.0±2.5 6.9±2.5 7.0±1.8 6.7±2.4 0.006 0.001 0.803

Overal impression 4.1±2.6 6.7±2.5 6.8±2.0 7.1±2.1 <0.001 <0.001 0.653

Summary score 31.4±

12.3

45.9±

15.2

45.7±

10.7

45.5±

14.2

<0.001 <0.001 0.967

Summary score and discriminative validity of the Orofacial Esthetic Scale

(OES).

|OES|

O R O FA C I A L E S T H E T I C S C A L E

Larsson et al 2010

•Throughly described development

•7 direct esthetic items and an eight global item

•Does not measure psychosocial aspects of

impaired orofacial esthetics

•Unidimensionality

•Psychometric tests in 119 patients

•Can be recommended to use together with other

instruments, such as OHRQoL scales.

N O R M AT I V E VA L U E S F O R O E S

Larsson et al 2014

N =1344

Normative values in the general Swedish population

Only 10% ”very satisfied” OE

Mean 50,3 of 70 – most people impaired esthetics

Tooth color” lowest score – 1 out of 5 reports satisfaction of

their tooth color

Oral och general health are related to orofacial esthetics

|OES|

N O R M AT I V E VA L U E S F O R O E S

Larsson et al 2014

”considered an important step in standardisation, and the

developed norms provide a frame of reference in the general

population to interpret the Orofacial Esthetic Scale scores.”

OES AND DENTAL ANXIETY

Carlsson & Hakeberg et al 2014

”the need to address the

esthetic aspects of dental

status in patients with DA ”

Psychometric properties of the Croatian version of the Orofacial

Esthetic Scale. Persic et al. Int J Prosthod 2011

Ongoing co-laboration with

Holland and a Dutch version of OES Westlear P, Larsson P et al

A chinese version of OES and its psychometric

properties Zhao Y, He SL 2013

German version of OES. Ongoing project Reissman

O E S P R O J E C T S A N D P U B L I C AT I O N S

Patient reported esthetic outcome of orthognatic

treatment Bengtsson M & Larsson P et al

O E S P R O J E C T S A N D P U B L I C AT I O N S

Esthetic outcome of single implant treatment after 15

years Winitsky N, Jemt T & Larsson P et al

Evaluation of ceramic restorations in the esthetic zone

in specialist clinics and general practitioners. Larsson P,

Nilner K et al

Orofacial esthetics and Dental Anxiety Carlsson V & Hakeberg et al 2014

Influence of different prosthodontic treament options Persic

S, Celebic A 2014

Thomas, age 47

OES as clinical outcome measure

in the clinic / clinical quality measure

OES score pre-treatment: 11

OES score post-treatment: 59

OES score pre-treatment: 21 OES score post-treatment: 65

OES score pre-treatment:12 OES score pre-treatment: 59

OES score pre-treatment: 19 OES score post-treatment: 60

OES score pre-treatment: 10 OES score post-treatment: 58

If you meet someone without a smile. Give her yours!