Keywords
dentofacial aesthetics - perception - children - adults
Introduction
It seems that today children become aware of these imposed needs and strive for perfection
at an earlier age.[1] When it comes to dentofacial aesthetics, today the slightest irregularity, diastema,
or mild rotation is considered as a reason for seeking orthodontic treatment. Children
are under the uncontrolled influence of the modern media. The media promote a perfect
appearance as the only acceptable one.[2]
[3] Parents, who are supposed to be the corrective factor in this misguidance, are not
able to resist it themselves. As a result, we have an increased desire for orthodontic
treatment at an early age, purely motivated by aesthetics.[4]
[5]
In the past, the onset of a puberty was seen to be a period of life when people become
highly aware of certain physical characteristics and also highly sensitive of them.[6] Nowadays, even younger school children and preteenagers have clear standards of
facial appearance and overall appearance.[7] Generally, children of all ages pay too much attention and are too critically focused
on the slightest physical imperfection of their face, teeth, smile, as well as the
other external features that help to form the first impression in other people.[8]
[9]
[10] During childhood, when social skills are acquired and built, excessive attachment
to physical characteristics can be dangerous in two ways. Overestimation of one’s
own or other people’s physical characteristics may result in some of the forms of
behavioral disorder in a child. The most commonly described are disorders of insufficiently
controlled behavior and disorders of excessively controlled behavior, with all the
accompanying short-term and long-term consequences, such as loss of motivation, decline
in school success, anxiety, depression, and some psychosomatic disorders.[11]
In the light of this, the aim of this study was to determine how much awareness of
dentofacial aesthetics is present among younger and older schoolchildren and their
parents and whether there is a correlation between age and the perception of dentofacial
aesthetics.
Materials and Methods
The aim of this research was to examine the attitudes and perceptions of dentofacial
aesthetics among different age groups. A cross-sectional study was performed. The
sample consisted of elementary-school students from the city of Sarajevo, Bosnia and
Herzegovina, and their parents. One public elementary school was randomly selected
from the list of all public and private primary schools registered in Sarajevo. This
study included 314 subjects: 157 children and 157 parents. The children’s group consisted
of 85 (54.14%) males and 72 (45.85%) females, aged 9 to 15 years. The total sample
consisted of 314 participants, divided into three groups: pre-teenage group (mean
age 10.5), teenage group (mean age 14.8), and adult group—parents of children (mean
age 40.2).
The instrument used in this study was a questionnaire approved by the Ethical Committee
of the School of Dental Medicine, University of Sarajevo. An integral part of the
questionnaire was a cover letter with all necessary information about the study, the
rights and obligations of the subjects and their parents, and the researchers with
precise instructions for filling in the questionnaire. A questionnaire and set of
color photographs were used to collect information about attitudes and perceptions
of pleasant or unpleasant appearance of teeth among the different age groups. For
the purpose of this research, set of six color photos of a dentofacial appearance
was used, as shown in [Fig. 1]. Subjects required to rank and rate them in relation to aesthetic acceptability,
from the most acceptable to the most unacceptable. The examinees rated the dentofacial
aesthetic based on a 1 to 6 numerical rating scale ([Table 1]). Additionally, they were to write whether the teeth displayed on each photograph
were considered beautiful—nice pleasant or ugly—unpleasant. The information obtained
was converted into data using a six-grade acceptance scale.
Table 1
Six-grade acceptance scale
|
Grade
|
Scale
|
|
1
|
The most acceptable appearance
|
|
2
|
Very acceptable appearance
|
|
3
|
Acceptable appearance
|
|
4
|
Unacceptable appearance
|
|
5
|
Very unacceptable
|
|
6
|
The most unacceptable
|
Fig. 1 The set of photos of dentofacial appearance.
Results
Data collected were analyzed using the Statistical Package for Social Statistics (SPSS)
version 17.0. Descriptive statistics were used to determine frequency distribution
and percentages for all variables. A chi-squared (x
2) test was used to determine the association between variables and a p-value < 0.05 was considered significant for all the differences and associations.
Chi-squared tests were used for data analysis ([Table 2]).
Table 2
Age and gender characteristics of study participants
|
Group
|
Mean age (y)
|
Male, n (%)
|
Female, n (%)
|
Total, n (%)
|
|
Preteenage
|
10.5
|
54 (39.13)
|
37 (21.02)
|
91 (28.98)
|
|
Teenage group
|
14.8
|
31 (22.46)
|
35 (19.88)
|
66 (21.02)
|
|
Adult (parent)
|
40.2
|
53 (38.40)
|
104 (59.09)
|
157 (50,00)
|
|
Total
|
|
138
|
176
|
314
|
[Figure 2] shows the percentage of subjects in three different age groups, who rated the same
degree of acceptability of six different dentofacial appearance.
Fig. 2 Perception of dentofacial appearance among different age groups.
For the dentofacial appearance shown at photos A, B, C, and F, an ANOVA (post hoc
tests—Tukey’s HSD) indicates that the difference is not statistically significant
relative to rank matching between all three subject groups.
For dentofacial appearance shown at photographs D and E, an ANOVA (post hoc tests—Tukey’s
HSD) indicates that statistical difference exists between the teenage group of subjects
relative to preteenage group of subjects and adult group of subjects.
Discussion
Recent research confirms the long accepted attitude that only an attractive appearance
is acceptable.[1]
[12] The results of previous studies showed that more attractive people are considered
more successful and are treated better,[13]
[14] The perception of aesthetics in a person’s general appearance and the perception
of facial aesthetics are also influenced by physical, psychological, social, and cultural
factors.[15]
[16]
[17] The results of the present study, given in [Tables 3]
[4], show that younger and older children have a clear perception of what are absolutely
desirable and undesirable dental aesthetics. In that context, the results are consistent
in relation to the gender and age of the subjects. Although no statistical significance
was observed in respect of gender and age, it is important to emphasize that a higher
percentage of older participants had a clear perception of desirable and undesirable
dental aesthetics. The difference of 5% was not statistically significant, but according
to the results given in [Tables 3]
[4], a slight increase from younger to older age was noted. Tole at al in their study
investigated the perception of dentofacial aesthetics in relation to gender, age,
and the psychology of personality. Their results show that the level of aesthetic
perception increases with age, which is in line with the present study.[18] A higher percentage of older children than younger has a clear attitude about what
is absolutely desirable, and what is not desirable in the appearance of teeth. Comparing
these results with the results of the parental study group ([Table 4]), it is notable that the percentages of perception of dental aesthetics in the group
of 14-year-old children are almost identical to the perception of the adults.
Table 3
The dentofacial aesthetic on a six-grade numerical rating scale per groups
|
Preteenage group
|
Teenage group
|
Adult (parents) group
|
|
Dentofacial appearance photos
|
Frequency (%)
|
Ranking on AAS
|
Frequency (%)
|
Ranking on AAS
|
Frequency (%)
|
Ranking on AAS
|
|
Abbreviation: AAS, aesthetic acceptability scale.
|
|
Well-aligned teeth, bad occlusion
|
54.9
|
4
|
78.0
|
4
|
55.0
|
4
|
|
Well-aligned teeth, optimal occlusion
|
86.2
|
1
|
90.0
|
1
|
90.6
|
1
|
|
Extremely crocked teeth, bad occlusion
|
83.3
|
6
|
88.8
|
6
|
85.6
|
6
|
|
Gap between upper central incisors
|
98.7
|
2
|
65.0
|
3
|
55.6
|
2
|
|
Slightly misaligned upper incisors
|
98.0
|
3
|
69.0
|
2
|
55.0
|
3
|
|
Misaligned teeth, good occlusion
|
53.0
|
5
|
82.1
|
5
|
79.0
|
5
|
Table 4
Ranking of the dentofacial appearance within various groups
|
Preteenage group
|
Teenage group
|
Adult (parents) group
|
Mean difference p
|
F test
|
p-Value
|
|
Dentofacial appearance photos
|
Frequency (%)
|
Ranking on AAS
|
Frequency (%)
|
Ranking on AAS
|
Frequency (%)
|
Ranking on AAS
|
|
|
|
|
Abbreviation: AAS, aesthetic acceptability scale.
|
|
A
|
54.9
|
4
|
78.0
|
4
|
55.0
|
4
|
0.3537
|
0.7860
|
0.06
|
|
B
|
86.2
|
1
|
90.0
|
1
|
90.6
|
1
|
0.4200
|
0.7329
|
0.06
|
|
C
|
83.3
|
6
|
88.8
|
6
|
85.6
|
6
|
0.3341
|
0.7332
|
0.06
|
|
D
|
98.7
|
2
|
65.0
|
3
|
55.6
|
2
|
0.6347
|
0.9552
|
0.07
|
|
E
|
98.0
|
3
|
69.0
|
2
|
55.0
|
3
|
0.2673
|
0.2392
|
0.07
|
|
F
|
53.0
|
5
|
82.1
|
5
|
79.0
|
5
|
0.3210
|
0.6806
|
0.06
|
The difference of 2.7% regarding the absolutely undesirable dental appearance that
14-year-old children rated more strictly than adults indicates that with aging people
become more moderate in expressing criticism. Stenvik et al in research conducted
on a sample of 18-year-old and 35-year-old Norwegian examinees investigated their
degree of satisfaction with self-dentofacial aesthetics. Among examinees who had been
classified as having an obvious need for orthodontic treatment, 54% declared dissatisfaction
at the age of 18 and 21% at the age of 35, which indicates the lower degree of concern
in the older age group. The authors concluded that concern about one’s own appearance
had become less important with age that is in line with our results.[19]
In further analysis of these results, it was observed that the highest percentage
of examinees in the younger groups evaluated the space between upper central incisors
(medial diastema) as very acceptable, rating it in second place on the aesthetic acceptability
scale (AAS) ([Table 3]). In the group of older children, medial diastema was rated as acceptable, and they
score it in third position on the scale of acceptance, while for 69% of adults it
was evaluated as very acceptable, in second place on the scale of acceptance. The
difference in the evaluation of the aesthetic acceptability of the specific appearance
of the upper anterior teeth between younger and older children is the result of their
different perception of the specific appearance of anterior upper teeth. In the research
by Espelande and Stenvik, the degree of individual perception of occlusion in 18-year-old
children was investigated on sample of 130 examinees. Their results showed that all
examinees had a higher degree of perception of anterior teeth aesthetics.[20] The results of the present study show that in the group of younger children, the
space between the anterior teeth was more acceptable than tight contact, while the
opposite finding was observed in older children. Similar results were published by
authors of related studies.[21]
[22] The probable cause may be found in the fact that in a large percentage of children
with mixed dentition (age 8–10), it is normal to have a space between the upper anterior
teeth, which in later age closes spontaneously. Children of this age have become accustomed
to this kind of dental appearance both in themselves and their peers, and therefore
they do not consider it to be unattractive, but even quite acceptable.[23] In contrast, 14-year-old children consider the space to be less acceptable, because
at the time of early permanent dentition and later in life, mild crowding of the front
teeth, which occurs after the eruption of the third molars, is more often present.
Since this their teeth have this appearance as do the majority of peers, 14-year-old
children find mild crowding more desirable than the diastema, which the 10-year-old
children prefer. Previous research confirmed the differences in the perception of
the aesthetics of anterior teeth that have developed due to age, culture, and other
factors.[24]
In the parental study group, the space between teeth and mild crowding was rated as
equally acceptable, 55.6% of parents rated the space between teeth as very desirable,
giving it second place in the rating scale, while for 55.0% of parents mild crowding
was rated as strongly acceptable in third place on the AAS ([Table 4]).
Children’s and parental perceptions of dentofacial appearance and the desire and need
for orthodontic treatment were studied by Kolawole et al. The authors stated that
twice the percentage of parents assessed the dentofacial appearance of their children
as a positive in comparison with their children.[25] The fact that in the present study no difference was found between the preference
or diastema or mild crowding could be explained by the fact that during the growth
and development of occlusion children often have diastema or mild crowding, so the
parents are accustomed to this appearance, rating it as equally acceptable. This common
appearance even if not ideal would be acceptable without too much criticism expressed.
Unfortunately, in the increasing trend of advertising and promotion of an ideal smile
as the only one desirable, the natural potential that people possess could be used
for the wrong purpose.[26]
[27]
[28]
[29]
That is why, at least dental professionals, especially in pedodontics and orthodontics,
must precisely potentiate and promote mild imperfections as part of a person’s personal
charm and individuality, and not satisfy their patient’s demands for the ideal (most
often completely artificial) aesthetics, as promoted by the mass media.[30]
[31]
The results in [Tables 3]
[4] show that the perception and acceptability of moderate irregularities differ between
children of younger and older ages. A poor relationship between dental arches, even
if the teeth in each individual series are correctly aligned ([Fig. 1A]), was considered unacceptable by 54.9% of subjects of younger school age and 78.0%
of the older subjects. Both age groups rated this type of dental appearance in fourth
place on the acceptability scale. Greater deviations in tooth positions in the dental
sequence, with a good ratio of dental arches (Fig. F), were assessed 53% of younger
and 82% of older children as unacceptable and assigned to fifth place on the assessment
scale of the dent appearance.
More than half of the subjects of the younger age (54.9%) perceived that only the
aesthetics of the dental arches, without a good interrelationship, is not enough to
be acceptable and desirable. At the same time, 53.0% of children in the younger age
group considered the poor aesthetics of the dental arches to be extremely unacceptable
even with functional occlusion ([Table 3]).
The fact that a slightly higher percentage of children in the younger age group even
preferred functional occlusion over the aesthetics of the dental arches is a very
surprisingly positive result at the present time. Nowadays, it has become normal to
be more appreciative of the form than the function. This result could be taken with
optimism as an indication direction in which the awareness of younger children should
be developed to continue to prefer good dental function over aesthetics.[31]
In the older subjects, the results show a rising trend to rate aesthetic deficiency
as more unacceptable even with adequate dental function. Seventy-eight percent of
the 14-year-old children placed good aesthetics with bad function in fourth place
on the AAS, while 82% placed good function with poor aesthetics in fifth place on
the scale of acceptance. So, a higher percentage of the 14-year-old children in relation
to the 10-year-old children preferred aesthetics over function ([Table 4]). These results confirm what most orthodontics and pedodontics witness every day.
In fact, currently younger children want orthodontic treatment only to improve aesthetics,
because the awareness that only straight teeth are acceptable is present at an increasingly
young age, even when function is not affected.[32] Demands for the improvement in dental aesthetics are generally increasing, although
there are differences in what is considered attractive and desirable because of different,
cultural, ethnic, socioeconomic factors.[33]
[34]
[35] Orthodontic treatment, especially fixed appliances, has side effects and potential
complications.[36]
[37]
[38]
[39] Therefore, it is necessary to work to raise awareness of the importance of functional
occlusion. Children of a young age must be educated to appreciate functionality more,
than to give preference to aesthetics overall, which would significantly reduce the
number of requests for orthodontic treatment.
To achieve this, it is necessary to work primarily on the education of teachers and
parents, through health education workshops and counseling centers.[40]
Conclusion
Awareness about dentofacial aesthetics was found in all three age groups in the present
study. Younger and older children, as well as adults, have clear perception of desirable
and undesirable dental aesthetic appearance. The level of perception increases from
the younger to the older age group. Attitudes about desirable and acceptable dental
aesthetics differ in younger children compared with older children and parents. Small
irregularities are not equally acceptable in the different age groups.
A space between the anterior teeth is more acceptable to younger children, while older
children are more receptive to mild density of the teeth. Younger children generally
express a higher degree of criticism toward dental imperfections, while older children
and adults are more moderate in their expression of criticism. Adults are less favorable
toward the perfect appearance of teeth compared with children of both age groups.
