Laypersons’ Perception of Facial and Dental Asymmetries

Authors: Bruno Pereira Silva, DMD1/Emilio Jiménez-Castellanos, MD, DDS, PhD2/ Rafael Martinez-de-Fuentes, DMD, PhD3/Joseph R. Greenberg, DMD, FAGD4/ Stephen Chu, DMD, MSD, CDT5

This article was cited by Digital Smile Design

There has been an increasing awareness and relevance of facial esthetics in contemporary societies in developing and industrialized countries. Social media is one vehicle responsible for the growing demand in esthetic dental treatment. It has invited dental clinical practices to not only treat functional dental pathology, but also to improve the esthetic condition of their patients.

Esthetics should also be taken into account in dental therapeutics together with restoring oral function. Functions such as chewing, phonation, and even breathing should be considered priority goals of rehabilitative work, but they must be harmonized with an appropriate esthetic concept for the individual patient to psychologically achieve his/her role in life. In published studies, great discrepancies can be observed in aspects that affect smile perception and the beauty of the face as a whole, such as asymmetries, midline shifting, and canting of the incisal plane.1–7 These can make a noticeable difference in the success rate of dental treatments, even when the restorative and functional rehabilitation goals have been achieved, if the esthetic expectations of our patients are not achieved.

Few authors seem concerned about the importance of facial context in the perception of dental composition discrepancies; most of these studies have used smile or retracted intraoral pictures, eliminating the facial structures to control and limit extraneous variables.4–7 Even though exceptions exist,8 the smile can rarely be evaluated outside its facial context in an objective manner. People usually communicate within a prudent or social speaking distance where the smile is always perceived as a facial gesture. In daily clinical practice, clinicians work within a position that shortens the social and visual speaking distance into the dentofacial field, neglecting the complete facial composition. The location of the maxillary dental midline relative to the face is often an important factor in restorative and/or orthodontic diagnosis and treatment planning, such as the relationship between the incisal plane and interpupillary line.9–11 Therefore, it is very important to step back from the usual dentofacial and dental working distance into the facial diagnostic position, with the patient in a vertical or standing posture and with an upright natural head position.

Some variations of facial asymmetry are not considered esthetic pathology, despite the nonexistence of objective criteria scientifically designed to differentiate normal and abnormal asymmetries.12 This judgment generally results from subjective criteria and the harmonic sense of the clinician or technician involved in the fabrication of the restoration.

In 1998, Beyer and Lindauer13 wrote about the importance of some structural facial asymmetries and what impact they had on the perception of dental esthetics. Reference was made to thresholds that vary between individuals, depending upon their facial characteristics. They also stated that the alignment of the dental midline in patients with either a deviated chin or chin and nose could be more complicated but did not refer to how these facial structures could interfere with the perception of dental midline deviations.

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