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Photographic and videographic assessment of

the smile: Objective and subjective evaluations


of posed and spontaneous smiles
Joan F. Walder,
a
Katherine Freeman,
b
Mitchell J. Lipp,
c
Olivier F. Nicolay,
c
and George J. Cisneros
d
Northampton, Mass, Delray Beach, Fla, and New York, NY
Introduction: Esthetic considerations play an increasingly important role in patient care, and clinicians need a
methodology that includes imaging techniques to capture the dynamic nature of the smile. Photographs of the
posed smile are routinely used to guide diagnosis and treatment, but there is no standardized and validated
method for recording the dynamic smile. The purposes of this study were to (1) determine whether a posed smile
is reproducible, (2) compare visual and verbal cues in eliciting a smile, and (3) compare the diagnostic value of
videography and photography in evaluating a patient's smile. Methods: The smiles of 22 subjects were simul-
taneously photographed and videotaped on 2 separate occasions. For objective comparisons, measurements of
the smile were obtained from 8 3 10 color still photographs and selected digitized video images. A panel con-
sisting of a layperson, an oral surgeon, an orthodontist, and a prosthodontist subjectively assessed the repro-
ducibility of the smile, posed vs spontaneous smiles, and the diagnostic value of video vs still images.
Results: Objective measurements showed that the posed smile can be reliably reproduced, whether captured
by videography or still photography. However, subjectively, the panel members detected differences between
the posed smiles taken on different days 80%of the time. The clinician panel members expressed a strong pref-
erence for videography over photography and for the spontaneous over the posed smiles. Conclusions: This
study emphasizes the need to continue to investigate and standardize the methods of eliciting and recording a
smile of diagnostic quality. (Am J Orthod Dentofacial Orthop 2013;144:793-801)
A
s part of a facial esthetic evaluation, the clinician
studies lip function and posture. During this
evaluation, the patient is often asked to smile,
and a split-second image of that dynamic action is
captured on a still photograph. This photograph, used
as part of the diagnostic process to determine a course
of treatment, remains as a permanent record in the
patients chart. If we want to depend on a still photo-
graph to reect the esthetics of a patients smile, it is
necessary to capture a true representation of that smile.
For instance, if the photo was taken a fewseconds earlier
or later, would it show the same smile? If a different
directive was used to elicit a smile, would it trigger the
same response? Would videography rather than photog-
raphy provide a more effective diagnostic impression?
Previous studies have qualitatively and quantitatively
addressed the movement of a smile.
1-5
Studies in the
psychology literature have found that people are better
able to detect posed emotion from motion photography
than from still photography.
6,7
Nonetheless, the dental
literature is surprisingly lacking in its discussion of the
dynamic nature of the smile as it relates to the methods
used to elicit, record, and reproduce it and how it
reects our patients' esthetics.
The aims of this study were to investigate the poten-
tial variability in current methods of evoking a smile for
analysis and to evaluate the relative diagnostic value of
videography vs photography in capturing a dynamic
event. It is necessary to be critical of the tools used to
determine a treatment plan and to make great efforts
to standardize them.
MATERIAL AND METHODS
Twenty-two subjects volunteered to participate in
the principal portion of this study. They were students,
a
Private practice, Northampton, Mass.
b
President and founder, Extrapolate, LLC, Delray Beach, Fla.
c
Clinical associate professor, Department of Orthodontics, College of Dentistry,
New York University, New York.
d
Professor, Department of Orthodontics, College of Dentistry, New York Univer-
sity, New York.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conicts of Interest, and none were reported.
Address correspondence to: George J. Cisneros, Department of Orthodontics,
College of Dentistry, New York University, 345 E 24th St, New York, NY
10010; e-mail, pedort@aol.com.
Submitted, April 2013; revised and accepted, July 2013.
0889-5406/$36.00
Copyright 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.07.012
793
ORIGINAL ARTICLE
faculty, and staff from Manhattan College, Bronx, New
York. The only exclusionary criteria were visible develop-
mental or traumatic abnormalities of the face or facial
musculature, and missing anterior teeth.
The subjects were simultaneously photographed and
videotaped on 2 days. All participants signed informed
consents but were not told that we were looking for
possible reproducibility of the smile or any other infor-
mation that would bias their responses.
The position of each subject's head was standardized
by a head holder designed specically for this study. The
holder positioned the head with a 3-point contact in
both the vertical and horizontal dimensions: 2 ear rods
were placed in the external auditory meati and a pad on
the forehead. A series of black rectangular markers, 1
inch long and1 inchapart, were placed onthe head holder
and captured in the photographs to correct for any alter-
ation in magnication from image to image. The head
holder was fastened to a stand, which held it in a constant
positionvertically andhorizontally. The height of the chair
was adjusted to accommodate for the subjects' variations
inheight. Measurements of the horizontal andvertical po-
sitions of the forehead pad were taken with a millimeter
ruler at the rst session, and the head holder was reset
to these same measurements for each subsequent session.
Two cameras were arranged so that each subject
could be photographed and videotaped simultaneously.
For the 2 cameras to be used simultaneously, thus
capturing the same smile, it was necessary to set up isos-
celes triangles between the subject and each camera
mounted on tripods (Fig 1). The centers of the 2 camera
lenses were placed 4 ft 7 in from the anterior portion of
the head holder and 2.25 in from the center (a line
extended from the midsagittal plane of the subject
setup). This made an angle of 2.34

from the midsagittal


plane of the subject to the center of each camera lens,
creating a negligible distortion as determined by an
optical error analysis.
For the still photography, at each session, 2 photo-
graphs of the subject were taken. The rst photograph
was prompted by a verbal directive and the second by a
visual directive. The verbal directive was give me a
nice, big smile, one that shows your teeth. A poster
board with color photographs of 6 people smiling broadly
was used for the visual directive, and the subjects were
told to smile like the people in the photographs. The
verbal directive was uniformly given rst to prevent the
subjects from relying on the memory of the visual image
when presented with the verbal command.
The frontal photographs were taken by the same oper-
ator (J.F.W.) using a Pentax K-1000 camera (Asahi Optical,
Tokyo, Japan) with a 90-mm F/2.8 macro lens (Sigma,
Tokyo, Japan) mounted on a tripod, 35-mm Kodachrome
ISO 64 slide lm (Eastman Kodak, Rochester, NY), and a
standardized camera-to-source distance of 4 ft 7 in. All
88slides, which resultedfromthe 22 subjects being photo-
graphed 2 times at the 2 separate sessions each, were then
converted into 8 310 color copies via a Kodak 1550 Plus
printer (Eastman Kodak) for analytical purposes. The still
images shown to the panel were cropped to include only
a standardized border beyond the vermilion of the lips.
For the videography, a Panasonic Palmcorder VHS-
C video camera (Matsushita Electric Corporation of
America, Osaka, Japan) mounted on a tripod was manu-
ally focused to show a close-up, full-face view of each
subject. VHS-C lm was used. The object-to-source dis-
tance was also 4 ft 7 in. The video camera was turned on
before the verbal directive and remained on throughout
the entire session.
Randomly, 1 image fromthe video footage (either the
verbal or the visual smile from either day 1 or 2) was
selected for each subject to use for comparison with
the still images. The apex or height of each of the 22
randomly selected smiles was determined by agreement
of 2 evaluators (J.F.W. and G.J.C.). In the case of a
disagreement, a third evaluator was used. The apex of
a smile was dened as the frame in which the smile
was the largest. To measure the video images, the apices
of the smiles were converted into 35-mm slides and then
into 8 310 color copies, using the Kodak 1550 Plus. The
Media Suite Pro video-editing program (Avid Technol-
ogy, Tewksbury, Mass) was used to create a videotape
of each subjects smile to be viewed by the panel.
In 13 of the 22 subjects, the video camera was able to
capture an unsolicited spontaneous smile. The smiles
were deemed spontaneous by 2 evaluators viewing the
unedited video footage using the following criteria:
(1) there was no cue by the photographer to smile before
the smile and (2) the subject appeared relaxed and was
conversing with the photographer. Two examiners,
with a third examiner consulted when there was a differ-
ence of opinion between the 2 original evaluators, also
selected the apices of these spontaneous smiles. The
apices of these smiles were then converted into 8 3 10
color copies with the Kodak 1550 Plus.
For an objective assessment and comparison of the
still and video-derived images described above, mea-
surements were taken twice by the same operator
(J.F.W.) with a vernier caliper to the nearest 0.1 mm,
then averaged (Fig 2).
A panel of 4 people was selected to provide subjec-
tive assessments of the smiles. The panel included a
prosthodontist (rater 1), an orthodontist (rater 2), a
layperson (rater 3), and an oral surgeon (rater 4).
The panel portion of this study was divided into 4
parts. Part 1 addressed the issue of reproducibility of
794 Walder et al
December 2013 Vol 144 Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
the smiles using still photography. Part 2 compared the
diagnostic value of the 2 media: videography and still
photography. With video technology, parts 3 and 4 pro-
vided comparisons of spontaneous and posed smiles. All
4 panel members were shown parts 1, 3, and 4, whereas
part 2 was shown to the professional members of the
panel only because it required a comparison of the diag-
nostic value of video vs still images.
The following is a description of the 4 parts shown to
the panel.
1. Still photographs day 1 vs day 2. By randomselection,
either the verbal or the visual set of still photographs
was selected for each subject to be shown to the
panel. The randomly selected smile photos were
cropped to display only a standardized border just
beyond the vermilion border of the lips so as not to
distract the panel withother facial features andextra-
neous details such as hairstyle and makeup.
Each panel member independently was asked to
determine whether he or she thought that the 2
smiles were the same. Twenty-six sets of smiles
were projected next to each other on a screen. To
ascertain the validity of each panel members re-
sponses, 4 of the 26 sets of photographs reviewed
were actually duplicates, with the same pictures
shown side by side.
2. Still photography vs videography. The 22 randomly
selected smiles were then shown to the 3 profes-
sional members of the panel in both the video and
still formats. This provided a subjective comparison
of the clinical value of the still and video smiles. The
panel members were asked to ll out a form that
asked 2 questions: (1) which is more useful diagnos-
tically, the still photo, the video footage, or no pref-
erence? and (2) do you have any comments
regarding preference?
3. Posed vs spontaneous smiles (uncropped). The 4 pan-
elists were shown the series of full-faced posed smiles
along with their spontaneous counterpart, both ob-
tained from the video footage. They were asked to
select the most diagnostically useful image. Diagnos-
tically useful was dened as the smile that appeared
to be the most natural, the one that seemed to best
represent the subjects unsolicitedsmile. The layperson
was toldtoselect the smile that appearedmost natural.
4. Posed vs spontaneous smiles (cropped). The 4 pan-
elists were also shown the series of spontaneous
Fig 1. Scaled diagram of equipment conguration: subject/headholder at the apex and 2 cameras at
each base of the isosceles triangles. A 2.34

angle was created from the midsagittal plane of the sub-


ject to the center of each camera lens for negligible distortion of images.
Fig 2. Objective measurements of still and video-derived
images: A, commissure to commissure; B, vermilion
border to vermilion border*; C, inferior border of the upper
lip to superior border of the lower lip*; D, maxillary incisal
edge to the inferior border of the upper lip*; E, maxillary
incisal edge to the vermilion border of the upper lip*; F,
maxillary incisal edge to the interpupillary line*; G, inter-
canthal distance. Also measured was the 1-in marker on
the head holder to determine the change in magnication.
*Measured at midpoint of commissure to commissure
distance.
Walder et al 795
American Journal of Orthodontics and Dentofacial Orthopedics December 2013 Vol 144 Issue 6
smiles along with their posed counterparts, with
both images cropped to display only a standardized
border beyond the vermilion of the lips. The panel
members were asked to select the most diagnosti-
cally useful image. Once again, diagnostically use-
ful was dened as the smile that appeared to be
the most natural, the one that seemed to best
represent the subjects unsolicited smile. The
layperson was told to select the smile that appeared
most natural.
The raw data were standardized to account for
magnication differences between the images
measured. For the data sets comparing still images
only, the measured length of the 1-in marker
(25.4 mm) in the image was used to adjust for changes
in magnication. The formula used in these cases is
shown in Equation 1.
We were unable to use the 1-in marker as a standard
measure for the video-derived images because the repro-
duced quality tended to blur the marker edges. Instead,
the intercanthal distance was used for each subject
because the data sets compared in this section were all
taken at the same time, and thus there was no concern
for change in head position or camera angulation. The
formula used to standardize the data set that compared
the video-derived images with the still images is shown
in Equation 2.
The formula used to standardize the data set that
compared the apices of the video-derived spontaneous
smiles and the video-derived posed smiles is shown in
Equation 3.
Statistical analysis
A power analysis was performed to determine the
number of subjects required for this investigation. The
maximum change in the width of a smile (commissure
to commissure) considered by the principal investigator
of this study (J.F.W.) to be diagnostically acceptable
was measured on 4 subjects. At 2 times, each subject
was asked to begin at his or her broadest smile and
then to slowly reduce the smile until the examiner
thought that the smile no longer had diagnostic quality.
The change in width was found to average 4 mm. The
full range of the smile was also measured; it averaged
13 mm. Using these estimates, we calculated that 22
subjects (11 men, 11 women) were required for the com-
parison between the different smiles obtained in this
study, for a type I error of .05 and a 2-tailed test with
80% power.
All analyses performed on the objective measure-
ments were done using the standardized data. The dif-
ferences between days 1 and 2 were tested for
signicance using either a paired t test or the Wilcoxon
signed rank test, depending on whether the assumptions
of normality were met for the t test. The same approach
was used to assess the signicance of the following: (1)
the differences between the still and video images, (2)
the differences between the verbal and visual cues in
the still photographs, and (3) the differences between
the spontaneous and posed smiles taken from the video.
Tests of signicance were 2-tailed, with a type I error of
.05. An intraclass correlation coefcient (ICC) for the
repeated measurements was computed to determine
reliability.
RESULTS
A total of 22 subjects (11 women, 11 men) partici-
pated in this study. They were between the ages of 20
and 49, with average ages of 24.7 years for the men
and 27.2 years for the women.
The average length of each subjects videotaped ses-
sion was about 57 seconds, with a range of 35 to 90 sec-
onds. The videotape segments averaged 49 seconds for
the women (range, 35-65 seconds) and 65 seconds for
the men (range, 45 -90 seconds).
variable measured mm
length of marker in still image mm
325:4 mm 1-inch marker (Equation 1)
variable measured mm
intercanthal distance mm
3intercanthal distance as measured in still images mm (Equation 2)
variable measured mm
intercanthal distance mm
3intercanthal distance as measured in spontaneous images mm (Equation 3)
796 Walder et al
December 2013 Vol 144 Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
We considered the reproducibility of the posed smile.
The results of the objective data are given in Table I; for
the most part, no statistically signicant differences
were found between the smile measurements taken on
day 1 and day 2. The exception was the difference in
commissure to commissure distance between the visu-
ally commanded smile on day 1 and the visually com-
manded smile on day 2. The mean difference in this
instance was 1.51 mm, with a standard deviation of
2.93 mm and a range of 10.57 mm.
No statistically signicant differences were found
when the verbally directed smiles of day 1 were
compared with the visually directed smiles of day 1
(Table II). The only statistically signicant difference in
measurement was found between the intercanthal dis-
tances recorded on the verbally directed smiles on day
2 and the visually commanded smiles on day 2. The
mean difference was 0.30 mm with a standard deviation
of 0.49 mm and a range of 1.73 mm.
For the results of subjective data, the ICC for agree-
ment among the raters in comparing the still images
taken on day 1 with the still images on day 2 was
0.52842; that was moderate agreement. The ICC for
this same group without the duplicates (identical slides)
was 0.28763; this was considered fair agreement. The
relative frequencies of the same subject's smiles on days
1 and 2 classied as the same or different for the panel
members were tabulated to assess the reproducibility of
the smiles within raters. The 2 smiles were determined to
be different 95% of the time by rater 1, 73% of the time
by rater 2, 64% of the time by rater 3, and 95% of the
time by rater 4. Overall, the panel determined the smiles
to be different in 83%of the cases. In addition, when the
laypersons responses were omitted from the distribu-
tion, 88% of the smiles were determined to be different.
Raters 1, 2, and 3 were able to identify all 4 duplicates,
and rater 4 recognized 3 of the 4 duplicates.
We also compared the videography with the still
photography. For the results of the objective data,
when comparing the still photographs with the videog-
raphy, 3 measurements had statistically signicant dif-
ferences: (1) the commissure to commissure distance,
(2) the maxillary incisal edge to the vermilion border of
the upper lip distance, and (3) the maxillary incisal
edge to the interpupillary line distance (Table III). The
average magnitude of the difference in the commissure
to commissure distance was 1.19 mm; the video distance
was smaller, with a standard deviation of 1.28 mm and a
Table I. Objective comparisons of smiles elicited on day 1 vs day 2 (n 5 22)
Objective measurement (mm)
Verbal Visual
Mean difference* Range* Signicance Mean difference* Range* Signicance
Commissure to commissure 0.9 8.9 NS 1.5 10.6 S
Vermilion upper lip to vermilion lower lip 0.4 9.0 NS 0.2 10.8 NS
Superior lower lip to inferior upper lip 0.5 9.1 NS 0.3 9.1 NS
Upper incisal edge to inferior upper lip 0.4 5.1 NS 0.1 4.2 NS
Upper incisal edge to vermilion upper lip 0.5 4.3 NS 0.3 5.6 NS
Upper incisal edge to interpupillary line 0.6 6.4 NS 0.1 5.8 NS
Intercanthal distance 0.1 3.8 NS 0.2 3.2 NS
NS, No statistically signicant difference; S, statistically signicant difference at the alpha \0.05 level.
*Standardized data.
Table II. Objective comparisons of verbally vs visually prompted smiles (n 5 22)
Objective measurement (mm)
Day 1 Day 2
Mean difference* Range* Signicance Mean difference* Range* Signicance
Commissure to commissure 0.5 11.6 NS 1.0 14.2 NS
Vermilion upper lip to vermilion lower lip 1.0 3.2 NS 0.4 13.6 NS
Superior lower lip to inferior upper lip 1.2 13.4 NS 0.4 11.8 NS
Upper incisal edge to inferior upper lip 0.4 6.2 NS 0.4 7.6 NS
Upper incisal edge to vermilion upper lip 0.1 6.3 NS 0.3 7.7 NS
Upper incisal edge to interpupillary line 0.1 1.8 NS 0.2 3.6 NS
Intercanthal distance 0.1 1.8 NS 0.3 1.7 S
NS, No statistically signicant difference; S, statistically signicant difference at the alpha \0.05 level.
*Standardized data.
Walder et al 797
American Journal of Orthodontics and Dentofacial Orthopedics December 2013 Vol 144 Issue 6
range of 4.76 mm. The mean difference in the maxillary
incisal edge to the vermilion border of the upper lip was
0.50 mm; the video distance was smaller again, with a
standard deviation of 0.66 mm and a range of 2.24
mm. The mean difference in the interpupillary line to
the maxillary incisal edge was 1.47 mm (video smaller),
with a standard deviation of 0.78 mm and a range of
2.64 mm.
In the results of the subjective data, the agreement
among raters for the comparison of the video footage
with the still images was not statistically signicant. Us-
ing a frequency distribution, overall, the panel preferred
the video 68% of the time, the still images 23% of the
time, and had no preference 9% of the time (Fig 3).
The preferences were 63%, 63%, and 77% for the video
by raters 1, 2, and 4, respectively (rater 3, the layperson,
was excluded from this portion of the panel).
We compared the spontaneous and posed smiles.
The objective data showed no statistically signicant
differences in the measurements of the spontaneous
and posed smiles from the video footage (Table IV).
However, this study was not designed with sufcient
power to address this issue. The number of subjects
(13) in this section was insufcient, and thus inferences
drawn from this might be limited.
The results of the subjective data showed that agree-
ment among raters with regard to the comparison of the
spontaneous smiles with the posed smiles was statisti-
cally signicant for the cropped images (ICC, 0.17149:
slight agreement) and not statistically signicant for
the uncropped images.
A frequency distribution showed the following
(Fig 4). The spontaneous smile was preferred 85% of
the time by rater 1 (prosthodontist), 77% of the time
by rater 2 (orthodontist), 62% of the time by rater 3
(layperson), and 77% of the time by rater 4 (oral sur-
geon). Overall, the panel preferred the spontaneous to
the posed smile 75% of the time. When the laypersons
responses were omitted from the distribution, the spon-
taneous smile was selected 79% of the time. When the
images were cropped, the panels preference for the
spontaneous smiles declined to 67%.
Fig 3. The professional panel preferred the video to still
images 68% of the time. The individual preferences
were as follows: 63%, 63%, and 77% preference for the
video by raters 1 (prosthodontist), 2 (orthodontist), and
4 (oral surgeon), respectively.
Table III. Objective comparison of smiles captured by
videography vs still photography (n 5 22)
Objective measurement (mm)
Mean
difference* Range* Signicance
Commissure to commissure 1.2 4.8 S
Vermilion upper lip to vermilion
lower lip
0.2 6.6 NS
Superior lower lip to inferior
upper lip
0.0 2.7 NS
Upper incisal edge to inferior
upper lip
0.1 1.8 NS
Upper incisal edge to vermilion
upper lip
0.5 2.2 S
Upper incisal edge to
interpupillary line
1.5 2.6 S
S, Statistically signicant difference at the alpha\0.05 level; NS, no
statistically signicant difference.
*Standardized data.
Table IV. Objective comparison of posed vs sponta-
neous smiles (n 5 13)
Objective measurement (mm)
Mean
difference* Range* Signicance
Commissure to commissure 0.1 22.6
y
Vermilion upper lip to vermilion
lower lip
0.7 8.2
y
Superior lower lip to inferior
upper lip
0.1 6.5
y
Upper incisal edge to inferior
upper lip
0.4 4.1
y
Upper incisal edge to vermilion
upper lip
0.1 5.2
y
Upper incisal edge to
interpupillary line
1.4 24.2
y
*Standardized data;
y
sample size (n) was insufcient to reach signif-
icance.
Fig 4. The spontaneous smile was preferred 75% of the
time overall. When limited to the professional panel mem-
bers, this preference increased to 79%. The individual
preferences were as follows: 85%, 77%, 62%, and 77%
preference for spontaneous smiles by raters 1, 2, 3, and
4, respectively.
798 Walder et al
December 2013 Vol 144 Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
DISCUSSION
In this study, we found that whether recorded with a
video or a still camera, prompted with a visual or a verbal
cue, or taken on day 1 or 2, the posed smile could be reli-
ably reproduced. Greater reproducibility was obtained
with objective measures; however, as noted by the panel
members, the eye of the diagnostician might be more
critical than objective measures.
The literature has addressed many aspects of the
smile, but only a few studies have even touched on
the aspect of the reproducibility of the smile.
1,2
Peck
et al
3
coached their subjects before taking smile records
and found that they were easily able to attain a repro-
ducible maximum smile. However, prior methods used
to determine smile reproducibility have been ambig-
uous or determined by visual inspection alone, and
were not a specic aim of the studies. The psycholog-
ical literature has often attributed specic characteris-
tics to the posed smile.
8-11
By imparting specic
attributes to the posed smile, this implies that the
posed smile is consistent.
Johnson and Smith
12
suggested that their smile
measurements could not be considered precise
because they did not use a device to limit head posi-
tion or correct for magnication changes. After re-
viewing the literature, we decided to use a head
holder to apply stringent control over the changes in
measurements that can occur with head position
changes. However, for clinical purposes, the use of a
head holder while taking diagnostic photographs or
video of a patient might hinder the patients ability
to smile naturally by restricting his or her ability to
respond normally. The reproducibility of natural head
position has been shown to be within a clinically
acceptable range of 2

.
13
Perhaps accurate informa-
tion could be obtained from facial photography or
videography if the patients were allowed to hold their
head in a more natural manner. Further investigation
comparing facial images taken in natural head posi-
tion with facial images taken when the subject is
placed in a head holder would address this issue
more denitively.
Analysis of the smiles by the panel members showed
that there might be subtleties about a smile that cannot
be measured objectively. More than 80% of the time, the
panel could distinguish between the smiles taken on
different days. When the data were limited to the profes-
sional panel members, the ability to discriminate be-
tween the 2 smiles increased, suggesting that the
practitioners eye might be more discriminating than
objective measures for diagnosis and treatment
planning.
To truly analyze an action, it seems logical that one
would require a tool to capture the dynamic nature of
that action. Nonetheless, the prevailing clinical ques-
tion in this study was whether the practice of ortho-
dontics requires a technique that can record the
entire dynamic range of the smile, or whether it is suf-
cient to rely on the standard still photographs for
diagnostic information. Are diagnostic photographs
providing sufcient information about the smile or
would videography be a better diagnostic tool? For
those interested in information regarding the height
of the smile alone, a still photograph might be suf-
cient, assuming that the photographer has captured
the apex of the smile. However, we found video to
be the method of choice by the clinicians. The panel
members comments supporting the preference for
video were the following: (1) the whole range of the
smile was visible, (2) it provided a record of muscle
function and strain, (3) it showed whether the smile
was guarded or not, (4) it revealed swallowing pat-
terns, (5) it demonstrated lip posture and compe-
tence, and (6) it provided 2 viewsthe patient at
rest and the patient smiling.
Previous studies have found that still images of a dy-
namic action are more difcult for the viewer to correctly
analyze. A xed representation of a facial expression can
remove many of the cues for interpretation of that
expression.
14
As the panel members suggested, they
preferred to see the entire range of the smile because it
gave them signicantly more information than did the
still images. Certainly, as Bruner and Tagiuri
15
main-
tained, a millisecond of exposure surely cannot represent
clinical observations.
Unlike past studies of facial esthetics, we attempted
to specically address the diagnostic value of obtaining
videographic records of the smile. Few studies have
touched on the smile as a dynamic action; however,
for the most part, it has been in relation to dental
and gingival display at maximum smile. Their focus
was a xed point at the height of the smile.
1,2,16,17
Studies in the plastic and reconstructive surgery
literature have evaluated smile dynamics and the
soft-tissue changes that occur when the face moves
from rest to maximum smile.
3-5
These studies do
recognize the value of closely evaluating the smile as
a dynamic action.
The video footage seemed to provide a reliable repre-
sentation of the subjects level of comfort during the
photographic or videographic sessions. In several in-
stances, the still image shown to the panel members ap-
peared to depict a relaxed person giving a relaxed smile.
However, when the video footage of this same smile was
viewed, it became obvious that the person was not at all
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American Journal of Orthodontics and Dentofacial Orthopedics December 2013 Vol 144 Issue 6
comfortable, and the smile was forced. Videography
might give practitioners insight into how patients feel
about their appearance or smile that can be missed in
a hectic clinical examination or the still photographs
taken by auxiliary staff.
The panel members were less likely to select the spon-
taneous smile when the images were cropped, removing
all other cues of facial expression. Duchenne
18
described
the use of 2 facial muscles to distinguish a deliberate
smile from a spontaneous smile: The rst (zygomatic
major) obeys the will but the second (orbicularis oculi)
is only put in play by the sweet emotions of the soul;
the .fake joy, deceitful laugh, cannot provoke the
contraction of the latter muscle. In 1980, Ekman
et al
10
conrmed Duchennes observations, nding
that most people cannot voluntarily contract the outer
portion of the orbicularis oculi and thus do not exhibit
this action in a deliberate smile.
A signicant aim of this study was to begin to ne-
tune our methods of eliciting and capturing smiles.
Two behavioral patterns recognized in this study are
worthy of discussion: (1) variations in response to the
verbal and visual cues, and (2) sex differences in eliciting
a posed smile. Although these ndings were not specif-
ically pinpointed in this study, they are of interest to
practitioners because they might help to better elicit
smiles from patients.
The principal investigator (J.F.W.) observed that 45%
of the subjects responded more easily to the verbal com-
mand, whereas only 18% seemed to smile more readily
when shown the visual cue. The remainder had no pref-
erences. The visual cue appeared to be confusing for
many subjects. When the investigator provided the visual
cue, several subjects asked What do you mean? or Do
you want me to imitate the smiles? A fewothers needed
to hear the instructions again. Studies have found indi-
vidual variations in the responses to verbal and visual
cues.
19
Perhaps it would be benecial to provide both
verbal and visual commands.
It was harder to elicit a posed smile from the men
than fromthe women. Five of the 11 men (45%) had dif-
culty smiling on command, but only 1 of the 11 women
(9%) had difculty responding to the command. A sub-
ject was considered to have difculty smiling on com-
mand if he or she did not respond with a facial
expression that resembled a smile or did not appear to
respond at all to the command as judged by the principal
investigator and another impartial observer. The average
length of the video footage used to capture the smiles of
the men (65 seconds; range, 45-90 seconds) was longer
than the average length of the video footage needed for
the women (49 seconds; range, 35-65 seconds). Part of
this discrepancy might be because all sessions were
directed by and all images were photographed by a
women (J.F.W.); thus, the men might have felt more in-
hibited to respond than did the women. Interestingly,
although it took the men longer to smile, there was no
difference in the number of male subjects (7 of 11)
compared with the female subjects (7 of 11) who showed
a spontaneous smile in the video footage. This would
seem to imply that men might not necessarily smile
less frequently than women in all situations, but they
might be less able to pretend to smile.
20-22
CONCLUSIONS
This study emphasizes the need to continue to inves-
tigate and standardize the methods of eliciting and
recording a smile of diagnostic quality. The following
are our specic conclusions.
1. Posed smiles can be reliably reproduced as measured
objectively, but, subjectively, differences were noted.
2. When the entire face is visible, practitioners can
detect important differences between posed and
spontaneous smiles. However, this ability is
decreased when only the smile is shown.
3. Spontaneous smiles are preferred to posed smiles by
professional diagnosticians.
4. Videography provides diagnostic information that
cannot be obtained with still photography alone.
5. Video images are preferred to still images by profes-
sional diagnosticians.
ACKNOWLEDGMENTS
We thank Graham Walker for his guidance and assis-
tance; Hugh Gilmore for his video-editing wizardry; and
the highly perceptive panel members for their enthusiasm
and remarkable attention to detail.
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