journal of dentistry 42 (2014) 11351142

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journal homepage: www.intl.elsevierhealth.com/journals/jden

Perceived changes by peer group of social impact

associated with combined orthodontic-surgical
correction of class III malocclusion
Aliza Jesani a,b, Andrew T. DiBiase b, Martyn T. Cobourne a,*,
Timothy Newton c
a

Department of Orthodontics, Kings College London Dental Institute, London, UK

Department of Orthodontics, East Kent Hospitals University NHS Foundation Trust, London, UK
c
Department of Social & Behavioral Sciences, Kings College London Dental Institute, London, UK
b

article info

abstract

Article history:

Objectives: Whereas the psychosocial benefits of orthognathic treatment for the individual

Received 5 February 2014

patient are established, there is little data relating to social perceptions in relation to

Received in revised form

changes in facial appearance as a result of combined orthodontic and orthognathic treat-

28 April 2014

ment. This study aimed to investigate the social impact of combined orthodonticorthog-

Accepted 4 May 2014

nathic surgical correction for class III malocclusion in Caucasian subjects.

Methods: This cross-sectional study compared perceptions of facial appearance prior to and
after orthognathic correction of class III malocclusion. Eighty undergraduate students were

Keywords:

shown photographs of four Caucasian subjects (2 male and 2 female) pre- and post-

Orthognathic surgery

orthognathic class III correction. Observers were asked to rate these subjects in relation

Social impact

to four different outcomes: (i) social competence (SC); (ii) intellectual ability (IA); (iii)

Orthodontics

psychological adjustment (PA); (iv) attractiveness. A mixed-model analysis of variance

Caucasians

(ANOVA) was calculated to determine the effect of each variable.

Results: Statistically significant differences were found in ratings of the same face before
and after treatment. After treatment, faces were rated as more psychologically adjusted,
more sociable, more likely to be successful and more attractive; with the mean psychological adjustment rating being associated with the most change (before treatment = 8.06 [SD
2.30]; after treatment = 6.64 [SD 2.03], t = 2.04, p < 0.001).
Conclusions: After combined orthodonticorthognathic correction of class III malocclusion
in Caucasians, individuals are rated by young adults as being better adjusted both psychologically and socially, more likely to be successful and more attractive.
# 2014 Elsevier Ltd. All rights reserved.

1.

Introduction

There is good evidence that in the absence of any previous

acquaintance and without any prior knowledge of an

individuals personality or behavioural traits, people will

make subconscious and subjective judgments of one another.1,2 A key factor in this decision-making process is a persons
appearance, which has been presented as one of the four key
determinants of interpersonal attraction.3 The face is thought

* Corresponding author at: Department of Orthodontics and Craniofacial Development, Floor 22, Guys Tower, Kings College London
Dental Institute, London SE1 9RT, UK. Tel.: +44 02071888028; fax: +44 02071881674.
E-mail address: martyn.cobourne@kcl.ac.uk (M.T. Cobourne).
http://dx.doi.org/10.1016/j.jdent.2014.05.002
0300-5712/# 2014 Elsevier Ltd. All rights reserved.

1136

journal of dentistry 42 (2014) 11351142

to be one of the main features in determining physical

attractiveness4,5 and in particular; the mouth, smile and eyes
have been specifically identified as key components.6,7 Faces
play a very important role in providing implicit impressions
and spontaneous inferences including social category, identity, emotion, psychological and physical traits, as well as the
inter-dependence of attributes.8 The appearance of an
individual can influence our behaviour towards them, in
relation to whom we offer to help, choose to date and employ.9
It has also been shown to have an impact on decisions such as
criminal justice10,11 and congressional elections.12 Numerous
studies have looked at the influence of facial appearance on
social perceptions. Evidence appears to support the notion of a
beautiful is good stereotype and suggests that facial appearance is used as a guide to infer a variety of characteristics,
including attractiveness, personality, sociability, intellectual
competence, mental health and personal achievement.13,14 It
has been postulated that the attractiveness effect is in fact,
driven by the perception that ugly is bad.15
There has been previous research investigating social
judgments made as a result of anomalies in dental appearance. Faces displaying a normal incisor relationship as
opposed to faces with missing lateral incisors, a crowded
dentition, prominent incisors or a unilateral cleft lip gain the
most favourable ratings in relation to perceived friendliness,
social class, intelligence and popularity.14 Whilst in young
adults, faces with incisor crowding and a median diastema
can be considered significantly less intelligent, sexually
attractive or beautiful and judged to belong to a lower social
class.16 The presence of dental decay can also have an effect
on peoples perceptions. Individuals with a non-carious and
intact dentition are rated more favourably with respect to
social, professional and aesthetic traits,17 with the position of
the caries rather than the extent being regarded as most
important.18,19 Caries present in central incisors was rated
lower than that in just the lateral incisors; whilst caries in all
four teeth was not rated significantly worse than that in only
the central incisors. More recently, four attributes of athletic,
social, leadership and academic abilities in relation to the nonideal and ideal smile have been investigated by manipulating
photographs. In all areas but academic performance, the ideal
aesthetic smile was rated higher.20
Collectively, all these studies have shown that facial
appearance has an effect on social perception irrespective
of social, ethnic and economic background. The area of
orthodontic treatment that has the most impact on facial
appearance is orthognathic surgery. A nine-year national
review carried out between 1997 and 2006 indicated that on
average, over 900 mandibular orthognathic procedures were
carried out annually in England.21 Orthognathic treatment
outcome can improve self-reported quality of life.2226 Considerable research has demonstrated the benefits of combined
orthognathicorthodontic treatment on the psychological well
being of the patient, as viewed by the patient him or herself27
29
; but to date, there has been no research investigating the
effects of orthognathic treatment on perceived social benefits,
and in particular, whether social perception is altered
following such treatment?
The aim of this study was to ascertain the influence of
orthognathic treatment in the management of class III

malocclusion on subjective ratings of personal characteristics, specifically in the following areas: social competence
(SC), intellectual ability (IA), psychological adjustment (PA),
and attractiveness in an adult patient. The null hypothesis
tested was that orthognathic treatment for class III malocclusion in Caucasian patients has no influence on the
appraisal individuals make about an adults personal characteristics.

2.

Materials and methods

Ethical approval for this study was obtained from the Kings
College London Biomedical Sciences, Dentistry, Medicine,
Natural and Mathematical Sciences Research Ethics Subcommittee (BDM RESC). Reference number: BDM/11/12-28.
This cross-sectional analytical questionnaire vignette
study compared participants perceptions of the personal
characteristics of various faces prior to and after orthognathic
treatment. The explicit interest of the investigator was
concealed during the whole procedure by simply informing
participants that the investigator was researching the way we
look at other people.
Each participant was given one of two questionnaire packs,
which contained four vignettes along with four corresponding
questionnaires. The participant was asked their perceptions in
the form of ten questions.

2.1.

Participants

On the basis of the effect sizes reported previously, the present

study was designed to have 80% power to detect standardised
mean differences of 0.5, which required seventy-two observers in the observation group.18,19
Eighty participants were drawn from undergraduate
students studying the BSc in Biomedical Sciences at Kings
College London University. This course covers all aspects of
biomedical science including biochemistry, genetics, cell
biology, physiology, pharmacology, cell and tissue structure
and function, statistics and issues related to the practice of
science, including ethics and communication. The range of
ages among the students was between 18 to 25 and the
male:female ratio was approximately 3:2. The average age of
those undergoing orthognathic treatment in a recent nineyear national survey was found to be 24 years.21 It was
therefore felt that the opinions of those falling in a
corresponding peer group of similar age would be ideal for
this study. Individuals with severely impaired vision were
excluded.

2.2.

Vignettes

Four patients who had previously undergone combined

orthodontic and orthognathic treatment at East Kent Hospital
University Foundation NHS Trust for the treatment of a class
III malocclusion were used in the study. There were two male
patients and two female. The cases differed in their pretreatment orthodontic characteristics and were chosen to
provide variation in pre-treatment attractiveness, as judged by
the research team.

journal of dentistry 42 (2014) 11351142

A vignette was made of each patient using extra-oral

photographs pre- and post-orthognathic treatment. Each
subject provided written consent for the use of his or her
facial images for research purposes. Those chosen for the
study were also free from oral pathology, ensuring that only
the affects of facial appearance were investigated. Four
standardised full-face colour photographs were used for each
subject to show: frontal (at rest and smiling); full profile and

1137

three-quarter profile views. In total, two Caucasian male and

two Caucasian female subjects of similar age were used. The
vignette packs were subdivided into Type A (Fig. 1) and Type B
(Fig. 2), with each containing one of the following sets of
photographs arranged such that no one observer was required
to comment on the same face: [Type A vignette pack: Male 1
Before, Male 2 After, Female 1 Before, Female 2 After; Type B
vignette pack: Male 1 After, Male 2 Before, Female 1 After,

Fig. 1 Vignette type A.

1138

journal of dentistry 42 (2014) 11351142

Fig. 2 Vignette type B.

Female 2 Before]. The researchers felt it was important that

observers did not see the same picture before and after surgery
in order to blind them to the independent variable and thus
avoid demand characteristics.
Subjects chosen all had combined maxillary retrognathia
and mandibular prognathism requiring bimaxillary surgery
for definitive correction.

2.3.

Measures

A structured questionnaire was utilised to inquire about the

four categories of personal characteristics associated with

physical appearance: social competence (SC), intellectual

ability (IA), psychological adjustment (PA) and attractiveness
(Appendix 1). The questionnaire was drawn from previous
studies in this area.13,18,19,30 The first three questions related to
sociability, the next three success, the next three related to
psychological adjustment, and a final single question asked
about perceived attractiveness. Scores were additive, derived
for all four scales following the standard procedure adopted in
previous studies by summing the individual item scores.
Where items had three responses (Yes No and Dont know),
responses of Yes were scored as a value of 1, and responses of
No or Dont know were given a value of 2. Scores on scales

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journal of dentistry 42 (2014) 11351142

Table 1 Analysis of variance: sociability.

Effect

F (sig)

Gender of photo

t = 0.97 ns

Before/after

t = 6.42
p < 0.001
F = 18.31
p < 0.001

Face

Groups
defined by
effect

Mean (SD)

Female
Male
Before

6.40 (2.18)
6.63 (1.97)
7.21 (2.06)

After
Male 1

5.82 (1.86)
7.18 (1.89)+

Male 2
Female 1
Female 2

Effect

were scored such that higher scores indicated more negative

attributes.

Results

Table 1 shows the results for ratings of sociability and suggests

differences in ratings for different faces, as might be expected.
In particular, Male 1 and Female 1 were seen as being less
sociable. However, there were no differences in ratings across
males and females. All faces were rated as significantly more
sociable after orthognathic treatment. Similarly, Table 2
suggests differences in ratings of possible success for different
faces; in particular, Male 1 was seen as being less successful.
Again, there were no differences in ratings across male and
female faces, and all faces were rated as significantly more
likely to be successful after orthognathic treatment. The same
pattern held for ratings of psychological adjustment and
attractiveness (Tables 3 and 4, respectively).

Table 2 Analysis of variance: success.

Effect

F (sig)

Gender of photo

t = 3.34
p = 0.001

Before/after

t = 3.76
p < 0.001

Face

F = 19.67
p < 0.001

Gender of photo

t = 12.05 ns

Before/after

t = 2.04
p < 0.001

Face

F = 21.13
p < 0.001

Mean (SD)

Male

6.93 (1.89)

Female
Before

7.66 (1.99)
7.70 (1.87)

After
Male 1

6.89 (2.00)
8.61 (1.69)+

Male 2
Female 1
Female 2

6.70 (1.80)=
7.14 (1.90)=
6.73 (1.88)=

+, = Similar postscripts indicate homogenous subsets (higher

scores indicate lower ratings of likely success).

Mean (SD)

Male
Female
Before

7.61 (2.34)
7.09 (2.18)
8.06 (2.30)

After
Male 1

6.64 (2.03)
7.20 (2.28)!

Male 2
Female 1
Female 2

6.98 (2.08)+!
8.86 (2.24)=
6.35 (1.69)+

Table 4 One way analysis of variance: attractiveness.

F (sig)

Gender of photo

t = 1.52 ns

Before/after

t = 5.83
p < 0.001

Face

F = 15.14
p < 0.001

Groups
defined by
effect

Mean (SD)

Male
Female
Before

2.74 (0.96)
3.00 (0.97)
3.17 (0.93)

After
Male 1

2.57 (0.92)
3.20 (0.89)=

Male 2
Female 1
Female 2

2.80 (0.99)!
3.14 (0.94)=
2.34 (0.80)+

+, =,! Similar postscripts indicate homogenous subsets. Scores

range from 1 = very attractive to 5 = very unattractive.

The magnitude of the effect size for the comparison of

photographs before and after surgery was calculated using the
formula proposed for Cohens d. The following effect sizes
were found: sociability d = 0.71; psychological adjustment
d = 0.66; attractiveness d = 0.65 and success d = 0.43. With the
exception of the variable perceived success, these represent
medium effect sizes, suggesting that the change represents a
moderately significant effect.

4.

Groups
defined by
effect

Groups
defined by
effect

+, =, ! Similar postscripts indicate homogenous subsets. Lower

scores indicate greater positive psychological adjustment.

Effect

Statistical method

The mean values of all variables were calculated for each face.
A mixed model analysis of variance (ANOVA) was calculated to
determine the effect of each variable.

3.

F (sig)

6.08 (1.91)=
7.38 (2.15)+
5.43 (1.75)=

+, = Similar postscripts indicate homogenous subsets (high scores

indicate lower sociability).

2.4.

Table 3 One way analysis of variance: psychological

adjustment.

Discussion

All four patients were perceived to be more psychologically

adjusted, sociable, successful and attractive following orthognathic treatment. There was evidence of variation between the
individual faces but not for gender of face. This data suggests that
the facial change following combined orthodontic and surgical
treatment of class III malocclusion contributes to the judgement
of the personality of an individual. The findings support previous
research that suggests poor dental and facial appearance exerts a
negative influence on the appraisal of social perception.14,1619
The effect sizes were, with the exception of the judgement of
success, in the range of 0.6 to 0.7 a medium effect size. There
are no available data on what would constitute a clinically
significant difference in these ratings, but this equates to a 60% to
70% difference in the individuals perception of the trait. We can

1140

journal of dentistry 42 (2014) 11351142

hypothesise that in social interactions, such as a job interview or

dating a 60% difference in perceived sociability would have an
impact on the interaction.
There are strengths and weaknesses within the methodological approach adopted for this study. The experimental
design is essentially a controlled design with separate
participants rating the before and after images of each patient.
Random allocation of participants to the different levels of the
independent variables is designed to mitigate the influence of
confounding variables. It remains a possibility that the
differences observed may be related to differences between
observers who saw the two different groups of vignettes.
However this is unlikely given that participants were
randomly assigned to each set, and the inclusion of both
before- and after- surgery photos in each set of photos. The use
of real-life images adds to the external validity of the study,
however previous studies have utilised digitally modified
faces or a silhouette of a standard face whilst varying a factor
related to facial appearance.13,17,18,30,31 This of course, allows
for increased standardisation of the treatment being assessed
and a reduction of bias due to fewer confounding factors, but
does not fully reflect a real-life situation. The photographs
used in this study were the exact photographs, un-modified
taken before and after orthognathic treatment, demonstrating
a true representation of an individual undergoing surgical
correction of a class III discrepancy. It therefore incorporated a
number of other factors that would not be present in mock-up
or silhouette images, such as facial changes one would expect
with growth and maturational changes of the patient. As a
result of using the true photographs, it was not possible to
eliminate the influence of additional confounding variables or
background influences relating to aesthetic components that
one could manipulate or standardise in an artificial set up of
digitally manipulated photographs. Although all patients
selected had a class III malocclusion the severity of dental
and skeletal discrepancies differed between the individuals. In
addition, the female subjects had varying amounts of makeup application in their before and after photographs, whilst
the presence of a tattoo on the neck of one of the subjects
(male 2) both before and after treatment, could also have
introduced some bias. In the case of the tattoo, this could have
been removed with computer software for the purposes of the
investigation; however, we wished to avoid image manipulation and a decision was therefore made to leave it. Indeed, it
should be remembered that for the undergraduate students
who participated in this study, the presence of a tattoo is
relatively commonplace within their society not necessarily
associated with negative connotations. The inability to control
for changes pre- and post in individual photographs may have
introduced alternative sources of variation in social perceptions. However the choice of photographs does enhance the
external validity of the research. Furthermore, photographs of
only four individuals were used in the present study, and this
is probably not sufficient to give a range of change pre- and
post-treatment. This study has demonstrated that the principle that social judgments change following treatment, but
larger studies with a greater range of faces are required to
demonstrate the full range of the effect.
The sample chosen to rate these images was composed
of undergraduate Biomedical science students. These individuals

were of different ethnic backgrounds, gender and were all

in the process of further education. This was not considered
to be a fair representation of the general population, but it
was felt that this particular age group would fall into the
peer group of the chosen orthognathic patients and their
opinions were considered valid. Demographic information
was not requested from the student sample group, so it
was not possible to assess the potential difference-specific
age, gender and ethnicity that may have contributed to
personality judgments. It has been commonly assumed that
an individuals cultural and ethnic background has an
influence on judgments made of other people. However a
recent meta-analysis showed that even diverse cultural
and ethnic groups agreed about who was and was not
attractive.1 A recent review of previous studies; however,
concluded that the perception of facial beauty does
appear to be influenced by our cultural environment and
our relative exposure to various face-types.32 Within the
sample used, a Western-cultural background was prevalent
and therefore this relationship may have not been exhibited.
The sample size was based on the ability to detect a
moderate effect size as predicted from previous studies. The
actual effect sizes found here are in three of the four cases
greater than anticipated suggesting that there was adequate
power in the study.
The results both support previous research within the field
of social perception and attractiveness and extend this to
consideration of the impact of orthognathic treatment on
social perceptions. It has been shown that level of attractiveness has an implication on behaviour towards an individual.
As a result of expected social characteristics it has been
postulated that good-looking people may develop desirable
qualities in response to others expectations.33 From the
limited sample group in this study, it appears that following
the alteration of facial appearance achieved in the correction
of class III malocclusion, all areas of social perception
concurrently improved, including overall attractiveness.
These results are important because they highlight the
indirect benefits this type of treatment can provide to an
individual in relation to their social situation. This study did
not explore the relationship between change in the individuals own perception of themselves and the social perceptions
made by others, this could be investigated in future studies.

5.

Conclusions

After combined orthodonticorthognathic correction of class

III malocclusion in Caucasians, individuals are rated by young
adults as being better adjusted both psychologically and
socially, more likely to be successful and more attractive.

Acknowledgements
The authors are grateful to Padhraig Fleming, Nick Goodger
and Jeremy McKenzie who between them treated some of the
patients in this study. We are also grateful to the undergraduate students at Kings College London who were involved in
evaluating the vignettes.

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journal of dentistry 42 (2014) 11351142

Appendix 1. Questionnaire used for each case in the study

Please look at the photograph attached to this questionnaire and complete the following questions concerning the person it
shows.
1) This person works for a large bank. How popular do you think this person is with their colleagues? (Please circle only one
answer)
Very popular
1

Quite popular
2

Neither popular or unpopular

3

Quite unpopular
4

Very unpopular
5

Quite unfriendly
4

Very unfriendly
5

2) How friendly does this person appear to you? (Please circle only one answer)
Very friendly
1

Quite friendly
2

Neither friendly or unfriendly

3

3) Do you think this person has a good social life? (Please circle only one answer)
Yes

No

I Dont Know

4) How successful do you think this person was at school? (Please circle only one answer)
Very successful
1

Quite successful
2

Neither successful or unsuccessful

3

Quite unsuccessful
4

Very unsuccessful
5

Quite unintelligent
4

Very unintelligent
5

5) How intelligent does this person appear to you? (Please circle only one answer)
Very intelligent
1

Quite intelligent
2

Neither intelligent or unintelligent

3

6) Do you think this person went to university? (Please circle only one answer)
Yes

No

I dont know

7) Do you think this person is extroverted or introverted? (Please circle only one answer)
Very extroverted
1

Quite extroverted
2

Neither extroverted nor Introverted

3

Quite introverted
4

Very introverted
5

8) Does this person appear to be a happy person? (Please circle only one answer)
Very happy
1

Quite happy
2

Neither happy or unhappy

3

Quite unhappy
4

Very unhappy
5

9) How self-confident does this person appear to you? (Please circle only one answer)
Very self-confident
1

Quite self-confident
2

Neither self-confident nor not self-confident

3

Not self-confident
4

Not at all self-confident

5

10) How would you rate this person? (Please circle only one answer)
Very attractive
1

Quite attractive
2

Neither attractive nor un-attractive

3

Not attractive
4

Very unattractive
5

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QUESTIONNAIRE

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