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lsPerceived changes by peer group of social impactassociated with combined orthodontic-surgicalcorrection of class III malocclusion

Aliza Jesani a,b, Andrew T. DiBiase b, Martyn T. Cobourne a,*,Timothy Newton c

aDepartment of Orthodontics, Kings College London Dental Institute, London, UKbDepartment of Orthodontics, East Kent Hospitals University NHS Foundation Trust, London, UKcDepartment of Social & Behavioral Sciences, Kings College London Dental Institute, London, UK

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 anoth-

er.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

a r t i c l e i n f o

Article history:

Received 5 February 2014

Received in revised form

28 April 2014

Accepted 4 May 2014

Keywords:

Orthognathic surgery

Social impact

Orthodontics

Caucasians

a b s t r a c t

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

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

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

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

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

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

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

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

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

(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 psychologi-

cal 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 psycho-

logically and socially, more likely to be successful and more attractive.

# 2014 Elsevier Ltd. All rights reserved.

* Corresponding author at: Department of Orthodontics and Craniofacial Development, Floor 22, Guys Tower, Kings College LondonDental 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.2014.05.0020300-5712/# 2014 Elsevier Ltd. All rights reserved.journal homepage: www.intl.e evierhealth.com/journals/jden

j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 21136to 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, identi-

ty, 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 appear-

ance 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 appear-

ance. 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 non-

ideal 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 Con-

siderable 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 IIImalocclusion on subjective ratings of personal character-

istics, 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 maloc-

clusion in Caucasian patients has no influence on the

appraisal individuals make about an adults personal char-

acteristics.

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 Subcom-

mittee (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 obser-

vers 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 nine-

year 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 pre-

treatment orthodontic characteristics and were chosen toprovide variation in pre-treatment attractiveness, as judged by

the research team.

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

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,

j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 2 1137Fig. 1 Vignette type A.

j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 21138Female 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

Fig. 2 Vignetphysical 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

te type B.

were scored such that higher scores indicated more negative

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.

Table 1 Analysis of variance: sociability.

Effect F (sig) Groupsdefined by

effect

Mean (SD)

Gender of photo t = 0.97 ns Female 6.40 (2.18)

Male 6.63 (1.97)

Before/after t = 6.42

p < 0.001

Before 7.21 (2.06)

After 5.82 (1.86)

Face F = 18.31

p < 0.001

Male 1 7.18 (1.89)+

Male 2 6.08 (1.91)=

Female 1 7.38 (2.15)+

Female 2 5.43 (1.75)=

+, = Similar postscripts indicate homogenous subsets (high scores

indicate lower sociability).

p < 0.001

After 2.57 (0.92)

Face F = 15.14

p < 0.001

Male 1 3.20 (0.89)=

Male 2 2.80 (0.99)!

Female 1 3.14 (0.94)=

Female 2 2.34 (0.80)+

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

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

j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 2 1139attributes.

2.4. 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. 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) Groupsdefined by

effect

Mean (SD)

Gender of photo t = 3.34

p = 0.001

Male 6.93 (1.89)

Female 7.66 (1.99)

Before/after t = 3.76

p < 0.001

Before 7.70 (1.87)

After 6.89 (2.00)

Face F = 19.67

p < 0.001

Male 1 8.61 (1.69)+

Male 2 6.70 (1.80)=

Female 1 7.14 (1.90)=

Female 2 6.73 (1.88)=

+, = Similar postscripts indicate homogenous subsets (higher

scores indicate lower ratings of likely success).Table 3 One way analysis of variance: psychologicaladjustment.

Effect F (sig) Groupsdefined by

effect

Mean (SD)

Gender of photo t = 12.05 ns Male 7.61 (2.34)

Female 7.09 (2.18)

Before/after t = 2.04

p < 0.001

Before 8.06 (2.30)

After 6.64 (2.03)

Face F = 21.13

p < 0.001

Male 1 7.20 (2.28)!

Male 2 6.98 (2.08)+!

Female 1 8.86 (2.24)=

Female 2 6.35 (1.69)+

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

scores indicate greater positive psychological adjustment.

Table 4 One way analysis of variance: attractiveness.

Effect F (sig) Groupsdefined by

effect

Mean (SD)

Gender of photo t = 1.52 ns Male 2.74 (0.96)

Female 3.00 (0.97)

Before/after t = 5.83 Before 3.17 (0.93)4. Discussion

All four patients were perceived to be more psychologically

adjusted, sociable, successful and attractive following orthog-

nathic 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

j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 21140hypothesise 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 methodo-

logical 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 make-

up 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 manipula-

tion 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 percep-

tions. 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 princi-

ple 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 individualswere 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 attractive-

ness 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 individu-

als 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 undergradu-ate students at Kings College London who were involved in

evaluating the vignettes.

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j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 2 1141Appendix 1. Questionnaire used for each case in t

Please look at the photograph attached to this questionnair

shows.

1) This person works for a large bank. How popular do you t

answer)Very popular Quite popular Neither popul

1 2 3

2) How friendly does this person appear to you? (Please circlVery friendly Quite friendly Neither friend

1 2 3

3) Do you think this person has a good social life? (Please cirYes No

4) How successful do you think this person was at school? (PVery successful Quite successful Neither successf

1 2 3

5) How intelligent does this person appear to you? (Please ciVery intelligent Quite intelligent Neither intellige

1 2 3 r e f e r e n c e s

1. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M,Smoot M. Maxims or myths of beauty? A meta-analytic andtheoretical review. Psychol Bull 2000;126:390423.

2. Uleman JS, Adil Saribay S, Gonzalez CM. Spontaneousinferences, implicit impressions, and implicit theories. AnnRev Psychol 2008;59:32960.

3. Crisp R, TR N. Essential social psychology. London: SAGEPublications Ltd.; 2010.

4. Riggio RF, Widaman KF, Tucker JS, Salinas C. Beauty is morethan skin deep: components of attractiveness. Basic Appl SocPsychol 1991;12:4239.

5. Synnott A. Truth and goodness, mirrors and masks. Part 1: asociology of beauty and the face. Br J Sociol 1989;40:60736.

6. Goldstein RE. Study of need for esthetics in dentistry. JProsthet Dent 1969;21:58998.

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8. Zebrowitz LA. Final faces find favour. Soc Cognit 2006;24:657701.

6) Do you think this person went to university? (Please circle onYes No

7) Do you think this person is extroverted or introverted? (PleasVery extroverted Quite extroverted Neither extrovert

1 2 3

8) Does this person appear to be a happy person? (Please circle Very happy Quite happy Neither happy o

1 2 3

9) How self-confident does this person appear to you? (Please cVery self-confident Quite self-confident Neither self-confident n

1 2 3

10) How would you rate this person? (Please circle only one answVery attractive Quite attractive Neither attractive

1 2 3

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS QU study

nd complete the following questions concerning the person it

k this person is with their colleagues? (Please circle only one

r unpopular Quite unpopular Very unpopular

4 5

nly one answer)r unfriendly Quite unfriendly Very unfriendly

4 5

only one answer)I Dont Know

se circle only one answer)r unsuccessful Quite unsuccessful Very unsuccessful

4 5

only one answer)r unintelligent Quite unintelligent Very unintelligent

4 59. Zebrowitz LA. Reading faces: window to the soul? BoulderColarado. Westview Press; 1997.

10. Blair IV, Judd CM, Chapleau KM. The influence of Afrocentricfacial features in criminal sentencing. Psychol Sci2004;15:6749.

11. Eberhardt JL, Davies PG, Purdie-Vaughns VJ, Johnson SL.Looking deathworthy: perceived stereotypicality of Blackdefendants predicts capital-sentencing outcomes. PsycholSci 2006;17:3836.

12. Todorov A, Mandisodza AN, Goren A, Hall CC. Inferences ofcompetence from faces predict election outcomes. Science2005;308:16236.

13. Newton JT, Prabhu N, Robinson PG. The impact of dentalappearance on the appraisal of personal characteristics. Int JProsthodont 2003;16:42934.

14. Shaw WC, Rees G, Dawe M, Charles CR. The influence ofdentofacial appearance on the social attractiveness ofyoung adults. Am J Orthodont 1985;87:216.

15. Griffin AM, Langlois JH. Stereotype directionality andattractiveness stereotyping: is beauty good or is ugly bad?Soc Cognit 2006;24:187206.

16. Kerosuo H, Hausen H, Laine T, Shaw WC. The influence ofincisal malocclusion on the social attractiveness of youngadults in Finland. Eur J Orthodont 1995;17:50512.

ly one answer)I dont know

e circle only one answer)ed nor Introverted Quite introverted Very introverted

4 5

only one answer)r unhappy Quite unhappy Very unhappy

4 5

ircle only one answer)or not self-confident Not self-confident Not at all self-confident

4 5

er)nor un-attractive Not attractive Very unattractive

4 5

ESTIONNAIRE

17. Eli I, Bar-Tai Y, Kostovestski I. At first glance: socialmeanings of dental appearance. J Public Health Dent2000;61:1504.

18. Kershaw S, Newton JT, Williams DM. The influence of toothcolour on the perceptions of personal characteristics amongfemale dental patients: comparisons of unmodified,decayed and whitened teeth. Br Dent J 2008;204:E9.[discussion 256257].

19. Somani A, Newton JT, Dunne S, Gilbert D. The impact ofvisible dental decay on social judgements: comparison ofthe effects of location and extent of lesion. Int Dent J2010;60:16974.

20. Henson ST, Lindauer SJ, Gardner WG, Shroff B, Tufekci E,Best AM. Influence of dental esthetics on social perceptionsof adolescents judged by peers. Am J Orthodont DentofacOrthoped 2011;140:38995.

21. Cunningham SJ, Moles DR. A national review of mandibularorthognathic surgery activity in the National Health Servicein England over a nine year period. Part 2. Patient factors. BrJ Oral Maxillofac Surg 2009;47:2748.

22. Cunningham SJ, Hunt NP, Feinmann C. Perceptions ofoutcome following orthognathic surgery. Br J Oral MaxillofacSurg 1996;34:2103.

23. Flanary CM, Barnwell GM, VanSickels JE, Littlefield JH, RughAL. Impact of orthognathic surgery on normal andabnormal personality dimensions: a 2-year follow-up studyof 61 patients. Am J Orthodont Dentofac Orthoped 1990;98:31322.

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surgical and conventional orthodontics. Am J Orthodont1986;89:38392.

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28. Jacobson A. Psychological aspects of dentofacial estheticsand orthognathic surgery. Angle Orthodont 1984;54:1835.

29. Kovalenko A, Slabkovskaya A, Drobysheva N, Persin L,Drobyshev A, Maddalone M. The association between thepsychological status and the severity of facial deformity inorthognathic patients. Angle Orthodont 2012;82:396402.

30. Jeremiah HG, Bister D, Newton JT. Social perceptions ofadults wearing orthodontic appliances: a cross-sectionalstudy. Eur J Orthod 2011;33:47682.

31. Naini FB, Donaldson AN, McDonald F, Cobourne MT. Theinfluence of combined orthodonticorthognathic surgicaltreatment on perceptions of attractiveness: a longitudinalstudy. Eur J Orthod 2013;35:5908.

32. Collins M. The eye of the beholder: face recognition andperception. Semin Orthodont 2012;18:22934.

33. Feingold A. Good looking people are not what we think.Psychol Bull 1992;111:30441.

j o u r n a l o f d e n t i s t r y 4 2 ( 2 0 1 4 ) 1 1 3 5 1 1 4 21142

Perceived changes by peer group of social impact associated with combined orthodontic-surgical correction of class III malocclusionIntroductionMaterials and methodsParticipantsVignettesMeasuresStatistical method

ResultsDiscussionConclusionsAcknowledgementsReferencesQuestionnaire used for each case in the study