Vol. 115 No. 4 April 2013

Perception of the esthetic impact of gingival smile on laypersons,dental professionals, and dental studentsMatheus Melo Pithon, DDS, MS, PhD, Adrielle Mangabeira Santos, DS, Ana Carolina Dias Viana de Andrade, DS,Eloá Mangabeira Santos, DS, Felipe Santos Couto, DS, and Raildo da Silva Coqueiro, PhDState University of Southwest Bahia, Bahia, Brazil

Objective. The aim of this study was to evaluate perceptions regarding esthetic appearance of the smile in cases oforthognathic surgery for correction of maxillary gingival display.Study Design. Alterations were made to an extraoral front-view photograph of a gingival smile in normal occlusion byrepositioning the maxilla to simulate bone tissue removal and gingival exposure. Images were printed on photographic paperattached to questionnaires distributed among laypersons, professionals, and dental students to evaluate degree of esthetics(n � 150). To evaluate degree of esthetics, an attractiveness-scale was used, with 0 representing hardly attractive, 5 attractive,and 10 very attractive.Results. All of the evaluated groups demonstrated that large gingival extension does not always affect esthetic appearance ofthe smile. Insufficiently visualized maxillary incisors were considered hardly attractive and received statistically lower scores(P � .05).Conclusions. According to esthetic parameters, gingiva play important roles in composition of the smile, but only when they

are exposed to a small extent. (Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:448-454)

The smile, being one of the features composing facialarchitecture, plays a role of fundamental relevance incontributing to the esthetics and attractiveness of theface.1,2 The pattern considered to be an attractive smileis the one that has both harmonious correlation betweenthe shape and colors of the teeth and a good proportionbetween lip and gingiva.3,4

Although studies have proved that women tend tohave a higher smile line than men, when smiling anindividual normally exposes from 1 to 3 mm of gingiva,emphasizing interdental and marginal gingival tis-sue.5-8 There are situations, however, in which theindividual exposes a large extension of gingiva in ex-cess of 3 mm when smiling, thus presenting a conditioncalled a gingival smile.9-12 This may result from verti-cal maxillary excess, short upper lip or combination ofthose factors.13,14

For correction of a gingival smile, in cases of bonediscrepancy with vertical maxillary excess, orthog-nathic surgery of the maxilla is considered to be themost adequate treatment.15-17

The use of approaches such a satisfactory reposition-ing of the bones of the face in relation to the base of theskull interferes in the facial features, providing esthet-ics and facial symmetry as well as minimizing gingivalexposure in the smile, promoting good visual percep-tion.1,16

Received for publication Feb 15, 2012; returned for revision Mar 26,2012; accepted for publication Apr 1, 2012.© 2013 Elsevier Inc. All rights reserved.2212-4403/$ - see front matter

http://dx.doi.org/10.1016/j.oooo.2012.04.027

448

The choice of technique for the correction of a gin-gival smile depends on factors such as appropriatediagnosis of the cause of excessive gingival exposure,whether or not there is a need to remove bone tissue,distance from the gingival margin to the cementoe-namel junction, and distance from this junction to thebone crest.17-20

Various authors have evaluated esthetic perceptionof the components that comprise the smile,4,21-24 butthere is little information available about perception ofthe gingival smile.

The aim of the present study was to evaluate degreeof perception of laypersons, professionals, and dentalstudents regarding esthetic appearance of the smile incases of orthognathic surgery of the maxilla for correc-tion of a gingival smile, by means of alterations inphotographs.

MATERIALS AND METHODSTo conduct this study, a frontal intraoral photograph ofa patient, a woman aged 45 years 10 months, withnormal occlusion, was used. The photograph used was

Statement of Clinical Relevance

Orthognathic surgery uses preestablished parame-ters of what would be ideal gingival exposure dur-ing the planning of surgery. However, informationabout the patient’s wishes is very important, there-fore the need to evaluate what the patient reallywants and not just what the professionals plan.

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taken with a digital camera (Canon Rebel XTI, 10megapixels), resulting in an image in which the con-stituents of the smile were shown, i.e., the lips, gingiv,a and teeth.

The real photograph was manipulated with the helpof Adobe Photoshop CS3 software. The changes in thephotograph were made in the region of the maxilla,with various compositions of gingival exposure. Withthe intention of simulating the possible results oforthognathic surgery, lengths of bone were removedfrom the maxilla. Ten images were obtained: the orig-inal and the result of removing 0.5, 1, 1.5, 2, 2.5, 3, 3.5,4, and 4.5 mm of the length of the maxilla.

The images were numbered, randomly printed onphotographic paper, and attached to a questionnaire anddistributed to laypersons, dental professionals, and stu-dents (n � 150) (Figure 1, Image 1). On a second sheet,the distribution of the same images was altered; theywere renumbered and submitted with the same ques-

Fig. 1. Image 1: 1) 0 mm, 2) 0.5 mm, 3) 1 mm, 4) 1.5 mmremoval of length of the maxilla. Image 2: 1) 2 mm, 2) 3 mm9) 4.5 mm, 10) 4 mm removal of length of the maxilla.

tionnaire to evaluate the degree of reliability of the

answers evaluated (Figure 1, Image 2). On additionalsheets, the images were individually printed, to beevaluated individually using a scale of attractiveness,where 0 was hardly attractive, 5 attractive, and 10 veryattractive. All of the evaluators were advised not tocompare the images of different sheets. The evaluationtime interval for each image was limited to 60 seconds.

Statistical procedureThe frequencies of the answers given by the dentistryprofessionals, students, and laypersons were comparedby means of the Fisher exact test. The scores of gradesawarded to each photograph were compared by meansof the Kruskal-Wallis test, and comparisons betweenpairs was performed using the Mann-Whitney test. Themeans of grades awarded to each photograph werecalculated in each group to determine the Spearmancorrelation coefficients, to evaluate the similarity be-tween the perceptions of the dental professionals, stu-

m, 6) 2.5 mm, 7) 3 mm, 8) 3.5 mm, 9) 4 mm, 10) 4.5 mmmm, 4) 1.5 mm, 5) 1 mm, 6) 2.5 mm, 7) 0.5 mm, 8) 3.5 mm,

, 5) 2 m, 3) 0

dents and lay persons. The level of significance adopted

ORAL AND MAXILLOFACIAL SURGERY OOOO450 Pithon et al. April 2013

was 5% (� � .05). The data were tabulated and ana-lyzed in the statistical program Bioestat (version 5.0).

RESULTSTable I shows the demographic data of the study par-ticipants. Of the 150 individuals, 53.3% were womenand the majority (60.0%) were in the age range from16 to 30 years.

Table II presents the perceptions of participants inthe research regarding the differences and preferencesin relation to Image 1. The data show that all of thedental professionals and students and almost all of thelaypersons noted differences between the images; therewere no significant differences in the frequency ofreplies among the groups. Among the participants thatwere able to note differences between the figures in theimage, there was statistical difference in the propor-tions among the groups regarding both the most pre-ferred figure and the least preferred figure, with ahigher proportion of professionals liking no. 4 the mostand no. 10 the least, whereas the students and layper-sons liked no. 5 the most.

Table III presents the perceptions of participants inthe research regarding the differences and preferencesin relation to Image 2. The data show that all of thedental professionals and students and almost all of thelaypersons noted differences between the images, andthere was no significant difference in the frequency ofreplies among the groups. Among the participants whowere able to note differences between the figures in theimage, there was also no statistical difference in theproportions among the groups, regarding both the mostpreferred and the least preferred photographs.

The mean grades awarded to each figure are pre-sented in Table IV. Images E and J were scored as themost and least attractive, respectively, by all 3 groups.The scores awarded to Images A, B, and J presentedsignificant differences among the groups. Comparisonsbetween pairs showed that dental professionals attrib-uted worse scores to Images A, B, and J compared with

Table I. Demographic data of study participants ingroups

Characteristic

Dentalprofessionals

(n � 50)

Dentalstudents(n � 50)

Laypersons(n � 50)

GenderMale 29 (58.0%) 13 (26.0%) 28 (56.0%)Female 21 (42.0%) 37 (74.0%) 22 (44.0%)

Age group, y�16 0 (0.0%) 0 (0.0%) 3 (6.0%)16-30 5 (10.0%) 49 (98.0%) 36 (72.0%)31-45 36 (72.0%) 1 (2.0%) 9 (18.0%)�45 9 (18.0%) 0 (0.0%) 2 (4.0%)

dentistry students and laypersons.

Positive and high correlations were verified betweenthe mean grades attributed by the 3 groups (Table V).All of the relationships verified were significant.

DISCUSSIONA smile considered to be standard is one that presentsthe total length of maxillary teeth extending up to thepremolars1,2 and a harmonious relationship of the teethregarding color, shape, and architecture of the lips andgingival tissues.9,17,19

Dentoskeletal deformities, particularly regardingvertical maxillary excess results in a gingival smilecharacterized by disproportion between the middle andinferior thirds of the face due to labial incompetenceand length of the lower portion of the face25,26 notresulting in a harmonious perception of the facialset.1,10

Effective correction of this condition can be per-formed with surgical treatment, prioritizing reposition-ing of the maxilla, because within esthetic parameters,there should be �3 mm of gingiva exposed whensmiling.10,27 Within the prevailing concepts in esthetictreatments in the field of orthodontics and orthognathicsurgery regarding diagnosis and treatment plan, thegoal is to provide harmony and balance of the facialfeatures.28

A recent study about the psychosocial effects oforthognathic surgery concluded that the majority ofpatients submitted to this treatment showed improve-ments in self-esteem, good relationship between phys-ical and facial beauty, and improvement in social rela-tionships.29

As in all clinical judgments, subjectivity in the per-ception of a profile may not be compatible when theopinion of dental professionals and patients are takeninto consideration.30 Therefore, our proposal in thepresent study was to evaluate, by means of alterationsin photographs, degrees of perception of laypersons,professionals, and dental students regarding estheticappearance of the smile in cases of orthognathic sur-gery for correction of gingival smile. No study with thisproposal was found in the literature, so the resultsfound here are unprecedented.

The method used consisted of modifying, with theaid of an image manipulation program, a frontal pho-tograph in which the patient presented normal occlu-sion with the presence of all of the teeth. In possessionof the manipulated photographs, an album wasmounted and attached to a questionnaire that waspassed on the dentists, dental students, and lay persons.The methodology of the research conducted in thisstudy was based on earlier studies found in the litera-ture, in which the results of possible treatments with

orthodontic intervention were evaluated by means of

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Table II. Perception of the participants regarding differences and their preferences regarding the images presentedin Image 1

Answer Dental professionals Dental students Laypersons P value

Perceive differences .329Yes 50 (100.0%) 50 (100.0%) 48 (96.0%)No 0 (0.0%) 0 (0.0%) 2 (4.0%)

Image I like most* .0061 1 (2.0%) 1 (2.0%) 3 (6.3%)2 1 (2.0%) 2 (4.0%) 0 (0.0%)3 2 (4.0%) 2 (4.0%) 4 (8.3%)4 23 (46.0%) 7 (14.0%) 10 (20.8%)5 9 (18.0%) 20 (40.0%) 16 (33.3%)6 8 (16.0%) 13 (26.0%) 10 (20.8%)7 6 (12.0%) 4 (8.0%) 1 (2.1%)8 0 (0.0%) 1 (2.0%) 4 (8.3%)9 0 (0.0%) 0 (0.0%) 0 (0.0%)10 0 (0.0%) 0 (0.0%) 0 (0.0%)

Image I like least* .0101 17 (34.0%) 19 (38.0%) 6 (12.5%)2 0 (0.0%) 1 (2.0%) 0 (0.0%)3 0 (0.0%) 0 (0.0%) 1 (2.1%)4 0 (0.0%) 0 (0.0%) 1 (2.1%)5 0 (0.0%) 0 (0.0%) 0 (0.0%)6 0 (0.0%) 1 (2.0%) 0 (0.0%)7 0 (0.0%) 0 (0.0%) 0 (0.0%)8 0 (0.0%) 0 (0.0%) 0 (0.0%)9 0 (0.0%) 0 (0.0%) 1 (2.1%)10 33 (66%) 29 (58.0%) 39 (81.3%)

*Answered only by individuals who perceived differences between the images.

Table III. Perception of the participants regarding differences and their preferences regarding the images presentedin Image 2

Answer Dental professionals Dental students Laypersons P value

Perceive differences .324Yes 50 (100.0%) 49 (98.0%) 47 (94.0%)No 0 (0.0%) 1 (2.0%) 3 (6.0%)

Image I like most* .1411 7 (14.0%) 7 (14.0%) 10 (21.3%)2 5 (10.0%) 10 (20.0%) 9 (19.1%)3 1 (2.0%) 0 (0.0%) 0 (0.0%)4 21 (42.0%) 13 (26.0%) 7 (14.9%)5 5 (10.0%) 5 (10.0%) 9 (19.1%)6 10 (20.0%) 14 (28.0%) 8 (17.0%)7 1 (2.0%) 0 (0.0%) 1 (2.1%)8 0 (0.0%) 1 (2.0%) 2 (4.3%)9 0 (0.0%) 0 (0.0%) 0 (0.0%)10 0 (0.0%) 0 (0.0%) 1 (2.1%)

Image I like least* .6201 1 (2.0%) 0 (0.0%) 0 (0.0%)2 0 (0.0%) 0 (0.0%) 0 (0.0%)3 16 (32.0%) 20 (40.0%) 12 (25.5%)4 0 (0.0%) 0 (0.0%) 0 (0.0%)5 0 (0.0%) 1 (2.0%) 0 (0.0%)6 0 (0.0%) 0 (0.0%) 1 (2.1%)7 2 (4.0%) 0 (0.0%) 2 (4.3%)8 1 (2.0%) 1 (2.0%) 0 (0.0%)9 15 (30.0%) 17 (34.0%) 19 (40.4%)10 15 (30.0%) 11 (22.0%) 13 (27.7%)

*Answered only by individuals who perceived differences between the images.

rent (M

ORAL AND MAXILLOFACIAL SURGERY OOOO452 Pithon et al. April 2013

modifications in photographs made with the use ofimage-editing programs.21,22

The use of computer programs that enable the ma-nipulation of structures that compose the face allowsfor analysis of the degree of influence of certain mor-phologic structures on facial and dental esthetic com-position. However, identification of the problem andthe form of treatment to choose so that there is correc-tion of the disposition of teeth, presents some complexparticularities.

It is worth pointing out that esthetic analysis of thesmile includes evaluation of all its components, such asthe arch of the smiles, tooth positions and structures,peculiarity of gingival esthetics, buccal corridor space,coincidence of the midline, and proportionality of theteeth.1

Recently a great deal attention has been paid to theperception of lay persons and dentistry professionalsregarding esthetic evaluations,21,22 which are of funda-mental importance in both the decision and the treat-ment to be performed.

The photograph of a 45-year-old patient was chosenbecause, over the course of many years, orthodontictreatment in adult patients �40 years old has becomecommon. Research conducted in the early 1990sshowed that 30% percent of patients in dental officesspecialized in orthodontics were �40 years old, and itwas estimated that this percentage would increase bythe end of the decade.31 The growth and developmentexpected in a child, which may help in the treatment ofmalocclusions, are factors that are not present in orth-odontic treatment in adults. When there is an associa-

Table IV. Mean grades (SD) awarded by the dental pPhotograph Dental professionals

Image A† 2.87 (2.17)a

Image B† 3.59 (2.01)a

Image C 4.99 (2.23)Image D 6.13 (1.96)Image E 6.96 (1.58)Image F 6.00 (1.73)Image G 4.87 (1.97)Image H 3.83 (1.80)Image I 2.69 (1.88)Image J† 1.62 (1.65)a

*The scores of grades were compared by means of the Kruskal-Wa†Mean values with different superscript letters are significantly diffe

Table V. Spearman coefficient of correlation of themean grades attributed to the photographsGroup of participants Dental students Laypersons

Dental professionals 0.99a 0.99a

Dental students 1.00 0.98a

aP � .01 (2-tailed).

tion of skeletal dysplasias, orthodontic treatment in an

adult patient must be associated with orthognathic sur-gery, because growth has ceased.

The results indicated that all of the dental profession-als and students and the majority of the laypersons, inan immediate view of the images, noted differences,without significant difference observed in the frequen-cies of replies among the groups. These data demon-strate that the results arising from orthognathic surgeryare directly reflected in esthetics with a high value ofperception, as has been presented in other studies.28,32

In an immediate view, from the point of view of thedental professionals evaluated, 46.0% most liked theimage that presented 1 mm of gingiva exposure whensmiling, whereas 40.0% of the students and 33.3% oflaypersons most liked the image in which onlythe fulllength of the maxillary incisors and interdental gingivawere visible (without gingiva exposure). There wasunanimity among the three groups evaluated, however,in selecting the image in which only the incisal portionof the central incisors were visible as being the leastattractive.

In a second evaluation, however, the results in Image2 demonstrated that the dental professionals and themajority of students and laypersons noted differencesamong the images.

From the dental professionals’ point of view, 42.0%most liked the image that presented 1 mm of gingivawhen smiling, among the dentistry students 28.0%most liked the image in which the total length of themaxillary incisors and interdental gingiva were visible(without gingiva exposure), and among the laypersons21.3% most liked the image in which only the middleand incisal portions of the maxillary incisors werevisible. The image in which �3 mm of gingiva wasexposed was elected by 32.0% of the professionals and40.0% of dentistry students as the least attractive, and40.4% of laypersons considered the least attractive im-age to be the one that showed only the incisal portion ofthe central incisors. These data are of great clinical

ionals, dental students, and laypersonsl students Laypersons P value*

(1.71)b 4.26 (2.39)b .005(1.77)b 4.79 (1.87)b .007(1.78) 5.99 (2.19) .065(1.75) 6.55 (2.00) .310(1.36) 6.80 (2.21) .515(1.82) 6.29 (2.14) .092(2.06) 5.50 (2.21) .236(1.95) 4.63 (2.36) .124(1.89) 3.63 (2.43) .054(1.92)b 2.94 (2.64)b .005

ann-Whitney test).

rofessDenta

3.764.405.596.647.396.795.504.553.542.73

llis test.

relevance considering that in cases of excessive gingiva

OOOO ORIGINAL ARTICLEVolume 115, Number 4 Pithon et al. 453

exposure resources must be used with the purpose ofreducing this exposure, either by orthognathic sur-gery,25 dental intrusion,14 increase in clinical crown,1

and, more recently, use of botulinum toxin,33 comparedwith cases with little exposure, which is very commonin older patients.

The instrument for measuring a subjective phenom-enon used in this study, establishing fixed points with“hardly attractive,” “attractive,” and “very attractive”served to demonstrate that there are differences in theevaluation of esthetics between dental professionals/students and laypersons. The image that showed onlyexposure of the tooth grown and gingival papilla wasscored as the most attractive. According to Garber andSalama,9 these results confirm that the gingiva plays afundamental role in the structural composition of thesmile; however, it should not be exposed to an extentexceeding 3 mm.

The image that presented exposure of the maxillaryincisors only, in turn, was scored as the least attractive.This result may be backed by the presence of a lowsmile line that denotes characteristics of aging. Think-ing of this during orthodontic planning, the orthodontistshould, whenever possible, use orthodontic resourcesthat extrude anterior teeth, such as for example, the useof anterior vertical elastics. Thus, the smile will bemore attractive, as noted from the results of the presentstudy.

These results also confirm those of other studies thathave reported that a high smile line does not alwaysaffect the esthetic appearance of the smile and can becharacterized as being more harmonious than the lowsmile line.17,23

The changes made were in exposure of the teeth,gum, and vertical maxillary height in these patients. Nochanges occurred in the position of the nose or lip, andit is worth pointing out that these two components arealso influenced by the surgical procedures of maxillaryimpaction for correction of the gingival smile. Anotherlimitation of this study concerns the patient having beenevaluated during the smile. It is known that duringorthognathic surgical planning, the patient is evaluatedat rest, because only thus is it possible to evaluate otherstructures such as the lips and nose.

Moreover, regarding perception, dental professionalsand students, as well as laypersons, are apt to perceivedifferences between the possible results arising fromorthognathic surgery. The results presented in the pres-ent study were shown to be of great clinical importance,because in the great majority of situations, profession-als plan treatment based on features that they considerto be pleasant, without listening to the most importantopinion, which is that of the patient him/herself. This

reality has changed over the past few years with the

popularization and use of computer programs that en-able virtual manipulation before surgical and orthodon-tic procedures.

CONCLUSIONAfter conducting this study, it could be concluded thatthe gingiva plays an important role in the esthetics ofthe smile, and its reduced or excessive exposure isconsidered to be antiesthetic; it requires special atten-tion during orthodontic planning so that the smile ismore attractive at the conclusion of treatment.

REFERENCES1. Bhuvaneswaran M. Principles of smile design. J Conserv Dent

2010;13:225-32.2. Guth E, Bacon W. [Smile in self-representation and self-esteem].

Orthod Fr 2010;81:323-9. French.3. Kepic TJ, O’Leary TJ, Kafrawy AH. Total calculus removal: an

attainable objective? J Periodontol 1990;61:16-20.4. Jørnung J, Fardal O. Perceptions of patients’ smiles: a compar-

ison of patients’ and dentists’ opinions. J Am Dent Assoc2007;138:1544-53.

5. An KY, Lee JY, Kim SJ, Choi JI. Perception of maxillaryanterior esthetics by dental professionals and laypeople andsurvey of gingival topography in healthy young subjects. Int JPeriodontics Restorative Dent 2009;29:535-41.

6. Geron S, Atalia W. Influence of sex on the perception of oral andsmile esthetics with different gingival display and incisal planeinclination. Angle Orthod 2005;75:778-84.

7. Savage KO, Arowojolu MO. Perception of gingival bleeding byNigerians. Afr J Med Med Sci 1997;26:91-3.

8. Isiksal E, Hazar S, Akyalçin S. Smile esthetics: perception andcomparison of treated and untreated smiles. Am J Orthod Dento-facial Orthop 2006;129:8-16.

9. Garber DA, Salama MA. The aesthetic smile: diagnosis andtreatment. Periodontol 2000 1996;11:18-28.

10. Ahmad I. Geometric considerations in anterior dental aesthetics:restorative principles. Pract Periodontics Aesthet Dent1998;10:813-22.

11. Kawamoto HK Jr. Treatment of the elongated lower face and thegummy smile. Clin Plast Surg 1982;9:479-89.

12. Levine RA, McGuire M. The diagnosis and treatment of thegummy smile. Compend Contin Educ Dent 1997;18:757-64.

13. Cronin T. Smile design governed by stability concerns: part III.Vertical relationships. Int J Orthod Milw 2007;18:35-6.

14. Lin JC, Liou EJ, Bowman SJ. Simultaneous reduction in verticaldimension and gummy smile using miniscrew anchorage. J ClinOrthod 2011;44:157-70.

15. Costa MR, Costa MG, De Pinho CB, Quintão CC. Correction ofsevere overbite and gummy smile in patients with bimaxillaryprotrusion. J Clin Orthod 2010;44:237-44.

16. dos Santos GG, Rego DM. The influence of a gummy smile onlip seal. J Int Acad Periodontol 2007;9:53-7.

17. Monaco A, Streni O, Marci MC, Marzo G, Gatto R, Giannoni M.Gummy smile: clinical parameters useful for diagnosis and ther-apeutical approach. J Clin Pediatr Dent 2004;29:19-25.

18. Dolt AH 3rd, Robbins JW. Altered passive eruption: an etiologyof short clinical crowns. Quintessence Int 1997;28:363-72.

19. Hwang WS, Hur MS, Hu KS, Song WC, Koh KS, Baik HS, et al.Surface anatomy of the lip elevator muscles for the treatment ofgummy smile using botulinum toxin. Angle Orthod

2009;79:70-7.

ORAL AND MAXILLOFACIAL SURGERY OOOO454 Pithon et al. April 2013

20. Li YY, Zhou YH, Lin JX. [Intruding upper incisors using mini-screw anchorage in patients with gummy smile]. Zhonghua KouQiang Yi Xue Za Zhi 2009;44:449-53. Chinese.

21. Pithon MM, Santos AM, Couto FS, da Silva Coqueiro R, deFreitas LM, de Souza RA, dos Santos RL. Perception of theesthetic impact of mandibular incisor extraction treatment onlaypersons, dental professionals, and dental students. Angle Or-thod 2011.

22. Johnston C, Hunt O, Burden D, Stevenson M, Hepper P. Self-perception of dentofacial attractiveness among patients requiringorthognathic surgery. Angle Orthod 2010;80:361-6.

23. Varlik SK, Demirbas E, Orhan M. Influence of lower facialheight changes on frontal facial attractiveness and perception oftreatment need by lay people. Angle Orthod 2012;80:1159-64.

24. Zhang YF, Xiao L, Li J, Peng YR, Zhao Z. Young people’sesthetic perception of dental midline deviation. Angle Orthod2010;80:515-20.

25. Ataoglu H, Uçkan S, Karaman AI, Uyar Y. Bimaxillary orthog-nathic surgery in a patient with long face: a case report. Int JAdult Orthodon Orthognath Surg 1999;14:304-9.

26. Schendel SA, Carlotti AE Jr. Variations of total vertical maxil-lary excess. J Oral Maxillofac Surg 1985;43:590-6.

27. Mikami I. [An evaluation of the functional lip posture]. Shigaku1990;78:339-76. Japanese.

28. Chaconas SJ, Fragiskos FD. Orthognathic diagnosis and treat-ment planning: a cephalometric approach. J Oral Rehabil

1991;18:531-45.

29. Hunt OT, Johnston CD, Hepper PG, Burden DJ. The psychoso-cial impact of orthognathic surgery: a systematic review. Am JOrthod Dentofacial Orthop 2001;120:490-7.

30. Rivera SM, Hatch JP, Dolce C, Bays RA, van Sickels JE, RughJD. Patients’ own reasons and patient-perceived recommenda-tions for orthognathic surgery. Am J Orthod Dentofacial Orthop2000;118:134-41.

31. Capelozza Filho L, Braga SA, Cavassan AO, Ozawa TO. Trata-mento ortodôntico em adultos: uma abordagem direcionada. RevDental Press Ortodon Ortop Facial 2001;6(5):63-80.

32. Ramieri G, Spada MC, Nasi A, Tavolaccini A, Berrone S. [Facialanthropometry and aesthetic perception in young Italian subjects:their use for orthognatic surgery]. Minerva Stomatol 2002;51:479-93.

33. Polo M. Botulinum toxin type A (Botox) for the neuromuscularcorrection of excessive gingival display on smiling (gummysmile). Am J Orthod Dentofacial Orthop 2008;133:195-203.

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