Article

How others perceive orthognathic patients: an eye-tracking study

Authors:
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

To test the hypothesis that the faces of patients with a severe Class III are contemplated differently from and assessed more negatively than skeletal Class I patients in direct face-to-face interaction. The eye movements of 24 randomly recruited evaluators were analyzed with a noninvasive, infrared high-speed camera while looking at 18 standardized frontal photographs of adult orthognathic Class III patients and 18 photographs of adults with skeletal Class I relationships as controls. Additionally, all images were assessed for appearance, symmetry, and facial expression. The Class III patients were rated significantly more negatively in terms of appearance, symmetry, and facial expression than the Class I individuals. The eye movement data revealed that orthognathic patients were appraised differently from the Class I individuals, with fewer fixations in the face center, especially around the mouth. Skeletal Class III patients were characterized as less attractive than Class I individuals. Faces of Class III patients were visually perceived with different eye movements. These differences in visual perception are described for the first time in the present study. Although they were small, they are an indication of an objectively different perception of faces that are rated subjectively as less attractive and more asymmetric and exhibiting a more negative expression.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... 11,32 Other fields included facelift (1), 10 coronal synostosis (1), 33 and an orthognathic patient (1). 34 Figure 2 demonstrates the timeline of the included studies ...
... 17,28 Color images were utilized in all studies except 4, where observers were shown black-and-white images. 20,21,33,34 One study recorded the interaction of mothers with their infants while wearing eye-tracking glasses, whereas all other studies used static images. 19 Life-sized images were shown in 6 studies. ...
Article
Background The use of eye-tracking technology in plastic surgery has gained popularity over the past decade due to its ability to assess observers’ visual preferences in an objective manner. Objectives The goal of this study was to provide a comprehensive review of eye-tracking studies in plastic and reconstructive surgery, which can aid in the design and conduct of high-quality eye-tracking studies. Methods Through application of Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines, a comprehensive search of articles published on eye-tracking across several databases was conducted from January 1946 to January 2019. Inclusion criteria included studies evaluating the use of eye-tracking technology in the field of plastic and reconstructive surgery. The resulting publications were screened by 2 independent reviewers. Results A total of 595 articles were identified, 23 of which met our inclusion criteria. The most common application of eye-tracking was to assess individuals with cleft lip/palate (9 studies). All 19 studies that evaluated fixation patterns among conditions vs controls reported significant differences between the 2 groups. Five out of 7 studies assessing visual data between preoperative and postoperative patients identified significant differences between the preoperative and postoperative groups, whereas 2 studies did not. Nine studies examined the relation between severity indices, attractiveness scores, or personality ratings and gaze patterns. Correlation was found in 7 out of the 9 studies. Conclusions This systematic review demonstrates the utility of eye-tracking technology as a quantifiable objective assessment and emerging research tool for evaluating outcomes in several domains of plastic and reconstructive surgery.
... Several studies have shown that beside visible dentofacial anomalies [3,4] and missing teeth [5], visible caries may also affect observers subjective ratings of peoples' facial attractiveness and provoke negative social judgements. When presenting computer-modified photographs of adults with or without caries lesions of the anterior teeth, subjects with caries were rated to be less socially and intellectually competent [6,7]. ...
... Stimulus presentation was controlled by an iMax 24"(IntelCore™ 2 Duo CPU, 3 . Images with neutral and emotional expression were paired and presented side by side with a visual angle of 7.11°. ...
Article
Objectives: This study aimed to analyse if children with untreated or treated caries (restorations/missing teeth) are perceived differently compared to children with healthy teeth and to explore possible differences in the perception by laypersons and dental experts. Methods: Eye movements of female experts (n = 20) and laypersons (n = 18) were recorded by eye-tracking while paired images (neutral expression/teeth not visible; emotional expression/smiling, teeth visible) of children with healthy teeth, with visible untreated or treated caries (restorations/missing teeth as a consequence of caries treatment), each n = 13, were presented. First fixation, total fixation time and number of fixations on the areas of interest (eyes, nose, mouth) in the first two seconds of presentation were determined. Furthermore, the images were rated regarding arousal, valence and attractivity. Statistical analysis was performed using Mann-Whitney-U- and Kruskal-Wallis-tests (α = 0.05). Results: Generally, laypersons spent more time exploring and fixating the eye region than the mouth, while dental experts more often first percept and longer and more often fixated the mouth region, especially in images with emotional expression. Dental experts, but not laypersons, were significantly longer fixating the mouth of children with untreated caries than the mouth of children with healthy teeth in images with emotional expression. When evaluating images with emotional expression, both dental experts and laypersons rated children with healthy teeth to be more attractive, pleasant and calm than children with untreated or treated caries. Conclusions: Children with visible treated and untreated caries were differently perceived by laypersons and dental experts than children with healthy teeth.
... Eye-tracking technology is an innovative method of gathering visual gaze data to attain unbiased, objective insight into the features of an image that draw a viewer's attention. By monitoring an observer's conscious and subconscious eye movements toward visually salient stimuli, eye tracking eliminates reporting biases and can identify a viewer's subconscious preferences [10][11][12][13][14][15][16]. Previously used in consumer marketing research and psychology, it has recently gained traction in plastic surgery to better evaluate aesthetic outcomes in postmastectomy breast reconstruction, unilateral cleft palate repairs, and cosmetic facial procedures [17][18][19][20][21][22][23][24][25][26][27][28]. ...
Full-text available
Article
Background Eye-tracking technology objectively measures the visual focus of subjects when assessing aesthetics. Identifying attention-drawing features can assist in improving patient satisfaction and perceived outcomes. Using eye-tracking technology, we characterized visual gaze patterns among plastic surgery patients versus laypeople when assessing pre- and post-abdominoplasty images.Methods Sixteen pairs of pre- and post-abdominoplasty images in AP and lateral views were shown to twenty women with and twenty women without a cosmetic procedure history. An eye-tracking device recorded visual gaze data as participants assessed the aesthetic value of the images.ResultsThe patient group spent 22.6% less time evaluating images (p < 0.05) but spent proportionally more time fixated on features of interest: the umbilicus (25.6% of their average viewing time vs 11.6%, p < 0.001), scar line (13.2% vs 5.1%, p < 0.001), and abdominal curvature (7.6% vs 3.6%, p < 0.001). Both groups most commonly first fixated on the umbilicus and abdominal curvature for AP and lateral views, respectively. The patient group’s average increase in aesthetic rating between pre- and post-procedural images was 30.4% higher than the lay group (p < 0.05). No correlation was noted between aesthetic ratings and time spent viewing the areas of interest.Conclusions Females who previously underwent cosmetic procedures are more favorable, faster, and focused reviewers of abdominoplasty images, fixating more on relevant anatomy and features than their peers. New patients may benefit from an eye-tracking-based assessment to align procedural planning and consultation with the anatomic areas they visually fixate upon.Level of evidence: Not ratable.
... The design of the photographs was similar to those in other studies of photographic evaluation of the facial appearance. 18,20,[25][26][27][28] Some studies have added other angulations or views to the picture, which might lead to a more detailed evaluation of the facial appearance. 29 However, we aimed for an overall impression of the face, through a limited number of photographs, instead of a detailed evaluation. ...
Article
Is there a variation in facial ideals depending on ethnic background that affects judgements of outcome in orthognathic surgery? How does the evaluation correlate with patient-reported outcome measures? Two evaluation panels, Singaporean and Swedish, judged photographs of patients undergoing orthognathic surgery taken before and after operation. Improvement in facial aesthetics was calculated between the two ratings. The result was compared between the panels and correlated with health-related quality of life (QoL) measures. Thirty male and 27 female patients aged between 18 and 28 years (mean 21) were included, and 52 subjects were eligible for comparison of health-related QoL. The photographic evaluation showed that both panels judged there to be significant improvement in facial aesthetics after treatment (p < 0.001). The Singaporean panel rated the overall facial appearance higher than the Swedish panel when evaluating photographs both before (p = 0.025) and after (p = 0.032) operation. Improvement of the overall facial appearance showed no significant difference between the panels (p > 0.30). No correlation between health-related QoL and improvement of facial appearance was found by either panel. Subjective evaluation of facial aesthetics in orthognathic surgery is unaffected by the observer’s ethnic origin. Independently of their ethnicity, the evaluation juries found that facial aesthetics improved after orthognathic surgery. Improvement reported by the juries corresponded to that reported by patients.
... The way the photographs were taken was similar to those described in other studies of photographic evaluation of facial appearance. 16,19,[21][22][23][24] Some studies have added other angulations or views, which might lead to a more detailed evaluation of the facial appearance. 25 However, the present study aimed for an overall impression of the face, through a limited number of photographs, instead of detailed evaluation. ...
Full-text available
Article
The outcome of treatment in orthognathic surgery is dependent on preoperative surgical planning. The main purpose of the present study was to evaluate from photographs the improvement in facial appearance after orthognathic surgery. In addition, the outcomes of two different planning techniques, 2-dimensional and 3-dimensional, were compared and the correlation between the outcome and health-related quality of life (HRQoL) assessed. The study was a randomised controlled trial with the intervention being either 2-dimensional or 3-dimensional treatment planning. An evaluation panel compared photographs taken before and after operation on patients with severe class III malocclusion. The change in facial appearance was rated, the two planning techniques compared, and the result correlated with previously published findings on cephalometric accuracy and HRQoL in the same group. Completed 12-month follow-up resulted in the inclusion of 57 subjects aged between 18 and 28 years at the time of operation (mean 21 years). We found significant differences between the two evaluations (p = 4.4E-9) but no significant difference in facial improvement between the planning techniques (p = 0.54). However, there was a correlation between cephalometric measurement of accuracy in the anterior maxilla and evaluation of improvement of facial appearance (p = 0.024, r = 0.30), but we found no correlation +between HRQoL and the evaluation of facial appearance (p = 0.31, r = -0.14). We conclude that there was an improvement in facial aesthetics after orthognathic surgery that was independent of the planning technique used. © 2019 The British Association of Oral and Maxillofacial Surgeons
... In this study, models with normal occlusion were selected, and the participants were not classified according to their facial morphological features or occlusal condition. Considering that malocclusion affects psychological conditions and draw some changes in eye gaze, 4,23,31,32 it may be postulated that the presence of malocclusion may influence the selfperception of facial attractiveness and/or facial esthetics. Thus, to further establish customized diagnosis in esthetic dentistry, the objective morphological features observed at different facial angles and subjective perception studies according to different malocclusion patterns may be helpful in the future. ...
Article
Objective: To examine the changes in visual attention influenced by facial angles and smile during the evaluation of facial attractiveness. Materials and methods: Thirty-three young adults were asked to rate the overall facial attractiveness (task 1 and 3) or to select the most attractive face (task 2) by looking at multiple panel stimuli consisting of 0°, 15°, 30°, 45°, 60°, and 90° rotated facial photos with or without a smile for three model face photos and a self-photo (self-face). Eye gaze and fixation time (FT) were monitored by the eye-tracking device during the performance. Participants were asked to fill out a subjective questionnaire asking, "Which face was primarily looked at when evaluating facial attractiveness?" Results: When rating the overall facial attractiveness (task 1) for model faces, FT was highest for the 0° face and lowest for the 90° face regardless of the smile ( P < .01). However, when the most attractive face was to be selected (task 2), the FT of the 0° face decreased, while it significantly increased for the 45° face ( P < .001). When facial attractiveness was evaluated with the simplified panels combined with facial angles and smile (task 3), the FT of the 0° smiling face was the highest ( P < .01). While most participants reported that they looked mainly at the 0° smiling face when rating facial attractiveness, visual attention was broadly distributed within facial angles. Conclusions: Laterally rotated faces and presence of a smile highly influence visual attention during the evaluation of facial esthetics.
Full-text available
Article
Objective: To study the influence of black space between the maxillary central incisors on the aesthetic visual perception of the face, via eye-tracking and visual analogue scale (VAS). Methods: Black space between the central incisors was created, for both sexes, as follows: control, 1-mm black space, 2-mm black space and 3-mm black space. Ninety raters participated in this study, divided into three groups: 30 laypeople, 30 nonorthodontists, and 30 orthodontists. After the visual calibration of each observer, eight photographs were presented in the Ogama® software concomitant with the use of the hardware The Eye Tribe®. Ogama generated information depending on the eye-tracking of each rater, regarding the time until the first fixation, time of fixation, heatmap, scanpath, and total time of fixation, to evaluate the areas deemed to be of interest according to the raters. Later on, the VAS was used, where each rater evaluated the images in an album on a scale of zero to 10 points. Results: The eyes and mouth were the areas more often noticed by the raters according to the heatmaps, while no significant difference was observed in time until the first fixation between the three groups of raters (p> 0.05). However, regarding the time of fixation on the mouth, a significant difference was observed (p< 0.05) when comparing the three groups. Conclusion: Black space has a negative effect on the aesthetic perception of the face. The amount of attention on the mouth is correspondent to the size of the black space.
Article
Introduction: Studies concerning the visual attention of laypersons viewing the soft tissue facial profile of men and women with malocclusion are lacking. This study aimed to determine the visual attention to the facial profile of patients with different levels of mandibular protrusion and facial background attractiveness using an eye-tracking device. Methods: The scanning paths of 54 Chinese laypersons (50% female, 50% male, aged 18-23 years) were recorded by an eye-tracking device when they observed composite female facial profile images (n = 24), which were combinations of different degrees of mandibular protrusion (normal, slight, moderate, and severe) and different levels of facial background attractiveness (attractive, average, and unattractive). Dependent variables (fixation duration and first fixation time) were analyzed using repeated-measures factorial analysis of variance. Results: For normal mandibular profiles, the fixation duration of the eyes was significantly higher than that of other facial features (P <0.001). The lower face and nose received the least attention. As the degree of protrusion increased from slight to moderate, more attention was drawn to the lower face accompanied by less attention to eyes in the unattractive group (P <0.05). When protrusion degree increased from moderate to severe, attention shifted from nose to lower face significantly in the attractive group (P <0.05). Attention shift from eyes to lower face was also found in the average group when protrusion degree rose to moderate protrusion from normal profile (P <0.05). A significant interaction between facial attractiveness and mandibular protrusion was found in the lower face duration (P = 0.020). The threshold point (the point of mandibular protrusion degree that evoked attention to the lower face) of the attractive facial background was higher than that of the unattractive background. Once evoked, the effect of mandibular protrusion of the attractive group tended to be stronger than that of the unattractive group, though without statistical difference. Conclusions: Eyes are the most salient area. The increasing degree of mandibular protrusion tends to draw attention to the lower face from other facial features. Background attractiveness can modify this behavior.
Article
Objectives: To test the hypotheses that there are differences between orthodontists, individuals with cleft lip and palate (CLP) and laypersons in the visual perception of faces with unilateral (UCLP) and bilateral cleft lip and palate (BCLP), the faces with UCLP and BCLP are visually perceived differently and the hierarchy of visual attention changes when viewing individuals with CLP. Setting and sample population: Department of Orthodontics and Experimental Psychology at Ege University, İzmir. Sixty images (faces with a social smile and at rest) of 30 volunteers (unaffected controls, UCLP, BCLP) were viewed by 80 participants: orthodontists, individuals with CLP and laypersons. Materials and methods: Eye fixations on four areas of interest were quantified: eyes, nose, upper lip and lower lip-chin. Time to first fixation, fixation before, fixation count and fixation duration parameters were analysed. Results: Orthodontists fixated on the upper-lip area more often than laypersons or individuals with CLP (F2.144=8.47, P=.00, η²=.19 in faces at rest). The upper-lip area received more fixations (F2.144=21.93, P=.00, η²=.23) and longer fixation durations (F2.144=28.86, P=.00, η²=.27) from all participants who gazed on faces with UCLP and a social smile. Conclusion: The hypotheses of the study were supported. Orthodontists and laypersons focused more attention on the upper lip and eyes in the resting position, respectively. The upper-lip area of the BCLP images captured more attention at rest.
Chapter
Het hebben van opvallende afwijkingen in het gezicht leidt vaak tot negatieve reacties bij anderen. Patiënten met schisis zijn een bekend voorbeeld hiervan. Deze reacties zijn meetbaar met behulp van een eyetracker. In deze bijdrage wordt uitgelegd hoe de visuele reacties bij het zien van een gezicht gemeten kunnen worden door middel van de eyetracker, een instrument dat sinds kort voor dergelijke doeleinden gebruikt wordt. De eyetracker is een krachtig instrument, daar het de initiële visuele reactie snel en nauwkeurig kan registreren. Uniek is dat het instrument spontane reacties meet en sociaal wenselijk gedrag van proefpersonen kan uitsluiten. De eyetracker is in staat om dergelijke verschillen in de visuele perceptie van gezichten met en zonder schisisstigmata te objectiveren.
Article
Premature unilateral coronal craniosynostosis results in distinctive cranial and facial abnormalities of varying severity, including orbital dystopia and an abnormal head shape. As the face is affected, these children may encounter stigmatization. To avoid this scenario, many parents elect for their child to undergo surgical correction. Laypeople's perception of children with either untreated or treated unilateral coronal craniosynostosis (UCS) has not yet been objectively evaluated. This study introduces eye tracking as an objective instrument in order to evaluate the perception of 14 children with coronal synostosis, both pre- and postoperatively. Age-matched healthy children served as a control group. Using standardized photos, the involuntary eye movements and the fixations of 30 unaffected laypeople were evaluated. In the untreated children, whose faces were characterized by striking orbital dystopia, the eyes drew more attention than those of the healthy children. The results of our study demonstrate that the operative correction of unilateral coronal synostosis results in the normalization of the asymmetry of the fronto-orbital region, whereas the C-shaped deformity of the midface, which is not addressed via surgery, subsequently attracts more attention. Eye tracking objectively evaluates both the perception of craniofacial abnormalities and the extent of the approximation of normality after surgical correction. We introduce eye tracking as an objective measurement tool for craniofacial abnormalities for the first time.
Full-text available
Article
Corrective jaw surgery, for patients with malocclusion and dysgnathia, is primarily performed to rehabilitate oral functions. However, the patients' motivation for orthognathic surgery often seems to be influenced as well by the desire for aesthetic correction of a facial anomaly. Preoperative screening for psychiatric problems such as body dysmorphic disorder is requisite. The majority of orthognathic patients experience a negative influence of their appearance on their psychosocial well-being. In addition, the hope for aesthetic improvement is not seldom an important incentive for visiting an oral and maxillofacial surgeon. In the literature, in addition to a positive effect of corrective jaw surgery on the patient's perceived appearance, an associated improvement in quality of life is described. Correction of a disharmonious face is at least as important to patients as oral function recovery.
Article
An accurate assessment of face symmetry is necessary for the development of a dentofacial diagnosis in orthodontics, and an understanding of individual differences in perception of face symmetry between patients and providers is needed to facilitate successful treatment. Orthodontists, general dentists, and control participants completed a series of tasks to assess symmetry. Judgments were made on pairs of upright faces (similar to the longitudinal assessment of photographic patient records), inverted faces, and dot patterns. Participants completed questionnaires regarding clinical practice, education level, and self-confidence ratings for symmetry assessment abilities. Orthodontists showed expertise compared with controls (P <0.001), whereas dentists showed no advantage over controls. Orthodontists performed better than dentists, however, in only the most difficult face symmetry judgments (P = 0.006). For both orthodontists and dentists, accuracy increased significantly when assessing symmetry in upright vs inverted faces (t = 3.7, P = 0.001; t = 2.7, P = 0.02, respectively). Orthodontists showed expertise in assessing face symmetry compared with both laypersons and general dentists, and they were more accurate when judging upright than inverted faces. When using accurate longitudinal photographic records to assess changing face symmetry, orthodontists are likely to be incorrect in less than 15% of cases, suggesting that assistance from some additional technology is infrequently needed for diagnosis.
Full-text available
Article
There is evidence that specific regions of the face such as the eyes are particularly relevant for the decoding of emotional expressions, but it has not been examined whether scan paths of observers vary for facial expressions with different emotional content. In this study, eye-tracking was used to monitor scanning behavior of healthy participants while looking at different facial expressions. Locations of fixations and their durations were recorded, and a dominance ratio (i.e., eyes and mouth relative to the rest of the face) was calculated. Across all emotional expressions, initial fixations were most frequently directed to either the eyes or the mouth. Especially in sad facial expressions, participants more frequently issued the initial fixation to the eyes compared with all other expressions. In happy facial expressions, participants fixated the mouth region for a longer time across all trials. For fearful and neutral facial expressions, the dominance ratio indicated that both the eyes and mouth are equally important. However, in sad and angry facial expressions, the eyes received more attention than the mouth. These results confirm the relevance of the eyes and mouth in emotional decoding, but they also demonstrate that not all facial expressions with different emotional content are decoded equally. Our data suggest that people look at regions that are most characteristic for each emotion.
Article
In orthodontic diagnosis, facial symmetry is important. The aim of the present study was to analyse the perception of various degrees of facial asymmetry exhibited by carefully designed virtual three-dimensional (3D) material. Three groups of raters (30 orthodontists, 30 maxillofacial surgeons, and 30 laymen) rated, using a six-point scale, the degree of asymmetry of eight randomly presented 3D faces exhibiting incremental soft tissue alterations. The faces were created by gradually transforming the nose or chin in increments of 2 mm away from the computed symmetry plane. Differences between the groups in analysis of facial asymmetry, the rating of facial stimulus, and right and left facial asymmetry were determined using a t-test. The results demonstrated that raters' profession did not influence the point at which they identified asymmetry. Even laymen were able to detect asymmetries when located near the midline of 3D faces. All raters identified asymmetries of the nose as more negative than those of the same degree of the chin. A left-sided deviation of the nose along the facial symmetry plane lead to a more negative rating of facial appearance, whereas a right-sided deviation of the chin was rated as less attractive. Nasal architecture plays a crucial role in the perception of symmetry. These findings provide clinicians with a greater understanding of how faces are perceived, a process which is of particular interest in treating orthognathic patients, and those with congenital anomalies.
Article
Although there is principal agreement that increased facial asymmetry is associated with decreased facial attractiveness, there are no studies analysing face perception in patients with a unilateral cleft lip and palate (CLP) (uCLP) compared to orthognathic Class III patients. To this end, three-dimensional (3D) data on the faces of 30 adults with a complete uCLP, 20 orthognathic patients with a severe skeletal Class III, and 20 adults with a skeletal Class I as a control group were generated. The 3D asymmetry of the facial soft-tissue was analysed. These data were compared with subjective ratings for attractiveness carried out by 100 laypersons. Compared to the controls, uCLP patients and orthognathic patients had a significantly higher facial asymmetry. No difference was found between uCLP patients and orthognathic patients. The attractiveness ratings showed that uCLP patients and orthognathic patients were rated less attractive compared to the controls. However, although there were no differences in the facial asymmetry between uCLP patients and orthognathic patients, the uCLP patients were rated significantly less attractive. This leads to the conclusion that not only the extent of asymmetry has an influence on attractiveness but also the location of asymmetry. For clinical use, these findings underline the importance of accurate as possible surgical reconstruction of the nasal morphology in uCLP patients.
ResearchGate has not been able to resolve any references for this publication.