Professional Documents
Culture Documents
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13
Perhaps accurate informa-
tion could be obtained from facial photography or
videography if the patients were allowed to hold their
head in a more natural manner. Further investigation
comparing facial images taken in natural head posi-
tion with facial images taken when the subject is
placed in a head holder would address this issue
more denitively.
Analysis of the smiles by the panel members showed
that there might be subtleties about a smile that cannot
be measured objectively. More than 80% of the time, the
panel could distinguish between the smiles taken on
different days. When the data were limited to the profes-
sional panel members, the ability to discriminate be-
tween the 2 smiles increased, suggesting that the
practitioners eye might be more discriminating than
objective measures for diagnosis and treatment
planning.
To truly analyze an action, it seems logical that one
would require a tool to capture the dynamic nature of
that action. Nonetheless, the prevailing clinical ques-
tion in this study was whether the practice of ortho-
dontics requires a technique that can record the
entire dynamic range of the smile, or whether it is suf-
cient to rely on the standard still photographs for
diagnostic information. Are diagnostic photographs
providing sufcient information about the smile or
would videography be a better diagnostic tool? For
those interested in information regarding the height
of the smile alone, a still photograph might be suf-
cient, assuming that the photographer has captured
the apex of the smile. However, we found video to
be the method of choice by the clinicians. The panel
members comments supporting the preference for
video were the following: (1) the whole range of the
smile was visible, (2) it provided a record of muscle
function and strain, (3) it showed whether the smile
was guarded or not, (4) it revealed swallowing pat-
terns, (5) it demonstrated lip posture and compe-
tence, and (6) it provided 2 viewsthe patient at
rest and the patient smiling.
Previous studies have found that still images of a dy-
namic action are more difcult for the viewer to correctly
analyze. A xed representation of a facial expression can
remove many of the cues for interpretation of that
expression.
14
As the panel members suggested, they
preferred to see the entire range of the smile because it
gave them signicantly more information than did the
still images. Certainly, as Bruner and Tagiuri
15
main-
tained, a millisecond of exposure surely cannot represent
clinical observations.
Unlike past studies of facial esthetics, we attempted
to specically address the diagnostic value of obtaining
videographic records of the smile. Few studies have
touched on the smile as a dynamic action; however,
for the most part, it has been in relation to dental
and gingival display at maximum smile. Their focus
was a xed point at the height of the smile.
1,2,16,17
Studies in the plastic and reconstructive surgery
literature have evaluated smile dynamics and the
soft-tissue changes that occur when the face moves
from rest to maximum smile.
3-5
These studies do
recognize the value of closely evaluating the smile as
a dynamic action.
The video footage seemed to provide a reliable repre-
sentation of the subjects level of comfort during the
photographic or videographic sessions. In several in-
stances, the still image shown to the panel members ap-
peared to depict a relaxed person giving a relaxed smile.
However, when the video footage of this same smile was
viewed, it became obvious that the person was not at all
Walder et al 799
American Journal of Orthodontics and Dentofacial Orthopedics December 2013 Vol 144 Issue 6
comfortable, and the smile was forced. Videography
might give practitioners insight into how patients feel
about their appearance or smile that can be missed in
a hectic clinical examination or the still photographs
taken by auxiliary staff.
The panel members were less likely to select the spon-
taneous smile when the images were cropped, removing
all other cues of facial expression. Duchenne
18
described
the use of 2 facial muscles to distinguish a deliberate
smile from a spontaneous smile: The rst (zygomatic
major) obeys the will but the second (orbicularis oculi)
is only put in play by the sweet emotions of the soul;
the .fake joy, deceitful laugh, cannot provoke the
contraction of the latter muscle. In 1980, Ekman
et al
10
conrmed Duchennes observations, nding
that most people cannot voluntarily contract the outer
portion of the orbicularis oculi and thus do not exhibit
this action in a deliberate smile.
A signicant aim of this study was to begin to ne-
tune our methods of eliciting and capturing smiles.
Two behavioral patterns recognized in this study are
worthy of discussion: (1) variations in response to the
verbal and visual cues, and (2) sex differences in eliciting
a posed smile. Although these ndings were not specif-
ically pinpointed in this study, they are of interest to
practitioners because they might help to better elicit
smiles from patients.
The principal investigator (J.F.W.) observed that 45%
of the subjects responded more easily to the verbal com-
mand, whereas only 18% seemed to smile more readily
when shown the visual cue. The remainder had no pref-
erences. The visual cue appeared to be confusing for
many subjects. When the investigator provided the visual
cue, several subjects asked What do you mean? or Do
you want me to imitate the smiles? A fewothers needed
to hear the instructions again. Studies have found indi-
vidual variations in the responses to verbal and visual
cues.
19
Perhaps it would be benecial to provide both
verbal and visual commands.
It was harder to elicit a posed smile from the men
than fromthe women. Five of the 11 men (45%) had dif-
culty smiling on command, but only 1 of the 11 women
(9%) had difculty responding to the command. A sub-
ject was considered to have difculty smiling on com-
mand if he or she did not respond with a facial
expression that resembled a smile or did not appear to
respond at all to the command as judged by the principal
investigator and another impartial observer. The average
length of the video footage used to capture the smiles of
the men (65 seconds; range, 45-90 seconds) was longer
than the average length of the video footage needed for
the women (49 seconds; range, 35-65 seconds). Part of
this discrepancy might be because all sessions were
directed by and all images were photographed by a
women (J.F.W.); thus, the men might have felt more in-
hibited to respond than did the women. Interestingly,
although it took the men longer to smile, there was no
difference in the number of male subjects (7 of 11)
compared with the female subjects (7 of 11) who showed
a spontaneous smile in the video footage. This would
seem to imply that men might not necessarily smile
less frequently than women in all situations, but they
might be less able to pretend to smile.
20-22
CONCLUSIONS
This study emphasizes the need to continue to inves-
tigate and standardize the methods of eliciting and
recording a smile of diagnostic quality. The following
are our specic conclusions.
1. Posed smiles can be reliably reproduced as measured
objectively, but, subjectively, differences were noted.
2. When the entire face is visible, practitioners can
detect important differences between posed and
spontaneous smiles. However, this ability is
decreased when only the smile is shown.
3. Spontaneous smiles are preferred to posed smiles by
professional diagnosticians.
4. Videography provides diagnostic information that
cannot be obtained with still photography alone.
5. Video images are preferred to still images by profes-
sional diagnosticians.
ACKNOWLEDGMENTS
We thank Graham Walker for his guidance and assis-
tance; Hugh Gilmore for his video-editing wizardry; and
the highly perceptive panel members for their enthusiasm
and remarkable attention to detail.
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