ORIGINAL ARTICLE

Perceptions of orthodontists, laypersons,

and patients regarding buccal corridors
and facial types
Yingyi Huang, Yili Xu, Fan Liu, Jiaqian Fan, Murong Li, and Yonghua Lei
Changsha, China

Introduction: The space on each side of the mouth, between the commissure of the mouth and the buccal sur-
face of the last visible tooth, is called the buccal corridor. The size of the buccal corridor can affect perceptions of
facial esthetics. We analyzed the perceptions of orthodontists, laypersons, and orthodontic patients regarding
the size of buccal corridors in people with brachyfacial, mesofacial, and dolichofacial types. Methods: Photo-
graphs of 1 male and 1 female model were modified digitally into brachyfacial, mesofacial, and dolichofacial
types. Each facial type was further modified to create 5 sizes of buccal corridors. Orthodontists, adult orthodontic
patients, and laypersons were invited to rate the photographs. Results: Orthodontists rated lower than the other
groups of raters when they evaluated the female model with the buccal corridors of 20% (P \0.05). Laypersons
could not distinguish the changes of the buccal corridors when evaluating the male model with brachyfacial and
mesofacial (P .0.05). Orthodontic patients rated significantly higher than the orthodontists and the laypersons
when evaluating the dolichofacial type of both models (P \0.05). Conclusions: Orthodontists are more sensi-
tive to the buccal corridors than are orthodontic patients and laypersons. It is only necessary to consider elim-
inating the patient’s buccal corridors when the buccal corridor area ratio is over 15%. (Am J Orthod
Dentofacial Orthop 2021;-:---)

F
acial esthetics has always been the goal of ortho- of buccal corridors is critical to the esthetic value of a
dontists and patients, and the smile plays an smile.3,4,8-10
important role in the evaluation of facial esthetics. The majority of studies used the buccal corridor linear
The buccal corridor is the bilateral space between the ratio (BCLR) to indicate the size of the buccal corri-
commissure of the mouth and the buccal surface of dors.11,12 BCLR is the percentage of the sum of the dis-
the last visible tooth. These spaces are very important tance buccal corridors width to the distance of the
for smile esthetics, especially when a person smiles. corners of the lips, which is convenient for researchers
Frush and Fisher1 stated that the absence of buccal cor- to calculate.8 However, Yang et al9 stated that 2-
ridors leads to an unnatural appearance. Moore et al2 dimensional area index buccal corridor area ratio
found that the smaller the buccal corridor, the more (BCAR), the ratio of the sum of bilateral buccal corridors
attractive the smile. Several studies reported that mini- area to the total smiling area, is more accurate than the
mal or excessive buccal corridors would affect the es- 1-dimensional linear index of BCLR because the buccal
thetics of a smile.3,4 Although a few researchers say corridors are 2-dimensional on frontal view. Thus
that buccal corridors make no difference to the evalua- BCAR is used more frequently among orthodontists
tion of smiles,5-7 most researchers claim that the size nowadays.7,13,14
Several researchers only focused on the lower-face
view when evaluating the buccal corridors.5,11,15,16
Department of Orthodontics and Prosthodontics, Center of Stomatology, Xian- However, such local and limited evaluation may lose
gya Hospital, Central South University, Changsha, China. their spatial relevance of the entire face in the macroes-
All authors have completed and submitted the ICMJE Form for Disclosure of thetic, miniesthetic, and microesthetic of facial ele-
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Yonghua Lei, Department of Orthodontics and Pros- ments.4 Woods et al17 stated that full-face view
thodontics, Center of Stomatology, Xiangya Hospital, Central South University, provides the raters to evaluating the smile in a natural
87 Xiangya Road, Changsha 410008, China; e-mail, [email protected]. way because people assess the smile in public naturally
Submitted, December 2019; revised, May 2020; accepted, June 2020.
0889-5406/$36.00 with the view of the whole face, including facial type,
Ó 2021. position and color of eyes, and even hairstyle in daily
https://doi.org/10.1016/j.ajodo.2020.06.051

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life. It is known that the assessment of buccal corridors in a random order, and the presentation time for each
differs on evaluating full faces and lower faces.18,19 photograph was 12 seconds; in the second stage, the
Patient-driven treatment planning has gradually photographs with the same BCAR were grouped in 1
become the mainstream of orthodontic treatment.8 Or- slide, totaling 5 slides numbered from 16 to 20. The or-
thodontic patients have more requirements for esthetics der of slideshow was 10%, 20%, 1%, 5%, and 15%, and
than the laypersons without orthodontic treatment the presentation time was 45 seconds per slide. The pre-
need.20 If the esthetic perceptions of orthodontists and sentation of the male model was displayed after the fe-
patients are not congruent, the orthodontic result may male model’s presentation. The slide transition effect
not be accepted by the patient even if the patient’s oc- “Drape” was set between slides. The raters could not re-
clusion function has improved.21 Therefore, it is impor- turn to the previous slide during the entire process of
tant for orthodontists to consider the esthetic perception assessment.
of patients when determining treatment plans. However, A visual analog scale (VAS) with 10 cm was used to
no report has compared the perception of buccal corri- assess attractiveness. It was anchored on the left at
dors in different facial types between orthodontists very unattractive and on the right at very attractive.
and orthodontic patients. Laypersons without esthetic The raters could mark the score anywhere in the line
backgrounds were selected by most of the researchers segment. The score was the length from the leftmost
because they are potential consumers.11 end of the line segment to the marker point, and the
We evaluated the esthetic perceptions of orthodon- score range was 0-10 points.
tists, laypersons, and orthodontic patients regarding Sixty orthodontists (13 males, 47 females; mean age,
the buccal corridor size in brachyfacial type, mesofacial 29.33 6 5.46), 60 laypersons (30 males, 30 females;
type, and dolichofacial type to provide some references mean age, 23.03 6 3.19) and 60 orthodontic patients
for the treatment design for orthodontists. (30 males, 30 females; mean age, 24.07 6 3.38) were
invited to evaluate the attractiveness of the photographs
MATERIAL AND METHODS by VAS after VAS usage training. In the second stage, the
A female and a male model were selected with facial raters were required to answer whether they could distin-
convexity between 165
and 175
, with individual guish the differences between photographs and to
normal occlusion, ideal smile arc, ideal smile line, and choose their favorite and least favorite photograph in
healthy periodontal situation (Fig 1). Two models were each slide.
taken from full-face photographs, which were digitally
modified and then used for this research. Both models Statistical analysis
signed informed consent. VAS has been primely used for pain research, and the
The initial front view, front view of the smile, and ranges of minimum clinically significant difference were
lateral view for each model were taken after smile from 0.5 cm to 1.3 cm for a 10 cm scale.25-29 Most
training. According to the method of Pithon,22 the front researchers concluded that 1 cm on a 10 cm for VAS is
views of smiles of 2 models were digitally modified by the minimum significant difference for pain
photograph editing software (Adobe Photoshop CC evaluation28,29 and Zange et al30 applied 1 cm as a min-
version 16.0; Adobe Systems, San Jose, Calif) which imal difference on a 10 cm for VAS in sample size calcu-
was used to remove the slight imperfections that might lation for buccal corridors assessment. Therefore, we
influence the evaluation of facial attractiveness. Accord- also used 1 cm as a significant difference in sample
ing to facial index (FI),23,24 the front view of smile was size calculation.
modified into brachyfacial type (FI, 80%), mesofacial Before our main study, our pilot study of 10 ortho-
type (FI, 87%), and dolichofacial type (FI, 94%). Pen dontists estimated the standard deviation of the VAS
tool was used to outline the smile area and buccal scores at 1.65 cm. The effect size for noticing a differ-
corridor on both sides, and the corresponding pixel ence between groups of 1 cm is 1/1.655 0.606. Using
number was recorded as the area of the region. Five sizes G*Power program (version 3.0 for Windows; Institute
of buccal corridors (BCAR 1%, 5%, 10%, 15%, and 20%) of Experimental Psychology, Heinrich Heine University,
were modified for each facial type, and a series of 15 D€usseldorf, Germany),31 we estimate a required sample
different smiles for each model were produced (Fig 2). size for a t test of a 2-group comparison at for
The photographs of each model were shown sepa- a 5 0.05 and power 5 0.85 at 40 persons per group.
rately by means of PowerPoint software (Microsoft, Red- For an analysis of variance (ANOVA)-based omnibus F
mond, Wash). The presentation was divided into 2 test of a 3-group comparison, we assume the means
stages: in the first stage, 15 photographs were shown are distributed 1 cm apart in a pattern of 4, 5, and

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Huang et al 3

Fig 1. The initial front view, front view of smile, and lateral view of the female and male models.

Fig 2. A, Set of 15 different pictures of the female model in brachyfacial, mesofacial, dolichofacial type.
BCAR from left to right is 1%, 5%, 10%, 15%, and 20%. B, Set of 15 different pictures of the male model in
brachyfacial, mesofacial, dolichofacial type. BCAR from left to right is 1%, 5%, 10%, 15%, and 20%.

6 cm. Given a standard deviation of 1.65 and equal raters, 5 different BCAR percentages in the photo-
group size, the effect size is 0.495, and the required sam- graphs, 3 facial types, male vs female model, and
ple size for a 5 0.05 and power 5 0.85 is 16 per group. gender of the rater. This report will focus on compar-
Because the number of comparisons between the 3 pri- isons according to rater group, BCAR, facial type, and
mary groups—orthodontists, laypersons, and orthodon- male vs female models. The primary results of interest
tics patients—is quite large, we increase the sample size are differences and similarities of the esthetic judg-
to 60 to adjust for multiple comparisons. Our sample ments of orthodontists, laypersons, and orthodontic
size estimates are only approximate because they are patients in responding to variations in BCAR and
based on the ANOVA model, which assumes normality facial type.
in the distributions of VAS scores, whereas we test our Scores were recorded in Excel (Microsoft) and sub-
main comparisons using nonparametric methods: mitted to SPSS software (version 23.0; IBM, Armonk,
Kruskal-Wallis for 3-group comparisons and Mann- NY) for statistical analysis. A chi-square test was used
Whitney U for 2-group comparisons. to compare the frequencies of the responses given by
The design of our study allows comparisons of VAS the raters regarding their perceptions and preferences.
scores by several ways of classification: 3 groups of Fisher exact test was used if the data of the expected

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Table I. Median and IQR of the scores given by orthodontists, laypersons, and orthodontic patients
Female model Male model

BCAR Facial type Rater group Median IQR P Median IQR P

1% Brachyfacial Orthodontists 5.56 2.72 0.800 5.51 2.67 0.148
Laypersons 5.65 1.99 4.51 2.62
Orthodontic patients 5.25 2.59 5.11 2.60
Mesofacial Orthodontists 5.75 2.05 0.792 6.35y 2.09 0.001*
Laypersons 6.04 1.83 5.43y 2.38
Orthodontic patients 5.90 1.63 6.48y 2.05
Dolichofacial Orthodontists 5.33y 2.03 0.046* 5.17y 1.83 \0.001*
Laypersons 5.48y 1.69 4.52y 2.24
Orthodontic patients 4.75y 2.38 5.83y 2.19
5% Brachyfacial Orthodontists 5.83 2.72 0.786 5.08y 2.28 0.003*
Laypersons 6.00 1.81 4.15y 2.40
Orthodontic patients 5.85 2.05 5.23y 2.45
Mesofacial Orthodontists 6.14y 2.01 0.010* 6.44y 2.14 0.023*
Laypersons 5.96y 1.87 5.18y 2.85
Orthodontic patients 6.61y 1.49 5.96y 2.52
Dolichofacial Orthodontists 5.55 2.02 0.097 5.67y 2.44 0.002*
Laypersons 5.90 2.25 4.81y 3.10
Orthodontic patients 4.81 2.20 6.51y 2.51
10% Brachyfacial Orthodontists 5.59 2.22 0.695 5.00 1.81 0.094
Laypersons 5.69 2.03 4.56 2.02
Orthodontic patients 5.50 1.71 5.11 1.93
Mesofacial Orthodontists 5.21y 1.96 0.009* 6.00y 1.85 0.002*
Laypersons 5.47y 1.61 4.95y 2.44
Orthodontic patients 4.51y 1.76 6.16y 1.70
Dolichofacial Orthodontists 4.91y 1.94 0.022* 5.23 2.76 0.456
Laypersons 5.25y 2.45 5.13 2.69
Orthodontic patients 5.52y 1.85 5.62 2.26
15% Brachyfacial Orthodontists 4.51 2.48 0.175 4.21 2.02 0.181
Laypersons 5.10 1.55 4.34 2.38
Orthodontic patients 4.60 1.58 4.84 2.93
Mesofacial Orthodontists 4.70 2.34 0.111 4.75y 2.38 0.022*
Laypersons 5.32 2.08 4.55y 2.70
Orthodontic patients 4.72 1.75 5.51y 2.52
Dolichofacial Orthodontists 4.00y 2.98 0.012* 5.02y 2.33 0.003*
Laypersons 4.56y 2.32 4.63y 2.69
Orthodontic patients 5.05y 2.13 5.52y 2.25
20% Brachyfacial Orthodontists 3.93y 2.79 0.043* 4.01 2.23 0.392
Laypersons 4.88y 2.06 4.05 2.24
Orthodontic patients 4.43y 1.50 4.41 2.32
Mesofacial Orthodontists 3.83y 2.76 0.022* 4.78 2.31 0.578
Laypersons 4.79y 2.22 4.38 2.68
Orthodontic patients 4.56y 1.83 5.00 2.21
Dolichofacial Orthodontists 3.99y 2.89 0.017* 4.04y 2.68 \0.001*
Laypersons 4.22y 1.57 3.96y 2.67
Orthodontic patients 4.76y 2.41 5.00y 2.55

IQR, Interquartile range.

*Significantly different (P \0.05); yValues in the same picture evaluation with different superscript letters are significantly different.

frequency \5 were .20% of the total. The level of orthodontists preferred 1%-10% buccal corridors on the
significance was set at 5%. female model with brachyfacial and dolichofacial and on
the male model with brachyfacial and mesofacial, and
RESULTS 1%-5% buccal corridors on the female model with mes-
The median values and ranges of the scores given by ofacial. They were unable to differentiate the degrees of
3 groups of raters are shown in Table I and Figure 3. The buccal corridors on the male model with dolichofacial

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Huang et al 5

Fig 3. Median values and ranges of the scores given by 3 groups of raters for brachyfacial, mesofacial,
and dolichofacial type of both the female and male model with each buccal corridor. *Scores were
significantly different among all levels of buccal corridors in the same facial type.

except when the corridor was 20% (Fig 3, A and B). The distinguish the degrees of buccal corridors on the male
laypersons preferred 1%-5% buccal corridors on the fe- model with brachyfacial and mesofacial (Fig 3, D).
male model with mesofacial and dolichofacial, 1%-10% When the orthodontic patients judged the female model,
buccal corridors on the female model with brachyfacial, they preferred brachyfacial with 1%-5% buccal corri-
and 5%-10% buccal corridors on the male model with dors, mesofacial with 5% buccal corridors, and dolicho-
dolichofacial (Fig 3, C and D). They were unable to facial with 10% buccal corridors more attractive

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(Fig 3, E). When they judged the male model, they freedom and minimal restrictions.7,8 This technique is
preferred dolichofacial with 1%-5% buccal corridors widely used in studies for esthetic assessment.11,33
and mesofacial with 1%-10% buccal corridors, but could In our study, there is no significant difference be-
not differentiate the degrees of buccal corridors in bra- tween the ratings of orthodontists and laypersons
chyfacial except when the corridor was 20% (Fig 3, F). when evaluating the female model except for 20%
For the female model, there was an agreement with buccal corridors in brachyfacial and mesofacial. The
respect to VAS ratings in all patients of the brachyfacial scores of 3 groups decreased as the buccal corridors
type regardless of BCAR. There were significant differ- became large, but the ratings of orthodontists decreased
ences among the scores given by 3 groups of raters more when the buccal corridor was 20%. The percep-
about brachyfacial with 20% buccal corridors, mesofa- tions of orthodontists and laypersons for the female
cial with 5%, 10%, and 20% buccal corridors, and doli- model are similar, but orthodontists have a higher sensi-
chofacial with 1%, 10%, 15%, and 20% buccal corridors tivity to the change of the buccal corridors. The large
(Table I). As for the male model, there are agreements buccal corridor seems not to be a very important factor
between the raters in 4 of 5 ratings of the brachyfacial in the smile attractiveness evaluation for laypersons
type. The 3 groups of raters differed in their judgment and orthodontic patients. Orthodontists paid more
about the brachyfacial with 5% buccal corridors, meso- attention to the smile and buccal corridors during overall
facial with 1%-15% buccal corridors, and dolichofacial facial evaluation than laypersons and orthodontic pa-
with 1%, 5%, 15%, and 20% buccal corridors (Table I). tients, most likely because of their professionalism and
Most raters were able to perceive the differences high sensitivity to esthetics. This result corroborates
among the photographs in relation to BCAR, and no sig- the findings described by some researchers.7,33 However,
nificant difference was observed among 3 groups of this is not consistent with the results of some previous
raters (Tables II and III). The percentages of favorite studies that have shown no difference in the perceptions
and least favorite photographs were significantly of orthodontists and laypersons.15,32
different among the 3 groups of raters in 10% buccal Orthodontists prefer the mesofacial type, but there is
corridors of the female model (Table II) and 20% buccal a tendency that as BCAR increased, their ratings for the
corridors of the male model (Table III). There is a ten- brachyfacial type increased, and their ratings for the do-
dency for orthodontists that the proportion of like bra- lichofacial type decreased. This demonstrated that the
chyfacial most increased and the proportion of like increase of the buccal corridor area has a less negative
dolichofacial most decreased when BCAR $15%, but influence on a person with brachyfacial type than with
no significant difference was found (Tables II and III). dolichofacial type. Moreover, a person with mesofacial
type seems to be able to better tolerate the changes of
DISCUSSION buccal corridors. This result is consistent with the result
Facial attractiveness in a full-face view is very impor- found by Meyer et al.7
tant for facial esthetics. It is possible that facial attrac- Laypersons could distinguish the changes of the fe-
tiveness dilutes the importance of the smile esthetics, male model’s buccal corridors but could not perceive
so controlling the background attractiveness of the the changes of the male model’s buccal corridors and
face to avoid bias should be considered. In the present tended to rate the male model low. When laypersons
study, we used Photoshop software to modify the facial evaluated the male model, as the buccal corridor
type and buccal corridors to control the variables and increased, their ratings decreased unless in brachyfacial
achieve the precision that can not be achieved by con- and mesofacial types. This implies that the increasing
ventional clinical photography.32 FI of 80% for brachy- buccal corridors in the male model have a negligible ef-
facial type, FI of 87% for mesofacial type, and FI of 94% fect on the esthetic evaluation of laypersons. The rea-
for the dolichofacial type were chosen to make the dif- sons may lie in that the buccal corridors of men are
ferences among the facial types more obvious. naturally larger than women,34,35 so the negative impact
Using a slide presentation to submit the photographs that large buccal corridors brought on men with dolicho-
could obtain a large number of ratings in a short time.2 facial type is diluted. However, Gul-e et al36 and Oshagh3
To avoid carry-over in the ratings of the different photo- stated that laypersons preferred smaller buccal corridors
graphs, the slide transition can eliminate the raters’ of men and larger buccal corridors of women, which are
impression of the previous photograph. Raters were inconsistent with the results of this study. The reason
not allowed to review the previous photographs.7,21,24 why researchers disagree on whether laypersons
The scoring line segment of VAS enables raters to ex- can3,16,37 distinguish the changes of the buccal corridors
press their response style in a line manner with more or not30 may relate to the gender of the model.38,39

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Huang et al 7

Table II. Perception of 3 groups of raters regarding differences and their preferences of the female model in relation
to BCAR
Female model

BCAR Replies Orthodontists Laypersons Patients P

1% BCAR Perceive differences 0.162y
Yes 59 (98.3) 57 (95.0) 54 (90.0)
No 1 (1.7) 3 (5.0) 6 (10.0)
Favorite photograph 0.526z
Brachyfacial type 16 (27.1) 17 (29.8) 10 (18.5)
Mesofacial type 37 (62.7) 32 (56.1) 34 (63.0)
Dolichofacial type 6 (10.2) 8 (14.0) 10 (18.5)
Least favorite photograph 0.339y
Brachyfacial type 18 (30.5) 19 (33.3) 24 (44.4)
Mesofacial type 1 (1.7) 3 (5.3) 3 (5.6)
Dolichofacial type 40 (67.8) 35 (61.4) 27 (50.0)
5%BCAR Perceive differences 0.390y
Yes 58 (96.7) 57 (95.0) 54 (90.0)
No 2 (3.3) 3 (5.0) 6 (10.0)
Favorite photograph 0.224z
Brachyfacial type 13 (22.4) 20 (35.1) 19 (35.2)
Mesofacial type 38 (65.5) 26 (45.6) 29 (53.7)
Dolichofacial type 7 (12.1) 11 (19.3) 6 (11.1)
Least favorite photograph 0.852y
Brachyfacial type 17 (29.3) 17 (29.8) 20 (37.0)
Mesofacial type 3 (5.2) 4 (7.90) 2 (3.7)
Dolichofacial type 38 (65.5) 36 (63.2) 32 (59.3)
10% BCAR Perceive differences 0.072y
Yes 60 (100.0) 58 (96.7) 55 (91.7)
No 0 (0.0) 2 (3.3) 5 (8.3)
Favorite photograph 0.033*,z
Brachyfacial type 11 (18.3) 22 (37.9) 12 (21.8)
Mesofacial type 43 (71.7) 28 (48.3) 31 (56.4)
Dolichofacial type 6 (10.0) 8 (13.8) 12 (21.8)
Least favorite photograph 0.023*,y
Brachyfacial type 22 (36.7) 17 (29.3) 24 (43.6)
Mesofacial type 0 (0.0) 3 (5.17) 6 (10.9)
Dolichofacial type 38 (63.3) 38 (65.5) 25 (45.5)
15% BCAR Perceive differences 0.537y
Yes 59 (98.3) 57 (95.0) 56 (93.3)
No 1 (1.7) 3 (5.0) 4 (6.67)
Favorite photograph 0.849z
Brachyfacial type 18 (30.5) 21 (38.8) 18 (32.1)
Mesofacial type 31 (52.5) 30 (52.6) 31 (55.4)
Dolichofacial type 10 (17.0) 6 (10.5) 7 (12.5)
Least favorite photograph 0.329y
Brachyfacial type 10 (32.2) 13 (22.8) 22 (39.3)
Mesofacial type 3 (5.2) 5 (8.8) 5 (8.9)
Dolichofacial type 37 (62.7) 39 (68.4) 29 (51.79)
20% BCAR Perceive differences 0.390y
Yes 58 (96.7) 57 (95.0) 54 (90.0)
No 2 (3.3) 3 (5.0) 6 (10.0)
Favorite photograph 0.434z
Brachyfacial type 21 (36.2) 21 (36.8) 14 (25.9)
Mesofacial type 33 (56.9) 30 (52.6) 31 (57.4)
Dolichofacial type 4 (6.9) 6 (10.5) 9 (16.7)
Least favorite photograph 0.074y
Brachyfacial type 12 (20.7) 14 (24.6) 23 (42.6)
Mesofacial type 5 (8.6) 2 (3.5) 3 (5.6)
Dolichofacial type 41 (70.7) 41 (71.9) 28 (51.9)

Note. Patients were orthodontic patients. Values are n (%).

*Significantly different (P \0.05); yFisher exact test; zChi-square test.

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Table III. Perception of 3 groups of raters regarding differences and preferences of the male model in relation to BCAR
Female model

BCAR Replies Orthodontists Laypersons Patients P

1% BCAR Perceive differences 0.507y
Yes 58 (96.7) 59 (98.3) 56 (93.3)
No 2 (3.3) 1 (1.7) 4 (6.7)
Favorite photograph 0.370z
Brachyfacial type 4 (6.9) 6 (10.2) 5 (8.9)
Mesofacial type 41 (70.7) 38 (64.4) 30 (53.6)
Dolichofacial type 13 (22.4) 15 (25.4) 21 (37.5)
Least favorite photograph 0.061y
Brachyfacial type 40 (69.0) 31 (52.5) 38 (67.9)
Mesofacial type 1 (1.7) 2 (3.4) 5 (8.9)
Dolichofacial type 17 (29.3) 26 (44.1) 13 (23.2)
5% BCAR Perceive differences 0.513y
Yes 58 (96.7) 58 (96.7) 55 (91.7)
No 2 (3.3) 2 (3.3) 5 (8.3)
Favorite photograph 0.140z
Brachyfacial type 3 (5.2) 4 (6.9) 9 (16.4)
Mesofacial type 43 (74.1) 40 (69.0) 30 (54.6)
Dolichofacial type 12 (20.7) 14 (24.1) 16 (29.1)
Least favorite photograph 0.338y
Brachyfacial type 34 (58.6) 28 (48.3) 35 (63.6)
Mesofacial type 1 (1.7) 2 (3.5) 3 (5.5)
Dolichofacial type 23 (39.7) 28 (48.3) 17 (30.9)
10% BCAR Perceive differences 0.507y
Yes 58 (96.7) 59 (98.3) 56 (93.3)
No 2 (3.3) 1 (1.7) 4 (6.7)
Favorite photograph 0.057y
Brachyfacial type 3 (5.2) 7 (11.9) 3 (5.4)
Mesofacial type 46 (79.3) 35 (59.3) 33 (58.9)
Dolichofacial type 9 (15.5) 17 (28.8) 20 (35.7)
Least favorite photograph 0.061z
Brachyfacial type 35 (60.4) 32 (54.2) 42 (75.0)
Mesofacial type 0 (0.0) 0 (0.0) 0 (0.0)
Dolichofacial type 23 (39.6) 27 (45.8) 14 (25.0)
15% BCAR Perceive differences 0.910y
Yes 58 (96.7) 57 (95.0) 56 (93.3)
No 2 (3.3) 3 (5.0) 4 (6.7)
Favorite photograph 0.455z
Brachyfacial type 9 (15.5) 6 (10.5) 7 (12.5)
Mesofacial type 38 (65.5) 36 (63.2) 31 (55.4)
Dolichofacial type 10 (17.2) 15 (26.3) 18 (32.1)
Least favorite photograph 0.716y
Brachyfacial type 35 (60.3) 29 (50.9) 33 (58.9)
Mesofacial type 2 (3.5) 3 (5.3) 4 (4.1)
Dolichofacial type 20 (34.5) 25 (43.9) 19 (33.9)
20% BCAR Perceive differences 1.000y
Yes 58 (96.7) 57 (95.0) 57 (95.0)
No 2 (3.3) 3 (5.0) 3 (5.0)
Favorite photograph 0.032*,z
Brachyfacial type 10 (17.2) 12 (21.1) 4 (7.0)
Mesofacial type 42 (72.4) 34 (59.7) 37 (64.9)
Dolichofacial type 5 (8.62) 11 (19.3) 16 (28.1)
Least favorite photograph 0.028*,y
Brachyfacial type 30 (51.7) 25 (43.9) 37 (64.9)
Mesofacial type 2 (3.5) 0 (0.0) 3 (5.3)
Dolichofacial type 25 (43.1%) 32 (56.1) 17 (29.8)

Note. Patients were orthodontic patients. Values are n (%).

*Significantly different (P \0.05); yFisher exact test; zChi-square test.

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Huang et al 9

For orthodontic patients, they gave the highest scores in pain study at first, and the minimal significant differ-
to BCAR within 1%-10% in all facial types for both ence on a standard 10 cm scale had been determined by
models except for the brachyfacial type in the male many researchers even though the value varied from
model. This indicates that the orthodontic patients are researcher to researcher slightly.25-29 However, this
more sensitive to the buccal corridors than the layper- value in esthetic assessment has not been determined.
sons, who are unable to distinguish the buccal corridors Some researchers used 1 cm30 or 1.5 cm8,10 as a minimal
changes of the male model. significant difference in buccal corridor study by refer-
Orthodontic patients made significantly higher rat- ring to the pain research. In the present study, we found
ings than orthodontists and laypersons when evaluating our raters conservative. During the ratings, the differ-
the dolichofacial type of both models. This may imply ence between the photographs could be perceived by
that orthodontic patients are more tolerant of dolichofa- the raters, but the scores were not changed so much,
cial type than the other 2 groups of raters. The increase and the differences between 2 groups which were statis-
in the buccal corridors area did affect the orthodontic tically significant in our results, were not always larger
patients’ esthetic evaluation for dolichofacial type, but than 1 cm. In addition, the buccal corridor is a minies-
they are more tolerant of large buccal corridors in doli- thetic feature of the smile, and its changes were diluted
chofacial than the other 2 groups of raters because of in a full-face view. Therefore, it is reasonable to assume
their preference for the dolichofacial type. da Silva Gou- that the minimum significant difference in VAS esthetic
lart et al24 reported that the dolichofacial type of face scores may \1 cm. In contrast, cultural background or
was considered acceptable or pleasant by the raters. In ethnicity may influence the determination of the mini-
contrast, the facial type is classified as a macroesthetic mal significant difference in VAS,26 and orthodontists,
feature of the face, which has a far greater impact on laypersons, and orthodontic patients may also have
facial esthetics than buccal corridors. Under the influ- different minimal significant differences in buccal
ence of the facial type, it is understandable that the or- corridor assessment. This is an interesting area for future
thodontic patients rated higher than the other 2 groups study, and once the minimal significant differences of
when evaluating large buccal corridors on dolichofacial. orthodontists, laypersons, and orthodontic patients are
The significant differences in the proportion of prefer- determined, our results and the previous findings could
ences among the 3 groups of raters strengthen our be more convincing.
conclusion that the orthodontic patients preferred the Our sample size estimates are only approximate
dolichofacial type. because we calculated them on the basis of the ANOVA
The size of buccal corridors can be controlled by ad- model. To adjust for multiple comparisons, we increase
justing the position of the buccal surfaces of the poste- the sample size from 16 to 60 per group. Nevertheless,
rior maxillary teeth,40 smile training,41 orthodontic or our comparisons might be underpowered because we
surgical expansion of the maxilla.2,30,35 For patients used nonparametric methods for most comparisons,
with moderate dental crowding, orthodontists usually whereas sample sizes were calculated on the basis of
choose arch expansion, molar distalization, or extrac- parametric methods.
tion. Choosing arch expansion to reduce the buccal cor- In the findings from the second stage, the preferences
ridors for better esthetics if the patient’s buccal corridors of orthodontists, laypersons, and orthodontic patients
are large (BCAR $15%) is suggested by our data. If the significantly differed only in 10% BCAR of the female
patient’s BCAR #10%, orthodontists can ignore the ef- model and 20% BCAR of the male model. Another lim-
fect of buccal corridors on the esthetics of the patient’s itation of this study is that the number of male and fe-
smile. male raters in each group may not be sufficient for
Most researchers focus on the perception of ortho- gender comparisons. Most of our results of gender com-
dontists and laypersons in smile attractiveness assess- parisons are nonsignificant except for a few examples,
ment,7,11,42 failing to pay attention to the perception which are probably chance findings, but there is a ten-
of orthodontic patients. However, the opinions of ortho- dency for laypersons to rate lower for the opposite sex
dontic patients are precisely the ones that need to be model. Further study is suggested inviting adequate
considered most. The perception of orthodontic patients raters with equal numbers of men and women for gender
still needs further research on the esthetics of buccal cor- comparisons.
ridors in different facial types. Another factor that may influence the raters’ evalua-
This study has some limitations that should be tion is that 2 models in our study have not received pre-
considered in interpreting the results. The 1 cm differ- vious orthodontic treatment so their torque of teeth may
ence we used in the sample size calculation may not not be the same. It is reported that buccolingual inclina-
be a minimal significant difference. The VAS was used tions of maxillary canines and premolars could affect

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10 Huang et al

smile attractiveness.43 Therefore, considering the influ- 7. Meyer AH, Woods MG, Manton DJ. Maxillary arch width and
ence that the torque of teeth might bring to the smile buccal corridor changes with orthodontic treatment. Part 2: attrac-
tiveness of the frontal facial smile in extraction and nonextraction
is suggested in subsequent studies involving buccal
outcomes. Am J Orthod Dentofacial Orthop 2014;145:296-304.
corridor assessment. 8. Ioi H, Kang S, Shimomura T, Kim SS, Park SB, Son WS, et al. Effects
of buccal corridors on smile esthetics in Japanese and Korean or-
CONCLUSIONS thodontists and orthodontic patients. Am J Orthod Dentofacial Or-
thop 2012;142:459-65.
On the basis of the findings of this study, the 9. Yang IH, Nahm DS, Baek SH. Which hard and soft tissue factors
following conclusions were drawn: relate with the amount of buccal corridor space during smiling?
Angle Orthod 2008;78:5-11.
1. Orthodontists are more sensitive to the buccal corri- 10. Parekh SM, Fields HW, Beck M, Rosenstiel S. Attractiveness of var-
dors than orthodontic patients and laypersons. iations in the smile arc and buccal corridor space as judged by or-
2. Orthodontic patients are more sensitive to the thodontists and laymen. Angle Orthod 2006;76:557-63.
buccal corridors than the laypersons, and their toler- 11. Cheng HC, Wang YC. Effect of nonextraction and extraction ortho-
dontic treatments on smile esthetics for different malocclusions.
ance for the dolichofacial type of face with large
Am J Orthod Dentofacial Orthop 2018;153:81-6.
buccal corridors is higher than the orthodontists 12. Cheng HC, Cheng PC. Factors affecting smile esthetics in adults
and the laypersons. with different types of anterior overjet malocclusion. Korean J Or-
3. It is only necessary for the orthodontists to consider thod 2017;47:31-8.
reducing the patients’ buccal corridors when the pa- 13. Meyer AH, Woods MG, Manton DJ. Maxillary arch width and
buccal corridor changes with orthodontic treatment. Part 1: differ-
tients’ BCAR is $15%.
ences between premolar extraction and nonextraction treatment
outcomes. Am J Orthod Dentofacial Orthop 2014;145:207-16.
14. Shook C, Kim SM, Burnheimer J. Maxillary arch width and buccal
AUTHOR CREDIT STATEMENT
corridor changes with Damon and conventional brackets: a retro-
Yingyi Huang contributed to conceptualization, spective analysis. Angle Orthod 2016;86:655-60.
methodology, investigation, and original draft prepara- 15. Krishnan V, Daniel ST, Lazar D, Asok A. Characterization of posed
smile by using visual analog scale, smile arc, buccal corridor mea-
tion; Yili Xu contributed to data curation, and manu- sures, and modified smile index. Am J Orthod Dentofacial Orthop
script review and editing; Fan Liu contributed to 2008;133:515-23.
resources and visualization; Jiaqian Fan contributed to 16. Abu Alhaija ES, Al-Shamsi NO, Al-Khateeb S. Perceptions of Jorda-
validation and formal analysis; Murong Li contributed nian laypersons and dental professionals to altered smile aes-
thetics. Eur J Orthod 2011;33:450-6.
to investigation; Yonghua Lei contributed to supervision
17. Woods M. Maxillary arch width and buccal corridor changes with
and project administration. orthodontic treatment: author’s response. Am J Orthod Dentofa-
cial Orthop 2014;146:136.
ACKNOWLEDGMENTS 18. Ker AJ, Chan R, Fields HW, Beck M, Rosenstiel S. Esthetics and
smile characteristics from the layperson’s perspective: a
The authors thank James Wiley for his guidance of computer-based survey study. J Am Dent Assoc 2008;139:
the statistical analysis, Ning Li for helping the English 1318-27.
writing, and Qixin Liu for her guidance in modifying 19. Springer NC, Chang C, Fields HW, Beck FM, Firestone AR,
photographs. Rosenstiel S, et al. Smile esthetics from the layperson’s perspective.
Am J Orthod Dentofacial Orthop 2011;139:e91-101.
20. McLeod C, Fields HW, Hechter F, Wiltshire W, Rody W,
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