The Open Dentistry Journal




ISSN: 1874-2106 ― Volume 14, 2020
REVIEW ARTICLE

Measuring Patient’s Orofacial Estheticsin in Prosthodontics: A Scoping Review of a Current Instrument



Saraventi Mursid1, Diah Ayu Maharani2, Lindawati Kusdhany1, *
1 Department of Prosthodontics, Faculty of Dentistry, University of Indonesia, Jakarta 10430, Indonesia
2 Department of Preventive and Public Health Dentistry, Faculty of Dentistry, University of Indonesia, Jakarta10430, Indonesia

Abstract

Objective:

Although prosthodontic treatment is aimed at improving oral function, esthetics has become the most common motivation for treatment. To ensure successful outcomes, valid and reliable instruments for comprehensively evaluating the esthetic aspects of prosthodontic treatment from both clinician perspective and patient self-assessment are needed. The literature on measurement tools used in prosthodontics to evaluate orofacial esthetic aspects was also studied.

Methods:

A scoping review was conducted to map existing instruments such as a questionnaire, index, or scale designed to evaluate orofacial esthetics by clinician and patient for prosthodontic treatment.

Results:

Of the 27 studies evaluated, the Orofacial Esthetic Scale (OES) was used mostly for evaluating a patient’s esthetic perception. The ‘Dental Esthetic Screening Index’ (DESI) was found as the most currently developed instrument with objective quantification for the clinical situation having good reliability and validity. The Prosthetic Esthetic Index (PEI) also has sufficient psychometric properties as an objective assessment tool for clinicians. But the PEI and the DESI are still rarely used in research and practice. Teeth color and position were determined to be the most important factors in recognizing esthetic impairment. Following tooth analysis (appearance, color, alignment, space, proportion, and wear), gingival appearance, smile analysis, facial analysis, and unaesthetic restoration or prosthesis were the most important esthetic factors identified.

Conclusion:

Esthetics is subjective and is influenced by many factors. Instruments for subjective and objective evaluation are needed to determine the esthetic perceptions of clinicians and patients. OES, PEI and DESI were found to be relevant instruments for this.

Keywords: Prosthodontics, Orofacial, Esthetics, Measurement, Prostheses, Dentofacial .


Article Information


Identifiers and Pagination:

Year: 2020
Volume: 14
First Page: 161
Last Page: 170
Publisher Id: TODENTJ-14-161
DOI: 10.2174/1874210602014010161

Article History:

Received Date: 29/10/2019
Revision Received Date: 06/03/2020
Acceptance Date: 07/03/2020
Electronic publication date: 22/04/2020
Collection year: 2020

© 2020 Mursid et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Prosthodontics, Faculty of Dentistry, Universitas Indonesia, Jakarta 10430, Indonesia; Tel: +628161107587; E-mail: lindaskusdhany@gmail.com





1. INTRODUCTION

Prosthodontics is an area of dentistry focused on improving oral function and esthetics. Prostheses are used not only to restore partial and total edentulism but also to restore tooth damage. Thus, they must achieve harmony in shape and color with the lips, gingiva, smile, and face. Nowadays, esthetic considerations are the most common motivation for patients seeking prosthodontic treatment. The term orofacial is used in this study because it describes a particular region of the body consisting of the face, mouth, teeth, including lips, while gingiva is a more suitable term to evaluate comprehensive esthetic in prosthodontics [1Larsson P, John MT, Nilner K, Bondemark L, List T. Development of an Orofacial Esthetic Scale in prosthodontic patients. Int J Prosthodont 2010; 23(3): 249-56.
[PMID: 20552092]
]. The esthetic concept in prosthodontic refers to the definition of esthetic in dentistry, which is the theory and philosophy that deal with beauty and the beautiful, especially with respect to the appearance of dental restoration, as achieved through its form and or color; those subjective and objective elements and principles underlying the beauty and attractiveness of an object, design, or principle [2Dannemand K, Özhayat EB. Recognition of patient-reported impairment in oral aesthetics. J Oral Rehabil 2014; 41(9): 692-9.
[http://dx.doi.org/10.1111/joor.12183] [PMID: 24836917]
]. An essential consideration in the pursuit of orofacial esthetics is the concept of body image, defined as each individual’s mental picture of his or her appearance. The role of esthetics in prosthodontic treatment is strongly related to the individual's self-esteem, psychosocial perspective, and, ultimately, his/her quality of life [3Chen P, Yu S, Zhu G. The psychosocial impacts of implantation on the dental aesthetics of missing anterior teeth patients. Br Dent J 2012; 213(11)E20
[http://dx.doi.org/10.1038/sj.bdj.2012.1090] [PMID: 23222358]
, 4Parashar P, Paliwal A, Parekh V, Shingala A, Patel S, Shah J. A complete analysis of quality of life measure and esthetic component in indore population. J Int Oral Health 2015; 7(10): 77-81.]. Therefore, esthetic interpretation during oral reconstruction should not be simply a subject of personal taste, from either the clinician’s or patient’s point of view. The patient’s perception of his/her oral health status, including esthetic perception as a subjective measure, is a significant component for measuring treatment outcomes [5Michaud PL, de Grandmont P, Feine JS, Emami E. Measuring patient-based outcomes: Is treatment satisfaction associated with oral health-related quality of life? J Dent 2012; 40(8): 624-31.
[http://dx.doi.org/10.1016/j.jdent.2012.04.007] [PMID: 22522414]
]. This subjectivity makes the assessment of esthetics challenging because the final result has to satisfy the patient’s esthetic perception, which should be one of the outcomes measured in prosthodontic treatment [6Leles CR, Morandini WJ, da Silva ÉT, de F Nunes M, Freire MC. Assessing perceived potential outcomes of prosthodontic treatment in partial and fully edentulous patients. J Oral Rehabil 2008; 35(9): 682-9.
[http://dx.doi.org/10.1111/j.1365-2842.2007.01839.x] [PMID: 18793353]
].

Clinical assessment is an important process to ensure successful prosthodontic treatment outcomes. Generally, esthetic analyses of prosthodontic treatment consist of several parameters, including facial, dentolabial, tooth, gingival, and smile analyses [7Van der Geld P. Smiling and speaking in a dental perspective: A dental and psychological approach 2012., 8Fradeani M. Esthetic rehabilitation in fixed prosthodontics Vol 1: Esthetic analysis: A systemic approach to prosthetic treatment 2004.]. Some experts have separated dental and facial esthetics into macroelements and microelements [9Mclaren E, Culp L. Smile Analysis. J Cosmet Dent 2013; 29(1): 94-108.]. A previous study established seven quantifiable parameters for orofacial esthetics from a literature review: smile line, lip line, incisal offset, location of the dental and facial midline, incisor angulation, and width-to-height ratio of anterior maxillary teeth, gingival contour and root coverage, and papilla height [10Frese C, Staehle HJ, Wolff D. The assessment of dentofacial esthetics in restorative dentistry: A review of the literature. J Am Dent Assoc 2012; 143(5): 461-6.
[http://dx.doi.org/10.14219/jada.archive.2012.0205] [PMID: 22547716]
]. However, there are no specific esthetic guidelines developed by a consensus of esthetic experts and the clinical evaluation; therefore, it often varies.

Esthetic perception is subjective for both clinicians and patients. Age, gender, and psychosocial factors influence patients’ perception and both gender and culture have been reported to influence the clinician’s judgment of esthetics [11Mehl CJ, Harder S, Kern M, Wolfart S. Patients’ and dentists’ perception of dental appearance. Clin Oral Investig 2011; 15(2): 193-9.
[http://dx.doi.org/10.1007/s00784-010-0393-y] [PMID: 20232095]
]. The esthetic conception is abstract and subjective; therefore, formulating a concrete treatment goal and good communication between dentists and patients is essential. Valid and reliable instruments are needed to systematize and accelerate this process. The purpose of this study is to review the published literature assessing the valid and reliable standardized instruments used in prosthodontics to evaluate orofacial esthetics by clinicians and patients. This study also aims to determine the orofacial esthetic aspects evaluated by patients and clinicians using existing measuring instruments.

2. MATERIALS AND METHODS

A scoping review was performed to identify the instruments that currently exist for assessing orofacial esthetic aspects and to investigate the elements that play a role in both the patient's perception and the clinician’s evaluation in prosthodontics. Scoping reviews are useful for mapping, collating, and summarizing existing literature on a topic and can assist researchers in identifying the nature and extent of the current research evidence [12Arksey H, Malley LO, Arksey H, Malley LO. Scoping studies : Towards a methodological framework Scoping. Int J Soc Res Methodol 2005; 8(1): 37-41.
[http://dx.doi.org/10.1080/1364557032000119616]
-14Peters MDJ, Godfrey CM, Khalil H, McInerney P, Parker D, Soares CB. Guidance for conducting systematic scoping reviews. Int J Evid-Based Healthc 2015; 13(3): 141-6.
[http://dx.doi.org/10.1097/XEB.0000000000000050] [PMID: 26134548]
]. Scoping studies differ from narrative or literature reviews because the scoping process requires analytical reinterpretation of the literature. Unlike the systematic review that might typically focus on a well-defined question where appropriate study design can be identified in advance, a scoping study tends to address broader topics where many study designs might be applicable. The systematic review might aim to provide answers to questions from a relatively narrow range of quality assessed studies, while a scoping study is less likely to seek to address very specific research questions nor, consequently, to assess the quality of included studies. The scoping review was chosen for this study because we need to identify and map the available evidence with a broader scope in a structured process that fulfils our study purposes. The five stages of the scoping review consist of identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting results [12Arksey H, Malley LO, Arksey H, Malley LO. Scoping studies : Towards a methodological framework Scoping. Int J Soc Res Methodol 2005; 8(1): 37-41.
[http://dx.doi.org/10.1080/1364557032000119616]
]. “What instruments are currently available to measure esthetics in prosthodontics?” was the question used as a guide for literature searches.

The approach to searching for this review followed the steps method recommended for systematic review using Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) flow diagram (Fig. 1).

The review focused on all available published English-language studies from the last 15 years. The PubMed, EBSCO, Pro Quest, and Google Scholar databases were searched using terms from Medical Subject Headings (MeSH) 2016 and other terms. The search strategy included combinations of the following MeSH terms: dental esthetics, perception, self-assessment, questionnaires, and scales to expand search coverage. Other keywords such as dentofacial esthetics, orofacial esthetics, dental appearance, satisfaction, and smile esthetics, were also used to find potentially eligible studies to be included in the review. The selected articles were screened by title and abstract. Studies related to orthodontics, malocclusion, and cleft abnormalities, as well as studies related to prosthodontics performed without using instruments such as questionnaires, scale, or index to assess esthetics were excluded from the study. Articles on implant research were not included because the assessment of implant esthetics mostly evaluates specific micro esthetic parameters [15Martin W, Pollini A, Morton D. The influence of restorative procedures on esthetic outcomes in implant dentistry: A systematic review Int J Oral Maxillofac Implants 2014; 29: 142-54.
[http://dx.doi.org/10.11607/jomi.2014suppl.g3.1]
]. The article selection process is described with the inclusion and exclusion criteria in Table 1.

3. RESULTS

This study adapted the search strategy method from Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement’s flowchart [16Moher D, Liberati A, Tetzlaff J, Altman DG, Group TP. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009; 6(7)e1000097
[http://dx.doi.org/10.1371/journal.pmed.1000097] [PMID: 19621072]
] (Fig. 1). After applying the inclusion and exclusion criteria to the titles and abstracts of the 92 articles found with the aforementioned search terms, 27 full-text articles were considered suitable for further analysis.

Tables 2 and 3 describe the instruments available from 2006 until 2020, representing the chronological overview of orofacial esthetic instruments for self-evaluation by the patient, and clinician evaluation.

The esthetic aspects of each instrument were evaluated, as well as their measurement method and psychometric properties. The studies were charted, and summaries were drafted, including the author, journal, publication year, aim, sample, and the instrument used. Table 4 summarizes the instruments identified through the scoping review.

Fig. (1)
The flow of search strategy process in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement.


Table 1
Inclusion and exclusion criteria for article selection.


Table 2
Chronological overview of orofacial esthetic instruments for self-evaluation.


Table 3
Chronological overview of orofacial esthetic instrument for clinician evaluation.


Table 4
Overview of studies using orofacial esthetic evaluation instruments from 2006 to 2020.


4. DISCUSSION

The success of prosthodontics treatment not only restores the function of the stomatognathic system but also provides a pleasing and esthetic appearance of restoration in harmony with the whole body. Clinical experiences and research showed that patients’ opinions of esthetic parameters often were different from clinicians. Even though it is not easy to measure because it is influenced by several factors such as age, gender, education level, and culture, the assessment has to be done. There are several ways to measure the patient’s self-perception of orofacial appearance; first is the satisfaction of orofacial esthetic appearance; second is the impact of its impairment, which is strongly related to the psychosocial quality of life [26Tin-Oo MM, Saddki N, Hassan N. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health 2011; 11(1): 6.
[http://dx.doi.org/10.1186/1472-6831-11-6] [PMID: 21342536]
, 28Al-Zarea B K. Satisfaction with appearance and the desired treatment to improve aesthetics Int J Dent 2013; 2013
[http://dx.doi.org/10.1155/2013/912368]
, 42Akarslan ZZ, Sadik B, Erten H, Karabulut E. Dental esthetic satisfaction, received and desired dental treatments for improvement of esthetics. Indian J Dent Res 2009; 20(2): 195-200.
[http://dx.doi.org/10.4103/0970-9290.52902] [PMID: 19553722]
, 43Wong AH, Cheung CS, McGrath C. Developing a short form of Oral Health Impact Profile (OHIP) for dental aesthetics: OHIP-aesthetic. Community Dent Oral Epidemiol 2007; 35(1): 64-72.
[http://dx.doi.org/10.1111/j.1600-0528.2007.00330.x] [PMID: 17244139]
]. These two methods also can be assessed in different periods of time; existing condition/previous dental treatment and after receiving treatment. In this review, we only analyzed instruments to evaluate the patient perception of orofacial appearance. In this scoping study, we found four instruments for assessing the patient's perception of orofacial aesthetic, which include the prosthodontic aspect. The measurements used by Tortopidis et al., Tin-Oo et al., Questionnaire Satisfaction with their own dental appearance' (QDA) and Orofacial Esthetic Scale (OES). The patients’ satisfaction regarding their orofacial condition was asked in all the instruments. All self-assessment instruments investigated the impact of esthetic impairment and or the desired treatment needed to overcome the problem, except the OES. The OES instead evaluates the overall satisfaction of the patient with his/her esthetic appearance. As the most common instrument used in research, the OES has good psychometric properties and has been adapted cross-culturally to several languages ​​such as; Croatia, Chinese, Albanian, Dutch, Germany, Arabic, and Spanish [25Persic S, Milardovic S, Mehulic K, Celebic A. Psychometric properties of the Croatian version of the Orofacial Esthetic Scale and suggestions for modification. Int J Prosthodont 2011; 24(6): 523-33.
[PMID: 22146251]
, 29Zhao Y, He SL. Development of the Chinese version of the Oro-facial Esthetic Scale. J Oral Rehabil 2013; 40(9): 670-7.
[http://dx.doi.org/10.1111/joor.12077] [PMID: 23829233]
, 32Reissmann DR, Benecke AW, Aarabi G, Sierwald I. Development and validation of the German version of the Orofacial Esthetic Scale. Clin Oral Investig 2014; 1-9.
[PMID: 25467234]
-34Wetselaar P, Koutris M, Visscher CM, Larsson P, John MT, Lobbezoo F. Psychometric properties of the Dutch version of the Orofacial Esthetic Scale (OES-NL) in dental patients with and without self-reported tooth wear. J Oral Rehabil 2015; 42(11): 803-9.
[http://dx.doi.org/10.1111/joor.12314] [PMID: 26037598]
, 37Alhajj MN, Amran AG, Halboub E, Al-Basmi AA, Al-Ghabri FA. Development, validation and psychometric properties of the Arabic version of the Orofacial Esthetic Scale: OES-Ar. J Prosthodont Res 2017; 61(3): 290-6.
[http://dx.doi.org/10.1016/j.jpor.2016.10.004] [PMID: 27888096]
, 40Simancas-Pallares M, John MT, Prodduturu S, Rush WA, Enstad CJ, Lenton P. Development, validity and reliability of the Orofacial Esthetic Scale - Spanish version. J Prosthodont Res 2018; 62(4): 456-61.
[http://dx.doi.org/10.1016/j.jpor.2018.05.003] [PMID: 29866446]
, 41Reissmann DR, John MT, Enstad CJ, Lenton PA, Sierwald I. Measuring patients’ orofacial appearance: Validity and reliability of the English-language Orofacial Esthetic Scale. J Am Dent Assoc 2019; 150(4): 278-86.
[http://dx.doi.org/10.1016/j.adaj.2018.11.024] [PMID: 30922458]
]. Although the instrument developed by Tortopidis et al. showed good reliability, there has been no report of its use in other published studies. The QDA was developed from an earlier version by Wolfart et al. [21Wolfart S, Quaas AC, Freitag S, Kropp P, Gerber W-D, Kern M. General well-being as an important co-factor of self-assessment of dental appearance. Int J Prosthodont 2006; 19(5): 449-54.
[PMID: 17323722]
]. Mehl et al. reintroduced it with the name of QDA in a shorter version and used several times to assess the perceptions of aesthetics for their research [11Mehl CJ, Harder S, Kern M, Wolfart S. Patients’ and dentists’ perception of dental appearance. Clin Oral Investig 2011; 15(2): 193-9.
[http://dx.doi.org/10.1007/s00784-010-0393-y] [PMID: 20232095]
, 23Mehl C, Kern M, Freitag-Wolf S, Wolfart M, Brunzel S, Wolfart S. Does the Oral Health Impact Profile questionnaire measure dental appearance? Int J Prosthodont 2009; 22(1): 87-93.
[PMID: 19260435]
, 31Mehl C, Wolfart S, Vollrath O, Wenz H-J, Kern M. Perception of dental esthetics in different cultures. Int J Prosthodont 2014; 27(6): 523-9.
[http://dx.doi.org/10.11607/ijp.3908] [PMID: 25390865]
, 44Mehl CJ, Harder S, Wolfart S, et al. Influence of dental education on esthetic perception. Int J Esthet Dent 2015; 10(3): 486-99.
[PMID: 26171449]
]. Even though used by Mehl et al., the QDA has not been proven to be valid and reliable, the scoring method and its interpretation are not explained in the published articles. Other instruments identified were questionnaires for patient satisfaction with esthetics and the need for dental esthetic treatment.

In this study, we recognized that there are several clinical measurements for assessing the aesthetic orofacial that includes the prosthodontic aspect. Tortopidis et al. made a questionnaire with the aesthetic aspect of prosthodontics covered by the measurement, but the interpretation of the summary score and its reliability was not reported [17Tortopidis D, Hatzikyriakos A, Kokoti M, Menexes G, Tsiggos N. Evaluation of the relationship between subjects’ perception and professional assessment of esthetic treatment needs. J Esthet Restor Dent 2007; 19(3): 154-62.
[http://dx.doi.org/10.1111/j.1708-8240.2007.00089.x] [PMID: 17518906]
]. Another measurement is the Smile Esthetic Index (SEI); it also has some prosthodontic aesthetic aspects associated with the overall smile assessment [19Rotundo R, Nieri M, Bonaccini D, et al. The Smile Esthetic Index (SEI): A method to measure the esthetics of the smile. An intra-rater and inter-rater agreement study. Eur J Oral Implantology 2015; 8(4): 397-403.
[PMID: 26669549]
]. This tool demonstrates the value of good agreement on inter-rater and intra-rater reliability tests but has not been reported in clinical or other studies. Esthetic evaluation instruments that have been tested for validity and reliability for prosthodontic cases are Prosthetic Esthetic Index (PEI) and also have good responsiveness [18Özhayat EB, Dannemand K. Validation of the prosthetic esthetic index. Clin Oral Investig 2014; 18(5): 1447-56.
[http://dx.doi.org/10.1007/s00784-013-1109-x] [PMID: 24068286]
, 36Øzhayat EB. Responsiveness of the Prosthetic Esthetic Scale. Clin Oral Investig 2017; 21(3): 907-13.
[http://dx.doi.org/10.1007/s00784-016-1841-0] [PMID: 27129583]
]. Developed by Ozhayat et al., this tool is for clinicians in daily practice or research because it considers structured aspects which include aesthetic prosthetic aspects of the face, mouth, prosthetic, and comprehensive dental aesthetic. PEI questionnaires have been reported to have been used in studies for assessing orofacial aesthetic impairment in prosthodontic [2Dannemand K, Özhayat EB. Recognition of patient-reported impairment in oral aesthetics. J Oral Rehabil 2014; 41(9): 692-9.
[http://dx.doi.org/10.1111/joor.12183] [PMID: 24836917]
]. The most current tool found was the ‘Dental Esthetic Screening Index’ (DESI) developed by Frese et al. in 2019, based on their review findings in 2012. The DESI was found to be a reliable and valid instrument for the quantitative assessment of dentofacial esthetics.

The ‘Professional assessment questionnaire of esthetic treatment need’, the PEI, and the SEI, although assessed clinically, remain influenced by the subjectivity of the clinician. However, this method is an effective way of evaluating because it is easy and fast in assessing an aesthetic disorder rather than a measurable objective examination. The scoring method, clinician’s experience, previous dental education, and culture can influence the clinician’s assessment [25Persic S, Milardovic S, Mehulic K, Celebic A. Psychometric properties of the Croatian version of the Orofacial Esthetic Scale and suggestions for modification. Int J Prosthodont 2011; 24(6): 523-33.
[PMID: 22146251]
, 31Mehl C, Wolfart S, Vollrath O, Wenz H-J, Kern M. Perception of dental esthetics in different cultures. Int J Prosthodont 2014; 27(6): 523-9.
[http://dx.doi.org/10.11607/ijp.3908] [PMID: 25390865]
, 35Peršić S, Čelebić A. Influence of different prosthodontic rehabilitation options on oral health-related quality of life, orofacial esthetics and chewing function based on patient-reported outcomes. Qual Life Res 2015; 24(4): 919-26.
[http://dx.doi.org/10.1007/s11136-014-0817-2] [PMID: 25294397]
, 44Mehl CJ, Harder S, Wolfart S, et al. Influence of dental education on esthetic perception. Int J Esthet Dent 2015; 10(3): 486-99.
[PMID: 26171449]
]. Guidelines to determine a scoring scale, such as that included in SEI, may help reduce subjectivity. Dichotomous questions, yes/no answers are easy to answer, but in terms of analysis, such questions will only separate respondents into two broad groupings, and finer comparisons are usually required. Likert scale questions and semantic differentials to measure attitude respondent towards perception, feeling, or opinion can indicate responses by the degree of positive and negative statements. Both Likert scale and semantic differentials usually incorporate'odd-numbered' steps and creating mid-point, which gives the respondent a choice to neither agree nor disagree [45Murray P. Fundamental issues in questionnaire design. Accid Emerg Nurs 1999; 7(3): 148-53.
[http://dx.doi.org/10.1016/S0965-2302(99)80074-5] [PMID: 10693384]
]. These should be considered because some respondents have the tendency to be ambivalent. The number of Likert scale choices and the selection of words such as always, often, seldom or sometimes might affect the pattern of the responses with different cultural backgrounds [46Lee J, Jones P, Mineyama Y, Xinwei E. Cultural differences in responses to a likert scale Res Nurs nad Heal 2002; 25: 295-306.
[http://dx.doi.org/10.1002/nur.10041]
]. In comparison, the DESI would provide a comprehensive index that allows for objective quantification of the clinical situation for reliable baseline and outcome assessment in esthetic dentistry compared with the PEI, the SEI, and the questionnaire of professional assessment. Extraoral and intraoral scores of the DESI quantification were done by a five-point rating scale that allows for stepwise gradation of the esthetic deviance to ideal.

The instruments identified in this review use a variety of esthetical aspects to determine the patient’s perception and the clinician’s evaluation. All instruments were found to cover all the aspects of prosthodontics esthetic analysis recommended in several references, including facial, dentolabial, tooth, gingival, and smile analyses. Tooth color and position were found to be the most important factors in recognizing esthetic impairment [26Tin-Oo MM, Saddki N, Hassan N. Factors influencing patient satisfaction with dental appearance and treatments they desire to improve aesthetics. BMC Oral Health 2011; 11(1): 6.
[http://dx.doi.org/10.1186/1472-6831-11-6] [PMID: 21342536]
, 28Al-Zarea B K. Satisfaction with appearance and the desired treatment to improve aesthetics Int J Dent 2013; 2013
[http://dx.doi.org/10.1155/2013/912368]
, 42Akarslan ZZ, Sadik B, Erten H, Karabulut E. Dental esthetic satisfaction, received and desired dental treatments for improvement of esthetics. Indian J Dent Res 2009; 20(2): 195-200.
[http://dx.doi.org/10.4103/0970-9290.52902] [PMID: 19553722]
]. Similar results have been reported by Dannemand et al., Somorodnitzki et al., and Oo et al. Tooth analysis (appearance, color, alignment, space, proportion, and wear), gingival appearance, smile analysis, facial, and unesthetic restoration or prosthesis were identified as important esthetic factors in this review.

These findings showed that scoping studies can provide an important result from the research question presented in this study. It can be useful as a starting point, based on the evidence to decide for the relevant instrument in esthetic prosthodontics research. As the limitation of this study, we found it very challenging to identify the relevant study with the resources available. But the recommendation step suggested by Levac et al. [13Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implement Sci 2010; 5(69): 69.
[http://dx.doi.org/10.1186/1748-5908-5-69] [PMID: 20854677]
] to involve at least two independent researchers and a reviewer to determine agreement in every stage surely solved the problem.

Furthermore, this finding can give preliminary results to conduct a systemized and comprehensive study to legitimize the best instrument for esthetic evaluation. The comprehensive and ideal criteria for the good instrument properties from the Scientific Advisory Committee (SAC) of the Medical Outcome Trust should include eight attributes; conceptual and measurement model, validity, reliability, responsiveness, interpretability, respondent and administrative burden, alternative forms and cultural and language adaptation [47Terwee CB, Bot SDM, de Boer MR, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol 2007; 60(1): 34-42.
[http://dx.doi.org/10.1016/j.jclinepi.2006.03.012] [PMID: 17161752]
].

CONCLUSION

Esthetics is subjective and is influenced by many factors. Instruments for subjective and objective evaluation are needed to determine the esthetic perceptions of clinicians and patients. OES is the most widely used instrument for self-evaluation in orofacial esthetics research. The PEI and the DESI were identified as the quantifiable valid and reliable tools used for orofacial esthetic evaluation by the clinician.

CONSENT FOR PUBLICATION

Not applicable.

FUNDING

The publication of this manuscript is supported by the Universitas Indonesia Grant No. NKB-0413/UN2.R3.1 /HKP.05.00/2019.

CONFLICT OF INTEREST

The author declares no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

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