In Dr. A.J. Ker and colleagues’ October JADA article, "Esthetics and Smile Characteristics From the Layperson’s Perspective: A Computer-Based Survey Study" (Ker AJ, Chan R, Fields HW, Beck M, Rosenstiel S. JADA 2008;139[10]:1318–1327), the authors present only nasal-tip-to-mentolabial-fold images to their "raters" for responses. This does not seem to satisfy the need for a full-face reference perspective. Yet the authors assert that "the sum of our findings provides an outline clinicians can use to assemble patient-centered orthodontic, restorative and periodontal treatment in a more comprehensive manner than has been possible to date." I respectfully submit that it does not.
Flores-Mir and colleagues1 and other authors have shown that laypersons naturally see dental esthetics as part of overall facial esthetics unless intentionally directed to a close-up view. Patthoff and Ozar2 wrote that "a dentist’s work should conform to the dental profession’s standards for teeth that are properly shaped and colored within an individual patient’s complete dentition and balanced with the patient’s gingival and facial features."
Previous work by this same school3 used full-face images of each subject alongside the nasal-tip-to-mentolabial-fold altered images to satisfy the validity of a full-facial reference. This was the "gold standard" for many of us who teach esthetic dentistry. By not using full-face images for reference in the present study, the subjects (laypersons) are being asked to rate a view that is foreign to them. This attempt by the authors to "reduce distractions" by not showing full-face views diminishes the validity of the results on the basis of previous literature and personal experience.
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