Beauty is the phenomenon of experiencing pleasure through the perception of balance (1). Aesthetics has become an important issue in modern society, as it seems to define one's character (2). When we smile, our smile could often become the target of close scrutiny by the person you are smiling at (3). In the past, functional demands were the main consideration in dental treatment, and today, with decrease in caries prevalence, the focus has shifted toward dental aesthetics (2).
Creation of a natural dental appearance has become an important task in all fields of dentistry, especially in prosthodontics and restorative dentistry (4). That is why clinicians must be prepared to meet the aesthetic demands and high expectations of their patients (5).
Patients and dentists may have conflicting opinions regarding a definition of an aesthetically pleasing smile (6). The attitude towards oral health is influenced by gender, level of education and social background of patients (7, 8), which means that various groups of patients have different attitudes towards the appearance of their teeth (9).
Quality evaluations may vary with clinical or patient assessments (4). The agreement between perception of subjects and clinical assessment of aesthetic dental treatment need was found to be very low, which highlighted discrepancies between perception of patients and dentists for aesthetic needs (10). Patients' perceptions and expectations regarding their appearance play a significant role in treatment planning (11). Apart from listening carefully to main complaints, clinicians must also be able to evaluate the patient's physical, biological, and aesthetic needs (12). Achieving patient’s satisfaction encourages them to make efforts in order to improve their smile (5). Aesthetic treatment represents a great challenge to a dental practitioner (12).
Ideally, dental materials should match the natural teeth (13, 14). Optical behaviour of the final restoration is determined by the colour of the underlying tooth structure, the colour of the luting agent, as well as the thickness and opacity of the material used (13).
Composite resins are most commonly used materials in restorative dentistry, and the thicknesses of one or several composite layers may drastically change the final outcome (15). Resin composite restorations represent a good treatment choice for severely damaged teeth (16, 17), but their durability is questionable due to discoloration, marginal fracture and wear.
Properties of dental ceramic-colour are stability, mechanical strength, clinical longevity, aesthetic appearance and compatibility with periodontal tissues (12). Many studies have proven that all-ceramic restorations offer a predictable and successful restoration (18-20).
The aim of this study was to assess the level of patients’ satisfaction with appearance of maxillary anterior teeth restorations when comparing them with the adjacent natural teeth and assessing objective aesthetic parameters - colour, shape and surface texture restorations, as well as their general impression of the restorations. The aim of this study was also to determine if there is a difference in patients’ assessment of restoration appearance with regard to gender.
MATERIALS AND METHODS
Maxillary anterior teeth restorations (composite fillings, different types of fixed conventional prosthodontic appliances) in patients attending private dental medicine practice were examined. The purpose of the research was presented to all participants and they gave their written consent. The patients with no restorations in this region, and those with periodontal and serious tooth mobility problems in maxillary anterior region were excluded. The participants were surveyed by means of a questionnaire containing questions about gender, age, and education level. The age of patients was recorded.
A total of 200 adult Caucasian subjects participated in the study (88 men, mean age 39 years; 122 women, mean age 40 years). All participants had composite filling restorations, acrylic faceted metal crowns, porcelain-fused-to-metal crowns or all-ceramic crowns on maxillary anterior teeth.
Patients evaluated the colour, anatomical shape and surface texture of maxillary anterior teeth restorations in comparison to adjacent natural teeth on Visual Analogue Scale from 1 to 3. Score 1 meant that the patient was completely satisfied with the characteristics thus giving a good grade. Score 2 meant that the patient was moderately satisfied with the characteristics and evaluated it as satisfying. Score 3 meant that the patient was completely dissatisfied with assessed restoration characteristic in relation to the natural tooth and evaluated it as bad. Finally, patients assessed general impression of their maxillary anterior teeth restorations and rated it as satisfactory (score 1) or non-satisfactory (score 2). The data were expressed in patients’ average assessment scores for colour, anatomical shape and surface texture as well as overall patients’ average assessment scores for every type of restoration and the overall patients’ average assessment scores for colour, anatomical shape and surface texture of all the restorations in general. The patients also assessed their general impression of restorations. The statistical analysis was made by using the statistical software SPSS 10.0 for Windows. T-test for independent samples, χ2 test and Logistic regression analysis were performed.
The Ethics Committee of the School of Dental Medicine approved this study.
200 patients, 88 males (44%, average age 39 years) and 122 females (56%, average age 40 years) participated in this study. The total age of the patients ranged from 18-72 years. Clinical examination revealed that patients had a total of 260 composite fillings and 113 crowns, of which 51 were acrylic faceted metal crowns, 34 porcelain-fused-to- metal ceramic and 28 all-ceramic crowns on maxillary anterior teeth. In this study, patients compared the appearance of different dental restorations (restorative and prosthetic) on the maxillary anterior teeth with the appearance of the adjacent natural teeth.
Assessment scores of all patients were distributed by gender. The differences in mean values (x) and standard deviations (SD) for patients’ average assessment scores for colour, anatomical shape and surface texture of composite fillings, acrylic faceted metal crowns, ceramic-fused-to-metal crowns and all-ceramic crowns as well as overall patients’ average assessment scores for every type of restoration between genders are shown in Figures 1, 2, 3, 4. The differences in mean values (x) and standard deviations (SD) for overall patients’ average assessment scores for the colour; anatomical shape and surface texture of all restorations in general between genders are shown in Figure 5.
T-test for independent samples showed that there was a statistically significant gender difference in patients’ assessment of colour and surface texture for composite fillings and overall patients’ average assessment score for colour of all assessments (p <0.05) (Table 1).
Figure 6 shows the distribution of the patients’ general impression with the restorations depending on gender. The results showed that in this study women were more dissatisfied with the general impression of their restorations on the upper teeth than men. X2 test showed that this difference almost reached the level of significance (p >0.05) (Table 2).
The next step was to identify the factors that influenced the patient's decision to give satisfactory or non-satisfactory general score for maxillary anterior teeth restorations appearance. For this purpose, logistic regression analysis was used. Specifically, it is a form of regression used for predicting and explaining binary categorical variables, in this case the overall impression with categories - satisfactory condition or non-satisfactory condition. Independent variables expressing overall patients’ average assessment scores for all tested types of restorations were included in testing. The results showed that only the independent variable for overall patients’ average assessment score for composite restorations almost reached the level of significance (p = 0.069) as the impact predictor of 5% (coefficient of determination R2 = 0.05) on the patients’ general impression (exponential coefficient of 2.343 and a confidence interval 0.936 to 5.865) (Table 3,). This result reveals that it is 2.3 times more likely that the patient's general impression is to be satisfactory if the patient evaluates the matching composite restorations and the natural maxillary teeth as satisfactory as well. It also shows that the general patients’ impression is described by the average patients’ score for composite restorations as a dependent variable within 5%.
Numerous factors are related with dental aesthetics, such as the colour and the shape of the teeth as well as the shape of the dental arch (21-29). These factors are affected by individual preferences (30, 31), cultural factors (30) and sociodemographic factors (32, 33). The appearance of the teeth could be influenced by gender (3, 4, 9, 34, 35), age (3, 9, 32-35) and education level (9, 34, 36, 37). Perceived dental treatments on anterior teeth also have an impact on dental aesthetics (9, 12, 38, 39).
In this study, participating patients had a total of 260 composite fillings and 113 crowns on maxillary anterior teeth, with 51 acrylic faceted metal crowns, 34 porcelain-fused-to- metal ceramic crowns and 28 all-ceramic crowns. The patients compared maxillary anterior teeth dental restorations with the appearance of the adjacent natural teeth for colour, shape and surface texture and evaluated their matching. These criteria defined rating scales for judgement of clinically important characteristics for dental restorations, and they were designed to reflect aesthetic qualities and functional performance of restorations fabricated from a variety of dental restorative materials (40) as in a study by Beier who did the same research (20).
Perception of tooth colour is a complex phenomenon that is influenced by many factors including lighting conditions, the optical properties of teeth (translucency, opacity, scattering of light, surface gloss), and the viewer's visual experience (41).
T-test for independent samples in this study showed that there was a statistically significant gender difference in the assessment of colour and surface texture of composite fillings as well as in overall average assessment grade for colour with women being less satisfied (p <0.05) (Table 1). First of all, it seems that the colour of the natural teeth and restorations in this study plays an important role in the assessment of the patient's appearance of maxillary anterior teeth and this is in accordance with recent studies which show that the tooth colour is one of the most important factors determining satisfaction with dental appearance (42). In general, people wish to have pearly white teeth (42, 43). Samorodnitzky-Naveh et al. have proven that lay people evaluate their teeth darker than professionals, and women assessed tooth shades more accurately than men (43). Dental appearance is an important feature in determining the attractiveness of the face, and thus plays a key role in human social interactions. The media and mass communication have provided an opportunity for educational awareness of alternative aesthetic materials. Today, patients are no longer satisfied with restorative solutions that provide ideal function without displaying restorations of beautiful, natural-looking teeth. A patient's preference toward a lighter shade should be addressed during treatment planning to match the patient's expectations for aesthetics and increase patient satisfaction of treatment outcome (43).
Furthermore, the results of this study also showed that gender had an impact on the assessment of maxillary teeth and restorations – it showed that women were less satisfied with it than men (p<0,05)(Figures 1, 2, 3, 4, 5).
Many other studies showed the same results (9, 35, 42). Some of them showed that women were reported to be more sensitive to the appearance of the teeth than men, and the importance of teeth decreased with ageing (35) and higher education levels (7) and these two additional factors are going to be discussed in our next study. It is also known that female gender is the main predictor for seeking dental therapy (3). Their self-esteem could be affected by physical injuries more than in males (7). However, despite numerous proofs that women are more demanding in terms of dental aesthetics, there are studies that did not find a statistically significant difference (38).
The results of this study also showed that only the average patients’ rating of composite restorations is the predictor of the patients’ general impression of the appearance of their maxillary anterior teeth with the impact of 5% (coefficient of determination R2 = 0.05) and the level of significance of 0.069 (Table 3). According to this result, it seems that the type of restoration is important in patient's self-assessment of maxillary anterior teeth restoration appearance, and overall satisfaction with dental aesthetics.
Composite restorations could lead to successful aesthetic outcomes (15, 17) if adequate techniques are applied. On the other hand, properties of dental ceramic are better colour stability, mechanical strength, clinical longevity, aesthetic appearance and compatibility with periodontal tissues in comparison with composite materials (12). All-ceramic restorations offer the best predicted and successful restoration with an estimated survival probability of 98% over 5 years (19) and 93.5% over 10 years (20).
Women in this study were less satisfied with the colour and surface texture of their composite fillings and all colour assessments (p<0.05). Their general impression of the maxillary anterior teeth restorations was lower as well (p=0.054).
Logistic regression analysis showed that the independent variable for overall patients’ average assessment score for composite restorations almost reached the level of significance (p = 0.069) as the impact predictor of 5% (coefficient of determination R2 = 0.05) on the patients’ general impression (exponential coefficient of 2.343 and a confidence interval 0.936 to 5.865).
Comprehension of past dissatisfaction with aesthetics of oral cavity and dental procedures and prevalence of aesthetic characteristics of dissatisfied patients as well as understanding the wishes for future dental treatments and improving aesthetics can be a guide to develop strategies of new procedures designed to improve dental aesthetics.