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Original Article
ARTICLE IN PRESS
doi:
10.25259/APOS_120_2022

Relationship of psychosociocultural factors with dental malocclusion and facial appearance

Department of Orthodontics, Faculty of Dentistry, Ordu University, Ordu, Turkey
Corresponding author: Suleyman Kutalmış Buyuk, Department of Orthodontics, Faculty of Dentistry, Ordu University, Ordu, Turkey. skbuyuk@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Hatal S, Buyuk SK. Relationship of psychosociocultural factors with dental malocclusion and facial appearance. APOS Trends Orthod, doi: 10.25259/APOS_120_2022

Abstract

Objectives:

The purpose of this study was to evaluate the relationship between psychosociocultural factors and dental malocclusion, facial appearance, and body perception.

Material and Methods:

The study was carried out with the participation of 112 female and 113 male individuals between the ages of 18 and 25. Individuals were asked to answer the Rosenberg Self-Esteem Scale, Physical Appearance Comparison Scale Revised, and Sociocultural Attitudes Towards Appearance Questionnaire 4-Revised questionnaires. Individuals were divided into three groups Class I, Class II, and Class III according to dental molar relationships. Standard facial and profile photographs of individuals in all groups were taken and soft-tissue measurements were performed.

Results:

There was no significant psychosociocultural difference between male and female individuals. However, individuals with Class III dental malocclusion compare their physical appearance more than other malocclusion groups and more experience body dissatisfaction (P > 0.05). Individuals with Class III dental malocclusion have higher lower face height, lower lip height, mentolabial angle, facial convexity angle, total facial convexity angle values, and lower forehead height/lower face height, nose height/lower face height ratio, and projection of the upper lip relative to the chin. Individuals with Class II dental malocclusion have lower chin height and anterior mandibular height/lower face height ratio, higher upper lip height/lower face height ratio, and upper lip height/anterior mandibular height ratio. Individuals with Class I dental malocclusion have a lower upper face height/lower face height ratio.

Conclusion:

Dental malocclusion groups have different facial soft tissue properties. Dental malocclusion and the facial appearance of individuals affect their lives in terms of psychosociocultural aspects.

Keywords

Dental malocclusion
Physical appearance
Soft-tissue analysis
Questionnaire

INTRODUCTION

Physical appearance has had an important role in human life for centuries from the past to present. Different physical appearances have become more important in social environments. People want to look beautiful and leave good impressions on others, both in their business and social lives.[1,2] Thoughts about appearance may differ according to the time lived and the cultural values of the society. Physical attractiveness standards are increasingly formed over time in society. While it is important for women to be thin and men to be muscular, gender standards are developing according to weight and body shape.[3]

The orofacial region is an important area of interest for humans. The value of the appearance of the teeth is increasing with the importance given to esthetics, and as a result, there is an increase in people’s requests for orthodontic treatment. People in need of orthodontic treatment are often more interested in improving their appearance and social acceptability than in improving their oral health or fulfilling their functional needs.[4]

One of the most important steps in orthodontic diagnosis and treatment planning is the evaluation of the patient’s facial soft tissues. Since the shape of the human face depends on both the structure of the hard tissue and the soft tissue covering it from the outside, a soft-tissue analysis should be performed to accurately assess the underlying skeletal incompatibility due to individual differences in soft-tissue thickness.

Facial soft-tissue analysis was performed using several methods such as direct anthropometry, two-dimensional photogrammetry, and three-dimensional methods such as laser scan and scanning digital 3D photogrammetry.[5-8]

Photogrammetry has been introduced as an alternative to direct measurements to determine distances between facial landmarks using both two- and three-dimensional methods.

This study aimed to evaluate the relationship between psychosociocultural factors and dental malocclusion, facial appearance, and body perception.

MATERIAL AND METHODS

This study was performed with the participation of 112 female and 113 male individuals between the ages of 18 and 25 who applied to Ordu University Faculty of Dentistry Department of Orthodontics for orthodontic treatment. Individuals with previous orthodontic treatment, cleft lip, palate, or syndromic disease, and a history of trauma were excluded from the study. This study was approved by the Clinical Research Ethics Committee of Ordu University (44/2021, date: April 18, 2021).

The patients answered the questions of the Rosenberg Self-Esteem Scale (RSE),[9] Physical Appearance Comparison Scale-Revised, and[10] Sociocultural Attitudes Towards Appearance Questionnaire 4-Revised.[11] According to molar bite relationships, patients were divided into three groups Class I, Class II, and Class III. There were 38 male and 38 female patients in the Class I malocclusion group. There were 37 male and 41 female patients in the Class II malocclusion group, and there were 38 male and 33 female patients in the Class III malocclusion group. Extraoral facial and profile photographic records were taken from the patients. The patients were seated in a chair and were asked to hold a 30-cm scale at cheek level when taking the front photo, and at the nose level when taking the profile photo. The photographs were taken with the patient sitting upright lips touching each other without straining in a natural head position.

The images were digitized, 13 linear measurements were performed on the frontal photographs, and 14 angular measurements were made on the profile photographs with the help of the software program (FACAD-trial version 3.8.4.2-Ilexis AB, Linkoping, Sweden). The measurements performed on the frontal photographs are shown in [Figure 1], and the measurements made on the profile photographs are shown in [Figures 2 and 3].

Figure 1:: Linear measurements on facial frontal photographs: 1. Forehead height, 2. Physionomic face height, 3. Upper face trio, 4. Mid-face trio, 5. Lower face trio, 6. Nose height, 7. Nose width, 8. Filtrum length, 9.Upper lip height, 10. Height of lower lip, 11. Height of upper vermilion, 12. Height of lower vermilion, and 13. Height of chin.
Figure 2:: Angular measurements on facial profile photographs: 1. Nasolabial angle, 2. Mentolabial angle, 3. Cervicomental angle, 4. Facial convexity angle, and 5. Total facial convexity angle.
Figure 3:: Angular measurements on facial profile photographs: 1. Lower face triple angle, 2. Midface triple angle, 3. Frankfurt mandibular plane angle, 4. Upper lip projection relative to the chin, 5. Lower lip projection relative to the chin, 6. Total vertical angle, 7. Maxillary angle, 8. Mandibular angle, and 9. Nasal angle.

Statistical Package for the Social Sciences 24.0 program (IBM Corp, Armonk, NY, USA) was used for statistical analysis. While evaluating the study data, an independent t-test was used for pair-wise group comparisons of normally distributed parameters in addition to descriptive statistical methods (Mean, standard deviation, median, frequency, ratio, minimum, and maximum). One-way analysis of variance was used in the comparison of three or more than three groups that are normally distributed. The post hoc least significant difference test was used. Significance assessment was performed at levels of P < 0.01 and P < 0.05.

RESULTS

There was no statistically significant difference in Rosenberg RSE, sociocultural Attitudes Towards Appearance Scale, and Physical Appearance Comparison Scales between genders (P > 0.05) [Table 1].

Table 1:: Comparison of scales by gender.
Parameter Male Female Pa-value
Mean SD Mean SD
Rosenberg Self-Esteem Scale 4.56 0.90 4.58 0.82 0.842
Scale of sociocultural attitudes toward appearance 2.43 0.49 2.33 0.60 0.168
Physical Appearance Comparison Scale 3.59 0.78 3.63 0.96 0.688

SD: Standard deviation, Paindependent t-test significance value

Rosenberg RSE values were found to be 4.50 ± 0.77, 4.58 ± 0.96, and 4.63 ± 0.83 for Class I, Class II, and Class III individuals, respectively, and there was no statistically significant difference between the groups (P > 0.05) [Table 2].

Table 2:: Comparison of scales by dental malocclusions.
Parameter Class I Class II Class III Pa-value Post hocb
Mean SD Mean SD Mean SD I-II I-III II-III
Rosenberg Self-Esteem Scale 4.50 0.77 4.58 0.96 4.63 0.83 0.639 NS* NS* NS*
Scale of Sociocultural Attitudes Towards Appearance 2.34 0.50 2.30 0.53 2.52 0.58 0.034 NS* 0.049 0.013
Physical Appearance Comparison Scale 3.66 0.89 3.88 0.76 3.26 0.85 0.001 NS* 0.004 0.001

SD: Standard deviation, Pa one-way analysis of variance significance value, Pb LSD parametric Post hoc significance value, NS: Statistically insignificant

Sociocultural Attitudes Towards Appearance scale values were found as 2.34 ± 0.50, 2.30 ± 0.53, 2.52 ± 0.58 for Class I, Class II, and Class III individuals, respectively. Sociocultural Attitudes Towards Appearance scale values in the Class III group are statistically significantly higher than the Class I and Class II groups (P < 0.05) [Table 2].

Physical Appearance Comparison Scale values were found as 3.66 ± 0.89, 3.88 ± 0.76, and 3.26 ± 0.85 for Class I, Class II, and Class III individuals, respectively. The Physical Appearance Comparison Scale values in the Class III group were statistically significantly lower than the Class I and Class II groups (P < 0.05) [Table 2].

When the mean and standard deviation values of men’s and women’s physiognomy face height, lower face triplet, nose width, philtrum height, upper lip height, lower lip height, upper vermilion height, lower vermilion height, and chin height were compared, there was a statistically significant difference in these measurements (P < 0.05) [Table 3].

Table 3:: Comparison of facial frontal measurements by gender.
Parameter Male Female Pa-value
Mean SD Mean SD
Forehead height 66.70 6.55 68.36 6.44 0.057
Physiomic face height 191.50 8.10 184.54 9.92 0.001
Upper face triad 50.62 5.95 51.25 5.88 0.425
Mid face trio 70.09 4.27 70.39 4.15 0.590
Lower face triad 70.77 5.70 62.89 4.81 0.001
Nose height 54.03 2.97 53.29 2.88 0.059a
Nose width 38.85 2.89 35.13 2.33 0.001
Filter length 16.04 2.39 14.31 1.83 0.001
Upper lip height 22.33 2.56 20.21 2.14 0.001
Lower lip height 17.65 2.86 16.39 2.19 0.001
Upper vermilion height 6.30 1.55 5.90 1.24 0.037
Lower vermilion height 10.44 1.94 9.76 1.69 0.005
Chin height 30.78 4.01 26.29 2.87 0.001
Forehead height/upper face height ratio 87.59 9.85 93.07 8.15 0.001
Forehead height/lower face height ratio 95.00 13.05 109.16 12.05 0.001
Ratio of upper face height to lower face height 108.47 8.60 117.37 8.60 0.001
Nose height/lower face height ratio 76.89 8.21 85.21 7.97 0.001
Upper lip height/lower face height ratio 31.58 2.84 32.16 2.49 0.101
Anterior mandibular height/lower face height ratio 68.42 2.84 67.84 2.49 0.101
Upper lip height/anterior mandibular height ratio 46.40 6.11 47.60 5.45 0.120
Upper vermilion height/upper lip height ratio 28.29 6.57 29.19 5.33 0.264
Ratio of the upper vermilion height/lower vermilion height 61.05 13.46 61.11 11.06 0.970
Intercanthal width/nose width ratio 86.34 7.99 93.12 8.10 0.001
Ratio of face width to physiognomy face height 75.37 3.49 75.48 3.81 0.821

SD: Standard deviation, Pa independent-t test significance value

There was no statistically significant difference between the groups in the frontal measurement values of forehead height, upper facial triad, midface triad, nose height, nasal width, philtrum length, upper lip height, upper vermilion height, and lower vermilion height values (P > 0.05) [Table 4].

Table 4:: Comparison of facial frontal measurements by dental malocclusions.
Parameter Class I Class II Class III Pa Post hocb
Mean SD Mean SD Mean SD I-II I-III II-III
Forehead height 68.48 6.06 67.19 7.12 66.87 6.32 0.284 NS* NS* NS*
Physiomic face height 188.48 9.66 185.94 9.70 189.85 9.38 0.042 0.103 0.384 0.014
upper face triad 51.99 5.34 50.76 6.56 50.01 5.65 0.120 NS* NS* NS*
mid face trio 70.01 4.10 70.41 4.06 70.31 4.51 0.833 NS* NS* NS*
lower face triad 66.46 6.46 64.78 5.90 69.53 6.57 0.001 0.100 0.004 0.001
nose height 53.52 3.01 53.97 2.85 53.46 2.98 0.502 NS* NS* NS*
Nose width 37.24 3.14 36.54 3.35 37.25 3.13 0.296 NS* NS* NS*
filter length 14.89 2.24 15.48 2.29 15.15 2.35 0.281 NS* NS* NS*
upper lip height 20.93 2.58 21.52 2.64 21.38 2.53 0.347 NS* NS* NS*
lower lip height 16.70 2.56 16.07 2.31 18.41 2.45 0.001 0.114 0.001 0.001
Upper vermilion height 6.03 1.34 6.05 1.45 6.22 1.46 0.683 NS* NS* NS*
Lower vermilion height 10.12 1.93 10.17 1.77 9.99 1.87 0.838 NS* NS* NS*
chin height 28.83 3.82 27.18 3.62 29.74 4.62 0.001 0.012 0.172 0.001
Forehead height/upper face height ratio 92.22 9.19 89.14 9.68 89.57 9.24 0.093 NS* NS* NS*
Forehead height/lower face height ratio 104.03 13.89 104.56 14.46 97.16 13.84 0.002 0.816 0.003 0.002
Ratio of upper face height to lower face height 112.69 8.48 117.29 9.71 108.30 8.69 0.001 0.002 0.003 0.001
Nose height/lower face height ratio 81.19 8.41 84.08 9.63 77.52 7.98 0.001 0.042 0.011 0.001
Upper lip height/lower face height ratio 31.50 2.35 33.21 2.46 30.78 2.65 0.001 0.001 0.082 0.001
Anterior mandibular height/lower face height ratio 68.50 2.35 66.79 2.46 69.22 2.65 0.001 0.001 0.083 0.001
Upper lip height/anterior mandibular height ratio 46.15 5.02 49.93 5.51 44.69 5.64 0.001 0.001 0.101 0.001
Upper vermilion height/upper lip height ratio 28.90 5.44 28.13 6.02 29.24 6.51 0.513 NS* NS* NS*
Ratio of upper vermilion height/lower vermilion height 60.25 10.87 60.12 13.15 63.02 12.70 0.275 NS* NS* NS*
Intercanthal width/nose width ratio 90.03 7.80 90.16 8.79 88.88 9.60 0.620 NS* NS* NS*
Ratio of face width to physiognomy face height 75.70 3.79 75.39 3.51 75.15 3.66 0.656 NS* NS* NS*

SD: Standard deviation, Pa one-way analysis of variance significance value, Pb LSD parametric Post hoc significance value, NS: Statistically insignificant

Physiognomic face height values in the Class II malocclusion group were statistically significantly lower than that of the Class III malocclusion group (P < 0.05). The lower facial triad values in the Class III malocclusion group were statistically significantly higher than that of Class I and Class II malocclusion groups (P < 0.05). The chin height values in the Class II malocclusion group were statistically significantly lower than that of Class I and Class III malocclusion groups (P < 0.05) [Table 4].

When the mean and standard deviation values of mentolabial angle, cervicomental angle, midface triad angle, and nasal angle were compared in all genders; there was a statistically significant difference in all measurements (P < 0.05) [Table 5].

Table 5:: Comparison of facial profile measurements by genders.
Parameter Male Female Pa-value
Mean SD Mean SD
Nasolabial angle 101.33 14.36 101.72 10.06 0.811
Mentolabial angle 127.04 14.66 131.64 13.74 0.016
Cervicomental angle 102.82 8.37 95.85 8.92 0.001
Facial convexity angle 167.23 6.73 166.05 6.34 0.177
Total facial convexity angle 141.01 5.92 140.33 9.54 0.519
Lower triad angle 34.33 3.26 34.83 2.84 0.225
Midface triad angle 28.45 2.11 29.16 1.89 0.008
Frankfurt mandibular plane angle 29.63 6.01 30.31 5.30 0.368
Projection of the upper lip relative to the chin 7.12 2.68 7.41 2.37 0.389
Projection of the lower lip relative to the chin 3.09 1.94 3.31 1.45 0.326
Total vertical angle 54.09 4.23 54.03 3.38 0.921
Maxillary angle 12.40 1.51 12.24 1.22 0.387
Mandibular angle 19.24 2.35 18.72 1.70 0.059
Nasal angle 22.44 1.90 23.07 1.71 0.010

SD: Standard deviation, Pa independent-t test significance value

Nasolabial and cervicomental angle values in the Class II malocclusion group were statistically significantly higher than in the Class III malocclusion group (P < 0.05). The mentolabial angle, facial convexity angle, and total facial convexity angle values in the Class III malocclusion group were statistically significantly higher than that of Class I and Class II malocclusion groups. Class I malocclusion group angle values are statistically significantly higher than Class II malocclusion group (P < 0.05). The projection values of the upper lip relative to the chin in the Class III malocclusion group were statistically significantly lower than the Class I and Class II malocclusion groups. The projection values of the upper lip relative to the chin in the Class I malocclusion group were statistically significantly lower than the Class II malocclusion group (P < 0.05) [Table 6].

Table 6:: Comparison of facial profile measurements by dental malocclusions.
Parameter Class I Class II Class III Pa-value Post hocb
Mean SD Mean SD Mean SD I-II I-III II-III
Nasolabial angle 100.47 12.22 104.33 11.85 99.57 12.75 0.042 0.052 0.660 0.019
Mentolabial angle 129.27 12.34 122.82 15.72 136.55 11.18 0.001 0.003 0.001 0.001
Cervicomental angle 99.38 9.15 101.18 9.18 97.32 9.32 0.040 0.226 0.178 0.011
Facial convexity angle 167.06 5.05 162.07 5.52 171.22 5.63 0.001 0.001 0.001 0.001
Total facial convexity angle 141.63 10.38 136.45 5.07 144.29 4.77 0.001 0.001 0.027 0.001
Lower triad angle 34.24 2.98 34.98 3.36 34.49 2.78 0.316 NS* NS* NS*
Midface triad angle 28.77 2.10 29.03 1.98 28.58 2.01 0.393 NS* NS* NS*
Frankfurt mandibular plane angle 29.09 5.10 29.68 5.95 31.22 5.78 0.063 NS* NS* NS*
Projection of the upper lip relative to the chin 7.08 1.93 8.94 2.29 5.61 2.17 0.001 0.001 0.001 0.001
Projection of the lower lip relative to the chin 2.89 1.40 3.52 2.07 3.18 1.54 0.072 NS* NS* NS*
Total vertical angle 53.48 3.60 54.73 3.99 53.94 3.81 0.123 NS* NS* NS*
Maxillary angle 12.15 1.21 12.51 1.38 12.31 1.52 0.275 NS* NS* NS*
Mandibular angle 18.56 1.76 19.28 2.34 19.11 1.99 0.077 NS* NS* NS*
Nasal angle 22.79 1.88 22.93 1.78 22.53 1.83 0.395 NS* NS* NS*

SD: Standard deviation, Pa one-way analysis of variance significance value, Pb LSD parametric Post hoc significance value, NS: Statistically insignificant

DISCUSSION

From past to present, physical appearance is one of the issues that people of all ages and genders care about. The feeling of anxiety felt due to appearance affects self-esteem and perceptions of the person’s appearance. According to the results of the study of Erman et al.,[12] in which the self-esteem of 100 university students was evaluated, no significant difference was found between gender. In the study of Yüceant[13] on 600 physical education teacher candidates, no significant difference was found between genders in terms of social appearance anxiety. In the study of Karazsia and Pieper[14] in which they evaluated body dissatisfaction, they found that all genders had body dissatisfaction at a similar rate. In our study, in the evaluations made according to the results of the Rosenberg RSE, the Sociocultural Attitudes Towards Appearance scale, and the Physical Appearance Comparison Scale, no significant psychosociocultural difference was found between men and women (P > 0.05).

Now in interpersonal interaction, the gaze focuses on the face, eyes, and teeth, especially since the teeth attract more attention, the dentofacial appearance is one of the important factors affecting attractiveness. The physical attractiveness of people with dentofacial deformities or dental disorders is lower than other people, and these people can be mocked and ostracized in the community or their group of friends.[15] Malocclusions negatively affect the psychology of people by causing the formation of functional and esthetic problems. Individuals who are not happy when they look in the mirror due to the appearance of their teeth say that they do not like themselves and cover their mouth with their hands while smiling, feel the need for orthodontic treatment to be better and happier.[16]

Kang and Kang,[17] in their study on 860 adult patients between the ages of 18 and 39 who needed orthodontic treatment, found that individuals were most affected by dental aesthetics psychosocially. Gerzanic et al.[18] showed in their study that 100 patients with Class II and Class III malocclusions who needed orthognathic surgery felt significantly less attractive, gave more importance to their appearance, and felt less secure in terms of facial appearance before orthognathic surgery. According to the results of our study, individuals with Class III malocclusion compare their physical appearance with each other and experience appearance anxiety more than those with Class I and Class II malocclusions.

From the past to the present, facial photography has been a part of keeping orthodontic records both before and after the treatment. It has been stated that in cases where dentists do not have the opportunity to take cephalometric radiographs, photography gains even more importance and is an important diagnostic tool. Measuring from photographs is less inconvenient and less costly for the patient, allows for a recording of the face that can be accessed later, and provides consistency in studies that can be attended by different observers who want to use different measurement techniques.[19,20]

In the study of Topaloğlu,[21] in which 3dMD images of individuals were evaluated, lower face height was measured as 68.25 ± 5.55 mm in Class I patients, 67.78 ± 5.03 mm in Class II patients, and 70.36 ± 6.15 mm in Class III patients. Similarly, in our study, the lower face height of individuals with Class III malocclusion was found to be higher than those with Class I and Class II malocclusions. In our study, the width of the nose and the height of the upper lip were found to be 38.85 ± 2.89 mm and 22.33 ± 2.56 mm in men, 35.13 ± 2.33 mm and 20.21 ± 2.14 mm in women, respectively. Consistent with our study, Ozdemir et al.[22] measured the width of the nose and the height of the upper lip as 38.4 ± 0.44 mm and 21.6 ± 0.31 mm in men and 34.8 ± 0.29 mm and 9.4 ± 0.29 mm in women, respectively.

Fernández-Riveiro et al.[6] found the chin height as 29.09 ± 2.93 mm in men and 25.85 ± 2.48 mm in women, according to their study on photographs. In our study, the chin height was found to be 30.78 ± 4.01 mm in men and 26.29 ± 2.87 mm in women, which indicates that the chin height of men is more than that of women. Among the malocclusion groups, the chin height was statistically significantly lower in the Class II malocclusion group compared to the Class I and Class III malocclusion groups.

The nasolabial angle was found to be 101.33 ± 14.36 in men and 101.72 ± 10.06 in women, and the angle values show great variability. Therefore, measurement results should be interpreted with care. Nanda et al.[23] found the nasolabial angle as 108.15 ± 13.18 in men and 102.78 ± 14.01 in women using video recordings in their study with 50 people aged between 21 and 36. McNamara et al.[24] found the nasolabial angle as 102.2 ± 8 in men and 102.4 ± 8 in women in a study conducted with Caucasians using lateral cephalometric radiographs.

In our study, mentolabial angle values were found to be lower in males than females, similar to the study of Moshkelgosha et al.[25] (127.04 ± 14.66 in males and 131.64 ± 13.74 in females). Among the malocclusion groups, the mentolabial angle values in the Class III malocclusion group were statistically significantly higher than the Class I and Class II malocclusion groups.

Godt et al.[26] found the soft-tissue convexity angle to be 165.73 in Class I patients, 162.87 in Class II patients, and 172.97 in Class III patients, according to their study on the profile photographs of patients with different skeletal malocclusions. Similarly, in our study, facial convexity angle values in the Class III malocclusion group were statistically significantly higher than in Class I and Class II malocclusion groups. The facial convexity angle values in the Class I malocclusion group were found to be statistically significantly higher than the Class II malocclusion group.

CONCLUSION

Class I, Class II, and Class III dental malocclusion individuals have the same level of self-esteem. Class III dental malocclusion individuals compare their physical appearance and experience appearance anxiety more than those with Class I and Class II dental malocclusions. Malocclusion groups have different facial soft-tissue features. The malocclusion and facial appearance of individuals affect their lives in terms of psychosociocultural aspects.

Ethical approval

This study was approved by the Clinical Research Ethics Committee of Ordu University (44/2021, date: April 18, 2021).

Authors contributions

SKB: Conceptualization; SH and SKB: Data curation; SH: Formal analysis; SH and SKB: Investigation; SH and SKB: Methodology, project administration, resources, software; SKB: supervision, validation, and visualization; SH and SKB: Roles/writing of original draft; SH and SKB: Writing-review and editing.

Declaration of patient consent

Institutional Review Board (IRB) permission was obtained for the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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