Forensic aesthetic facial damage—AFD expert’s valuation is a concerning matter in court as expressively vary in between experts. In fact, differences can be quite significant suggesting examiners age, sex and professional qualification may influence this valuation. Aiming to offer a systematic and more objective evaluation, some methods for assessing AFD had been proposed lately. Known as Aesthetic Impairment Impact Perception (AIPE), Cobo-Plana’s revised methodology (2010) was idealized to minimize the examiner’s subjectivity by means of answering an ordered sequence of questions related to the specific damage perception. This research aims to access AFD perception differences (simulated cases) in between Lawyers, Heath professionals (Physicians and Dental surgeons) and general professionals (laypeople) under AIPE methodology in order to allow a better comprehension of AFD when dealing with forensic expertise cases. Within Groups perceptions varied (p < 0.05) when evaluating lesions below “important” severity grade. Raters over 35 Years age scored higher AFD lesions, and rater’s sex (as an independent variable) did not express any significant difference in AFD scoring. The tendency of under-rating AFD lesions below very important severity grade was observed being a matter of major concern considered their prevalence and the effective consequences involved to the victim. These results recommend extra caution when performing AFD evaluation and consequently expertise reports, claiming a more judicious analysis based on consolidated standards and suggest, examiners to be more perceptive to physical damage evaluation in order to include social perceptions and reactions, mainly, victims feelings and constrains over their aesthetic loss.
The prevalence of oral and maxillofacial trauma increased in the last decades following a growing trend in traffic and labor accidents, urban violence and even professional malpractice. In many cases, these traumas consolidate with evident sequels—expressed clinically as scars [
AIPES categories are defined based on increasing grades and points from: 1) not relevant lesion, zero score; 2) slight injury, values 1 to 6 points; 3) moderate, 7 - 12 points; 4) medium, 13 - 18 points; 5) important 19 - 24 points; 6) very important, 25 - 30 points; 7) truly important lesion, 31 - 50 points. These scores (points) are directly transformed in economic values [
Considered AIPE’s systematic and guided approach and the fact is being successfully used in Spain Court since 2014 (modifications RDL n 8/2015 and Law 5/20151) and aiming to improve and better equalize the expert analysis on AFD evaluation, the present study accessed, under AIPE application, health professionals, lawyers and laypeople perceptions in a given set of cases and confronted those results (adherence) to the expected golden standard values.
The present research was approved by University of São Paulo Dentistry Scholl Committee of Ethics on June 24, 2015, under the protocol: CAAE: 43009915.2.0000.0075.
To access AFD perceptions in between health professionals, lawyers and lay people the present research worked on a convenience sample of 391 subjects in accordance to the recommended theoretical sample size.
As a pre-requisite to join this research, participants should be graduated in College and should have signed an informed consent.
Dental Surgeons specializing in Forensic Dentistry (included in previous research) [
Health professionals not Physicians or Dental Surgeons.
Nine sets of photographs simulating six different grade cases of AFD were provided to the participants. Each case contained images in frontal, oblique, and lateral views presented in overview and in close-up following Fernandes et al. protocol [
The golden standard values for each simulated lesion were set under a three-experienced forensic experts’ evaluation, in a process that included AIPE’s author ratification, in this sense, all simulated cases were drawn considering AIPE’s principles in order to correspond to a clear classification.
Scorings within and between groups of professionals were compared using Chi Square tests, Student’s T test and ANOVA with a significance level of 5%. All tests were performed with SPSS 17.0 (IBM -Armonk, NY, USA) software package.
The sample consisted of 391 subjects (223 females and 168 males), out of which 93 were Lawyers, 93 were Physicians, 107 were Dental Surgeons and 98 were professionals out of the Health sciences and Law. The mean age of the sample was 39 years old, being 49.4% of them over 35 years age.
To access the 0 - 50 AFD scoring an ANOVA test was used to analyze potential perception differences in between the three professional groups. Significant variations were noticed in six of the nine lesions (p < 0.05), being lawyers’ group (G1) the one that scored less all cases (
Examiners aged above 35 years tended to score AFD higher than the examiners aged below 35 years (p < 0.05). This phenomenon occurred in 6 out of the 9 lesions, consistently the lower severity ones (
Case | Sex | Gold Standard | Under-rated | Expected | Over-rated | P value within groups |
---|---|---|---|---|---|---|
L1 | F | 1 | 19.4% | 47.6% | 33.0% | 0.003* |
L2 | F | 3 | 61.9% | 25.8% | 12.3% | 0.162 |
L3 | F | 4 | 66.5% | 25.6% | 7.9% | 0.164 |
L4 | M | 5 | 62.8% | 24.9% | 12.3% | 0.205 |
L5 | F | 1 | 22.3% | 48.3% | 29.4% | 0.179 |
L6 | M | 6 | 56.3% | 43.7% | 0.250 | |
L7 | F | 3 | 74.9% | 17.6% | 7.4% | 0.167 |
L8 | M | 0 | 37.7% | 62.3% | 0.000* | |
L9 | M | 5 | 70.3% | 20.0% | 9.7% | 0.133 |
Total Mean | 54.3% | 32.4% | 21.8% |
AIPE grade scores: 0 = not relevant lesion; 1 = slight injury; 2) moderate; 3) medium; 4) important; 5) very important; 6) truly important lesion.
Group | Lawyers | Heath professionals | Laypeople | P value within groups | |
---|---|---|---|---|---|
L1 | Under-rated | 29.00% | 20.50% | 8.20% | 0.003* |
Expected | 43.00% | 49.50% | 48.00% | ||
Over-rated | 28.00% | 30.00% | 43.90% | ||
L2 | Under-rated | 67.70% | 63.50% | 53.10% | 0.162 |
Expected | 23.70% | 25.50% | 28.60% | ||
Over-rated | 8.60% | 11.00% | 18.40% | ||
L3 | Under-rated | 72.00% | 68.50% | 57.10% | 0.164 |
Expected | 21.50% | 25.00% | 30.60% | ||
Over-rated | 6.50% | 6.50% | 12.20% | ||
L4 | Under-rated | 71.00% | 62.80% | 55.10% | 0.205 |
Expected | 18.30% | 26.10% | 28.60% | ||
Over-rated | 10.80% | 11.10% | 16.30% | ||
L5 | Under-rated | 30.10% | 21.00% | 17.30% | 0.179 |
Expected | 45.20% | 50.50% | 46.90% | ||
Over-rated | 24.70% | 28.50% | 35.70% | ||
L6 | Under-rated | 54.80% | 60.00% | 50.00% | 0.25 |
Expected | 45.20% | 40.00% | 50.00% | ||
Over-rated | |||||
L7 | Under-rated | 78.50% | 73.50% | 74.50% | 0.167 |
Expected | 16.10% | 20.50% | 13.30% | ||
Over-rated | 5.40% | 6.00% | 12.20% | ||
L8 | Under-rated | 0.00* | |||
Expected | 52.70% | 40.50% | 17.50% | ||
Over-rated | 47.30% | 59.50% | 82.50% | ||
L9 | Under-rated | 76.30% | 72.00% | 60.80% | 0.133 |
Expected | 14.00% | 20.00% | 25.80% | ||
Over-rated | 9.70% | 8.00% | 13.40% |
Group | L1 | L2 | L3 | L4 | L5 | L6 | L7 | L8 | L9 |
---|---|---|---|---|---|---|---|---|---|
Lawyers | 4.10 | 8.14 | 13.65 | 22.64 | 3.94 | 33.15 | 5.96 | 2.43 | 20.18 |
Heath | 4.45 | 9.15 | 14.88 | 25.05 | 4.27 | 33.30 | 7.04 | 3.22 | 22.69 |
Laypeople | 6.86 | 11.62 | 17.26 | 26.47 | 5.67 | 35.83 | 8.66 | 6.59 | 24.33 |
Total | 4.97 | 9.53 | 15.18 | 24.83 | 4.55 | 33.90 | 7.19 | 3.87 | 22.50 |
P | 0.001 | 0.002 | 0.006 | 0.100* | 0.114* | 0.114* | 0.014 | 0.000 | 0.006 |
AFD: Aesthetic facial damage; G1: Lawyers; G2: Physicians and Dental surgeons; G3: lay people; GT: total sample; L: lesion; F: female; M: male; p: p-value considering a significance rate of 5%; *: statistically not significant.
Age | L1 | L2 | L3 | L4 | L5 | L6 | L7 | L8 | L9 |
---|---|---|---|---|---|---|---|---|---|
<35 | 3.98 | 8.42 | 14.04 | 24.97 | 3.61 | 33.86 | 6.16 | 2.68 | 23.05 |
>35 | 5.99 | 10.67 | 16.36 | 24.69 | 5.50 | 33.94 | 8.25 | 5.09 | 21.93 |
Mean | 4.97 | 9.53 | 15.18 | 24.83 | 4.54 | 33.90 | 7.19 | 3.87 | 22.50 |
p | 0.001* | 0.002* | 0.004* | 0.756 | 0.003* | 0.936 | 0.001* | 0.000* | 0.223 |
Designed to access maxillofacial AFD perception, the present research focused, more specifically, those professionals usually involved in the forensic scenario, such as Lawyers and Health Professionals. Additionally, the perception of laypersons (represented by a group of professionals not related to Health Sciences and Law) was also investigated as being of crucial importance in such context [
When dealing with AIPE’s scoring system is important to consider examiners perceptions over two aspects: The 0 - 6-severity graduation and the 0 - 50 valuation scale. Although both aspects are correlated, their practical purposes differ, as so differ their statistical behavior in terms of sensitivity due to scale range, and because of this, had to be analyzed in separate steps. This aspect, however, does not affect any of the results and conclusions of the research.
Participant’s adherence to Golden Standards severity classification values tended to express under-rating. The mean severity classification adherence was of 32.4%.
Any significant variation was observed within groups, except of lesions 1 and 8 where laypeople tended to overestimate the evaluation.
Cases 2 & 7, Case 3 and cases 4 & 9—were those that expressed the major under-rating frequencies (over a 62.8% frequency). This scenario is a matter of major concern as according to the Mapfre Foundation [
Considered AIPES’ 0 - 50 scoring system, the groups expressed different perceptions when dealing with lesions below “important” severity range. According ANOVA test, the mean values divergence in between the groups were, so, considered significant (p < 0.05) for lesions 1 to 3 and from 7 to 9, and not significant for lesions 4 and 6, whose correspondences are to “very important” and “extremely important” lesions respectively.
When dealing with all cases involving different perceptions, Lawyers group was the one that rated the lower scores. One of the possible reasons behind this outcome is intrinsic to lawyers formation and practice relying on the “General Theory of Law”, in which, underrating is a natural aspect of a litigant process to allow a more tangible quantification for both sides involved in a lawsuit [
Assuming rater’s sex and age as independent variables, another important aspect observed over AIPES’ 0 - 50 scoring system was that while the examiners sex didn’t express any significant AFD perception divergence (internally and within the groups), examiners over 35 years of age scored higher the presented lesions.
Fernandes et al. [
The observed results pointed that the health professional’s valuation is in between Lawyers perceptions and Laypeople perception. Considered of fundamental importance to the forensic health professional perception, as pointed by the literature, tend to be more critical in relation to facial aesthetics [
Aesthetic perception and judgement are not just cognitive processes, but also involve feelings, and studies of these experiences require conceptualization and measurement of these emotions [
Transposing the perception of AFD from the scientific and academic field to the social scenario consists of a humanitarian process from which new perspectives may emerge to aid justice and society. Moreover, AFD is perceived not only in Court, but also in social daily activities [
These results recommend extra caution when performing the great majority of AFD expertise analysis. Evaluation and consequently expertise reports claim a judicious analysis based on consolidated standards. Examiners are encouraged being more perceptive to physical damage evaluation in order to include social perceptions and reactions, mainly, victim’s feelings and constrains over their aesthetic loss.
The authors declare no conflicts of interest regarding the publication of this paper.
Mazzilli, L.E.N., Sakaguti, N.M., Fernandes, M.M., Plana, J.A.C., Bouchardet, F.C.H. and de Oliveira, R.N. (2020) Relevant Aspects of Expert Interest in the Perception of the Facial Aesthetic Damage. Forensic Medicine and Ana- tomy Research, 8, 1-10. https://doi.org/10.4236/fmar.2020.81001