SPECIAL ARTICLE
The enigma of facial beauty: Esthetics, proportions, deformity, and controversy Farhad B. Naini,a James P. Moss,b and Daljit S. Gillc London, United Kingdom The study of the face and the ability to alter its form have fascinated mankind for thousands of years. The clinical ability to alter dentofacial form, whether through orthodontics, facial growth modification, or surgery, requires an understanding of facial beauty, including the evaluation of facial esthetics, proportions, and symmetry. The purposes of this article were to give a brief contemporary overview of our concepts of facial beauty and esthetics and to consider a long-standing and controversial debate on the treatment of patients with dentofacial deformities. (Am J Orthod Dentofacial Orthop 2006;130:277-82)
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rthodontists have a special interest in facial beauty, although, over time, the relative importance of esthetics has waxed and waned in relation to other considerations. In part of his ongoing review of orthodontic history, Wahl1 wrote, “Now it appears that facial esthetics is again in the forefront as we realize why patients come to us in the first place.”1 Perceptions of facial beauty are multifactorial, with genetic, environmental, and cultural foundations.2 Beauty can be defined as a combination of qualities that give pleasure to the senses or to the mind. Esthetics is the study of beauty and, to a lesser extent, its opposite, the ugly. The 18th century philosopher Alexander Baumgarten, who established esthetics as a distinct field of philosophy, coined the term, which is derived from the Greek word for sensory perception (aisthesis).3 The first question to consider is difficult to answer: is the origin of the human perception of facial beauty dependent on each person’s sense perception, or is this sense common to all people? Is facial beauty a quality of the observed face, or does the sensory enjoyment of the observers also depend on their own ideas, feelings, and judgments, which themselves have a direct relationship to sensory enjoyment. The philosopher David Hume (1741) said, “Beauty in things exists in the mind which contemplates them,”4 and the writer Margaret a
Consultant, Director of Research and Graduate Education, Orthodontic Department, St George’s Hospital and Medical School, Kingston Hospital, London, United Kingdom. b Professor, Orthodontic Department, Royal London Hospital, London, United Kingdom. c Consultant, Orthodontic Department, Eastman Dental Hospital, London, United Kingdom. Reprint requests to: Dr Farhad B. Naini, Consultant, Orthodontic Department, St George’s Hospital and Medical School, Blackshaw Rd, London, SW17 0QT, United Kingdom; e-mail,
[email protected]. Submitted, April 2005; revised and accepted, September 2005. 0889-5406/$32.00 Copyright © 2006 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2005.09.027
Wolfe Hungerford (1878) famously said, “Beauty is in the eye of the beholder.”5 Both of these quotations, and their respective philosophical ideologies, assume that the “sense” is subjective to each person. However, the 18th century philosopher Francis Hutcheson said, “Esthetic judgements are perceptual and take their authority from a sense that is common to all who make them,” and “The origin of our perceptions of beauty and harmony is justly called a ‘sense’ because it involves no intellectual element, no reflection on principles and causes.”6 The philosopher Immanuel Kant (1790) reiterated this view, saying that, “The beautiful is that which pleases universally without a concept.”7 Therefore, if a beautiful face “pleases universally,” then some part of our sense perception must be common to all men and women. After all, when we describe a face as beautiful, we do not merely mean that it pleases us. We are describing the face, not our judgment. We will often point to features of the face to back up our statement. A paradox therefore emerges. Obviously one cannot make a judgment about the beauty of a face one has never seen. Therefore, facial beauty is related to some quality of the observed face that tends to be universally accepted. However, each person’s ideas and feelings, like a conditioned response, also have a direct relationship to his or her judgment, hence the difference in the extent of rating a face as beautiful depending on the “eye of the beholder.” This philosophical question and its related argument continue to be debated. However, beauty undoubtedly has a strong influence on human life. According to Shakespeare, “Beauty itself doth of itself persuade the eyes of men without an orator.”8 The philosopher Pascal commented, “Had Cleopatra’s nose been shorter, the whole face of the world 277
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would have changed!”9 From Homer’s Helen of Troy, whom the poet Christopher Marlowe described as having a “face that launched a thousand ships,”10 to Queen Nefertiti, whose name literally means the “Perfect One,” to modern models and actors, facial beauty has always been the most valued aspect of human beauty. The next question therefore is how do we know that a face is beautiful? What guides and validates our judgment? Our perception of facial beauty might have its foundation in our heredity, environment, or perhaps both. Langlois et al11 found that infants as young as 3 months of age can distinguish between attractive and unattractive faces, showing signs of preference for the former. It is unlikely that by 3 months of age an infant will have been subjected to or responded to any cultural or environmental influences; therefore, this is evidence to support a genetic theory. The evolutionary basis is that facial beauty, including facial symmetry and secondary sexual characteristics, is a requirement for sexual selection, leading to reproduction.12 A study by Martin13 found that both white and black American men preferred black female faces with white features, whereas black African men showed a preference for black female faces with Negroid features. This lends support to environmental or cultural reasons for the human perception of facial beauty. However, Perrett et al14 found that both white and Japanese men and women ranked female faces as most attractive when youthful facial features, such as large eyes, high cheekbones, and narrow jaws, were evident. Esthetic judgments therefore seem to be similar across various cultural backgrounds. A meta-analysis by Langlois et al15 seemed to confirm that there is crosscultural agreement about facial attractiveness. Studies by Sir Francis Galton,16 Charles Darwin’s cousin, provide evidence to support averageness as the ideal,17 with composite facial photographs of subjects gaining higher attractiveness ratings than individual facial photographs.18 However, Perrett et al14 showed that, contrary to this averageness hypothesis, the mean shape of a group of attractive faces is preferred to the mean shape of the sample from which the faces were selected. In addition, attractive composite faces were made more attractive by exaggerating the shape differences from the sample mean. Therefore, an average face shape is attractive but might not be optimally attractive,19 and highly attractive facial configurations are not necessarily average.20 FACIAL PROPORTIONS
The assessment of facial beauty is essentially subjective.21 In the 16th century, the artist Albrecht Dürer
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said, “I know not what beauty is, but I know that it affects many things in life.” Dürer explained that, although the concept of facial beauty was immersed in subjectivity, the assessment of facial proportions could be undertaken objectively.22 He maintained that disproportionate human faces were unesthetic, whereas proportionate features were acceptable if not always beautiful. Therefore, the appropriate goal for the orthodontist’s clinical examination is to find facial disproportions.23 The inevitable question is, therefore, where did the evidence for ideal facial proportions originate? In representing the human form, painters and sculptors in the past developed many canons or guidelines. These were mainly based on the “good eye” of the respective artist, which is anecdotal evidence. However, many of these guidelines are still used by clinicians today, albeit somewhat modified from the originals. A major preoccupation of Greek sculptors was the idealization of human proportions. In the fifth century BC, one of the most famous, Polycleitus, wrote a theoretical work that discussed ideal mathematical proportions for the parts of the human body. In his Canon, he also described the importance of the concept of symmetry in the human form, called “symmetria.” In the first century BC, the Roman architect Marcus Vitruvius Pollio wrote his famous work, The Ten Books on Architecture. In Book 2, Chapter 2, Vitruvius defined symmetry as “a proper agreement between the members of the work itself, and relation between the different parts and the whole general scheme, in accordance with a certain part selected as standard. Thus in the human body there is a kind of symmetrical harmony . . . and so it is with perfect buildings.”24 Although the relationship between bilateral facial symmetry and beauty remains to be clarified,25 evidence seems to suggest that mild facial asymmetry is compatible with facial beauty.26 Vitruvius also described the facial trisection, emphasizing that the ideal face can be divided vertically into 3 distinct thirds, a concept still used today in planning facial surgery. The great Renaissance artist and thinker Leonardo da Vinci emphasized the importance of harmony between art and science. Leonardo defined proportion as the ratio between the respective parts and the whole.27 The figure of Vitruvian man (Fig 1), which Leonardo based on guidelines described by Vitruvius, shows the importance of proportions in the human form. He also studied the proportions of the human head (Fig 2). The distance from the hairline to the inferior aspect of the chin is one-tenth of a man’s height. The distance from the top of the head to the inferior aspect of the chin is one-eighth of a man’s height. These have important
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Fig 1. Leonardo da Vinci’s Vitruvian man, ca 1490. This famous figure shows that proportionate human form fits perfectly in perfect geometric shapes— circle and square, with navel at center. Vertical facial trisection is shown. Vertical face height (hairline to inferior aspect of chin) is one tenth of standing height. Interestingly, this is equal to length of hand (courtesy of Gallerie dell’Accademia, Venice).
clinical implications. If a patient’s vertical facial proportions are to be altered with surgery, the treatment plan must take into account the proportion of the patient’s total face height to his or her standing height and stature. The use of absolute numeric values of facial measurements rather than facial proportions can be misleading, because the vertical facial height of a patient who is 6 feet tall is different from that of a patient 5 feet tall. Dürer, in 1525, maintained the importance of studying facial proportions, criticizing artists of his day, and saying, “They have not learnt Geometry, without which no one can either be or become an absolute artist.”22 Therefore, the guidelines used by clinicians today are mainly based on those initially described in art. The
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Fig 2. Leonardo da Vinci’s Male head in profile with proportions, ca 1490. Vitruvian anterior vertical facial thirds are evident: hairline to eyebrows, eyebrows to base of nose, base of nose to below chin. Lower facial third is again divided into upper third (upper lip) and lower two-thirds. Ear is one third of facial height. What later came to be described as Frankfort plane and its perpendicular, facial vertical from soft-tissue nasion, are also shown (courtesy of Gallerie dell’Accademia, Venice).
orthodontic specialty, however, has been at the forefront in the assessment of the facial soft-tissue profile,28 mainly because of the use of lateral cephalometric radiographs that provide many analyses.29-35 Clinicians therefore can assess facial esthetics more objectively by diagnosing and helping to correct facial disproportions. Since the establishment of our specialty over 100 years ago, orthodontic theory and practice have been based on the Angle paradigm.36 The goal of treatment was to produce perfect occlusion of all the teeth, and facial beauty was thought to follow. Although this concept was discredited with the introduction and growth of cephalometrics, the basic idea that the dentofacial skeleton determined the goals of treatment remained intact.37 It is only recently that the concept of the soft-tissue
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paradigm, focusing the diagnosis and treatment of dentofacial problems on the soft tissues of the face rather than on dentoskeletal structures, has emerged in orthodontics and orthognathic surgery.23 The dentoskeletal structures of the face are like the scaffold over which the soft tissues drape. However, it is the soft-tissue proportions, not the skeletal proportions, that are the goals of treatment.38 Proffit et al23 have led the way in the emergence of this paradigm shift, placing greater emphasis on the clinical examination of the patient and our assessment of the soft-tissue changes that occur with each dentoskeletal change and with age, thus allowing for greater accuracy in treatment planning. FACIAL PROPORTIONS AND THE GOLDEN PROPORTION
An often-quoted but rarely substantiated concept is that of the “golden proportion.”39 The mathematician Euclid (ca 325-265 BC) described this in The Elements, his treatise on mathematics. The origin of this concept is unknown, having been attributed to both Pythagoras and Plato. In his edition of Euclid’s Elements, the mathematician Luca Pacioli (1509) renamed the golden proportion the “divine proportion” because he thought the concept could not be rationalized. Pacioli also published a treatise entitled De Divina Proportione (On Divine Proportion) for which Leonardo da Vinci drew figures of symmetrical and proportionate faces and bodies. Later in that century (1597), the first known calculation of the golden proportion as a decimal was given by Maestlin in a letter to his former pupil, Kepler.40 The number is 0.618 for the length of the longer segment of a line of length 1 when it is divided in the golden proportion. The ratio of the shorter section to the longer section of the line is equal to the ratio of the longer section to the whole line. The point at which the line is divided is known as the golden section and is represented by the symbol ⌽ (phi) derived from the name of the Greek sculptor Phidias who incorporated it into the architectural design of the Parthenon.41 There have been attempts to correlate ideal facial proportions with the golden proportion.42 However, in a 3-dimensional study analyzing the faces of professional models, the authors found that they did not fit the golden proportion and, interestingly, that they had various malocclusions and a wide range of cephalometric values.43 In another study of the esthetic improvement of patients having orthognathic surgery, the authors found that, whereas most subjects were considered more attractive after treatment than before, the proportions were equally likely to move away from or toward the golden
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proportion.44 Therefore, more research evidence is required to substantiate the true significance of this fascinating concept in the clinical assessment of facial esthetics. FACIAL DEFORMITY AND THE CONTROVERSIAL DEBATE
The final question concerns patients with facial anomalies of varying magnitudes and whether they should be treated, especially when the deformity is not part of an active disease process. A person’s self-perception of facial appearance is of utmost importance. It has been said, “Nothing has so marked influence on the direction of a man’s mind as his appearance, and not his appearance itself so much as his conviction that it is attractive or unattractive.”45 There is, of course, considerable individual variation in people’s abilities to adapt to their facial deformities, whatever the severity, with some remaining comparatively unaffected and others having significant difficulties that affect their quality of life. It has even been argued that facial deformity might be a social disability, because it impacts not only the person affected, but also contributes to the opinions other people form of them.46 Although these opinions can change as interpersonal relationships develop, a person’s first impression on others might well affect his or her self-esteem and quality of life.47 Research seems to indicate that mild to moderate facial deformities actually cause a patient greater psychological distress than severe facial deformities.48 This could be because other people’s reactions towards milder deformities are less predictable, whereas more severe deformities tend to evoke more consistent reactions, albeit negative, allowing the patient to develop better coping strategies. The variability in people’s reactions to milder facial deformities also causes considerable patient distress. Most patients seeking orthodontic treatment or facial esthetic surgery fit into the mild or moderate category in terms of facial deformities, as opposed to craniofacial malformation syndromes or severe facial trauma or disease. There is a long-standing and controversial debate about the ability to alter facial appearance. The debate centers on whether a patient with a facial deformity should learn to live with his or her facial appearance. This argument states that a psychologically healthy patient should be able to adjust to the social environment. The supporters of this view also state that education of the public and changes in public attitudes toward visible facial differences are the correct way forward. The argument against this case states that the negative effects of facial deformity on a patient’s
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psychosocial well being are enough to warrant clinical intervention. The 2 sides seem unable to reach common ground. We believe that there is merit in both sides of the argument, and that they are not mutually exclusive. There is no doubt that attitudes in society toward all types of deformity have changed, and public education is undoubtedly the most important factor, with charities such as Changing Faces49 helping to both educate the public and change public opinion regarding facial deformities. Modern society’s media-fuelled obsession with the so-called perfect appearance is at best unhelpful and at worst detrimental. People compare themselves to those who are unrealistically portrayed by the media to represent cultural ideals of beauty, and, if their own appearances do not measure up, this might result in body-image dissatisfaction, possibly leading to altered self-recognition and conditions such as eating disorders and body dysmorphic disorder.50 Therefore, although it is unrealistic to expect the media’s obsession with appearance to significantly change, greater responsibility on the media’s part would be commended. In addition, television documentaries, perhaps interviewing patients and families of patients with dentofacial anomalies, and following patients through their daily lives as they describe their challenges, would undoubtedly be useful for educating the general public. Such education might help lessen society’s intolerance for what is considered an abnormal facial appearance and contribute to transforming the public’s perception of those with facial deformities. However, it would be simplistic and possibly unethical to withhold treatment on the basis that the problem is with attitudes in society alone. If treatment can significantly improve a patient’s quality of life, then it is for the patient to make the ultimate informed decision of whether treatment is the correct way forward. CONCLUSIONS
The aim of this article was to briefly describe our contemporary understanding of facial beauty and to debate the challenges faced by patients and clinicians in the treatment of dentofacial deformities. There is no doubt that the philosophical debate and the research will continue, because our clinical practice should always be based on a sound knowledge of theory. One may only conclude that patients requiring alterations in facial appearance remain a considerable clinical challenge.
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