What defines beauty? A review of historical facial evaluation

According to the saying, “Beauty is in the eye of the beholder” by Margret Hungerford[1] in 1878, the beauty of a person is not inherent to that person but is determined by the viewer. Beauty is subjective, relative and referential. What appears beautiful to one individual may not be the case for another.

In the field of orthodontics, it is important to keep that message in mind especially when treating patients from diverse racial and ethnic backgrounds with different esthetic preferences.[2–5]

Orthodontists are trained to carefully analyze the face from different aspects, and consequently, they form personal biases regarding what is believed to be an esthetic profile.[6,7] According to Dr. Charles Tweed and Dr. William Downs, these biases were to some extent a result of studies evaluating the Class I facial profile, which was used as the norm for objective evaluation, especially regarding treatment.[6,7] These Class I facial norms were established from the Caucasian male viewed by Tweed and Downs, among others, whose studies were limited to Caucasians.[6,7]

These classic studies, however, did not evaluate people of other ethnicities when establishing these norms. According to recent studies by Mejia-Maidl, Hall, Chan and Park et al., examining the soft-tissue profile preferences of Mexican Americans, African Americans, Asian Americans and Caucasians, orthodontists should consider that people from different ethnicities have perceptions of beauty that can vary from the classic norm.[2–5]

The following studies have shown these ethnicities have different facial profile preferences when compared with Caucasian standards, indicating it is perhaps better for orthodontists to strive for beauty based on patient preferences when treating individuals of different ethnic groups.

Mexican American profiles

Mejia-Maidl et al.[2] conducted a study that compared facial profile preferences of Mexican Americans and Caucasians. Their research compared esthetic preferences of low- and high-acculturated Mexican Americans with Caucasians preferences. The ethnic groups were asked to evaluate esthetic preferences of lip protrusions from computer animation images of males and females from Mexican descent (Fig. 1 — Three sample frames {maximum retrusive, unaltered and maximum protrusive} of two men and two women used for the computer animations {Mejia-Maidl et al.[2]}.) and found that: (a) most Mexican Americans preferred upper or lower lip positions to be less protrusive than did Caucasians, particularly for female computer animation images; (b) there was a statistically significant difference between mean midpoint of acceptability of lower and upper female lip positions between Caucasians and low-acculturated Mexican Americans compared with Caucasians and high-acculturated Mexican Americans; (c) for both male and female computer animation images, low-acculturated Mexican American judges considered the most attractive upper and lower lip positions to be less protrusive; and (d) Caucasian judges, when compared with low-acculturated Mexicans, had larger mean zones of acceptabilities for both male upper and lower lip positions and female lower lip positions.

The results of this study suggested the level of acculturation of the ethnic groups can have significant influences on laypersons’ judgments of lip profile preferences and should be taken into consideration during orthodontic treatment planning.

African American profiles

Hall et al.[3] led a study that assessed the facial profile preferences of African American and Caucasian laypersons and orthodontists in an attempt to better understand the role of ethnicity in the perception of beauty. Their study evaluated cephalometric radiographs of African American and Caucasian patients and silhouette images of African American and Caucasian profiles and discovered that: (a) African American and Caucasian lay persons and orthodontists preferred the African American sample to have a greater profile convexity and greater skeletal convexity than they preferred for the Caucasian sample; (b) African American orthodontists preferred more prominent and protrusive upper and lower lips for the African American sample than for the Caucasian sample yet Caucasian orthodontists and laypersons did not share this preference; and (c) when using Z-angles to evaluate the preferences for soft-tissue convexity, the Z-angles for the African American profiles were outside the normal range because Caucasian and African American orthodontists and laypersons all preferred a more protrusive profile for African Americans profiles than they selected for the Caucasian sample (Fig. 2 — Angular measurements of soft tissue. 1) Z-angle; 2) facial angle; 3) angle of Convexity {Hall et al.[3]} and Fig. 3 — Profiles representing mean Z-angle chosen as acceptable by all raters for (A) Caucasian sample and for (B) African American sample {Hall et al.[3]}).

In this study, the Z-angle is defined as a profile line established by drawing a line tangent to the soft-tissue chin and to the most anterior point of either the lower or upper lip, whichever is most protrusive, and extending it upward to the Frankfort plane (Fig. 2). The norm values for the Z-angle were originally derived from a sample of Caucasian patients, and thus as shown in this study, these norm values are not always applicable when evaluating esthetics of other ethnicities.

These results show that a single standard of facial esthetics does not work when critically evaluating facial esthetics of various ethnic groups. It is important that orthodontists recognize diverse ethnic groups can have different facial esthetic preferences and address these differences during treatment.

Chinese American profiles

Chan et al.[4] conducted a research study in 2008 investigating Asian-Chinese soft-tissue profile preferences from the Caucasian perspective (Fig. 4 — A male’s facial profile is altered, and a survey consisting of the following picture choices, A–G, is completed to determine the most attractive male facial profiles: A: bimaxillary protrusion; B: protrusive mandible; C: retrusive mandible; D: normal profile; E: retrusive maxilla; F: protrusive maxilla; G: bimaxillary retrusion {Chan et al.[4]} and Fig. 5 — A female’s facial profile is altered and a survey consisting of the following picture choices, H–N, is completed to determine the most attractive female facial profiles: H: retrusive mandible; I: retrusive maxilla; J: bimaxillary protrusion; K: protrusive mandible; L: normal profile; M: protrusive maxilla; N: bimaxillary retrusion {Chan et al.[4)}). The results of this study indicated the most appealing profile to Caucasians was the Class I or bimaxillary retrusive profiles of Chinese Americans for both men and women. The least attractive profile was the protrusive mandible for Chinese males, and the protrusive mandible and retrusive mandible were least attractive for Chinese female profiles. However, what about the assessment of the Asian profile from the Asian perspective?

Korean American profiles

Park et al.[5] researched the differences in facial profile preferences between Caucasian orthodontists and Korean American patients. The objectives of this particular study were to determine the: (a) profile preferences using altered profile images of a Korean male and female (Fig. 6 — Frames of extreme distortions and unaltered images of all six movies {Park et al.[5]}), (b) difference in preference between the Korean American patients and Asian orthodontists, (c) difference in preference between the Korean American patients and the Caucasian orthodontists, (d) difference in preference between the Asian orthodontists and Caucasian orthodontists and (e) difference in preference between two groups of Korean American patients with two levels of acculturation.

The results of the study revealed: (a) there was a significant difference between the most pleasing and midpoint of the acceptability of males and females, although there was no difference in the zone of acceptability between the Caucasian orthodontists and the Korean American patients; (b) the Korean American patients preferred a more protrusive nose on females and a more retrusive chin on the male image than did the Caucasian orthodontists; (c) there was a borderline difference between the Asian orthodontists and the Caucasian orthodontists, suggesting a possible difference in preference of the nose size of females. Asian orthodontists preferred a larger nose than the Caucasian orthodontists; (d) there was also a significant statistical difference between the more-acculturated Korean American patients and the less-
acculturated Korean American patients; (e) the more acculturated group also preferred a less prominent nose for the female profile than the less acculturated, who preferred a more prominent nose for the female profile; (f) between the other groups, there were no statistical significant mean differences.

Further studies are necessary to confirm and find other differences in profile preferences. Based on this study by Park et al., Caucasian orthodontists must be aware of the possible differences of profile preferences when seeing patients of other ethnic groups.

Conclusion

According to these studies, esthetic facial profile preferences of laypersons and dental professionals from different backgrounds are significantly influenced by culture and ethnicity. When comparing preferences of lip protrusion between Mexican American and Caucasian laypersons, Mejia-Maidl et al. found Mexican American laypersons preferred upper or lower lip positions of Mexican American computer animation images to be less protrusive than did Caucasian laypersons.[2]

The level of acculturation also affected facial profile preferences: low-acculturated Mexican American’s and Caucasian’s profile preferences differed in the mean preferred positions of the lower and upper lip of Mexican American images, whereas high-acculturated Mexican American and Caucasian preferences did not.

When examining African American facial profiles, Hall et al. discovered African American and Caucasian orthodontists and laypersons preferred a greater facial convexity and more prominent upper and lower lips for African Americans than for Caucasians.[3]

When evaluating the angular relationship of the lower face using the Z-angle, the African American facial profiles that were most appealing to African American and Caucasian orthodontists and laypersons differed from the Z-angle norms.

These Z-angle norms were originally formulated from Caucasian profiles, signifying that current norms of facial esthetics are not always appropriate for individuals of other ethnicities.

While studying Asian American soft-tissue profiles from the Caucasian perspective, Chan et al. noted Caucasian orthodontists, dental students and laypersons preferred a bimaxillary retrusive profile for Chinese Americans. The least preferred profile selected for Chinese Americans was a protrusive mandible for males and protrusive and retrusive mandible for females.4 On the contrary, when evaluating the Asian American profile from the Asian perspective, Park et al. showed Korean-American orthodontic patients preferred a more protrusive nose for females and retrusive chin for males in contrast to Caucasian orthodontists.5 Caucasian orthodontists preferred a smaller nose for Korean American females compared to Asian orthodontists.

The results of these studies suggest a single standard of facial esthetics should not be applied generically to diverse racial and ethnic groups. These observations highlight the importance of attention to patient individuality and esthetic preferences when treatment planning individuals from different cultures.

Successful orthodontic treatment includes attaining the most visually pleasing profile achievable; thus, it is important for the orthodontist to be mindful of the various ethnic groups’ perception of beauty and the individual’s preferences before initiating treatment. Facial variations and the facial esthetic preferences of different ethnicities must be considered as important and distinctive considerations for orthodontic diagnosis and treatment planning.

Note: References are available from the publisher.

About the authors

Tali Elfersi is a senior dental student at University of Southern California School of Dentistry. Contact her at elfersi@usc.edu. Dr. Esther Moon is orthodontic resident at University of Southern California School of Dentistry. Contact her at esther mo@usc.edu.