ORIGINAL ARTICLE

Contribution of facial components to the

attractiveness of the smiling face in male
and female patients: A cross-sectional
correlation study
Joana Godinho,a Roger Peres Gonçalves,b and Luis Jardima
Lisboa, Portugal, and Edinburgh, Scotland

Introduction: Esthetic improvement is a key motivator in undergoing orthodontic treatment. This study aims to
quantify the contribution of the smile and other facial components to the overall esthetics of attractiveness.
Methods: The attractiveness of 60 subjects (30 men, 30 women), aged 18-35 years, before orthodontic treat-
ment, was retrospectively evaluated by 8 laypersons using the Visual Analog Scale. Pearson and stepwise cor-
relations were calculated between the attractiveness of the smiling face and the attractiveness of facial
components; namely the smile, nose, eyes, hair, chin, eyebrows, and skin. Results: A strong correlation be-
tween the face and smile attractiveness was found (r 5 0.71) for the whole sample. No significant correlations
were found between attractiveness and the other facial components. When divided by gender, the smile
(r 5 0.70) and the eyes (r 5 0.51) correlated with the attractiveness of the smiling face for men. For women,
the face registered a significant correlation with the smile (r 5 0.83) and the skin (r 5 0.37). Conclusions: In
general, smile attractiveness was strongly correlated with the attractiveness of the smiling face, which is the
only significant component. For men, the smile was responsible for 49% of the variation in the attractiveness
of the smiling face, the eyes for 22%, and the hair for 6%. For women, 69% of the variation in facial attractiveness
could be attributed to smile. (Am J Orthod Dentofacial Orthop 2020;157:98-104)

H
uman society has always attempted to quantify
ideals of esthetics and the development of per-
ceptions of attractiveness, with a multitude of
theories on the essence of beauty.1 From an interest in
the geometry of facial harmony to the esthetic revolu-
tions brought about by fashion and the media, beauty
has interested poets, philosophers, and scientists over
the centuries.2-4
The influence of physical attractiveness in everyday
life is undeniable and occurs in a more or less conscious
way.5,6 A beautiful face can affect character evaluation,
choice of partner, and job opportunities.1 The quest to
improve appearance is motivated by the positive impact
of attractiveness in these social interactions.7,8
a
Faculdade de Medicina Dent
aria, Universidade de Lisboa, Lisboa, Portugal.
b
Private practice, Edinburgh, Scotland.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Joana Godinho, Faculdade de Medicina Dent
aria,
Universidade de Lisboa, Rua Professora Teresa Ambr
osio, Cidade Universit
aria,
1600-277 Lisboa, Portugal; e-mail, jgodinho@mail.com.
Submitted, July 2018; revised and accepted, January 2019.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.01.022
98
Malocclusions influence the perception of attractive-
ness, intelligence, personality, and behaviors.9,10
Individuals with a normal occlusion are considered
more attractive, intelligent, pleasant and extroverted;
anterior crossbites lead to negative perceptions, and
people with several diastemas are seen as the least
conscientious and agreeable.9 A recent study of the ef-
fect of teeth arrangement on human resources personnel
showed that people with ideal smiles were considered
smarter and more appropriate for the job.11
Physical attractiveness plays a substantial role in
interpersonal relationships, and the face is the central
contributor.7,8 Discrimination is relatively frequent
among people with facial differences and the search
for ways to improve facial esthetics, such as
orthodontic treatment, orthognathic surgery, or
cosmetic treatments, has increased over the years.12,13
Research into facial attractiveness is focused on
defining which facial traits are associated with beauty.1
Some studies have shown a preference for symmetrical
and average faces, but specific features beyond the
mean exist in beautiful faces.13-15 No single element in
the face is responsible for attractiveness as a whole,
Godinho, Gonçalves, and Jardim
and proportions between the parts are also important.
Przylipiak et al8 showed that attractiveness of the human
face increased when the eyes were enlarged, and the size
of the nose and the mouth was reduced. On the other
hand, increased interocular distance has been reported
to be less attractive.16
In conversation, attention is mainly focused on the
mouth and the eyes.17 Lerner and Karabenick concluded
that teeth were of the utmost importance for the whole
face, followed by the eyes, nose, mouth, and hair
texture.18 Understanding the influence of each element
for facial attractiveness as a whole could help in quanti-
fying the limits of orthodontics when the teeth and the
soft tissues undergo treatment.19
Differences in facial shape between men and women,
such as larger jawbones and more prominent cheek-
bones in men, are accentuated in puberty by hormones
such as testosterone and estrogen.20 There is consider-
able evidence, even across different cultures, that femi-
nine features increase the attractiveness of women's
faces. These include a smaller nose, a thinner face, and
a more pointed chin.15,21 Neonate features such as
large eyes and thick lips are also attractive in
women.21 Men seem to value youth in women, because
of a strong relationship between age and the ability to
produce offspring.20
In judging the appearance of the opposite sex,
women value attractiveness less than men.1 The rela-
tionship between masculine features and the attrac-
tiveness of faces is more ambiguous for men than
that for women. Despite some findings showing a
preference for more masculine and dominant faces,
others have shown that feminine characteristics and
faces of low dominance in men are of increased attrac-
tiveness.20
The primary goal of this study was to analyze the
contribution of different facial elements on the frontal
evaluation of the attractiveness of smiling faces. As a
secondary goal, the hypothesis of gender differences in
the correlation between attractiveness of the smile,
hair, eyebrows, eyes, nose, chin and skin, and the attrac-
tiveness of the smiling face, was evaluated.
MATERIAL AND METHODS
The material for this cross-sectional study was
collected from 60 consecutive patients (30 men and
30 women) of European ancestry, with a mean age
of 23.7 years. The patients were selected from the files
of the Department of Orthodontics, University of Lis-
bon, in Portugal. Inclusion criteria involved no previ-
ous orthodontic treatment and the presence of
maxillary incisors and canines, of normal shape and
American Journal of Orthodontics and Dentofacial Orthopedics
99
size. Exclusion criteria were cavities or fillings on the
anterior maxillary teeth, gingivitis or periodontal dis-
ease evident when smiling, and craniofacial anomalies.
Data were collected over 2 months following approval
by the University of Lisbon School of Dentistry Ethics
Review Board. Selected subjects were invited to sign
an informed consent, and frontal face photographs
were taken of patients smiling in a natural head
position, on a neutral background. Individuals were
standing, relaxed and looking straight ahead. In cases
when the subjects' head were significantly turned up
or down, the clinician would guide it toward the cor-
rect orientation.22 A posed smile was used, and the
face was free of makeup, glasses, jewelry, and hair.
The camera was held by the orthodontist at a standard
distance of 1.5 m and the same height as the patient's
head. The photographic equipment consisted of a
digital single-lens reflex camera (D80; Nikon, Tokyo,
Japan).
Different facial components were isolated from the
original photograph of the smiling face, namely the
smile, nose, eyes, chin, hair, eyebrows, and skin (Fig
1) using Adobe Photoshop software (Adobe Systems,
San Jose, Calif). All the pictures were then set up in
a PowerPoint presentation (Microsoft Corp, Redmond,
Wash), maintaining their relative size and proportion,
using a dark background. A Visual Analogue Scale
(Fig 2) was included in every slide, with the indicators
for unattractive on the left side, and attractive on the
right.23
A total of 600 images (60 smiling photographs, 420
element images, and 120 repetitions) were divided into
9 macro-enabled PowerPoint presentations (Fig 3)
with no time restrictions to fill out. PowerPoint files
were sent and returned by e-mail, and a minimum of
2 weeks separated each of the 9 sessions. One investi-
gator (R.G.) controlled the timings, sent the e-mails,
and identified the gender of the individuals to be as-
sessed in each set of images. Session 9 was composed
of 15 repeated images from each type to assess the error
of the method (Fig 3).
The photographs were evaluated by 8 laypersons (4
men and 4 women) chosen randomly from the campus
of the University of Lisbon. They were of European
ancestry, with a mean age of 21.2 years, with no history
of orthodontic treatment, and participated voluntarily.
The number of individuals to enter the study was
calculated in a pilot investigation with a minimum of
55 patients needed to achieve a significance level of
0.05 with a power of 0.9. Eight evaluators were found
to be the minimal number leading to strong values of in-
traclass correlation (ICC; $0.8). There were no dropouts
among the evaluators.
January 2020
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100 Godinho, Gonçalves, and Jardim

Fig 1. Men and women's facial components isolated from the smiling frontal photographs. A, skin; B,
eyebrows; C, eyes; D, hair; E, nose; F, smile; and G, chin.

Fig 2. Example of a slide with the Visual Analog Scale.

January 2020
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Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Godinho, Gonçalves, and Jardim
photographs
photographs
photographs
photographs
1st session: women 2nd session: women 3rd session: women
5th session: men 6th session: men 7th session: men
Fig 3. Distribution of the variables through the slide show presentations.
Statistical analysis
Statistical analysis was done using SPSS version 20.0
for Macintosh (IBM Company, Armonk, NY). The mean,
standard deviation, and range were calculated. The
Shapiro-Wilk test was used to evaluate the normality
in sample distribution. ICC was used to evaluate random
errors. A Pearson correlation was used with a signifi-
cance level of 0.05, followed by stepwise regression to
assess the correlation between attractiveness of the
face and the components. The data were also stratified
by gender to see whether the correlations in attractive-
ness of the smiling face and the components were the
same in men and women.
RESULTS
Intraobserver agreement was good with ICC values
between 0.82 and 0.92. Descriptive statistics (mean,
standard deviation, and range), as well as the results of
the Shapiro-Wilk test for the total sample and by gender
are presented in Table I. Normal distribution was verified
for the attractiveness of the smiling face and the compo-
nents evaluated.
The Pearson correlation between the attractiveness
of the smiling face and the components was very signif-
icant (P\0.01) for the smile and the face (r 5 0.74). Sig-
nificant correlations were also found between the
different facial components (Table II). In the stepwise
regression model, the smile was the only predictive var-
iable (r2 5 0.54).
When divided by gender, for men, Pearson correla-
tions between the attractiveness of the components
and the smiling face demonstrated a significant
American Journal of Orthodontics and Dentofacial Orthopedics
101
photographs
photographs
women
photographs
photographs men
4th session: women
9th session
8th session: men
correlation (P \ 0.01) between smile (r 5 0.70) and
eye (r 5 0.51) attractiveness and face attractiveness
(Table III). For women, a significant correlation
(P \0.01) was found between the attractiveness of smile
and face attractiveness (r 5 0.83) and between
(P \0.05) the skin and face attractiveness (r 5 0.37).
This gender difference was evident in the stepwise
regression (Table IV). In men, the smile, eyes, and hair
were predictive components. Cumulative r2 values were
0.49 for smile; 0.71 for smile and eyes; and 0.77 for
smile, eyes, and hair. In women, the only predictive var-
iable for facial attractiveness was the smile (r2 5 0.69).
DISCUSSION
In dentistry and particularly in orthodontics, when
evaluating the treatment need and the results obtained,
it is essential to quantify the importance of the smile in
terms of facial attractiveness. A small number of articles
have focused on assessing the significance of each facial
component to overall attractiveness, and this research
was therefore designed with this objective.
In the present sample, the robust overall correlation
found between facial and smile attractiveness
(r 5 0.74) could be because the attention is focused
on the mouth, and consequently on the smile in social
interactions.24 The mouth is the center of communica-
tion of the face, playing a significant role in facial
expression.17
In an article with frontal smiling photographs, facial
harmony and aligned teeth were more critical for layper-
sons and orthodontists than the eyes, lips, hair, and skin,
a result that is consistent with the findings of the present
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102 Godinho, Gonçalves, and Jardim

Table I. Descriptive statistics and Shapiro-Wilk test results for the face, smile, nose, eyes, chin, hair, eyebrows, and
skin attractiveness in the total sample and by gender
Mean SD Range P Mean SD Range P Mean SD Range P

Variable Men and women (n 5 60) Men (n 5 30) Women (n 5 30)

Face 32.3 10.7 11.6-55.1 0.4 35.7 9.1 17.1-50.5 0.6 29.0 11.4 11.6-55.1 0.2
Smile 33.4 14.1 7.4-73.3 0.4 33.1 12.6 11.0-61.1 0.8 33.7 15.6 7.4-73.3 0.5
Nose 38.8 11.4 18.8-66.6 0.2 38.2 10.2 22.6-61.1 0.1 39.4 12.6 18.8-66.6 0.8
Eyes 53.7 13.9 25.3-77.8 0.2 50.8 13.6 25.3-77.7 0.9 56.6 13.7 29.3-77.1 0.2
Chin 34.6 12.5 12.6-57.3 0.1 38.1 12.5 17.3-57.3 0.1 31.1 11.6 12.6-54.8 0.3
Hair 46.0 11.1 20.9-68.9 0.6 44.1 11.6 20.9-68.9 0.6 47.9 10.4 25.8-64.9 0.6
Eyebrows 43.2 10.6 23.3-72.1 0.7 38.5 9.3 23.3-60.0 0.5 47.9 9.9 30.1-72.1 0.9
Skin 47.1 9.8 25.4-64.3 0.1 46.4 11.6 25.4-64.3 0.1 47.9 7.7 31.8-61.0 0.4
Note. P values from the Shapiro-Wilk test, used to verify normality in sample distribution.
SD, standard deviation.

Table II. Pearson correlation results between all the Table IV. Results of the stepwise correlation for men
variables and women
Variable Smile Nose Eyes Chin Hair Eyebrows Skin Variable r r2 partial r2 cumulative P
Full-face 0.74* 0.00 0.14 0.23 0.20 0.02 0.19 Men (n 5 30)
Smile - –0.01 0.06 0.25 0.17 0.16 0.32y Smile 0.70 0.49 0.49 \0.001
Nose - - 0.19 0.06 0.11 0.29y 0.04 Eyes 0.84 10.22 0.71 \0.001
Eyes - - - –0.06 0.24 0.23 –0.08 Hair 0.88 10.06 0.77 0.02
Chin - - - - –0.01 –0.01 0.53* Women (n 5 30)
Hair - - - - - 0.26y 0.26y Smile 0.83 0.69 0.69 \0.001
Eyebrows - - - - - - 0.29*

*The correlation is significant (P \0.01); yThe correlation is signifi- face was shown to the evaluators, and they were asked
cant (P \0.05). to focus concentration on 1 part, leading to compara-
tively weaker correlation values.
When trying to define an attractive face, some fea-
Table III. Pearson correlation results between the face tures such as symmetry, average appearance, and
and the components attractiveness, for men and secondary sexual characteristics influence the judg-
women ment.1,15 An attractive face could be partly a
Smiling face composition of several attractive components.
Significant correlations were found between the parts,
Men (n 5 30) Women (n 5 30)
such as the chin and the skin (r 5 0.53), and the skin
Variable Pearson r r2 Pearson r r2 and the smile (r 5 0.32). Although facial elements
Smile 0.70* 0.49 0.83* 0.69 were isolated as much as possible, some overlap
Nose –0.13 0.02 0.12 0.01 occurred; when the skin was shown, the chin was also
Eyes 0.51* 0.26 0.00 0.00 visible, which could explain this correlation. Significant
Chin 0.16 0.03 0.15 0.02
Hair 0.28 0.08 0.26 0.07
values can also be attributed to chance. Correlations
Eyebrows 0.11 0.01 0.25 0.06 between some components were not significant, which
Skin 0.13 0.02 0.37y 0.13 is not surprising because a beautiful face could have
some less attractive components. In addition, small
*The correlation is significant (P \0.01); yThe correlation is signifi-
elements such as the eyebrows can be challenging to
cant (P \0.05).
evaluate, leading lay evaluators to ascribe a mean
value to them.
research.25 Other authors have concluded that teeth Isolating the facial components for evaluation pre-
were less critical in facial evaluation when compared sented some challenges. Small elements might not
with other components such as the eyes, cheeks, chin, have enough of an impact to be thoroughly evaluated
hair, lips, nose, and skin.19 It must be noted, however, and can be difficult to appraise and differentiate by a
that a different method was used, where facial compo- lay judge. On the other hand, a more evident element
nents were not presented separately. Instead, the full- could include different components leading to the

January 2020
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Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Godinho, Gonçalves, and Jardim
judgment of more than 1 variable. The process of cutting
the initial picture and hiding some areas was as meticu-
lous as one can be, so we could isolate most of a compo-
nent and avoid overlapping structures in the same
image.
The Visual Analog Scale is an easy, practical, and reli-
able measuring method, and it has been used in similar
studies.7,26,27 In this research, although the same
evaluators participated voluntarily 9 times every
2 weeks, there were no withdrawals, which probably
was because of the convenience of using the Visual
Analog Scale incorporated as a sliding bar in the
PowerPoint presentation. Evaluators could send it by
e-mail, instead of having to be present at viewing
sessions.
Because gender differences were found in previous
studies, division of the original sample was under-
taken.9,28-30 The 60 orthodontic patients were divided
into 30 men and 30 women, and some distinctions
were found according to gender. Previous studies
have shown that sexual dimorphism plays an essential
role in attractiveness, which could explain the
differences.15,31,32 Feminine and masculine faces start
to become differentiated in adolescence, as a sign of
sexual maturity and the search for a partner. In men,
testosterone stimulates the growth of zygomatic
bones, the middle third of the face, and supraciliary
arches, drawing attention to the eyes. Estrogen in
women inhibits the growth of these characteristics.32
Neonate features have been reported to be attractive
in women,33 which can help to explain the correlation
found between the skin and the facial attractiveness.
The stepwise regression for men included the smile,
eyes, and hair as significant predictors of overall attrac-
tiveness. For women, only the smile was significant. The
correlation in women between the components, skin,
and smile (Table II) placed the skin outside the stepwise
regression. The smile itself accounted for 49% of the
variability in the evaluation of facial attractiveness in
men and 69% in women, registering a high value.
Some studies in the literature corroborate these findings,
showing that smile attractiveness is more important to
women than to men.19,34 For men, the eyes and smile
explained 71% of the variance in facial attractiveness,
which is also a significant number, because only 2
facial components were taken into account. Recent
investigations using eye-tracking and evaluating women
demonstrated that the eyes were the most important
feature, followed by the mouth.35 However, being the
first component to focus the evaluator's attention does
not necessarily mean that it is the most essential.
The present study has some limitations. Attractive-
ness was evaluated using photographs. Although
American Journal of Orthodontics and Dentofacial Orthopedics
103
popular, these are static 2-dimensional representations.
In dynamic records, other emotional patterns are
analyzed, and attractiveness can be judged differ-
ently.5,36 However, dynamic records are not common
practice, and facial attractiveness ratings from video
clips were shown to be similar to static images.37
Other features might influence judgments concern-
ing attractiveness. A recent article reported that the
contribution of facial parts to the judgment of whole-
face attractiveness changed over time, with increased
exposure to the photograph.38 In addition, the facial
view presented might influence the contribution of the
different parts for the evaluation of the overall facial
characteristic.39
It is important to notice that strong correlations were
found in the stepwise correlations. High r2 cumulative
values were present (Table IV). For men, the attractive-
ness of the 3 components of smile, eyes, and hair could
explain 77% of the variance in the attractiveness of the
smiling face. For women, the smile could explain 69% of
the variance of the attractiveness of the smiling face as a
whole. These results show the importance of the smile in
facial esthetics. Future studies evaluating gender differ-
ences on the impact of orthodontic treatment on facial
attractiveness are suggested.
CONCLUSIONS
A significant correlation between the attractiveness
of the smile and the smiling face was verified when
judged by laypersons. No significant correlations were
found between the attractiveness of the face and the
other components considered, namely the nose, eyes,
chin, hair, eyebrows, and skin.
For men, the attractiveness of the face correlated
with the attractiveness of the smile and the eyes.
Together with the hair, these 3 components contribute
77% in explaining the variance of the judgment of the
smiling face.
For women, a strong correlation was found between
the attractiveness of the smile and the face. This compo-
nent by itself could explain 69% of the variance in the
evaluation of the attractiveness of the smiling face.
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