242520416khaniya Bharathan

“PHOTOGRAPHIC ASSESSMENT OF FACIAL COMPONENTS IN
FACIAL ESTHETICS AS PERCIEVED BY ORTHODONTISTS,
ARTISTS AND PHOTOGRAPHERS – AN IN VIVO STUDY.”
Dissertation submitted to
THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY
In partial fulfillment for the Degree of
MASTER OF DENTAL SURGERY
BRANCH V
DEPARTMENT OF ORTHODONTICS
2013-2016
CERTIFICATE
This is to certify that this dissertation titled “PHOTOGRAPHIC ASSESSMENT
OF FACIAL COMPONENTS IN FACIAL ESTHETICS AS PERCIEVED BY
ORTHODONTISTS, ARTISTS AND PHOTOGRAPHERS – AN IN VIVO STUDY” is
a bonafide research of work done by Dr. KHANIYA BHARATHAN under my guidance
during her postgraduate study period between 2013-2016.
This dissertation is submitted to THE TAMILNADU DR.M.G.R. MEDICAL
UNIVERSITY, in partial fulfillment for the degree of Master of Dental Surgery in Branch
V-Orthodontics.
It has not been submitted (partially or fully) for the award of any other degree or
diploma.
Dr. JAGADEEP RAJU, MDS Dr. R .K. VIJAYAKUMAR, MDS
Guide and Reader Professor and HOD
Department of Orthodontics Department of Orthodontics
Sri Ramakrishna Dental College & Hospital Sri Ramakrishna Dental College & Hospital
Coimbatore. Coimbatore.
Date: DR. V. PRABHAKAR, MDS
Place: Coimbatore Principal,
Sri Ramakrishna Dental College &Hospital,
Coimbatore.
ACKNOWLEDGEMENT
I would like to take this opportunity to express my gratitude to all those who have
guided me through the research process and compilation of the dissertation.
I would like to thank my father Shri. A K Bharathan and my mother Smt. Anitha
Bharathan whose blessings, affection and motivation has always been my guiding light.
It is with deep sense of gratitude and respect that I express my thanks to my beloved
guide Dr. Jagadeep Raju, Reader, department of Orthodontics and Dentofacial Orthopedics,
Sri Ramakrishna Dental College, Coimbatore for his valuable guidance, constant
encouragement, motivation and kind co-operation without which the work would not have
been completed.
I express my heartiest gratitude and respect to Dr. R K Vijayakumar, Professor and
HOD, Department of Orthodontics and Dentofacial Orthopedics, Sri Ramakrishna Dental
College, Coimbatore for his guidance in completing this dissertation.
I would also like to express a thousand thanks to Dr. Pradeep Kumar, Dr. Fayyaz
Ahamed, Dr. Afrose Kanna, Department of Orthodontics and Dentofacial Orthopedics, Sri
Ramakrishna Dental College, Coimbatore, for their kind hearted support as well as being a
part of the study as Orthodontist observers.
I am grateful to our beloved Director Lt.Gen.(Dr) Murali Mohan and Principal
Dr. V. Prabhakar for their kind help and cooperation in completing this work.
I thank Dr. Sasikumar, Professor, department of orthodontics, R.V.S. Dental college,
Coimbatore for being an integral part of this study and for all his valuable suggestions.
I thank Dr. R.V.K. Varma, Director, Ahalia Heritage Village, Palakkad for granting
me permission to conduct my research in their prestigious institute.
I thank Artists Devan Madangarly, Harikrishnan, Selvakumar and Photographers
Dr. R.V.K. Varma, Hashim and Johnson for their patient observations they made during
the assessment of the photographs.
I thank my colleagues Dr. Mohamed Yaseen, Dr. Mohamed Bava, Dr. Sangeeth,
Dr. Indra, Dr. Neeraja, Dr. Monish, Dr. Sindhu and all others who have given a helping
hand in the whole process of my research till the submission of the dissertation.
I thank all the students of Sri Ramakrishna Dental College who was part of my
research for their patient cooperation throughout the study.
I thank Dr. Sekkizhar, Assistant Professor, P.S.G. institute of Management Studies
for guiding me with the statistics part of the study and clearing all my doubts with patience.
I thank my in-laws Shri. P.M. Balakrishnan and Smt. Santha Balakrishnan for
beliving in my dreams. I thank my son Master Shrihaan Dhruv for being an obedient baby
whenever I wasn’t around. I thank my sisters Shilpa and Shreya for their motivation and
support they rendered whenever I needed it.
Last but not the least, I thank my husband, Dr. Subin for his love, encouragement,
patience and support he offered during the course of the work.
THANK GOD!
CONTENTS
1. INTRODUCTION 1
2. REVIEW OF LITERATURE 5
3. MATERIALS AND METHODS 26
4. RESULTS 39
5. DISCUSSION 51
6. SUMMARY AND CONCLUSION 61
7. BIBLIOGRAPHY
Introduction
Introduction
INTRODUCTION
In the ever evolving field of beauty, professionals of many fields have
elaborated on their perception of aesthetics. Aesthetics and beauty have fascinated
human beings from the very dawn of mankind, inspiring countless artists,
philosophers and scientists. Facial attractiveness is something that is intuitively
perceived rather than measurable with instruments. Scientific research on physical
attractiveness is justified because it is connected to the features of the perceiver and
the person perceived. Although in modern days a common layman's notion is that
judgments of beauty are a matter of subjective opinion, recent findings suggest that
people might share a common taste for facial attractiveness and that their preferences
may be an innate part of the primary constitution of our nature. Several experiments
have shown that 2 to 8 months old infants prefer looking at faces which adults rate as
being more attractive. Such findings give rise to the quest for common factors which
determine human facial attractiveness. Various hypotheses, from cognitive,
evolutional and social perspectives, have been put forward to describe the common
preferences for facial beauty.
The term aesthetics is derived from the Greek word for sensory perception or
aesthesis and was coined by the 18thcentury philosopher Alexander Baumgarten who
established aesthetics as a separate field of philosophy. Aesthetics is defined as ‘the
science of beauty in nature and arts or the appreciation or the enjoyment of
beauty.Now it appears that facial esthetics is again in the forefront as we realize why
patients come to us in the first place72.
1
Introduction
Contemporary society places significant emphasis on physical appearance in
general and on facial attractiveness in particular40. Though body image determines
attractiveness, the face is considered as a slightly more important predictor of overall
attractiveness and the eyes, oral region and complexion significantly contributes to
overall facial attractiveness.11 Appearance has an important influence in one’s social
interaction with others and has a bearing on one’s own self-esteem. It has been shown
that people with attractive features are regarded socially as more competent,
successful and likeable.82
Although there is universal or cross-cultural agreement on the perception of
attractiveness, there is a body of evidence which indicates that these perceptions are
either environmentally induced, genetic in origin or share an evolutionary basis 12. The
perception of beauty is an individual preference that may be influenced by training,
cultural and ethnic factors51. The subjective nature of facial beauty is best illustrated
by the writer Margaret Hungerford’s classic statement ‘Beauty is in the eye of the
beholder’(1878), suggesting that esthetic judgments are based on individual taste and
purely subjective and this allows for great variability among lay people in judgments
of pleasing faces and among practitioners when developing individualized treatment
plans.82
The study of facial esthetics was, earlier, primarily the subject of artists and
philosophers. Today, facial appearance is an essential diagnostic criteria to be
considered in comprehensive orthodontic treatment planning.44 The goal of enhancing
patient appearance requires us to revisit fundamental concepts of art and beauty that
were present during the early development of orthodontic doctrine61.
2
Introduction
Art played an important role in Angle’s orthodontic school. He inquired for an
artist who might write for him some fundamental rule which might govern the
character of faces that came into the hands of his students so that they would have the
assurance that all deformity would be corrected, he couldn’t find any one to give him
the rule. Wuerpel, an art professor and a visiting professor in Angle’s school, taught
the students about Greco-Roman sculpture and facial proportion.1 There is little
debate about the many advancements that Angle made in orthodontics, most notably
his system of classifying malocclusion. But perhaps more attention should be paid to
his inclusion of art in the orthodontic search for quantifying facial beauty. Art
instruction was an integral part of the Angle curriculum, but it has gradually
disappeared from the modern residency program.
When did modern orthodontics diverge from art? Advances in orthodontic
technology, especially radiographic cephalometry, led to a shift away from the art of
orthodontic diagnosis and treatment planning as practitioners increased their reliance
on measurements. Angle never used cephalometric radiography, because it was
introduced 1 year after his death2. Clinical examination, once the hallmark of
orthodontic diagnosis, became secondary to the information gained from lateral
cephalometric radiographs and plaster study models.
An interesting question within the field of orthodontics is which facial features
are determinants of these interpersonal judgements. Do we only look at the position of
the teeth and eyes to estimate someone’s attractiveness? Is it the teeth, the symmetry
of a face, or a combination of several facial features? In order to answer this question,
3
Introduction
several researchers have focused onthe importance of various facial features in the
assessment of facial aesthetics.58
In investigations of facial aesthetics, judgments of panels often been
compared, but conflicting results have been reported. Differences in study design
may, to a large extent, be responsible for these conflicting results. In addition, factors
related to the individual characteristics of the panel members such as professional
background, age, gender, and geographical region may also influence the ratings.
Photography is another contemporary branch dealing with facial aesthetics. A
portrait photographer has the ability to understand the facial features of his subject
which he aesthetically captures to give them a pleasing photograph of themselves.
The aim of this study was (i) To establish the perception of facial aesthetics
by different professionals namely orthodontists, artists and photographers. (ii) To
investigate the most influential facial characteristics involved in rating overall
attractiveness.
4
Review of literature
Review of Literature
REVIEW OF LITERATURE
Harvey Peck and Sheldon Peck (1970)5reviewed many refined concepts of facial
esthetics from ancient Egypt through the Renaissance and Western civilization
recorded in sculpture. They mentioned that society today possess ideals of facial
esthetics, and the disciplines of psychology and sociology helps in identifying popular
esthetic preferences. It was also stated that the orthodontic community has neglected
to study the public‟s esthetic viewpoint. And only one American study since 1937 had
attempted to reflect general public‟s judgment of the face in selecting a normal
sample for orthodontic analysis.
Frances C. Macgregor (1970)4 states that the area in and around the mouth is both
emotionally charged and strongly connected with one‟s self-image. As an instrument
of speech and eating, as well as a mirror of emotions, it also has unique social and
psychological implications and symbolic meaning. Any abnormality in this area,
therefore, is not only highly visible and obtrusive but, as research has shown, tends to
evoke a type of aversion which is esthetic. A second handicapping factor has to do
with the degree to which such defects interfere with the flow of social interaction. The
man without an arm can partially hide its absence in a sleeve, a cripple in a
wheelchair can attend a dinner without generating uneasiness. But the same cannot be
said for those with facial defects. Because in normal interaction the eyes attend the
face and any irregularity can be distracting and produce uneasiness.
Hirschberg, Jones and Haggerty (1978)7 conducted studies on facial perception and
recognition and suggested that faces differ markedly from other physical objects of
5
equal complexity; thus faces convey information over and above what is physically
apparent at a visual level.
B. Prahl Andersen (1978)8 reviewed the results of literature and studies and
concluded that the orthodontist, the patient, the significant others and society at large
define and interpret malocclusions and craniofacial malformations differently. He
states that inorder to determine the indication for treatment, factors such as social
sufficiency of the patient should be considered. Cosmetic work should not, while
functional problems go untreated, be done because the paying patient gets the service.
Yet, it should be realized that a malocclusion may become handicapping not because
of the functional disability, but because it may adversely affect social relationships.
Discrepancies between the views of the dental profession and the potential patients on
malocclusion and the need for treatment was analyzed. For malocclusions with or
without impairment of the function the self perception of the patient may be different
from and of more relevance than the professional judgment of the orthodontist. Before
going into orthodontic treatment, the social sufficiency of the patient should be
evaluated.
W.C. Shaw, (1981)11 did a study to determine whether the social attractiveness of a
child would be influenced by his or her dentofacial appearance. Black and white
photographs of the child's face was standardized except that a different dentofacial
arrangement was demonstrated. These were normal incisors, prominent incisors, a
missing lateral incisor, severely crowded incisors, and unilateral cleft lip. The
experimental procedure was such that the effect and interaction of different levels of
facial attractiveness, different dentofacial arrangements, sex of the photographed
6
child, and sex of the judge could be analyzed and the hypothesis that children with a
normal dental appearance would be judged to be better looking, more desirable as
friends, more intelligent, and less likely to behave aggressively was upheld.
W.C. Shaw, G. Rees, M. Dawe, and C. R. Charles, (1985)17 aimed to determine
whether the social attractiveness of a young adult would be influenced by his or her
dentofacial appearance. Black and white photographs of an attractive male, an
unattractive male, an attractive female, and an unattractive female were obtained and
modified so that, for each face, five different photographic versions were
available.Faces displaying a normal incisor relationship gained the most favorable
ratings for eight of the ten characteristics examined, and in four of these differences
across the range of dental conditions were statistically significant. These were
perceived friendliness, social class, popularity, and intelligence. The prominent
incisor condition was rated highest for compliance and honesty, while the condition
representing a unilateral cleft consistently attracted low ratings showing that
background facial attractiveness of either the male or female stimuli was often more
assertive than the individual dental condition. The hypothesis that young adults with a
normal dental appearance would be judged to be more socially attractive over a range
of personal characteristics was upheld.
Ruth Evans and William Shaw (1987)21 A standardized rating scale of dental
attractiveness could be used to assist the determination of treatment priority, as a tool
in patient counselling when assisting subjects to gain a realistic impression of their
relative dental attractiveness, and to generate reproducible measures in various areas
of orthodontic research. The development of a simple 10 point rating scale (SCAN)
7
illustrated by representative dental photographs across the range of values, is
described. High inter-judge correlations were found for othodontists, parents and
children using the scale. Children who underrated their own dental attractiveness also
had a low mean score for their general self-esteem.
W. J. S. Kerr and J. M. O'Donnell (1990)25 performed a study using full-face and
profile photographs. Full-face views generally were rated more attractive than profile
views and Class II and Class III malocclusion subjects were rated lower than Class I
malocclusion subjects. While the art student and parent panels were less critical in
their appraisal of facial attractiveness, they were less sensitive to the changes brought
about by orthodontic treatment than the orthodontist and dental student panels,
although all could appreciate an improvement in the Class II Division I group.
Cunningham, Barbee and Pike (1990)23 showed that men were especially attracted
to „neonatal-type‟ features in women (large foreheads, large, wide set eyes, small nose
and chin and full lips) while females were attracted to males who had „mature‟
characteristics such as wide jaws, strong chins and relatively thin lips.
„Expressiveness‟ was also a feature of the most attractive male and female faces. This
included attributes such as a broad smile and high-arched eyebrows.
Alley and Cunningham (1991)28 contended that the most attractive faces are not
average; rather they are atypical in terms of specific facial features as well as overall
facial structure. Generally, attractive faces were said to exhibit characteristics of
youthfulness such as a smaller mouth, smaller vertical and transverse dimensions,
fuller lips and prominent eyes and cheekbones.
8
Perrett, May and Yoshikawa (1994)39 showed that the mean shape of a group of
attractive faces was preferred to the mean facial shape of the sample from which the
faces were selected. This supports the view that an average face is attractive but not
optimally so and that highly attractive faces are neither average.
Robert H. J. Peerlings, Anne M. Kuijpers-Jagtman, and Jan B. Hoeksma,
(1995)41 aimed to develop a measurement scale to quantify facial aesthetics. Four
series of 36 standardized facial photos were judged twice by eight orthodontists, eight
laymen, and eight children and the results showed that the reproducibility of rating
facial aesthetics is good and a high level of agreement was found between the ratings
of different panels. A mean overall score for each judged photograph could be
calculated. Thus, for each age and sex group a metric scale was composed, consisting
of five photographs with their scores and these scales can be used to evaluate the
results of orthodontic treatment with respect to facial aesthetics.
S.M. Cochrane, S.J. Cunningham, N.P. Hunt (1997)46 designed a study to
determine whether both orthodontists and the general public prefer a Class I facial
profile and the results indicated that the orthodontists were significantly more likely
than lay persons to choose a Class I skeletal profile but they pointed to a more general
conclusion that it is vitally important in orthodontic and orthognathic treatment
planning to ascertain what the patient expects. Failure to communicate well with the
patient may lead to dissatisfaction, even if the results are technically sound. Clinicians
should use some form of video-image analysis to ensure that they agree with their
patients about proposed treatment plans
9
Essam A. AI Yami, Anne M. Kuijpers Jagtman and Martin A.Van'tHo (1998)49
conducted a study where in scoring of the AC of the IOTN was under taken on the
dental casts and increments between the observations at the two ages were calculated.
They found a highly significant influence of orthodontic treatment on facial and
dental aesthetic scores in the group which was not treated orthodontically at the first
observation, but was treated orthodontically at the second observation. No correlation
was found between the increments in the facial aesthetic score and those in the dental
aesthetic score and indicated that facial and dental aesthetics are influenced by
different factors, and both should be evaluated when judging dentofacial aesthetics.
Gillian Rhodes, Fiona Proffitt, Jonathon M. Grady, and Alex Sumich (1998)50
stated that volutionary, as well as cultural, pressures may contribute to our perceptions
of facial attractiveness. Biologists predict that facial symmetry should be attractive,
because it may signal mate quality. They tested the prediction that facial symmetry is
attractive by manipulating the symmetry of individual faces and observing the effect
on attractiveness, and by examining whether natural variations in symmetry (between
faces) correlated with perceived attractiveness. Attractiveness increased when we
increased symmetry, and decreased when we reduced symmetry, in individual faces
and natural variations in symmetry correlated significantly with attractiveness.
Perfectly symmetric versions, made by blending the normal and mirror images of
each face, were preferred to less symmetric versions of the same faces. Similar results
were found when subjects judged the faces on appeal as a potential life partner,
suggesting that facial symmetry may affect human mate choice and thus concluded
that facial symmetry is attractive and discuss the possibility that this preference for
symmetry may be biologically based.
10
Nguyen and Turley (1998)52 reviewed time-related changes in aesthetic facial ideals
and showed that over the course of the first 90 years of the twentieth century
Americans have come to demonstrate a preference for male and female Caucasian and
African American models with progressively fuller and more prominent lips.
R.J. Eddler (2001)55 states that within the margin of error that most surgeons and
orthodontists operate, there is a reasonable body of evidence to suggest that collective
judgments of facial attractiveness are justified. The common denominator that
appealed to all of them appears to be a modified version of averageness and in that,
post-treatment, a patient‟s facial appearance would be closer to the mean of the
population than hitherto.
Julie C. Faure, CarolienRieff, and Jaap C. Mai (2002)58 conducted a study to
evaluate the effect of facial symmetry and inter-ocular distance on the assessment of
facial aesthetics, factors that are often suggested as major contributors to facial
aesthetics. The results of the study showed that symmetry and inter-ocular distance
enlargement have a negative effect on facial aesthetics.
Marquardt (2002)59 has expanded on this concept and introduced the Golden
Decagon Mask, a configuration that describes the golden proportion in two
dimensions. In his search for a quantifiable measure of attractiveness, Marquardt
studied the faces of movie stars and models and found that the golden ratio occurred
more frequently in more attractive faces than in less attractive individuals. The
configuration that described the golden ratio in two dimensions was an acute golden
triangle with sides of 1,618 and a base of one or an obtuse triangle with a base of
1,618 and sides of one. These together formed a golden pentagon which if duplicated,
11
inverted and superimposed on itself produced the golden decagon. This resulted
initially in a Golden Decagon Mask for a post-pubescent female and the subsequent
development of a different mask for the young child and post-pubescent male.
David M. Sarver and Marc B. Ackerman (2003)61 states that the “art of the smile”
lies in the clinician‟s ability to recognize the positive elements of beauty in each
patient and to create a strategy to enhance the attributes that fall outside the
parameters of the prevailing esthetic concept. Smile analysis has to be an integral part
of orthodontic diagnosis and review the dynamic records are needed and new
technologies have enhanced the ability to see the patients more dynamically and
facilitated the quantification and communication of newer concepts of function and
appearance. The authors presented a comprehensive methodology for recording,
assessing, and planning treatment of the smile in 4 dimensions.
Marc B. Ackerman and James L. Ackerman (2002)62, states that smile analysis and
smile design involves a compromise between two factors that are often contradictory:
the esthetic desires of the patient and orthodontist, and the patient‟s anatomic and
physiologic limitations. They explained that using digital video and computer
technology, the clinician could evaluate the patient‟s dynamic anterior tooth display
and incorporate smile analysis into routine treatment planning and concluded that
esthetic smile design is a multifactorial decision-making process that allows the
clinician to treat patients with an individualized, interdisciplinary approach.
C. Flores-Mir et al (2004)64conducted a study to compare the aesthetic perception of
different anterior visible occlusions in different facial and dental views (frontal view,
lower facial third view and dental view) by lay persons and concluded that the
12
aesthetic impact of the visible anterior occlusion was greater in a dental view
compared with a full facial view. The anterior visible occlusion, photographed
subject, view type are factors, which influence the aesthetic perception of smiles. In
addition, gender and level of education had an influence.
Naini and Moss (2004)65 stated that the perception of facial attractiveness is
multifactorial and is founded primarily on genetics, culture and environmental factors.
The perceptual judgement of facial aesthetics is based on a „sense‟ which is largely
independent of intellectual input yet takes into consideration the influence of specific
facial features. However, beauty also has a universal appeal often related to some
observed physical quality or perceived emotional attribute in a face. Philosophical
debate therefore varies between those embracing the universal nature of beauty and
those who believe that the perception of beauty is very much an individual assessment
strongly influenced by one‟s own ideas and feelings.
R. M. A. Kiekens et.al (2005)68 conducted a study to develop a simple and valid
measuring system for facial aesthetics. The scores were performed on a visual
analogue scale (VAS) with separate sets of reference photographs for girls and boys
and they concluded that the new system was simple and flexible in its use, and
reproducible and valid for assessing facial aesthetics in young Caucasians and that the
system could be used in further investigations on the evaluation of facial aesthetics.
Helen Knight and Olly Keith (2005)67 assembled a group of photographs
representing a standardized spectrum of facial attractiveness, against which
orthognathic treatment outcomes could be compared and also investigated the
influence of the relationship between ANB differences and anterior lower face height
13
(ALFH) percentages on facial attractiveness. Antero-posterior (AP) discrepancies, as
measured by soft tissue ANB, showed minimal correlation with facial attractiveness.
They suggested that in faces where the ANB varies widely from 5 degrees, the face is
considered less attractive. The ALFH percentage also showed minimal correlation
with facial attractiveness but there was a trend that suggested that greater ALFH
percentages are considered less attractive in female faces, while in males the opposite
trend was seen. Thus in order to judge the outcome of orthognathic treatment, the
series of ranked photographs produced by the non-clinician group should be used as
the „standard‟ to reflect lay opinion.
Stamatia Matoula and Hans Pancher (2006)75 conducted a study to answer if facial
beauty related to specific skeletofacial morphology. It was seen that while comparing
attractive with non attractive females, in attractive female the soft tissue profile was
more convex, and the distances of the upper and lower lips to the „„Esthetic Line‟‟ (E-
line) were smaller. When comparing non attractive females with non attractive males,
in males the soft tissue profile was more convex, and the distances of the upper and
lower lips to the E-line were smaller and thus it was concluded by the authors that
facial beauty in frontal view is related only to a minor degree to specific skeletofacial
morphology in lateral view.
Tamas Bereczke1 and Norbert Mesko (2006)76 conducted a study in which male
raters judged the attractiveness of young females with neotenous and mature facial
features, with various hair lengths and revealed that the physical appearance of long-
haired women was rated high, regardless of their facial attractiveness being valued
high or low. Women rated as most attractive were those whose face displayed
14
neotenous features in the center of the face (large eyes, small nose) and sexual
maturity features, such as long head hair at the periphery. Furthermore, desirable
psychological and social traits were attributed to individuals with different hairstyles:
male raters associated long hair with the image of a determined, intelligent,
independent, and healthy individual, whereas short hair was associated with
characteristics such as honest, caring, emotional, and feminine.
R. M. A. Kiekens, J. C. Maltha, M. A. Vant Hof and A. M. Kuijpers
Jagtman(2006)74 conducted a study to examine the contribution of objective
measures representing anterior-posterior and vertical characteristics, dental esthetics,
or their combination that are used in daily orthodontic practice in the assessment of
facial esthetics. Dental esthetics as expressed by the Aesthetic Component of the
Index of Orthodontic Treatment Need (AC/IOTN) appeared to be the most important
indicator for facial esthetics. The authors developed a new parameter, the „„horizontal
sum‟‟ that was found to be a reliable variable for the anterior-posterior characteristics
of the patient. Addition of this newly defined parameter to the AC/IOTN improved
the prognostic value from 25% to 31%.
Halazonetis (2007)77 found only minor differences in the average facial shape of
adolescents between the ages of seven and seventeen years, and generally, most
clinicians use the „ideal‟ norms for all patients irrespective of their age or gender
Krzysztof Koscinski (2007)79 reviewed the universal patterns in facial preferences.
Many facial features contributed to facial attractiveness - averageness and symmetry
that are preferred by males and females, probably because they signal genetic quality
and developmental stability. Men prefer highly feminized female faces because they
15
reflect high estrogen levels and low testosterone levels. This indicated that the woman
is reproductively healthy. Women, on the other hand, prefer a moderate level of male
facial masculinity, since facial masculinity that is too pronounced signals high level of
testosterone and, thereby, a poorly developed pro-family personality. In women, facial
hair is detrimental to facial attractiveness. In men, the effect is not consistent. Faces
with a clear complexion are attractive to both men and women. Men prefer light and
smooth skin in women. Positive facial expressions also enhance facial attractiveness.
Many factors, in particular skin condition and facial proportions, affect perceived age,
which is an important component of facial attractiveness. Men in particular strongly
prefer youthful-looking female faces. Facial preferences enable an individual to
recognize reproductively fit mates. Therefore, facial preferences are adaptive,
although non-adaptive mechanisms related to general brain function also play a role.
Pieter Van der Geld et al. (2007)80 in their study to investigated self-perception of
smile attractiveness and to determined the role of smile line and other aspects
correlated with smile attractiveness and their influence on personality traits.
Participants judged their smile attractiveness with a patient-specific questionnaire. It
was seen that size of teeth, visibility of teeth, and upper lip position were critical
factors in self-perception of smile attractiveness (social dimension). Color of teeth and
gingival display were critical factors in satisfaction with smile appearance (individual
dimension). Participants, smiling with teeth entirely displayed and some gingival
display (two to four millimeters), perceived their smile line as most esthetic. Smiles
with disproportional gingival display were judged negatively and correlated with the
personality characteristics of neuroticism and self-esteem. Visibility and position of
teeth correlated with dominance.
16
Chiarella Sforzaa et al. (2008)81 conducted a study to identify possible esthetic
canons in facial size and shape of Italian adolescent boys and girls which showed that
attractive adolescents had wider, shorter, and less deep faces than reference
adolescents, with a relatively larger forehead and maxilla, and a reduced mandible
relative to the maxilla. Lips were larger and more prominent, and the nasolabial angle
was reduced, but in older boys the effect was reversed. The prominence of the soft-
tissue profile, and of the maxilla relative to the mandible, were larger in attractive
boys, but smaller in attractive girls than in their reference peers. In the horizontal
plane, attractive „„young‟‟ adolescents had a flatter face, while the opposite pattern
was observed in the „„old‟‟ adolescents, with a relatively more prominent chin. Thus
esthetic reference values could be used to determine optimal timing and goals in
orthodontic treatment.
Ferring and Pancherz (2008)83 evaluated the extent to which facial proportions
changed in comparison with the divine values during growth. Their investigation
showed that the facial proportions changed only minimally between the ages of six
and a half years and thirty years, indicating that these proportions seemed to be
predetermined already in childhood, with only slight variations during growth with no
discernible gender differences. In addition, it appeared that people with attractive
faces demonstrated greater concordance with the golden proportions than did those
with average faces.
Vinod Krishnan, Sunish T. Daniel, Don Lazar, and Abin Asok (2008)85 evaluated
the perception differences between dental specialists and laypersons; and
quantification of smile characteristics with the smile arc, buccal corridor
17
measurements, and a modified smile index (MSI). Frontal posed smile photographs
were taken of all subjects and it was found that no perception difference between the
specialists and the laypersons on overall smile evaluation. Women had more
consonant smile arcs than men, and there was high correlation between the right and
left buccal corridor spaces in men and women. The MSI showed no correlation to the
facial index, but there was a negative correlation of the MSI with the mandibular
width-facial height index.
Caroline de Deus Tupinamba Rodriguesa et al. (2009)86 conducted a study to
evaluate the attractiveness of a smile according to variations from esthetic norms,
photographic framing, and the order of the presentation of photographs. A photograph
of an individual was selected and digitally manipulated to create the following smiles:
an ideal control smile (I), a smile with diastema (D1), a smile with midline deviation
(LM3), a smile with deviation from the long axes of the lateral incisors (10D),and a
smile with an inverted smile arc (LSRV). The photographic framings used (face vs.
mouth) and the order of presentation of the photographs did not influence the rankings
and thus it was concluded that the absence of variations from beauty norms of a smile
has a positive impact on its esthetic perception, but variations from the norms do not
necessarily result in reduced attractiveness.
Shyam Desai, MadhurUpadhyay and Ravindra Nanda (2009)87 conducted a study
to define age-related changes in the smile. There was a decrease of 1.5 to 2 mm in
maxillary incisor display during smile with increasing age, but the smile index
showed a significant increase. In accordance with some other studies, most subjects
(78%) had average smile height. No subject in the 50 and over age group had a high
18
smile, and no subject in the 15-to-19 year group had a low smile. All dynamic
measurements indicated a pattern of decreasing change from rest to smile, especially
evident after ages 30 to 39 years. Thus as a person ages, the smile gets narrower
vertically and wider transversely. The dynamic measures indicate that the muscles‟
ability to create a smile decreases with increasing age.
Chris Johnston et al., (2010)88 performed a study to test the hypothesis that the self-
perception of dental and facial attractiveness among patients requiring orthognathic
surgery is no different from that of control patients. Happiness with dental and facial
appearance was assessed using questionnaires completed by 162 patients who
required orthognathic treatment and 157 control subjects. It was inferred that
orthognathic patients were less happy with their dental appearance than were controls.
Class II patients and women had lower happiness scores for their dental appearance.
Among orthognathic patients, the „„shape‟‟ and „„prominence‟‟ of their teeth were the
most frequent causes of concern. Older subjects, women, and orthognathic patients
were less happy with their facial appearance. Class III orthognathic patients, older
subjects, and women were more likely to have looked at their own face in profile. A
greater proportion of Class II subjects than Class III subjects wished to change their
appearance. The authors concluded that women and patients requiring orthognathic
surgery had lower levels of happiness with their dentofacial appearance. Although
Class II patients exhibited the lowest levels of happiness with their dental appearance,
there was some evidence that concerns and awareness about their facial profile were
more pronounced among the Class III patients.
19
David C. Havensa et al. (2010)89 evaluated the role of the posed smile in overall
facial esthetics, as determined by laypersons and orthodontists and found that the
pretreatment face without the smile to be significantly more attractive than the face
with the smile or the smile-only photographs. Dissimilar results were seen post
treatment. There was not a significant difference between the three post treatment
photographs. The two panels agreed on the proportion of „„attractive‟‟ subjects but
differed on the attractiveness level of each individual subject. They concluded that
presence of a malocclusion has a negative impact on facial attractiveness. Orthodontic
correction of a malocclusion affects overall facial esthetics positively an laypeople
and orthodontists agree on what was attractive. Overall facial harmony was
considered the most important characteristic used in deciding facial attractiveness.
Ana B. Macias Gago, Martin Romero Maroto and Antonio Crego (2012)90
conducted a study to determine if the faces considered more beautiful in a young
population exhibit the same parameters used by orthodontists to assess successful
results. The females tended to a Class II malocclusion, with the mandible slightly
retrusive to the maxilla and males tended to a Class III and showed a straighter profile
with a prominent chin; the face height ratio was higher in males. There were no
significant differences between genders for lower lip to E plane. The findings of the
study showed that the faces considered more attractive fulfilled the cephalometric and
facial norms.
Jintu Fan, K.P. Chau, Xianfu Wan, Lili Zhai (2012)91 investigated the relationship
between facial attractiveness and facial proportions using computer generated facial
images which have the advantage of excluding the influence of hairstyle, facial
20
expression as well as skin tone and texture. By analyzing the relationship between the
facial proportions of 432 computer generated facial images and their attractiveness
ratings, they identified the optimum proportions for an attractive female face and
further established a model of predicting facial attractiveness from four principle
components of facial proportions with good predictability
Matheus MeloPithon et. al (2012)92 evaluated the degree of perception of
laypersons, dental professionals, and dental students regarding dental esthetics in
cases with mandibular central incisor extraction. They used a smile photograph of a
person with normal occlusion and all teeth, modifications were made to reflect the
extraction of a mandibular incisor of various compositions and sizes. After
manipulation the images were printed on photographic paper, attached to a
questionnaire and distributed to laypersons, dental professionals, and dental students
and it demonstrated that the skill of the dental professionals and dental students in
perceiving the difference between cases of normal occlusion and cases where an
incisor was lacking. The photograph in which the lateral incisors were shown to be
larger than the central incisor was the one that obtained the highest value among the
cases of extraction in all groups of evaluators. It was thus concluded that dental
professionals and dental students are more skillful at identifying deviation from
normality.
Peter M. Prendergast (2012)94states that patients are often specific in their request
for facial rejuvenation procedures like nose reduction, nose tip elevation, lip
enhancement, brow lift, or chin augmentation. Creating the aesthetic “ideal” relies
less on site-specific reduction, augmentation, or straightening of facial features and
21
more on a holistic approach, considering each feature as it relates to the rest of the
face. The aesthetic surgeon should be mindful of average and ideal proportions and
facial angles as they apply to the patient‟s race so that rejuvenation procedures can be
performed with the goal in mind of achieving an attractive and harmonious
appearance. Facial proportions and angles could be easily determined in the office
using photogrammetric analysis. With this information, the surgeon should educate
the patient on the role of facial proportions in aesthetics, discuss the most appropriate
measures, and tailor a plan to achieve the best results. Once there is an understanding
of the importance of proportion in facial aesthetics, the proposed surgical plan is
usually more acceptable, even if it deviates from the patient‟s initial requests.
Santosh Kumar, Sumit Gandhi, Ashima Valiathan (2012)93 compared the
perceptions of orthodontists, general dentists, and laypersons regarding smile esthetics
after symmetrical and asymmetrical alterations in anterior teeth and their supporting
tissues . It was observed that orthodontists were more critical when evaluating smile
images compared to general dentists and laypersons. Symmetrical or asymmetrical
alterations in the mesio-distal width of the lateral incisor of up to 2 mm was not
perceived as unesthetic by general dentists and laypersons and thus concluded that
laypersons are more accepting of minor variations in anterior tooth size and alignment
than orthodontists.
Anand Awadhesh Tripathi, Ragni Pradip Tandon and Navin Hantodkar (2013)95
conducted a study to find the divine proportion in young attractive North Indian
women. Evaluation was based on Ricketts RM (1982) Divine Proportion Analysis on
frontal facial photographs of the women. Results showed that the subjects in the group
22
adhered to the golden proportions and concluded that the ratios in transverse and
vertical dimension as well as soft tissue of attractive face affirm to the divine
proportion.
Krzysztof Koscinski (2013)96 studied the the association between attractiveness of
facial images and clips was tested on a larger sample than has previously been
reported and features under the face owner‟s control (scalp and facial hair, makeup,
mouth expression) were controlled for. Two types of facial images were used:
photographs and frames extracted from films. The importance of facial averageness,
femininity/ masculinity, symmetry, fattiness, skin health, and mouth expression for
attractiveness proved similar for static and dynamic stimuli and this leads to the
optimistic conclusion that results of studies relying on attractiveness assessments of
static facial images are ecologically valid.
Patil Chetan et al (2013)97 conducted a study to evaluate smile in different age
groups and to detect gender differences in smile. Digital videographic records of 241
randomly selected subjects were obtained for smile analysis. The results of the study
showed that all dynamic measurements i.e. change in upper lip length, upper lip
thickness, commissure height and intercommissural width from rest to smile
decreased with age in both males and females. Changes in upper lip length and
commissure height on smiling were greater in males as compared with females of the
same age groups. Changes in intercommissural width on smiling were greater in
females as compared with males in all age groups. It was concluded that smile
changes with increase in age, and the changes differ between males and females.
Females had a wider smile as compared with males of similar age groups.
23
Sercan Akyalcina et al. (2014)98 conducted a study to investigate the common
denominators of an esthetically pleasing smile in patients who were considered to be
successfully treated upon the submission to American Board Orthodontics (ABO)
clinical examination. A total of 462 patients were examined. Ninety subjects that
fulfilled the inclusion criteria were included. Standardized digital smile photographs
of the subjects were rated by 30 panel members, including orthodontists, general
dentists, and parents of orthodontic patients, using a numeric version of the visual
analog scale. There was a significant difference between the three groups for the
comparison of smile arc relationship and they concluded that a harmonious smile arc
relationship and less gingival display during a smile are significantly associated with
smile attractiveness in patients considered successfully treated according to ABO
standards.
Amit Pratap Majethi, Vaishali Devidas Vadgaonkar, Kiran Jayant Deshpande,
Parag Vishnu Gangurde, (2015)99 conducted a study evaluate the perception of
aesthetics by different professionals of different communities in India by a
photographic study. The communities to which the professionals belonged were North
Indian, South Indian, Maharashtrian, Gujarati and Parsi. Five different facial
photographic views each for male and female were obtained. These photographs were
then subjected to changes in increments of 2 mm and 4 mm in retrusive and protrusive
profile in after which they were evaluated by different professionals of different
communities according to their preference from most liked to least liked. They found
that the aesthetic preferences differed widely among different professionals of
different community and the established aesthetic norms can be utilized by the dental
fraternity in general and Orthodontist‟s in particular in diagnosis and treatment
24
planning of Samples belonging to different communities to have the treatment
outcome in unison with the established soft tissue norm for that particular community.
25
Materials and methods
Materials and Methods
MATERIALS AND METHODS
MATERIALS USED IN THE STUDY
1. Mouth mirror
2. Straight probe
3. SLR digital camera, Canon 600D
4. Tripod
5. Light source
6. Plumb line
7. Measuring tape
8. Computer software‟s - Adobe Photoshop, GOM Player
9. Questionnaire
10. Consent form
11. Printout of photographs – 4x6 inch size
12. Photo album
26
METHODOLOGY:
SELECTING THE SAMPLE:
SOURCE OF DATA
Frontal view photograph of 22 dental students of Sri Ramakrishna Dental
College and Hospital, Coimbatore were used for the study.
METHOD OF COLLECTION OF DATA
100 subjects of age 18-24 years were randomly selected and the samples were
then segregated based on the inclusion criteria.
Inclusion criteria
1. Age 18 – 24 years
2. No previous orthodontic or maxillofacial surgeries done
3. Complete permanent dentition
4. No active periodontal disease and no periodontal treatment except scaling and
polishing.
5. No severe malocclusion (IOTN Grade 1 and 2)
6. Not wearing glasses
7. No dental or facial trauma
8. No congenital defect
22 subjects, fulfilling the inclusion criteria were selected as the study samples. All the
subjects signed an informed consent. (Page No.34)
27
SELECTING THE EVALUATOR:
Evaluation Panellists belonged to three different professions as follows:
1. Orthodontist
2. Artist
3. Photographer
The Orthodontists were Professors at various Dental institutions in Coimbatore.
Photographers and Artists were from Ahalia Heritage Village, Palakkad, a prominent
institution promoting contemporary and heritage art forms.
CAPTURING THE PHOTOGRAPH:
Subject was made to sit in natural head position. The background was
standardized to be white in color. The vertical orientation of the head was
standardized by a plumb line that was suspended to a hook on the right side of the
subject. The camera to patient distance was standardized to be 1 meter for all the
subjects. The camera was connected to a 2-strobe lighting source that illuminated the
subject indirectly from a flash that reflected from a photographic umbrella. The
horizontal level of the floor was checked using a spirit level (Figure 1). The camera
was fixed on tripod stand such that the center of the lens focused on the subnasale of
the subject.
28
Figure 1 – Standardization of Camera
The subject was asked to look straight at a distant object in natural head
position. The subject was then asked to rehearse the phrase “CHELSEA EATS
CHEESECAKE ON THE CHESAPEAKE” in order to relax the muscles. The subject
was then asked to relax, gently touch the lips together and then start smiling. This
dynamic range of smile was video recorded using the digital (SLR, Canon 600D)
camera. The duration of video clip for each subject was 10 seconds. (Figure 2)
Figure 2 - Standardization of subject
29
The raw video clips of each subject was transferred to a computer and using
commercially available video editing software (GOM player) the streaming video
was converted to individual photographic frames at a rate of approximately 30
frames/sec. Thus the video was converted into 300 frames. The frame that best
represented the subjects natural/posed unstrained social smile as advocated by
Ackerman et al “as the voluntary smile a person uses in social settings or when
posing for a photograph, social smile is “posed” which means that it is not
elicited or accompanied by emotion and this type of smile can be sustained as a
static facial expression and does not appear strained” was selected. The frame
identified as the “held” smile by the examiner was selected, which was 1 of the 15
consecutive frames in which the smile did not change.
PHOTO EDITING
The selected posed smile frontal photograph of each subject was cropped
using Adobe Photoshop 7.0. to create three types of images.
The first image („„face with the smile‟‟) (Figure 3) was created by cropping
the full face with posed smile in 4 x 6–inch proportions, standardizing each photo so
that the head size would be the same in all photographs.
The second image („„face without the smile‟‟) (Figure 4) was created by
cropping the full facewith posed smile into 4 x 6–inch proportions and standardizing
each photo so that the head size would be the same in all photographs. From each of
these cropped images, the smile region was hidden by a 3 x 5–inch brown box (same
proportions as the third image).
30
The third image („„smile” image) (Figure 5) was a cropped image of only the
teeth and lips. These photographs were cropped in a standardized way using a 3 x 5–
inch grid. The image remaining inside the grid was used as the smile photo for the
study.
Figure 3 - Face with the Smile

Figure 4 - Face without the Smile
Figure 5 - Smile
31
Finally, after editing, all of the images were printed on 4 x 6–inch sheets of
HPH Photo Paper using a HPH Photo smart printer. The 3 x 5–inch images of the lips
and teeth will be centered in landscape format on the 4 x 6–inch pieces of photo
paper. The images of the full face, with and without the brown box covering the smile
region and smiling photo were printed in portrait format to fill the 4 x 6-inch photo
paper. The photos were placed in photo album.
The questionnaire containing 11 questions (Page No. 35) were given to each
of the evaluator along with the 3 photographs of the subjects to elicit the perception of
each of the subjects. The evaluators were instructed to answer the questions from 1 to
8 looking at image 1 (Face with smile), question 9 by looking at image 2 (Face
without the smile) and questions 10, 11 by looking at image 3 (smile only).
The evaluators scored the subjects based on their level of attractiveness as
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
32
SRI RAMAKRISHNA DENTAL COLLEGE AND HOSPITAL,
COIMBATORE.
DEPARTMENT OF ORTHODONTICS & DENTOFACIAL ORTHOPEDICS
Name:
Age/ Sex:
Occupation:
Address:
Phone:
E-Mail:
DECLARATION:
I have fully understood the nature and purpose of the study
“PHOTOGRAPHIC ASSESSMENT OF FACIAL COMPONENTS IN FACIAL
ESTHETICS” being conducted by Dr. Khaniya Bharathan and I have agreed to
participate in the study. I hereby grant Dr. Khaniya Bharathan irrevocable and
unrestricted right to use and publish photograph of me or which I may be included for
publishing this study in any manner and medium and to alter the same without
restriction. I hereby release Dr. Khaniya Bharathan from all claims and liability
relating to said photographs.
Signature of participant: Date:
33
SRI RAMAKRISHNA DENTAL COLLEGE & HOSPITAL,
COIMBATORE
DEPARTMENT OF ORTHODONTICS & DENTOFACIAL ORTHOPAEDICS
PHOTOGRAPHIC ASSESSMENT OF FACIAL COMPONENTS IN FACIAL
ESTHETICS
NAME OF SUBJECT: NAME OF OBSERVER:
OCCUPATION:
1. How would you rate the overall harmony of the face?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
2. Give your rating on the symmetry of the face and its influence on facial
attractiveness?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
34
3. What is your opinion about the proportion of eyes to the face?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
4. What do you feel about the proportion of the nose to the face?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
5. How would you rate the shape of the lips on smile?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
6. What is your opinion about the shape of the forehead and its role in facial
esthetics?
a) Not attractive
b) Average
c) Attractive
35
d) Very attractive
e) I don‟t know
7. What is your opinion about the role of chin in overall facial attractiveness?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
8. What is your comment about the cheekbone in overall facial attractiveness?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
9. What is your opinion about the smile and the role it plays on overall facial
attractiveness?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
36
10. What is your opinion about the arrangement of teeth during smile?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
11. What is your opinion about the exposure of gums during smile?
a) Not attractive
b) Average
c) Attractive
d) Very attractive
e) I don‟t know
37
Figure 6 - Diagnostic Figure 7 - Plumbline Figure 8 - Tripod

instruments
Figure 9 - Measuring tape Figure 10 - SLR Digital

camera (Canon 600D)
Figure 11 - Light source
38
Results
Results
RESULTS
A total of 22 samples were included in this study (18 females, 4 males, age
range 18-24 years). These samples were evaluated by 3 orthodontists, 3 artists and 3
photographers.
RELIABILITY OF THE QUESTIONNAIRE –
The Cronbach’s alpha statistical analysis was performed to check the
reliability of the questionnaire. A Questionnaire is considered reliable when, the
values obtained after performing Cronbach’s alpha statistical analysis is > 0.7. The
value obtained for the questionnaire used in the present study was 0.831 (Table 1)
which indicated its reliability.
Table -1 Cronbach’s alpha statistical analysis result
Cronbach’s Alpha N of items
0.831 11
Cronbach’s alpha statistical analysis was also done to check the reliability
of the questions in the questionnaire. Each question was deleted from the
questionnaire and the Cronbach’s alpha analysis was checked. The values obtained
were not greater than the original value of 0.831 (Table 2) which indicated the
reliability of the questions and none of the questions needs to be deleted.
39
Results
Table 2 – Item-total statistics
Scale Mean if Scale Variance Corrected Item- Cronbach's Alpha

Item Deleted if Item Deleted Total Correlation If Item Deleted
Overall Appearance 26.0591 22.494 .613 .807
Symmetry of the face 26.1364 23.187 .567 .812
Proportion of eyes 26.0182 23.443 .420 .825
Proportion of the
26.3136 23.431 .505 .817
nose
Shape of the lips on

26.0864 22.399 .523 .815
smile
Shape of the forehead 26.0000 23.991 .400 .825
Role of chin 25.9000 23.232 .534 .815
Cheekbone 25.8727 23.518 .486 .818
Smile 25.9909 21.936 .597 .808
Arrangement of teeth 25.8273 22.856 .491 .818
Exposure of gums 25.9318 23.224 .424 .825
FACIAL FEATURES CONTRIBUTING TO OVERALL FACIAL
ATTRACTIVENESS –
Regression analysis
The regression analysis was performed to study the individual facial features.
The analysis was used to determine how well each facial feature predicted the overall
attractiveness. The results of the orthodontist group (Table 3) showed that the facial
40
Results
feature most strongly associated with overall attractiveness was symmetry of face
(0.413) followed by role of cheekbone (0.27) and shape of the lips (0.201). Exposure
of gums (0.132) was the least considered facial feature.
With respect to the artists group (Table 3), regression analysis showed that the
most important facial feature was symmetry of face (0.565), followed by shape of
forehead (0.381) and the role of chin (0.282). The least associated feature was the role
of smile (0.156).
The photographers group (Table 3), according to regression analysis showed
that cheekbone (0.584) was the facial feature most strongly associated with overall
attractiveness and least associated facial feature was the symmetry of face (0.371).
41
Results
Table no: 3 Regression analysis
Unstandardized Standardized
OCCUPATION Model T Sig.
Coefficients Coefficients
B Std. Error Beta
Photographer 1 (Constant) .941 .333 2.826 .006
Cheekbone .584 .121 .515 4.804 .000
2 (Constant) .458 .333 1.374 .174
Cheekbone .438 .119 .386 3.693 .000
Symmetry of the face .371 .103 .378 3.616 .001
Artist 1 (Constant) .478 .266 1.800 .077
2 (Constant) -.212 .321 -.661 .511
Shape of the forehead .360 .107 .290 3.358 .001
3 (Constant) -
-.785 .345 .026
2.278
Role of chin .303 .091 .268 3.317 .002
4 (Constant) -
-1.004 .354 .006
2.840
Role of chin .282 .090 .250 3.151 .003
Thesmile .156 .077 .169 2.019 .048
Orthodontist 1 (Constant) .762 .235 3.239 .002
2 (Constant) .381 .237 1.603 .114
Role of chin .337 .090 .368 3.746 .000
3 (Constant) .167 .245 .682 .498
Role of chin .319 .087 .348 3.664 .001
Exposure of gums .150 .062 .194 2.412 .019
4 (Constant) .112 .241 .467 .642
Role of chin .259 .090 .283 2.882 .005
Exposure of gums .127 .062 .165 2.056 .044
.141 .070 .177 2.011 .049
smile
5 (Constant) -.093 .251 -.372 .712
Cheekbone .217 .098 .230 2.220 .030
Role of chin .105 .111 .115 .945 .348
Exposure of gums .130 .060 .168 2.167 .034
.176 .070 .219 2.513 .015
smile
6 (Constant) -.095 .251 -.378 .707
Cheekbone .274 .076 .291 3.592 .001
Exposure of gums .132 .060 .170 2.197 .032
.201 .064 .251 3.128 .003
smile
42
Results
Factor analysis
Factor analysis was used to study individual facial features. It is a useful tool
for investigating variable relationships for complex concepts. It was used to identify
possible underlying factors for overall facial attractiveness. The factor analysis was
performed individually for each of the group. The variables that are grouped into
factor component 1 combine and contribute to overall facial attractiveness
individually for each of the professionals.
In the orthodontist group the 11 variables were grouped into 2 factors (Table
4). Arrangement of teeth, gingiva, smile, symmetry of the face, shape of lips,
proportion of eyes and nose to face formed factor component 1. The proportion of
nose, role of chin, role of cheekbone and shape of forehead formed the factor
component 2. This suggests that the orthodontist group considered arrangement of
teeth, gingiva, smile, symmetry of the face, shape of lips on smile, proportion of eyes
and the proportion of nose to combine and contribute to overall facial attractiveness.
Table no: 4, Factor analysis of Orthodontist group
Component
1 2
Arrangement of teeth .885
Gingiva .830
Smile .682
Symmetry of the face .661
Shape of the lips on smile
.563
Proportion of eyes .529
Proportion of nose .516 .417
Chin .898
Cheekbone .858
Forehead .733
43
Results
Factor analysis for the artist group was performed and the 11 variables were
grouped into 4 factors (Table 5). Smile, symmetry of face, shape of lips on smile
and arrangement of teeth formed the factor component 1. Exposure of gums formed
the factor component 2. The proportion of eyes, shape of the forehead, proportion of
the nose and the role of chin formed the factor component 3. Cheekbone formed the
factor component 4. The artist group considered the factors smile, symmetry of face,
shape of the lips on smile and arrangement of teeth to combine and contribute to
overall facial attractiveness.
Table no 5: Factor analysis of Artist group
Artist Component
1 2 3 4
Smile .815
Shape of lips on smile .715
Exposure of gums .744
Shape of the forehead .716
Proportion of the nose .594 -.420
Role of chin .423 .415
Cheekbone .867
Factor analysis for the photographer group was performed and the 11 variables
were grouped into 3 components (Table 6). Smile, arrangement of teeth, shape of lips
on smile, proportion of nose and exposure of gums formed the factor component 1.
Role of cheekbone, role of chin and proportion of eyes formed factor component 2.
Symmetry of face and shape of forehead formed the factor component 3 . The
analysis showed that the photographers considered smile, arrangement of teeth, shape
of lips while smiling, proportion of nose and exposure of gums to combine and
contribute to overall facial attractiveness.
44
Results
Table no: 6 Factor analysis of Photographer group
Photographer Component
1 2 3
Smile .859
.699
smile
Proportion of the nose .626
Exposure of gums .459 .447
Cheekbone .744
Role of chin .744
Shape of the forehead .898
Intra class correlation for individual groups
Intra class correlation statistical analysis was performed to check the order of
preferences for the three groups. The values range between -1 to +1 and correlation is
better when value is closer to +1. Results showed ( Table 8) the order of preferences
(Table 7). Significant correlation was seen for symmetry of the face (0.652), shape of
lips (0.624), cheekbone (0.543), role of chin (0.522) and shape of forehead (0.513) for
the orthodontist group. There was significant correlation for symmetry of face
(0.646), forehead (0.534), shape of lips on smile (0.502) and role of chin (0.501) for
the artist group. Photographer group presented with a significant correlation for
cheekbone (0.669), overall appearance (0.571), smile (0.535) and shape of lips on
smile (0.519). Pie charts represents the preferences of each group, orthodontist group
(Pie chart 1), artist group (Pie chart 2), photographer group (Pie chart 3)
45
Results
Table no: 7 Rank order of facial characteristics based on Intra Class correlation
Orthodontist rank order Artist rank order Photographer rank order
Symmetry of face (11%) Symmetry of face (12%) Cheekbone (14%)
Shape of lips on smile (10%) Shape of forehead (10%) Overall appearance (12%)
Overall appearance (9%) Overall appearance (9%) Shape of lips on smile (11%)
Chin (9%) Chin (9%) Smile (11%)
Cheekbone (9%) Shape of lips on smile (9%) Exposure of gums (9%)
Shape of forehead (9%) Exposure of gums (8%) Proportion of eyes (8%)
Smile (8%) Arrangement of teeth (7%) Arrangement of teeth (8%)
Arrangement of teeth (8%) Cheekbone (7%) Proportion of nose (8%)
Proportion of eyes (7%) Proportion of nose (6%) Shape of forehead (3%)
Proportion of nose (7%) Proportion of eyes (6%) Chin (2%)
Exposure of gums (5%) Smile (5%) Symmetry of face (2%)
Table no: 8 Intra Class correlation for individual groups
ORTHODONTIST ARTIST PHOTOGRAPHER

Overall Appearance 0.483 0.489 0.571
Symmetry of face 0.652 0.646 0.119
Proportion of eyes 0.43 0.317 0.194
Proportion of nose 0.434 0.339 0.366
Shape of lips on smile 0.624 0.502 0.519
Shape of forehead 0.513 0.534 0.119
Role of chin 0.522 0.501 0.079
Cheekbone 0.543 0.353 0.669
Smile 0.472 0.276 0.535
Arrangement of teeth 0.448 0.346 0.378
Exposure of gums 0.283 0.394 0.41
Overall rating Mean-score 0.523 0.619 0.551
46
Results
Pie chart 1: Intraclass correlation of orthodontist group
Overall rating
Mean-score Orthodontist Overall
Appearance
10% Exposure
0% Symmetry of 10%
of gums face
Arrangement of 0% 0% Proportion of
eyes
teeth
9%
9%
Proportion of
Smile nose
9% 9%
Shape of lips on
Cheekbone smile
11% Shape of 13%
Role of chin forehead
10% 10%
Pie chart : 2 Intraclass correlation for artist group
Artist Overall
Overall rating Appearance
Mean-score 0% 9%
12%
Exposure of gums Symmetry of face
8% 12%
Arrangement of
teeth Proportion of
7% eyes
Smile 6%
5%
Proportion of
nose
Cheekbone 6%
7%
Shape of lips on Shape of
Role of chin smile forehead
9% 9% 10%
47
Results
Pie chart : 3 Intraclass correlation for photographer group
Overall Overall
rating Photographer Appearance
Mean-score 12%
Symmetry
12%
of face
Exposure of 2%
gums
9% Proportion
of eyes
Arrangemen 8%
t of teeth Proportion
8% of nose
Smile 8%
11%
Shape of lips
Cheekbone
on smile
14% Shape of 11%
Role of chin
forehead
2% 3%
CORRELATION BETWEEN THE GROUPS -
Spearman rank correlation
Spearman rank correlation statistical analysis was performed to check the
correlation between the three groups of observers (Table 9).The analysis was used to
determine the rating relationship between the groups. The P-value < 0.05 was
significant ( P-Value decreases as correlation increases). The mean score of overall
rating between the three observers showed a significant correlation between
Orthodontist and Artist group (0.003). There was no significant correlation between
the Photographer and Artist group (0.027) and between the Photographer and
Orthodontist group (0.041). Spearman rank correlation statistical analysis suggests
that the view about overall facial attractiveness significantly correlates for
Orthodontists and Artists.
48
Results
Table no 9: Spearman’s rank correlation
Overall rating Mean-score

Correlations Photographer Artist Orthodontist
Spearman's rho Photographer Correlation 1.000 0.479 0.439
Coefficient
Sig. (2-tailed) . 0.027 0.041
N 22 22 22
Artist Correlation 0.479 1.000 0.609
Coefficient
Sig. (2-tailed) 0.027 . 0.003
N 22 22 22
Orthodontist Correlation 0.439 0.609 1.000
Coefficient
Sig. (2-tailed) 0.041 0.003 .
N 22 22 22
Intra class correlation between the groups
Intra class correlation statistical analysis (Table 10) was performed to check
the agreeability between the three groups (orthodontists, artists and photographers)
(Graph 1). The overall rating mean score between the groups showed highest
correlation between the Orthodontist and artist group (0.609), and least correlation
between the artist and photographer group (0.339) followed by the photographer and
orthodontist group (0.289). Intra class correlation statistical analysis suggests
agreeability about overall facial attractiveness significantly for the Orthodontists and
Artists.
49
Results
Table no 10: Intra class correlation
Artist Vs Artist Vs Photographer Vs

Orthodontist Photographer Orthodontist
Overall Appearance 0.452 0.114 0.133
Symmetry of the face 0.713 0.214 0.069
Proportion of eyes 0.062 0.516 0.538
Proportion of the nose 0.338 0.573 0.523
Shape of the lips on smile 0.739 0.544 0.467
Shape of the forehead 0.175 0.188 0.520
Role of chin 0.221 0.158 0.410
Cheekbone 0.368 0.271 0.265
Smile 0.558 0.251 0.182
Arrangement of teeth 0.498 0.251 0.214
Exposure of gums 0.417 0.403 0.533
Overall rating Mean-score 0.609 0.339 0.289
Graph no: 1 Intraclass correlation
0.800
0.700
0.600
0.500
0.400
0.300
Artist Vs Orthodontist
0.200 Photgrapher Vs Artist
0.100 Orthodontist Vs Photographer
0.000
50
Discussion
Discussion
DISCUSSION
The primary objective of this study was to establish the perception of facial
aesthetics by different professionals namely orthodontists, artists and photographers
and the secondary objective was intended to reveal the most influential facial
characteristics involved in rating overall attractiveness.
The shape, colour, distance from other structures, and movement of the
dimensional components of the face impact the process of attaining facial perception.
The recognition of faces requires perceptual learning to identify the information
necessary to differentiate one individual from another and an ability to encode
something unique about them. The discrimination of faces along gender, ethnicity or
age dimensions demands an ability to perceive the features in individual faces that are
common to a specific group, but which also serve to distinguish one group from
another.54
The hair, face outline, eyes, and mouth are important for perceiving and
remembering faces, and the upper part of the face is more useful for face recognition
than the lower part. The facial photographs are effective in providing a valid way of
analysing facial attractiveness. The three-quarter view of the face results in better
recognition than the frontal view but it reveals more about the nose, and less about
eyes and mouth, which are probably the more important features due to their role in
communication. Frontal view has a disadvantage of flatness, but this is compensated
by the fact that it reveals all the dimensions and relations of the internal features, such
51
Discussion
as the eyes and mouth are rated more attractive than profile views17 and therefore the
frontal view facial photographs were taken for the subjects.
Ackerman et al48 among others have defined two main types of smiles: Social
smiles and enjoyment smiles. A social smile is the voluntary smile a person uses in
social settings or when posing for photograph. The social smile is posed which means
that it is not elicited or accompanied by emotion and can be sustained as a static facial
expression that does not appear strained9. Enjoyment smiles are involuntary and are
elicited by the laughter. The posed smile is used routinely when evaluating facial
aesthetics and smile characterises because the posed smile is reproducible and can be
generated on command and has been referred to as reliable reference for measurement
and characterization of the smile48,20.
Duchenne24 described the use of 2 facial muscles to distinguish a deliberate
smile from a spontaneous smile: The zygomatic major that obeys the will and the
orbicularis oculi that is only put in play by the sweet emotions of the soul but cannot
be provoked by the fake joy, deceitful laugh. Ekmanet al9 confirmed Duchenne‟s
observations, finding that most people cannot voluntarily contract the outer portion of
the orbicularis oculi and thus do not exhibit this action in a deliberate smile and so in
the present study frontal view posed smile photographs were taken.
Photographs of the subjects were taken in Natural head position which is a
standardized and reproducible position, of the head in an upright posture, the eyes
focused on a point in the distance at eye level, which implies that the visual axis is
horizontal. A plumbline was used to orient the head of the subject to his or her NHP
and this is called the registered natural head position (RNHP)78
52
Discussion
Video recordings were done instead of taking static images because capturing
the subjects smile images with conventional 35mm photography has the drawback of
difficulty in standardizing photographs due to differences in camera angles, distances
to the patient, head positions, and discrepancies between intraoral and extraoral
photographic techniques and its reproducibility is impossible. Standardized digital
videography allows us to capture a patient‟s speech, oral and pharyngeal function, and
smile at the same time.57 Quantitative and qualitative analysis of lip–tooth–gingival
relationships are easily accomplished with the aid of digital videography. Anterior
tooth display is not the same during speech as in smiling so by taking a video clip of
both, we can evaluate all aspects of anterior tooth display. This helps the orthodontist
to review the video clip with the patient, in order to familiarize the patient with his or
her own smile. To relax the muscles, the subject was asked to say a short phrase
“CHELSEA EATS CHEESECAKE ON THE CHESAPEAKE” and then asked to
relax, gently touch the lips together and then start smiling.
Passive coaching encourages the patient to give a natural unstrained posed
social smile followed by an enjoyment smile. Digital video players allow slow motion
assessment of the dynamic smile. The digital video camera was mounted on tripod
stand, and set at a fixed distance in the records room. The video camera captured a
ten-second clip which was converted to 300 individual photographic frames and the
frame that best represented the patient‟s social smile which was 1 of the 15
consecutive frames in which the smile did not change was selected. 57
The questionnaire consisting of 11 questions were given to each of the
observers along with the 3 photographs of the subjects to elicit the perception about
53
Discussion
each of the subjects. The reliability of using a questionnaire as a tool to elicit
perception was confirmed using Cronbach’s alpha statistical analysis. The validity
and reliability of the questions in the questionnaire was checked by deleting items
using Cronbach’s alpha statistical analysis, but was found that none of the
questions needed to be omitted to increase the validity of the questionnaire.
Evaluations of the subjects in this study were done by nine panelists consisting
of three orthodontists, three artists and three photographers. Howells and Shaw
(1985)17 stated that for evaluation of facial aesthetics, a panel of two persons can give
acceptable reliability, but for improvement, they advocated a further increase in panel
size. R.M.A. Kiekens et al.( 2006)74 stated that a panel of seven randomly selected
laymen and/or orthodontists is sufficient to obtain reliable results in the aesthetic
evaluation of adolescent faces, using photographs and a Visual Analogue Scale
(VAS).
To establish our main objective which was to elicit the perception of facial
aesthetics by different professionals namely orthodontists, artists and photographers,
Spearmans rank correlation and Intraclass correlation between the groups was
performed. The highest correlation was seen between the Orthodontist and Artist
group. Least correlation was found between the artist and photographer group
followed by the photographer and orthodontist group.
The relationship between the artists and orthodontist began way back from
infinitude. It was only as recently as the mid-1970s that true evidence in the form of
mean data derived from growth studies became available for clinical use. Until then
improving an individual‟s facial appearance relied on the guidelines based on the
54
Discussion
experience of Renaissance artists during the fifteenth and sixteenth centuries. „The
Lance Bearer‟, a famous sculpture by Polykleitos, one of the famous artists of the
fifteenth century BC, conforms to certain laid down proportions one of which states
that the head and face together comprises two of fifteen equal vertical segments into
which the human form could be divided, a principle which holds true today14.
Roman architect Vitruvius‟s famous trisection is still recommended and used by
orthodontists and orthognathic surgeons today, i.e. 2000 years later41. The rule of
fifths, dividing the ideal face transversely into five equal eye widths, which is being
followed today, was well represented in the drawing of proportions of the head (eye)
by Da Vinci. Many other Renaissance artists contributed to an overall scheme of
proportions that subsequently became the norm for the use by artist, and
subsequently by surgeons and orthodontists55 and therefore substantiating the results
of this study which shows the highest correlation between the orthodontist and artists
group.
On the other hand photography has little to do with facial proportions unlike
an artist or an orthodontist who largely depend on facial proportions to define facial
aesthetics. A photographer relies on other techniques such as ambient light, camera
angle, composition etc to bring the best out of his subject to create an aesthetically
looking photograph. This maybe the reason for minimal correlation of the
photographer with the other two groups.
Further the study was intended to reveal the most influential facial
characteristics involved in rating overall attractiveness, the secondary objective. The
regression analysis, which is a statistical process for estimating the relationships
55
Discussion
among variables was performed to study the individual facial features. The analysis
predicted that the facial feature most strongly associated with overall attractiveness
according to orthodontist‟s was symmetry of face, followed by cheekbone and shape
of lips and the least associated facial feature being the exposure of gums. The four
factors symmetry of face, cheekbone, shape of lips and exposure of gums were able to
justify overall attractiveness and the rest of the features were removed. The artists
considered the symmetry of face, shape of forehead and role of chin as the most
important facial feature and the least associated feature was the smile. According to
the photographers cheekbone was the facial feature most strongly associated with
overall attractiveness and least associated facial feature was symmetry of face. This
shows that overall facial attractiveness is more important than dental attractiveness.
Several studies have examined the effects of various dental features on facial
attractiveness using full-face photographs. The findings of this study are similar to
that of Shaw and colleagues,11, 16, 31, 71, 73

who noted that the background facial
attractiveness is often more assertive than the individual dental condition. They
observed that the overall facial appearance of the patient may be more important than
the smile region and that facial esthetics is not dependent on any isolated facial
characteristic. The facial feature most strongly associated with overall attractiveness
was cheeks and the feature least associated were nose and teeth.71 whereas in this
study it was seen that symmetry of the face, cheekbone, shape of lips on smile were
strongly associated with overall attractiveness and least associated feature was
exposure of gums and smile.
56
Discussion
Various studies done previously have shown the importance of facial features
for overall attractiveness. Peck and Peck (1994)38 found higher cheek bones, a
thinner jaw and larger eyes as most attractive. Keating (1985)15 confirmed on the
importance of features such as inter-eye distance, face length, face width, mouth size,
and cheek. Cunningham et al., (1990)23 found that mature features such as prominent
cheekbones, square jaws, or a large chin are positively linked with attractiveness of
males and juvenile facial features such as large and wide eyes, greater inter-eye
distance, a small chin and a wide smile are positively linked with attractiveness of
females. The results of studies by Cunningham (1986)18 and Meerdink et al.,
(1990)27 agree on the importance of nose size and cheek width in the perception of
facial attractiveness, which is also seen in this study.
To emphasise on the role that smile plays on overall facial attractiveness the
factor analysis, which is a statistical method used to describe variability among
observed correlated variables was performed individually for each of the group in
which the variables were grouped into factor components. The variables grouped into
factor component 1 combine and contributed to overall facial attractiveness
individually for each of the professionals whereas the remaining components were
removed and was not considered to contribute to facial attractiveness. For the
orthodontist group arrangement of teeth, gingiva, smile, symmetry of the face, shape
of lips, proportion of eyes and nose to face formed factor component 1 which stated
that these are the potential factors that contribute to overall attractiveness.
The artist group considered the factor component1 i.e. smile, symmetry of face
and shape of the lips on smile and arrangement of teeth to combine and contribute to
57
Discussion
overall facial attractiveness. The photographers considered smile, arrangement of
teeth, shape of lips while smiling, proportion of nose and exposure of gums i.e. the
factors of component 1 to combine and contribute to overall facial attractiveness. This
shows that smile does play an important role while rating overall attractiveness along
with the other facial features. McNamara et.al.(2010)89 in their study found that
overall facial harmony and tooth alignment are the two most important characteristics
for overall attractiveness. The two least important characteristics were skin and hair,
which is not in favour of this study. But they agreed on the importance of each facial
characteristic when rating a smile, which is similar to this study.
In order to establish an order of preference for facial components, individually
for the three groups of professionals the Intraclass correlation statistical analysis
for individual groups was done, which basically is a statistical analysis that assesses
the reliability of ratings by comparing the variability of different ratings of the same
subject to the total variation across all ratings and all subjects. The values range from
-1 to +1 and those which had a value > 0.5 was significant. As per the values
obtained, the individual groups showed their order of preference for overall facial
attractiveness. Shape of lips on smile was preferred by all the three professional
groups. The artists and orthodontists showed similar preference for symmetry of face,
chin and forehead. The photographer and orthodontist group preferred cheekbone.
The photographer group preferred smile and overall appearance.
Orthodontists and artist have considered the symmetry of face as the most
important feature for overall facial attractiveness. Facial symmetry and averageness
have been studied previously, leading to conflicting results. They have been created
58
Discussion
by combining several individual faces into one composite face. Thornhill and
Gangestad., (1993)32, Gangestad et al., (1994)35 argued that the degree of
averageness and symmetry in faces is an essential factor in the perception of
attractiveness which is similar to the findings of this study. Langlois and
Roggman.,(1990)26, Grammer and Thornhill (1994)36 have found that symmetrical
faces are indeed perceived as more attractive which is similar to this study.
Apart from eliciting the facial characteristics which account for attractiveness,
modern researchers try to describe underlying mechanisms for these preferences.
Thornhill, R. & Gangsted, S.W. (1999)53, Andersson, M. (1994)34, Møller, A.P. &
Swaddle, J.P. (1997)47 refer to the evolutionary origins of attractiveness preferences
and another mechanism through a cognitive theory - a preference for attractive faces
might be induced as a by-product of general perception or recognition mechanisms. A
third view has suggested that facial attractiveness originates in a social mechanism,
where preferences may be dependent on the learning history of the individual and
even on his social goals.47
The highest correlation was seen between the orthodontist and artists group
followed by the photographer and artist group and finally the photographer and
orthodontist group. This highest degree of agreeability between the orthodontist and
artists was probably because of the similarity in the scheme of proportions that was
used by the artists and orthodontists. The symmetry of the face, cheekbone and shape
of lips on smile were strongly associated with overall attractiveness and least
associated feature was exposure of gums and smile which shows that the overall facial
59
Discussion
appearance of the patient may be more important than the smile region and that facial
esthetics is not dependent on any isolated facial characteristic.
60
Summary and conclusion
Summary and Conclusion
SUMMARY AND CONCLUSION
A study was carried out on 22 subjects each of whom was evaluated by nine
panelists consisting of three orthodontists, three artists and three photographers. All
the subjects were selected based on the inclusion criteria for standardization. The
dynamic recording of smile was accomplished with digital videography. The
recording of the frontal view was done using SLR digital camera, Canon 600D that
was mounted on a tripod at a fixed distance from the subject sitting in natural head
position. The subject was asked to rehearse a phrase, relax and then start smiling. A
ten-second video was taken and the raw video was transferred to a video editing
software (GOM player). The streaming video was converted into 300 frames. The
frame that best represented the subjects natural/posed unstrained social smile was
selected, which was 1 of the 15 consecutive frames in which the smile did not change.
The selected posed smile frontal photograph of each subject was cropped
using Adobe Photoshop 7.0. to create three types of images the first image being the
face with the smile, the second image the face without the smile and the third image
the smile only . The photos were placed in a photo album. A questionnaire containing
11 questions were given to each of the evaluators along with the 3 photographs of the
subjects to establish the perception of facial aesthetics by different professionals
namely orthodontists, artists and photographers and to investigate the most influential
facial characteristics involved in rating overall attractiveness.
61
Summary and Conclusion
Analyses were performed to check the validity of the questionnaire and the
questions in the questionnaire and to elicit the perception of facial attractiveness
between the 3 professional groups and within the individual groups. Results inferred
that the correlation was highest between the orthodontist and artists group followed by
the photographer and artist group and finally the photographer and orthodontist group.
Preferences for facial component differed between the three groups. The orthodontist
group showed symmetry of face, cheekbone and shape of the lips to be strongly
associated with overall attractiveness and exposure of gums to be least associated
facial feature. Whereas the artists group considered the symmetry of face, shape of
forehead, role of chin to be the most associated feature and the least associated feature
was the smile. According to the photographers group cheekbone was the facial feature
most strongly associated with overall attractiveness and least associated facial feature
was the symmetry of face.
In conclusion, the view about overall facial attractiveness significantly
correlates for Orthodontists and Artists. The perception by the three professionals
confirms that facial esthetics is not dependent on any isolated facial characteristic and
overall facial attractiveness is more important than dental attractiveness.
62
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“PHOTOGRAPHIC ASSESSMENT OF FACIAL COMPONENTS IN

FACIAL ESTHETICS AS PERCIEVED BY ORTHODONTISTS,

ARTISTS AND PHOTOGRAPHERS – AN IN VIVO STUDY.”

THE TAMILNADU Dr. M.G.R. MEDICAL UNIVERSITY

In partial fulfillment for the Degree of

MASTER OF DENTAL SURGERY

This is to certify that this dissertation titled “PHOTOGRAPHIC ASSESSMENT

OF FACIAL COMPONENTS IN FACIAL ESTHETICS AS PERCIEVED BY

ORTHODONTISTS, ARTISTS AND PHOTOGRAPHERS – AN IN VIVO STUDY” is

a bonafide research of work done by Dr. KHANIYA BHARATHAN under my guidance

during her postgraduate study period between 2013-2016.

This dissertation is submitted to THE TAMILNADU DR.M.G.R. MEDICAL

Dr. JAGADEEP RAJU, MDS Dr. R .K. VIJAYAKUMAR, MDS

Guide and Reader Professor and HOD

Department of Orthodontics Department of Orthodontics

Date: DR. V. PRABHAKAR, MDS

Place: Coimbatore Principal,

Sri Ramakrishna Dental College &Hospital,

guided me through the research process and compilation of the dissertation.

I express my heartiest gratitude and respect to Dr. R K Vijayakumar, Professor and

HOD, Department of Orthodontics and Dentofacial Orthopedics, Sri Ramakrishna Dental

College, Coimbatore for his guidance in completing this dissertation.

part of the study as Orthodontist observers.

I am grateful to our beloved Director Lt.Gen.(Dr) Murali Mohan and Principal

I thank Dr. Sasikumar, Professor, department of orthodontics, R.V.S. Dental college,

me permission to conduct my research in their prestigious institute.

I thank Artists Devan Madangarly, Harikrishnan, Selvakumar and Photographers

the assessment of the photographs.

research for their patient cooperation throughout the study.

I thank Dr. Sekkizhar, Assistant Professor, P.S.G. institute of Management Studies

support they rendered whenever I needed it.

patience and support he offered during the course of the work.

3. MATERIALS AND METHODS 26

6. SUMMARY AND CONCLUSION 61

In the ever evolving field of beauty, professionals of many fields have

elaborated on their perception of aesthetics. Aesthetics and beauty have fascinated

philosophers and scientists. Facial attractiveness is something that is intuitively

perceived rather than measurable with instruments. Scientific research on physical

attractiveness is justified because it is connected to the features of the perceiver and

determine human facial attractiveness. Various hypotheses, from cognitive,

preferences for facial beauty.

established aesthetics as a separate field of philosophy. Aesthetics is defined as ‘the

science of beauty in nature and arts or the appreciation or the enjoyment of

patients come to us in the first place72.

Contemporary society places significant emphasis on physical appearance in

general and on facial attractiveness in particular40. Though body image determines

attractiveness, the face is considered as a slightly more important predictor of overall

overall facial attractiveness.11 Appearance has an important influence in one’s social

successful and likeable.82

Although there is universal or cross-cultural agreement on the perception of

perception of beauty is an individual preference that may be influenced by training,

of pleasing faces and among practitioners when developing individualized treatment

philosophers. Today, facial appearance is an essential diagnostic criteria to be

considered in comprehensive orthodontic treatment planning.44 The goal of enhancing

were present during the early development of orthodontic doctrine61.

Art played an important role in Angle’s orthodontic school. He inquired for an

disappeared from the modern residency program.

When did modern orthodontics diverge from art? Advances in orthodontic

orthodontic diagnosis and treatment planning as practitioners increased their reliance

on measurements. Angle never used cephalometric radiography, because it was

orthodontic diagnosis, became secondary to the information gained from lateral

cephalometric radiographs and plaster study models.

An interesting question within the field of orthodontics is which facial features