SPECIAL ARTICLE
The enigma of facial beauty: Esthetics,
proportions, deformity, and controversy
Farhad B. Naini,a James P. Moss,b and Daljit S. Gillc
London, United Kingdom
The study of the face and the ability to alter its form have fascinated mankind for thousands of years. The
clinical ability to alter dentofacial form, whether through orthodontics, facial growth modification, or surgery,
requires an understanding of facial beauty, including the evaluation of facial esthetics, proportions, and
symmetry. The purposes of this article were to give a brief contemporary overview of our concepts of facial
beauty and esthetics and to consider a long-standing and controversial debate on the treatment of patients
with dentofacial deformities. (Am J Orthod Dentofacial Orthop 2006;130:277-82)
O
rthodontists have a special interest in facial
beauty, although, over time, the relative im-
portance of esthetics has waxed and waned in
relation to other considerations. In part of his ongoing
review of orthodontic history, Wahl1 wrote, “Now it
appears that facial esthetics is again in the forefront as
we realize why patients come to us in the first place.”1
Perceptions of facial beauty are multifactorial, with
genetic, environmental, and cultural foundations.2 Beauty
can be defined as a combination of qualities that give
pleasure to the senses or to the mind. Esthetics is the
study of beauty and, to a lesser extent, its opposite, the
ugly. The 18th century philosopher Alexander Baum-
garten, who established esthetics as a distinct field of
philosophy, coined the term, which is derived from the
Greek word for sensory perception (aisthesis).3
The first question to consider is difficult to answer:
is the origin of the human perception of facial beauty
dependent on each person’s sense perception, or is this
sense common to all people? Is facial beauty a quality
of the observed face, or does the sensory enjoyment of
the observers also depend on their own ideas, feelings,
and judgments, which themselves have a direct rela-
tionship to sensory enjoyment. The philosopher David
Hume (1741) said, “Beauty in things exists in the mind
which contemplates them,”4 and the writer Margaret
a
Consultant, Director of Research and Graduate Education, Orthodontic De-
partment, St George’s Hospital and Medical School, Kingston Hospital,
London, United Kingdom.
b
Professor, Orthodontic Department, Royal London Hospital, London, United
Kingdom.
c
Consultant, Orthodontic Department, Eastman Dental Hospital, London,
United Kingdom.
Reprint requests to: Dr Farhad B. Naini, Consultant, Orthodontic Department,
St George’s Hospital and Medical School, Blackshaw Rd, London, SW17 0QT,
United Kingdom; e-mail, farhad@naini.freeserve.co.uk.
Submitted, April 2005; revised and accepted, September 2005.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.09.027
Wolfe Hungerford (1878) famously said, “Beauty is in
the eye of the beholder.”5
Both of these quotations, and their respective phil-
osophical ideologies, assume that the “sense” is sub-
jective to each person. However, the 18th century
philosopher Francis Hutcheson said, “Esthetic judge-
ments are perceptual and take their authority from a
sense that is common to all who make them,” and “The
origin of our perceptions of beauty and harmony is
justly called a ‘sense’ because it involves no intellectual
element, no reflection on principles and causes.”6 The
philosopher Immanuel Kant (1790) reiterated this view,
saying that, “The beautiful is that which pleases uni-
versally without a concept.”7
Therefore, if a beautiful face “pleases universally,”
then some part of our sense perception must be com-
mon to all men and women. After all, when we describe
a face as beautiful, we do not merely mean that it
pleases us. We are describing the face, not our judg-
ment. We will often point to features of the face to back
up our statement.
A paradox therefore emerges. Obviously one can-
not make a judgment about the beauty of a face one has
never seen. Therefore, facial beauty is related to some
quality of the observed face that tends to be universally
accepted. However, each person’s ideas and feelings,
like a conditioned response, also have a direct relation-
ship to his or her judgment, hence the difference in the
extent of rating a face as beautiful depending on the
“eye of the beholder.”
This philosophical question and its related argu-
ment continue to be debated. However, beauty un-
doubtedly has a strong influence on human life. Ac-
cording to Shakespeare, “Beauty itself doth of itself
persuade the eyes of men without an orator.”8
The philosopher Pascal commented, “Had Cleo-
patra’s nose been shorter, the whole face of the world
277
278 Naini, Moss, and Gill
would have changed!”9 From Homer’s Helen of Troy,
whom the poet Christopher Marlowe described as having
a “face that launched a thousand ships,”10 to Queen
Nefertiti, whose name literally means the “Perfect One,”
to modern models and actors, facial beauty has always
been the most valued aspect of human beauty.
The next question therefore is how do we know that
a face is beautiful? What guides and validates our
judgment?
Our perception of facial beauty might have its
foundation in our heredity, environment, or perhaps
both. Langlois et al11 found that infants as young as 3
months of age can distinguish between attractive and
unattractive faces, showing signs of preference for the
former. It is unlikely that by 3 months of age an infant
will have been subjected to or responded to any cultural
or environmental influences; therefore, this is evidence
to support a genetic theory. The evolutionary basis is
that facial beauty, including facial symmetry and sec-
ondary sexual characteristics, is a requirement for
sexual selection, leading to reproduction.12
A study by Martin13 found that both white and
black American men preferred black female faces with
white features, whereas black African men showed a
preference for black female faces with Negroid fea-
tures. This lends support to environmental or cultural
reasons for the human perception of facial beauty.
However, Perrett et al14 found that both white and
Japanese men and women ranked female faces as most
attractive when youthful facial features, such as large
eyes, high cheekbones, and narrow jaws, were evident.
Esthetic judgments therefore seem to be similar across
various cultural backgrounds. A meta-analysis by Lan-
glois et al15 seemed to confirm that there is cross-
cultural agreement about facial attractiveness.
Studies by Sir Francis Galton,16 Charles Darwin’s
cousin, provide evidence to support averageness as the
ideal,17 with composite facial photographs of subjects
gaining higher attractiveness ratings than individual
facial photographs.18 However, Perrett et al14 showed
that, contrary to this averageness hypothesis, the mean
shape of a group of attractive faces is preferred to the
mean shape of the sample from which the faces were
selected. In addition, attractive composite faces were
made more attractive by exaggerating the shape differ-
ences from the sample mean. Therefore, an average
face shape is attractive but might not be optimally
attractive,19 and highly attractive facial configurations
are not necessarily average.20
FACIAL PROPORTIONS
The assessment of facial beauty is essentially sub-
jective.21 In the 16th century, the artist Albrecht Dürer
American Journal of Orthodontics and Dentofacial Orthopedics
September 2006
said, “I know not what beauty is, but I know that it
affects many things in life.” Dürer explained that,
although the concept of facial beauty was immersed in
subjectivity, the assessment of facial proportions could
be undertaken objectively.22 He maintained that dispro-
portionate human faces were unesthetic, whereas propor-
tionate features were acceptable if not always beautiful.
Therefore, the appropriate goal for the orthodontist’s
clinical examination is to find facial disproportions.23 The
inevitable question is, therefore, where did the evidence
for ideal facial proportions originate?
In representing the human form, painters and sculp-
tors in the past developed many canons or guidelines.
These were mainly based on the “good eye” of the
respective artist, which is anecdotal evidence. How-
ever, many of these guidelines are still used by clini-
cians today, albeit somewhat modified from the origi-
nals.
A major preoccupation of Greek sculptors was the
idealization of human proportions. In the fifth century
BC, one of the most famous, Polycleitus, wrote a
theoretical work that discussed ideal mathematical
proportions for the parts of the human body. In his
Canon, he also described the importance of the concept
of symmetry in the human form, called “symmetria.” In
the first century BC, the Roman architect Marcus
Vitruvius Pollio wrote his famous work, The Ten Books
on Architecture. In Book 2, Chapter 2, Vitruvius
defined symmetry as “a proper agreement between the
members of the work itself, and relation between the
different parts and the whole general scheme, in accor-
dance with a certain part selected as standard. Thus in
the human body there is a kind of symmetrical harmony
. . . and so it is with perfect buildings.”24 Although the
relationship between bilateral facial symmetry and
beauty remains to be clarified,25 evidence seems to
suggest that mild facial asymmetry is compatible with
facial beauty.26 Vitruvius also described the facial
trisection, emphasizing that the ideal face can be
divided vertically into 3 distinct thirds, a concept still
used today in planning facial surgery.
The great Renaissance artist and thinker Leonardo
da Vinci emphasized the importance of harmony be-
tween art and science. Leonardo defined proportion as
the ratio between the respective parts and the whole.27
The figure of Vitruvian man (Fig 1), which Leonardo
based on guidelines described by Vitruvius, shows the
importance of proportions in the human form. He also
studied the proportions of the human head (Fig 2). The
distance from the hairline to the inferior aspect of the
chin is one-tenth of a man’s height. The distance from
the top of the head to the inferior aspect of the chin is
one-eighth of a man’s height. These have important
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 3
Fig 1. Leonardo da Vinci’s Vitruvian man, ca 1490. This
famous figure shows that proportionate human form fits
perfectly in perfect geometric shapes— circle and square,
with navel at center. Vertical facial trisection is shown.
Vertical face height (hairline to inferior aspect of chin) is
one tenth of standing height. Interestingly, this is equal
to length of hand (courtesy of Gallerie dell’Accademia,
Venice).
clinical implications. If a patient’s vertical facial pro-
portions are to be altered with surgery, the treatment
plan must take into account the proportion of the
patient’s total face height to his or her standing height
and stature. The use of absolute numeric values of
facial measurements rather than facial proportions can
be misleading, because the vertical facial height of a
patient who is 6 feet tall is different from that of a
patient 5 feet tall.
Dürer, in 1525, maintained the importance of study-
ing facial proportions, criticizing artists of his day, and
saying, “They have not learnt Geometry, without which
no one can either be or become an absolute artist.”22
Therefore, the guidelines used by clinicians today are
mainly based on those initially described in art. The
Naini, Moss, and Gill 279
Fig 2. Leonardo da Vinci’s Male head in profile with
proportions, ca 1490. Vitruvian anterior vertical facial
thirds are evident: hairline to eyebrows, eyebrows to
base of nose, base of nose to below chin. Lower facial
third is again divided into upper third (upper lip) and
lower two-thirds. Ear is one third of facial height. What
later came to be described as Frankfort plane and its
perpendicular, facial vertical from soft-tissue nasion,
are also shown (courtesy of Gallerie dell’Accademia,
Venice).
orthodontic specialty, however, has been at the fore-
front in the assessment of the facial soft-tissue profile,28
mainly because of the use of lateral cephalometric
radiographs that provide many analyses.29-35
Clinicians therefore can assess facial esthetics more
objectively by diagnosing and helping to correct facial
disproportions.
Since the establishment of our specialty over 100
years ago, orthodontic theory and practice have been
based on the Angle paradigm.36 The goal of treatment
was to produce perfect occlusion of all the teeth, and
facial beauty was thought to follow. Although this
concept was discredited with the introduction and
growth of cephalometrics, the basic idea that the
dentofacial skeleton determined the goals of treatment
remained intact.37
It is only recently that the concept of the soft-tissue
280 Naini, Moss, and Gill
paradigm, focusing the diagnosis and treatment of
dentofacial problems on the soft tissues of the face
rather than on dentoskeletal structures, has emerged in
orthodontics and orthognathic surgery.23 The den-
toskeletal structures of the face are like the scaffold
over which the soft tissues drape. However, it is the
soft-tissue proportions, not the skeletal proportions,
that are the goals of treatment.38 Proffit et al23 have led
the way in the emergence of this paradigm shift,
placing greater emphasis on the clinical examination of
the patient and our assessment of the soft-tissue
changes that occur with each dentoskeletal change and
with age, thus allowing for greater accuracy in treat-
ment planning.
FACIAL PROPORTIONS AND THE
GOLDEN PROPORTION
An often-quoted but rarely substantiated concept is
that of the “golden proportion.”39 The mathematician
Euclid (ca 325-265 BC) described this in The Elements,
his treatise on mathematics. The origin of this concept
is unknown, having been attributed to both Pythagoras
and Plato. In his edition of Euclid’s Elements, the
mathematician Luca Pacioli (1509) renamed the golden
proportion the “divine proportion” because he thought
the concept could not be rationalized. Pacioli also
published a treatise entitled De Divina Proportione (On
Divine Proportion) for which Leonardo da Vinci drew
figures of symmetrical and proportionate faces and
bodies. Later in that century (1597), the first known
calculation of the golden proportion as a decimal was
given by Maestlin in a letter to his former pupil,
Kepler.40 The number is 0.618 for the length of the
longer segment of a line of length 1 when it is divided
in the golden proportion. The ratio of the shorter
section to the longer section of the line is equal to the
ratio of the longer section to the whole line. The point
at which the line is divided is known as the golden
section and is represented by the symbol ⌽ (phi)
derived from the name of the Greek sculptor Phidias
who incorporated it into the architectural design of the
Parthenon.41
There have been attempts to correlate ideal facial
proportions with the golden proportion.42 However, in
a 3-dimensional study analyzing the faces of profes-
sional models, the authors found that they did not fit the
golden proportion and, interestingly, that they had
various malocclusions and a wide range of cephalomet-
ric values.43 In another study of the esthetic improvement
of patients having orthognathic surgery, the authors found
that, whereas most subjects were considered more attrac-
tive after treatment than before, the proportions were
equally likely to move away from or toward the golden
American Journal of Orthodontics and Dentofacial Orthopedics
September 2006
proportion.44 Therefore, more research evidence is
required to substantiate the true significance of this
fascinating concept in the clinical assessment of facial
esthetics.
FACIAL DEFORMITY AND THE
CONTROVERSIAL DEBATE
The final question concerns patients with facial
anomalies of varying magnitudes and whether they
should be treated, especially when the deformity is not
part of an active disease process.
A person’s self-perception of facial appearance is of
utmost importance. It has been said, “Nothing has so
marked influence on the direction of a man’s mind as
his appearance, and not his appearance itself so much
as his conviction that it is attractive or unattractive.”45
There is, of course, considerable individual variation in
people’s abilities to adapt to their facial deformities,
whatever the severity, with some remaining compara-
tively unaffected and others having significant difficul-
ties that affect their quality of life. It has even been
argued that facial deformity might be a social disability,
because it impacts not only the person affected, but also
contributes to the opinions other people form of them.46
Although these opinions can change as interpersonal
relationships develop, a person’s first impression on
others might well affect his or her self-esteem and
quality of life.47
Research seems to indicate that mild to moderate
facial deformities actually cause a patient greater psy-
chological distress than severe facial deformities.48
This could be because other people’s reactions towards
milder deformities are less predictable, whereas more
severe deformities tend to evoke more consistent reac-
tions, albeit negative, allowing the patient to develop
better coping strategies. The variability in people’s
reactions to milder facial deformities also causes con-
siderable patient distress. Most patients seeking orth-
odontic treatment or facial esthetic surgery fit into the
mild or moderate category in terms of facial deformi-
ties, as opposed to craniofacial malformation syn-
dromes or severe facial trauma or disease.
There is a long-standing and controversial debate
about the ability to alter facial appearance. The debate
centers on whether a patient with a facial deformity
should learn to live with his or her facial appearance.
This argument states that a psychologically healthy
patient should be able to adjust to the social environ-
ment. The supporters of this view also state that
education of the public and changes in public attitudes
toward visible facial differences are the correct way
forward. The argument against this case states that the
negative effects of facial deformity on a patient’s
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 130, Number 3
psychosocial well being are enough to warrant clinical
intervention. The 2 sides seem unable to reach common
ground.
We believe that there is merit in both sides of the
argument, and that they are not mutually exclusive.
There is no doubt that attitudes in society toward all
types of deformity have changed, and public education
is undoubtedly the most important factor, with charities
such as Changing Faces49 helping to both educate the
public and change public opinion regarding facial
deformities. Modern society’s media-fuelled obsession
with the so-called perfect appearance is at best unhelp-
ful and at worst detrimental. People compare them-
selves to those who are unrealistically portrayed by the
media to represent cultural ideals of beauty, and, if their
own appearances do not measure up, this might result
in body-image dissatisfaction, possibly leading to al-
tered self-recognition and conditions such as eating
disorders and body dysmorphic disorder.50 Therefore,
although it is unrealistic to expect the media’s obses-
sion with appearance to significantly change, greater
responsibility on the media’s part would be com-
mended. In addition, television documentaries, perhaps
interviewing patients and families of patients with
dentofacial anomalies, and following patients through
their daily lives as they describe their challenges, would
undoubtedly be useful for educating the general public.
Such education might help lessen society’s intolerance
for what is considered an abnormal facial appearance
and contribute to transforming the public’s perception
of those with facial deformities.
However, it would be simplistic and possibly un-
ethical to withhold treatment on the basis that the
problem is with attitudes in society alone. If treatment
can significantly improve a patient’s quality of life,
then it is for the patient to make the ultimate informed
decision of whether treatment is the correct way for-
ward.
CONCLUSIONS
The aim of this article was to briefly describe our
contemporary understanding of facial beauty and to
debate the challenges faced by patients and clinicians in
the treatment of dentofacial deformities. There is no
doubt that the philosophical debate and the research
will continue, because our clinical practice should
always be based on a sound knowledge of theory. One
may only conclude that patients requiring alterations in
facial appearance remain a considerable clinical chal-
lenge.
Naini, Moss, and Gill 281
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