ORIGINAL ARTICLE

Facial profile preferences: Differences in the

perception of children with and without
orthodontic history
Luka Cala,a Stjepan Spalj,b Martina Slaj,c Marina Varga Lapter,d and Mladen Slaje
Zagreb, Croatia

Introduction: Improved facial esthetics can be fully achievable only if facial preferences of the treated group
are known. We hypothesized that facial profile perception and preferences could be influenced by orthodontic
treatment. Methods: Differences in facial profile preferences between children with and without an orthodon-
tic history were investigated in a sample of 1626 children aged 12 to 19 years (mean age, 14.8 6 2.2 years)
from 24 public schools in Zagreb, Croatia, randomly selected by using a cluster sampling procedure. Eight
profile distortions for each sex, morphed by a digital imaging technique, were used for estimation. Analysis
of variance (ANOVA), Bonferroni, and 2 independent sample t tests were used to compare the preferences
of the groups. Results: A straight profile was the most favored in both sexes, regardless of previous orthodon-
tic history. A bimaxillary alveolar protrusive profile with thicker lips was preferred among the female profiles,
and a bimaxillary retrusive profile with flat lips and a prominent chin was preferred among the male profiles.
Orthodontic history and personal facial profile had little effect, and sex had a slightly greater influence on
personal facial profile preferences. Conclusions: It seems that orthodontic therapy has no clinically relevant
influence on facial profile preferences. Depending on the patient’s sex, orthodontists should have different
criteria for treating borderline patients with bimaxillary dentoalveolar protrusion and mandibular prognathism.
(Am J Orthod Dentofacial Orthop 2010;138:442-50)

components of cephalometric analysis. Ackerman et al8

I
mprovement in facial esthetics is the main objective
of orthodontic treatment. From the times of Kings-
ley,1 Angle,2 and Case,3 much attention has been
devoted to facial balance and esthetics. The introduction
of cephalometry shifted the attention from esthetics to
hard-tissue norms. Subsequent cephalometric analyses,
such as those developed by Downs,4 Steiner,5 and Rick-
etts,6 incorporated soft-tissue profiles norms, but only as
secondary and adjunct to hard-tissue norms. Only
recently, soft-tissue analysis started to receive adequate at-
tention. Arnett and Bergman7 pointed to facial esthetics,
soft-tissue profile, and smile line as the most important
From the Department of Orthodontics, School of Dental Medicine, University of
Zagreb, Zagreb, Croatia.
a
Resident.
b
Postgraduate student.
c
Research assistant.
d
Professor.
e
Professor and head.
Supported by grants from the city of Zagreb and the Croatian Ministry of
Science, Education and Sport (grant 065-0650444-0436 to Mladen Slaj).
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Martina Slaj, Department of Orthodontics, School of Dental
Medicine, University of Zagreb, Gunduliceva 5, 10 000 Zagreb, Croatia; e-mail,
martina.slaj@sfzg.hr.
Submitted, May 2008; revised and accepted, October 2008.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.10.024
442
analyzed the esthetics of posed smiles and developed
SmileMesh, a computer application for determining the
vertical position of incisors during orthodontic treatment.
Sarver and Proffit9 stated that cephalometric findings are
no longer the major determinant of treatment goals in
modern orthodontics. Increased interest in facial esthetics
stimulated studies on differences in facial preferences
based on social status, race, sex, age, and education.
Kokich et al10 demonstrated differences in esthetic prefer-
ences among laypeople, dentists, and orthodontists, and
concluded that aberrations from ideal that are not estheti-
cally pleasant to orthodontists and dentists could be
acceptable to laypeople.
In contemporary orthodontics, decisions about
extraction are made not only on the basis of calculated
amounts of dental crowding and cephalometric norms,
but also from soft-tissue analyses. The lips are sup-
ported by the maxillary incisors, and alteration of the in-
cisors’ position changes the lip profile. Thus, extraction
of premolars and retraction of maxillary incisors by 4
mm results in approximately 4 mm of lower lip retrac-
tion and 3 mm of upper lip retraction.11 There is some
evidence that the sizes of the nose and the chin in rela-
tion to the lips influence the attractiveness of the facial
profile, and that profile preferences are sex-related.12
A straighter profile with a more prominent chin is
American Journal of Orthodontics and Dentofacial Orthopedics Cala et al 443
Volume 138, Number 4

Fig 1. Set of female facial profile distortions (Türkkahraman and Gökalp13; reprinted with permission
from the Angle Orthodontist). A, Bimaxillary dentoalveolar retrusion, B, straight profile, C, bimaxillary
dentoalveolar protrusion, D, retrognathic mandible, E, prognathic maxilla and retrognathic mandible,
F, prognathic mandible, G, retrognathic maxilla and prognathic mandible with increased overbite,
H, prognathic and posteriorly rotated mandible with anterior open bite.

favored in men, and more lip protrusion is favored in
women.12 Although much attention has been devoted
to soft-tissue profiles, studies on the perception of facial
profiles in children are lacking. The purposes of this
study were to determine the facial profile preferences
among children and adolescents, and whether the per-
ception of facial profile is influenced by orthodontic
treatment, sex, or type of personal profile.
MATERIAL AND METHODS
Data were collected during an epidemiologic survey
between September 2006 and February 2007 in 24
public schools in Zagreb, Croatia. The schools were
randomly selected by using a cluster sampling proce-
dure with special attention paid to the location and
type of school. A total of 1626 children (white Euro-
peans) aged 12 to 19 years (mean age, 14.8 6 2.2 years)
were asked to rate the profile distortions. The sample
included 713 boys (30.4% with orthodontic history)
and 913 girls (41.3% with orthodontic history). The
Ethical Committee of the School of Dental Medicine
at the University of Zagreb approved this study. For
assessing facial preferences, 2 sets of color photographs
were used, representing 8 male and 8 female profile
distortions. The sets were digitally produced, morphed,
and standardized by a method described by
Türkkahraman and Gökalp13 (Figs 1 and 2). The
profiles were coded from A to H, representing the
following skeletal and dentoalveolar features: (A)
bimaxillary dentoalveolar retrusion, (B) straight
profile, (C) bimaxillary dentoalveolar protrusion,
(D) retrognathic mandible, (E) prognathic maxilla and
retrognathic mandible, (F) prognathic mandible, (G)
retrognathic maxilla and prognathic mandible with
increased overbite, and (H) prognathic and posteriorly
rotated mandible with anterior open bite.
The subjects were instructed to rank the profiles on
a scale from 1 to 8, with 1 the most esthetic and 8 the
least esthetic. The images were presented in a pile for
444 Cala et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2010

Fig 2. Set of male facial profile distortions (Türkkahraman and Gökalp13; reprinted with permission
from the Angle Orthodontist). A, Bimaxillary dentoalveolar retrusion, B, straight profile, C, bimaxillary
dentoalveolar protrusion, D, retrognathic mandible, E, prognathic maxilla and retrognathic mandible,
F, prognathic mandible, G, retrognathic maxilla and prognathic mandible with increased overbite,
H, prognathic and posteriorly rotated mandible with anterior open bite.

each rater to sort. Male and female profiles were rated
separately. The images could be considered to represent
typical Croatian profiles. Information on each rater’s
age, sex, orthodontic history, and personal facial profile
was also obtained. Orthodontic history was assessed as
a dichotomous variable—with or without a history of
orthodontic treatment. The types of presented profiles
were determined visually by the investigators and
grouped as convex, straight, and concave.
The data were analyzed by using the statistical soft-
ware (version 9.0, SAS Institute, Cary, NC). The Levene
test was used to determine the homogeneity of vari-
ances, and the Kolmogorov-Smirnov test was used to
assess the normality of distribution. The 2 independent
sample t test was used to compare differences in facial
profile preferences for subjects with and without
orthodontic history and for the sexes. Analysis of
variance (ANOVA) was used for comparing profile
groups, with the Bonferroni post-hoc test for subjects
with equal variances and the Games-Howell test for
those without equal variances. A confidence level of
0.05 was considered statistically significant.
RESULTS
Orthognathic facial profile B was the most pre-
ferred, and retrognathic profile E, with a prognathic
maxilla and a retrognathic mandible, was the least
preferred among both male and female distortions.
The bimaxillary alveolar protrusive profile with thicker
lips was considered esthetically more attractive among
the female profiles (sequence: B, C, D, and A), and
the bimaxillary retrusive profile with flat lips and
a prominent chin among the male profiles was the
most attractive (sequence: B, A, C, and D). As shown
in Tables I through III, orthodontic history and
personal facial profile had little effect on facial profile
preferences, but sex had a slightly greater influence.
Specific results are presented below.
Mean scores for the female and male profiles with
respect to the raters’ orthodontic history are shown in
Table I. Children with a previous orthodontic history
rated female profile C higher than children with no
orthodontic history (P 5 0.036). Raters with an ortho-
dontic history rated male profile E lower then those
with no orthodontic history (P 5 0.018).
American Journal of Orthodontics and Dentofacial Orthopedics Cala et al 445
Volume 138, Number 4

Table I. Comparisons of mean scores of profiles regarding orthodontic history

Female profiles Male profiles

Profile Subjects Mean SD Significance* Mean SD Significance*

A No orthodontics 4.76 1.96 2.98 1.87

Orthodontic history 4.92 1.92 0.100 2.98 1.75 0.946
Total 4.82 1.95 2.98 1.83
B No orthodontics 1.44 1.13 1.59 1.31
Orthodontic history 1.47 1.17 0.623 1.50 1.22 0.159
Total 1.45 1.15 1.56 1.28
C No orthodontics 2.38 1.16 3.04 1.30
Orthodontic history 2.25 1.14 0.036† 2.97 1.23 0.306
Total 2.33 1.15 3.02 1.28
D No orthodontics 4.08 1.48 4.35 1.42
Orthodontic history 4.09 1.50 0.926 4.31 1.42 0.622
Total 4.08 1.48 4.34 1.42
E No orthodontics 7.15 1.52 6.89 1.63
Orthodontic history 7.23 1.47 0.306 7.09 1.50 0.018†
Total 7.18 1.50 6.96 1.59
F No orthodontics 5.11 1.43 4.89 1.39
Orthodontic history 5.00 1.37 0.139 4.88 1.42 0.875
Total 5.07 1.41 4.88 1.40
G No orthodontics 5.75 1.41 6.31 1.37
Orthodontic history 5.75 1.37 0.986 6.35 1.24 0.562
Total 5.75 1.39 6.33 1.32
H No orthodontics 5.22 1.84 5.77 1.66
Orthodontic history 5.11 1.80 0.213 5.75 1.55 0.812
Total 5.18 1.83 5.76 1.62

*Two independent samples t test; †P \0.05.

Both male and female subjects rated female and
male profiles B the highest, and female and male
profiles E the lowest. The boys and girls evaluated
the male profiles more similarly than the female
profiles (Figs 3 and 4). Girls gave significantly
higher scores to female profiles with bimaxillary
dentoalveolar protrusion and straight profiles than did
the boys (P \0.001). Boys gave higher scores to
convex female profiles D and E than did the girls
(P \0.005). Girls also rated straight and prognathic
profiles higher in males (B and F) than did the boys
(P \0.001).
The results of profile preferences with respect to sex
among children with and without orthodontic history
are shown in Figures 5 and 6. Orthodontic history
significantly influenced profile preferences in girls.
Girls with a positive orthodontic history tended to
give better scores to bimaxillary dentoalveolar
protrusion in female profiles than girls with no
orthodontic history (P 5 0.044). The same group
evaluated straight profiles in males better (P 5 0.007).
Boys with orthodontic history rated female profile G
and male profile D higher than did boys with no
history of previous orthodontic treatment (P 5 0.05
and P 5 0.007, respectively).
The results of the influence of the judges’ personal
profiles on facial profile preferences are shown in
Tables II and III. Children of both sexes with straight
profiles and orthodontic history rated female profile B
higher than children with convex personal profiles
(P 5 0.012). Statistically significant differences were
found in preferences of female profiles D and F (P 5
0.009 and P 5 0.018, respectively) and male profiles
A and H in children of both sexes without
orthodontic history (P 5 0.031 and P 5 0.001,
respectively).
There were only minor differences between girls
and boys in scoring profile distortions when their ortho-
dontic history and personal profile were combined.
DISCUSSION
It was suggested that improved appearance of teeth
and facial profile achieved by orthodontic therapy could
have an influence on perceptions of oral environ-
ment.14,15 We hypothesized that the perception of
facial profile by children could also be influenced by
previous orthodontic treatment. Our goal was to
determine general facial profile preferences among
children and adolescents, and whether previous
446 Cala et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2010

Table II. Comparisons of mean scores of profiles regarding personal profile in the group with orthodontic history
Female profiles Male profiles

Profile Personal profile Mean SD Significance Mean SD Significance

A Straight 4.89 1.88 2.97 1.77

Convex 5.00 1.94 2.91 2.01
Concave 5.00 1.92 0.907 2.91 1.56 0.965
B Straight 1.42 1.06 1.47 1.17
Convex 2.03 2.26 0.012*,† 1.94 1.61
Concave 1.36 0.55 (straight & convex) 1.65 1.50 0.083
C Straight 2.27 1.13 2.99 1.23
Convex 2.50 1.40 3.03 1.27
Concave 2.16 1.02 0.442 2.85 1.06 0.785
D Straight 4.18 1.53 4.40 1.42
Convex 3.94 1.43 4.06 1.26
Concave 4.24 1.68 0.656 4.03 1.59 0.154
E Straight 7.27 1.43 7.03 1.56
Convex 6.71 1.95 6.80 1.68
Concave 7.09 1.63 0.098 6.87 1.59 0.63
F Straight 5.02 1.39 4.89 1.43
Convex 4.76 1.60 4.79 1.72
Concave 4.82 1.49 0.481 4.85 1.48 0.924
G Straight 5.69 1.43 6.35 1.25
Convex 5.63 1.63 6.26 1.52
Concave 5.97 0.98 0.522 6.56 1.28 0.586
H Straight 5.07 1.82 5.69 1.59
Convex 5.15 1.76 6.03 1.52
Concave 5.21 1.93 0.898 6.15 1.20 0.144
†
*ANOVA with the Games-Howell post-hoc test; P \0.05.

Table III. Comparisons of mean scores for profiles regarding personal profiles in the group with no orthodontic history
Female profiles Male profiles

Profile Personal profile Mean SD Significance Mean SD Significance

A Straight 4.79 1.97 2.98 1.84

Convex 4.63 2.01 2.68 1.66 0.031†,‡
Concave 4.86 2.33 0.863 3.76 2.47 (concave & convex)
B Straight 1.41 1.14 1.57 1.30
Convex 1.39 0.63 1.56 0.92
Concave 1.66 1.14 0.44 1.82 1.80 0.552
C Straight 2.38 1.13 3.00 1.27
Convex 2.26 0.94 3.15 0.95
Concave 2.51 1.31 0.618 3.09 1.03 0.726
D Straight 4.17 1.48 0.009*,‡ 4.39 1.44
Convex 3.49 1.25 (convex & straight) 4.00 1.64
Concave 4.43 1.69 (convex & concave) 4.33 1.29 0.251
E Straight 7.15 1.49 6.86 1.66
Convex 7.28 1.28 7.00 1.63
Concave 7.03 1.53 0.776 7.03 1.42 0.741
F Straight 5.08 1.43 0.018*,‡ 4.87 1.40
Convex 5.66 1.53 (convex & straight) 4.95 1.45
Concave 4.76 1.67 (convex & concave) 4.88 1.84 0.94
G Straight 5.7 1.45 6.32 1.39
Convex 5.8 1.42 6.83 0.92
Concave 5.71 1.43 0.92 6.18 1.38 0.055
H Straight 5.19 1.85 5.80 1.64 0.001†,‡
Convex 5.33 1.64 5.76 1.43 (concave & straight)
Concave 5.03 1.99 0.794 4.73 1.92 (concave & convex)

*ANOVA with the Bonferroni post-hoc test; ANOVA with the Games-Howell post-hoc test; ‡P \0.05.
†
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 4
Fig 3. Comparison of mean scores for male profiles re-
garding the rater’s sex; asterisks represent significant
differences between the sexes according to t tests.
orthodontic history, sex, and personal facial profile type
have an effect on those preferences.
Various physical, psychological, and social factors
that affect perceptual judgments are related to the devel-
opment of a personal concept of facial esthetics.16
Several studies investigated facial esthetic preferences
of different races, ethnicities, and cultures and described
the differences among them. It was suggested that the
profile standards of Ricketts, Steiner, and Holdaway do
not apply to Africans,17 and that orthodontists and layper-
sons of African descent prefer more convex bialveolar
protrusive profiles than white orthodontists and white
laypersons.18-20 Africans’ profile preferences are
straighter than the norm for their race, but more
protrusive than white standards.21 Asians, on the other
hand, prefer straight or bimaxillary retrusive profiles
with a more protrusive nose in females and a more
retrusive chin in males than do white people.22-26
Hispanics prefer the upper and lower lip positions to be
less protrusive than those of whites, and the mean
protrusion preference among whites is significantly
greater than the norm of Ricketts norm for whites.27
In spite of these findings, there is a general prefer-
ence among orthodontists and laypersons for an orthog-
nathic profile, and orthodontists consider the most
pleasing profile to be more forward than do laypeople.28
The raters in this study also preferred orthognathic
Cala et al 447
Fig 4. Comparison of mean scores for female profiles
regarding the rater’s sex: asterisks represent significant
differences between the sexes according to t tests.
profile in both sexes. McCarthy et al29 found that a large
chin, which describes a prognathic mandible, is a more
masculine trait, and a softer chin, which describes
a more retrognathic profile, is a more feminine trait.
Both orthodontists and laypeople are more tolerant of
bimaxillary protrusion in women than in men, and fuller
lips could also enhance extreme retrognathic and
prognathic profiles.24,30 This agrees with our results;
raters of both sexes liked bialveolar protrusive female
profiles better. This finding can be clinically important
for borderline girls and lead to a decision to treat
them without extractions. Extraction of 2 maxillary
premolars could result in many changes of upper lip
and incisor positions, especially in patients with a thin
upper lip, in whom an increased nasolabial angle will
be most obvious.31 The most attractive male profile in
our study was straight, followed by the profile with
a more prominent chin. That can be clinically applicable
in borderline patients in deciding between surgical and
camouflage treatment of prognathic male patients.
Also, in male patients with severe crowding, extraction
treatment can be better justified. Similar esthetic prefer-
ences were found in a Turkish population, leading to the
same conclusions in treatment protocols.13
Prior orthodontic treatment significantly influenced
profile preferences in girls. Girls with a positive ortho-
dontic history gave better scores to bimaxillary
448 Cala et al American Journal of Orthodontics and Dentofacial Orthopedics
October 2010

Fig 5. Comparison of mean scores for female profiles regarding orthodontic history and sex.

Fig 6. Comparison of mean scores for male profiles regarding orthodontic history and sex.

dentoalveolar protrusion in female profiles and straight
profiles in males. The clinical implication of these
results is that orthodontic treatment could enhance
esthetic perceptions in girls.
Clinicians often overlook the fact that a person
behaves in response to the perceptions and not to
the actual physical characteristics of the face.16
Orthodontic patients and their parents might not be
aware of the actual pretreatment profile and tend to
overestimate the position and protrusion of 1 jaw or
both jaws.19,32
The judges’ types of profiles in our study had little
effect on facial profile preferences. There are some dif-
ferences in perception of existing profiles and
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 138, Number 4
preferred changes of facial profiles between adults
with and without a history of orthodontic treatment.
This suggests that orthodontic subjects are less tolerant
of variations in facial features than nonorthodontic
subjects.33
The differences in facial profile preferences in this
study were influenced by sex, orthodontic history, and
personal profile type. Although some differences were
statistically significant, this did not change the general
sequence of preferences of male and female profiles.
The ideals of both male and female beauty are estab-
lished early and are widespread even in children and ad-
olescents, probably because of the influence of mass
media and peer groups. Our results will enhance our
understanding of the ways our patients make esthetic
judgments.
CONCLUSIONS
1. An orthognathic straight profile was most favored
by both sexes regardless of orthodontic history
and personal profile. The bimaxillary alveolar pro-
trusive profile with thicker lips was preferred
among the female profiles, and the bimaxillary ret-
rusive profile with flat lips and a prominent chin
was preferred among the male profiles.
2. Orthodontic history and personal profile have little
effect on facial profile preferences of laypeople.
3. Although the rater’s sex had a statistically signifi-
cant effect on facial profile preferences, it did
not influence the general sequence of profile
preferences.
We thank Hakan Türkkahraman, Suleyman Demirel
University, Isparta, Turkey, and Hatice Gökalp, Univer-
sity of Ankara, Ankara, Turkey, for allowing us to use
their morphed profile distortions.
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