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ORIGINAL ARTICLE
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 183-191

Perceptions of facial proportions and lip competency on facial attractiveness among people of Telangana origin


Department of Orthodontics and Dentofacial Orthopedics, Army College of Dental Sciences, Secunderabad, Telangana, India

Date of Submission18-Jan-2019
Date of Acceptance19-Aug-2019
Date of Web Publication17-Oct-2019

Correspondence Address:
Dr. Prasad Chitra
Professor & HOD, Department of Orthodontics, Army College of Dental Sciences, Secunderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_9_19

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  Abstract 


Context: Modern orthodontics focuses on soft tissue paradigms. Successful treatment outcomes are dependent on the patient's self-impression. Understanding individual differences in perception of facial attractiveness across orthodontics, their patients and other dental specialists would help obtain optimal and satisfactory results.
Aim: To determine facial frontal proportions and lip position preferences among lay people, general dentists, specialists, and orthodontists to estimate differences in perceptions.
Materials and Methods: 200 raters divided into Group 1 [50 each of orthodontists, general dentists, specialist dentists (oral surgeons, endodontists, periodontists, prosthodontists, and pedodontists)] and Group 2 (50 lay individuals of Telangana origin) participated in a questionnaire-based survey comprising photographs of one male and one female of Telangana origin with mesoprosopic faces and competent lips morphed as leptoprosopic and euryprosopic with lip positions morphed as potentially incompetent and incompetent. Raters evaluated and ranked each set of three altered frontal images on a 3-point Likert scale and lips on a 6-point Likert scale.
Statistical Analysis Used: Means and standard deviation for the entire sample population and independently for gender and professional groups were obtained. Mann–Whitney test to compare rankings of each male and female image according to gender and Kruskal–Wallis test to compare rankings of male and female images between the four groups were done.
Results: Mesoprosopic faces were most attractive in males and females followed by leptoprosopic and euryprosopic patterns. Male and female subject values did not differ significantly when analyzed. Orthodontists and specialist dentists found mesoprosopic male and female faces to be most attractive. Euryprosopic female faces were deemed more acceptable by lay public. Competent lip images were found to be most attractive. Potentially incompetent lips in males and incompetent lips in females were least attractive.
Conclusion: These findings can assist orthodontists in treatment planning. Lower facial height changes can be assessed, and effects on overall patient esthetics can be determined for treatment results to closely mimic patient expectations.

Keywords: Facial attractiveness, facial proportion, frontal profile, Telangana population


How to cite this article:
Verma S, Chitra P. Perceptions of facial proportions and lip competency on facial attractiveness among people of Telangana origin. J NTR Univ Health Sci 2019;8:183-91

How to cite this URL:
Verma S, Chitra P. Perceptions of facial proportions and lip competency on facial attractiveness among people of Telangana origin. J NTR Univ Health Sci [serial online] 2019 [cited 2019 Nov 15];8:183-91. Available from: http://www.jdrntruhs.org/text.asp?2019/8/3/183/269495




  Introduction Top


Esthetics is a key motivational reason for patients seeking orthodontic treatment and one of the most important goals of orthodontic treatment. Facial attributes such as averageness, symmetry, and sexual dimorphism contribute to overall facial attractiveness. An accurate assessment of facial symmetry in both lateral and frontal profiles is necessary for accurate diagnosis and treatment planning in orthodontics. An understanding of individual differences in perceptions of facial symmetry between patients and dentists will lead to more successful and satisfactory treatment.

It has been seen that the esthetic preferences of the public can be diverse due to difference in ethnicity and racial background.[1],[2] In addition, factors such as sex, age, education, socioeconomic status, and geographic location affect the esthetic preferences of the public. Thus, the evaluation of facial attractiveness is subjective and further influenced by factors such cultural training and specific training (dentists and individuals related to the art fields).

Most previous studies[3],[4],[5],[6] have evaluated perception of attractiveness in profile standards of Caucasians, African-Americans, Japanese, Jordanian, and Chinese but not in Telangana population. Despite the fact that a patient determines personal attractiveness from the frontal view and studies which show that interpersonal communication is mainly frontal, most studies in orthodontics that deal with facial esthetics have been based on lateral profile images.[7] Thus, till date, there has been no study evaluating the effects of vertical dimension on frontal facial attractiveness.

Controversy remains in literature as to whether laypeople and professionals agree in their perceptions of facial attractiveness.[8] Various techniques have been used to evaluate facial attractiveness and profile esthetics. Silhouettes,[9] line drawings,[10] photographs,[3],[11],[12] and artist sketches[11] have all been used in the past.

Lip position is also a crucial element in overall facial esthetics, posttreatment stability, and function. Facial harmony and esthetics can be obtained by a well-balanced relationship between lip, chin, and nose. Several studies[13],[14],[15],[16] have been conducted to evaluate the effect of lip position on esthetic preferences in lateral profiles. However, the same has not been seen in the frontal view.

Thus, we aimed to determine facial frontal proportions and lip position preferences among lay people, general dentists, dental specialists, and orthodontists to estimate differences in perceptions, if any, among them. This would ultimately enable better understanding between clinicians and patients, with greater levels of patient satisfaction.


  Materials and Methods Top


The study was reviewed and approved by Ethics Committee of the Army College of Dental Sciences, Secunderabad, India (ACDS/IEC/23/Dec 2015).

Source of data

Color frontal photographs of one adult male and one female subject of Telangana origin with a well-balanced and pleasing face with ideal Angle's Class I occlusion were obtained using standardized protocols. Lateral cephalograms in natural head position were obtained for both the subjects. Prior informed consent was obtained from both subjects whose profiles were assessed by raters.

Method of collection of data

Facial profiles were generated taking color profile photographs of one male and one female Telangana subject using a Canon 800 D DSLR camera with a Canon 100 mm × 2.8 mm 1:1 macro portrait lens to eliminate distortion. Subjects had an Angle's Class I skeletal and dental relation, competent lips, symmetrical facial proportions in sagittal, transverse and vertical dimensions, and no previous history of orthodontic treatment or orthognathic/craniofacial surgery. Digital lateral cephalograms in natural head position (NHP) were taken for both subjects [Figure 1] and [Figure 2].
Figure 1: Digital radiograph of male subject

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Figure 2: Digital radiograph of female subject

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Generation of profiles

Digital radiographs were uploaded in Nemoceph 2D imaging software version 10 (build 10.4.2.58). Identification of cephalometric landmarks and tracings were carried out for both the subjects. They showed normal lower facial height proportions with Eastman normal of average lower anterior facial height (LAFH)/total anterior facial height (TAFH) ratio of 45:55 [Figure 3] and [Figure 4].
Figure 3: Nemoceph reading of male subjects showing normal facial height proportions with Eastman normal of average LAFH/ TAFH ratio of 45:55

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Figure 4: Nemoceph reading of female subject showing normal lower facial height proportions with Eastman normal of average LAFH/TAFH ratio of 45:55

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Adobe Photoshop CS 2 (version 9.0; Adobe Systems Inc., San Jose, CA, USA) software was used to create morphed images of faces [Figure 5] and lips. For leptoprosopic face, LAFH/TAFH ratio of 55% was increased by four standard deviations (SD) and vice versa for euryprosopic faces. The leptoprosopic image was created by stretching the soft tissue profile at subnasale and euryprosopic face by depressing the soft tissue profile at the same point.
Figure 5: Adobe photoshop CS 2 (version 9.0) software used to create morphed profiles

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A four-page questionnaire similar to the one used by Abu-Arqoub and Al-Khateeb[7] with normal and morphed images was used for ranking images. The first page included subject information, the second page the male altered images [Figure 6], the third page the female altered images [Figure 7], and the fourth page the morphed lip images [Figure 8].
Figure 6: Altered male frontal images: (a) leptoprosopic facial profile: lower facial height was increased with LAFH/TAFH ratio more than 55%, (b) original photographs with LAFH/TAFH ratio equal to 55% according to Eastman normal, (c) euryprosopic facial profile: lower facial height was decreased with LAFH/TAFH ratio was less than 55%

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Figure 7: Altered female frontal images: (a) leptoprosopic facial profile: lower facial height was increased with LAFH/TAFH ratio more than 55%, (b) original photographs with LAFH/TAFH ratio equal to 55% according to Eastman normal, (c) euryprosopic facial profile: lower facial height was decreased with LAFH/TAFH ratio was less than 55%

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Figure 8: Altered lip images: (a) Female with competent lip, (b) male with competent lips, (c) male with potentially incompetent lips, (d) female with potentially incompetent lips, (e) female with incompetent lips, and (f) male with incompetent lips

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Rating of profiles

A total of 250 questionnaires were prepared and distributed. Fifty questionnaires were rejected for inadequate information. Groups of general public, general dentists, specialist dentists, and orthodontists were selected for rating profiles. In all, 200 evaluators took part in the study with 50 in each group.

The raters were provided with one questionnaire each and evaluated and ranked each set of three altered frontal images for male and female frontal photographs on a 3-point Likert scale and lips on a 6-point Likert scale. Score 1 was allocated to the most attractive facial photograph and score 3 was allocated for the least attractive facial image with score 6 for the least attractive lip image.

Statistical analysis

The findings obtained were subjected to statistical analyses using Statistical Package for Social Sciences (version 23; SPSS Inc., Chicago, IL, USA). Means and SD were calculated for entire sample population and independently for gender and professional groups. Mann–Whitney test was used to compare rankings of each male and female image according to gender, and Kruskal–Wallis test was used to compare rankings of male and female images between four groups.


  Results Top


Ranking of the morphed images by the entire sample

The mean and SD scores for male and female images are depicted in [Table 1] as ranked by the total sample. Male profile B and female profile B were most attractive based on the least mean score, while male profile C and female profile C were found to be least attractive with the highest mean score. The mean and SD scores for lip images are depicted in [Table 2] as ranked by the total sample. Lip posture A and B were found to be most attractive. Lip postures C and F were found to be least attractive.
Table 1: Mean And Sd Of The Ranking Scores Of Male And Female Images By The Total Sample

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Table 2: Mean And Sd Of The Ranking Scores Of Lip Postures By The Total Sample

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Ranking of the profile images between genders

The mean and SD scores for male and female images as ranked by both raters are depicted in [Table 3]. No significant difference was found between genders in the ranking of male and female images. The mean and SD scores for male and female images as ranked by the female and male raters are depicted in [Table 4]. In addition, no difference in perception was seen for lip postures between male and female images.
Table 3: Mean And Sd Of The Ranking Scores Of Male And Female Images According To Gender

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Table 4: Mean And Sd Of The Ranking Scores Of Lip Postures According To Gender

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Ranking of the profile images between the four different groups

The mean and SD for the male and female images as ranked by four different groups are depicted in [Table 5]. Male profile B and female profile B were found to be more attractive by orthodontists and specialist dentists than general public orgeneral dentists. No differences in the rankings for female profile A, male profile A, and C were seen. Female profile C was liked more by general public than orthodontists.
Table 5: Mean And Sd Of The Ranking Scores Of Male And Female Images Between Four Different Groups Based On Education

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The mean and SD for lip postures as ranked by four different groups are depicted in [Table 6]. Lip postures A and B were perceived to be significantly more attractive to orthodontists and other specialists, whereas lip posture E and F were least attractive. Lip postures E and F were found to be acceptable by general public and lip posture D the least attractive.
Table 6: Mean And Sd Of The Ranking Scores Of Lip Postures Between Four Different Groups Based On Education

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  Discussion Top


This study was carried out to throw more light on the existing controversies and lack of consensus in published literature on perception of facial attractiveness in frontal views. The principal aim of the study was to investigate the influence of changing vertical facial proportions in frontal esthetics in subjects of Telangana origin and to determine whether these rankings were influenced by gender and profession.

Perception of frontal images and lip images by total sample

This study showed the sample population perceived mesoprosopic female faces with a normal LAFH/TAFH ratio to be the most attractive followed by leptoprosopic female faces with increased LAFH/TAFH ratio. Similarly, mesoprosopic male faces were perceived to be more attractive followed by leptoprosopic male faces. Euryprosopic (reduced LAFH/TAFH ratio) male and female profiles were considered to be least attractive.

The results of this study are in contradiction with the findings of Varlick et al.[17] who conducted a study in Anatolian Turks to assess influence of lower facial height on frontal facial attractiveness and found a preference for increased lower facial height in males and decreased lower facial height in females. This could be attributed to the methodology using silhouettes for assessment of attractiveness and raters comprising nonprofessional low- and middle-class Anatolian Turks.

The preference for mesoprosopic male profiles by Telangana population was similar to a study conducted by Abu-Arqoub and Al Khateeb[18] in Jordanian population on lateral profiles. Similar findings were seen by De Smit and Dermaut[19] and Johnston et al.[20] in Caucasian population. In Turkish population, Turkkahraman et al.[21] found that orthognathic profile was the most preferred.

For female profiles, reduced lower facial height was found most preferred by Abu-Arqoub and Al Khateeb[18] in Jordanian population and Ioi et al.[22] in Japanese population. However, Telangana population preferred mesoprosopic faces with normal LAFH/TAFH ratio in both sexes.

In this study, leptoprosopic face with increased LAFH/TAFH ratio was perceived more attractive than euryprosopic face with decreased LAFH/TAFH ratio in Telangana population. These findings are in agreement with Erbay and Caniklioglu[23] in Turkish adults who found that increased lower facial proportions were more attractive than reduced lower facial proportions.

However, this finding was in disagreement with the study by Gautam et al.,[24] who found lateral profiles with reduced lower facial proportions to be more attractive in Asian population. Other studies which are in disagreement are by De Smit and Dermaut,[19] Michiels and Sather,[25] Johnston et al.[20] in Caucasian population, and Ioi et al.[22] in Japanese population along with Abu-Arqoub and Al-Khateeb[18] in Jordanian population.

In lip profiles, females with competent lips were perceived to be most attractive followed by males with competent lips. Lip profile of males with potentially incompetent lips was least attractive followed by males with incompetent lips.

Thin vermilion borders and show of lower teeth are associated with unattractiveness. This is in accordance with Scott et al.[26] who determined the influence of variations in size of vermilion borders of the upper and lower lips on perceptions of attractiveness of various occlusal traits and concluded that occlusal traits were perceived to be more attractive with thick vermilion borders. They also concluded that lip incompetence was an important indicator when assessing vertical facial relations. Increased interlabial gap can indicate vertical maxillary excess, gummy smile, short upper lip, mouth breathing, and increased incisor exposure.

Perception of the frontal images and lip images by different groups (general public, general dentists, specialist dentists, and orthodontists)

Mesoprosopic male and female frontal profiles were selected by four groups to be most attractive. However, orthodontists gave significantly lower mean scores to mesoprosopic male and female frontal images making it the most attractive. Specialist dentists and general dentists have almost similar perception. Euryprosopic female pattern was more accepted by general public than orthodontists and specialist dentists.

These results are agreement with Maple et al.[8] who suggested that preferences of facial attractiveness by laypersons, orthodontists, and oral surgeons in Central Ohio were similar with some significant differences. These differences could be due to the training received by orthodontists and specialist dentists. Orthodontists and specialist dentists' study profiles extensively are conditioned to focus on the area of interest that pertains to these specialities – lip, chin, and dentoalveolar regions. On the other hand, laypersons rarely notice the profile view of the face unless they view it in a photograph. Laypersons might also concentrate on other facial features such as complexion, size and shape of nose, chin shape, and hairstyle, which can ultimately influence their perception.

Tauk et al.[7] assessed facial profile preferences in Lebanese population and found that orthodontists, dentists, and lay people shared the same profile preferences. They also found that it was important to use the entire facial profile to assess facial beauty.

In a recent study conducted by De Melo et al.,[27] orthodontists agreed with laymen on evaluation of the frontal view and disagreed on the profile view, especially when images were esthetically unpleasant or acceptable. This study found more agreement of perception of facial attractiveness between laypersons and dentists than with orthodontists and specialist dentists. This is in agreement with Abu-Arqoub and Al-Khateeb[18] who found that normal LAFH in lateral profile was considered to be most attractive by both layperson and dentists. They also found that dentists preferred reduced LAFH to be significantly more attractive than other groups which is congruent with the results for male profiles.

Mesaros et al.[28] assessed facial attractiveness by general dentists and found similar results. Most general dentists considered overdevelopment of lower one-third of face unattractive. However, for females, euryprosopic profile was found to be most attractive by general public followed by dentists. Other studies with similar results include Cochrane et al.[29] and Ioi et al.[25]

In lip profiles, competent lips in males and females were perceived to be most attractive and incompetent lips least attractive by orthodontists. However, general public and dentists ranked males with potentially incompetent lips to be least attractive, and rankings for incompetent male and female lip profiles were similar. Astute judgment of lip competency by orthodontists and other specialists can be attributed to a conscious well-streamlined thought process while making esthetic decisions. A major limitation of the study was that incompetent lip profiles were misconstrued as smiling profiles by lay persons and dentists. It was observed that dentists often focused more on the teeth than lips. Both reasons can be attributed to the better ranking of incompetent lip profiles. Peck and Peck[12] found that orthodontists had a tendency to develop a concept of internal facial esthetics which means little consideration was given to soft tissue relationships and layperson's concept of facial beauty developed strictly on external observations. For the general public, it was a subconscious effortless decision. According to studies conducted by Sarver et al.,[30] esthetic considerations in orthodontic and orthognathic treatment planning should not be solely based on hard tissue changes as soft tissue often fails to respond predictably to hard tissue changes. Thus, the results of this study can be correlated with treatment needs of patients.

Discussion related to the perception of the profile images by gender

No significant differences were found in the perception of profile images by male and female raters in overall results and according to groups. However, Varlick et al.,[17] in their study of influence of lower facial height changes on frontal facial attractiveness, did not take into consideration the rater's gender along with other parameters such as age, education, and personal profile.

Previous studies failed to find significant gender differences in assessment of facial esthetics by different population assessors which include De Smit and Dermaut,[19] Barrer and Ghafari,[31] Cochrane et al.,[29] Tauk et al.,[7] and Abu-Arqoub and Al-Khateeb.[18]

However, Turrkaharaman and Gokalp[31] determined general esthetic preferences of a Turkish population in lateral profile and found that sex, age, education, social status, geographic location, and personal profile affect the public's profile preferences. Female raters were most critical judges when determining facial attractiveness.

Numerous studies[4],[14],[29] in orthodontic literature have been conducted on lip prominence. Lip prominence is strongly influenced by both ethnicity and gender of both patients and judges. Nocorrelation was found for lip competence unlike Nomura et al.[4] who investigated the effect race, gender, and ethnicity on varying lip positions in lateral profiles.

Morphed photographs of male and female subjects from Telangana, India, were used along with raters of same ethnic origin to assess the perception of facial attractiveness in Telangana population. The questionnaire had an option for choosing ethnic origin. This gave us an opportunity to include only Telangana population into the study. Thus, the study was specific to the region.

Subjects were chosen after digital lateral cephalometric analysis to confirm equal upper, middle, and lower thirds and a Class I skeletal pattern.

Furthermore, responses from raters were grouped into four categories: general public, general dentists, orthodontist, and specialist dentists which aided in understanding perceptions of lay people with individuals from different fields of dentistry.

Even though the sample size was adequate, while carrying out the study, it was felt that there was a need to incorporate more number of morphed images and types of raters with varied socioeconomic status and age groups which would enable more detailed understanding of preferences.

Frontal facial images were used since laypersons rarely notice the profile view unless they see it in photographs. However, the assessment can be affected by other variables such as complexion, size, and shape of the nose, chin shape, and hair style. These variables can be further studied to know the extent of their effect on facial attractiveness. Furthermore, three-dimensional video imagery along with animation could be used to broaden the study scope and obtain precise results with minimal bias.


  Conclusion Top


Overall results showed that mesprosopic faces were most attractive followed by leptoprosopic and euryprosopic types in Telangana population. No significant difference in perception was seen between sexes. Between four groups based on education, it was found that orthodontists preferred mesoprosopic male and female faces, but general dentists and general public accepted leptoprosopic and euryprosopic faces as normal in both sexes. Euryprosopic female faces were more acceptable to general public.

These findings assist orthodontists and general practitioners as the lower facial height can be inadvertently altered during orthodontic and prosthetic therapy. It can also aid in motivating patients and understanding their perceptions. With increasing importance being given to soft tissues as primary determinants of treatment planning, the findings of the study could be applied to various population groups to fulfil patient expectations to the highest possible extent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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