XXVI Congresso Internazionale Odontostomatologico CCOS Monte-Carlo 14 Novembre 2014 FACIAL AND DENTAL AESTHETICS Estetica facciale e del sorriso DR. FARHAD B. NAINI BDS (Lon), MSc (Lond), FDS.RCS (Eng), M.Orth.RCS (Eng), FDS.Orth.RCS (Eng), GCAP (KCL), FHEA Consultant Orthodontist and Honorary Lecturer at St George's University Hospital and Kingston Hospital, London - United Kingdom Facial beauty and aesthetics have fascinated humankind for thousands of years, and with that fascination has emanated the ability to alter facial form, with and without surgery. Dentistry, Orthodontics and Orthognathic surgery provides unique methods of altering both the form and function of the craniofacial complex. The dentist s role in this treatment pathway is paramount and requires an understanding of aesthetic principles as well as technical knowledge. The purpose of this presentation is to provide an exploration of the historical and scientific perspectives on facial aesthetics, including discussions regarding the significance of facial beauty, the perception of beauty and the various hypotheses for facial beauty. We will also cover the evidence for facial attractiveness, including normative values, facial attractiveness research and proportional canons, with an analysis of the great minds of past centuries. Particular focus will be placed on the Italian Renaissance, and the genius of Leonardo da Vinci. Finally, we will discuss the clinical implications of this information in the analysis of facial form and dysmorphology, and the interaction of art and science in dentistry, orthodontics and orthognathic surgery. Definition of beauty and aesthetics It is almost impossible to clearly and accurately define beauty. Definitions often do not and cannot elucidate the full significance of the concept of beauty. Beauty may be defined as 'a combination of qualities that give pleasure to the senses or to the Mind. The Oxford English Dictionary defines beauty as: A combination of qualities, such as shape, colour, or form, which pleases the aesthetic senses, especially the sight. The Renaissance artist and thinker Leon Battista Alberti (1404-72) defined beauty as: The summation of the parts working together in such a way that nothing needs to be added, taken away or altered. The various definitions of beauty and facial beauty all essentially describe the assemblage of graceful features that please the eye and mind of an observer, yet the definitions are philosophical, debatable and non-specific. Three variables exist in the definitions of beauty: The graceful features: The human face is comprised of a number of features e.g. the eyes, nose, lips, etc., with a wide array of shapes, sizes, relative positions and colours. Their assemblage: Which components of which features and in which combinations result in a beautiful face? The observer: Does each observer see and sense the same beauty? The number of variables makes it clear that the concept of beauty is difficult to explain with complete clarity. ln Dreams of a Final Theory: The Search for the Fundamental Laws of Nature (1993), the Nobel prize-winning theoretical physicist Steven Weinberg eloquently writes: I will not try to define beauty, any more than I would try to define love or fear. You do not define these things; you know them when you feel them Aesthetics is the study of beauty and, to a lesser extent, its opposite, the ugly. The eighteenth-century German philosopher Alexander Baumgarten (1714-62) established aesthetics as a distinct field of philosophy with the publication of his treatise aesthetica (c. 1750). Baumgarten re-coined the term 'aesthetics' to mean 'taste' or 'sense' of beauty, thereby inventing its modern usage; the term 'aesthetics' is derived from the Greek word for sensory perception (aisthétikos). Baumgarten defined aesthetics as 'the science of sensual cognition. In effect, Baumgarten separated the concept of beauty from its ancient link related to goodness. Baumgarten defined taste as the ability to judge according to the senses, instead of according to the intellect; such a judgment of taste is based on feelings of pleasure or displeasure. Facial beauty: scientific perspectives The scientific studies of the possible proposed explanations for facial beauty in terms of ideal' proportions, bilateral symmetry, averageness, babyfaceness and sexual dimorphism have been described above. The other area of scientific research in the understanding of facial beauty is termed facial attractiveness research, i.e. the scientific study of facial 1
beauty and physical attractiveness. The purpose of such research is to find quantifiable evidence for the attractiveness of various facial parameters using contemporary layperson and patient population survey preferences rather than subjective interpretations or observations made by artists or clinicians. Importance of facial beauty The significance of facial beauty is immense, with psychological, sociological, philosophical, moral and scientific conceptions, often intertwined. Beauty is a multidimensional concept that undoubtedly has a strong influence on human life. In Western literature beauty has been described as everything from a 'social necessity' to a gift from God' (Aristotle). The poet John Milton refers to the 'strange power' of beauty, describing beauty as Nature's brag'. The French philosopher Blaise Pascal commented, 'Cleopatra's nose, had it been shorter, the whole face of the world would have been changed!' From Homer s Helen of Troy, who the poet Christopher Marlowe described as having the 'face that launched a thousand ships', to Queen Nefertiti, whose name literally means the 'Beautiful One', to modern-day models and actors, facial beauty has perhaps always been the most valued aspect of human beauty. Facial beauty is an important factor in an individual's self-image and in relation to outsiders' perceptions. Self-image and negative self-perception A person's own perception of their facial appearance and any associated deformity is of great importance. Of course, there is considerable individual variation in people's abilities to adapt to their facial deformity, whatever the severity. Some individuals remain comparatively unaffected, while others may have significant difficulties, which affect their quality of life. Outsiders' perceptions In The Wisdom of Life, the philosopher Arthur Schopenhauer (1788-1860) writes: 'Beauty is partly an affair of health. It may be reckoned as a personal advantage; though it does not, properly speaking, contribute directly to happiness. It does so indirectly, by impressing other people; and it is no unimportant advantage, even in man. Beauty is an open letter of recommendation, predisposing the heart to favour the person who presents it. [emphasis added]. The effects of outsiders' perceptions may be categorized as follows: Social disability It has been argued that facial deformity may be a 'social disability' as it impacts not only on the individual affected, but is also noticed by and reacted to by others. Attractive children tend to be perceived more positively by their parents, by teachers who perceive more attractive children as being more intelligent, and in professional life where less attractive adults are perceived as having fewer qualifications and less potential for employment success. Although an individual's facial appearance contributes to the opinions other people form of them, obviously these opinions may well change as interpersonal relationships form. Nevertheless, an individual's first impression on others may well affect their own selfesteem and quality of life. Stereotyping It is suggested that people tend to stereotype others based on their facial appearance. For example, individuals with significant Class II malocclusions and mandibular retrognathia/retrogenia may be seen as weak and possibly idle, whereas individuals with significant Class III malocclusions and mandibular prognathism may be seen as aggressive personality types. Children in the school environment can be unsympathetic and hostile to those with visible differences, with teasing and bullying being everyday occurrences. The frequency of teasing directed at those with visible dentofacial differences is significant. Severity of deformity The psychological distress caused by a facial deformity is not proportional to its severity. Research seems to indicate that facial deformities of a mild to moderate nature actually cause patients greater psychological distress than severe facial deformities. This is thought to be because other people's reactions towards milder deformities are more unpredictable whereas more severe deformities tend to evoke more consistent reactions, albeit negative, allowing the patient to develop better coping strategies. The variability in people reactions to milder facial deformities also results in considerable patient distress. It is important to note that the majority of patients seeking orthodontic treatment or orthognathic surgery fit into the mild/moderate category in terms of facial deformity, as opposed to craniofacial malformations syndromes or severe facial trauma/disease. The Renaissance 2
The Renaissance refers to a progressive cultural period in European history that began in Italy around 1400 and lasted there until the end of the 1500s. Elsewhere in Europe it began later and lasted until the 1600s. An important characteristic of the Renaissance was the rediscovery, translation and study of ancient literature, including Greek and Roman, i.e. a revival of learning. Certain notable individuals began to actively search for knowledge rather than accepting what already existed. The term rinascita was coined by the historian Giorgio Vasari (1511-74) in 1550, but the use of the term 'Renaissance' (French for 'rebirth ) to describe this period of history was invented by historians in the 1800s. As with all periods in history, the Renaissance was epitomized by a handful of individuals- scholars who went against the grain of normal society. This led to the Italian term uomo universal, the Renaissance 'universal man', an individual of universal learning with a broad-ranging knowledge of both the arts and the sciences a concept epitomized in Leonardo da Vinci. The arts and the science were closely tied and influenced each other. In the history of the development of facial proportional canons another notable individual appeared in the High Renaissance prior to Leonardo; the work of Leon Battista Alberti was a considerable influence on that of Leonardo da Vinci. 'Beauty is a form of consonance of the parts within a body (manifested as proportional correspondence in the parts and in the whole), according to number, shape and position, such that nothing may be added, taken away or altered, but for the worse, as dictated by the absolute and fundamental rule of Nature'. Leonardo Da Vinci It was during his Milanese period that Leonardo embarked on writing his own theory of art. He always stressed the concept of saper vedere ('knowing how to see'). From 1490 onwards Leonardo began to write; his studies and diagrams were written down in his notebooks, or on individual sheets of paper, which made up thousands of closely written and abundantly illustrated pages. Of these, a number of codices have been prepared and preserved, including the Windsor Collection (Royal Library, Windsor) and the Codex Atlanticus (Biblioteca Ambrosiana, Milan) collected by the sculptor Pompeo Leoni at the end of the sixteenth century; and the Arundel Manuscript (British Museum). His writings, although never completed, may be interpreted as preliminary stages of works destined for eventual publication. In the margin of one of his anatomical works he implores his 'colleagues' to see that his works are printed. It is from Leonardo's notebooks and associated sketches that his theories and ideas regarding human proportions, and his quest for the ideal facial proportions may be gleaned. Leonardo defined proportion as the ratio between the respective parts and the whole. Leonardo advised that beautiful faces and figures should be chosen and measured in order to find the ideal proportions - but he stresses: 'make an effort to collect the good features from many beautiful faces, but let their beauty be confirmed rather by public renown than by your own judgement'. This advice forms the foundation of modern research into perceptions of facial attractiveness. Leonardo advises: 'Measure on yourself the proportion of the composition of your limbs, and if you find any discordant part, take note of it and make very sure that you do not adopt it in the figures that are composed by you...' Leonardo's iconic figure of Homo Vitruvianus or Vitruvian Man, which Leonardo based on guidelines described by Vitruvius, albeit with his own corrections and modifications, represents 'ideal' male proportions based on man's navel as the centre of the perfect geometrical forms, a circle and a square, enclosing man with outstretched arms. This figure is a useful starting point for a study of Leonardo's proportions studies. Leonardo also produced studies of the proportions of the human head. The most important of these figures are presented here with a selection of Leonardo's notes that are relevant to the description of his proportional canons as related to the study of craniofacial proportional relationships. In addition to Leonardo, a number of other Italian masters made enormous contributions to art and each made subtle additions to the understanding of human beauty among them the great Michelangelo (1475-1564), Sandro Botticelli (1445-1510) and Raphael (1483-1520). These Italian masters made substantial contributions to the understanding of human proportions and significantly advanced the understanding of scientific perspective in art. References 1. Naini FB. Facial Aesthetics: Concepts and Clinical Diagnosis. Oxford: Wiley-Blackwell, 2011. 2. Vasari G. The Llives of the Artists (1550). (Oxford World s Classics). Trans Bondella JC, Bondella P. Oxford: Oxford University Press, 1991. 3. Alberti LB. De Pictura ( On Painting, 1435) Trans. Spencer JR. New Haven: Yale University Press, 1970. 4. Kemp M. Leonardo da Vinci: The Marvellous Works of Nature and Man. Oxford: Oxford University Press, 2006. 5. Pacioli L. de Divina Proportione (1494). Venice: Paganinum de Paganinis, 1509. 6. Clark K. Leonardo da Vinci. Cambridge: Cambridge University Press, 1939. 3
7. Pedretti C. Leonardo da Vinci: Notebook of a Genius. Milan: Powerhouse Publishing, 2001. 8. Richter JP. Literary Works of Leonardo da Vinci, 2 nd edn. Oxford: Oxford University Press, 1939. 9. Naini FB, Cobourne MT, McDonald F, Wertheim D. The aesthetic impact of upper lip inclination in orthodontics and orthognathic surgery. Eur J Orthod. 2014 Jul 12. pii: cju015. Male Head in Profile with Proportions, c. 1490, Leonardo da Vinci. (Gallerie dell Accademia, Venice) Leonardo s Square (Detail, Study of proportions and study of horsemen for the Battle of Anghiari, c. 1490, Leonardo da Vinci. (Gallerie dell Accademia, Venice) The vertical 0 meridian line and the horizontal line later termed the Frankfort Horizontal plane are evident in the facial diagrams depicted by Leonardo da Vinci (mirror image detail, Male Head in Profile with Proportions, c. 1490). (Gallerie dell Accademia, Venice) Craniofacial soft tissue surface landmarks 4
Three-dimensional computed tomography reconstructions Having established the facial midline on a 3D computerized tomographic reconstruction (shown), further vertical lines may be drawn parallel to the facial midline through any pair of bilateral landmarks suspected of being asymmetrical. The orientation of these lines in relation to the facial midline may be evaluated, in addition to the horizontal distance of each of the bilateral landmarks to the facial midline Horizontal references planes drawn through bilateral structures will be nearly parallel in the symmetrical skull. The relative orientation of these horizontal planes will demonstrate vertical asymmetry. This figure illustrates horizontal planes through the supraorbital and mental foramina and the inferior chin plane The maxillofacial frame is a useful method of analyzing facial symmetrical relationships. R, right; L, left; SO, supraorbital foramen; IO, infraorbital foramen; M, mental foramen; Md, mandibular foramen; HM, head of the malleus 5
Superimposition of serial 3D surface images provides an indication of changes in the facial soft tissues as a result of asymmetrical growth; warm colours represent increasing convexity and cold colours represent increasing concavity Leonardo s commissure-limbus-eyebrow peak line. (Detail, Study of Proportions of the Face, Eyes and Eyebrows, Leonardo da Vinci, c. 1490, Biblioteca Reale, Turin) Ideal smile curvature (smile arc) 6