THE IMPORTANCE OF FACIAL AESTHETICS

Facial attractiveness is recognised as being important in situations as diverse as education, relationships and employment. An individual’s facial appearance is one of their most obvious characteristics and facial disfigurements are judged to be among the least desirable handicaps. Facial aesthetics clearly has universal importance but is of particular relevance in the field of dentistry.

The face has a profound social significance and any feature which causes an individual to deviate significantly from the norm can be considered a handicap. It is estimated that around 1% of the adult population has ‘a scar, blemish or deformity which severely affects their ability to lead a normal life’.¹ Such deformities range from something as straightforward as a dental anomaly to a complex craniofacial deformity.

Recent years have seen advances in our views on facial aesthetics. It is now more acceptable to be concerned about facial attractiveness and it is also more acceptable for an individual to seek cosmetic procedures in an effort to improve aspects of the face which he or she dislikes. This is reflected in the increase in surgical procedures such as orthognathic treatment and also in the increased demand for orthodontics and cosmetic restorative procedures.

In today’s society we tend to be subjected to many more one-off encounters than in the past. This means that people are judged constantly on the basis of their attractiveness and facial attractiveness in particular. There is considerable evidence to suggest that those who are attractive have certain advantages over less attractive people. For example, research has shown that teachers expect greater personal, academic and social success from an attractive child than from a less attractive child,² and, in job interviews where applicants had identical qualifications, certain personnel decisions were influenced by the attractiveness of the applicant.³ The understanding of the importance of facial appearance in first-time encounters has developed considerably since this early research. It is now understood that, although facial attractiveness is important in the first few minutes of an encounter and influences initial impressions, other qualities, such as social skills and self-esteem, also come into play. Difficulties which disfigured people have can be divided into two distinct areas: social and cultural (i.e. the view from outside) and the impact on individual perceptions of self-concept and emotional well-being (i.e. the view from the inside).^4,5 For this reason some researchers have recommended psychological interventions, including social interaction skills training, for facially disfigured people in an attempt to counteract the stigma of facial disfigurement.⁶

The severity of a facial disfigurement is not a good predictor of the extent of psychological distress. Macgregor⁷ and Lansdown et al.⁸ noted that individuals who have obvious facial deformity tend to be treated with compassion, whereas those with lesser deformities (for example, a marked overjet) are more likely to be subjected to teasing and ridicule. These individuals may then feel anxious in social situations because they are not sure how others will respond to them. This, in turn, can have profound effects on their ability to socialise and develop positive self-esteem. It is possibly due to this that the demand for cosmetic dentistry and orthodontics has increased in recent years. Improved dentofacial appearance is usually the motivating factor for these forms of treatment, ahead of the desire for improved dental health or function.⁹

DENTOFACIAL DEFORMITY AND ITS MANAGEMENT

Dentofacial Deformity and Orthodontic Treatment

Individuals are frequently stereotyped based on dental features, especially during childhood and adolescence, and dental and facial features are significant targets for nicknames, harassment and teasing among children.^10,11 Shaw¹² studied the influence of certain dentofacial features on a child’s social attractiveness and the hypothesis that children with normal dental appearance would be judged better looking, more intelligent and more desirable as a friend was upheld. Findings such as these, along with society’s emphasis on aesthetics, are undoubtedly a driving force for the ever-increasing demand for orthodontic treatment.

The effect that malocclusion has on body image and self-esteem remains the subject of some controversy. It is often assumed that individuals with malocclusions will possess low self-esteem and that intervention will improve this, although it appears that the relationship between perceptions of attractiveness and self-esteem is complex and nowhere near as clear-cut as it may initially appear.¹³ Albino et al.¹⁴ found that parent-, peer- and self-evaluations of dental-facial attractiveness significantly improved following orthodontic treatment but there was no evidence that treatment improved self and parental evaluations of social competency and self-esteem.

Studies have shown that dental practitioners tend to be more critical of dentofacial aesthetics than are the general public.^15,16 It is therefore important that treatment is not forced on those patients who do not perceive a problem, as they are unlikely to cooperate. It is also important not to allow parents to dictate treatment for a child; the child’s cooperation is required if treatment is to be successful and unfortunately an enthusiastic parent does not always have an enthusiastic and motivated child!

Dentofacial Deformity and Restorative Treatment

Patients who request restorative treatment to improve their appearance have motivating factors similar to those pursuing orthodontic treatment, namely improvement in aesthetics. However, the dentist’s perceptions of ideal aesthetics are not necessarily the same as those of the patient. Neumann et al.¹⁷ asked patients to complete questionnaires about personal aesthetic satisfaction and oral self-image. Their results showed discrepancies between clinical findings and the patients’ self-perception and satisfaction, which reinforces the necessity for clinician and patient to plan together for aesthetic treatment. This area is further complicated by the fact that there are no ‘aesthetic norms’ and clinicians therefore have to be guided partly by their professional judgement and partly by what the patient wishes to achieve. The patient’s wishes need to be taken into account but the clinician should ascertain that these are achievable. If not, the patient should be told at the outset if post-treatment dissatisfaction is to be avoided.

Facial Deformity and Orthognathic Treatment

More severe dentofacial problems or craniofacial malformations frequently require orthognathic intervention (a combination of orthodontics and surgery). The source of motivation is one of the most i/>