European Journal of Orthodontics 14 (1992) 483-488
I 1992 European Orthodontic Society
The ranking of facial attractiveness D. P. Roberts-Harry, I. S. Hathorn, and C. D. Stephens University of Bristol Dental Hospital and School, Bristol, U.K.
SUMMARY A method of assessing facial attractiveness is described in which facial photographs were ranked by adults in order from the most to the least attractive. The rankings of a group of normal 10-year-old children were compared to those given to a group of similarly aged patients with repaired clefts. Most previous methods have grouped patients into categories, but this tends to obscure individual differences in facial attractiveness: patients with small differences in appearance are generally placed in the same group. In the ranking technique described in this paper these individual differences were not obscured. Those individuals with repaired clefts were consistently judged as being less attractive than those in the normal group. It is suggested that this method could be further developed to assess the cosmetic benefit produced by treatment of facial deformity.
Introduction
Correction of severe dental malocclusion, skeletal deformity, and clefts of the lip and palate are treatments directed at improving both occlusal function and facial appearance. Facial appearance is clearly important to an individual's social well being. There is good evidence that patients with facial deformity, suffer from a variety of psychosocial problems and this has been extensively reviewed by Bull and Rumsey (1988). Macgregor (1951) and, more recently, Jones et al. (1979) and Shaw et al. (1980) have shown that patients with facial deformities are often subjected to teasing, nicknaming, and social discrimination. Shaw (1981) found that children with a normal dental appearance were judged to be better looking, more desirable as friends and less likely to behave aggressively than children with a dentofacial anomaly. Clifford and Clifford (1986) suggested that social rejection of these children may ultimately lead to difficulty in obtaining employment and attracting members of the opposite sex. Bull and Rumsey (1988) have reviewed the effect of facial appearance on the ability to find partners of the opposite sex. Research suggests that society's judgement of the quality of facial appearance achieved in the correction of dentofacial deformity may be just as important as a clinician's assessment of the surgical result. Little work has been undertaken to determine whether such treatment produces the desired results in terms of improved facial
appearance and therefore no data are available to compare the effectiveness of differing surgical regimes in the treatment of facial deformity. Research is beginning to suggest that the treatment of patients with clefts of the lip and palate achieves significantly different results dependent on the centres at which they are treated (Mars et al., 1987,) and differing treatment methods employed (Dahl et al., 1981; Roberts-Harry et al., 1991). There is a high level of agreement between examiners when assessing facial attractiveness from photographs (Iliffe, 1960; Udry, 1965; Patzer, 1985) and several studies have employed the ranking of photographs in order to assess this, for example, Alley (1988), Lundstrom et al. (1987), Bell et al. (1985), Shaw (1981), and Shaw and Humphreys (1982). Tobiasen and Hiebert (1988) found that there was good agreement between children when judging the faces of normal children compared with those having repaired clefts of the lip and palate. These young observers could make judgements of attractiveness in the cleft face and rated them less positively than the non-cleft face. However, the photographs used in many of these studies have not been adequately standardized and apparent differences in judgements of attractiveness might well have been produced by different patient posture, for example, smiling, lighting, and film processing. These methods have largely relied on rating the individuals into categories ranging from very good
484
looking to very unattractive. Because each group comprises a range of appearances individual variation is masked. An illustration of this might be a patient with a moderate dental appearance, for example, Group 4 of the aesthetic component of the Index of Orthodontic Treatment Need (IOTN) (Shaw et al., 1991). Despite an improvement in the alignment of the teeth, such a patient might well pass from the bottom to the top of that particular group without moving up into the next category. The classification of the teeth would be unaltered despite a modest improvement in dental appearance. Current treatment is often based on dental appearance and health grounds alone using, for example, the IOTN. Whilst these procedures may be useful for assessing priority of treatment need, there is currently no reliable method of assessing the degree of handicap imposed by an unusual facial appearance. The literature suggests the need to consider dental appearance in the context of facial appearance as a whole. At present it is not possible to quantify the cosmetic benefit of treatment aimed at improving facial appearance. Aims of the study
The aims of this study were two-fold: 1. To develop a system of ranking facial photographs in order of the degree of facial attractiveness using a standardized photographic technique. This method of ranking facial attractiveness aims to provide a basis for judging the changes in facial appearance produced by various treatment regimens. 2. To determine whether and to what extent patients with repaired clefts differ in facial attractiveness from normal individuals.
D. P. ROBERTS-HARRY ET AL.
attending a single class at a Bristol junior school. To avoid the possible effects of racial bias only Caucasians were included. These subjects had full face photographs taken against a standard background. Colour prints were made which were standardized for enlargement, colour, tint and brightness. Howells and Shaw (1985) suggested that standardized full face photographs can be used for accurate determination of facial attractiveness, hence, care was taken to use only photographs in which the face was properly centred with the eyes looking directly ahead. A panel of nine adults, aged from 35 to 48 years, was assembled to reflect contemporary clinical and lay opinion. This included six clinicians and three lay members of the public from a variety of backgrounds and occupations. The clinicians comprised three orthodontists, two post-graduate students, and one general dental practitioner. The 44 photographs from the two groups were assigned a number and labelled on the reverse side. Each member of the panel ranked these by placing them in a line in order of preference, i.e. from the most to the least attractive. Each member of the panel carried out the ranking on two occasions separated by not less than 2 weeks. Each observer undertook this task independently and the photographs were shuffled between rankings by an independent assistant. The data so obtained were analysed using the Spearman rank correlation coefficient. This test was chosen in order to check the agreement between observers and the consistency of the same examiner on two occasions. In order to provide an overall assessment of the facial attractiveness of each photograph, the rank values given by each observer for that photograph were summed and the totals for each again ranked thus producing a rank sum for each patient (Siegel, 1956).
Subjects and method
A group of 44, 10-year-old children comprising 25 with repaired unilateral clefts of the lip and palate (19 male, 6 female) and 19 without clefts (10 male, 9 female) was used in order to embrace a wide range of facial appearance in children. Those individuals with clefts of the lip and palate were treated at the same hospital in Bristol and had been operated on by the same surgeon. The normal group were all the children
Results and discussion
The results are presented in Tables 1-3 and in Fig. 1. High intra-examiner agreement was found between repeated rankings. The correlations for the rankings are summarized in Table 1 and ranged from 0.71 (observer 5, a post-graduate dental student) to 0.96 (observer 1, an orthodontist with an interest in cleft palate patients).
THE ASSESSMENT OF FACIAL ATTRACTIVENESS
485
Figure I Patients ranked (a) most to (d) least attractive. Photograph (b) was the least attractive of the non-cleft group and photograph (c) the most attractive of the group with clefts.
486
D. P. ROBERTS-HARRY ET AL.
Table 1 The intra-examiner correlations between the first and second ranking of the photographs. Observer
Sex
Correlation
1(O) 2(O) 3(O) 4 (GDP) 5(PG) 6(PG) 7(L) 8(L) 9(L)
M M F F F F F
0.96 0.93 0.97 0.87 0.71 0.95 0.90 0.94 0.93
F M
O = orthodontist, GDP = general dental practitioner, PG = post-graduate student, L = lay member of the public. M = male, F= female.
Table 2 The range of both intra- and inter-group correlations of the observer groups.
Orthodontists Clinicians Lay members
Intra
Inter
0.81-0.89 0.57-0.88 0.63-0.81
0.57-0.93 0.47-0.93 0.47-0.90
The highest inter-examiner correlations were between the orthodontists in the panel as shown in Table 2. This is perhaps because they have a common interest in facial appearance. It may also indicate that they have a mutual interpretation of facial attractiveness not shared by others, Table 3
especially in patients with a degree of facial deformity. The most useful data were obtained when the individual two rankings for each photograph were summed and this sum subsequently ranked. By this means an overall consensus in terms of attractiveness was obtained. Table 3 shows the order in which the patients were ranked for attractiveness as determined by this method. The photograph of case number 27 was judged the most attractive with a rank sum of 101 and number 5 the least attractive with a rank sum of 805. These photographs are shown in Fig. l(a) and l(d). The individuals with clefts of the lip and palate were numbered from 1 to 25, and these photographs were all judged less attractive than the non-cleft group, i.e. none of the cleft patients was ranked as more attractive than any of the non-cleft individuals. The least attractive of the non-cleft group was case number 33 which was ranked at 19 (rank sum of 383) and the most attractive of the cleft group was case number 19 ranked at 20 (rank sum 385). These photographs are shown in Fig. l(b) and l(c), respectively. It should be noted that the level of inter-examiner correlation was no different when examining those individuals with or without clefts. The patients with clefts were generally perceived as less attractive when judged by the orthodontists than by the lay members of the panel. This is in accordance with the findings
Ranking of the sum of the ranks [1 (most)—45 (least attractive)].
Rank Rank sum Case no. Sex
1 101 27
2 3 107 119 32 35 F F F
4 150 43 M
5 161 39 F
6 7 8 9 170 172 175 200 30 37 29 36 M F M F
10 206 28 M
11 212 40 M
Rank 12 13 14 15 16 17 Rank sum 215 225 232 260 306 308 Case no. 31 42 26 38 34 44 Sex M M F F M F
18 315 41 M
19 383 33 M
20 385 19 M
21 407 25 F
22 459 6 F
Rank 23 24 25 26 27 28 Rank sum 462 481 500 510 521 536 Case no. 10 8 24 12 23 9 Sex M M F M M F
29 545 18 M
30 552 22 M
31 566 4 M
32 605 16 M
33 607 17 M
Rank 34 35 36 37 38 39 Rank sum 609 612 647 652 654 665 Case no. 1 11 3 21 2 14 Sex M M M M F M
40 667 7 M
41 673 15 M
42 723 13 M
43 744 20 F
44 805 5 M
M = male, F = female.
487
THE ASSESSMENT OF FACIAL ATTRACTIVENESS
of Evans and Shaw (1987), and perhaps indicates a heightened awareness of the characteristic appearance of patients with clefts. It could be that the lay members of the panel were not so distracted by the repaired cleft and relied more on the overall facial appearance. Although care was taken in standardizing the photographs there were nevertheless slight variations in film tint and head posture. Clearly, any variations may introduce a degree of bias and may influence the examiners' rankings. Specialist equipment is required in order to produce the standardized stimuli. Therefore, the method of taking and processing these photographs needs further refining so that these variables can be standardized. On close examination of the data it is clear that some of the photographs are much more consistently ranked than others; for example, patient number 20 was placed in ranks 43 and 44 by eight of the examiners and none ranked this photograph higher than 39. It should be possible to produce a larger, more comprehensive set of photographs for which there is particularly high agreement between judges. This could then be used as a basis against which photographs of patients can be judged to measure the effect that different treatment regimes have on facial appearance.
Conclusions
The facial attractiveness of photographs with standardized frontal views of patients with repaired clefts of the lip and palate, and normal children was assessed by a group of dentally qualified and lay adults. High inter- and intraexaminer agreement was found. A method of ranking the photographs from most to least attractive was used, thus highlighting individual variations in facial appearance. Patients with repaired clefts were consistently ranked as facially less attractive than normal individuals by both lay and professional judges. It is suggested that the use of standardized photographs might provide the basis of judging or clinical audit of treatment aimed at improving facial appearance. This would be similar to the assessment of aesthetic need for orthodontic treatment as described by Evans and Shaw (1987).
Address for correspondence D P Roberts-Harry Department of Orthodontics University of Bristol Dental Hospital and School Lower Maudlin Street Bristol BS1 2LY Acknowledgements
We would like to thank Mr R. Pigott for allowing us to use the photographs of his patients and Mr T. Hughes, Senior Lecturer in Medical Statistics, Department of Epidemiology and Public Health Medicine, University of Bristol, for his statistical advice. In addition, we are grateful to those individuals who acted as panel members in the ranking procedures. References Alley T R (ed.) 1988 Social and applied aspects of perceiving faces. Lawrence Erlbaum Associates, New Jersey Bell R, Kiyak A, Joondeph D R, McNeill R W, Wallen T R 1985 Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. American Journal of Orthodontics 88: 323-332 Bull R, Rumsey N 1988 The psychology of facial appearance. Springer-Verlag Inc., New York Clifford C, Clifford M 1986 Social and psychological problems associated with clefts: motivations for cleft palate treatment. International Dental Journal 36: 115-119 Dahl E, Hanusardotter B, Bergland O 1981 A comparison of occlusion in two groups of children whose clefts were repaired by three different surgical procedures. Cleft Palate Journal 18: 122 Evans R, Shaw W C 1987 Preliminary evaluation of an illustrated scale for rating dental attractiveness. European Journal of Orthodontics 9: 314-318 Howells D J, Shaw W C 1985 The validity and reliability of ratings of dental and facial attractiveness for epidemiological use. American Journal of Orthodontics 88: 402-408 Iliffe A 1960 A study of preferences in feminine beauty. British Journal of Psychology 51: 267-273 Jones B M, Gabe M J, Shaw W C 1979 Experience of teasing and harassment in children attending plastic surgery clinics. Unpublished project report, Dental School, Welsh National School of Medicine, Cardiff, East Glamorgan, UK Lundstrdm A, Woodside D G, Popovitch F 1987 Panel assessment of facial profile related to mandibular growth direction. European Journal of Orthodontics 9: 271-278 Macgregor F C 1951 Some psychosocial problems associated with facial deformities. American Sociological Review 16: 629-638
488 Mars M, Plint D A, Houston W J B , Bergland O, Semb G 1987 The Goslon Yardstick: a new system of assessing dental arch relationships in children with unilateral clefts of the lip and palate. Cleft Palate Journal 24: 314-322 Patzer G 1985 The physical attractiveness phenomena. Plenum, New York Roberts-Harry D P, Evans R, Hathorn I S 1991 The effects of different surgical regimes on nasal symmetry and facial attractiveness in cleft lip and palate patients. Cleft PalateCraniofacial Journal 28: 274-278 Shaw W C 1981 The influence of children's dentofacial appearance on their social attractiveness as judged by peers and lay adults. American Journal Orthodontics 79: 399-415 Shaw W, Meek S, Jones D 1980 Nicknames, teasing, harassment and the salience of dental features
D. P. ROBERTS-HARRY ET AL. among schoolchildren. British Journal of Orthodontics 7: 14-18 Shaw W C, Humphreys S 1982 Influence of children's dentofacial appearance on teacher expectations. Community Dentistry and Oral Epidemiology 10: 313-319 Shaw W C, Richmond S, O'Brien K D, Brook P, Stephens C D 1991 Quality control in orthodontics: Indices of treatment need and treatment standard. British Dental Journal 170: 107-112 Siegel S 1956 Nonparametric statistics for the behavioural sciences. McGraw-Hill Kogakusha Ltd., Tokyo Tobiasen J M, Hiebert J M 1988 Reliability of aesthetic ratings of cleft impairments. Cleft Palate Journal 25: 313-317 Udry R 1965 Structural correlates of feminine beauty preferences in Britain and the U.S.: A comparison. Sociology and Social Research 49: 330-342
I 1992 European Orthodontic Society
The ranking of facial attractiveness D. P. Roberts-Harry, I. S. Hathorn, and C. D. Stephens University of Bristol Dental Hospital and School, Bristol, U.K.
SUMMARY A method of assessing facial attractiveness is described in which facial photographs were ranked by adults in order from the most to the least attractive. The rankings of a group of normal 10-year-old children were compared to those given to a group of similarly aged patients with repaired clefts. Most previous methods have grouped patients into categories, but this tends to obscure individual differences in facial attractiveness: patients with small differences in appearance are generally placed in the same group. In the ranking technique described in this paper these individual differences were not obscured. Those individuals with repaired clefts were consistently judged as being less attractive than those in the normal group. It is suggested that this method could be further developed to assess the cosmetic benefit produced by treatment of facial deformity.
Introduction
Correction of severe dental malocclusion, skeletal deformity, and clefts of the lip and palate are treatments directed at improving both occlusal function and facial appearance. Facial appearance is clearly important to an individual's social well being. There is good evidence that patients with facial deformity, suffer from a variety of psychosocial problems and this has been extensively reviewed by Bull and Rumsey (1988). Macgregor (1951) and, more recently, Jones et al. (1979) and Shaw et al. (1980) have shown that patients with facial deformities are often subjected to teasing, nicknaming, and social discrimination. Shaw (1981) found that children with a normal dental appearance were judged to be better looking, more desirable as friends and less likely to behave aggressively than children with a dentofacial anomaly. Clifford and Clifford (1986) suggested that social rejection of these children may ultimately lead to difficulty in obtaining employment and attracting members of the opposite sex. Bull and Rumsey (1988) have reviewed the effect of facial appearance on the ability to find partners of the opposite sex. Research suggests that society's judgement of the quality of facial appearance achieved in the correction of dentofacial deformity may be just as important as a clinician's assessment of the surgical result. Little work has been undertaken to determine whether such treatment produces the desired results in terms of improved facial
appearance and therefore no data are available to compare the effectiveness of differing surgical regimes in the treatment of facial deformity. Research is beginning to suggest that the treatment of patients with clefts of the lip and palate achieves significantly different results dependent on the centres at which they are treated (Mars et al., 1987,) and differing treatment methods employed (Dahl et al., 1981; Roberts-Harry et al., 1991). There is a high level of agreement between examiners when assessing facial attractiveness from photographs (Iliffe, 1960; Udry, 1965; Patzer, 1985) and several studies have employed the ranking of photographs in order to assess this, for example, Alley (1988), Lundstrom et al. (1987), Bell et al. (1985), Shaw (1981), and Shaw and Humphreys (1982). Tobiasen and Hiebert (1988) found that there was good agreement between children when judging the faces of normal children compared with those having repaired clefts of the lip and palate. These young observers could make judgements of attractiveness in the cleft face and rated them less positively than the non-cleft face. However, the photographs used in many of these studies have not been adequately standardized and apparent differences in judgements of attractiveness might well have been produced by different patient posture, for example, smiling, lighting, and film processing. These methods have largely relied on rating the individuals into categories ranging from very good
484
looking to very unattractive. Because each group comprises a range of appearances individual variation is masked. An illustration of this might be a patient with a moderate dental appearance, for example, Group 4 of the aesthetic component of the Index of Orthodontic Treatment Need (IOTN) (Shaw et al., 1991). Despite an improvement in the alignment of the teeth, such a patient might well pass from the bottom to the top of that particular group without moving up into the next category. The classification of the teeth would be unaltered despite a modest improvement in dental appearance. Current treatment is often based on dental appearance and health grounds alone using, for example, the IOTN. Whilst these procedures may be useful for assessing priority of treatment need, there is currently no reliable method of assessing the degree of handicap imposed by an unusual facial appearance. The literature suggests the need to consider dental appearance in the context of facial appearance as a whole. At present it is not possible to quantify the cosmetic benefit of treatment aimed at improving facial appearance. Aims of the study
The aims of this study were two-fold: 1. To develop a system of ranking facial photographs in order of the degree of facial attractiveness using a standardized photographic technique. This method of ranking facial attractiveness aims to provide a basis for judging the changes in facial appearance produced by various treatment regimens. 2. To determine whether and to what extent patients with repaired clefts differ in facial attractiveness from normal individuals.
D. P. ROBERTS-HARRY ET AL.
attending a single class at a Bristol junior school. To avoid the possible effects of racial bias only Caucasians were included. These subjects had full face photographs taken against a standard background. Colour prints were made which were standardized for enlargement, colour, tint and brightness. Howells and Shaw (1985) suggested that standardized full face photographs can be used for accurate determination of facial attractiveness, hence, care was taken to use only photographs in which the face was properly centred with the eyes looking directly ahead. A panel of nine adults, aged from 35 to 48 years, was assembled to reflect contemporary clinical and lay opinion. This included six clinicians and three lay members of the public from a variety of backgrounds and occupations. The clinicians comprised three orthodontists, two post-graduate students, and one general dental practitioner. The 44 photographs from the two groups were assigned a number and labelled on the reverse side. Each member of the panel ranked these by placing them in a line in order of preference, i.e. from the most to the least attractive. Each member of the panel carried out the ranking on two occasions separated by not less than 2 weeks. Each observer undertook this task independently and the photographs were shuffled between rankings by an independent assistant. The data so obtained were analysed using the Spearman rank correlation coefficient. This test was chosen in order to check the agreement between observers and the consistency of the same examiner on two occasions. In order to provide an overall assessment of the facial attractiveness of each photograph, the rank values given by each observer for that photograph were summed and the totals for each again ranked thus producing a rank sum for each patient (Siegel, 1956).
Subjects and method
A group of 44, 10-year-old children comprising 25 with repaired unilateral clefts of the lip and palate (19 male, 6 female) and 19 without clefts (10 male, 9 female) was used in order to embrace a wide range of facial appearance in children. Those individuals with clefts of the lip and palate were treated at the same hospital in Bristol and had been operated on by the same surgeon. The normal group were all the children
Results and discussion
The results are presented in Tables 1-3 and in Fig. 1. High intra-examiner agreement was found between repeated rankings. The correlations for the rankings are summarized in Table 1 and ranged from 0.71 (observer 5, a post-graduate dental student) to 0.96 (observer 1, an orthodontist with an interest in cleft palate patients).
THE ASSESSMENT OF FACIAL ATTRACTIVENESS
485
Figure I Patients ranked (a) most to (d) least attractive. Photograph (b) was the least attractive of the non-cleft group and photograph (c) the most attractive of the group with clefts.
486
D. P. ROBERTS-HARRY ET AL.
Table 1 The intra-examiner correlations between the first and second ranking of the photographs. Observer
Sex
Correlation
1(O) 2(O) 3(O) 4 (GDP) 5(PG) 6(PG) 7(L) 8(L) 9(L)
M M F F F F F
0.96 0.93 0.97 0.87 0.71 0.95 0.90 0.94 0.93
F M
O = orthodontist, GDP = general dental practitioner, PG = post-graduate student, L = lay member of the public. M = male, F= female.
Table 2 The range of both intra- and inter-group correlations of the observer groups.
Orthodontists Clinicians Lay members
Intra
Inter
0.81-0.89 0.57-0.88 0.63-0.81
0.57-0.93 0.47-0.93 0.47-0.90
The highest inter-examiner correlations were between the orthodontists in the panel as shown in Table 2. This is perhaps because they have a common interest in facial appearance. It may also indicate that they have a mutual interpretation of facial attractiveness not shared by others, Table 3
especially in patients with a degree of facial deformity. The most useful data were obtained when the individual two rankings for each photograph were summed and this sum subsequently ranked. By this means an overall consensus in terms of attractiveness was obtained. Table 3 shows the order in which the patients were ranked for attractiveness as determined by this method. The photograph of case number 27 was judged the most attractive with a rank sum of 101 and number 5 the least attractive with a rank sum of 805. These photographs are shown in Fig. l(a) and l(d). The individuals with clefts of the lip and palate were numbered from 1 to 25, and these photographs were all judged less attractive than the non-cleft group, i.e. none of the cleft patients was ranked as more attractive than any of the non-cleft individuals. The least attractive of the non-cleft group was case number 33 which was ranked at 19 (rank sum of 383) and the most attractive of the cleft group was case number 19 ranked at 20 (rank sum 385). These photographs are shown in Fig. l(b) and l(c), respectively. It should be noted that the level of inter-examiner correlation was no different when examining those individuals with or without clefts. The patients with clefts were generally perceived as less attractive when judged by the orthodontists than by the lay members of the panel. This is in accordance with the findings
Ranking of the sum of the ranks [1 (most)—45 (least attractive)].
Rank Rank sum Case no. Sex
1 101 27
2 3 107 119 32 35 F F F
4 150 43 M
5 161 39 F
6 7 8 9 170 172 175 200 30 37 29 36 M F M F
10 206 28 M
11 212 40 M
Rank 12 13 14 15 16 17 Rank sum 215 225 232 260 306 308 Case no. 31 42 26 38 34 44 Sex M M F F M F
18 315 41 M
19 383 33 M
20 385 19 M
21 407 25 F
22 459 6 F
Rank 23 24 25 26 27 28 Rank sum 462 481 500 510 521 536 Case no. 10 8 24 12 23 9 Sex M M F M M F
29 545 18 M
30 552 22 M
31 566 4 M
32 605 16 M
33 607 17 M
Rank 34 35 36 37 38 39 Rank sum 609 612 647 652 654 665 Case no. 1 11 3 21 2 14 Sex M M M M F M
40 667 7 M
41 673 15 M
42 723 13 M
43 744 20 F
44 805 5 M
M = male, F = female.
487
THE ASSESSMENT OF FACIAL ATTRACTIVENESS
of Evans and Shaw (1987), and perhaps indicates a heightened awareness of the characteristic appearance of patients with clefts. It could be that the lay members of the panel were not so distracted by the repaired cleft and relied more on the overall facial appearance. Although care was taken in standardizing the photographs there were nevertheless slight variations in film tint and head posture. Clearly, any variations may introduce a degree of bias and may influence the examiners' rankings. Specialist equipment is required in order to produce the standardized stimuli. Therefore, the method of taking and processing these photographs needs further refining so that these variables can be standardized. On close examination of the data it is clear that some of the photographs are much more consistently ranked than others; for example, patient number 20 was placed in ranks 43 and 44 by eight of the examiners and none ranked this photograph higher than 39. It should be possible to produce a larger, more comprehensive set of photographs for which there is particularly high agreement between judges. This could then be used as a basis against which photographs of patients can be judged to measure the effect that different treatment regimes have on facial appearance.
Conclusions
The facial attractiveness of photographs with standardized frontal views of patients with repaired clefts of the lip and palate, and normal children was assessed by a group of dentally qualified and lay adults. High inter- and intraexaminer agreement was found. A method of ranking the photographs from most to least attractive was used, thus highlighting individual variations in facial appearance. Patients with repaired clefts were consistently ranked as facially less attractive than normal individuals by both lay and professional judges. It is suggested that the use of standardized photographs might provide the basis of judging or clinical audit of treatment aimed at improving facial appearance. This would be similar to the assessment of aesthetic need for orthodontic treatment as described by Evans and Shaw (1987).
Address for correspondence D P Roberts-Harry Department of Orthodontics University of Bristol Dental Hospital and School Lower Maudlin Street Bristol BS1 2LY Acknowledgements
We would like to thank Mr R. Pigott for allowing us to use the photographs of his patients and Mr T. Hughes, Senior Lecturer in Medical Statistics, Department of Epidemiology and Public Health Medicine, University of Bristol, for his statistical advice. In addition, we are grateful to those individuals who acted as panel members in the ranking procedures. References Alley T R (ed.) 1988 Social and applied aspects of perceiving faces. Lawrence Erlbaum Associates, New Jersey Bell R, Kiyak A, Joondeph D R, McNeill R W, Wallen T R 1985 Perceptions of facial profile and their influence on the decision to undergo orthognathic surgery. American Journal of Orthodontics 88: 323-332 Bull R, Rumsey N 1988 The psychology of facial appearance. Springer-Verlag Inc., New York Clifford C, Clifford M 1986 Social and psychological problems associated with clefts: motivations for cleft palate treatment. International Dental Journal 36: 115-119 Dahl E, Hanusardotter B, Bergland O 1981 A comparison of occlusion in two groups of children whose clefts were repaired by three different surgical procedures. Cleft Palate Journal 18: 122 Evans R, Shaw W C 1987 Preliminary evaluation of an illustrated scale for rating dental attractiveness. European Journal of Orthodontics 9: 314-318 Howells D J, Shaw W C 1985 The validity and reliability of ratings of dental and facial attractiveness for epidemiological use. American Journal of Orthodontics 88: 402-408 Iliffe A 1960 A study of preferences in feminine beauty. British Journal of Psychology 51: 267-273 Jones B M, Gabe M J, Shaw W C 1979 Experience of teasing and harassment in children attending plastic surgery clinics. Unpublished project report, Dental School, Welsh National School of Medicine, Cardiff, East Glamorgan, UK Lundstrdm A, Woodside D G, Popovitch F 1987 Panel assessment of facial profile related to mandibular growth direction. European Journal of Orthodontics 9: 271-278 Macgregor F C 1951 Some psychosocial problems associated with facial deformities. American Sociological Review 16: 629-638
488 Mars M, Plint D A, Houston W J B , Bergland O, Semb G 1987 The Goslon Yardstick: a new system of assessing dental arch relationships in children with unilateral clefts of the lip and palate. Cleft Palate Journal 24: 314-322 Patzer G 1985 The physical attractiveness phenomena. Plenum, New York Roberts-Harry D P, Evans R, Hathorn I S 1991 The effects of different surgical regimes on nasal symmetry and facial attractiveness in cleft lip and palate patients. Cleft PalateCraniofacial Journal 28: 274-278 Shaw W C 1981 The influence of children's dentofacial appearance on their social attractiveness as judged by peers and lay adults. American Journal Orthodontics 79: 399-415 Shaw W, Meek S, Jones D 1980 Nicknames, teasing, harassment and the salience of dental features
D. P. ROBERTS-HARRY ET AL. among schoolchildren. British Journal of Orthodontics 7: 14-18 Shaw W C, Humphreys S 1982 Influence of children's dentofacial appearance on teacher expectations. Community Dentistry and Oral Epidemiology 10: 313-319 Shaw W C, Richmond S, O'Brien K D, Brook P, Stephens C D 1991 Quality control in orthodontics: Indices of treatment need and treatment standard. British Dental Journal 170: 107-112 Siegel S 1956 Nonparametric statistics for the behavioural sciences. McGraw-Hill Kogakusha Ltd., Tokyo Tobiasen J M, Hiebert J M 1988 Reliability of aesthetic ratings of cleft impairments. Cleft Palate Journal 25: 313-317 Udry R 1965 Structural correlates of feminine beauty preferences in Britain and the U.S.: A comparison. Sociology and Social Research 49: 330-342
