I spent the day watching a DVD of Dr. G. William Arnett’s presentation from the 2012 Seattle Study Club Symposium on “Control of Facial Aesthetics”. I came away having learned quite a bit, but also clear I need to go take a course with Dr. Arnett and get the rest of the story, especially for my complex ortho referrals. One of the things I learned is I am most likely under-diagnosing the possibilities orthognathic surgery has to offer as I spend most of my time looking at the occlusion and dental esthetics. Dentistry controls the facial aesthetics through a variety of factors that include the character of the enamel, shape of the teeth, position of the teeth and jaws and completion of aesthetic procedures. In ideal dentistry the occlusion will indicate when orthognathic treatment is necessary, but analysis of the facial aesthetics will dictate the type of treatment required. Simply solving an orthodontic case to create a Class one occlusal relationship doesn’t arbitrarily dictate aesthetic success. Dr. Arnett showed multiple examples of class one orthodontic results where the final result was unaesthetic from a perspective of the face. If the class one dental solution isn’t created in a place that supports the soft tissues to create an esthetic, balanced facial appearance, is the case successful? Ultimately even when orthognathic surgery is completed if the goal is to align the bite, and we do not plan from the point of view of soft tissue support, the result can be functional and unattractive.
For instance when reviewing the upper lip projection having a thorough understanding of the past orthodontic history is critical. A history of class II orthodontic mechanics suggests a need for a LeFort One Advancement if the patient is a surgical candidate and has deficient maxillary facial features. Analysis of the maxillary projection can determine the cause of Class 2 and Class 3 occlusions, the upper jaw or the lower jaw. In truth most of the Class two and class three occlusions we see are due to a combination of issues on the maxilla and the mandible. In addition analyzing upper lip projection is important in understanding the esthetic and facial implications of upper incisor retraction during orthodontics.
Over the years one of the things that has been truly powerful is learning together with the specialists I work with. This is the perfect opportunity to invite my orthodontist and oral surgeon and learn together!
Lets also remember and take into consideration the differences that exists among people of different ethnicities and cultures when it comes to what is considered to be beautiful. We will fail if we try and apply the same standards of what is considered ” Esthetic” in the caucasian population to all of the other ethnicities. For example the amount of acceptable overjet,protrusion and proclination of the upper incisors and as the result fullness of the upper lips can differ greatly from one ethnic group to the other and yet both still can be considered to be esthetic with a nice facial balance and profile.
A dolicofacial caucasian patient might be seen as not pretty and we would consider extraction in such a patient to correct a class II malocclusion and crowding by retracting the upper anterior teeth whereas in another ethnic group the same patient would be best served by not extracting and keeping her incisors and profile at the starting postion. Likewise in a brachyfacial class II caucasian patient we would not want to extract in order to correct the malocclusion and crowding and keep the teeth in their starting position or maybe even advance them some.