Winter 2000 Presentation Summary:

Profound changes are coming to the decision making process by which orthodontists currently evaluate, diagnose, and plan treatment for their patients. The preceding 50 years has provided us with a wealth of knowledge and understanding about facial growth and development, sophisticated measurement techniques, and computer-assisted projection of tissue changes. The next decades will witness an expanded scope of vision with an enhanced appreciation for the impact of age-related changes that will challenge the wisdom of some of our current treatment concepts.

Currently, our evaluation is static in its temporal and animated scope. Our patient evaluations are weighted towards measurements of bones and teeth We diagnose our patients in the here and now without regard to facial changes that are predictable in the coming decades. We diagnose and treatment plan from a profile prospective. The patient and others also evaluate from a frontal perspective. . In the future, greater emphasis will be placed on soft tissue changes under the influence of orthodontic treatment.

Today’s adult orthodontic patients are predominately between the ages of 28 to 35 years old. In ten years they will be 38 to 45. What will happen to those faces in ten years? Looking at the profile we can note that the nasal tip will drop. The upper lip will become thinner, as will the lower lip to a lesser degree. Lower face height may decrease. In that decade, females will note an increase in adipose tissue below the border of the mandible.As our patients view themselves in the mirror over time, they will see a number of unwanted changes. Eyes will become more heavily hooded, facial lines and wrinkles will become more pronounced. The upper lip will become longer, diminishing the visible vermilion border and obscuring more of their smile. And, these changes will increase with each passing decade.Much of this wear and tear of time can be ameliorated by the tender mercies of a plastic surgeon. Plastic surgery to lift, tuck, and tighten facial tissues can reverse some of the signs of age, but not all. Dr. Sarver alludes to these tightening procedures as "making the bag smaller." In his estimation, when the soft tissues in question can be influenced by orthodontic tooth movement or orthognathic surgery, the preferred solution may be to "fill the bag back up."

Perhaps the time is right to rethink the need for extraction of one or more teeth to alleviate arch length discrepancies. Expansion will increase labial prominence and make the vermilion border more visible, which will help smooth out wrinkles and provide a broader smile. However, if stability of the end result is thereby placed in question, permanent retention is an acceptable solution. Periodontal procedures to insure gingival longevity have long been available.

Although surgical options to expand the facial envelope are well understood, their indications in facial rejuvenation should receive more consideration. Maxillary repositioning can lengthen a shortened face, provide a more youthful incisor projection and greater labial prominence, and increase the visible vermilion border. Incisors that have disappeared under a sagging upper lip can reassume their youthful exposure. Mandibular advancements and liposuction can reverse the softening of infra-mandibular chin and throat contours.

A greater consciousness of future maturational soft tissue changes will lead to an alteration of treatment strategies for adolescent patients. The cervical headgear may play a roll in the management of an open bite in the patient with a short lower face. Where indicated, extruded molars lengthen the face, and tipping the palatal plane can provide more incisor display over the ensuing years.

Crowding in the adolescent dentition is often resolved with second bicuspid extraction. While this may avoid undesirable flattening of facial contours, it will do nothing to enhance dental display. Given an awareness of inevitable facial change (at age 16 the female upper lip thickness starts to decrease and philtrum length increases), palatal expansion and lower arch width increase may be preferable treatment.

Dr. Sarver advocates a greater emphasis on soft tissue evaluation of the orthodontic patient. whereas previous appraisals concentrated on a lateral view of the hard tissues, the perspective should change to include a frontal and oblique evaluation of the face. He also recommends that diagnosis take a more dynamic view. The human face is constantly changing and, to the extent that this can be anticipated, it should be taken into account when making decisions for the present. For our adult patients it would be helpful to discuss aging and the face early on to prepare them for what is coming down the road.

To read more about these ideas, please see AJO/DO (2000) 117:575–76 for an article by Sarver and Ackerman, entitled: "Orthodontics about face: The re-emergence of the esthetic paradigm."

Previous Article              Next Article

Top of the Page

Copyright © 1999 - 2006 Pacific Coast Society of Orthodontists. All Rights Reserved.

Please review our legal notices and privacy policy.

Created by WebResults.