THE IMPORTANCE OF ESTHETICS
Patients who choose to undergo orthodontic or surgical
treatment do so for a variety of reasons but almost all want treatment to
correct functional problems. If the correction of the patient's malocclusion has
compromised esthetic relationships, then patient unhappiness may follow, even
if all functional goals are met. Patients obviously prefer esthetic improvement
with their functional correction if possible.
The issues
of patient satisfaction and happiness are very complex because of matters such
as patient expectation, self-assessment, and psychological and even psychiatric
conditions present before and after treatment. One of the contributing factors
in patient satisfaction involves the always subjective evaluation of facial
esthetics. Facial appearance considered ideal by one individual or group may
not be judged so by others. One's dental and facial appearance is important not
only in the role that attractiveness plays to others but also in one's
self-concept! Perception of appearance, particularly of the face, affects
mental health and social behavior, with significant implications for
educational and employment opportunities and mate selection.
The patient's perception of his or her profile and the need for treatment are not necessarily consistent with the clinician's diagnosis
based on cephalometric criteria. Wilmot et al stated that "The clinician
must clearly address the patient's motivations for orthognathic treatment in addition
to other demographic variables regardless of the severity of the
deformity."
There are many methods of facial analysis attempting to
quantify beauty. Differences in analyses and how each professional evaluates a
face usually depend on training backgrounds. Patient ethnicity, familial
characteristics, and personal preference are the main determinants of how a
person may feel about the esthetics of his or her own.
Orthodontic facial analyses have a predisposition to
profile and cephalometric appraisals because a great deal of study and effort
has been expended by the profession to determine averages and normative values
(called norms) from which treatment decisions can be made. Tooth and bony
appraisals are also emphasized because that is the area in which orthodontists
and oral surgeons direct their treatment. Plastic surgeons emphasize
soft-tissue analysis.
There is no substitute for thorough clinical evaluation
and recording of the resting and dynamic soft-tissue relations of the face when
evaluating patients. Static records such as plaster models, photographs, and
cephalometric data for subsequent analysis are simply not adequate for
excellent coordination of hard-tissue planning and esthetic outcome
Any
analysis based on cephalometric or facial "normative values" has one
inherent weakness and that is that beauty is not the norm.
ESTHETICS AS MOTIVATION FOR
ORTHODONTICS
The potential negative effect of the dentofacial
disfigurement on the psychic and social well being of children is an idea readily
accepted by many lays and professional people The rationale underlying treatment
recommendations based on esthetic impairment comes from the belief that
impaired appearance resulting from malocclusion will adversely affect
self-esteem, which in turn can lead to poor social adjustment and affective
disorders.
The opposing rationale is that the psychologically healthy
individual will adjust to his or her appearance and that low self-esteem simply
creates negative self-valuation. The current trend in Orthodontics is
comprehensive care delivery. This requires the inclusion of esthetics as a part
of the overall diagnosis. Parents must weigh the cost/benefit for their child
and may choose to provide orthodontic treatment to their children to enhance
dentofacial esthetics, alleviate psychosocial problems, or improve function
and/or prevent future dental disease. A study by Dan et al on a series of 297
adolescent patients highlights reasons for seeking treatment as the following:
1. Appearance of teeth-84%
2. Advice of dentist-52%
3. Appearance of face-41 %
FACIAL AND DENTAL ANALYSIS
x
Orthodontists
are accustomed to a very quantitative facial and cephalometric patient
evaluation should learn facial evaluation by proportionality and more
subjective evaluation criteria than linear measurements. Treatment decision
making may be determined by what is most esthetically appealing rather than by
what the cephalometric norms may be. This becomes all the more important
because they are usually the first professionals asked to make decisions that
have permanent effects on the final facial form The esthetic and functional
goals for growing patients should be the same as they are for adults. The
methods of treatment that we use to achieve the desired esthetic and functional
outcome make up the difference in treatment approaches
Facial
skeletal growth patterns in the adolescent that often are improved through
orthodontics and growth modification include the following:
1.
Mandibular deficiency-Redirection of skeletal growth
vectors with headgear is the most commonly used method. Functional appliances
have the potential to improve mandibular projection and are often combined with
headgear for maximum treatment effect.
2.
Maxillary horizontal deficiency-Relatively recent
developments in maxillary protraction and nonsurgical advancement of the
maxilla offer the orthodontist the chance to improve or correct this deformity
if it is moderate in severity.
3.
Vertical maxillary excess-Superiorly directed headgear
can retard the vertical growth of the maxilla and diminish the severity of this
deformity. Other therapies, such as bite block functional appliances and
vertically directed chin cups, have been shown to be effective in diminishing
vertical maxillary growth.
4.
Horizontal maxillary excess-This may be treated either
through retardation of anteroposterior growth with headgear or through
camouflage via premolar extraction and retraction of the anterior teeth.
Areas of a skeletal deformity that are not easily improved or corrected by orthodontics or
growth modification include the following:
1.
Mandibular
Prognatbism- Sutural growth of the maxilla is more easily affected than
the more complex growth characteristics of the mandible. In the past, attempts
to retard excessive growth of the mandible have been made through extra-oral
forces applied via chin cup. Because the mandible grows by the apposition of bone
at the condyle and along its free posterior border, this method is not as
successful as the use of extra-oral forces to the maxilla. The contemporary
view of mandibular growth is that condylar growth is largely a response to
translation as the surrounding mandibular hard and soft tissues grow; in the
past, it was thought that the condyle had a "cartilage growth center,"
which might react to forces placed on it. Although the treatment results from
most chin cup cases are often disappointing, they can be quite effective in
cases in which a short-lower facial height is present, because the application of
chin cup force can result in a down-and-back rotation of the mandible.
2.
Vertical
Maxillary Growth Deficiency-Any control or influence of this growth pattern is
difficult, and there is little evidence
3.
Chin
Deficiency-Relative improvement in chin projection may occur with
treatment designed to increase anteroposterior projection of the mandible, but
growth of the chin point itself is not affected by orthodontic or orthopedic
treatment.
All clinicians in the contemporary medical and dental
environment must consider whether their goals of treatment are consistent with
the treatment goals of the patient. Almost all practicing orthodontists have
had the experience of providing camouflage treatment with good intentions, but
in the end were disappointed in the facial outcome. Also disappointing is
seeing the adult patient who has undergone orthodontic treatment as a child and
now expresses unhappiness with facial esthetic characteristics that may be a
direct result of the orthodontic treatment. Plastic surgeons who don't
recognize the contribution of the teeth and the facial skeleton to facial
esthetics will achieve good results in a large percentage of their cases, but
there will be a number of patients in whom soft tissue surgery alone is
inappropriate camouflage of an underlying dento-skeletal problem. The
camouflage simply cannot achieve the same level of esthetic outcome as do
interdisciplinary approaches to treatment.
The contemporary orthodontist should be able to visualize
the long-term dental and facial goals of treatment and counsel the parent and
patient as to what treatment choices may offer the maximum chance of both
dental function and dentofacial esthetics. This means that the orthodontist's
comprehensive vision will be improved and expanded if his or her knowledge of
expected soft-tissue growth patterns is integrated with traditional dental and
skeletal planning. Orthodontic plans that include esthetic finishing options
offered by the dentist, periodontist, oral and maxillofacial surgeon, and
plastic surgeon may not be suitable for all patients (or even all orthodontists,
for that matter!), but their discussion is an important aspect of informed
consent. Also, the various options that can enhance the final esthetic outcome
are often appreciated by the patient be
The most
comprehensive recent studies of facial proportions are those of Farkas et al in
which extensive cross-sectional facial measurements were obtained from
Canadians of Northern European ancestry. The proportional relationship of
height and width is more important than absolute values in establishing the overall
facial type.
Attractive faces tend to have common proportions
and relationships that generally differ from normative values. The ideal face
is vertically divided into equal thirds by horizontal lines adjacent to the
hairline, the nasal base, and menton
