Orthodontics and dentofacial orthopedics, which includes braces, can affect your face in both subtle and significant ways. The result will depend entirely on the sizes of the teeth, positions of the teeth, muscle function and the positions of the jaws relative to each other and the skeletal base, or skull. Every component of the head and neck will in some way affect how we, as orthodontists, will address the three critical goals of the art and science of orthodontics:
Fulfilling each of these goals optimally is the challenge that we, as orthodontists, have been trained to do, and experience plays a huge part in the successful result we expect to deliver. Of the three goals, the one everyone focuses on the most are the aesthetics (the beautiful smile and facial harmony). Prior to the late 1970’s, this was the goal that we could influence the least as the skeletal structure that is the foundation for the alignment of the teeth could not be significantly altered except for early palatal expansion or some form of growth modification that included headgear or removable functional appliances such as the Frankel or Bionator. For orthodontists in those days, creating a functional bite was the highest priority, with stability a close second, and aesthetics a distant third since we really couldn’t change the front to back positions of the jaws and dental movements that were more compensatory. We just needed to get a bite to fit!
Let us look at a patient whose lower jaw was too far forward of the upper jaw, a prognathia or underbite. To create a bite that would fit reasonably well, it meant tipping the upper front teeth forward beyond their normal, stable inclinations while leaning the lower front teeth back to keep them behind the upper anterior teeth. This correction frequently meant removing two or four bicuspids to shift groups of teeth into their new positions. Did this bite correction help to improve the look of the patient? Usually not! And the reverse situation would also not improve the profile or appearance of someone with a weak chin or retrognathia.
Envisioning these two examples should illustrate that the teeth as well as the skeletal structures will greatly influence the soft tissue drape, and any change in the hard structures of the face will influence the overall appearance of that face.
Thankfully, in the 1970’s a group of orthodontists and oral surgeons at Parkland Hospital, Dallas Texas, developed a technique that is referred to as orthognathic surgery. In short, it allows orthodontists to correct bite problems created by poor skeletal relationships where the problems actually were: by normalizing the skeletal relationships. No more are dental compensations needed to create a functional bite. And the resulting aesthetic changes that accompanied the skeletal and dental result were astounding and eventually became very predictable.
Soft tissue predictability relative to hard tissue changes became a critical research focus following this development. Many university orthodontic departments were evaluating the aesthetic changes incurred following surgery, including the thousands of cases the orthognathic surgery faculty at Northwestern University oversaw and directed. This faculty, which included Dr. Skarin as well as the late internationally renowned TMJ specialist Harold T. Perry, D.D.S, Ph.D. , the late oral surgeon, Roger Kallal, D.D.S. and the late Don Apfel, D.D.S., M.S. among others directed a focused research that directly collaborated with the developer of the first computerized surgical predictability program, Richard Walker, D.D.S. of DentoFacial Software, Toronto Canada. This research has been the basis of soft tissue predictability and has been emulated by other commonly used 3D orthodontic software.
Now, does that mean that every case needs surgery to affect the appearance of your face? Not at all. But each common skeletal problem that affects the eventual alignment of the teeth will have an effect on your appearance, whether it is a vertical problem such as an overbite or an open bite, or an anterior-posterior problem described earlier such as the underbite or overjet, or a transverse problem where one jaw may be too wide or too narrow. The extent or severity of any of these conditions will determine what the best approach will be, and with the advent of early first-phase treatment options, many of these problems can be addressed early and will reduce the severity of the skeletal problem and will allow for an excellent result without surgery.
How about a problem that is strictly dental, as in spacing or crowding, and the jaw relationships are just fine? Yes, your profile and appearance can also be changed depending on how the teeth are moved and aligned. If one has a lot of spaces between the teeth and has an attractive and ideal profile, the spaces need to be closed toward the front of the mouth so that the lips will stay where they are. If the profile is full, then retraction of the teeth toward the back of the mouth would be the better choice. The same goes for crowded cases that might require tooth removal. Teeth removed further back in the mouth will affect the profile the least. Thickness of the tissues involved in the hard tissue changes will also affect how the appearance looks. So as you can tell, a lot goes into deciding what the right choice of treatment will be and requires a thorough and comprehensive evaluation of every potential treatment option. In treatment cases planned by Dr. Skarin, you will be given every possible treatment plan that can address either all of the concerns present, or alternate treatment plans that will generate an excellent bite with excellent stability that will be a choice that best fits your concerns. As is frequently quoted, there are many roads to Rome, and it can be added that some are two lane and some interstate.
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