ORTHODONTIC TREATMENT – COSMETIC WAY / ESTHETIC ORTHODONTICS

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 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 of his or her profile and need of 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 lay 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 the negative self-valuation. The current trend in Orthodonics 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
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 vertical growth of the maxilla and diminish the severity of this deformity. Other therapies, such as biteblock 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 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 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 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

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