Facial Esthetics: Where Dentistry Meets Artistry
Michael G. Arvystas, AB, DMD
With the rapid advances in dental materials and technology, the demands and expectations for esthetic dentistry have become increasingly high. As providers of dental care in various specialties, dentists are obligated to present patients with total treatment approaches to maximize health and esthetics.
It is of vital interest to patients to integrate and coordinate treatment and not to limit the treatment to an isolated specialty. Severe skeletal and dental malocclusions are multifactorial and include considerations of facial esthetics, function, and ideal dental occlusion. In many routine dental malocclusions, orthodontic treatment alone may be limited in obtaining ideal facial and esthetic dental occlusions. The initial correction of a Class II malocclusion to an ideal Class I occlusion does not terminate the dentist’s obligation to the patient. Dentists must inform patients of their total dental needs, not just of the providers’ limited specialties. Oral health providers must evaluate the face, smile, lip line, buccal corridor of the smile, black triangles, and spacing, as well as provide esthetic anterior tooth shape, correct mesial-distal space in agenesis cases for implant treatment, and establish proper gingival height contours. Often, one-sided approaches to multifaceted problems produce compromised results.
The Class II Division I malocclusion must be evaluated from sagittal relationships, with consideration given to transverse and vertical relationships of the dental arches, as well as basal jaw relationships. A patient who has a Class II malocclusion with decreased anterior facial height, mandibular overclosure, and deep bite has drastically different facial characteristics than a patient who has an excessive anterior facial height and a steep mandibular plane angle. The Class II Division II patient who has excessive anterior alveolar development with unfavorable upper incisor to upper lip relation showing too much of the tooth crowns and gingival tissue requires a different treatment approach than a patient with Class II Division I malocclusion but normal anterior alveolar development and good maxillary incisor to upper lip relation. The Class II Division I malocclusion with maxillary incisor protrusion and an acute nasolabial angle should be treated differently than a Class II Division I malocclusion with proper axial inclination of the maxillary incisor teeth and a normal soft-tissue nasolabial angle.
Many other combinations and permutations exist that pertain to the Class II Division I malocclusion category with variations, such as an orthognathic maxillary base with a retrognathic mandible or prognathic maxillary base with orthognathic mandible. The Class III malocclusion must also be evaluated from sagittal relationships with consideration given to transverse and vertical relationships of the dental arches, as well as basal jaw relationships.
The fact that skeletal Class III malocclusions have many discrete subtypes, which can range from a Class III open bite to a Class III close bite, reinforces the importance of individual variation. Some of the common features mentioned in the literature on skeletal Class III patterns are as follows: negative SNA–SNB difference, shorter SN length, comparative maxillary retrusion, relative maxillary deficiency, obtuse gonial angle, greater mean total effective lengths of the mandible, a significant straight-line morphology of the mandible, and the position of the glenoid fossa.
The individual’s facial proportions and symmetry must be considered carefully. The important concern is the balance and proportion between the various facial structures to achieve harmony in a particular individual.
Enlow and Moyers1 have illustrated some of the basis for craniofacial variations. Their schematic diagrams demonstrate the structural variations that can be produced by different dimensional relationships and alignment of the anatomic parts of the craniofacial complex, thereby showing the manner in which structural variations produce balance in facial harmony. At times, the intrinsic adaptations and compensations do not camouflage the structural imbalance, and a disharmonious facial deformity results. A simple example of this intrinsic adaptation can be illustrated by the position of the glenoid fossa; if the corpus of the mandible is excessively large but the glenoid fossa is positioned posteriorly in the temporal bone, the patient can have a pleasing orthognathic profile. If the mandibular body is normal size and the the glenoid fossa positioned anteriorly, a Class III profile may result. If the corpus of the mandible is excessive and glenoid fossa positioned anteriorly, a gross unesthetic Class III profile may occur. Logically, many other combinations and permutations can cause this facial imbalance.
The localization of the area of disproportionality in this craniofacial deformity is complex. Artists, such as Albrecht Dürer,2-4 in the 16th and 17th centuries were obsessed with finding a geometric formula for proportions in arts from which could be derived a general law that would embrace all the particular varieties of the human face and physique. Using the ancient principle of coordinates for the study of proportions, Dürer, who was attempting the impossible, varied the proportions to produce different facial types. His four-volume text called Four Books of Human Proportions was published after his death in 1528.
Quantifying facial esthetics5 using anthropometrics in art, dentistry, and plastic surgery to determine the esthetics of the face has a long history. The establishment of rigid measurements and proportion values as characteristics of the ideal face is unnatural because it negates the natural variations that are always present in a general population. Quantitative analysis of various facial qualities enables the clinician to refer to the most typical signs of the attractive face. The clinician, just like the artist, must possess artistic talent and good clinical judgment to achieve an esthetic result fitted to the needs of a particular face.
1. Enlow DH, Moyers RE. Growth and architecture of the face. J Am Dent Assoc. 1971;82(4): 763-774.
2. Dürer A. Of the Just Shaping of Letters from the Applied Geometry of Albrecht Dürer. New York, NY: The Grolier Club; 1917.
3. Dürer A, Rogers B, eds. The Construction of Roman Letters. Cambridge, UK: Dunster House; 1924.
4. Dürer A, Strauss WL, eds. The Human Figure: The Complete Dresden Sketchbook. New York, NY: Dover Publications; 1972.
5. Arvystas M. Orthodontic Management of Agenesis and Other Complexities. London, UK: Martin Dunitz Ltd; 2003.
About the Author
Michael G. Arvystas, AB, DMD
Professor of Orthodontics
Montefiore Medical Center
Albert Einstein College of Medicine
New York, New York
American Board of Orthodontics
New York, New York
Denville, New Jersey