A Voice in the Arena: The Outside-In Template: Part 1 by Dr. Chad Foster

Part 1: The “why” of the template

by Chad Foster, DDS, MS, editorial director

Orthodontics is a game of millimeters. Our profession has built an extraordinary level of precision around incredibly small measurements. A few tenths of a millimeter of error in bracket placement can objectively alter finishing. One or two millimeters of crowding can very often swing an extraction decision. A millimeter discrepancy in overjet or overbite can move a patient from normal to malocclusion. We spend years learning to see these differences. And rightly so—they matter!

Those “inside millimeters” are important. But altering them in our patients is not without effects in other important areas. Changes to those inside millimeters very often impact both facial and smile aesthetics. The position of the dentition, down to the millimeter, directly influences a multitude of lower-one-third facial traits and the aesthetic value of how the teeth are displayed within the smile frame. Those “outside millimeters” of the face and smile are tangibly affected by how an orthodontist handles the inside millimeters. The question then becomes: Are those outside millimeters worth prioritizing as well?

I believe most orthodontists would answer yes. I don’t think the issue is that our profession believes facial and smile aesthetics are unimportant. I simply think our diagnostic system has evolved to prioritize one set of millimeters much more consistently than the other.

The inside millimeters are familiar territory: alignment, occlusion, overbite, overjet, midlines, and many others. They are objective, measurable, and supported by well-established standards. We know what success in these areas looks like because we have defined it so clearly.

The outside millimeters are different. These characteristics are often less standardized and more subjective, making them inherently more difficult to measure and their ideal endpoints more debatable. Our system reflects that difference: The inside millimeters tend to be defined, measured, and acted upon much more consistently than the outside ones.

Over time, that difference has shaped the way many of us diagnose and treatment-plan. Based on our education and training, orthodontists typically begin diagnosis on the inside—looking at the teeth and occlusion first. We zoom in to solve the puzzle of alignment and occlusion, carefully measuring those inside millimeters, while the outside millimeters are often judged more informally, if at all. When diagnosis begins with the teeth, it is only natural that our treatment goals become anchored to and revolve around the teeth.

Aesthetics are inherently subjective, and because of that subjectivity, it can be tempting to dismiss small changes to the face and smile as less important. Interestingly, other aesthetic disciplines do not necessarily treat small changes that way. Plastic surgeons, cosmetic dentists, dermatologists, and other facial aesthetic specialists routinely make treatment decisions around subtle changes in facial proportions and relationships measured in millimeters and even fractions of a millimeter. The explosive growth of the facial aesthetics industry is difficult to ignore—it reflects enormous consumer demand for exactly these kinds of subtle aesthetic changes.

Our patients are no different. Most simply do not realize that orthodontic treatment routinely influences many of these same facial and smile characteristics. They often arrive believing that we just straighten teeth and correct bites.

When presented with new patient records, we are all given the opportunity to assess the face and smile. I have no doubt that most orthodontists reading this do look at those things. But I would wager that far fewer of us actually start with them, in isolation, and give those observations enough value that we carry them with us when we eventually dive into the inside millimeters of alignment and occlusion.

I want to emphasize an important distinction: Looking at the face is not the same thing as starting with the face. And where we start matters.

Psychologists have long described the concept of confirmation bias: Once we form an initial impression, we naturally tend to prioritize information that supports that impression. In orthodontics, if diagnosis begins with the teeth and occlusion, those findings can anchor the treatment goals. Facial and smile findings do not disappear, but they can diminish in value and fade into the background when interpreted through the lens of a tooth-oriented treatment plan that has already begun to take shape.

Today, every new patient in my practice is evaluated in the same order: face, then smile, and finally teeth. Only after I’ve developed an impression of the patient’s face and smile do I begin evaluating the occlusion, alignment, radiographs, and the other traditional components of orthodontic diagnosis. I’m not suggesting that any of those things become less important—they should not. I’m simply changing the order in which I look at them.

That simple change has profoundly affected four areas of my practice: how I diagnose and treatment plan, how I discuss treatment goals with patients, how I keep those goals top of mind during treatment, and how I evaluate my outcomes after treatment.

To make that process consistent, I developed a very simple diagnostic tool. It involves a template, a red marker, and a black marker, and it takes less than 30 seconds to complete. I call it the Outside-In Facial and Smile Template. It is simply a quick visual roadmap that records the patient’s unique and relevant pretreatment facial and smile characteristics and keeps those outside millimeters from getting lost as I turn my attention to the inside ones.

In Part 2, we’ll get into the “what” of the Outside-In Template: exactly which facial and smile characteristics I evaluate, what I mark as excessive or deficient, and how I create the template for every new patient. Part 3 will address the “how”: how I use it during diagnosis and treatment planning, how I discuss it with patients, how I use it during treatment, and how I return to it when evaluating the final result.

Until then, try one simple experiment. With your next several new patients, resist the temptation to look at the teeth first. Look at the facial photos in isolation. Then look at the smiling photos. Only after that, look at the intraoral photos. You don’t have to change your treatment philosophy or your mechanics.

Just change the order: Face. Smile. Teeth.

See if it changes what you see.