A Voice in the Arena: The Outside-In Template: Part 2 by Dr. Chad Foster

by Chad Foster, DDS, MS, editorial director

In Part 1 of this series, I introduced the idea of the “inside” and “outside” millimeters of orthodontics. We are exceptionally well trained to identify, measure, and act upon the inside millimeters of alignment and occlusion. The purpose of the Outside-In Template is simply to evaluate and prioritize the outside millimeters of the face and smile (which often directly influences the inside millimeters) before our hard-wired dental brains attempt to solve the tooth and occlusion puzzle.

The template itself is intentionally simple. There are certainly more in-depth, quantitative, and time-consuming diagnostic methods for evaluating the face and smile. This template is instead a practical tool designed to create a quick reference map of a patient’s aesthetic traits that appear out of balance. It is truly an everyday tool: It takes less than 30 seconds to complete and can be used easily for every new patient. It is also useful regardless of an orthodontist’s particular aesthetic philosophy or treatment bias. There are multiple ways I use the template, which I’ll discuss in Part 3—the “how.” For now, let’s focus on the “what.”

As discussed in Part 1, I evaluate every patient in the same sequence: face, then smile, and finally teeth. The template follows that same sequence. The first section records what I see in the nonsmiling facial photographs (Fig. 1). The second records what I see in the smiling photographs (Fig. 2). Only after completing those two sections do I then move “inside” to evaluate the alignment, occlusion, radiographs, and other diagnostic information.

Fig. 1

Fig. 2

Fig. 3

First: the face
When evaluating the nonsmiling facial photographs, I concentrate on five broad areas: vertical facial height, the midface, nose prominence, lip position and characteristics, and chin prominence.

Vertical facial height in our dentofacial world refers primarily to the lower one-third of the face. I am looking for whether that dimension appears proportionally excessive, deficient, or reasonably balanced within the rest of the face. A deficient lower facial height may present with a more square frontal facial form, excess chin projection, compressed soft tissues, a decreased vertical smile window, and inadequate incisor display. Excessive lower facial height presents very differently and may be accompanied by a “long-face” appearance, deficient chin projection, soft-tissue strain, and excessive gingival display. These relationships are particularly important to orthodontists because treatment mechanics that alter the vertical dimension and mandibular plane angle can influence several of these traits simultaneously.

Next, I evaluate the midface. Are there adequate projection and support, or does the midface appear deficient? Are the soft tissues in this area appropriately supported, or do they have a more deficient or “sunken” appearance?

I also look at nose prominence, but with an important distinction. Orthodontic treatment does not change the anatomy of the nose. Facial aesthetics, however, are relational. Changes in the relative projection of the midface, lips, and chin can change the context in which the nose is perceived. For that reason, I want to recognize when nasal prominence is an important component of the pretreatment facial balance, even when it is obviously not a structure I intend to treat directly.

The fourth area is lip position and characteristics. One distinction I find particularly useful is the difference between “full lips” and what I call “circumoral fullness.” These are not at all synonymous in my opinion. A patient can have very large, full, aesthetically pleasing lips without excessive circumoral fullness (see bottom images of Fig. 3). Conversely, even in a thin-lipped patient, bimaxillary dental protrusion can create unaesthetic excessive circumoral fullness around the mouth independent of actual lip size (see top image of Fig. 3). I also look for deficient lip projection, thin lip volume, limited vermilion display, lip strain, and other characteristics that may be influenced by the position of the underlying dentition. The importance of where we as orthodontists position the maxillary incisors in the anteroposterior (AP) dimension should not go unappreciated.

Finally, I assess chin prominence. Is the chin deficient, excessive, or appropriately balanced with the rest of the face? Importantly, chin prominence and facial height have an interesting relationship. By way of mandibular rotation, a short lower face can make the chin appear more dominant, while a long lower face can diminish apparent chin projection.


Next: the smile
After evaluating the face, I move to the smiling photographs. A critical requirement here is that the photographs capture a full and natural smile. Without that, much of what follows becomes unreliable. My smile evaluation again concentrates on five specific areas: smile window and lip animation, gingival display, incisor display, smile arc, and arch width.

First, I look at the smile window and lip animation. How is the dentition framed by the lips? Is the smile vertically compressed? Is there asymmetry in lip animation? The lips create the frame through which our orthodontic result will ultimately be viewed, so understanding that frame is essential before evaluating the teeth within it.

Next is gingival display. Excessive gingival display can obviously have multiple causes, and determining those causes will eventually influence the appropriate treatment. At this stage, however, I simply want to recognize whether gingival display is excessive, deficient, or favorable within that individual patient’s smile.

Incisor display is evaluated in two dimensions: vertical and anteroposterior. Vertically, I look at how much maxillary incisor is displayed within the smile frame. Anteroposteriorly, I evaluate the projection of the incisors within the smile using the lateral smiling photograph. Obviously both can be profoundly affected by decisions we later make regarding intrusion, extrusion, torque, retraction, or advancement.

I then assess the smile arc—the relationship between the curvature of the maxillary incisal edges and the lower lip. I record whether the smile arc is excessive (exaggerated) or deficient (flat or reversed). A difference of only a few millimeters vertically can meaningfully change the harmony of this subtle trait.

Finally, I evaluate arch width as it presents within the smile. Does the maxillary dentition adequately fill the smile, or does it appear constricted within that patient’s individual lip frame?

There are also several miscellaneous findings I may record, including a canted anterior line of occlusion, maxillary midline deviation, chin asymmetry, or any other notable soft-tissue characteristic that I want to keep in mind.


Excess or deficiency only
Again, the power of the template comes from its simplicity. For each characteristic, I am essentially asking one question: Where are the excessive and deficient aesthetic traits within this patient’s unique face and smile?

Traits in excess are marked in black. Deficient traits are marked in red. Traits that I consider within normal limits are not marked at all. I specifically want the template to draw my attention toward only the traits that I appraised as out of harmony.

It is important to emphasize that the template is not intended to find something “wrong” with every patient’s face or smile. The goal is simply to identify those excessive or deficient traits that may be affected—positively or negatively—by the orthodontic treatment I am about to provide.

Once those observations are recorded, I finally move to the teeth and the traditional orthodontic diagnosis. The difference is that I now arrive there carrying a roadmap of that patient’s unique face and smile. It is a map that took less than 30 seconds to create, yet it can have great value throughout treatment from start to finish. The outside millimeters in those aesthetically sensitive areas can now remain top of mind as I make decisions about how to handle the inside millimeters.

That is the “what” of the Outside-In Facial and Smile Template: five specific areas of the face, five specific areas of the smile, all evaluated before the teeth. Figure 4 lays out all the potential markings (all marked red for this example). It is important to note that this example lists all the traits in order to understand the markings. In real practice, for any given patient, there are only a few traits marked on the template. Remember that traits within normal limits are not marked. On average, I am typically only marking three to four traits as excessive or deficient per patient. For some patients less and for some patients more.

Fig. 4

In Part 3, we’ll get to what I believe is the most important piece—the “how.” I’ll explain how I incorporate the template into diagnosis and treatment planning, how I discuss potentially sensitive aesthetic observations with patients and parents, how I reference the template throughout treatment, and how I return to it after treatment to evaluate the final result.

Patients come to orthodontists for many reasons, but improving appearance is most often cited as the highest motivating factor of all. Yes, you are a tooth straightener and a bite fixer and those are important roles. You are also a dentofacial orthopedist with more influence over the traits of the lower third of the face than any other health care provider that will ever touch that patient.

A template, a red marker, a black marker, and 30 seconds.

Sometimes a very simple tool can help us see—and remember—all the millimeters that matter. 

Download the Outside-In Facial and Smile Template