A Voice in the Arena: The Outside-In Template: Part 3 by Dr. Chad Foster

Part 3: The ‘how’ of the template

by Chad Foster, DDS, MS, editorial director

In Part 1 (the “why”) of this series, I introduced the concept of the “inside” and “outside” millimeters of orthodontics and explained why I believe the order in which we diagnose matters. In Part 2 (the “what”), I introduced the Outside-In Facial and Smile Template, a simple tool that takes less than 30 seconds to complete and records the excessive and deficient aesthetic traits of a patient’s face and smile. The goal was to create a quick visual road map of those outside millimeters before turning our attention to the familiar dental and occlusal puzzle. Now, in this final article, I’d like to explain the “how”: how I use that road map in everyday practice to make the outside millimeters a more intentional part of the decisions I am already making.

Diagnosis and treatment planning
As orthodontists, we are exceptionally well trained at solving the puzzle of alignment and occlusion. But there are often multiple reasonable ways to solve that puzzle. That’s the beauty of orthodontics! In small ways, those different approaches may have very different consequences for the patient’s face and smile. Starting with the outside millimeters helps us identify the facial and smile characteristics we may want to improve, preserve, or at least avoid making worse before our dental findings begin shaping the treatment plan.

Consider two patients with similar deep bites. One presents with mildly deficient lower facial height and mildly excessive chin prominence, while the other has mildly excessive lower facial height and mildly deficient chin projection. Their inside millimeters may suggest a nearly identical dental problem, but their outside millimeters may lead us to approach the vertical mechanics very differently. The same principle applies to incisor AP positioning, where patients with similar dental protrusion may have very different lip anatomy, profile characteristics, and aesthetic priorities.

Importantly, the template doesn’t dictate which treatment plan is correct or eliminate the need for compromise. It helps us recognize competing aesthetic priorities and make those compromises more intentionally. Different orthodontists may reasonably choose different approaches based on their clinical philosophies, and that’s perfectly fine. My goal is simply to ensure that the facial and smile consequences of our decisions are consciously considered rather than discovered after the fact, or not noticed at all.

Patient communication
The second application occurs during the new patient consultation, where how we communicate matters just as much as what we communicate. Most patients come to us thinking primarily about straightening teeth and correcting bites, often unaware that orthodontic treatment can influence subtle characteristics of their face and smile. I believe we sometimes limit the scope of what we offer patients to the things they already know to ask for, rather than taking the opportunity to educate them about the full extent of our expertise and the possibilities of treatment. As I once heard Dr. Tom Pitts state so effectively, “Patients don’t know what they want until we show them what they can have.” I briefly explain that we are specialists in orthodontics and dentofacial orthopedics, and that I create a simple template of their unique facial and smile characteristics to reference throughout treatment. For some traits, I will work hard to improve them, preserve them, or at least avoid making them worse.

There is an important distinction, however, between explaining the purpose of the template and discussing the specific aesthetic characteristics I’ve marked on it. I routinely do the former, but how and whether I discuss the latter varies from patient to patient. Facial aesthetics can be sensitive, particularly with children and adolescents, so I always lead with the patient’s aesthetic strengths and approach these discussions positively and thoughtfully. The goal is never to point out flaws or create insecurities, but rather to explain what orthodontics may influence while learning which characteristics matter to that patient.

I’ve found that when these conversations are approached correctly, patients and families almost without exception genuinely love them and are extremely appreciative that we care about these things. In fact, I believe most orthodontists underestimate just how much patients value a millimeter or two of beneficial change in their face or smile. It’s remarkable to see how, once patients understand what orthodontic treatment may influence, some of those outside millimeters become even more important to them than traditional inside treatment goals. And while I didn’t develop this approach with the intention of creating a “practice differentiator,” it absolutely has become just that for our practice. Patients recognize and appreciate when we care about the outside millimeters just as much as the inside ones.

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During active treatment
This third application may be the most practically valuable of all, and it addresses a challenge inherent to the way we practice orthodontics. During the initial examination, we have the opportunity to evaluate the patient’s full face and natural smile through photographs, conversation, and direct observation. But once treatment begins, the overwhelming majority of our clinical time is spent during routine adjustments with the patient reclined in the dental chair, mouth open and upside down, while we are zoomed in on the teeth. This is an excellent position for evaluating the inside millimeters of alignment and occlusion, but a terrible position for appreciating the outside millimeters of the face and smile. And yet, this is the position from which we make so many important adjustments and pivots throughout treatment.

Think about how many decisions we make from that position. Orthodontic treatment is rarely a perfectly straight path from bonding to debonding, and even our best treatment plans require modifications along the way. We reposition brackets, move bite turbos, change elastic patterns, bend wires, alter force systems, add or remove auxiliaries, change appliances, and modify our approaches to intrusion, extrusion, torque, and AP tooth positioning. These little pivots are a routine and necessary part of treatment, and most are made in response to what we observe inside the mouth. The challenge is that many of those same mechanical decisions also influence the outside millimeters of the face and smile, making it remarkably easy to lose sight of the aesthetic priorities we identified months or even years earlier.

Of course, we can always revisit the pretreatment photographs or have the patient sit upright for another facial and smile evaluation. But wouldn’t it be helpful to also have a quick visual reminder of those original aesthetic priorities at every appointment? In my practice, the completed Outside-In Template is displayed in Dolphin Imaging at chairside during adjustments. Its red and black markings provide an immediate road map of the patient’s original facial and smile characteristics as I consider mechanical changes. Those outside millimeters remain top of mind alongside the inside ones, without requiring me to mentally reconstruct the entire facial diagnosis.

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Evaluating the final result
The fourth application comes when treatment is complete. As orthodontists, we are accustomed to critically evaluating our results through the familiar standards of alignment, occlusion, overjet, overbite, midlines, and finishing details. No doubt those are all important, but I believe that same level of attention should extend to the outside millimeters we identified before treatment. When reviewing the final facial and smile photographs, I reference the original template and ask what happened to those characteristics. Did we improve deficient incisor display or smile arc? Did we preserve or improve lip position or presentation? Did our vertical mechanics improve facial balance, or did we inadvertently compromise something along the way?

Not every marked trait represents something we intended or were able to change, but each provides an opportunity to examine the aesthetic consequences of our treatment. Sometimes those outcomes reinforce our decisions, while other times they reveal compromises or unintended effects worth remembering for the next patient. If we evaluate only the finished teeth as if they were stone models, we risk overlooking important lessons about how our mechanics influenced the patient’s face and smile. The template provides a simple way to close that diagnostic loop, returning us to the same outside millimeters with which we began.

Putting it all together: A clinical example
One patient who illustrates the practical value of this approach is a 15-year-old female with mild mandibular retrognathia, Class II occlusion, and crowding (Figs. 1–5). Her outside-in facial evaluation revealed two competing aesthetic characteristics: deficient chin projection and mildly deficient lower facial height. In the absence of surgery, improving one of these characteristics could come at the expense of the other. Increasing her lower facial height through clockwise mandibular rotation would likely further weaken her already deficient chin projection. In my aesthetic judgment, her deficient chin projection was the more unfavorable of these two characteristics, so preserving and possibly improving it just a bit became the greater priority when selecting her treatment mechanics after the parents declined the ideal surgical option.

Bite turbos on all four mandibular molars became an important part of my vertical control strategy, and the case actually finished with a 3-degree reduction in her mandibular plane angle rather than the clockwise rotation that was more likely with Class II elastics. Equally important was preserving the favorable AP, vertical, and transverse aesthetic display of her beautiful maxillary dentition within her face and smile rather than compromising it to accommodate the deficient mandible. The final result reflects those priorities while navigating the inherent compromises of the deficient lower jaw and nonsurgical Class II treatment. Another orthodontist may have opted for different priorities and compromises, and that is OK! My decisions were made with my outside millimeter preferences firmly in mind. For a much more detailed discussion of this case, including the mechanics and more clinical records, see my article “Bite Turbos Meet Outside-In Aesthetics” in the May 2025 issue of Orthotown.

Closing thoughts
Throughout this series, I’ve emphasized that the Outside-In approach doesn’t require abandoning traditional orthodontic diagnosis, changing your treatment philosophy, or prioritizing facial aesthetics above healthy, functional occlusion. I’m simply advocating for a very simple, effective, and consistent process of recognizing the outside millimeters alongside the inside ones. We already possess the clinical knowledge to influence many of these characteristics; the template provides a simple structure for remembering to consider them.

A template, a red marker, a black marker, and less than 30 seconds to record the facial and smile findings. Explaining its purpose to patients is equally efficient yet powerful, and referencing it during treatment requires just a few seconds at each adjustment. For such a small investment of time, I believe it can meaningfully influence how we diagnose, communicate, treat, and evaluate our outcomes.

If you take only one thing away from this series, I hope it’s the willingness to interrupt your usual diagnostic routine for your next several new patients. Look at the face first, in isolation, then the natural smile, and only afterward move inside to the teeth and occlusion. Record the excessive or deficient aesthetic traits, keep them visible throughout treatment, and revisit them when evaluating the final result.

As specialists in orthodontics and dentofacial orthopedics, all of the millimeters that our treatments influence deserve our attention.

Face. Smile. Teeth. Always and only in that order.

Download the Outside-In Facial and Smile Template