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Straight Talk David Sarver, DDS

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A Profession’s Focus
by David Sarver, DDS

Times have changed since I graduated from my graduate orthodontic program. As time has passed I have gained a greater appreciation of some not-so-technical issues crucial to our profession. I have been able to expand my vision as an orthodontist by understanding that what is most important to me is not always what patients identify as most important to them. This realization has given me new insight.

In the United States, parents strive very hard to teach their children to use correct manners, to maintain respect for others, to educate them and to "prepare them for the world." The parents of my current patients (particularly those who were former patients themselves) give me great insight into the importance of orthodontic treatment in their lives. They articulate openly and consistently the opinion that the most important service provided for them was enhancement of their appearance that resulted in the improvement of their self-image, self-esteem and confidence. The role of the orthodontist has clearly become part of that important process in preparing children for competing for jobs, for courting spouses, and all the things that come with a positive appearance and a beautiful smile. What I want to relate in this editorial is best illustrated in the telling of their stories.

Years ago, I completed a treatment presentation to a family. The father was employed in the retail business, a business that works on the principle of buying products, marking them up for the desired amount of profit and then establishing a price. When I finished discussing the orthodontic concerns and treatment goals for his child he asked the obvious question, "How much does this cost?" I gave him the figure, and he immediately went into the "wounded father" mode of exasperation. He pointed to a set of demonstration models with brackets and wires mounted. "How much do those things cost?" he asked. I replied, "You mean the brackets?" and he answered, "Yes, what is your mark-up on those?" My response was simple, "If it is brackets you want to buy, I can sell you a cup of them for $100." Now, that might not have been the answer my practice consultant would have relayed, but my point is, the father saw all the things that we had talked about in his child's treatment in the wrong terms. He thought he was buying braces (how many times does your front desk receive a phone call enquiring "How much do braces cost?") but what I was selling was knowledge, vision and treatment. In today's environment, we spend a lot of time discussing what types of brackets we use, our latest technology, etc. and miss explaining the point of what treatment is all about.

Case #1
Let me tell you a story that emphasizes this point. About 10 years ago, a patient (Figs. 1 & 2) came in for a consultation with her parents.

She had a Class II malocclusion with impinging deep bite. She also presented with a very gummy smile, and my thoughts ranged from what growth changes I might anticipate, to what appropriate therapy at the appropriate time might be, to asking if she would ultimately be an orthognathic candidate. Also, at age 10, both active and passive eruption was not complete, so her teeth were short and we know that with growth and maturation the upper lip lengthens at a greater rate, reducing the gumminess of the smile. Timing of treatment was critical for growth modification and timing of periodontal treatment if needed. After treatment presentation and an extensive discussion with the parents, we treated the patient through growth modification via high pull headgear and periodontal crown lengthening. With a favorable growth response, her final result at age 15 was outstanding. The final photographs (Figs. 3-5) are of her at age 18 as she was leaving for college.

The mother came in about a year later and wanted to share an old photograph with me. It was a picture of her daughter at age seven (Fig. 6).

The mother was very animated during our initial consultation for her daughter's treatment. She explained the animation saying it was "because I realized that my daughter had a chance to be what I hoped she would be." She continued, "I just had it in my head that nobody would be able to do anything for my daughter until she was 18 years old. When you started talking about your goals and how important the timing was for us to be successful, I was stunned." This story helps me understand the human side of our profession.

Case #2
This adult multi-disciplinary patient was referred by her dentist for me to prepare her occlusion for veneers (Figs. 7-10).

The dentist also had a bigger plan in mind because he called prior to her visit to fill in the important background. He had known her for a while and felt that veneers would help her some, but that she had larger issues to consider. He had mentioned orthognathic surgery as an option and that I might be better equipped to present and discuss that option with her. What characteristics did he recognize? She had all the characteristics of the aged face: severely diminished lower facial height, thin lip vermilion and poor lip projection, deep commissures with down-turned lips and deep nasolabial folds. After using computer imaging to demonstrate the changes she could anticipate, we decided on a comprehensive treatment plan of orthodontics and surgery to advance both the maxilla and mandible (to increase skeletal volume) with downgraft of the anterior maxilla to increase incisor display. Simultaneously with the jaw surgery, the facial plastic surgeon was included for rhinoplasty. All of this discussion was facilitated with the use of digital imaging so the patient had a visual of the progress and results. We followed the plan and finished her orthodontic treatment. She then returned to her dentist for some beautiful veneers and crowns for final restoration of her teeth and the finishing touch on restoring the youthfulness of her appearance.

Here are the final pictures (Figs. 11-14). At the visit for her final pictures, I asked her a question: "Before you had this treatment, when you walked into a room, what was it like?" Her answer floored me. She responded, "I was invisible." Her answer made me realize that sometimes we look at solutions too mechanically. In other words, what I saw was a need for more tooth display, more lip support, more vertical dimension and what I needed to do to set up for the dentist's work. It wasn't until the finish that I really understood that the overall treatment plan totally changed her life and her outlook on life.

She gave me a picture of herself and her date on a recent cruise, and with a wink said, "He is 10 years younger than I am!" Surely the technology we have in terms of computers, the vast improvement in appliances and customized appliances are a great leap forward in our ability to treat patients. But in my opinion, these technologies should not be the focal point of how people see or assign a value to us.

Are we defined by the brackets we use or by the technology we sell? No. Our biggest value is not the mechanical system, but the knowledge we have to see and establish treatment goals. While our education is rigorous and mechanically oriented in science and medicine, the most important thing we do is to visualize our treatment goals, see what the patient wants for an outcome and then know how to make it happen.

Technology is an incredibly useful tool, but it is an adjunct which facilitates our ability to first, establish treatment goals with the patient and second, maximize our chances of achieving that outcome. Our focus has been, and always be, on achieving the best result for the patient that we can possibly achieve.
Author’s Bio
Dr. David Sarver is in private practice orthodontics and has authored or co-authored more than 60 scientific articles, 12 book chapters and is the author of Esthetics in Orthodontics and Orthognathic Surgery. He is also co-author (with Dr. Proffit and White) of the text Contemporary Treatment of Dentofacial Deformity, and co-author of the fourth edition of Proffit's classic textbook Contemporary Orthodontics.
Orthotown Magazine
September 2025
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