Embrace Progress: Cosmetic Orthodontics by Dr. Daniel Grob

Dentaltown Magazine

by Dr. Daniel Grob, DDS, MS, editorial director, Orthotown Magazine

Is all orthodontic treatment cosmetic? Is it possible to have an excellent orthodontic result and not have the optimum cosmetic benefit?

Ouch! Is this any way to open an article in an orthodontic magazine? Well, let’s be honest: Sometimes—because of circumstances beyond our control, or systemic bias and standard operating procedures within the industry—we look at the results of our best efforts and come to the conclusion that the patient could look better if a different approach or no approach had been undertaken.

We are not alone.

In my previous, short-lived life, my prosthodontic experience presented the same dichotomy or choice. Other dental specialties also often force practitioners to decide between mechanical stability (based on engineering principles, geometry and force vectors) and aesthetic demands (based on rather vague concepts and appearance concerns).

I’ll never forget the mother of one of my young patients asking if anything could be done for her maxillary lateral incisor. The brief history is that periodontal involvement of this tooth resulted in severe bone loss. The periodontist was pounding his chest over his ability to “save” the tooth. It looked terrible! There were, of course, huge dark triangles, and gingival contours were uneven. We ultimately decided to remove and replace for ultimate cosmetics, not just the “ideal” of saving the tooth.

To illustrate the choices we have in delivering aesthetics, let’s draw on a couple of classic articles published by leaders in their respective fields.


Dr. Earl Pound was probably one of the most famous complete-denture researchers and practitioners in his day. The name may not be familiar to many Orthotown members, but understand that just like our time when message boards are filled with heated discussions regarding placement of teeth in orthodontic treatment—basically, extraction versus non-extraction—the era of complete dentures had a similar predicament: Either place the teeth over the bone or somewhere out in space.

Many of Pound’s concepts and thoughts appear in the article “An Introduction to Denture Simplification” (Journal of Prosthetic Dentistry, Vol. 27, p. 570).

It was thought that placement of teeth over the bone was mechanically required for stability, and even to preserve the remaining amount of bone for the future. However, as you might recall, bone resorbs in a gradually Class 3 fashion with time—that is, the mandibular bone becomes more prognathic and the maxillary bone becomes more retrognathic. To solve this predicament, Pound advocated a system of trial and final dentures that took into account this as well as other muscular and bony factors. His result was the aesthetics phonetic and function system, sometimes known as the branching technique.

The system, in addition to trial dentures, employed placement of maxillary teeth for maximum aesthetics to the upper lip and face. Attention was then drawn to phonetics, which allowed for placement of lower teeth that supported the pronunciation of several sounds, most notably “fifty to fifty-five.” Lastly, function was addressed with placement of the posterior teeth.

When all was said and done, the beautiful smile many times did not result in the teeth over the residual bone. However, they functioned well, and the patients were able to control their new teeth because they were placed in harmony with function and balance of the lips, cheeks and tongue.


Orthodontic training is focused on performing the correct treatment after a thorough and complete diagnosis. Photos, casts, X-rays and clinical exams provide us with a treatment plan that we are convinced is proper for each patient. It’s difficult to try various plans, especially if it involves removing permanent teeth. This topic is timely because in upcoming and current issues, some treatment planning will be presented that deviates slightly from what many of us have been taught and most of us accept—namely, diagnosing position of the teeth in a sagittal plane of space with angular, linear and functional measurements in a two-dimensional plane.

This topic was selected after an online posting of a classic article by Dr. Levern Merrifield regarding the limits of the dimensions of the denture: “Dimensions of the Denture, Back to Basics” (AJO/DO, Vol. 106, p. 535).

There are numerous valid and timeless points to be made in the article. Granted, casts, etc., are three-dimensional in scope, but what if in analysis we were to include the facial musculature and tongue position that are responsible for the cosmetic smile? Do these rather vague factors change over time? Is lip incompetence truly the inability of the lips to close together, or is it more than that? Could it be that forward or low tongue posture is responsible for the strain appearance of the mentalis muscles? Could it be that maxillary teeth trapped forward of a hyperactive lower lip will magically relax when the incisors are positioned more upright or vertical to the horizontal plane in space? Is it acceptable to have teeth look great if they present an upright appearance but are still forward of the classic anterior limiting plane that we’ve come to love?

These are just a few of the questions that need to be addressed as we move toward ultimate cosmetics delivered to patients. I can already hear the objections to some of these new concepts as they relate to stability and retention. Let me respond with this article in the early 1980s, when a classic paper was released by Drs. Little, Wallen and Riedel that pretty much addressed orthodontic retention as we knew it: “Stability and Relapse of Mandibular Anterior Alignment: First Premolar Extraction Cases Treated by Traditional Edgewise Orthodontics” (Am J Orthod 1981; 80:349–65).

Namely, even with extraction treatment, a large percentage of patients had crooked teeth or relapse in their follow-up visits. This should alert us to the fact that we are dealing with much more than simple concepts of placing teeth to measurements and angles.

The message is: As we move forward with new diagnostic abilities and treatment paradigms involving concepts regarding transverse, vertical occlusal plane variables, we need to continue to document our treatments and reevaluate our success based on these new variables.

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