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A Voice in the Arena: A Case for 'Outside-In" by Dr. Chad Foster

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A Voice in the Arena:

by Chad Foster, DDS, MS, editorial director

As I wrote in “Outside-In Dentofacial Diagnosis,” my first article for Orthotown magazine, I use and advocate a very specific approach to orthodontic diagnosis. The method is as simple as it is effective in prioritizing dentofacial aesthetic traits.

Every time your treatment coordinator brings you a new patient composite layout, I recommend making a strict practice of looking at only the nonsmiling facial photos first. Then the smiling photos are assessed. And finally the intraoral structures are assessed, including the teeth and occlusion—always in that order, and for every new patient exam. (On a side note, in regard to aesthetics, this is also the best way to globally evaluate your finished cases).


A great case to discuss
Looking at the case of this 34-year-old patient, observing the facial nonsmiling photos first, I notice weak chin projection and somewhat thin lips with minimal vermilion display.

Next, evaluating the smile, I notice narrow arches, reasonably good vertical upper incisor position and a steep occlusal plane that allows a relatively good smile arc, but maxillary posteriors are a bit hidden vertically because of that steep plane.

Intraoral photos show Class 2 occlusion, a narrow maxillary arch (more dental in nature than skeletal, and compensated to be narrow because of the retrognathic position of the lower jaw), crowding in both arches, a very deep overbite and a Division 2 (lingually inclined) maxillary central incisor position, with both lips resting on this compensated and undersupported tooth position.
Dentofacial Aesthetics
Fig. 1
Dentofacial Aesthetics
Fig. 2
Dentofacial Aesthetics
Fig. 3
Dentofacial Aesthetics
Fig. 3
Dentofacial Aesthetics
Fig. 5
Dentofacial Aesthetics
Fig.6


Priority on not opening vertical in weak chin patients
In patients with weak chin projection where orthopedic or surgical mandibular advancement is not part of the plan—like this patient, who declined the ideal surgical option—there is very high priority on limiting molar eruption as much as possible to prevent increasing the mandibular plane angle, which would increase the lower one-third vertical facial height and further decrease chin projection as the jaw rolls down and back.

I’m a big fan of turbos on U4s in Class 2 ramp shape—it’s a fantastic tool—but, like everything, case selection is important and I would not use them in this case because of their allowance of molar eruption. Instead, I would place bite turbos on both L6s and L7s to limit their eruption. Limiting vertical helps in our maxillary central incisor goals as well—the more the mandibular plane opens, the more Class 2 the patient becomes and the more we have to chase overjet with elastics or possibly maxillary IPR, which would both act to lose torque/restrain/retract the forward position of the maxillary incisors.


Prioritizing the maxillary central incisor aesthetic position
I want the maxillary central incisors to be aesthetically dominant—to project from a more ideal position within her maxilla (the normal jaw). I’d like them to roll further forward in regard to their labiolingual inclination for the sake of thin lip support and aesthetic projection of her maxillary dentition.


Very special features
This patient shows some cool anatomy. Notice the marginal collar of bone present on the cephalometric X-ray in the area of the lower anteriors, and the associated robust hard- and soft-tissue appearance of the periodontium in that area on photos. For reasons already stated, I want her upper incisors to go forward for multiple aesthetic reasons! In doing so, it is important to also consider occlusion and coupling of the upper and lower incisors. It’s not reasonable for every patient to procline the lower anteriors to meet in a U1 ideal aesthetic position. Again, case selection is important.

Given this patient’s unique anatomy, she would likely tolerate this movement better than a patient who has weaker periodontal support in that area. Additionally, she also shows excellent buccal phenotype in the premolar and molar areas to better allow significant dental expansion as a major smile aesthetic enhancement. Notice the upper posteriors in linguoversion— a dental compensation to the retrognathic lower arch. This is definitely an ideal case for dental expansion, instead of orthopedic, because the origin of the problem in the maxilla is dental (compensation) in nature.


Maxillary central incisor vertical aesthetic evaluation
So many interesting things in this area! Aesthetic vertical incisor position of the maxillary central incisors is critical to smile aesthetics. This vertical position, smile arc and occlusal plane are all related but independent variables.

This patient’s U1 vertical position is close to ideal within her smile—this is a common compensation in Class 2 patients, where U1s have been allowed to overerupt, while the opposite is true in Class 3 patients—and a steep occlusal plane has also resulted in a good smile arc. Correction of her overbite is important, but any intrusion of upper anteriors should be avoided to not harm the U1 vertical position. While the smile arc is good, I don’t like the vertical position of her maxillary posteriors in her smile; they are too high and hidden vertically a bit.

The diagnostic flow of information to our brains is best prioritized from outside-in. More to come on this topic in the future!
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