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A Voice in the Arena: The Architects of the Lips: Part 1 by Dr. Chad Foster

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A Voice in the Arena: The Architects of the Lips: Part 1

by Chad Foster, DDS, MS, editorial director

Orthodontists are the architects of dentofacial aesthetics. That is a very strong statement, but true. Over the next few months, I will be sharing a multi-part case study presentation on the topic of lips. It is my belief that when it comes to lip aesthetics, there is not a single health care provider that plays as pivotal a role in its natural beauty as orthodontists. We are the architects of the lips. We practice with the ability to enhance, diminish, or maintain lip aesthetics. If you are an orthodontist that takes excellent photos and evaluates your cases from the “Outside-In,” you are already aware of the truth in that statement. You already know that through your work you are actively enhancing, diminishing, or maintaining lip aesthetics in many of your patients. If you’re an orthodontist who doesn’t take excellent photos or pay close attention to your patients’ lips, guess what—you’re still actively enhancing, diminishing, or maintaining lip aesthetics. You just might not know it or might not care to notice a millimeter here or a millimeter there.

The broader school of thought throughout the 20th century (and largely held today) was that ideal facial aesthetics were essentially identical to skeletal and dental norms. The early cephalometric pioneers, including Brodie, Broadbent, Downs, Steiner, Ricketts, and Tweed (all of whom are legends and greatly advanced us to where we stand today), believed that achieving standardized skeletal/dental numbers and a textbook Class I occlusion would inherently produce ideal facial aesthetics. To put it simply, all an orthodontist has to do is hit the ideal cephalometric numbers and align the arches into a Class I relationship and facial harmony will take care of itself. Wherever the soft and hard structures of the face find themselves positioned after that winning orthodontic formula inherently is the most ideal and most beautiful facial presentation possible for that person.

However, multiple contemporary studies and paradigm reviews indicate that cephalometric norms and a textbook Class I occlusion are neither necessary nor sufficient for achieving ideal facial aesthetics. The soft-tissue response to tooth and skeletal positioning is highly variable, perception of attractiveness is shaped by numerous nonocclusal factors, and much of the research shows only limited or nonlinear correlations between cephalometric measurements and perceived beauty (Ackerman; Sarver; Yu et al.; Godinho et al.; Sundareswaran; Zorlu and Camci).

In so many ways in dentistry, it really is the maxillary central incisor that is king. Central incisor dominance dictates smile aesthetics in a variety of ways. Beyond just smile aesthetics, the central incisor is also specifically why orthodontists are the architects of the lips. Both it’s A-P position and labiolingual inclination directly affect lip projection, lip roll, lip anatomy, the perception of lip volume, and vermilion display. The facial influence of the maxillary central incisor doesn’t end there—it also directly affects the aesthetic presentation of surrounding circumoral tissues, including the oral commissures, nasolabial folds, cheek–lip interface, mentolabial sulcus, and the mentalis and subnasale regions. As the architects of dentofacial aesthetics, where we position the maxillary central incisor matters. It matters a lot.

The truth is that aesthetics are subjective. Regardless of your treatment philosophy or aesthetic preference, I hope that you will join me in the series to come. My goal is not to dictate what lip aesthetics are or change your mind if you disagree with some or all of what I share and discuss. I hope you do disagree with some of the cases or thoughts shared! Where would the inherent art and subjectivity be in strict unanimity? My goal is simply to put you in my brain to see through my eyes for a few thousand words and a half a dozen cases. If it challenges you thereafter to think or see things a bit differently, that is great. On the other hand, if it just further drives you deeper into your own aesthetic preference, that is great too!

But I do aim to achieve one measure of unanimity: that you won’t finish this series without agreeing that millimeters—and even tenths of millimeters—matter. Because they absolutely do. Make no mistake about it, the billion-dollar world of facial and soft tissue aesthetics is measured in those units. There are levels to that game and the very highest levels are absolutely differentiated and defined by those same units.

It is an unfortunate reality that people today seek to do all sorts of costly, invasive, and artificial things to their faces and lips that look anything but naturally beautiful. Most of our patients have little understanding of the foundational role an orthodontist plays in that world. Most of them just want straight teeth. I have a prediction to make. Those of us who practice simply as “teeth straighteners and bite fixers”—a group that includes the majority of orthodontists—are heading down a very different path from those who strive to be architects of dentofacial aesthetics. While those paths may diverge by only a few degrees in direction (and perhaps in cephalometric numbers), their ultimate destinations, I believe, differ by orders of magnitude. 
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