A Voice in the Arena: The Architects of the Lips: Part 5 by Dr. Chad Foster

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A Voice in the Arena: The Architects of the Lips: Part 5

by Chad Foster, DDS, MS, editorial director

Orthodontists have always been meticulous about millimeters. We measure them, plan around them, and build entire treatment philosophies on their control. A fraction of a millimeter in alignment, overjet, or torque can define whether a case is finished well or exceptionally. For all the precision we demand on the inside—the teeth, the occlusion, the cephalometric values—we have historically not held ourselves to the same standard on the outside. Yet we directly influence many of those “outside millimeters” more principally and more naturally than any other aesthetic healthcare provider.

My goal in this series has been to offer that the millimeters we control externally—particularly in the lips—can be just as consequential as the millimeters we control internally. In fact, to many of our patients, they may matter more.

The maxillary incisors are not simply dental units to be aligned within an arch. They are the primary architectural interface between the dentition and the face. Their anteroposterior position and inclination directly influence lip projection, vermilion display, lip roll, and the broader circumoral complex. When we move incisors, we are not merely correcting occlusion—we are reshaping the most expressive and socially significant feature of the lower face.

As David Sarver emphasized in his macroesthetic philosophy, orthodontic diagnosis must begin with the face, not the teeth. External facial landmarks—not internal measurements—are ultimately what determine perceived harmony and attractiveness.1

And the key point is this: The magnitude of change required to alter that perception is incredibly small.

The world of facial aesthetics is measured in millimeters

Across plastic surgery, dermatology, and facial aesthetics literature, one theme is remarkably consistent: Subtle changes in soft tissue—often on the order of millimeters—can significantly alter perceived attractiveness.

Studies evaluating lip augmentation demonstrate that even modest increases in lip projection or volume can significantly improve attractiveness ratings, while exceeding a narrow threshold leads to a decline in perceived beauty.2 This reinforces that aesthetic preference exists within a very tight biologic and perceptual range.

Similarly, aesthetic analyses in facial plastic surgery emphasize precise proportional relationships—such as vermilion height and lip ratios—where even small deviations are readily perceived by both clinicians and laypeople.3 These are not large, dramatic changes; they are refinements measured in millimeters.

Further supporting this, prospective clinical research on soft-tissue augmentation shows that patient satisfaction closely tracks subtle volumetric changes over time, indicating that patients are highly sensitive to even small alterations in facial contour.4

Patients are voting—with demand

If there were any doubt that patients care about millimeters in lip position, the modern aesthetic marketplace has made it clear.

Lip augmentation has become one of the most commonly performed aesthetic procedures, with more than 1.3 million procedures performed annually in the United States alone.5 Over the past two decades, these procedures have increased by more than 300%, reflecting a sustained and growing demand for subtle enhancement of lip form and position.6

Importantly, this demand is not for exaggerated or artificial outcomes. Contemporary aesthetic trends consistently favor natural, minimally perceptible improvements—changes that often fall within a millimeter or two of difference.

Surveys of facial plastic surgeons further show that younger patients are increasingly seeking early, subtle interventions aimed at refinement rather than transformation, highlighting a strong consumer preference for controlled, precise aesthetic changes.7

Patients are not only able to perceive these small differences—they actively seek them out.

Orthodontists naturally control what others artificially manufacture

Herein lies a critical paradox.

While patients pursue subtle improvements in lip aesthetics through injectables and surgical procedures, orthodontists already possess one of the most powerful and natural tools for influencing lip position: the maxillary incisors.

Unlike fillers, which artificially increase volume, orthodontics alters the structural foundation of the lips. It determines where the lips rest, how they project, and how they interact with the surrounding facial structures. It allows for enhancement, preservation, or reduction of lip prominence through biologic means.

No other specialty operates at this interface with the same level of control and integration.

And yet, historically, this influence has often been treated as an afterthought.

Orthodontic treatment has largely been guided by internal metrics—alignment, occlusion, and cephalometric norms—with the assumption that soft tissue will respond favorably. However, both contemporary orthodontic philosophy and broader aesthetic research demonstrate that this assumption is unreliable. Soft-tissue response is variable, perception of beauty is subjective, and small positional changes can have disproportionately large aesthetic consequences.

The responsibility of precision

If we accept that millimeters can matter on the outside as much as they do on the inside, then our treatment philosophy must evolve.

This does not mean abandoning occlusion, stability, or periodontal considerations. Elevating facial aesthetics—particularly lip position—does not mean that we discount those other important “inside” goals. It means that both are appreciated, and the compromises of different treatment alternatives are understood.

It requires a shift in how we evaluate outcomes:
  • Not just: Are the incisors aligned? But: Where are they positioned within the face?
  • Not just: Is the overjet corrected? But: What effect did that correction have on the lips?
  • Not just: Did we achieve ideal numbers? But: Did we enhance the patient’s facial presentation?

It also requires recognizing that patients may not fully understand or articulate these concerns during treatment planning. However, the broader aesthetic marketplace demonstrates clearly that patients place high value on subtle improvements in lip appearance.

A call to recalibrate

Orthodontics stands at a pivotal moment.

One path continues to prioritize internal measurements as the only endpoints of value. The other embraces a broader responsibility—recognizing that the external consequences of our treatment decisions are also worth consideration.

The divergence between these paths may be measured in millimeters, but the difference in outcomes can be profound. We are not simply aligning teeth. We are shaping faces as well. And nowhere is that more evident than in the lips.

The broader field of facial aesthetics has already established what our patients inherently understand: millimeters matter. They influence perception, attractiveness, and self-image. Patients seek these changes, invest in them, and value them deeply. It is time for orthodontics to value those “outside millimeters” as well. Or at the very least, engage in discussions with our patients regarding them relative to our treatments.

Because as the architects of the lips, we are already working at that scale—whether we choose to acknowledge it or not. I hope you have enjoyed this series! 

References

1. Sarver DM. Dentofacial Esthetics: From Macro to Micro. 1st ed. Quintessence Publishing; 2015.
2. Swanson E. Attractiveness of upper lip augmentation: a randomized study. Sci Rep. 2023;13:1–8.
3. Farkas LG, Katic MJ, Forrest CR. International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg. 2005;16(4):615–646.
4. Sundaram H, Signorini M, Liew S, et al. Global aesthetics consensus: hyaluronic acid fillers and patient satisfaction. Aesthet Surg J Open Forum. 2021;3(3):ojab030.
5. American Society of Plastic Surgeons. 2022 Plastic Surgery Statistics Report. Published 2023.
6. Bertossi D, Nocini R, Nocini PF. Trends in lip augmentation: a review of current practice. Dermatol Ther. 2019;32(5):e13057.
7. American Academy of Facial Plastic and Reconstructive Surgery. Annual Survey Results. Published 2022.


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