To apply an orthodontics treatment, apart from studying the teeth, we must also look at the rest of the face to evaluate the extent to which the treatment will affect it.
By analysing the face, we can establish the origin of the dental problem and choose the adequate treatment to solve it.
We will fully analyse the face, making a front and side analysis, including the lips and their relationship to the surrounding areas and the teeth; lastly, we will study the tongue and its position in the mouth.
To make this analysis we watch the patient talk in the surgery, sitting in the chair, and study pictures taken of their face and mouth from different angles. This helps us to establish the treatment best suited to each patient. To make the decision, different aesthetic criteria must be taken into account: the patient’s age now and in the future, their facial features, and even the fashion.
We will analyse their face from the front and from the side.
Frontal analysis: Face length
The patient may have a long, medium-long, normal or short face.
A long and narrow face goes by the technical term of being Dolichofacial
This kind of face also has a narrow dental arch; i.e. the part of the mouth inside the lips is narrow. This is independent of the size or width of their smile, which depends on the horizontal length of their lips.
If this kind of patient has a wide labial smile, but a narrow dental arch, their teeth will not completely fill the space when smiling, revealing dark spaces at either side of the mouth. This means that we must widen the tooth arch in such a way that the mouth appears full of teeth when making a broad smile, like in the case of the actress Julia Roberts.
In the United States they favour very wide smiles, full of teeth when looked at from the front. In Europe we tend towards a more “natural” approach, where the smile is somewhat narrower.
In this facial type the muscles are weaker and crowded teeth can be straightened relatively easily.
However, if the teeth are very crowded due to a narrow arch with no space for all of them, sometimes one or several teeth must be extracted. The advantage of these weaker muscles is that the spaces left by the extractions close easily and the other teeth come into line quite quickly.
If the teeth are crowded but we do not make the required extractions, on bringing the front teeth into line they will open like a fan, making it impossible to bite properly. This is what we call an anterior open bite.
Medium length, “normal” or Mesofacial face
These patients have normal length faces, and their muscles are neither too tight nor too weak, meaning that they neither interfere with nor favour tooth alignment.
The treatment type and its duration will depend on the extent to which the teeth are crowded, as well as on their position in the jaw bone. The osseous relationship between the upper and lower jawbone is also a factor.
Short and square or Brachyfacial face
These patients have very strong facial muscles, making it more difficult to move their teeth.
All teeth are in a specific initial position, in all kinds of face, because the neuromuscular balance has pushed them into that position. Of course the size of the teeth and jawbones also have an influence, as does the relationship between the upper and lower jaw.
If we want to change the position of the teeth, we will have to ‘fight’ with the muscles which have pulled them into that position.
Treatment is more difficult in the case of strong muscles, particularly with respect to keeping the new positions in place over time.
In patients with a short face and strong muscles, the tendency is not to extract teeth, because the spaces take longer to close. They have the advantage that the teeth are always in occlusion, i.e. their top and bottom teeth are in contact with one another. There is no risk of an open bite.
Side or profile analysis
- The profile is straight when a straight line runs from the point of the nose, to the upper edge of the lips and the forward edge of the jaw.
- If the lips are in front of the line running from the point of the nose to the chin, the profile is convex.
- If the lips are inside the line, it is concave.
Convex or cambered profile
Here the muscles are weak, and the lips don’t close against one another, making them stick out. In other words, these patients have thick lips. Thick lips are weaker and apply less strength than thin lips.
This profile, like all others, has a racial component and is found above all in African Americans and in some exotic races. Today this kind of profile is fashionable and marks current beauty trends. Many of the models and actresses considered beautiful today (Irina Shayk, Penelope Cruz, Angelina Jolie) were born with this profile. Others have their lips filled to achieve the look.
The aesthetic criterion is important in borderline cases of crowded teeth where, to fit all teeth in the mouth, we ask ourselves whether or not to remove one or more teeth.
When the teeth are crowded, on aligning them they move forward and tilt outwards. Sometimes they don’t fit into the bone, entailing the likelihood that the roots would come out if they were forced into it. In this case we would have to extract one or more teeth, generally a premolar on both sides, either from the top or the bottom, or both. This will allow the teeth to move into their correct position.
Today the tendency is not to extract teeth, since forward-sitting teeth give more labial support and mean that adult patients have fewer wrinkles on the upper lip.
In the 50s, 60s and 70s, the tendency was to extract, since the fashion was inward-curved concave profiles, typical in Caucasians, and particularly Anglo-Saxons. While it looked great on teenage girls, when they developed into adults they had more wrinkles on their upper lip, known as “barcode” wrinkles.
In men, this labial support criteria is not considered to hold the same aesthetic importance given that, owing to a thicker skin type, they do not experience as many wrinkles in this area.
Concave or inward curved profile
Here the lips and mouth are behind the line running from the point of the nose to the chin.
This profile has strong muscles and thin lips, and is more typically found in Caucasians. Owing to this muscular strength, when the teeth are crowded and have to be aligned, the tendency is not to extract in order to prevent the mouth from sinking inwards.
But the teeth mustn’t be brought too far forward as it would be difficult to keep them in that forward position given that the muscles push them backwards. The patient would have to wear retainers (removable or fixed transparent pieces worn behind the tongue) for life.
Sometimes the concave profile is not a problem caused by the mouth, but by the nose and chin protruding more than usual. This can be seen on the cephalometric study carried out on the skull X-rays. If highly accentuated, an aesthetic operation on the nose and the chin may be considered in order to obtain a good profile. Queen Leticia had this kind of operation performed shortly after she married.
This is the one now considered aesthetically ideal for Caucasian women. The lips touch the line running from the point of the nose to the chin.
In any event, the initial condition of the bones and teeth is always important. Depending on the above, the professional will make their decision according to their experience and aesthetic criteria, taking account of the patient’s opinion whenever possible.
Although we have above all looked at aesthetics in women, in men the situation is similar, although with some variations. For example, it is not as important as it is in women to leave a man with a slightly inward facing profile because the “barcode” is less obvious and can be concealed with a moustache if desired.
In certain cases, such as mandibular class III, where the lower jaw is more prominent than the upper, in women the tendency is to treat and correct the issue using orthodontics and even bone surgery; however, in the case of men and if the larger jaw is not overly pronounced, only orthodontics is used. This is because leaving a slightly prominent jaw in a man can be considered to project an image of strength or virility.
The orthodontics study is essential in obtaining a good result.