Patients who choose to undergo orthodontic or surgical treatment do so for a variety of reasons but almost all want treatment to correct functional problems. If correction of the patient’s malocclusion has compromised aesthetic relationships, then patient unhappiness may follow, even if all functional goals are met. Patients obviously prefer aesthetic improvement with their functional correction if possible. The issues of patient satisfaction and happiness are very complex because of matters such as patient expectation, self-assessment, and psychological and even psychiatric conditions present before and after treatment. One of the contributing factors in patient satisfaction involves the always subjective evaluation of facial aesthetics. Facial appearance considered ideal by one individual or group may not be judged so by others. One’s dental and facial appearance is important not only in the role that attractiveness plays to others but also in one’s self-concept! Perception of appearance, particularly of the face, affects mental health and social behaviour, with significant implications for educational and employment opportunities and mate selection.
The patient’s perception of his or her profile and need of treatment are not necessarily consistent with the clinician’s diagnosis based on cephalometric criteria. There are many methods of facial analysis attempting to quantify beauty. Differences in analyses and how each professional evaluates a face usually depend on training backgrounds. Patient ethnicity, familial characteristics, and personal preference are the main determinants of how a person may feel about the aesthetics of his or her own.
Orthodontic facial analyses have a predisposition to profile and cephalometric appraisals, because a great deal of study and effort has been expended by the profession to determine averages and normative values (called norms) from which treatment decisions can be made. Tooth and bony appraisals are also emphasized because that is the area in which orthodontists and oral surgeons direct their treatment. Plastic surgeons emphasize soft-tissue analysis.
There is no substitute for thorough clinical evaluation and recording of the resting and dynamic soft-tissue relations of the face when evaluating patients. Static records such as plaster models, photographs, and cephalometric data for subsequent analysis are simply not adequate for excellent coordination of hard-tissue planning and aesthetic outcome.
The potential negative effect of the dentofacial disfigurement on the psychic and social well-being of children is an idea readily accepted by many lay and professional people. The rationale underlying treatment recommendations based on esthetic impairment comes from the belief that impaired appearance resulting from malocclusion will adversely affect self-esteem, which in turn can lead to poor social adjustment and affective disorders. The opposing rationale is that the psychologically healthy individual will adjust to his or her appearance and that low self-esteem simply creates the negative self-valuation. The current trend in Orthodontics is comprehensive care delivery. This requires the inclusion of esthetics as a part of the overall diagnosis. Parents must weigh the cost/benefit for their child and may choose to provide orthodontic treatment to their children to enhance dentofacial esthetics, alleviate psychosocial problems, or improve function and/or prevent future dental disease.
Orthodontists are accustomed to a very quantitative facial and cephalometric patient evaluation, should learn facial evaluation by proportionality and more subjective evaluation criteria than linear measurements. Treatment decision making may be determined by what is most esthetically appealing rather than by what the cephalometric norms may be. This becomes all the more important because they are usually the first professionals asked to make decisions that have permanent effects on the final facial form. The esthetic and functional goals for growing patients should be the same as they are for adults. The methods of treatment that we use to achieve the desired esthetic and functional outcome make up the difference in treatment approaches.
All clinicians in the contemporary medical and dental environment must consider whether their goals of treatment are consistent with the treatment goals of the patient. Almost all practicing orthodontists have had the experience of providing camouflage treatment with good intentions, but in the end were disappointed in the facial outcome. Also disappointing is seeing the adult patient who has undergone orthodontic treatment as a child and now expresses unhappiness with facial aesthetic characteristics that may be a direct result of the orthodontic treatment. Plastic surgeons who don’t recognize the contribution of the teeth and the facial skeleton to facial aesthetics will achieve good results in a large percentage of their cases, but there will be a number of patients in whom soft tissue surgery alone is inappropriate camouflage of an underlying dento-skeletal problem. The camouflage simply cannot achieve the same level of aesthetic outcome as do interdisciplinary approaches to treatment.
The contemporary orthodontist should be able to visualize the long-term dental and facial goals of treatment and counsel the parent and patient as to what treatment choices may offer the maximum chance of both dental function and dentofacial aesthetics. This means that the orthodontist’s comprehensive vision will be improved and expanded if his or her knowledge of expected soft-tissue growth patterns is integrated with traditional dental and skeletal planning. Orthodontic plans that include aesthetic finishing options offered by the dentist, periodontist, oral and maxillofacial surgeon, and plastic surgeon may not be suitable for all patients (or even all orthodontists, for that matter!), but their discussion is an important aspect of informed consent. Also, the various options that can enhance the final aesthetic outcome are often appreciated by the patient.