Orthodontics case study: treat 'the face' not 'the teeth'

As dentists, we focus much of our attention on the oral cavity. However, the treatment we perform within this confined space often affects the whole facial structure. For this reason, it is imperative to look beyond stone models. G. Ross Segal, DMD, MS, presents a case where orthodontics had a huge positive influence on the facial appearance of a young girl whose teeth were already relatively straight.

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As dentists, we focus much of our attention on the oral cavity. However, the treatment we perform within this confined space often affects the whole facial structure. For this reason, it is imperative to look beyond stone models. In general, whenever a dentist performs an initial evaluation, it is fundamental to begin with an evaluation of the face. For example, in cases where a patient has a “flat” profile, one may be more inclined to pursue a nonextraction approach with the goal of maintaining or accentuating lip support. The opposite is true for patients with excessive lip strain. Rachael’s case is a good example.

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From the beginning, Rachael’s dad wasn’t convinced that his daughter needed orthodontic treatment. After all, her teeth were already relatively straight, as can be seen in the photos below.

Fig. 1: Initial upper occlusalFig. 2: Initial lower occlusal


Rachael’s dad was reluctant to even schedule a consult appointment, but his dentist insisted that significant improvements could be made to Rachael’s appearance. The fact is that both Rachael’s dad and the dentist were correct in their assessments. In other words, the teeth won’t look much straighter, but Rachael’s appearance would be significantly improved. How could that be?

Upon initial examination, it was evident that Rachael could not close her lips without displaying a significant degree of mentalis strain. In addition, Rachael was not happy with her protruded lower lip.

Fig. 3: Initial frontal rest
Fig. 4: Rachael's profile


Therefore, the treatment plan for Rachael was based mainly on her facial appearance as opposed to any tooth irregularity. Despite the fact that there was no crowding, extraction of four bicuspids was still indicated, with the goal of creating space for retraction of the incisors.

Fig. 5: Rachael's progress upper occlusalFig. 6: Rachael's progress lower occlusal


Uprighting the incisors resulted in better facial balance, elimination of mentalis strain and retraction of the protruded lower lip.

Fig. 7: Rachael's profile beforeFig. 8: Rachael's profile final


Rachael’s dad never imagined that dental treatment could have such a positive influence on her appearance. A couple of weeks ago, I saw him at the local coffee shop, and he shared with me how happy his daughter is with her facial transformation. When he walked away, an older lady sitting in the adjacent lounge chair had overheard this discussion about improving facial appearance and asked me if I was a plastic surgeon. She was more than a little surprised to hear I was a dentist.

G. Ross Segal, DMD, MS, received his dental degree from The University of Pennsylvania and then went on to obtain his specialty in orthodontics certificate and Master’s in Science from Temple University. In 2011, he was among three orthodontists in the country selected as “The Top 40 under 40” by Incisal Edge magazine. Dr. Segal has lectured nationally at dental conferences and is an annual guest lecturer at Temple University.

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