Facial Considerations in the Esthetic Treatment of the Adult Orthodontic Patient Dr. David Sarver Summary by: Dr. Robert Nemeth Because Dr. Sarver believes appearance is more than just the dentition, he emphasized the need for a broader vision of esthetics by analyzing many facial features. He stressed the importance of the entire face and its "opportunities" rather than just "the smile." David recommended the need for quantitative data in all three planes of space with a de-emphasis of static records. For treatment optimization we need openness to opportunities and a skeptical scrutiny of past analysis. Records should include written, photographic, and video recordings so that planning can be accomplished by proportionality. He reminded us that visual characteristics are relative and age dependent. Dr. Sarver's classification of appearance and esthetics considers macroesthetics, miniesthetics, and microesthetics. His macroesthetics includes profile, vertical proportions, lip fullness, chin projection, nasal projection, and big ears among other facial features. Miniesthetics according to Sarver involves incisor display, transverse smile, smile symmetry, crowding and smile arc. Microesthetics looks at gingival heights, triangular holes, emergence profiles of the teeth, spacing, tooth shade, tooth shape, and incisor angulations. He presented four (4) guidelines in his broader vision of esthetics by saying that dental and facial relationships must be evaluated in all three dimensions in both rest and dynamically over time. Since the predominant characteristic of aging is lip thinning and loss of elasticity, extending the soft tissue envelope is paramount in our analysis of the adult patient. In addition, the clinical appearance of the anterior teeth should almost always override the traditional cephalometric measurements to gain a measure of the resting and dynamic soft tissue relations. He discussed skeletal aging citing Rolf Behrent's study and informed the audience of the characteristics of soft tissue aging through each decade. Dr. Sarver compared the appearance of youthful and aging lips and mentioned how the orthodontist makes a life time decision regarding continued youthfulness (whenever the intervention). The aging face shows macro and miniesthetic changes: decreased lower facial height, lower nasal tip, decreased vermillion, less lip projection, and deepened nasolabial fold; decreased incisor display at rest and on smiling, change in tooth shade, and decreased lip turgor. Treatment strategies should therefore involve soft tissue support, increased lower facial height, and increased tooth display. In his concept of appearance driven treatment planning, he also presented his concepts of dental and skeletal volume. The concept of dental volume should include consideration of lip turgor, the nasolabial fold, vermillion display, proclination of the incisors, and how laminates influence macroesthetics and incisor display. He stated that the loss of skeletal support with age contributes to soft tissue changes and demonstrated how orthognathic surgery can reverse aging characteristics by re-establishing the necessary bony support. He showed how plastic surgeons use malar augmentation to "fill in" behind the aging facial skin tissue. Lastly, rejuvenation of the aging lips through lip augmentation and lip lift surgery was presented to demonstrate increased lip projection and turgor for a more youthful appearance. At the conclusion, one felt that the orthodontist was the influential member of a team also comprised of the prosthodontist, maxillofacial surgeon and plastic surgeon dedicated to continued youthfulness of our population.