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126 Interview with David Sarver, D.M.D., M.S

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126 Interview with David Sarver, D.M.D., M.S E ARVER LAX S/F NC E LL E 2008 EXC 2008 Interview with David Sarver, D.M.D., M.S. by David Sarver, D.M.D. HF: David, it’s exciting to have you on our program for the AACD’s 2008 Annual Vestavia Hills, AL Scientific Session. When I’ve heard you lecture, it’s impressive how you see the www.sarverortho.com big picture of creating and maintaining a beautiful smile not only at the comple- tion of treatment, but also throughout the aging process. While viewing “the art Hugh Flax, D.D.S. of the smile,” what must an “esthetic orthodontist” be doing? Atlanta, GA www.flaxdental.com DS: Thank you, Hugh. It’s exciting for me also, because of the opportunity we have to contribute to the “cross-fertilization” of knowledge and technique between all aspects of dentistry. Even though I’m an orthodontist, I have really focused in the past several years on the remarkable progress made recently in cosmetic dentistry and how we can not only collaborate in in- terdisciplinary care, but how the very same principles of esthetic dentistry are applied to my orthodontic cases to further enhance my outcomes. I have long had an interest in the aging process on the face and how important it is for us to understand how this has an impact on our orth- odontic decisions. As orthodontists, we often are the first in line in to make decisions that can affect a child’s facial appearance for his or her lifetime. This can be positive… or it can be negative. The reduction in extraction rates in orthodontic cases can, in large part, be attributed to the recognition that loss of lip and facial soft tissue support is a normal aging process. The transition to orthodontic thinking is pretty simple: Reduc- tion in dental volume in some facial types results in less lip and soft tissue support, thus accelerating the aging characteristics of the face and perioral apparatus. However, a word of caution—anything can be overdone and overexpansion is not recommended. As far as the smile is concerned, substantial data indicate that incisor dis- play diminishes with age. For the orthodontist, that means that smile evaluation must include the measurement of both maxillary incisors is displayed at rest and how much on smile. This gives us at least a start The Journal of Cosmetic Dentistry 126 Fall 2007 • Volume 23 • Number 3 SARVER /FLAX EXC 2008 E LL E C E Figure 1: This young patient was first seen Figure 2: In addition to closing the Figure 3: The smile 10 years after for treatment of the maxillary midline diastema, the plan was directed to increase completion of treatment diastema. Her clinical exam demonstrated anterior tooth display. The resulting a flat smile arc with inadequate incisor smile display was much more youthful in display on smile. appearance. in gauging where our patient’s These parents (and many oth- HF: Why hasn’t contemporary ortho- smile is on the age scale. Think er parents of adolescents) are dontics kept pace with this con- about this: When we look at aware of what their own orth- cept? texts in plastic surgery, orth- odontic experiences were like, DS: That is an interesting question. odontic, and cosmetic dentist- and think only about “crooked I have had the privilege of co- ry, the facial and “ideal smile” teeth.” On clinical examina- authoring with Bill Proffit his illustration is usually a 25-year- tion, we noted that the patient classic orthodontic text, Con- old female. In reality, most of showed about 3 mm of upper temporary Orthodontics. This text our orthodontic patients are incisor at rest (5 to 6 mm is de- is considered the standard in 10 to 14 years old. Simply put, sirable in that age group) and orthodontics and, in the latest when I finish treatment on a 8 mm of upper incisor display edition, we have placed great 14-year-old, I want the child to on smile. Crown height was 10 emphasis on the issues we have look like a 14-year-old, not like mm. We differentially placed just discussed. However, you a 25-year-old. If they look 25 her brackets and adjusted the and I both know that textbooks when I finish their orthodontic mechanics in such a way that tend to be read by students treatment at age 14, then when the upper incisors were brought who have to read them; and they are 25 their smile will down and the anterior maxilla that most practicing clinicians look 35! In other words, what were encouraged to develop are not likely to read any text- the appliance “should be do- more vertically. The resulting book from cover to cover. So, in ing” is to be cognizant of how smile display was much more my mind, contemporary ortho- the smile ages and to place the appropriately youthful in ap- dontics is certainly on pace with teeth in the smile framework to pearance (Fig 2). A photograph smile concepts, but knowledge account for this characteristic. of the patient 10 years later disseminates at varying rates Let’s use an actual patient as an (Fig 3) demonstrates how this into our profession just as it example. The patient shown in expansion of orthodontic vi- does in all areas of dentistry. sion has contributed to the Figure 1 was brought in by her HF: Orthodontists tend to have a fairly beauty of her facial and smile parents for treatment of what standard set of records, which take appearance into adulthood. was obvious to them—the into account many static relation- maxillary midline diastema. The Journal of Cosmetic Dentistry Fall 2007 • Volume 23 • Number 3 127 E ARVER LAX S/F NC E LL E 2008 EXC 2008 Figure 4: Computer databasing programs facilitate the clinical examination and store the information we measure in a retrievable and systematically usable format. ships of hard tissues. Please share of what we term biometric mea- ment to be able to view a “repeat- with us what you believe should be surement (which simply means able” smile? the new standard of documenta- direct measurement of the rest- DS: The stages of the smile are tion and treatment planning in ing and dynamic relationships made up of several compo- orthodontics. of hard to soft tissue). The nents: (1) the smile is initiated DS: The standard record of three measurement of upper incisor by muscle bundles origination facial photographs and six in- at rest and on smile is a perfect from the dense fascia of the na- traorals is still pretty much the example. This is information solabial fold; (2) this upward gold standard, but we supple- not available from models, ce- movement is then combined ment those records with images phalometric measurements, with the levator muscles and; of the close-up smile, oblique or photographs. We have also (3) when these contract, the facial, and oblique smile. We developed computer-database upper lip is pulled upward and augment intraoral pictures with programs that greatly facili- backward towards the nasola- what are fairly standard cosmet- tate the clinical examination bial fold. The term smile style ic dental images—the anterior and store the information we was first coined by the plastic teeth with a black background measure in a retrievable and surgeon L.R. Rubin in 1974, to highlight contacts, connec- systematically usable format who defined three types of tors, embrasures, halos, etc. (Fig 4). smile styles1 The major change in our orth- HF: What are the differences in “smile • Commissure smile. In this, the odontic records is not only styles” that patients exhibit, and corners of the mouth turn the addition of some images, why it is important during treat- upward due to the pull of the but that we also teach the use zygomaticus major muscles. The Journal of Cosmetic Dentistry 128 Fall 2007 • Volume 23 • Number 3 SARVER /FLAX EXC 2008 E LL E C E Figure 5: The short philtrum exhibited Figure 6: The V-Y cheiloplasty goes beyond Figure 7: The final resting relationship of in this patient is a vexing problem in the alar cinch by the use of vertical the upper lip demonstrates an improves treatment planning. It represents an orientation of the incisions and closure, Cupid’s bow, lip competence, and esthetic issue both at rest and on smile. lengthening the resting length and longer philtrum demobilizing the upper lip. This is also referred to as the The cuspid smile tends to be much importance as the maxil- “Mona Lisa smile.” associated more with exces- lary incisors. In the veneer case, • Cuspid smile. In this smile, the sive gingival display, and also the shade differential from the upper lip is elevated uniformly is associated with “hypermo- maxillary teeth to the mandibu- so that the corners of the mouth bile lip,” which can be af- lar incisors may be so great that turn upward at the same time fected through plastic surgery the lower incisors are also indi- (i.e., the entire lip rises like a techniques, specifically the V-Y cated for restoration. window shade). cheiloplasty. We utilize the V-Y The importance of the repeat- cheiloplasty to lengthen the • Complex smile. Here, the upper able smile is very much like short lip, and to demobilize lip moves superiorly as in the centric relation and centric oc- the smile with a natural appear- cuspid smile but the lower lip clusion. In the treatment of the ance. In V-Y cheiloplasty, an also moves inferiorly in simi- smile, we recommend a consis- incision is made in the anterior lar fashion.
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