Sa r v e r /Fl a x e ll nc 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 Sa r v e r /Fl a x 2008 Exc e ll c

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 Sa r v e r /Fl a x e ll nc 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 Sa r v e r /Fl a x 2008 Exc e ll c

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. This is termed the tent evaluation. There are two maxilla in the vestibule, with “starburst smile.” defined types of smiles: Theun - a vertical incision behind the posed (spontaneous) smile and The smile style is important because philtrum. Mattress sutures are the posed smile. The unposed of the difference in how much then used to close these inci- smile is involuntary and reflects the upper and lower dentitions sions, resulting in a vertical scar emotion. Lip elevation in the are demonstrated upon smiling. closure, and reorientation of unposed smile often is more For example, the commissure the muscles to reduce the mo- animated, as seen in the laugh- smile may show more tooth bility of the upper lip on smile ing smile, for example. The posteriorly than anteriorly; and, (Figs 5–7). posed smile is a learned smile, in the orthodontic case, may re- The complex smile means that with lip animation being fair- quire some incisor extrusion; the lower incisors are going ly reproducible similar to the and, in the restorative case, may to be on display more than in smile that may be rehearsed for allow some leeway as far as gin- the other two smile types. For photographs or school pictures. gival margin placement. the orthodontist, this means The posed smile, because of its that the lower incisors hold as

The Journal of Cosmetic Dentistry Fall 2007 • Volume 23 • Number 3 129 Sa r v e r /Fl a x e ll nc Exc 2008

Figure 8: Utilizing digital video clips with segmentation of the flow of images results in a “smile curve” that helps us determine the repeatable and most consistent smile.

repeatability, is considered the tograph recordings should also tant dimensional considerations “treatment” smile. include profile, oblique, and needed to create an ideal smile? In clinical practice, standard frontal close-up smiles. We have DS: The concepts of “smile cur- records include film or digital also been utilizing dynamic re- vature” and “buccal corridor” photographs, radiographs, and cordings of smiles and speech are smile attributes that have study models (mounted or un- with digital videography. Digi- been around for quite some mounted plaster or electronic tal video and computer technol- time. Smile curvature (in ortho- models). Universal standard fa- ogy enables us to record anteri- dontics, we term this the smile cial images consist of the fron- or tooth display during speech arc) relates to the curvature of tal at rest, frontal smile, and to smiling at the equivalent of the maxillary occlusal plane profile at rest images. Although 30 frames per second. We typi- and the curvature of the lower these orientations provide an cally take five seconds of video lip on smile. If they are paral- adequate amount of diagnostic for each patient, yielding 150 lel, they are termed consonant; information, they do not con- frames for comparison. These and, if they are not, they are flat tain all the information needed clips allow us to visualize the or reverse. Buccal corridor refers for smile evaluation and quan- smile from beginning to end, to the “dark spaces” in the cor- tification. To treat the smile, we and to produce what I term the ners of the smile and is defined need to expand our records, smile curve (Fig 8). The smile as the space between the out- and we use computerized data- curve allows us to visualize the ermost dental component and basing of direct clinical exami- greatest number of frames that the inner commissure in the nation. appear to be the same, (i.e., the smile framework. Interestingly, sustained smile consistent with Records needed for contem- while these concepts are very definition of the posed smile). porary smile visualization and hot topics now, they originated quantification can be divided HF: All of our AACD members will in the early 1950s from Frush 2 into two groups: Static and dy- appreciate the importance of the and Fisher, both denture prost- namic. We recommend that in “smile curvature” and “buccal cor- hodontists. Their description addition to the accepted three ridor” in creating a fully displayed defined inappropriate denture facial image orientations, pho- smile. What are some of the impor- esthetics; in other words, a den- ture that does not look natural

The Journal of Cosmetic Dentistry 130 Fall 2007 • Volume 23 • Number 3 Sa r v e r /Fl a x 2008 Exc e ll c

Figure 9: This patient was nearing the end of orthodontic Figure 10: But recovery was possible, after reassessment treatment, and her smile arc was somewhat flattened as an and placement of brackets to increase incisor display and unfortunate result of orthodontic treatment. improvement of the consonance of the smile arc.

is characterized by a flat smile it turns out that several orth- DS: Well, abundant lip support is arch, or obliterated buccal cor- odontic studies indicate that, es- considered esthetically desir- ridors. sentially, the wider the better.5-7 able in today’s society, especial- In the past several years, we Now we are much more careful ly for females. You only have have seen two studies that re- in bracket placement so that to pick up a couple of fashion veal that in as many as one third smile arcs are not flattened, and magazines and look at the cov- of our cases, we are flattening we are selecting arch forms that er and advertisements to see smile arcs as part of orthodon- are broader. This broader arch that lip fullness is “in.” Long- 10,11 tic treatment.3,4 There are many form concept for esthetics is in term studies in orthodontics reasons for this, including skel- conflict with some other orth- have documented the general etal pattern, regimented bracket odontic goals; namely, stability principle of aging of the lips— placement, the focus on cuspid of result. Long-term research that there is loss in lip thick- guidance (resulting in incisor from the University of Wash- ness from age 14 onward—par- 8 intrusion when extruding cus- ington clearly shows that ca- ticularly more in the upper lip pids) and many other factors. nine expansion is an unstable than the lower lip. Therefore, If your readers are interested, movement (in any event, in- maintaining of or improving they may go to www.sarver- tercanine width diminishes as lip balance is part of our goal in ortho.com and download (in we get older). Therefore, expan- treatment planning. While in- the “Professional” section) the sion of the intercanine width is creasing lip support may seem article on smile arc and the im- discouraged. So how do we get to be only an orthodontic or portance of upper incisor posi- broader smiles for esthetic pur- surgical possibility, in reality, tion in the smile. An example poses, but also obey the stabil- how veneers are designed can 9 of an orthodontically flattened ity rules? Some limited studies also improve lip support. The smile arc is depicted in Figure 9. indicate that premolar expan- patient seen in Figure 11 is an In this case, we simply reset the sion is indeed stable, and when example. She asked what might maxillary and mandibular an- we want to improve the width be done to improve her smile. terior brackets more superiorly of the smile for esthetics, we try I explained that her problem to provide extrusion to the up- to expand premolar but not ex- was not an orthodontic one, per incisors and reestablish the pand the intercanine width. but one of dental attrition smile arc curvature (Fig 10). HF: Perioral soft tissues have a great (Fig 12); and that she needed her dentist’s help more than While Frush and Fisher2 de- impact on smile esthetics. Please mine. Noting that she had fairly scribed very broad arch forms explain your thoughts on how ag- thin lips, downturned commis- as being unesthetic in dentures, ing affects the lips and subsequent- ly the smile. sures, and lack of lip support,

The Journal of Cosmetic Dentistry Fall 2007 • Volume 23 • Number 3 131 Sa r v e r /Fl a x e ll nc Exc 2008

Figure 12: The root cause of her smile problem was one of severe dental attrition.

Figure 11: This patient presented for orthodontic smile improvement. Her smile was characterized by diminished incisor display, tooth shade issues, and loss of crown height.

her dentist proceeded to mini- Each individual has his or her attaining Class I cuspid rela- mally prepare his veneers. By own attractive attributes. What tionships solves the “problem.” adding incisor length he not looks good for one person may However, if we have not recog- only added support to the up- not look good on another; and, nized that the midface may be per lip, but also some eversion as clinicians we must be careful ideal and we are distorting the to the lower lip, improving lip not to force our own concepts midface to fit the occlusal goals, fullness. This patient’s final and “ideal” on our patients. we have adversely affected a smile is shown in Figure 13 and In medicine and in dentistry, positive attribute. In smile es- the increased lip support in Fig- we have been taught the “prob- thetics, a good example is the ure 14. lem-oriented” treatment-plan- orthodontic patient who has a HF: I love your idea that “rules” should ning model. In this scenario, moderately “gummy” smile. In not always be adhered to but, we identify all the problems opening a deep bite in these pa- rather, be interpreted as guidelines that the patient has and then tients, we may elect to intrude in treatment planning. Why is it execute a treatment plan to upper incisors to reduce gum- important to focus not just on the solve as many problems as pos- miness to the smile. However, if problems that our patient’s pres- sible. Where the hazards lie is the smile arc is consonant and ent to us, but also to preserve what in not recognizing the positive we intrude maxillary incisors, is right about someone’s appear- attributes a patient has, and in we unfortunately flatten the es- ance? adversely affecting them in the thetic smile arc. DS: The answer to this question re- pursuit of correcting the prob- HF: One of the exciting things that we ally revolves around our teach- lems. The classic orthodontic are doing at our Annual Scientific ing that dentistry is both art and example in is the patient with Session next May in New Orleans science. Rigid measurements as a Class II malocclusion because is bringing together the “Birming- “ideals” or “rules” simply are of a deficient mandible. If Class ham Team” of you, AACD mem- not applicable on the individu- I occlusion is the problem, ber Dr. Paul Koch, and plastic sur- al any more than rules exist on then extraction of maxillary geon Dr. Danny Rousso to show what makes a “good” painting. premolars and retraction of the the dynamics of interdisciplinary incisors to reduce overjet and

The Journal of Cosmetic Dentistry 132 Fall 2007 • Volume 23 • Number 3 Sa r v e r /Fl a x 2008 Exc e ll c

Figure 13: Restoration with veneers Figure 14: The length and soft tissue included appropriate crown thickness and support resulted in improved lip length resulting in more incisor display, support—a youthful enhancement of better tooth color, and a resting lip posture. consonant smile arc.

care at its finest. What are some of incisors also may be treatment Vestavia often return to Vesta- the secrets to your success? options. If the patient goes to via either to visit their parents, DS: We believe that this is a com- a facial plastic surgeon, the so- or to settle. Having been in monsense application of plan- lution is a new chin and nose, practice 28 years, I am, in many ning in a multidisciplinary because that is what the plastic families, treating the children environment—and we agree surgeon does. We all have to of children I treated years ago! that not one of us alone can recognize what benefits each These factors have allowed me provide the ultimate outcome patient the most and achieves to capture long-term (20 to 25 for our patient. All of us should their goals, not ours. years) records on a number of be educated in what the rest of HF: Your presentations are famous for my cases, and have allowed the team (including the perio- their dynamic and multimedia ap- me to study aging character- dontist and the oral and maxil- proach to showing how orthodon- istics firsthand (and learning lofacial surgeon) does, to avoid tics is extremely critical to devel- that decisions I made 25 years what I term diagnosis by proce- oping long-term beautiful smiles. ago may or may not have been dure. This can best be illustrated What do you have in store for the particularly advantageous to by the aforementioned patient AACD audience in New Orleans? my patient’s long-term appear- ance). I am fortunate that most who has Class II malocclusion DS: I have found that the best way (but not all) of my decisions with a mandibular deficient to teach the concepts of how were good. In any event, we use skeletal relationship and pro- our faces change longitudinally multimedia technology to cali- file. If the patient goes to the is through multimedia super- brate and overlay multiple im- oral and maxillofacial surgeon imposition of our images. I ages in a “morphing” pattern, first, then mandibular advance- practice in Vestavia Hills, Ala- which briefly demonstrates ment is recommended. If the bama, a suburb of Birmingham the principles we are trying to patient initiates the treatment (a medium-sized city), where teach. We all have seen time- with the orthodontist, then the population tends to be fair- lapse photographs of a rose mandibular advancement may ly stable. By that, I mean that blooming; it is far more inter- be recommended; or extraction many of the children raised in of premolars and retraction of esting to watch a child “bloom”

The Journal of Cosmetic Dentistry Fall 2007 • Volume 23 • Number 3 133 Sa r v e r /Fl a x in front of your eyes, and then enter into middle age. These images track how our patients change over the years; they are truly fascinating.

References e ll nc Exc 2008 1. Rubin, LR. The anatomy of a smile: Its im- portance in the treatment of facial paraly- sis. Plast Reconstr Surg 53:384-387, 1974. 2. Frush JO, Fisher RD. The dynesthetic in- terpretation of the dentogenic concept. J Prosthet Dent 8:558-581, 1958. 3. Hulsey CM. An esthetic evaluation of tooth- lip relationships present in then smile. Am J Othodon 57:132-144. 1970. 4. Ackerman J, Ackerman MB, Brensinger CM, Landis JR. A morphometric analysis of the posed smile. Clin Orthod Res 1:2-11, 1998. 5. Moore T, Southard KA, Casko JS, Qian F, Southard TE. Buccal corridors and smile esthetics. Am J Orthod Dentofacial Orthop 127(2):208-213, 2005. 6. Parekh S, Fields HW, Beck M, Rosenstiel S. Attractiveness of variations in the smile arc and buccal corridor space as judged by orthodontists and laymen. Angle Orthod 76(4):557-563, 2006. 7. Parekh S, Fields HW, Beck M, Rosenstiel S. The acceptability of variations in smile arc and buccal corridor space. Orthod Cranio- fac Res 10(1):15-21, 2007. 8. Little RM, Wallen TR, Riedel RA. Stability and relapse of mandibular anterior align- ment-first premolar extraction cases treat- ed by traditional edgewise orthodontics. Am J Orthod 80(4):349-365, 1981. 9. BeGole EA, Fox DL Sadowsky C. Analysis of change in arch form with premolar ex- pansion. Am J Orthod Dentofacial Orthop 113(3):307-315, 1998. 10. Vig RG, Brundo GC. Kinetics of anterior tooth display. J Prosthet Dent 39(5):502- 504, 1978. 11. Dickens S, Sarver DM, Proffit WR. The dy- namics of the maxillary incisor and the upper lip: A cross-sectional study of rest- ing and smile hard tissue characteristics. World J Orthod 3:313-320, 2002.

______v

The Journal of Cosmetic Dentistry 134 Fall 2007 • Volume 23 • Number 3