CENTENNIAL SPECIAL ARTICLE

Interactions of hard tissues, soft tissues, and

growth over time, and their impact on
orthodontic diagnosis and treatment planning
David M. Sarver
Birmingham, Ala, and Chapel Hill, NC

The approach to orthodontic diagnosis has changed gradually but steadily over the past 2 decades. The shift
away from diagnosis based entirely on hard tissue evaluations has been a result of a broadened recognition
of the importance of facial and smile appearance to our patients, and how they change over time. The purpose
of this article is to describe and illustrate the integration of the new soft tissue paradigm into long-term treatment
planning, with a focus on the esthetic goals of treatment. (Am J Orthod Dentofacial Orthop 2015;148:380-6)

T
he changes in approach to orthodontic diagnosis
have been gradual but steady over the past 2 de-
cades. The shift from diagnosis based entirely on
hard tissue–based evaluations has been a result of a
broadened recognition of facial and smile appearance
by our patients, and thus by the orthodontic specialty.
The current popularity of the “selfie” illustrates this
point. Last year, I had the experience of riding a gondola
to the top of a Colorado mountain—a 30-minute trip. In
the gondola was a young lady whom I became fascinated
in watching because, from the bottom of the mountain
to the top, I counted that she took no less than 28 selfies!
Different poses, some smiling (smiles are important!),
some not (so is resting lip posture), but frontal pictures
nonetheless. She might have suffered from a slightly
excessive amount of narcissism, but many occupants
of this large gondola documented their experience in
similar fashion.
Orthodontics has evolved in many intellectual and
practical steps. What develops intellectually naturally is
Adjunct professor, Department of Orthodontics, University of Alabama, Birming-
ham, Ala; adjunct professor, Department of Orthodontics, University of North
Carolina, Chapel Hill, NC.
The author has completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: David M. Sarver, 1705 Vestavia Parkway, Vestavia
Hills, AL 35216; e-mail, sarverd@sarverortho.com.
Submitted, revised and accepted, April 2015.
0889-5406/$36.00
Copyright Ó 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.04.030
380
challenged, tested, and then eventually incorporated
into clinical practice as “what works.” Let's start with a
look at the evolution of hard tissue diagnosis and how
it became so centered in cephalometrics. Cephalometric
radiography was originally introduced to gain under-
standing of patterns of growth, development, and matu-
ration. By the 1950s and 1960s, the combination
naturally led to a focus on hard tissue elements and
treatment plans based on study models and “normative”
cephalometric measurements, and clinicians drifted
away from the clinical examination of patients.1 Evalu-
ation of the patient's soft tissues is now a critical step in
orthodontic treatment planning.2 In problem-oriented
treatment planning, the orthodontist identifies and
quantifies functional and esthetic abnormalities that
need correction or improvement.3 Further evolution of
the concept of problem-oriented diagnosis and treat-
ment planning should now entail identification of
both the normal and the positive elements of a patient's
appearance or smile that should be maintained or
enhanced. This is termed “problem- and goal-oriented
treatment planning” (Fig 1). When clinicians focus solely
on correcting the problems they see, they sometimes
overlook the patient's positive attributes and in doing
so run the risk of unfavorably affecting the patient's es-
thetics. The classic illustration concerns the Class II pa-
tient with a normal midface and a deficient mandible
treated with maxillary premolar extractions and maxil-
lary incisor retraction, resulting in flattening of the up-
per lip and an unflattering profile. In this approach to
Sarver
Fig 1. Problem- and goal-oriented treatment planning
has expanded problem-oriented treatment planning so
as not to overlook the patient's positive attributes and
run the risk of negatively affecting esthetics.
treatment, the problem was identified as a dental Class II
malocclusion, and the extraction sequence was quite
adequate to treat that problem. However, the facial
esthetic appearance was ignored and deleteriously
affected. In a more contemporary illustration, standard
approaches to orthodontic treatment result in flattening
the smile arc in about a third of patients, probably
because it was not a factor considered in the treatment
plan.4,5 During the clinical examination, we should
document not only problems but also the positive
elements that need protection. It is difficult to clearly
illustrate this approach to treatment verbally or in
writing only, so I have chosen to illustrate the
integration of the new soft tissue paradigm into long-
term treatment planning. The focus will be on the
esthetic goals of treatment.
If our only goal is a Class I occlusion, treatment can
often be efficient and even easy. On the other hand, pa-
tients and parents are inclined to focus primarily on the
enhancement of appearance. If our only goal is aimed at
the “social 6,” then this treatment can also be efficient
and even easy. Contemporary treatment, of course,
should have a broader scope, looking at both occlusion
and appearance. Attainment of both excellent occlusion
and excellent esthetics can indeed be quite difficult, but
with the patient's approval, it is the goal that we should
all strive to achieve. To treat only the occlusion treats
only half of the patient. If the same effort we have placed
almost entirely on occlusion for decades is now put into
enhancing appearance, we begin to be able to offer our
patients treatment that promotes well-being on many
levels, both functionally and esthetically. We will
emphasize in this paper the importance of the clinical
American Journal of Orthodontics and Dentofacial Orthopedics
381
examination of the soft and hard tissues, their resting
and dynamic (smiling) relationships, and the knowledge
of how they change over time.
At some point in my orthodontic experience, it began
to puzzle me that we would attempt to base our ortho-
dontic treatment on a 2-dimensional lateral headfilm,
taken in 1/60th of a second, and make the complex de-
cisions of orthodontic treatment that are expected to
endure decades of change. As a result of his research
into craniofacial development, AJO-DO Editor-in-
Chief Dr Rolf Behrents6 stated that “It is clear [that]
the ability of cells, tissues, and organs to produce change
in the craniofacial complex ceases perhaps only at death
and not at some developmental event along the way.”
This is the world of the contemporary orthodontist,
dealing with a continuously changing substrate in
both the adolescent and the adult, thinking far in
advance of the outcome.
SYSTEMATIC EVALUATION AND TREATMENT
GOAL SETTING
Soft tissue changes occur over time, and it is usually
the orthodontist who best understands the comprehen-
sive principles of dental and skeletal development,
maturation, and aging in addition to the many other
facets of dental practice.
The 12-year-old girl in Figures 2 and 3 came with a
chief complaint of “the dentist said I needed braces”
because of her Class II deepbite malocclusion.
Although correction of her malocclusion was the
reason for seeking treatment, she obviously exhibited
an excessive amount of gingivae on smiling, and this
was thoroughly discussed with her parents as an
esthetic objective of treatment. Gummy smiles like this
patient's often have multifactorial etiologies, and
diagnosis is often dictated by the background of the
person making the diagnosis—“diagnosis by procedure.”
Let me illustrate with this patient. If she was initially
seen by an oral surgeon, the recommendation might lean
toward surgery and maxillary impaction when of age; if
she was seen initially by a periodontist, crown length-
ening likely would be the treatment of choice; and if a
cosmetic dentist was consulted, crown lengthening
with the possibility of porcelain veneers would most
likely be recommended. The purpose of this article is
to illustrate a more globally oriented diagnostic regimen
that requires a thorough knowledge of both craniofacial
and soft tissue changes to better equip the diagnostician
to direct appropriate treatment. This comprehensive
knowledge is essential in a global diagnostic approach
that includes both the functional and esthetic demands
of today's orthodontic environment. In our diagnostic
September 2015  Vol 148  Issue 3
382 Sarver

Fig 2. This 12-year-old girl has a convex profile and moderate mandibular deficiency, the etiology for
her Class II malocclusion. She has a slightly short lower facial height and significant lip incompetence.
When smiling, she demonstrated excessive gingival display.

4. Hypermobile smile: elevation of the upper lip on

Fig 3. Her original malocclusion was a Class II deepbite.
regimen, we have carefully attempted to document all
possible etiologies of, for example in this case, the exces-
sive gingival display on smile.7 These include the
following.
1. Vertical maxillary excess: the clinical characteristics
include excessive incisor display at rest, lips apart
posture, lip strain, and excessive lower facial height.
2. Short crown height: short crown height has 2 basic
etiologies—gingival encroachment and incisor attri-
tion. Gingival encroachment in an adolescent can
include delayed active eruption or delayed passive
eruption, and in both an adult and an adolescent,
gingival hypertrophy.
3. Short philtrum height: depending on the patient's
age, the ideal philtrum position is 2 to 3 mm shorter
than the commissure height. As we will demonstrate
later, this is highly variable with age.
smiling varies between persons. How do we tell
when someone has a hypermobile smile? Empiri-
cally, if the patient does not have an excessive
incisor display at rest and has normal crown height
and facial height, then excessive gingival display
would be attributable to excessive elevation of the
upper lip on smiling. Recent studies have demon-
strated that the average upper lip elevation is
around 23% of its resting length.8
5. Retroclined or supererupted maxillary incisors:
these are most often seen with dentoalveolar
compensation for a Class II skeletal relationship.
The patient's initial referral was prompted by the
dentist's suggestion that an orthodontic consultation
was indicated because of her Class II deepbite—the func-
tional reason for orthodontic treatment. Her esthetic
evaluation began with the global approach of macro-,
mini-, and microesthetic evaluations; we start from the
outside in.9 This must be done in order, and the reason
will be illustrated later. With her lips in repose and
then in smiling, the systematic clinical examination for
this patient was quantified as follows.
Macro-esthetic evaluation
1. Short lower facial height. Having thirds of equal
height is typically accepted as the most desirable
vertical facial proportionality. However, an impor-
tant key for orthodontists is the lower facial third,
because this is the area over which we have the
most influence and control.
2. Lip incompetence of 5 mm.

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Sarver
Fig 4. With lips in repose, the philtrum was 15 mm, much
shorter than the commissure, with all of the maxillary inci-
sors displayed at rest.
Fig 5. On smiling, she displayed a crown height of 8 mm
(a problem), a gingival display of 7 mm (a problem), and a
consonant smile arc (desirable, to be protected).
3. Convex profile with mandibular deficiency. It is the
etiology of the Class II malocclusion.
Mini-esthetic examination (Figs 4 and 5)
1. Philtrum height of 15 mm. The philtrum height is
measured in millimeters from subspinale (the base
of the nose at the midline) to the most inferior
portion of the upper lip on the midline. The abso-
lute linear measurement is not particularly impor-
tant, but what is significant is its relationship to
the maxillary incisor and the commissures of the
mouth. This relationship changes significantly
over time. In an adolescent, it is common to find
the philtrum height to be shorter than the commis-
sure height. This difference can be explained by
the differential and vertical lip growth over the
American Journal of Orthodontics and Dentofacial Orthopedics
383
Fig 6. With age, the philtrum height increases at a greater
rate than does commissure height, resulting in a flatter
and thinner upper vermilion.
Fig 7. The increase in upper lip length also contributes to
the decreased incisor display at rest.
long term10 (Fig 6), because over the patient's life-
time, the philtrum's vertical length increases at a
greater rate than the commissure, contributing to
the flattening and aging of the upper lip in repose
and contributing to decreased incisor display at
rest (Fig 7) and decreased gingival display on smil-
ing (Fig 8).
2. Maxillary incisor display of 8 mm at rest (Fig 4).
3. Maxillary central incisor display of 8 mm (100%) on
smiling (Fig 4).
4. Gingival display of 7 mm on smiling (Fig 5).
5. Retroclined maxillary incisors in compensation for
the mandibular deficiency.
6. A consonant smile arc (Fig 5).
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Fig 8. The increased upper lip length also contributes to
the decreased gingival display on smiling.
Micro-esthetic examination
1. Crown height of 8 mm. The expected crown height
at her age should be about 9 mm, normally
maturing to an average of 10.5 mm at the comple-
tion of active and passive eruption (Fig 9).11
2. Incomplete eruption or passive eruption.
3. A thick periodontal phenotype.
TREATMENT PLAN
In addition to correction of the functional issues of
the Class II deepbite, the esthetic treatment plan is deter-
mined by esthetic issues (primarily the excessive gingival
display on smiling) coordinated with the protection
strategy (maintain the consonant smile arc).
Let's revisit the etiologies of the gummy smile in
comparison with this patient's clinical examination.
This problem-oriented and goal-oriented approach to
the esthetic problems results in the clinical examination
and a biometric documentation to help determine our
treatment plan. The etiologies of the gummy smile are
the following.
1. Vertical maxillary excess. Our patient did have the
clinical characteristics of excess incisor display at
rest and lip incompetence but did not have a long
lower facial height. Therefore, vertical maxillary
excess can be eliminated as an etiology. To intrude
the mandibular incisors does not affect the facial
height, and to intrude the maxillary incisors may
reduce the gingival display but will flatten her smile
arc. Logically, since the face is short, the deepbite
should be opened through posterior extrusion to in-
crease the lower facial height.
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Sarver
Fig 9. Incisor crown height increases dramatically during
adolescence and tapers off in later years.
2. Short philtrum in relation to commissure height. Her
philtrum height of 15 mm was short compared with
the 22-mm commissure height; thus, it shows up on
our macro-esthetic problem list.
3. Excessive smile curtain. Since her smile curtain was
not significantly in excess of 23%, hypermobility of
the lip is eliminated from the potential etiologies.
4. Upright maxillary incisors. Her maxillary incisors
were upright in compensation for her mandibular
deficiency, thus resulting in an increase in gingival
display. We planned to use high-pull headgear for
anteroposterior growth modification as well as
vertical forces to aid in reduction of the gummy
smile.
5. Short crown height. We measured her incisor crown
height at 8 mm. The expected crown height at her
age should be about 9 mm. In her case, crown height
might improve with the continuation of passive
eruption, but crown lengthening might be recom-
mended if needed at the appropriate time.
At first blush, an orthodontist might naturally
consider opening the deep overbite through maxillary
incisor intrusion to decrease the gumminess of the smile.
But in our clinical examination, we noted that the pa-
tient had a consonant smile arc, an ideal feature that
we assiduously wish to avoid altering. The short philtrum
would be expected to contribute to an increased gingival
display on smiling, but as we have seen previously in this
article, the philtrum increases in length consistently over
time. This change is reflected in a reduced incisor display
at rest and a reduction in gingival display on smiling. We
expect less gingival display as the patient matures, so or-
thodontic treatment was directed to upright the maxil-
lary incisors and reevaluate crown height at an
Sarver
Fig 10. Posttreatment photographs with lips in repose,
reflecting the change in philtrum height and reduced lip
incompetence, and with a full-face smile.
Fig 11. The final close-up smile image.
appropriate time in her treatment. Over the 2-year treat-
ment time, the expected upper lip changes were occur-
ring, but the crown height remained a problem. In the
final stages of treatment, we referred her to a periodon-
tist, who determined that she had incomplete active
eruption, and crown lengthening was performed with
osseous and soft tissue surgery. Orthodontic treatment
was finished to an excellent esthetic and functional
outcome.
TREATMENT SUMMARY
Our treatment consisted of fixed appliance therapy
combined with growth modification (high-pull head-
gear) to correct the Class II malocclusion. The deep over-
bite was approached with reverse-curve mandibular
archwires to extrude the posterior teeth, thus length-
ening the lower facial height. The improvement in
gingival display on smiling was a result of lip growth,
increased crown height supplemented with periodontal
crown lengthening, and axial uprighting of the maxillary
incisors (Figs 10-12).
American Journal of Orthodontics and Dentofacial Orthopedics
385
Fig 12. Seven years after completion of treatment.
CONCLUSIONS
There are really 2 major points to be made here. First
is the importance of looking at the patient clinically at
the beginning of developing our diagnosis and treat-
ment plan. In fact, this assessment has been practiced
for quite a long time; clinicians have drifted back to it
in practice, and it has just slowly formalized. As a resi-
dent, I remember that many of my teachers referred to
the “window-shade diagnosis,” the act of holding an
actual cephalometric head film (not digital), untraced,
up to the window to eyeball the dentoskeletal relation-
ships. Using a systematic approach to the clinical assess-
ment, we have quantified many aspects of the initial
examination. As a result, we are able to establish data
on soft tissue maturation and aging in the perioral
area and how it significantly influences our treatment
planning. The idea of soft tissue–based treatment plan-
ning has become an important part of teaching and clin-
ical practice. So, the second point is that it is not just the
finish that is important, but also what is appropriate for
the patient's age and for achieving and maintaining it
for as long as possible. The concepts and data we have
presented will serve the practitioner for the wide variety
of patients seen in contemporary practice.
REFERENCES
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2. Proffit WR, Fields HW, Sarver DM. Contemporary orthodontics. St
Louis: Mosby Elsevier; 2012.
3. Ackerman JL, Proffit WR. The characteristics of malocclusion: a
modern approach to classification and diagnosis. Am J Orthod
1969;56:443-54.
4. Hulsey CM. An esthetic evaluation of lip-teeth relationships pre-
sent in the smile. Am J Orthod 1970;57:132-44.
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5. Ackerman JL, Ackerman MB, Brensinger CM, Landis JR. A
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