Traveling over the last couple weeks I was able to indulge in my second favorite pastime – people watching. In doing so in Italy and especially in Croatia I was stuck repeatedly by interesting, beautiful and handsome people who shouldn’t be. They shouldn’t be because if an orthodontist was able to get a cephalometric radiograph on those individuals they would have told them they were broken and needed fixing… and believed it to be fact… and their assessment would have been supported by the vast majority of our orthodontic peers.

“But beautiful people are outliers” I can hear you saying. You might even quote Poe saying, “There is no exquisite beauty without strangeness of proportion” and this is true though it still belies the glaring weakness of our “standards”, our “method of assessment” and our attempts to define beauty. Even so, let’s run with this objection and talk about the middle of the Bell curve – the 80 percent of us who make up the vast majority of humans. No matter the genotype or the phenotype, most faces “just work” in spite of breaking the rules, averages, ranges, medians, and values we orthodontists try to impose. Not only do these faces work, they work well and people are able to function in society, find a mate and procreate even though much of this depends on having what others deem, at minimum, a “normal” face.
How can this be?
I would like to propose that in the absence of outright deformity, almost any recognizably human face will suffice and even thrive among similar or even superior peers. I would further propose that tooth alignment and straightness along with tooth color and shapeliness have far more to do with the public’s perception and rating of beauty than do any of the myriad of arbitrarily defined orthodontic measures (Angle classification, IMPA. E Line, Upper 1 to SN and the like). What’s that you say? These aren’t arbitrary numbers? They were defined through serious study and survey?
I’ll say it again. They. Are. Arbitrary. Period.
When you take the massive diversity that is humanity and try to boil it down to a few numbers based on the evaluation of one or even a few populations and then apply the result to ANY one individual, you are throwing dull darts in the dark. I know you disagree. You can rest assured that most orthodontists agree with you.
Seeing how you still don’t believe me, let’s try this. Put down your textbook, go to a place where people who don’t look like you are found and just sit and watch. Pick out every person you see with what you consider a terrible profile and watch them especially. Then have a look at people that others obviously consider attractive and look at their profile. If you perform this exercise with an open mind instead of with the purpose of defending your beliefs then our discussion should be over.
Fine. I get it. You still don’t buy what I’m selling… How about this? How do you think high angle, Class II parents view each other and view their high angle, Class II kids? Think about that and really step back and LOOK at the new patient in front of you next time before you open your mouth and dump all that nerd talk on someone who was perfectly happy before you told them they were broken. What’s the advantage of pointing out a supposed problem that is not life threatening, is not impeding function and even looks pretty good when judged by their peers to someone who came to you to get their teeth straight?
I can’t wait to hear your answers but just remember that “because it’s always been that way” is not a reason….

12 thoughts on “Our Obsession with Profiles is Unfounded

  1. Well said. But our “norms” still have tremendous value but should be thought of as a direction to treat TOWARDS, rather than the ideal end points for everyone.

    1. You can certainly look at it that way but it’s the same thing in my mind. If you’re trying to move towards something then you’ll be more successful the closer you get to that in your result. I think that’s an antiquated mindset given the massive changes in what is considered beautiful. However, the great thing about orthodontics is that we can all treat as we see fit and as long as your patients are happy then you’re right! Thanks for sharing your view.

  2. Ben, I could not agree with you more. Although frecuently, patients don’t understand how their teeth affect their facial aesthetics, for example, how an advancement of those retruded incisors could create more prominent lips, patients don’t see facial aesthetics, or care about it the way we do (as we I refer to “the blessed, the elite, the enlightened….the orthodontists”).
    But…I Ask you…don’t people have a right to know they’re ugly? And it’s our responsability, as orthodontists, to inform them accordingly. I guess not. I’ve never heard a plastic surgeon say “whoao that nose is hideous!”, to a lady who just wanted a little lipo.
    So maybe we’d be better off asking, like the afformentioned plastic surgeons, “what is it you don’t like about your appearance?” and work from there. And not by ruining a persons day saying “you’re hyperdivergent, retognathic, class II, decreased airway, with degerative joint disease, Williams Syndrome, long faced syndrome, mouth breather, and need surgery right away”, when all they wanted was to straighten there right central incisor that went astray when their wisdom teeth erupted (but that’s another can of worms).

    1. Ugly is a relative thing and so is beauty. Confidence level plays a TREMENDOUS role in both. I’m here to help people be the best they can be and I’ll use my judgement to help each individual maximally. There is no one answer and our ability to find the best course of action for each patient is what we get paid big bucks for. Thanks so much for posting. You’ve really added to the conversation by brining this aspect into play.

  3. Orthodontics for eons was based on a 2-D assessment based on early teachings of “acceptable”, using the available diagnostic methodologies and limitations of serial lateral cephalometric imaging to assess “changes” in the face due to treatment/growth etc. For many of us old dogs, we have been profile based for all the years we have been (or were) in practice.
    When one sits in on some facial assessment and aging courses given by MDs (dermatologists, plastics, ENT reconstructive surgeons, etc.) one sees now, a broader approach to facial aesthetics based on all of the components/dimensions of the face. They too have relied on profiles to start, but moved away from that sagittal view only a long time ago.
    Sagittal views were a good start, but now it is orthodontics turn to reduce all diagnosis and treatment planning from just one dimension and understand the face in all dimensions. Diversity of our patients now, new dimensions in imaging with photography and ionizing radiation (yes CBCT and the like) will continue to evolve and make the future even more interesting and exciting for those who are continual students, willing to learn and change. For 39 years, in this profession of orthodontics, I have seen some incredible changes. The future will be even more fun.

  4. This is the best thing you’ve written and perhaps the most important conversation you’ve started. It seems you’re implying that we shouldn’t discuss surgery if the patient doesn’t have those treatment goals.

    That would be a great freedom to the orthodontic community – too often I look at a 13 year old girl and her daddy who thinks she’s the most precious thing in the world and wonder what kind of damage I might do by implying to her pre-teen personality that she’s imperfect.

  5. Do you take cephs on every adolescent, cause I sure don’t unless my treatment really needs the information it provides, for the reason you touch on here. I look at the face and teeth after alignment and usually that tell the story.

  6. When I was doing my training I had an instructor tell me that I needed to extract in a case because the cephalometric numbers said so. I gave him a look and said lets see how we can treat the case non extraction. Recently I had a case that I knew I could treat non extraction and the parents were thrilled. I finished her with bimaxillary protrusion with out moving the incisors labially. I hated how the case looked… Mom and dad were very happy and both are bimax. It can be difficult not to be biased to our own sense of esthetic.

    1. EXACTLY. It’s not our face or our head. We are like waiters in a nice restaurant – we know what we like and we advise but we are not the ones paying the tab. Obviously we want to do no harm but I think orthodontists have misinterpreted that to mean “to do nothing we don’t agree with”.

      1. That is a great analogy, I’m gonna steal it! 😉 Thanks Ben!

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