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Interview

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

D. Sarver, D.M.D. Hugh Flax, DDS


Vestavia Hills, AL Atlanta, GA
www.sarverortho.com www.flaxdental.com

The goal of this section is to provide insights into the thoughts and perspectives of some of
dentistrys premier educators. In this issue, AACD Conference Advisory Co-Chair Dr.
Hugh Flax (HF) interviews Dr. David Sarver (DS). Dr. Sarver is scheduled to present at
the AACDs 24th Annual Scientific Session in New Orleans in May 2008. For more in-
formation on AACDs conference, log onto www.aacd.com

Reprinted with permission, The Journal of Cosmetic Dentistry, 2008 American Academy of Cos-
Received: 28 September 2006 metic Dentistry, All Rights Reserved. Telephone 608/222-8583; Fax 608/222-9540; www.aacd.com
Accepted: 24 January 2007 Journal of Dentistry, Tehran University of Medical Sciences, Tehran, Iran (2007; Vol: 4, No.3)

HF: David, its exciting to have you on our same principles of esthetic dentistry are
program for the AACDs 2008 Annual applied to my orthodontic cases to further
Scientific Session. When Ive heard you enhance my outcomes. I have long had
lecture, its impressive how you see the an interest in the aging process on the
big picture of creating and maintaining a face and how important it is for us to un-
beautiful smile not only at the completion derstand how this has an impact on our
of treatment, but also throughout the ag- orthodontic decisions. As orthodontists,
ing process. While viewing the art of the we often are the first line in to make de-
smile, what must an esthetic orthodon- cisions that can affect a childs facial ap-
tist be doing? pearance for his or her lifetime. This can
DS: Thank you, Hugh. Its exciting for me be positive or it can be negative. The
also, because of the opportunity we have reduction in extraction rates in orthodon-
to contribute to the cross-fertilization tic cases can, in large part, be attributed
of knowledge and technique between all to the recognition that loss of lip and fa-
aspects of dentistry. Even though Im an cial soft tissue support is a normal aging
orthodontist, I have really focused in the process. The transition to orthodontic
past several years on the remarkable pro- thinking is pretty simple: Reduction in
gress made recently in cosmetic dentistry dental volume in some facial types re-
and how we can not only collaborate in sults in less lip and soft tissue support,
interdisciplinary care, but how the very thus accelerating the aging characteristics

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Fig 1. This young patient was first seen for treatment of the maxillary midline diastema. Her clinical exam demon-
strated a flat smile arc with inadequate incisor display on smile (A). In addition to closing the diastema, the plan was
directed to increase anterior tooth display. The resulting smile display was much more youthful in appearance (B).
The smile 10 years after completion of treatment (C).

of the face and perioral apparatus. How- of how the smile ages and to place the
ever, a word of cautionanything can be teeth in the smile framework to account
overdone and overexpansion is not rec- for this characteristic. Lets use an actual
ommended. patient as an example. The patient shown
As far as the smile is concerned, substan- in Fig 1A was brought in by her parents
tial data indicate that incisor display di- for treatment of what was obvious to
minishes with age. For the orthodontist, themthe maxillary midline diastema.
that means that smile evaluation must in- These parents (and many other parents of
clude the measurement of both maxillary adolescents) are aware of what their own
incisors displayed at rest and how much orthodontic experiences were like, and
on smile. This gives us at least a start in think only about crooked teeth. On
gauging where our patients smile is on clinical examination, we noted that the
the age scale. Think about this: When we patient showed about 3 mm of upper in-
look at texts in plastic surgery, orthodon- cisor at rest (5 to 6 mm is desirable in
tics, and cosmetic dentistry, the facial that age group) and 8 mm of upper inci-
and ideal smile illustration is usually a sor display on smile. Crown height was
25-year-old female. In reality, most of 10 mm. We differentially placed her
our orthodontic patients are 10 to 14 brackets and adjusted the mechanics in
years old. Simply put, when I finish such a way that the upper incisors were
treatment on a 14-year-old, I want the brought down and the anterior maxilla
child to look like a 14-year-old, not like a was encouraged to develop more verti-
25-year-old. If they look 25 when I finish cally. The resulting smile display was
their orthodontic treatment at age 14, much more appropriately youthful in ap-
then when they are 25 their smile will pearance (Fig 1B). A photograph of the
look 35! In other words, what the appli- patient 10 years later (Fig 1C) demon-
ance should be doing is to be cognizant strates how this expansion of orthodontic

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DS: The standard record of three facial photo-


graphs and six intraorals is still pretty
much the gold standard, but we supple-
ment those records with images of the
close-up smile, oblique facial and oblique
smile. We augment intraoral pictures
with what are fairly standard cosmetic
dental imagesthe anterior teeth with a
black background to highlight contacts,
connectors, embrasures, halos, etc. The
major change in our orthodontic records
is not only the addition of some images,
Fig 2. Computer databasing programs facilitate the but that we also teach the use of what we
clinical examination and store the information we term biometric measurement (which sim-
measured in a retrievable and systematically usable for- ply means direct measurement of the
mat.
resting and dynamic relationships of hard
vision has contributed to the beauty of to soft tissue). The measurement of upper
her facial and smile appearance into incisor at rest and on smile is a perfect
adulthood. example. This is information not avail-
HF: Why hasnt contemporary orthodontics able from models, cephalometric meas-
kept pace with this concept? urements, or photographs. We have also
DS: That is an interesting question. I have had developed computer database programs
the privilege of coauthoring with Bill that greatly facilitate the clinical exami-
Proffit his classic orthodontic text, "Con- nation and store the information we
temporary Orthodontics". This text is measure in a retrievable and systemati-
considered the standard in orthodontics cally usable format (Fig 2).
and, in the latest edition; we have placed HF: What are the differences in smile styles
great emphasis on the issues we have just that patients exhibit, and why it is impor-
discussed. However, you and I both tant during treatment to be able to view a
know that textbooks tend to be read by repeatable smile?
students who have to read them; and that DS: The stages of the smile are made up of
most practicing clinicians are not likely several components: (1) the smile is initi-
to read any textbook from cover to cover. ated by muscle bundles originating from
So, in my mind, contemporary orthodon- the dense fascia of the nasolabial fold; (2)
tics is certainly on pace with smile con- this upward movement is then combined
cepts, but knowledge disseminates at with the elevator muscles and; (3) when
varying rates into our profession just as it these contracts, the upper lip is pulled
does in all areas of dentistry. upward and backward towards the na-
HF: Orthodontists tend to have a fairly stan- solabial fold. The term smile style was
dard set of records, which take into ac- first coined by the plastic surgeon L.R.
count many static relationships of hard Rubin in 1974, who defined three types
tissues. Please share with us what you be- of smile styles [1].
lieve should be the new standard of Commissure smile. In this, the corners of
documentation and treatment planning in the mouth turn upward due to the pull of
orthodontics. the zygomaticus major muscles. This is

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Fig 3. The short philtrum exhibited in this patient is a vexing problem in treatment planning. It represents an esthetic
issue both at rest and on smile (A). The V-Y cheiloplasty goes beyond the alar cinch by the use of vertical orienta-
tion of the incisions and closure, lengthening the resting length and demobilizing the upper lip (B). The final resting
relationship of the upper lip demonstrates an improved Cupids bow, lip competence, and longer philtrum (C).

also referred to as the Mona Lisa smile. short lip, and to demobilize the smile
Cuspid smile. In this smile, the upper lip with a natural appearance. In V-Y
is elevated uniformly so that the corners cheiloplasty, an incision is made in the
of the mouth turn upward at the same time anterior maxilla in the vestibule, with a
(i.e., the entire lip rises like a window vertical incision behind the philtrum.
shade). Mattress sutures are then used to close
Complex smile. Here, the upper lip moves these incisions, resulting in a vertical scar
superiorly as in the cuspid smile, but the closure, and reorientation of the muscles
lower lip also moves inferiorly in similar to reduce the mobility of the upper lip on
fashion. This is termed the starburst smile (Fig 3). The complex smile means
smile. that the lower incisors are going to be on
The smile style is important because of display more than in the other two smile
the difference in how much the upper and types. For the orthodontist, this means
lower dentitions are demonstrated upon that the lower incisors hold as much im-
smiling. For example, the commissure portance as the maxillary incisors. In the
smile may show more tooth posteriorly veneer case, the shade differential from
than anteriorly; and, in the orthodontic the maxillary teeth to the mandibular in-
case, may require some incisor extrusion; cisors may be so great that the lower in-
and, in the restorative case, may allow cisors are also indicated for restoration.
some leeway as far as gingival margin The importance of the repeatable smile is
placement. The cuspid smile tends to be very much like centric relation and cen-
associated more with excessive gingival tric occlusion. In the treatment of the
display, and also is associated with hy- smile, we recommend a consistent
permobile lip, which can be affected evaluation. There are two defined types
through plastic surgery techniques, spe- of smiles: The unposed (spontaneous)
cifically the V-Y cheiloplasty. We utilize smile and the posed smile. The unposed
the V-Y cheiloplasty to lengthen the smile is involuntary and reflects emotion.

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Fig 4. Utilizing digital video clips with segmentation of the flow of images results in
a smile curve that helps us determine the repeatable and mostconsistent smile.

Lip elevation in the unposed smile often cords needed for contemporary smile
is more animated, as seen in the laughing visualization and quantification can be
smile, for example. The posed smile is a divided into two groups: Static and dy-
learned smile, with lip animation being namic. We recommend that in addition to
fairly reproducible, similar to the smile the accepted three facial image orienta-
that may be rehearsed for photographs or tions, photograph recordings should also
school pictures. include profile, oblique, and frontal
The posed smile, because of its repeat- close-up smiles. We have also been util-
ability, is considered the treatment izing dynamic recordings of smiles and
smile. speech with digital videography. Digital
In clinical practice, standard records in- video and computer technology enables
clude film or digital photographs, radio- us to record anterior tooth display during
graphs, and study models (mounted or speech to smiling at the equivalent of 30
unmounted plaster or electronic models). frames per second. We typically take five
Universal standard facial images consist seconds of video for each patient, yield-
of the frontal at rest, frontal smile, and ing 150 frames for comparison. These
profile at rest images. Although these clips allow us to visualize the smile from
orientations provide an adequate amount beginning to end, and to produce what I
of diagnostic information, they do not term the smile curve (Fig 4). The smile
contain all the information needed for curve allows us to visualize the greatest
smile evaluation and quantification. To number of frames that appear to be the
treat the smile, we need to expand our re- same, (i.e., the sustained smile consistent
cords, and we use computerized databas- with definition of the posed smile).
ing of direct clinical examination. Re- HF: All of our AACD members will appreciate

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Fig 5. This patient was nearing the end of orthodontic treatment, and her smile arc was somewhat flattened as an
unfortunate result of that treatment (A). But recovery was possible, after reassessment and placement of brackets to
increase incisor display and improvement of the consonance of the smile arc (B).

the importance of the smile curvature regimented bracket placement, the focus
and buccal corridor in creating a fully on cuspid guidance (resulting in incisor
displayed smile. What are some of the intrusion when extruding cuspids) and
important dimensional considerations many other factors. If your readers are in-
needed to create an ideal smile? terested, they may go to www.sar-
DS: The concepts of smile curvature and verortho.com and download (in the Pro-
buccal corridor are smile attributes that fessional section) the article on smile
have been around for quite some time. arc and the importance of upper incisor
Smile curvature (in orthodontics, we term position in the smile. An example of an
this the smile arc) relates to the curvature orthodontically flattened smile arc is de-
of the maxillary occlusal plane and the picted in Fig 5A. In this case, we simply
curvature of the lower lip on smile. If reset the maxillary and mandibular ante-
they are parallel, they are termed conso- rior brackets more superiorly to provide
nant; and, if they are not, they are flat or extrusion to the upper incisors and rees-
reverse. Buccal corridor refers to the tablish the smile arc curvature (Fig 5B).
dark spaces in the corners of the smile While Frush and Fisher [2] described
and is defined as the space between the very broad arch forms as being unesthetic
outermost dental component and the in- in dentures, it turns out that several or-
ner commissure in the smile framework. thodontic studies indicate that, essen-
Interestingly, while these concepts are tially, the wider the better [5-7]. Now we
very hot topics now, they originated in are much more careful in bracket place-
the early 1950s from Frush and Fisher [2] ment so that smile arcs are not flattened,
both denture prosthodontists. Their de- and we are selecting arch forms that are
scription defined inappropriate denture broader. This broader arch form concept
esthetics; in other words, a denture that for esthetics is in conflict with some
does not look natural is characterized by other orthodontic goals; namely, stability
a flat smile arch, or obliterated buccal of result. Long-term research from the
corridors. In the past several years, we University of Washington [8] clearly
have seen two studies that reveal that in shows that canine expansion is an unsta-
as many as one-third of our cases, we are ble movement (in any event, intercanine
flattening smile arcs as part of orthodon- width diminishes as we get older). There-
tic treatment [3,4]. There are many rea- fore, expansion of the intercanine width
sons for this, including skeletal pattern, is discouraged. So how do we get broader

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Fig 6. This patient presented for orthodontic smile improvement.


Her smile (A). The root cause of her smile problem was one of
severe dental attrition (B).

smiles for esthetic purposes, but also explained that her problem was not an or-
obey the stability rules? Some limited thodontic one, but one of dental attrition
studies [9] indicate that premolars expan- (Fig 6B); and that she needed her den-
sion is indeed stable, and when we want tists help more than mine. Noting that
to improve the width of the smile for es- she had fairly thin lips, downturned
thetics, we try to expand premolars but commissures, and lack of lip support, her
not expand the intercanine width. dentist proceeded to minimally prepare
HF: Perioral soft tissues have a great impact his veneers. By adding incisor length he
on smile esthetics. Please explain your not only added support to the upper lip,
thoughts on how aging affects the lips but also some eversion to the lower lip,
and, subsequently, the smile. improving lip fullness. This patients fi-
DS: Well, abundant lip support is considered nal smile is shown in Fig 7A and the in-
esthetically desirable in todays society, creased lip support in Fig 7B.
especially for females. You only have to HF: I love your idea that rules should not
pick up a couple of fashion magazines always be adhered to but, rather, be in-
and look at the cover and advertisements terpreted as guidelines in treatment
to see that lip fullness is in. Long term planning. Why is it important to focus not
studies in orthodontics [10,11] have just on the problems that our patients
documented the general principle of ag- present to us, but also to preserve what is
ing of the lipsthat there is loss in lip right about someones appearance?
thickness from age 14 onward DS: The answer to this question really re-
particularly more in the upper lip than the volves around our teaching that dentistry
lower lip. Therefore, maintaining of or is both art and science. Rigid measure-
improving lip balance is part of our goal ments as ideals or rules simply are
in treatment planning. While increasing not applicable on the individual any more
lip support may seem to be only an or- than rules exist on what makes a good
thodontic or surgical possibility, in real- painting. Each individual has his or her
ity, how veneers are designed can also own attractive attributes. What looks
improve lip support. The patient seen in good for one person may not look good
Fig 6A is an example. She asked what on another; and, as clinicians we must be
might be done to improve her smile. I careful not to force our own concepts and

2007; Vol. 4, No. 3 145


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Fig 7. Restoration with veneers included appropriate


crown thickness and length resulting in more incisor
display, better tooth color, and a consonant smile arc
(A). The length and soft tissue support resulted in im-
proved lip supporta youthful enhancement of resting
lip posture (B).

ideal on our patients. In medicine and sors, we unfortunately flatten the esthetic
in dentistry, we have been taught the smile arc.
problem oriented treatment-planning HF: One of the exciting things that we are do-
model. In this scenario, we identify all ing at our Annual Scientific Session next
the problems that the patient has and then May in New Orleans is bringing together
execute a treatment plan to solve as many the Birmingham Team of you, AACD
problems as possible. Where the hazards member Dr. Paul Koch, and plastic sur-
lie is in not recognizing the positive at- geon Dr. Danny Rousso to show the dy-
tributes a patient has, and in adversely af- namics of interdisciplinary care at its
fecting them in the pursuit of correcting finest. What are some of the secrets to
the problems. The classic orthodontic ex- your success?
ample is the patient with a Class II mal- DS: We believe that this is a common sense
occlusion because of a deficient mandi- application of planning in a multidisci-
ble. If Class I occlusion is the problem, plinary environmentand we agree that
then extraction of maxillary premolars not one of us alone can provide the ulti-
and retraction of the incisors to reduce mate outcome for our patient. All of us
overjet and attain Class I cuspid relation- should be educated in what the rest of the
ships solves the problem. However, if team (including the periodontist and the
we have not recognized that the midface oral and maxillofacial surgeon) does, to
may be ideal and we are distorting the avoid what I term diagnosis by proce-
midface to fit the occlusal goals, we have dure. This can best be illustrated by the
adversely affected a positive attribute. In aforementioned patient who has Class II
smile esthetics, a good example is the or- malocclusion with a mandibular deficient
thodontic patient who has a moderately skeletal relationship and profile. If the
gummy smile. In opening a deep bite patient goes to the oral and maxillofacial
in these patients, we may elect to intrude surgeon first, then mandibular advance-
upper incisors to reduce gumminess to ment is recommended. If the patient initi-
the smile. However, if the smile arc is ates the treatment with the orthodontist,
consonant and we intrude maxillary inci- then mandibular advancement may be

146 2007; Vol. 4, No. 3


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recommended; or extraction of premolars These images track how our patients


and retraction of incisors also may be change over the years; they are truly fas-
treatment options. If the patient goes to a cinating.
facial plastic surgeon, the solution is a
new chin and nose, because that is what REFERENCES
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