Something to Smile About
When I interviewed for admission to Baylor Dental College's orthodontic program nearly 25 years ago, Dr. Bob Gaylord, the department chairman, asked me why I wanted to be an orthodontist rather than remain a general dentist. I had thought about it and discussed it a great deal with my wife Lue, but you can't just scuttle seven years of general practice, a comfortable income, and a stable life without some misgivings.
I told Dr. Gaylord that I had finally realized that dental patients only appreciate two things that dentists do--improving appearance and relieving pain--and that most of what I was doing for patients accomplished neither. Patients would often tell me, "This tooth never hurt until you filled it (with silver amalgam). Now it hurts every time I drink something cold." And they were right. The cement bases we had were so weak, ineffective, or damaging that you were usually better off not using them. Thermal changes would continue to evoke strong reactions until a layer of secondary dentin was deposited against the pulp. Nor did I endear myself to patients with third molar surgery, periodontal therapy, or root canal fillings.
Regarding esthetics, there was little to offer patients. There were no composite bondings, no porcelain veneers, no Maryland bridges or translucent cast porcelain restorations. Essentially, if a porcelain jacket looked good, it was fragile; if it was bonded to gold for strength, it looked opaque and lifeless. A better product simply didn't exist--the restorations performed on most movie stars were just as lifeless as the ones I did.
If you really cared about improving dental appearance, orthodontics was almost the only refuge. And even orthodontists were limited in the improvement that proper alignment could achieve. Orthognathic surgery was limited to mandibular setbacks, because the sophisticated mandibular advancements, chin augmentations, and maxillary procedures that we routinely use today were just beginning in the '60s.
In the past, about the only esthetic augmentation in orthodontics was a cautious and conservative enamel reshaping of incisal edges. Now, with esthetic bonding, we can entirely reform teeth without compromising their pulpal health. Indeed, orthodontists can now draw from an eclectic combination of periodontal, restorative, and surgical procedures to augment orthodontic therapy. This is good news for both orthodontists and their patients; heretofore, we often had to leave our patients with less-than-ideal smiles because of limitations in materials as well as in other dental disciplines. But these improvements will go for naught if we don't appreciate and make use of the new array of esthetic aids.
I would encourage all orthodontists to expand their training extensively in bonding and porcelain restorations, surgical orthodontics, and modern periodontal therapy. Many orthodontists will never want to perform these procedures themselves, but increased familiarity can only benefit their patients and facilitate discussions with their patients' general dentists and specialists.
Because of limitations in esthetic techniques and the knowledge and skill to use them, dentists have tended to emphasize function over esthetics. This permitted dentists to dominate the doctor-patient relationship, since the layman knew little about how teeth were supposed to work. Unfortunately, many dentists have tried to extend this dominance into esthetics, relying on their own opinions rather than those of their patients. The most successful dentists, however, have been those who accept the patient as the final arbiter of personal esthetics. This partnership is a natural evolution that dentists should eagerly endorse, because modern society is convinced that well being, acceptance, and success are directly related to attractiveness. Beautiful smiles are no longer simply desirable options, but urgent needs that sometimes outweigh even health concerns.
I predict that this new emphasis on esthetics will result in a new public perception of dentists. This isn't to say that esthetics will now dominate to the exclusion of function. In fact, it has always seemed to me that when dental esthetics are really good--proper tip, torque, intercuspation, and so on--good function just naturally occurs. But I think in the near future, dentists who emphasize total esthetics will be perceived as true health professionals who can really deliver services the public wants and is willing to pay for. Who knows? Writers and producers like Alan Alda and Terry Louise Fisher might even begin to portray us in scripts as something other than one-dimensional boobs.
Orthodontists who continue to think of themselves as tooth straighteners amid this esthetic revolution are going to be as disadvantaged as the 1950s rail companies, which misconceived their mission as being in the railroad business rather than the business of transporting people and goods. The railroads have never regained markets lost to airlines and trucking companies, and probably never will.
Orthodontists with a limited view of their professional purpose will likewise wither. We are not in the braces business. We are in the smile business, and we had better know how to deliver those smiles to a more sophisticated, demanding, and expectant public.