Orthodontics about face: the re-emergence of the esthetic paradigm.

The emphasis and direction of orthodontic treatment planning philosophies over the past century is a story almost all orthodontists are familiar with. In the latter part of the 19th century, Norman Kingsley, the leading orthodontist of the era, emphasized the esthetic objectives of orthodontic treatment. In the Kingsley paradigm, the articulation of the teeth was clearly secondary to facial appearances. Exercising considerable intellectual influence in the early 20th century, Edward Angle’s emphasis on occlusion led him to teach that optimal facial esthetics always coincided with ideal occlusion and that esthetics could essentially be disregarded because it took care of itself. Later, both Tweed and Begg challenged Angle’s nonextraction philosophy partially on esthetic grounds. Throughout most of the 20th century, the idea persisted that occlusion was the primary objective of orthodontic treatment, with esthetics playing only a secondary role. Even when orthognathic surgery developed in the 1970s and growth modification treatment reappeared for children, the goal was to obtain better occlusion more than better facial proportions. In the 1980s, the introduction of new esthetic materials in restorative dentistry led to the widespread adoption of “esthetic dentistry.” At about the same time, it became clearer to all involved that orthognathic surgical goal setting was esthetically driven. Although ideal occlusion remained the primary functional goal, it was acknowledged that the esthetic outcome was critical for patient satisfaction. Esthetic considerations in the selection of other orthodontic treatment approaches—expansion versus extraction, camouflage versus correction of jaw relationships—began to receive the emphasis they deserve. For centuries, artists and physicians alike have tried to quantify the ideal proportions of the face. These attempts continue to this day, attractive to orthodontists because they provide guidelines for esthetics. One hundred years ago, Professor Wuerpel explained to Angle