Orthodontic diagnosis and treatment planning for braces is in a period of remarkable change, away from a previous focus on dental occlusion and hard tissue relationships and toward a great emphasis on soft tissue adaptation and proportions. Perhaps one say that the twentieth century was dominated by the Angle paradigm, in which the primary goal of orthodontic treatment was the dental occlusion and the secondary goal was skeletal jaw relationships. In that view, the soft tissues were expected to more or less take care of themselves. If the hard tissues were correct, then the soft tissues also were presumed to be correct. Unfortunately, this is not necessarily the case, especially when the teeth are displaced to achieve a good occlusion despite a jaw discrepancy. Not only parents and patients, but also orthodontists who are more and more aware of cosmetic dentistry, now notice and disapprove of the esthetic liability and know that treatment success in orthodontics must be judged by more than the dental occlusion.
The transition now is toward what is called the soft paradigm, in which the primary goal of braces treatment is to obtain the best possible adaptation and proportions of the soft tissues of the face and mouth, and the secondary goal braces treatment is functional dental occlusion. The modern view acknowledges the limitations on orthodontic treatment created by the soft tissues. For example, the position of the teeth must be established with periodontal health in mind, which places significant limitations on the amount of arch expansion, and tongue versus lip/ cheek pressures determine the possibilities for dental arch form. The concept of functional occlusion reflects a greater awareness that the teeth are rarely in contact during mastication and that one of the goals of the treatment that orthodontic patients will injure themselves during bruxism.
The modern view also explicitly acknowledges the reality that the major goal of orthodontic treatment for the greater majority of patients is improvement of dental and facial esthetics. This goal is not “just cosmetics”. It reflects the patient’s desire to improve their social acceptability and eliminate discrimination based on appearance, which can affect their quality of life greatly. Until recently, orthodontists considered the relationship of the teeth to the facial skeleton and the relationship of the jaws to each other primarily in the context of angular and dimensional measurements.
