​

Most dentists are trapped in tooth-centric thinking—a myopic perspective that dooms their cases before they begin.

They start with what’s broken. They focus on what needs fixing. They plan from pathology instead of possibility. And in doing so, they miss the fundamental truth that master clinicians have always understood: Teeth don’t exist in isolation. They exist within a complex biological, functional, and aesthetic system that begins with the face.

In our previous exploration of The Paradigm Shift: The Treatment Planning Philosophy That Guarantees Success, we established how elite dentists think in systems rather than symptoms. Now, we dive deeper into the application of that principle through what I call “Face-First Planning”—the interdisciplinary approach that transforms treatment outcomes by reversing traditional diagnostic sequences.

This isn’t theoretical. When you begin with facial integration and work inward—rather than starting with teeth and working outward—everything changes. Diagnosis becomes clearer. Treatment becomes more predictable. Results become extraordinary rather than merely adequate.

The difference is perspective. And perspective, more than technique, determines success.

The Facial Framework: Starting Where Biology Intended

Reversing Traditional Diagnostic Sequences

The conventional approach to treatment planning follows a fundamentally flawed sequence—it begins with teeth and works outward. This inside-out approach violates every principle of biological development, where the face forms first, then the jaws, then the occlusion, and finally the teeth.

Master clinicians flip this sequence entirely, creating what I call the “Biological Sequence Protocol”—starting with the face and working inward. This approach mirrors how nature builds a human, addressing root causes rather than symptoms.

Think of it like building a house. The traditional approach is like choosing the furniture before designing the rooms, then figuring out the floor plan, and finally considering the foundation. A master builder would never approach construction this way—they’d start with the foundation, then frame the structure, then design the interior spaces, and only then select the finishes.

Dentistry deserves no less logical an approach. The face provides the foundation and framework within which everything else must function.

The Facial Flow: Coachman’s Revolutionary Insight

Christian Coachman, alongside colleagues Kyle Stanley and Bruno Silva, revolutionised aesthetic dentistry by introducing the concept of “Facial Flow”—the idea that facial features create natural guidelines that dictate ideal dental positions.

Their insight was both simple and profound: rather than imposing arbitrary aesthetic standards, the most natural and harmonious results come from following the inherent flow of the patient’s unique facial features.

The facial flow begins with horizontal references—the interpupillary line establishing the natural horizon of the face. This isn’t just an aesthetic abstraction; it’s the reference line our brains instinctively use to orient visual perception. When dental restorations violate this natural reference, they immediately appear “off” to observers, even if they can’t articulate why.

Imagine a painting hanging slightly crooked on a wall. Even a one-degree tilt immediately draws attention and creates discomfort. The same happens with dental work that violates facial reference lines—it creates subconscious visual tension.

The facial midline creates another critical reference, but not in the way most dentists think. It’s not about perfect symmetry; it’s about balanced asymmetry. Coachman’s genius was recognising that natural faces have “harmonious asymmetry”—perfect symmetry actually looks artificial and uncanny. Instead, the goal is to create dental midlines that complement the natural facial asymmetry while creating the impression of balance.

This concept becomes clear when you compare identical twins. Despite having virtually identical genetic coding, their faces develop subtle asymmetries that make them distinguishable. These aren’t flaws—they’re the natural variations that make faces appear authentic.

Perhaps most revolutionary was Coachman’s insight about the smile arc—the relationship between the curvature of the incisal edges and the lower lip during smiling. This seemingly simple relationship has profound implications for aesthetic outcomes.

Consider a real-world example: a 45-year-old executive came to my office unhappy with previous cosmetic work from another dentist. The individual teeth looked beautiful—perfect shape, ideal proportions, excellent margins. Yet the overall effect was clearly wrong. Why? The dentist had created a flat smile arc that contradicted the natural curve of the patient’s lower lip, creating a visual disconnect between the teeth and face.

When we redesigned the case using Coachman’s principles—allowing the smile arc to follow the natural curve of the lower lip—the result looked so natural that people couldn’t identify what had changed, only that the patient somehow looked younger and more vibrant.

The Dynamic Facial Assessment

Static photographs tell only half the story. The face exists in motion, and understanding these dynamics is essential for natural results.

The transition from rest to full smile—what I call the “dynamic envelope”—reveals critical information about how teeth should appear within the context of natural facial movement. Lip mobility, tissue restriction patterns, and muscular function all influence how dental restorations will appear in real-world situations.

Think of facial dynamics like a theatre production. Static photos are like looking at the stage set without actors. You might see beautiful scenery, but you have no idea how the performance will unfold. Only by watching the actors move through the space can you understand how the set works with the performance. Similarly, only by assessing facial dynamics can you understand how dental restorations will work with the patient’s natural expressions.

A patient’s resting facial position might hide significant gingival display that becomes apparent only in full smile. Another patient might have asymmetric lip elevation that creates uneven tissue display. These patterns aren’t defects to be “corrected”—they’re natural attributes that must inform our restorative choices.

The Orthodontic Integration: Beyond Alignment

Why Ortho Thinking Matters for Every Restorative Dentist

The restorative dentist who lacks orthodontic vision is like a surgeon without anaesthesia—forced to create painful compromises due to missing capabilities.

Understanding orthodontic principles doesn’t mean you need to become an orthodontist. It means you need to see what orthodontists see—the relationship between skeletal patterns, tooth positions, and long-term stability.

The orthodontic perspective begins with appreciating that teeth exist within a growth matrix. They aren’t static objects placed randomly in bone—they’re dynamic elements responding to skeletal frameworks, functional forces, and developmental patterns.

The interceptive orthodontic approach revolutionised orthodontic thinking by addressing growth and development earlier—with profound implications for restorative dentistry. The insight that many adult dental problems originate in childhood growth patterns teaches us to recognise when tooth position is merely compensating for skeletal discrepancies.

Consider a common scenario: A patient presents with severely lingually inclined lower incisors. The traditional restorative approach might involve aggressive preparation to “correct” the appearance. But an orthodontically-informed clinician recognises this inclination as compensation for a Class II skeletal relationship—nature’s attempt to create functional contact despite a recessive mandible. Addressing the symptom (tooth position) without understanding the cause (skeletal relationship) inevitably leads to compromised results.

The Critical Face-Type Assessment

Understanding facial typology is essential for appropriate treatment planning. The three primary patterns—each with distinct implications for treatment:

1. Brachyfacial Pattern (Horizontal Grower)

• Wide, square facial form
• Low mandibular plane angle
• Deep bite tendency
• Strong musculature
• TMD risk profile: joint loading and wear

The brachyfacial patient presents unique challenges and opportunities. Their powerful masticatory muscles generate exceptional forces that can fracture restorations designed for average patients. Yet these same patients often demonstrate remarkable adaptability to occlusal changes due to their muscular strength and control.

Think of the brachyfacial patient as analogous to a powerful sports car—capable of generating tremendous force but also requiring robust components and careful handling. Their strong musculature creates incredible bite force, sometimes exceeding 250 pounds per square inch on molars. Restorations must be designed accordingly, with material selection and thickness requirements that may far exceed what’s needed for other patients.

The deep bite tendency in these patients creates special considerations for anterior guidance. Without proper management, destructive wear patterns develop rapidly, often creating flat anterior wear facets that destroy both aesthetics and function.

2. Mesofacial Pattern (Balanced Grower)

• Proportionate facial form
• Average mandibular plane angle
• Balanced bite relationship
• Moderate muscle development
• TMD risk profile: moderate and varied

The mesofacial patient represents the “textbook” case that dental education typically prepares us for. Their balanced growth pattern and moderate musculature create fewer extremes to manage, but this apparent simplicity can be deceptive.

These patients are like all-terrain vehicles—capable in most circumstances but still requiring appropriate guidance. Their very adaptability sometimes masks developing problems until significant damage has occurred. Without the obvious warning signs that extreme facial types demonstrate, dysfunction can progress quietly.

The moderate muscle development in mesofacial patients creates a balanced occlusal force that works well for most restorative approaches. However, this balance depends on maintaining proper vertical dimension and guidance patterns. When these are disrupted, even mesofacial patients can develop significant dysfunctional patterns.

3. Dolichofacial Pattern (Vertical Grower)

• Long, narrow facial form
• High mandibular plane angle
• Open bite tendency
• Weaker musculature
• TMD risk profile: muscle strain and dysfunction

The dolichofacial patient presents perhaps the most complex restorative challenges. Their vertical growth pattern often creates dental compensations that severely limit restorative options without orthodontic intervention.

These patients are comparable to precision instruments—finely tuned but with limited tolerance for deviation. Their typically weaker musculature provides less adaptability to occlusal changes, making even minor modifications potentially symptomatic.

The open bite tendency in dolichofacial patients creates special considerations for anterior guidance. Without adequate vertical support, these patients often develop muscle symptoms rather than wear patterns, experiencing pain before teeth show damage. This can make diagnosis challenging, as the traditional signs of occlusal dysfunction—wear facets and mobility—may be absent despite significant discomfort.

The vertical facial pattern also typically correlates with reduced tongue space, increasing the likelihood of airway issues that further complicate treatment planning.

The Airway-Occlusion Connection: The Hidden Driver of Dental Destruction

The airway’s influence on dental health represents one of the most significant paradigm shifts in modern dentistry. It’s not just an orthodontic consideration—it’s a foundational element that affects everything from occlusal stability to restoration longevity.

When a patient struggles to breathe through their nose, a cascade of adaptations begins that ultimately express themselves as dental problems. This isn’t theoretical—it’s a physiological reality that plays out in predictable patterns.

Imagine trying to run a marathon while breathing through a straw. That’s the daily reality for patients with compromised airways. Their bodies make whatever adaptations necessary to prioritise breathing—even at the expense of ideal dental function. After all, you can survive with worn teeth, but not without oxygen.

The sequence unfolds like a row of falling dominoes: restricted airway leads to mouth breathing, which typically requires forward head posture to open the airway. This altered head position changes the resting position of the mandible, creating new patterns of muscle recruitment and tooth contact. Over time, these adapted positions become the “new normal,” resulting in wear patterns, muscle symptoms, and joint remodelling that appear as isolated dental issues but actually stem from breathing compensation.

Sleep-disordered breathing represents the night-time expression of these same issues. When patients can’t maintain airway patency during sleep, they develop bruxism not as a primary disorder but as a protective mechanism. The brain, sensing inadequate oxygen, triggers jaw movement to restore airway space. These patients don’t have a grinding problem—they have a breathing problem that manifests as grinding.

This understanding revolutionises our approach to parafunction. Most dentists treat bruxism as the primary condition, providing splints that manage symptoms without addressing the cause. Master clinicians recognise that for many patients, especially those with dental wear inconsistent with their daytime habits, sleep-disordered breathing is the underlying driver.

The implications for restorative dentistry are profound. A beautiful full-mouth reconstruction that ignores underlying airway issues is like building a magnificent house on a sinkhole—it’s not a question of if it will fail, but when.

Consider a characteristic case: A 42-year-old patient presents with generalised wear, morning headaches, and fatigue despite adequate sleep. Traditional dentistry might focus on occlusal adjustment, equilibration, and protective appliances. But the master clinician sees the constellation of findings—scalloped tongue, retrognathic mandible, high vaulted palate, narrow dental arches—that point to airway compromise as the primary driver of dental destruction.

This patient doesn’t primarily need restorative dentistry—they need airway improvement first, whether through orthotic therapy, orthodontic expansion, positive airway pressure, or surgical intervention. Performing comprehensive restorative treatment without addressing the airway would be like replacing tires on a car with misaligned wheels—the new tires will wear out just as quickly as the old ones.

For patients with moderate to severe sleep-disordered breathing, oral appliance therapy can significantly reduce bruxism events by maintaining airway patency. In cases where dental treatment planning is complicated by severe airway issues, CPAP therapy prior to restorative work can be transformative, allowing the musculature to return to normal function without the overlay of protective parafunction.

The relationship between airway and orthodontics is equally significant. Traditional orthodontics focused solely on tooth alignment can worsen airway problems by retracting teeth into already deficient arches. Modern airway-centred orthodontics, championed by practitioners like Dr. Mahoney, prioritises arch development and airway maintenance, recognising that proper tooth position depends on adequate skeletal foundation.

This isn’t just about avoiding harm—it’s about recognising that orthodontic treatment can significantly improve airway function when properly planned with expansion protocols, proper tongue posture training, and attention to sagittal jaw relationships. The goal isn’t just straight teeth—it’s optimal breathing that supports long-term dental stability.

The Occlusal Compass: Navigating Philosophy Differences

Making Sense of Competing Occlusal Theories

Few areas of dentistry create more confusion than occlusal philosophy. Different “schools” appear to contradict each other—Kois vs. Dawson vs. Pankey—leaving many practitioners paralysed by uncertainty.

Master clinicians resolve this confusion by understanding that these approaches aren’t contradictory but complementary—different tools for different scenarios.

The Occlusal Philosophy Integration Matrix:

1. Kois Approach
   • Risk-based evaluation
   • Adaptive capacity assessment
   • Comprehensive risk categorisation
   • Emphasis on biological factors
   • Best for: Complex risk assessment and staging
2. Dawson Approach
   • Complete dentistry framework
   • Centric relation focus
   • Systematic examination sequence
   • Emphasis on joint-muscle-tooth relationship
   • Best for: Complete reconstruction and dysfunction
3. Pankey Approach
   • Sequential treatment planning
   • Cross-arch stabilisation principles
   • Progressive case development
   • Emphasis on thorough foundation
   • Best for: Phased treatment and system stability

The common thread among these philosophies is the recognition that occlusion must serve the entire system—not just create pretty contacts. The differences lie primarily in assessment approach and terminology rather than fundamental principles.

The Centric Relation Clarification

Perhaps no concept generates more confusion than centric relation. Master clinicians understand that centric relation isn’t a mysterious position—it’s simply the most musculoskeletally stable joint position from which to build occlusion.

The CR Practical Definition:

• Most superior position of the condyles
• Against the eminentiae
• Properly seated in the glenoid fossae
• With the discs properly interposed
• Independent of tooth contact

This position matters because it provides reproducibility, joint health, and stability—three essential characteristics for predictable dentistry.

When CR Matters Most:

1. Major Reconstruction Cases
   • Multiple tooth replacement
   • Vertical dimension changes
   • Occlusal plane alterations
   • Complete arch restoration
2. Dysfunction Resolution
   • TMD management
   • Painful muscle symptoms
   • Mobility and wear patterns
   • Unstable occlusion
3. Growth Disharmony Cases
   • Skeletal discrepancies
   • Developmental abnormalities
   • Compensation management
   • Complex orthodontic-restorative

In The Paradigm Shift, we discussed the critical conformative vs. reorganisation decision. When reorganising occlusion, centric relation provides the stable reference point from which all changes can be developed.

The Occlusal Scheme Selection

Master clinicians select occlusal schemes based on systematic evaluation of the patient’s specific characteristics rather than dogmatic adherence to a single approach:

The Scheme Selection Framework:

1. Canine Guidance Indications
   • Healthy periodontium
   • Strong canine support
   • Limited parafunction
   • Aesthetic requirements
   • Normal skeletal relationship
2. Group Function Indications
   • Compromised canine support
   • Heavy parafunction history
   • Wear distribution requirement
   • Skeletal asymmetry
   • Limited envelope of function
3. Balanced Occlusion Indications
   • Complete denture prosthetics
   • Severe skeletal discrepancies
   • Neuromuscular disorders
   • Specific implant protocols
   • Extreme parafunction cases

The key insight: Occlusal scheme should match the patient’s specific needs and limitations rather than the clinician’s philosophical preference.

The Ortho-Restorative Interface: Maximising Interdisciplinary Outcomes

When to Move Teeth vs. When to Restore Them

One of the most crucial decisions in complex dentistry is determining when orthodontics should precede restorative treatment. This isn’t about preference—it’s about creating optimal biological and functional outcomes.

The Orthodontic Necessity Matrix:

1. Absolute Orthodontic Indications
   • Significant crowding or spacing
   • Severe axial inclination issues
   • Transverse skeletal problems
   • Vertical dimension discrepancies
   • Midline deviations exceeding 2mm
2. Relative Orthodontic Indications
   • Mild-moderate spacing or crowding
   • Minor axial inclination issues
   • Limited vertical or horizontal discrepancies
   • Occlusal plane discrepancies
   • Root proximity concerns
3. Restorative-First Indications
   • Minimal alignment issues
   • Severe tooth structure loss
   • Significant decay or structural compromise
   • Patient limitations preventing orthodontics
   • Urgent aesthetic or functional needs

The elite approach isn’t “either/or” but “which first?” Master clinicians sequence treatment to maximise outcomes while respecting patient constraints.

The Pre-Restorative Orthodontic Protocol

When orthodontics precedes restorative work, specific objectives guide the tooth movement. This isn’t about “perfect alignment”—it’s about creating the optimal foundation for subsequent restorative procedures.

The Pre-Restorative Movement Framework:

1. Space Creation and Distribution
   • Ideal proportional spacing
   • Restorative material requirements
   • Emergence profile planning
   • Proximal contact positioning
2. Root Position Optimisation
   • Parallelism for prosthetic support
   • Strategic root separation
   • Implant site development
   • Long-axis alignment for force distribution
3. Gingival Architecture Development
   • Papilla position optimisation
   • Level marginal gingiva creation
   • Emergence profile enhancement
   • Aesthetic zenith positioning
4. Functional Alignment
   • Occlusal plane leveling
   • Guidance pattern establishment
   • Envelope of function enhancement
   • Parafunction management

This strategic approach ensures that orthodontics serves the restorative outcomes rather than merely creating straight teeth.

Skeletal Disharmony: When Teeth Can’t Solve the Problem

Recognising Limitations of Dental Compensation

Perhaps the most common error in complex dentistry is attempting to solve skeletal problems with dental solutions. Master clinicians recognise when dental procedures alone cannot overcome skeletal limitations.

The Skeletal vs. Dental Decision Matrix:

1. True Skeletal Discrepancies
   • Maxillomandibular relationship > 6mm discrepancy
   • Significant vertical disproportion
   • Transverse maxillary deficiency
   • Mandibular asymmetry or retrognathia
2. Dental Compensation Limitations
   • Excessive tooth inclination required
   • Unstable periodontal outcomes likely
   • Aesthetic compromises unavoidable
   • Functional limitations inevitable
3. Combined Approach Indicators
   • Moderate skeletal components
   • Multiple system involvement
   • Phased correction potential
   • Limited surgical acceptance

The critical insight: Attempting to solve skeletal problems with dental-only solutions creates unstable, unaesthetic, and biologically compromised results. Recognizing these limitations is the hallmark of master-level diagnosis.

The Surgical-Orthodontic Interface

When skeletal discrepancies exceed the envelope of dental compensation, surgical approaches become necessary. This isn’t a failure—it’s appropriate recognition of biological reality.

The Skeletal Correction Framework:

1. Orthognathic Surgery Indications
   • Severe Class II/III skeletal patterns
   • Significant vertical disproportion
   • Adult growth completion
   • Functional or aesthetic concerns
   • Failed dental compensation
2. Skeletal Anchorage Opportunities
   • Moderate skeletal discrepancies
   • Specific tooth movement needs
   • Limited surgical acceptance
   • Combined dentofacial approaches
   • Growth modification potential
3. Camouflage Limitation Recognition
   • Understanding biological boundaries
   • Realistic outcome projections
   • Risk-benefit analysis
   • Stability predictions

Master clinicians neither overtreat nor undertreat—they match the intervention to the actual problem, even when that means recognising the need for referral or collaboration.

Dento-Medical Aesthetics: The Emerging Frontier

Beyond Teeth: The Complete Facial Transformation

The most advanced interdisciplinary vision recognises that true facial harmony extends beyond dentistry to include the integration of medical aesthetic procedures. This isn’t about becoming a plastic surgeon—it’s about understanding the complete facial context.

The Facial Enhancement Integration:

1. Lip Position and Function
   • Lip mobility assessment
   • Perioral rhytid evaluation
   • Lip support requirements
   • Dynamic display analysis
2. Anti-Wrinkle Applications
   • Lip flip techniques for gummy smile
   • Masseter reduction for bruxism
   • Perioral refinement integration
   • Dynamic wrinkle management
3. Volume Management
   • Lip border definition
   • Philtrum enhancement
   • Nasolabial fold softening
   • Marionette line reduction
4. Combined Protocol Design
   • Strategic timing of procedures
   • Dental-medical sequencing
   • Maintenance planning
   • Comprehensive facial planning

Dr. Kyle Stanley’s pioneering work on lip flip procedures demonstrates how selective neuromodulator application can dramatically enhance smile aesthetics by addressing gummy smile through medical means rather than aggressive dental procedures.

The integration of these approaches creates outcomes impossible with dentistry alone—particularly for patients with aging-related changes that affect smile display and facial proportion.

The Interdisciplinary Case Process: From Theory to Practice

Creating Seamless Team Integration

Theoretical understanding means nothing without practical implementation. Master clinicians create specific protocols for managing interdisciplinary cases that ensure seamless communication and execution.

The Interdisciplinary Workflow Protocol:

1. Comprehensive Records Collection
   • Standardised photography protocol
   • Complete radiographic series
   • Digital scan acquisition
   • Video documentation of function
2. Multi-Specialist Analysis Process
   • Sequential specialist evaluation
   • Collaborative planning session
   • Role definition and sequencing
   • Outcome responsibility assignment
3. Patient Presentation Approach
   • Unified treatment message
   • Sequential expert explanation
   • Complexity simplification
   • Outcome visualisation emphasis
4. Execution Coordination System
   • Timeline development and sharing
   • Progress verification points
   • Transition quality control
   • Complication management protocol

This systematic approach ensures that complex interdisciplinary cases maintain continuity and quality throughout extended treatment sequences.

Your Interdisciplinary Vision Development

The mastery of interdisciplinary vision doesn’t happen by accident. It requires deliberate development and systematic exposure to complex treatment philosophies.

The core insight from our exploration of The Paradigm Shift remains central: great dentistry requires systems thinking. Interdisciplinary vision simply extends that thinking beyond the boundaries of traditional dental education.

Your journey to interdisciplinary mastery begins with recognising that teeth exist within faces, not merely within mouths. When you truly internalise this perspective, everything about your diagnosis and treatment changes.

Your Next Steps:

• Mind Over Matter: Deepen your understanding of the psychological aspects of comprehensive care in my book “Mind Over Matter: The Psychology of Dental Success.”
• 10 Days, 10 Mental Models: Subscribe to my intensive email series that delivers the ten most powerful thinking frameworks directly to your inbox over ten consecutive days.
• In-Depth Youtube Content: Watch my full-length videos that demonstrate these principles in action on actual cases with step-by-step analysis.
• Strategic Mentorship: Book a focused consultation to discuss how personalized guidance can accelerate your development of interdisciplinary vision and face-first planning expertise.