When older adult patients request esthetic enhancement they are mainly concerned about the lower incisors. In fact, for older adult patients, the impact of the mandibular incisors is at least as important as that of the upper jaw incisors on their facial esthetics. This article discusses the importance of specifically documenting this claim and proposes that the diagnostic evaluation of older adult patients should routinely include two specific photos.

Faced with a patient who has extensive esthetic enhancement demands, simply aligning the teeth and achieving a functional occlusion might not suffice.

The goal of this article is to help orthodontists to analyze and to optimize the positioning of upper anterior teeth so as to improve the esthetics of the smile.

Of course, esthetics is not an objective notion. Therefore, maintaining good communication with our patients is essential. Nonetheless, esthetic rules as they are defined in the literature will serve as a “framework” for creating a smile.

In this context, the orthodontist will have to take into account the shape of the teeth, particularly since not all shapes are ideal. In fact, the incisors have three main shapes: rectangular, triangular and ovoid. The shape of the teeth will perhaps guide orthodontists in their choice of treatment. Opting for stripping will be the preferred treatment in some cases.

Similarly, orthodontists have to take into consideration incisal edge defects caused by wear associated with the initial malocclusion that becomes more apparent after alignment. In some cases, a simple recontouring or enameloplasty of the incisal edges will be sufficient and should be discussed with the patient before it is performed using a simple and reliable procedure.

Requests for orthodontic treatment have changed over the last few years due to the influence of social discourse and the promotion of the ideal of a forever young and ‘‘perfect’’ body.

The esthetic nature of these requests, even if they have always been implied in any orthodontic consultation, has changed and recently esthetics has been increasingly emphasized by prospective patients.

One consequence of these urgent requests is that orthodontists are on a slippery slope to becoming service providers and they therefore run the risk of no longer being recognized as Health Professionals.

Another consequence is that we now have patients with a very different ‘‘profile’’ which we will attempt to define in this article.

We will discuss esthetic treatment requests and the respective problems for each of three orthodontic age groups (children, adolescents and adults). We will illustrate these problems with three specific clinical cases. And since we are not trained to either identify or successfully manage the problems associated with this type of request, each of us has had to come up with our own clinical response. However, once we are certain or even suspect that we are dealing with a patient at risk (we will define this later) for whom an orthodontic solution is not appropriate, we then have to overcome our own reservations and refer the patient to a mental health professional whose specialized care will make it possible for the patient to become clearer about esthetic requests.

In most cases after everything is resolved, we can then professionally and respectfully take on the management of the patient. By taking these precautions, we will conduct ourselves as Health Professionals who seriously assess both the somatic and psychological dimensions of our patients’ requests.

By limiting its objective to correcting dysmorphisms of the dento-alveolar arches, current treatment of malocclusions loses a great deal of effectiveness that technical procedures might otherwise achieve. An inadequate understanding of the mechanics of the facial envelope can allow the dysmorphisms and breathing dysfunctions associated with malocclusions to persist.

However, the oral fissure has a profound impact on the mechanical behavior of the facial envelope. Like an operational command, it transforms the local mechanics of the facial envelope by creating a phenomenon of a concentration of stress and deformations whose manifestations are visible not only on facial soft tissues, but also on their cartilage and osseous supports. This phenomenon also influences the physiology of the facial muscles by distorting them as they are forced to adapt to the fissure, and by guiding the functional adaptations of the envelope.

Basically, the impact of this phenomenon on the structural organization of the facial envelope is transformed by the oronasal morphophysiologic integration of the structures of the face and practitioners must necessarily adapt their therapy to address these problems. Finally, the functional relationship between the nasal mucosa and the cavernous sinus increasingly broadens orthopedic perspectives for therapy that will most importantly encompass the cephalic hypothalamic-pituitary axis.

The effectiveness of a procedure appropriately initiated by practitioners of DFO due to their specific expertise will require them to exercise a greater attentiveness to the global functionality of this complex into which the face is integrated.