How to Buy the Perfect Smile

Donald Trump did it. So did Cindy Crawford, Chris Rock, Heidi Klum and even Martin Amis. If you're thinking cosmetic surgery, think again: Their secret is cosmetic dentistry. Those immaculately white, perfectly proportioned teeth beaming from the pages of InStyle magazine were probably created in the chair of a cosmetic dentist. In the past 10 years, the rich and famous as well as the girl next door are more likely to have turned to a cosmetic dentist than a cosmetic surgeon to polish their image. In fact, some cosmetic surgeons and cosmetic dentists have begun working in tandem, because a patient with a new, younger face isn't satisfied to show it off with a mouthful of worn, yellow, aging teeth. Even surgery-phobes who'd sooner bungee-jump than submit to liposuction think nothing of plunking down $600 to have their teeth whitened. And starlets are discovering that a boob job may do less for a career than a dazzling set of pearly whites.

Cosmetic dentistry has come of age just in time for a languishing profession looking to replace the bread-and-butter business of filling cavities. “In the past, dentistry was disease-driven,” explains Dr. Jeffrey Ingber, a Center City prosthodontist. “But fluoride has drastically reduced decay, and periodontia has cut down on infected gums, so we now treat 'ugly' disease. Cosmetic dentistry has saved dentists.” Thanks to the popularity of TV shows like Extreme Makeover , where the dramatic effects of cosmetic dentistry are the wow factor in nearly every redo, people are flocking to dentists for procedures they never knew existed.

Nobody worries these days about preserving teeth to be able to chew a steak in the retirement home. What's driving baby boomers to the dentist's office isn't fear of dentures; it's the desire to look young and stave off the effects of aging. Study after study has shown that attractive people earn more money, get promoted faster, and have more active social lives. A survey conducted by the American Academy of Periodontology found that half the people interviewed consider the smile the first feature they notice — yet 80 percent of those surveyed weren't happy with how they look when they say “Cheese.” The impact of the smile is enormous, not only in terms of appearance but in developing self-confidence. “People who are ashamed of their teeth don't smile, and they are perceived as being sad even if they're not,” says Philadelphia cosmetic dentist Dr. Donald Katz. “Give them new teeth, and they are transformed.”

With the advent of sophisticated materials and techniques, cosmetic dentistry has evolved into a skilled blend of art and science. “When I started practice in the '70s,” says Bryn Mawr dentist Dr. Joseph Greenberg, “I'd been taught to fix a tooth by matching it to the one next to it.” The standard then was based on something called the “golden proportion,” a mathematical theory dictating that each tooth should be a certain size in relation to its neighbors. “Now,” Greenberg continues, “I begin by looking at the whole face and the smile.”

Influenced by plastic surgery, cosmetic dentistry has developed elaborate criteria for what the right smile is. The shape of the face and its vertical and horizontal planes are major factors. For a long face, you want short teeth and a broader smile; for a moonface, you want longer teeth. There are gender considerations, too. Females have “high” smiles that display more gum, and our teeth are nicely curved to create a softer look. Male smiles are “low,” showing less gum and more angular, textured teeth. In a perfect smile, the top teeth should follow the curvature of the lower lip. As we age, our teeth get worn down and tend to be straight across. The new dentistry is all about correcting an array of defects, from color to size to shape.

The best cosmetic dentists make teeth that aren't so perfect they look fake, and they may even add slight color variations determined by a high-tech color-mapping instrument. Cookbook dentistry is out, and along with it, the picket-fence Hollywood smile. “Somebody can spend $20,000 for beautiful teeth that look awful on them,” says Ingber. “Your smile should match your age, your personality and your self-image. You don't give a set of 20-year-old teeth to a 55-year-old woman, and you don't put flashy teeth in somebody dull and boring.”

And lest you think this is all a bit frivolous, consider the view of Dr. Leonard Abrams, a founding member of the American Academy of Aesthetic Dentistry, who says, “Dental appearance isn't just about vanity. It's an important health-care service and a quality-of-life issue.”

Whitening Your Teeth

Whenever 26-year-old Allison Schwartz, a paralegal-in-training, saw herself in a photo, she was embarrassed by her yellow teeth. Years of smoking and drinking coffee had left stains that no amount of brushing could remove. Now that she was getting married, in December 2003, she couldn't bear the possibility that in her wedding pictures, her gown would be whiter than her teeth. “I'm only getting married once,” she said, “and I want everything to be perfect.” When she thought of the cost of the dress, the party, the band, the flowers, another $600 to bleach her teeth just wasn't a big deal. And when it turned out that “BriteSmile,” an office-based tooth-whitening system, was running a special for $500, she hopped into the chair at the posh Rittenhouse Square offices of Dr. Joseph Roberts. She put on her CD headphones, reclined “with all this gook on my teeth,” and actually fell asleep. One and a half hours later, she left with her teeth as white as bathroom tile; the only adverse effect was some sensitivity that lasted about a day. “It was worth every penny,” Schwartz says, “and I'll do it again in two years, when I need it.”

Between 1996 and 2000, demand for tooth-whitening increased 300 percent, according to the American Academy of Cosmetic Dentistry, with the largest audience being people under age 50. It's the Botox of dentistry, ideal for an instant-gratification society that views discolored teeth, along with wrinkles, as a sure sign of aging. Teeth stains are caused by chemical reactions between plaque and tobacco and beverages like coffee, tea, red wine and cola. Bleaching treatments first became available in the early 1990s, with the development of soft plastic trays custom-made from an impression of the patient's teeth. These are filled with a gel-like hydrogen peroxide bleach and worn in the mouth nightly for a few weeks. The average concentration of peroxide is 15 percent, but it can be adjusted lower if patients complain of gum sensitivity, or as high as 20 percent for faster results. Many dentists still believe that at-home bleaching is the gold standard. The trays, which cost $300 to $600 to make, last for years, and the only additional expense is the bleaching gel, which can run up to $80 per package. Whenever you need a touch-up, pop in the trays for a few nights — and voila, stains disappear.

In the past few years, the duration and inconvenience of at-home bleaching have made it a second choice to the more popular in-office bleaching systems like BriteSmile and Zoom, in which the process is accelerated by an activating light. First, a soft rubber guard is placed in the patient's mouth to hold it open. The dentist protects the gums with a rubber dam. Next, a clear gel of 15 percent peroxide is painted on the teeth, and the patient lies still while a high-intensity light shines into the mouth, causing a chemical reaction that helps the bleach penetrate the tooth surface. There are three 20-minute sessions; in between, the gel is suctioned off and replaced. Immediately after bleaching, the teeth are chalk-white, because of dehydration that occurs during the process. In a day or so, that intense brightness fades to normal. Some people experience a short-lived sensitivity to hot and cold.

The $600 treatment should last for two years. (Because at-home bleaching provides the equipment for periodic touch-ups, it lasts as long as you are diligent with follow-up.) The best bleaching results occur with yellow and brown stains. Gray is harder to lighten; stains from trauma and tetracycline are the most difficult of all and require repeat treatments — if not unorthodox methods. Dr. Najeed Saleh, an Israeli-born dentist who has a private practice in Bryn Mawr and is part of the oral/maxillofacial department at the University of Pennsylvania, was able to remove a particularly stubborn stain from inside the front tooth of a pretty young woman; it had turned brown from a combination of trauma and internal bleeding. He inserted a bleaching material into the cavity of the tooth and plugged it in place with a temporary filling, in effect bleaching the tooth from the inside out instead of vice versa, as it's usually done. Four days later, he removed the filling, rinsed out the bleach, and sealed the cavity with a white resin. Now, you can't tell which tooth was stained.

If your teeth are only slightly discolored, you can get a four- to-five-shade improvement with Crest Whitestrips. These are adhesive-like tapes with a concentration of peroxide that are applied across the teeth nightly and cost $29.95 for a 28-day supply. Drugstore trays aren't recommended because they can irritate the gums, according to Jeffrey Ingber, the prosthodontist. The aggressively marketed whitening toothpastes selling for $3.95 to $7.95 a tube have low amounts of bleaching agents that do virtually nothing.

Restoring and Sculpting Your Teeth

A 10-year-old falls off his bike and breaks a tooth. A teacher hates the Lauren Hutton gap between her two front teeth. An aspiring model has a lovely smile, except for a crooked incisor. A 70-year-old grandmother's gums have receded, exposing a notched line where her teeth meet the roots; it's unsightly and sensitive. A salesman has tried unsuccessfully to bleach the embarrassing tetracycline stains from his teeth. These people are all ideal candidates for bonding.

Bonding ushered in the era of stick-on dentistry when, 30 years ago, a dentist found a way to make an artificial plastic material adhere to tooth enamel. Before that, the only way to change the shape of a tooth or repair a chip was with an expensive crown. Now, using this moldable plastic, dentists suddenly became sculptors. The basic technique generally still uses a “blue light” — a concentrated wavelength of normal light that initiates and accelerates the hardening of the resin. But the materials have evolved from relatively weak, opaque plastics that often looked like Chiclets to strong, stable, light-refracting lifelike composites that bond not only to the outer tooth surface, but to the dentin underneath, making it possible to repair a broken tooth where the enamel has been destroyed.

Despite its enormous versatility, bonding has been overshadowed by veneers — gleaming, ultra-thin porcelain covers that look like fake fingernails and are permanently adhered to teeth. Porcelain veneers (also called laminates) are made from ceramic glass, while bonding materials are plastic, making them less lustrous. It's a little like comparing the translucency of Lenox china to the opacity of Tupperware. Porcelain veneers take up stains, but they can be polished. The resin in bonded teeth is more porous and also discolors, but it can't be whitened. Porcelain veneers, which are designed by dentists but made by technicians in a laboratory, should last about 15 years. Bonding is good for about 10 and requires far more artistry from the dentist, who works directly on the tooth. “I love doing bonding because of the hands-on experience. It's a real challenge and thrill,” says Dr. Tara Sexton, a Bala Cynwyd general dentist specializing in cosmetics, who recommends it for small repairs, camouflaging localized discoloration, reshaping rotated teeth — and limited budgets. Bonding will set you back $300 to $600 per tooth. Veneers, depending on the lab charges, the material and the dentist's reputation, start just below $1,000 a tooth and escalate to $2,500. A set of uppers and lowers can cost $25,000 to $30,000.

For my own teeth, Jeffrey Ingber suggested veneers, but I didn't want to spend the money, so I chose bonding instead — and wasn't the least bit disappointed. Before we embarked on the project, Ingber showed me exactly how I would look by applying — but not setting — the bonding material to the teeth we were changing. He filled in a small gap near my front tooth, and layered resin on the back teeth so that they no longer receded when I smiled. He filed down one of my pointy lower teeth and aligned the rest by bonding the edges into a straight line. The change was subtle but significant.

The process took about three hours. Each tooth was done individually and first etched with a small power sandblaster that roughed up the surface of the enamel so the resin would seep in and stick. Next, Ingber painted the tooth with a clear resin that acts as a kind of glue, and on top of that went the gooey composite, squeezed out of a tube. Determining the shape and thickness of the composite and matching the color is critical, and this is where skill really counts. The material is tricky to control, and the dentist must work quickly before it hardens. When Ingber was satisfied, he applied a blue light to the tooth for a few seconds to initiate the adhesive phase. Then he moved on to the next tooth. I had no pain whatsoever. When I left the office with my “improved” teeth, I went to lunch, told I could eat whatever I wanted.

Bonding was more than adequate for retooling my smile. But the holy-cow-I-can't-believe-it makeovers on television are the result of veneers , which entered the dental picture in 1983, when a New York dentist figured out a way to bond porcelain directly to tooth enamel. They're pricey, but quick, relatively painless, and often quite dramatic. Because laminates have become a profit center for dentists, they may be overused. If a dentist suggests you need a dozen veneers, ask why, and what other options he can offer. “If the reason is strictly to improve color,” Jeffrey Ingber cautions, “get up and walk out.” Such full-scale veneers would only be appropriate if the staining was due to tetracycline.

Like bonding, veneers have evolved from their rather crude beginnings into refined, durable ceramics that enable the dentist, like a fine hair-colorist, to create stunningly natural shadings. The translucency of the porcelain reflects light the way a natural tooth does, and the newest materials are tough as well as beautiful. They can alter the shape, color, size or arrangement of teeth, and in some cases can be an alternative to orthodontics.

Gloria, a business executive (many patients interviewed for this article requested that we use only their first names), had never been satisfied with her smile, but it wasn't until she was in her mid-40s that she began to suffer some gum recession and was motivated to do something about it. “The first thing I always notice in a person is their teeth and smile,” she says. “Someone can be well manicured and well dressed, but if they have bad teeth, it spoils everything. Without a gorgeous smile, forget it!”

A model-friend of hers with magnificent veneers referred her to Leonard Abrams at the Pennsylvania Center for Aesthetic and Implant Dentistry. Abrams, known locally as the dean of cosmetic dentistry, showed her a computer-generated graphic of how her veneers would look, and any doubt she had vanished. After her gum problems were corrected by a periodontist, she returned to Abrams for two visits. To make space for the laminates, he lightly sanded the teeth to be veneered, removing a slice of enamel about the width of a business card. He took impressions to get the shape of the laminates, as well as photos of her mouth with little color chips next to her teeth as a shade guide. All of this was sent to a lab. She left with a light coat of temporary bonding. A month later she returned, and the laminates were adhered to her teeth. The visits lasted about two hours. There was no pain and no anesthesia. “I get compliments all the time now,” Gloria says. “Everybody admires my teeth. I used to avoid smiling. Not anymore.”

Gloria's smile was definitely improved by the addition of veneers, but it was nothing compared to the spectacular transformation of Katelynd D'Andrea, an 18-year-old college freshman whose new smile was akin to a personality transplant. D'Andrea was born with a congenital condition that affected her mouth, her eyes and her skin. Some of her teeth came in late, some never came in at all, and the ones that did were stunted, misshapen, and overlaid with excess gum. Always embarrassed by her smile, she grew up shy and quiet, preferring to stay in the background where she wasn't noticed. By her sophomore year in high school, she'd finished growing and was ready to begin the cosmetic dentistry that would take at least a year. “It was important to me that it be finished for my senior picture,” D'Andrea says. “I didn't want to look back on my life someday and remember myself the way I was.”

Leonard Abrams, along with his colleague, Fernando Presser, used a combination of four implants (more about that later) and a total of 20 upper and lower veneers to turn a moth into a butterfly. “It was like night and day,” her mother says. “She literally grew up overnight. It made her much more outgoing. Her teeth were so gorgeous, I decided to get veneers myself.”

Last September, D'Andrea entered college with a self-confidence she'd never had before. “I'm more open with people now,” she says. “I don't have to hide anything. I'm a different person inside.”

When teeth are too damaged for veneers, it may be necessary to use crowns (or caps, as they are also called). Crowns are in order when teeth are broken, worn down, weakened by fillings or decay, or missing altogether. Sometimes they're placed in the front of the mouth if there isn't enough tooth structure to hold a veneer, but they are nearly always used on back teeth, where veneers would crack under the heavy chewing load. While a veneer is applied to the surface of a tooth, a crown is like a slipcover fitting over a tooth that has been filed and shaped into a stump. Years ago, crowns were made of metal and covered with plastic, which discolored over time. In the early '60s, it became possible to fuse porcelain to gold or silver, and crowns entered the modern era.

Lately there's a lot of enthusiasm for metal-free crowns, made entirely from ceramic material. Unlike metal, which blocks light, these all-ceramic crowns reflect and refract rays exactly like a natural tooth, which gives them an aesthetic edge, particularly for prominent front teeth. And they're a boon for patients who happen to be allergic to metal or averse to having it in their bodies. Tests have shown, however, that these ceramic crowns are prone to fractures and micro-cracks in back teeth, and several of the early products are already off the market, although there are some promising results with a new material called zirconium. To date, these all-ceramic crowns don't have the durability or longevity of porcelain on metal, and they certainly are not recommended for the big choppers in back.

It usually takes two visits to make a crown; neither is painful, but the first requires a shot of novocaine. At the initial visit, the dentist meticulously selects the color for your “slipcover” from what looks like a packet of porcelain paint chips. “To get the best match, it's important to have full-spectrum lighting that mimics natural light,” says Dr. Joseph Greenberg, who is trained in both periodontics and prosthodontics. “A good crown should have the same color gradations as the surrounding teeth.” Next, the dentist shaves about 1.5 millimeters from the top and sides of the tooth, until it looks like a pencil stub. The crown will be cemented on top. Then comes the impression, after which you sit for about 20 minutes while a temporary crown is made, fitted, and cemented in. Temporaries are notorious for falling out, and you may need a trip back to the dentist to be refitted until your crown is ready. That takes from four to six weeks, at which time the temporary comes off, the area is cleansed, and the final crown becomes yours forever — or at least for five years (more, if you see a specialist).

A general dentist will make a crown for as little as $700. A trained cosmetic prosthodontist charges anywhere from $1,000 to $2,500. “Every crown takes on the qualities of the practitioner,” says Joe Greenberg. “The materials are pretty much the same. What you pay for is the skill, the precision and the artistry of the dentist and the lab technician.”

Replacing Your Teeth

Implants were invented serendipitously by Pi Branemark, a Swedish orthopedic surgeon who, in 1956, was interested in studying blood circulation in living bone. For his research, he rigged up a glass tube with a titanium base (which is compatible with living tissue) and inserted it into the bone of a rabbit. Months later, when he tried to remove his contraption, the titanium had bound to the bone and wouldn't budge. For the next nine years, Branemark experimented with titanium devices in dogs, until he was comfortable transferring his results to a technology that would hold teeth in humans. He published his astounding accomplishment in 1975, and the days of dentures were immediately numbered.

Many other companies make implants today, but Branemark is considered the Rolls-Royce. An implant costs anywhere from $1,500 to $2,800, depending on the problem and the location; the price of the crown is additional. Dr. Louis Rose, a Center City periodontist who attended both medical and dental school, says nothing is good for life, but Branemark implants come close. He began performing implants in 1983, and very few of his patients have yet reported problems. Pain varies depending on the number of implants, the health of the tissue, and whether bone grafts are necessary. You could be swollen with chipmunk cheeks and uncomfortable for several days, or you could go to work the next morning. Carolyn, a reading specialist from northern New Jersey, had eight implants put in on a Thursday; two days later, without a trace of black and blue, she threw a party for a dozen guests.

The basic concept hasn't changed over the years. The dentist still drills a channel into the bone and literally screws in the implant, the same way you thread a screw into a piece of wood. The real revolution is the ability to grow bone to anchor the implant. That's why the procedure is so often done by a periodontist who specializes in gum and bone surgery. Bone loss caused by disease and aging used to be a major limitation in choosing implant candidates: Just as you can't put a screw into a wall that crumbles, you can't put an implant where there isn't enough strong bone to keep it in place. Today, when periodontists can't graft bone, they can build it, sometimes by stuffing the socket with finely ground cow bone that meshes into human bone. Or they can stimulate the patient's bone to develop on its own with newly engineered protein growth factors that are pouring out of laboratories.

Straightening Your Teeth

As recently as 10 years ago, most adults got braces because they had few other choices. “Lately, I've seen a dramatic shift from medical necessity to aesthetic orthodontia,” says Dr. Alice Amsterdam, whose orthodontic practice is about 30 percent adult. “We are a society that demands perfection and can afford it. People recognize that they are judged by their teeth, and in the working world especially, they have to look good.”

Amsterdam says her adult patients find braces a much more challenging experience than do the kids she sees — they're more sensitive to changes in their bite, they complain more, and they need a lot of pampering. “Ask a child if they have any questions, and they bounce out of the chair and head for the door,” she says. “Ask an adult, and they sigh, 'Where do I begin?'”

It typically takes about two years to move teeth into the desired positions via adult orthodontry, and the cost ranges from $4,500 to $7,500. The average patient is a woman in her 40s who is starting to see the effects of aging. Dr. Peter Greco, a Center City orthodontist who focuses mainly on adults, once put braces on a woman in her 80s. She told him her husband had died, so she could finally do whatever she wanted.

Today's braces aren't the kind you wore as a kid, where each tooth had its own metal band. Since the '80s, with the advent of bonding, orthodontists have been able to stick translucent ceramic brackets directly to teeth, then attach a silver wire that gets adjusted monthly. The latest rage in orthodontia is a custom-designed contraption called “Invisalign,” an individualized series of clear, removable, variably sized trays, similar to the ones used in tooth-bleaching, that costs an average of $6,400. The trays are changed every two weeks until the teeth reach their desired alignment.

Frederick Wirth, a 60-year-old Reading neonatologist, had wanted braces for years. “You can really tell the age of a person by their teeth,” he says, “and I didn't want to spend the rest of my life without a nice smile. At the same time, I was unwilling to go through the discomfort of wires and the disfigurement of a mouth full of metal.” When he heard about Invisalign on TV, he went for it. He had a series of 27 trays that he wore 24/7 for a year, taking them off only for meals, when he gave speeches, or when he attended parties where he'd be nibbling all night on hors d'oeuvres. “The whole time I wore them, only one person asked, 'What's that on your teeth?' — and I never took so much as an aspirin for pain,” says Wirth. He's now thrilled with his smile and only wishes he'd done it sooner.

It's easy to understand the appeal of Invisalign. Because it's removed at meals, you can eat whatever you want. You should see the dentist every two weeks, but there are never emergency visits caused by broken brackets shoving wires into your cheek. Peter Greco warns, however, that the company's aggressive marketing campaign could allow the system, which he says hasn't been subjected to “vigorous investigative scrutiny,” to be used on inappropriate patients. “We're not selling shoes here,” he says. “We're in health care. This is being promoted as a practice-builder that brings in good money. You can see 10 Invisalign patients in the time it takes to see two with traditional braces.” He's also worried that the process may exacerbate gum and bone disease, to which adults are far more susceptible than kids. In short, Invisalign has its place, but it's not for everybody.

Balancing Your Teeth and Gums

Susan, a retired school administrator, was always self-conscious about what she describes as a “gummy” kind of smile: “My lip went way up, so it looked like my gums were bigger than my teeth.” Her periodontist, Louis Rose, suggested raising her gum tissue and exposing more of her teeth, so the two parts would be balanced. “After I did it, people told me, 'You look great,'” Susan says, “but they didn't know why. To me, it was a major change. I present myself far more confidently.”

I learned during an interview with Rose that I actually had a minor version of the same problem. He pointed out that what I thought was my perfect smile actually had too much gum covering some of the upper rear teeth, and my two lower center teeth presented as short and stubby. The procedure to get rid of the excess gum turned out to be a lot like a manicure for my mouth, except that instead of trimming and pushing back the cuticle, Rose removed the unnecessary gum tissue using clippers and a scalpel. (Dr. Kenneth Siegel, a Blue Bell dentist, does this procedure with a laser, which he claims shortens the healing time.) I had a shot of novocaine, so there was no pain during the process — and practically none after, either, although I took an Advil that night just in case. In a week I was healed, and delighted with the result.

Reshaping Your Jaw

When you look at comedian Jay Leno, the first thing you notice is his oversized jaw. While this abnormality hasn't impeded his success, it probably made him the butt of jokes growing up that he could have avoided with orthognathic surgery. This highly specialized discipline is often carried out by doctors whose 10-year training combines four years of dentistry, two and half years of medicine, and three and half years of oral and maxillofacial surgery, often followed by a fellowship in cosmetic surgery.

Orthognathic surgeons address a variety of problems related to facial imbalance: an oversized lower jaw like Leno's; an undersized lower jaw like the cartoon character Beavis; a long upper jaw characterized by a “gummy” smile; or an uneven jaw that sags to one side. The orthognathic surgeon's tools are drills, saws, and titanium screws and plates that are used to reposition the jaw by cutting it in one or more places and removing or adding bone. The surgery, which should be done at an academic center like Penn, Jefferson or Temple, is nearly always preceded by extensive orthodontia to move the teeth so they'll be compatible with the reconfigured jaw. The changes are nothing short of remarkable.

Dr. David Stanton, part of a team of oral and maxillofacial surgeons associated with the University of Pennsylvania's Center for Human Appearance, operated on a pretty 20-year-old college student whose upper jaw had grown so large that her smile was all gum and no teeth. By cutting and shortening the jaw, he moved her gums up and under her lip, and her smile became perfectly normal.

Orthognathic surgery can cost as much as $10,000, because it involves a short hospital stay. Years ago, patients had their jaws wired for six to eight weeks; now, screws and plates are used to hold the jaw in place, and soft foods can be eaten immediately. Expect a fair amount of swelling, and mild to moderate pain for at least two weeks. A male patient whose bite was so bad that he had to cut his food into tiny pieces in order to chew was playing football three months after his operation.

Dr. Harvey Rosen, a Pennsylvania Hospital cosmetic surgeon who is trained in maxillofacial surgery, incorporates orthognathics in lieu of a chin implant in about one out of 10 of his face-lifts, where he wants to build a stronger chin line. When he suggested it to Donna, a 52-year-old business consultant, she was surprised. “I came for a face-lift because my neck was flabby,” she says, “and I hadn't really thought much about my weak chin until he pointed it out and said the work would hold up better if he did more than just tighten the neck muscles and skin. Afterward, when I looked in the mirror, I saw what a big difference it made.”

If Donna's case was fairly routine, Julie's was more like the fairy tale where the ugly duckling becomes a swan. By the time Julie was 15, her upper jaw had grown so long that she had a distinctive “horsey” look and a noticeable overbite that made it difficult for her to close her mouth without straining. She always knew she'd need orthodontia, but orthognathics was unexpected. Rosen moved her upper jaw toward her nose and shifted her lower jaw and chin forward. As a result, her nose looked smaller, and her face became properly proportioned. She looked totally different. “Some of my friends didn't recognize me,” she says happily. “I look so much better. When I see pictures of myself from before, the change is huge. And it wasn't as bad as I thought it would be.”

“Orthognathics is the single instance in all of cosmetic surgery,” says Harvey Rosen, “where you can potentially transform someone with a misshapen face into an attractive person.”