Boundary Lines
Considering the Limits & Potential of Dento-Facial Esthetics
From the shoulders up, every aspect of the head and neck affect a person's esthetics and self-confidence. More specifically, the hard and soft tissues of the middle and lower third of the face contribute, to a large or small extent, to dento-facial esthetics, and they're all interrelated. Today, dentists and cosmetic physicians are changing the manner in which they correct issues affecting dental and facial esthetics and embracing a more comprehensive dento-facial approach.
In some cases this involves traditional dental treatments alone. In others, a combination of dentistry and injectable fillers and neurotoxins may be indicated, the latter provided by the dentist in states where it's permissible within the scope of practice, or by another licensed professional as part of an interdisciplinary treatment plan.
For example, in orthodontics, dentists recognize today the complexity of the skeletal pattern that patients bring in addition to their smile, explains David M. Sarver, DMD, MS, an adjunct professor in the Department of Orthodontics at UNC at Chapel Hill School of Dentistry. Therefore, his approach incorporates the macro-esthetics (facial form), mini-esthetics (the smile), and micro-esthetics (dental proportion, shape, shade, etc) of the dento-facial relationship in order to expand the diagnostic horizon.
"For example, orthodontists tend to see a patient with a gummy smile as having an orthodontic problem; we want to move the upper incisors up to reduce excessive gingival display," Sarver suggests. "But, interestingly, we now recognize that orthodontic diagnosis is merging very much toward cosmetic dentistry, where we're recognizing smile design a lot more. Therefore, we are conscious that maxillary incisor intrusion may result in a flatter and unaesthetic smile arc."
According to John C. Kois, DMD, MSD, director of the Kois Center and affiliate professor of the Graduate Restorative Program at the University of Washington, there are four key components of the smile that affect dento-facial esthetics. The first is the skeletal position of the maxillary and mandibular jaws. The second is the teeth, specifically their dentoalveolar position, shape, biomechanical status, and color. The third is the position and symmetry of the gingival architecture. The fourth is the movement characteristics of the lips.
"There are so many aspects to dento-facial esthetics; it's not just what we do with the teeth," emphasizes Ronald Goldstein, DDS, clinical professor of oral rehabilitation at Georgia Health Sciences University—School of Dentistry. "There's a lot of study and understanding required to treat the overall face."
The first step is examining the eight different muscles affecting the lower part of the face, including the orbicularis oris, mentalis, levator labii superioris, nasi, major and minor zygomaticus, and even the platysma, Goldstein says. These affect the lower part of the face with expression. There are genetic and aging factors, as well as facial bones to consider.
"The facial skeleton, including the teeth, supports the soft tissue, and adjacent soft tissue esthetic units influence each other," notes Constantinos Laskarides, DMD, assistant professor and course director of oral and maxillofacial surgery at Tufts University School of Dental Medicine.
For example, depending on the patient's age, if esthetic adjustments are rendered to the forehead in between the eyes alone (ie, using injectable neurotoxin), changes occur in the lower and mid face, explains Warren Roberts, DMD, a private practitioner in Vancouver, Canada, who also heads a study club dedicated to dento-facial esthetics. Similarly, when someone presents with a hyperactive platysma muscle in the neck, that muscle inserts at an angle of the mouth, pulling the mouth down. If that muscle can be relaxed, the angle of the mouth is affected.
"We have now come into the era when dentists can treat total facial esthetics. It is impossible to separate the smile from the rest of the face," says Louis Malcmacher, DDS, president of the American Academy of Facial Esthetics. "Patients have lips, cheeks, chins, and all the soft tissue around the mouth. All of that together with the teeth make up a great looking smile, and the realm of soft tissue esthetics is an important part of overall dental esthetics and total facial esthetics."
The lips, being among the soft tissues that affect the smile and facial esthetics, create a picture frame to the teeth and smile, explains Bruce G. Freund, DDS, CEO and co-founder of the American Academy of Facial Cosmetics. Detracting from the esthetics of the lips, similar to how craze lines detract from the teeth, are smokers lines, vertical lines above the lips. In addition, nasolabial folds from the corner of the nose to the corner of the mouth—which increase with age, and marionette lines—which extend from the corners of the lower lip down toward the jaw line, also affect the esthetics of the teeth and smile and overall dento-facial esthetics.
"Dental and medical professionals tend to practice what I call diagnosis by procedure. In other words, the diagnosis is not as much a diagnosis as it is seeing what I do as what bothers the patient," Sarver explains. "Let's use the gummy smile example again. If the person shows so much gingiva on smile to the point that it bothers them, the oral and maxillofacial surgeon feels that they need their upper jaw moved up; in the periodontist's office, they feel that they need their crowns lengthened; in the orthodontic office they may need a variety of things, but mostly orthodontic intrusion of the maxillary anterior teeth; and in the cosmetic dental office, the tendency is to recommend crown lengthening and/or veneers. As professionals, we owe the patient a broader vision and a more synergistic treatment plan."
This month, Inside Dentistry examines the current trends for correcting overall dento-facial issues that affect a patient's satisfaction with their appearance, with an emphasis on problems that can be addressed with dental treatments, injectable fillers and neurotoxins, and/or a combination of both. It is the goal of this feature to present information about what currently is possible—and to what extent—and by which professionals. Note: The statements and opinions expressed are solely those of the interviewees, and Inside Dentistry does not endorse or condone any specific treatment recommendation.
How Dentistry Can Enhance Dento-Facial Esthetics
Dental treatments such as restorative dentistry and orthodontics may affect a multitude of facial esthetic parameters, including upper and lower lip support, lip esthetics, horizontal and vertical proportions of the face (eg, especially the lower third), skin wrinkles, and lines, including perioral rhytids and nasolabial folds, explains Laskarides.
"Diagnosis is critical to determine which or how many components of the smile present a problem. Treatment would then be directed toward correcting the component or components contributing to the dento-facial esthetic compromise," Kois emphasizes. "For instance, skeletal problems are corrected with orthognathic surgery. Dentoalveolar position problems are best addressed through orthodontics; shape and biomechanical compromises with restorative dentistry; and color with whitening or restorative dentistry."
The position and symmetry of the gingival architecture would be corrected with esthetic crown lengthening, root coverage, and/or grafting, Kois continues. The hypermobile movement characteristics of the lips could be improved with surgery or injectable neurotoxin (eg, Botox), he adds.
"In restorative dentistry, we're talking about everything from restoring vertical dimension to building out the arches and also controlling the arrangement of teeth. In major cases, restorative dentistry has made a huge difference in facial appearance," Goldstein elaborates. "We deal in illusions in restorative dentistry, and the illusions work well both in proportion and sizing of teeth to the face, not just to the smile."
The problem lies in too few dentists being aware of the overall proportion of the smile to the face because it's not taught to the extent that it should be in very many dental schools, Goldstein observes. Understanding facial esthetics and total harmony requires additional study and understanding, he says.
"By bringing the teeth out facially, dentists can support the lip better, and by supporting the lip better, you support vertical lines above the lip, as well as the nasolabial folds. That's one way of using the teeth to make the facial esthetics look nicer," Freund suggests. "By lengthening the teeth dentists create a better-looking smile because as they lengthen the teeth, they might be angling them out facially, and by doing that, create the lip support."
Additionally, Freund says that when vertical dimension is re-established—something lost through wear and aging, the corners of the mouth turn down, which makes people look like they're frowning rather than smiling. By replacing the lost vertical dimension and raising the posterior teeth up higher, the corners of the mouth are raised, creating a younger appearance.
However, others suggest that esthetic dental treatments like veneers only treat the teeth and do not really affect the soft tissues that complete the smile. "What is esthetic about putting veneers on teeth when the patient still has thin, uneven lips, deep nasolabial folds, radial lip lines, and downturned corners of the mouth?" Malcmacher asks. "Yes, you have done the patient a wonderful service for their teeth, but it doesn't matter if you did 28 veneers on a patient because you have only given them great-looking teeth without treating and enhancing the oral and peri-oral area; you have not given them a great-looking smile."
Where Do Injectables Fit?
According to Laskarides, bothboth categories of non-invasive facial esthetic treatments—dermal fillers and chemical denervation (ie, Botox)—have a very wide range of both FDA-approved and off-label applications. These include improving lip volume to managing HIV-related lipoatrophy; alleviating glabella lines to improving an excessive gummy smile; improving nasolabial folds to elevating the corners of the mouth; and much more. In addition to dermal fillers and chemical denervation, there are other non-invasive procedures that may be included in the same discussion, such as chemical peels, laser skin resurfacing, mesotherapy, non-ablative radiofrequency treatments, and more, he adds.
"Botox and dermal fillers are perfectly suited for soft tissue esthetic dental treatment and can enhance the oral and peri-oral areas. Botox can be used for many dental therapeutic uses, such as treating radial lip lines commonly known as smokers lines, around the lips, excessive gingival display, facial pain, TMJ syndrome, bruxism, orthodontic relapse, downturned corners of the mouth, and myriad indications in the oral and maxillofacial areas," Malcmacher notes. "Dental therapeutic uses of dermal fillers include adding immediate volume to areas around the mouth, such as the nasolabial folds, marionette lines, and lips to create the proper lip lines, smile lines, and phonetics."
Botox and dermal fillers frequently are used in combination, especially in the lower half of the face where many esthetic problems require treatment of muscles as well as replacing volume in the face, Malcmacher explains. This is accomplished following comprehensive live patient hands-on training for dental esthetic therapeutics as part of an overall dental treatment plan.
Without question, the superficial appearance of the face is easily seen with aging, when there are more wrinkles. As the face ages, some of these wrinkles can be modified or made to look better with dermal fillers, and in some cases, Botox. According to Goldstein, a major treatment using Botox is helping to control the lip in high lip line cases where orthognathic surgery may need to be done to totally correct the high lip line, but the patient does not wish to undergo the surgical procedure. Or, if someone has a lip deformity where the lip rises more on one side than the other, Botox can play a role when injected by someone skilled in controlling where the lip goes and how much of it is raised and where, Goldstein says.
"Most times, we do that with illusion, but it's working with a plastic surgeon or a dermatologist to do that," Goldstein explains.
According to Sarver, Botox probably has the biggest application in treating the gummy smile by correcting a hypermobile lip that elevates more than normal. However, the drawback of using the neurotoxin for this purpose is the transient nature of its effects—only 6 months, which therefore necessitates repeat treatments.
The Combination Approach
As with most clinical treatments, whether a combination of interdisciplinary approaches or not, Laskarides says dento-facial therapies are appropriate only when the benefits of the procedure(s) outweigh the risks and the provider is trained, skillful, and knowledgeable enough to provide no less than the standard of care and manage possible complications.
Kois explains that when a patient presents to the dental team, the contributing components that are adversely affecting dento-facial esthetics would be evaluated. Many times, the ability to do orthognathic surgery or more invasive therapies is not an option for all patients. Dentists are then in a quandary about other minimally invasive options that would be effective to offer their patients that could help the patient achieve the desired outcome.
"If the patient has vertical maxillary excess, the most appropriate treatment would be orthognathic surgery. It is also obvious today with some of the advances in surgically assisted orthodontics that some of these patients can be corrected even with orthodontics," Kois observes. "However, when the lip moves in excess of 10 millimeters, it is impossible to achieve an outcome that doesn't display a gummy smile without making the teeth longer than is usually pleasing."
Therefore, when the lip mobility can be decreased, the concerns for a gummy smile can be reduced without the need for more invasive treatment, Kois elaborates. The more problematic patients are those that have more than one of the problems at the same time. For instance, a patient that has vertical maxillary excess, short clinical crowns, and a very hypermobile upper lip typically presents with a more unattractive smile. By performing gingival surgery and reducing lip mobility, very often the patient's vertical maxillary excess can be masked and the outcome very acceptable.
"Additionally, we know that lip mobility decreases through aging; therefore, we may consider trying to manage lip mobility as an issue only during the more critical, youthful times when the patient is more bothered by that," Kois says. "As they age, they might not need it anyway and, therefore, they can get some correction for a period of time that it's the most important for them."
According to Goldstein, whose concept of dentistry involves group diagnosis and specialist consultations to achieve the best treatment plan possible, combination approaches to dento-facial treatment is almost always possible—if not appropriate. Such combination treatment can involve prosthodonists, orthodontists, periodontists, and plastic and oral surgeons.
"A clearer, more synergistic understanding of the problems a patient has is needed in order to determine what parts of the puzzle are suited to different specialties and treatments," Sarver emphasizes. "How would this patient benefit from my knowledge of dento-facial esthetics? Do they have a jaw problem and need rhinoplasty and veneers? That is true interdisciplinary treatment that combines the best talents in the right place so the patient benefits spectacularly."
According to Freund, cosmetic restorative dentistry enables dentists to close spaces, change tooth shape and color, and effect some changes to facial appearance with veneers or crowns and other procedures. However, if somebody has a high smile line and a very gummy smile, changing the tooth shape and whitening won't help this condition. Here, a combination approach involving injectable neurotoxin might be appropriate.
"By placing a little neurotoxin at the corners of the nose, you can prevent that muscle from lifting up, giving that patient some beautiful-looking teeth and taking away the gummy smile," Freund explains. "That's an example of where a combination would work well."
Similarly, marionette lines and creases at the corners of the mouth can be corrected by increasing vertical dimension by raising up the posterior teeth and/or, at the same time, placing filler at the corners of the mouth, Freund continues. This creates a latticework to lift up the skin and is another example of a combination approach that can be very easily accomplished by the dentist.
However, time of treatments and therapies is important, notes Roberts. He suggests that dento-facial therapies involving dermal fillers and neurotoxins are ideally performed prior to smile design, rather than after, particularly because Botox, dermal filler, and laser treatments could affect the appearance of incisal length, for example. Although having such treatments performed afterwards does not always yield an unattractive or uncomplimentary result, he advises incorporating completed facial esthetics into the smile design.
Who Makes the Call?
By far, the dental team has the best training for determining which key components of the smile are contributing to the dento-facial esthetic problem," asserts Kois. "They also have the best training for correcting those components."
Laskarides notes that only the dental clinician who will have adequate training, skills, and knowledge could be in the best position to determine which dento-facial cosmetic services are needed.
"A dentist is an expert in facial esthetics, and they have to be. They are giving injections all day long which create anesthetics in the facial area and affect different muscles of the face, so they have to know the anatomy inside and out," Freund emphasizes. "In addition, in order for a dentist to make a denture, a thorough knowledge of facial esthetics is required—such as the relationship of the eyes to the nose, and to the mouth and to the lips, and to the teeth. So, when it comes to determining what's needed to correct dento-facial problems, the dentist is the best one to make the call."
Roberts does acknowledge that decisions about which dento-facial treatments are needed could be interdisciplinary, but that ultimately if a dentist is involved, a much better treatment results. That's because dentists know the desired end result in terms of positions in the overall smile design—whether for the teeth, lips, etc.
However, Sarver suggests that the real answer is the individual with the better understanding of all of the disciplines (eg, restorative dentistry, orthodontics and periodontics, plastic surgery) and how to tie them together. Therefore, it's incumbent upon such an individual to be willing to take on the responsibility for coordinating an interdisciplinary team.
"We're really talking about interdisciplinary treatment planning and collaboration among a greater variety of professionals than we usually think of," Sarver asserts.
"When it comes to total facial esthetics, a dentist is the only healthcare professional who can really accomplish a combination approach because we are the only ones who can treat the teeth," explains Malcmacher. "A cosmetic physician can only take them so far, but if the patient walks out of their office with unsightly teeth, then that patient still has a long way to go toward reaching their esthetic goals. Once a dentist is well-trained to perform Botox and dermal filler procedures, they are the best choice for total facial esthetics."
Dermal Fillers & Botox in the Scope of Dental Practice
I believe the use of injectable dermal fillers and neurotoxins for dento-facial esthetic treatments should be in the scope of practice for dentists, only after adequate training, preferably by a nonprofit educational institution, such as a postgraduate course offered by a university, and not a company with commercial interest," says Laskarides. "However, at this time, neither dental nor medical schools provide undergraduates with this type of training. Currently it is commonly provided during specialty training in dermatology, oral and maxillofacial surgery, plastic surgery, and occuloplastic surgery."
Judging from the dentists that have attended programs at the Kois Center, the use of Botox in dental practice is growing, observes Kois, who estimates that currently 5 to 10% of the dentists he works with are using it. These dentists have taken additional training and been pleased with the outcomes they've generated.
Right now, nearly 35 states allow dentists to do both facial esthetic and therapeutic procedures with Botox and dermal fillers, and nearly all states allow dentists to use these materials for dental therapeutic and dental esthetic treatment, says Malcmacher, who works with many state boards in establishing educational requirements and protocols for facial injectable treatment in dentistry. "It is absolutely now within the scope of practice for dentists, both general dentists and dental specialists of all kinds, to use Botox and dermal fillers."
According to Freund, the medical profession in different states has hindered dentists' use of injectable dermal fillers and neurotoxins, despite the fact that dentists are experts when it comes to injections and the oral and facial anatomy they affect. He emphasizes the dentist's dual roles as oral physician (ie, tooth and tissue repair, implant placement or sinus lift) and anesthesiologist (ie, local and/or general), adding that with proper education and training in the specific guidelines for fillers and neurotoxins (eg, number of units, where to place), dentists can incorporate these options when appropriate into dento-facial esthetic treatments.
However, according to Gerard Kugel, associate dean for research at Tufts University School of Dental Medicine, while there may be guidelines for use of injectables, there currently are no dentistry-wide industry standards or regulations governing their use. This could present potential risks not only for patients, but for dentists, also, from a legal perspective.
While dentists are good at administering injections and loading anesthetic, loading a syringe with a neurotoxin is something different, says Goldstein. In particular, he emphasizes the need for training beyond weekend courses.
"I've seen many failures from dentists, unfortunately, who have taken weekend courses or one or two courses and then performed very difficult cases that really should have been in the hands of a prosthodontist or multiple specialists," Goldstein recalls. "You just can't compare what you learn in a weekend course to prosthodontic or periodontal residencies, or to what plastic surgeons have had in their years of training."
According to Malcmacher, the American Academy of Facial Esthetics provides more than 50 intensive courses a year that comprehensively prepare dentists in the use of injectable dermal fillers and neurotoxins in which instruction focuses on anatomy, physiology, pharmacology, mechanism of action, integration with dental esthetic and therapeutic plans, and live patient hands-on clinical diagnosis and treatment. He adds that it is important for dentists to learn through one-on-one comprehensive mentored training from a very experienced faculty and use their own patients as models so that they can see the results of their treatment.
"In Botox, if you're taking a course I really find that you're not going to be able to learn enough in one day to go out and do it with confidence," says Roberts, who teaches injectable neurotoxins for dentists at the Pacific Training Institute, as well as through The Botox Study Club. "My personal prejudice is that it should be a comprehensive introductory course."
Sarver feels it is perfectly appropriate for dentists to deliver care involving injectable dermal fillers and neurotoxins—providing they're properly trained and the treatment is medically and legally sound. However, Sarver clarifies that it is essential that they understand all the other options that a patient may choose from before selecting those alternatives.
Conclusion
According to Freund, with the proper education, training, and skills development, any dentist that is creative and artistic, whether cosmetic dentist, periodontist, orthodontist, or other specialist, can help provide comprehensive dento-facial treatment. And, where permissible within the scope of practice, this could involve incorporating injectable dermal fillers and neurotoxins.
However, Kugel emphasizes and reiterates that proper and thorough training is of paramount importance. If dento-facial treatments require dermal fillers and neurotoxin, referrals to skilled specialists can still provide the multidisciplinary treatment that will satisfy the patient's overall treatment objectives.
"It wasn't until truly I started reading cosmetic dental literature and attending cosmetic dental meetings that I realized what I didn't know," admits Sarver. "Now, we are very much committed to understanding the full scope of what there is to offer patients beyond what we can provide."
What can be provided to patients as comprehensive dento-facial esthetic treatments, however, is incumbent upon early diagnosis and intervention that cultivates an understanding of what the patient truly wants—with the dentist serving as the captain commanding the treatment ship, Goldstein asserts. Dentists should be arbiters of where the patient needs to go to receive the best treatment, part of which may be plastic surgery.
In the future, however, research may demonstrate additional beneficial dentally related uses for injectable neurotoxins, Roberts suggests. For example, he alludes to research involving hyper-activation of the platysma muscles in patients with risk factors for gingival stripping.
"In dentistry, we are on the tip of that iceberg. You have to sometimes step outside the box to consider what's possible. If we had 20 years ago told you that we were going to make a paper thin porcelain that would last, you would have laughed and said it's impossible because at that time, it was," Roberts says. "Now we are looking at things like parafunctional habits, which are detrimental to placing porcelain, and using Botox to lower all the thresholds, restore patients properly, and get them out of pain. Dentists and skeptics have to be a little bit open minded and not just think Botox is about wrinkles, but consider how we can incorporate it more into dentistry as the years go by."
