Written by Andrew M. Lewis, DDS, FACD, FAGD, FASDA Wednesday, 31 December 2003 19:00
Is dentists, we all have had training in removable prosthodontics, and we already know how to do "face-lifts" around the mouth, below the nose, and above the chin (Figures 1 through 4). Many of us have made "plumpers" (dentures that plump out the cheeks). Where there is no support for the lips and face due to missing teeth, we know how to add a border-molded flange to lift and support the face, and in doing so, counter gravity's downward pull on aging skin (Figure 5). This is what denture aesthetics is all about. It's defined as the cosmetic effect produced by a dental prosthesis that affects the desirable beauty, attractiveness, character, and dignity of the individual.1 Full dentures can make one look younger because there is almost no limit to what the dentist can create with them.2
|Figure 1. Edentulous smile with unsupported facial tissue.||Figure 2. "Face-lifted" smile"”a goal in denture fabrication.|
|Figure 3. Unsupported face with classic aging facial anatomy.||Figure 4. "Face-lift" around the mouth with dentures inserted.|
|Figure 5. Border molded flange to lift and support the face.|
The success of the cosmetic industry, including plastic surgery, cosmetic dentistry, and the popularity of the keep-fit industry, attests to a widespread concern that wrinkles, shifting body fat, and other "disfigurements" may inhibit or damage self-esteem and personal relationships. Concealment of age has become a preoccupation of the Western world.3
Until now, there has not been an intraoral device that could provide support for the face (as our aesthetic dentures have done) for our dentate patients. This article describes a new device and technique for providing noninvasive "face lifts" for dentate patients.
|Figure 6. "Angel Lift"-FDA approved intraoral prosthetic devices.||Figure 7. "Angel Lift" placed on stone
This technique involves the use of a newly introduced device called Angel Lift (Medical Matrix, LLC), which utilizes patented technology and is an FDA-approved intraoral prosthetic device that is noninvasive, custom-fitted, and removable (Figures 6 and 7). The device is a combination of a silicone compound and hardened resins. When in place, it will reduce and/or remove facial wrinkles, aging lines, and frown lines around the lip, chin, and cheek areas.
Common conditions that the Angel Lift devices (maxillary and mandibular) will improve are senior scowl, hollow cheek, vertical lipstick lines, marionette lines, and witch's chin. Neither occlusion nor speech is affected, and the patient has only a slight awareness that the devices are present in the mouth. The objective of this technique is to provide dentate patients with immediate and long-lasting face-lift effects without having surgery, shots, bruising, or healing time associated with invasive procedures.
FACTORS IN FACIAL APPEARANCE
|Figure 8. Facial muscles that attach to the orbicularis oris.|
In dentate patients, the lips rely on 2 types of support: (1) intrinsic support from muscles, fibrous connective tissue, and glands; and (2) support from underlying structures such as the anterior teeth and associated alveolar bone.4,5 Normal facial appearance and skin tone depend on the proper position and functional length of the muscles that attach to the orbicularis oris6 (Figure 8). These muscles include the zygomatic, quadratus labii superior, caninus, mentalis, quadratus labii inferior, triangularis, buccinator, and risorius.7 The loss of support of these muscles, combined with laxity of subcutaneous connective tissue and fat atrophy, result in an aging facial appearance. There is a deepening of the nasolabial fold, a drooping of the corners of the mouth, and a loss of vermilion border of the lips. There is a depression of the lips with exaggerated wrinkling. Occlusal wear and loss of vertical dimension make the chin more prominent, and the contours of the philtrum and mentolabial sulcus are altered.8
Radiation from the sun and smoking cause loss of elasticity and the formation of wrinkles. Smoking can speed up one's skin-aging process by up to 10 years.9 Adding volume to the face helps all of these physical characteristics,10 and this is accomplished with the Angel Lift technique. The devices do not make the lips any fuller, and they may cause some inward rotation of the lips.
Dr. Irwin Smigel has taught "nonsurgical face- lifts" for years by building out restored teeth to the buccal and facial, usually with bonding, veneers, and crowns. His technique helps reposition the muscles of facial expression and therefore helps restore a youthful appearance.11 There is a close functional and aesthetic interrelationship between the teeth, bone, gums, and lips. The overall lip shape and facial profile are the result of the underlying support as well as the amount of lip tissue available.12
Many people have temporary Botox injections (purified protein toxin produced by the clostridium botulinum bacteria) and/or collagen procedures done on an ongoing basis (usually every 3 to 8 months) in order to achieve face-smoothing and face-lifting results. They pay between $1,000 and $2,000 yearly, per lip area, for multiple treatments. Other people have invasive plastic surgery procedures performed. The Angel Lift devices are totally noninvasive and are very cost-effective for the patient because they last for years.
Included in the large number of people who can benefit from this noninvasive technique are hemophiliacs who desire a "face-lift" but have been unable to undergo invasive procedures and patients afflicted with Bell's Palsy (idiopathic facial nerve paralysis or Antoni's palsy), who have a unilateral drooping at the corner of the mouth and are unable to smile.13 We can bulk up the affected side on the Angel Lift device and give a lift to their drooping perioral area. As their face returns to normal, the device can be reduced accordingly. Anyone with facial asymmetries resulting from cancer surgery and even angular chelitis patients can benefit from the facial support provided by these devices.
I would recommend that the dentist consider completing any oral surgery in addition to any periodontal, orthodontic, and restorative treatment before performing the Angel Lift procedure. This is important for the overall fit and comfort of the intraoral devices, especially if any treatment will change the contours of the most distal teeth (where the clasps will attach) and/or change the contours of the vestibule.
|Figure 9. Before "cosmetic preview."||Figure 10. After "cosmetic preview" with rope wax in vestibules.|
So that you and your patient can have a clear understanding and realistic expectations of the benefits of the Angel Lift technique, I recommend that the dentist and patient do a "cosmetic preview" together. Using red rope wax (Hygenic Corp) in an amount that is estimated to achieve the desired results, place the wax in the vestibule (usually behind the cuspids), especially where there are any depressed areas on the face. I find red easier to see as compared to the whitish rope wax, but either will work. Involve the patient until you are both pleased with the results (Figures 9 and 10).
Take before-and-after photos of this cosmetic preview. Consider one copy for the patient, one copy for your records, and one copy for the Angel Lift laboratory. (A Polaroid photo can be sent with the case, or digital photos can be uploaded to the Web site at angellift.com.) Consider limiting the border of the photo from the nose to the chin because this is the area that Angel Lift will affect. Full-face pictures tend to have too much visual information, and the face-lift effects that we are creating are located only around the mouth area. I suggest that photographs be underexposed and taken at minus 2 f-stops at a 450 angle because this picture usually shows more of what we are able to accomplish with Angel Lift. I like to use my Polaroid Macro 5 (Polaroid Corp) at the 1x setting (with the right flash turned off) when I take my pictures from the patient's right side.
|Figure 11. Alginates with full vestibular roll, frenums, and last molars.||Figure 12. Stone models, not "over-trimmed." Note vestibular anatomy.|
|Figure 13. Capturing contours of the distal-most teeth for clasp attachment.||Figure 14. Upper Angel Lift platform.|
Take an alginate impression of both upper and lower arches, even though you may only be making one Angel Lift device. Be sure that you have captured the frenums and the full vestibular roll, including the contours of the distal-most tooth, on both sides, where the clasps will be located (Figure 11). Pour models in yellow stone and be sure to use enough stone to capture the entire vestibule. When trimming the model, be sure not to grind any of the vestibule away (Figures 12 and 13). Carefully pack and mail the case along with any photos and drawings. Be sure to indicate if you want 2 Angel Lifts, or specify if you require only 1 upper or lower device. Send the models to an Angel Lift laboratory. The lab will fabricate and return the platforms (Figure 14) to you in approximately 1 week.
|Figure 15. Waxed-up Angel Lift platforms ready for shipping.|
On the second patient visit, place the platforms gently on each arch and be sure they feel comfortable. Place red rope wax (as practiced in the "cosmetic preview"), and add and subtract as you and the patient desire until the patient is pleased. The rope wax will soften when it's in the mouth, making it easier to mold into the desired shape. For accuracy of fit, the wax should copy the frenums in their working and functional movements. Be sure the patient is standing when looking in the mirror. (Remember, we are fighting gravity, and the face will look different when lying back in the dental chair.) Place these waxed platforms in cold water so they won't distort, then return them on the models for safe shipping (Figure 15). For the second time, send the models along with any photos or instructions to an Angel Lift laboratory. The lab will process the case and return it in approximately 1 week.
|Figure 16. Pressure indicating paste to help identify pressure points.||Figure 17. Before Angel Lift close-up.|
|Figure 18. After "Angel Lift close-up.||Figure 19. Before and after Polaroids front, quarter, and side views.|
On the third patient visit (the delivery visit), use the same fitting and adjustment techniques as you would for inserting any removable prosthetic device, eg, Pressure Indicating Paste (Mizzy, Figure 16). After the patient's approval of his or her "new look," any modifications can be smoothed and polished using Angel Lift polishing burs. Take before-and -after photos for your records (which can be done moments apart!) and give the patient his or her copy, nicely presented with your business card, so they can tell others about you and their new Angel Lift devices (Figures 17 through 19).
|Figure 20. Computer enhanced. Note softening of black lines.|
The last photo (Figure 20) in this article is computer-enhanced to show the desired changes that Angel Lifts gave to my patient. Note the new fullness of both the mentolabial and nasolabial sulci, the softening of the hollow cheeks, and the reduced marionette lines. The witch's chin is greatly reduced, and there is an overall improvement in skin tone.
The Angel Lift devices are not designed for eating; if they are accidentally dislodged, they could break under excessive biting forces. However, in certain social situations, and with a little creativity, one can choose softer foods that don't require much force to chew. It is important to note that when the appliances are taken out of the mouth, the muscles and skin won't let the face fall immediately back to its original form, which makes this transition less noticeable. This limitation should be defined to the patient along with precautions for keeping the devices away from heat when they are out of the mouth. For daily maintenance, rinse the devices under cold water. It is not recommended to soak them in commercial denture cleaners or mouthwashes since this may affect the surface texture of the devices. On occasion, they may be placed in vinegar for 15 minutes or in a proprietary Angel Lift cleaning solution. Because of their design and location in the vestibules, these devices are much easier to clean than other removable devices because most of the surface is convex.
This article has described a new, noninvasive device and technique for achieving "face-lift" effects in a conservative manner. A license to provide the Angel Lift devices to patients is issued to dentists who complete a 1-day course and become certified in the technique. (The location, dates, and times of these certification courses can be found on the Web site.)
Incorporating this new technique into a dental practice can increase new patient flow, does not require the purchase of new equipment, does not involve significant chair time, and provides a noninvasive solution for many patients seeking improved facial appearance. We are catering to our largest patient base aging baby boomers. They are educated, have a long life expectancy, and are anxious to enjoy it by looking youthful and attractive for as long as possible.11
I personally have been using both upper and lower Angel Lift devices in my mouth, and my patients and friends say that I look 5 to 10 years younger. I place them in my mouth in the morning and take them out when I return home in the evening. I remove them only when I'm eating. My own experience is an excellent way to educate patients about this new technique.
1. Academy of Denture Prosthetics: Glossary of Prosthodontic Terms. J Prosthet Dent. 1977;38:79.
2. Goldstein RE. Change Your Smile, Quintessence Publishing Co., Inc., 1997;248.
3. Zarb GA, Bolender CL. Prosthodontic treatments for edentulous patients. Mosby, Inc. 2004;12;30.
4. Martone AL, Effects of complete dentures on facial aesthetics. J Prosthet Dent 1964:4:231-255.
5. McCartney JE. Prosthetic problems resulting from facial and intraoral changes in the edentulous patient. J Dent 1981:71-83.
6. Woodburne AM. Essentials of human anatomy. Oxford Univ Press. 1965; 216.
7. Boucher,CO, Hickey, JC, and Zarb, GA, Prosthodontic Treatment for Edentulous Patients, The C.V. Mosby Company.1975;7:336
8. Tautin, FS, Denture esthetics is more than tooth selection. J Prosthet Dent 1978; 40:2:127.
9. Dollemore D, Giuliucci M. Age Erasers for Men, Rodale Press, Inc. 1994;340-341.
10. Brandt F. The latest in facial rejuvenation. American Society for Dental Aesthetics, 27th International Conference on Aesthetic Dentistry, Bal Harbour, FL, 2003.
11. Smigel, I. The non-surgical face lift: restoring a youthful appearance by repositioning the muscles of facial expression. Contemporary Esthetics and Restorative Practice, Oct,.2000;12-14.
12. Rifkin, L.., Creating Beautiful Smiles. Anti-Aging and Cosmetic Surgery Magazine. Issue 3.
13. Univ. of Pittsburgh Medical Center. http://bellspalsy.upmc.com/Diagnosis.htm. Oct. 10, 2003.
Disclosure: Dr. Lewis lectures nationally and internationally for Medical Matrix, LLC.
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