Facial Aesthetics in Dentistry

Dentistry Today


Cosmetic dentistry has been one of the centerpieces for most dental practices and is no longer relegated to those few “cosmetic dentists” that have looked to limit their practices. Even if a dentist is only placing tooth-colored composite resins restorations, aesthetic principles need to fall into place to achieve an optimal result both clinically and facially. Unfortunately, most of the time we as dentists have limited ourselves to the intraoral arena of aesthetics when in reality, the beautiful picture you are painting inside the mouth does not stand alone but is only part of the story.
We all can do a magnificent job of making teeth look great and giving people a healthy and beautiful smile. Aesthetic dentistry has been an absolute boom over the last 30 years when it comes to such innovative techniques as teeth whitening and minimally invasive veneers. Now that the teeth are looking much better aesthetically, isn’t it time to consider the perioral areas around the smile? If the teeth look great but we ignore the rest of the face, then we have really limited what we can accomplish with aesthetic dentistry. 
The advancements in aesthetic dentistry have been nothing short of spectacular when you think about it. In terms of dental materials, composite resins perform better and are more aesthetic than ever before. Certainly, when the perfect self-bonded, strong-for-all-surfaces, no microleakage, bioactive-restorative material comes out, that will take us to the next level. However, we have a ways to go before that happens. Teeth whitening can now be done in less than one hour. Minimally invasive veneers at 0.3 mm can’t get much thinner. CAD/CAM and other technologies will definitely impact all of these areas in the future by making aesthetic delivery systems that will make procedures faster. The final result though will all be the same—patients will still be receiving a beautiful smile just like they are today. 
What can possibly be next in aesthetic dentistry? Once the teeth are straight, you can’t get them any straighter. Once the teeth are their whitest (for example a 010 shade as some patients request), you can’t get them any whiter. The question is, where else is there to go? How do we break through the plateaus we are at in aesthetic dentistry?

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It is certainly time to advance what we have done in cosmetic dentistry by incorporating the surrounding tissues outside of the mouth and completing the entire aesthetic dental picture that we are creating. It is about time that we realize that aesthetic dentistry does not begin or end inside the lips. Teeth need to fit into the entire framework of the face. This is especially true of the immediate areas which surround and outline the mouth. While expectations include a perfect midline, golden proportions, white teeth, and exquisite occlusion on your completed aesthetic makeover case; if unsightly nasolabial folds, marionette lines, and downward facing oral commissures frame your patient’s nice white teeth, then there is something missing from the aesthetic result that you are trying to create.
Most photos that I see of dental aesthetics are retracted intraoral views of the final result. You can certainly see in the retracted view that the margins are precise, embrasure form and the emergence profile are correct, and all other accepted dental principles have been met. That is the picture that seems to impress dentists the most, when in reality no one else in the world looks at or really even cares about that view. We need to start looking at the view that is most important to the patient and to everyone else—that is the full-face view of a finished case. It is time to provide a complete case of aesthetics that would include both hard and soft tissues, in and out of the mouth.


Dermal filler therapy restores the lost volume in the soft tissues of the face. Younger people have that “baby face” smooth skin look which fills their cheeks and face. As people age, volume is lost as collagen and the fat pads dissipate and people develop deeper folds and/or wrinkles in their face.
Dermal fillers have been widely accepted by patients worldwide as a correction of this aging process because of their immediate effects, reasonable cost, and ease of delivery. If you are a male, you may not know what I am talking about. Ask the females in your life and office if they have heard of dermal fillers. Start asking patients if they have ever had botox or dermal fillers, and you will quickly find that these are immensely popular aesthetic therapies.
As a general rule (with many exceptions), aesthetic injectable treatment includes botulinism toxin (Botox Cosmetic) for the top half of the face and dermal fillers for the bottom half of the face. Dermal fillers are primarily used for the nasolabial folds, the oral commissures, and the marionette lines. These are the areas that frame the teeth and are certainly within the realm of every dentist to treat. We already inject these areas on a daily basis so we are very familiar with the anatomy of the lips and surrounding areas. Dermal fillers are gently placed in these areas through an extraoral injection right underneath these folds and creases to plump them up. The only difference is that you typically inject these areas intraorally when you deliver local anesthesia. As a general dentist, although you may not realize it, you are already familiar with the anatomy in these areas. Dermal filler materials are easy to deliver. They are injected underneath the skin in the nasolabial fold, marionette lines, and oral commissures which add volume to these facial areas, plump them up, and smooth out the facial wrinkles. Lip augmentation is also done with dermal fillers. As we age, our lips get thinner and the corners of lips begin to turn down. A little bit of dermal filler material properly placed in the lips can make a huge difference in the end result of any cosmetic dental case.


Certainly, a dentist should not pick up dermal fillers and begin injecting patients. Training is an absolute must in developing the proper clinical and aesthetic skills to deliver this treatment successfully. I have trained many dentists in dermal filler and botulinism toxin facial injectable therapies. Dentists are by far the easiest healthcare professionals to train in these areas. There is a very short learning curve for dentists since they already know how to deliver injections.
Dentists need to have competency in understanding the mechanisms of these materials and also need to review and understand the facial expression muscles. In addition, one must learn the indications, risks, and benefits of these treatments and hands-on live-patient training in placing these materials and in preventing/managing complications is very important. Dentists also need to learn how to integrate these aesthetic therapies with aesthetic dental principles and challenges such as high lip lines. With some practice, one can be well on the way to performing these procedures. Many state dental boards allow dentists to deliver these aesthetic facial injectable therapies within the realm of dentistry. Liability insurance companies are also starting to cover botulinism toxin and dermal filler therapies after a dentist shows proof of proper training.


One of the biggest advantages a dentist has, in performing dermal filler therapy, is the ability to deliver profound dental anesthesia for these procedures. Most of the other health professionals who delivered this therapy are poorly educated in dental anesthesia techniques and, even after learning them, are unable to do these procedures as well as any dentist can. Therefore, what usually happens is that most dermatologists and plastic surgeons forego dental anesthesia and use some form of topical anesthesia cream or ointment on the skin for a period of 20 to 45 minutes prior to performing dermal filler therapy. It has been my observation that most of the patients that I witnessed who had used only topical anaesthetic creams were very uncomfortable during the procedure and immediately stated that they would never go through this again.
Traditionally, plastic surgeon and dermatologist offices are the most common providers of these services. What I mean by that is that most dermal fillers are placed by nurses and medical aestheticians who work in an office of a plastic surgeon or a cosmetic dermatologist. I am not putting anybody down, but I would bet when it comes to injection experience and technique, oral and facial anatomy, and the natural skills that are required to provide these services, dentists are much better trained in these areas than plastic surgeons, dermatologists, or their employees.
In the past, we as cosmetic dentists would try to build a relationship with plastic surgeons and try to work on aesthetic cases together and establish a cross-referral arrangement. Very few dentists were ever successful at this. This was because most plastic surgeons were not convinced that this relationship would be fruitful because of the dentist’s lack of knowledge of plastic surgery procedures. As my experiences have grown in the realm of dermal fillers, and in teaching and speaking with other healthcare professional colleagues, I have found that cosmetic dermatologists and facial plastic surgeons often wonder why it has taken so long for dentists to get into this field—especially when understanding that it is a totally natural fit and complement to everything that dentists are trying to accomplish in complete aesthetic dentistry. I have had many requests from plastic surgeons who want to take us out to lunch because we are now considered to be a strong referral source and they are much more interested in working with us as peers.

Figure 1. A 48-year-old female with moderate nasolabial folds.

Figure 2. JUVÉDERM Ultra (Allergan), a hyaluronic acid dermal filler, was used to return the volume in the patient’s face.

Figure 3. Thinning lips, mild nasolabial folds, and a high asymmetrical lip line on the left side were the patient’s main concerns.

Figure 4. The popular dermal filler Restylane (Medicis) smooths out the nasolabial folds, adds more volume to the face and lips, and corrects the lip line issue without surgical correction.


There are temporary dermal fillers, and there are permanent dermal fillers. Depending on the dermal filler used, the effects of dermal filler therapy can last anywhere from 6 months to a lifetime. Most healthcare professionals do not use permanent dermal fillers because if something goes wrong, they have just created a permanent problem that may need surgery to correct which becomes a liability. Most dermal fillers placed are overwhelmingly temporary in nature and will dissolve in a time period of 6 to 18 months.
The choice of dermal filler material is very important depending on the areas you are volumizing and correcting. It is essential to know which material you are using and as with everything else, the right material should be used and the right application.
There are a number of dermal filler materials on the market. Different types of collagen have been used in the past but are not very popular these days. Calcium hydroxylapatite is also a naturally occurring substance in the body and is used in a dermal filler called Radiesse (BioForm Medical). Radiesse is a thicker, more viscous material which may last longer than hyaluronic acid fillers as it takes longer for the calcium hydroxylapatite material to break down. Radiesse can be used for deeper facial folds but cannot be used for lip augmentation.
Hyaluronic acid dermal fillers are by far the most popular today. Hyaluronic acid is a naturally occurring substance in the body and is lost as we age. Hyaluronic acid adds volume to the facial structures and can create a very natural appearance. These fillers can be used for the areas of the lower face and also can be used for lip augmentation. Hyaluronic acid fillers are more fluid and may last anywhere from 6 months to one year. Some examples of dermal filler products in this category are Restylane (Medicis) and JUVÉDERM Ultra (Allergan). Figures 1 and 2 show before and after photos of a patient where a moderate nasolabial fold correction was done using JUVÉDERM Ultra. Figures 3 and 4 show before and after photos of a patient where Restylane was used with various techniques to correct multiple issues.
By their very nature, dermal filler therapies are temporary procedures and need to be repeated over time—usually every 6 months or so. For a dentist, this requires a little different thought process than the dentistry that we put into the mouth which we expect to last much longer—preferably 5 to 10 years, or ideally for the patient’s entire lifetime. Dermal filler therapy is much more like teeth whitening in terms of its temporary nature and the need for repeat treatments. Patients who have not had dermal filler therapy before need to be educated that this is a cosmetic therapy that needs to be repeated on a regular basis.
Interestingly, because of the temporary nature of the dermal filler materials, liability issues and treatment that can go wrong are very limited. The areas that you have treated with dermal fillers will completely return to normal within 6 to 12 months so there is no long lasting effect that occurs with this treatment. Most dental treatment is much more invasive than dermal filler therapy.


You would be amazed at the number of patients in your practice who currently use dermal filler therapy and botulinism toxin therapy. A dentist recently called me to relate that as they asked their team members if getting trained in dermal fillers is a good idea, some of the women in the office “confess” to the dentist that they have been getting botulinism toxin therapy and dermal filler therapy for a long time. He was shocked!
Dermal filler therapy is an immensely popular treatment. Any patient who has had this kind of therapy before doesn’t need any kind of education and they basically walk in and say, “Let’s get started.” They know what to expect and will be very pleased that you can attain a profound level of anesthesia to make this a completely comfortable experience.
Dermal filler procedures are easy to accomplish by general dentists with proper training. Patients are motivated to accept these therapies, are very comfortable with their dentist giving these injections, and prefer to have these procedures done using local dental anesthesia. With the thorough understanding of aesthetics that we have, all of this makes the dentist the healthcare professional of choice to deliver these procedures. Dermal filler therapy is the perfect complement and next breakthrough for aesthetic dentistry.

Dr. Malcmacher is a practicing general dentist in Bay Village, Ohio and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for CLINICIANS REPORT (formerly Clinical Research Associates), he has served as a spokesman for the Academy of General Dentistry and is a consultant to the Council on Dental Practice of the American Dental Association. He works closely with dental manufacturers as a clinical researcher in developing new products and techniques. For close to 3 decades, he has inspired his audiences and consulting clients to truly enjoy doing dentistry by providing the knowledge necessary for excellent clinical and practice management. His group dental practice has maintained a 45% overhead since 1988. He can be reached at (440) 892-1810 or dryowza@mail.com. His lecture schedule can be found at commonsensedentistry.com where you can also find information about dermal filler and botox training for dentists, building the best dental team ever, big case acceptance success, and sign up for his afforable monthly consulting programs, teleconferences, audio CDs, and free monthly e-newsletter.


Disclosure: Dr. Malcmacher reports no conflict of interest.