Total Facial Aesthetics for the General Practitioner

Dentistry Today
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Cosmetic dentistry has been one of the backbones in every dental practice for the last several decades. Any dental practice that is placing tooth-colored composite resin restorations is certainly practicing under the cosmetic dentistry umbrella with most dentists performing whitening procedures, aesthetic crowns and bridges, and veneers. All of these topics have become part and parcel of daily dental practice worldwide. Dentistry has made huge advancements in the cosmetic realm and now that cosmetic dentistry has evolved to being a staple in every dental practice, you really have to ask yourself what is coming up next in the cosmetic dental field.

Before Image. Preoperative intraoral condition before any treatment with porcelain veneers..
After Image. Lifestyle total facial aesthetic photograph of a very pleased patient.

Figure 1. Patient feels her first set of veneers are too bulky and too opaque, but is not yet ready to have her work redone.

Figure 2. Patient presents 6 months later, wanting a total facial aesthetic consultation and exhibiting substantial problems with her initial veneers.

Figure 3. Retracted view of broken veneers due to problems with her occlusion, material choices, and bonding failures.

Figure 4. Retracted view after removal of initial porcelain restorations.

Figure 5. Right retracted preparation view.

Figure 6. Left retracted preparation view.

Figure 7. Seated case—notice the lifelike appearance of the veneers and crowns demonstrated by the texture and translucency.

Figure 8. Close-up view demonstrating excellent gingival response.

I have taught aesthetic dental courses for dental professional for years. We have said that if a dentist puts veneers on 4 to 6 teeth, typically cuspid to cuspid, you are giving patients great looking teeth. If you place 8 to 10 veneers and fill up the buccal corridors by veneering the bicuspids, then you are giving patients a great looking smile.
In truth, no matter how many veneers you place in a patient’s mouth, you are still only giving that patient great looking teeth. A great looking smile encompasses the teeth as well as all of the soft tissues around the mouth. Why in the world should a patient leave your office with these beautiful white teeth with deficient lips, wrinkles around the mouth, and deep nasolabial folds? Extend that further to the oral and maxillofacial areas and, if you can perform extraoral soft-tissue as well as intraoral soft- and hard- tissue aesthetics, then we enter the realm of a new category called total facial aesthetics.
Botulinum toxin (BOTOX) and dermal fillers have made a huge impact in the elective aesthetic field. By far, these are the 2 fastest growing cosmetic treatments, especially over the last 7 to 8 years. The dollar amount spent on BOTOX and dermal fillers far exceeds the combined dollars spent for breast implants and liposuction. No other healthcare provider in the facial aesthetic field cares about or is more proficient with proper aesthetic smile lines, lip-lines, vertical dimension, and phonetics than the dental practitioner. Since these procedures are all delivered through a series of injections, I would submit dentists are the most skilled injectors based on our training and daily practice.

THE QUICK BOTOX PRIMER
BOTOX is a trade name for botulinum toxin, which comes in the form of a purified protein. The mechanism of action for BOTOX is really quite simple. BOTOX is injected into the facial muscles but really doesn’t affect the muscle at all. Botulinum toxin affects and blocks the transmitters between the motor nerves that innervate the muscle. There is no loss of sensory feeling in the muscles. Once the motor nerve endings are interrupted, the muscle cannot contract. When that muscle does not contract, the dynamic motion that causes wrinkles in the skin will stop. The skin then starts to smooth out, and in approximately 3 to 10 days after treatment, the skin above those muscles becomes nice and smooth. The effects of BOTOX last for approximately 3 to 4 months, at which time the patient needs retreatment.
The areas that BOTOX is commonly used for are smoothing of facial wrinkles in the oral and maxillofacial areas. BOTOX has important clinical uses as an adjunct therapy in temporomandibular joint (TMJ) and bruxism cases, and for patients with chronic TMJ and facial pain. BOTOX is also used to complement aesthetic dentistry cases, as a minimally invasive alternative to surgically treating high lip-line cases, for denture patients who have trouble adjusting to new dentures, periodontal cases, gummy smiles, lip augmentation, and also for orthodontic cases where retraining of the facial muscles is necessary. No other healthcare provider has the capability to help patients in so many areas as do dentists.

THE QUICK DERMAL FILLER PRIMER
Dermal fillers will volumize creases and folds in the face in areas that have lost fat and collagen as we age. After age 30 years, we all lose approximately 1% of hyaluronic acid from our bodies. Hyaluronic acid is the natural filler substance in your body. The face starts to lack volume and appears aged with deeper nasolabial folds, unaesthetic marionette lines, a deeper mentalis fold, thinning of the lips, and turning down the corners of the lips. Hyaluronic acid fillers such as Restylane and Juvederm Ultra are then injected extraorally right underneath these folds to replace the volume lost, which creates a younger look in the face. Dermal fillers can be used for high lip-line cases, asymmetrical lips around the mouth, lip augmentation, and completing cosmetic dentistry cases by creating a beautiful, young-looking frame around the teeth. The effect of dermal fillers typically last anywhere from 6 to 12 months, at which point the procedure needs to be repeated. Both BOTOX and dermal fillers are procedures that take anywhere from 5 to 15 minutes.
There is one huge advantage dentists have in delivering dermal fillers over any other healthcare professional. Most physicians and nurses use topical anesthetics and ice on the skin to numb the patient. Some actually learn how to give dental anesthesia, but very few are proficient at it. As you may imagine, this will be a painful procedure when done this way. Indeed, this is the reason that many patients prefer dentists to deliver dermal fillers.

CASE REPORT
The patient is a 42-year-old female who approximately 2 years ago wanted a smile makeover. We did not see her initially; the first picture of her (showing her preoperative smile) came from another dentist (Before Image). The patient had presented with a Class 1 occlusion and a midline discrepancy. Periodontally, she was healthy. She desired a more even appearance to her teeth and a whiter color. The midline discrepancy was of no aesthetics consequence to her. She also requested a minimally/noninvasive approach to veneers. All-ceramic crowns had been placed on teeth Nos. 8 and 9 and they did not quite match the shade of her natural teeth. Although the shade discrepancy was minor, this concerned her. She had read about a popular minimally invasive veneer technique and was referred through a cosmetic referral service for veneers.
The photo in Figure 1 shows the same patient after her minimally invasive veneer treatment. This was taken when she first presented to our office. She expressed disappointment with the veneers done by her previous dentist for a few reasons. She felt that the teeth had no character, were “dead looking,” and not lifelike at all. She especially felt that her cuspids were too bulky, both in their appearance and in the feel of them on the inside of her cheeks. This picture is representative of the biggest challenges and complaints that many dentists have about no prep/minimally prep veneers—that they can often appear too opaque and too bulky. At this point, the patient was not yet interested in further treatment to correct her smile, even though she was unhappy with the results.

Importance of Occlusion
This case clearly demonstrates the important role of occlusion in a restorative/aesthetic case. Figure 2 shows this same patient a few months later. She was still unhappy with the appearance of the veneers, but a much greater concern were the fractures that had occurred. Figure 3 shows a retracted close-up view of her case. The incisal one third of the veneer had broken on tooth No. 5; the veneer on tooth No. 7 had completely come off and a temporary veneer had been hastily placed; and the all-ceramic crown on tooth No. 8 had fractured at the gingival third. This is a combination of material and bonding failures as well as poor management of the case from both a clinical and laboratory perspective.
Upon occlusal examination, her occlusion had not been equilibrated within normal limits. This patient also reported having facial pain on both sides of her face and in her temple areas. (Notice how square the angles of her jaws appear.) This was not due to her skeletal structure but to the excessive function of her masseter muscles. That, combined with the contraction intensity of her masseter and temporalis muscles, significantly contributed to her facial pain. The patient also requested a total facial aesthetic evaluation and complained about her marionette lines, which ran from the corners of her mouth down to her chin. She also expressed an interest in smoothing the facial wrinkles around her lips, the crow’s feet wrinkles at the corner of her eyes when she smiled caused by the zygomaticus muscles, as well as the wrinkles in her forehead. You can now see the advantage that the dental professional has in all of these procedures. We are in a unique professional position and we can learn the skills to fully treat the patient.

Retreatment
Figure 4 shows the removal of all the veneer and composite materials, as well as the 2 all-ceramic crowns on teeth Nos. 8 and 9. Here is where this case really presents a challenge, and why working with a talented aesthetic dental ceramist really pays off. You can imagine that the all-ceramic crowns will be at least 3 to 4 mm thick circumferentially while some of the other restorations (Cristal Veneers [The Aurum Group]) may range anywhere from 0.3 mm to 1.0 mm on different teeth, and even on the same tooth. When working with a minimally invasive approach, the ceramist has to have an excellent understanding of the porcelain being used in order to provide the clinician with a finished case where the shades of all the different restorations will match. This is especially true when doing no-prep/minimal-prep veneers.
Figures 5 and 6 show the right and left retracted views in which all of the preparations, except the central incisors, are minimally prepared in enamel. When the appropriate materials are used to fabricate the restorations, keeping the preparations in enamel will certainly increase the final strength of this veneer case.

Facial Rejuvenation Therapy
The preparation appointment also included the following facial injectable treatment—BOTOX was delivered to the following sites: 12 units to the forehead area for the forehead wrinkles and facial pain, 8 units in each lateral obicularis oculi for the crow’s feet wrinkles, 12 units in each temporalis muscle and 20 units in each masseter muscle for the treatment of facial pain and to reduce the intensity of the muscle contraction, and 7 units in the obicularis oris muscle to smooth the lip-lines. Approximately 0.8 mL of a dermal filler material (Juvederm Ultra) was placed in the patient’s marionette lines bilaterally as well as in her upper and lower lips to add subtle volume.

Completed Case
Figure 7 shows the completed case after insertion and after occlusal equilibration. The resulting veneers and crowns are excellent in terms of size and shape and have completely eliminated the bulkiness and lack of texture that the patient previously complained about. You can see the excellent adaptation, texture, and color match that was achieved with a closeup of teeth Nos. 7 through 10 in Figure 8. The dental laboratory ceramist did an incredible job in achieving this match, which makes my job seating these veneers incredibly easy. We were able to use the exact same shade of cement on every restoration in this case. This saves a tremendous amount of time by removing the guesswork normally involved in choosing different resin cement shades for different teeth because of the porcelain thickness differences of the restorations.
The full-face photograph of the patient is shown in the After Image. The patient reported that her facial pain was gone because of the equilibrations and the BOTOX therapy. Dermal filler therapy had smoothed out the lower face folds. Comparing this to the postoperative picture of the veneers she had previous to our retreatment; the new veneers appeared very lifelike, not at all bulky, have definition and with the combined treatment of facial injectables and veneers, we were able to go beyond the teeth and give this patient a great looking, natural smile.

CLOSING COMMENTS
This case demonstrates another interesting point when blending these procedures together—any dentist who has already been trained in both veneers and facial injectable therapy will tell you that in these kinds of cases, the BOTOX and dermal filler procedures are much quicker and easier to accomplish than the operative dentistry procedures. By comparison, the total treatment time for the veneers was approximately 2 hours in this case, while the treatment time for both BOTOX and dermal fillers was only 18 minutes.
Training is the key to developing the skills needed to handle total facial aesthetic procedures. There is a typically a short learning curve with facial injectables because dentists are already well-trained and comfortable with injections. One must become competent and have an understanding about: the mechanisms of these materials; the muscles of facial expression; and the indications, risks, and benefits of these treatments. It is important to participate in hands-on training in placing these materials and in preventing/managing complications. With proper training, you can be well on your way to performing total facial aesthetics.

Acknowledgment
Heartfelt gratitude is extended to the talented ceramists and the entire dental technician team at Aurum Group Ceramic Dental Laboratories for the technical work presented in this case.


Dr. Malcmacher is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, he is the president of the American Academy of Facial Esthetics. He is on the faculty of the American Academy of Facial Esthetics, which provides training in BOTOX and dermal filler procedures. He can be reached at (440) 892-1810, e-mail dryowza@mail.com, or visit his Web site, commonsensedentistry.com

Disclosure: Dr. Malcmacher is a paid consultant for Aurum Ceramics.

Dr. Krever is a board certified family physician specializing in aesthetic medicine and is a member of the International Association for Physicians in Aesthetic Medicine, the American Society of Laser Medicine and Surgery, the BOTOX Cosmetic Physician’s Network, and is a Diplomate of the American Board of Family Medicine. Dr. Krever is a leader in the field of nonsurgical aesthetic treatment. Dr. Krever is an outstanding educator known for her dynamic teaching style. She is on the faculty of the American Academy of Facial Esthetics, which provides training in BOTOX and dermal filler procedures. She can be reached at kkreve@gmail.com.

Disclosure: Dr. Krever reports no conflicts of interest.

Dr. Feck has an extensive background in cosmetic dentistry and facial aesthetics. He is a sought after speaker, educator, author, and practitioner of dental-facial cosmetics. Dr. Feck has a special interest in clinical pharmacology as it relates to medical and dental practice. Dr. Feck practices in a multidoctor practice in Lexington, Ky, that concentrates on dental-facial aesthetics. He is on the faculty of the American Academy of Facial Esthetics, which provides training in BOTOX and dermal filler procedures. He can be reached via e-mail at tony@tonyfeck.com.

Disclosure: Dr. Feck is a paid lecturer for Aurum Ceramics.