Dentists and facial aesthetics: a perfect match?

The picture and the frame: Ruth Brady explores why dentists are perfectly suited to the field of facial aesthetics.

A cynical, middle-aged teacher, whose face was well on its journey south, once sat next to me at a local pub quiz. Watching me score well on the anatomical questions, she enquired what I did for a job. After I informed her, she delivered her judgement with real authority: should she ever feel that she’d benefit from such a treatment, she’d go straight to a plastic surgeon and never consider going to a dentist.

Thankfully, an eminent plastic surgeon in Leeds disagrees, because he sends all the patients who don’t require surgery to me! I chose not to tell her this, though, as I didn’t want to even tempt her to become one of my patients. I’ve learnt over the years that the way to continue enjoying one’s work, in the latter stages, is to be a little bit more selective about who one treats, especially in this job!

Much of the general public held the same view as her until a few years ago, as well as some dental colleagues. And this is why I’ve been invited to write this article, to change that perception and encourage more dentists to understand why these types of treatment slot so harmoniously into the dental camp.

After all, we have such a widely transferable skill set. With the correct anatomically based training in facial aesthetics, added to our existing dental knowledge, we are actually the perfect professionals to deliver these treatments.

Why are we so suited to the job?

In the aesthetics procedures referred to as non-surgical, treatment is carried by injection-based techniques, not scalpels. Dentists handle syringes all day long, with great delicacy and stability, using multi-point finger rests on the face, something that was fundamental in our early training.

Unlike some other medical and non-medical personnel who carry out such treatments, we understand the need to be ‘anchored’ onto the patient’s face for precision and safety, since we handle both syringes and rapidly rotating instruments. And that is just the start!

Consider also the immense knowledge that we already possess regarding facial analysis, including jaw relationships, dental arch shapes, smile lines, lip and soft tissue support, profiles and facial angles, as well as that of temporomandibular disorders and its relation to masseter hypertrophy and widened jawlines. We also understand the psychology of how to treat a nervous patient.

All this information bears such direct relevance to the subject that we have an absolute head start on everyone else, if you will excuse the pun, before even training on the foundation level aesthetics courses.

I cannot emphasise enough how valuable my past dental experiences have been to my present aesthetics career, enabling me to achieve some quite amazing full-face improvements. Without this background of dental knowledge, I do not feel that I could perform to the same level.

Case study

In the full-face case pictured here, I made some quite dramatic changes to the structure of this dental nurse’s chin, cheeks, lips, peri-oral area and jawline. One could be forgiven for assuming these results were achieved by surgery. But, in fact, during one single three-hour session, her face appeared to be transformed.

I placed various hyaluronic acid dermal fillers, at differing depths, to give the desired structure and appearance, and I used a fine blunt cannula to do this.

It was inserted via tiny holes, created by a small introductory needle. Only one tiny bruise occurred on the jawline during the whole process, but nothing more.

There was no downtime, and she was back at work with me the next morning, looking and feeling beautiful.

Completing the look, the botulinum A toxin, which was injected into certain facial expression muscles a week earlier, started to take effect around the same time, stabilising the gummy smile and melting away the lines on the upper face. Her increase in confidence was as obvious as her increase in psychosocial wellbeing.

These treatments are not completely permanent and could require repeating from time to time to maintain the look, but they do cause the tissues to increase collagen production and help slow down the ageing process. The permanence of surgery can have its downsides too, for obvious reasons.

Picture and frame

When I qualified, a good aesthetic result was judged to be when new restorations blended in with the existing teeth, irrespective of the original shade.

I’m reminded here of a very embarrassing moment, when at a smart occasion, I kindly and discreetly whispered to the person next to me that there was some lipstick stuck to her front teeth. But rather than say teeth, I said ‘crowns’ by mistake. As the words fell out of my mouth, I wanted the ground to swallow me up. She looked at me with horror, enquiring how I knew!

Darker shades were commonly used in more mature mouths, blending in with the existing teeth, changes in scleral colour and maturing skin changes. But with new trends emerging, even older patients are asking for brighter, whiter, straighter smiles, while still desiring a ‘natural’ look.

When the new teeth clash with the way the rest of the face looks, the word ‘natural’ goes straight out of the window. The beautiful new ‘picture’ clashes with the older, tattier ‘frame’. The thinning lips with downturned corners and radiating peri-oral lines spoil the entire new look, the whole mouth area probably demarcated by deepening folds, caused by the mid-face fat cascading obliquely downwards.

The patient’s initial satisfaction with the look you have created suddenly changes gear when they realise that something doesn’t match. They either realise that the teeth look ‘false’ or the face, in contrast, suddenly appears to look older.

Worse still, as the new porcelain retains its youthful look, the facial appearance changes are in a fast decline as the hormone levels deplete. The parallel situation of wearing unnatural looking hairpieces on older heads comes to mind!

Frame upgrades

This is why it could be useful for you as dentists to be able to deliver facial aesthetic treatments alongside the dentistry. You are constantly improving the picture, so why not learn new skills to upgrade the frame?

The lips are the jewel in the centre of the peri-oral area. They frame the new teeth. When they deflate, they lose attractiveness. They are not just the organ for speech and a sphincter to provide a tight seal to the mouth, but they are also regarded as the only visible sexual organ! They bear a direct relationship to sexual attractiveness, which in itself can have an obvious knock-on effect.

Since you have the manual dexterity and the knowledge to analyse the frame while understanding the role of the supportive structures behind the lips, why not stretch your talents further and consider training in this field? It is such a rewarding thing to do.

The better I do my job, the more natural the results look, the more it goes under the radar, because people don’t look treated. Just so with restorations of the teeth, albeit with the modern desire for younger looking smiles! But the more they stand out as different from the age of the face, the more ‘false’ they look, just as when upper teeth are youthfully restored, but not the lowers.

Missing a trick

Should we be concentrating purely on teeth, as some suggest, even in the case of orthodontics?

If you still think that the answer is yes, then you are missing a trick! In previous times, improvements to lip support were achieved by altering the shape and fullness of the dental arch if possible, and that was all we could do, either orthodontically, restoratively or prosthetically. This was most obvious in full denture work, where tooth position could be so easily altered, and flange thickness could be enhanced to support the soft tissues.

The importance of a good soft tissue support by the dentition was never better demonstrated than when a patient took their full upper denture out and the cheeks and peri-oral tissues collapsed!

Conversely, provision of a new set of dentures offering good support could literally take years off the appearance of the face. Since fewer patients need full dentures nowadays, it is now useful to be able to restore the soft tissues by some other means, enabling deficiencies in the natural underlying dental support to be better masked.

Orthodontically, jaw relationship discrepancies can lead to compromised results. However, augmentation of the chin and peri-oral support on such adult patients can totally change that end goal and give rise to greater levels of satisfaction all round!

These techniques are now commonly used in a preventive way too, to slow down the ageing and stop tissue collapse, as well as to enhance or correct features, such as in facial reconstruction.

After good training and careful practice, the shape, definition, projection and smoothness of most facial features can be returned closer to the original form or improved still further.

Facial reconstruction

This is a field that I have moved into more recently. I have been improving the form and appearance of cleft lips, for example, for a few years by improving the symmetry and projection and Cupid’s bow. These procedures can be life changing to the patient, and so satisfying to deliver, but never more so than recently, while treating a major trauma case.

Last summer, a patient was referred to me for soft tissue correction after a horrific horse-riding accident. The surgeons used 26 plates to reposition the facial skeleton, using a recent photograph as a guide. There were areas of fat loss too and motor nerve damage.

The face on one side showed gross compensatory hyperactivity, while the other was almost paralysed. This highlighted the already afflicted appearance, even though the surgeons had done an amazing job.

Using the knowledge and techniques that I had practised over the past two decades, I have been able to transform her appearance to a point where she now looks and feels completely ‘normal’ again, and this has been the most humbling and satisfying experience of my 40-year career so far.

Full face analysis or feature isolation

If the lips and peri-oral area are now considered as the ‘frame’, they should also be harmonious with the rest of the face. What’s more, the invention of the flexible blunt cannulae has presented us with an arguably much ‘safer’ way of working within multiple layers right across the face.

So, the subject has now evolved into a full-face consideration, as opposed to the earlier way of analysing the features in isolation.

Using Steiner’s line – a hypothetical line that extends from the forward-most projection of the chin to the tip of the nose – it is possible to highlight, for example, whether the lips are over- or under-projected and to judge whether the chin is in the right position within the profile.

We have all seen patients whose lips are so projected that they appear to enter the room before the rest of the face, but this look is emphasised when the patient is retrognathic.

If chin projection was considered alongside lip augmentation, the unnatural result could be prevented, so long as the rest of the lip design was executed correctly to a realistic anatomical form.

In full-face analysis, the features of the forehead, chin, nose and cheeks are all considered, as the change in projection of one may require improvement of another, until the profile is back in harmony.

One gets used to understanding the discrepancies in the profile while viewing from the front, without turning the patient’s head. Dentists are already so good at this as we spend our working lives analysing the face from all angles, and it comes so naturally to us.

Psychological impact

Although some requests for treatment may be driven by pure vanity, in my experience, most people just strive to look for a better version of themselves, as it has a significant impact on their overall psychosocial wellbeing. To be constantly told that one looks angry, miserable or tired when, in fact, they aren’t, has a real negative affect on their mood.

When one looks in a mirror, the image of the face that stares back should fit with the emotions and perceived age of the bearer!

To be pleased with one’s image is an uplifting experience psychologically. To be embarrassed by a ‘gummy smile’, for example, or to possess exaggerated mentalis muscle action during forced closure of ‘incompetent lips’ can be upsetting to those afflicted.

Confidence levels increase after treatment, and life experiences can be enhanced, leading to more fulfilment in life overall.

Pain management

Botulinum toxin, used commonly across the face to smooth out unwanted wrinkles, also plays a big part in the treatment and prevention of temporomandibular disorder (TMD), by reducing the size and power of the masseter muscles, alongside spasm in other masticatory ones.

Since this treatment should encompass an analysis of the occlusion and reasons for the parafunctional habits, as well as the provision of a suitable dental appliance, only dental clinicians with an adequate knowledge in this field should carry it out.

However, there are many other medical and non-medical personnel injecting the masseter muscles, purely for aesthetic reasons, without realising the possible implications on the occlusion and health of the jaw joint.

Plastic surgery, without the surgery

Many people think the word ‘plastic’ has strange connotations when associated with surgery. The word comes from the Greek word ‘plastikos’, meaning ‘to change shape’.

In cosmetic surgery and dentistry, ‘plasty’ is used as a suffix in the name of many surgical procedures that are designed to bring about an improvement in shape, such as blepharoplasty, rhinoplasty and gingivoplasty, many of which involve the use of scalpels and traditional surgical techniques.

Nowadays, these changes in shape can often be achieved without surgery or any extended recovery period. One can completely alter the profile and frontal aspect of a face without causing any noticeable bruising.

To a patient, it can feel as though a miracle has been performed, as the change is instantaneous. As a dentist, it is extremely rewarding to be able to deliver such beautiful and natural results in this way!

One of my proudest moments was when a famous New York plastic surgeon responded to one of my posts, which showed a full face improvement. His comment was simple. He said: ‘Wow!’ Then, in response, the following day, he put on a similar result, achieved by surgery. I responded with another ‘Wow!’.

Dermal filler placement

Here is some food for thought!

Liposuction often uses larger cannulae in a brusquer action to release and extract excess fat and is considered to be surgical. In contrast, dermal filler placement uses fine cannulae in a delicate action for minimal bruising but is considered to be non-surgical. The former aims to reduce excess padding, the latter to deliberately increase the padding and structure.

Yet both aim to give a seamless definition to the body or face, with improved contours. So, aren’t these procedures, in effect, almost opposites of the same, be it surgical or non-surgical? Surgery is completely permanent and irreversible, whereas this type of treatment is not, but it still has a lasting impact as it changes the tissues by generating collagen production.

Conclusion

I hope that I have convinced many of you as to the value of these treatments as an adjunct to traditional dentistry.

Be under no illusion of the scale to which this subject is massively expanding, especially now that regenerative medicine has entered the ring!

For some of you, there could be a burgeoning career ahead that you had never considered going into before. I hope this article has raised some interest.

This article first appeared in Private Dentistry magazine. To receive a copy, sign up to Dentistry Club.

Follow Dentistry.co.uk on Instagram to keep up with all the latest dental news and trends.