Aesthetic treatments to create a more youthful appearance have become increasingly popular
and many adults are specifically seeking cosmetic enhancement of the lips and smile. However,
deficiencies in dental volume frequently need to be corrected or camouflaged in order to restore
peri-oral contours to a more youthful and dental aesthetic form. This case report is presented as an
illustrative example of the challenges of re-establishing facial harmony and masking underlying
dental problems to re-establish proper dental aesthetics using dermal fillers.
The following patient presented for dental aesthetic therapy with a chief concern of a "jowly
appearance," and a comprehensive dentofacial assessment was performed. The oblique extra-oral
view (Fig. 1) demonstrated the patient's macro-aesthetic features with pertinent findings being:
Her profile image (Fig. 2) exhibited
significantly retruded lips and an excessive
mentolabial sulcus. Upon smiling,
asymmetric lip elevation was apparent
and the quality of her smile appeared
notably guarded (Fig. 3). Examination
of her profile while smiling (Fig. 4),
revealed significant retroclination and
retrusion of the dentition of her upper
incisors (relative to Andrew's goal anterior
- Descent of the anterior cheek mass and prominent nasolabial folds which hide the
- A "jowled" appearance with reduced definition of the jawline and mild volume loss in
the pre-jowl sulcus lateral to the chin pad.
- Downturned oral commissures and marionette lines which will prevent showing the
dentition when she attempts to smile.
- Reduced vermillion display of the lips resulting in improper lip and smile lines relative
to the dentition.
During the patient interview, it
was disclosed that she had been treated
orthodontically as a child and that
four bicuspids were extracted as part
of her orthodontic treatment. While
dentoalveolar deficiencies are frequently
due to congenital underdevelopment,
they can also be produced
orthodontically through over-retraction
of the dentition, especially in
bicuspid extraction cases. Extractions
might indeed be necessary in a number
of cases to achieve both macroaesthetic
and micro-aesthetic goals in
treatment, but the decision must be
approached with regard to the facial
changes that occur with age. Orthodontic anchorage also must be carefully managed to avoid
facial decline. Although it would be unwise to make assumptions about the nature of this
patient's hard tissue insufficiency, it is obvious that deficient hard tissue support from the
dentition has contributed to her accelerated soft tissue descent, which is her chief concern.
Ideal dental aesthetic rejuvenative treatment for this patient would include surgically
assisted orthodontics and veneers to improve incisor position, color and contour as well as
restore dentoalveolar volume by moving tooth mass forward in the face. An increase in dental
volume through orthodontics and veneering would also facilitate improved volumization with
dermal fillers as the soft tissues become more responsive with adequate hard tissue support.
However, the patient declined treatment of the dentition. The patient also elected not to
address her asymmetric lip elevation with botulinum toxin (Botox) as this was not a major
concern for her.
Restoring Peri-oral Volume
Achieving greater dental and facial harmony using dermal fillers requires comprehensive
treatment of the peri-oral region and lips to mimic what would have been achieved with the
orthognathic surgery that she declined. Treatment of the patient's pre-jowl sulcus, labiomental
fold, and marionette lines will produce a more defined jawline and bring the depth of the
labiomental crease more in line with the lower lip and chin. Volume added adjacent to the
chin and to the marionette lines will help to lift the patient's down-turned oral commissures
by increasing structural support. Additionally, volumization of the patient's nasolabial folds
will attenuate the droopy appearance of the anterior cheek mass so that the upper lip will have
more support and she can have a wider aesthetic smile. The lip augmentation will address the
patient's diminished vermillion display and attempt to create fuller lips to establish a proper smile lip line, where, in a full smile, the bottom of the
upper lip will straddle the gingival margins of the upper
central incisors. Focusing solely on facial lines and folds
would fail to address the underlying dentoalveolar insufficiency
and lead to an unbalanced result.
The clinician must be fully aware of the dynamic
interplay between different facial regions and how each affects the other. For instance, volumizing
the labiomental crease, though important in addressing the soft tissue consequences of
deficient dentoalveolar volume, can reduce lower vermillion display. Alternatively, volumization
of the nasolabial folds can weigh down the oral commissures from the additional mass
added superior to the lips and would negate the positive effects achieved by treatment of the
marionette lines. Furthermore, treatment of the peri-oral regions without lip augmentation
would negatively impact vermillion display, increase relative lip retrusion and would not
accomplish the dental aesthetic goals that need to be achieved.
In order to facilitate precise delivery and placement of the dermal fillers, profound anesthesia
was attained prior to treatment by performing long buccal, infraorbital and mental dental
blocks 2% lidocaine with 1:100,000 epinephrine.
The lower lip-chin complex was treated first. Radiesse 1.5ml (Merz Aesthetics), a
resorbable calcium hydroxylapatite material in a gel carrier, was the author's dermal filler of
choice for volume restoration in this region. Prior to delivery, the Radiesse was mixed with 0.3ml of 2% lidocaine without epinephrine. Due to the abundance of vasculature crossing the
jawline in the area of the pre-jowl sulcus, a flexible cannula 27g x 38mm was used to prevent
intravascular injection and to reduce bruising. A small entrance hole was made with a 21g x
1.5 in needle (Terumo Medical) to facilitate entry of the cannula into the deep dermal layer.
Approximately 2ml of Radiesse were delivered into the pre-jowl sulcus, labiomental fold and
marionette lines. Molding and smoothing of the delivered dermal filler material was performed
Following treatment of the lower lip-chin complex, the nasolabial folds were filled using
1.5ml of Radiesse using the same cannula technique described above. Care was taken not to
over-treat the nasolabial folds and counteract the lift to the oral commissures attained by treatment
of the marionette lines.
Subsequent to treatment of the perioral regions, lip augmentation was performed.
Juvederm XC 1.0ml (Allergan), a resorbable cross-linked hyaluronic acid with lidocaine, was
utilized for ideal lip volumization. A total of 0.8ml Juvederm XC was delivered into the bodies
of the upper and lower lips until an appropriate relationship to the surrounding soft tissues
was achieved. Particular attention was paid to the labiomental crease. The delivered material
was sculpted to provide appropriate contours and the remaining 0.2ml of Juvederm XC was
used to fill superficial rhytids.
The final result was assessed three weeks post-operatively (Fig. 5, 6). The patient's dental
aesthetic and facial balance was enhanced remarkably. There was notable improvement in the
jawline, labiomental crease, oral commissures, vermillion display, lip lines, smile design and
lip contour. Additionally, she smiles with much more confidence in spite of unaddressed dental
issues (Fig. 7).
Injectable pharmacologics such as Botox and dermal fillers have now become mainstream
in the dental profession. This clinical case demonstrates the profound role dermal fillers in the
oral and maxillofacial areas can play in addressing dental aesthetic problems integral to treatment
of the smile and peri-oral region.The relationships between a patient's dentition, the surrounding
soft tissue and the patient's facial characteristics are both intimate and dynamic and
cannot be ignored. I would highly recommend that all dental professionals become interested
in providing these dental aesthetic treatments themselves as all dentists have the skill set to
learn how to successfully place Botox and dermal fillers. Having had extensive training with
the American Academy of Facial Esthetics, I personally have become very comfortable with
the utilization of injectable pharmacologics in practice as primary therapy for dental aesthetic
and dental therapeutic uses and find them extremely important in expanding the treatment of
aesthetic dental options.
As health-care professionals delivering therapeutic treatment in the oral and maxillofacial
areas, it is our moral, ethical and legal responsibility to give the patient all of the available
options for treatment. The American Academy of Facial Esthetics teaches over 80 live patient
training programs annually for dentistry including at dental university continuing education
programs and major dental meetings. It is time for every dental professional to learn to provide
these services so they can provide non-invasive and non-surgical excellent aesthetic and
therapeutic outcomes for their patients.
* Dentistry performed by Dr. Scott Frey