Beauty is Skin Deep

With the popularity of television shows like “Extreme Makeover” and “The Swan,” the demand for cosmetic surgery is exploding. However, some of the most dazzling transformations on these TV programs are not due to chin implants or liposuction but rather because of the new smile that is unveiled. Cosmetic dentistry is integral to facial esthetics and with the increasing demand for beautiful smiles, dentistry as a whole has an important role to play. As dentists and dental hygienists receive the most education and training and have the most experience in the peri-oral area than any other health care professional, why shouldn’t they participate in the facial procedures used to attain a beautiful smile? Louis Costa, II, DMD, MD, discusses facial rejuvenation procedures and how dentistry can benefit from entering this new age of facial esthetics.
—Dimensions of Dental Hygiene

Louis Costa, II, DMD, MD, is a board certified facial plastic surgeon and a dentist. He is the chief surgeon at the Southeastern Cosmetic Surgery Center in Charleston and an instructor at the Medical University of South Carolina, Charleston. His practice is entirely devoted to surgery of the face.

What are some of the smile problems that can be corrected and how are they corrected with facial esthetic procedures?

The most common issues are the detracting lines around the mouth, the lips themselves, and accentuated nasolabial folds. All of these peri-oral tissue problems can be treated with filler materials. The most commonly treated is the nasolabial fold that runs between the nose and the lip. The objective of all the filler materials is to thicken the subepithelial tissues to obliterate or make the wrinkles look less deep.

The wrinkles appear because the tissue is thin and the tissues around the mid-face actually drift down and forward with age. So the tissue that is damming up from the mid-line back to the mid-face manifests as wrinkles. If a patient over 40 with peri-oral wrinkles supports her cheeks up and back, those lines improve as do the deeper nasolabial folds. This is a true effect of aging but an alignment of the collagen fibers in these areas also allows a fold to develop that isn’t there when a more random alignment of those fibers exists. It seems to be a maturation of the collagen in the dermis as well as a migration of the tissues themselves.

The mesial drift of the facial tissue is down and forward, which creates nasolabial folds and a jowling effect. The buccal fat pad of the cheek migrates over the mandible and forms a jowl that obscures the jaw line. Laxity in the neck also occurs where patients who never had a double chin in their youth either have banding or a double chin as they approach their 40s and 50s. Then there are the marionette lines that appear where the commissures of the mouth begin to drop and the line gets longer and longer until it drifts below the inferior border of the mandible and becomes the typical puppet look. Nasolabial folds and the marionette lines are effectively treated with filler materials.

What are filler materials and how are they used?

The first and most popular filler material is Collagen^®. An injectable filler, Collagen derives from purified cow collagen. It does not contain any live cells and is sterile. One of its drawbacks is a high incidence of allergic reaction. The longevity also varies from 3 to 6 weeks to as long as 6 months, which is both an advantage and a disadvantage. If the patient is not pleased with the outcome, the effects disappear, but for those concerned with expense, its brief longevity is not very cost-effective.

Gore-tex is another filler called Soft Form^®. It is a permanent synthetic implant. In my practice there were problems with the distensibility. As the augmentation matured, the lip became stiff. Even though patients looked good in relaxation, they did not look good when they smiled because their commissures would not distend. So Gore-tex fell into disfavor with many doctors.

A new addition to the filler category is Restylane, which was approved by the Food and Drug Administration (FDA) for facial use in January 2004. Restylane is hyaluronic acid, a part of human skin. Restylane has several advantages: there is essentially no allergic reaction, it is sterile in its clinical form, there are no live cells involved, it has a clinical duration of approximately 9 months, and ease of application. Restylane does cost about twice as much as Collagen, but it lasts three times as long by most assessments. I think you generally get a better esthetic result with Restylane because it has fewer irregularities.

On the horizon for the face and currently used in other areas of the body is Radiance. It is microspherical hydroxyapatite and has been used in periodontal surgery, oral surgery, craniofacial surgery, and other parts of the body where osteosynthetic materials are desirable. It does not turn into bone when it’s injected into soft tissue. When Radiance is placed in the soft tissues of the sub-epithelium, it stays pliable. It has been used in other forms besides the the injectable, microspherical form for implants in checks, chins, and other augmentations. However Radiance is not FDA approved for the lips yet. It can be used legally off label, meaning it is FDA approved for use in the human body, but not specifically for the lips. Considered permanent, Radiance will most likely be released with a 5-year duration claim. It will be FDA approved for the anterior facial structures within the next year.

Cymetra is another filler material that is injectable human collagen. It doesn’t appear to offer any advantage over the bovine Collagen other than because it is derived from humans rather than animals, a skin test for allergic reaction is not necessary. But in terms of duration, it doesn’t last any longer than the bovine Collagen.

Are there other options besides injectable fillers?

Yes, fat autotransplantation and Alloderm are also used. With the fat injection, the advantage is that patients are not allergic to their own tissue. The disadvantage is that it requires surgery on another anatomic site of the body with those potential complications like infection and scar for access as well as if any irregular harvesting occurred. The fat is usually acquired by suction-assisted lipectomy. The longevity is also not much better than Collagen.

Alloderm is a subepithelial dermal graft harvested from cadavers. It is a portion of the human dermis that’s left with its original architecture, is dehydrated, and then rehydrated by the clinician with normal saline before use. Alloderm is also used in periodontal surgery. The lip augmentation procedure requires an incision at the corner of the lip, a tunnel is made side-to-side, and a strip of the Alloderm in the appropriate size is drawn into the lip with a retracting instrument. The ends are trimmed with a single suture placed at each corner and the lip augmentation is complete.

We have found the graft to be permanent but the clinical response has varied. At 1 year, 30% to 50% of our patients feel that their lip is smaller than after the initial procedure. I have gone into the lip later and the graft is still there so it’s either that patients get used to the swelling that occurs after the surgery and are a disappointed after it goes down or there’s ingrowth. Because the tissue of the lip is displaced with the implant, the muscular tissue and the surrounding tissue let themselves grow into the implant so the volume is less even though the graft is still present. On the other hand, 50% to 70% of our patients love it.

This procedure is done under local anesthesia. The dentist is far more adept at achieving anesthesia for these procedures than a medical doctor. Because it requires the same regional block for the maxilla, mental blocks for the mandible and/or infiltration in the buccal vestibules of each.The dentist is best trained to understand adequate pain control management and the anatomic changes being made to the patient’s smile.

Who can provide these type of treatments?

The average dental professional understands more about medicine than the medical professional understands about dentistry. Treating the lips with fillers and some of the more aggressive forms of treating the peri-oral tissues have traditionally been referred to a medical doctor.

Dentistry has put itself in a glass box. Most dentists and dental hygienists understand the anatomy of the lips and the tooth/lip relationship much better than any other medical counterpart. What medical profession focuses in the peri-oral area? None.

These procedures, by default, ended up with dermatologists and plastic surgeons, who have very little training in the interaction of the teeth with the associated peri-oral tissues. Dental professionals understand the peri-oral area as part of the intrinsic knowledge of their basic training. I have encouraged dentistry to believe that we serve the patient base better when we accept more of this responsibility and realize the role that we play.

Are dentists, with the training that they have, licensed to do these procedures?

This depends on the dental practice act in each state. Most of the practice acts provide for it and the verbiage that defines dentistry is treatment of the teeth, the supporting structures, as well as contiguous peri-oral anatomy. The lips are part of the oral-facial matrix that dental professionals are trained to treat. Your treatments are only as good as your diagnosis—in any setting whether it be cardiovascular surgery or dentistry.

What tends to happen in dentistry is when a patient presents with a poor tooth/lip relationship, dentistry tends to think it is all related to the cervical contours of the premaxillary area teeth. The diagnosis may be that the patient has a thin lip. When I encourage my dental colleagues and auxiliary staff to think outside the box, it is not simply a matter of ego or an interest in increasing the cash flow of the practice, it is a matter of what dental professionals are best trained to do. When a patient presents with an open bite, dental professionals should expand their diagnostics to include thinking that this lip needs lengthening or it would look better if it were fuller. And who is best trained and qualified to meet the patient’s objectives? In my opinion, more often than not, that would be an adequately trained dentist.

What precautions should dental hygienists take when treating patients with recent facial procedures?

Most of the injectable products are stable at 72 hours. As a rule of thumb, there shouldn’t be any retraction of the commissures. A rubber dam should not be placed. There shouldn’t be any intra-oral photography requiring retractors or an aggressive prophylaxis where the lips were retracted or a bite block placed less than 72 hours after an injectable application. In the elective, nonsurgical setting, x-rays should also be avoided.

What is the role of the dental hygienist in the facial esthetics arena?

I think the hygienist should be active in recommending this treatment to patients. Dental patients expect that their dental professional will be able to discuss esthetics with them. When patients say esthetics, they are not just talking about their anterior dentition. They’re talking about their smile, their face. If the dentist decides not to provide these types of services himself, then I believe that the dentist and/or dental hygienist should be the primary treatment planner.

Gordon Christensen, DDS, MSD, PhD, talks about a small study he performed in his lectures. He put on his initial patient questionnaire: are you interested in esthetics, esthetics and function, or just function. The vast majority put at least esthetics and function. It would be interesting to ask patients if they think esthetics means just what your teeth look like or the way the esthetic units come together to form your smiling countenance. I venture 100% are going to say, “Esthetics are more than just my teeth.”

So what should a dental hygienist say to a patient who has thin lips or a gummy smile who is not interested in orthognathic surgery and who has no internal joint derangement or myofacial complaint? I suggest, “In my opinion, you should consider specifically treatment of the lips, which may include lip augmentation.” Dental hygienists have some exciting opportunities on the horizon and they may be better qualified to talk about these options than anyone else out there and in some instances to do it. My nurses do the Restylane procedure. A hygienist is much better qualified to understand the lips and, in my opinion, is better qualified than a registered nurse to inject the Restylane. The application of filler materials to the lips and peri-oral tissues is much less complicated than deep root planing. Nurses are qualified depending on the nursing practice acts in individual states, but it is a delegated responsibility. If dental hygienists and dentists are going to get into this, they must meet the standard of care and the same clinical results as the dermatologist or the plastic surgeon. With proper training, this can easily be accomplished.

Dentistry should break out of its self-imposed glass box and reach out to these new and exciting opportunities to better serve our patients and to further the professions of dentistry and dental hygiene.

From Dimensions of Dental Hygiene. June 2004;2(6):8-10.