Aging skin is an inevitable process that occurs as we gradually get older. Several factors have been associated with this process which include both genetic and environmental factors.Exposure to sun, pollution, and various chemicals have been known to cause skin and/or DNA damage speeding the aging process.A number of changes to the skin may occur as a result including skin atrophy, telangiectacia, fine and deep wrinkles, yellowing (solar elastosis) and dyspigmentation.Furthermore, a number of additional physical/environment factors including poor diet, lack of exercise, caffeine intake, smoking and drug use are additional factors known to speed the aging process.

Facial anatomy

Facial anatomy remains one of the fundamental aspects for any facial esthetic regimen and the dentist is well situated as much educational background is provided during dental school. It remains important to understand and review facial anatomy, facial features and facial landmarks to safely implement the various therapies described. The face is comprised of various layers including the skin, connective tissue, subcutaneous fat layers as well as muscles, ligaments and underlying bone. Within this network, an array of arteries, veins and nerves also exist.

As such, the role of the clinician in understanding these facial features, characteristics and the anatomy underlying the face becomes pivotal to minimize and counteract the aging process. The desire to achieve a rejuvenated look has become increasingly popular owing to its generally lower costs associated with treatment (when compared to the 90s for instance) which has made it more frequently accessible to more individuals.

Characteristics of age-related facial anatomy changes 

Regardless of how beautiful one’s appearance was in their youth, age-related changes and loss of facial volume and features is inevitable. These are often more pronounced and specific to certain areas. A gradual loss of soft tissue occurs in the upper midface region in conjunction with a downward migration of superficial buccal fat. Consequently, the upside-down triangle associated with a youthful look becomes inversed with a larger proportion of soft tissue drooping below the midface found with aging. Both males and females tend to have different ideal characteristics when assessing overall attractiveness and the rate of aging varies between all individuals based on genetics, environmental factors, sex and ethnicity.

Subcutaneous fat and connective tissue

 The subcutaneous fat embedded in the connective tissue of the face acts as a ‘volumizing cushion’ of facial soft tissues. It plays a prominent role protecting the face from external injury but also ensures a continuous supply of essential fluids and nutrients to facial tissues. In the face, areas with high fat compartments are typically well defined and homogeneous in layer. These include the cheeks, nasolabial folds, the glabella, and the jaw-chin region. In older patients, this specific tissue decreases with age with a resulting atrophy typically caused from reduced blood flow. Notice also that a very thin subcutaneous fat layer exists in the area of the temples and forehead, and almost none exists in the periorbital and perioral region. These areas are therefore more prone to wrinkles and folds with aging and are one of the first visible sign of facial aging in individuals.

Blood supply 

A prominent and complex blood vascular network exists practically throughout the entire region of the face. The peripheral skin layers receive its blood supply from fine capillary vessels. These small vessels allow adequate diffusion into all blood layers. When injecting into areas of the face, a thorough knowledge regarding the whereabouts of the major blood vessels is crucial. This will avoid potential complications related to intravascular injections, most commonly reported with fillers. Importantly, the anatomy of the facial arteries and veins is important. 

Innervation 

Along with blood supply to the face, a complex innervation system exists within the face mainly from 2 sources: the trigeminal and the facial nerve. The sensory innervation of the face is provided by the trigeminal nerve. This nerve is divided into 3 branches including the V1 ophthalmic nerve which exists the orbit via the supraorbital foramen and fissure and supplies sensation to the upper part of the face. The V2 maxillary nerve which exists from the infraorbital foramen and innervates the midface. And the V3 mandibular nerve that innervates the mandibular and temporal regions.

Every Dental Practice Requires Facial Esthetic Dentistry

Cosmetic dentistry has become a focal point for most dental practices, and it is no longer limited to a few “cosmetic dentists” who sought to restrict their practices. Even if a dentist uses tooth-colored composite resins to restore teeth, esthetic principles must be followed to obtain the best clinical and facial results.

Unfortunately, we as dentists limit ourselves to the intra-oral realm of esthetics, when in fact, the lovely image you’re painting inside the mouth is just part of the tale.

We can all do a fantastic job of making people’s teeth look amazing and giving them a friendly and attractive smile. When it comes to cutting-edge procedures like teeth whitening and minimally invasive veneers, cosmetic dentistry has exploded in the last 30 years.

What about the peri-oral around the mouth now that the teeth are in good shape? If we focus on the teeth but forget the rest of the face, we’ve severely limited what we can do with esthetic dentistry.

When you think about it, the advances in esthetic dentistry have been nothing short of amazing. Composite resins are more esthetic and work better than ever before in terms of dental materials. Without a doubt, the ideal self-bonded, solid for all surfaces, no microleakage, bioactive restorative material can take us to the next stage, but we still have a long way to go.

Teeth whitening can now be completed in under an hour. At.3mm, minimally invasive veneers can’t get any thinner. CAD-CAM and other innovations will undoubtedly have an effect on all of these fields in the future by allowing for more efficient esthetic delivery systems. However, the end result will be the same: patients will continue to receive a beautiful smile, just as they do now.

What might be the next step in esthetic dentistry? You can’t make your teeth any straighter once they’re sober. You can’t make the teeth any whiter until they’re the whitest 010 color, as some patients request. The question is: where else can you go? How can we smash through the esthetic dentistry plateaus we’ve reached?

IMPROVING THE STATE OF ESTHETIC DENTISTRY

It’s past time to take what we’ve learned in cosmetic dentistry and apply it to the surrounding areas outside of the mouth, which will complete the overall esthetic dental image we’re constructing.

It’s past time for us to recognize that esthetic dentistry doesn’t start or end with the lips. Teeth must be able to blend into the face’s overall structure. This is particularly true in the areas immediately surrounding and encircling the mouth.

The majority of dental esthetics images I see are retracted intra-oral views of the final product. The margins are precise, the embrasure shape and emergence profile are correct, and all other agreed dental principles have been met in the withdrawn view.

That is the image that seems to please dentists the most, even though no one else in the world looks at it or thinks about it. We need to start with the view that matters most to the patient and the rest of the world, which is the full-face view of a completed case. It’s time to give a comprehensive case of esthetics that includes both hard and soft tissues, both inside and outside the mouth.