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A New Look at Facial Aging


and what we, as dental professionals, can do to reverse it, improve and create proper lip and smile lines, and accomplish total dentofacial esthetics.

It is incredible that it has been nearly 10 years since my first article on total facial esthetics appeared in a dental journal. Now, after much writing on the topic by myself and the faculty of the American Academy of Facial Esthetics (AAFE), and having trained more than 16,000 dental professionals to date, we have learned how facial esthetics and dental esthetics are one and the same, how volumizing the face directly impacts lip and smile lines, and how we can use the latest facial injectables to smooth, tighten, and lift the face like never before. Creating outstanding facial esthetics is now essential to every restorative dental treatment plan.

One of the best ways to understand facial aging and how it directly affects patients is to compare a mother and daughter. When your parents told you that as you got older, you were going to look like them, guess what? They were right! Most of us—especially if we maintain a similar lifestyle as our parents— will age in a very similar way.


When it comes to facial aging, most clinicians seem to think the only loss that occurs is the collagen and fat that disappears over time, which is why older patients’ faces look like they have “dropped.” About age 35, people begin to lose approximately 1% of their facial collagen and fat every year.1 This is when people begin to see differences in their faces. Early signs of facial volume loss begin in the midface cheek area due to having less hyaluronic acid and collagen production and natural collagen loss. This means that the cheeks begin to flatten out, particularly in the zygomatic process area, and the face begins to look slimmer and more angular. Some patients may notice that they have to apply makeup differently in order to highlight cheekbones that are no longer being held up by natural collagen.

What does this mean to the dental professional? Allow me to illustrate facial aging, which every dental clinician understands inherently but doesn’t always think about consciously. When most people in their teens, 20s, and up to mid-30s smile and talk, their upper teeth are easily seen and make up the greatest part of their dental esthetics. As people age into their 40s and beyond, we see less and less of their upper teeth. When they smile and talk, this is the time when lower teeth can be seen more clearly. What happened to their dentition? Absolutely nothing! What is occurring here is that the distance between the bottom of their nose and the top of their upper lip actually lengthens due to the loss of support as the lower lip begins to trend downward. It is the phenomenon that occurs as a natural result of facial aging—losing volume in the middle to upper face directly affecting the lip and smile lines—that is essential to dental esthetics. This is exactly why it has become more well established and accepted over the last decade or more that dental and facial esthetics are one and the same. It stands to reason that dental professionals are the primary clinicians to deliver the best total facial esthetics.

Let’s take a look at this mother-daughter comparison side by side so you can get a good picture of facial aging. These two lovely patients came in together to the AAFE Training Center for evaluation and are a perfect example of what I have been describing thus far. Let’s look at the 23-year-old daughter in Figure 1 at rest. Are you envious of all of that beautiful facial collagen she has? If you are, that is because you are not 23 years old! Look at those full cheeks with a nice transition to the anterior malar region and lid-cheek junction, minimal nasolabial folds, straight (and even slightly turned up) oral commissures, nice lips, and a smooth, defined jawline.

Now, look at the same areas in her 60-year-old mother, and see what volume-loss changes have occurred: flattened cheeks, heaviness in the anterior cheeks, bags under the eyes, deep nasolabial folds, thin lips, downturned oral commissures, marionette line development, undefined jawline with saggy jowl development. Want to know what the daughter will look like in 40 years? You are seeing it right before your eyes.

Take a look at Figure 2, which is a split face of mother and daughter at rest. I want to point out one more very crucial difference between mother and daughter. Look at the distance from the bottom of the nose to the top of the upper lip on both of them. You can clearly see how the mid-to-upper face volume loss will affect the mother’s ability to smile. Let’s take a look at that in Figure 3.

This image shows the mother and daugh-ter each at a full smile. The daughter’s smile is easy and beautiful because of the facial volume support; she easily shows all of her upper teeth. The daughter also demonstrates ideal lip and smile lines, with the bottom of the upper lip straddling the gingival margins of the upper teeth in a full smile.

Solid-filler PDO threads are polydioxanone suture threads precisely placed to lift sagging skin, create sharp jawlines, and replace natural collagen over time. These are a newer addition to the injectable arsenal, which have greatly added to our ability to deliver nonsurgical, minimally invasive total facial esthetics.

The combination of these injectables gives clinicians an incredible array of tools that can smooth (Botox®), volumize ( fillers), and lift (PDO threads) to achieve total facial esthetics like never before.

Contrast that with the mother’s smile, which demonstrates the classic “mad dog” look of many older people. In an effort to show her upper teeth, the mother is having difficulty using only the zygomaticus major and minor muscles to bring up the corners of her mouth into a full smile due to the lack of midface volume and the heaviness in the anterior malar area. She is also engaging the upper lip elevator muscles, such as the levator labii superioris muscles, which results in this “mad dog” smile. Replacing volume with hyaluronic acid dermal fillers in the mother’s mid-to-upper face would restore some of the support needed to reestablish the proper lip and smile lines, giving her a more youthful-looking smile. Figure 4 shows the split-face mother-daughter comparison where this is more clearly demonstrated.


Let’s see how treatment with facial injectables—such as Botox®, dermal fillers, and solid-filler polydioxanone (PDO) thread-lifts—in the mid and upper face can provide the support needed for optimal dental and facial esthetics. Here is a very quick primer on these injectables.

Botox® is a neurotoxin injected into motor muscles to relax them, which in turn eliminates facial wrinkles caused by muscle movement, facial pain caused by muscles, and can alter muscle movements through muscle recruitment to improve facial and dental esthetics.

Dermal fillers are typically hyaluronic acid dermal fillers, which are injected into the dermal layers of the skin to replace lost collagen and fat, thereby replacing the volume lost by facial aging in the upper, mid, and lower facial areas.

Figure 5 shows before and after photos of another patient at rest. Her concerns were that she could not smile as she had in the past to show her beautiful upper veneers placed a few years prior, and she was concerned about the loss of facial volume. You can clearly see the loss of facial volume in many areas, one being the distance between the bottom of her nose and the top of the upper lip at rest in the before photo. The loss of facial volume is clearly responsible for the long upper lip. Compare this area in the before and after photos.

Treatment included Botox® in the following facial muscles: the procerus, corrugators, frontalis, and orbicularis oculi. Midface and lower-face volumization—including anterior and posterior cheek enhancements, nasolabial fold treatment, marionette line treatment, oral commissure treatment, and lip enhancements—were accomplished with dermal fillers (Juvederm® Ultra Plus, Juvederm® Voluma). To complete treatment, bilateral solid-filler PDO thread lifts were accomplished using a three-vector technique starting in the zygomatic areas to the nasolabial folds, oral commissure, and lower jowl as well as a jawline lift originating at the corner of the mandible to create a sharp jawline border.

The before and after photos of the smiling patient in Figure 6 tell the whole story. The midface volume support with dermal fillers and solid-filler PDO thread lifts in the mid-to-upper facial areas, as well as lip filler, provide much more support for the upper lip both at rest and smiling. Look how much higher the upper lip rests because we have restored the midface volume, which now completely supports the lip and smile lines so that in the after photo, the lip lines are perfectly placed where the bottom of the upper lip straddles the gingival margins of the upper teeth. This allows the patient to show her beautiful veneers when she smiles.

Facial injectable therapy with Botox®, dermal fillers, and solid-filler PDO thread lifts is now an integral part of every dental treatment plan. Dentists need to be trained in facial injectable therapy, as patients are getting these services elsewhere by less qualified professionals who do not know the oral and maxillofacial areas as well as dental professionals. From the practice point of view, these services provide the highest profitability and popularity by patients by far; no other dental procedure compares.2

I have said this for years, and certainly believe that this is now well accepted in dentistry—dental esthetics is facial esthetics, and vice versa. They are truly one and the same. Botox® and dermal fillers are the number one and number two most requested non surgical patient procedures 3; nothing else comes close. I’m also noticing that solid-filler PDO threads are fast becoming a third integral treatment in facial esthetics.

These nonsurgical, minimally invasive injectables—especially when used together—provide total facial esthetic results that dental professionals around the world (including more than 16,000 AAFE-trained dental professionals) are using in their practices daily ( figure 7). When properly trained, dental professionals can deliver the best esthetic and therapeutic facial treatment outcomes for their patients.

1. Shuster S, Black MM, McVitie E. The influence of age and sex on skin thickness, skin collagen and density. Br J Dermatol. 1975;93(6):639-643.
2. Malcmacher L. BOTOXonomics. Dental Economics website. https://www.
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