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New Horizons in Esthetic Dentistry

Cosmetic dentistry has been one of the backbones in every dental practice for the last couple of decades. Any dental practice that is placing tooth-colored composite resins restorations is certainly practicing under the cosmetic dentistry umbrella with most dentists performing whitening procedures, esthetic crowns and bridges, and veneers. All of these topics have become part and parcel of daily dental practice in North America. Dentistry has made huge advancements in the cosmetic realm and now that cosmetic dentistry has evolved to being a staple in every dental practice, you really have to ask yourself what is coming up next in the cosmetic dental field.

The question is, where else is there to go? We can’t possibly get teeth any whiter without patients looking like they are from Mars. We can’t get teeth any straighter once they are straight. What is the next thing on the horizon when it comes to esthetic dentistry?

After investigating this thoroughly, I would submit that the next big advance we will have in cosmetic dentistry would be the surrounding tissue outside of the mouth which will complete the entire picture of what we are trying to accomplish with esthetic dentistry in the mouth.

Dermal filler therapy has been widely accepted by patients in North America, much more so than cosmetic dentistry. You don’t need to believe me – just ask the women in your life and in your office if they have had or heard of dermal fillers. Start asking patients if they have ever had Botox® or dermal fillers and you will quickly find that these are immensely popular esthetic therapies.

What does a dermal filler do? Simply put, a dermal filler is a material that is injected underneath the skin in the labionasal fold, marionette lines, and oral commissures which plump up these areas and smooth out the wrinkles. Lip augmentation is also done with dermal fillers. Traditionally, plastic surgeons and dermatologists offices are the most common providers of these services. Notice that I said that their offices provide these services. What I mean by that is that nurses and medical estheticians who work in an office of a plastic surgeon or a cosmetic dermatologist place most dermal fillers. I am not putting anybody down, but I would bet when it comes to injection experience and technique, oral and facial anatomy, and the natural skills that are required to provide these services, dentists are much better trained in these areas than plastic surgeons, dermatologists, or their employees.

Generally, when you look at the entire world of esthetic injectable treatment, botulinum toxin (Botox Cosmetic®) generally is for the top half of the face and dermal fillers are for the bottom half of the face. The main areas where dermal fillers are used are in the nasolabial folds, the oral commissures, and the marionette lines. These are the areas that frame the teeth and mouth and are certainly within the realm of dentistry and dental treatment. Dermal fillers are gently placed in these areas through an extra oral injection right underneath these folds and creases to plump them up. By the way, these are exactly the same areas that you routinely inject. The only difference is that you typically inject these areas intraorally when you deliver local anesthesia. You as a general dentist are already familiar with the anatomy in these areas and you didn’t even realize it.

One of the biggest advantages a dentist has in performing dermal filler therapy is the ability to deliver profound dental anesthesia for these procedures. Most of the other health professionals who delivered this therapy are poorly educated in dental anesthesia techniques and even after learning them are unable to do as good of a job as any dentist can in anesthetizing a patient. Therefore, what usually happens is that most dermatologists and plastic surgeons forego dental anesthesia and use some form of topical anesthesia cream or anointment on the skin for a period of 20 to 45 minutes prior to performing dermal filler therapy. It has been my observation that most of the patients that I witnessed who had used topical anesthetic creams were very uncomfortable during the procedure and immediately stated that they would never go through this again.

Interestingly, as my experiences have grown in the dermal filler field and in speaking with other healthcare professional colleagues, cosmetic dermatologists and facial plastic surgeons often express wonder why it has taken so long for dentists to get into this field, seeing that it is a totally natural fit and complement to everything that we are trying to accomplish in total esthetic dentistry and general dentists have the natural skill set to accomplish dermal filler therapy.

How long do dermal fillers last? Well, depending on the dermal filler used, the effects of dermal filler therapy can last anywhere from six months until forever. There are temporary dermal fillers and there are permanent dermal fillers. Typically, most healthcare professionals shy away from a permanent dermal filler because if the filler is placed in an improper position, its permanence becomes a huge issue and a liability. Most dermal fillers placed overwhelmingly are temporary in nature and will then dissolve in a time period of six to eighteen months.

There are essentially two types of dermal fillers, hyaluronic acid dermal fillers and calcium hydroxylapatite dermal fillers. Hyaluronic acid is a naturally occurring substance in the body and is lost as we age. Hyaluronic acid adds volume to the facial structures. These fillers are more fluid and it typically takes more filler material to eliminate the wrinkles and may last anywhere from six months to a year. Juvederm® and Restylane are two popular names of hyaluronic acid dermal fillers.

Calcium hydroxylapatite is also a naturally occurring substance in the body and is used in a popular dermal filler called Radiesse®. Radiesse® is a thicker, more viscous material which typically will last longer than hyaluronic acid fillers as it takes longer for the calcium hydroxylapatite material to break down. In addition to this, as the calcium hydroxylapatite in the filler material breaks down, it is naturally replaced by the body with collagen and will keep the area wrinkle free longer.

The choice of dermal filler material is very important depending on the areas you are injecting and correcting. It is essential to know which material you are using and as with everything else, the right material should be used the right application.

Dermal filler therapy for a dentist requires a little different thought process than the dentistry that we put into the mouth. We typically want our dentistry to last for a long time, preferably five to ten years or ideally for the patient’s entire lifetime. Dermal filler therapy are different because it is by its nature a temporary therapy that will only last from six to eighteen months depending upon the type of material used. Patients who have not had dermal filler therapy before need to be educated on that fact that this is a cosmetic therapy that needs to be repeated on a regular basis.

Interestingly, because of the temporary nature of the dermal filler materials, liability issues and treatment that can go wrong are very limited. The simple reason being is that the areas where you use dermal fillers will completely return to normal within six to twelve months so that there is no long lasting result that can occur with this treatment. Like anything else, you have to take into account the anatomy of your patient, what you are trying to accomplish and know which dermal filler materials will work best in each circumstance.

Training is the key to developing the skill to performing this exciting treatment for patients. I have trained many dentists in facial injectable therapies such as dermal filler and botulinism toxin therapies. There is a very short learning curve because dentists are already well trained in injections. What you need to learn is competency in understanding the mechanisms of these materials, reviewing the facial expression muscles, indications, risks and benefits of these treatments, and hands on training in placing these materials and preventing and managing complications. With some practice, you can be well on your way to performing these procedures. Many state dental boards allow dentists to deliver these esthetic facial injectable therapies so check with your own state board.

Dermal filler therapy is a natural progression of where we are going in the cosmetic dental industry. These procedures are easy to accomplish by general dentists with proper training. Patients are motivated to accept these therapies and would be excited at having this done under local dental anesthesia, again making the dentist the healthcare professional of choice to deliver these procedures. This is the perfect complement and the next step in complete cosmetic dentistry.

Dr. Louis Malcmacher is a practicing general dentist and an internationally known lecturer, author, and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, Dr. Malcmacher is a consultant to the Council on Dental Practice of the ADA. You can contact him at 440 892-1810 or email His website is where you can find information about his lecture schedule, audio cd’s, download his resource list, and and sign up for a free monthly e-newsletter.

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