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Facial Rejuvenation as Part of Smile Design

Warren Roberts, DMD

Integration into the dental practice

Once performed mostly only at spas and by medical professionals such as dermatologists, there is definitely a place for esthetic and therapeutic Botox in dentistry. A thorough look at the facts surrounding facial rejuvenation procedures that use Botox may cause a paradigm shift in the dental profession’s attitude toward these treatment modalities. When I was very young, my father, a famous seine boat fishing captain, instilled the idea in me that the key to success is to use the latest technology to chart your course before the tide begins to change. Recognizing that the tide in dentistry was indeed changing, we decided to include facial rejuvenation procedures into our “smile design” treatment. Our most exciting adventure to date has been opening a facial rejuvenation/esthetic dentistry clinic, and we are enjoying the practice of dentistry more today than we ever have before. A cosmetic, dental, or medical procedure used to restore a younger appearance to the face without surgery, facial rejuvenation can include a number of treatment modalities, such as Botox and dermal fillers. These two most common procedures are both minimally invasive and reversible. The treated muscles will return to their pretreatment condition approximately 3 to 4 months after the initial Botox treatment. Hyaluronic-acid dermal filler is naturally resorbed by the body within 9 months to 1 year after treatment. Botox (which is the natural, purified protein of the Clostridium botulinum bacteria) is used to cosmetically soften lines and wrinkles of the face and neck. Hyaluronic-acid dermal fillers restore the volume that is lost through the natural aging process. Both Botox and dermal fillers are natural adjuncts to esthetic dentistry. With their effect on tooth display and the draping of the soft tissue around the mouth, incorporating these modalities into treatment plans can have a major impact on the esthetic outcome of smile makeovers and comprehensive restorative treatment. Even if dentists are not inclined to provide these treatments themselves, they should educate themselves in how Botox and dermal fillers can influence the dental treatment they provide.

How This Fits in Esthetic Dentistry

Photography has taken on an ever-increasing role in the provision of esthetic dentistry. Photographs are an integral part of cosmetic imaging that allow a patient to preview a potential course of treatment, laboratory communication, andaccurate record keeping. In facial rejuvenation, patients often have difficulty understanding and communicating what they want to improve. A series of photographs that allows patients to view themselves from all angles is required but, until recently, none existed.To fill this need the Pacific Training Institute for Facial Aesthetics (PTIFA) created the Roberts Facial Rejuvenation Photography (RFRP) series of 29 digital photographs. The RFRP series helps the dentist to critically analyze the face and demonstratehow the muscles used in the facial expression affect the smile design. At PTIFA, we were the first to begin to mark (and photograph the markings) all of the muscles prior to injection. The patients appreciate our attention to detail, our painless injection technique, and complete marking. By varying the dose, we noticed a decrease in headaches, migraines, temporomandibular joint disorder, and myofascial pain. There is a huge crossover and synergy between esthetic and therapeutic Botox treatment. A huge pearl: If you relieve headaches andmigraines on a team member, they tell every patient that walks in the door.PreventionWhen patients are interested in enhancing the appearance and features of their teeth, they also frequently want toimprove their overall facial appearance. In the past, they would seek treatment for facial enhancement elsewhere; however, dentists are uniquely skilled to provide these treatments for their patients. Who else has better training and amore solid understanding of facial anatomy than dentists? Who else is more skilled at giving injections in this area of the body? Who else do patients trust to work in the areas surrounding their mouths? If dentists can be trained to performdelicate endodontic procedures, sinus lifts for implants, and other involved procedures, they are certainly capable of performing tiny injections into the superficial muscles of the face and injecting resorbable gels into superficial areas of theskin—especially given the fact that these injections can have a direct influence on other treatments the dentist may beproviding. For example, the muscles responsible for the “mid-face expression” can have a drastic esthetic effect onsome patients. Have you ever met a beautiful person only to have them smile and show an inch of gingival tissue? Veryoften, treatment for a “gummy smile” is an invasive surgical Leforte I procedure or surgical crown lengthening.Alternatively, Botox may significantly improve that appearance. Often all that is required to improve the appearance is a2-unit placement of Botox. In many cases, a 2-minute, $50 procedure every 3 to 4 months can provide an alternative,non-invasive, esthetic improvement.


Our initial training in injecting Botox and dermal fillers was provided by a physician colleague. The anatomy training wasminimal, and the acceptance of negative side effects by our medical colleagues was distressing. Additionally, the medicaltraining does not appreciate the dramatic effects the treatment of the upper face can have on the dental exposure.There was a lack of standardization in the area of facial rejuvenation education. In 2014 the Alberta Dental Association &College (ADA&C) developed a “standard” for facial rejuvenation, Botox, advanced Botox, fillers, extraoral lasers, and facelifts (for qualified oral and maxillofacial surgeons). It is a thorough document to provide the ultimate in patient care byestablishing practitioner proficiency and competency. The program is anatomy-based, with the result being no negativeside effects. An intensive review of facial anatomy facilitates an understanding of each muscle’s effect on the face atvarious ages. The program also reviews the facial aging process and what motivates a patient to have esthetic changesperformed. The RFRP series, which is an ADA&C mandatory requirement, is taught to the entire team because it is thecornerstone for successful results. Supervised, hands-on treatment gives the dental practitioner a sound foundation forinjection technique. Attendees leave with the skills and support necessary to start their facial rejuvenation journey andimmediately implement the training.Furthermore, it is important for both patients and clinicians to realize that Botox and hyaluronic-acid dermal fillers havetransient effects and need to be replenished at 3- and 9-month intervals, respectively. Dental offices are renowned fortheir 3- and 6-month recare appointments. The magic lies in incorporating Botox treatments into the practice’s recareprogram. Facial rejuvenation can be seamlessly incorporated into an already-existing recare system, and provide patientswith a discreet way of maintaining their Botox and dermal fillers.ConclusionHaving successfully incorporated Botox and dermal fillers into our practice, we also created PTIFA to share what we hadlearned with our dental and medical colleagues. The highest “standard” in the world was set by the ADA&C, and PTIFAwas the first to have ADA&C accreditation for their programs. When you consider selecting a course, ask if it meets theADA&C Accreditation.Once we had learned the basic skills, the major challenge we faced was how to incorporate these skills into our dentalpractice. As is the case after taking any new course and learning new skills, the most difficult task is training your teamto incorporate the newly learned information into the practice’s existing systems. We provide complete team training thatfacilitates the immediate implementation of newly acquired skills. Although it can be challenging, this training caninvigorate the team and provide stimulation for those eager to improve themselves and expand their horizons in the artand science of dentistry. The training we provide dental teams through PTIFA draws on our own experiences that wegained as pioneers in blending dentistry and facial rejuvenation.To provide ongoing educational support, we also established the world’s first Botox Study Club. Our offerings includeonline training, live webinars, and further hands-on training in a variety of locations throughout Canada and the UnitedStates.It is time for dentists to take a good look at facial rejuvenation and sail with the tide. Our patients deserve our attentionand commitment to learn these ubiquitous treatments.

This article was published in Inside Dentistry, December 2016.