Signs of premature ageing can be caused or exacerbated by the loss of teeth or posterior support. Dr Anil Shrestha describes a multi-disciplinary approach to the correction and restoration of facial proportions through dentistry
The dentition is an integral part of facial aesthetics—the teeth are a central part of the maxillofacial boney scaffold upon which the soft tissues of the face hang. The loss of teeth and the dentoalveolar complex, or the boney structure supporting the teeth, often leads to a loss of soft tissue support and signs of premature ageing and wrinkling.
Most patients are concerned with the appearance of their anterior teeth when seeking cosmetic dental treatments, although the posterior teeth provide the posterior support and maintain facial proportions. This has a pivotal influence on any additional treatments patients may be having around the circumoral structures and the whole of the facial soft tissues.
Most of these concerns centre around the colour and alignment of the teeth, but there are subtle deleterious effects on the appearance of the smile due to the effects of teeth ageing. Advanced tooth wear from erosion, attrition and abrasion can cause the face to appear aged prematurely. Often our patients and non-dental colleagues attempt to correct the soft tissue changes without consideration of the dental hard and soft tissues and the maxillo-facial skeletal structure that supports them.
Youthful smiles generally reveal 75-100% of the maxillary teeth below the intercommissural line, but reductions in this to below 40% and near to zero can cause the face to appear markedly aged. It is important to restore the correct length and proportion of teeth in the overall scheme of restoring the face to give a youthful appearance.
It is well known that improvement in the appearance of teeth in terms of size, shape, colour, position and correct alignment can significantly increase a patient’s confidence. There is overwhelming evidence that the psychological benefits of an attractive smile can have positive effects on the confidence and success of an individual in personal and professional inter-relationships.
Over the last twenty years, dentists have become acutely aware of the range of facial aesthetic treatments that can harmonise and integrate with dental treatments. A significant number of dentists are currently training in and carrying out facial aesthetic treatments with facial injectables. In the same vein, an increasing number of aesthetic practitioners are beginning to appreciate the importance of dental treatments in facial aesthetics in the overall holistic management of their patients.
Quite often, patients requiring significant facial aesthetic treatments also happen to be in need of extensive dental restorative treatments. It is not uncommon to find that patients who seek extensive facial aesthetic treatments can have major concerns regarding their need for restorative dental treatments. This can include loss of multiple teeth with surrounding hard and soft tissue atrophy—loss of the labile dentoalveolar complex, which supports tooth roots, can cause marked changes in soft tissue support, especially in the perioral area.
Loss of the dentoalveolar processes and the teeth in which they sit can cause collapse of the soft tissues, which patients will often seek to reconstruct with facial aesthetic treatments such as dermal fillers. In fact, the restoration of the teeth and the dentoalveolar complex can help support the soft tissues and obviate the need for injectable treatments to restore soft tissue bulk or eradicate premature wrinkling.
Loss of face height and resultant overclosure of the mouth due to loss of posterior teeth, the posterior stability, cannot be corrected by soft tissue aesthetic procedures alone.
There are certain underlying base skeletal patterns that cannot be fixed with facial aesthetic treatments unless the underlying skeletal pattern is changed. This may be required for severe Class II (retrognathic/retruded chin) or Class III (prognathic/protruded chin) defects, where there is a variation from the ideal Class I maxillary-to-mandibular relationship. Advances in orthognathic surgery over the last thirty years now make the correction of the underlying skeletal pattern a predictable form of major facial reconstruction.
However, if there is a significant discrepancy in skeletal patterns, teeth restoration can only have a limited effect. The skills of a good craniofacial or maxillofacial surgeon, combined with restorative and orthodontic specialties, can give an overall change in profile and resultant improvement in the appearance of the smile. To carry out such work, the separate sub-specialties of dental surgery need to be used, including: maxillo-facial or orthognathic surgery; orthodontics, to change the position of the teeth; and dental implant surgery and prosthodontics, to replace teeth with prosthetics and restore tooth structure.
This kind of treatment is becoming more commonplace and several UK centres provide specialist treatment. I have been working with my specialist colleagues at the Lister House ICED practice for over twelve years. We are able to offer the interdisciplinary skills of maxillo-facial surgeons Mr Robert Bentley from the London Oro-maxillofacial Surgeons Centre and Mr Stephen M Dover from the Cranio-facial supra-regional unit in Birmingham. Orthodontic treatments are carried out by orthodontists such as Dr Darsh Patel in Harley Street and Mr Peter Huntley in Solihull have helped to produced great results.
In terms of case management, it is generally ideal if the overall, holistic view is seen by the prosthodontist who has an overview of the patient and carries out a full case assessment, with clinical and radiographic assessment in the first instance.
Before an interdisciplinary treatment of this nature can be undertaken, the patient’s commitment needs to be evaluated carefully and they need to give their fully informed consent. Patients must be given a clear indication of the likely costs involved in the treatment, which will include separate payments to each of the specialists involved in treatment, additional costs for any general anaesthesia if required, and ongoing maintenance costs for the duration of their lives, including three-monthly hygienist visits post-treatment.
They also need to be given a clear estimate of how long the treatment is likely to take from start to finish. These interdisciplinary treatments can typically last for three years or longer, which is a significant investment in time and money for the patient.
Before beginning treatment, patients must also have existing pathologies cleared, including the extraction of any teeth of hopeless prognosis or irrelevance, the removal of boney pathologies and conservation treatment for dental caries.
It is imperative that the dental hygienist carries out a full-scale debridement of the mouth and full pocket charting is completed. Any signs of periodontal disease that could compromise the longevity of the teeth or implants—whether due to peri-implantitis or peri-implant mucositis—needs to be treated. These patients will need to be placed on and commit to a long-term maintenance programme with specialist dental hygienists.
The use of a multi-disciplinary dental team is usually called into force when it is apparent that the positions of the teeth are far from ideal, such that the usual restoration with crowns, bridges or implants would not produce the ideal tooth emergence profiles from diagnostic models.
For example, shifting of the mid-line or exceptional spacing of the teeth can compromise the end result, so orthodontic treatment will be required. Skeletal discrepancies—where the mandible is either retrognathic (skeletal Class II) or prognathic (skeletal Class III, or where the maxillary bone is retruded and underdeveloped)—require Le Fort maxillary advancement or saggital slit osteotomy treatments to correct the mandibular relationships.
The orthodontist, oral surgeon and prosthodontist will normally meet together to establish where the ideal setup can be created. The Kesling setup is an established and dated method of sectioning each individual tooth in the upper and lower jaws on an articulated model and placing them in the correct positions. The same diagnostic procedure can now be carried out in virtual reality using a CT scan and implant, and maxillofacial computer software. Therefore, surgery and its end result can be planned safely prior to surgery and be highly predictable.
The orthodontist will work very closely with the maxillofacial surgeon to ensure that interarch space and positions of the maxilla and mandible and their remaining teeth are ideal. Once oral surgery has been carried out, the orthodontist can start aligning the teeth. This can sometimes be reversed so that the teeth are repositioned prior to orthognathic surgery being carried out.
Once the teeth have been positioned as close to the ideal planned positions as possible, the prosthodontist liaises with the orthodontist to ensure that group teeth function is achieved to establish canine, anterior and lateral guidance patterns. Any spaces requiring replacement of units are then either expanded or closed to millimetre accuracy, to allow the provision of dental implants, if required.
It is even possible to move teeth to allow development and migration of autogenous bone prior to implant placement. The implant surgeon will then carry out implant surgery and necessary grafting or bone augmentation, and the implants are allowed to integrate for a period of up to six months before being loaded.
Finally, restorative treatments can be carried out using crowns, veneers or implant restorations to restore the final appearance as well as face height and function of the teeth. If there is a significant amount of natural tooth structure remaining, prior to final restoration and to be as conservative as possible in our aesthetic treatments, bleaching techniques can be used to improve the smile.
This includes the use of endodontic therapy, or root canal fillings, to preserve natural teeth wherever possible and the use of conservative techniques to restore the teeth rather than replace them wholesale using implants, crowns or veneers. Classically-trained prosthodontic specialists are trained in and favour this type of conservative dental treatment.
It is not uncommon for these reconstructions to stem from facial trauma or severe dental neglect. The ageing of the dental tissues is the other most common cause of patients electing to seek treatment. These multi-disciplinary cases will often result in such significant aesthetic improvement from the underlying skeletal pattern to the end result, creating a symmetrical, even smile and improvement in function, that additional facial aesthetic treatments are not necessary.
This holistic multidisciplinary approach requires tremendous levels of skill from the various specialists and a highly co-ordinated level of cooperation and teamwork. The results can be stunning and life-changing for the patient and it is hoped that understanding that this type of treatment is achievable will add a different dimension to the treatments being offered by our non-dental, facial aesthetic colleagues.
Dr Anil Shrestha is a registered specialist in prosthodontics who trained at the Eastman Dental Institute in London. He has his own private specialist referral practice at Lister House in Wimpole Street and is clinical director of Smiles Dental.