Dr. Louis Malcmacher, with Dr. Anthony Feck and Dr. Kristine Krever, MD

	“The esthetics of the smile involves more than just the teeth. Cosmetic dental materials placed by an artistic operator can create ‘that movie star look,’ but what about the ‘frames’ around those smiles? The perioral tissues are areas that can contribute to making people appear older than they would like. This month, Drs. Malcmacher, Krever and Feck discuss the use of dermal fillers to help these patients make not only their teeth look younger, but make their face look younger as well. It makes perfect sense that with the dentists’ vast experience in dealing with this area of the patient’s anatomy that they become a primary source of delivery for these types of perioral procedures.”-Dr. Robert Lowe, Team Lead

	Cosmetic dentistry has been a backbone in every dental practice for the last few decades. Any dental practice that places tooth-colored composite resin restorations is certainly practicing under the cosmetic dentistry umbrella, with most dentists performing whitening procedures, esthetic crowns and bridges, and veneers. All of these procedures have become part of daily dental practice in North America. Dentistry has made huge advancements in the cosmetic realm.

	Now that cosmetic dentistry has evolved to become a staple in every dental practice, you really have to ask yourself, “What is coming up next in the cosmetic dental field?”

	Another question to think about 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 say the next big advancement in cosmetic dentistry will come outside the mouth in the surrounding oral and perioral tissues. Through dermal filler therapy, we will complete the entire picture of what we are trying to accomplish with esthetic dentistry.

	Patients in North America have widely accepted dermal filler therapy, much more so than cosmetic dentistry. You don't need to believe me-just ask the women in your life and in your office what they know about dermal fillers. Start asking patients if they have 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 of the nasolabial folds, marionette lines, and oral commissures and plumps them up and smooths out wrinkles and depressions in these areas. Lip augmentation also is done with dermal fillers (

	Traditionally, patients go to plastic surgeon and dermatologist offices for these services. Notice I said their offices. Nurses and medical estheticians who work in a plastic surgeon’s or dermatologist’s office 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.

	Dermal fillers are mainly used 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. Dermal fillers are gently placed in these areas through an extraoral injection right underneath these folds and creases to plump them up. By the way, these are the same exact areas you routinely inject. The only difference is 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. Most of the other health professionals who deliver 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 most dermatologists and plastic surgeons forego dental anesthesia and use some form of topical anesthesia cream or an ointment on the skin for a period of 20 to 45 minutes before performing dermal filler therapy. From what I’ve observed, most patients are very uncomfortable during the procedure when topical anesthetic is used and many decide they don’t want to go through it 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 ask why it has taken so long for dentists to get into this field, seeing that it is a totally natural fit and a complement to everything we are trying to accomplish in total esthetic dentistry. They appreciate that general dentists have the natural skill set to accomplish dermal filler therapy.

	How long do dermal fillers last? Depending on which dermal filler you use, the effects of dermal filler therapy can last anywhere from six months to several years. There are temporary dermal fillers and there are permanent dermal fillers. Most dermal fillers placed are temporary and will dissolve in six to 18 months.

	Interestingly, because of the temporary nature of the many dermal filler materials, liability issues and treatment complications are very limited. Why? The areas where you use dermal fillers will completely return to normal within six to 12 months so there is virtually no long-lasting negative results that can occur with this treatment. Like anything else, you have to take into account the anatomy of your patient and 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 perform this exciting treatment for patients. I have trained many dentists in facial injectable therapies such as dermal filler and botulinum toxin therapies. There is a very short learning curve because dentists already are well trained in injections. What you need to learn is competency in understanding the mechanisms of these materials, reviewing the facial expression muscles, indications as well as the risks and benefits of these treatments. Hands-on training in placing these materials, as well as preventing and managing complications, is another important part of training. 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.

	Implementing dermal filler therapy in your practice 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 to have it 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 internationally known lecturer, author and dental consultant known for his comprehensive and entertaining style. An evaluator for Clinicians Reports, he is on the faculty and is president of the American Academy of Facial Esthetics, which provides training in Botox and dermal filler procedures. He can be reached at 440-892-1810, 

Dr. Kristine Krever, MD, is a board-certified family physician specializing in esthetic medicine. She is a Diplomate of the American Academy of Facial Esthetics.

Dr. Anthony Feck has an extensive background in cosmetic dentistry and facial esthetics. This sought-after speaker, educator, author and practitioner of dental-facial cosmetics is a Diplomate of the American Academy of Facial Esthetics.

Articles

 The Set-Up  “The esthetics of the smile involves more than just the teeth. Cosmetic dental materials placed by an artistic operator can create ‘that movie star look,’ but what about the ‘frames’ around those smiles? The perioral tissues are areas that can contribute to making people appear older than they would like. This month, Drs. Malcmacher, Krever and Feck discuss the use of dermal fillers to help these patients make not only their teeth look younger, but make their face look younger as well.