Smart Cosmetology: The Dental Face

In one of my previous articles, I examined the anatomy, physiology and functions of the face and their general impact on facial appearance [1]. In the second publication of the series I discussed the characteristic pattern of facial changes in patients with nasal breathing disorders, which I labeled the Nasal Face [2].

In this article I focus on external facial manifestations linked to the dental system. The upper and lower jaws occupy approximately 70% of the face and define the appearance of its middle and lower parts.
Elena Shchelokova
Founder and Medical Director
Face Clinic
13, Prechistenka
119034, Moscow, Russia

Email for correspondence:
Elena Shchelokova
Founder and Medical Director
Face Clinic
13, Prechistenka
119034, Moscow, Russia

Email for correspondence:

Dental Face

As is well known, it is changes in the lower third of the face that make it seem old in the first place. However, gravitational pull alone cannot be responsible for these changes, as otherwise it would be possible to calculate the rate of sagging depending on a person’s age, height and weight. Besides, gravitational pull would result in a uniform sagging of the cheeks along the line of the lower jaw. However, in reality, the soft tissues of the face shift in the direction of the mouth and jowls (Fig 1).
Fig.1. (A) This is the shape of the face that we would see if gravitation were the main factor in facial sagging.
(B) Actual age-related soft tissue displacement.
(C) Actual age-related changes in the shape of the face.
In my view, these specific changes in facial contours are due to lower jaw and lip movement. The lower jaw is maximally lowered at the chin and minimally at the jaw angles. This leads to the most intense tissue stretching occurring in the central zone of the middle and lower thirds of the face. Constant movement of the lips also contributes to soft tissues shifting towards the perioral area. I am convinced that this is one of the main factors leading to sagging cheeks, deepening nasolabial folds, drooping corners of the mouth, degradation of facial contours and the appearance of jowls and a double chin.

To date, it has been proven that morphological changes in the bone structures of the face begin to be seen from the age of 30. With time they become more pronounced, in particular, in the upper and lower jaws (Figs. 2 and 3).
Fig 2 (A, B). Structural changes in the face skeleton. Reprinted from Aesthetic Plast Surg. 2012; 36(4): 753–760.
Fig. 3 (A, B, C). Structural changes in the mandible.
In my view, these changes in bone structure are due to the characteristic attachment and functioning of facial muscles. The most pronounced changes are seen in those places where the muscles attached to the bone experience the biggest loads being involved in the performance of such functions as opening and closing of the mouth, chewing, swallowing, speech and emotional expression.

The presence or absence of teeth and their pressure on the bone during chewing also lead to bone atrophy and simultaneous changes in the functioning of facial muscles, which further affects bone structure.

Taking into account the specific functioning and attachment type of facial muscles (with one end attached to the bone and the other to the skin), as well as their interaction, it is logical to suppose that any changes in the dental system will lead to external manifestations on the face.

Let’s consider some examples. In order for the mouth to be closed at rest, there are special receptors on the teeth, lips and tongue - markers of mouth closure. They detect the correctness of teeth closing and determine the specific work of facial muscles.

When the teeth do not close properly, we see hypertension of the masseter, the platysma and the muscles of the bottom of the oral cavity. Constant hypertension will lead to (Fig. 4) the outward expansion of the angles of the lower jaw (1), the appearance of marionette lines (2), wrinkles around the lips (3), chin tensing (4), platysmal bands and a second chin (5).
Fig. 4. Typical appearance of the lower third of the face in patients with muscle hypertension resulting from dental closure disorders.
The most common source of problems is dental occlusion. According to statistics, about 80% of the adult population suffer from such problems as malocclusion, jaw displacement, high dental fillings, incorrect prosthetics, lack of teeth, chewing on one side, jaw bone malformations (micro-, retro-, latero- prognathia), orthodontic treatment, stress, poor posture, etc. (Fig. 5).
Fig. 5. A typical facial appearance of jaw bone malformation.
Displacement of the lower jaw to the right or to the left leads to asymmetry of the face, lips and facial expression (Fig. 6).
Fig. 6 (A, B). A patient with lower jaw displacement.
Prolonged absence of one or more teeth leads to the formation of wrinkles or folds on the face in the projection of the missing teeth and/ or asymmetric hypertonicity of the masticatory muscles (Fig. 7).
Fig. 7. Asymmetric hypertonicity of the masticatory muscles
When the patient tries to hide unattractive or missing teeth, there is excessive work of all perioral muscles accompanied by the formation of nasolabial folds and marionette lines, wrinkles around the mouth, less defined facial contours and characteristic facial expressions with an unattractive smile (Fig. 8).
Fig. 8. A characteristic pinched lip smile produced when trying to hide unattractive or missing teeth.
If the patient chews on one side, muscle asymmetry develops, which will be reflected in the asymmetry of the face and facial expressions (Fig. 9).
Fig. 9. Asymmetry in the hypertonicity of the masseter and nasolabial folds at rest (A) and during movement (B).
During orthodontic treatment with braces, muscle hypertonicity of the perioral area develops as the tissue around the mouth is stretched to cover the braces. In addition, patients, wishing to hide the braces, form a typical smile with a pursed chin.

Because treatment with braces lasts a long time, specific facial manners are formed, accompanied by the hypertonicity of the masseter, the perioral muscles and the platysma. These manners persist even after treatment is completed. This leads to a typical facial expression with drooping corners of the mouth, pursed lips and chin with a pronounced mental crease, as well as characteristic mimic patterns of the lips and the perioral area (Fig. 10).
Fig. 10. Habitual tightening of the lips when wearing braces.
When under stress, patients tend to clench their teeth, which leads to the hypertonicity of the masseter, muscles of the perioral region and the platysma (Fig. 11).
Fig. 11. Facial expression of stress.
With poor posture, the muscles of the neck and the entire lower third of the face are tensed up, which results in wrinkles and folds in the lower third of the face and the appearance of a second chin (Fig. 12).
Fig. 12. The effect of posture on head position and manifestations of aging.
The dental system is closely connected to the nose and the sinuses. Their impact on each other is quite considerable. The muscles that propel air through the nasal passages are also involved in lip articulation. Combined nasal and dental pathologies lead to the appearance of wrinkles and folds in the middle and lower thirds of the face, as well as tissue shift forward and downward due to the greatest muscle activity in these areas (Fig. 13).
Fig. 13. A patient with combined nasal and dental pathologies.
External changes in the lower third of the face, and how pronounced they are, depend, to a large extent, on the condition of the dental system rather than age alone.

A correct understanding of the pathogenesis of facial changes allows us to create an optimal algorithm for their prevention and elimination. Therefore, Face Medicine needs an interdisciplinary approach: although cosmetologists can prevent the appearance or progression of different facial changes, they cannot completely eliminate problems of the dental and nasal systems that caused them in the first place.

For example, orthodontic treatment with braces or mouth guards, in most cases, requires correction of muscle hypertonicity in the lower third of the face with botulinum toxin in order to avoid unstable or unsuccessful outcomes (Fig. 14).
Fig. 14. The scheme of botulinum toxin treatment for muscle hypertonicity in the lower third of the face during orthodontic treatment.
In the case of hypertonicity of the masseter, application of botulinum toxin will reduce dental attrition as well as damage to dental appliances, and prevent facial asymmetry (Fig. 15).
Fig. 15. The scheme of botulinum toxin treatment for the hypertonicity of the masseter.
In our clinic, we have developed the Smart Cosmetology approach which allows us to improve patients’ appearance and, if necessary, increase the effectiveness of dental correction.

Joint work of cosmetologists and dentists during long-term orthodontic or prosthetic treatment may considerably boost both treatment outcomes.

If the patient refuses dental correction, cosmetic camouflage for external manifestations of dental problems is also possible (Fig. 16-18).
Fig. 16. Before (A) and after (B) correction.
Restoring the volume in the middle zone of the face with hyaluronic acid allowed us to hide the external manifestations of dental pathology (micrognathia of the upper jaw) and make the face more beautiful.
Fig. 17. Before correction (A); immediately after correction (B); 3 months later, after additional correction (C).
Correction of external manifestations of micrognathia with hyaluronic acid changes the face’s contours, making it more exquisite and refined.
Fig. 18. Before (A) and after (B) correction.
Harmonization of the lower third of the face with hyaluronic acid and botulinum toxin in a patient with malocclusion.
In recent years dentistry has been developing very rapidly. But it is important to keep in mind the systemic influence of the dental system on the structures of the face because external manifestations of both dental problems and incorrect dental treatment may negatively affect the patient’s appearance.

In my previous articles I have described how long-term problems with eyesight and nasal breathing form specific patterns on the face. Similarly, problems of the dental system manifest themselves in the form of wrinkles, folds, changes in the shape of the face, and facial asymmetry. In our clinic we view such changes from the perspective of Smart Cosmetology and regard them as the ‘diagnostic map of the face’ (DMF), which allows us to design a maximally adaptive correction plan.

All in all, it must be recognized that the face is a system of the body, alongside its digestive, respiratory, etc. systems. Many of the external aesthetic changes seen on the face are in fact symptoms of impaired functioning of the visual, nasal or dental systems. This is why they should be properly diagnosed for correct further treatment. An interdisciplinary approach to the correction of aesthetic problems of the face developed by our clinic is the most effective prevention and treatment technique in modern Face Medicine.

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