As life expectancy increases, the aging inhabitants of modern society are becoming increasingly intent on preserving as youthful and attractive an appearance as possible. This attitude often motivates individuals to improve their physical condition, use make-up and beauty products, dress youthfully and perhaps, ultimately seek cosmetic facial surgery. This surgery is an expensive and daunting prospect for the majority of people, and carries with it the risk of complications of general anaesthetic and surgery. Recently, however, there has been an increase in the growth of non-surgical alternatives to rejuvenate the aging face. Numerous industries have prospered by jumping on the "non-surgical facelift" bandwagon.

The role of the dentist has been to help to create a youthful and attractive smile for their aging patients. There has been an increase in the demand for veneers, bleaching, white cosmetic fillings and more natural looking crowns. It has been suggested that when this has been achieved, the whole face is enhanced and rejuvenated simply as a result of the improvement to the smile^[1]. Many patients will want more tangible results.

The Dentalfacelift™, provided by Added Dimension Dentistry (ADD), offers aging patients dramatic improvements not only on the mouth but on the whole face. These improvements are having far reaching effects on the lifestyles of patients and are changing the patient's whole attitude towards life. These results only serve to confirm my belief that the role of the dentist must go far beyond merely looking in the mouth. This work also raises the question of whether our training equips us to deal with the psychological aspects of treating patients troubled or even traumatised by the demands of a society increasingly obsessed by youth and beauty.

Facial Aging
The aging process of the face affects everyone.

In order to achieve facial rejuvenation with any facelift procedure the surgeon must understand the physiology of aging.

The age-related changes that the facial skin and subcutaneous tissue undergo have been studied extensively and histologically the process is one of atrophy^[2],[3]. As a person ages there is a diminished thickness and elasticity of skin, loss of subcutaneous tissue, decreased adherancy of the soft tissue envelope, gravity assisted sagging and the induced formation of wrinkles in the areas of frequent motion. In the past it was thought that facial aging is almost exclusively a result of soft tissue changes in patients with full dentition.^[4]

There is some controversy as to the effect of bony changes and the aging face. Vicuna and Giottoninni have described a procedure to augment bone volume in the midface region which reverses the decrease in the antero-posterior projection of the midface.^[5] This, they explain, is due to remodelling of the facial skeleton that takes place with age, as described by Enlow.^[6] There is some evidence to back-up this theory, that relative maxillary retrusion occurs as a natural consequence of aging and leads to the formation of the naso-labial folds.^[7]

The effect of edentulism in facial aging is secondary to alveolar bone loss. The bone loss causes reduced alveolar height and resorption of the labial and buccal surface, which results in thinning of the alveolar ridge, resulting in a decrease in the size of the alveolar arch. As a result of these bony changes, the lips shift posteriorly and vertical rhytids appear. Loss of lower vertical height also leads to forward and upper movement of the chin and this leads to the typical "sunken look" of the edentulous face. Similar displacement of the soft tissue can appear as sunken or hollow cheeks in the patients who have had molars extracted. In addition, in some patients there is significant soft tissue atrophy or soft tissue thinning with aging that defies correction by soft tissue shifting. Submalar depressions, or sunken cheeks, usually do not develop because the closed bite (secondary to loss of alveolar height) produces a relative excess of cheek soft tissue.

Facelift procedures can vary extensively. In general, the facelift operation can be divided into conventional and deep plane procedures^[8]. Deep plane facelifts try to achieve a longer lasting effect and are supposed to achieve better results. All the deep plane procedures are relatively new, and many methods are not yet used widely.

Several studies have suggested the use of facial implants or bone substitute to rejuvenate the face. These, apart from the study of Giottoninni, have been based on the concept of ptosis. Submalar augmentation of the canine fossa and inferior zygoma has been used to enhance rhytidectomy, providing a support for the totic overlying soft tissues. Hydroxyappetite has likewise been used to augment the facial skeleton.

These procedures can be used on the edentulous patient but do not address the bone changes that follow loss of teeth. For the edentulous patient, it has been suggested that oral implants would provide a stable platform^[9]. Any facelift procedure should be attempted after this.

The Add Dentalfacelift® can achieve results comparable to many of the procedures carried out by the facial cosmetic surgeon. The effects can be seen not only on the lower face, but also on the eyes, nose and cheeks. The effects of aging on the face have been studied extensively^[10]. In this article we shall study how the Add Dentalfacelift® can reduce these. The areas we will study are: the skin, the forehead and eyes, the cheeks, the nose, the lips and surrounding area, the mandibular line, the chin and lower facial profile, and the neck. In the following articles we will look at the technique in more detail.

The Skin
The normal aging process of the skin includes gradual thinning, atrophy, dryness, skin fragility and wrinkling. As skin collagen content decreases with aging, there is an increase in skin laxity. The wrinkled skin on the aged face appears darker because less light is reflected from it. The Add Dentalfacelift® seems to increase the elasticity of the skin, decreases the wrinkles and the thickness of the skin seems to increase. The decrease in wrinkling causes the skin to appear lighter, as more light is now reflected off it. This must be kept in mind when choosing the colour of the teeth for the patient.

Before Add Dentalfacelift®	After Add Dentalfacelift®, skin is thicker, more elastic and lighter

The Forehead and Eyes
The youthful forehead exhibits no wrinkles, eyebrows positioned well above the superior orbital ridges. Aging causes vertical and horizontal forehead wrinkles and sagging of the eyebrows.

The youthful periorbital area shows a well shaped and well positioned eyebrow, a well defined upper eyelid platform and supratarsal crease, the absence of bulging, excessive skin or wrinkles in the upper and lower eyelids. In the aging face there may be redundant skin above the upper eyelid, bulging orbital fat and drooping of the corners of the eyes. The skin at the corner of the eyes shows wrinkles (crow’s feet). Underneath the lower eyelid, there are wrinkles, redundant skin and muscle, and bulging fat, leading to the typical "bags" underneath the eyes.

Excessive loose skin over upper eyelid, touching the eyelashes, "bags" under eyes drooping of corner of the eyes, eyebrow ptosis.	Youthful periorbital areas and forehead
Before Add Dentalfacelift®	After Add Dentalfacelift® Eyes much brighter and bigger, and have lost the "sad" look.
Youthful periorbital areas and forehead	Aged face showing "crows feet," loose skin above the upper eyelid, nearly touching the eyelashes
Before Add Dentalfacelift® Loose skin over the upper eyelid touching the eyelashes	After Add Dentalfacelift® Skin much firmer, more of the eyelashes can be seen.
before Add Dentalfacelift® Front view of the same patient.	After Add Dentalfacelift® Front view of the same patient -skin much firmer above and below the eyes.

Cheeks
The youthful appearance of this area is consistent with a well defined cheek prominence located approx 10mm lateral and 15mm inferior to the lateral canthus. The overlying skin is smooth. The common manifestation of aging is a loss of a normally positioned cheek prominence and a skeleton like hollowing defect. The skin may appear sucked in around the bony prominence, producing the gaunt look of old age.

Cheeks look much flatter with age - gaunt look of old age.	Youthful prominent cheeks
Before ADD facelift Cheeks don’t look as sunken as they should because of the closed bite (secondary to loss of alveolar height. This produces a relative excess of soft tissue.	After Add Dentalfacelift® The lower facial height was increased and initially the sunken cheeks looked far worse. 6 months later, with bony remodelling and improvement in muscle structure and collagen, cheeks look much better.

The Nose
The youthful aesthetic nose varies in appearance among different ethnic groups and between men and women. It generally has a straight dorsum, a well defined tip, with good projection and rotation, a normal (90-110 degress) nasio-labial angle and almond shaped nostrils. Aging causes an increase in vertical length, a decrease in tip projection, a tip droop and a change in the shape of the nostrils to a more rounder shape. In the edentulous, the base of the nose appears wider.

The effect of age on the nose - drooped tip and small hump develops on the dorsum.	Youthful nose
Before Add Dentalfacelift®	After Add Dentalfacelift® Increased elevation of the nose tip, eliminating tip droop from before.

The Lips & surrounding area
In youth, there is an absence of wrinkles in the area around the lips. Labial folds are very thin or not present. There is a full display of the vermillion border. Lower lip vermillion display of 1.5-2 times that of the upper lip. Changes of the aged face include prominent naso-labial folds, fine vertical rhytids, altered tooth display (gravitational soft tissue displacement decreases upper tooth display and increases the exposure of the lower anterior teeth) and loss of exposed vermillion. Lips are the central feature in the lower third of the face. When they are full and well defined, they impart a sense of youth, health and attractiveness to the bearer. Thin flat lips, on the other hand, imply fragility and senility. In profile, the upper lip should lie 3.5mm anterior to a line connecting the subnasal and the pogonion. On average the lower lip should be 2mm anterior to the line. Corners of the lips tend to droop downwards and join up with the marionette folds.

In the edentulous patient, because of the rapid absorption of alveolar bone, the lips are displaced posteriorly, giving rise to vertical rhytids and decreased display of the vermillion. Cheeks appear hollow as well. The naso-labial folds also become very prominent.

The effect of age and edentulism. The naso-labial folds, starteing from the lateral aspect of the nose are joining Up with the marionette folds, starting from the corners of the jaw line.	Youthful perioral area
Before Add Dentalfacelift®	After Add Dentalfacelift® Vermillion show improved. Naso-labial and "marionette" folds better. Wrinkles improved.
Sunken look of old age - a patient wearing dentures giving very little lip support	Youthful convex lower facial profile
Before Add Dentalfacelift® Concave lower profile of the aged edentulous patient - the "witch" profile	After Add Dentalfacelift® Much improved lower profile

Mandibular Line
A smooth well-defined jaw line is associated with youth. Accumulation of fat in the neck or appearance of jowls disrupts the smooth jaw line. Jowls are caused by ptosis of the skin, superficial musculoaponeurotic system (SMAS) and muscles, and accumulation of subcutaneous fat.

Ragged mandibular line of old age	Youthful mandibular line
Before Add Dentalfacelift®	After Add Dentalfacelift® Jowls appear much better. Neck tissue is much firmer and demarcation between neck and face much cleaner.

The Chin
The apex of the chin is usually high above the mandibular line. In profile the chin is well projected relative to the nose and lips and in general, smoothly and acutely joins the neck. An aged appearance is produced by chin descent and the prominence of "marionette grooves" that continue from the naso-labial folds to below the mandible. In the edentulous patient a "witches" chin is created by soft tissue sag and overclosure.

Chin droop and "marionette" folds of old age	Youthful chin
Before Add Dentalfacelift®	After Add Dentalfacelift® Chin droop improved

The Neck
An aged neck shows fat accumulation, soft tissue sag and wrinkles. Fibres of the medial edge of the platysma create two long folds of tissue that hang from the mandible and curve posteriorly to their inferior aspect to meet the clavicle. These bands create the characteristic "turkey gobbler deformity."

With the Add Dentalfacelift®, the neck may appear to worsen as there now seems to be excessive skin tissue. However, given time, this does tighten up and improvements in the neck can be seen.

Aging effect on neck	Youthful neck
Before Add Dentalfacelift®	After Add Dentalfacelift® Neck has not deteriorated but muscles have firmed up.

^[1] Garner JK (1997). Non-surgical facelifts via cosmetic dentistry: fact or fiction. Curr Opin Cosmetic Dent 4:76-80
^[2] Gilchrist BA (1982). Age associated changes in the skin. J Am Geriatr Soc 30:139
^[3]Lapiere CM (1990). The aging dermis: the main cause for the appearance of "old skin." Br J Dermatol 122(Supplement 35):5-11
^[4] Bartlett SP, Grossman R & Whitaker LA (1992). Age related changes of the cranio-facial skeleton: an anthrometric and histologic analysis. Plast Reconstr Surg 90:592-600
^[5] Vicuna RG & Giottonini AS (1994). Bone expansion in facial rejuvenation surgery. Aesthetic Plast Surg 18:85-90
^[6] Enlow DH (1968). The human face. New York: Harper & Row
^[7] Pessa JE, Zadoo VP, Mutimer KL, Haffner C, Yuan C, DeWitt AI & Garza JR (1998). Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft tissue changes into an integrated model of mid facial aging. Plast Reconstr Surg 102:205-212
^[8] Miller AJ & Graham D (1997). Comparison of conventional and deep plane facelift. J La State Med Soc 149:406-411
^[9] Albrektsson T, Blomberg S, Branemark & Carlsson GE (1987). Edentulousness - an oral handicap. Patient reaction to treatment with jaw bone anchored prosthesis. J Oral Rehab 14:503
^[10] Gonzalez-Ulloa M, Simoria F & Flores E (1971). Anatomy of the aging face: transactions of the fifth international congress of plastic and reconstructive surgery. Ed 1, London, Butterworth & Co. Ltd.