Dentofacial aesthetics for the older patient

A colleague once told me this story about a patient of his. An elderly gentleman came in with several badly decayed front teeth. The teeth were quite rotten, discolored and malaligned. He thought to himself that he could be a hero to this patient because no matter what he did, he would have vastly improved the function and aesthetics of his teeth. However, as he commence the restorative work, he discovered that restoring function was the easy part but aesthetics is a different ball game, the profile of the patient notwithstanding. The patient was exacting in his demand for aesthetics, no different from a younger patient. A mutual friend who was in the car industry then said that the guy who drives an old beat up car to a car dealership to collect his new car will not accept a single scratch on the new car. How true.

Older patients with extremely bad dentition are a major demographic group in my practice. They have not taken good care of their teeth for decades, resulting in multiple decayed and broken down teeth with advance gum disease. It is amazing how they managed function with such teeth for so many years. Perhaps it is the fear of the dentist or maybe a lack of awareness that led to such neglect. Regardless, they eventually present themselves for treatment. But notwithstanding the fact that they have been having such rotten teeth for so long, these patients are as aesthetically demanding as any. There is no age-limit on the desire to look good.

Some of these patients are in need of total teeth replacement with dental implants, others may be able to salvage some of their natural teeth and replace only the missing ones. Regardless of whether partial or full mouth teeth replacement, dental implants requires sufficient bone mass to achieve integration with the jawbone. However, having residual bone mass after loss of teeth will only achieve a functional success but that may not equate with an aesthetic prosthesis.

A patient who has lost all teeth for a long time would also have lost a significant about of the original bone mass in the jaw. The jaw bones does not only hold the teeth but is also a supporting structure of the facial skin, especially the lips. This is why removable dental prosthesis like a denture consists of not just the false teeth but the flanges as well. The flanges serves to replace the bulk of bone in the jaw that props up the lip. Without the denture in the mouth, the lips lose the support and collapse, giving rise to perioral wrinkles as well as a sunken face. In these patients, even if the bone stock is sufficient to place full mouth dental implants, bone grafting is still needed to rebuild the lost bone, not for implant support, but to provide support to the facial skin and lips.

The trend in implant dentistry today is towards minimalism. This is a consumer-driven trend and dentists and dental implant manufacturers are bending towards it. Naturally, everybody wants to have less invasive treatment but that is only the means to an end. The end is to have a functional and aesthetic prosthesis that can last a long time with practical maintenance. Sometimes, a minimalist approach like the All-on-4 concept is the solution and in other circumstances, a more complex solution involving reconstructing the jaw bone in addition to implant placement is needed to achieve the aesthetic demands of the patient.

It is not uncommon for older patients to tell me that aesthetics are not important and that they only want to have a functional set of teeth. However, experience taught me not to believe that. Older patients are used to a particular look, they way they look when they smile, when they talk, when they eat, etc. By saying they are not into aesthetics, they are saying that they are not looking for a complete makeover. They want subtle cosmetic enhancement, something that family and friends will notice that they look better without noticing that it is the teeth. In short, that’s what most cosmetic surgery patient wants. Very few actually want to have the complete makeover type of in-your-face transformation. Even if the patient himself is truly not concern, family and friends will always be ready to offer their opinion, which will eventually influence the patient.

Older patients are no less aesthetically conscious than younger ones and there should be no difference in the rigor in the aesthetic planning on the basis of age. In some cases, it may be beneficial to have family members involved in the planning stage to ensure optimal results.