Hyaluronic Acid in Mitigating Perioral Region Aging: Comparison
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Please note this is a comparison between Version 2 by Lindsay Dong and Version 1 by Henrique Oliveira.

Aging can have a negative impact on the perioral region, affecting both appearance and self-esteem. Dentists offer various treatment options to address these changes, using surgical and non-surgical techniques. One such technique is facial filling with hyaluronic acid, a minimally invasive approach to improve the perioral region’s function and aesthetics and counteract aging effects. 

  • aging
  • orofacial harmonization
  • hyaluronic acid
  • dentistry

1. Introduction

Human aging refers to the natural, gradual, and irreversible physiological and psychological changes in individuals as they progress through their lifespans. It encompasses a wide range of biological processes that lead to a decline in various bodily functions and an increased vulnerability to age-related diseases and illnesses. As people age, cells, tissues, and organs undergo degenerative changes, reducing their strength, flexibility, and overall vitality. Additionally, aging is often accompanied by cognitive decline, decreased sensory perception, and increased susceptibility to chronic conditions. While aging is a universal phenomenon, the rate and expression of these changes can vary among individuals due to genetic, lifestyle, and environmental factors [1].
The face is a visible reflection of human aging. The various changes in the face resulting from the overall aging process include the development of wrinkles and folds, fine lines, age spots, poor skin tone and texture, loss of skin elasticity and firmness, and imbalanced distribution of soft tissues. The underlying structures of the face, such as the subcutaneous cellular tissue areas and facial muscles, also change, leading to a loss of volume, sagging, and changes in facial contours [2,3][2][3]. Furthermore, signs of face wear can affect interpersonal relationships in various ways, such as influencing perceived character or personality traits and contributing to erroneously projected emotions that may not reflect the individual’s true feelings [4,5][4][5].
Non-surgical and minimally invasive options are increasingly being used to promote facial rejuvenation. Topical or laser-based therapies are insufficient to allow for volumetric rejuvenation, so the use of Botox and dermal fillers have gained increased notoriety by helping reduce the appearance of wrinkles, fine lines, and sagging skin, thus providing a more refreshed and youthful appearance of the face [6,7][6][7]. The burst in popularity of Botox and dermal fillers, the increasing patient population, and the need for quick solutions and long-lasting results have led to an increase in practitioners operating in the facial rejuvenation field. For example, dermatologists and plastic surgeons are health professionals that provide many therapeutic options in this field [8,9,10][8][9][10].
The aging of the perioral region is also a dentist’s professional activity sector [11], and “orofacial harmonization” is one of its professional abilities already considered in Portuguese law [12], encompassing techniques, procedures, and products with therapeutic, rehabilitation, or even prevention applications, such as botulinum toxin (Botox) or hyaluronic acid (HA). Depending on their expertise and training, dentists are health professionals who can offer non-surgical facial treatments using Botox (it freezes muscle) and HA (a dermal filler that gives fullness to the muscle) to address fine lines and wrinkles around the mouth and jaw area [13,14][13][14]. Dentists can also improve facial aesthetics in conjunction with the application of dental procedures such as dental implants, orthodontic treatments, or oral rehabilitation, which contribute to a more balanced and harmonious facial appearance [15,16][15][16].
Due to its therapeutic benefits, Botox is frequently employed in managing temporomandibular joint disorder (TMJD) and facial pain within the oral maxillofacial region. Injecting Botox into specific muscles can effectively relax the affected areas, relieving muscle spasms and reducing pain associated with TMJD. Additionally, Botox has effectively alleviated chronic facial pain, such as trigeminal neuralgia and myofascial pain syndrome. Moreover, Botox finds utility in dental aesthetics, as it can enhance smile aesthetics by targeting the muscles responsible for excessive gingival display or gummy smiles. Furthermore, it can aid therapeutic dental treatments by minimizing muscle contractions during orthodontic adjustments or prosthodontic rehabilitation procedures [13,14,17][13][14][17].
In dentistry, fillers, such as HA, are commonly employed to address various aesthetic and functional concerns. One area where fillers find utility is in treating a gummy smile, which occurs when an excessive amount of gum tissue is exposed while smiling. By strategically injecting fillers in the upper lip or around the gum line, the appearance of a gummy smile can be minimized, creating a more balanced and harmonious smile. Fillers are also used during gingivectomy procedures, where excess gum tissue is removed to enhance the smile’s aesthetics or facilitate better oral hygiene. Moreover, fillers can aid in periodontal and implant surgeries by supporting and shaping the soft tissues around the affected area, aiding in proper healing and optimal implant placement. Additionally, fillers can enhance lip and perioral volume, allowing patients to achieve fuller and more youthful-looking lips and address fine lines and wrinkles in the surrounding areas. Overall, fillers are versatile in dentistry, contributing to functional [18] and cosmetic treatment approaches [17,19,20][17][19][20].

2. Hyaluronic Acid in Mitigating Perioral Region Aging

2.1. Non-Surgical Modalities and Various Applicabilities of HA in Dentistry

Li et al. [26][21] showed consistent positive outcomes of non-surgical approaches, such as botulinum toxin and dermal fillers, in mitigating signs of facial aging. The interventions effectively reduced wrinkles and expression lines and restored facial volume while improving skin texture and tone. The authors emphasized the significance of personalized treatment planning and careful patient selection to achieve optimal results and minimize potential adverse effects. These findings underscore the importance of non-surgical methods as valuable options for mitigating facial aging, with dentists playing a crucial role in providing these treatments to patients.
Shuai et al. [30][22] conducted a survey in China to examine the public’s preference for non-invasive facial rejuvenation methods, specifically dermal fillers with HA and neurotoxins. The reported results showed that more than half of the respondents had chosen some non-invasive facial rejuvenation, with dermal fillers being the most popular technique. These findings suggest a growing demand for non-surgical approaches like HA-based treatments as alternatives to invasive methods. It was also found that the primary motivation for individuals seeking these treatments was to enhance their appearance, highlighting the importance of facial aesthetics in decision-making. Safety played a crucial role in treatment selection, with patients favoring non-invasive options that provide effective results with minimal risk. However, the authors reported a relatively low awareness and knowledge among the public regarding non-invasive facial rejuvenation procedures that dental practitioners can perform. 
In sum, these studies show that HA is becoming more popular in dental medicine as a non-surgical treatment option. It offers aesthetic benefits, anti-inflammatory and antibacterial properties, and tissue-regeneration capabilities. Additionally, the public prefers non-invasive treatments. Therefore, dental professionals should consider integrating HA into their practices to meet patient needs and achieve better results.

2.2. Dentists as Specialists

In the study published by Tran Cao [31][23], the use of botulinum toxin and dermal fillers in dentistry to enhance patient attractiveness was explored. The author examined the historical and current applications of these treatments in facial aesthetics, their administration techniques, potential implications for dentistry, and the role of dentists in providing these treatments. The study found a growing demand for botulinum toxin and dermal fillers in dentistry as more dentists incorporate them into their practices to improve patients’ perceived attractiveness, confidence, quality of life, and satisfaction. However, the need for proper training of dentists and awareness of potential risks associated with these treatments was also highlighted. Spatafora et al. [34][24] provide, in their research, valuable information about the role of dentists in aesthetic procedures within dentistry, as do the findings published by Zupi [33][25] and Tran Cao [31][23]. The study emphasizes the increasing recognition and appreciation of dentists’ ability to provide integrated care based on scientific knowledge and advanced techniques. Dentists’ understanding of facial structure enables them to achieve aesthetic and functional harmony, restoring lost volume and improving patients’ attractiveness. However, dentists’ involvement in non-surgical aesthetic modalities raises essential legal and ethical considerations. The study highlights the importance of dentists being aware of and adhering to regulations, guidelines, legal restrictions, ethical standards, and specific professional practices related to aesthetic treatments. The need for ongoing training and education for dentists interested in incorporating aesthetic treatments into their practices is also highlighted, along with the importance of these health professionals holding a sound background covering both technical aspects and legal/ethical considerations in dental practice. The abovementioned findings are also supported by Chaput et al. [35][26], who shed light on the legal regulations surrounding the use of dermal fillers, specifically HA, by dentists in France. The authors report that dentists possess the necessary knowledge and expertise to perform aesthetic treatments with dermal fillers, which suggests adequate training for these procedures. The discussion emphasizes the impact of these regulations on dentistry as they establish guidelines for dentists offering these treatments.

2.3. Pharmacodynamics of HA

Bukhari et al. [32][27] explore the pharmacodynamics and rheological characteristics of HA in skin rejuvenation and aesthetic procedures. HA can retain water, improve skin hydration, and act as a dermal filler to reduce wrinkles and enhance skin elasticity. Understanding the rheological properties of HA is crucial in predicting its effectiveness, integration into the skin, response to facial expressions, and gradual dissipation of clinical effects, as stated by Dastoor et al. [36][28]. Both studies emphasize how analyzing these properties helps physicians select the right product, determine injection techniques and volume, and optimize aesthetic results, safety, and patient satisfaction. When administered correctly by qualified professionals, HA has proven benefits in skin rejuvenation, wrinkle filling, hydration increase, and improved skin elasticity, findings that are also corroborated by Wang et al. [42][29], Gavard Molliard et al. [43][30], and Fagien et al. [44][31].

2.4. Skin Aging

Rogerio et al. [28][32] introduce the Mimicking Intraoral Mucosal Tissues (MIMT) concept in orofacial aesthetics. This concept aims to replicate the characteristics and properties of oral mucosal tissues in dental procedures and restoration. By using materials and techniques that mimic the natural tissues of the mouth, dental professionals can achieve more natural aesthetic results, where restoration and prosthetics blend seamlessly with the surrounding tissues. Mimicking the characteristics of intraoral tissues, such as texture, color, and elasticity, the materials used in dental procedures can provide greater comfort and adaptation for patients. In addition, the authors suggest that incorporating dermal HA fillers, such as those in the Restylane® product line, along with the MIMT concept, can provide natural and long-lasting results in orofacial rejuvenation, as they consider the unique qualities of intraoral mucosal tissues. The research studies by Kapoor et al. [58][33], Rauso et al. [59][34], Hernandez et al. [60][35], and Islam et al. [61][36] also address different aspects of skin aging and the aesthetic approaches used for facial rejuvenation, adding evidence that HA and botulinum toxin are safe and effective options in dentistry for facial rejuvenation, thus supporting the abovementioned findings. These fillers can fill wrinkles, increase skin hydration, improve elasticity, and provide a more youthful and balanced appearance. The studies report the importance of recognizing the anatomy and physiology of the oral and maxillofacial region and the appropriate application techniques to achieve optimal aesthetic results. 

2.5. Skin and Lip Rejuvenation

Dantas et al. [27][37] aimed to assess the safety and effectiveness of using hyaluronic acid (HA) for enhancing the lips’ appearance. The researchers discussed the process of injecting HA into the lips, explored various HA formulations available, and examined the potential benefits and risks associated with this treatment. Furthermore, the study compared the attractiveness of lips with different thicknesses after undergoing hyaluronic acid fillers, as perceived by dental surgeons, facial harmonization specialists, and laypersons. The results demonstrated that HA injections were a safe and effective method for rejuvenating the lips. The treatment significantly improved lip volume, contour, and overall appearance, with a low risk of adverse effects. Perenack [37][38] examines the impact of aging on lip structure and its implications for oral aesthetics. The article discusses various treatment options to enhance the appearance of aging lips, including injectable lip augmentation fillers, lip lift surgeries, and maxillofacial surgery. Injectable fillers are highlighted as a minimally invasive technique that can effectively improve the look of the lips and perioral region. The study also mentions using fillers to address concerns like nasolabial folds and marionette lines, which are common aesthetic issues for patients. Furthermore, it refers to several recent studies that explore different techniques and therapeutic approaches to rejuvenate the lips and perioral region [26,65,66][21][39][40].

3. Conclusions

Using hyaluronic acid as a mechanism to mitigate the effects of face lower third aging following orofacial harmonization procedures in dentistry offers significant benefits to patients, improving the aesthetic appearance of the face, increasing patients’ self-esteem and satisfaction, and providing a better quality of life. Nonetheless, a note is made regarding the frail methodological evidence level in the selected articles due to limitations such as small sample sizes, absence of control groups, inadequate randomization, and insufficient statistical analyses, emphasizing the need for more methodologically rigorous studies to be published.

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