Athena - Health & Research Journal of Escola Superior de Saúde Fernando Pessoa is an open access quarterly peer review publication dedicated to scientific dissemination of health care related scientifc knowledge. Its mission is to disseminate emerging research and development produced by the entire academic and scientific community, which is original and innovative, highlighting the pedagogical and scientific development of the Health Sciences in response to the needs of the person, family and community. ISSN: 3051-6013
Escola Superior de Saúde Fernando Pessoa
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Introduction: Facial aging is a progressive phenomenon that affects multiple layers of the face, including the skin, adipose tissue, muscles, and bony structure. Loss of muscle tone, particularly in the elevator muscles, contributes to tissue laxity, wrinkle formation, and the degradation of collagen and elastin, which compromises skin firmness and elasticity. External factors such as sun exposure, smoking, and pollution can accelerate this process. Radiofrequency, a technology that generates an alternating electrical current, induces molecular vibrations in tissues and, when applied at lower temperatures, triggers an inflammatory response, stimulating neocollagenesis and neoelastogenesis, thereby promoting regeneration and facial rejuvenation. Objective: This study aims to provide a detailed overview of the therapeutic applications of radiofrequency, as well as the underlying mechanism of action in skin and adipose tissue remodeling. Additionally, it examines safety considerations, criteria for evaluating treatment outcomes, and specific factors to consider during radiofrequency therapy to ensure effective treatments while minimizing patient recovery time and adverse effects. Methodology: A literature search was conducted using the PubMed and ScienceDirect databases, employing the following keywords: “collagen,” “elastin,” “skin aging,” “skin laxity,” “dermal rejuvenation,” and “radiofrequency therapy.” Inclusion criteria were articles published between 2014 and 2024, containing the keywords in the title or abstract, and available in full text. Exclusion criteria included duplicate articles and publications whose content did not align with the proposed topic. Results: Neocollagenesis, the synthesis of new collagen fibers, is stimulated by thermal energy between 37°C and 44°C, triggering an inflammatory response that activates fibroblasts to produce type I and III collagen, promoting dermal firmness and renewal. Neoelastogenesis is a more complex and less active process in adults, but regenerative treatments can stimulate the production of tropoelastin, which organizes into mature elastic fibers, restoring skin elasticity. Radiofrequency emerges as an effective non-surgical alternative to attenuate signs of aging. However, the standardization of protocols and safety across different skin phototypes requires further investigation. Combining radiofrequency with laser treatment has shown efficacy but requires additional research to understand its synergy and safety. Discussion: Radiofrequency therapy demonstrates clear potential in facial rejuvenation by promoting collagen and elastin remodeling, which improves skin firmness and elasticity. Its non-invasive nature makes it particularly suitable for patients seeking aesthetic enhancement without surgical intervention. However, variability in treatment protocols and responses among different skin types emphasizes the need for standardized guidelines and further clinical studies. Combining RF with other energy-based therapies may enhance outcomes, but careful evaluation is required to ensure safety and efficacy. Conclusions: In conclusion, radiofrequency acts through selective dermal heating, promoting collagen denaturation and stimulating neocollagenesis and neoelastogenesis, which enhance skin structure and elasticity. Even as a standalone treatment, radiofrequency effectively reduces the signs of skin aging, producing notable results that support its application in Dentistry, particularly in orofacial harmonization, as a highly effective tool in clinical practice.
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Phased lip and perioral augmentation with hyaluronic acid: effects on facial esthetics in a 38-year-old female patient
Introduction: The lips, as the central element of the lower third of the face, play a fundamental role in emotional expression, social interactions, and the definition of individual identity. Objective: To demonstrate the importance of combining perioral filling techniques to achieve a harmonious and long-lasting outcome in patients presenting signs of aging. Methodology: The treatment followed a phased approach to ensure progressive and safe results: 1) Botox® botulinum toxin was injected into the depressor anguli oris muscles (2 units), the mentalis (4 units), and the platysma muscle at the level of the mandibular contour (3 points per side of the face, 2 units each), aiming to reduce muscle contraction. The plan included a full-face approach using 56 units of Botox®, with 20 units applied to the lower third. 2) Lip filling was performed in two sessions (January 27, 2024, and July 6, 2024), using a volumizing technique with a 25G cannula and lip contour definition with a 27G needle. In the first session, 1 ml of hyaluronic acid was applied. In the first session, lip contouring was not performed, only volumization using a retroinjection technique and perioral restructuring using a bolus technique in the infracommissural region, distributed in deep and superficial subcutaneous layers, to restore structural support. In the second session, the combined retroinjection technique was used, combined with bolus application in the lower lip, concluding with lip contouring and philtrum definition. Results: The comparative analysis between pre- and post-treatment stages revealed a progressive and significant improvement in lip volume, accompanied by the preservation of naturalness and facial proportion balance. Cephalometric evaluation demonstrated adequate maintenance of the labiomentonian relationship, with preservation of the nasolabial and labiomental angles, which are essential for the aesthetic harmony of the facial profile. These parameters confirm that the volumetric enhancement was achieved without compromising the functional and structural positioning of the lips relative to the adjacent bony structures. The final clinical outcome was deemed satisfactory by both the patient and the clinical team, with no complications or adverse effects observed during the follow-up period. Discussion: With aging, progressive lip atrophy occurs, resulting in decreased volume, loss of contour definition, and the formation of perioral rhytids, due to the reduction of subcutaneous fat, altered muscle tone, and bone resorption. Conclusions: The phased protocol allowed for a discreet and progressive increase in lip volume, minimizing the risk of complications such as vascular compression. The combination of perioral filler and botulinum toxin contributed to a harmonious and natural overall result. A detailed clinical evaluation and appropriate planning are essential for achieving satisfactory and safe aesthetic results.
Ethics and deontology in facial harmonization and orofacial therapeutics: listening to decide
Introduction: Orofacial harmonization and therapeutics is currently distinguished as an area closely connected with Dental Medicine and structured around the application of clinical procedures, aiming to promote both aesthetic and functional balance. The principles of ethics and deontology inherent to health theories and practices apply to orofacial harmonization and therapeutics and encompass concepts designed to ensure patient well-being. It is crucial that professionals possess up-to-date and detailed knowledge, perform comprehensive and individualized clinical assessments, prioritize ethics and deontology, and inform patients about the risks and benefits of each procedure. Objective: This study aimed to describe the phases involved in constructing a questionnaire for Dentists and 5th-year students of the Integrated Master’s in Dental Medicine, to explore concerns regarding ethics and deontology related to the clinical practice of orofacial harmonization and therapeutics. Methodology: This research is based on the development of a Measurement Instrument directed at Dentists (Portugal) / Dental Surgeons (Brazil) and final-year students of the Integrated Master’s in Dental Medicine (Portugal) / Dentistry (Brazil), addressing ethics and deontology and Professional Practice in orofacial harmonization and therapeutics. Initially, the construct and the dimensions to be assessed were defined, followed by the development of a set of items and the type of scale to be used for evaluation. A content analysis was conducted with recognized experts in this field, who provided feedback on dimensions, item formulation, comprehensibility of the instrument’s questions, degree of pertinence, relevance, and the scales used. The questions comprising the “ethics and deontology” dimension of the questionnaire, already submitted and approved by the Ethics Committee, are presented. A new landmark, the Jowl point (Jw), was determined by palpation of the anterior portion of the masseter and the position of the mandibular ligament. The lowest point between these two structures was defined as Jw. Based on the cutaneous cephalometric points gonion (Go’) and menton (Me’), a new angle (Go’-Jw-Me’) was proposed to measure jowl ptosis. Statistical analysis was performed in Excel, considering mean, standard deviation, minimum, and maximum values. Results: The finalized measurement instrument includes a total of 17 questions in the “ethics and deontology” dimension. The topics addressed are: photographic documentation in orofacial harmonization and therapeutics; videographic documentation in orofacial harmonization and therapeutics; dissemination of patient information in orofacial harmonization and therapeutics; advertising in orofacial harmonization and therapeutics; commercial pressure in orofacial harmonization and therapeutics; inclusion of procedures in the Dental Council’s nomenclature table; regulation in orofacial harmonization and therapeutics; clinical practice in orofacial harmonization and therapeutics; training in orofacial harmonization and therapeutics; integration in multidisciplinary teams; medico-legal consequences in orofacial harmonization and therapeutics. Discussion: Exploring the perspectives of orofacial harmonization and therapeutics professionals in the context of ethics and deontology is essential today. As the number of new professionals and knowledge in this area rapidly increases, adhering to principles and values that guide professional behavior and respect autonomy, beneficence, non-maleficence, and justice is fundamental. Conclusions: The formalization of rules and duties regulating the practice of this area and establishing standards of conduct and professional practice guidelines can be strongly complemented by the perception of those practicing orofacial harmonization and therapeutics. The administration of the constructed questionnaire presented here may assist in decision-making and regulation in this field.
Orofacial harmonization: variation of the cervico-mental angle with age
Introduction: Cephalo and profilometric studies are essential for facial analysis based on objective and clear criteria that can support clinical decision-making in orofacial harmonization. Objective: This study aims to analyze the results of research on the variation of the cervico-mental angle with age, dependent on the lower third of the face and the cervical region. Methodology: Observational, cross-sectional, prospective research study, approved by the Ethics Committee of Fernando Pessoa University (number FCSPI/528/24). Fifty women were evaluated, divided into five age groups (18–24; 25–34; 35–44; 45–54; >55). Each participant voluntarily signed three informed consent forms (participation in the study, performance of the cephalometric radiograph, and use of photographs in dental medicine). The cervico-mental angle evaluated in the cephalometric analysis, using cephalometric radiographs and photographic analysis, is formed by the intersection of line A (perpendicular to the plane formed between the articulare and gonion points with the line tangent to the menton) and line B (joining the gnation and cervical points). It is classified as grade I (normal; <20°), grade II (21°–40°), grade III (41°–60°), and grade IV (>60°). Inclusion criteria were: age over 18 years, agreement with the terms and consents, and completion of the radiograph and photographic analysis. Exclusion criteria included prior aesthetic treatments, medical conditions limiting exposure to radiation, deformities in the analyzed region, or any other condition preventing the use of the methodology Results: Using cephalometric analysis (Nemoceph) and Excel, it was possible to calculate and compare the variation of the cervico-mental angle. In this sample, an increase in the angle with age was observed, with the youngest group (18–24 years) classified as grade I and the oldest group (>55 years) as grade II. In addition to aging, this variation is also influenced by increased weight (leading to greater submental adipose tissue), skin laxity, lifestyle habits, metabolic changes, and tooth loss. Consequently, a loss of definition in the cervico-mandibular contour and mandibular angle was noted. Discussion The cervico-mental angle increases with age due to factors such as fat accumulation, skin laxity, and tooth loss, leading to a loss of definition in the lower face. Assessing this angle is essential in orofacial harmonization to guide aesthetic and functional interventions. Conclusions: Young patients exhibit a well-defined cervico-mandibular contour, a cervico-mental angle of approximately 90°, and minimal local skin laxity and adiposity. With aging, the contour and definition gradually diminish, leading to an increase in this angle. Considering this parameter in Oral Health is crucial for maintaining orofacial balance.
Non-surgical treatment of gummy smile with botulinum toxin: clinical case
Introduction: Gummy smile, or excessive gingival display, is defined as the exposure of more than 2–3 mm of gingival tissue when smiling, with the aesthetic threshold generally starting at 3 mm. This condition affects approximately 10% to 30% of the general population and its perception can vary significantly depending on cultural and individual factors. The causes of gummy smile are multifactorial, involving skeletal, dentoalveolar, and muscular components. Objective: This clinical case of gummy smile treatment using botulinum toxin, aiming for a minimally invasive and effective aesthetic solution. Methodology: Botulinum toxin (Botox®) was applied to the upper lip elevator muscles, specifically at the Yonsei point, the confluence of the levator labii superioris alaeque nasi, levator labii superioris, and zygomaticus minor muscles (doses are described in the legend of each clinical case), following an assessment of hyperactivity in the upper lip elevator muscles. After application, patients were instructed not to massage the area and to avoid intense physical activity for the next 24 hours. A follow-up evaluation appointment was scheduled 15 days after the procedure. Photographs were taken at rest and during maximum smile both before the procedure and at the evaluation visit. Results: The application of botulinum toxin at the Yonsei point in each of the three clinical cases reduced gingival display to levels highly satisfactory for the patients, without altering lip dynamics or aesthetics at rest or during smiling. Regardless of whether excessive vertical maxilla or altered passive eruption was the main cause of the gummy smile, the patients preferred to continue using botulinum toxin as the sole treatment to correct excessive gingival exposure. Discussion Botulinum toxin is an effective, minimally invasive alternative for gummy smile correction, offering consistent aesthetic results while avoiding the risks and recovery associated with surgical interventions. Conclusions: Botulinum toxin has proven to be a safe and effective option for correcting gummy smile, providing satisfactory aesthetic results without significant complications, even in the presence of other concurrent causes of gummy smile. These cases reinforce the viability of botulinum toxin as an alternative to surgical procedures for gummy smile correction.
Is botulinum toxin effective in all muscle groups of the perioral region? clinical study
Introduction: Botulinum toxin is widely used to modulate muscle activity in the perioral region for the treatment of orofacial dysfunctions, gummy smile, and to reduce dynamic or static wrinkles. Its application aims to relax muscles such as the levator of the upper lip, orbicularis oris (upper portion), mentalis, and depressor anguli oris, providing both aesthetic and therapeutic benefits. Objective: The results of the research study are presented, comparing the clinical outcomes with those described in the literature following the application of botulinum toxin protocols. Methodology: Cross-sectional research study, approved by the Ethics Committee of Fernando Pessoa University. A total of 41 individuals were evaluated. Initially, muscle alterations resulting in a gummy smile or dynamic/static wrinkles in the region of the orbicularis oris (upper portion), depressor anguli oris, or the mentalis area were observed. For the application of botulinum toxin, four groups were considered: gummy smile (botulinum toxin in the levator labii superioris and zygomaticus minor muscles to reduce gingival exposure greater than 3 mm), Menton (botulinum toxin in the mentalis muscle to reduce the “orange peel” effect), depressor anguli oris (botulinum toxin in this muscle to reduce marionette lines), and orbicularis oris (upper portion) (botulinum toxin in this muscle to reduce “barcode” wrinkles). After validation by the patient, data collection included a clinical questionnaire, photographic records, and application of botulinum toxin protocols. At the follow-up visit, 10 to 15 days after the procedure, photographic records were repeated. Inclusion criteria were: individuals aged between 20 and 70 years; residents in Portugal; without cognitive impairments and/or psychiatric disorders. Exclusion criteria were: patients with contraindications for botulinum toxin application, generalized muscle disease, or infection/ inflammation at the intervention site. Results: A statistically significant reduction in muscle contraction was observed in the gummy smile, Menton, and depressor anguli oris groups. The group with the greatest magnitude of muscle activity reduction was the gummy smile group (100% efficiency), followed by the Menton group with 93% efficacy, and the depressor anguli oris group with 75% efficacy. In the orbicularis oris (upper portion) group, no changes were identified (0% efficacy). Discussion: Botulinum toxin demonstrates efficacy in various facial applications, including the treatment of gummy smile, improving chin contour, optimizing facial symmetry, and softening the appearance of nasolabial folds. The safety profile of botulinum toxin is well-documented, with adverse effects generally being mild and self-limiting. In this study, no significant adverse events were reported. Conclusions: Clinically, there is evidence of therapeutic success in three of the four groups evaluated. The reduction in muscle contraction in the gummy smile, Menton, and depressor anguli oris groups using botulinum toxin was statistically significant; however, no reduction in muscle contraction was identified in the orbicularis oris (upper portion) group. Likewise, the safety of the protocols used was confirmed.
Integrated facial harmonization with orthodontics: correction of gummy smile after orthodontic treatment
Introduction: Facial esthetics is intrinsically linked to the smile, which is shaped by the interaction between teeth, gingiva, and lips. A harmonious smile requires a balanced proportion among these elements, with gingival exposure limited to 3 mm. When gingiva is excessively exposed during smiling, it is characterized as a gummy smile, a condition that may have a significant psychological impact and impair patients’ social interactions. The higher prevalence in females can be explained by the fact that male patients typically present with a lower smile line. Objective: To demonstrate, through a clinical case, the effectiveness of integrating facial harmonization procedures with previous orthodontic treatment, focusing on the minimally invasive and predictable correction of gummy smile. Methodology: This is a clinical case report. The patient underwent a detailed assessment after completing orthodontic treatment, including anamnesis, photographic records, panoramic radiograph, lateral cephalometric radiograph, and cephalometric analysis. Based on the clinical and functional findings, an individualized treatment protocol was established: 19 Gingivoplasty: Performed on teeth #13, #12, #22, and #23 to increase the height of the clinical crowns and achieve more balanced proportions; 29 Botulinum Toxin: Application of 2.5 U of botulinum toxin (Botox®) diluted in 2 ml of saline solution at each point of the levator labii superioris muscles (right and left) and at two points on the menta Results: The initial and final images demonstrate the effectiveness of the treatment in harmonizing the gummy smile and improving the aesthetics of the lower third of the face. There was a reduction in the gingival band present in the smile, with consequent aesthetic gain, due to the increase in clinical crowns and the impossibility of a more active contraction by the levator labii superioris muscle after the application of botulinum toxin. Discussion: The improvement observed in the reduction of gingival display highlights the critical role of the mimic muscles, particularly the levator labii superioris, in the etiology of a gummy smile. Hyperactivity of this muscle leads to excessive elevation of the upper lip, resulting in increased gingival exposure during smiling. The application of botulinum toxin effectively decreases this muscle’s contraction, limiting lip elevation and thus reducing the visible gingival band. This approach offers a minimally invasive treatment option that addresses the functional muscular cause without altering the underlying skeletal or dental structures. Alternative treatments for gummy smile include surgical lip repositioning, myotomy, and crown lengthening procedures, each targeting different anatomical factors depending on the etiology. Orthognathic surgery is reserved for cases involving skeletal discrepancies such as vertical maxillary excess. Overall, botulinum toxin represents a safe, reversible, and effective method to harmonize the smile by modulating muscle activity, contributing to improved facial aesthetics and patient satisfaction. Conclusions: The integration of facial harmonization procedures with orthodontics represents an effective, predictable, and minimally invasive alternative for the correction of gummy smile in patients previously treated orthodontically. These treatments (Orthodontics and Facial harmonization) complement each other and allowed the patient to increases the level of satisfaction with her facial appearance, which positively impacted her self-confidence, socialization, and quality of life.
The role of ultrasound in orofacial harmonization: a literature review
Introduction: The use of ultrasound in orofacial harmonization has revolutionized treatments, providing greater safety and precision for healthcare professionals. This technology enables real-time visualization of internal facial structures, reducing risks and optimizing clinical practice in orofacial harmonization. Consequently, the use of ultrasound enhances outcomes and increases the predictability of treatments. Objective: To analyze the effectiveness of ultrasonography in facial procedures for orofacial harmonization, highlighting its valid use as a precision tool for diagnosis, planning, execution, and postoperative follow-up. Methodology: A literature review was conducted using articles from the PubMed, B-On, and Google Scholar databases, limited to the period 2015–2025. The keywords used were: “Ultrasound,” “Orofacial Harmonization,” “Orofacial Anatomy,” and “Diagnosis.” Inclusion criteria were the presence of these keywords in the publication, and full-text articles published in English or Portuguese. Exclusion criteria included duplicate articles and publications whose content did not correspond to the proposed topic. Results: The use of ultrasonography increases the accuracy of diagnosis and treatment planning, improves the prevention of complications, and optimizes outcomes and safety in clinical procedures. Ultrasonic images are produced by ultrasonic pulses transmitted to the tissues through a probe, generating a piezoelectric effect, whereby different tissues reflect varying degrees of sound. Ultrasound in orofacial harmonization allows for comprehensive facial mapping, including skin and subcutaneous thickness, tendons, muscles, joints, vessels, and organs. It is therefore an important tool for analyzing maxillofacial fractures, periapical lesions, and cervical lymphadenopathies, as well as for evaluating the masticatory and cervical muscles, temporomandibular joint, and salivary glands. Moreover, ultrasound is essential for identifying high-risk anatomical areas, enabling detailed visualization of the vascular complexity in these regions. It facilitates the analysis of previous treatments by detecting and identifying fillers, assessing arterial and arteriovenous malformations, and studying age-related changes. Consequently, it contributes to more precise selection of orofacial harmonization procedures and biomaterials, such as hyaluronic acid, botulinum toxin, biostimulators, and botulinum peptides, among others. Discussion Ultrasonography enhances the precision and safety of orofacial harmonization procedures, but its benefits are dependent on the clinician’s proficiency with this imaging modality. Conclusions: Currently, therapeutic success in orofacial harmonization increasingly depends on the incorporation of ultrasonography into clinical practice. The use of ultrasound with high-frequency linear probes (7.5–12 MHz) can generate high-resolution images of the head and neck regions. As a non-ionizing examination, it offers advantages such as the ability to perform regular follow-ups without complications or health risks to the patient, enabling continuous and precise assessment and contributing to safer and more predictable procedures. A disadvantage arises when the dental practitioner is not familiar with this complementary diagnostic tool, potentially limiting its clinical benefits for patients.
Masseter hypertrophy: how does botulinum toxin revolutionize treatment?
Introduction: Masseter hypertrophy is a rare clinical condition characterized by excessive development of the masseter muscle, which can compromise both facial aesthetics and masticatory function. Its etiology remains undefined, although factors such as parafunctional habits, temporomandibular joint dysfunction, and congenital predisposition are frequently implicated. Treatment may include surgical and non-invasive approaches, with botulinum toxin type A being a safe and effective option. By blocking acetylcholine release, it induces temporary paralysis of the masseter, promoting muscle atrophy. Objective: This study aims to analyze the effects of botulinum toxin on reducing the volume of the masseter muscle in patients with masseter hypertrophy. It also seeks to evaluate the impact of the toxin on masticatory function and associated symptoms. Furthermore, it intends to describe and discuss the properties of botulinum toxin, understanding how these characteristics justify its application in the treatment of masseter hypertrophy. Methodology: A literature search was conducted in the PubMed, ScienceDirect, B-on, and Elsevier databases using the keywords: Masseter, Hypertrophy, Botulinum Toxin, Anatomy, Treatment, covering the period between 2015 and 2025. Articles published in English and Portuguese were considered, without exclusion based on methodology. Inclusion criteria were the presence of the keywords in the publication and full-text availability in English or Portuguese. Exclusion criteria included duplicate articles and publications not directly related to the proposed topic. Results: The findings show that botulinum toxin type A is an effective intervention for reducing masseter muscle volume in these patients. Reduction in muscle thickness is most evident between 12 weeks and 6 months after injection, with treatment response depending on the administered dosage, requiring periodic reassessment to maintain results. Ultrasound-guided injection demonstrates advantages in toxin distribution and in minimizing adverse effects. Discussion Although botulinum toxin provides benefits in facial remodeling and symptom relief, the lack of standardization in clinical protocols highlights the need for further research to determine the optimal dosage and most effective injection points. Conclusions: Botulinum toxin represents a safe and effective alternative for the treatment of masseter hypertrophy, allowing symptomatic control and aesthetic improvement without the need for surgical intervention. However, additional clinical studies are necessary to standardize application protocols and ensure long-term treatment safety.
Jawline rejuvenation and mental artery: high-risk injection sites
Introduction: Mandibular line rejuvenation is an aesthetic procedure that enhances facial contouring, providing a more youthful and harmonious appearance. However, the mandibular region presents high-risk areas for injectable techniques, particularly due to the presence of the mental artery and its branches. Objective: The aims of the present study are to identify the main complications arising from orofacial harmonization procedures associated with the presence of the mental artery, as well as to determine the risk zones related to mandibular line rejuvenation techniques. Methodology: A literature search was conducted in PubMed and B-On using as inclusion criteria articles published between 2019 and 2025 that contained the keywords in the title/abstract and provided free access to the full abstract. Duplicate articles and/or those whose content did not correspond to the proposed topic were excluded Results: The mental artery is a terminal branch of the inferior alveolar artery, which originates from the first portion of the maxillary artery. It divides into incisive branches (supplying the anterior mandibular region, anterior teeth, and dental alveoli) and mental branches. The mental artery exits through the mental foramen, where it communicates with the inferior labial artery and the submental artery. Injuries to the mental artery may cause hemorrhage near the mental foramen and the chin. With aging, skin layers become thinner, leading to delayed wound healing, increased skin fragility, and reduced cellular turnover, with consequent impact on tissue remodeling. In the mental artery, blood flow decreases, which may be an etiological factor for alveolar bone atrophy. The intersection between the mandibular body and the ramus forms the mandibular angle, which tends to increase with aging as the cortical bone becomes thinner, porous, and demineralized. The definition of the mandibular angle and the chin are the main areas targeted for rejuvenation of the lower third of the face. Mandibular line contour tends to decrease with age due to resorption in the ramus and chin regions. Facial retaining ligaments anchor the skin and subcutaneous tissue to the deeper planes, maintaining a youthful appearance. However, with aging, these structures weaken, leading to the formation of jowls and disruption of mandibular continuity. An inverted triangle is progressively replaced by a square-shaped face due to age-related facial changes. Ecchymosis, edema, hematomas, granulomas, and delayed-onset nodules are common complications. Compression of the mental nerve or direct intravascular injection into the mental artery may cause severe pain and vascular complications such as necrosis. Discussion Mandibular line rejuvenation represents an effective approach to restoring lower facial harmony; however, the proximity to high-risk anatomical structures, particularly the mental artery, highlights the need for careful technique selection to minimize complications. Conclusions: The lower third of the face is fundamental for a youthful and harmonious appearance, primarily due to the definition of the mandibular line. It is a critical region where numerous complications may arise because of its close relationship with anatomical structures such as the mental artery. Mandibular line rejuvenation may involve surgical or non-surgical methods, the latter being less invasive, effective, and generally preferred by patients to enhance the appearance of the lower facial third. Among the most commonly used agents are hyaluronic acid, poly-L-lactic acid, polymethylmethacrylate, and hydroxyapatite.
Orofacial harmonization and longevity: a new cephalometric approach for jowl measurement – an observational study
Introduction: Aging is a process that affects the entire facial structure. With advancing age, an accumulation of tissue appears along the mandibular line, known as jowls (the “bulldog” appearance), resulting from volume loss, skin laxity, and the downward displacement of fat compartments toward the lower third of the face. These changes compromise jawline definition, giving the face a squared appearance. Measuring this phenomenon may assist in planning treatments in orofacial harmonization. Objective: To present preliminary results of a research study analyzing soft profile points from facial photographs to identify and measure the degree of jowl ptosis associated with aging. Methodology: A cross-sectional and prospective observational study, approved by the Ethics Committee of Fernando Pessoa University (FCS/MED 401/23-2). Twenty-five women participated, divided into five age groups (18–24, 25–34, 35–44, 45–54, and over 55 years), between April and May 2023, in Figueiró, Santiago, Portugal. Inclusion criteria: age over 18 years, anamnesis, and informed consent. Exclusion criteria: previous aesthetic treatments, deformities in the study area, or conditions that could compromise results. Frontal and profile photographs were obtained for manual marking of cephalometric points. A new landmark, the Jowl point (Jw), was determined by palpation of the anterior portion of the masseter and the position of the mandibular ligament. The lowest point between these two structures was defined as Jw. Based on the cutaneous cephalometric points gonion (Go’) and menton (Me’), a new angle (Go’-Jw-Me’) was proposed to measure jowl ptosis. Statistical analysis was performed in Excel, considering mean, standard deviation, minimum, and maximum values. Results: A classification of ptosis was developed, using the values from the youngest group as reference (normal: 180°–170°, with no unaesthetic signs). Additional categories were defined: mild (169°–160°), moderate (159°–150°), and severe (<150°). The smaller the angle, the greater the ptosis. Among participants, 35% were classified as normal; 24% as mild; 28% as moderate; and 16% as severe. Groups over 35 years showed a greater distribution of ptosis, with a trend of angle reduction across age ranges. Discussion: The results suggest that the Go’-Jw-Me’ angle has potential as an objective parameter to assess the severity of jowl ptosis related to aging, although studies with larger samples are needed for validation. Conclusions: Despite study and sample limitations, it can be concluded that: (i) there is a relationship between aging and jowl severity; (ii) the new angle (Go’-Jw-Me’) may support diagnosis, planning, and treatment of the lower third of the face; (iii) facial analysis is essential in orofacial harmonization. Future studies should include a larger sample to validate the classification and refine reference values.
The role of exosomes in the biology of aging: a literature review
Introduction: The skin, the largest organ of the human body, is vital for separating the internal environment from the external, maintaining internal homeostasis, and protecting the organism from environmental factors that may disrupt this functional balance. Over time, genetic and epigenetic factors contribute to the aging process. The skin is the first to show signs of aging, increasing the demand for aesthetic treatments. One of the procedures that has shown promising results in slowing down aging is exosome therapy. Objective: Thus, this study aimed to analyze the importance of using these vesicles in promoting skin longevity. Methodology: Articles were selected according to inclusion and exclusion criteria and their relevance between 2022 and 2024 through a bibliographic search on PubMed and B-On. Keywords used included: “Aging,” “Cosmetics,” “Exosomes,” “Regenerative Medicine,” “Skin,” and “Tissue Regeneration.” Results: The skin is composed of an epithelial tissue, the more superficial layer (epidermis), and a connective tissue, the deeper layer (dermis). The epithelium is a stratified keratinized squamous tissue, with keratinocytes being the most abundant cell population, responsible for keratin formation and skin barrier function. The connective tissue is organized into a looser, vascularized papillary dermis and a deeper, fibrous reticular dermis. Several cell populations are present in this tissue, with fibroblasts playing a key role in producing and maintaining the extracellular matrix, including collagen and elastic fibers, which provide structure, integrity, and elasticity to the skin. Over time, changes occur in both epithelial and connective tissues, including keratinocyte atrophy and decreased skin hydration, as well as reduced fibroblast metabolism, leading to alterations in the abundance and organization of elastic and collagen fibers. Among the various aesthetic procedures used to combat aging, exosome therapy stands out. Exosomes are small extracellular vesicles (30–100 nm in diameter) produced by nearly all cell types. They can carry a variety of molecules, including DNA, RNA, and growth factors, and mediate extensive intercellular communication. Among the various sources, exosomes derived from stem cells are the most effective in promoting proliferation and stimulating the metabolism of several cell populations, particularly keratinocytes and fibroblasts. Consequently, there is an increase in collagen, elastic fibers, and skin barrier function, giving the skin a more youthful appearance and reducing existing wrinkles. Discussion: Exosome therapy appears promising in delaying skin aging by stimulating keratinocyte and fibroblast regeneration, increasing collagen and elastic fibers. Despite positive results, further clinical studies are needed to validate application protocols and long-term safety. Conclusions: Exosome therapy has proven to be an excellent option for addressing skin aging. Through its ability to promote cellular regeneration and tissue repair, combined with other aesthetic procedures, it can effectively reduce the impact of aging. Further studies are needed to expand and deepen its clinical application.
Midface support as a prerequisite for lower face reconstruction: clinical case
Introduction: Facial aging involves bone resorption and loss of deep fat layers, which, together with migration of superficial fat pads and excess skin, leads to tissue ptosis from the midface onto the lower face. The result is an excess of tissue volume in the lower third, often perceived by patients as aging limited to this area. Consequently, they seek filler treatments that frequently disrupt facial balance and overload the lower third. Objective: This clinical case aims to highlight the importance of a sequential approach in orofacial harmonization, starting with the midface, to achieve more natural and balanced aesthetic results in the lower face and to reduce the risk of overfilling this area. Methodology: A detailed review of the planning and execution of the orofacial harmonization procedures was carried out. The focus was on filler techniques applied to the midface, using hyaluronic acid to lift and support the malar and zygomatic areas. Product selection was based on the patient’s specific needs, considering the viscosity and expected duration of the fillers. Two 1.2 ml syringes of ArtFiller® Volume (Fillmed) were used. A total of 0.5 ml was injected at each Ristow point, with the remaining 0.7 ml from each syringe placed laterally to cover the zygomatic region. After supporting the midface, an additional 1.2 ml syringe of ArtFiller® Volume (Fillmed) was applied, 0.6 ml in each labiomental fold, to eliminate shadowed areas and illuminate and rejuvenate the lower face. Results were evaluated using before-and-after photographs, complemented by detailed patient feedback. Results: A 64-year-old female patient, smoking 20 cigarettes per day, not currently taking any medication, dissatisfied with the accentuation of her nasolabial folds. The malar and zygomatic regions lacked support, with pronounced bone resorption around the orbital areas and visible infraorbital fat pads, in addition to depression of the labiomental region. Patient photographs demonstrated significant improvements in facial harmony, with a smooth and natural transition to the lower third, highlighting the effectiveness of the sequential approach. Patient feedback reported high satisfaction, noting a rejuvenated and more natural appearance without the “overfilled” look often associated with extensive lower-face filler treatments. Discussion Sequential midface treatment is crucial in orofacial harmonization, as it enhances overall facial balance, minimizes filler use in the lower third, and ensures a natural, harmonious result. Conclusions: This clinical case highlights the importance of reconstructing, filling, and supporting the midface before intervening in the lower third. Such sequential planning not only improves facial aesthetics but also reduces the amount of product needed in the lower third, maintaining a natural appearance and avoiding an overfilled look.
Regenerative medicine using plant- and animal-derived exosomes: how to decide?
Introduction: Exosomes are vesicles secreted by animal and plant cells, measuring 30 to 150 nm in diameter. They play a fundamental role in intercellular communication, enabling the modulation of cellular activity, including regeneration. Thus, they are considered promising strategies in the context of Regenerative Medicine, particularly in Orofacial Harmonization. Both types of exosomes - animal and plant-derived - present clinically significant advantages with distinct applications, which can be strategically adapted to therapeutic needs, individual patient profiles, and ethical preferences. Objective: To analyze the therapeutic potential and decision-making factors in using animal- or plant-derived exosomes for regenerative applications in orofacial harmonization. Methodology: This narrative review was conducted through a comprehensive search of PubMed, B-On, Science Direct, and Scielo using the keywords: "exosomes," “animal-derived,” “plant-derived,” "extracellular vesicles," "skin rejuvenation," and "aesthetic medicine," combined with Boolean operators ("AND" and "OR") to refine and expand results. Studies, reviews, and clinical trials with full-text access in English, published from 2024 to the present, were included. Exclusion criteria were duplicate articles, restricted-access publications, and studies not aligned with the proposed topic. Results: Animal-derived exosomes, from mesenchymal stem cells, demonstrate high biocompatibility with human tissues and strong efficacy in intensive regenerative treatments. They contain high concentrations of growth factors, cytokines, and microRNAs essential for cellular regeneration, stimulate fibroblast proliferation, promote neocollagenesis and elastogenesis, and reduce inflammation and oxidative stress. These effects contribute to repairing aged or damaged skin, improving firmness, elasticity, and hydration. While minimally invasive and with low risk of adverse reactions compared to conventional treatments, strict purification is required to mitigate immunological and infectious risks. They are contraindicated in patients with oncological, autoimmune, or immunosuppressive conditions, as well as pregnant and lactating women. Plant-derived exosomes offer a more accessible, immunologically safe, and environmentally sustainable alternative. They are rich in natural antioxidants and anti-inflammatory agents that help reduce oxidative stress and skin inflammation, promoting a rejuvenating effect. Their application is typically less invasive and topical, but contraindications include allergies to specific plant components or existing wounds or skin irritations in the application area. In Portugal, regulations regarding the origin, isolation, purification, identification, and use of exosomes are still under development, requiring rigorous, standardized evaluations for safety and efficacy. Discussion Choosing between animal- and plant-derived exosomes depends on therapeutic goals, biological effects, and safety considerations. Animal exosomes provide strong regenerative potential, while plant exosomes offer antioxidant and anti-inflammatory benefits. Combining both may enhance outcomes and allow more personalized treatments. Conclusions: Decisions regarding the use of animal- or plant-derived exosomes should be guided by patient-specific therapeutic objectives, biological rationale, and safety profiles. The future integration of both exosome types represents a promising innovation in orofacial harmonization, potentially delivering more effective, personalized regenerative treatments.
Facial rejuvenation in a patient aged 50+ using multiple orofacial harmonization techniques: a clinical case
Introduction: The face is an anatomical unit of great aesthetic and functional relevance, playing a central role in facial harmony, individual expressiveness, and the perception of orofacial esthetics, where the aging process becomes most evident. Objective: To illustrate a clinical case of facial rejuvenation in a 51-year-old female patient using different orofacial harmonization techniques. The aim was to achieve natural and harmonious results through a sequential and individualized therapeutic approach. Methodology: The treatment was performed as part of the Facial Harmonization Course at Face Design Academy® in partnership with Instituto de Reabilitação Oral do Norte Education. Results: This clinical case describes the therapeutic approach in a 51-year-old female patient who reported dissatisfaction with her aged facial appearance and a constantly tired and saddened expression. Although healthy, the patient was a smoker and had never undergone any previous facial esthetic procedures. After a detailed anamnesis and comprehensive facial assessment, a diagnosis was established, and an individualized treatment plan was designed to promote three-dimensional facial restructuring by sequentially addressing the different anatomical planes, ensuring a harmonious and natural outcome. Discussion The facial aging process results from the complex interaction between intrinsic factors, such as genetic predisposition, production of reactive oxygen species, and hormonal changes (with estrogen levels peaking in the mid to late 20s in women, then decreasing by 50% by the age of 50, and dropping even further after menopause), and extrinsic factors, including skin damage and the cumulative impact of lifestyle choices such as excessive sun exposure, smoking, and poor nutrition. The combination of these factors leads to reduced skin thickness, sagging, and wrinkle formation. Conclusions: Facial aging is an individual process resulting from the interaction between genetic and epigenetic factors. For effective therapeutic planning, it is essential to understand the morphofunctional changes that occur in the different anatomical layers of the face throughout the aging process, including bone structures, subcutaneous tissues, musculature, and skin.
Bridging knowledge and collaboration: The role of global scientific dialogue and interdisciplinary research in health sciences
In the contemporary landscape of Health Sciences, the role of academic research and scientific dialogue is paramount to advance the understanding of complex health issues. As the demands on public health systems increase, fostering a comprehensive and inclusive research environment is essential to address the multifaceted challenges of healthcare. Academic publication serves as the cornerstone of scientific communication, enabling the dissemination of novel findings and facilitating critical discourse among scholars and practitioners across the globe. Through rigorous peer-reviewed publications, researchers contribute to the global pool of knowledge, ensuring that scientific progress is not only shared but also critically evaluated, thus advancing both theoretical and practical aspects of health-related fields. The importance of these publications extends beyond mere dissemination; they represent the synthesis of evidence, translating scientific inquiry into actionable knowledge that can inform and guide policy, clinical practices, and public health strategies. Science recognizes the importance of engaging students as early-stage researchers, cultivating their analytical skills, and encouraging their active participation in scientific inquiry. Early exposure to research not only enhances the educational experience but also fosters a sense of responsibility and ownership over the scientific process. By nurturing a culture of curiosity and critical thinking, we equip students with the tools necessary to become the next generation of healthcare researchers, leaders, and innovators. Furthermore, the inclusion of multiple generations in research teams enriches the scientific process. The intergenerational exchange of knowledge and experience fosters mentorship, enhances the transfer of tacit knowledge, and ensures that research efforts remain dynamic and forward-looking. The collaboration between experienced researchers and emerging scholars ensures the continuity of expertise while simultaneously promoting the infusion of fresh perspectives and innovative ideas into ongoing research projects. This edition includes a compilation of scientific works around ​​orofacial therapeutics and harmonization presented at the III International Symposium on Orofacial Harmonization of the Portuguese Association of Orofacial Harmonization and Therapeutics. The event explores interdisciplinarity and highlights the importance of including young researchers into research projects and the power of collaboration in Health Sciences. The collaboration between academic institutions, healthcare professionals, and students is essential for ensuring that research remains relevant, impactful, and ultimately beneficial to society. By bridging academic silos and encouraging cross-generational collaboration, we can accelerate the pace of discovery and translate scientific findings into real-world solutions. The future of Health Sciences research lies in the establishment of robust and collaborative networks that transcend barriers and frontiers.