The aging smile, honestly.

Hydrogen or carbamide peroxide diffuses into enamel and dentine and oxidises the chromophores that age has deposited; it is the most-trialled cosmetic intervention in dentistry. The 2024 systematic review of 30 studies concluded that "all types of bleaching have been shown to be effective in changing colour", that in the head-to-head comparisons the at-home carbamide-peroxide tray had "a lower recurrence", and that sensitivity appears higher with in-office and combined protocols (professional whitening review). The prognosis review of 24 studies found colour "stable between 1 and 2.5 years regardless of the type of bleaching agent or the forms of administration", with severe discolourations relapsing sooner (home bleaching prognosis). And the ritual of the white diet failed its test: a network meta-analysis of seven trials found cola, coffee, tea, grape juice and red wine during bleaching produced the same colour change as abstaining (white diet meta-analysis).

Whitening lifts the natural tooth only; it does not change fillings, crowns or veneers, so they are matched afterwards. In the EU, products above 0.1% hydrogen peroxide may only be used by or under a dentist and are capped at 6%; the strips and pens sold direct are legally weaker versions, and the "peroxide-free" ones are abrasives and blue pigments. Sensitivity is the price — a desensitising toothpaste before and during reduces it (desensitising toothpaste review) — and the goal is a shade that matches the whites of your eyes, not the veneers on television.

Bonding adds tooth-coloured resin to the edge or face of a tooth, sculpted and cured in the chair, without drilling. It restores the 1–2 mm of incisal length that wear removes — and that the lip, lengthening at the same time, no longer reveals — and it recreates the gentle curve of a young edge. The evidence is unusually good for something so cheap: across three university clinics, 667 anterior build-ups placed over eleven years were followed in 198 patients; overall survival was 98.8% at two years, 91.7% at ten and 77.6% at fifteen, while functional survival — counting repaired chips as survivals — was 98.5% at fifteen, and clinical quality was rated excellent or good for most (anterior composite multicentre study). The systematic review behind it pooled 17 studies of 1,821 anterior composites followed for at least three years: annual failure rates of 0 to 4.1%, fracture the commonest reason to fail, and colour or surface stain the commoner complaint when a restoration had been placed for looks (anterior composite systematic review). The dominant failure was chipping, and a chip is polished or patched in twenty minutes.

Composite stains and dulls faster than porcelain and needs polishing at the hygienist; a heavy grinder needs the night guard first. But it is reversible, repairable and removes nothing, which makes it the right first answer for a short, flat or chipped edge — and often the last. If the whole front of the tooth is discoloured or fractured, the veneer row is next.

A veneer is a thin shell bonded to the front of a tooth after a fraction of a millimetre of enamel is removed; it changes colour, length, shape and alignment at once, and it is the engine of every "smile makeover". The survival literature is large. The 2025 meta-analysis of 29 studies found pooled survival at 10.4 years of 96.13% for feldspathic porcelain, 93.70% for leucite-reinforced glass-ceramic and 96.81% for lithium disilicate, with no significant difference between materials — but complication rates that differed sharply: technical, aesthetic and biological complications over the decade of 41%, 20% and 7% for feldspathic against 6%, 2% and 0.5% for lithium disilicate (veneer survival meta-analysis). An earlier systematic review of 30 studies agreed on high survival and warned that estimates beyond 20 years do not exist (porcelain veneer survival review). Resin-composite veneers pooled at 88% survival over two to eight years, with roughness, colour mismatch and marginal staining the usual complaints (composite veneer meta-analysis).

The tier is for the survival evidence, not for the decision. Enamel removal is permanent — a veneered tooth needs a veneer for life — and a veneer placed under a lip that has lengthened to hide it changes nothing in conversation. Bonded to enamel rather than dentine, on a patient who has stopped grinding, in lithium disilicate, on no more teeth than actually show: those are the conditions the meta-analyses describe. The Safety section covers the "full set of crowns" that has replaced veneers in some markets.

Recession is the gum migrating down the root, and it is nearly universal: 81% of adults at a millimetre or more, 48% at three millimetres or more, 16% at five (recession meta-analysis), highest in men and smokers, and rising through life in the European study (European prevalence). The exposed root is darker than enamel, so a receded front tooth looks longer and yellower at once — the "long in the tooth" of the idiom. Periodontists have randomised the repairs for thirty years: the meta-analysis of 13 randomised trials found the coronally advanced flap plus connective-tissue graft superior to the flap alone for keratinised tissue, building on earlier reviews that had found the combination the most likely to achieve complete root coverage (root coverage meta-analysis), and a meta-analysis of 24 randomised trials found a donor-free acellular dermal matrix matched the patient's own graft for root coverage, with more attachment gain and less keratinised tissue (dermal matrix vs connective tissue graft).

The surgery takes an hour, the result is a gum line that sits where it did at 25, and it is the only row on the page that both rejuvenates the smile and protects the tooth — covered roots stop being sensitive and stop decaying. It needs a periodontist who does it weekly and a patient who has stopped the over-brushing or smoking that moved the gum.

Teeth hold the lips out and the lower face up. Lose one at the front and the lip loses a prop; lose them all and the vertical dimension of the face falls with the bone that follows them. Implants are the replacement with survival data: across 18 prospective studies of contemporary implant systems, the summary ten-year survival was 96.4%, with a more conservative sensitivity estimate of 93.2% and 91.5% in patients aged 65 and over (10-year implant survival). They preserve the bone around them in a way a denture, which rests on the gum and lets the ridge resorb beneath it, cannot.

Dentures still matter for the many who have them: when 102 edentulous older adults were 3D-scanned before and after complete dentures, the changes were "most noticeable in the perioral region: wider rima oris, longer upper lip, wider upper vermilion, and more protruded profile" — and the denture faces remained "shorter and more retruded" than the dentate controls (denture 3D study); a stereophotogrammetry study of 30 edentulous and 30 dentate people quantified the same residual collapse (facial proportion study). Reviews now describe hyaluronic-acid filler as an adjunct for the perioral collapse that a prosthesis cannot fully correct (HA in edentulous patients). The order is fixed: teeth, then prosthesis, then — if anything — filler.

Adult teeth move: lower incisors crowd through the decades, upper incisors tip and drift as bone and gum change, and the smile line loses its curve. Clear aligners are the adult-acceptable way to move them back. The systematic reviews are cautious and consistent: aligners "may produce clinically acceptable outcomes that could be comparable to fixed appliance therapy for buccolingual inclination of upper and lower incisors in mild to moderate malocclusions", at low-to-moderate certainty, with most other tooth movements less predictable (aligner effectiveness review); an earlier meta-analysis of four controlled trials found a significant advantage in chair time and treatment duration for mild-to-moderate cases and no difference in stability (aligner meta-analysis).

The aesthetic point is display: a straightened, slightly proclined upper incisor shows more at rest and on speech, and an even lower arch stops the crowded lower teeth from being the ones that appear. The costs are months of trays, retention for life, and the recession risk the Safety section describes in a thin, receded gum. Orthodontics also moves gum: aligning teeth is one of the four treatments the papilla review found to reduce black triangles.

Excess gum on smiling is the opposite of the aged pattern — high smiles are seen in 45% of women in their twenties and 19% over 50 (Brazilian women's smiles) — but for the woman it bothers, the fixes are dental. Lip repositioning sutures the inside of the upper lip lower so it cannot rise as far: the meta-analysis of 13 studies with at least six months' follow-up found gingival display reduced by 3.06 mm at six months, 2.91 mm at twelve and 2.76 mm at 36, and the modification with periosteal suturing held 5.22 mm at six months and 4.94 at twelve (lip repositioning meta-analysis). Where the teeth are short because gum covers them (altered passive eruption), aesthetic crown lengthening trims the gum and bone to reveal the tooth; a split-mouth randomised trial in 28 patients found the minimally invasive flapless version as stable as the open-flap one at twelve months, with high satisfaction and low morbidity (crown lengthening trial).

The toxin alternative — two to four units into the lip elevators, 3.4 mm less gum for three months — is graded in the Botox guide. Surgery is once and permanent; toxin is a quarterly subscription that lets you try the result first.

The interdental papilla — the pink triangle of gum between two teeth — recedes with the rest of the gum and with bone loss, leaving a dark triangle that ages a smile more than most people realise and that lipstick cannot hide. The 2024 systematic review found 45 studies of reconstruction: 15 of hyaluronic-acid injection, six of platelet-rich fibrin, 16 of soft-tissue grafting and four of orthodontics; all "seem to improve outcomes at a minimum three months", the connective-tissue graft has the most robust long-term evidence, and "there is insufficient evidence to make recommendations to clinicians" (papilla reconstruction review). A representative injection study treated 15 deficient papillae with 0.5 ml of HA: the black-triangle area fell from 0.54 mm² to 0.13 at one week and had drifted back to 0.26 by four (HA papilla study).

The honest options are three: the injected filler for a small triangle, repeated as it fades; reshaping the teeth' contact points with composite so the triangle closes from above (the restorative answer, in the bonding row); and, for a larger loss, accepting it or the graft. The "gum filler" clinics now sell is the first of these with a longer name.

The trials are real. In the pivotal study, 180 adults aged 18–65 with very thin or thin lips were randomised 3:1 to up to 1.5 ml of small-gel-particle HA per lip or no treatment: 93% of treated lips improved at least one grade on the validated fullness scale at eight weeks against 29% untreated, self-rated improvement was 97% at eight weeks and 74% at 24, with swelling in 58% and bruising in 44%, mostly mild (lip filler pivotal trial). Treating the lip and the radial lines together produced treatment success in 76% against 11.6% and an "aesthetically meaningful improvement in perioral rhytides" (lips and lip lines trial); a flexible gel designed for the moving lip was non-inferior to the standard at eight weeks with about 20% less volume and held fullness and wrinkle improvement to 48 weeks (flexible lip filler trial). The filler guide and the thin lips guide grade the products.

Then the caveat the trials cannot answer, because they enrolled thin lips rather than aged ones: the aging upper lip has lengthened and thinned, not shrunk, and "isolated volume augmentation is not a causal method of upper lip rejuvenation" (MRI study). Filler that restores the white roll, defines the Cupid's bow and everts the border a little gives back vermilion show without length; filler that adds a millilitre to the body of a long lip adds weight to a curtain that already hangs too low. Half a millilitre, placed at the border, by someone who says no to more, is the version the aging smile needs.

The muscles of the mouth are the one thing on this page that changes in a fortnight. For the gummy smile, a meta-analysis of 17 studies found a mean 3.42 mm reduction in gingival exposure at two weeks, effective for at least twelve weeks and back near baseline by 24 — best for smiles showing up to 4 mm of gum (gummy smile meta-analysis). For corners that turn down, a few units into the depressor anguli oris lets the elevators win, with the evidence resting on a retrospective series and anatomical mapping (depressor anguli oris series). For the thin upper border, the "lip flip" everts the vermilion by a millimetre for two to three months in small studies (lip flip review). Each is graded on its own in the Botox guide.

The aging-smile use is diagnostic as much as cosmetic: a mouth that reads better after four units in the corners has told you the surgeon's operation is worth discussing, and one that does not has saved you the fee. The risks are functional — a weak lip that spills a drink, a crooked smile for three months from a misplaced unit — and the injector who does the lower face weekly is the one to choose.

The lines that fan from the red lip into the white are dynamic while they are young and etched once the elastin has gone; the etched ones are removed by taking the surface off. Two split-face trials set the standard. In 20 women, half the perioral area was dermabraded and half treated with an ultrapulsed CO2 laser, judged by ten blinded plastic surgeons: the laser side had a significantly higher erythema score at one month and "a small but significantly greater improvement in perioral wrinkles at 6 months", and 13 of the 20 judged the laser side the better result despite more intra-operative pain — though asked which they would recommend to a friend, they split evenly (dermabrasion vs CO2 trial). In 15 volunteers, superpulsed CO2 on one side and dermabrasion on the other gave no significant difference in wrinkle score at four months, with less crusting and faster re-epithelialisation after dermabrasion (dermabrasion vs superpulsed CO2). In a 2025 randomised comparison, three sessions of a 1,550 nm erbium-glass laser or a combined Er:YAG and Nd:YAG protocol both improved supralabial lines and pigmentation in 36 women with darker skin types (fractional laser comparison).

Resurfacing changes the surface stage of the lip classification and nothing else — a lengthened lip is a lengthened lip with smoother skin. The lip lines guide grades every option for the lines in depth, including the retinoid that makes the result last and the pigment risk in darker skin.

Surgeons learned it from the skeleton: the maxilla, the pyriform region and the prejowl mandible "resorb in a specific and predictable manner with aging", and "failure to address changes in the skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure" (facial skeleton review). Filler placed deep on the bone at the pyriform aperture and the chin, and in the marionette and prejowl area, rebuilds the platform the lip rests on; the chin has its own pivotal randomised trial and the marionette and perioral area a phase 3 programme, both graded in the filler guide and the marionette lines guide. For the deflated perioral compartments, a comparison of 65 facelift patients with perioral fat transfer against 65 without found the fat group had "a two times more significant improvement in perioral aesthetics" on blinded wrinkle-scale review at a year or more (perioral fat transfer study), and structural fat with CO2 resurfacing improved fine lines, folds and pigment on blinded scoring in 17 women (fat and CO2 study).

For the edentulous, reviews now describe the same logic — HA to correct the uncompensated bone loss a prosthesis leaves behind (HA in edentulous patients). The order does not change: replace the teeth, then support the base, then decide whether the lip itself needs anything.

If the aging upper lip is a longer curtain, the lift shortens the rod. Through an incision hidden in the crease at the base of the nose, a bullhorn-shaped strip of skin is removed and the lip advanced upward, restoring the 14-mm philtrum of youth, re-exposing the upper incisors at rest and rolling the vermilion outward. The 2023 systematic review found nine studies with quantitative measurements — eight surgical, one non-surgical — with "surgical procedures seem to have better longevity", good satisfaction and no severe complaints (lip lift techniques review); the second review found four eligible studies, 92% of patients women with a mean age of 36.6, the bullhorn excision in three of the four, and improvement on anthropometry and satisfaction "maintaining results for varying periods of time (from 12 to 59.1 months)" (subnasal lip lift review). The philtral-height study offers the measurement to plan it by (philtral height).

The tier reflects the evidence, not the logic: no one has randomised a lip lift, and the series report satisfaction more than measured relapse. The risks are a visible scar if it is placed or closed badly, a widened nostril base, a lip that no longer closes at rest if too much is taken, and — in a young face with a naturally long lip — an expression that is no longer yours. It is a surgeon's operation, done after the teeth are the length they should be, because a lifted lip over worn incisors shows the wear.