The Transgender Smile

With all the current publicity regarding males transitioning to females and the celebrities, such as Caitlin Jenner, who have transitioned on the front pages of news and magazine publications, I thought I would do this newsletter article on the smile and its importance in this process.

About twelve years ago, I was asked by Dr. Douglas Ousterhout, M.D. to collaborate with him to create smile designs for some of his transitioning patients.

For decades, Dr. Ousterhout has pioneered the field of plastic surgery known as “facial feminization surgery” or FFS. He has been the pre-eminent plastic surgeon in feminizing the facial-cranial structures of transgendered women. The procedures he developed, refined, lectured on, and trained other surgeons on are the gold standard of today’s FFS. I was honored that he asked me to treat the smiles of many of his wonderful patients.

In short form, the surgery involves converting and sculpting the bony structures from male to female. This generally consists of removing the Adam’s apple and re-contouring the forehead by removing or sculpting the bone in the mid-portion of the forehead and over the eyebrow and orbit area. The surgery converts the strong prominent forehead to a smaller, slightly concave one that slopes forward from hairline to brow.

By significantly reducing and contouring the skeletal structures underneath key facial features, the male face can be remodeled to a female face. The larger proportions of the male will be made into the smaller and softer proportions of a female.

The nose and forehead are almost always done together. The temporal fossa area can be sculpted and/or augmented by injecting medical grade plastic resin.

A typical patient will require forehead, chin, and jaw feminization, temporal fossa augmentation, nose reshaping, upper lip reduction, and thyroid cartilage reduction. Cheek implants, chin implants, and general facial soft tissue plastic surgery, as well as hairline and scalp advancement, are usually involved as well.

Proportion and symmetry are paramount throughout the process. The surgeon cannot feminize the skull by just lifting the skin. Altering the skeleton is the only way to move someone from distinctly male to distinctly female.

CASE I:
I collaborated with Dr. Ousterhout on the final positioning of the upper lip while creating and “transitioning” this patient’s smile. We had to coordinate our appointments as this patient was flying from London for this procedure and all the details and timing had to be meticulously planned. There was no room for errors, misjudgments or time delays.

The patient was seen six months previous just before the bony structures were adjusted by surgery. Models, photographs, and consultation were done as well as the final wax-up and appropriate guides and molds. All were ready and available when the patient returned for the final procedures.

She first saw me for tooth preparation, impressions, temporization and photos, which then gave the plastic surgeon a guide for his soft tissue and lip raising surgery, which he did three days later. About two and a half weeks later I was able to cement the final restorations.

The timing had to be perfect – there were no do-overs! Three days later, she returned to London.
Usually trans-women disappear into their new and different life and never return. But in this case, she returned to San Francisco for vacation and I was pleased that she came to the office to thank me and my staff and to show off her final makeover and the results of her facial feminization surgery and new smile (Figures 1, 2, 3, & 4).

Figure 1	Figure 2
Figure 3	Figure 4

CASE II:
The patient for case II flew in from Singapore to see Dr. Ousterhout, as he is the developer and leading authority in facial feminization surgery (FFS).

Her case was quite a challenge as you can see – crossbites, malposed teeth, missing teeth, and discolored teeth. To make things more difficult, we had to do the case now! I did not have the luxury of a pre-op wax-up as the case was last-minute scheduled and Dr. Ousterhout asked me to “make it happen.”

I did a complete upper and lower free hand composite mock-up (intra-oral wax-up): bonding, re-contouring, adding, subtracting, designing, prepping, at the same time as the tooth preparation and temporization. I used this direct mock-up, as taught in the PAC hands-on programs, to make my own prep guides and temporization putty molds (Figure 5).

All my learned skills over the years of creating smiles and educating other dentists in smile design, preparation principles and temporization, as well as VISUALIZING and executing the entire procedures and expected results, all came into play on this one very important day. As you can see, the results were quite dramatic (Figure 6, 7, 8, & 9).

Figure 6

Figure 7

Figure 8

Figure 9

The patient returned to Singapore three days after cementation. She sent me a picture of her final results and a note of thanks.

We reiterate during the PAC hands-on programs, how changing a person’s smile can change their life. Playing a small, but vital part helping a person “transition” has been extremely rewarding. To contribute to helping a human be the person they were meant to be and bringing them happiness and freedom, I am glad to do my part.

I am grateful to Dr. Ousterhout for allowing me the privilege of collaborating in treating some of his transgender patients.

If you have questions about my article or if you would like to send a case, please contact the Pacific Aesthetic Laboratory Group at www.pacificaestheticdentalstudio.com, Gary Vaughn, CDT, CTO (916) 786-6740, or via email [email protected].