Marionette Lines: What Causes Them and the Treatments That Actually Soften Them

Noticed lines running down from the corners of your mouth that make you look sad or tired? Dr. Liza Wakim explains what causes marionette lines, which treatments actually soften them, and why the answer sometimes starts with your bite.

Marionette lines are one of the most common concerns I hear from patients in their 40s and beyond. They often say their face looks sad or tired, even when they feel perfectly happy. Those downturned corners can change the whole expression of the lower face.

Because I treat the lower face every day, I look at marionette lines a little differently. Yes, filler and Botox can help. But sometimes part of the cause is in the mouth itself: worn teeth, missing teeth or an old denture that no longer supports the face. In this post I will walk through the causes and the treatments that actually make a difference.

The short version

• Marionette lines run from the corners of the mouth down toward the chin. They come from volume loss, ligament and skin changes, and a muscle that pulls the mouth corners down.
• Hyaluronic acid filler is the most common treatment, and it can be combined with Botox to lift the downturned corners.
• Laser treatments can improve skin quality, and restoring a collapsed bite can help in some patients.
• Results vary. Creams can improve skin texture but will not fill a deep line.

What marionette lines are

Marionette lines are the vertical lines or folds that run from the corners of the mouth down toward the chin, named after the hinged jaws of a marionette puppet. They tend to deepen with age and can give the face a downturned, sad or tired look, even at rest.

What causes marionette lines

Volume loss and ligament changes

With age, the fat pads of the face shrink and shift downward, and the ligaments that anchor the soft tissue to bone loosen. An anatomical study of why marionette lines appear found that they form at a boundary in the lower face where tissue held in place by ligaments meets tissue that is free to sag. As volume above that line drops, a crease forms.

The DAO muscle pulling down

A small muscle called the depressor anguli oris (DAO) runs from the corners of the mouth down to the jaw. Its job is to pull the corners of the mouth down, as when you frown. When it is strong or overactive, it can deepen the downturn and make marionette lines more noticeable. Research on the DAO and botulinum toxin explains why relaxing this muscle can lift the corners slightly.

Skin aging and sun

Over time, skin loses collagen and elasticity, and sun exposure and smoking speed that up. Thinner, looser skin folds more easily along the marionette line.

Tooth loss and bite collapse: the dental factor

This is the part people rarely hear about. Your teeth and jawbone support your lips and the lower third of your face. When teeth are worn down, missing, or replaced by an old denture that no longer fits well, the lower face can lose some of its height and support. Research on denture patients shows that restoring the bite with a new denture can measurably change the soft tissue around the mouth, and a study in the British Dental Journal found that increasing the vertical dimension of the bite affected facial appearance, not just around the mouth. In patients like this, filler alone may not be enough.

Treatments that soften marionette lines

Hyaluronic acid filler

Filler is the most common in-office treatment. It is placed beneath the line and near the mouth corner to restore lost volume and support. A long-term study of hyaluronic acid filler for marionette lines found lasting improvement with good tolerability. The FDA notes that results are temporary and that side effects like swelling and bruising are common. See how long dermal fillers last and dermal fillers before and after.

Botox for the downturned mouth

A small, precise dose of Botox in the DAO muscle can relax the downward pull and let the corners of the mouth rest slightly higher. It does not fill the line itself, so it is often combined with filler. This is an off-label use, and placement matters: too much, or in the wrong spot, can affect your smile or speech.

Laser skin tightening

Laser treatments can improve skin texture and fine lines around the mouth. They do not replace volume, so they work best alongside filler for deeper lines. My post on SmoothLase around your smile explains one option we offer.

Restoring the bite

If worn or missing teeth or an old denture are part of the picture, restoring proper tooth height and support can improve how the lower face looks and functions. This is a bigger conversation than filler, but for the right patient it addresses the cause rather than the symptom.

Filler gone wrong: what causes a heavy or droopy result and how it is fixed

“Marionette lines filler gone wrong” is a common search, and the concerns usually fall into a few groups:

• A heavy or bulky lower face: too much filler, or filler placed too superficially, can make the area look full or heavy instead of lifted.
• Lumps or uneven areas: small irregularities can happen, especially early on while swelling settles.
• A droopy look: treating the line alone, without addressing lost support higher in the face or the pull of the DAO, can sometimes make the mouth corners look heavier.
• Bruising and swelling: common and temporary, according to the FDA.

The reassuring part is that hyaluronic acid filler can usually be dissolved with an enzyme if a result is not right. The best prevention is a conservative approach: treating the cause of the line, using the right amount of product, and building results gradually.

Call your provider right away if you have severe pain, skin that turns pale, blue, gray or mottled, or any vision change after filler. The FDA warns these can be signs that filler has blocked a blood vessel, which needs urgent treatment.

What results and recovery look like

• Filler: results show right away and improve as swelling settles over one to two weeks. Mild swelling, tenderness and bruising are common for a few days.
• Botox: results build over about one to two weeks.
• Laser treatments: some redness for a few days is typical, and results build over a series of sessions.
• Bite restoration: changes appear as the final restorations are placed.

Realistic expectations matter. Treatments soften marionette lines; they do not erase every crease, and results vary from person to person.

When to see a provider

Book a consultation if:

• Marionette lines bother you, or people often ask if you are tired or upset
• You want to understand which option, or combination, fits your face
• You have worn teeth, missing teeth or an old denture and wonder if it is affecting your face
• You had filler elsewhere and are unhappy with a heavy or uneven result

Learn more about our filler injections and SmoothLase treatments.

Frequently asked questions

Can you get rid of marionette lines without filler?

You can soften them without filler in some cases. Botox to the muscle that pulls the mouth corners down, laser treatments for skin quality, daily sunscreen and retinoids can all help. If worn or missing teeth are part of the cause, restoring the bite can help too. Deeper lines from volume loss usually respond best when filler is part of the plan.

Does Botox work on marionette lines?

Botox does not fill the line, but it can help by relaxing the depressor anguli oris, the muscle that pulls the corners of the mouth down. This can let the corners rest slightly higher. It is often combined with filler, it is an off-label use, and careful placement is important to avoid affecting your smile.

How long does marionette filler last?

It depends on the product, the amount used and your body. Many hyaluronic acid fillers last many months, and some studies show improvement lasting a year or longer. Because the mouth area moves a lot, results may fade a little sooner than in less active areas. Touch-ups are common.

Can missing teeth cause marionette lines?

They can contribute. Teeth and jawbone support the lips and the lower face. When teeth are worn down, missing or replaced by a poorly fitting denture, the lower face can lose height and support, which can make lines around the mouth look deeper. Restoring the bite can improve this in some patients.

Do creams help marionette lines?

Creams with ingredients like retinoids, plus daily sunscreen, can improve skin texture and fine lines over time and help slow further aging. They cannot replace lost volume or lift a deep fold, so they work best as support alongside in-office treatments.

Can filler be dissolved?

Hyaluronic acid fillers, the type most often used for marionette lines, can usually be dissolved with an enzyme called hyaluronidase. Providers use it to correct lumps, a heavy result or, in rare urgent cases, blocked blood flow. This reversibility is one reason hyaluronic acid fillers are a common choice.

Find out what will work for your face

The best plan for marionette lines depends on what is causing them, and that is different for everyone. If you are in or around Washington, PA, you can request a consultation at Enhanced Wellness or call us at (724) 225-5070. Results vary, and we will only recommend treatments that fit your face and goals.

Sources

• Why do marionette lines appear? An anatomical study. PubMed Central.
• Long-term efficacy and tolerability of a hyaluronic acid filler for marionette lines. Clin Cosmet Investig Dermatol. 2023.
• Botulinum toxin to the depressor anguli oris. Aesthet Surg J. 2024.
• U.S. Food and Drug Administration. Dermal fillers (soft tissue fillers).
• Quantitative 3D evaluation of facial soft tissue modifications following complete denture treatment. PubMed Central.
• Mohindra NK, Bulman JS. The effect of increasing vertical dimension of occlusion on facial aesthetics. Br Dent J. 2002;192(3):164-168.

Elizabeth Wakim

Dr. Elizabeth Wakim, DDS, is the founder of Enhanced Wellness. She’s a compassionate and highly-regarded dentist with her own practice in Washington, Pennsylvania, known for providing modern, comprehensive dental care, botox and facial aesthetics with a focus on patient comfort and anxiety reduction, serving general, cosmetic, and pediatric dentistry needs.