DTME0511

Media CME DENTALTRIBUNE Middle East & Africa Edition6 2 Hours Take a cosmetic practice to the next level with facial injectables Minimally invasive cosmetic facial procedures are quickly becoming the most exciting and controversial topic in cos- metic dentistry. In my mind, thereis nobetterclinicianwith the capabilities and qualifica- tions to provide these proce- dures than the dental profes- sional. Over the last three to four years, we have trained hundreds of practitioners in the art of facial injectables. In doing so, we have found that dentists have the greatestinherentskillsandartis- tic ability when compared to any other professional.  Dentists often ask me why I thinkthattheyarequalifiedto do these procedures. In re- sponse, I ask them some simple questions:  UÊ Which medical profes- sional injects the most patients on a daily basis?  UÊ Who knows the ins and outs ofgivingaspainlessofan injection as possible?  UÊ Who knows how to anes- thetize the tissues of the face via intraoral techniques?  UÊ Who is in tune, on a daily basis, to facial and peri-oral anatomy and symmetry?  UÊ Who knows the dental and skeletal relationships on the soft tissue of the face?  UÊ Who knows the anatomy of a proper lip line?  UÊ Whom do patients trust (every six months) to contin- uously inject them? The answer, of course, is you do! Using facial injectables is a natural progression for the cos- metic dentist. For example, we all understand that enhancing a patient’s smile is more than just placing some laminates. In our courses, we tell clinicians to imaginetheteethasapictureand the lips as their frame. When you look at a middle- aged woman with beautiful ve- neers and a thin, colorless upper lip with many smoker’s lines, it tends to dampen the cosmetic ef- fect. As a matter of fact, when you start planning those veneers, you should be taking into ac- count the effect the veneers will have on lip support, as well as in- cisal show, both in relaxed and animated positions. Then, when you enhance her lip, you have to take into account the proper lip outlineandvolume,aswellasin- cisal show. Inotherwords,thetwoproce- dures go hand in hand. Which medical professional could pos- sibly understand this better than a dentist? The first thing the practi- tioner needs to realize is the dif- ference between Botulinum toxin (Botox® and Dysport®) and facial fillers (Restylane®, Perlane®, Juviderm® and Radiesse® among many others). Botulinum toxin is a clear fluid medication that comes in a lyophilized (freeze dried) form. It is then mixed with saline and injected subcutaneously or in- tramuscularly with the intention of weakening the target muscle. Contrary to popular belief, it does not “fill” lines, nor does it “smooth” wrinkles. In order for a muscle to con- tract, a signal is sent down the motor nerve terminal and at its nerve ending, acetylcholine is sentacrossthegaptothe muscle. This signals the muscle to con- tract. Botulinum toxin does not allow acetylcholine to cross from the motor nerve terminal to the muscle. Technically speaking, the toxin causes a “chemical dener- vation” of the muscle. If the mus- cle cannot contract, then the overlying skin cannot wrinkle. On the other hand, filler ma- terials fill in a depression or wrinkle and can add volume or contour to the face. They are gel- like in consistency and come in prefilled syringes. The most common type of filler currently being used in the United States is hyaluronic acid (Restylane, Per- lane and Juviderm). Hyaluronic acid isapolysaccharidecomplex found in normal human tissue. Because it is not a protein, the risk of allergic reaction is ex- tremely low. There is another filler material, Radiesse, that is made up of calcium hydroxyla- patite (CaHA) microspheres sus- pended in a water-based gel car- rier.Thisissimilartothehydrox- ylapatite found in our teeth and bones. Another important learning aspect is which areas require botulinumtoxinand whichareas require filler material. Many times,acombinationofboth ma- terialsisrequiredforthemostes- thetic effect. When looking at the aging face, it is important to under- stand the difference between static wrinkles and dynamic wrinkles. If you tell a patient to relax her facial muscles and not make any movements, and you see a wrinkle or groove at rest, this would be a static wrinkle (see nasolabial fold). By defini- tion, botulinum toxin would do very little for these wrinkles or grooves because the toxin would “relax” the underlying muscles. However, in this pa- tient we know that even if the muscles are relaxed, they still have this wrinkle at rest. There- fore, filler (or combination ther- apy) would be better. A dynamic wrinkle is one that is caused by animation or muscle function (see forehead). In this instance, botulinum toxin would do very well. It would weaken the underlying muscle and cause a chemical denerva- tion. In turn, this would stop the overlying skin from wrinkling. Fig. 1: 62-year-old female with a chief complaint of ‘thin and misshapen’ lips. (Photos/ Provided by Dr. Zev Schulhof) Fig. 2: One week after augmenta- tion with 1 cc of Restylane. Fig. 6: Two weeks after Botox treat- ment. Fig. 7: Patient presents for lunchtime ‘liquid facelift.’ Fig. 3: Botulinum toxin blocks release of acetylcholine from the nerve terminal. Fig. 4: Perlane, one of the hyaluronic acids, in its prefilled syringe. Fig. 5: Dynamic wrinkles of the fore- head during animation. Fig. 8: Fifteen minutes later, intra-oral cheek, nasolabial folds and marionette line augmentation. Fig. 9: This 23-year-old female complained of a ‘retruded’ chin. Fig. 10: Fifteen minutes later using 2 cc of Radiesse. (mCME articles in Dental Tribune (always page 6) has been approved by HAAD as having educational content acceptable for (Category 1) CME credit hours. Term of approval covers issues published within one year from the distribution date (September, 2010). This (Volume/Issue) has been approved by HAAD for 2 CME credit hours.