E2 ORTHO TRIBUNE Dental Tribune Middle East & Africa Edition | 2/2019 Improving the facial balance in an adult using slow arch development techniques Fig. 2: The Homeoblock appliance. By Dr Derek Mahony, Australia, & Dr Theodore R. Belfor, USA Introduction Anti-ageing is a branch of medicine focused on how to prevent, slow or reverse the effects of ageing, thus helping people to live longer and healthier lives. Recently, however, more evidence-based medicine has led to anti- ageing becoming a multi- billion-dollar industry. In the past few decades, the market for anti-age- ing products and services has grown into a global industry valued at an estimated US$261.9 billion in 2013, up from US$162 billion just five years before, according to BCC Research, a publisher of technology market re- search reports based in Wellesley in the US.1 The recent medical literature and evidence-based medicine show that, as we age, there seems to be a loss of fat volume in some areas of the face, as well as a change in the mor- phology of the facial skeleton. Facial soft-tissue augmentation by injec- tion has become increasingly popu- lar as a minimally invasive option for patients seeking cosmetic facial enhancement. Replacing lost soft- tissue volume allowed for a more comprehensive approach to total fa- cial rejuvenation. It has been demon- strated that orthodontic treatment with an intra-oral orthopaedic den- tal appliance (Homeoblock, Ortho- Smile) increases soft-tissue volume and enhances facial symmetry, pro- ducing soft-tissue changes consist- ent with improved facial esthetics.2 Fig. 3: The pretreatment face, the post-treatment face at six months and nine months, and finally, a morphometric evaluation of the change. This appliance can be added to the treatment protocol of facial injection to create a relatively non-invasive in- terdisciplinary approach to midface enhancement. With this article, we show how or- thopaedic/orthodontic appliance therapy, in conjunction with the placement of dermal fillers for the reduction of lines/wrinkles and de- pressions in the face, can produce desirable facial soft-tissue enhance- ment. Furthermore, we show that the volumetric changes achieved by this combined treatment approach can produce a desirable result, name- ly a more youthful appearance. Case study A healthy woman in her mid-sixties presented for treat- ment with a strong desire to improve her facial appearance (Fig. 1). Her oral hygiene was good and there was no active periodontal disease. She had head- ache symptoms and clinical exami- nation showed a disc displacement with reduction on her right side, with a maximum jaw opening of 38 mm. Her centre line was displaced 2 mm to the right and lined up when she opened < 10 mm, indicating that she had a mandibular displacement to the same side. A Homeoblock ap- pliance, with a 5 mm bite block on the right side (to decompress her temporomandibular joint), was fab- ricated and delivered (Fig. 2). When she closed on the bite block, her oc- clusion freed up and the muscles realigned the mandible so that her centre line lined up correctly. Her headache symptoms were relieved in three weeks and her maximum opening was improved to 42 mm. The patient continued Homeoblock treatment for nine months. Intra-oral and extra-oral photo- graphs were taken to monitor treat- ment, and 3-D stereophotogramme- try was performed. Extra-oral 3-D digital photographs were taken with a facial capture system (3dMD). A fa- cial capture system (3dMD/Kodak) and stereophotogrammetry were used to generate a clinically accurate digital model of the patient’s facial surface. It uses a technique of stereo- triangulation to identify external surface features viewed from at least two cameras. This approach incor- porates the projection of a unique, random light pattern that is used as the foundation for triangulating the geometry in 3-D. The capture takes < 2 ms per frame. The data is processed and a highly precise < 0.5 mm root mean square of the distance meas- ured is calculated, creating a digital model of the patient that is ready for immediate clinical use. Stereo- photogrammetry for quantifying facial morphology was introduced in a study published in the Journal of Dentistry in 1996.3 It was concluded that “stereophotogrammetry is a suitable 3-D registration method for quantifying and detecting develop- ment changes in facial morphol- ogy”.3 Evaluating the patient’s face over the nine months of Homeoblock treat- ment for her temporomandibular dysfunction showed a change in the morphology of the face (Fig. 3). Mor- phometric analysis was performed by superimposing before and after 3-D images and using finite element modelling. Thousands of triangu- lar reference points were used to establish the change. The blue area indicated no change and the red to orange areas showed an increased di- mension of up to 2.9 mm. We saw an increased volume above and under the eyes, the zygomatic region, the upper lip, and the marionette and pre-jowl areas. From the facial pho- tographs, we could see a reduction in the lines, wrinkles and depressions (Figs. 4 & 5). After nine months, the patient’s fa- cial changes prompted her to go for- ward with injections of dermal fill- ers. She was given 1 ml of Restylane (Galderma) for lip enhancement and two 1.3 cc corrections with Radiesse (Merz Aesthetics) in the pre-jowl and marionette areas and along the inferior border of the mandible, and the inferior and lateral borders of the zygoma (Fig. 6). Results Post-treatment, the patient’s face appeared more youthful with better defined cheekbones and a firmer jaw line. The skin appeared smoother with fewer lines, wrinkles and de- pressions (Figs. 7a & b). Fig. 1 Pretreatment facial and anterior intra-oral photographs (note deep dental overbite). with an increase in structural com- plexity, in association with biological processes.”4 Palatal expansion pre- sumably, switches on osteoblastic genes associated with active boney deposition and concomitant remod- eling of the spatial matrix ensues.”4 In relation to the changes around the eyes, we must recall that the max- illa forms the floor of the orbit and skeletal changes may become ap- parent after expansion;4 specifically, changes in orbital morphology may be reflected on the skin of the face: as the lower eyelids become tighter, the lateral canthus becomes more horizontal; facial width increases, particularly at the zygomatico-max- illary sutures; and the craniofacial form, putatively, not only functions better, but looks more attractive.4 These changes have been docu- mented in children, where palatal expansion is an everyday occur- rence. The current article documents similar changes in a non-growing adult. Combining the results of pala- tal expansion and the placement of dermal fillers, we obtained a very satisfactory improvement in facial aesthetics. Editorial note: A list of references can be obtained from the publisher. This article was originally published in ortho international magazine of orthodontics, Issue 2/2018. Discussion Facial changes related to palatal ex- pansion are clearly outlined in Sin- gh: “The maxillary complex shows a change in size (and/or mass) allied Dr Derek Mahony is a Specialist Orthodontist. He can be contacted at derek.mahony@fullfaceorthodontics. com.au Fig. 4: Morphometric evaluation of the final results: finite element analysis showed increased facial volume with a directional change of almost 4 mm, indicated by the red to orange colour. Fig. 5: Superimposing the red post-treat- ment face over the blue pretreatment face, we can graphically illustrate the volumetric changes that occurred during our treatment. There was an increase in volume in the frontal, supraorbital, infe- rior orbital, zygomatic, nasal base, upper lip, nasolabial depression, and marionette and pre-jowl areas. Fig. 6: Morphological facial changes in the lips, zygoma and jowl area after the placement of 1 ml Restylane and 1.3 cc Radiesse. Note the deeper red to orange colour in the areas where the injections were placed. Figs. 7a & b: Before and after facial photographs.