Dental Tribune U.S. Edition

2B COSMETIC TRIBUNE The World’s Dental Newspaper · US Edition Publisher & Chairman Torsten Oemus t.oemus@dental-tribune.com Chief Operating Officer Eric Seid e.seid@dental-tribune.com Group Editor & Designer Robin Goodman r.goodman@dental-tribune.com Editor in Chief Cosmetic Tribune Dr. Lorin Berland d.berland@dental-tribune.com Managing Editor/Designer Implant, Endo & Lab Tribunes Sierra Rendon s.rendon@dental-tribune.com Managing Editor/Designer Ortho Tribune & Show Dailies Kristine Colker k.colker@dental-tribune.com Online Editor Fred Michmershuizen f.michmershuizen@dental-tribune.com Account Manager Mark Eisen m.eisen@dental-tribune.com Marketing Manager Anna Wlodarczyk a.wlodarczyk@dental-tribune.com Sales & Marketing Assistant Lorrie Young l.young@dental-tribune.com C.E. Manager Julia E. Wehkamp j.wehkamp@dental-tribune.com C.E. International Sales Manager Christiane Ferret c.ferret@dtstudyclub.com Dental Tribune America, LLC 116 West 23rd Street, Suite 500 New York, NY 10011 Tel.: (212) 244-7181 Fax: (212) 244-7185 Published by Dental Tribune America © 2011 Dental Tribune America, LLC All rights reserved. Cosmetic Tribune strives to maintain utmost accuracy in its news and clini- cal reports. If you find a factual error or content that requires clarification, please contact Group Editor Robin Goodman at r.goodman@dental-tribune.com. Cosmetic Tribune cannot assume respon- sibility for the validity of product claims or for typographical errors. The pub- lisher also does not assume responsibility for product names or statements made by advertisers. Opinions expressed by authors are their own and may not reflect those of Dental Tribune America. Do you have general comments or criti- cism you would like to share? Is there a particular topic you would like to see articles about in Cosmetic Tribune? Let us know by e-mailing feedback@ dental-tribune.com. We look forward to hearing from you! Tell us what you think! f CT page 1B lips as their frame. When you look at a middle-aged woman with beautiful veneers and a thin, colorless upper lip with many smoker’s lines, it tends to dampen the cosmetic effect. As a matter of fact, when you start planning those veneers, you should be taking into account the effect the veneers will have on lip support, as well as incisal show, both in relaxed and animated positions. Then, when you enhance her lip, you have to take into account the proper lip outline and volume, as well as incisal show. In other words, the two procedures go hand in hand. Which medical pro- fessional could possibly understand this better than a dentist? The first thing the practitioner needs to realize is the difference 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 lyophi- lized (freeze dried) form. It is then mixed with saline and injected sub- cutaneously or intramuscularly 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 contract, a signal is sent down the motor nerve terminal and at its nerve ending, acetylcholine is sent across the gap to the muscle. This signals the muscle to contract. Botulinum toxin does not allow acetylcholine to cross from the motor nerve terminal to the muscle. Technically speaking, the toxin causes a “chemical denervation” of the muscle. If the muscle cannot con- tract, then the overlying skin cannot wrinkle. On the other hand, filler materials 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, Perlane and Juviderm). Hyaluronic acid is a polysaccharide complex found in normal human tissue. Because it is not a protein, the risk of allergic reaction is extremely low. There is another filler material, Radiesse, that is made up of calci- um hydroxylapatite (CaHA) micro- spheres suspended in a water-based gel carrier. This is similar to the hydroxylapatite found in our teeth and bones. Another important learning aspect is which areas require botulinum toxin and which areas require filler material. Many times, a combination of both materials is required for the most esthetic effect. When looking at the aging face, it is important to understand the dif- ference 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 definition, botulinum toxin would do very little for these wrinkles or grooves because the toxin would “relax” the underlying muscles. How- ever, in this patient we know that even if the muscles are relaxed, they still have this wrinkle at rest. There- fore, filler (or combination therapy) would be better. A dynamic wrinkle is one that is caused by animation or muscle func- tion (see forehead). In this instance, botulinum toxin would do very well. It would weaken the underlying muscle and cause a chemical denervation. In turn, this would stop the overlying skin from wrinkling. For the beginning injector, we generally recommend starting with three areas of the face that gen- erally receive botulinum toxin and three areas that generally receive filler material. In the botulinum toxin Clinical COSMETIC TRIBUNE | May 2011 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.