August 2018
Volume 14, Issue 8

Facial Injectables for Dentists

Incorporating botulinum toxin and hyaluronic acid fillers to address patients’ needs

Bianca Velayo, DMD

The field of dentistry is experiencing tremendous advancements with the advent of new materials and technologies, especially in the field of cosmetic dentistry. According to the American Academy of Cosmetic Dentistry's Cosmetic Dentistry State of the Industry Survey 2015, there was an increase in the number of patients seeking cosmetic dentistry as well as an increase in the average production per cosmetic patient per visit.1 The most popular cosmetic dental procedures were whitening, veneers, and bonding.

The heightened focus on esthetics is a global phenomenon, and the United States is leading the world in nonsurgical procedures, particularly in those involving botulinum toxin and hyaluronic acid fillers.2 As dentists, we are constantly learning about the latest developments so that we can best serve our patients. Incorporating BOTOX® Cosmetic and hyaluronic acid fillers into dental practice is a natural progression because dentists are very comfortable working in the oral and maxillofacial region. Furthermore, BOTOX Cosmetic and dermal fillers are safe and quick-acting, have few side effects, and are easy to administer.

BOTOX Cosmetic is the trade name for a purified protein, botulinum toxin serotype A (BoNT-A), which is derived from botulinum toxin. It works by preventing the release of acetylcholine from the motor nerve endings. There are three BoNT-A containing products on the market: BOTOX Cosmetic, Xeomin®, and Dysport®. When injected in minuscule amounts, they cause temporary muscle paralysis. Their effects last 3 to 4 months, after which the muscle activity returns to normal. Dentists can be considered ideal practitioners to administer facial injectables because we typically set 3- to 6-month recall appointments-a time span that coincides with the same time span in which patients will be ready for facial retreatments.

Applications for Dental Treatment and More

Based on its mode of action, BoNT-A can only be applied to muscles. BoNT-A has many uses, but within the dental practice, it is most beneficial for patients who suffer from temporomandibular joint disorder (TMD), bruxism, or related migraines. For cosmetic purposes, BoNT-A is ideal for dynamic wrinkles that result from the contraction of muscles. Primarily, it is used to treat the frontalis, glabellar region, crow's feet, and peri-oral lines. For deeper wrinkles that may or may not be caused by the activity of the musculature, including those caused by aging, gravity, or sun damage, hyaluronic acid fillers such as JUVÉDERM®, BELOTERO BALANCE®, or Restylane® are effective. These fillers are temporary and last up to 6 to 12 months. Dermal fillers can also be used for cosmetic purposes such as lip augmentation and gingival enlargement to reduce the appearance of "black triangles."

It is our duty and obligation to provide patients with the best dentistry possible, which means providing them with all available treatment options. Traditionally, we've prescribed occlusal splints/guards for patients who suffer from bruxism. There are major compliance issues among patients with occlusal guards due to discomfort. Sometimes, patients even wear holes through their guards. This is only a reactive solution for bruxism and does not address the root cause of the issue, which can be due to masseteric hypertrophy, pathologic clenching, or TMD. When treatment planning restorative work, especially implants, it is also critical to evaluate the patient's occlusal wear and load. Bruxism can cause an excessive occlusal load on implants, which can contribute to bone loss and implant failure.3 Administering BoNT-A into the masseter and/or temporal muscles is clinically proven to be an effective treatment for bruxism.4

In some esthetic cases, patients with clinically long crowns, thin lips, or gummy smiles can challenge us. In limited cases, gingivectomy can provide great results for patients with short clinical crowns and excessive gingival display. However, some patients are not good candidates for gingivectomy because their clinical crown length is already long. A more aggressive approach could involve periodontal flap surgery with osseous reduction, possible crown lengthening, or even orthognathic surgery. A simpler and more conservative approach to mask the appearance of a gummy smile and improve the facial esthetics is combination therapy involving BoNT-A and fillers. The muscles responsible for creating a smile are zygomaticus minor, levator labii superioris alaeque nasi, and levator labii superioris. Administering Botox Cosmetic into the "Yonsei point," where the smile muscles intersect, has been shown to aid in gummy smile treatment.4 A hyaluronic acid filler could also be used to supplement the treatment by enhancing the thin upper lip, improving the smile line and overall facial harmony.

Increasingly, patients have begun to understand the value of dentistry to improve facial esthetics. Although there has been some pushback regarding the introduction of facial injectables into the dental field, BoNT-A is becoming the standard treatment for facial pain, migraines, and bruxism.

Getting Started

Check your state's regulations on the administration of facial injectables by a dentist. Each state has different limitations on which dental providers can administer facial injectables, how advertising is handled, and whether injectables can be administered for therapeutic and/or cosmetic purposes. Most states require or highly recommend continuing education and training. To satisfy this requirement, there are plenty of live patient facial injectable training courses available that are also geared toward dentists. As dentistry arrives at the intersection of health, function, and cosmetics, it is important for us to listen to our patients' concerns and offer all possible solutions to address their needs.

About the Author

Bianca Velayo, DMD, is the owner of Green Valley Smiles Dentistry, a Pacific Dental Services-supported practice, where she has been administering facial injectables since 2016.

References

1. Cosmetic Dentistry State of the Industry Survey 2015. American Academy of Cosmetic Dentistry website. https://www.aacd.com/surveys. Published January 2016. Accessed April 5, 2018.

2. The International Study on Aesthetic/Cosmetic Procedures Performed in 2016. International Society of Aesthetic Plastic Surgery website. https://www.isaps.org/medical-professionals/isaps-global-statistics/. Published June 2017. Accessed April 5, 2018.

3. Zhou Y, Gao J, Luo L, et al. Does bruxism contribute to dental implant failure? A systematic review and meta-analysis. Clin Implant Dent Relat Res. 2016;18(2):
410-420. doi:10.1111/cid.12300.

4. Hwang WS, Hur MS, Hu KS, et al. Surface anatomy of the lip elevator muscles for the treatment of gummmy smile using botulinum toxin. Angle Orthod. 2009;79(1):70-77.

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