Facethetic Oct-Dec 2014 by Guident Journal

EDITORIAL

Oct-Dec 2014

Everything is possible when you just believe in yourself! Itâ&#x20AC;&#x2122;s my great pleasure to inform you that our Facethetics is One year old now. With a lot of Congratulations I would like to thanks our advertisers first, with which Facethetics was able to meet all the financial challenges. Thanks to our mentors, our editorial and review board members for inspiring the Facethetics Dr. Abdul Hameed Editor

team to such a successful outcome, our writers for their contribution, dedication, enthusiasm and insight which made a real difference. And in the last but not the least thanks to all of you our dear readers for your love without which this achievement would not be possible. Your support is behind us all the way. Coming to end of 2014 and stepping into a brand new year full of hopes I would first like to take the opportunity to wish our supporters a very happy and a prosperous new year from team Facethetics. it just seems like yesterday that We started delivering plethora of smiles through nothing but pure knowledge contributed by our valued authors and appreciated by numerous academicians, clinicians and researchers belonging to varied disciplines worldwide. But here we are celebrating successful completion of a year- A milestone in the journey of Facethetic. We would not have reached this milestone without your valuable support and trust in us.

quality work keeping up to date with recent technologies. We also pledge to do better and consistently strive towards achieving excellence in every possible discipline. Keeping up a quality standard of erudite would be impossible without our board of reviewers who have done a commendable job by screening every single article with utmost care and high principles to drive away plagiarism and to only support and promote originality. I would like to extend my regards to all those who work behind the scenes in making this journal worthwhile. A special recognition to all the authors who have tried their level best to provide us with best of their work. It is only because of your unseen hard work that Facethetics is reaching this kind of milestone. We try our best to publish all the good work. But due to some unforeseen circumstances if your valued work has not appeared in our editions, kindly do not lose heart and provide us more chance to serve you better. Facethetic drives itself with a motto of delivering smiles to all those who crave for knowledge. In the days to come we aim at increasing our fan base by rendering much more to the world in the form of first hand information. We also aim at developing our multi disciplinary approach which we had embraced right from the start. Bridging all kinds of stigma we aim at being the first to cater to the needs of varied disciplines to function as one. Thank you once again for all your love and support. Happy New Year

Editor Dr. Abdul Hameed

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Associate Editor Dr. Jeevan Prakash V.

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Chief Co-Ordinator Dr. Rabiya A Hameed

Facethetics has been consistently rendering

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Facethetics

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EDITORIAL

Oct-Dec 2014

In December 2013, the first issue of Facethetics was published with aim of bringing awareness in the field of facial aesthetics from various specialities like plastic surgery, cosmetic dermatology, cosmetic dentistry and related fields. The journal focussed on promoting innovations, sharing on concepts and techniques. Regardless about the speciality of the doctor, this journal strived to integrate the various disciplines towards achieving one goal, updating oneself in the latest procedures in the emerging field of Cosmetic surgery. In the last decade, every field dealing with aesthetics has advanced in giving better results to the patients, bringing down the treatment duration, reaching results which were not possible 10 years back by research, innovation and newer equipments. In the field of dermatology, lasers have evolved to treat various skin conditions, fractional Co2, pixel erbium for improving results and reducing downtime, fractional Qs Nd Yag Laser for pigment & tattoo removal Now other technologies which uses non ablative radiofrequency, fractional microneedle RF, High frequency ultrasound devices for skin rejuvenation and skin sculpting. I-Lipo and Cryolipolysis for non surgical fat reduction has changed the way we treat areas of unwanted fat. In the field of Cosmetic Dentistry, advancement in deformity correction and enhancement surgery using newer prosthetics and techniques have revolutionised the approach towards dental aesthetics. As the advancement of procedure and equipments are employed by us so is the cost of treatment. Though cosmetic surgery has given many patients the look they always wanted, it has to be made accessible to patients whose future and life depends on correcting the defects which prevents them from

having a normal life. It is our duty to offer the best care for our people who can’t afford to look beautiful. Finally a balance has to be achieved between cost and benefit for the patients. Ethics in aesthetic surgery has to give importance; an aesthetic surgeon never acts against the patients’ best interests or in a way that may harm a patient. Consultant aesthetic surgeons may decline to operate on patients

Dr. Avitus John Raakesh Prasad Guest Editor

if they do not believe that the surgery is in the patients’ best interests. Aesthetic surgeons should be reluctant to operate on those with unrealistic expectations, as the risks of surgery may outweigh any benefits. The editorial team at Facethetics are a young and motivated team who are trying to encourage articles from upcoming doctors from various specialities and further improve the high standard of publication. As Facethetics continues to evolve the editorial staff is very much open for all suggestions to further improve the Facethetics experience. We invite you to share your comments as well as your positive and negative criticisms, and would like to thank all the authors who have given your continuing support and interest in making Facethetics what it is today. After one year and 3 issues, Facethetics is now planning to publish in Middle East and expand its article contributions from other specialities related to face aesthetics.

Review/Advisory Board Dermatology / Tricology Dr. Avitus John Raakesh Prasad Dr. Chetna Ramchandani Vibhu Mendiratta Dr. Vibhu Mendiratta Anti-Aging Medicine Anti-Aging Dr. Vrushali Medicine Rane Khan Dr. Vrushali Rane Khan Plastic Surgery Plastic Surgery Dr. Maqsood Dr. Maqsood Venkatesh Dr. Venkatesh

Esthetic Dentistry Dr. Manesh Lahori Dr. Shourya Sharma Dr. Ankur Aggarwal Dr. Parvez Alam Khan Dr. Deepak Mehta

International Advisory Mr. Avi Meystel Dr. Louis Malcmacher Dr. James Jesse Dr. Geoff Knight Dr. Jun-Woo Park

The Views expressed in this issue are those of the contributors and not necessarily those of the Magazine. Though every care has been taken to ensure the accuracy and authenticity of information, “FACETHETICS” is however not responsible for damages caused by misinterpretation of information expressed and implied within the pages of this issue. All disputes are to be referred to Delhi Jurisdiction.

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Facethetics

CONTENTS

FACIAL REJUVENATION - THREAD FACE LIFT

A REVIEW

Aging is the natural biological process. As age advances the facial tissue recedes due to dissolution of collagen and elastin fibers, which leads to sagging, deep creases, folds and wrinkles. Sites which are regularly affected are the cheeks, the eyebrows and other areas around the eyes and the neck characterize the aging face in the form of orbital rim prominence, deepening of nasolabial fold, brow ptosis and jowl formation (jowl repeating twice in this sentence).

TREATMENT OF ACNE VULGARIS WITH THE USE OF INTENSE PULSED LIGHT

Most lasers emit a single, characteristic wavelength, whereas flash lamps in IPL systems emit the entire visual optical spectrum as well as a part of the near infrared (NIR) spectrum from 400nmn -1200nm. This extended spectrum can be utilized to treat to various aspects of acne, acne induced pigmentation and erythema following acne. This article helps in understanding the potential use of IPL in acne therapy. Device:

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Intense Pulsed Light with inbuilt RF and cooling. Use of 400/ 415 nm filters. Indications: IPL can be used for Grade 1 & 2 Acne, post acne pigmentation, post acne redness.

also. The smile is most recognizable signal in the world. Smiles are such important part of the communication that we can see them far more clearly than any other expression.

HAIR LOSS AND BALDNESS IN WOMEN

DENTISTS DOING BOTOX?

Q & A With Dr. Ajay Rana Dr. Ajay Rana, a renowned Dermatologist & Aesthetic Physician, founder and director, Institute of Laser and Aesthetic Medicine (ILAMED), has worked in France at the University Hospital of Besançon and in Germany at the Klinikum University of Greifswald, where he is now a Professor and Dermatologist Attaché.

GUMMY SMILE ITS TREATMENT OPTIONS

AND ROLE OF BOTOX

IT’S ABOUT TIME!

BOTULINUM TOXIN:

A NEW AVENUE IN DENTISTRY

Botulinum toxin is a neurotoxin, best known for its beneficial role in facial aesthetics but recent literature has highlighted its usage in multiple non-cosmetic medical and surgical

CONTENTS

Oct-Dec 2014

conditions. This article reviews the current evidence pertaining to Botox use in the dental conditions. Most of the dental conditions can be treated by targeting masseter and temporalis muscle. US Food and Drug Administration have recently approved the use of Botox in chronic migraine, thereby acknowledging it as a safe treatment to manage such conditions.

ZOOM- IN’TO A FOCUSED ‘MYTHS VS TRUTHS’ SERIES THAT HELPS US UNDERSTAND AND RELATE TO FACTS WITH ‘READY TO PRACTICE TIPS ON TOOTH WHITENING

As the patients seek the expertise of aesthetic dental practitioners to whiten their smiles, their expectation as regards a dramatic shade change are on the higher side. Teeth Whitening today has a considerable volume in our routine clinical practice. My endeavor, through this series of articles on this topic , will be to present a systematic analysis of myths and doubts, commonly pertaining to Teeth Whitening, and methods to

overcome the challenges of even most difficult whitening cases, with greater predictability possible.

than

previously

DIRECT LAMINATE

VENEERS – PART III

Much about the way we wish to present ourselves to the world is based upon current concepts of fashion and beauty, the criteria of which are constantly changing.The smile is much the same, during the ‘30’s an attractive smile was the “cupid doll” look, small mouth with slightly pouted lips. Extraction orthodontics worked well in this era but not today when an attractive smile just fits in between the ears. We recognize people by their eyes and once we have established who we are talking to the mouth plays an important role in flagging the emotional aspects of conversation. Even if we are not consciously aware of it our mouths are continuously being scrutinized at a subliminal level during conversation.

DERMAL AGEING PATHOMECHANISM

PART I

Dermal ageing is a multifactorial process clinically divided into intrinsic and extrinsic ageing and ultraviolet radiation being the main factor responsible for premature skin ageing. Pathogenesis of ageing is continuous process elucidated physiological changes in various tissues resulting in impaired function and repair mechanism. Facial dermal aging involves the dermis epidermis and subcutaneous tissue. Numbers of treatment strategies are available to delay or treat the facial skin ageing. Understanding the mechanism of ageing process will help in developing methods to reverse it. In this article we are trying to outline the mechanism of dermal ageing.

Event Celender

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FACIAL PLASTIC SURGERY

Oct-Dec 2014

FACIAL REJUVENATION - THREAD FACE LIFT A REVIEW Dr. Abdul Hameed Aging is the natural biological process. As age advances the facial tissue recedes due to dissolution of collagen and elastin fibers, which leads to sagging, deep creases, folds and wrinkles. Sites which are regularly affected are the cheeks, the eyebrows and other areas around the eyes and the neck characterize the aging face in the form of orbital rim prominence, deepening of nasolabial fold, brow ptosis and jowl formation (jowl repeating twice in this sentence). Aesthetics being the prime concern in modern era many patients’ prefer to overcome the problems associated with aging process. Aesthetic surgery literature describes an array of rejuvenation techniques. With newer technology and innovation patients prefer simple, less invasive, and precise with rapid recovery procedures. At the same time provide effective, safe, relatively long-lasting, and natural results. Thread lift may be a good alternative compared to the more invasive procedures available necessary to correct problems. The procedure can be customized based upon your desired results. It can also be easily adjusted or reversed if desired.

AREAS THAT CAN BE TREATED ARE Facial Anatomic Zone

Number of Threads Brows — above the lateral canthus 6 Total Mid face — between the lateral 2 per side canthus and the corner of the mouth Lower face — between the corner of the 2 per side mouth and the jawline Jowls — straddle the jawline 2 per side Neck — below the jawline 2 per side

FACTORS WHICH DETERMINE THE OUTCOME OF SUCCESS IN THREADLIFT 1.

Aging process.

Understanding technique of the lifting concept.

Facial Anatomy.

Kinetics of facial muscles.

Correct determination of indications and contraindications.

INDICATION X Total

face Lift

X Contour X Facial

adjustment

paralysis

X Improvement X Promoting X Skin

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of the small wrinkles on the face

skin elasticity

texture improvement

Oct-Dec 2014

CONTRAINDICATIONS Absolute contraindication X Persisting

skin infection and inflammation

X Pregnancy X On

anticoagulant medication

X Blood

related diseases

Relative contraindication X Serious

and deep sagging

X Patients

with scar on the face

X Autoimmune

diseases

RISKS AND COMPLICATIONS X Relatively

no improvement.

X Sometime

sutures became visible beneath skin.

X Sensitivity

or numbness in the treated area subsides in few weeks time.

X Infection

very rarely.

X Scarring. X Sometimes

migration of the threads, resulting in facial

asymmetry. X Retraction

of the skin in entry and exit points of needles

X Short-term

(up to 3 months) and unstable results

DISCUSSION Facelift to correct facial aging has been, so far a complicated and time taking procedure with longer recovery time. Literature describes various rejuvenation techniques. The Papyrus Ebers indicates that the ancient Egyptians were the first to document remedies that stillremain a part of our modern cosmetic armamentarium. Facial Rejuvenation methods evolved from skin-only rhytidectomy into a range of soft-tissue repositioning and SMAS lift adaptations. Maximum procedures during 1980’s to1990byTessier are highly invasive. But in past few decades minimally invasive techniques have been popularized, and these Innovations in operative techniques generally contribute to get better results, greater satisfaction with reduced operative morbidity. Thread lift Revitalizing is a safe and successful technique for facial rejuvenation. The immediate effect is the lifting of the tissue, due to the mechanical lifting action produced by the thread. Various thread lifting techniques have been proposed but all the techniques of thread-lift rely on a basic physics of lifting of tissue with subcutaneous placement of cogged/barbed threads along a pre determine

FACIAL PLASTIC SURGERY trajectory. Former thread lifts were either floating or fixed types. But after considering the functional anatomy of face given by Mendelson combination technique are preferred over single technique. Mendelson classified face in to two region separated by vertical line from the lateral orbital rim. The combine facelift technique has some benefit over single thread lift technique. First the functional anatomy of face is considered. Secondly the pull of threads is stronger than formerly used. Last the post-operative broadening in the malar area is minimized, particularly in Asian population. Region Technique of thread lift Anterior region Mobile area Floating type thread Lateral region Fixed area or Fixed type thread relatively fixed area The final results of thread-based lifts can only be evaluated sub¬jectively with a standard Global Aesthetic Improvement Scale (GAIS). Rachel et al reported that the incidence of complica¬tions or early recurrence was independent of patient age, type of thread, or technique. The lifting effect is because of the cutaneous reaction (fibrosis) that occurs along the length of the thread, and that persists effectively and remains steady even after the treatment is complete or thread is removed. Barbs along the thread act as cogs to grasp and lift mechanically the relaxed facial tissue. The barbs open like an umbrella when it is pulled against the predetermined trajectory and form a support structure that lifts the sagging tissue. Global Aesthetic Improvement Scale (GAIS) Degree Description Exceptional improvement Excellent corrective result Very improved patient Marked improvement of the appearance, but not completely optimal but a touch-up is advised Improved patient Improvement of the appearance, better compared with the initial condition, Unaltered patient The appearance substantially remains the same compared with the original condition Worsened patient The appearance has worsened compared with the original condition Issue 2 Vol. 1

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FACIAL PLASTIC SURGERY

Oct-Dec 2014

CONCLUSION Face Thread lift, rejuvenating procedures are gaining popularity as it is a simple, less invasive, performed under local anesthesia as a day care office procedures, short healing time, reliable and have long lasting effects. Other rejuvenating procedures can be combined with thread lift such as botulinum toxin, dermal fillers, chemical peels, LASERS and other aesthetic procedure with added advantage. However, it should also be emphasized that thread lift is a relatively new procedure and like all other newer procedures, it also requires further understanding study and development.

The vector of the force

Dr. Abdul Hameed Blue line divides the face into the anterior and lateral regions

Dr. Abdul Hameed is a consultant maxillofacial and cosmetic surgeon, practicing in Mumbai India. He is organizing Head of â&#x20AC;&#x153;Being Dentistâ&#x20AC;? a group with the aim of constant learning and better serving. He has presented many scientific papers & posters, won awards and attended Workshops to keep abreast of the latest developments in the field of maxillofacial and cosmetic field.

Position of thread

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DERMATOLOGY

Oct-Dec 2014

TREATMENT OF ACNE VULGARIS WITH THE USE OF INTENSE PULSED LIGHT Dr. Avitus John Raakesh Prasad

ABSTRACT Most lasers emit a single, characteristic wavelength, whereas flash lamps in IPL systems emit the entire visual optical spectrum as well as a part of the near infrared (NIR) spectrum from 400nmn -1200nm. This extended spectrum can be utilized to treat to various aspects of acne, acne induced pigmentation and erythema following acne. This article helps in understanding the potential use of IPL in acne therapy. Device: Intense Pulsed Light with inbuilt RF and cooling. Use of 400/ 415 nm filters. Indications: IPL can be used for Grade 1 & 2 Acne, post acne pigmentation, post acne redness. Facility: IPL can be carried out in a clinic or hospital setting or a nursing home with a small operation theatre. Informed consent and counseling: The dermatologic consultation should include detailed assessment of the patientâ&#x20AC;&#x2122;s skin condition and skin type. An informed consent is mandatory to protect the rights of the patient as well as the practitioner. All patients must have carefully taken preoperative and postoperative pictures. Parameters: Depends on the indication, the area to be treated, the acceptable downtime for the desired correction, and to an extent the skin color. Anesthesia: There is acceptable pain and is tolerated well by patients but may require topical anesthesia. In most cases, topical cooling and numbing using icepacks is sufficient, even in an apprehensive patient. Postoperative care: The newer IPL with RF systems are safe, even in type V & VI skin

types, and postoperative care is minimal. Postoperative sun avoidance and use of sunscreen is mandatory. Keywords: Intense Pulsed Light, IPL with RF, Acne, pigmentation, Erythema

INTRODUCTION Intense pulsed light (IPL) devices are non-laser high intensity light sources that make use of a high-output flashlamp to produce a broad wavelength output of noncoherent light, usually in the 400 to 1200nm range. Light pulses generated by most modern devices are produced by bursts of electrical current passing through a xenon gas-filled chamber.1 The lamp output is then directed toward the distal end of the handpiece, which, in turn, releases the energy pulse onto the surface of the skin via a sapphire or quartz crystal. Individual systems use different cooling systems, such as a cryogen spray, contact cooling, or forced refrigerated air, to protect the epidermis in contact with the conduction crystal of the handpiece.2 An Advanced treatment option for a most common skin problem. Acne treatment mode is one of the most important functions of an IPL. Most commonly used function in my practice is this mode and it gives my patients a new approach to their acne problem. It addresses both acne and pigmentation issues in a single treatment.

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DERMATOLOGY There are few principles and concepts in IPL which forms the basis of treatment: I. Thermal Relaxation Time (TRT):3 Defined as the time required for a structure to lose 50% of the peak heat acquired to the surrounding tissue. II. Selective Photothermolysis: 3 Anderson and Parrish coined the term “selective photothermolysis”. It describes site-specific, thermally mediated injury of microscopic tissue targets by selectively absorbed pulses of radiation (Anderson 1983).

IPL ACNE MODE

Oct-Dec 2014

absorption and the Q bands represents the several weaker absorption at longer wavelengths. When exposed to Blue light porphyrins act as photosensitizers and generate highly reactive free-radical species, one of which is singlet oxygen. These radicals are potent oxidizers and destroy the lipids in the cell wall of P. acnes. Illumination of the endogenous coproporphyrin with blue light (407- 420 nm) apparently plays a major role in P. acnes photoinactivation.4,5 Newer IPL uses RF which is incorporated in the sides of the crystal, when RF energy is passed along with IPL it causes dermal contraction with shrinkage of sebaceous gland and sebum suppression. This causes decrease in sebaceous activity for some time which helps in reduction of acne and a better clinical outcome when treating acne.

The wavelength useful for acne is 410nm and above. The blue light has a wavelength of around 415 - 475 nm. High intensity blue light emitted from IPL system acts on the porphyrins released from Propionibacterium acnes.

P.acnes produces and accumulates endogenous porphyrins, namely protoporphyrin, uroporphyrin, and coproporphyrin III, as part of its normal metabolic and reproductive processes. The strongest porphyrin photo excitation coefficient (407–420 nm) lies in the Soret band. The peak is named after its discoverer Jacques-Louis Soret.

Blue light also has anti-inflammatory effects in inflamed acne by down-regulating interleukin (IL)-1, a proinflammatory cytokine, which is a chemo-attractant of inflammatory cells, and a stimulant of other inflammatory mediators.6 Multi-pulsing gave better results than single pulse mode in acne lesions.7

WHY & WHEN TO DO IPL FOR ACNE : 1.

Patients not responding to conventional modalities ( Resistance ).

Patients fed up of taking antibiotics and are looking for an alternative.

Need for a quicker recovery.

PATIENT SELECTION The graph shows excitation spectrum of protoporphyrins. The soret band represents the highest peak of light

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Grade 2 and 3 Acne responds better. Grade 1 is treated better with comedolytics.

Avoid doing in nodulocystic since there is more chances of scarring. A course of antibiotics is given to reduce the inflammation then decide on doing an IPL treatment.

DERMATOLOGY

Oct-Dec 2014

Giving an antibiotic can kill P.Acnes thereby reducing the available target porphyrin for the IPL treatment and affect your outcome but more number of P.Acnes and inflammation can make a simple IPL treatment end up in severe scarring due excess heating up of target tissue.

CONTRAINDICATIONS 1.

Patients currently on or having taken isotretinoin in the past 6 months.

Patients with unrealistic expectations.

Try to avoid in Pregnant women as for any other Laser treatment.

Avoid in nodulocystic acne.

PARAMETERS 1. Filters : The 410 / 415 nm filter is used, the spectrum of visible light form blue 410nm along with green 510nm, yellow 560nm up to 1200nm is emitted. 2. Energy : In light based medicine, fluence which may be more properly referred to as radiant exposure, is a measurement of energy over treatment area. The area is usually the spot size of the light device. Fluence is described as the energy delivered per unit area and it has units of J/cm2. In Acne mode energy / fluence is used starting at 15 J/cm2 to as high as 25 J/cm2 depending on skin type, lower joules for darker skin. The energy is sufficient for the blue light to excite the target porphyrins, but it is not sufficient enough for the green and yellow light to reach its targets. But this suboptimal energy is sufficient to treat the post acne redness and prevent pigmentation following acne. 3. Pulse duration: a. Pulse Width: The time each pulse is On measured in milliseconds ( ms). The pulse width can be from 2ms to 4ms depending on target. The use of pulse helps in targeting the chromophore more specifically and giving the optimum results. b. Pulse Delay:The time interval when the light is Off between Pulses measured in milliseconds ( ms).The light is delivered in pulses of On and Off time. The pulse delay is to give time for the epidermis to cool between pulses. Minimum of 10ms is set which can be increased depending on the skin type the maximum pulse delay depends on the different IPL company.

Since most of the IPL comes with an inbuilt contact cooling the pulse width of 10ms is sufficient for all treatment modes. 4. Number of Pulses: The use of pulsing is to deliver the given fluence ( joules ) in a divided two, three, or five small consecutive pulses. This can improve the absorption of the wavelengths by the target chromophore and in turn protecting the epidermis. 5. RF energy: IPL action on the target tissue creates an initial relatively small temperature gradient, and by applying RF energy next, a larger temperature gradient is obtained at the target chromophore. This allows heating of the target to a sufficiently high temperature to destroy the target without heating the surrounding skin tissues preventing collateral damage. Rf energy of 10 â&#x20AC;&#x201C; 30 W is used for a time of 0.3 to 0.5 seconds.

MY EXPERIENCE I have been using the first generation IPL followed by second generation IPL and then finally IPL with RF. And in my experience of trial and error I have deduced certain settings but the reader is free to experiment and try the settings which he or she feels is best for the patient. For acne I prefer to use 10 to 20 J / cm 2 ( Higher joules for lighter skin ). The Pulse Width ( PW ) varies between 3.0 ms to 6.0 ms ( Higher Pulse duration for lighter skin ). The Pulse Delay ( PD ) varies from 10 ms to 30 ms ( Higher for darker skin ). Minimum Pulse delay of 10ms is sufficient in newer IPL Systems but if 20ms settings is available with your machine you could keep the pulse delay at 20ms. Shorter pulse delay increases the therapeutic effect but it increases epidermal burns in Asian skin. Donâ&#x20AC;&#x2122;t try to keep higher joules in Acne treatment since shorter wavelengths causes more epidermal burns and blistering when used with higher joules. After several acne treatments I experienced that IPL with auto cooling, posed a problem since cooling the epidermis too much hinders with the outcome of the treatment.

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DERMATOLOGY

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In Acne I usually keep crystal cooling only for 2 – 3 seconds if 15 to 20 J / cm2 and 4 – 5 seconds if 20 – 25 J / cm 2 joules are used. In case of IPL systems with RF you can ON the RF and use RF energy of 15 – 20 W with on time of 0.3 to 0.5 seconds.

Two treatments of IPL two weeks apart with energy 20 J/cm2, 410nm cut off filter, reduction in acne and oiliness of the skin.

The Table given below illustrates what settings I prefer to use in Acne treatment. The pulse duration/ Pulse Width (PW) can be increased in subsequent pulses and the Pulse Delay (PD) can be altered to user preference. After doing one pass over the affected areas with the 410/415nm filter, you can do a second pass using the 510/530nm(green) filter, which will reduce the erythema and melanin aggregation resulting in a better treatment outcome.

Three treatments of IPL two weeks apart with energy 22, 24, 26 J/ cm2respectivel with 410nm cut off filter followed by three treatments with 530 nm(green)filter energy 28 J/cm2 resulted in better clearance of acne and post acne pigmentation.

ADDITIONAL BENEFITS OF DOING IPL IN ACNE 1.

Post-acne Pigmentation improves along with Acne. The remaining spectrum of an IPL ( 510nm) treats pigmentary changes which is associated with acne.

Textural and Skin tone improvement. Activation of fibroblasts cytokine secretion and the resultant stimulation of collagen, elastin, and glycosaminoglycans, by the 560nm – 585nm wavelength yield a simultaneous improvement in skin color and general appearance.

The smoother appearance of the skin is due to sebaceous gland shrinkage.

Reduction of oiliness of skin.

Medical management followed by IPL treatment two weeks apart with energy 20 ,& 22 J/cm2 410nm cut off filter and one treatment with 530nm filter at 26 J/cm2 resulting in reduction in acne, post acne pigmentation and oiliness of the skin.

NOTE ON USE OF AMINOLEVULINIC ACID AND (ALA) & IPL Topical 5- Amino levulinic acid (ALA) is applied it the affected areas then after 1 -3 hours, IPL (400- 420nm) light is used. Photoinactivation of Propionibacterium acnes is induced by converting topical ALA into protoporphyrin IX which is activated by intense pulsed light (IPL).8

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However, the problems associated with photodynamic therapy is that it is expensive to perform, it is time consuming, and it is more painful than blue light alone. Patients have reported erythema, stinging, pruritus, pain, and tightening after this intervention.9

Rojanamatin J, Choawawanich P. Treatment of inflammatory facial acne vulgaris with intense pulsed light and short contact of topical 5-aminolevulinic acid: a pilot study. Dermatol Surg. 2006 Aug;32(8):991-6.

Goldman MP, et al. Comparative benefit of two thermal spring waters after photodynamic therapy procedure. J Cosmet Dermatol. 2007 Mar; 6(1):31–5.

REFERENCES 1.

Raulin C, Greve B, Grema H. IPL technology: a review. Lasers Surg Med. 2003;32:78–87.

Weiss RA, Sadick NS. Epidermal cooling crystal collar device for improved results and reduced side effects on leg telangiectasias using intense pulsed light. Dermatol Surg. 2000;26(11):1015–1018.

Anderson RR, Parrish JA. Selective photothermolysis: precise microsurgery by selective absorption of pulsed radiation. Science 1983,220:524–7

Arakane K, et al. Singlet oxygen (1 delta g) generation from coproporphyrin in Propionibacterium acnes on irradiation. Biochem Biophys Res Commun. 1996 Jun 25; 223(3):578–82.

Ashkenazi H, et al. Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light. FEMS Immunol Med Microbiol. 2003 Jan 21;35(1):1724.

Shnitkind E, et al. Anti-inflammatory properties of narrowband blue light. J Drugs Dermatol.2006 Jul–Aug; 5(7):605–10.

M Kumaresan and C R Srinivas. Efficacy of IPL in treatment of acne vulgaris. Indian J Dermatol. 2010 Oct-Dec; 55(4): 370–372.

Dr. Avitus John Raakesh Prasad Dr. Avitus John Raakesh Prasad, is a Dermatologist and Laser surgeon practising since Dec 2003, specialisation in Laser based surgeries, Vitiligo surgeries and FUE Hair Transplantation. 15-21 days intensive training on Dermatosurgery and Lasers is provided to dermatologist and plastic surgeons from India and abroad. He constantly updates his knowledge and share his experience with fellow doctors. Dr. John has been an inspiration for many dermatologists and plastic surgeons across the country for performing innovative procedures & laser based surgery. At least 12 -15 CMEs on dermatology, dermatosurgery, lasers are conducted by Dr Avitus John. One day training programme on introduction to various laser technologies and application in cosmetic dermatology is held every 3 months. He is also author of the book Intense Pulsed Light - Applications in Dermatology and Aesthetic Medicine.

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DERMATOLOGY

Oct-Dec 2014

HAIR LOSS AND BALDNESS IN WOMEN Dr. Ajay Rana

Dr. Ajay Rana, a renowned Dermatologist & Aesthetic Physician, founder and director, Institute of Laser and Aesthetic Medicine (ILAMED), has worked in France at the University Hospital of BesanĂ§on and in Germany at the Klinikum University of Greifswald, where he is now a Professor and Dermatologist AttachĂŠ. In 2009 he created the Institute of Laser and Aesthetic Medicine (ILAMED), which is AICTE approved and affiliated to the University of Greifswald, Germany (www.ilamed.org). ILAMED offers training programmes for Cosmetologists, General Physicians, Dermatologists & Plastic Surgeons. ILAMED is an offshore center of the University of Greifswald,

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Germany for the International Diploma in Aesthetic Laser Medicine (www.laserstudium.eu). Q. I am only 29 years old and have started losing hair about 2 years ago, and the problem is getting worse now. What can be the cause of my hair loss? Meghna, New Delhi A. In women as in men, the most likely cause of scalp hair loss is androgenetic alopecia, which is related to the production of androgenetic (male) hormones and their effect on the hair follicle. However, hair loss in women may occur for other reasons such as temporary shedding

DERMATOLOGY

Oct-Dec 2014

of hair (telogen effluvium) after a major illness, surgery, or pregnancy, or certain skin, etc . Appropriate investigations may be conducted to determine the specific cause(s) of your hair loss. Q. How do I know I am having hair loss, what are the symptoms? Divya, Hyderabad A. Hair thinning in women is different from that of male pattern baldness: hair thins mainly on the top and crown of the scalp. It usually starts with a widening through the center hair part. The front hairline remains. However, the hair loss rarely progresses to baldness in the patterns that occur in me. In any case, you should not hesitate to consult if you have any worry regarding your hair loss. Q. What is the treatment available for female hair loss as I have already used Minoxidil for some years without any effect? Ragini, Chennai A. Female pattern baldness usually does not mean that a woman has a medical disorder and you do not need treatment if you are comfortable with your appearance. However, for many women, it may affect self-esteem or cause anxiety. Hair loss in female pattern baldness becomes permanent, if not treated. In most cases, hair loss is mild to moderate, and the FDA apporved drug Minoxidil may slow or stop hair loss. However, hair loss starts again when Minoxidil is stopped. For a permanent and more complete solution you may want to consider hair transplantation. At Klinik Esthetika we use both the manual and the most advanced Robotic System (NeoGraft) for hair transplantation with no downtime.

Dr. Ajay Rana Dermatologist & Aesthetic Surgeon Founder & Director Institute of Laser & Aesthetic Medicine (ILAMED) New Delhi

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ESTHETIC DENTISTRY

Oct-Dec 2014

GUMMY SMILE ITS TREATMENT OPTIONS AND ROLE OF BOTOX Dr. Shourya Sharma & Dr. Natasha Gambhir

During the last 15-20 years demand for facial esthetics have increased in most part of the world .There has been seen a large number of increase in facial surgeries and use of different type of lasers around the world. But the most interesting thing to seen in our dental world is the use of botox and dermal fillers which are popular in use in western countries and slowly catching up in India and Asia also. The smile is most recognizable signal in the world. Smiles are such important part of the communication that we can see them far more clearly than any other expression. In today’s world a nice smile can act as powerful tool of communication ,an unpleasing smile can equally have a negative effect and this is one of the reasons why young and even old patients these days are going for orthodontic treatments and facial treatments. An undeniable psychological benefit of cosmetic procedures is the increase in self-esteem. In turn, improvement in self-esteem changes the scope of several of these cosmetic procedures to another level: therapeutic. In orthodontics, facial esthetics are enhanced in several conventional ways; the 2 primary ones are alignment of the dentition and balancing of the patient’s profile. Additionally, measures to improve the smile are often-sought procedures. In particular, those with a “gummy smile,” so called due to excessive display of gingival tissue in the maxilla on smiling, can be self-conscious, embarrassed, or even psychologically affected, and thus seek intervention.

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A “gummy smile” is a condition in which a person shows a larger than average amount of gum tissue when smiling and has a disproportionate gum-to-tooth ratio. Although a gummy smile is considered a normal variation of human anatomy, many people with gummy smiles suffer from embarrassment, self consciousness, and even a general lack of self esteem. They often dislike their smile and wish there was something they could do to change it.

WHAT CAUSES A GUMMY SMILE? A gummy smile can be caused by a variety of factors, including the following: 1.

2. 3. 4. 5. 6. 7. 8.

Excessive overgrowth of gum tissue (hyperplasia) due to medications such as Dilantin, Cyclosporine, and numerous calcium channel blockers Excessive overgrowth of gum tissue due to orthodontic treatment Inflammation associated with poor oral hygiene, gum disease or faulty dental restorations Congenital gingival enlargement from hereditary and metabolic disorders Developmental variations of the upper jaw bone (maxilla) Hyperactive upper lip muscle, causing the upper lip to rise up higher than normal when smiling (high lip line) Dental malocclusion Excessive growth of bone (exostosis) on the outer surface of the maxillary (upper) jaw

Oct-Dec 2014

MUSCLES ASSOCIATED WITH GUMMY SMILE

ESTHETIC DENTISTRY MILD GUMMY SMILE

If the amount of gum tissue displayed when smiling is less than 25% of the length of the teeth, it is considered a mild gummy smile.

The Muscles Associated With Gummy Smile Are X Levator

labii Superioris

X Levator

Labbi Superioris Alaeque Nasii

X Zygomaticus

Major

X Zygomaticus

Minor

X Depressor

MODERATE GUMMY SMILE

Septii

TYPES OF GUMMY SMILE Gummy smiles are classified according to the gummy smile scale. This scale measures the amount of gingival tissue (gum tissue) displayed as a percentage of tooth height. In other words, your gummy smile classification is based on the amount of gum tissue that shows in relation to how much tooth structure is displayed when you smile. Gummy smile can be mild, moderate, advanced, or severe.

If the amount of gum tissue displayed when smiling is between 25% and 50% of the length of the teeth, it is considered a moderate gummy smile.

ADVANCED GUMMY SMILE

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ESTHETIC DENTISTRY If the amount of gum tissue displayed when smiling is between 50% and 100% of the length of the teeth, it is considered an advanced gummy smile.

SEVERE GUMMY SMILE

If the amount of gum tissue displayed when smiling is greater than 100% of the length of the teeth, it is considered a severe gummy smile.

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GINGIVECTOMY A gingivectomy is a simple surgical procedure used to correct a minor gummy smile. This procedure is used to remove excess gum tissue and to better contour the gum tissue around the teeth. During a gingivectomy, a minimal amount of gum tissue is removed using a dental laser or by a technique called radiosurgery. The procedure is painless, requires no sutures, and the gums heal within two weeks.

Before gingivectomy

There are different types of gummy smiles that affect all areas of the mouth. Single teeth may be affected, as well as groups of teeth, or the entire smile. Some people are unhappy with the amount of gum tissue that shows above their front teeth (anterior teeth) when they smile. Gummy smiles may also occur on only one side of the mouth, known as a unilateral posterior gummy smile, or on both sides, known as a bilateral posterior gummy smile. No matter what the classification or location of the gummy smile, there are various treatment options available to you.

TREATMENT OPTIONS

During procedure

If you suffer from a gummy smile and are bothered by the way it looks, you donâ&#x20AC;&#x2122;t have to live with it any longer! There are many treatment options available to correct a gummy smile: gingivectomy, crown lengthening surgery, and lip lowering surgery and use of botox and dermal fillers which is getting much of recognition at the present time. The method used to treat your gummy smile will be determined by an experienced surgeon who is familiar with gummy smile correction. The treatment modality used is chosen based on the amount of excess gum tissue displayed when you smile, your underlying skeletal anatomy, and the mobility of your upper lip. After gingivectomy

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Oct-Dec 2014

ESTHETIC DENTISTRY

CROWN LENGTHENING SURGERY

LIP LOWERING SURGERY

More advanced gummy smiles require more extensive gum tissue reduction. A procedure known as crown lengthening surgery can be performed to achieve this tissue reduction. Crown lengthening is done under local anesthesia for total patient comfort. During the procedure, the gum tissue is gently lifted off the underlying bone. Soft tissue is removed and some of the underlying bone is modified, and the gum tissue is contoured and placed in a desired new position. The teeth now look longer and the gums less prominent.

Lip lowering surgery is a soft tissue procedure used to reduce gingival display to improve the look of a gummy smile. It is often used when a patient has a hyper-mobile upper lip or a skeletal discrepancy that causes an excessive amount of gum tissue to show when smiling. By surgically lowering the upper lip, less gum tissue shows when smiling, which leads to a more natural and pleasant looking smile. It is far more conservative than orthognathic surgery and can be completed right here in the comfort of our dental office. Lip lowering surgery requires local anesthesia similar to that given to a patient receiving ordinary dental restorations. The surgery consists of making an incision in the gum tissue and mucous membrane above the upper teeth, removing a section of tissue, and re-attaching the upper lip in a lower position so that it covers the gum tissue. Once the upper lip is sutured into its new position, the muscles responsible for pulling the lip high above the gum line during normal smiling will be more restricted. This results in a more pleasant looking smile with less gingival display and a reduction of the gummy smile.

Before crown lengthening

Before lip lowering During procedure

During procedure After crown lengthening

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ESTHETIC DENTISTRY

Oct-Dec 2014

PROCEDURE FOR INJECTION

After lip lowering

BTX-A, THE SMILE, AND ESTHETICS BTX-A has been under clinical investigation since the late 1970s for the treatment of several conditions associated with excessive muscle contraction. Produced by the anaerobic bacterium C botulinum, there are 7 serotypes of BTX. BTX-A is the most potent and the most commonly used clinically type. Botox is a purified BTX-A isolated from the fermentation of C botulinum. It is a stable, sterile, vacuum-dried powder that is diluted with saline solution without preservatives. BTX-A blocks neuromuscular transmission by binding to acceptor sites on motor or sympathetic nerve terminals, thus inhibiting the release of acetylcholine. This inhibition occurs as the neurotoxin cleaves SNAP-25, a protein integral to the successful docking and release of acetylcholine from vesicles in nerve endings. When injected intramuscularly at therapeutic doses, BTX-A produces partial chemical denervation of the muscle, resulting in localized reduction in muscle activity. Botox has been approved by the Food and Drug Administration as a safe and effective therapy for blepharospasm, strabismus, cervical dystonia, and hemifacial spasm since 1989; in 2002, it received approval for the treatment of glabellar lines associated with corrugator and procerus muscle activity, and, in 2004, approval was obtained for the treatment of primary axillary hyperhidrosis. The National Institutes of Health Consensus Conference of 1990 also included it as a safe and effective therapy for other nonlabeled uses. The use of BTX-A for many facial cosmetic procedures has been described extensively in the literature.

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For correction of gummy smile, Botox is injected into the hyperactive elevator muscles of lip blocking excessive contractions and thus prevent the lip from being pulled too far up while smiling. It will be important for the patient to avoid taking aspirin or related products, such as ibuprofen (e.g., Advil) or naproxen if possible after the procedure to keep bruising to a minimum. Prior to injection, reconstitute vacuum-dried BOTOX, with sterile normal saline without a preservative; 0.9% Sodium Chloride Injection is the only recommended diluents. Draw up the proper amount of diluents in the appropriate size syringe, and slowly inject the diluents into the vial. BOTOX should be administered within four hours after reconstitution. During this time period, reconstituted BOTOX should be stored in a refrigerator (2째 to 8째C). Reconstituted BOTOX should be clear, colorless and free of particulate matter. Mario Polo has advocated injection of botox at LLS, LLSAN, LLS /ZM overlap and in severe cases at depressor nasii & OO also. The ideal dosage might be 2.5 U per side at the LLS & LLSAN, 2.5 U per side at the LLS/ZM sites, and 1.25 U per side at the OO sites. Very recently Hwang et al5; Yonsei University College of Dentistry, Seoul, Korea have proposed a injection point for botulinum toxin-A, and named it as YONSEI POINT and they recommend dose of 3U at each Yonsei point

Yonsei point is located at the centre of the triangle formed by: 1.

levator labii superioris [LLS],

levator labii superioris alaeque nasi [LLSAN],

zygomaticus minor [Zmi].

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CONCLUSION Botulinum toxin which was and still a substance to be feared from is now perceived as a Magic drug. Botox due to its mechanism of action which is weakening of the activity of muscle temporarily can be drug of choice in many treatments like hyperactive muscles in cases of gummy smile and it can be even used in cases of black triangles and many other treatment modalities. But one has to train his/her self before starting the treatment with Botox as it looks simple but is very complex. So to help you around with Botox IAOFE will be always there for you with number of its courses.

REFERENCES 1.

Dr Sadashiv Daokar etal Non-invasive correction of gummy smile (ISRO vol12 issue 2, 2013)

Polo Mario :Botulinum toxin type A for neuromuscular correction of excessive gingival display on smiling. Am Orthod&DentofacialOrthop 2008;133:195-203

Kanhu Charan Sahoo : Botox in gummy smile â&#x20AC;&#x201C; A Review ( IJDS March 2012, Issue 1, Vol 4)

Dr Kurpis DDS, Treatment of Gummy Smile (www. kurpisdentistry.com)

Dr Dolly Patel, Botulinum toxin and Gummy smile- A Review (ISRO, Vol 4, Issue 1 Jan-Feb 2013)

Images of Treatment by AAFE

SOME OF CASES BY AAFE

Dr. Shourya Sharma BDS, MDS, Certified Botox Surgeon by American Academy of Facial Aesthetics, USA Private Practitioner CEO IAOFE

Dr. Natasha Gambhir

BDS, MDS Assistant Professor, Santosh Dental College and Hospital India Head IAOFE

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ESTHETIC DENTISTRY

Oct-Dec 2014

DENTISTS DOING BOTOX? IT’S ABOUT TIME! by Louis Malcmacher DDS, MAGD

Botox and dermal fillers have made a huge impact in the elective aesthetic field. By far, these are the two fastest growing cosmetic treatments, especially over the last decade. The dollar amount spent on Botox and dermal fillers far exceeds the combined dollars spent for breast implants and liposuction.With that in mind, there is a definite place in the dental practice for both Botox and dermal fillers therapy. Dentists should be joining other health-care practitioners who deliver these services. In truth, dentists should be the primary health-care practitioners to deliver these procedures to patients. After speaking to thousands of dentists about these procedures through my lectures, I’ve found that we as a dental industry are pretty much ignorant of what these the rapies even are, how they are delivered, what the science is behind them, and what they can accomplish for our patients. A little bit of knowledge will go a long way in helping you understand about the clinical and business advantages to integrating these therapies into your office.

THE REAL FACIAL SPECIALISTS The first question everybody asks is, “Don’t Botox and dermal fillers procedures belong in a plastic surgeon’s or dermatologist’s office?” Dermatologists and plastic surgeons were the first health-care providers to train and

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integrate these therapies into their offices but that does not make these “specialty” procedures by any means. These procedures are delivered to patients by other physicians including OB/GYNs, ophthalmologists, gastroenterologists, internists, registered nurses, physicians’ assistants, medical aestheticians (who might or might not be medical personnel), and even podiatrists! I submit that dentists are the true specialists in the area of the face, much more so than these other health-care personnel. In several states, a registered nurse or physicians’ assistants can have an independent practice outside of the physicians’ office and perform Botox, dermal fillers, chemical and laser microdermal abrasion, sclerotherapy, and mesotherapy. Even within dermatology and plastic surgery offices, registered nurses and physicians’ assistants are the primary providers of Botox and dermal fillers. Many nurses have told me that their training was completely on the job with absolutely no additional training in facial anatomy, physiology, pharmacology of the products and adverse affects. They just learned where to place these materials by watching and learning. We, as dentists, really have to start standing up for ourselves and realize how advanced our training has been in the oral and maxillofacial areas (that means the face from chin to forehead) compared to just about any other health-care professional who is allowed to deliver Botox and dermal fillers to patients. Dentists often challenge me that these

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ESTHETIC DENTISTRY

procedures are best left to physicians. The question that you really have to ask yourself is, “Why?” An ophthalmologist, general plastic surgeon, dermatologist, OB/GYN, most other MDs, nurses, and physicians’ assistants do not even come close to knowing the facial, oral and perioral areas the way a general dentist does. Dentists are much more familiar with how to take care of complications in these facial areas than other health-care providers. Yet they are allowed to deliver Botox and dermal fillers in some states where dentists are excluded from doing so. Dentists do many more invasive procedures in the facial areas than all of these physicians and personnel combined.

and has uses in orthodontic cases where retraining of the facial muscles is necessary. No other health-care provider has the capability to help patients in so many areas as do dentists.

I completely understand that the thought of Botox and dermal fillers is foreign to our dental mindset simply because we have never been involved in these areas before. You might also remember a time when implants were foreign to dentistry, when many dentists said we should not get involved because that would change our mindset of trying to save teeth.When teeth whitening was first introduced into the dental market, many dentists called it malpractice. It is time to really start learning about how Botox and dermal fillers can help us in dentistry.

Fig 2: Patient very satisfied with aesthetic result and also reports relief of migraines and TMJ pain.

THE BOTOX PRIMER Botox is a trade name for botulinum toxin, which comes in the form of a purified protein. The mechanism of action for Botox is really quite simple. Botox is injected into the facial muscles but really doesn’t affect the muscle at all. Botulinum toxin affects and blocks the transmitters between the motor nerves that innervate the muscle. There is no loss of sensory feeling in the muscles. Once the motor nerve endings are interrupted, the muscle cannot contract. When that muscle does not contract, the dynamic motion that causes wrinkles in the skin will stop. The skin then starts to smooth out, and in approximately three to 10 days after treatment, the skin above those muscles becomes nice and smooth. The effects of Botox last for approximately three to four months, at which time the patient needs retreatment. The areas Botox is commonly used are the forehead, between the eyes (glabellar region), and around the corners of the eyes (crow’s feet) (Figures 1 and 2) and around the lips. Botox has important clinical uses as an adjunct in TMJ and bruxism cases, and for patients with chronic TMJ and facial pain. Botox is also used to complement aesthetic dentistry cases, as a minimally invasive alternative to surgically treating high lip line cases, for denture patients who have trouble adjusting to new dentures, in lip augmentation,

Fig 1: Patient seeks smoothing of facial wrinkles in her forehead, between the eyes, and crow’s feet around eyes.

THE DERMAL FILLER PRIMER Dermal fillers will volumize creases and folds in the face in areas that have lost fat and collagen as we age. After age 30, we all lose approximately one percent of hyaluronic acid from our bodies. Hyaluronic acid is the natural filler substance in your body. The face starts to lack volume and appears aged with deeper nasolabial folds, unaesthetic marionette lines, a deeper mentalis fold, the lips start to thin, and turning down the corners of the lips (Figure 3). Hyaluronic acid fillers such as Restylane and Juvederm are then injected extraorally right underneath these folds to replace the volume lost which creates a younger look in the face (Figure 4). Dermal fillers can be used for high lip line cases, asymmetrical lips around the mouth, lip augmentation, and completing cosmetic dentistry cases by creating a beautiful, young-looking frame around the teeth. The effect of dermal fillers typically last anywhere from six to 12 months at which point the procedure needs to be repeated. Both Botox and dermal fillers are procedures that take anywhere from five to 15 minutes. There is one huge advantage dentists have in delivering dermal fillers over any other health-care professional. Most physicians and nurses use topical anesthetics and ice on the skin to numb the patient. Some actually learn how to give dental anesthesia but very few are proficient at it. As you might imagine, this will be a painful procedure when

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ESTHETIC DENTISTRY done this way. Indeed, this is the reason that many patients prefer dentists to deliver dermal fillers. The interesting thing here is that most dentists inject in the same areas where Botox and dermal fillers are injected for cosmetic results. The only difference is that you inject intraorally into these facial structures while Botox and dermal fillers injections are extraoral injections. Another reason that dentists are the best professionals to deliver these applications is also because we are the best injectors around. We inject anesthetic for a living and we know how to make these injections comfortable, quick, and relatively painless for our patients. The dentists I have trained for Botox and dermal fillers all report that their patients compare us to the other health-care professionals they previously visited for these procedures. They say the dentists’ injections are quicker and much more comfortable. Fig 3: 43-year-old female with moderate nasolabial folds and uneven lips.

Fig 4: Aesthetic result achieved with younger look and fuller and symmetrical lips.

WHAT ABOUT ADVERSE REACTIONS? People always ask me about adverse reactions to Botox and dermal fillers. The long-termed safety of Botox has become very well established clinically, with millions of injections delivered every single year. Botox treatments are the most commonly performed cosmetic procedures in the United States and would not be so if there were common adverse reactions. The most common dermal fillers used are made of hyaluronic acid which, as we mentioned, are naturally occurring substances in the body.When the effects of Botox and dermal fillers are gone, they are gone completely with no residue or after effects present. I always tell dentists who are worried about adverse reactions to pick up the pharmacology sheet that comes with your local anesthetic. You will find far more adverse reactions that can occur with the use of common local anesthetics – having significant effects on the cardiovascular system, nervous system and muscular system. That sheet describes far worse reactions than with Botox and dermal fillers,

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Oct-Dec 2014

yet we are comfortable using these every single day. The reason is because we are knowledgeable about the use of local anesthetic, we have studied what it can and cannot do, and we have been trained in how to deal with any complications. The same will be true once you are properly trained with Botox and dermal fillers.

YOU CAN TEACH AN OLD DOG NEW TRICKS Every dentist who has been trained in Botox and dermal fillers completely understands why we as dentists should be performing these procedures. I’ve heard estimates that about 10 percent of practicing dentists have been trained in these procedures. Training is absolutely essential, just as it is with anything that is new to you. I have personally trained hundreds of dentists in Botox and dermal filler therapy and it is quite amazing to see dentists go through a wonderful transformation through the course. You see, you already know the facial anatomy – it’s somewhere in your brain from dental school and we just have to bring it back to the surface. You already know how to give an injection and this is just a different kind of injection to learn. You already understand the physiology, skeletal structures, the musculature vascular and nervous system of the face, and overall facial aesthetics. Do you think for a moment that other health-care professionals know or are concerned about the proper ratios of lips to teeth, the smile considerations when the patients go into a partial or a full smile, proper phonetics, and how the teeth relate to the soft tissue surrounding the mouth? I have found just a few plastic surgeons and dermatologists who have a very cursory understanding of this, but don’t really give it much thought at all. There are general medical education companies that will teach courses on Botox and dermal fillers. Generally, some of this course is wasted on dentists as there is a definite lack of dental knowledge as to how these procedures can be used in conjunction with other dental procedures. There are other procedures that are done with Botox and dermal fillers that are not used around the face and would be completely outside of the dentist’s realm. Training for the dentist is significantly different than training for other health-care professionals as our procedures are limited to the face and the training must include how to best use these materials for the clinical dental uses mentioned above in addition to smoothing of facial wrinkles and volumizing facial folds.

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WILL MY MALPRACTICE INSURANCE COVER THESE PROCEDURES? Malpractice issues are rare for Botox and dermal filler cases. That being stated, I have always been a strong advocate that professionals should have malpractice insurance that covers all the procedures they perform.Most dental liability insurance companies are not currently set up to cover dentists for Botox and dermal filler procedures. Thismeans that your malpractice insurance carrier will not cover you for these procedures. Many dentists have contacted me to tell me that their malpractice insurance agent informed them that dentists are prevented from doing botox and dermal fillers in their state. This is simply untrue. While most insurance agents are well intentioned, they are afraid of losing your business. I have proven many insurance agent wrong on this issue. What is relevant is what your state board tells you â&#x20AC;&#x201C; not your insurance agent. Here is the great news for you and your insurance agent â&#x20AC;&#x201C; there are third party add-on malpractice liability insurance carriers that will cover dentists who have been properly trained for these procedures. These policies will be in addition to the malpractice insurance you already have.

STATE DENTAL BOARDS Most dentists are surprised to learn that there are many states where general dentists are allowed to perform both Botox and dermal fillers in the oral and maxillofacial areas from chin to top of the forehead. There are some states that might allow one but not the other. There are states where dentists are not allowed to perform these therapies at all. There is no question that the tide is certainly turning for this to be accepted nationwide. More state dental boards are allowing these procedures and it is happening rapidly. Certainly, it is appropriate for dentists to use Botox and dermal fillers for dental uses within the scope of dentistry as defined by your state practice act. It is high time that our state dental associations (which represent dentists) begin advocating to the state dental boards (who work for the public) and to their state legislatures for dentists to begin doing these procedures in those states that arenâ&#x20AC;&#x2122;t yet on board. I have consulted with many state dental boards about these issues. The more state dental board members become educated about what

ESTHETIC DENTISTRY these procedures are and how dentists are the best healthcare professionals to provide these services, the faster the shift will be to allow dentists to do these procedures in those states.

POST-OP INSTRUCTIONS Instead of the naysayers in dentistry who always doubt our abilities as healthcare professionals, it is time to stand up and realize how well trained, clinically proficient and knowledgeable we truly are in all of the oral and maxillofacial areas.We need to realize that we have valuable contributions to make in facial aesthetics and it is time to get on board.

Dr. Louis Malcmacher Dr. Louis Malcmacher is a general and cosmetic dentist located in Bay Village, OH. He is president of the American Academy of Facial Esthetics www. FacialEsthetics.org and is a consultant to the dental industry. Dr. Malcmacher is a well-known lecturer and author, known for his comprehensive and entertaining style. He speaks to thousands of dental professionals every single year and trains dentists hands-on on Botox and dermal filler procedures and all aspects of general dentistry. His lecture schedule can be seen on his website at www.CommonSenseDentistry.com . Dr. Malcmacher also intensively trains sales teams and does marketing consulting with dental companies. Dr. Malcmacher can be reached at 440-892-1810 or email drlouis@FacialEsthetics.org .

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Oct-Dec 2014

BOTULINUM TOXIN: A NEW AVENUE IN DENTISTRY Dr. Ambika Chawla, Dr. Shourya Sharma

ABSTRACT Botulinum toxin is a neurotoxin, best known for its beneficial role in facial aesthetics but recent literature has highlighted its usage in multiple non-cosmetic medical and surgical conditions. This article reviews the current evidence pertaining to Botox use in the dental conditions. Most of the dental conditions can be treated by targeting masseter and temporalis muscle. US Food and Drug Administration have recently approved the use of Botox in chronic migraine, thereby acknowledging it as a safe treatment to manage such conditions.

types A, B, E, and (rarely) F. Types C and D cause toxicity only in animals. However, the toxin can be used in a controlled manner to treat various neuro muscular disorders. The various botulinum toxins possess individual potencies, and care is required to assure proper use and avoid medication errors. Recent changes to the established drug names by the FDA were intended to reinforce these differences and prevent medication errors.

MECHANISM OF ACTION INTROD UCTION Onabotulinumtoxin A, commercially known as Botox is a neurotoxin produced by Clostridium botulinum, a grampositive anaerobic bacterium. The bacteria produces Botulinum toxin (abbreviated either as BTX or BoNT) which is broken in to seven types of neurotoxin (labeled as types A, B, C, D, E, F, and G], which are antigenically and serologically distinct but structurally similar.1 Botox is commonly associated with botulism which can occur following ingestion of contaminated food or from a wound infection. Human botulism is caused mainly by

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The BTX molecule is synthesized as a single chain and then cleaved to form the dichain molecule with a disulfide bridge The light chain acts as a zinc endopeptidase similar to tetanus toxin with proteolytic activity located at the N-terminal end. The heavy chain provides cholinergic specificity and is responsible for binding the toxin to presynaptic receptors; it also promotes light-chain translocation across the endosomal membrane.

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Time line December 1989

Decemebr 2000

April 2002

Figure 1

Botulinum toxin acts by binding presynaptically to high-affinity recognition sites on the cholinergic nerve terminals and decreasing the release of acetylcholine, causing a neuromuscular blocking effect. This mechanism laid the foundation for the development of the toxin as a therapeutic tool. Recovery occurs through proximal axonal sprouting and muscle re-innervation by formation of a new neuromuscular junction. De Paiva and colleagues suggest that eventually the original neuromuscular junction regenerates.2 The first accurate and complete description of the clinical symptoms of food-borne botulism was published between 1817 and 1822 by the German physician Justinus Kerner, who also developed the idea of a possible therapeutic use of botulinum toxin, which he called “sausage poison.” Kerner started animal experiments and clinical experiments on himself and developed hypotheses on the pathophysiology of the toxin, suggested measures for prevention and treatment of botulism, and, finally, developed visions and ideas about future perspectives regarding the toxin, including the idea of its therapeutic use.3 In the 1950s, Dr. Vernon Brooks discovered that when onabotulinum toxin A is injected into a hyperactive muscle, it blocks the release of acetylcholine from motor nerve endings. In 1980, Dr. Alan B. Scott, of Smith-Kettlewell Eye Research Institute, used onabotulinum toxin A for the first time in humans to treat strabismus. Since then the toxin has been used to treat various neuromuscular conditions, it has been approved by FDA for the conditions mentioned in Table 1.

July 2004

October 2010

September 2013

Indications approved BOTOX® was approved by the US Food and Drug Administration (FDA) for the treatment of strabismus, blepharospasm, and hemifacial spasm in patients aged younger than 12 years Onabotulinum toxin type A received FDA approval for treatment of cervical dystonia FDA announced the approval of BOTOX® Cosmetic to temporarily improve the appearance of moderateto-severe frown lines between the eyebrows (glabellar lines). FDA approved BOTOX® to treat severe underarm sweating, known as primary axillary hyperhidrosis that cannot be managed by topical agents, such as prescription antiperspirants. FDA approved BOTOX® injection to prevent headaches in adult patients with chronic migraine. Chronic migraine is defined as having a history of migraine and experiencing a headache on most days of the month FDA approved onabotulinumtoxin A (BOTOX®) for the temporary improvement in the appearance of moderate to severe lateral canthal lines, known as crow’s feet. This is the only FDA-approved drug treatment option for lateral canthal lines Table 1

BOTOX AND DENTISTRY More recently, botulinum toxin has been suggested as part of the armamentarium for the management/treatment of various orofacial conditions and a considerable body of literature has been developed describing or investigating its efficacy and safety. To date, most of the reports relate to botulinum toxin A and there are few well controlled double blind studies. As mentioned before, the toxin targets neuromuscular junction, hence this property can be used to treat conditions where over-activity of the muscles prevails.

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ESTHETIC DENTISTRY The management of temporomandibular disorders, which involve the masseter and temporalis muscle, is usually done with physiotherapy, exercises, behavioural type therapy, oral appliances (most often stabilizing type), anti-inflammatory medications, muscle relaxants, analgesics or some combination of these. Rarely surgical intervention is indicated. Botulinum toxin can be a useful adjunct, particularly when these have failed to provide adequate relief, particularly in cases involving muscular hyperactivity. There is evidence that it has a place in the treatment of dystonia, masticatory muscle hyperfunction, myofascial pain and, to some extent, bruxism.4 Lee et al in 2010 in a double blind, randomized controlled study reported use of botulinum toxin injection as an effective treatment for nocturnal bruxism, where the toxin was delivered in the masseter muscle.5 Botox injection in the Lateral pterygoid muscle leads to the disappearance of joint clicking clinically and a significant improvement in disc position as shown on MRI.6 Botox was found to be a safe and effective therapy for both acute and prophylactic treatment of migraine headaches.7 Numerous multicentre double-blind placebo controlled trials support the use of Botox as a prophylactic therapy for migraine. The technique involves injections into muscles innervated by the facial or trigeminal nerves (e.g. procerus, corrugator, frontalis, temporalis and suboccipital), specific sites of pain distribution or a combination of both. 8 The role of Botox in the treatment of drug-refractory trigeminal neuralgia has been evaluated in three studies. All three studies found Botox to be an effective treatment with the majority of the patients reporting a reduction or even disappearance of the pain. Botox was found to be effective in combination with pharmacotherapy, prior to considering more invasive therapies such as surgery or gamma knife radiosurgery. As such, Botox is a particularly valuable treatment for elderly patients and those with adverse anaesthetic comorbidities.9 Other than therapeutic uses in orofacial region, botox has been widely used in cosmetic applications. These applications can be combined with dental treatment to give patients better results. Mario Polo reported BTX-A injections for the neuromuscular correction of gummy smiles caused by hyperfunctional upper lip elevator muscles was effective and statistically superior to baseline smiles, although the effect is transitory.10 The gummy smile correction has also been suggested to be used in

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conjunction with orthodontic treatment to enhance its results.11 Patients who are chronic jaw clenchers frequently present with masseteric hypertrophy. The increased size of these muscles is evident in the patient’s facial appearance, which is often altered, e.g., the jaw can appear swollen and misshapen. To treat this, surgical resection was commonly resorted to which often resulted in substantial contracture. A pilot study revealed that Botox injection in patients with masseter hypertrophy offers a safe and effective medical alternative for masseter reduction surgery. The satisfaction rate with aesthetic results was very high, most patients saw maximum results at 1 to 2 months, and most patients returned at 6 to 8 months for reinjection. The ideal candidate has soft tissue fullness, and men and women of diverse ages can be treated successfully.14 Treatment modalities such as implants which are contraindicated in cases of excessive parafunctional activity, can be given with help of botox therapy. After multiple implants or when immediate loaded implants are placed, osseo-integration can be impeded by excessive functional forces in patients with bruxism or clenching. Over loading of the implants results in implant failure by loosening of the implant components or prevention of osseo-integration. The muscular relaxation achieved with prophylactic use of Botox injections to the masticatory muscles can be beneficial by allowing implant structures better osseo-integrated.12 Botox has been successfully reported to be used for the treatment of mandibular dysfunction characterised by an intense muscular tension with limited mouth opening following prosthetic rehabilitation.13 However, limited research has been done where botox has been combined with treatment modalities like full mouth rehabilitation, hence caution should be exercised while prescribing such treatment on patient’s overall health and psychology. The effect of the botox on the muscles is temporary, as much as 3 to 6 months and the muscle activity returns to base levels once the effect subsides. It has been noted that multiple applications in a patient prolongs the duration of action of the drug.1 A proper case evaluation and medical history should be taken before case selection. Botox is relatively contraindicated in neuromuscular diseases such as myasthenia gravis, Eton-Lambert syndrome, in sensitivity to toxin, pregnancy, Medications and supplements such as Aspirin, vitamin E, Ginkgo, St, John’s Wort, Ibuprofen, Motrin, are all blood thinning and can increase the risk

ESTHETIC DENTISTRY

Oct-Dec 2014 of bruising/swelling after injections. A few side effects observed are ecchymosis, redness, swelling, transient flu like symptoms, peaking of eyebrows. However these are temporary side effects but they can be avoided by identifying the anatomical landmarks and administering correct dosage. Although the drug is considered generally safe, reactions but more recently, some severe, potentially life threatening side effects, distant from the site of injection have been described.

An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. Persaud et al. J R Soc Med Sh Rep 2013;4:10.

Use of botulinum toxin a for drug-refractory trigeminal neuralgia: preliminary report. Bohluli et al. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111:47–50

In conclusion, Botox may be combined as adjunct to therapeutic as well as cosmetic dental procedures.

11. Adjunctive Treatment of Gummy Smile Using Botulinum Toxin Type-A (Case Report). Dolly P. Patel, Sandip A.Thakkar, Jaymin R.Suthar. IOSR Journal of Dental and Medical Sciences (JDMS). Volume 3, Issue 1(Nov.- Dec. 2012), PP 22-29.

The concept of dentists using botox as a treatment modality is relatively new, however with proper training there is an increasing trend all over the world with dentists administering botox to their patients in head and neck region. In spite of this debate that whether dental professionals should administer botox or refer patients to their medical counterparts, research shows that addition of botox to certain dental treatments as mentioned above can be beneficial to the patients.

10. Botulinum toxin type A (Botox) for the neuromuscular correction of excessive gingival display on smiling (gummy smile) Mario Polo. Am J Orthod Dentofacial Orthop 2008;133:195-203)

12. Prophylactic use of botulinum toxin in dental implantlogy. Ihde S. Cranio-maxillofacial Implant Dir 2007;2:3-8. 13. Botulinum Toxin Type-A Treatment for Severe Trismus of Occlusal Origin. Batifol and Harding-Kaba, Anaplastology 2014, 3:1. 14. Botulinum Toxin for Masseter Reduction in Asian Patients. Jeffrey Ahn, Corinne Horn, Andrew Blitzer. Arch Facial Plast

REFERENCES 1.

The origin, structure, and pharmacological activity of botulinum toxin. Simpson LL. Pharmacol Rev. Sep 1981;33(3):155-88.

Functional repair of motor endplates after botulinum neurotoxin type A poisoning: biphasic switch of synaptic activity between nerve sprouts and their parent terminals. Paiva et al. Natl Acad Sci U S A. 1999 Mar 16; 96(6):3200-5

Historical aspects of botulinum toxin: Justinus Kerner (17861862) and the “sausage poison”. Erbguth FJ, Naumann M. Neurology. Nov 10 1999;53(8):1850-3

Dr. Ambika Chawla MDS

Peridontology & Implantology American Academy of Implant Dentistry

The therapeutic use of botulinum toxin in cervical and maxillofacial conditions: an evidence-based review. Ihde SKA, Konstantinovic VS. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e1-e11

AAFE Certified for Botox & Dermal Fillers

Effect of botulinum toxin injection on nocturnal bruxism: A randomized controlled trial. Lee et al. Am J Phys Med Rehabil 2010;89:16–23.

Dr. Shourya Sharma

Botulinum toxin injection for management of temporomandibular joint . Emara et al. International Journal of Oral & Maxillofacial Surgery, 2013-06-01, Volume 42, Issue 6, Pages 759-764.

Botulinum toxin type A (BOTOX) for treatment of migraine headaches: An open-label study. Binder et al. Otolaryngol Head Neck Surg December 2000 vol. 123 no. 6 669-676

BDS, MDS, Certified Botox Surgeon by American Academy of Facial Aesthetics, USA Private Practitioner CEO IAOFE

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Oct-Dec 2014 ESTHETIC DENTISTRY ZOOM- IN’TO A FOCUSED ‘MYTHS VS TRUTHS’ SERIES THAT HELPS US UNDERSTAND AND RELATE TO FACTS WITH ‘READY TO PRACTICE’ TIPS ON TOOTH WHITENING Effective sensitivity management– REDEFINED (beyond ﬂuoride Rx to include ACP) to improve the success of tooth whitening and greatly improve patient compliance. This is an Initiative by M&M Dental Associates and Philips ZOOM in an effort to build conﬁdence in Tooth Whitening so more patients can easily avail of successful treatments which are non –invasive , actually enjoyable and much desired. The vision is to use whitening as a means to focus on better oral wellbeing and care.

Dr. Rumpa Wig

INTRODUCTION As the patients seek the expertise of aesthetic dental practitioners to whiten their smiles, their expectation as regards a dramatic shade change are on the higher side. Teeth Whitening today has a considerable volume in our routine clinical practice.My endeavor, through this series of articles on this topic , will be to present a systematic analysis of myths and doubts, commonly pertaining to Teeth Whitening, and methods to overcome the challenges of even most difficult whitening cases, with greater predictability than previously possible.

MYTHS VS TRUTHS IN TOOTH WHITENING MYTH NO 4 :Fluoride – The final authority in the management of sensitivity associated with whitening. Your patients want whiter, more youthful smiles and they want them now. There are more in-office whitening options available today than ever before. Along with these come questions about managing sensitivity, which impedes most treatments. Let’s understand sensitivity and new advances that have furthered the state of the art in sensitivity management beyond fluoride.

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SENSITIVITY MANAGEMENT MADE EASY AND ACHIEVABLE All forms of vital tooth whitening 1.

Are associated with some level of sensitivity

And it is greater with higher concentrations of peroxide.

The first and most effective method of sensitivity management is to choose gels with lower concentration of Peroxide. Use of curing lights and lasers with high concentration gels causes increase in heat and increased dentinal tubular activity leading to unbearable sensitivity. Inform the patient that sensitivity comes from the pulpal nerve being stimulated by the hydrogen peroxide.This can range from a dull “all over” ache to a localized “shooting” pain referred to as a “zinger” to one or two teeth. The etiology of this sensitivity results from the easy passage of the peroxide through the enamel and the dentin to the pulp, which takes 5 to 15 minutes. Most sensitivity experienced will cease within 24 to 48 hrs. The hydrodynamic theory is widely accepted as the mechanism of action of dentin hypersensitivity. (Figure2).

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Oct-Dec 2014

: Its exactly what the name suggests !

The Science Behind ACP Technology Products containing ingredients that form Amorphous Calcium Phosphate (ACP) readily precipitate ACP on and into tooth-surface defects.

Tooth enamel is composed almost entirely (97% by weight) of a calcium phosphate mineral in the form of carbonated hydroxyapatite

The ACP rapidly hydrolyzes to form hydroxyapatite. In the presence of Fluoride, fluorapatite is formed

ACP precipitates on the surface and within the lumens of open dentinal tubules to occlude – result – reduced sensitivity

Figure 2 : Hydrodynamic theory

Pain is caused by fluid movement within the dentinal tubules caused by the influx of H2O2.

The odontoblasts near the pulp and the “A” Delta nerve fibers are stimulated resulting in pain.

REBUILDING SCIENCE

The mechanism of action for most desensitizing agents is either to desensitize the pulpal nerve so that the fluid flow and resulting changes in pressure do not cause the mechanoreceptor to fire; or to occlude exposed tubules so there can be no fluid movement. 5% Potassium Nitrate (KNO3) is the best chemical to reduce this pain. It prevents re-polarization of the nerve fiber so the excitability of the nerve is reduced. Most whitening gels have fluoride thatreduce tubular movement and KNO3 that desensitizes the nerve. Fluoride actually needs to be present in more than 2000ppm to be effective for sensitivity management. They take a while to be absorbed and act gradually on the enamel and in the tubules. Most whitening gels have less than the required concentration of fluoride and may not be as effective in sensitivity management. Now,Products with Amorphous Calcium Phosphate (ACP) along with Fluoride and Potassium nitrate,synergistically help to reduce sensitivity caused by tooth whitening. The best developed product is Relief - By Discus Dental , now a part of Philips Oral Healthcare and available in all Zoom Whitening kits.

ACP & Relief Dramatically Reduces Sensitivity – By blocking Dentinal Tubules Rebuilds Enamel- By creating a new coat of hydroxyapitite over enamel Helps Reduce Caries - Fluoride Improves Luster- Fills surface defects Reduces Fadeback when whitening

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ESTHETIC DENTISTRY (Microscopic evidence of Use of ACP–Reliefto occlude tubules and manage sensitivity)

Oct-Dec 2014

Patient selection is a very important part of managing sensitivity. Set realistic expectations about poten¬tial results based on a complete oral exam. X Start

with a “before” photo with the VITA shade tab in place. And end with the same “after “treat¬ment photo. (Figures 3 and 4 ) You may want to treat existing issues before recommending whitening treatment and disqualify any patient that who is perio-involved, exhibits failing restorations or is otherwise in an unhealthy oral state.

Figure – 3

Figure - 4

X Identify

and chart any areas of translucent or hypo-calcified enamel. Patients with A 3 or darker, gray shades VITA C and D, tetracycline or fluorosis staining should use chair¬side whitening in conjunction with take- home custom tray whitening products to achieve the greatest results.

This practice should be used with all patients who undergo Chairside-Whitening to either enhance or stabilize their results.

Protocols for better management of Chairside Whitening Sensitivity

In addition, custom trays can be used to deliver the Relief ACP gel. It contains 0.75% amorphous calcium phosphate, 0.22%NSF and 5% KNO3. A published study demonstrated that applying potassium nitrate for 10 to 30 minutes in a whitening tray can be successful in reducing sensitivity in over 90% of patients. Pre-Procedure

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If the patient is concerned about sensitivity before the procedure, deliver Neutral Sodium Fluoride toothpaste with 5% KNO3 ,after the pre-screening appointment.

Instruct use of the product 2x/day, minimum one week prior to the chair-side treatment. This is a good time to take impressions for the take-home trays. A patient , who has been given a product and has impressions taken ,will feel that the “treatment” has begun, and is much less likely to change their mind or cancel their chair-side appointment!

When take-home trays are ready or foam tray available, the patient can wear a Relief ACP gel in the trays 10 -30 minutes before the procedure.

On the day of the chair-side whitening procedure, give the patient 400-600 mg of Ibuprofen or other antiinflammatory drug before the procedure begins. This helps tissue management and inflammation and also helps managing pain and anxiety.

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Oct-Dec 2014

DURING THE PROCEDURE a.

Protect worn incisal edges of any teeth with a bonding agent only (no etch) and cure. Relief ACP can also be applied to these worn edges.

Patients with recession are good chair-side whitening candidates, provided the exposed dentin is covered with dam material.

A desensitizing gel like Relief ACP can be applied to the lingual surface of the teeth during the chair-side pro¬cedure. This way the 0.5% KNO3 can begin working to “numb” the nerve. c.

Check the patient for any tissue blanching or irritations after the dam is removed. Apply Vitamin E oil to the patient’s lips to promote re-hydration. Aloe Vera gel or “Orabase” with benzocaine is good to apply to any tissue burns if they occur. Avoid placing KNO3 products on of this tissue due to a stinging effect from this salt.

POST-PROCEDURE Place the Relief ACP desensitizing gel in the trays for the patient to wear home. They should keep the tray in for at least 30 minutes and repeat as often as needed. Send the patient home with a syringe of this gel. This is the BEST method to reduced post-op pain. The KNO3 will prevent re-polarization of the nerves and products with ACP & fluoride will occlude any open dentinal tubules.

CONCLUSION Sensitivity management has moved beyond fluoride. ACP (Amorphous Calcium Phosphate ) is quickly absorbed into the enamel and ensures a more holistic management of sensitivity and improves whitening effect. ACP repairs erosion of enamel and occludes tubules to provide healing and health to enamel while effectively inhibiting and substantially reducing sensitivity. This provides : -

Lustre with whitening

Reduces fadeback

And provides anti-caries protection to teeth.

ACP whitening is ADA approved and proven scientifically and practically, to deliver as it claims. Incase you need to ask any further questions please feel free to email me atrumpa4u@gmail.com . You can follow me on FB too. I sincerely look forward to your valuable feedback and invite you to review future series where we would debate, better understand and deflate many of the prominent myths associated with tooth whitening. ‘Zoom in !’to an exciting exclusive section on Tooth Whitening – the first in the Dental Media in India.

Additional ibuprofen can be taken but do not exceed 1200mg within 24 hours period. Stronger pain medicine could be prescribed if needed. There are many options to help prevent tooth whitening sensitivity. Even with all of the options covered, 100% of your patient will not be completely pain free during whitening process. But, by following the detailed stepby step procedures covered in the article you can help a majority of them achieve great success in their whitening treatment.

Dr. Rumpa Wig Dr. Rumpa Wig has graduated from College of Dentistry, Indore, and then completed PG (Certification) in Aesthetic Dentistry from New York University, USA. She is a Key Opinion Leader for the Philips range of Whitening Products . She is a national and International Speaker on Aesthetic Dentistry , an Accredited Member & currently a Director on the Board of the IAACD ( Indian Academy of Aesthetic and Cosmetic Dentistry ) and also a member of European Society of Cosmetic Dentistry. She has a Premier Dental practice in Bhopal with specialization in Aesthetic Dentistry for over 2 decades .

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Oct-Dec 2014

DIRECT LAMINATE VENEERS – PART III Dr. Geoffrey M Knight

PARAMETERS OF A SMILE Much about the way we wish to present ourselves to the world is based upon current concepts of fashion and beauty, the criteria of which are constantly changing. The smile is much the same, during the ‘30’s an attractive smile was the “cupid doll” look, small mouth with slightly pouted lips. Extraction orthodontics worked well in this era but not today when an attractive smile just fits in between the ears.

For the majority of people an aesthetic smile is based upon symmetry, parallelism and mirror imaging. Figure 1. Further to this there are a number of basic landmarks that require attention if an aesthetic smile is to be achieved. Nothing is ever set in concrete and compromises are usually part of the outcome, however getting the best achievable result is getting as many landmarks incorporated into a smile as practicable.

We recognize people by their eyes and once we have established who we are talking to the mouth plays an important role in flagging the emotional aspects of conversation. Even if we are not consciously aware of it our mouths are continuously being scrutinized at a subliminal level during conversation. When planning a smile, incorporating contemporary concepts of aesthetics play an essential part of having a happy patient at the procedure’s completion. A wider smile and a brighter smile are starting points for achieving a successful outcome when placing laminate veneers. This means that laminates usually need to be placed from the first bicuspid to first bicuspid on the opposite arch and the value of the teeth increased and often the hues lightened. A word of caution here: super white can be okay on a female, because she can enhance their face with make up, whereas often an older male looks unusual with an “Arlington Smile”.

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Figure 1. A well balances attractive smile

Nov-Dec 2014

ESTHETIC DENTISTRY

MID LINE

GINGIVAL LINE

The mid line is best positioned in the middle of the smile and should be in the patientâ&#x20AC;&#x2122;s vertical axis. Shifts in the position of the mid line are difficult to compensate, however small adjustments to the mesial aspects of the central incisors prior to placing laminates may assist in creating a vertical line Figure 2.

The gingival line is described as a curved line parallel with the smile line but with slightly less curvature. The line contacts the zeniths of the central incisors and canines and should pass slightly above the lateral incisors. Figure 3.

ANTERIOR EMERGENCE PROFILE The anterior emergence profile is the profile of the central incisors parallel to the lateral facial profile of the patient whilst smiling. Figure 4.

Figure 2. Mid line should be in the central position of the smile and vertical.

SMILE LINE The smile line is achieved by asking a patient to smile and contouring the incisal margins of the upper laminates parallel to the lower lip. If a patient has an asymmetrical lip line use the plane between the eyes as a reference point. Figure 3.

Figure 4. Anterior emergence profile is parallel to the lateral profile of the patients whilst smiling.

LATERAL EMERGENCE PROFILE The lateral emergence profile consists of the profiles of the distal margins of the teeth. They should be parallel and mirror images with a slight mesial incline. The emergence profile of the outer laminate should be parallel with the facial aspect of the first visible natural tooth. Figure 5.

TEETH LENGTH WIDTH PROPORTIONS As a rule of thumb the ratio between the width of a tooth and the height should fall within the range of the Golden Proportion (ratio 0.618). Furthermore the width of the facial aspect of the lateral incisor should be about .6 the width of the central incisor and the facial aspect of the canine about .6 the width of the lateral. Figure 5.

Figure 3.Smile line runs parallel with the lower lip whilst smiling and the gingival line has a slightly less curvature.

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Oct-Dec 2014

0.6

Figure 5. Lateral emergence profiles should be parallel and mirror images of each other with a slight mesial inclination. Length, width and facial aspects of teeth should reflect the Golden Proportion ratio.

0.6

Figure 7. Parameters of a smile.

The next paper in this series will demonstrate a sequence for placing, contouring and polishing direct laminate veneers.

GINGIVAL AND INCISOR EMBRASURES With aging, gingival embrasures open and incisal embrasures close. The reversal of this phenomenon has the effect of rejuvenating a smile. Incisal emergence profiles should be parallel and mirror images and the lengths of the contact areas should shorten slightly towards the lateral. The depth of the incisal embrasures increase slightly moving laterally from the central incisors. Figure 6.

Dr. Geoff Knight Is a general dentist and internationally noted dental speaker with special interests in Minimal Intervention Aesthetic Dentistry. He has pioneered a number of innovative clinical procedures in aesthetic dentistry and the pharmacological Figure 6. Gingival embrasures need to be minimal and incisal embrasures slightly increased to create a youthful appearance. Emergence angles of incisal embrasures should be parallel and mirror images of each other.

THE TOTAL PACKAGE The culmination of these parameters forms the basic landmarks of an aesthetic smile. Figure 7.

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management of caries. He has consulted widely across the dental industry and is named on several patents. He has been published in Quintessence International, Australian Dental Journal and Journal of Periodontal Research. He has produced a series of clinical videos and written numerous articles on aesthetic and adhesive dentistry that have been translated and published internationally in a number of languages, he have been writing articles for the Australian Dental Association News Bulletin for about 20 years and there are over 100 articles, available on website www.dentalk.com.au.

ANTIAGING

Oct-Dec 2014

DERMAL AGEING PATHOMECHANISM PART I Dr. Rabiya A Hameed

ABSTRACT

SKIN ANATOMY AND PHYSIOLOGY

Skin is the largest organ of the body and serves as a barrier against foreign particle and also protects the internal organs.

INTRODUCTION Ageing is a complex process resulting in reduction in the bodyâ&#x20AC;&#x2122;s biological function, leading to inefficient in the way of coping with the metabolic stress. The mechanism of cutaneous or dermal ageing is divided into intrinsic (chronologic) and extrinsic ageing, which is influenced by environmental factors. Both intrinsic and extrinsic mechanism share molecular pathway. In this article we will review several aspects of dermal ageing. There are multiple theories on the mechanisms of dermal ageing that includes oxidative stress, loss of telomeres, mtDNA mutation and hormonal changes.

Other functions X Protect

against radiation

X Thermal

regulation.

X Sensory

organ.

X Biochemical X Regulation

synthesis.

of water and electrolytes.

It is complex organ divided into epidermis, dermis and hypodermis. X Thin

epidermis is made up of keratinocytes, melanocytes and antigen presenting Langerhans cells.

X Dermis

forms the main bulk of the skin, with vascular and nerve supply of the skin resides here.

X The dermal connective tissue is made of collagen and elastin.

Type I collagen is the most abundant, whereas Type III, V, VII in lesser amount. X Other

than collagen and elastin extra cellular proteins includes proteoglycans and fibronectin.

X The third layer is subcutaneous tissue, which comprises of fat

cell. X Apart

from this hair follicle, sebaceous gland and sweat glands are also present in skin.

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ANTIAGING PATHOMECHANISM OF DERMAL AGEING Intrinsic Mechanism It is a natural consequence of ageing which is genetically predetermined. With time passage skin becomes thinner, atrophic, wrinkled and dry. This is because of reduction in fibroblast, hydroxyproline, and glycosylated hydroxyline enzyme responsible for post-translational processing of collagen. Oxidative stress During intrinsic ageing the Reactive oxygen species level rises, whereas antioxidant activity declines. Because of increase in ROS activity a number of phosphorylase mediated kinases get activated such as MMP (matrix metalloproteinase) leading to collagen degradation. Mutation in DNA and telemorase Extrinsic factor (UV radiation) causes direct or indirect dimeneralization of contiguous pyrimidines on the DNA, resulting in the formation of cyclobutane pyrimidine dimers leading to the mutation. This is responsible for most of the functional changes seen in the dermal ageing. Likewise UVR also damages telomerase as it targets the dithymidine residues and G bases on chromosomes. It does not allow any gene encode and forms 3dimensional structure called T loop. UVR destabilizes the T loop configuration leading to DNA damage which causes apoptosis. Ageing and Sex steroid The sex steroid play important role in supporting skin structure and function. With age dehydroepiandrosterone and its sulphate analogue decrease both in females and males. In male population reduction with decrease in steroid harmones compromises wound healing. Following the menopause, concentration of estradiol drops considerably, resulting in thinner, drier skin with reduced elasticity.

Oct-Dec 2014

COMMENT Ageing is integrated process, and the change that occurs in the various tissues such as skin, muscle, fat and bone are interrelated. Change in one of these tissue results in overall alteration in the appearance. Each of the changes in the tissues can be treated in an aesthetic practice in different ways.

Dr. Rabiya A Hameed

Dr. Rabiya A. Hameed is a Consultant Cosmetic Dentist in Umrao Hospitals Mira Road, Mumbai, India.

AUTHOR GUIDELINES The following instructions have been included under this section. The sole aim of this publication is to produce a journal that will provide most upto date information on topics related to general/specialized Facial Esthetics. The journal publishes papers on all aspects on Facial Plastic Surgery, Dermatology, Antiaging, Tricology, Skin Care & Aesthetic Dentistry. Manuscripts prepared according to the requirements are invited for editorial review and publication. X It should be original article , case report , investigative research and review articles X Abstract must to submit with the Article or Case Report. X Submitted manuscripts should not have been published elsewhere in any format or be under consideration for publication elsewhere. X The photographs in the manuscript and the photographs of the authors should have a minimum resolution of 300 dpi. X It is mandatory for all authors to submit their high resolution photographs. X Title page must be submitted with article mentioning the Authorâ&#x20AC;&#x2122;s Name, Designation with College Name & Correspondence Address. X The maximum limit for authors for a manuscript is three authors.

Increased glycation Ultraviolet radiation causes increase tissue concentration of advanced glycation end products resulting in the formation of ROS. When collagen becomes glycated it loses its flexibility and its susceptibility to mechanical stimuli is increased. Its replacement is inhibited because glycated collagen resists degradation by MMPs.

X In case of case report it is mandatory that all authors have to be associated with the same institute, clinic, and centre. X Manuscript font should be Times New Roman & font size should be 10pt. X The editorial board will take minimum of 15 days to convey its decision regarding the submitted manuscript. X Post Graduate Students or Interns must to mention their Head of the Department. Name or Guide Name as Co-Author, Otherwise manuscript will not consider. X All Authors can directly send their Manuscript at info@facethetics. in

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