Facethetic by Guident Journal

RNI No. DELENG18623

Vol. 1, Issue 3, January - March 2015 |

100/-

A JOURNAL FOR COMPLETE FACIAL ESTHETICS....

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editorial

EDITORIAL editorial

Dr. Abdul Hameed EDITOR Dr. Abdul Hameed Editor Consultant Oral Surgeon

Dr. Abdul Hameed EDITOR Editor

Apr-Jun 2014 Jan-Mar 2015

Apr-Jun 2014

We are gratified with the immense response received from all over the nation from practioners, researchers, students and academicians, because of which we successfully released the first edition of Facethetic. We aim at building We are gratified with the immense response received Webridges are privileged and flattered that Facethetics has expanded to from between various disciplines of medicine, dentistry all over the nation from practioners, researchers, our shores. Facethetics serves as a professional platform wherestudents and other allied health sciences while keeping abreast with every specialty will be able tobecause discern theofeffective in and academicians, whichtreatments we successfully recent advancements in each domain. remarkable aesthetic, anti-ageing and regenerative medicine.The Multi-specialty released the first edition of Facethetic. We aim at building retort obtained after conception this scientific education seems to be a new buzzword of around the world. journal As the bridges between disciplines dentistry proved that our professional field was always in dire need multi specialty journal in various the aesthetic market, weof aremedicine, proud to have and other allied health sciences while keeping abreast a role ininters changing the educational paradigm within our specialty. ofan disciplinary approach. Working forward not to with Aslet evidence of this changing paradigm, Facethetics has quickly recent advancements in each domain. The remarkable down the hopes of the curious multitude who endeavor grown to be the largest ‘independent’ aesthetic journal in India and enretort route obtained for novel after data, Facethetic first issuejournal conceptionreleased of thisitsscientific abroad attracting more and more people. Our goal from the very with plethora of first hand info. Being at the juvenile proved that our professional field was always in dire need beginning has been to build educational bridges between what stage scores of teething trouble was encountered, which many consider thedisciplinary core specialtiesapproach. associated with aestheticforward surgery not to ofan inters Working was effectively atofbay our panel. This and medicine- dermatology, facialvenerated plastic surgery, plastic let down aesthetic the kept hopes thebycurious multitude who endeavor surgery, maxillofacial surgeon oculoplastic surgery and cosmetic proclamation would never have taken shape without the issue en route for novel data, Facethetic released its first dentist. No other journal has all at its a mission to gather with the extended support from thecore members associated with plethora first thetojuvenile world’s leading experts of from eachhand of theseinfo. fields Being and allowatthem it, whose continued guidance and timely insights into exchange with of oneteething another trouble was encountered, which stageideas scores technical issues promoted unveiling of an inter disciplinary wasimmense effectively kept at We baytake by our venerated It journal gives to introduce youpleasure the latest ofpanel. this of thispleasure magnitude. toissue thank and This fledgling journal that would was bornnever last year. It has been shape a fascinating proclamation have taken without the congratulate all the members without which this would and extended lovely journey for all of us involved in it to witness the success support from all appreciate the members associated been impossible. We also the amount of with of have our dream. it, whose continued guidance insights time and patience each author has and put intimely to deliver an into On behalf of the entire Facethetics team, I would like to thanks technical issues promoted anedition. inter disciplinary article, the best of which were unveiling featured inof this The once again for your support and interest. We look forward to more erudition rendered by Facethetic will only better itself journal of this magnitude. We take pleasure to thank contributions from you. Come forward and share your knowledge.in and imminent issues. At the this imperative juncture Facethetic congratulate allto the members without which this would A its special recognition all authors who have tried their level best to provide us with best of their work. And last but not the least also takes an opportunity to invite all the like minds have been impossible. We also appreciate the amount of wewho thankthink theknowledge team members Facethetics for their very is ofgained onlyhas when itinishelpful, shared timeall and patienceanything each author putencouraging to deliver an proactive and moretothan else, aFacethetic genuinely and commendably, consolidate with make it The article, the best of which were featured in this edition. attitude without which this would have been a much more difficult a distinguished resource in days to come. task.erudition rendered by Facethetic will only better itself in Thank you all once again itsofimminent issues. Atthose thiswho imperative juncture Facethetic Motto delivering smiles to all crave for knowledge.

also anforopportunity invite Thank you takes once again all your love andtosupport.

all the like minds who think knowledge is gained only when it is shared commendably, to consolidate with Facethetic and make it a distinguished resource in days to come. Thank you all once again

Dr. Abdul Hameed

Printed, Published & Owned by Manzar Aftab Naqvi

Associate Editor Dr. Jeevan Prakash V.

RNI No. : DELENG18623

Chief Co-Ordinator Dr. Rabiya A Hameed

Editor Editorial Co-Ordinator Dr. Abdul Hameed Dr. Madhu Bangera

Associate Editor Layout Prakash & DesignV. Dr. Jeevan

ArmanShariq DalalRoomi Mohd.

Chief Co-Ordinator Dr. Rabiya A Hameed

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| Issue 1 Vol. 1 Editorial Co-Ordinator 4 Facethetics Dr. Madhu Bangera

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Facethetics | Issue 3 Vol. 1 4Layout & Design

D Dr Dr Dr A Dr Pl Dr Dr

Apr-Jun 2014 Apr-Jun 2014

editorial editorial

Jan-Mar 2015

EDITORIAL

It takes great pleasure to announce the success of a newly It takes great pleasureofto facial announce the success of a newly launched journal Cosmetics (Facethetics), launched journal facial Cosmetics (Facethetics), published by Ivory ofIndia publication dedicated to the published India publication dedicated to the fascinatingby andIvory the challenging world of facial esthetics. fascinating and the challenging worldsurgery of facial esthetics. Today, the small field of facial plastic which was a Today, the small field of facial plastic surgeryand which was a subspecialty under plastic surgery has grown has taken It and gratification to and penhas down subspecialty plastic surgery has grown taken thegives shapeme as under ahonor separate and a extremely challenging super the editorial forIt the issue of this academically the shape as itself. a separate and ais extremely challenging super speciality in is now a very broad area of interest speciality itself.that Itscientific is now iscategories. a very broad ofcategory interest with magazine veryindiverse In area each rich is going to make its debut at with very diverse scientific categories. In each category we have publications and journals dealing with different Dermacon 2015. we haveofpublications dealing with aspects cosmetology.and Alljournals these publications anddifferent journals Being a dermatologist, I have often felt aspects of cosmetology. All these publications andlimited journals are restricted to small sections making it difficult to share are to small sections making it difficult to share withrestricted all specialities. in the surgical approach to several aesthetic with alldermatological specialities. and indications. Having a Our view is to share the knowledge globally as far as possible multi-speciality approach always seemed more Our is to share the knowledge globally as far as possible withview no boundaries and restrictions to particular field in logical and fruitful restrictions than limiting oneself toin with particular is field orderno to boundaries expand the and field. This is whytofacethetics open single speciality. order expand thecategories field. Thisinvolved is why facethetics is open to all to professional in cosmetic field.

to professional categories involved in writing cosmetic field. Weall welcome papersfor on basic facial plastic surgery, What started me,science, as just an We welcome paperstrichology, on basic science, facial plastic surgery, cosmetic dentistry, dermatology, antiaging and article a few months back has now become cosmetic dentistry,articles trichology, dermatology, antiaging and research oriented on the same. We also encourage aresearch very oriented enriching articles on thetechnologies, same. at We Facethetics. also encourage submission of papers onexperience newer methods and Additionally, as onmost authors have been submission newer technologies, methods and products. of papers products. practicing in different fields of medicine and We wish all our ofreaders and authors, a happy and different parts the world; this educational We wish all our readers authors, a scientifically rich New Year and hope you can join usand in journey has been a multifaceted one. happy scientifically NewofYear hopeproject you can in ensuring the rich success this and exciting andjoin weus look

Iensuring wish tothe Facethetics &contributions. Dr. Abdul Hameed to success your of this exciting project and we look forward receiving forward to receiving your contributions. continue this engaging journey and I urge more dermatologists to actively participate in this educational exchange.

ASSOCIATE EDITOR

Dr.Vrushali Rane Khan Guest Editor D.N.B. (Skin & VD), Consultant Dermatologist

Thanks

Dermatology / Tricology Dermatology Dr. Avitus John/ Tricology Raakesh Prasad Dr. Avitus Raakesh Prasad ChetnaJohn Ramchandani 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

Dr. Jeevan Prakash V. Dr. Jeevan Prakash V. ASSOCIATE EDITOR

Review/Advisory Board Review/Advisory Board Esthetic Dentistry Esthetic Dentistry Dr. Manesh Lahori Dr. Manesh Shourya Lahori Sharma Dr. Shourya Sharma Ankur Aggarwal Dr. Ankur ParvezAggarwal Alam Khan Dr. Parvez Alam Khan Deepak Mehta Dr. Deepak Mehta

International Advisory International Mr. Avi MeystelAdvisory Mr. Avi Meystel Dr. Louis Malcmacher Dr. Louis JamesMalcmacher Jesse Dr. James Jesse Geoff Knight Dr. Geoff Knight Jun-Woo Park 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. Allindisputes be referred to Delhi Jurisdiction. The Views expressed this issueare aretothose 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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pinhead array forms a closed circuit of bipolar RF current that passes into the epidermis and deeper into the dermis. (Figure 1B) This results in heating of areas which are directly targeted by the electrode-pins to temperatures leading to ablation and resurfacing of the skin directly in contact with and below the array, leaving intact or slightly affected zones in between the targeted areas. In the short term, the preserved tissue helps to maintain skin integrity. In the long term, it serves as a pool of cells that promote wound healing.

CONTENTS

A CASE REPORT OF USING THE BIODEGRADABLE FIXATION DEVICE (ENDOTINE) FOR DOUBLE CHIN WITH ORTHO-GNATHIC SURGERY

Figure 1A. Showing the tip showing consists of parallel rows of bipolar arranged electrode-pins.

newer machines. Bifractional tips passes deeper RF energy and effective for deeper dermal remodelling. Monofractional is mainly used for superficial dermal remodelling. The distance between the electrodes is directly proportional to the energy delivered and depth of penetration. If deeper work is needed lesser number of pins is used to prevent collateral damage in epidermis when higher energy is used.

Jan-Mar 2015

The radiofrequency modality in the bipolar electrode scheme applies the configured energy in a “pyramid”

(RF) energy to effectively tighten and rejuvenate the skin.

Figure 2A. Showing the disposable tip which can detached after use

UNDERSTANDING OF STEVENSJOHNSONS SYNDROME AND ITS MANAGEMENT:REVIEW ARTICLE

First described in 1922, as an immuneRecently, Orthognathic surgery has complex–mediated hypersensitivity developed technically with a lot of reaction that is a severe expression attention and played a leading role Figure 1B. RF current flows between the positive and negative mini-electrodes such that part of the electrode-pinhead array forms a closed circuit of erythema multiforme. Stevens bipolar RF current passes into the epidermis and deeperanomalies. into the dermis. Control ofof this current allows varying degrees of tissue impact. In the space in that solving dentofacial of no current flow a healing reservoir of epidermis and dermis is obtained. Johnson syndrome (SJS) and Toxic But, for the purpose of improving Epidermal Necrolysis (TEN) are aesthetic as well as functional aspects, variants of a same disease arbitrarily the patient treated with orthognathic separated by percentage of body surgery has some complaints about surface area involvement in both lack of the amount of improvement conditions. It is characterised by in nasal and neck area after surgery. erythematous macules leads to NOVEL MINIMALLY epidermal detachment and mucous INVASIVE FRACTIONAL membrane erosions. SJS typically involves the Skin and mucous MICRONEEDLE membrane; sometimes in its minor RADIOFREQUENCY presentation it involves mouth, DEVICE AND nose, eye, respiratory tract and GI. It is important to diagnose StevensAPPLICATIONS Johnson syndrome (SJS) and toxic IN COSMETIC epidermal necrolysis (TEN) and DERMATOLOGY manage them properly because chances of missing are more. SJS is The field of cosmetic dermatology in a serious systemic disorder with the the treatment of tissue tightening and potential for severe morbidity and scar remodelling has developed very even death. The mortality rate of SJS rapidly over the past several years, and TEN is high: even in moderately with many new devices appearing on severe cases. the market that utilize radiofrequency

Facethetics | Issue 3 Vol. 1

FACIAL PIGMENTATION

Face is the key to fortune as the old saying goes. The saying becomes further more relevant in the present day times as possessing attractive external persona and cosmetic appeal have become essential for professional and personal success . A tiny facial blemish or an innocuous spot , scar or imperfection can shatter self esteem or erode the confidence of an individual thus resulting in poor quality of life. Nature has blessed Asian skin with color which protects us from the harmful effects of UV light and helps in vitamin Dsynthesis . Skin Color is contributed by – melanin, hemoglobin and carotenoids , former being the most important determinant of skin color. All races have equal number of color producing cells known as melanocytes irrespective of their skin color, however it is the size and arrangement of these tiny sacs which carry the melanin pigment in them (melanosomes) that determines the final color of skin. Caucasians or white races have smaller melanosomes which lie in one place in contrast to the darker races which have larger melanosomes that lie scattered throughout the pigment cell .

Jan-Mar 2015

DIRECT LAMINATE VENEERS – PART IV

Once the technique for integrating varying shades and composite types to construct a single laminate has been mastered and the anatomical landmarks of a smile understood, the placement of laminate veneers becomes a series of sequential steps, each one following the other to successful completion. > A successful clinical outcome depends upon achieving healthy gingival tissues prior to any aesthetic procedure. > Remove any unsatisfactory restorations and prepare retentive slots in existing indirect restorations.

WHITENING VS. BETTER ENAMEL CARE (ACP WHITENING) – ‘WANT’ OR ‘NEED’ BASED DENTISTRY?

Do we really have a definition for ‘want’ based and ‘need’ based Dentistry? What we do have is a broad perspective of ‘want’- based and ‘need’- based dentistry. Simply, ‘want based’ would be that which the patient asks for and is not a critical need of the hour. ‘Need based’ dentistry would be that which is the

need of the hour or when treatment is given when the patient is in difficulty or in pain. Most of our practices are devoted to ‘need based’ dentistry merely because that is the bulk of the patients we get People do not want to come to the dentist unless they have a problem to address. We are a little different from the western world. They have patients that come into a dentist’s office with requests that are not need based. That’s probably because they come in for hygiene appointments, are comfortable with the clinic and then are very aware and comfortable seeking additional work done to enhance their smiles. Western Dental offices also are much more aggressive in offering treatments with special offers than Indian offices are. Since we do not have typical hygiene departments in our dental offices we tend to miss out on entire section of society till the need arises.

CONTENTS

thought is to the word that the feeling is to the facial expression. He pointed out in 1806 that a smile could convey a thousand different meanings, yet it is the most easily recognized expression. And because the mouth is one of the focal points of the face , it should come as no surprise that the smile plays a major role in how we perceive ourselves, as well as in the impressions we make on the people around us. A charming smile can open doors and knock down barriers that stand between you and a fuller, richer life. An attractive or pleasing smile clearly enhances the acceptance of the individual in the society where he belongs and the character of the smile influences to the great extent the attractiveness and the personality of the individual.

PRINCIPLES OF CREATING A SMILE

Event Celender

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facial plastic FACIAL PLASTIC surgery SURGERY

Dec. 2013 Jan-Mar 2015

A CASE REPORT OF USING THE BIODEGRADABLE FIXATION DEVICE (ENDOTINE) FOR DOUBLE CHIN WITH ORTHO-GNATHIC SURGERY Dong-Ju Choi, Se-Heung Choi, Byeong-Gi Park, Sang-Sik Chae1, Tae-Sun Lee1, Jun-Woo Park Department of Oral and Maxillofacial Surgery, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Korea Department of Oral and Maxillofacial Implantology, Graduate School of Clinical Dentistry, Hallym University, ChunCheon, Korea1

IntroductIon Recently, Orthognathic surgery has developed technically with a lot of attention and played a leading role in solving dentofacial anomalies. But, for the purpose of improving aesthetic as well as functional aspects, the patient treated with orthognathic surgery has some complaints about lack of the amount of improvement in nasal and neck area after surgery. It is possible to solve in skeletal problems during surgery, while still unpredictable in soft tissue asymmetry after surgery1. In order to improve these soft tissue asymmetry, the orthognathic surgery need more additional aesthetic surgeries like - chin surgery (chin augmentation, chin reduction), rhinoplasty, facial contouring surgery, and submadibular soft tissue surgery. Above all, especially loose condition below the chin, in other words – Double chin, is generated by locally accumulation of fat through stretching of thin muscle in the neck area. This is the main factor causing the patient’s dissatisfaction, but the suitable surgery is not developed still now. In case of excessive soft tissue below the chin area, local resection or liposuction are widely used for treatment. But, it is impossible to remove all fat tissue completely and if the body weight is increased, the new fat is likely to be concentrated in the region of liposuction area by accumulation of additional fat in residual original fat tissue.2 Traditionally, the 2-stage surgery which means soft tissue repositioning surgery after maxillofacial surgery

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ABSTRACT Orthognathic surgery has been accepted by professions as a useful method to obtain remarkable result in oral and maxillofacial deformities. Now, in development of this method with additional aesthetic surgery, above of them, the soft tissue lifting with absorbable Endotine device is considered as a very excellent method. We reported the case which showed a good result to improve double chin with two jaw surgery and Endotine esthetic surgery simultaneously Key Words – orthognathic surgery, double chin, Endotine.

is preferred, because the change of hard and soft tissue after facial asymmetry surgery has been known as no significant relevance in vertical change and this surgery is more predictable.3 The prognosis of 2-stage surgery is more predictable, but duration of treatment is so long and the patient’s discomfort is increased by more surgical procedures. In recent years, several methods to improve soft tissue incongruity with orthogranthic surgery have been introduced to decrease the patient’s discomfort. Among these many methods, ENDOTINE Ribbon(Coapt System Inc., United state) has been proven its reliability and ease, so it is widely used in forehead or mid-face lifting.4,5,6 However, it is not yet widely used to treat double chin and a few discussion about this method applicated to orthognathic surgery has been performed.

Jan-Mar 2015 In this case, the reflected prominent double chin was treated with using a two-jaw surgery and Endotine Ribbon for double chin lifting at the same time. The operation procedure was simple and the result was so effective. So we report this case, becasue aesthetic improvement is good and excellent and patient’s satisfaction is also high.

case report 1. Patient information A 29-year-old female patient visited the Department of Oral and Maxillofacial Surgery, Kangdong Sacred Heart hospital, Hallym University complaining of asymmetry and malocclusion for orthognathic surgery in November 2012. The patient was referred our clinic after orthodontic treatment in private dental clinic for orthognathic surgery. She was single and had high expectation for aesthetic part and she wanted to improve mid-face depression, long face, double chin and malocclusion. 2. Clinical and radiological examination As the result of clinical examination, difference of the canting of maxillary posterior area was not big with just

FACIAL PLASTIC SURGERY 1mm, and asymmetry of the maxilla was not severe. Nasolabial angoe was more than 90 degrees and mild depression was shown in mid-face area. Maxillary anterior teeth was exposed about 5mm in relaxed state, and freeway space was about 4mm. Nose tip was slightly bent to right side, and both upper and lower lip and chin point was shifted to left side about 2mm. Upper and lower central incisors were shifted to left side about 1mm from midline. The occlusion relationship was shown as class I tendency. (fig 1) In radiographs, the maxillar was mild retrognathism and vertically long tendency compared to whole facial aspect. The mandible was shown as a little protrusion and the both angle were more developed. Chin area was longer than the average. Overall, the mandible was shown asymmetry to be shifted left side. (fig 2) The treatment purpose of this patient was improvement of openbite by malocclusion in functional aspect and long face in aesthetic aspect. These problems were planned to treat by Le Fort I osteotomy of the maxilla and mandible BSSRO, angle reduction, and genioplasty. But it was expected to be more severe her double chin after orthognathic surgery, so chin lifting with Endotine Ribbon

Figure 1. Preoperative extraoral and intraoral photographs.

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Jan-Mar 2015

Figure 2. Preoperative radiographs.

3. Orthognathic surgery with chin lifting In January 2013, under general anesthesia Le Fort I osteotomy of the maxilla and mandible BSSRO , angle reduction, and genioplasty was performed. The maxilla was to upward movement about 3mm in anterior and 4mm in posterior. Additionally, the Medpor augmentation was performed in both depressed paranasal area. The genial

area was to backward movement about 2mm and upward about 4mm, so lower part of face was more shorted than before surgery. Also the angle reduction was performed. After orthognathic surgery, the incision was performed in behind of the both ears by rhytidectomy approach and the soft tissue of double chin area was lifted by Endotine Ribbon. The operation time took an additional 30 minutes

Figure 3. Endotine Ribbon and intra-operation photographs.

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and the patient did not appeal any special discomfort with lifted chin area. The precautions of not to greatly extend the neck and excessively shake her head were kept in mind and she was shown to relatively rapid recovery. Immediately after surgery, the effect of lifting did not be recognized prominent and she had concern about being touched Endotine Ribbon device under the skin. But, it was not care much more because it was absorbable material. 4

FACIAL PLASTIC SURGERY days after surgery, the stitch out was done and wound was very aesthetically excellent result because the incision line was back in the ear. 4. 2 weeks after surgery The swelling on op site was reduced after surgery. Further improved facial aspect and decreased double chin after applying Endotine Ribbon were shown after surgery.

Figure 4. 2 weeks after surgery.

5. 6 weeks after surgery The patient’s facial swelling on op site was nearly subsided and facial expressions were also natural. The side effect

such as loosing of fixed endotine Ribbon was not appeared and the patient was very satisfacted in solving all problems on her face at the same time.

Figure 5. 6 weeks after surgery.

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FACIAL PLASTIC SURGERY dIscussIon The various methods are used to solve disharmony of facial soft tissue. Many procedures like liposuction surgery, botulinum toxin injection, and facial lifting with absorbable material are perfomed for this problem, but above all, the facial lifting with absorbable Endotine are more used to advantage in more simple and predictable result.7,8 Endotine device is anatomically fixed to the structure site called SMAS - Superficial Muscular Aponeurotic System. In 1976, Mitz V. defined at first the SMAS layer as structure divided into between superficial and deep adipose tissue in parotid and cheek region.9 After the study, the phenomenon of sagging the facial skin is just for skin and SMAS structure connected with skin is known as important structure with sagging. SMAS has been recognized as an essential structure in facial lifting. It is located under the skin of the face as a single layer structure composed of a continuous, constant and close to spread over the entire face. SMAS and skin are connected with strong fiber septum(fibrous septa) and moved together when the muscle acts. Therefore, the skin and SMAS should be pulled strongly upward and fixed with periosteum or deep tissues, so it can be maintained for a long time and not recurred. In 2007, Ryan N. researched about Endotine midface st 4.5 device for 121 patients in mid-face lifting and it was known as simple, effective, and easy to learn technique. Among them, 78 patients were treated with rhytidectomy or blepharoplasty and it was revealed to more prominent result.10 In addition, Anthony P in 2007 reported many cases of eyelid cosmetic rhinoplasty with mid-face lifting using endotine fixation.11 In 2007, Allison M. reported adventages of Endotine about no require a metal screw, no need for suture, and no remove the device after healing. However, possible complications are expected about exposure of device, need for repositioning by asymmetry after surgery, or tenderness of device under the very thin skin. Additional expensive costs are also considered.12 On the other hand, concerns about side effects are going to be bigger, while a lot of interest is with facial lifting. In 2006, Jennifer L reported some side effects like alopecia on brow fixation, loss of elevation, implant palpability, and paresthesia. And he measured the thickness of the 14 skulls for more safe facial lifting procedure.13 In orthognathic surgery area, Choi JY etc in 2010 reported that the procedure of Endotine Ribbon with orthognathic surgery in 10 patients were shown good results about solving lip cant or disharmony of gonial angle area.14 In this case, the chin lifting was applied to the patient who was expected more severe double chin symphtom after orthognathic surgery and the result is so successful. In general, the tongue and hyoid bone is more downward to

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Jan-Mar 2015 keep the airway physiologically when the mandible moves to backward.15 This makes more obtuse angle of between neck and chin. So, movement of the mandible to backward makes the form of chin and neck anesthetic in double chin patients. In this respect, more good results can be obtained in well-selected patients in procedure with orthognathic surgery. The patient should be felt some discomfort because the excessive extension and rotation of neck were avoided to fixed entotine device with periosteum and skin layer. Also, the tenderness of device under the thin skin seems inevitable shortcoming. The manufacture describes the device would be absorbed completely in 12 months through hydrolysis. So its safety is somewhat verified. But the more studies are needed about fixation periods by loss of strength of the material itself, integrity and force to downward because of its complete absorbable characteristics.

conclusIon To date, the facial lifting technique was reported successful for solving the soft tissue disharmony in maxillofacial region. But it is not yet being so many operations with orthognathic surgery at the same time which is shown most noticeable improvement. This is thought to be result of factors that uncertain prognosis and longer operation time are contemplated when the hard and soft tissue surgery are done at the same time. However, if more certain anticipated indication was taken through accurate diagnosis and analysis of facial soft tissue, the Endotine Ribbon procedure with orthognathic surgery would be a great effective method. References are available on request

Dr. Jun-Woo Park Dr. Jun Woo Park is Assistant, Associate, Head Professor, Dept. of Oral & Maxillofacial Surgery, Kangdong Sacred Heart Hospital, School of Medicine, Hallym University, Dean of Graduate School of Clinical Dentistry, Hallym University(dent.hallym.ac.kr), President of Pan-Pacific Implant Society (ppis.org), He Is Also Member of Educational Committee, International Association of Oral & Maxillofacial Surgeons, and Honourary President Korean Association of Maxillofacial Plastic & Reconstructi Ve Surgeons (kamprs. org) Dong-Ju Choi, Se-Heung Choi, Byeong-Gi Park, Sang-Sik Chae, Tae-Sun Lee

Dec. 2013 Jan-Mar 2015

DERMATOLOGY dermatology

NOVEL MINIMALLY INVASIVE FRACTIONAL MICRONEEDLE RADIOFREQUENCY DEVICE AND APPLICATIONS IN COSMETIC DERMATOLOGY Avitus John Raakesh Prasad, Sheeba Grace, Vijay Kumar J.

IntroductIon The field of cosmetic dermatology in the treatment of tissue tightening and scar remodelling has developed very rapidly over the past several years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to effectively tighten and rejuvenate the skin.1,2 What originally began with a single monopolar RF device has progressed into a world in which there are skin-tightening devices that utilize, besides monopolar RF energy, bipolar energy and tripolar energy, and newer machines that boast five and eight poles of RF energy. Microneedle / Fractional RF is a newer technology used for skin rejuvenation, tightening, body sculpting, and scar remodeling. These technologies provide an alternative to ablative lasers, and are said to reduce the incidence of side effects and increase patient compliance. Microneedle / Fractional RF induce dermal neocollagenesis causing minimal or no epidermal disruption, thereby limiting adverse effects and very minimal down-time of few hours to 2-3 days.

MechanIsM of actIon of radIofrequency based devIces

ABSTRACT Skin resurfacing has evolved rapidly over the past 15 years from ablative techniques to nonablative methods and most recently fractional ablative resurfacing. This article helps in understanding this new technology and its uses. This Nonlaser systems based on RF technology is used for skin rejuvenation, tightening, body sculpting, and scar remodelling. Device: Fractional / Microneedle RF is gaining popularity as an alternative to fractional and non ablative lasers in terms of efficacy, outcome and minimal downtime. Indications: This newer technology can be used for several indications such as skin tightening, periorbital tissue tightening, treatment of nasolabial lines and jowl, scar revision and remodelling, treatment of photodamaged skin and primary axillary hyperhidrosis. Facility: Microneedle RF 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 patient’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 radiofrequency systems are safe, even in type V & VI skin types, and postoperative care is minimal. Proper postoperative care is important in avoiding complications. Post-treatment edema and redness settle in a few hours. Postoperative sun avoidance and use of sunscreen is mandatory. Use of Epidermal growth factor gel helps in faster healing and recovery time. Key Words – Fractional RF, Microneedle RF, Sublative RF, radiofrequency

RF energy is produced by an electric current rather than by a light source. Radiofrequency energy is conducted electrically to tissue, and heat is produced when the tissue’s | Facethetics

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DERMATOLOGY inherent resistance (impedance) converts the electrical current to thermal energy. This reaction is dictated by the following formula: energy (J) = I 2 x R x T (where I = current, R = tissue impedance, and T = time of application). (3) High-impedance tissues, such as subcutaneous fat, generate greater heat and account for the deeper thermal effects of RF devices. Radiofrequency energy can be transferred from an electric field to charged particles in the target tissue via 3 mechanisms: the orientation of electric dipoles that already exist in the atoms and molecules in the tissue, polarization of atoms and molecules to produce dipole moments, or displacement of conduction electrons and ions in the tissue. In all 3 mechanisms, heat is generated by the movement of particles in response to an electric field respectively by the collisions between the transmission charges and immobile particles.4 Various considerations are required for there to be successful transfer of the RF energy into thermal energy, including the size and depth of the tissue being treated, as one needs to consider the tissue impedance of the skin being treated. Since RF energy produces an electrical current instead of a light source, tissue damage can be minimized, and epidermal melanin is not damaged either. Using this theory, RF energies can be used for patients of all skin types since does not act on any chromophores mainly melanin and allows for different depths of penetration based on what is to be treated, allowing for ultimate collagen contraction and production of new collagen.5

evolutIon of radIofrequency devIces The first device in this technology was a monopolar radiofrequency (RF) device that was US FDA approval for noninvasive treatment of the periorbital rhytids in 2002, and for the full face in 2004 using this proven mechanism of skin tightening.6,7 Disadvantages of that 1st generation device included inconsistency of clinical results and significant discomfort during treatment. Newer bipolar and multipolar RF devices are constantly being developed to improve results and minimize discomfort. Monopolar systems deliver current through a single contact point with an accompanying grounding pad kept at a different location in contact with the body that serves as a low resistance path for current flow to complete the electrical circuit.3 Monopolar electrodes concentrate most of their energy near the point of contact, and energy rapidly diminishes as the current flows toward the grounding

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Jan-Mar 2015 electrode.7 Bipolar devices pass electrical current only between two adjacently positioned electrodes applied to the skin. No grounding pad is necessary with these systems because no current flows throughout body to complete the circuit.8 The tripolar / multipolar RF systems exclusively utilize the effects of combining unipolar RF and bipolar RF energies in one applicator to simultaneously heat deep and superficial tissue layers, while protecting the surface skin.7 The tripolar RF technology uses sophisticated algorithms to control the treatment electrodes which change the current and polarity to achieve variable energy focus in different fat layers resulting in visible clinical results. This system is also used for the treatment of skin laxity and facial recontouring. Newer devices have been introduced, like the Viora Reaction™ (Viora, NJ, USA) which also utilizes three poles of RF energies, but is distinguished from the other devices in that it emits its RF energies at different RF frequencies which is unique to this machine. Clinical trials with this device have not been published except individual case reports. Another new device, the Venus Freeze™ (Venus Concepts, AZ, USA) uses eight poles of RF energy and pulsed magnetic fields to have its effect on skin rejuvenation and body contouring. Clinical published studies with this device are also not yet available. This article will focus on the Fractional Microneedle RF (FMRF) which is a very new technology which has been developed and upgraded in the last 2 years.

What Is sublatIve (superfIcIal) fractIonal rf Fractional RF was developed to address the shortcomings of ablative and non-ablative device modalities performing ablation on small microscopic “ dots ” of skin allowing rapid healing with minimal pain and downtime.9,10 In Sublative Rejuvenation™ the treatment is delivered via a hand-held applicator that is fitted with a square disposable tip at its distal end. The tip consists of parallel rows of bipolar arranged electrode-pins, forming an array of positively and negatively charged electrodes for multiple delivery of 1 MHz of RF energy. ( Figure 1A) Energy up to 20 J can be delivered at a 5% or 10% coverage rate via 64 or 144 (according to the specific tip) equally spaced electrode-pins, each approximately 200 µm in diameter. Radiofrequency delivery via dry skin flows between each pair of positively and negatively

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charged electrode-pins such that part of the electrodepinhead array forms a closed circuit of bipolar RF current that passes into the epidermis and deeper into the dermis. (Figure 1B) This results in heating of areas which are directly targeted by the electrode-pins to temperatures leading to ablation and resurfacing of the skin directly in contact with and below the array, leaving intact or slightly affected zones in between the targeted areas. In the short term, the preserved tissue helps to maintain skin integrity. In the long term, it serves as a pool of cells that promote wound healing.

The tips can be monofractional to bifractional tips in newer machines. Bifractional tips passes deeper RF energy and effective for deeper dermal remodelling. Monofractional is mainly used for superficial dermal remodelling. The distance between the electrodes is directly proportional to the energy delivered and depth of penetration. If deeper work is needed lesser number of pins is used to prevent collateral damage in epidermis when higher energy is used.

Figure 1A. Showing the tip showing consists of parallel rows of bipolar arranged electrode-pins.

Figure 2A. Showing the disposable tip which can detached after use

The radiofrequency modality in the bipolar electrode scheme applies the configured energy in a “pyramid”

Figure 1B. RF current flows between the positive and negative mini-electrodes such that part of the electrode-pinhead array forms a closed circuit of bipolar RF current that passes into the epidermis and deeper into the dermis. Control of this current allows varying degrees of tissue impact. In the space of no current flow a healing reservoir of epidermis and dermis is obtained.

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Figure 2B. Monofractional and Bifractional tips.

shape, which creates a predetermined controlled wound with a small epidermal component and larger volume in deeper tissue. (Figure 3B) Ablative technology commonly forms a conical or columnar injury zone. The term “sublative” is a derivative of “sub-ablative,” referring to the ability to generate heat energy well beneath the ablated zone below the epidermal surface and where the effect is largely caused by a large volume of heated tissue.

Figure 3B. Heat generated as a “pyramid” shape, which creates a predetermined controlled wound with a small epidermal component and larger volume heating in deeper tissue.

mainly in the mid-dermis, where it has the most effect on wrinkles and scars.

Figure 3A. RF energy passed through epidermis in a fractional array.

Sublative rejuvenation causes limited epidermal disruption less than 5% of the surface is treated with one pass which translates to minimal downtime for patients and makes it an optimal choice for darker skin. The bulk of the effect is coagulative and occurs

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This unique technology provides the capability to combine epidermal fractional microablation and deep nonablative dermal heating allowing the optimal multilayer treatment needed for conditions which would benefit from dermal remodelling.

What Is MIcroneedle / fractIonal MIcroneedle rf Microneedle RF works by the same principle of dermal remodelling by Sublative RF but with the use of microneedles

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which are inserted into the skin to desired depth and RF current is passed. In microneedle RF the treatment is delivered through probe tip which consists of an array of microneedles over a minimum area of 10 mm2 that form an array of positively and negatively charged electrodes. The microneedles delivered bipolar radiofrequency energy in a fractional manner that can be inserted into the skin at a depth of 0.5 to 3.5 mm depending on level of treatment in the dermis.

DERMATOLOGY The microneedles array can consists of needles as low as 25 needles per tip to 81 needles per tip. Some tips have higher number of needles for superficial dermal remodelling. The microneedles can be insulated except the tip or noninsulated. Non-insulated microneedles causes epidermal thermal injury which can produce epidermal resurfacing while insulted microneedles work in the dermal zone causing profound dermal remodelling. The microneedles can also be blunt which will work as the same mechanism as Sublative RF working through the epidermis into deeper part of dermis. The sharp microneedles in contrast deliver the RF energy directly to the desired zone of the dermis creating better treatment outcome. (Figure 5B)

Figure 4A. In the microneedle tip, the length of needles can be adjusted to pass RF energy through epidermis in a fractional array into the desired depth in dermis.

Figure 4B. In Sublative RF tip, the RF energy is passed from the epidermis into upper dermis.

Figure 5A. sharp insulated/uninsulated tip, the Rf current is passed directly into deep dermis for target dermal remodelling.

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Jan-Mar 2015 is delivered to a deeper part of dermis then needle length is shortened and again the RF energy is placed above the previous heated zone. (Figure 6) This creates different zones of dermis heated at the same treatment improving the results with better dermal remodelling.

paraMeters Parameters have individual variations depending on different equipment since each company has a different interface. Few basic parameters which are common to most of the Microneedle RF equipment are discussed below.

Figure 5B. In Blunt tip it works like the Sublative RF tip, RF energy is passed from the epidermis into upper dermis. This causes thermal injury to the lower epidermis and upper dermis.

More the distance between the needles, longer needles can be used and deeper the needles can be passed into the dermis with higher RF energy delivery. Different needles lengths are available are separate tips. Newer tips have manual and motorised adjustment of length of needles, this is very useful since the same tip can be used to deliver RF energy to different levels in the dermis. The RF energy

Continuous or Pulsed wave.

ON and OFF time.

Energy.

Depth adjustment of needles.

Manual Vs Automated needle insertion.

Number of Passes.

contInuous or pulsed Wave Continuous wave means when the RF energy is passed, it continuously delivers the energy till the foot switch or ON button is pressed. There is no ON or OFF time associated with it. Pulsed wave has an oscillating wave when the ON button or foot switch is pressed and it has an ON and OFF time. (Figure 7) When a continuous wave is used there is no cooling phase since there is no ON and OFF time which can be painful for the patients. The pulsed mode can be single or repeat. Single mode means only one wave of pulse is passed when the foot switch is pressed. Repeat mode means multiple waves of the pulse are delivered till the foot switch is ON.

Figure 7

on and off tIMe

Figure 6A. In Blunt tip it works like the Sublative RF tip, RF energy is passed from the epidermis into upper dermis. This causes thermal injury to the lower epidermis and upper dermis.

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The ON and OFF time is set in seconds and it is used only when the pulsed wave mode is selected. Ideally as low as 0.5 seconds to 3 seconds is kept as ON time. The OFF time is the time given for the cooling of the treated area before the next wave passes, it reduces the discomfort to the patient.

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The OFF time can be equal to ON time or more than ON time, it all depends on the patients comfort.

energy The energy is in watts or joules. Its set to a value depending on the depth of penetration and also the amount of heat needed to be delivered to the dermis. The energy E in joules (J) is equal to the power P in watts (W), times the time period t in seconds (s): E(J) = P(W) × t(s), joules = watts × seconds (J = W × s). Example : What is the energy in joules when a power or 10 watts is used for time duration of 2 seconds? Using the formula it can be derived as E(J) = 10W × 2s = 20J. An Energy joules of 10 – 40J can be used depending on the condition and location of treatment area.

The needle depth is available as preset needle length ranging from 0.5mm to 3.5mm. Newer machines have adjustable needle length. The benefit is that in preset needles if energy has to be delivered at different depth in same treatment session then different needle sizes have to be used but in newer adjustable needles, the same needle can be adjusted by increasing /decreasing the needle length thereby being cost efficient and time saving.

Manual vs autoMated needle InsertIon Manual insertion of needles is done by the user but it can lead to difference in depth penetration. But in newer automated needle insertion, the handpiece pushes the needle to the same depth every time it inserts giving precision to the treatment. Passes Passes means treating the area again after few minutes of completing the first pass treatment. The number of passes can be from 2 to 4 passes depending on the area being treated. Near the eye and forehead will need one to two passes, the cheek and chin two to four passes and for the neck two passes is sufficient.

Figure 8. The basic parameters interface is shown with an ON time of 1.5secs and OFF time of 3.0secs and Power of 10 W which is calculated to 15 joules

depth adjustMent of needles

Anaesthesia Topical anaesthetic under occlusion for 30 – 45 minutes is enough. Tumescent anaesthesia can be given if larger and deeper area are being treated for example in the treatment of axillary hyperhidrosis. Contraindications 1.

Patient who is on a pacemaker.

Pregnancy.

Skin infections like herpes simplex which can be treated accordingly.

Previous use of thread lifts in the area you have planned for FMRF.

Indications 1.

Improving superficial fine lines and wrinkles of the face, eyes, neck.11

Improving the elasticity of aged, striae and photodamaged skin.12,13,14,15,16

Treating scars of all types but particularly acne scars.17,18,19,20 It has a great advantage over laser for darker skin types. Its effective because of deeper treatment levels and without the pigmentation risks.21

Tightening loose skin on all parts of the body including: arms, chest, knees, abdomen. There are no limitations as to where the skin can treated on the body.

New method of treatment for acne22,23,24and hyperhidrosis25

Figure 9. Shows a rotating scale which has depth adjustment from 0.5mm to 3.5mm.

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Advantages 1.

No exclusion of patients based on skin type, safer on all skin types.

Downtime is limited to only about 2 days of sunburn like sensation and slight redness.

Minimally invasive.

Shorter procedure time and downtime compared to Co2 fractional laser.24

Lower risks such as post-inflammatory hyperpigmentation and scarring.26

Can be combined with fractional lasers for better treatment outcome.27

Targetted dermal remodelling can be achieved. This remodeling involves heat-related collagen shrinkage and an initial inflammatory phase followed by increased levels of matrix metalloproteinases (MMPs) that degrade the fragmented collagen matrix followed by production of new collagen( Neocollagenesis).28 Use of 0.5mm needle or non-insulated can cause thermal injury to epidermis causing epidermal remodelling. Thus, for effective resurfacing to occur, regeneration of the epidermis as well as portions of the dermis is required, thereby improving both the appearance and health of the aged skin.29

results

Figure 10A. Closeup of Acne scar before Fractional microneedle RF.

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Figure 10B. Closeup After two treatments of Microneedle RF of 20-25 J, two passes in each sessions. 1.5-3.0mm depth of needle. Note the levelling of the boxcar scars with improvement in ice pick scars seen on the bottom right corner.

Figure 11A. Acne boxcar scar before Fractional microneedle RF.

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developments will continue to keep RF technology at the forefront of the dermatologist’s armamentarium for skin tightening and rejuvenation.

references 1.

Gold MH. Tissue tightening – a hot topic utilizing deep dermal heating. J. Drugs Dermatol. 6(12), 1238–1242 (2007).

Gold MH. Tissue tightening – update 2010. Submitted for publication. J. Clin. Aesthet. Dermatol. 3(5), 36–41 (2010).

Fitzpatrick R, Geronemus R, Goldberg D, Kaminer M, Kilmer S, RuizEsparza J. Multicenter study of noninvasive radiofrequency for periorbital tissue tightening. Lasers Surg Med 2003;33:232-42.

Stuchly M, Stuchly S. Electrical properties of biological substances. In: Gandhi OP, ed. Biological Effects and Medical Applications of Electromagnetic Energy. Upper Saddle River, NJ: Prentice Hall; 1990:76-112.

Michael H Gold. The Increasing Use of Nonablative Radiofrequency in the Rejuvenation of the Skin. Expert Rev Dermatol. 2011;6(2):139143. More references are available on request

Figure 11B. After one of Microneedle RF of 20 J, two passes. 2.5-3.0mm depth of needle. Improvement seen after 6 weeks.

post treatMent care Mild redness and swelling may occur a few hours and up to 24 hours after treatment. Massage and excessive sun exposure should be avoided at this time. More aggressive treatments may result in skin flaking or scabbing as the new skin layer regenerates. Do not exfoliate by force. Apply enough sunblock. Avoid a sweaty exercise, spicy and strong tasting food.Avoid drinking alcoholic beverages. Avoid having a swim and taking a sauna for the time being. Use of antibiotics and antinflammatory can advocated. Moisturisers, broad spectrum sunscreens and avoiding direct ultraviolet exposure are highly recommended during this recovery phase. Use of epidermal growth factor can enhance healing and ensures faster recovery.

conclusIon Fractional ablation and resurfacing with fractional RF canachieve effective skin rejuvenation with effects on both the epidermis and dermis.This newer RF delivery system can be accurately optimized to treat a wide range of clinical conditions by modulating the energy level and coverage rate with good correlation with histological signs at the cellular level. Fractional RF treatment is safe, easily tolerated and effective in reducing wrinkles with an overall improvement in skin texture. Future

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. Dr. Sheeba Grace Dr. Vijay Kumar J.

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UNDERSTANDING OF STEVENSJOHNSONS SYNDROME AND ITS MANAGEMENT:-REVIEW ARTICLE Dr. Rabiya A Hameed

INTRODUCTION First described in 1922, as an immune-complex–mediated hypersensitivity reaction that is a severe expression of erythema multiforme. Stevens - Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are variants of a same disease arbitrarily separated by percentage of body surface area involvement in both conditions. It is characterised by erythematous macules leads to epidermal detachment and mucous membrane erosions. SJS typically involves the Skin and mucous membrane; sometimes in its minor presentation it involves mouth, nose, eye, respiratory tract and GI. It is important to diagnose Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) and manage them properly because chances of missing are more. SJS is a serious systemic disorder with the potential for severe morbidity and even death. The mortality rate of SJS and TEN is high: even in moderately severe cases. Complications are seen in patients who survived from this too. Several classifications has been recommended to distinguish between SJS and TEN, the simplest is as follows. »» Less than 10% of body surface area involved – SJS »» 10-30% of body surface area involved – SJS/TEN (Overlapping Type) »» More than 30% of body surface area involved - TEN

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ABSTRACT Non-steroidal anti-inflammatory drugs are commonly prescribed in dental practice after minor oral surgical procedures, root canal treatments, periodontal surgeries etc. Dentists prescribing these medications must know about possible side effects and warn their patients. One such potential complication of commonly used drugs, like NSAID’s, is Stevens-Johnson syndrome, a potentially fatal condition that manifests mainly on the skin and mucosal surfaces but also affects other vital organs. Stevens-Johnson syndrome otherwise known as erythema multiforme. Stevens-Johnson Syndrome(SJS) and Toxic Epidermal Necrolysis (TEN) are variants of a spectrum of conditions characterised by erythematous macules evolving to epidermal detachment and mucous membrane erosions. In SJS there is less than 10% body surface area involvement; where as in TEN more than 30% and 10-30% overlaps cases. The mortality rate of disease is high that’s why it is important to be able to recognise disease early and manage them properly. In this article the clinical features of this condition and multidisciplinary management of the patient are described in brief.

Jan-Mar 2015 PATHOPHSIOLOGY SJS/TEN is an immune-complex mediated hypersensitive disorder that caused by multiple drugs and body’s response to its metabolites. An inability to detoxify the drug and its metabolites, serves as heptans, which complexes with host epithelial tissues there by initiating immune response. Initiated immune triggers various mediators such as Fas, Ligand and tumour necrosis factor (TNF), leading to apoptosis of keratinocytes.

dermotology involvement, sometimes leads to corneal ulceration, anterior and uveitis. It does not limit to Skin and mucous membrane, it spreads to involve Pulmonary and digestive and renal system. Gastrointestinal tract involvement will result in diarrhoea, malena and oesophageal necrosis. Renal involvement will result in proteinuria, haematuria and azotaemia. Pulmonary involvement shows shortness of breath, hypoxia and haemoptysis. The course of the disease is unpredictable and is depend upon various factors. Sepsis is the most important cause of mortality. Extensive erosions put patients at risk of infection will result in pulmonary complications and multi-organ failure.

MANAGEMENT OF SJS/TEN SJS and TEN are life threatening conditions that need early diagnosis and extremely intensive care with experienced multidisciplinary team work. Withdrawal of all potential causative agents is essential for a favourable outcome. Morbidity and mortality increase if the causative agent is withdrawn late. It is been observed that death rates were lower in cases where the half life of causative agent is less and withdrawal is less than 24 hour.

GENERAL MANAGEMENT (CHART - 1) RECOGNISING SJS AND TEN It is easy to recognise SJS/TEN early if signs and symptoms are familiar to us, especially the initial ones (Prodromal Signs) such as Fever, malaise, cough, stinging eyes and sore throat. Later patient develops skin eruptions that start as an erythematous lesion followed by maculae. Initially these lesions are discrete maculae, later ruptures and coalesce with each other. The rash first appears on the face and upper part of the trunk and proximal part of the extremities and spread rapidly to the rest of the body. Nikolsky sign (separation of epidermis from dermis with lateral pressure) can be demonstrated. It is an important sign but not pathognomonic sign of this disease. Finally the apoptotic epidermis comes off leaving large areas of red exudative dermis exposed. The skin and mucosal lesions are painful. Mucosal involvement in SJS/TEN usually starts as Erythema, followed by painful erosions on the buccal, ocular and genital mucosa and usually it involves more than one site. In Large no of patients, conjunctival

General Management 1

Early withdrawal of causative drug.

• Withdrawal of the offending drug improves outcome • More effective for drugs with shorter half-lives but it is difficult for drugs with longer half-lives.10

Early transfer to higher • Improves outcome centre • This improvement has been attributed to proper nutrition, avoidance of antibiotics and corticosteroids, and implementation of clearly defined wound management procedures.11

Good nursing supportive care

Adequate nutrition

and • mainstay of treatment for these patients • Integral part of management as SJS/TEN is a hypermetabolic state • Factors to consider with regard to oral feeds are temperature, acidity (hot, cold and acidic food and beverages worsen pain), texture and moisture of food as smooth, moist food is more tolerable than rough, abrasive food. • Important to encourage oral feeds to avoid adhesions in the upper GIT.

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Skin Care

• Careful protection of the exposed dermis • Daily baths and the use of clean, sterile, non-adhesive dressings

Fluid Supplement

• Careful monitoring of fluid balance with strict input and output charts is essential because the patients have significant insensible fluid loss and often present with dehydration and renal impairment.

SPECIFIC MANAGEMENT (CHART - 1) Specific Management 1

Systemic steroids

• Controversy regarding use of systemic steroids • Patients in septic shock, treatment with low doses of hydrocortisone is useful. • Blocks Fas/Fas ligand interaction, preventing progression of keratinocyte apoptosis

Intravenous immunoglobulin

Plasmapheresis and haemodialysis

• Early administration stops the progression of disease • To remove drug metabolites and responsible cytokines from circulation but it is questionable

PROGNOSIS Depending on the severity, last up to a few weeks. The prognosis is not related to type or dose of the causative medication. A SCORTEN prognostic scoring system8 has been developed to correlate the mortality with selected parameters.

DISCUSSION Numerous studies have shown that up to 10% of the total number of hospital admissions are because of adverse drug reaction. Fortunately, only about 2% of adverse cutaneous reactions are severe and very few are fatal such as SJS/ TEN. SJS is a severe adverse drug reaction characterized by widespread lesions affecting the mouth, eyes, pharynx, larynx, esophagus, skin and genitals. It almost invariably involves the oral mucosa. The spectrum of severe cutaneous adverse drug reactions includes SJS or TEN; All cases of SJS and TEN should be confirmed by biopsy. In Biopsy initial lesion shows suprabasal layer apoptotic keratinocytes. Later lesion shows full-thickness epidermal necrosis and separation of epidermis from dermis. As numbers of conditions are similar to these diseases so it is important to rule out the SJS/TEN from them by histopathological study (Table-1). SJS and TEN can be easily confused with erythema multiforme. In 1993, a group of experts proposed a new classification in which SJS was separated from the EM spectrum and added to TEN and created a new spectrum of severe drug related disease. The lesions in our patient had an atypical appearance and epithelial detachment exceeding 10% BSA. Table -1 Similar Disease conditions Erythema multiforme major Staphylococcal scalded skin syndrome Purpura fulminant Disseminated intravascular coagulation with skin necrosis Acute generalised exanthematous pustulosis Generalised bullous fixed drug eruption Chemical Burns Graft-versus- Host

More than 100 drugs have been associated with the development of SJS/TEN. Table -2 Table 2 Drugs and SJS/TEN Allopurinol Carbamazepine

Prognostic factors

Points

SCORTEN

Mortality

Age > 40

0-1

3.2%

Nevirapine

Heart rate>120/min Cancer or haematologic complication >10% of body surface area

1 1

2 3

12.1% 35.8%

NSAIDs(Oxicam)

58.3%

90%

Serum urea>10mm/l Serum Bicarbonate<20mm/l 1 Serum glucose>14mm/l

Lamotrigine

Phenobarbital Phenytoin Phenylbutazone Sulphadiazine Sulfapyridine Sulfamethoxazole Sulfasalazine

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Jan-Mar 2015 In our case NSAIDs was the causative agent and was no evidence of intake of any other drug. Drug-induced SJS/TEN is characterized by mucosal erosions2014 and Jul-Sept widespread distribution of purpuric Dec. macules and 2013 epithelial detachment. 1 to 2 weeks before the onset of mucocutaneous manifestations, Prodromal phase constant. of symptoms, RED is between 60% and 80%. present The with value flu-like sore throat, headache, be the morewidth attractive when emotive and isconversely a wellOnce of the central incisor calculated, the arthralgias, myalgias, fever, bullous and other rashes. Early balanced face on a staticisobservation throw symmetry width of central incisor multipliedmay by the same RED diagnosis without theofprompt recognition andface withdrawalunof or harmony gearthe and may make proportion to determine width of thethe frontalappear aspect of Hence, the facial aesthetic surgeona must be an allaesthetic. potential causative drugs is essential favourable the lateral incisor. And the resulting lateral for incisor width is astute observer of cases, not just the static must analysis of the facial outcome. In severe the patient be transferred multiplied by the RED yield width of proportions butsame also of theproportion dynamics ofto how theaindividual tounits higher centre andwhen measures such as itenvironmental the frontal view of the canine. mathematical come together in The action. Also mustformula be taken temperature control, careful and aseptic handling, used to calculate the width of the maxillary central into consideration that restructuring all the facesincisor onand one template be similar making clones inAnd a factory forsterile any RED proportion given a taken. fixed view width. this fieldwould creation must beto Complications such facial restructuring mustthe take into intravascular consideration width isthat determined by measuring frontal view width asand thromboembolism and disseminated the psychological need, the prevalent local culture, between the distal aspects of the coagulation and damage vital organs such as kidney There are many systemstothat come together tothe make up a failure) deteriorate 2 (multiorgan maxillary canine whichthe is prognosis. (frontal view the beautiful face. Theteeth underlying skeletal system, theofdental

dermotology Dr. Rabiya A Hameed dental

cosmetic

antiaging

Dr. Rabiya A. Hameed is a CONCLUSION: Consultant Cosmetic Dentist the use of biomaterials to have more predictable outcomes From the above discussion it is important to understand in Wockhardt Hospitals of materials used as grafts.

that smile we create should be Surgeons appealingmust andhave most The the brotherhood Aesthetic Facial Fellow in Aestheticof Medicine importantly functional as well. We as cosmetic dentists the propriety to ensure that the skills are imparted to those should carefully and deliver must the best to the our Mira Mumbai, India.This who Road, seek, with noanalyze bias. knowledge not be propertyby of considering one or a group but and mustevery be available all, so patients each factorsfor discussed that it stands the test ofitscrutiny and makes sure that results a above. Scientifically is proved in order to create are reproducible. the knowledge thus gained must be beautiful smile theAll principle of Golden Proportion or RED kept in a repository which is easily accessible to one and proportions can be systematically applied to evaluate and all. It does good to keep in mind ‘Beauty is only skin deep, to improve dental in a-predictable way. The main but ugly goes cleanesthetics to the bone. Dorothy Parker’ aim of smile makeover should be conservative, less tooth reduction and greater durability.

AUTHOR GUIDELINES

units, 6theteeth)/2(1+RED+RED2) sensory and function units of theofeyes, ears, anterior =width central Dr. Dr. Jeevan mouth & lips, the nose, the skin covering the skeletal and incisor. the musculature and the hair. Though there are experts in The following instructions have been included under this section. The sole aim of this publication is to produceV. a journal that will provide most upto date information on Prakash eachrelated domain, there has also a constant overlapping topics to general/specialized Facialbeen Esthetics. The journal publishes papers on all aspects on Facial Plastic Surgery, Dermatology, Antiaging, Tricology, Skin Care & of specialties when dealing the face. The time now for editorial review and publication. Aesthetic Dentistry. Manuscripts prepared with according to the requirements are invited DISCUSSION: has come together to bring together all the expertise in Dr. V. Jeevan Prakash is a Xgolden It should be original article ,(1.618 case like report ,1.0) investigative researchthe and review the individual specialties Maxillofacial Surgeon, TheX proportion : the describes ratioarticles Maxillofacial Surgeon in the Dentist, The Plastic & Reconstructive Surgeons, The between themust dimensions ofthe a Article larger and a smaller length. X X Abstract to submit with or Case Report. private practice in Bangalore Dermatologists and the Otolaryngologists together in the Various authors have various regarding the use XX Submitted manuscripts should notopinions have been published elsewhere in anyofformat orand be under publication is aconsideration Professorfor and Head elsewhere. interest of the patient to approach the problem holistically. golden proportion in smile desigening. ofa minimum Department College X X The photographs in theto manuscript the photographs of the authors should have resolutionat of 300 dpi. The time has come finally and define a niche super specialty Campus, Narnadi, Jhanwar called thedentistry “Aesthetic Facial where there is X It is mandatory for all authors to submit Surgery” their resolution photographs. In X modern esthetics hashigh become extremely Road, Jodhpur (Rajasthan). He specializes in Maxillofacial amalgamation of the said specialties with each one doing important. This dental artwith does not occurtheautomatically XX Title page must be submitted article mentioning Author’s Name, Designation with College Name & Correspondence Address. trauma at best from their domain. Dr. Rabiyareconstructive, A. Hameed is aAesthetic Facial surgery and butXisX The carefully and incorporated in the treatment maximumplanned limit for authors a manuscript is three authors. The times has come to for embrace technology like never Orthognathic surgery.Dentist Dr. Jeevan Prakash received his Consultant Cosmetic plan which helps in creating an attractive smile which X X In case of report is mandatory that all authors have to be associated same institute, clinic, and centre. before. It case now, toit implement better analytic tools for with a thein undergraduate degree from the SJM Dental College & Hospital Umrao Hospitals enhances the look ofand an individual and also the acceptance more predictable ofsize results. It is now, Chitradurga, Karnataka, India. His Maxillofacial training was X X Manuscript font should be reliable Times Newoutcome Roman & font should be 10pt. in our society. Mira Road, Mumbai, India. to harness the power of Nano technology in designing from the Bapuji Dental College and Hospital, Rajiv Gandhi XX The editorial board will take minimum of 15 days to convey its decision regarding the submitted manuscript. better instruments, to use the power of laser to decrease the University of Health Sciences, Bangalore, Karnataka India. X X Post Graduate or Internsand must to to mention Head of the Department. Name or Guide Name as Co-Author, Otherwise manuscript will not consider. downtime of Students the patients designtheir newer treatment Author of numerous journal articles, and has delivered options for hitherto unexplored conditions, to understand XX All Authors can directly send their Manuscript at info@facethetics.in lecture on various topic on maxillofacial surgeries.

Dr. Rabiya A Hameed

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DERMATOLOGY dermatology

Jan-Mar 2015 Dec. 2013

FACIAL PIGMENTATION Vibhu Mendiratta

Pigmentation is quite common in Indians and often turns out to be a complex diagnostic problem. Genetic and racial factors are important.

Nature has blessed Asian skin with color which protects us from the harmful effects of UV light and helps in vitamin D synthesis . Skin Color is contributed by – melanin, hemoglobin and carotenoids , former being the most important determinant of skin color. All races have equal number of color producing cells known as melanocytes irrespective of their skin color, however it is the size and arrangement of these tiny sacs which carry the melanin pigment in them (melanosomes) that determines the final color of skin. Caucasians or white races have smaller melanosomes which lie in one place in contrast to the darker races which have larger melanosomes that lie scattered throughout the pigment cell . The “pigment factory “ or the melanocytes lie in the superficial layer of skin called the epidermis . The production of melanin depends on several external and internal factors. The melanocytes can be easily stimulated to produce more melanin by ultraviolet rays in the sun light, frictional force on skin, chemical injury , hormonal changes during pregnancy , drugs , autoimmune diseases such as thyroid etc.

1. Congenital- Refers to conditions that are usually present at birth or appear in the first few years of life. Some of them are familial namely melanocytic naevi or the pigmented moles while others are isolated abnormalities. Pigmentation can only be limited to skin or it may be associated with abnormalities in brain, eyes, ears , teeth and the musculoskeletal systems . Pigmented moles, cafe- au-lait macules, lentigines are some common spotty pigmentary problems which may involve the face.

Facial hyperpigmentation implies pigmentation or darkening of skin involving predominantly the face and the neck .

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causes of facIal pIgMentatIon can be broadly classIfIed Into

2. Acquired – Comprises of conditions that appear later on in life . The cause may be genetic but is external in most of the cases. Pigmentation may be progressive, may show gradual darkening and spread to other areas , may have associated symptoms like photosensitivity , itching , burning etc. Establishing the cause in acquired pigmentation requires a detailed personal history and some lab tests . Melasma, toxic melanosis, pigmented cosmetic dermatitis and post inflammatory and drug induced pigmentation are some common conditions in the Indian scenario.

Jan-Mar 2015 congenItal Naevus of ota-It is a congenitally acquired speckled grayish - blue pigmentation, predominantly involving sclera, conjunctiva, forehead, scalp, alae nasi and ears. The distribution is mainly restricted to distribution of trigeminal nerve. This disorder is most common in Asian people.It is usually not visible at birth, but become progressively darker in childhood and persist in adult life. Café- au lait macules ( CALMS)- Are flat, brownish macules which are well marginated and the size may vary from .5mm to > 1.5 mm. Number can be variable ( one – many) . More than 6 CALMS > 1.5 mm are indicative of Neurofibromatosis. Conginatal melanocytic naevus- Are brownish to grayish –blue patches, plaques or papules . They may be small in size or as large as 20 cm. Some of these show excessive localized hair growth ( hypertrichosis) . These moles show increased skin rugosity with time, darkening of color and giant naevi may also develop melanoma.

acuIred condItIons a. PATCHY PIGMENTATION / SPOTS EPHILEDS/FRECKELS- It is a light colored , poorly defined , pale brown, macular lesion, usually less than 3mm in diameter which appears on sun exposed sites such as face, arms and hands during period of UV exposure.It is commonly seen in individuals who have red or light colored skin and hair. Freckles concentrate over the centrofacial area and tend to fade or become lighter in winter months. LENTIGINES- These are also hyperpigmented macular skin lesions which occur over both exposed and the sun protected areas namely face, extremities, trunk and mucosae. Lentigines persist throughout the year and do not fade away as. there is an increased proliferation of melanocytes in response to sun exposure in faired skinned people. Lentiginosis may be seen in some inherited genetic syndromes like Peutz- Jegher’s syndrome, Cronkhite- Canada syndrome where lentiginosis is seen in association with intestinal polyps. b. DIFFUSE PIGMENTATION MELASMA- It is also known as mask of pregnancy. It is a multifactorial disorder and can be seen in anemia, thyroid gland dysfunction, after anticonvulsant and oral contraceptive therapy. This common acquired facial hypermelanosis is seen in both men and women but is more common in the latter. It occurs mainly in sun exposed facial skin , occasionally affecting the forearms. Many cases are attributed to pregnancy. It is not uncommon at any time during the years of reproductive activity and has been attributed, without acceptable proof, to a variety of ovarian disorders. It affects the upper lip, cheeks, forehead and chin and is more apparent following sun exposure. Melasma can be superficial (epidermal) or mixed (epidermal – dermal ) or dermal when the pigmentation is in the dermis. Dermal melasma appears grayish blue in color

DERMATOLOGY and is quite challenging to treat. In superficial melasma, the affected skin is brown in colour. The pigmentary changes are seen over the cheeks, nose, forehead and the chin. Melasma is usually bilateral. RIEHL’S MELANOSIS– It is a distinctive pattern of greybrown facial pigmentation. The condition is more frequent in women. Exposure to industrial solvents containing tar derivatives, photosensitizers in cosmetics and fragrances are suspected to be the cause. Brownish-grey pigmentation develops quite rapidly over the greater part of the face but is more intense on the forehead and temples. Smaller pigmented macules, often perifollicular, lie beyond the indefinite margin. The pigmentation may extend to the chest, neck and scalp, and occasionally involves hands and forearms. Horny plugs fill the follicles and there may be some scaling. OCHRONOSIS- It is a bluish grey pigmentation of skin, due to deposition of homogentisic acid in connective tissue. It can be ether due to exogenous or endogenous cause. Exogenous ochronosis is seen with use of hydroquinone prepration and phenol. Exogenous ochronosis is becoming increasingly common in the modern times due to indiscriminate use of skin lightening creams for a prolonged period . Higher concentrations of hydroquinone ( > 2%) are more likely to cause this pigmentation. Milder cases show only macular spotty pigmentation whilst more advanced cases develop irregular stippling, papulation and pigmented colloid milia. These features tend to be most prominent over cheeks and temples. LICHEN PLAUS PIGMENTOSUS- This disorder is commonly seen in India and Middle East. The macular hyperpigmentation involves chiefly the face, neck and upper limbs, although it can be more wides pread, and varies from slate grey to brownish black; it is mostly diffuse, but reticular, blotchy and perifollicular forms are seen. Mucosal involvement can be seen in some cases. ADDISONS DISEASE- Hyperpigmentation in Addison disease is diffuse brownish colour. Predominantly affect sun exposed part. It is more prominent over the creases of palm and soles. Involvement of mucosa like oral, genital mucosa is common. Other features suggestive of Addison disease should be looked in such cases.The hypermelanosis is the result of increased secretion of melanotrophic hormones by the pituitary. Affected patients have elevated plasma levels of β-MSH-like immunoreactivity. CUSHING SYNDROME- Pigmentation is of similar pattern as seen in Addison disease. Seen in around 10% patient of cushing syndrome. It results from increased secretion of ACTH and β-MSH by the pituitary and may suggest the presence of a pituitary tumour. The hair is often darker and there are sometimes multiple lentigines and longitudinal pigmented bands in the nails. HYPERTHYROIDISM- Facial Pigmentation is seen in about 10% cases of primary thyrotoxicosis. It can be

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DERMATOLOGY diffuse Addisonian like pigmentation, but involvement of mucosa, nipple and genitalia is less common.The eyelids are occasionally conspicuously pigmented (Jellinek’s sign). Some patients show chloasmal rather than diffuse pigmentation.

Jan-Mar 2015

f. g. h.

History of topical hydroquinone application, application of hair dye History of multiple cosmetic usage History related to any systemic illness

treatMent hyperMelanosIs assocIated WIth other systeMIc dIsease NEOPLASTIC DISEASE- Oat cell carcinoma of the bronchus is associated with pigmentation due ectopic secretion of ACTH. There will be cachectic state with diffuse pigmentation as in Addison’s disease. There can be diffuse slate grey colour pigmentation secondary to melanoma and melanogenuria. LYMPHOMA– Diffuse Addisonian pigmentation can be a rare manifestation of Hodgkin’s disease (10%) and 1 or 2% cases of lymphosarcoma and lymphatic leukaemia. Diffuse progressive hyperpigmentation with pigmented purpura like lesion can also be a manifestation of mycosis fungoides. SYSTEMIC SCLEROSIS, SCLERODERMA AND MORPHOEA- Diffuse pigmentation of face involving predominantly forehead and lateral aspect of cheek and extremity is commonly seen. Reticulate pigmentation of upper back and chest is not uncommon. Along with pigmentation skin is bound down and indurated. Hyperpigmentation in systemic sclerosis is seen most commonly in patients with pigmented skin, and is less common in whites. Keratinocyte endothelin-1 production has been implicated as playing a central role in the pathogenesis of cutaneous hyperpigmentation in systemic sclerosis, as has local expression and systemic release of a stem cell factor.Pigmentation may also be a conspicuous feature of morphoea and is occasionally the presenting symptom. LUPUS ERYTHEMATOSUS- In systemic lupus erythematosus, diffuse pigmentation of light-exposed skin occurs in about 10% of cases. It may gradually darken, although the disease is controlled by treatment. RENAL FAILURE– Diffuse hyperpigmentation of face and hand is common in chronic renal disease. ANAEMIA- Vitamin B 12 deficiency can cause mottle and dapple pigmentation of face, hand and feet. Occasionally folic acid deficiency can cause diffuse pigmentation. PRIMARY BILIARY CIRRHOSIS- Hyperpigmentation is particularly striking on sun-exposed sites.

approach to patIent History a. b. c. d. e.

Ethnicity- pigmentary disorders are more common in fair skinned people Onset of pigmentation- congenital / acquired Aggravation with sun exposure – present in cases of freckels Associated with pregnancy History of OCP intake

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General measures- Photoprotection, avoidance of aggravating factors(if any) b. Medical treatmentXX Broad spectrum sunscreens XX Hydroquinone 4%- efficacy of treating melasma with 4% hydroquinone, for 3 months, is well demonstrated by placebo controlled trials. XX Side effects- local irritation, exogenous ochronosis XX Retinoic acid- 0.1% retinoic acid can be use XX Triple combination- hydroquinone 4%, tretinoin 0.05%, flucinolone acetonide 0.01% (modified kligman’s formula) can be used once at night for melasma, riehls melanosis, and in some cases of lichen planus pigmentosus. XX Side effects- burning and irritation, ochronosis(with prolonged application) XX Azelaic acid- 20% azelaic acid as a depigmenting agent, azelaic acid is moderately effective in treatment of melasma. XX Retinoic acid- 0.1% can be used in solar lentigenosis with moderate benefit. XX Lasers- A variety of lasers are available for treating the hyperpigmentation which include Q – switched ruby laser, Erbium Yag Laser.

Dr. Vibhu Mendiratta Dr. Vibhu Mendiratta is working as professor at Lady Hardinge Medical College. She has special interest in pediatric dermatology and has to her credit the prestigious Commonwealth Fellowship in Pediatric Dermatology from Great Ormond Street Hospital for children , London.. She is the Founder secretary of the Society for pediatric Dermatology, Delhi and was president of Delhi State Branch of IADVL , 2011. She has vast clinical experience in the infectious, pigmentary, papulosquamous and autoimmune blistering and allergic skin diseases. She has also authored several book chapters, published more than 80 scientific articles and presented papers in the National and International conferences.. She was awarded the “Developing Country Dermatologist Award- from Society for Pediatric Dermatology, USA in 2007., and WHO fellowship in the year 2011..

Jan-Mar 2015

ESTHETIC DENTISTRY

DIRECT LAMINATE VENEERS – PART IV Dr. Geoffrey M Knight

PUTTING IT ALL TOGETHER Once the technique for integrating varying shades and composite types to construct a single laminate has been mastered and the anatomical landmarks of a smile understood, the placement of laminate veneers becomes a series of sequential steps, each one following the other to successful completion.

reduce crevicular exudate. An antidote solution of Sodium Bicarbonate on hand is essential to neutralize any acid spills. XX Etch

for 5 seconds with 37% phosphoric acid, wash and air dry. Figure 2.

TECHNIQUE SUMMARY XX A

successful clinical outcome depends upon achieving healthy gingival tissues prior to any aesthetic procedure. Figure 1.

Fig : 2 XX Brush

a thin layer Resin Modified Glass Ionomer Cement mixed to a creamy consistency the over the surfaces to be laminated. Gently blow air over the teeth to disperse any pooling before photo curing for 10 seconds.

XX Apply

a thin layer of resin bond and cure for 5 seconds. This seals the tooth surfaces and reduces cervical staining. Figure 3.

Fig : 1 XX Remove

any unsatisfactory restorations and prepare retentive slots in existing indirect restorations.

XX Remove

pellicle from cervical margins with a 12 fluted tungsten carbide bur and clean remaining facial surfaces with a pumice prophylaxis.

XX Treat

the gingival margins with an astringent, such as Trichloroacetic acid (TCA)*, to prevent bleeding and to

Fig :3

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ESTHETIC DENTISTRY

Jan-Mar 2015

XX Using

a micro brush apply a thin layer of white tint over all tooth surfaces. The tint may be reapplied until any discolouration on the tooth is fully masked. The white tint acts as a reflector to throw transmitted light back through the resin and will enhance the brightness of the final laminate.

XX Next

apply a thin layer of base shade micro hybrid resin over each tooth to be laminated at a thickness of no more than ½ a millimetre and spot cure for 5 seconds. These materials have a high chroma, natural fluorescence and optical properties that will achieve superb natural tooth effects Figure 4.

Fig : 6 XX Contour veneers following aesthetic landmarks, using coarse

emery discs, pointed diamonds, 12 fluted carbide burs and fine Sof-lex disc.

XX Assure

that emergence profiles are parallel and mirror images of teeth in the adjacent quadrant. Figure 7.

Fig: 4 XX Brush

a thin layer of resin bond over each surface.

XX Next apply a small amount of micro fill resin over the cervical

third about, 1-2 shades darker than body shade and spot cure 5 seconds. Figure 5.

Fig : 7 XX Contour

proximal surfaces with abrasive metal strips and abrasive tape.

XX Check

the occlusion to make sure there are no interferences in either centric or lateral excursions, particularly at the limits of mandibular movement.

XX Finish

surface with Tungsten Carbide burs, rubber discs and Sof-lex polishing discs. Figure 8.

Fig : 5 XX Brush a layer of resin bond over the composite and remaining

tooth surface.

XX Apply body shade, placing vertical grooves with a flat plastic.

white tints sparingly and fold in the grooves to create thin white lines. Spot cure.

Fig : 8

XX Apply

XX Brush

resin bond over the incisal third of the laminate, apply incisal shade and spot cure.

XX Cure

all surfaces for 20 seconds.

XX Recall

patient at 1 week to check occlusion, margins, air bubbles and polish. Figure 9.

XX Separate

proximal contacts with a separating disc and insert paper points to prevent overhangs and to absorb any crevicular exudate.

XX Insert

a Mylar strip so that the paper point wedges the cervical margin.

XX Apply

resin bond followed by an incisal shade.

XX Fold

the Mylar strip around the proximal contour, hold in place and cure.

XX Cure

all surfaces for 20 seconds. Figure 6. Fig : 9

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Jan-Mar 2015 XX Recall

patient again in 3 months to fine tune the occlusion and for final polishing.

OCCLUSION Whilst composite and porcelain laminate veneers may fracture due to a random event such as biting on a hard object, most fractures result from nocturnal para functional clenching or grinding on laminates that encroach upon the occlusal envelope, often at the physiological limits of mandibular movement.

ESTHETIC DENTISTRY Patients and dental personnel must wear protective glasses when using TCA. Do not use Sodium Bicarbonate solution in the eyes. Neutralizing Solution Make up a solution by adding a spoon full of NaHCO3 to a proprietary Chlorhexidine Mouthwash. This will prevent bacteria from growing in the solution as would occur if straight tap water was used. Have the solution on hand whenever TCA is being applied.

Patients are usually unaware of such activity and clenching or bruxing is diagnosed by aligning upper and lower incisal wear facets, usually with difficulty and complaints from the patient. The wear facets will align at or near the limits of mandibular movement and the cause of persistent fractures will often become evident.

IN CONCLUSION Placing direct laminate veneers without tissue preparation is compatible with the philosophy of minimal intervention aesthetic dentistry and encourages better informed patients to seek out such practitioners. Upon mastering direct laminates a clinician is in a position to expand these skills to include single composite resin crowns, the placement of direct resin bridges and more complex clinical applications such as rebuilding vertical dimension for patients with gross occlusal wear.

CAUTION WITH THE USE OF TRICHLOROACETIC ACID TCA is a powerful chemical cauterizer and astringent that arrests gingival exudate and reduces the possibility of cervical staining. Place a small amount in a Dappen’s dish and transfer the acid to the mouth with a perio probe. The white eschar that forms on the gingivae is self limiting and will usually have disappeared by the completion of the procedure without scarring or gingival recession. Patients feel no pain when it is applied to gingival tissues or oral mucosa. If the acid inadvertently contacts a patient’s skin, it can be readily neutralized with a solution of Sodium Bicarbonate swabbed over the contaminated surface.

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 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.

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ESTHETIC DENTISTRY

Jan-Mar 2015

WHITENING VS. BETTER ENAMEL CARE (ACP WHITENING) – ‘WANT’ OR ‘NEED’ BASED DENTISTRY?

Dr. Rumpa Wig

Recap previous articles

Myth 1: 8 – 10 shades possible? What does it mean? Factual Truth 1: Re-arrange shade guide as per chroma(light to dark) and not on hue (colour) . Result of 10 shade jump is achieved fastest with an in-office power bleach system. Myth 2: Higher the concentration peroxide … better the result? Factual Truth 2:Just because you use the highest peroxide does not mean you will get the best possible whitening result. In fact you are advised by the ADA to use peroxide of as low a concentration as possible. The role of catalysts and sensitivity markers have been proven to aid whitening and optimal results can be obtained with lower concentrations of peroxide. Myth 3: Do Tooth Whitening lights really work to better whitening results? FactualTruth:It’s not the light but the chemistry between the light and gel that needs to be checked. Most lights have heat chemistry with the gel to hasten oxidation. This just hastens the effect, does not better it. Lights like ‘Zoom’ have a photo-reactive chemistry with the gel that betters whitening 3 times with minimal heat. Therefore it uses only 25% hydrogen peroxide. B1 in 45 minutes in most patients.

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Myth 4 : Is Fluoride the final authority on sensitivity? Factual Truth 4: No. Fluoride is not the final authority on sensitivity management. It is best achieved in combination of ACP (amorphous Calcium Phosphate) + Fluoride + KNO₃. ACP is a very important new entrant in management of sensitivity as it enhances the uptake of fluoride and synergistically aids enamel care to result in much better sensitivity management than achieved by fluoride alone. Proven and supported by the ADA.

MYTH NO 5:WHITENING IS ‘WANT BASED ‘DENTISTRY! Should treatment focus be Vanity or Dentistry?

INTRODUCTION Do we really have a definition for ‘want’ based and ‘need’ based Dentistry? What we do have is a broad perspectiveof ‘want’- based and ‘need’- based dentistry. Simply, ‘want based’ would be that which the patient asks for and is not a critical need of the hour. ‘Need based ‘ dentistry would be that which is the need of the hour or when treatment is given when the patient is in difficulty or in pain. Most of our practices are devoted to ‘need based’ dentistry merely because that is the bulk of the patients we get.

Jan-Mar 2015 People do not want to come to the dentist unless they have a problem to address.

ESTHETIC DENTISTRY WHAT PATIENT RESPONSES DO WE EXPECT WITH THESE NEW PARADIGMS ?

We are a little different from the western world. They have patients that come into a dentist’s office with requests that are not need based. That’s probably because they come in for hygiene appointments, are comfortable with the clinic and then are very aware and comfortable seeking additional work done to enhance their smiles. Western Dental offices also are much more aggressive in offering treatments with special offers than Indian offices are. Since we do not have typical hygiene departments in our dental offices we tend to miss out on entire section of society till the need arises.

TRUST

CONFIDENCE

COMFORT

STRONG RELATIONSHIPS

INCREASE IN VISITS

MORE REFFERALS

PRACTICE GROWTH

THE NEED OF THE HOUR IS THAT WE ADDRESS THE WANTS OF OUR PATIENTS MORE EXPLICITLY , AND IN DOING SO ,ALSO TAKE CARE OF THEIR NEEDS!

We have touched upon this subject in every article, but today it is the only topic of focus as it is the future of Whitening and deserves special attention in your practice.

Whitening has remained an appointment that is given out , if the patient asks for whitening.

WHAT IS ACP?

In this article , I humbly attempt to change that myth , that keeps whitening in the domain of vanity – ‘beauty without a purpose’ and therefore a ‘wantbased’ treatment! Whitening ,when done right , does not need to be a ‘want’ but can actually be a platform where you can address more than just whitening ! We need to transform the bleaching appointment into a Pro-active Care appointment or ‘need to change the health of your enamel before trouble comes’ kind of appointment. You possibly cannot change the health of enamel by keeping it dirty yellow or brown. The colour of health on the enamel is WHITE. Sounds Interesting? It is, especially when the hygiene appointment is not interesting enough to get the patient on the chair regularly to address his needs in time. Let’s get started.

PARADIGM SHIFTS REQUIRED BY THE CLINIC 1.

Patient’s tooth Smile is the Dentist’s responsibility.

Active care to Proactive care. Protecting and highlighting smiles are also our responsibility.

Heal to health to Beauty. Dental health comes before vanity.

Progression of treatment –

WHAT IS ACP WHITENING?

ACP is an abbreviation for Amorphous Calcium Phosphate. ACP is created when dissolved Calcium ions and phosphate ions react to form a non-crystalline insoluble salt. Due to the reactive nature of the chemicals involved, the calcium and phosphate must be stored separately until they are applied to the tooth surface. You will find them dispensed in dual barrel syringes. Tooth demineralization from acid results in dulling, loss of tooth luster, and a higher susceptibility to caries. The oral environment can naturally rebuild enamel, through a process called remineralization, to some extent on its own, but the extent of remineralization is controlled by pH and the amount and availability of calcium and phosphate ions present in the mouth. Remineralization can easily be reversed in an under-saturated environment. The rebuilding of enamel is a slow kinetic reaction which can be rapidly sped up by the addition of ACP-forming components into the oral environment. Amorphous Calcium Phosphate (ACP) is the reacted complex of calcium and phosphate ions that precipitate and can grow on tooth surfaces in the oral environment.

Non – invasive tominimally invasive toinvasive with maximum care. Natural Enamel is precious !

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Issue 3 Vol. 1

ESTHETIC DENTISTRY HOW DOES ACP WHITENING WORK?

Jan-Mar 2015 Effective Desensitizer ACP mimics the natural desensitizing process by eliminating the source of sensitivity by plugging dentinal tubules with calcium phosphate, the tooth mineral. This is similar to the process of sclerosis, where salivary mineral precipitates slowly over time in these tubules and reduces sensitivity. ACP simply speeds this process considerably with the same mineral at much higher concentrations. ACP has been clinically shown to dramatically reduce dentinal hypersensitivity by occluding dentinal tubules. Philips-Discus Dental whitening gels, such as Nite White ACP, Daywhite ACP , Dash , Zoom Whitespeed ,are the only professional whiteners to combine patented ACP technology with the proven effectiveness of Potassium Nitrate to establish a new standard for patient comfort in professional whitening.

ACP WHITENING ISA 3 PRONGED ACTION PLAN! 1. Whitening 2.

Fluoride & KNO₃

3. ACP The differentiating factor is ACP ! Peroxide, fluoride, potassium nitrate and ACP are dispensed in a dual barrel syringe to provide a fresh blend of a multi-action system that : - heals surface defects, - remineralises, - strengthens and protects the enamel while whitening.

BENEFITS OF ACP WHITENING Rebuilds Enamel The deposition of hydroxyapatite onto teeth rebuilds enamel and restores luster through a process called remineralization. Preliminary research by Flaitz & Hicks at the University of Texas, Huston, showed that, “The addition of calcium phosphate to whitening agents reduces the susceptibility of enamel to in-vitro lesion initiation and progression.”

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Improved Appearance – Restores Enamel Luster ACP has been clinically shown to improve the smoothness and luster of teethby filling superficial tooth defects and improving the overall smoothness and luster of patients’ smiles.

Jan-Mar 2015 Lasting Results In clinical studies, patients who used a take-home dental tooth whitener containing ACP experienced less fadeback six months after treatment compared to patients who used an identical take-home whitener without ACP.DA

ESTHETIC DENTISTRY “NEED” for PROACTIVE CARE,‘OralWELLNESS’called lifestyle dentistry which is the order of the day! That it adds to your bottom lines, only helps the cause. A word of caution, patients are well-informed and they will catch up to ACP whitening earlier than you might ! Food for thought: Patients are looking for whitening. Does your office suggest that you are ahead of the game with treatment options that are both appealing and actually good for your patients? A professional Dental Office has to do more than ‘look good ‘and ‘feel good’ ….. It has to DO GOOD.

The compelling evidence suggests that we take the step forward to change : XX Our

perception,

XX Our

protocols,

XX Our

communication, and

XX Our

products to include ACP whitening as the right way to whiten.

Philips Oral healthcare has an entire range of :XX Light-

We often find it difficult to promote whitening in practice. The difference now is that health &healing are associated with whitening.ACP -WHITE IS GOOD!Talk about it! If you need artwork - posters , table tops etc you can call M&M dental Associates , that customize artwork to your clinic requirements for ACP Whitening. They are the channel Partners for Philips in India. www.mmdental.com IF YOU HAVE ANY QUERIES ……( THIS IS THE LAST PARA AS IN ALL PREVIOUS ARTICLES . Please take the same from your previous journal ) .

assisted ACP whitening : Philips ZOOM !

XX Non-light

assisted In-Office ACP Whitening : DASH ,

XX Tray

assisted home whitening with Nitewhite ACP and DaywhiteACP

XX And , independent ACP delivery in the form of Relief ACP gel.

They are the only ones in the world to offer ACP Whitening a patent acquired from the ADA.

CONCLUSION Bleaching is a ‘want based’ treatmentoption.‘ACP whitening’ is not! With ACP whitening, it is easier to promote oral health,wellbeing and healing to preserve and conserve what nature gave us before we promote Cosmetic Dentistry. We now have a tool that helps us reverse neglect and get our enamel back to shape. Patients get it, if we project it in the right way. Being in shape is not a one-time exercise. Easy Regular care goes a long way to preserve and protect your enamel. It has to be hygiene, whitening and finally ‘health of enamel’ that is the protocol for whitening success. “WANT”now metamorphs into

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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Issue 3 Vol. 1

ESTHETIC DENTISTRY

Jan-Mar 2015

PRINCIPLES OF CREATING A SMILE THE CONCEPT OF BIO-ESTHETIC DENTISTRY Dr. Vinisha Vipin Sharma

In our modern competitive society, a pleasing appearance often means the difference between success and failure in both our personal and professional lives. Scottish physiologist Charles bell (1774-1842) was quoted as remarking that the thought is to the word that the feeling is to the facial expression. He pointed out in 1806 that a smile could convey a thousand different meanings, yet it is the most easily recognized expression. And because the mouth is one of the focal points of the face , it should come as no surprise that the smile plays a major role in how we perceive ourselves, as well as in the impressions we make on the people around us. A charming smile can open doors and knock down barriers that stand between you and a fuller, richer life. An attractive or pleasing smile clearly enhances the acceptance of the individual in the society where he belongs and the character of the smile influences to the great extent the attractiveness and the personality of the individual.

SMILE DESIGNING Is a process whereby the complete oral hard and soft tissues are studied and evaluated and certain changes are brought about which will have a positive influence on the overall esthetics of the face. These changes are governed by the principles of bio-esthetic dentistry. Hence, a good smile

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design would naturally and effortlessly blend with the rest of the face to provide an esthetic and functional complex.

PRINCIPLES The Principles of Smile Design govern how naturally attractive your smile is – or isn’t! When art, science, form and function are blended optimally by nature or an experienced cosmetic dentist, the results can be simply amazing! Experienced cosmetic dentists understand and use these principles to transform dull average smiles into successful confident smile. 1. Central incisor width/height ratio The width/ height ratio should be 80 %. For example if width were 8.0 mm and the height 10 mm, the ratio (8/10) would be equal.

Jan-Mar 2015 2. Mesial Inclination Each upper tooth visible during smiling should have a slight inclination or tilt that is towards midline of the mouth.

ESTHETIC DENTISTRY 5. Smile at rest 2-4 mm of upper teeth should be visible at rest. This amount decreases with age as the window of the mouth begins to sag downwards showing more of lower teeth.

Surprisingly if these lines are extended downwards they would meet or converge at or near navel point of stomach.

3. Midline The position of the midline between the central incisors should be a line drawn from between the eyes down through the nose, lips and chin. The angle of the midline should not be tilted to the left or right, but should be straight up and down.

4. Colour and shade The teeth should be uniform in colour and shade. The presence of stains, markings necessitates the treatment for the same.

6. Gingival symmetry The gum tissue frames the teeth and forms a curtain for the teeth. The gingival margin should be scalloping and symmetrical on both the sides. Balance and symmetry are important for an attractive smile.

7. Gingival margin height The height of gingival margin over the lateral incisors should be slightly lower than the height of gingiva over adjacent central incisor and canines.

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ESTHETIC DENTISTRY 8. Gaps/ Diastema Diastemas are unsightly gaps present between the anterior teeth. They should be restored with full coverage crowns or composite restorative material.

11. Smile Line The incisal edge of the maxillary central incisors should be parallel or follow the contour of lower lip at rest or when smiling.

9. Gummy/ Gingival smile When an excess of gingiva superior to the maxillary anterior teeth is displayed upon full smile, it is termed a gingival smile. The gingival smile is known by a variety of terms including “gummy smile, high lip line, short upper lip, and full denture smile.” Ideally 1-3 mm of gingiva should be visible above the teeth.

12. Horizontal plane The left to right horizontal biting plane of the mouth should parallel the floor or horizon when standing. It should also parallel a line drawn between eyes i.e. inter papillary line.

10. Gingival Zenith The upper most height of gingival margin over each tooth is called the gingival zenith. The height of the gingival margin over each tooth varies from tooth to tooth. It should be centered over each lateral incisor and should be 2/3rd of the way across the face of the tooth for central incisors and canines.

Jan-Mar 2015

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13. Gingival health Healthy coral pink gingival is indicative of a good gingival health. For an attractive smile gingiva should be free of calculus and bleeding or halitosis.

Jan-Mar 2015 14. Contact points The contact points between two teeth should step upward with each tooth. They should not gradually migrate upwards from tooth to tooth.

15. Crowding or Mal-alignment Crowding is usually present if there is lack of space for teeth to erupt or if the jaws are too small. Mal-alignment of teeth lead to lack of oral hygiene maintenance and poor facial and esthetic appearance.

16. Incisal Embrasures The silhouette between front teeth should be triangular in shape i.e the outline shape between incisors should symmetrically increase in size moving away from the midline. A good definition and separation between incisal edges of front teeth is indicative of a harmonious smile.

17. The Golden proportion The Golden Proportion is an art of ages follows the “rule of thirds”. It is used as a tool by the cosmetic dentists to create a pleasing smile that is balanced with the face. It states that each tooth away from the midline should be

ESTHETIC DENTISTRY two-thirds as wide as the previous tooth. For example: Measure the width of a central incisor in your mouth or on a photograph. Divide this width by the width of the lateral incisor next to it. The central incisor should be 1.6 times as wide as the lateral, and the canine 0.6 times as wide as the lateral, and so forth. (Example: Ideally, if the central incisor is 10 mm wide, the lateral incisor should be twothirds of this amount, or about 6.5 mm, and the canine should be two thirds of that or about 4.4 mm).

18. Black triangle It is the spacing between anterior and posterior teeth due to underlying bone loss. When this process takes place underlying gingival papilla shrinks which allows darkness from the back of teeth to show through and mimic a black triangle.

19. Anterior guidance The relationship of anterior teeth with function is also an important for determining a balanced occlusion. The contour and position of upper and lower anterior teeth is so critical that even a millimeter in incisal edge location can be unacceptable to some patients. 20. Vertical dimension The loss of vertical dimension makes your face appear older. The vertical distance between the nose and the chin can be short due to improper growth and development of the jaws and deep bite, or because of attrition or missing teeth. As a rule of thumb, the measurement between the marginal gingival and central incisor edge on occlusion averages between 17-21 mm. For most people this creates a vertical proportion to the lower 1/3rd of the face that is pleasing to the eye.

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ESTHETIC DENTISTRY estHetic dentistry D. Rare adverse effects of longer duration that can be serious and are not technique dependent » Immediate hypersentivity reactions » Urticaria » Anaphylaxis » Soft tissue edema » Dyspnoea

Characteristics seen in YOUNGER TEETHXX Long,

rectangular central incisors

cases

XX Prominent

incisal embrasures

XX Mammelon pattern , greater thickness and volume of enamel

giving it a pronounced halo

XX Lighter XX 65%

colour and increased value

width – length ratio

Characteristics seen in MATURE/ OLDER TEETHXX Square

shape of central incisors

XX Central

incisor is shorter

XX Decreased XX Sharp

and angular incisal corners

XX Darker XX 90%

Preoperative incisal embrasures

colour and decreased value

width-length ratio

Tools to aid in making patients look youngerXX Creating XX Make

central dominant is the key

the teeth lighter with the centrals the lightest

XX Central

incisors should Post be longer operativeand lateral incisors should be shorter ( 60-65% width-length ratio) than a line drawn from the centrals to the cuspids

XX Central

incisors

incisors should be more facially placed than lateral

XX Increased XX More

incisal translucency

texture and anatomy to the incisors

XX Characterization

of incisal edges by mammelons and avoiding straight planes

XX Rounded XX Incisal

Pre operative incisal line angles

embrasures with more depth and volume

XX In

a relaxed lip position or M position , tooth display should be 3-4 mm

In order to create harmony between facial and functional structures, clinicians must consider principles of Bioesthetic dentistry that enable objective and subjective assessment of the patient’s condition and subsequent Post operative

40 38

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Jan-Mar 2015 Apr-Jun 2014 development of a comprehensive, multidisciplinary treatment plan. conclusIon Bio-esthetic is defined as the study medicine or theory With plastic Dentistry surgeons, dermatologists, internal of the beauty of living things in their natural form and physicians, obstetricians gynecologists, opthamologists, function. requiresphysicians’ a complete evaluation various podiatrists,It nurses, assistants, andofmedical aspects of the(who patient’s cavitybeand facial structures aestheticians may oral not even medically trained) including eyes, posture, andand the aging process. delivering expressions, BOTOX to pa tients in the oral maxillofacial To fully this approach, it is therefore necessary for areas, it isgrasp certainly time to recognize that dentists can be just as proficient in these injections than anyasofathese healthcare dentists to observe components single, collective providers. Dentists also have much expertise in the oral unit. and maxillofacial areas. We are also trained to be experts In general, the goals of Bio-esthetic dentistry include in the muscles of mastication and the muscles of facial maximizing the anterior guidance and making the expression which routinely receive these treatments. posterior segment vertical, which minimizes the influences Hands-on is absolutely essential inoflearning how of condylartraining guidance on the morphology the posterior to provide these procedures and intertwining them with teeth. dental treatment plans. With proper training, dentists are Once natural formthan andany function been restored usuallythe more proficient of thesehas other healthcare we can create more harmony by Rejuvenation Spa professions in providing these treatments to patients, both Dentistry which comprises for dental and cosmetic needs. of lasers, dermal fillers, microdermabrasion, skin rejuvenation, and Botox. It is time to broaden our horizons as a profession and The fusion cosmetic dentistry with aesthetic use all of theoftools available to us. BOTOX therapy facial is a treatments achieves maximum client and practice benefits. conservative, minimally invasive treatment that can expand Dental practicesoptions are expanding the oflevel of aesthetic/ our therapeutic for the benefit our patients and cosmetic justwe thearesmile thedental whole is a naturaltreatments progressionfrom of where going to in the face to create a kinder, gentler feeling regarding dentistry industry. However, as these spa-like amenities are working; the term “dental spa” sometimes is misunderstood. It’s not about clients walking around in robes, but more about providing aesthetic enhancement treatment procedures in addition to quality dentistry.

Dr. Vinisha Pandey Dr. Vinisha Pandey, is an Endodontist and Cosmetic dentist, working as an assistant professor in the department of Conservative dentistry & Endodontics at Rama Dental College, Kanpur. Pioneered in a number of innovative clinical procedures in aesthetic dentistry with special interests in Smile designing and makeovers using lasers, botulinum toxin and fillers. Published many articles in international and national journals. Achieved Standard competency in dental lasers from University of California, San Fransisco (UCSF) and Botulinum toxin & fillers training from International Academy of Facial Esthetics (IAFE). Keeps abreast of latest developments in cosmetic & dental field.

Jan-Mar 2015

March 2015 2015 WSRM World Congress Date: 19th-22nd March 2015 Location: Mumbai, India Email: zita@iprasmanagement.com Website:http://www.ipras.org/

Indian Event Calender January-2015 IAOFE Botox and Dermal Filler Training Course Date: 15th,17th,18th-January-2015 Venue: Sense of Smile, Greater Kailash-2, Delhi Contact No. : 9810833218 Email: shourya@iaofe.com Website: www.iaofe.com

February 2015

March 2015

IAOFE Botox and Dermal Filler Training Course

Date : 14th-15th Feb.-2015 Venue : Edudent Training Institute, Indiranagar, Bengaluru Contact No. : 9810833218 Email: shourya@iaofe.com Website: www.iaofe.com

Date: 7th-8th-March-2015 Venue: Sense of Smile, Greater Kailash-2, Delhi Contact No. : 9810833218 Email: shourya@iaofe.com Website: www.iaofe.com

Issue 3 Vol. 1

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International Event Calendar September 2015 32nd Annual Meeting of the Ohio Dermatological Association Date: September 9th-12th 2015 Venue:Hilton Columbus at Easton, Columbus Contact Name:Cynthia K. Bartunek Company:Ohio Dermatological Foundation Phone:330.720.3847 Fax:330,372.6734 Email:ODAExec@gmail.com

Jan-Mar 2015 June 2015 23rd World Congress of Dermatology (ILDS) Date: June 8, 2015 -June 13, 2015 Venue: Vancouver, Canada Email: info@derm2015.org Website: http://www.derm2015.org/

January 2015 March 2015 American Academy of Dermatology, 2015 Annual Meeting Date: March 20-24, 2015 Venue: San Francisco, Calif.

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8th Oculoplastic Symposium Date: January 21, 2015 Tel: 435- 729-9459 Email: srussell@gunnerlive.com http://www.plasticsurgerypractice.com

Jan-Mar 2015

International Event Calendar

March 2015

November 2015

13th Anti-Aging Medicine World Congress

10th WORLD CONGRESS OF THE INTERNATIONAL

Date: March 26th-28th, 2015 Tel: +33 (0)1 56 83 78 00 Fax: +33 (0)1 56 83 78 05 Website: http://www.euromedicom.com/

ACADEMY OF COSMETIC DERMATOLOGY (IACD) Date: 14th-16th November 2015, Venue: Rio de Janeiro, RJ Brazil Tel: +55 21 2286 2846 E-mail: contato@iacdRio2015.com.br, www.iacdRio2015.com.br

April 2015

October 2015

4th World Congress of Dermoscopy

11th EADV Spring Symposium â&#x20AC;&#x201C; The European Academy of Dermatology and Venereology

Date: 16th 18th,April 2015. Venue: Vienna, Austria, Website: http://www.dermoscopy-congress2015.com

Date: 7-11-October-2015 Venue: Belgrade, Serbia Website: www.eadv.org

Issue 3 Vol. 1

Facethetics

A Publication Group

INDIAâ&#x20AC;&#x2122;S LEADING PUBLICATION GROUP REACHING GLOBALLY

A Journal For Dental Professionals

A Journal For Complete Facial Esthetics A Publication Group

A Journal For Medical Professionals

IVORY INDIA F-41/B, GF, Barkat Apartment, Shaheen Bagh, Abul Fazal Enclave-II Okhla, New Delhi-110025, Tel: (+91) 11-26941512 For Any Query Please Contact: info@ivoryindia.in