Home Clinical Esthetics With Botulinum Toxin, Fillers And Imaging Technology

Esthetics With Botulinum Toxin, Fillers And Imaging Technology

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Presenting outcomes to patients who present to our offices requesting changes in their facial esthetics can be a challenge. With clinical expertise and experience the dentist may be able to visualize the end result well, but how do we communicate this to our patients? What do we do when our dental reconstructions are completed, but the patient still wants us to evaluate and improve their facial contours?

Modern techniques allow the practitioner to determine the final prosthetics and virtually present them. The LumiSmile mobile application (DenMat, denmat.com) is available through the Apple App Store and is used to show the patient their new smile in a matter of minutes. In the past if we wanted to show a patient how their tooth esthetics could be changed, we would make an impression and have our dental laboratory create a diagnostic wax up. This would be returned to us and at a second consultation appointment we could sit next to the patient and show them these hard models. That’s fine, but often the patient could not really appreciate what the final esthetics would be like in their mouth, with their lips and facial features. We would also be spending valuable chair time with this second consultation. These excess dental appointments can be difficult for both the patient and the doctor.

The technology of LumiSmile has actually been around for many years, but in the past it was only available in a printed form after a photo was taken with a digital camera. Today, the app used in conjunction with our smart phones make the process of creating the pre-operative photograph simple and non-invasive to the patient. We create a patient profile through the LumiSmile app and simply snap a frontal full face photo which is then uploaded. In minutes, the team at DenMat creates the esthetic virtual design. This newly created smile makeover is sent to the dentist and the patient via email or text. We then can sit and have a conversation about the cosmetic options. This all can be completed in one chairside visit. The LumiSmile technology is completely portable and easily accessible from the smart phone.

In our practice, it has helped us educate our patients as to the benefits of our treatment and has increased patient acceptance. Now the patient can, within 20 minutes, evaluate the esthetics and share with their families and become motivated to proceed with treatment. Our experience has been that the patient immediately shares the before and after photos and often places them on social media networks. What an awesome way to market your practice in a positive way. Our patients become emotionally involved in this entire process.

LumiSmile is available through the DenMat Smile Discovery program. The intention is to increase esthetic cases by allowing the patient to become directly involved in the design. The process is fast and seamless.

Figure 1: Pre-operative view of unesthetic peg lateral incisors.

Here, our young patient presents with peg laterals that she wanted corrected. Figure 1 illustrates the concern the patient had with the esthetics of her lateral incisors. At first, she insisted on preparation of her maxillary anterior teeth to give her a “Hollywood” smile. Our professional dilemma was that her teeth were actually very healthy and esthetic. We wanted to be able to show her how just improving the contours of her lateral incisors, we could dramatically improve her smile.

The LumiSmile mobile app was used to show our patient the potential esthetic improvements we could make both with just improving the laterals and changing the maxillary anteriors in total. After snapping the photo on an iPhone, it was downloaded on the app and within 20 minutes the virtual design was sent to us and the patient. (Figure 2) The motivation to move forward was intense and the past apprehension with dental procedures seemed alleviated.

Figure 2: Within approximately 20 minutes, the patient and doctor receive the pre-operative facial photo and post-operative potential digital design of new crowns.

A final tool used in the practice that helps create proficiency and efficiency is the portable soft tissue NV PRO3 microlaser. (Figure 3) It weighs only 1.9 ounces and is easily transported from operatory to operatory. Its cordless design and excellent shape make it our favorite to use. It is really not much bigger than a Sharpie. The class IV laser device has a lithium ion battery with over and undercharge protection and delivers thirty minutes of continuous operation at 1.2 watts or power. The twelve preset procedural settings are used for all periodontal, restorative and orthodontic treatments.(4)

Figure 3: The NV PRO3 diode laser

There is a wireless foot pedal and audible notifications to make the patient aware of its active use. The fiber tips are disposable. The soft tissue laser can deliver between 0.1 and 2.0 watts of power in continuous wave or pulse mode. The wavelength of this tool is 808nm (+/- 5nm).

Figure 4: The NV PRO3 efficiently and quickly laser troughs the crown preparations in lieu of conventional retraction cord.

The NV PRO3 diode laser eliminated the need for us to use retraction cord following preparation of the teeth for esthetic crowns. (Figure 4) The laser is reasonably non-invasive and helps in hemostasis around the margins. This allows for precise impressions and accurately fitting crowns.

It is a fast procedure with the average time for me to retract using the diode laser to be about 30 seconds. Because we are essentially cutting the tissue around the prepared teeth, the fiber tip is initiated using dark occlusal paper. The tip is kept in constant motion to eliminate damage to collateral tissue. The laser fiber creates less damage to periodontal ligament fibers than packing retraction cord.(4)

Figure 5: Final Emax crowns seated

The team at the dental laboratory (DenMat) fabricated Lithium Disilicate crowns with cutback (Emax) to create the final esthetic result (Figure 5).

Another popular therapy to meet the esthetic requests of our patients is the use of botulinum toxins and collagen fillers. The lip flip procedure is utilized using botulinum toxin, Dysport, to create fuller lips. Lips, of course, are a most integral part of perceived facial beauty. The lip flip is a non surgical process that adds volume to the lips and reshapes them. The pink portion of the upper or lower lips is increased and the distance between the lips and the nose are reduced.(1,2)

As dentists, along with our dental laboratories, we can create amazing transformations of the dentition. The restorations create a more youthful appearance. However, appearance of the face is also altered with aging. The toxin is injected into affected muscles or glands using a 30 gauge 1 inch needle. Doses are tailored according to the mode of use and individual patients, and the dose depends on the mass of muscle being injected.(1)

Six units of toxin are placed around the vermillion border of narrow lips.

Figure 6: Pre and post operative views of the botulinum toxin lip flip procedure.

After a few days, the toxin activates creating the illusion of fuller lips. The patients are instructed to go rest with no stenuous activity for a couple of days. Regular interval injections may be required depending on the dose and the individual’s susceptibility. (Figure 6)

Figure 7Figures 7 and 8: Pre and post operative views of collagen fillers used to improve the facial features of our happy patient.

Collagen dermal fillers can also be utilized to minimize fine lines and wrinkles following our dental reconstructions as seen in Figures 7 and 8. In the midface, Lyft or Voluma (HA fillers) are placed creating a lifting effect. The cheeks appear fuller and lift the midface fat pads which decreases the nasolabial folds. Placing fillers, such as Restalyn, Silk or Defyne in nasolabial folds decreases lower face sagging.3 Also, filler in marionette lines improves down-turning of the corners of the mouth. Fillers placed in the lips will improve the cupid’s bow and philtrum as well as the vermillion border. Volume in deficient lips can also be increased. The esthetic results can last up to several years, but can be accentuated periodically.

These small improvements have a large impact on the esthetics of the patient. The results can be seen quickly and the patients love it. The use of botulinum toxin and fillers can be a profitable treatment for the dental practice. Obviously, proper training is required. The fees charged to the patient for Botox range for from $10.50-14 per unit. For example, treating the forehead may take 25-40 units. Treating around the mouth may take 6 units and around the eyes 9-12 units. Fillers range from $550-800. Professional fees are normally two times the cost of the product and may depend on the time spent by the dentist. Products such as Dysport costs the practice around $535 per 300cc vial. Lyft is about $292, Refyne and Defyne around $333 and Silk is $281 on average.

Conclusion

The NVPRO3 microlaser is an excellent investment that can be used for many dental procedures. Uncovering buried dental implants, without the need for local anesthetic infiltration, troughing around a crown preparation, thus eliminating the need for retraction cord, for outstanding traditional polyvinyl siloxane impressions.

The LumiSmile mobile app is an excellent adjunct to our patient education. Often patients are unaware of the positive results we can accomplish as dentists. Certainly, showing before and after photographs of past treatments is fairly conventional as is doing diagnostic wax ups of study models. This innovation allows us to virtually design a prosthetic case in a very short amount of time all in a single dental visit. The motivation and excitement created as we are able to improve the quality of life of our patients make this a valuable asset in my practice.

Botulinum toxins and collagen fillers are another adjunct to our potential treatment modalities. They provide the final “icing on the cake,” so to speak on our esthetic dentistry. Proper training is paramount in the success of their use, but the techniques have improved our patient’s image to a high degree.

REFERENCES:

(1) https://maccablo.com/botox-lip-flip-cosmetic-treatments/ 

(2)  https://www.ncbi.hlm.nih.gov/pmc/articles/PMC2856357/ 

(3) https://www.webmd.com/beauty/cosmetic-procedures-collagen

(4) Stomatol, A. Effectiveness of a Diode Laser in Addition to Non-Surgical Periodontal Therapy: Study of Intervention. Annali Di Stomatologia. 2015, Jan-Mar; 6(1). 15-20.

Dr. Stephanie Tilley is a graduate of the University of Alabama School Of Dentistry. Dr. Tilley is a native of Pensacola, FL and has been practicing dentistry in her hometown since 1998. Dr. Tilley keeps up with the latest in dentistry by attending continuing education seminars on topics such as oral surgery, implants, veneers, periodontal disease, cosmetic procedures, and much more. Dr. Stephanie has also done extensive training at Las Vegas Institute and The Engel Institute with Dr. Timothy Kosinski and Dr. Todd Engel. She is a member of Academy of General Dentistry, American Dental Association, Florida Dental Association, Alabama Dental Association, Academy of Laser Dentistry, Oral Implantology and the Academy of American Facial Esthetics. Dr. Tilley can be reached at mail@emeraldcoastsmiles.com.

Dr. Timothy Kosinski is an Affiliated Adjunct Clinical Professor at the University of Detroit Mercy School of Dentistry and serves as the Associate Editor of the national AGD journals. He is a past president and editor of the Michigan AGD. Dr. Kosinski has placed over 14,000 dental implants and published over 190 articles on the clinical and prosthetic phases of implant dentistry. He received the Academy of Dentistry International’s Humanitarian Award “in recognition of significant contributions to the enhancement of the quality of life and the human condition.” Dr. Kosinski can be reached at 248-646-8651, drkosin@aol.com or www.smilecreator.net.

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