Feeling Good and Looking Great

June 2013 AGD Impact by Dr. Louis Malcmacher

14 AGD Impact | www.agd.org | June 2013

Feeling Good and Looking Great The Relationship Between Esthetics and Therapeutics

There is a misconception in dentistry that esthetic procedures and therapeutic treatment are two separate entities that have nothing to do with each other. However, nothing could be further from the truth. Dental esthetics is often very similar to dental therapeutics, and vice versa. In fact, nearly all of dental therapeutics falls completely within the realm of dental and facial esthetics.

More than 30 years ago, dental professionals fought a similar battle regarding the use of porcelain veneers. At that time, bonding a thin piece of feldspathic porcelain onto tooth enamel was revolutionary. The original porcelain veneers were no-preparation restorations, and controversy developed over whether they were actually therapeutic or just simply esthetic.

During that time, dentistry was much more about function than it was about esthetics, and some believed that giving patients porcelain veneers for esthetic reasons was an unethical practice that cheapened dentistry. This same outcry rose once again when tooth-colored restoratives were introduced. Prior to this time, amalgam was the restorative of choice and it served its therapeutic purpose well. Because of this, many dental professionals who preferred the newer composite resin restorations were told that they were doing unnecessary dentistry. Porcelain inlays and onlays also were hit with the same argument—gold was the material of choice for posterior restorations (it still is, but no one wants it), and those who chose otherwise were accused of giving into patients’ desires without considering their best interests.

But as you all know, all of the above mentioned procedures are now well integrated into most dental practices and well accepted by the profession and patients alike. Although all of these therapies were developed in the name of dental esthetics, we learned over time that, when done well by the clinician, they all can be successful and serviceable for decades. Dental esthetics itself cannot survive on its own without a dental therapeutic component that allows it to function as a long-term, excellent dental restoration.

Soft tissue esthetics and therapeutics

In recent years, botulinum toxin (BOTOX®, Dysport®, Xeomin®) and dermal fillers (Juvéderm®, Restylane®, Belotero®, Expression®) have made their way into dentistry for both esthetic and therapeutic uses in the oral and maxillofacial areas. Some of the same controversies from the past have resurfaced, and just like in the days of old, most of the comments come from dental professionals who have not yet been trained in these nonsurgical, minimally invasive techniques—they have no idea what these techniques are and what can be accomplished by using them.

Botulinum toxin has a more than 20-year history in the treatment of temporomandibular joint (TMJ) syndrome and myofascial pain. Because botulinum toxin affects head and neck muscles and their relationship to the dentition, it is now a common adjunctive treatment for many dental cases, whether it’s used for esthetics or therapeutics. I routinely use botulinum toxin for TMJ syndrome, myofascial pain, maxillary gingival excess (gummy smile), bruxism, differential diagnosis, orthodontic relapse, retention of removable prostheses, and treatment of angular cheilitis.

Dermal fillers are used commonly to add volume to the midface and supporting soft tissue structures around the mouth so that the patient’s smile actually shows porcelain veneers, implants, or any other dental work from molar to molar. We also use dermal fillers to establish proper lip lines, smile lines, and phonetics, as well as to eliminate deficient interdental papilla (commonly referred to as black triangles), completely changing the way we look at this most frustrating challenge.

The integration of esthetics and therapeutics

Botulinum toxin is used whenever there is a muscular component to myofascial pain, which occurs 85 percent of the time, according to some studies. When a patient is properly evaluated and properly treated, botulinum toxin is highly effective in relieving TMJ syndrome and myofascial pain in a comprehensive treatment plan. Botulinum toxin is well-known to the general public as a wrinkle remover in the areas between the eyes, in the forehead, and around the eyes. Whether utilized for dental therapeutics or esthetic purposes, the injections are administered in the exact same muscles, in the exact same pattern in each muscle, and at the exact same dosages.

Of course, the patient will have smooth skin in these areas when the treatment is completed. In fact, we often use this as a differential diagnostic tool to determine if the treatment has helped the patient’s facial pain and if that facial pain is indeed based in the muscle. If the treatment plan determines that the patient’s myofascial pain is coming from the forehead muscle, the frontalis, botulinum toxin is injected into that muscle. If the patient’s pain diminishes and the patient returns with smooth skin in the treated area, then we have confirmed the relationship between the facial pain and the muscle; we know the botulinum toxin is working because the skin is smooth.

However, if the pain still exists and the skin still has wrinkles when the patient returns to the office for evaluation, then we know that the botulinum toxin may not be working or an incorrect dosage was administered. From there, we can begin to increase the dosage and monitor the results. If the patient returns with smooth skin but still has some facial pain, then we know the botulinum toxin is working but that this particular muscle may have no relationship or a limited relationship to the patient’s condition, which will require further diagnostic testing or a referral.

Some dental professionals have commented to me that the use of botulinum toxin in dentistry should be limited to therapeutics only—and not be used for esthetics (as if it were possible to actually separate the two). But as we have seen, you cannot separate the therapeutic from the esthetic and vice versa, whether you’re dealing with porcelain restorations or botulinum toxin. With proper pharmacological and anatomical training in their use, botulinum toxin and dermal fillers have become well integrated into dentistry now, for both esthetics and therapeutics. Just ask any patient who could not find relief with numerous other dental therapies, especially in the area of facial pain, and whose dental esthetics now include both the oral cavity and the area around it.

Louis Malcmacher, DDS, MAGD, is a practicing general dentist and an internationally known lecturer and author known for his comprehensive and entertaining style. Dr. Malcmacher is the president of the American Academy of Facial Esthetics (AAFE). Contact him at impact@agd.org.