Botulinum Toxin for Facial Harmony: How this Unconventional Treatment Can Expand Your Practice

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Dentists are known for their pursuit of perfection. It’s one of the traits that define the profession; arguably, the only trait more significant is their desire to help and serve their patients. Altamiro Flávio, DDS, author of a new clinical book Botulinum Toxin for Facial Harmony, is a dentist who possesses both of these traits. Twelve years ago, he discovered a treatment that could greatly benefit his patients, but he lacked the education and experience to provide it. In order to meet this patient need, he embarked on an educational journey that would drastically change his practice philosophy and the course of his career.

The Importance of the Face in Dentistry

So many of the treatment-planning decisions that dentists make involve careful consideration of the face. A good clinician uses reference points of the face when planning restorative or prosthodontic treatments; further, an esthetic result relies on the clinician’s ability to successfully harmonize the character of the teeth with the character of the face.

“In order to be able to produce esthetic smiles, we must first understand the face itself,” says Christian Coachman, DDS, CDT, founder of Digital Smile Design. “All professionals who work with smile rehabilitation should also be experts on the face. We have noticed a lack of facial knowledge by dentists as well as a lack of knowledge of smiles by plastic surgeons, and this gap should not exist. The integration of face and smile knowledge will transform the way we impact people’s lives by modifying their facial expressions.”

“Early in our college days we learn that we must analyze not just the patient’s mouth but also the face,” Dr Flávio emphasizes. “Thirty years ago, this was easy to say but not feasible to do. These days we have facial references and concepts like Digital Smile Design that use facial aspects to build, reshape, and position the teeth. But imagine if the facial aspects that we use as reference points are not adequate. What can we as dentists do?”

The answer to this question isn’t as complicated as you may think, and it comes in a little glass vial.

“In 2006, I participated in a smile competition sponsored by the Brazilian Society of Aesthetic Dentistry,” Dr Flávio recalls. “During this kind of competition, some very important dentists judge before-and-after photographs from cases of dental work related to esthetics. During the prequalification process, one of the judges told me that although my work was beautiful, the lips of the patient showed some asymmetry, so I probably wouldn’t win. I ended up winning third place, and I then referred the patient in this case to a plastic surgeon, Dr Marcio Rocha, for surgery to fix the asymmetry.”

But during the consult, Dr Marcio told him that surgery was not an option: the best way to fix the asymmetry was botulinum toxin treatment. By observing the treatment and its results, Dr Flávio realized this was a fast, precise, minimally invasive, and reversible procedure, and he wanted to be able to offer it to his patients. So he took his first course at the renowned Ligia Kogos Dermatology Clinic in São Paulo, and thus began his journey with botulinum toxin treatment in dentistry.

Who Treats the Face

Countless other dental clinicians have also found ways to implement botulinum toxin treatment into their practices in ways that enhance and augment dental treatments. But is this overstepping? Is the face part of dentistry’s jurisdiction, or should it be left to a plastic surgeon or dermatologist? Why should dentists treat facial concerns?

“There are some people who say that dentists should only be allowed to treat the perioral area while dermatologists should treat the rest of the face,” Dr Flávio says. “I disagree because of the risk created when botulinum toxin treatment is managed by multiple clinicians. Because of immunogenicity, a patient must wait 4 months between botulinum toxin treatments. If a patient receives another round of treatment before that window has passed—perhaps because they are being treated by a dermatologist for wrinkles while also receiving anti-bruxism treatment from a dentist—it will provoke a vaccine effect from the patient’s immune system and decrease the action of the botulinum toxin in subsequent treatments.”

Treating areas so close to each other with different professionals may also interfere with the final result of both treatment plans because of how areas of the face affect each other. Dr Flávio stresses that the decision to be treated by a dentist or by a physician is up to the patient—the important thing is that it be one or the other, not both. Nonetheless, while a dentist possesses the foundational knowledge to learn botulinum toxin treatments for the face, dermatologists lack the dental knowledge required to provide structural and therapeutic treatments for the mouth. Dentists are also uniquely equipped to manage esthetic harmony and integration between the mouth and the face.

“It is not possible to delegate the mouth to physicians,” Dr Flávio stresses, “because they are more versed in anti-aging treatment for the mouth, and their main treatment focus is often the upper third of the face. With the treatment options we have today, including botulinum toxin, we as dentists can address those esthetic and functional facial issues. The mouth is part of the face; it should not be evaluated separately.”

Teaching the Science Behind Facial Esthetics

In order to spread awareness of the possible applications of botulinum toxin in dentistry, Dr Flávio developed a continuing education course called “A Smile for Each Face,” which combines dental topics such as facial analysis, digital planning, dental anatomy, direct and indirect veneers, and restorations with dermatologic topics like botulinum toxin, facial fillers, and viscosupplementation. He has since taught on these topics in 6 different countries, helping others to expand the treatment options they can offer their patients.

“During my courses,” Dr Flávio explains, “students learn the name, function, and position of each facial muscle. As a teacher, I know that visualization is a very strong component of the learning process. Some time ago, I was at a birthday party where I saw children running around with butterflies and other animals painted on their faces. I realized I could use this technique as a learning aid for my students. So at the end of my courses, in order to complete the learning process my students must be able to draw the muscles on someone’s face. It’s a way to own the knowledge. It wouldn’t work if the drawing was made over a photograph of a face, as the muscles should be located by considering the palpation of muscles and bones and also the muscular activity. Similarly, injections are not made on a photograph—they are made directly on the patient’s face.”

Dr Flávio’s painting exercise brings to the surface the muscular structures that the students will need to locate and treat in their patients, forming a direct connection between theoretical knowledge and practice. Location is paramount for successful botulinum toxin treatment, and the painting teaches students how to visualize the current state of the patient’s muscles and imagine the results of potential treatments. They are then able to reimagine the patient’s face and work to achieve those treatment goals. But what exactly can botulinum toxin treatment accomplish in dentistry?

Applications of Botulinum Toxin in Dentistry

The main benefit of botulinum toxin in a dental practice is to provide a more comprehensive treatment plan for your patients. So it makes sense to consider both therapeutic and structural benefits alongside esthetic ones.

In his book Botulinum Toxin for Facial Harmony, Dr Flávio breaks down the steps of this treatment-planning process in a concept called facial analysis. By using mathematic rules to analyze the face, clinicians can identify facial issues as well as reasons to improve those esthetic issues.

“When we use the rules of facial analysis to evaluate our patients’ faces scientifically, we realize that esthetics is indeed an objective topic rather than a subjective one.” Dr Flávio explains. “During the first appointment, dentists should analyze the patient’s face and identify all possible issues, not only around the mouth but across the whole face,” he says. “When presenting the diagnosis and treatment plan to the patient, the dentist should never split the procedures into ‘dental’ and ‘facial.’ For instance: A patient who has dental attrition from bruxism can be treated with Botox injections to decrease the muscle power before the tooth reconstruction is performed. This allows the dentist to first treat the cause (bruxism) and then the consequence (dental attrition). If this same patient has wrinkles and an inadequately positioned eyebrow, the treatment plan should address those issues as well so that the patient receives therapeutic, anti-aging, and structural benefits all from the same treatment plan. Many books on this topic tell you how to do these procedures, but none of them tell you why to do it. The reader will find the reasons for esthetic treatments in my book.”

The procedures described in Dr Flávio’s book are organized by individual muscle, and all information required for the treatment—anatomical details, instructions for locating the muscle, injection protocol, and safety warnings—is provided in the same place to increase the efficacy of the book as a clinical resource. Illustrations show the location of the muscle both in a cadaver and in a patient, and videos that can be accessed via QR code show how to locate the injection points for each muscle. Detailed treatment instructions for dosage, syringe type, and needle size are included for each procedure, as well as guidelines on how to evaluate results anthropometrically to determine whether esthetic treatment goals have been met.

In cases where dentistry has already established traditional solutions, such as a gummy smile, dentists may hesitate before considering a treatment that necessitates repetition. There are advantages and disadvantages to every treatment. In many situations, the advantages of botulinum toxin as a minimally invasive, reversible treatment may outweigh the perceived disadvantage of its duration of effectiveness.

“My students often complain that botulinum toxin treatments only last 5 months,” Dr Flávio says. “When they do this, I ask them to name one antibiotic, anti-inflammatory, anesthetic, or antidepressant that has an effect that lasts as long. When we think of it this way, the duration time becomes one of the greatest advantages of the toxin.”

The use of botulinum toxin expands the range of what dentists can treat for their patients. With this tool, dentists can better serve their patients with esthetic facial concerns not only by correcting what’s inside the mouth, but also by adjusting the overall presentation of the face.

“I get excited when I see the final results of treatment in my daily practice,” Dr Flávio emphasizes. “This professional accomplishment is a great reward. These days, the world experiences very fast development in medical areas. All professionals must evolve to absorb these changes, and dentists are no different. With botulinum toxin, we now have a great opportunity to use the knowledge we learned when studying anatomy and physiology in dental school by spreading the benefits of botulinum toxin treatment to the perioral region and the facial area. I incorporated the use of botulinum toxin into my daily practice not because it’s a hot topic, but to address my patients’ needs. Now, I can’t see myself working without botulinum toxin in my office.”

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Altamiro Flávio, DDS, graduated from the Federal University of Goiás College of Dentistry in 1990 and went on to become a specialist in dental prostheses at the Federal University of Uberlândia in 1992. In 2010, he created a continuing education course called “A Smile for Each Face,” which included topics such as facial analysis, digital planning, dental anatomy, direct and indirect veneers, restorations, botulinum toxin, facial fillers, and viscosupplementation. He continues to teach courses like this all over the world, and he also teaches the specialization course in restorative dentistry at the Brazilian Association of Dentistry in Goiás. Dr Flávio is an accredited member of the Brazilian Society of Aesthetic Dentistry and a founder of the Brazilian Society of Botulinum Toxin and Facial Implants. He maintains a private practice in Goiânia, Brazil.

 

Botulinum Toxin for Facial Harmony

Altamiro Flávio

The mastery of dentistry brings esthetic knowledge of the face that is applicable to more than just the teeth. In the process of performing a complete facial analysis, the practitioner can identify asymmetries and concerns localized to an area—such as the forehead, eyebrows, nose, or lower face—and offer Botox therapy to increase facial harmony. This book outlines the many clinical uses for Botox, with detailed illustrations and case presentations to support each procedure. The first part of the book covers systematic facial analysis, photographic documentation, and how to plan treatment. Special attention is paid to the anatomy and physiology of the face and the identification of injection points. Detailed treatment instructions for dosage, syringe type, and needle size are included for each procedure, as well as guidelines on how to evaluate results anthropometrically to determine whether esthetic treatment goals have been met. This stunning book will change the way you approach facial analysis and widen your esthetic treatment options for patients.

160 pp; 359 illus; ©2018; ISBN 978-0-86715-787-1 (B7871); Available now! $148