The patient underwent orthodontic treatment, improved aesthetics with composite Tetric Evo Ceram® veneers, and hyaluronic acid and botulinum toxin (Botox) were applied to correct and enhance the smile and lip contour.

acid hyaluronic, Botox, composite veneers, orthodontic treatment,

Authors: Juan Pablo and Mauricio sanchez

Introduction:

The patient underwent orthodontic treatment with metal brackets. When her treatment ended, the patient was not satisfied with her aesthetics, so it was decided to improve with the completion of composite veneers, thus improving the dental sensitivity that the patient had. As a result, the patient and the colour and shape of the teeth were changed.

steps to make composite veneers

Once the selective carving was done, in this case, the carving was carried out more where the stains were more profound, and the colour did not have to be changed so much. The carving was less deep.

Once the carving was done, alcohol was applied to clean the dental surface. It was left for 20 seconds. Then, it was washed, and 37% orthophosphoric acid was used between 4 and 5 minutes; it was passed, and a layer of adhesive was applied. Finally, I removed the excesses with the air syringe and photopolymerized them.

The next step was applying an Evo Ceram bleach XL syringe mixture. Next, the composite was placed in layers to separate the teeth’ transparent plastic bands, and in some cases, Teflon was used.

Once the composites were light-cured, they were polished with a very fine Arkansas bur and diamond bur, designing the contours, the emergence profile, and the incisal inclination.

Subsequently, the next step was polishing using the polishing discs, from the coarsest to the finest. This polishing process is the longest and usually requires several appointments until the patient is happy with the colour and shape.

Photos of the realization of veneers

Initial photo after brackets

Photos during the preparation for veneers in composite Xl bleach Tetric Evo Ceram®

Maxilla

In the photo, it can be seen that there is a combination of a very light colour with yellow. This is because the patient disagreed with such a light colour. As the veneers were increasingly polished to reduce the tonality, the composite gradually diminished, appearing the dentin.

 

 Hyaluronic acid

Hyaluronic acid is a great tool to improve facial aesthetics and skin health.

There are two types or two large groups and different variables within them.

These groups are:

1. Hyaluronic acid stiffer: Used to give support and lift functions to parts of the Face that have descended, such as the tip of the nose or the eyebrows. Another use is to restore or restore the strength of the tissues.

2. Hyaluronic acid softer: It is used to improve the contour of facial expressions, such as the front of the jawline. The idea is to achieve facial proportions.

The lip will be upper lip of 1 cm and the lower of 1,618 cm in women; this was written by Swift & Remington in 2011(Swift and Remington, 2011).

Some characteristics do not change. Instead, they are constant, such as the intercanthal distance, the forehead’s height, the nasal spine’s anterior position, genetics, age, and ethnic characteristics.

3. Injected botulinum toxin A (BTXA) into the normal contralateral smile muscles to weaken them and restore symmetry to active and passive movements by neutralizing these overacting muscles(Sadiq, Khwaja and Saeed, 2012).

Different Areas where can put hyaluronic acid in the Face.

Photo taken from the article by McKee et al. 2019(Mckee et al., 2019).

 

Referral

 The patient attended the Doctor Lluch dental clinic (Valencia, Spain).

Patient Complain

« I want to have more striking lips and improve my profile without being artificial. My smile is not symmetrical when I laugh, and I want to improve it. »

Medical history

Age: 65 years old.

Actual diseases: None.

Allergies: Pollen, dust.

Family conditions: Her father died of cancer, and her mother died from systematic failure.

Tobacco history: Not smoker.

Alcohol intake: No, usually.

Treatments performed before Hyaluronic acid treatment:

1. Cleaning and applying airflow are carried out.

2. Radiological diagnostic method: Periapical radiographs and orthopantomography. A CBCT(Leonardi Dutra et al., 2016) was performed when even better image detail was needed to assess periodontal health.

3. Perio chart shows the deep pockets and soft tissue conditions:

A. CAL generalized were 2 mm in molars and 1 mm in anterior teeth.

B. Plaque localized.

C. Thin biotype.

D. Gingivitis induced by biofilm(Caton et al., 2018) localized in molars.

G. The CPITN code was 1 for the majority of her teeth.

4. The patient was taught the instructions and good brushing and flossing techniques. An electric toothbrush is recommended since, according to Ccahuana-Vasquez et al.(Ccahuana-Vasquez et al., 2019), 2019 reduces the level of plaque and gingivitis compared to the manual toothbrush.

 To control plaque levels in the patients, it was recommended to use some tablets to detect plaque after brushing. Thus, they would know if the plaque is being removed and where they need to brush better.

5. Sistematic revaluation was recommended after four months to check the periodontal evolution.

Attitudes towards previous treatment

She did not want to do it to him; she did not want to seem artificial but knew I was missing a case of aesthetics, which is why she did it.

 

Systematic orofacial examination

Dolychofacial patient initially from Colombia, with upper and low maxilla facades.

 

 Initial Face’s photos:

*Meso brachyfacial pattern.

*Thirds not provided; frontal are increased.

*Inter-labial distance in anterior un-occlusion of 4 mm.

*Pupillary and commissural lines are parallel.

*Labiomental angle open.

*Cheeks full.

*Deviation of the jaw 1 mm to the right when she closes her mouth.

*Facial and pupillary midline are not perpendicular.

*Inter-labial distance in anterior un-occlusion 4 mm.

*Effortless lip engagement.

*Lip competence.

*Inter-commissural width matches the middle limbus of the eyes.

* profile convex.

* flat union between the philtrum and Cupid’s bow.

* Nasal-labial angle of 100º.

* Lips contained within the aesthetic plane of Ricketts.

Lips photos

*Sup Lip 1 mm.

*Inf Lip 1.2 mm.

Smile photo:

Smile examination

* Lip smile line: When she smiles, a deviation of the smile line is seen on the left side, showing more lower than upper teeth.

* Lower line matches with the facial midline.

* Asymmetrical smile.

* Upper midline deviated 1 mm to the right concerning the facial and upper midline.

Diagnosis

1. The patient presents a loss of lip volume, which is more noticeable in the upper; the contours are not well defined, being more apparent when the patient is in profile.

The nasolabial angle is not very open, and the labial-chin angle is almost straight.

The tip of the nose is slightly drooping, and the grooves of the columella are distorted.

2. The patient does not have Hyperkinesis(de Sanctis Pecora and Shitara, 2021), which consists of static and dynamic asymmetry of the Face, leading to significant functional and aesthetic problems, such as a more pronounced nasolabial fold deviation of the corner of the mouth laterally up or down and a narrower eye-opening. Nevertheless, it does present an asymmetry when it smiles due to a greater intensity of the angle depressor muscle of the left mouth.

Alternatives to the treatment:

1. A combination with minor surgery or laser application achieves a natural look even in elderly patients with prolonged philtrum(Wollina and Goldman, 2018).

2. Plastic surgery.

Treatment

1. 4 mm deep was applied superficially with a 27G needle, deep hyaluronic acid from the Revolax brand, for the lip contour.

2. the Revolax TM soft brand was used for lip filling.

3. For the wings of the nose, philtrum, and tip of the nose, the Revolax TM deep was used.

4. Fill the peri-oral tissue around the mouth with Hyaluronic acid.

De Maio et al. 2017(De Maio et al., 2017) said that the perfect lip includes a visible transition line or border between the vermillion and skin, a V-shaped cupid’s bow, a full medial tubercle and vermillion, an ascendant line in the oral commissures; this is our aim, and also to get an aesthetic proportion between upper and down lips of 1:1618(Swift and Remington, 2011).

4. Botulinum toxin (BtXA) is applied to the depressor muscle of the left side commissure; 2 U was injected.

 Options

Conveniences

1. Hyaluronic acid has many applications due to its excellent biodegradability, biocompatibility, nontoxicity, and non-immunogenicity. Sudha & Rose  2014(Sudha and Rose, 2014)
2. Long-term use.

Inconveniences

1. Apply hyaluronic acid inside the upper labial artery since it is 4.29±1.54 mm deep between the corner of the mouth and the Cupid’s bow(Wollina and Goldman, 2020).
2.  Lip necrosis.

Application technique:

1. It must be done gently and slowly, causing minor damage, inflammation and pain. McKee and Lalonde 2017(McKee and Lalonde, 2017) published this.

2. The lips being an area with so much irrigation and nearby nerve endings, Benzocaine topical anaesthesia was applied in the vestibule of the upper and lower teeth from 2.4 to 1.4 and from 3.5 to 4.5.

3. After waiting two minutes, 2% lidocaine was applied to the infraorbital nerves, accessing intraorally at the level of the canines.

4. Then, anaesthesia is reinforced by placing the upper incisors in the vestibular and the vestibular fundus.

5. For the lower part, anaesthesia was applied at the level of the mental nerve. After this, In the lower lip, what was done was drawing a parallel line of the wings of the nose. It was filled by directly clicking between the red line and the skin area. The acid was applied to two points in the lower lip, with one point in each quadrant.

These points were located on the lip ridge; 5 ml and 10 ml were applied to fill the lip’s centre.

6. Soft hyaluronic acid was placed on the upper lip. The upper lip was applied at three points in each quadrant, 5 ml at each point to increase the nasal ridge and improve the Cupid’s bow and 10 ml for the lip filler.

In total, 80 ml was applied, 10 ml being for the tip of the nose and 10 ml in the columella.

Photo of frontal view immediately after the treatment:

 

 

 Facial photos after one week:

 

 

Baseline Vs post-treatment after two months

Evolution and prognosis

The aesthetic results have met the expectations of the patient. She did not want to improve the beauty of her lips and nose profile, but she was charming after the treatment.

The patient is scheduled within a year for an annual check-up.

Overall

In this case, I learned that aesthetics is too variable depending on who judges it. The patient was delighted, even without perfecting it, since more hyaluronic acid would have been needed for the nasolabial folds, chin, and malar area.

In this case, I only wanted a minor touch-up, and the patient was satisfied, so it was the most important thing.