The Use of Botox and Dermal Fillers in Oral Implantology










1112
40
The Use of Botox and
Dermal Fillers in Oral
Implantology
RANDOLPH R. RESNIK AND AMANDA M. SHEEHAN
T
he eld of oral implantology is constantly changing because
of the advances in technology and science. With a better
understanding of the dynamic relationships of the soft
tissues surrounding the orofacial complex, the use of injectable
botulinum toxins (BTXs) and dermal llers has become an inte-
gral part of dentistry. With respect to oral implantology, dental
implant clinicians are in a unique position to evaluate and treat
patients with these products. ese pharmacologic agents may
be used to control parafunctional habits, help restore function,
relieve pain, and supplement facial esthetics in conjunction with
implant prosthetic procedures. Currently, the two most popular
treatments used in conjunction with oral implantology procedures
include the use of injectable neurotoxins (BTX) and injectable
dermal llers (hyaluronic acid).
Injectable Neurotoxin (Botulinum Toxin)
Botulinum toxin, rst used in humans in the 1970s, has become
very popular in dentistry. In 2002 Botox was approved in the
United States for cosmetic treatment and for the treatment of
excessive forces from hyperfunctional muscle activity. ere exist
eight dierent serotypes of BTX (i.e., designated as A to H), with
some being puried for therapeutic injections into hyperactive
muscles. Today, botulinum toxin type A (BTX-A; puried isolate
from fermentation of the bacterium Clostridium botulinum) is the
most potent and widely used serotype in clinical practice. BTX-A
is a stable compound that is present in a vacuum-dried powder
that currently is marketed under three dierent brand names:
Botox, Dysport, and Xeomin. ey all contain the same active
ingredient of BTX-A; however, they dier in their formulation:
onabotulinum toxin A (Botox), abobotulinum toxin A (Dysport),
and incobotulinumtoxin A (Xeomin).
Mechanism of Action
In general, BTX-A blocks the neuromuscular transmission by
inhibiting the release of acetylcholine from motor nerve terminals,
which results in a reduction of muscle contractions. Acetylcho-
line is a neurotransmitter that is responsible for muscle contrac-
tions. e muscle inhibition occurs in multiple steps (binding,
internalization, translocation, and cleavage) by BTX-A cleaving
to a protein (SNAP-25), which is an integral part of acetylcho-
line docking and release from vesicles in the nerve endings. When
injected intramuscularly, BTX-A produces a chemical denerva-
tion of the muscle, which results in a reduction of muscle activity
(Fig. 40.1).
1
e eects of the botulinum neurotoxins are temporary because
the nerve terminals will recover back to their normal function. Ini-
tially axonal sprouts arise from the aected nerve in response to
growth factors from the inactive muscle. e axonal sprouts form
new immature synapses to the injected muscle, which allows neu-
romuscular transmission to return to normal.
How Supplied and Preparation
In the United States BTX-A is manufactured as a puried neurotoxin
complex supplied as a white powder in sterile glass vials. Each vial
contains either 50, 100, and 200 units (U) of BTX-A, with an
expiration date of 2 years when stored properly at −5°C to −20°C.
e BTX-A vial should always be refrigerated until use. Because
of its powder form, the BTX-A must be reconstituted with 0.9%
NaCl sterile saline solution. Most commonly, BTX-A is supplied in
a 100-U vial that is usually diluted with 2 or 4 mL of saline, which
results in a 5.0/2.5-U BTX-A per 0.1 mL solution. Commonly the
dilution is dictated by the muscle or region being treated, or by the
clinicians preference. Usually a 1.0-mL tuberculin syringe with a
26- to 30-gauge needle is used to draw up the required solution
for administration.
2
Once opened and reconstituted, the solution
must be used within 24 hours because the BTX-A and diluent
contain no preservatives. e solution should be stored in a refrig-
erator at 2°C to 8°C (36°F–46°F). If preservatives are used, the
shelf-life is signicantly increased. Hexsel etal.
3
have shown that
refrigerated, reconstituted BXT-A can be used for up to 6 weeks
without loss of ecacy (Table 40.1 and Fig. 40.2).
Generalized Botulinum Toxin Type A Injection Technique/
Dose
In general, injections should be made perpendicular to the skin sur-
face and intramuscularly into the belly of the muscle. However, in
some situations a more customized injection pattern may be required.

Acetylcholine
Synaptobrevin
SNAP-25
Syntaxin
Axon
Synaptic cleft
Acetylcholine receptor
Muscle cell
A
SNARE
Complex
BTA receptor
BTA light chain
Cleavage of SNARE proteins
BTA
B
Frown Lines
Forehead
Lines
Bunny Lines
Gummy Smiles
Dimpled Chin
Platysmal Bands
Eyebrow Shaping
Crows Feet
Lip Lines
Marionette Lines,
Sad Smile
Fig. . (A and B) Diagram depicting the action of botulinum toxin at the neuromuscular junction. (A) Normal acetylcholine release. Synaptobrevin and
VAMP-2 (not shown) on the surface of the vesicle containing acetylcholine joins with SNAP-25 and syntaxin on the internal axonal surface. This forms a
complex that allows fusion of the vesicle with the membrane to release acetylcholine into the synaptic cleft. Acetylcholine binds to its receptor on the sur-
face of the muscle cell, opening voltage-gated sodium channels that result in membrane depolarization. (B) Action of botulinum toxin. Botulinum toxin type
A (BTA) is internalized by the axon when bound by its receptor on the cell surface. The light chain of the toxin is taken up and cleaves the SNARE proteins
before the acetylcholine vesicles can bind. The result is a lack of acetylcholine release into the synaptic cleft and subsequent paralysis of the muscle. (C)
Common facial anatomic areas for Botox injections. (A and B: From Miller J, Clarkson E. Botulinum toxin type a: review and its role in the dental office.
Dent Clin North Am. 2016;60:509-521.)

For muscle injections in the orofacial region, skin preparation should
always be completed using aseptic alcohol wipes and dry sterile gauze
sponges. In most clinical situations the muscles should be injected
bilaterally to minimize complications from asymmetry or unequal
nerve involvement (i.e., number of units will vary depending on the
target muscle). When considering the ideal dosing amount, the total
number of units will depend on the area of interest, muscle mass,
and strength and gender of the patient. In general, men will require
more units than women. Care should be taken when choosing the
dilution being used because higher dilution may result in further
migration of the BTX-A and may result in unwanted eects.
Duration of Action
e U.S. Drug Administration recommends an injection fre-
quency of once every 3 months with the lowest eective dose.
In some patients multiple injections may over time result in the
development of antibodies to BTX-A, which results in eect
reduction and inactivating the toxin activity. However, in general
the length of ecacy varies among individuals and is dependent
on the patient’s metabolism of the toxin and the use or activity of
the muscle being treated.
Botulinum Toxin Type A Uses in Implant
Dentistry
1. Parafunctional habits
2. Temporomandibular joint syndrome/temporomandibular dys-
function (TMJ/TMD)
3. Excessive tissue display (gummy smile)
Parafunctional Habits
Masseter Muscle Hyperactivity
A common sequela of patients with parafunction is masseter
hypertrophy. e masseter muscle is one of the primary muscles
of mastication. When the masseter muscle is hyperactive or over-
used, the facial appearance often enlarges and results in a negative
cosmetic impact with altered facial lines. Muscle function is also
altered, which results in excessive force being placed on the teeth/
implants. Studies have shown a signicant reduction in masseter
muscle volume with an average reduction in mass of 22% and up
to approximately 35% reduction after the continued use of BTX-
A
4
(Figs. 40.3 and 40.4).
Anatomy. e masseter muscle is a thick quadrilateral muscle
that consists of two heads: (1) supercial and (2) deep.
Supercial: e larger supercial head arises by a thick aponeurosis
from the maxillary process to the zygomatic bone and from
the anterior two-thirds of the inferior border of the zygomatic
arch. e bers pass inferior and posterior, and are inserted in
the angle of the mandible and inferior half of the lateral surface
of the mandibular ramus.
Deep: e smaller deep head arises from the posterior third of the
lower border and the medial surface of the zygomatic arch. Its
bers pass in a downward and forward direction to be inserted
into the upper half of the ramus as high as the coronoid process
of the mandible. Anteriorly the supercial head conceals the
deep head and posteriorly is covered by the parotid gland.
Innervation and Blood Supply. e masseter is innervated by
the anterior division of the mandibular division (V3) of the tri-
geminal nerve. e pathway of innervation is gyrus precentralis >
genu capsula interna > nucleus motorius nervi trigemini > nervus
trigeminus > nervus mandibularis > musculus masseter. e blood
supply to the masseter muscle is derived from three blood vessels:
the masseteric branch of the maxillary artery, the facial artery, and
the transverse facial branch of the supercial temporal artery.
Function. e primary function of the masseter muscle is ele-
vation of the mandible. e masseter muscle parallels the medial
pterygoid muscle; however, it is signicantly stronger and its
supercial bers can be responsible for protrusive movements.
5
Botox Technique. Injection into the masseter muscle for the
treatment of masseter hypertrophy was rst discussed by von
Lindern etal.
6
ey suggested injections into the zygomatic arch
and mandibular angle. However, this method revealed a higher
risk for injection into the parotid gland, which led to signicant
complications. Hu etal.
7
determined a safe zone for injection sites
into the masseter muscle. ey recommended the safest entry
point to be in the central compartment of the masseter muscle
as to avoid injections into the parotid gland and the mandibular
branch of the facial nerve. e parotid gland is located super-
cial and at the posterior margin of the muscle. Branches of the
facial nerve also run supercial to the muscle. e delineation of
the “safe zone” is a line drawn from the lower ear to the angle of
the mouth (superior margin). e anterior extent is determined
by palpation and the posterior extent is the posterior angle of the
mandible (Fig. 40.4). e inferior border is delineated by the infe-
rior border of the mandible.
Mapping Injection Sites. An outline of the muscle needs to be
completed to determine the maximum areas of contraction and
tension points of the masseter muscle. Initially a line is drawn with
a removable skin marker from the lateral commissure (corner of
the mouth) to the bottom of earlobe (small pointed eminence of
the external ear that projects over the meatus). e inferior border
of the mandible is outlined, and the anterior and posterior borders
of the muscle are marked. e patient is asked to clench his or her
teeth, and the maximum contraction points are documented and
marked. Skin markings can easily be removed with alcohol swabs.
Injection Technique. Two syringes of reconstituted 25 U of
BTX-A are drawn up in into syringes and approximately 5 U is
injected deep into the belly of the muscle at each tension point. In
most cases the needle is inserted perpendicular to the skin surface
(Fig. 40.5).
Studies. Many studies have shown the successful reduction
in masseter hypertrophy via BTX-A injections.
7-10
With multi-
ple injections, concomitant reduction in gross masseter size has
been shown to be up to 40%.
8
Raerty etal.
11
showed masseter-
induced bite force reduction of up to 85% at week 3 after injec-
tions and 65% less at week 7. However, clenching returned to
Dilution Table for Botulinum Toxin Type A
BTX-A VIAL
Diluent Added
(0.9% NaCl)
Resulting Dose
(Units/0.1mL)
50 units 1.25 mL
1.0 mL
4.0 units
5.0 units
100 units 2.50 mL
2.0 mL
4.0 units
5.0 units
200 units 5.0 mL
4.0 mL
4.0 units
5.0 units
TABLE
40.1
1114
PART VII Soft and Hard Tissue Rehabilitation

A
B
C D
F
E
H
G
Fig. . Reconstitution of Botulinum Toxin Type A (BTX-A). (A) 0.9% Sodium Chloride Vial (B) Using an appropriate-size needle and syringe, draw
up 1, 1.25 or 2.5 mL of 0.9% preservative sterile saline. (C) Invert needle and tap side to expel any air bubbles. (D) Insert the needle and slowly inject the
saline into the BTX-A. Vacuum must be present in the vial, which demonstrates that sterility of the vial is intact. (E) Remove the syringe, then gently mix
the vial with the saline by rotating the vial. Record the date and time of reconstitution on the label. (F) Using a small tuberculin syringe draw up the required
amount of solution; angle the needle into the bottom corner of the vial to allow for full extraction of solution. Do not completely invert the vial and expel any
air bubbles in the syringe barrel. (G and H) Final syringes with BTX-A solution are ready for injection.

1116
PART VII Soft and Hard Tissue Rehabilitation
A
B
Superficial head
of masseter
muscle
Deep head of
masseter muscle
C D E
Fig. . Masseter Hypertrophy. (A) Masseter muscle. (From Nanci A. Ten Cate’s Oral Histology:
Development, Structure, and Function. 9th ed. St. Louis, MO: Elsevier; 2018.) (B) Radiograph depicting
large antegonial notch resulting from the excessive force on the angle of the mandible. (C) Enlarged
facial appearance from hypertrophied muscle. (D) Image of patient with missing dentition in lower left.
(E) Resultant hypertrophy of right masseter and atrophy of left masseter.
Anterior
Masseter
Border
AB
C
Posterior
Masseter
Border
Mandibular
Angle
Safety
Zone
Mandibular Border Line
Commissure - Ear Lobe Line
Fig. . Masseter Muscle. (A) Injection boundaries. (B) Masseter hypertrophy. (C) Reduction of
masetter mass after Botox injections.

1117
CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantology
A
C
EF
D
B
Fig. . Masseter Mapping and Injection Technique. (A) Skin Marker, (B) Commissure—ear lobe line
drawn. (C) Inferior border of mandible trajectory evaluated. (D) Inferior border points marked. (E) Inferior
border and posterior border points connected. (F) Anterior masseter muscle border marked.
baseline values faster as the result of other muscles compensating.
Van Zandijcke and Marchau
12
described in 1990 the use of 100
U of BTX-A injections to the temporalis and masseter muscles
in patients with brain injuries. e mean duration of response
was approximately 19 weeks and mean peak eect (abolishment
of grinding) was approximately 3.5 weeks. In general the targeted
musculature usually adapts to the injections, and frequency of
injections usually decreases because of the atrophy of the muscles.
Complications. Injections in the masseter muscle area are rela-
tively safe with minimal side eects. Inaccurate injection location

1118
PART VII Soft and Hard Tissue Rehabilitation
G
I J
H
Fig. ., cont’d (G) Posterior masseter muscle border marked. (H) Tension points determined. (I and J)
Injection of 5 units deep into the belly of the muscle at each point.
or too high injection volume may lead to excessive swelling, bruis-
ing, facial muscle weakness, and xerostomia. Postoperatively,
patients may report a “thicker” saliva and usually this is related
to higher doses and injections into the parotid gland. Injections
made too far anteriorly may lead to BTX-A diusion into adjacent
muscles, leading to smile alteration (Fig. 40.6).
Temporalis Muscle
e temporalis muscle (also called the temporal muscle) is considered
a muscle of mastication and arises from the temporal fossa.
Anatomy. e temporalis muscle is a broad, fan-shaped mus-
cle of mastication on the lateral aspect of the skull. It arises
from the temporal fossa, which is a large depression on the
lateral aspect of the skull. A temporal fascia completely covers
the surface of the muscle. e muscle bers converge as they
descend through a space between the zygomatic arch and end
with the temporalis tendon. e temporalis tendon is consid-
ered a very thick tendon that inserts at the coronoid process of
the mandible (Fig. 40.7).
Innervation and Blood Supply. e third division of the man-
dibular branch of the trigeminal nerve innervates the temporalis
muscle by the deep temporal nerves. e deep temporal branches
of the maxillary artery, along with the middle temporal artery,
contribute to the blood supply of the muscle.
Function. e temporalis muscle is considered the strongest
muscle of mastication. It can be divided into two functional parts,
the anterior and posterior. e anterior temporalis runs vertically
and is responsible for elevation of the mandible. e posterior
temporalis runs horizontally, and contraction results in retrusive
movements of the mandible.
13
Botox Technique
Mapping Injection Sites. e anterior, posterior, and supe-
rior extent of the temporalis muscle is marked with a skin
marker. As the patient clenches his or her teeth, the maximum
areas of contraction and/or tension points are marked within
the boundaries.
Injection Technique. e injection technique for the tempora-
lis muscle usually consists of two injections, supercial and deep,
according to the location of the areas of maximum contraction.
e supercial injections are positioned into the thinner upper
portions of the temporalis muscle in a fan shape. e deeper injec-
tion involves the split of the supercial temporalis fascia, which is
located approximately 1.5 mm superior to the zygomatic arch
15
(Figs. 40.8 and 40.9).
Duration. When BTX-A is injected for parafunctional habits
in temporalis muscles, patients appear to require repeated injec-
tions at approximately 5 months. Other studies have shown injec-
tions to be repeated every 6 months.
14

1119
CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantology
Temporomandibular Joint Syndrome (TMJ)/
Temporomandibular Dysfunction (TMD) Pain
e use of BTX-A has been shown to treat TMJ or TMD com-
plications, with the injection of the masseter and temporalis
muscles. Guarda-Nardini etal.
16
demonstrated the use of Botox
in the treatment of decreasing myofascial pain symptoms in
bruxers, compared with saline injections. Baker etal.
17
evaluated
the use of masseter and temporalis injections for patients exhib-
iting chronic masticatory myofascial pain dysfunction. Results
showed a decrease in overall pain and overall maximum volun-
tary opening.
Success rates are variable in the treatment of patients with TMJ.
Studies have reported that BTXs used for the treatment of TMD
disorders may cause dysphagia
18
or temporal drooling.
19
However,
in both of these reports greater than 100 U was administered.
Temporomandibular Dysfunction/Temporomandibular
Joint Technique
e TMD/TMJ BTX-A technique is very similar to the tra-
ditional masseter and temporalis muscle techniques, with the
only dierence being dictated by myofascial trigger points. To
determine the location of injections for TMD/TMJ technique,
myofascial trigger points must be located. Trigger points are
hyperirritable areas within the fascia surrounding the muscle,
which may dier from areas of maximum contraction. Usually in
TMD/TMJ cases, one or more trigger points are generally pres-
ent, which on palpation will cause transmission of pain along the
muscle or neuronal tracks. Disruption of the trigger points have
been reported to bring short- and long-term pain relief.
20
1. Palpate for two trigger points in the masseter and mark with a
skin marker.
2. Palpate for three trigger points in the temporalis and mark with
tissue pen.
B
A
Fig. . Smile Alteration Complication: (A) Normal smile, (B) Smile
alteration resulting from injection on the right side which was too medial,
which inadvertently diffused and affected the Risorius muscle. Note the
constricted smile on the right side.
T
emporalis
muscle
Fig. . Temporalis Muscle. (From Nanci A. Ten Cate’s Oral Histology:
Development, Structure, and Function. 9th ed. St. Louis, MO: Elsevier;
2018.)
Fig. . Temporalis Muscle Boundaries.

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111240The Use of Botox and Dermal Fillers in Oral ImplantologyRANDOLPH R. RESNIK AND AMANDA M. SHEEHANThe eld of oral implantology is constantly changing because of the advances in technology and science. With a better understanding of the dynamic relationships of the soft tissues surrounding the orofacial complex, the use of injectable botulinum toxins (BTXs) and dermal llers has become an inte-gral part of dentistry. With respect to oral implantology, dental implant clinicians are in a unique position to evaluate and treat patients with these products. ese pharmacologic agents may be used to control parafunctional habits, help restore function, relieve pain, and supplement facial esthetics in conjunction with implant prosthetic procedures. Currently, the two most popular treatments used in conjunction with oral implantology procedures include the use of injectable neurotoxins (BTX) and injectable dermal llers (hyaluronic acid).Injectable Neurotoxin (Botulinum Toxin)Botulinum toxin, rst used in humans in the 1970s, has become very popular in dentistry. In 2002 Botox was approved in the United States for cosmetic treatment and for the treatment of excessive forces from hyperfunctional muscle activity. ere exist eight dierent serotypes of BTX (i.e., designated as A to H), with some being puried for therapeutic injections into hyperactive muscles. Today, botulinum toxin type A (BTX-A; puried isolate from fermentation of the bacterium Clostridium botulinum) is the most potent and widely used serotype in clinical practice. BTX-A is a stable compound that is present in a vacuum-dried powder that currently is marketed under three dierent brand names: Botox, Dysport, and Xeomin. ey all contain the same active ingredient of BTX-A; however, they dier in their formulation: onabotulinum toxin A (Botox), abobotulinum toxin A (Dysport), and incobotulinumtoxin A (Xeomin).Mechanism of ActionIn general, BTX-A blocks the neuromuscular transmission by inhibiting the release of acetylcholine from motor nerve terminals, which results in a reduction of muscle contractions. Acetylcho-line is a neurotransmitter that is responsible for muscle contrac-tions. e muscle inhibition occurs in multiple steps (binding, internalization, translocation, and cleavage) by BTX-A cleaving to a protein (SNAP-25), which is an integral part of acetylcho-line docking and release from vesicles in the nerve endings. When injected intramuscularly, BTX-A produces a chemical denerva-tion of the muscle, which results in a reduction of muscle activity (Fig. 40.1).1e eects of the botulinum neurotoxins are temporary because the nerve terminals will recover back to their normal function. Ini-tially axonal sprouts arise from the aected nerve in response to growth factors from the inactive muscle. e axonal sprouts form new immature synapses to the injected muscle, which allows neu-romuscular transmission to return to normal. How Supplied and PreparationIn the United States BTX-A is manufactured as a puried neurotoxin complex supplied as a white powder in sterile glass vials. Each vial contains either 50, 100, and 200 units (U) of BTX-A, with an expiration date of 2 years when stored properly at −5°C to −20°C. e BTX-A vial should always be refrigerated until use. Because of its powder form, the BTX-A must be reconstituted with 0.9% NaCl sterile saline solution. Most commonly, BTX-A is supplied in a 100-U vial that is usually diluted with 2 or 4 mL of saline, which results in a 5.0/2.5-U BTX-A per 0.1 mL solution. Commonly the dilution is dictated by the muscle or region being treated, or by the clinician’s preference. Usually a 1.0-mL tuberculin syringe with a 26- to 30-gauge needle is used to draw up the required solution for administration.2 Once opened and reconstituted, the solution must be used within 24 hours because the BTX-A and diluent contain no preservatives. e solution should be stored in a refrig-erator at 2°C to 8°C (36°F–46°F). If preservatives are used, the shelf-life is signicantly increased. Hexsel etal.3 have shown that refrigerated, reconstituted BXT-A can be used for up to 6 weeks without loss of ecacy (Table 40.1 and Fig. 40.2).Generalized Botulinum Toxin Type A Injection Technique/DoseIn general, injections should be made perpendicular to the skin sur-face and intramuscularly into the belly of the muscle. However, in some situations a more customized injection pattern may be required. AcetylcholineSynaptobrevinSNAP-25SyntaxinAxonSynaptic cleftAcetylcholine receptorMuscle cellASNAREComplexBTA receptorBTA light chainCleavage of SNARE proteinsBTABFrown LinesForehead LinesBunny LinesGummy SmilesDimpled ChinPlatysmal BandsEyebrow ShapingCrows Feet Lip LinesMarionette Lines, Sad Smile• Fig. . (A and B) Diagram depicting the action of botulinum toxin at the neuromuscular junction. (A) Normal acetylcholine release. Synaptobrevin and VAMP-2 (not shown) on the surface of the vesicle containing acetylcholine joins with SNAP-25 and syntaxin on the internal axonal surface. This forms a complex that allows fusion of the vesicle with the membrane to release acetylcholine into the synaptic cleft. Acetylcholine binds to its receptor on the sur-face of the muscle cell, opening voltage-gated sodium channels that result in membrane depolarization. (B) Action of botulinum toxin. Botulinum toxin type A (BTA) is internalized by the axon when bound by its receptor on the cell surface. The light chain of the toxin is taken up and cleaves the SNARE proteins before the acetylcholine vesicles can bind. The result is a lack of acetylcholine release into the synaptic cleft and subsequent paralysis of the muscle. (C) Common facial anatomic areas for Botox injections. (A and B: From Miller J, Clarkson E. Botulinum toxin type a: review and its role in the dental office. Dent Clin North Am. 2016;60:509-521.) For muscle injections in the orofacial region, skin preparation should always be completed using aseptic alcohol wipes and dry sterile gauze sponges. In most clinical situations the muscles should be injected bilaterally to minimize complications from asymmetry or unequal nerve involvement (i.e., number of units will vary depending on the target muscle). When considering the ideal dosing amount, the total number of units will depend on the area of interest, muscle mass, and strength and gender of the patient. In general, men will require more units than women. Care should be taken when choosing the dilution being used because higher dilution may result in further migration of the BTX-A and may result in unwanted eects. Duration of Actione U.S. Drug Administration recommends an injection fre-quency of once every 3 months with the lowest eective dose. In some patients multiple injections may over time result in the development of antibodies to BTX-A, which results in eect reduction and inactivating the toxin activity. However, in general the length of ecacy varies among individuals and is dependent on the patient’s metabolism of the toxin and the use or activity of the muscle being treated.  Botulinum Toxin Type A Uses in Implant Dentistry 1. Parafunctional habits 2. Temporomandibular joint syndrome/temporomandibular dys-function (TMJ/TMD) 3. Excessive tissue display (gummy smile)Parafunctional HabitsMasseter Muscle HyperactivityA common sequela of patients with parafunction is masseter hypertrophy. e masseter muscle is one of the primary muscles of mastication. When the masseter muscle is hyperactive or over-used, the facial appearance often enlarges and results in a negative cosmetic impact with altered facial lines. Muscle function is also altered, which results in excessive force being placed on the teeth/implants. Studies have shown a signicant reduction in masseter muscle volume with an average reduction in mass of 22% and up to approximately 35% reduction after the continued use of BTX-A4 (Figs. 40.3 and 40.4).Anatomy. e masseter muscle is a thick quadrilateral muscle that consists of two heads: (1) supercial and (2) deep. Supercial: e larger supercial head arises by a thick aponeurosis from the maxillary process to the zygomatic bone and from the anterior two-thirds of the inferior border of the zygomatic arch. e bers pass inferior and posterior, and are inserted in the angle of the mandible and inferior half of the lateral surface of the mandibular ramus.Deep: e smaller deep head arises from the posterior third of the lower border and the medial surface of the zygomatic arch. Its bers pass in a downward and forward direction to be inserted into the upper half of the ramus as high as the coronoid process of the mandible. Anteriorly the supercial head conceals the deep head and posteriorly is covered by the parotid gland. Innervation and Blood Supply. e masseter is innervated by the anterior division of the mandibular division (V3) of the tri-geminal nerve. e pathway of innervation is gyrus precentralis > genu capsula interna > nucleus motorius nervi trigemini > nervus trigeminus > nervus mandibularis > musculus masseter. e blood supply to the masseter muscle is derived from three blood vessels: the masseteric branch of the maxillary artery, the facial artery, and the transverse facial branch of the supercial temporal artery. Function. e primary function of the masseter muscle is ele-vation of the mandible. e masseter muscle parallels the medial pterygoid muscle; however, it is signicantly stronger and its supercial bers can be responsible for protrusive movements.5 Botox Technique. Injection into the masseter muscle for the treatment of masseter hypertrophy was rst discussed by von Lindern etal.6 ey suggested injections into the zygomatic arch and mandibular angle. However, this method revealed a higher risk for injection into the parotid gland, which led to signicant complications. Hu etal.7 determined a safe zone for injection sites into the masseter muscle. ey recommended the safest entry point to be in the central compartment of the masseter muscle as to avoid injections into the parotid gland and the mandibular branch of the facial nerve. e parotid gland is located super-cial and at the posterior margin of the muscle. Branches of the facial nerve also run supercial to the muscle. e delineation of the “safe zone” is a line drawn from the lower ear to the angle of the mouth (superior margin). e anterior extent is determined by palpation and the posterior extent is the posterior angle of the mandible (Fig. 40.4). e inferior border is delineated by the infe-rior border of the mandible.Mapping Injection Sites. An outline of the muscle needs to be completed to determine the maximum areas of contraction and tension points of the masseter muscle. Initially a line is drawn with a removable skin marker from the lateral commissure (corner of the mouth) to the bottom of earlobe (small pointed eminence of the external ear that projects over the meatus). e inferior border of the mandible is outlined, and the anterior and posterior borders of the muscle are marked. e patient is asked to clench his or her teeth, and the maximum contraction points are documented and marked. Skin markings can easily be removed with alcohol swabs. Injection Technique. Two syringes of reconstituted 25 U of BTX-A are drawn up in into syringes and approximately 5 U is injected deep into the belly of the muscle at each tension point. In most cases the needle is inserted perpendicular to the skin surface (Fig. 40.5). Studies. Many studies have shown the successful reduction in masseter hypertrophy via BTX-A injections.7-10 With multi-ple injections, concomitant reduction in gross masseter size has been shown to be up to 40%.8 Raerty etal.11 showed masseter-induced bite force reduction of up to 85% at week 3 after injec-tions and 65% less at week 7. However, clenching returned to Dilution Table for Botulinum Toxin Type ABTX-A VIALDiluent Added (0.9% NaCl)Resulting Dose (Units/0.1mL)50 units 1.25 mL1.0 mL4.0 units5.0 units100 units 2.50 mL2.0 mL4.0 units5.0 units200 units 5.0 mL4.0 mL4.0 units5.0 units TABLE 40.11114PART VII Soft and Hard Tissue Rehabilitation ABC DFEHG• Fig. . Reconstitution of Botulinum Toxin Type A (BTX-A). (A) 0.9% Sodium Chloride Vial (B) Using an appropriate-size needle and syringe, draw up 1, 1.25 or 2.5 mL of 0.9% preservative sterile saline. (C) Invert needle and tap side to expel any air bubbles. (D) Insert the needle and slowly inject the saline into the BTX-A. Vacuum must be present in the vial, which demonstrates that sterility of the vial is intact. (E) Remove the syringe, then gently mix the vial with the saline by rotating the vial. Record the date and time of reconstitution on the label. (F) Using a small tuberculin syringe draw up the required amount of solution; angle the needle into the bottom corner of the vial to allow for full extraction of solution. Do not completely invert the vial and expel any air bubbles in the syringe barrel. (G and H) Final syringes with BTX-A solution are ready for injection. 1116PART VII Soft and Hard Tissue RehabilitationABSuperficial headof massetermuscleDeep head ofmasseter muscleC D E• Fig. . Masseter Hypertrophy. (A) Masseter muscle. (From Nanci A. Ten Cate’s Oral Histology: Development, Structure, and Function. 9th ed. St. Louis, MO: Elsevier; 2018.) (B) Radiograph depicting large antegonial notch resulting from the excessive force on the angle of the mandible. (C) Enlarged facial appearance from hypertrophied muscle. (D) Image of patient with missing dentition in lower left. (E) Resultant hypertrophy of right masseter and atrophy of left masseter.AnteriorMasseterBorderABCPosteriorMasseterBorderMandibularAngleSafetyZoneMandibular Border LineCommissure - Ear Lobe Line• Fig. . Masseter Muscle. (A) Injection boundaries. (B) Masseter hypertrophy. (C) Reduction of masetter mass after Botox injections. 1117CHAPTER 40 The Use of Botox and Dermal Fillers in Oral ImplantologyACEFDB• Fig. . Masseter Mapping and Injection Technique. (A) Skin Marker, (B) Commissure—ear lobe line drawn. (C) Inferior border of mandible trajectory evaluated. (D) Inferior border points marked. (E) Inferior border and posterior border points connected. (F) Anterior masseter muscle border marked.baseline values faster as the result of other muscles compensating. Van Zandijcke and Marchau12 described in 1990 the use of 100 U of BTX-A injections to the temporalis and masseter muscles in patients with brain injuries. e mean duration of response was approximately 19 weeks and mean peak eect (abolishment of grinding) was approximately 3.5 weeks. In general the targeted musculature usually adapts to the injections, and frequency of injections usually decreases because of the atrophy of the muscles. Complications. Injections in the masseter muscle area are rela-tively safe with minimal side eects. Inaccurate injection location 1118PART VII Soft and Hard Tissue RehabilitationGI JHFig. ., cont’d (G) Posterior masseter muscle border marked. (H) Tension points determined. (I and J) Injection of 5 units deep into the belly of the muscle at each point.or too high injection volume may lead to excessive swelling, bruis-ing, facial muscle weakness, and xerostomia. Postoperatively, patients may report a “thicker” saliva and usually this is related to higher doses and injections into the parotid gland. Injections made too far anteriorly may lead to BTX-A diusion into adjacent muscles, leading to smile alteration (Fig. 40.6). Temporalis Musclee temporalis muscle (also called the temporal muscle) is considered a muscle of mastication and arises from the temporal fossa.Anatomy. e temporalis muscle is a broad, fan-shaped mus-cle of mastication on the lateral aspect of the skull. It arises from the temporal fossa, which is a large depression on the lateral aspect of the skull. A temporal fascia completely covers the surface of the muscle. e muscle bers converge as they descend through a space between the zygomatic arch and end with the temporalis tendon. e temporalis tendon is consid-ered a very thick tendon that inserts at the coronoid process of the mandible (Fig. 40.7). Innervation and Blood Supply. e third division of the man-dibular branch of the trigeminal nerve innervates the temporalis muscle by the deep temporal nerves. e deep temporal branches of the maxillary artery, along with the middle temporal artery, contribute to the blood supply of the muscle. Function. e temporalis muscle is considered the strongest muscle of mastication. It can be divided into two functional parts, the anterior and posterior. e anterior temporalis runs vertically and is responsible for elevation of the mandible. e posterior temporalis runs horizontally, and contraction results in retrusive movements of the mandible.13 Botox TechniqueMapping Injection Sites. e anterior, posterior, and supe-rior extent of the temporalis muscle is marked with a skin marker. As the patient clenches his or her teeth, the maximum areas of contraction and/or tension points are marked within the boundaries. Injection Technique. e injection technique for the tempora-lis muscle usually consists of two injections, supercial and deep, according to the location of the areas of maximum contraction. e supercial injections are positioned into the thinner upper portions of the temporalis muscle in a fan shape. e deeper injec-tion involves the split of the supercial temporalis fascia, which is located approximately 1.5 mm superior to the zygomatic arch15 (Figs. 40.8 and 40.9). Duration. When BTX-A is injected for parafunctional habits in temporalis muscles, patients appear to require repeated injec-tions at approximately 5 months. Other studies have shown injec-tions to be repeated every 6 months.14  1119CHAPTER 40 The Use of Botox and Dermal Fillers in Oral ImplantologyTemporomandibular Joint Syndrome (TMJ)/Temporomandibular Dysfunction (TMD) Paine use of BTX-A has been shown to treat TMJ or TMD com-plications, with the injection of the masseter and temporalis muscles. Guarda-Nardini etal.16 demonstrated the use of Botox in the treatment of decreasing myofascial pain symptoms in bruxers, compared with saline injections. Baker etal.17 evaluated the use of masseter and temporalis injections for patients exhib-iting chronic masticatory myofascial pain dysfunction. Results showed a decrease in overall pain and overall maximum volun-tary opening.Success rates are variable in the treatment of patients with TMJ. Studies have reported that BTXs used for the treatment of TMD disorders may cause dysphagia18 or temporal drooling.19 However, in both of these reports greater than 100 U was administered.Temporomandibular Dysfunction/Temporomandibular Joint Techniquee TMD/TMJ BTX-A technique is very similar to the tra-ditional masseter and temporalis muscle techniques, with the only dierence being dictated by myofascial trigger points. To determine the location of injections for TMD/TMJ technique, myofascial trigger points must be located. Trigger points are hyperirritable areas within the fascia surrounding the muscle, which may dier from areas of maximum contraction. Usually in TMD/TMJ cases, one or more trigger points are generally pres-ent, which on palpation will cause transmission of pain along the muscle or neuronal tracks. Disruption of the trigger points have been reported to bring short- and long-term pain relief.20 1. Palpate for two trigger points in the masseter and mark with a skin marker. 2. Palpate for three trigger points in the temporalis and mark with tissue pen.BA• Fig. . Smile Alteration Complication: (A) Normal smile, (B) Smile alteration resulting from injection on the right side which was too medial, which inadvertently diffused and affected the Risorius muscle. Note the constricted smile on the right side.Temporalismuscle• Fig. . Temporalis Muscle. (From Nanci A. Ten Cate’s Oral Histology: Development, Structure, and Function. 9th ed. St. Louis, MO: Elsevier; 2018.)• Fig. . Temporalis Muscle Boundaries. 1120PART VII Soft and Hard Tissue Rehabilitation 3. Clean injection areas with alcohol wipes. 4. Using four tuberculin syringes, draw up (2) 20-U syringes and (2) 25-U syringes. 5. Inject 10 U into each trigger point in the masseter. 6. Inject 12.5 U into temporalis anterior fan, 7.5 U into the mid-dle, and 5 U into the temporalis posterior fan. (Fig. 40.10). Excessive Tissue Display (Gummy Smile)In the rehabilitation of the dental implant patient, clinicians are often confronted with excessive display of maxillary gingi-val tissue on smiling. e “gummy smile” results in diculty in restoring patients because of nonideal esthetics and displeasure BCDAEGF• Fig. . Temporalis Technique. (A) Maximum areas of contraction and/or trigger points evaluated while the patient clenches his teeth. (B) Trigger points are marked with skin marker. (C) Final tension points. (D) Anterior and superior borders are marked. (E) Final boundary outline and tension points. (F and G) Five units of botulinum toxin type A per injection point. 1121CHAPTER 40 The Use of Botox and Dermal Fillers in Oral ImplantologyBCAD E• Fig. . Temporomandibular Dysfunction/Temporomandibular Joint Technique: Clean Injection Areas With Alcohol Wipes. (A and B) Palpate for (A) two trigger points in the masseter and (B) three trigger points in the temporalis, and mark with tissue pen. (C) Using four tuberculin syringes, draw up (2) 20-U syringes and (2) 25-U syringes. (D) Inject 10 U into each trigger point in the masseter. (E) Inject 12.5 U into anterior fan, 7.5 U into the middle, and 5 U into the posterior fan of the temporalis muscle.in the prosthesis-tissue junction. Caution should be exercised with the treatment of gummy smiles because vertical maxillary excess is historically treated surgically by means of maxillary impaction via a Le Fort 1 osteotomy procedure. For patients exhibiting delayed passive eruption, gingivectomies are the ideal treatment. Botox can be used for correction of hyper-functional upper lip elevator muscles. erefore, before treat-ment, it is crucial that the etiology of the gummy smile be ascertained.Kokich etal.21 described an excessive gingival-to-lip distance of 4 mm or more, which they classied as “unattractive” by lay-people and dental professionals. Excessive gingival display has been shown to have a prevalence rate of approximately 11% of the population, with more women displaying excessive gingiva than men, with a 2:1 female:male ratio.22,23,24ere exist two types of smiles in the literature, the “social” and the “enjoyment” smile. e social smile is a voluntary, unstrained and static facial expression that is usually used as a greeting. e lip component is due to the muscular contraction of the eleva-tor muscles of the lip. In contrast, the enjoyment smile is invol-untary and usually results from laughter or pleasure. e upper and lower lip elevator and depressor muscles are responsible for the full expansion of the lips, which show maximum anterior tooth display.25 A cosmetic smile has been dened as display-ing less than 2 mm of the gum tissue. Any smile showing more than 2 mm is classied as a gummy smile or excessive gingival display.26 When treating these patients, it is imperative to have a preoperative photo of their enjoyment smile showing their maxi-mum lip movement, to properly assess the needs and outcome of the BTX-A treatment. In summary, a thorough intraoral and extraoral examination is imperative because the excessive gingi-val display may be treated with BTX-A only when it caused by hypermobility of the lip, not when the excessive gingival display is the result of the position of the maxilla (skeletal position) or a short upper lip (Fig. 40.11).EtiologyIn the production of a smile, many muscles are involved, includ-ing orbicularis oris, levator labii superioris alaeque nasi (LLSAN), levator labii superioris (LLS), zygomaticus major (ZM), and depressor septi nasi muscle. In cases of true hyperfunctional upper lips, the primary muscle responsible for the hyperactiv-ity with resultant excess display of gingiva is the LLSAN. e LLSAN is translated from the Latin as the “lifter of the upper lip and wing of the nose.” is muscle originates from the upper frontal process of the maxilla and inserts into the skin of the lateral nostril and upper lip. Its main action involves elevation of the upper lip and is also involved in dilation of the nostrils and creation of associated deep nasolabial folds (Fig. 40.12 and Box 40.1). Injection TechniqueHwang etal.,27 at Yonsei University College of Dentistry, have proposed an injection point for the treatment of a gummy smile, 1122PART VII Soft and Hard Tissue RehabilitationABC• Fig. . (A–C) Excess tissue “gummy smiles” examples.Layer 1Layer 2Layer 3Layer 41. Depressor anguli oris4. Depressor labii inferioris5. Risorius6. Platysma7. Zygomaticus major9. Orbicularis oris10. Levator labii superioris 11. Mentalis12. Levator anguli oris13. Buccinator8.Levator labii superioris alaeque nasi2. Zygomaticus minor3. Orbicularis oculi38102751641191213• Fig. . Image depicting the muscles of facial expression and injection site locations. (From Afifi AM, Djohan R. Anatomy of the head and neck. In: Neligan PC, ed. Plastic Surgery. Vol. 3: Craniofacial, Head and Neck Surgery. 3rd ed. London: Elsevier; 2013.) 1123CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantologywhich is named the Yonsei point. e Yonsei point is located at the center of a triangle formed by LLS, LLSAN, and zygomaticus minor muscles. e merger of these muscles can be felt by palpat-ing lateral to the nose while smiling and is roughly 1 cm lateral to the ala of the nose and 3 cm superior from the lateral oral com-missure. Hwang etal.27 have recommended a dose of 3 U at each injection site (bilaterally).Achieving ideal outcomes for the treatment of excessive tissue display is extremely technique sensitive, with excess treatment often occurring in transverse elongation and dysfunctional anima-tion of the maxillary lip. erefore clinicians early on their learn-ing curve should treat these areas cautiously and gradually, with multiple low-dose treatments over a longer time period in lieu of a single bolus in one appointment.28 Ideally the lip at rest and high lip line should be documented with photographs by measuring from the gingival zenith to the inferior border of the upper lip. Patients with natural asymmetry to their smile may need dierent amounts of BTX-A on each side to achieve an ideal smile level. e asymmetry should be reevaluated at a 2-week interval, and more BTX-A can be added to the hyperactive side (Figs. 40.13 to 40.15).Facial asymmetry corrected with Botox should be over a 4-week period, with approximately 2 U administered bilaterally at the initial visit and 1 U administered 2 weeks later. is technique usually will result in a more symmetric smile.Duration. e duration of action of BTX-A is not permanent, lasting on average for 6 months with a range of 4 to 8 months.29 In most cases, BTX-A needs to be administered approximately two to three times a year, depending on how much muscle activity is present. e therapeutic eects will usually appear in 24 to 72 hours and peak in 1 to 4 weeks, with a decline after 3 to 4 months.30 Studies. Polo22 showed favorable results with a mean gin-gival exposure reduction of 5.2 mm. Although the amount of Orbicularis Oris MuscleOrigin: maxilla and mandibleInsertion: skin around the lipFunction: muscle encircling the mouth is a sphincter muscle and is responsible for closing the mouth; it is known as the “kissing muscle,” because it is used to pucker the lips Levator Anguli Oris MuscleOrigin: maxilla inferior to the infraorbital foramenInsertion: modiolusFunction: lifts the upper lip Zygomaticus Major MusclesOrigin: zygomatic boneInsertion: orbicularis at modiolusFunction: works with the risorius muscle to assist in laughing and smiling by lifting the corners of the mouth Zygomaticus Minor MusclesOrigin: malar surface of the zygomatic boneInsertion: orbicularis orisFunction: draws the upper lip backward, upward, and outward and is used in smiling Levator Labii Superior MuscleOrigin: medial infraorbital marginInsertion: skin and muscle of the upper lipFunction: elevates the lip Levator Anguli MuscleOrigin: maxillaInsertion: modiolusFunction: elevates the angle of the mouth medially Levator Labii Superior Alaeque Nasi MuscleOrigin: nasal boneInsertion: nostril and upper lipFunction: dilates the nostril and elevates the upper lip and nose Depressor Anguli Oris MuscleOrigin: tubercle of mandibleInsertion: modiolus of mouthFunction: depresses angle of mouth Depressor Labii Inferior MuscleOrigin: oblique line of mandible between symphysis and mental foramenInsertion: integument of the lower lip, orbicularis oris, modiolusFunction: depression of the lower lip Risorius MuscleOrigin: parotid fasciaInsertion: modiolusFunction: retracts the angle of the mouth to produce a smile Buccinator MuscleOrigin: alveolar processes of maxilla and mandibleInsertion: fibers of orbicularis orisFunction: compresses the cheeks against the teeth • BOX 40.1 Facial Muscles Anatomy and FunctionInjection Point• Fig. . Yonsei Point. Is located 1 cm lateral to the ala of the nose and 3 cm superior to the oral commissure. 1124PART VII Soft and Hard Tissue Rehabilitationgingival display increased from 2 weeks to 24 weeks, the amount of original display had not returned at 24 weeks. Park etal.31 showed a mean reduction in masseter thickness of up to 2.9 mm, measured at 3 months postoperatively. With multiple injections, eventual atrophy of the masseter muscle resulted in requiring less frequent doses, with a recommended recall of 4 to 6 months.Complications. In the treatment of the gummy smile, many complications may arise consisting of asymmetries, lip sagging, lip protrusion, exaggerated lip elongation, and interference with speech. As stated, the clinician must be able to distinguish hyperfunctional upper lips from other causes of gummy smiles. For instance, attempts to treat maxillary excess conditions with BTX-A may lead to unnatural results from the excessive loss of function needed to prevent gingival display. When short clinical crowns are present, tissue alteration in the form of a gingivoplasty should be completed to obtain esthetic crown lengthening. In general, vertical maxillary excess cases are usu-ally treated with a maxillary impaction via Le Fort I osteotomy. Generalized Botulinum Toxin Type A Postoperative InstructionsPostoperative care is very important with BTX-A patients because deviation from the following instructions may lead to increased complications: 1. Patients should be instructed not to touch or massage the injected areas for a minimum of 4 hours. is will prevent the dispersion of BTX-A into adjacent sites and allow the BTX-A to penetrate the targeted area for ideal eect. 2. Patients should restrict physical activity for a minimum of 24 to 48 hours because this will minimize inammation. 3. Patients should avoid alcohol and smoking. Excessive perspi-ration (e.g., exercise, sauna) should be avoided because tissue healing may be aected. 4. Patients should be instructed to refrain from lying down for at least 4 hours after injections in the face because this may alter the dispersion of the BTX-A. 5. Patients should be educated on potential bruising, redness, and swelling, which are common after the injections. ese side eects usually will resolve within 7 to 10 days. 6. Patient education is important on expectations because results may not be immediate. Usually changes will be seen as early as 3 to 7 days, with maximum results after 14 days. Generalized Contraindications to BotoxGeneralized contraindications to Botox include32:• Psychologicallyunstable patientsor patients who have ques-tionable motives and unrealistic expectations• Individualswhoaredependentonintactfacialmovementsandexpressions for their livelihood (e.g., actors, singers, musicians, and other media personalities)• Patients aicted with a neuromusculardisorder (e.g., myas-thenia gravis, Eaton-Lambert syndrome, tardive dyskinesia, stroke)• Individuals who are allergic to any of the components ofBTX-A or BTX-B (i.e., BTX, human albumin, saline, lactose, and sodium succinate) or eggs• Patients who are currently taking specic medications thatmay interfere with neuromuscular impulse transmission and may potentiate the side eects of BTX (e.g., aminoglycosides, penicillamine, quinine, and calcium blockers); drug classes that have been shown to aect BTX-A include anticholinergic drugs, muscle relaxants, other botulinum neurotoxin products, dopamine-blocking drugs, and some over-the-counter vita-mins such as vitamin E, sh oils, Omega 3 fatty acids, and coenzyme Q10• Pregnantorlactatingindividuals(BTXsareclassiedaspreg-nancy category C drugs)• Patientswithpresenceof infection at the proposed injectionsite Generalized Complications to BotoxGeneralized complications to Botox include:• MigrationofBTX-Aintoassociatedmusclesneartheinjectionsite• Headacheoru-likesymptoms• DiscomfortorpainatinjectionsiteAB• Fig. . Gummy Smile Injection Points (Yonsei). (A) Gummy smile, (B) Yonsei injection points. 1125CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantology• Spread of BTX-A toxin eects, which spread to unwantedmuscle or anatomic areas; this is most likely a result of the incorrect injection site or too great a volume administered• Breathingorswallowingcomplicationsthatmayoccurimme-diately or weeks after injections• Swelling,rash,headache,localnumbness,painatinjectionsite,bruising, respiratory problems, or allergic reactions• Antibioticshavebeenshowntoshortenthelengthofdurationof BTX-A Injectable FillersAnother pharmacologic agent that is becoming increasingly popu-lar in implant dentistry is dermal llers. In the past, injectable llers such as liquid silicone and bovine collagen were used to replace or enhance the volume of subcutaneous tissue. However, these products exhibited a high incidence of allergic and foreign body reactions. Today, many llers without the side eects that were associated with the earlier agents are on the market. ese ABCDEF• Fig. . Gummy Smile Technique. (A and B) Have patient smile as large as possible and document with photos. (C) Injection site is cleaned with alcohol wipe. (D) Palpate for the levator labii superioris alaeque nasi muscle and mark with tissue pen bilaterally. (E) Have patient smile and verify vertical movement of marked areas. (F) Draw up two separate tuberculin syringes with 1 to 2 U of BTX-A. 1126PART VII Soft and Hard Tissue Rehabilitationnewer ller products are classied as either “permanent” (e.g., polymethylmethacrylate [PMMA], calcium hydroxyl appetite, and expanded polytetrauoroethylene) or “nonpermanent” (e.g., collagen or hyaluronic acid). Currently, the most commonly used llers in dentistry are hyaluronic acid products such as Juvéderm (Allergan) and Restylane (Medicis).33 ese ller products have the advantage of being supplied in various viscosities, are easy to handle, have safe antigenicity, and eects can be reversed or dis-solved using hyaluronidase (reversal agent) (Table 40.2).Signicant advances in the injectable dermal ller markets have led to a growing interest and increased usage. ese minimally invasive injectable procedures have been geared toward the treat-ment of facial aging and facial enhancement; however, they are becoming more popular in dental implant-related areas. Approx-imately 3 million soft tissue procedures were performed in the United States in 2016, of which the majority were of hyaluronic acid–based llers.34With respect to dental implant patients, many patients are at an advanced age, with associated facial aging symptoms. erefore the implant clinician must consider the benets of rejuvenation techniques for maximizing the cosmetic outcomes in association with the implant procedures. In today’s implant practice, the stan-dard is for the implant dentist to consider the benets of facial volume restoration when performing implant surgery on patients who may benet from these products.Hyaluronic acid llers have become popular in the United States and global markets because they are user friendly, are stable at room temperature, are available in single preloaded syringes that require no preparation, are relatively inexpensive, and have the ability to be reversed with hyaluronidase. Addi-tional advantages include they exhibit longer duration of action in comparison with collagen preparations and require no allergy testing.Hyaluronic acid is an anionic, simple nonsulfated glycosamino-glycan widely found throughout connective, epithelial, and neural tissues. e natural hyaluronic acid contributes to tissue repair via cell hydration and lubrication. With age, the hyaluronic acid in the skin decreases, which results in decreased dermal hydration. If the skin is exposed to excessive ultraviolet B rays, cells within the dermis will induce the loss of hyaluronic acid from dermal tissue, resulting in photoaging.Hyaluronic acid has a large particle size that leads to its inher-ent hydrophilic nature, thus allowing it to retain large amounts of water (can absorb up to 1000 times its molecular weight). When injected under the skin the hyaluronic acid llers attract and bind water, thus providing volume to the skin. Because of its nonim-munogenic nature, it is devoid of many of the allergenic collagen llers that were prevalent in the past.e modern hyaluronic acid–based llers are created by cross-linking the hyaluronic acid chains by conjugation with butanediol GHIFig. ., cont’d (G) Inject 1 to 2 units into levator labii superioris alaeque nasi muscle bilaterally by inserting needle halfway the depth of the needle. (H and I) After 2 weeks the patient should be evaluated for symmetry and adjusted if needed. 1127CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantologydiglycidyl ether. e cross-linked hyaluronic acid may be pro-cessed in various ways that yield homogeneous gels (the Juvé-derm family) or suspensions of particles in gel carriers (NASHA Restylane). erefore, each type of hyaluronic acid ller contains varying amounts of hyaluronic acid and through the various cross-linking processes, dierent properties of gels and varying degrada-tion rates result (Fig. 40.16).Mechanism of Actione use of hyaluronic acid stimulates cell proliferation, migration, angiogenesis, and reepithelialization, and reduces collagen and scar formation.35 In comparison with collagen injections, hyal-uronic acid products do not require preinjection testing and pro-duce relatively reproducible, longer-lasting results.36 How Supplied and PreparationCurrently, there are three major companies, Allergan, Medicis, and Merz, that have multiple hyaluronic acid llers on the market. ere is no universal ller that is appropriate for every application or for every patient. It is important to understand the physical properties of the llers and how they interact for predictable clini-cal outcomes. Each of the major brands have multiple hyaluronic acid options in their lines that are specically designed for dier-ent treatment sites. It is important to properly understand and fol-low the indications for usage for each hyaluronic acid ller being used. Some of the more common dermal llers include: Restylane (Sub-Q, Uppsala, Sweden) was the rst hyaluronic acid product sold in the United States. Restylane is supplied as a gel with a particle size of 400 μm. is product is most commonly used to treat nasolabial folds, the lips, and the oral commis-sures. It can also be used for cheek augmentation and to im-prove deformities of the chin and prejowl sulcus. However, it is not generally used for the treatment of ne lines.Perlane (Sub-Q, Uppsala, Sweden) is a hyaluronic acid product of nonanimal origin. It has a large particle size (1000 μm) and is used to treat moderate-to-severe wrinkles and folds. is prod-uct contains 0.3% lidocaine to decrease injection discomfort.Juvéderm (Allergan Inc., Santa Barbara, Calif.) has many advan-tages over Restylane. It is usually softer and produces fewer lumps in the skin when injected close to the surface. Juvéderm is popular in correcting slight or moderate nasolabial folds in patients with ne skin. It is also used for lip enhancement and to treat minor defects in facial contours. Juvéderm has multiple • Fig. . Available Dermal Fillers (Allergan, Irvine, Calif.). Available Dermal FillersMaterial Brand Name Duration and BiodegradabilityAutologous fat Temporary and biodegradableHyaluronic acid Restylane®, Restylane Perlane®, Restylane Lipp®, Restylane Touch®, Restylane Vital® Macrolane® 20, 30Juvederm Ultra 1, 2, 3®, Juvederm Voluma® Hylaform®, Hylaform Plus®, Hylaform Fineline® Others: Rofilan Forte®, Matridur®, Puragen®, Glytone®, Isogel®, Prevelle®, etcTemporary and biodegradableCollagen Zyplast®/Zyderm® (bovine) Cosmoderm®/Cosmoplast® (human) Evolence®, Permacol®, Fibroquel® (porcine)Temporary and biodegradableCalcium hydroxylapatite Radiesse®Semipermanent and biodegradablePoly L-lactic acid Sculptra®/New Fill®Semipermanent and biodegradableβ-Tricalcium phosphate with hyaluronic acidAtlean®Semipermanent and biodegradablePolyacrylamide gel Aquamid® Bio-Alcamid®Permanent and not biodegradablePolymethyl methacrylate Arteplast®, Artecoll®, Artefill®Semipermanent and not biodegradableDermalive®/ Dermadeep®Dimethylsiloxane polymers Silicone Permanent and not biodegradableFrom Carruthers A, Carruthers J. Botulinum Toxin: Procedures in Cosmetic Dermatology Series. St. Louis, MO: Elsevier; 2018. TABLE 40.2 1128PART VII Soft and Hard Tissue Rehabilitationsublines of products with dierent viscosities. One of their re-cent products is Juvéderm Volbella, which is a soft, smooth gel used to increase lip fullness and correct perioral lines. Another popular Juvéderm product is Juvéderm Voluma, which is used for the cheek area and for midfacial volume loss. Juvéderm Vol-lure is commonly used in nasolabial folds and perioral restora-tion.Restylane Lipp (Allergan Inc., Santa Barbara, Calif.) is a specic hyaluronic acid gel that is designed for lip augmentation. e benet of this material is that it lasts approximately 12 months; however, it must be homogenously distributed. Injecting exces-sive volume may lead to the inability of massage to redistribute the material.BELOTERO ® (Merz) is a high-quality hyaluronic acid dermal llers with patented CPM® (Cohesive Polydensi ed Matrix) technol-ogy that integrates easily to smooth various tissues. It is mainly used for wrinkles or ne lines as well as restoring facial volume.Versa (Revanesse) hyaluronic acid is for nasolabial folds in mid to deep dermis. Indicationse main indication for the use of dermal llers is for facial reju-venation. Another popular area to use Dermal llers are used to correct volume deciencies to enhance facial contours. One of the most common areas is the nasolabial fold, which forms a pronounced furrow as patients age. Specically, in implant dentistry the use of dermal llers for black triangles is becom-ing increasingly popular. In addition, with respect to implant prosthetics, because of hard and soft tissue loss, dermal llers are being used for lip augmentation, facial augmentation, and com-missures for the treatment of angular cheilitis or a downturned smile (Fig. 40.17). General TechniqueA denite learning curve exists when injecting dermal llers. It is imperative the clinician obtain adequate training and practice in performing these procedures. Depending on the anatomic area, there exists a variation in the amount of injected material, along with the depth and angle of injection. In addition, the clinician must understand the ideal dermal lling agent specic to the area of treatment. e viscosity of the material selected will dictate the gauge of needle used to deliver the dermal ller, with 30 gauge being the most commonly used. Lighter body materials often used in the lips may use a 32 gauge, while heavier bodied materials may require a 27 gauge. Microcannulas have grown increasingly popular because they yield advantages such as fewer injection points, leading to less trauma to the tissue and blood vessels. Injection Techniqueere exist two general techniques for injecting dermal llers into tissue: Retrograde technique: Needle is advanced and syringe plunger is depressed as the needle is withdrawn.Anterograde technique: Plunger is depressed as soon as needle is placed subdermally so the ller elevates the subcutaneous tis-sues, which reduces the incidence of vascular perforation. Specically, there are a number of detailed injecting techniques that have been developed over the years. Each of the following techniques allow for a tailored approach which is specic for the anatomic location and clinical outcome expected. Some of the more common techniques include linear threading, fanning, serial puncturing, or cross-hatching. A combination of multiple tech-niques is often used. 1. Linear threading: e full length of the needle is inserted into the tissue and the ller is injected as the syringe is slowly retracted. is technique results in the ller remain-ing in the location of the injection, therefore not spreading or dissipating throughout the tissue. e linear threading or “tunneling” technique is ideal for straight, narrow lines and wrinkles. 2. Serial puncture: Multiple injections are placed serially along the length of the treatment so the ller will merge in a continuous line. is technique is usually indicated for small, ne lines and wrinkles. 3. Fan technique: One line of the ller material is injected by the linear threading technique; then the direction is changed and injected along a new line. 4. Cross-hatching: e linear threading technique is used at the periphery of the treatment area; the needle is withdrawn and is inserted adjacent to the rst site and the procedure is repeated. is method is carried out continuously at right angles to the original line (Fig. 40.18). Duration of ActionIn general, temporary dermal llers usually last from 6 to 12 months; however much variation exists depending on the treat-ment location, patient’s anatomy, and muscle use. Newer tempo-rary llers are coming onto the market that have longer durations, ranging from 18 months to 24 months. Lateral FaceLift created byDermal FillerMedial FaceLight SourceLateral FaceShadowMedial FaceLight Source• Fig. . Photo of general indications for dermal fillers. (From Aicken M. Dermal filler doses. Aesthetics. 2017;4:41. © Aesthetics Media Ltd) 1129CHAPTER 40 The Use of Botox and Dermal Fillers in Oral ImplantologyPermanent FillersWith the scope of procedures increasing with soft tissue augmenta-tion, an increasing demand for permanent llers is becoming more prevalent. e U.S. Food and Drug Administration denes perma-nent llers as materials that are composed of nonabsorbable or per-manent materials.9 Permanent llers are advantageous in providing long-term results; however, they carry the potential for irreversible complications. erefore these agents require clinicians with experi-ence and a higher level of expertise. Currently, in the United States, the available permanent llers are PMMA and liquid injectable sili-cone. e use of liquid injectable silicone and PMMA is advanta-geous because they require no maintenance procedures that result in increased inconvenience, cost, and pain. e main disadvantage of permanent llers is that they cannot be reversed or removed eas-ily. e postoperative side eects associated with permanent llers tend to be far greater than temporary llers. A second disadvantage of permanent llers is their lack of adaptability or modication as facial tissues change shape.37  Dermal Filler Use in Implant Dentistry 1. Black triangle 2. Lips 3. Face/cheek augmentation because of midfacial volume loss 4. Commissure (downturned smile and angular cheilitis)Black Trianglese soft tissues adjacent to a dental implant ideally need to be in harmony with adjacent teeth and/or implants. Unfortunately, especially in the maxillary anterior region, it is not uncommon for there to be a lack of papilla tissue (black triangle), resulting in non-ideal esthetic and functional issues. Papilla tissue may be lost from trauma, tooth loss, lack of adjacent contact area, or associated bone loss. e reconstruction of interdental papilla is a complicated and dicult periodontal treatment. ere exist very limited options in the surgical treatment of this problem. To further complicate the situation, food particles often accumulate in the space and create esthetic issues (Fig. 40.19).EtiologyIn anterior regions of the dentition, the interdental papilla is usu-ally of a pyramidal form, whereas in the posterior regions the papillae are more attened in the buccolingual direction. Tarnow etal.38 have shown that the level of the bony crest to the con-tact area has a direct correlation between the presence or absence of interproximal papillae. eir results showed when there was 5 mm or less from the contact area to the crestal bone, 100% of the time papillae were present. When the distance was 6 mm or greater than 7 mm, respectively, 56% or 27% of the time papil-lae were present. Other studies have shown papillae decrease with increasing distance between adjacent roots and have become more prominent with increasing distance from the contact area to the alveolar crest.39Tarnow, in a second study, showed increased crestal bone loss when the interimplant distance was less than 3 mm.40 erefore papilla loss would occur when implants adjacent to each other are placed too close. However, many additional fac-tors are signicant in determining whether papillae are present, which include tooth size and shape, implant/tooth position, periodontal status, tissue biotype, and possible prosthesis overhang/mist.Nordland and Tarnow41 have proposed a classication using three reference points that include the contact point, facial and apical extent of cement-enamel junction (CEJ), and interproximal extent of CEJ. From these criteria a classication was reported with four descriptions of papilla: Normal: interdental papilla occupies embrasure space to the apical part of the interdental contact pointClass I: tip of interdental papilla occupies space between the in-terdental contact point and the most coronal part of the CEJClass II: tip of interdental papilla lies at or apical to the CEJ but coronal to the apicalmost part of the CEJ on facial aspectClass III: tip of interdental papilla lies at level with or apical to the facial CEJInjection Technique. A hyaluronic gel is injected 2 to 3 mm apical to the tip of the papilla. e tissue is entered with the needle until bone is contacted. e needle is slightly pulled back and material is deposited to plump up the papilla. A gentle massage and molding of the ller is completed, ideally with a cotton swab. Approximately 0.1 to 0.15 ml of product is used routinely per papilla treated (Fig. 40.20). Usually, papillary injected need to be repeated every 6 months. 1234567891. Linear threading technique 2. Serial puncture technique3. Fan technique 4. Cross-hatching technique• Fig. . Dermal Filler Techniques. (1) Linear threading; (2) serial puncture; (3) fan; and (4) cross-hatching.• Fig. . Black Triangle. Maxillary anterior between #8 and #9 result-ing in an unesthetic result. 1130PART VII Soft and Hard Tissue RehabilitationLipsWhen evaluating patients for comprehensive dental care involving dental implants, the lips are an often overlooked anatomic area. Lips are an essential part of the facial symmetry of the patient and esthetics. In society today patients are more esthetically conscious and view lips as needing to be fuller and more pronounced. When the vermilion lip is thin, facial harmony may be disrupted. With the aging process, there becomes a less exposed vermilion, consist-ing of increased loss of vermilion bulk and length.Anatomye lips are referred to as the “Labium superius oris” (upper) and “Labium inferius oris” (lower). e anatomy of the upper lip extends from the base of the nose superiorly to the nasolabial folds laterally and inferiorly to the free edge of the vermilion border. ABCDE• Fig. . Black Triangles Technique. (A) Obtain a photo of the black triangle area as a baseline. Anesthetize area to be treated via local infiltration. (B) Inject hyaluronic acid dermal filler into papilla with the bevel of the needle down and angled in the direction that the papilla needs to be bulked. (C) Shape papilla using cotton-tip applicators. Often multiple appointments are needed to achieve ideal outcome. (D) Immediate post-operative view. (E) 2-week post-operative view after two treatments. 1131CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantologye vermilion border is dened as the junction of the lips and the skin, and the area with the borders is termed the vermilion zone.e vermilion border of the upper lip is known as the “Cupid’s bow.” Along the upper vermilion/skin border, two elevations of the vermilion form the Cupid’s bow, which are raised vertical columns of tissue that form a midline depression called the philtrum.42 e eshy protuberance in the center of the upper lip is the tubercle, which is also known as the pro-cheilon (Fig. 40.21). Most Common Lip Issuese most common patient complaint concerning the lips is a deating vermilion, mainly from insucient volume. Usually female lips are fuller and bulge forward in comparison with male lips. e most ideal approach to lip augmentation depends on the deciency and the patient’s esthetic expectations. Most com-monly the upper lip is treated more often than the lower. In gen-eral, genetically thin lips are treated with a deeper-placed ller, followed by volume correction with a supercial ller arch. When cosmetic enhancement is required, a supercially placed ller for expansion of the vermilion is ideal.42 Injection TechniqueJacono43 has postulated a classication of 15 anatomic lip zones that is used to direct llers for lip augmentation and to customize lip contour and size. is intended technique allows for better direction of the ller placement to create more fullness and main-tain shape. He maintains ve major zones within the lip region: vermilion/white roll, subvermilion, peristomal, philtral column, and commissural. e subvermilion corresponds to the dry muco-sal lip, and the peristomal at the junction of dry and wet muco-sal lip. e vermilion/white roll can be further subdivided in the upper lip to include lateral, Cupid’s bow apical, and central phil-tral zones, whereas the lower lip vermilion is divided into medial and lateral zones. e subvermilion is subdivided into medial and lateral zones, and the peristomal into medial and lateral zones (Fig. 40.22). 1. Anesthesia is completed with an infraorbital block on the max-illa and a mental or inferior alveolar on the mandibular arch. 2. Dierent techniques are advocated for lip ller placement. e serial puncture and linear threading are usually used when applying the antegrade or retrograde method. e choice of one technique over another is usually personal preference of the cli-nician. 3. Medium-depth llers are usually used for lip augmentation, such as: (1) Restylane, (2) Juvéderm Ultra, and (3) Esthélis Basic with the use of a 30-gauge needle or a 27-gauge cannula (Fig. 40.23). Lip Injection Complications Complicationse most common complications from lip ller injections include post-injection lumps and nodules. Improper technique or over-aggressive injection may lead to irregularity or lumpiness, which usually occurs when overcorrection is completed. If the ller prod-uct is placed too supercial, beading can occur, leaving an unes-thetic result. If large nodules or lumps are present, hyaluronidase injections may be used to dissolve the product. Herpetic labialis reactivation may be prevented with oral antivirals (acyclovir, fam-ciclovir, or valaciclovir) (Fig. 40.24). Faceere are two common areas in the face that directly impact esthetics with dental implant patients. ese include the nasola-bial folds and marionette lines, which become more prominent Lower vermillion borderOral commissureUpper vermillion borderPhiltrum ridgesCutaneous upper lipCupid’s bowBody of the lipsOral commissure• Fig. . Lip Anatomy.AB• Fig. . Lip Injection Anesthesia. (A) Maxillary infraorbital injection. (B) Mandibular mental nerve block. 1132PART VII Soft and Hard Tissue RehabilitationAB CDE• Fig. . Lip Technique. The lip augmentation is initiated by anesthetizing the upper and lower lips with bilateral Gordon Modified infraorbital blocks, mental blocks, (A) infiltration lateral to commissure of the mouth. (B, C, and D) Generally, begin by outlining the lips by injecting the subvermilion border starting at the commissure by placing retrograde threads. (E) Massage the outline using Vaseline to smooth.continued 1133CHAPTER 40 The Use of Botox and Dermal Fillers in Oral ImplantologyFGHIJFig. ., cont’d (F). After the outline is completed, place two linear threads through the philtrum columns. Massage to smooth using cotton-tip applicator. (G- H) Assess for asymmetries and correct with threading or serial punctures. (I and J) Fill the lower and upper body of the lips to your liking. Massage well to smooth any irregularities. 1134PART VII Soft and Hard Tissue Rehabilitation• Fig. . Lip Complications: Edema and Ecchymosis.AB• Fig. . (A and B) Dermal filler sites within the facial area.with the aging process and loss of teeth/bone. e problem with these areas is the loss of volume and that they develop folds that become unesthetic. e darks lines associated with these areas are from a “shadow,” which results from an elevated lateral compo-nent and less elevated medial area (i.e., a step is present between the two tissue areas)44 (Fig. 40.25).Goal of Facial FillersBasically, the goal of facial llers is reduction of the “steps,” which will reduce the loss of the shadow and the appearance of the lines. Nasolabial Folds/Nasolabial CreaseAs patients age, the vertical lines at the corner of the mouth become more evident. e zygomatic retaining ligaments become lax and the malar soft tissue migrates downward along the direc-tion of the Zygomaticus Muscles (ZM), which results in bulging against the nasolabial crease. e skin lateral to the crease will stretch and become redundant, which results in the formation of a prominent nasolabial fold.45 Anatomic Area. e nasolabial folds include two skin folds that are located from the side of the nose to the corners of the mouth, which is made up of bulging fat pads. Basically this is the area that separates the cheek from the upper lip. e extent of the fold is at the junction of the nasal alar, the cheek, and the upper lip. As the fold progresses inferiorly, it will be in either a straight, convex, or concave shape and ends below and lateral to the corner of the mouth.46 is anatomic area has been termed “smile” or “laugh” lines.47 When patients smile, multiple muscles are respon-sible for the accentuation of the fold. e ZM muscle will pull the cheeks superior and laterally, and the orbicularis oris muscle pulls the upper lip inferiorly and medially. e levator anguli oris will contract, which results in the skin fold crease deepening and becoming more prevalent. e nasolabial crease, or sulcus, is the facial line between the upper lip and cheek, extending from the alae nasi to the lip commissure. Injection Technique. In the treatment of nasolabial folds, volume of material is paramount to restoring contour. Usually a thicker dermal ller material is utilized deeper into the tissue space. If supercial placement of a thinner dermal ller is used, lack of contour will result with minimal longevity. Most com-monly, the retrograde linear threading technique is used along the nasolabial fold. Caution should always be exercised in stay-ing medial to the fold while depositing the product. If ller is injected laterally, deepening of the fold will occur resulting in esthetic issues.Complication. Caution should be exercised in injecting in the subcutaneous layer lateral to the ala because the angular artery is most commonly located and the risk for vascular occlusion is higher (Fig. 40.26). Marionette LinesMarionette lines are associated with advancing age and are dependent on facial structure and anatomy. ey are bilateral extensions of the nasolabial crease, which are directed inferiorly. Anatomic Area. e marionette lines are formed mainly from the depressor anguli oris muscle and platysma muscle. Injection Technique. e ller is ideally placed inferiorly in the subcutaneous layer and dermis in the oral commissure. To achieve a tissue eversion, inject in a fanning direction, which forms a tent pole eect. e use of the ller in the depressor anguli oris and mentalis and platysma below the mandibular margin allows the lateral oral commissure to elevate, restoring a more harmonious expression. Complications. Injecting above or lateral to the lines will increase the shadowing eect by increasing the step (Fig. 40.27).  1135CHAPTER 40 The Use of Botox and Dermal Fillers in Oral ImplantologyAngular CheilitisAngular cheilitis is diagnosed by the presence of redness, inam-mation, maceration, and ssuring of the oral commissures. Patients usually describe a painful, burning area at the corners of the mouth. In many cases mastication is impacted and range of opening is compromised. Etiology. e etiology of angular cheilitis is multifactorial and involves many conditions that promote a moist environment within the oral commissure area. Deciencies in iron, riboavin (B2), folate (B9), cobalamin (B12), or zinc have been associated with this disorder. In addition, a decrease in vertical dimension from tooth loss, bone resorption, or inability to wear prostheses leads to the development of angular cheilitis. In almost all cases Candida albicans contributes to the pathophysiology of angular cheilitis. Injection Technique. erapeutic use of dermal llers in the lips and perioral structures has become increasingly popular in implant dentistry (Fig. 40.28). Treatment of the lips and perioral structures ABCDEF• Fig. . Nasolabial Fold. (A) Nasolabial fold marked with skin marker. (B) Using the anterograde linear threading technique, dermal fillers are extruded along the nasolabial fold. (C and D) Be sure to stay medial to the fold while depositing product because extending laterally will result in deepening the fold. (E and F) Final medial injections. 1136PART VII Soft and Hard Tissue RehabilitationABCDFE• Fig. . Marionette lines follow the line down from the nasal labial fold, ensuring that you stay medial to the fold again. (A) Fan across in an upward vector to lighten the marionette lines (B–D). Follow with fanning or cross-hatching above the marionette lines in an upward direction (E and F). Massage well to eliminate any bumps from the product.yields various practical dental improvements in orthognathic soft tissue prole, retention of removable prosthetics, proper phonet-ics, asymmetric smiles, and loss of soft tissue prole due to missing teeth. In treating the oral commissures a signicant decrease in angular cheilitis has been noted. Injection of dermal llers has been shown to restore the commissure anatomy and decrease the sulcus area to minimize recurrence. However, the clinician must investi-gate all possible etiologies of the angular cheilitis and treat accord-ingly. Nutritional deciencies and a collapsed vertical dimension of occlusion have been associated with angular cheilitis. Antican-didal treatment may be used alone or in conjunction with der-mal ller treatment. e injection technique for angular cheilitis includes having the patient opening wide, and injection of dermal ller directly into the commissure with a linear thread technique. e threading or fanning technique may be used also under the lower lip in an upward vector to increase elevation of the tissue. Reversals for Dermal FillersDermal llers are advantageous because they exhibit reversibility with an enzyme, hyaluronidase. Hyaluronidase is a naturally occur-ring protein in the body and will catabolize hyaluronic acid usually within 24 hours through hydrolysis. is reversal agent is mainly used when overcorrection or misplacement of the dermal ller occurs. Complications With Dermal FillersDermal llers are associated with complications, some that can be quite severe. A through medical history is advised before injecting dermal llers. A history of hypertrophic scars or keloids may contraindicate the procedure. A history of herpes simplex infections may require premedication with valacyclovir 1137CHAPTER 40 The Use of Botox and Dermal Fillers in Oral Implantologyor other antivirals before lip injections. Patients who take anti-coagulant therapy or certain vitamins should be treated with caution because of increased risks associated with bleeding and bruising.e most common complication of dermal llers includes an asymmetric appearance caused by too much material being injected into a particular site. Clinicians should always attempt to undertreat specic areas because overtreatment is extremely dif-cult to remedy.More common local complications appear as redness, inam-mation, and bruising. is often occurs secondarily from trauma caused by the injections. Erythema usually resolves within hours; however, edema may last for multiple days. Edema may be reduced by minimizing the number of injection sites, using epinephrine-containing anesthetics, and applying ice/cold compresses after the procedure. It has been suggested that using a product such as arnica (homeopathic herb) may reduce the eects of the trauma from the injections.Injection to the proper angle and depth is of utmost impor-tance; being too supercial may result in the “Tyndall eect,” where the skin appears bluish at the injection site. Tissue necrosis may also occur if the ller occludes a blood vessel. In the event of suspected tissue necrosis, immediate reversal with hyaluronidase is advised and close postoperative care is imperative. Complications48Early Onset (Immediate > 15 Days)Due to the procedure, not ller relatedErythemaPain bruisingSwelling at injection siteInfection (viral or bacterial) can be related to ller due to biolmDue to ller behavior and placement techniqueOvercorrectionMisplacementHypersensitivity (type IV reaction)Vascular occlusionGranuloma Late Onset (> 15 days)Due to the procedure, not ller relatedChronic infectionItchingDue to ller behavior and placement techniqueSkin discolorationNodules (product accumulation)Hypertropic scarringHypersensitivity (type IV reaction)ABCD• Fig. . Angular Cheilitis. (A) With the patient opening wide, inject directly into the commissure with a linear thread. (B) Follow with linear thread in the lower lip line. Massage lip to smooth. (C) Optional fanning below to fill any depressions. (D) Often this treatment is done in combination with injecting the depressor anguli oris with botulinum toxin type A. 1138PART VII Soft and Hard Tissue RehabilitationConclusione use of Botox and dermal llers have been shown through the literature to be valuable adjuncts in implant dentistry. ese pharma-cologic agents are successful in treating many facial and maxillofacial musculature dysfunctions as they provide an overall conservative, minimally invasive treatment approach. Most notably, Botox may be indicated for the treatment of parafunctional habits that may be detrimental to the overall dental implant success. In addition, the use of Botox in the treatment of various temporomandibular joint syndrome/temporomandibular dysfunction (TMJ/TMD) disorders and excessive tissue display (gummy smiles) have been shown to suc-cessful. e use of dermal llers have become popular for facial and cheek soft tissue augmentation as well as for the treatment of angular cheilitis. With respect to dental implants, papilla loss leading to the formation of black triangles may be treated with dermal llers lead-ing to the reversal of the open spaces. erefore, with the advances of technology and science, the use of Botox products as well as dermal llers are becoming more popular and have become a mainstay in implant dentistry.References 1. Binder WJ, Blitzer A, Brin MF. Treatment of hyperfunctional lines of the face with botulinum toxin A. Dermatol Surg. 1998;24:1198–1205. 2. Delcanho R. Botox injections. In: Selvaratnam P, Niere K, Zuluaga Maria, eds. Headache, Orofacial Pain and Bruxism. Churchill Living-stone; 2009:347–356. 3. Hexsel DM, De Almeida AT, Rutowitsch M, et al. Multicenter, double blind study of the ecacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application. Dermatol Surg. 2003;29:523–529. 4. Kim HJ, Yum KW, Lee SS, etal. 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