Hyaluronic acid injection procedures and orthodontic … · Hyaluronic acid works like a sponge and...

Address for correspondence:

J.-P. SALAMA,24, rue d’Alsace,92300 [email protected]

DOI: 10.1051/odfen/2012205 J Dentofacial Anom Orthod 2012;15:305� RODF / EDP Sciences

1

Conflict of interests declared by the author: NONEArticle received: 09-2011.

Accepted for publication: 01-2012.

Hyaluronic acid injectionprocedures andorthodontic practice

Jean-Pierre SALAMA

ABSTRACT

In France, the Public Health Code was amended in 2004, and now allowsdentists to treat facial tissues adjacent to the mouth: and hence, they can nowbridge the gap between maxillary sinuses and the mouth area by performinghyaluronic acid injection procedures in the perio-buccal soft tissues.

Accordingly, the National Council of the Order of Dental Surgeons authorizesthe practice of hyaluronic acid injection for therapeutic use.

In this article, we will define the legal framework for which we will be heldliable as it pertains to hyaluronic acid injection procedures.

After explaining the physico-chemical properties of hyaluronic acid, we willstudy the mechanisms of ageing, the architecture of the face and variousmethods of injection.

We will look at the indications and counter indications for the use ofhyaluronic acid injection, particularly in terms of its therapeutic usefulness forrehabilitating soft tissue when transitioning from a maxillary full-arch prosthesisto an implant born bridge.

Hyaluronic acid makes it possible to offset the lack of buccal margin of theresin-based removable prosthesis.

KEY WORDS

Hyaluronic acid,

Naso-labial folds,

Cannula,

Reticulation.

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1 – INTRODUCTION

Over the last 10 years, dentistshave noticed an increasing numberof patients seeking consultation forreasons other than dental discomfort.

Presently, because of the evolutionof new technologies and the improve-ment of dental instruments, dentistscan change the color of teeth, modifytheir position and appearance withveneers, and realign teeth, withoutbonding brackets by using transparentspl ints such as the Invisal igntechnique.

Finally, it is important to differenti-ate between skin-filling molecules orfillers and botox (botulinum toxin).These are two totally different proce-dures and our patients often confuseone with the other.

As for fillers, dentists can literally filldermal breakdown with hyaluronicacid.

In the case of botox, only plasticsurgeons or maxillo-facial surgeons,dermatologists or ophthamologistscan use toxin to block the signal ofthe nerve to the muscle.

2 – LEGITIMIZATION

The main priority of our patients isto improve their smiles.

However, the smile is not justlimited to the teeth, it also includesthe appearance of the lips that coverthe teeth, the naso-labial folds thatsurround them, the presence or not ofepidermal and dermal breakagearound the mouth and, marionettelines or oral commissures.

The appearance of the tissue adja-cent to the mouth is key to thesuccessful completion of our dentalprocedures for restoration and en-hancement. Therefore, dentists havea legitimate claim for treating tissuesurrounding the mouth because theright to include hyaluronic acid injec-tions into our practice has beenlegislated and approved and is nolonger a matter of debate.

In fact, the amendment of thePublic Health Code signed into lawon August 9, 2004 concerning den-

tists, specifies that treatment of tissueadjacent to the mouth clearly fallswithin their area of expertise.

After giving us permission to set upa website and to use MEOPA (oxygenand nitrous oxide mixtures) at thechair, the National Council of theOrder of Dental Surgeons publishedon its site: ‘‘We are eminently quali-fied to administer hyaluronic acidinjections’’.

On February 14, 2012, the secretaryof the Minister of Health, XavierBertrand, during an interview withChristian Couzinou, president of theNational Council of the Order ofSurgical Dentists, concluded that hya-luronic acid injections in the naso-labialfolds as well as in perio-buccal areawere in complete harmony with theprofessional training of dentists.

Accordingly insurance companiesnow insure dentists for this type ofprocedure.

JEAN-PIERRE SALAMA

2 Salama J.-P. Hyaluronic acid injection procedures and orthodontic practice

3 – LEGISLATION

When the purpose of a procedure isto repair a morphological anomaly,dentists are legally obliged toimplement specific methods of treat-ment, however, the therapeutic con-tingency must be taken into account;there is no legal obligation to guaran-tee results. Strict adherence to meth-ods of treatment involves greateraccountability.

Legally, an estimate of cost must becompleted and signed.

Dentists must provide individualizedinformed consent forms to their pa-tients that clearly indicate all thedifferent risks incurred by undergoingtreatment with injections of hyaluronicacid. These forms should also besigned.

Hyaluronic acid is a natural absorb-able molecule; therefore, the aftereffects are rare and transitory, andvery often just a result of the injectionitself.

Before performing this procedure,dentists must certify that they aretrained in this procedure and musttake out a rider on their professionalliability insurance policy with theirinsurance carrier.

Finally, to complete the patient’sfile, the dentist must take before andafter injection photos of the patient: atrest with both full face and profileviews, and while propulsing the lipsand making faces in order to ‘‘puckerthe lips’’.

4 – SOME HISTORY

4 – 1 What is hyaluronic acid?

Much like the history of trying tobridge the gap between maxillarysinuses and the mouth area, theprocess leading up to the use ofhyaluronic acid by dentists has beenlong and arduous. Initially, during face-lift procedures, plastic surgeons usedautologic fillers made from the fat ofthe patient to fill wrinkles, much asdentists used autologic bone (espe-cially from the iliac crest and theramus) to fill the maxillary sinus.

Then, non-resorbable injectable fil-lers were used more or less success-fully but some had catastrophicresults. Namely, Dermalive whichcaused severe granulomatous reac-tions which were not curtailed even

with strong doses of corticosteroids.In fact, following the reactions to thenon-resorbable filler and the corticos-teroid therapy, corrective surgery wassometimes necessary.

Hyaluronic acid was first isolatedfrom the vitreous fluid of a bovine eye.

The etymology of the word remindsus and means vitreous; it contains ahigh percentage of uronic acid.

Hyaluronic acid or sodium hyaluro-nate is actually a complex polysac-charide, called Glycosaminoglycane.

Hyaluronic acid is a naturally occur-ring substance in the human bodyfound mainly in the joints, the placen-ta, the eye and the dermis. In fact,roughly 50% of the hyarlonic acid inour body is found in the skin.

HYALURONIC ACID INJECTION PROCEDURES AND ORTHODONTIC PRACTICE

J Dentofacial Anom Orthod 2012;15:305 3

Hyaluronic acid works like a spongeand can soak up moisture: eachmolecule can absorb from 500 to1000 times its own weight in water.

But as the body ages, the quantityof hyaluronic acid decreases; so,surgeons came up with the idea ofusing it to compensate for this loss .For example, it is used in ophthalmo-logical surgery (cornea transplants,cataracts, glaucoma, etc.) and to treatosteoarthritis of the knee.

Figures 1a to 1cThree photos of the patient :

a. at rest,b. three quarters,c. exaggerated puckering to sometimes reveal der-

mal breakage that is not visible when at rest.

Figure 2Hyarulonic acid formula.

JEAN-PIERRE SALAMA


Cosmetically, it can be used forfacelifts. This is one of the mostimportant uses of hyaluronic acid andwe will say more about this later in thearticle. Hyaluronic acid is a biocompa-tible and biodegradable substance; itis a naturally produced lubricant that isquickly absorbed: by mechanical fric-tion in areas of the face which moveor wrinkle frequently, by hyaluroni-dases, a family of enzymes whichdegrade it and, by free radicals whichcirculate in the body. Therefore, sinceit traps free radicals, hyaluronic acidhas anti-oxydant properties.

It is a non-species specific mole-cule and there is no differencebetween endogenous and exogen-ous molecules.

As individuals grow older, the quan-tity of hyaluronic acid decreases andthis quantitative change triggers aqualitative deterioration of the softtissues and also slows cellular pro-cesses to regenerate and repair.

It possesses viscoelastic propertiesthat play an important role in strength-ening the extracellular matrix andreinforcing buffering actions. All these

Figure 3Free molecules of hyaluronic acid.

Figure 4The reticulation takes place in a two dimension planeand a three dimension space, to obtain a tridimensionalmatrix which can last to up to approximately 1 year.

Figure 5The reagent that failed to bond is eliminated.

(Photographs made available by the Laboratoire Allergan,Sophia Antipolis, Mougins.)



rheological properties promote cellularmigration and proliferation and, indoing so, facilitate the healing pro-cess. Additionally, it has an anti-agingeffect, since it supports collagensynthesis, restores the integrity offibroblasts, stimulates growth factorsand inhibits the synthesis of collage-nase (Wang, 2007).

This free molecule in the body has ahalf-life of approximately 48 hours. Asa result, all the injected hyaluronic acidis completely resorbed in approxi-mately 4 days.

The injected molecule is finallycompletely absorbable in 8 to 12months, based on the area that isinjected, on the blood flow and, on thedegree of molecular reticulation.

That is why it was thought that wecould reticulate hyaluronic acid,namely, create a bond betweenthe molecules with a chemicalreagent, in order to increase its mole-cular mass and limit the mechanismsof degradation.

The reagent that was used is BDDE(Butanediol Diglycidyl Ether): bonding

Figure 6A 30 year old woman has well-defined contours that form a perfect oval.

A 50 year old woman shows the first alterations in muscle volume and appears tired.A 75 year old woman’s physiognomy looks old because of sagging cutaneous, fat and muscular tissues.

Source: Coleman, Sydney R. M.D. Structural Fat Grafting. St. Louis, Mo.: Quality Medical, 2004.

JEAN-PIERRE SALAMA


agent (molecule bonding two othermolecules) chosen for its remanenceand manual injectability. When ex-posed to hyaluronic acid, the bondingreagent crosslinks the molecules.

The more hyaluronic is reticulated,the more it becomes viscous, turninginto a liquid, then a gel and finally intoa solid; biological membranes madeup of hyaluronic acid are in fact beingstudied for the purpose of GuidedBone Regeneration (GBR).

The resorption time for these mem-branes is approximately 8 months.

The first hyaluronic acid gels wereparticulate and because of this, theycould migrate from the areas wherethey were injected. The consistencywas granular. Today, we have gelswith a smooth consistency allowingfor more fluid and easier injectionswith longer lasting results.

Hyaluronic acid is considered amedical device since it works bymechanical action (friction from facialmovements), whereas a medicationworks by pharmacological, metaboli-cal, and immunological action.

Figure 7Needle punctures (by serial puncture) to treat the naso-labial fold.

Figure 8First injection in the center of the philtrum.

Figure 9Second injection equidistant commissure-philtrum.

Figure 10Repeat these two injections contralaterally.



Because of this, hyaluronic acid doesnot require a marketing authorization(MA) but only a simple CE markingdelivered by a nearby branch ofFrench Health Products SafetyAgency (AFSSAPS). The use of anymedical device is authorized in thecontext of our practice.

5 – FACIAL ANATOMY REVISITED

It is essential for practitioners tohave a solid grasp of the anatomy ofthe muscles, fat layers, nerves andvessels before they administer injec-tions of hyaluronic acid.

It is also important to correlatemodifications of dosage and the basicstigmas of skin ageing in order toregulate the dosage.

Figure 11Retrograde linear threading injection points to treat thenaso-labial folds.– in red : 1st linear threading injection,– in green : 2nd linear threading injection,– in blue : 3rd linear threading injection,– in pink : 4th linear threading injection.

Figure 12Insertion of the needle.

Figure 13Retrograde linear threading injection.

Figure 14Length of the 2nd point.

Figure 15Retrograde linear threading injection.

JEAN-PIERRE SALAMA


The facial muscles underly andsupport the tissues of the mouth andassociated areas. They weave a veri-table mesh under the dermis andcontinue along adjacent muscles.They have a fixed osseous insertion

as well as a mobile cutaneous inser-tion; when they surround an orifice,they have a dilating or constrictingaction.

There are only two facial muscleswithout an osseous insertion: they arepart of the superficial musculo-apo-nevrotic system (SMAS); the risoriusmuscle and the platysma muscle areresponsible for the signs of ageingbecause of the shortening of theplatysmal chords in the region of theneck.

Finally, it is important to understandthe physiology of ageing. As we age,the muscles shorten and send deepfat pads to the facial surface. This fat,under the influence of gravity, has atendency to sag, and over the years,results in loss of the oval visage aswell as skeletalization.

6 – DIFFERENT TECHNIQUES FOR ADMINISTERING INJECTIONS

Three main techniques for adminis-tering injections can be combined:

serial puncture, retrograde linearthreading and with a cannula.

Figure 16Injection with a cannula.

Figures 17a to 17hResults ‘‘Before – After’’.



6 – 1 – Injection bymulti-puncture

Several contiguous intradermal nee-dle punctures must be made along thenaso-labial fold.

By using this technique and makingthree needle punctures, at the centerof the orbicularis muscle of the lipsand at junction of the mucous mem-brane and in the keratinized tissue ofthe lip, the dentist can restore thevolume of the lip.

6 – 2 – Retrograde linearthreading injections

In this type of injection, the dentistinserts the needle up to the guard atan angle of approximately 20o to theplane of the epidermis, then once theneedle is in, the hyaluronic acid isslowly injected while the needle iswithdrawn.

Step by step, the whole area istreated.

This technique will allow us toredraw the border of the lip by makingcontiguous retrograde linear threadinginjections along the whole peripheryof the lips.

6 – 3 Injection with a cannula

This technique, which was intro-duced approximately 3 years ago,makes it possible to treat the naso-labial folds and other areas by using aflexible blunt-tipped cannula that lookslike needles used for injection of astandard inferior aveolar nerve block.

It is painless, and by using a singlepuncture site, it is possible to treat allareas of the face that the dentists dealwith, namely: the naso-labial folds, theupper and lower red lip, its border, theupper and lower white lip, and themarionette lines.

Injection with a cannula is infinitelyless traumatic than the needle techni-que because a cannula is blunt-tippedand consequently cannot break thepath of an artery and cause bruising ora hemotoma.

There is a single puncture site: itextends one centimeter beyond thecommissure of the lips.

The principal advantage of thistechnique is that it produces veryfew hematomas and bruises.

7 – CONCLUSION

Hyaluronic acid not ony allowsdentists to treat morphological anoma-lies related to ageing, but also tocorrect resorptions of the alveolarprocesses in order to perfect prosthe-tic procedures. Since the emergenceof implantology, in many casesdentists have been able to providepatients with complete implant-

supported bridges, instead of extract-ing all their remaining teeth and mak-ing full dentures for them.

In fact, when dentists made fulldentures, we had to spend a lot oftime adjusting the buccal wax rimwhich supports the lip; from now on,we can use hyaluronic acid to correct

JEAN-PIERRE SALAMA


the volume of the soft tissues whentransitioning to a fixed bridge.

Understanding the ageing processis essential when beginning the pro-cess of rehabilitating soft tissues.

By doing a complete analysis ofpatients, listening to their concerns,

and performing their intra-oral exam-inations, we can choose the fillerproduct best suited for their case.

This type of collaboration with ourpatients will ensure that therapeutictreatment will be successful.

REFERENCE WORKS

Baspeyras M. Legislation des techniques de comblement des rides et de la toxinebotulique en 2007. Cours pour le DU de techniques d’injection et de comblement.Paris : 10 mai 2007.Flageul G, Godefroy M, Lacoeuilhe G. La fonction therapeutique de la chirurgieesthetique. Ann Chir Plast Esthet 2003;48:247-56.Hascall VJ, Laurent TC. Hyaluronan: structure and physical properties. http://www.glycoforum.qr.jp/science/hyaluronan/HA01/HA01E.htmlInoue S. Skin hyaluronan: its metabolism and roles in skin physiology. Connect Tissue2001;33:235-43.Kamara F. La prevention du risque juridique. IMCAS (Paris) : Janvier 2004.Penneau J. La responsabilite du medecin. Connaissance du droit. 3

e

ed. Paris : Dalloz,2004.Pons-Guiraud A, Bui P. L’art du comblement et de la volumetrie en esthetique. RueilMalmaison : Arnette Edition, Coll. Dermatologie esthetique, 2009.Salama JP. Une molecule pas comme les autres : l’acide hyaluronique. Dental Tribune.Esthetique tribune, edition française 2011; 3(12):26.Sargos P. Le devoir d’information du medecin dans la jurisprudence de la cour decassation. Ann Chir Plast Esthet 1998;43:668-73.Wang F, Garza LA, Kang S, Varani J, Orringer JS, Fisher G, et al. In vivo stimulation ofde novo collagen production caused by cross-linked hyaluronic acid dermal fillerinjections in phtodamaged human skin. Arch Dermatol 2007;143:155-63.Zbili M. Classification des levres et protocoles therapeutiques : experience personnelleavec le Juvederm. J Med Esth Chir Dermatol. 2004 mars;XXXI(121):17-24.

WEBSITE REFERENCED

– http://www.ordre-chirurgiens-dentistes.fr/uploads/media/Lettre_ministere_acide_hyaluronique.pdf



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