TEETH + SKIN (AADFA's Patient Magazine) SEPT/OCT 2020 Edition.

A A D FA T E E T H + S K I N M AG A Z I N E

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CONTENTS EDITOR Tennille Gardiner

CONTRIBUTORS Tennille Gardiner Dr Myles Holt Dr Daniel Sister Tim Pittorino Dr Christeen Youssef Kathy Briggs Josie Dunn Dr Victor Siouclis Julie Siouclis

EDITORIAL COMMENT & ENQUIRIES admin@AADFA.net

PUBLISHED BY: Australasian Academy of Dento-Facial Aesthetics

FOR ADVERTISING ENQUIRIES Email: admin@AADFA.net

TO SUBSCRIBE GO TO www.AADFA.net/ magazine

While every effort is made to ensure the accuracy of information contained in this publication, the authors, publishers, editors, their employees and agents shall not be held responsible or in any way liable for errors, omissions or inaccuracies in the publication, whether arising from negligence or otherwise or for any consequence arising therefrom. © Copyright 2020.AADFA. All Rights Reserved. This publication is subject to Copyright. No part of it may be reproduced, in any form, without the prior written permission of AADFA.

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DENTAL-SPA CONCEPT

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COVER STORY : AUSTRALIA'S BEST DENTAL SPA NOMINEE

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CARBOXY THERAPY IN AESTHETIC PRACTICE

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SKIN CARE

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THE ART OF THREADS

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PYRAMID TECHNIQUE

The New Face of Dentistry. Are you getting left behind?

The beautiful truth about Luke Dunn Dental

Daniel Sister describes the beneficial use of CO2 in improving aesthetic results The right ingredients matter

A WORLD FIRST Teeth Whitening & Skin Rejuvenation Combo

NUTRITION & YOUR SKIN How does diet affect your skin?

THE BEAUTIFUL BENEFITS OF EXERCISE Why are we ageing faster than we should?

AUSTRALIA'S BEST DENTAL SPA NOMINEE AADFA Interviews Dr Victor Siouclis of Family Care Dental & Aesthetics

FACIAL REHABILITATION A dentist's full potential

PDO THREADS.... BETTER THAN BOTOX The next big thing!

CHEWING THE FAT The concept of double chin reduction in the dental chair

RETINOIDS : THE KNOCK-OUT PUNCH Fighting poor skin health, ageing and aesthetics is a constant battle

A comprehensive review of the use of threads in Dentistry ; including types, techniques and areas of the face that can be treated The latest techniques for improving "black triangles" using HA Filler

A A D FA T E E T H + S K I N M AG A Z I N E

De n tal- S pa Concept: The Ne w Face of De n ti stry FROM GENERAL DENTISTRY TO THE LATEST FACIAL AESTHETIC AND REJUVENATION TECHNIQUES, AADFA MEMBER DENTAL SPAS ARE CREATING A ONE-STOP HEALTH AND BEAUTY EXPERIENCE FOR THE PATIENT WHO HAS LIMITED TIME AND IS LOOKING FOR CONVENIENCE IN A PLEASING AND SOOTHING ATMOSPHERE.

WORDS BY : TENNILE GARDINER

During lockdown smart AADFA Practitioners used the time wisely to examine every aspect of their Practice and Business and have redesigned, rebranded, revitalized and re-opened with an attractive new "dental-spa" concept. The dentalspa concept was not only attractive to new patients when they re-opened their doors but allowed Dentists to be more profitable more quickly by diversifying their services to offer existing patients more therapies, more choice and more options.

where you lie back and tensely examine the popcorn ceiling while a stranger examines your mouth, poking your gums and occasionally smearing fruit-flavoured polishing paste onto your chin. Best case scenario is you leave with satisfyingly clean teeth and the burning desire to run home and wash your face.

But the experience of going to the dentist, a classic locus of dread and discomfort, has changed. Across Australia & New Zealand, a growing number of AADFA member practices offer patients cushy amenities like blankets, massage chairs, beautiful smelling candles, noise-cancelling headphones,

A standard visit to the dentist might go something like this: You are ushered into a putty-coloured room,

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Above. A beautiful dental spa in Sydney - Tailored Teeth Dental & Cosmetics

light snacks, and barista made coffees on arrival.

They have TVs mounted on the ceiling, where patients can play the Netflix show of their choosing.

They give out warm scented towels, so people can wipe off the gritty cleaning crud caked on their faces. They offer facial aesthetic and rejuvenation services like; Botox, Dermal Filler, Thread Lifts, Fat-dissolving injections, LED facials, Chemical Peels, CGF Micro-Needling, Carboxy Therapy, Face Masks, Skincare and so much more...think of it like a one-stop shop where you can receive all of your dental, facial aesthetic and rejuvenation services under one roof! No longer do we have to drive from

one side of the city to the other against traffic to visit multiple clinics, we now have the option to receive EVERYTHING we could need in the one place!

For patients that want that high-end, CrĂŠme de la CrĂŠme experience - they will now find that at an AADFA Member Dental-Spa! The question is....are you and your Practice being left behind?

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AADFA TEACHINGS HAVE CHANGED THE WAY WE PRACTICE AND WE NOW SEE THE PATIENTS' FACE AS A WHOLE. THEREFORE; WE NOW DIAGNOSE AND TREATMENT PLAN THE FACE AS A WHOLE, INSTEAD OF STOPPING AT THE ORAL CAVITY AND IGNORING THE REST OF THE FACE. THIS ALLOWS US TO PROVIDE MORE COMPREHENSIVE RESULTS FOR OUR PATIENTS. QUEENSLAND AADFA MEMBER

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Above. CGF / Microneedling taught on the AADFA “Phlebotomy” Program

"Changing the Face of Dentistry" (a term AADFA introduced) where we take patients from smile makeover to entire face makeover. The fusion of cosmetic dentistry with aesthetic facial treatments achieves maximum client and practice benefits. Today’s appearance-minded society is providing opportunities for dentists to appeal to their patients’ desire for both wellness and beauty.

AADFA Member Dental practices are expanding the level of aesthetic and rejuvenation treatments from just the smile to the whole face to create a kinder, gentler feeling regarding dentistry. Most of these practices are attempting to allay many dental patients’ fears by providing a relaxing atmosphere along with soothing hyaluronic acid face masks post treatment. However, as these spa-like amenities are working, the term “dental spa” sometimes is misunderstood. It’s not about clients walking around in robes, but more about providing aesthetic and rejuvenation procedures in addition to quality dentistry.

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"THE AADFA SLOGAN “A SMILE DOESN’T END WITH BEAUTIFUL TEETH, NOR SHOULD A TRIP TO THE DENTIST” PUTS IT BEST. NO LONGER ARE WE FOCUSSING SOLELY ON THE TEETH, WE NOW CONSIDER FACIAL MUSCULATURE, FAT DISTRIBUTION, SKIN CONDITION AND LIFESTYLE BEFORE BRINGING ALL THESE ASPECTS TOGETHER INTO PLANS THAT REPRESENT SIGNIFICANT AND COMPREHENSIVE, LONGLASTING IMPROVEMENTS TO PATIENTS’ HEALTH AND APPEARANCE." NSW AADFA MEMBER

Above. LED Therapy taught on AADFA’s “FACE” and “FLUORESCE” modules.

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"THERE’S A LARGE CONVENIENCE FACTOR IN HAVING ALL OF THESE ALLIED HEALTH SERVICES AVAILABLE IN ONE SPOT THAT CAN BE TIED IN QUITE NICELY WITH A GENERAL DENTAL VISIT. AMUSINGLY, SOME OF MY PATIENTS SEEK OUT AESTHETIC TREATMENTS AT OUR CLINIC WITHOUT LETTING THEIR FRIENDS OR FAMILY KNOW THEY’RE DOING IT. HAVING THE TREATMENT CARRIED OUT AT THE DENTAL CLINIC GIVES THEM A DEGREE OF CONFIDENTIALITY. THERE MUST BE A LOT OF PEOPLE OUT THERE PUZZLED WHY THEIR PARTNERS REQUIRE SO MUCH DENTAL WORK!" AADFA MEMBER - WA

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THERE ARE 3 TYPES OF DENTAL SPAS 1. Pampering: providing aromatherapy, warm towels, and specialty made coffees / teas on arrival.

2. Therapeutic: providing facials, chemical peels, LED light therapy. As taught on the AADFA “FACE” and "FUTURE"Modules.

3. Rejuvenation Spa Dentistry (The Crème de la crème of Dental-Spas): providing all of the above plus skin care, facial aesthetic procedures like; Botox, Dermal Filler, Thread Lifts, Facial Fat Reduction Treatments, as well as an extensive facial rejuvenation menu like; microdermabrasion, chemical peels, LED light therapy, CGF / PRP, Skin Needling and so much more. This level of Dental Spa is created when an AADFA member completes the entire AADFA Fellowship Pathway.

In concert, all 3 of the Dental Spa concepts will benefit your patients and your practice.

The key to having a successful dental spa is letting patients know that dentistry is not just about the teeth, but also care and improvement of the face. Facial Aesthetic and Rejuvenation treatments are great adjuncts that complement a makeover with ortho, crowns, whitening and implants.

Right. A stylish Dental Spa in Cairns - Luke Dunn Dental

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"MY JOURNEY WITH AADFA TO FACIAL AESTHETICS AND REJUVENATION BEGAN OUT OF NECESSITY AS I WAS CONSTANTLY FRUSTRATED AT THE LACK OF HARMONY BETWEEN ADJUNCTIVE FACIAL AESTHETIC TREATMENTS MY PATIENTS WERE RECEIVING OUTSIDE OF THE PRACTICE AND THE DENTAL COSMETIC TREATMENTS I WAS PERFORMING. BUILDING A SOLID FOUNDATION WITH THE SMILE AND BITE IS THE FIRST STEP TO IMPROVING FACIAL AESTHETICS, HOWEVER OFTEN AESTHETIC TREATMENT PLANS COMPILED EXCLUSIVELY OUTSIDE THE DENTAL ENVIRONMENT, IN PARTICULAR TREATMENTS WITH DERMAL FILLER, ATTEMPT TO CAMOUFLAGE DENTAL OR SKELETAL DEFICIENCIES WITH SOFT TISSUE AUGMENTATION THAT MAKE IT NEAR IMPOSSIBLE TO CREATE A STABLE, AESTHETIC RESULT FOR THE LONG-TERM." AADFA MEMBER – NSW

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“I’M CERTAIN MY DENTIST IS GOOD AT WHAT HE DOES, BUT I PLAN ON GOING BACK PURELY BECAUSE OF ALL THE PAMPERING, AND MY SKIN HAS NEVER LOOKED SO GOOD” AADFA MEMBER PATIENT

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Entering a dental spa is different from entering a typical dental clinic. At a Dental-Spa, clients instantly feel relaxed and at ease. Before being seated for a dental service or facial aesthetic and rejuvenation services, clients are offered a specialty made drink on arrival, and a warm scented hand towel to start the visit with serenity and relaxation.

A dental concierge meets the patients’ every need.

Upon arrival, clients can use headphones and watch a movie, or listen to music.

Because fancy amenities are not yet standard, they can make a big impression on patients.

Where Can I Learn More?

AADFA is running a fellowship training pathway for Dentists who want to transition their Practice to a thriving Dental Spa Clinic.

To Learn More and Register, visit: www.AADFA.net or email: admin@AADFA.net

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Above. Azura Dental & Cosmetics nestled in the cosmopolitan beachside suburb of Grange, SA

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THE B E A UTIFUL TR UTH BEST DENTAL SPAS OF AUSTRALIA WITH AN EYE FOR AESTHETICS AND A FOCUS ON FACTS, DR LUKE DUNN IS NOT ONLY PASSIONATE ABOUT SEAMLESSLY UNITING THE ART AND SCIENCE OF DENTO-FACIAL AESTHETICS, HE’S ALSO DEDICATED TO EDUCATING AND EMPOWERING HIS PATIENTS, AND THAT’S THE BEAUTIFUL TRUTH ABOUT LUKE DUNN DENTAL.

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worst. As highly trained medical practitioners with an in-depth knowledge of head and neck anatomy, dentists are uniquely placed to provide a wide range of facial aesthetic and rejuvenation treatments. AADFA is the only organisation of its kind in Australasia and has driven these regulatory changes, resulting in more and more dentists offering a range of facial aesthetic and rejuvenation treatments in conjunction with dental treatment.

We chat to Josie Dunn; Managing Director and Co-Owner of Luke Dunn Dental in Cairns, Far North Queensland about how her and Dr Luke have created an incredibly successful "dental spa" practice. As a business and as a team, Josie and Luke continue to grow and evolve, and with their recent surgery renovation and extension, this power couple have so much to be proud of! Josie and Luke are shaking things up after introducing their "FACE FACTS" live demonstration evenings, and we are excited to hear all about it and follow their incredible journey!

It is for these reasons that, in 2017, Dr Dunn decided to undertake advanced training through AADFA, he has since completed the entire AADFA training pathway and he was among the first AADFA Practitioners to receive his Honorary International Fellowship with AADFA in New York in December 2019.

Congratulations on being nominated as one of Australia's Best Dental Spas in Queensland!

We want to know, how did your Aesthetic & Facial Rejuvenation journey start?

What facial aesthetic treatments do you offer?

With the frightening lack of regulation throughout the cosmetic and beauty industry, facial aesthetic and rejuvenation treatments commonly fall into poorly trained, un-qualified hands. For the patient, this can mean undesirable results at best and adverse reactions / health complications at

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Anti-wrinkle injections

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Dermal filler

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PDO thread lifting

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Injection lipolysis

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What are some of the facial rejuvenation treatments available at Luke Dunn Dental?

What is one of the most popular treatments at your Practice?

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Chemical peels

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Anti-wrinkle injections

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CGF micro-needling

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Dermal filler

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LED light therapy

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CGF micro-needling

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PDO Mono threads

What's your go to treatment for yourself?

We absolutely love CGF micro-needling and can’t live without our anti-wrinkle injections!

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How did you go about implementing the Dental Spa concept into your existing Dental Practice?

Dr Dunn introduced facial aesthetics and skin rejuvenation into our practice over a period of time. Gradually introducing these new services allowed us time to ensure our patients understood why Dr Dunn was incorporating facial aesthetics into Luke Dunn Dental and the subsequent benefits this presented to them. Dr Dunn and our team spent (and still spend) time educating patients about these various procedures, and, as a result, we're finding they've not only embraced the collaboration of facial aesthetics and dentistry, but that they're becoming more aware of potential risks where these treatments are offered by unskilled, unqualified practitioners. This was how the concept for our FACE FACTS live demonstration evenings was born; out of our sheer frustration with a widely unregulated “beauty” industry. Due to the lack of transparent, unbiased, scientific facts available to the public, all too often, we were (and sadly still are) coming across patients who’ve been misled and grossly misinformed about various treatments, results and products. In a bid to educate and empower our patients and the wider public, FACE FACTS was born. FACE FACTS guests are given the rare opportunity to watch Dr Dunn perform live facial aesthetic and rejuvenation procedures, ask him questions and receive his informed, unbiased answers based on actual scientific facts. Our continuing endeavour through FACE FACTS is to completely change the public’s perception of these procedures, how - and by whom - these procedures should be performed, and, most importantly, why.

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How did you initially hear about AADFA?

and informative. It tied together all the previous training modules and aided us in incorporating the concept of complete dento-facial rejuvenation into our practice. “FACE” was the last module Dr Dunn completed, although he feels, in hindsight, that he would have benefited by attending “FACE” earlier in the progression of his AADFA training!

When Dr Dunn decided he wanted to branch out into the world of facial aesthetics and rejuvenation, he began researching online and learned that AADFA is the most comprehensive and widelyrecognised training organisation specifically for dentists.

Would you say implementing Aesthetic & Facial Rejuvenation treatments at Luke Dunn Dental has grown your practice? What would be the uptake percentage for Aesthetic & Facial Rejuvenation services?

How have the AADFA teachings changed the way you practice?

AADFA teachings have changed the way Dr Dunn practices as he now sees the face as a whole, therefore he now diagnoses and treatment plans the face as a whole instead of stopping at the oral cavity and ignoring the rest of the face. This allows us to provide more comprehensive results to our patients.

Implementing facial aesthetics and rejuvenation treatments into Luke Dunn Dental has undoubtedly grown our practice, both with existing dental patients and also by attracting new patients who come to us specifically for facial treatments performed by a high calibre dentist. The vast majority of those new patients now also see us for dental treatment. The uptake percentage would be about twenty percent of our annual turnover and is continually climbing.

Tell us, how did completing the AADFA "FACE" module benefit Luke Dunn Dental?

The AADFA “FACE” module was extremely helpful

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Now tell us how much you LOVE treating Aesthetic & Facial Rejuvenation patients?

For Dr Dunn and his team, offering facial aesthetic and rejuvenation treatments has many benefits. For us, there’s nothing better than improving a patient’s confidence and health. It’s wonderful to be able to offer treatments and receive such positive feedback from our patients.

Do you think patients LOVE the fact that they can receive everything under one roof? From dental treatments, to Botox and Fillers, Skin Needling, Skincare and peels?

There is absolutely no doubt that our patients love the option of receiving their facial aesthetics and skin rejuvenation treatments in conjunction with their dental treatment. At Luke Dunn Dental, we have many patients who have now tied in their regular anti-wrinkle injections with their routine dental cleans.

For any Dentist considering entering the world of Aesthetic & Facial Rejuvenation Dentistry, what's your advice?

AADFA has developed a comprehensive training structure that provides dentists and auxiliary staff with specific skills, industry knowledge and invaluable information, allowing them to successfully and more safely implement and provide a range of skin rejuvenation and aesthetic treatments.

Our advice to any dentist considering entering the world of facial aesthetics and rejuvenation would be to undergo AADFA training. AADFA offers ongoing support to its members, assisting dental practitioners in providing quality, leading and beneficial rejuvenation services to patients in conjunction with dental treatments. There is no other organisation like AADFA for dentists, and the service and support are world-class. The other advice we’d offer to dentists considering branching into facial aesthetics is to ensure their team are one hundred percent onboard, willing and passionate about the integration of these services into their practice.

AADFA: Thanks Luke & Josie for allowing us into your stunning Practice and sharing your journey with us. Nothing makes us happier than seeing AADFA Certified Practitioners taking their Practice to the next level and truly succeeding! Your story is inspiring to say the least! Congratulations to you both on being nominated as one of "Australia's BEST Dental Spas", this nomination is well deserved!

AADFA are flying around the nation with a camera crew to interview Australia's BEST Dental Spas! Did you catch us on Channel 9?

Think your practice is Australia's or New Zealand's BEST Dental Spa? We’re now accepting nominations across Australia and New Zealand for the "BEST DENTAL SPA" Awards!

If you know an amazing dental spa who deserves to be recognised and crowned "BEST DENTAL SPA", head to www.AADFA.net or email admin@AADFA.net and start your nomination.

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CA RB OXYT HERAPY IN A E S THETIC PRACTICE DANIEL SISTER DESCRIBES THE BENEFICIAL USE OF CARBON DIOXIDE IN IMPROVING AESTHETIC RESULTS AND SPEEDING UP RECOVERY TIME.

WORDS BY : DANIEL L. SISTER MD, FRCM (Aesthetic Doctor, Dr Sister Ltd, London, UK)

ABSTRACT In 1953 a group of cardiologists ascribed to the hospital of Clermont Ferrand, used carbon dioxide therapy in patients with illness related to poor blood circulation, fat accumulation, and peripheric organic and functional arteriopathies (Atherosclerotic, Buerger’s disease, Raynaud’s disease). Since then, carbon dioxide has been widely used to address issues surrounding poor blood circulation. More recently, it has been utilised in aesthetic medicine to assist with treatment results and speed up healing.

Carboxytherapy is said to work by tricking the body, as by injecting a small amount of carbon dioxide gas into the area, it will increase the dispatch of oxygen laden red blood cells to the area to pick up the new ‘waste’ carbon dioxide that the body will then naturally eliminate via the lungs. By increasing the amount of oxygen getting to the area, cells will become more active and thus speed up any healing or new cell production required to rejuvenate the area.

The action is through the Bohr effect and multiple studies have investigated the CO2 effect on the lymphatic system, fibroblasts, and ECM.

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CARBON DIOXIDE HAS VASODILATORY PROPERTIES THAT MAKE IT USEFUL TO THE MEDICAL COMMUNITY. THE DILATION OF BLOOD VESSELS LEADS TO A DECREASE IN BLOOD PRESSURE AND A BETTER FLOW OF OXYGEN-RICH BLOOD

Carbon dioxide is made up of one carbon atom (C) and two oxygen atoms (O), O-C-O, hence CO 2. All humans and animals produce it during respiration as well as plants and trees via photosynthesis, which aids their growth.

How does carboxytherapy work?

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All cells in the body, regardless of their role, release carbon dioxide as a waste product. Carbon dioxide is the ‘cost of doing business’ of any cell.

Carbon dioxide is an odourless, invisible gas first discovered in 1648 (by Van Helmont) and Boyledescribed its anti-infective properties in the 17th century and by Lavoisier in the 18th century.

Lalouette, in 1777, proposed the serial application of CO2 for treatment of chronic skin ulcers in the lower limbs.

Whenever we breathe in oxygen, it is picked up by red blood cells. Each red blood cell carries four oxygen molecules, which it takes from the lungs to the heart via the blood vessels and then into the arteries and on a journey around the body to where they’re needed.

Whenever they encounter an area with high levels of carbon dioxide (which has been created by cellular metabolism), the red blood cells release oxygen molecules and pick up the carbon dioxide that they have produced.

Further beneficial health benefits of carbon dioxide were discovered in France in the 1930s when it was noted that bathing in the pools of carbon dioxiderich water at the Royat Spas helped speed up wound healing.

Carboxytherapy is said to work by tricking the body, this works by injecting a small amount of carbon dioxide gas into the area, it will increase the dispatch of oxygen- laden red blood cells to the area to pick up the new ‘waste’ carbon dioxide that the body will then naturally eliminate via the lungs.

In 1953 a group of cardiologists ascribed to the hospital of Clermont Ferrand, used this therapy in patients with illnesses related to poor blood circulation, fat accumulation and peripheric organic and functional arteriopathies and Jean Baptiste Romuef M.D. published a paper about his 20 years of experience in the subcutaneous injection of CO2.

By increasing the amount of oxygen getting to the area, cells will become more active and thus speed up any healing or new cell production required to rejuvenate the area.

Carbon dioxide has vasodilatory properties that make it useful to the medical community. The dilation of blood vessels leads to a decrease in blood pressure and a better flow of oxygen-rich blood around the body.

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Physiology: the Bohr effect

At rest, with normal ventilation, the human body consumes 250 mL/min of oxygen (transported from the lungs to tissues) and exhales 200 mL/min of CO2 (removed from tissues and excreted through pulmonary alveoli).

Carbon dioxide helps the release of oxygen from haemoglobin and, as a result, the pH decreases, allowing the tissue to obtain enough oxygen to meet its demands.

In the case of hyperventilation, oxygen consumption can increase up to 4000–5000 ml/minute, and CO2 can increase to 4000–4500 ml/minute.

It is demonstrated by comparing the oxygen dissociation curves when there is less carbon dioxide present and when there is more carbon dioxide in the blood.

During carboxytherapy an average of 30–50 ml/ min CO2 are administered per session: the mild increase in CO2 levels are easily and, therefore, promptly resolvable by mild hyperventilation at the end of treatment, without risk of hypercapnia and respiratory acidosis.

When carbon dioxide, in the presence of the catalyst carbonic anhydrase, diffuses into the blood plasma and erythrocytes, most of it reacts with water and the following dynamic equilibrium is established: H2O + CO2 = H2CO3.

Hypercapnia occurs when the lungs are unable to excrete CO2 and, therefore, pCO2 (partial pressure of carbon dioxide) significantly increases at the alveoli level. When the alveolar pCO2 reaches 60–75 mmHg, the patient can experience severe dyspnoea.

Carbonic acid (H2CO3) dissociates to form hydrogen ions and hydrogen carbonate ions. H2CO3 = H+ + HCO3The negatively charged HCO3- ions, inside the erythrocytes, diffuse from the cytoplasm to the plasma. This is balanced by diffusion of chloride ions (Cl-) in the opposite direction, maintaining the balance of negative and positive ions either side.

With a further increase to the pCO2 up to 80– 100mmHg, the patient may become drowsy and lethargic (hypercapnic coma). With pCO2 alveolar levels of 120– 150 mmHg, the excessive CO2 dampens the respiratory bulbar centre.

The dissociation of carbonic acid increases the acidity of the blood (decreases its pH). Hydrogen ions (H+) then react with oxy-haemoglobin to release bound oxygen and reduce the acidity of the blood. Hb.4O2 + H+ = HHb+ + 4O2. It is this reversible reaction that accounts for the Bohr effect.

In normal conditions (healthy patients), there is no possibility to cause severe hypercapnia by carboxytherapy.

The primary excretion of CO2 and protons (H+) is performed by the kidneys and lungs. Severe damage to these organs (renal or respiratory failure) may lead to an excessive accumulation of CO2. In congestive heart failure, vessel circulation markedly slows down, and, consequently, the amount of CO2 removed from tissues is significantly lowered. Chronic congestive heart failure is another pathophysiologic condition causing CO2 accumulation in which using carboxytherapy is questionable.

What happens during carboxytherapy treatment?

Carboxytherapy is similar to mesotherapy (a series of small injections with a thin needle), but it delivers medical grade carbon dioxide gas in a controlled flow/ dose below the skin’s surface, rather than tiny quantities of a liquid formulation.

Side-effects and contraindications

Carboxytherapy should also be avoided in patients under treatment with carbonic anhydrase inhibitors (acetazolamide, diclofenamide). As the use of the inhibitor obstructs the primary process by which CO2 can be excreted through the lungs and kidneys.

During treatment, some patients may feel slight discomfort, pressure or a stinging sensation as the gas is delivered to the tissues, (often described as a crackling sensation) as well as ecchymoses. Other side-effects can include minor swelling, redness (caused by the vasodilation), lasting anywhere from 1–5 days depending on the area treated. In the case of cellulite treatment, a warm sensation can be felt in the region for up to 24 hours.

Severe anaemia implies a significant decrease in red blood cell numbers, which is a substantial decline in the availability of the leading carrier by which CO2 can be usually transferred to the lungs and kidneys to be eliminated. Severe anaemia also signifies a decrease in haemoglobin levels, and this reduces the possibility of CO2 binding to form carbaminohaemoglobin, the second most relevant CO2 carrier from tissues to lungs and kidneys.

Major adverse events are uncommon. In gynaecological laparoscopic surgery, large amounts of CO2 are used to expand the abdominal cavity (up to 4 litres of CO2) without any toxic effect.

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A decrease in plasmatic protein levels may be caused by chronic liver insufficiency that constitutes another contraindication for carboxytherapy.

Another contraindication is the presence of gaseous gangrene. This severe infectious disease is caused by anaerobic bacteria entered in the body through skin wounds and is characterised by extensive tissue damage, necrosis, oedema and severe generalised deteriorated conditions.

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CARBOXYTHERAPY IS SIMILAR TO MESOTHERAPY, BUT IT DELIVERS MEDICAL GRADE CARBON DIOXIDE GAS IN A CONTROLLED FLOW/DOSE BELOW THE SKIN’S SURFACE, RATHER THAN TINY QUANTITIES OF A LIQUID FORMULATION.

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Nasolabial folds and marionette lines on the face (A) before, and (B) after treated with 12 sessions of carboxytherapy, twice a week for the first 3 weeks and then once weekly for 6 more weeks.

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A A D FA T CE OESTMHE T+ I C S KDI N E NMTA I SGTARZYI NMEA G A Z I N E

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CARBOXYTHERAPY WORKS IN THREE COMPLEMENTARY WAYS. FIRST, CARBON DIOXIDE MECHANICALLY KILLS FAT CELLS BY BREAKING OFF THEIR MEMBRANES. SECOND, IT HAS A STRONG VASODILATORY EFFECT ON THE CAPILLARIES IN THE AREA. IT ALSO INCREASES THE PERCENTAGE OF OXYGEN IN THE TISSUE. AND THIRDLY, IT IMPROVES THE CUTANEOUS ELASTICITY AND INDUCES A REJUVENATION OF THE DERMIS.

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Indications and clinical data

where the gas was injected intradermally, as compared to where it was injected subcutaneously.

The most common aesthetic uses of carboxytherapy are for treating cellulite, fat reduction, striae (stretch marks), acne scarring, skin laxity, dark circles under the eyes and wrinkle reduction. Therefore treatments are generally focussed on the face, neck, arms, abdomen, and thighs.

Improved adiposity through lipolysis The effects of CO2 therapy lipolysis include: •

Fracturing of the adipose tissue

In 2001, the University of Siena (Italy) investigated CO2 treatment of localised fat deposits on the thighs, knees and/or abdomen in 48 women. The CO2 was administered via subcutaneous injections twice weekly for 3 weeks (equalling a total of 6 treatment sessions).

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Release of triglycerides in the intercellular spaces

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Adipocytes present thin fracture lines in the plasma membrane. These lines did not involve the connective spaces where the major vascular structures are located

The results showed that on average, the women lost 2 cms of circumference from their thighs, 1 cm from the knees, and almost 3 cms from the abdomen.

The skin in the treated areas also appeared thicker than before treatment, with cellulite appearing smoother. Few minor side-effects were observed but all resolved very quickly.

Brandi C et al. wrote in his study: ‘Carbon dioxide therapy in the treatment of localised adiposities: clinical study and histopathological correlations’, published in Aesthetic Plast Surgery, ‘The data regarding measurements of the maximum circumference of the thigh, knee, and abdomen taken before and at the end of the study showed a significant reduction in all patients.’

In 2004 the same university published another study looking at the effects of carbon dioxide on skin irregularity and its use as a complement to liposuction. Forty-two patients treated for fatty tissue accumulations on the thighs and knees were divided into three groups. In group 1, only liposuction was performed; in the second group, carboxytherapy was administered 3 weeks after liposuction in twice-weekly applications for 10 consecutive weeks; and in the third group, carboxytherapy alone was delivered, again twiceweekly, for 10 consecutive weeks.

At the injection site, the CO2 gas penetrates and spreads to other tissue nearby, and keeps on doing its work liberating bradykinin, serotonin, histamine, and catecholamine, which stimulate the beta-adrenergic receptors, producing lipolysis (destruction of fat cells).

When the CO2 comes in contact with fat, it diffuses, with part of it going to red blood cells. This is where it attaches to the haemoglobin and sends oxygen to the tissue, which then permits metabolic reactions.

The results were then analysed by reporting on variations in circumference measurements and skin elasticity after 2 months. The authors noted that liposuction alone did not generally have a positive enough effect on skin irregularity and could, in fact, cause uneven areas; however, the addition of carboxytherapy provided an improvement in skin smoothness and elasticity. Carbon dioxide therapy also showed positive results in reducing fat accumulation as the circumferential measurement results of those treated with liposuction and carbon dioxide were better than for those treated with liposuction alone.

Carboxytherapy works in three complementary ways. First, carbon dioxide mechanically kills fat cells by breaking off their membranes. Second, it has a strong vasodilatory effect (causes dilation of blood vessels) on the capillaries in the area. It also increases the percentage of oxygen in the tissue. Wider vessels mean bigger and stronger blood flow to the area. The increase in oxygen is important because it eliminates the built-up fluid from between the cells. And thirdly, it improves the cutaneous elasticity and induces a rejuvenation of the dermis.

In March 2008, a Brazilian study looked at whether the intradermal and subcutaneous injection of carbon dioxide into the skin of rats would increase the turnover of collagen. Following biopsies, it was noted that collagen turnover had increased compared to the control animals (which were injected with only saline) and that the collagen formations were more pronounced in the areas

Carboxytherapy is generally cheaper for patients than a course of Endermologie®, Smartlipo®, Ultrashape®, Velasmooth®, Thermage®, Accent® or Coolsculpt®, plus it’s a much cheaper investment for your clinic in terms of equipment, clinical environment, insurance and per patient accessories.

It is also much easier to transport from clinic to clinic, and there is almost no risk for the patient.

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Dark circles under the eyes One of the major causes of dark circles under the eyes is vascular pooling. The capillary network under the lower eyelids can become congested for a number of reasons. Normally tears drain from the eyelids into the nose, but if there is an obstruction due to chronic nasal congestion from seasonal allergies, previous nasal fracture, or a deviated septum, the drainage doesn’t function well, and the blood flow to the lower eyelids becomes sluggish, giving rise to a boggy blue tinge.

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PHalterations(aciditylevels)

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Freeradical increase

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Temperature alterations

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Oxydo-reduction alterations

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Lymphaticstasis

The glucosaminoglycans (GAG) are responsible for the movement of blood in a microcirculation. When GAG is reduced, there is also a decrease in the movement of the microcirculation, with less blood circulating and an alteration in the form of the fat cells, oedema, and fibrosis can occur.

The lack of oxygenation to lower eyelid skin allows the bluish cast to show through the thin skin.

Carboxytherapy works to improve the capillary network of the lower eyelids, as well as to increase the dermal collagen layer in the lower eyelid skin.

By injecting a small amount of carbon dioxide gas into the affected areas, blood flow is increased and improved capillary networks are formed. The bluish cast is replaced with a healthy pink tone.

Once a series of treatments have been completed, the skin has a more luminous appearance that lasts approximately 6 months.

The accumulation of this thick liquid produces irritation in the fibroblasts. They start to produce collagen in larger volumes; as a result, there is traction in the dermis, which causes the ‘orange peel’ look.

When CO2 is injected in the affected area, the situation is reversed. Vessel dilatation occurs and the speed of the microcirculation improves. The tissue receives more oxygen, toxins are eliminated, and the oedema reduces.

Stretch marks

Through the therapeutical effects mentioned before, it re-establishes the morphology and functionality of the microcirculation; by raising the quantity and speed of the blood flow, diminishing the accumulation of liquids between the cells, disintegrating the fat of the hypodermis, and diminishing the fibrosis. In a few weeks, natural local metabolism is stimulated, due to the increase in the microcirculation, the elimination of toxins, and the activation of the lipolysis process (destruction of the adipose tissue).

When treating stretch marks, note that studies show a better response to treatment when the marks are recent, and still red in colour, rather than when they are older with a more faded, silvery appearance.

Newer stretch marks will most likely require treatment once a week for 2–4 weeks, although in some cases (depending on severity) a single session is enough. Older stretch marks will need 3 or 4 treatment sessions at 3–4 weekly intervals.

Cellulite

Conclusion

Cellulite is partly a circulatory disorder at a local level. When drainage of fat cells does not occur, waste and impurities build up.

New equipment makes carboxytherapy a very easy to perform, cheap, and versatile option to treat multiple and various skin conditions. From vascular disease to dark circles under the eyes. From cellulite to fat deposits. From psoriasis to stretch marks and scars.

Cellulite is the result of a number of biochemical and metabolic alterations which all begin in the interstitial matrix and on connective structure levels, these include:

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SK I N CARE : THE RI GHT I N G R E DI ENTS MATTER

A A D FA T E E T H + S K I N M AG A Z I N E

Establishing the foundations of great skin health must always start with establishing a regular athome routine, using products with scientifically proven ingredients , at the right concentrations.

Skincare products that are defined as cosmeceuticals are a hybrid between cosmetics and pharmaceuticals and they represent one of the most important innovations in modern skincare. The huge growth in this industry over the last decade has seen the last decade has seen the introduction of a lot of products that claim this classification yet fail to deliver the high standards that we expect from this class of product.

The expectation is that, because they are a blend of cosmetics and pharmaceuticals, these products should provide benefits above and beyond simple cosmetics. They are viewed as alternatives to prescriptive medications and have become a valuable tool for physicians to compliment and enhance the results of in-office procedures. So how do we know which cosmeceutical products are effective in the pursuit of healthy skin?

While it is important to understand that there is no single ingredients that will fix all the contributory factors of a particular skin concern - there is no quick

fix or magic potion after all - there are definitely stand out ingredients that are "must haves" if a skin care routine is to move beyond the rudimentary. As clinicians, we must be able to differentiate between less effective products, marketing hype, and those that will actually improve skin health and appearance. The way to do this is to identify and understand the science behind their ingredients.

Yet just having a certain ingredient isn’t enough, they must also contain the right concentrations and the ingredients must be in the right form and pH to be active. An effective cosmeceutical skincare range should have a combination of targeted ingredients that work synergistically and are proven by independent scientific studies to be capable of more than simply delivering moisture to the skin.

An important group of cosmeceutical ingredients to look for are anti-oxidants and anti-inflammatories.

Targeting inflammation and free radical damage to the skin by oxidation has become one of the most important elements of managing skin health and aesthetics. There are many anti-oxidant/antiinflammatory cosmeceutical ingredients, but 3 of the most effective, that work synergistically, are Vitamin C, Alpha Lipoic Acid and Vitamin E.

A A D FA T E E T H + S K I N M AG A Z I N E

Vitamin C Topical Vitamin C requires a pH of 3.5 or less for optimal absorption and while many products boast they contain Vitamin C, they use forms that will not remain stable in skincare formulas. Sodium Ascorbyl Phosphate and a few other Vitamin C derivatives have been found to be incredibly stable, absorbed evenly and therefore effective in topical skincare products. Clinical studies have found Vitamin C Phosphate splits enzymatically in the skin to release the more active, but less stable, form of Vitamin C called l-ascorbic acid. Vitamin C has been repeatedly shown to be an effective anti-oxidant, protects the cells against free radicals and UV damage. Furthermore, it has been found to counteract skin deterioration by promoting new collagen formation and also has de-pigmenting properties.

Vitamin E Vitamin E is oil soluble anti-oxidant that cannot be synthesized by humans. It is the predominant antioxidant present in the stratum corneum and results in improved skin structure and support, leading to improved appearance of wrinkles, skin texture and pigmentation.

In addition to providing antioxidant protection, Vitamin E is thought to act as a penetration enhancer, aiding the passage of other ingredients through the skin barrier as it intercalates with the lipid bilayer of the stratum corneum, altering the characteristics of permeability. It is non-irritating like other penetration enhancers and also acts as an emollient aiding moisturisation. The ideal active form to have as an ingredient is alpha-tocopherol at 0.1-1%.

Left. Improvements in skin clarity and reduction of pigmentation after 2 months of topical Vitamin C use.

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ALPHA Lipoic Acid (ALA) An equally important anti-oxidant/anti-inflammatory in its own right, ALA is known for preventing cellular damage, having been shown to penetrate through the skin to the dermal and even subdermal layers. However a unique property of ALA is that it is a powerful co-enzyme anti-oxidant. As Vitamin C and E do work synergistically to boost each others performance, the levels of both can be readily depleted from the skin through UV exposure. ALA has the ability to regenerate levels of Vitamins C and E in the skin, regenerating them after photooxidation, which is why it is often combined with C and E in skincare formulas.

and we will be discussing more in coming editions of the ACD magazine, however they do stand out as some of the most effective ones to look out for.

When deciding which products to sell within our practices, or to recommend patients to buy, it is vital we are able to weed through marketing hype and select only those products that are formulated with a combination of ingredients scientifically proven to be effective in improving skin health and aesthetics, getting the results our patients and ourselves are looking for.

Ensuring patients are following a structured athome routine is a vital first step to improving skin health and aesthetics and must be in place prior to providing active therapies like Botox, Dermal Fillers, micro-needling etc. Make sure you attend AADFA’s “FACE� training to get all of the information you need to achieve the best results for your patients!

The active form, R-Alpha Lipoic Acid, soothes inflammation; boosts collagen formation and can act as a depigmenting agent as well as reducing fine lines and wrinkles when taken orally and applied topically.

The ingredients that are mentioned here are not the only important ingredients in skincare products

Improvements in skin quality and fine lines after 3 months of topical Vitamin C, E and AHA use.

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TE ETH WHITENING & R E JUVE NATION COMBO A WOR LD FIRS T

A A D FA T E E T H + S K I N M AG A Z I N E

Over the last few decades, teeth whitening has become the foundation of cosmetic dentistry, representing one of the most cost effective, minimally invasive, entry level options for patients wishing to enhance the appearance of their smile. When looking at developing an “AADFA Style”, complete intra- and extra-oral, DentoFacial Aesthetic treatment plan for patients, teeth whitening should be high on the list of proposals.

During our AADFA training pathway we share a system for conducting an extra-oral examination which ALWAYS starts with taking a tooth shade for EVERY patient – such is the importance of whitening procedures in achieving the best overall aesthetic result and in driving business success.

However, recent years have also presented greater challenges to Dental Practices in maintaining perceived value of in-office procedures, in the face of growing competition from non-dentist teeth whitening services.

At the same time, to provide more comprehensive dento-facial care to patients, many Dentists have made the move to offer facial rejuvenation therapies, such as Botox and Dermal Fillers, within their practice, alongside traditional dentistry. These services have long been thought of as diversifying our dental businesses to ensure new streams of revenue at a time when traditional dental business is getting tougher. However, if used wisely, facial rejuvenation procedures can also help to revitalise the demand for waning intra-oral dental procedures as well.

One such example is the unique protocol, developed by AADFA in a world-first, using LED skin therapy with in-office teeth whitening.

Adopting this procedure allows Dental practices to set themselves apart and market a novel treatment that kills two birds in one appointment, providing skin rejuvenation at the same time as teethwhitening. It enables Dentists to once again create a point-of-difference against non-dentist whitening services, as well as justifying the higher cost of treatment.

Patient’s expect a light to be used with in-office teeth whitening, but by restricting the light to just the oral cavity, Dentists are missing an opportunity offer more unique services to patients and to stand out in a competitive market.

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YELLOW 830nm YELLOW - 830nm (Sub-dermal Penetration) (sub-dermal penetration)

RED RED--633nm 630nm (Deep-dermal Penetration) (deep dermal penetration)

BLUE BLUE -- 415nm 415nm (Superficial / Mid dermis) Dermis) (superficial/mid

Wound Healing

Wound Healing

Pain Relief

Pain Relief after dental implants post-surgery/ after dental implants extractions

Generalised Generalised Skin SkinRejuvenation Rejuvenation

Anti-Bacterial Anti-Bacterial

post-surgery/extractions Muscle // Joint Joint Pain Muscle Pain Arthritis TMD Arthritis //TMD

Muscle Spasm / Bruxism

Muscle Spasm / Bruxism

Fibroblast Fibroblast Stimulation Stimulation Increases IncreasesCollagen Collagen Synthesis Synthesis

Treatment of Active Treatment ActiveAcne Acne

TemporarilyIncreases IncreasesBlood BloodCirculation Circulation& Reduces Inflammation Temporarily Circulation Reduces Inflammation Temporarily Increases Blood &&Reduces Inflammation

LED therapy addresses a broad range of clinical issues, depending on the wavelength selected and its tissue penetration profile. Often a combination of wavelengths, used synergistically, is the best approach.

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See the Light!

Many of the available in-office teeth whitening systems have promoted the use of light based technologies to enhance results. While such an approach has seen much debate around the need for, or the effectiveness of, the light itself, there is little doubt that in the eyes of a paying patient, there is the perception that a light provides a more high-end, scientifically advanced therapy, together with better clinical results. However, with non-dental services now offering similar looking therapies, these traditional approaches fail to stand out.

the resolution of active acne. Several orthodontists are now utilising such a device for their adolescent patients during each orthodontic adjustment appointment.

However, when it comes to the unique skin rejuvenation, teeth whitening combination developed by AADFA, our interest lies in utilising “red” light at a wavelength of 633nm. Extensive research demonstrates that this wavelength is optimal for stimulating fibroblasts and collagen synthesis in the skin, leading to generalised tissue rejuvenation.

So it’s time for dental practices to see the benefit of a new type of light.

The Procedure

Low-Level Light Therapy (LLLT), is the therapeutic use of incident light to photomodulate cellular function. Several brands exist, which provide devices consisting of an array of Light-Emitting Diode (LED) technology. LED devices harness the properties of different wavelengths of light and, depending on the wavelength selected, can stimulate various tissue responses in the skin.

When performing the combined therapy, it does not matter whether you currently utilise a lamp for in-office teeth whitening or use a purely chemical based process. If not using a lamp for teeth whitening, then you simply apply the whitening agent as normal and position the LED skin rejuvenation device over the patient’s entire face.

If using a lamp for whitening, then the agent is applied to the teeth; the whitening lamp focused on the teeth; and the LED device positioned over the top of it all, to cover the full-face area.

Each device allows the operator to switch easily between different wavelengths or even blend wavelengths for synergistic effects. For example, selecting “yellow” light at a wavelength of around 830nm, provides improved tissue healing and relief of pain. This treatment has been shown to be beneficial in the treatment of Temporomandibular Joint Disorders and in post-surgical healing.

The procedure for LED therapy is like that for most prominent in-office teeth whitening systems, in that results are best achieved with several cycles, each of approximately 15 minutes exposure. This enables the two treatments to be performed simultaneously with the minimum of additional effort.

Research has shown that using “blue” light at a wavelength of 415nm, is anti-bacterial and aids in

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An LED device, positioned over the entire patients face, can be used as a dual treatment of skin rejuvenation combined with in-office teeth whitening.

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Above 1. Generalised improvement in skin health and quality following several treatments using red LED therapy and a visible reduction in lines and wrinkles.

Above 2. A dramatic improvement in acne following several treatments using green LED therapy.

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The Resullts While Dentists are familiar with the results that can be achieved using in-office whitening treatments, they may not be aware of the dramatic improvements that can be obtained through the concurrent use of LED therapy.

The great attraction of LED-based technologies is that they are cost-effective, pain-free methods for achieving real improvements in skin health, for almost any patient, without the side effects, physical trauma or thermal damage that we see with many other light and laser based skin rejuvenation technologies. This makes LED devices among some the best options for dental clinics wanting to introduce skin rejuvenation therapies for the first time, where the focus should be on achieving results for patients, across a range of clinical indications, with minimal downtime and low complication rates – key factors in successfully expanding your clinical offerings.

Indeed, LED devices are so simple to use, that many practices delegate this responsibility to Hygienists, Assistants or Therapists and the treatment can even be used as a stand-alone therapy or at the end of a hygiene visit, such is its versatility – the combinations are only limited by your creativity.

This dual approach raises the perceived level of service in the patients’ eyes; allowing Dentists to justify their higher cost of in-office whitening treatment (or even raise the fees); and to differentiate the practice in a competitive market by promoting a service involving a unique approach of dual skin rejuvenation and whitening in the same appointment. When we look at the driving force behind patients choosing to undergo facial rejuvenation services generally in the dental chair rather than in other cosmetic clinics (eg. Botox, Dermal Fillers, etc), one main reason for this is the convenience of being able to tick several items off a busy “todo” list, at one location, in a single appointment.

By allowing dentists to effectively become a “one-stop-shop” for patients needs, these simple LED devices re-energise in-office whitening procedures and allow dentists to stay ahead of the game by truly enhancing the entire smile from the inside, out.

To learn more about this procedure and the latest materials and methods in teeth whitening in general, be sure to attend AADFA’s brand NEW training program called “FLUORESCE”!

Email admin@AADFA.net or visit the AADFA website for more details.

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NUTRITION & YOUR SKIN HOW DOES DIET AFFECT YOUR SKIN

"

AFTER TWENTY FIVE YEARS TRAINING AND NUTRITION COACHING MY DRIVE ONLY GROWS – A DEDICATION TO HELPING PEOPLE GET FIT AND FEEL THEIR ABSOLUTE BEST EVERY DAY.

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about tim

The highest nutrition qualifications from Paul Check, Charles Poliquin and Reed Davis supported my work as co-founder of the hugely successful Bodyism Clean and Lean diet book series in London. Today I'm advisor on Australia’s most successful online weight loss program - Michelle Bridges 12 Week Body Transformation.

Nutrition coaching high profile clients like Hugh Grant and Jesinta Campbell has been a rewarding experience but my favourite clients are everyday people.

A Bachelor of Health Science and personal training initially fuelled my interest in nutrition. But it was a battle with my own health that gave me true direction – a practical and enjoyable approach to nutrition and health.

Experience has shown me government dietary guidelines are impractical and mainstream nutrition practices are based on inaccurate data. I understand what people in our society need and the changes they are willing to make to improve their wellbeing.

I'm excited to announce the latest string to my bow; I will be joining the AADFA team as a Health and Fitness presenter to bring you AADFA’s newest module “FUEL”.

“FUEL” will help you master the science of nutrition!

As you know, diet and skin go hand in hand. If you want great Skin then you need to be fuelling your body with the right ingredients!

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How does your diet affect your skin?

The aging process, including the aging of your skin cells is accelerated with oxidative stress.

Oxidative stress causes free radical damage which is accelerated by:

Just like many organs your skin is under constant reconstruction, and needs daily uptake from a wide variety of nutrients, including:

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Sleep deprivation

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Deep fried foods

1. Omega-3 Fatty acids from fish & seafood, avocados, nuts - especially walnuts.

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Processed Foods (Everything in a packet, bag, box, can or container)

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Drugs – Tobacco

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Alcohol

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Stress in general

2. Vitamins C & E – That work together to have a calming effect on the skin.

3. Selenium – That protects the body from free radical damage and the rainbow of colours from vegetables.

It’s easy to get bogged down in details with these particular nutrients or certain “Super” foods, but here’s the simple truth; When your diet is made up of 80% fresh fruits, vegetables, nuts, seeds, organic meats, unprocessed dairy and filtered water your skin will look and function at it’s best. However the majority of people these days have it in reverse with 80% heavily processed foods and 20% natural, a good example is breakfast, most people start the day with refined cereals, grains and processed dairy (most milks), it’s no wonder modern man is the most depressed, addicted and malnourished we’ve been in recorded history.

Of course hormones and genetics play a key role, however the above factors are the variables that are 100% within our control, the one I will focus on in this diet is diet.

Each and every piece of food we eat literally becomes our eyes, teeth, hair and organs, including our largest organ - the skin.

At one end of the scale we have our stress-free, all organic, meditating hippie in Byron Bay, and if she doesn’t spend all day in the sun then this hippie is likely to have bright eyes, strong healthy teeth, highly functioning organs, including glowing skin.

As a starting point to better overall health and glowing skin, each meal should contain at least six ingredients, so vegemite on toast with butter doesn’t quite cut it, however a muesli with fresh (not dried) fruits, nuts and seeds with a milk that agrees with your stomach is a healthier way to start your day and start the wide variety of nutrients flowing in.

At the other end of the scale we have our high-flying, city-living corporate working 50+ hour weeks, full of constant time-pressure and deadlines, to cope with this frantic pace he is downing between 4-6 shots of espresso a day, eating on the run and buying from the closest food court.

Be more like the long-living Asian cultures with ageless complexion that eat 40 different types of food a day, as opposed to the average UK person that has the same 12 foods every week.

Even if our corporate warrior orders the occasional salad he is unlikely to absorb most of the nutrients, as the presence of caffeine as well as the constant stress is severely inhibiting his ability to absorb these nutrients, which results in even lower energy which then leads to self-medicating with antiinflammatories, more caffeine and largely useless supplements.

So if you can’t count at least 6 different colourful fresh foods on each plate then start mixing it up. Soups, broths and salads are an easy way to stack up dozens of ingredients that contain literally thousands of nutrients, micronutrients and phytonutrients.

For your entire 20’s you can lead either of the above 2 lifestyles and still look pretty good, however as you approach your 30’s and the youthful hormones start to run out, the corporate warrior will feel and now look terrible. Not only with weight gain, but dark circles from a toxic liver, dehydrated and old-looking skin that lacks the collagen due to a decade of abuse.

Rather than drain your brain with counting calories and feeling hungry all day try adding a few more fresh foods to your meals and you’ll soon start to look and feel younger, mentally sharper and allround happier.

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the beautiful benefits of exercise WHY ARE WE AGEING FASTER THAN WE SHOULD?

Exercise, we all know it’s good for us, and most of us need to do more, but why is the entire planet gradually getting fatter, slower and sicker?

While this is a huge question, a lot of it comes down to priorities. Very few (if any) working people leave their place of employment with unfinished jobs. They will get in early, work through lunch, stay up till midnight, whatever it takes to get the job done. In short, they prioritise their work above their health, which is why the vast majority of people on the planet are ageing way faster than they should, this can be seen in their general lack of energy, their inability to deal with stress, and, if it’s really bad, you can see it in people’s skin.

A A D FA T E E T H + S K I N M AG A Z I N E

Exercise is often sold to the vanity Smurf in us all, exercise more and you’ll lose weight, be more attractive and overall happier. Although it only works like this in commercials, Exercise has hundreds of other benefits including the prevention of debilitating conditions such as diabetes, arthritis and dementia to name a few. It also has the benefit of making your skin look and feel better; it does this through a number of channels: 1. Less Stress- Exercise decreases your stress hormones, when you’re less stressed you will have less stress-related wrinkles.

2. Circulation– Any exercise that gets your blood pumping boosts circulation, which brings both oxygen and nutrients to the surface of your skin. A solid workout also produces sweat which can help the body rid itself of toxins and flush impurities out of your pores forming clearer and brighter skin, this is why you shouldn’t wear make up before you train, it can actually block and irritate your pores – more on this in a minute.

3. Better Antioxidant delivery – Antioxidants, along with oxygen work by neutralising free radical damage, which is the main trigger for cellular damage and collagen breakdown.

4. More Collagen- To a lesser degree physical activity can boost collagen levels and slow down some signs of ageing.

5. New Blood Vessels- Multiple studies have confirmed that regular exercise can boost new blood vessel formation in the skin. This is especially important when we hit our 40’s (trust me on this one). Studies show up to a 50% reduction in blood flow to the deeper layers of our skin, which means the nutrient supply is reduced, a great reason to get out there and sweat yourself young.

6. Sweat More - Sweating helps to cool the surface of the skin, flushes out grime and impurities and can even prevent harmful bacteria such as E.coli and Staphylococcus from setting up shop on your skin.

7. Build Muscle- Building muscle mass through weight training exercises can help decrease the appearance of loose skin, especially if the loose skin is from weight loss.

A A D FA T E E T H + S K I N M AG A Z I N E

Being Skin Smart When you sweat / perspire, your pores open up letting potential bacteria seep into your pores, which is why you should start your workout with a freshly cleaned face. For the boys a razor shave cuts away the dead skin cells, which is why we look and feel better after a shave. For the females an exfoliation will have a similar effect.

2. In order to make this a regular habit find an exercise that you LOVE to do.

3. Start your workout with clean skin, as any form of make up or product on your skin will block your pores and inhibit the flushing process.

4. As you sweat wipe it away to avoid bacteria entering your pores. You don’t want to block the garbage truck when it’s taking away your internal toxins.

During training, continually pat your skin to keep it clean, then immediately afterwards give your hands and face a good wash.

5. Stay hydrated with pure water before, during and after your workout. For the next level of clean, add some Aloe Vera concentrate in your water bottle.

When your skin is hot after working out from either your internal body heat or the external environment, or the double-whammy of training hard out in the sunshine, then this will cause your skins antioxidant levels to drop as the protein increases, which, when done excessively can damage your skins collagen supply which can eventually lead to sun spots, dry skin and premature aging.

6. Your liver is the main detoxification organ.

Keep that flushed with a whole foods diet, lots of pure water and you guessed it – Regular exercise.

7. Prevention is always better than cure. So be smart and start up a healthy skin routine in your 20’s and 30’s so your skin remains clear, cleansed and free from pre-mature cellular ageing.

Take home messages.

1. It’s important to do some form of exercise on a consistent basis that makes your heart pump and your skin sweat.

Tim loves helping people feel better through intelligent exercise, real life nutrition and a worry-free mindset.

Follow Tim on his Instagram Page @tim_pittorino .

See Tim at the launch of “FUEL” at the 2020 “FAT” and “FACE” modules!

AADFA Members will also see Tim present the "Health & Fitness Masterclass Series" and the "Nutrition Masterclass Series" online!

Both Masterclass Series are FREE & EXCLUSIVE to AADFA Members.

Visit www.AADFA.net for more information on the “FUEL” module.

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B E ST DENTAL SPA nominee BEST DENTAL SPAS OF AUSTRALIA NOTHING MAKES US HAPPIER THAN SEEING AADFA PRACTITIONERS TAKING THEIR PRACTICES TO THE NEXT LEVEL AND TRULY SUCCEEDING IN THE DENTAL SPA SPHERE! ON OUR JOURNEY TO CROWN "AUSTRALIA'S BEST DENTAL SPA" WE WILL BE INTERVIEWING NOMINEES FROM ALL AROUND AUSTRALIA, WHO HAVE CREATED LUXE PRACTICES OFFERING EVERYTHING TEETH AND SKIN IN A SPA-LIKE BOUTIQUE ENVIRONMENT.

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AADFA interviews Dr Victor Siouclis of Family Care Dental & Aesthetics who has been nominated as one of Victoria's BEST Dental Spas.

practitioners to offer facial aesthetic treatments.

I have a thorough knowledge of facial structures, including teeth, bone, muscle, fat, nerves and blood vessels, which is paramount for patient safety.

Almost equally important is an understanding in facial proportions, symmetry and aesthetics, to achieve a natural, harmonious result.

Dr Vic tells us he loves the variety his job allows him now that he has incorporated aesthetic and facial rejuvenation procedures into his practice in Hoppers Crossing, Victoria.

I see Botox and Dermal Filler treatments as another “tool in my toolbox” to assist my patients in improving their smiles and skin health.

Congratulations on being nominated as one of Australia's Best Dental Spas in Victoria! We want to know, how did your Aesthetic & Facial Rejuvenation journey start?

I have undergone comprehensive, industry leading education with AAADFA: aquiring the necessary theoretical knowledge and practical skills needed to successfully deliver aesthetic and therapeutic facial therapies across the dento-facial region safely and effectively; adhering to the highest clinical and ethical standards.

Facial Aesthetics & Rejuvenation was an area my wife, Julie and I had an interest in. I saw it as an opportunity to expand the range of services I offer for my patients.

My Wife Julie heads the skin health division of our practice and has selectively added clinically proven treatments to offer our patients, we work really well as a team!

After attending our first AADFA course, we agreed whole-heartedly that ‘skin health’ could be seamlessly incorporated with ‘dental health’.

It makes sense; the face is a Dentists area of expertise, Dentists are one of the most qualified

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What facial aesthetic treatments do you offer? inserted into the skin to areas of the face to lift sagging skin. They provide a new support scaffolding that also helps to stimulate collagen.

We have meticulously selected treatments that offer scientifically proven results, with minimal to no downtime.

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Botulinum Toxin for therapeutic purposes, to alleviate tmj pain, correction of a “gummy smile”, or relief from tension head aches.

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Anti Wrinkle Treatments with Botulinum Toxin.

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Dermal fillers are a wonderful, long lasting treatment to help improve facial symmetry, for facial rejuvenation and to replace lost volume.

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Lips, of course are my specialty. As a dentist I understand the anatomy of the lip, to achieve a beautiful enhancement as well as the importance of the surrounding oral areas such as; philtrum, oral commissures, and marionettes. I view the face in it's entirety and offer treatments to areas such as tear troughs, temples, cheeks, nose, chin and jawline.

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PDO Thread Lifts are a non-surgical face lift with little to no downtime! PDO Threads are

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HydraFacial is a multi-stage facial treatment that performs a deep cleanse and exfoliation, painless extraction of blocked pores and delivers nutrient serums to the skin. It is a results driven facial that delivers a noticeable improvement in skin tone and texture.

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Omnilux LED light therapy is a 20 minute non invasive treatment that uses specific frequencies of light to stimulate the body’s natural processes and boost skin performance.

After blissfully lying under the sleep inducing (and serotonin producing) glow, the skin is noticeably plumper, more radiant and more even in texture and colour. Omnilux rejuvenates skin by boosting collagen synthesis and is clinically proven to improve the appearance of lines and wrinkles.

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BBL (broad band light) harnesses the power of light and is the new standard in treating skin conditions. BBL’s photo-thermal energy will eliminate fine blood vessels that cause redness and reduce unwanted melanin that produces age and sun spots. Skin feels smoother, pores appear less noticeable, and uneven pigmentation will fade.

collagen. It is a great treatment for all skin types and treats fine lines, hyperpigmentation, pore reduction, acne scarring, skin laxity and texture.

BBL offers “ForeverYoung PhotoFacial ". A revolutionary treatment that sends light energy deep into skin to boost the bodies natural ability to fight ageing by activating certain genes associated with youth, while turning off other genes tied to ageing! New skin cells are actually programmed to be younger, resulting in beautiful, youthful skin.

Dermastamp collagen induction therapy, creates very fine micro channels into the skin to help trigger the skins wound healing response and induce growth factors to help stimulate

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PRP/CGF therapy harnesses the body’s regenerative processes to rejuvenate skin. We draw blood from the patient’s arm and using a specially designed centrifuge, a concentration of Platelet Rich Plasma and Concentrated Growth Factors are extracted. These platelets play an important role in healing and stimulating tissue repair for total face rejuvenation.

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Chemical Peels are designed to noticeably improve the skin’s appearance. They exfoliate, hydrate and even the appearance of the skin and are power packed with skin enhancing benefits!

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Priori Skin Care. I cannot stress enough the importance of a medical grade cosmeceutical skin care regimen!

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What's your go to treatment for yourself?

practice? What would be the uptake percentage for Aesthetic & Facial Rejuvenation services?"

I love the BBL ForeverYoung PhotoFacial. It addresses all my concerns and gives me the long term benefits of changing gene expression in my skin to keep it ‘ForeverYoung’. I always get comments that my skin is looking amazing after a treatment.

The facial aesthetic side of the business grew organically from the daily flow of our existing patients and has steadily grown each year as we’ve added additional services and have had patients returning for further treatments and from patient referrals. This side will only continue to grow with the projected forecast for minimally invasive aesthetic treatments on the up and up.

What is one of the most popular treatments at your Practice?

Family Care Dental & Aesthetics has become quite “insta-famous “ for our 90 minute Signature HydraFacial which includes the Omnilux LED light therapy. It’s a results driven facial - it's very relaxing.

We have a line of chilled patients with glowing skin leaving our clinic every day! They love the look and feel of their skin - and they love seeing the "gunkiejar” which contains all of the dead skin cells, blackheads, congestion, makeup and oil that has been removed from their skin!

Now tell us how much you LOVE treating facial aesthetic and facial rejuvenation patients?

It’s true! You don’t get the same level of enthusiasm from patients coming in for a filling!

I feel honoured that my patients trust me with their treatment and that they have confidence in me to enhance and rejuvenate in a natural and subtle way.

It’s a real privilege.

How did you go about implementing your Dental Spa into your existing Dental Practice?

Do you think patients LOVE the fact that they can receive everything under one roof? From dental treatments, to Botox and Fillers, Skin Needling, Skincare and peels?

It’s a seamless crossover. I included a basic skin check in my regular check up and cleans (as taught by AADFA on the "FACE" module). Our patients tend to be first timers with injectables, they feel confident and trust me to take care of them. Once I explain that my field of expertise is the entire face - they get it, and then they refer their friends and family.

Oh yes! I’ve had my practice for 25 years and I’ve kept so many of my original patients over this time. My team have been with me for most of this time also. We’ve built great relationships and love seeing our patients more often to discuss new treatments we offer.

Skin patients become dental patients and vice versa, I love the variety it brings to my schedule.

Do your staff love the aesthetic & facial rejuvenation procedures that you offer?

How did you initially hear about AADFA? What was your drive to incorporate aesthetic & facial rejuvenation procedures into your practice?

The staff LOVE receiving the facial rejuvenation treatments! I have the best looking team in town!

Not only are they a walking advertisement with their flawless, glowing skin - but they can honestly recommend and vouch for the effectiveness of the treatments we offer. It makes the patients feel at ease when enquiring about the treatments - and also, it gives a deeper level of trust.

The internet! AADFA trainings are truly world class, incorporating such a high standard of education and practical experience and each module builds on the knowledge of the previous module to give all graduates a comprehensive understanding of facial aesthetics and rejuvenation.

For any Dentist considering entering the world of Aesthetic & Facial Rejuvenation Dentistry, what's your advice?

How have the AADFA teachings changed the way you practice?

Build your knowledge. Attend as many AADFA seminars and trainings as possible. The safety of your patient is always your primary concern. Then learn all there is to know about products and techniques.

Neurotoxin and dermal fillers are being used for so much more than just anti wrinkle and volume. Study faces! After you understand the science, what takes

On completion of the AADFA modules, I was truly inspired to be able to offer these treatments to my patients and help them understand the importance of sunscreen and skin health. I have such a passion for giving my patients a ‘full face smile make over’!

Would you say implementing Aesthetic & Facial Rejuvenation treatments has grown your

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you to the next level as an injector, is an understanding of beauty - for males and females. It is an art. To give just the right highlight to the cheekbones. The perfect soft pout to the lips, with a defined Cupid’s bow and vermillion border, an upturn of the lip and an enhancement of the pillows in the lip. To achieve a balanced profile with careful placement of filler in the chin, jawline and nose. To give a refreshed look to sunken tear troughs. To recognise that some temporal hollowing is giving an aged appearance.

When you can recognise how a treatment can give your patient the enhancement they are looking for, you have a happy, loyal patient for life.

Follow us on Instagram and Facebook @FamilyCareDentalAndAesthetics

What's the practice instagram and facebook links?

You can find out more about us and the treatments we offer at www.familycaredentalhc.com.au 57 57

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Facial rehabilitation a dentist’s full potential DR MYLES HOLT DISCUSSES WHAT IS NOW POSSIBLE WITHIN THE REALMS OF NON-SURGICAL FACIAL PROCEDURES FOR DENTISTS AND WHY EVERY GREAT DENTIST SHOULD HAVE THESE TOOLS IN THEIR PRACTICES TO REACH THEIR FULL POTENTIAL.

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The use of non-surgical facial procedures as antiageing therapies is certainly a big business and does bring its own rewards, especially financial, but eventually it becomes repetitive and routine, much like a scale and clean or teeth whitening.

It is the ability to have these remarkable tools in your toolkit and to be able to use your extensive knowledge of head and neck anatomy, combined with your aesthetic eye, to provide life- changing rehabilitation to a patient’s face that carries with it the greater levels of satisfaction, professional achievement and financial reward we all seek.

Every dentist knows the amazing benefits that can come from performing an incredible dental rehabilitation. Those benefits are numerous for the patient who receives the sparkling, healthy new smile; ranging from the elimination of pain and disease, through to improved self-esteem and social presence; but they are also tangible for the dentist.

Performing a complete make-over using advanced techniques, skills and materials is, on most occasions and in almost every way, immeasurably more rewarding than providing a simple scale and clean, Class 1 restoration or even teeth whitening.

Achieving a result which transcends basic dental work and has an impact on the patient’s life, brings with it a sense of achievement; a feeling of real purpose and a level of pride and satisfaction that is the very thing that keeps good dentists in a profession that is increasingly demanding.

Beyond the lines & wrinkles When AADFA first pioneered the Dento- Facial concept in Australasia coining the term and starting to train dentists and their teams in various skin and facial rejuvenation procedures over 10 years ago, many thought that it was just about improving the cosmetic appearance of facial lines and wrinkles.

Well the very same is true for those dentists who have advanced their knowledge and skillset to include non- surgical facial rejuvenation procedures. However, while much has been made over the past decade of dentists using tools like BOTOX® and Dermal Fillers for cosmetic purposes, to treat lines and wrinkles; and while this is certainly a nice service to provide, few people realise that it’s only the tip of a much bigger and more satisfying professional iceberg.

However this was never the message that AADFA delivered and the organisation is now famous for advocating the full-face concept – utilising the high levels of skill, knowledge and ability of dental teams, to restore health, vitality and aesthetics across the entire facial region, intra and extra-oral – which is an approach that only dentists can fully provide and enables them to provide life-changing results for their patients.

Figure 1. The height of dental achievement and satisfaction lies in being able to successfully tackle complex cases and provide life-changing results – the same is true of facial aesthetic treatments.

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For example, Botulinum toxin injections can be used to treat either the affected or the unaffected side of the face in patients suffering from the aforementioned facial contortions resulting from Bell’s Palsy. By relaxing facial muscles that have become restricted, or reducing muscle activity of the unaffected side, dentists can successfully balance the movement of the face, creating a more harmonious aesthetic appearance and improving a patient’s self-esteem (Fig. 3).

Slowly the message started to gather momentum within the profession and dentists began to see the potential in being able to utilise muscle relaxant injections (e.g. BOTOX®), for the reduction of “gummy smiles”, reducing occlusal loads during the placement of immediate implants; reducing the bulk of hypertrophic masseter muscles and relieving the symptoms of TMD/Bruxism.

Dentists also saw the immediate benefits provided by being able to use Dermal Filler injections to enhance lip proportions; framing intra-oral work that had been so meticulously fabricated, but until now been let down by the deteriorating extra-oral surrounds; and the benefit of those same injections to re-build a lost inter-dental papilla – the dreaded “black triangles”.

Dermal Filler injections are also much more useful than for just an aesthetic lip enhancement. Fig. 4 shows the case of a young woman who was involved in a motorcycle accident, during which she suffered extensive and disfiguring trauma to the mid and upper portions of the left side of her face.

But while being able to relieve a patient’s TMD symptoms, reduce their gummy smile and close their black triangles is definitely more rewarding and professionally satisfying for a dentist than just improving the appearance of their facial lines and wrinkles, such procedures are still not representative of a dentist using these techniques and materials to their full potential as a healthcare provider.

Subsequent reconstructive surgery left her with prominent scarring and the complete removed of certain fat compartments from beneath her left eye (e.g the Sub-Orbicularis Oculi Fat).

These compartments of fat provide necessary volume, structure and support to the mid-face and as a result of losing these, a pronounced midface ledge and substantial depressive infra-orbital hollow was visible and became the source of ridicule during schooling years and deflated selfesteem.

Only when a dentist is able to utilise advanced materials, techniques, knowledge of facial anatomy and their aesthetic eye to tackle complex cases, will true professional satisfaction and a sense of pride prevail and the dentist truly be delivering the concept of Complete Dento- Facial Aesthetics, rather than just basic injections.

Facial rehabilitation in the dentists’ hands

Utilising a keen knowledge of facial anatomy and advanced techniques learnt during AADFA programs, dentists were able to restore the lost structure, facial contour and quality of life in under 15 minutes and without anaesthesia!

In cases of Bell’s Palsy the most common cause of unilateral facial paralysis, various asymmetric and non-aesthetic facial patterns can develop due to the mismatch between the affected and unaffected sides. In some cases, the paralyzed side of the face droops, while the normal side appears to be hyperanimated, with the lip being pulled toward the normal side, creating a highly asymmetric smile that almost appears like a snarl (Fig. 3).

Dermal Filler materials are also extremely useful when dentists wish to create substantial changes to facial contours and profiles in cases where surgical intervention is either not possible or not desired.

The techniques can be successfully blended with traditional orthodontics to create the illusion of a more Class I soft tissue profile by either advancing the mid-face in Class III individuals, or the chin in Class II patients (Fig. 5).

In other cases, patients can develop “synkinesis,” or involuntary facial movements or spasms that occur during intended voluntary movements.

For example, when trying to smile, the muscles that lift the corner of the mouth also result in the simultaneous and unintentional activation of the muscles that draw the face and the corner of the mouth down. This tug of war distorts the face and often results in a frozen smile.

Finally, perhaps the most advanced aesthetic cases, demanding the use of a multi-pronged treatment approach, are those involving patients with marked unilateral flaccid paralysis resulting from stroke (Fig. 6).

As in previous examples, BOTOX® can be used to balance muscle function/ dynamics; dermal filler can be used to improve facial contours, structure and proportion; while innovative techniques, introduced to Australia by AADFA, called PDO Thread Lifts (essentially sutures), are able to reposition flaccid tissues with a great degree of control. These procedures can easily be combined in the dental chair under simple local anaesthetic.

Dentists who have completed AADFA’s comprehensive structured pathway of learning and possess advanced tools, beyond just basic Botox and Filler, can confidently blend various techniques to provide more complex facial rehabilitation in cases that can be truly life-changing.

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Figure 2. Most dentists are aware that facial treatments can do more than treat wrinkles – like improving TMD/Bruxism & a gummy smile, or to fill interdental papillae – but few realise their full potential.

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Figure 3. A snarled smile due to the functional mismatch resulting from Bell’s Palsy. Strategic application of BOTOX®injections (black dots) by a dentist with advanced AADFA training, results in a harmonious and life-changing outcome.

Figure 4. Motor accident resulting in significant facial deformity was corrected by dentists using Dermal Filler injections.

Figure 5. A dentist treating a Skeletal Class II patient, has been able to achieve a Class I soft- tissue profile by advancing the chin & jawline, while also strengthening the nasal dorsum Figure 6. The after effects of a stroke can be improved upon by a dentist utilising a combination of therapies, including Botox®, Dermal Filler and PDO thread lifts to reduce laxity and elevate/reposition facial tissues.

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To learn more or to refer

If you are looking to refer a patient for procedures using BOTOX® , Dermal Filler or a plethora of other facial rehabilitation therapies but you’re not sure who to trust, AADFA has a handy directory on the website (www.AADFA.net/directory), which lists Member Dentists in your local area, alongside their clinical competencies.

AADFA’s catchphrase is that, “A smile doesn’t end with beautiful teeth” and this is certainly true in cases where marked asymmetries, deficiencies or deterioration present major aesthetic challenges.

In order to achieve the best results for patients, dentists must have more than just intra-oral tools at their disposal and know how to blend intra and extra-oral techniques to achieve harmonious results.

By referring to an AADFA Member, you can be assured that your patients will be in the hands of a well-trained, highly skilled practitioner who is bound by a stringent Code of Conduct and best practice guidelines.

It is certainly astonishing to see what is now possible in a dental practice, with AADFA’s comprehensive training pathway, leading to an international fellowship, a world-first, recognised by insurers and product manufacturers as being the pre-eminent education in the industry.

AADFA’s pioneering work equips dentists with the tools, skills and understanding to safely and effectively tackle even the most complex cases, enabling them to achieve life-changing results like never before. For dentists wishing to incorporate these techniques in to their practice, AADFA run training programs throughout Australia and New Zealand, as well as internationally. For further details, visit the AADFA website or email: admin@AADFA.net

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P DO THR EADS...

B e tte r than Botox!

WORDS BY : DR MYLES HOLT

One of the most common questions we get asked at AADFA HQ is: "What's The Next BIG Thing?"

When it comes to achieving the best facial rejuvenation results, it is well known that a multipronged approach to treatment remains necessary to tackle the multi-faceted nature of the ageing and skin deterioration process. The mainstays of this approach over the last few of decades have been botulinum toxins, dermal fillers, chemical peels, lights/ lasers and micro needling. However, none of these approaches has ever really been able to provide a simple, effective and low cost approach to issues of skin laxity or “sagging”, especially in the lower face. It is within this area that we are now seeing “The Next Big Thing” !

It seems like every month we see the launch of a new cream or treatment making wild claims about being the most advanced breakthrough in skin rejuvenation; delivering unparalleled results; often without needles and with no associated pain or downtime. Needless to say, the VAST majority of these “game- changers” are anything but, amounting to little more than marketing hype and doing nothing other than further confusing already poorly informed consumers. The notion of a single magic bullet for facial rejuvenation remains a myth.

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AGE 70 YEARS

Descent or “sagging” of facial tissues, caused by a loss of Collagen, Elastin & Extracellular Matrix; the downward pull of gravity & depressor muscles eg. Platysma; a weakening of retaining ligaments & deflation of supporting structures, leads to a loss of the Pyramid of Youth and the development of Nasolabial Folds, Marionette Lines, Jowls and Neck folds.

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Facial Ageing & Skin Laxity The facial ageing process is a three- dimensional, multi-factorial, never- ending process that; while involving predictable histological changes in the skin with time; is complicated by a variety of extrinsic influences (eg. smoking, sun exposure), which vary for each individual. However, regardless of the contributing factors, the overall macro image of facial ageing predictably involves changes in skin structure, elasticity and texture; changes in underlying skeletal and muscle support; the development of various lines and wrinkles; and a volume loss and re-distribution of subcutaneous fat compartments. This can typically be described in terms of a loss of the “Pyramid of Youth” or facial “Descent” and for all the advances over the years in skin rejuvenation, skin laxity has remained a difficult area to address.

were to wait until it was severe enough to warrant undergoing surgical repositioning (traditional face lifts and bletheroplasty), or to attempt improvement and prevention through the use of expensive technologies such as High Intensity Focused Ultrasound (HIFU) and Radiofrequency (RF), which provide unpredictable results at best and only truly work the mildest of cases.

In response to this growing demand for simple, cost effective solutions to mild to moderate skin laxity issues, doctors in South Korea pioneered the use of Facial Threading techniques which enable the repositioning of sagging skin in a predictable, immediate, non-surgical and low cost procedure.

With sagging skin being one of the most commonly complained about conditions in the facial aesthetics field, it is little wonder that the past 5 – 7 years has seen a massive upsurge in the use of non-surgical facial threads and with results that are far more dramatic than the use of Botox and Dermal Fillers, with far fewer potential complications, this is a trend that is only set to continue.

Skin laxity is most commonly seen in the lower face as a deepening of marionette lines, naso-labial folds and the development of jowls along the jawline, however we also see descent commonly in the brow region as well. For decades, the only options for patients to address concerns over skin laxity

Before and After. Facial Thread treatment to improve skin laxity and the severity of the nasolabial folds, marionette lines and jawline “jowling”

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What are Threads & how do they work?

The idea of threads to improve facial laxity and assist in skin rejuvenation developed from research and experience in both surgical facelift procedures and the use of acupuncture. Two types of facial threads exist which reflect the two distinct, yet concurrent, goals of therapy, which are to:

constructed from fine filaments of Polydioxanone (PDO). PDO is a colourless, crystalline, biodegradable synthetic non-animal based polymer. It has been used as a suture material for wound closure for many decades and has now been utilized in facial thread treatments for over 15 years.

When speaking of PDO threads, we usually talk in terms of “mono threads”, which are simple PDO strands used solely to achieve the goal of dermal revitalization; and in terms of “cog threads”, which are PDO strands with hook-like projections, used for both dermal enhancement and to engage and “lift” sagging tissues.

1. Stimulate neo-collagenesis and neovascularization via an inflammatory mediated wound healing mechanism, leading to improved skin tone and texture (similar to many other skin rejuvenation therapies), resulting in skin rejuvenation/tightening through guided stimulation of Collagen, Elastin, Reticulin & Extracellular; and

Biodegradation of PDO occurs through a process of hydrolysis over a period of about six to eight months and while immediate “lifting” effects can be seen immediately upon product placement, results continue to improve as time goes on.

Despite the threads themselves degrading after this period, full results are maintained for up to two years as an area of elastic fibrosis develops around where the thread was inserted, thereby creating a dense structural supporting framework long after the thread has dissolved.

2. To engage the subdermal tissues with projections or hooks stemming from the thread itself, enabling the tissues to be instantly pulled, lifted and fixed in a new and desirable elevated position. This is effectively a means of mechanical support and a physical lifting, repositioning and recontouring sagging tissues.

While many materials have been tried in the past, the safest and most successful products are now

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Figure 1. A simple “mono” thread in its carrier needle Figure 2. A “cog” thread with side projections for engaging and lifting the skin.

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Figure 1. Local anaesthetic is administered and the desired thread pattern outlined on the skin.

Figure 2. Contained within its carrier needle or cannula, the thread is inserted to the desired depth.

Figure 3. The carrier needle or cannula is removed, leaving the thread in place.

Figure 4. Once the thread has been placed in the required position, the remaining projecting end of the thread is cut so the entire length disappears in to the skin and is undetectable.

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Threads can also be used to treat the neck region to tighten loose skin and to strengthen the jawline.

Amazing results can be achieved when combining PDO threads with CGF using AADFA’s world first “Concentrated Lift” technique.

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What does treatment involve?

The main reasons that PDO facial threads have become the next “BIG” thing in skin rejuvenation is because of the ease of use and the excellent reproducible and sustainable results that can be achieved during a half hour procedure, in the chair, under local anaesthesia, that also results in only minor side effects (eg mild transient bruising and swelling), and the very low incidence of complications.

marionette lines. In the overall spectrum of facial rejuvenation, Threads are ideally used early in a treatment plan, after the use of Botulinum Toxin to reduce the action of depressor muscles like Platysma and before the use of dermal fillers which can often only serve to weigh the face down further.

The ability to actually reposition tissues is reducing, and in some cases eliminating, the relevance on the use of other more expensive and unpredictable therapies.

After the skin is thoroughly cleansed, local anaesthetic is administered to the area to receive the threads and the desired pattern of thread placement is drawn on the skin with a temporary marker pen. The threads are able to be inserted as they are fixed to either a delivery needle or cannula in order to be placed at the correct depth within the skin. Once the thread is placed in the desired location, the carrier needle or cannula is removed, leaving the thread in situ.

Combination treatments As mentioned previously, the best results are achieved in facial rejuvenation when a combination of therapies are used together to tackle the various aspects of the ageing process. This is another major advantage of using PDO Threads. The carrier needles or cannulas allow substances like hyaluronic acid and blood concentrates like Concentrated Growth Factors (CGF), to be delivered to the deeper layers of the skin and further stimulate tissue recovery.

Post-operatively patients can experience some transient mild bruising and swelling, as well as a feeling of tightness for several days. However, when compared to the long, uncomfortable recovery times of traditional surgical procedures, and the potential complications of other non-surgical enhancements, like vascular occlusion with dermal fillers, it is little wonder people are lining up to be “threaded”.

Where can I learn more?

AADFA runs a practical, hands-on 2-day program in the use of PDO threads for the treatment of skin laxity and generalized skin rejuvenation, called “FIBER”. This program is run in conjunction the “PHLEBOTOMY” program, which teaches you the skills of Venipuncture; the use of CGF for facial rejuvenation and intra-oral applications; as well as how to successfully combine CGF with PDO Threads to achieve maximum results in a worldfirst technique developed by AADFA, called the “Concentrated Lift”. Are you ready to give your practice a “Concentrated Lift”?

What can Threads treat?

As a skin rejuvenation therapy, PDO threads can be used to address fine lines and wrinkles, as well as improving skin tone and texture. With their mechanical “lifting” effect, threads are able to aid in cheek and mid-face enhancement; treat jowls and enhancing jawlines; offer solutions for nose augmentations and brow lifts; and improve the appearance of double chins, nasolabial folds and

Don't get left behind, join AADFA for the combined "PHLEBOTOMY" and "FIBER" module.. Learn more at www.AADFA.net

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Chewing the fat. the concept of double chin reduction in the dental chair AS DENTAL PRACTITIONERS IN AUSTRALIA AND NEW ZEALAND WERE AMONG THE FIRST IN THE WORLD TO INCORPORATE THE LATEST FAT BUSTING THERAPIES INTO DENTAL PRACTICE IN 2019; REDUCING THE HEALTH AND AESTHETIC IMPACT OF EXCESSIVE FAT DEPOSITS IN DOUBLE CHINS, JOWLS, CHEEKS AND UNDEREYE REGIONS IN THEIR PATIENTS; THE QUESTION IS NO LONGER, “SHOULD PRACTITIONERS BE OFFERING THESE SERVICES”, BUT RATHER, “IF YOU’RE NOT, ARE YOU FAILING TO DELIVER A COMPREHENSIVE SERVICE AND FULL SCOPE OF PRACTICE?”

WORDS BY : DR MYLES HOLT

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Dentists can no longer treat the teeth and mouth as if it were isolated from the rest of the face.

A A D FA T E E T H + S K I N M AG A Z I N E

Introduction - Do you have a problem?

With over 5000 Dental Practitioners across Australia and New Zealand having undergone training to incorporate extra-oral facial therapies into their practice, there is now a general acceptance that these skin services fall firmly within the remit of the dental profession.

Moreover, it has reached the point where if you’re a Dental Practitioner who fails to examine and consider the skin and other prominent facial structures adjacent to the oral cavity, on each and every patient, you may have a problem. It would be likely that you are falling behind your colleagues and below the standard of modern day Dentistry, as the mouth, teeth and jaws can no longer be treated as if they are isolated from the rest of the face.

If you don’t have the tools in your armamentarium to successfully address skin and facial deterioration and ill-health, just as you would the teeth and gums; if you don’t have the training and ability to harmonise the dynamics and aesthetics of the extra-oral with the intra-oral; if you can’t even at least advise a patient as to how they can naturally enhance the health and aesthetics of their lips; then you are arguably failing to fulfil the full scope of modern dental practice. Without doubt, a failure to address the extra-oral facial structures that frame the oral cavity would make it extremely unlikely that you could appropriately diagnose and formulate a comprehensive and holistic treatment plan, let alone obtain truly informed consent for advanced procedures.

This is especially true for modern aesthetic cases, given that smile design is now so facially driven. It would be difficult to claim you truly obtained fully informed consent; for procedures ranging from orthodontics and gummy smile, through to TMD and anterior aesthetic cases; without any consideration or discussion having taken place around the impact of and on, the extra-oral facial features and how structures adjacent to the teeth and gums interplay with what is done intra-orally.

Considering this, the profession really has reached a point where, as a dental practitioner, you either stick to cleans, root canals and simple restorations, or you understand the entire dento-facial complex and factor all aspects in to your more advanced restorative, orthodontic and aesthetic treatment plans. By simply offering intra-oral dentistry, especially advanced procedures, you run the very real risk of being caught out, failing to provide comprehensive care.

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The entire dento-facial complex must be understood, considered and discussed with patients to ensure informed consent and comprehensive care.

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The best way to understand and achieve the concept of Complete Dento-Facial Aesthetics & Health, is by thinking in terms of addressing each of the different layers of the face.

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The Dento-Facial Concept Thankfully, most quality dental practitioners have made this connection and over the last ten years, Dentistry has become the fastest growing sector in the broader “facial aesthetic” industry. Both practitioners and Patients alike have come to realise the value and need to blend facial advice and treatment alongside traditional intraoral approaches.

The benefits to patients are obvious, with surveys revealing their preference for receiving skin therapies from a dental practice being due to convenience and time-saving; improved quality of care, outcomes and skill compared to other clinics; together with trust in a long-standing professional relationship and the knowledge that there is exceptional levels of infection control and regulation. Equally, those practitioners who have already embraced this concept have found the rewards being that they reach their full potential as a professional; offering higher and more rewarding levels of care; while also staving off industry competition and dramatically increasing practice revenue.

Dental practitioners already well-versed in the industry leading concept of Complete Dento-Facial Aesthetics & Health, understand that this approach is best understood and implemented by thinking in terms of the different layers of the face. Because the typical pattern of dento-facial ageing and deterioration is the result of the dynamic, multi-factorial and cumulative effects of various assaults, anatomical and histological changes in a range of different tissues over time, there is no single, “magic bullet” approach to restoring health, vitality and aesthetics to the facial region.

Instead, Dental Practitioners must utilise a variety of proven techniques, applied intra- and extra-orally, that are specifically designed to target each individual layer of the face – different treatments, targeting different structures and different aspects of the ageing/deterioration process. These techniques, learnt individually along a pathway of structured, continuous learning, can achieve incredible results when combined to form a multi-pronged, comprehensive and holistic dento-facial treatment plan. Dental Practitioners are really the only healthcare providers who can provide comprehensive dento-facial care, as we are the only ones who can set the foundations intra-orally, before further enhancing the extra-oral tissues.

Excepting we all understand the options that can be utilised intra-orally to restore structure, function, health and aesthetics, the mainstay of this approach extra-orally, over the last decade, has been the use of botulinum toxin (BOTOX) and dermal filler injections. Most Dental Practitioners would have heard of these treatments by now, yet few understand that this is far from the end of the story. There is a necessarily much broader picture and while these treatments remain as crucial steps in any dento-facial treatment plan, they are only one small aspect of the overall concept.

BOTOX specifically targets the muscle layer, while dermal fillers restore volume and facial contours lost following changes to facial fat, muscle and bony structures. It is here that many dental practitioners fall flat.

Many have only trained in Botox and Filler treatments and think that they are practising the full concept of Complete Dento-Facial rejuvenation. They have moved from focusing just on the mouth, to focusing on the mouth and a limited number of other structures.

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Beyond Botox As stated, the broader picture must necessarily involve dental practitioners including treatments which address all tissue layers, to achieve optimal dento-facial health and aesthetics.

Until 2017, dental practitioners had little in the toolkit to combat significant skin laxity, often having to wait until it was advanced enough to warrant a referral to the plastic surgeon. Technologies such as High-Intensity Focused Ultrasound (HIFU) and Radio Frequency (RF), were unpredictable, expensive, painful and only worked in the mildest of cases. This changed dramatically with the introduction of Facial Thread Lifting techniques, with Australian and New Zealand dental practitioners becoming some of the first in the world to be able to offer these services to patients.

This means learning about and offering therapies that specifically target surface layers - epidermal and dermal (skin) changes - including a decreased rate of epidermal cell turnover, an increase in pigmentation, loss of collagen and elastin support, deterioration of skin tone and texture, and the formation of superficial fine lines and wrinkles. An approach to these layers must include therapies such as chemical peels, micro-needling, laser/light therapy, as well as topical homecare products, since Botox and Dermal Fillers have almost no effect on these surface problems.

Thread Lifting has enabled practitioners to address deeper structural issues and concerns over skin laxity, effectively performing early intervention, nonsurgical face-lifting to re-drape and re-position the facial tissues, making other therapies more effective.

None of this would have been possible without the Australasian Academy of Dento-Facial Aesthetics (AADFA), who registered the first ever Polydioxanone (PDO) Facial Threads in Australia and New Zealand.

At the other end of the spectrum, practitioners must learn and offer options for addressing issues stemming from deeper facial planes. Chief among these problems is the notion of facial “Descent” after an initial process of “Deterioration” and “Deflation” in the more superficial layers – essentially from a macro perspective – this is the typical “sagging” skin seen with more advanced aging and facial deterioration.

However, none of these approaches has ever really been able to provide a simple, effective and low cost approach to the issue of excessive facial fat layers.

Image: @thedermadentist

Skin rejuvenation procedures, like micro-needling, LED therapy and chemical peels are now administered, during routine dental visits, by the whole dental team.

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Chewing the Fat Deterioration and changes in subcutaneous fat compartments and excessive localised facial fat deposits, commonly present as unsightly and disproportionate facial contours/bulges in the under-eye region, cheeks, naso-labial region, jowls and the dreaded “double-chin” sub-mental region – significantly detracting from achieving optimal dento-facial health and aesthetics. With more than 2/3 of people surveyed identifying a double chin, jowls and under-eye bags as being their three major facial concerns, it’s time for dental practitioners to include treatment options for these areas in their armamentarium.

What we require is effective techniques, to add to our overall dento-facial tool-kit, which allow us to specifically target individual facial fat compartments and to eliminate fat deposits on a permanent basis.

For decades, the only option was to wait until the issue was severe enough to warrant undergoing surgical procedures, like liposuction (physical removal of fat cells).

In response to a growing demand for targeted, simple, non-invasive, cost effective solutions for permanent facial fat reduction, several procedures have now been developed, each using different methods to achieve permanent lipolysis (fat cell destruction). Australian and New Zealand Dental Practitioners will be among the first in the world to be able to utilise these services after participating in a new program, from AADFA, which introduces practitioners to:

While the best approach and core principle of any fat reduction and general weight loss strategy remains improved lifestyle choices, there are generally three problems that limit the effectiveness and predictability of a simple diet and exercise plan.

Firstly, as you would expect, patient compliance is problematic and possibly the biggest limiting factor, but beyond this, there are two physiological reasons why diet and exercise alone simply can’t achieve the results we desire. Improved lifestyle choices result in a general, non-specific fat reduction and do not allow us to “spot” target individual areas., like double-chins or jowls. Furthermore, fat cells in adults are not made or destroyed with diet and exercise, they are simply inflated or deflated like a balloon as fat is gained or lost – that is, the number of actual fat cells an adult has remains constant throughout life and is unaffected by periods of fat/ weight gain or loss.

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Cryolipolysis – fat cell freezing, utilising extreme cold

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Thermal Lipolysis – fat cell melting, with technologies such as RF and HIFU

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Injection Lipolysis – fat cell dissolving, using injectable drugs, such as Belkyra from the manufacturers of Botox

These procedures experience minimal side effects/ complications and achieve incredible results to define jawlines, balance facial proportions, stimulate new collagen, elastin and blood flow and refine the cervico-mental angle.

Only a multi-pronged treatment plan, targeting intra- and extra-oral structures, can achieve spectacular, harmonious results. This case benefitted from a combination of Botox, Dermal Filler, Thread Lifts and micro-needling, alongside teeth whitening and invisalign.

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Figure 1. Patient being injected with fat dissolving drug, Belkyra, in the dental chair Figure 2. Before & After targeted injection lipolysis for double chin correction

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Conclusion Dental Practitioners are really the only practitioners who can seamlessly manage holistic treatment plans involving a combination of intra- and extraoral therapies.

Visit www.AADFA.net to learn more about the "FAT" module and the AADFA "Fellowship" Training Pathway.

In line with this concept, of treatment planning FULL dento-facial health and aesthetics, the last decade has seen Dentists moving beyond just providing Botox and Dermal Filler injections, to entire dental teams, Hygienists and OHTs, now offering an extended array of services, alongside traditional dentistry, to achieve the best results.

This truly is the practice of Dentistry reaching its full potential.

To Learn More AADFA’s latest program "FAT" is designed to specifically cater to one of the most sought after treatments and combat one of the most problematic health and aesthetic issues – facial fat deposits.

"FAT" introduces Dentists to the various options available for modern medical fat reduction in the head and neck region.

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RETINOIDS: THE KNOCK-OUT PUNCH WORDS BY : AADFA

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The Gold Standard

Fighting poor skin health, ageing and aesthetics is a constant battle, with every great approach to maintenance and rejuvenation inevitably following a multi-pronged program, due to the complex and multi-factorial nature of skin ageing and the deterioration process.

Chief among these proven ingredients are a group of naturally occurring beta-carotene or Vitamin A derivatives called Retinoids that are considered the gold standard of skincare and a MUST HAVE in any at-home regime that is serious about achieving results.

Just like maintaining the health of the teeth and gums, what the patient does at home is more than half the battle – you can use all the fancy treatments and technologies you like, but none of it will last or look as good as it could if the patient isn’t doing their part at home each day.

When applied to the skin topically, retinoids are a potent anti-oxidant and act on certain skin receptors to achieve their benefits by regulating normal cell activity at a molecular level. By regulating gene expression, Retinoids can normalise growth and differentiation of keratinocytes (fundamental skin cells); stimulate the manufacture of Collagen and Elastin (two fibers that give skin its elasticity); aswell as inhibiting the production of Collagenase (an enzyme that breaks down collagen and elastin).

Retinoids therefore combat skin deterioration by both building proteins that strengthen the skin and inhibiting proteins that cause skin breakdown.

Previously we have seen how daily sunscreen use is imperative and is the most important product patients can use at home every day to ensure ongoing skin protection and the avoidance of skin health and aesthetic issues. But when it comes to actively reversing damage already done and treating existing issues, is there a magic bullet, non-negotiable product to use for this as well?

THE ANSWER IS A GROUP OF INGREDIENTS CALLED RETINOIDS!

During AADFA’s “FACE” training program, Dentists are educated on the best types of at-home skincare products for different types of patients; their different skin types; and their different clinical problems. From cleansers and serums, through to moisturisers, there are several key, scientifically proven, active ingredients that Dentists need to instruct patients to use, that combine synergistically to achieve the best results. Imparting this information allows patients to cut through all the marketing hype of the thousands of products that do little and cost a lot – proper skincare doesn’t need to be expensive.

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3 Figure 1. Resolution of acne after daily tretinoin use for 12 weeks Figure 2. Improvement in periorbital lines and pigmentation following 4 weeks of Tretinoin use daily Figure 3. Reduction in pigmentation and fine lines with daily tretinoin use

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Types of Retinoids By stimulating and normalising keratinocyte migration and desquamation, Retinoids thin the stratum corneum layer, which leads to the desired clinical benefits, but can also make the skin more photo-sensitive. For this reason, patients MUST be instructed to apply sunscreen daily. Concurrent use of products containing Alpha or Beta Hydroxy Acids may reduce the efficacy of Tretinoin and these ingredients should not be immediately layered, nor should Retinoids be used during pregnancy or breast-feeding.

The first topical retinoid product—Tretinoin—was approved, under the brand name Retin-A, over 50 years ago as a prescription acne treatment.

Dermatologists soon noticed that patients on Retin-A experienced not just clearer skin but softer, more vibrant skin with less pigmentation and fewer wrinkles.

Tretinoin is the acid form of Vitamin A and is also known as Retinoic Acid or all-trans retinoic acid. Only available on prescription, it is the most signicant and well-researched topical anti-acne and anti-wrinkle agent, with decades of research proving its efficacy in reducing fine wrinkles, smoothing rough skin and lightening brown spots with as little as 4 weeks of daily use.

Dentists and Dental Teams can provide an invaluable service to patients by helping them negotiate the barrage of skincare product claims and directing them to products with a scientifically proven track record of real results, that don’t cost the earth. There is no ingredient that comes close to Retinoids, especially Tretinoin, in delivering the knock-out punch against skin ageing.

While Tretinoin is the most potent Retinoid, other Vitamin A esters exist, such as Retinyl Palmitate, Retinol and Retinaldehyde,which are available in over-the-counter preparations. These esters must first be converted to Retinoic Acid by the skin, before they can be utilized, thus their considerably lower potency with results from these forms typical taking at least 12 weeks.

How to Use Retinoids Tretinoin is the best form to use, if possible, and it comes in a variety of strengths and forms such as gels and creams, with a small amount being mixed and applied to the skin with moisturiser each evening.

However, one of the major potential issues of Tretinoin is that it can result in initial skin irritation, dryness, redness and flaking, until the skin becomes accustomed, at which stage these side effects will likely diminish.

If a patient has sensitive skin and these symptoms are too intense or do not cease after a couple of weeks of use, this is where the less potent forms, such as Retinol, can be used which will likely avoid these issues, balancing tolerance with less immediate results.

DO NOT MISS THE AADFA "SKIN TALK" WEBINAR SERIES - WE TALK TO THE EXPERTS ABOUT EVERYTHING SKIN! You can pre-register by emailing admin@AADFA.net

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t he a r t of threads a comprehens ive r e vi e w DR. CHRISTEEN YOUSSEF PROVIDES A COMPREHENSIVE REVIEW OF THE USE OF THREADS IN AESTHETIC MEDICINE, INCLUDING TYPES, TECHNIQUES AND AREAS OF THE FACE THAT CAN BE TREATED

Demand for minimally-invasive methods for the improvement of age-related soft tissue changes to the face and body are gradually increasing.

Thread lifting is a cosmetic procedure that lifts and realigns sagging tissue to enhance the facial contour, tighten the tissue and volumize the area of application. These threads are classified according to their absorbability, form (barbed or non-barbed) and length (long or short). The mechanical action

produced by the threads gives an immediate lifting effect, which contrast the falling of the area treated.

The type, form, length of thread, the technique used during the procedure and practitioners knowledge are key factors for optimum facial rejuvenation results. Minimally invasive procedure such as thread lifting has been proven to be effective for lifting and long term facial rejuvenation and could be a great alternative for surgical procedures

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AGEING IS A COMPLEX BIOLOGICAL process; it provokes many structural changes, particularly to the face, which are usually influenced by gravity, bone resorption, and soft tissue atrophy including the displacement of fat along with facial skin changes.

However, thanks to practitioners understanding these factors, along with our in-depth knowledge on the mechanism of ageing, new techniques to reverse the signs of ageing have been developed.

Surgical procedures have long been considered the gold standard for facial rejuvenation; however, surgical procedures are associated with possible complications, such as infection, hematomas, skin necrosis, seromas and injury to the frontal and marginal branches of the facial nerve. Minimally invasive procedures to reverse the signs of ageing are gradually emerging as an alternative for patients to reconstructive surgery as they do not require an extended recovery period, yet retain high-satisfactory results, and decreased morbidity.

Thread lifting, also called a ‘lunchtime facelift’, was pioneered by Sulamanidze and colleagues in the early 1990s and gained popularity among dermatologists, dentists, plastic surgeons, and other cosmetic surgery practitioners due to its short downtime and immediate potential aesthetic improvement.

This procedure lifts the skin and can also be complementary to injectable fillers for its volumising effect, energy-based procedures for skin tightening, and muscle relaxation by neuromodulators. In addition, it counteracts the force of gravity and chronological signs of ageing while avoiding large incisions.

Over the years, as thread lifting techniques have become more in demand, the discovery of suture materials have also progressed with the addition of barbs and cones to non-absorbable suture materials.

Recently, the use of absorbable sutures has been the material of choice since it also offers excellent benefits. Aside from being degradable to human biological processes, it is also safer compared to permanent threads due to its minimal complications.

This study consists of a literature review of thread lifting in regards to its types, forms, and techniques to be applied during the procedure together with an in-depth pre-treatment assessment to ensure a successful and promising result.

Methods The search was carried out through systematic review from PUBMED database for studies to retrieve the literature using the following keywords. Thread lifting absorbable threads, non-absorbable threads, thread lifting technique, the efficacy of thread lifting and thread lifting for facial rejuvenation. All articles have been evaluated, and those studies which are not relevant to the topic have been removed. Full-text articles were summarized to come up with this topic review.

Result The mechanism of thread lifting Thread lifting involves the use of a suture made from a material usually used to close wounds. This material, when inserted under the skin, can tighten and lift the loose or saggy areas in various parts of the face and body while adding definition, particularly on facial contours. There exist two mechanisms underlying the effect of thread lifting.

The first mechanism exhibits a purely mechanical lifting. This involves the distribution of the gravity load to the surrounding areas via the thread. The second mechanism takes place after the placement of the threads subcutaneously, which initiates a foreign body reaction in the form of lymphocyte infiltration, collagen deposition and fibrosis. Fibrotic tissue and capsule formation play an important role in the ability of the suture material to lift tissue and hold, remodel and support to maintain an elevated position to prevent future ptosis. The effect of repositioned ptotic tissue, neovascularization and neocollagenesis in thread lifting influences the skin texture, structure, tone and contour.

The variety of sutures and techniques that are currently available reflects the origins of thread lifting. A promising outcome of a thread lifting procedure depends on the proper selection of the type of thread according to its mode of absorption, form, and length.

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Type of threads according to the mode of absorption Thread materials used for a lifting procedure are available in absorbable and non-absorbable forms.

Absorbable thread material is gradually broken down over time by various processes such as hydrolysis and proteolytic enzymatic degradation and are absorbed by the body.

Commercially, the most common type of bioabsorbable thread material is primarily composed of polydioxanone, poly-lactic acid, or polycaprolactone. A polydioxanone (PDO) thread is the most popular suture material used for thread lifts in recent years. It is made up of colourless, crystalline, bio-absorbable synthetic polymers that were developed specifically as a wound closure material. This material is fully absorbed within the body through hydrolysis in approximately 6 months and are the site for only a minimum foreign body tissue reaction in the vicinity of the implant and are less likely to harbour bacteria due to its monofilament nature. PDO has low tissue reactivity and prolonged tensile strength, which made it garner preference over others in the use of thread lifting. However, PDO threads retain their shape for 12 weeks and become fragmented after 24 weeks and fully dissolved in 48 weeks according to the study performed by Sulamanidze GM11.

Poly-lactic acid (PLA) is a biocompatible polymer derived from lactic acid that has been used in many applications, such as orthopaedic pins and sutures. PLA is another popular dermal filler material and induces a bio- stimulatory effect via a capsule formation orchestrating macrophages, fibroblasts, and collagen. The degradation time of PLA into water and carbon dioxide ranges from 9 to 30 months, which is longer than the 6-month duration reported for PDO. PLA threads can be fully absorbed by the body in approximately 2 years.

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Poly-caprolactone is the newest type of bioabsorbable monofilament suspension thread of synthetic origin. Polycaprolactone breaks down within the body through hydrolysis as with PDO threads and may last for 1.5 to 2 years. According to Wong et al., it regenerates collagen over a longer time than PDO and PLA threads.

Histologically, all implanted biomaterials aggravate the recruitment and combination of macrophages and the development of giant cells that are dominant early responders to biomaterial implantation. These cells bind themselves to the biomaterial surface and promote fibrosis that results in the development of a fibrotic capsule around it. Implanted biomaterials regardless of their composition, induce a cellular and tissue response whereby the type of response depends on the nature of biomaterial implanted.

The cutaneous fibrotic reaction that appears along the length of an absorbable thread remains constant even when the material is fully absorbed by the body.

In a histological study by Lee et.al, all three types of bio- absorbable threads have been implanted into rat skin to evaluate the histological changes that occur into the implanted bio-absorbable material. Collagen, being the most abundant protein produced in humans, is a fundamental contiguous formation of the interstitium in the skin. There are 28 different types of collagen and a higher proportion of collagen type 1 and 3 can be found in human skin compared to other collagen types. Type 1 collagen accounts for approximately 80% and type 3 collagen for approximately 10% of the adult human dermis. Type 3 collagen is the primary component of the granulation tissue and is rich in embryonic tissue. It also plays an important role in fibrillogenesis. These two types of collagen

PDO HAS LOW TISSUE REACTIVITY AND PROLONGED TENSILE STRENGTH, WHICH MADE IT GARNER PREFERENCE OVER OTHERS IN THE USE OF THREAD LIFTING.

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act together to form broad extracellular fibres that confer the tensile strength of the human dermis.

Chang et al., found in their study that PDO, PLLA and PCL predominantly induced type 3 collagen in rats in contrast to the study by Wong et al., in which PDO and PLA threads only induced type 1 collagen while PCL induces both type 1 and type 3 collagen.

The fibrous sheaths surrounding each thread type contained relatively similar amounts of collagen. The volume of collagen formation, regardless of the type, depends on the surface area of the thread implanted.

in accordance with the direction of pull. Its function is to grasp tissue, distribute tensile strength along the length of the suture and elevate or compress and counteract skin laxity along a specific trajectory to address ptosis. Barbed or cogs do not require suspension to produce a lifting effect since they are self-supporting and can also greatly minimise the stress relaxation and cheese wiring associated with 2-point fixation.

Barbed threads can be also classified according to the orientation of the barbs, which includes unidirectional, bi- directional or multi-directional barbed threads. Unidirectional barbed threads are characterised by a single line of unidirectional thorns. The cogged side is introduced into the tissue that requires elevation, creating a lifting effect perpendicular to the long axes of the sutures and allows fibrosis to occur within the tissues, which, in turn, provide pull that limits the detachment of the skin tissue. It is designed to anchor from a higher fixation point, such as the temporal fascia. Bidirectional threads elevate soft tissue and anchor them to the stable temporalis or mastoid fascia. Bidirectional barbed threads were originally developed by Marlen Sulamanidze in Russia and named the APTOS (anti-ptosis) thread. This type of orientation has no anchoring points due to its two-way direction of barbs at the suture midpoint and has a needle on each end. It is inserted within a hollow needle and placed in a manner that it cannot move in either way. Another type of orientation is multi-directional barbed threads that fix and support the skin in various directions to achieve the lifting effect in the tissue and new collagen generation.

According to a study performed by Yoon et al., PDO threads demonstrate a collagen-producing effect for more than 48 weeks provided that the procedure is performed for the purpose of collagen production. In a study from Kulkarni, subcutaneous implantation of PLLA has demonstrated a very mild inflammatory response with evidence of a foreign body reaction in the first week, fibroplastic activity and proliferation by week 2 and growth of tissue fibres by week 4 with no further inflammatory reaction. Cutright reported in his study that the degradation of PLLA suture is gradual and is attended by a giant cell reaction and the size of the suture gradually increases as a result of an inflammatory reaction as well as the infiltration of tissue between the strands.

Absorbable threads, whether they are PDO, PLLA or PCL have their own unique functions when it comes to lifting. PDO threads are better at repositioning and revitalizing tissue but not for providing lift so may be better suited for younger patients. PLLA threads are also applicable for rejuvenation and for patients requiring a small amount of tissue lift. PCL threads can be used for both rejuvenation and for tissue that requires a moderate lift.

Non-barbed threads can be either monofilament plain, monofilament screw or spiral. These types of threads are free from cogs or barbs and are implanted ‘free-floating’. The use of non-barbed thread may cut through tissue at the point of maximal tension unless placed among deeper, tougher tissue, such as the SMAS, and anchored at a stable structure, such as the periosteum. This procedure induces temporary oedema that has a bio-stimulatory effect. Non-barbed or unidirectional threads, since they are both anchored in a stable structure, allow for an easier post-operative correction if there is an asymmetry of the face from the thread insertions. The immediate lifting result of these threads was similar to results seen after an acupoint therapy where multiple injections stimulate a variety of acupuncture points, thereby improving the blood flow, lymph improvement and adjustment of strained muscles.

Non-absorbable threads are a type of thread that is relatively unaffected by the biologic activities of the body tissue and is therefore permanent unless removed. The in vivo tissue response around a non-absorbable material involves fibroblasts that encapsulate the suture by fibrous capsule formation. Adjacent macrophages and foreign body giant cells respond in a process known as frustrated phagocytosis, where they attempt to degrade the non- degradable suture. Its main advantage over absorbable threads is their long-lasting effect; however, it is associated with complications.

Another factor that can influence the efficacy of a thread lifting procedure is by its form of thread used, which can be either barbed or non-barbed.

Threads with tiny hook-like projections cut into their long axes are referred to as barbed sutures. This form of thread is produced by cutting or moulding

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ACCORDING TO A STUDY PERFORMED BY YOON ET AL., PDO THREADS DEMONSTRATE A COLLAGEN- PRODUCING EFFECT FOR MORE THAN 48 WEEKS PROVIDED THAT THE PROCEDURE IS PERFORMED FOR THE PURPOSE OF COLLAGEN PRODUCTION.

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Length of threads

Technique, application and procedure

The thread lifting technique adopted by the practitioner also depends on the length of threads to be used in specific areas of the face and body.

Short sutures are a type of thread shorter than 90 mm in length. While long suture techniques use a thread longer than 90 mm6. Appropriate thread length was selected depending on the length of the insertion area.

To best counteract facial ageing, proper planning of vector positions should be made during the assessment. These vectors must be placed perpendicular to the plane the practitioner intends to elevate. These vectors are determined based on the desired movement of the tissues and how much it can be mobilised during the assessment and are always placed endoscopically in a superior–lateral direction.

Principles of thread lifting

Thread implantation is a sterile procedure; therefore, the treatment areas must be carefully prepped and draped in a sterile fashion. The number of threads used is dictated by the degree and distribution of lift required. Each suture is marked with one entry point and two exit points according to the vectors chosen. A combination of 1–2% lidocaine mixed with 1:200,000 epinephrine for analgesia and hemostasis is injected into the skin and the subcutaneous layer at entry and exit sites 1 hour before the implantation.

Typically, this mixture is applicable for cogged or barbed threads or any threads longer than 90 mm.

7–15% lidocaine creams can be used for superficial plain threads. A local anaesthetic is not required for needle pathways as it may cause tissue distortion.

Facial ageing is a result that correlates to a threedimensional process with anatomic, biochemical and genetic factors; as a result, alteration in the position of the soft tissue and overlying muscles causes the appearance of ageing. Thorough knowledge of the facial anatomy, especially the SMAS, superficial and deep fascias, and compartments of the face, as well as the nerves, is required for a successful thread lifting treatment.

There are several natural ageing changes to examine before considering a facial rejuvenation procedure.

The first includes the gradual ptosis of the cheek skin below the inferior orbital rim with descent of the lax lower eyelid skin. This creates a skeletonized appearance with hollowness around the infraorbital area, descent of the malar fat pads with the loss of malar prominence in projection, a prominence and deepening of the tear trough area, and lastly a marked enhancement of the nasolabial fold. These areas are the hallmark of the so called ‘triangle of youth’.

The surgeon creates a hole in the skin to the subcutaneous tissue in a perpendicular fashion past the deep aspect of the dermis. This is achieved using an 18 G needle that serves as an entry point for the suture for lifting. Threads are then placed perpendicular to the skin and advanced at about 5 mm. At this point, the needle is redirected in the subcutaneous plane an advanced in the predetermined vector. The length of each vector depends on how much pull is required for the soft tissue to be lifted. Once the suture is placed, a minimum amount of tension can be applied to the superior suture with a thumb or finger gently over the surface of the suture without advancing the tissue. Suspension techniques either lift the SMAS or rearrange facial structures at the supraperiosteal level.

Incisions to be made, however small and wherever the place of insertion in the face, should be made in a location where they can be hidden to minimize unwanted and visible scars.

Optimum lifting through thread lifting can be achieved through understanding and appreciation of the vectors, which improves the outcomes by repositioning ptotic soft tissue into a vertical direction.

Facial rejuvenation using threads is based on two general concepts according to Tavares et.al.; first is the subcutaneous suspension using SMAS as the fixation basis with tissue elevation using the posterolateral vectors, and the second is the fixation based on the subperiosteal detachment and en bloc repositioning of all structures using purely vertical vectors.

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Thread lifting treatment Selection of the right candidate Patient selection is paramount to any cosmetic procedure since it is the basis for determining operative success. Patients who are suitable for thread lifting should have mild skin laxity, mild fat pad prolapse and superficial rhytids. Usually, women between 35–45 years old who begun to see more prominence of the jaw, relaxed mid- facial appearance or slight bags under the eyes or on the neck. Patients with advanced facial lipoatrophy, excessive skin laxity that requires removal of the skin as well as muscular prolapse and including those patients who request immediate results are not suitable for thread lifting. Patients with low body fat percentage have more favourable outcomes, while obese patients tend to have less than favourable results which can be explained by complex fat distribution in the face and fat density that these patients have. The practitioner must assess the patient and understand the primary concern of the patient before selecting the appropriate technique and suture type to use.

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IT IS ALSO IMPORTANT TO PLACE THE THREAD AT THE CORRECT DEPTH AS INCORRECT PLACEMENT MAY EITHER CAUSE SKIN RIPPLING OR DIMPLING.

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Application

Midface

As mentioned earlier, the thread lifting insertion technique can be distinguished through the length of the thread to be used, i.e., whether it is a long suture or short suture. In general, permanent threads are approved for the correction of facial and cervical ptosis while absorbable threads are only approved for soft tissue procedures as well as suturing incisions.

The main task in lifting the midface area is to create a high contour to the bucco-zygomatic region by elevating the soft tissue ptosis that is situated between the nasolabial fold and lachrymal groove.

Placing threads within the subcutaneous fat in the form of steep arches followed by pulling the ends to straighten the suture and accordingly pushing together the soft tissue along the length of the thread towards the middle. The middle portion of the thread passes relatively deep, catching the SMAS from the depth toward the surface with its elevated fatty tissue.

Short sutures, usually consisting of plain or screw polydioxanone threads, use the ‘free-floating’ method for implantation. The number of threads required to be inserted in a patient depends on the severity of skin laxity or the adipose tissue present.

Needles can be inserted into the dermis plane for skin tightening and rejuvenation while minimising the excess adipose tissue can be achieved by inserting the needle deeper into the subcutaneous plane.

Lower face A lower facelift improves the definition of the jawline and enhances the shape of the face. In lifting the mental regions, threads should be implanted parallel to the mandibular edge with a slight arch-like sagging within the area of the hanging lip. The depth of implantation varies on the skin and fat thickness, along with the degree of involution alterations.

Long sutures are usually barbed, including bi-directional and unidirectional threads. Since unidirectional threads have an anchoring point, the technique applied is often the fixed method. In contrast, for bi-directional threads, the ‘free-floating’ method is used because of a lack of anchoring points. The incision point for the fixed method should be located at the deep temporal fascia or periosteum to customize the anchoring point.

Neck Placement of threads in the neck is very distinct from a midface lift as neck anatomy is more complex as it also includes platysma and other neck muscles and resident vasculature. The practitioner should be aware and must distinguish the difference between excess tissue due to excess fat, excess laxity and ski descent. Vectors of the neck are more horizontal than those placed in the mid- face. Vectors must be placed in a straight line at a 90 degrees angle to the medial border of the platysma muscle, defined by the extent of neck redundancy.

It is also important to place the thread at the correct depth as incorrect placement may either cause skin rippling or dimpling.

Approaches for different locations Brow Lift A brow lift aims to provide a pleasing arch to the brow with the highest point in the line vertically with the lateral limbus or just lateral to this. The proposed path of the suture is marked on the skin from the scalp behind the hairline to the lateral third of the brow.

Upper face Suture lifting of the temporal area is an important rejuvenation procedure for the upper face and acts by lifting the tail of the eyebrow, the lateral canthus and the upper cheek. Elevation of tissue by 2-3 mm in the periorbital area provides a noticeable improvement.

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THE ULTIMATE GOAL OF FACIAL REJUVENATION IS TO ADDRESS THE NEEDS OF THE PATIENTS WHO SEEK A MORE ENHANCED AND YOUTHFUL APPEARANCE SAFELY AND EFFICIENTLY TO ACHIEVE A LONG-LASTING RESULT.

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Discussion The ultimate goal of facial rejuvenation is to address the needs of the patients who seek a more enhanced and youthful appearance safely and efficiently to achieve a long-lasting result. With the advancement of these techniques and the demand for a rapid recovery, minimally invasive procedure, such as thread lifting have gained in popularity.

of treatment in addressing facial ageing, the risk of complications is still the reason why many individuals shift to minimally invasive procedures.

Non-absorbable materials, on the other hand, despite promising results, practitioners must still take caution since previously marketed product shared from several studies have experienced unsuccessful outcomes. Thread lifting using absorbable materials should be considered a reasonable alternative to face lifting in the appropriately selected patients since these materials are able to achieve excellent results with a low record of morbidity and rapid recovery and downtime.

Since the introduction of thread lifting procedures in lifting the soft tissue of the face and shifting volume without making any incisions have been in demand, several evolutions of pattern, method and material have been developed to provide a better result.

Ideally, adhesion to adjacent tissues is a result of the homogenous fibrous capsule that forms around the threads under the skin 4 weeks after the implantation.

Conclusion A thread lifting procedure using absorbable materials has proven to be effective for lifting, long term facial rejuvenation, and could be a great alternative for invasive procedures. Different threads and specific techniques differ per case. The type, form, length and composition of threads together with an indepth assessment should be considered necessary before conducting any thread lifting procedure. A successful outcome of the treatment is also based on how good the patient selection is, excellent pre and post-operative care and on how knowledgeable a practitioner is when it comes to the underlying anatomical and biological changes of the face.

The dermal papillae will demonstrate a greater thickness that indicates interstitial collagen growth.

Permanent sutures used for thread lifting have a number of drawbacks due to the high complication and revision rates reported. Most of the reported cases experience infection, migration, severe pain, skin dimpling and foreign body reactions. Alongside the complications recorded for permanent sutures, additional concern involves the difficuly of removal, which often leaves residual fragments that continue to be symptomatic.

Recently, the use of absorbable threads in thread lifting procedures have regained market demand.

A variety of studies have been reported that these types of materials demonstrate a positive outcome and rare to no complication and faster healing.

Histological studies also demonstrated that these materials–PDO, PLLA, and PCL–exhibit collagen formation type 1 and type 3 that gives the skin a more moisturised, revitalised, and firm result.

A quick non-surgical procedure, such as thread lifting, regardless of the technique to be applied should consider the fact that deeper tissue, such as the subcutaneous SMAS and subperiosteal, must be repositioned before the skin is pulled or resected.

As the thread lifting procedure for facial rejuvenation continues to improve, new techniques and materials are also being developed that can be effective to each appropriate patient. These materials will likely lead to additional improvements in efficacy. Since a surgical procedure is still the most effective choice

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i n j e ct a py ramid to get rid of a t r i angle DR MYLES HOLT DISCUSSES THE LATEST TECHNIQUE FOR IMPROVING "BLACK TRIANGLES" USING HYALURONIC ACID INJECTION

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AADFA's expertise in the field of Dento-Facial Aesthetics was recognised by the team at The Doctors TV when we were approached to assist in developing a segment around using dermal filler injections to improve interdental papilla deficiencies or "black triangles". The segment aired across the globe in February 2018 and if you missed it, you can view it on the AADFA instagram page @AADFA_Australia

The topic of Dentists taking a more holistic approach to Facial Aesthetics, by utilising Botox and Dermal Filler injections extra-orally, has certainly excited the profession in recent years.

Hyarulonic Acid is a naturally occuring linear polysaccharide present in the extracellular matrix of connective tissue, synovial fluid, and other tissues. It possesses various physiological and structural functions, such as anti-inflammatory, antioedematous, anti-bacterial and visco-elastic effects, which explain its benefits in the treatment of various anti-inflammatory conditions and wound healing.

Modern Dentists are now using Botulinum Toxin (Botox) with great success for the treatment of "Gummy Smile", TMD and Bruxism, while also utilising Hyarulonic Acid (HA) Dermal Fillers throughout the facial region to enhance lips and soft tissue profiles/deficiencies. The abilities of Dentists to apply these techniques has resulted in improved aesthetic outcomes for patients and increased revenues for practices.

Recently though, the Australasian Academy of Dento-Facial Aesthetics (www.AADFA.net), has been involved in the development of a reliable method for addressing intra-oral aesthetic deficiencies using HA Filler.

Yet many Dentists are still unaware of the potential benefits that these materials offer intra-orally as well.

The presence or absence of healthy, attractive, well-proportioned intra-oral soft tissues, the "Pink Aesthetics", can enhance or diminish the overall facial aesthetics of our patients. Maintenance of the interdental papilla is of particular concern to periodontists, restorative dentists, and patients, as in addition to aesthetic deformities like the dreaded

HA products have long been known for their ability to be used intra-orally to improve everything from the healing of extraction sockets and implant sites, through to the treatment of apthous ulcers and periodontal pockets.

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"Black Triangles", a loss of papilla can also lead to phonetic problems and lateral food impaction.

subsequently supported this basic data. Such findings provide Dentists with several criteria and guidelines to follow, such as adjusting the position of the contact area relative to the crestal bone, to reduce the chance of papilla deficiencies and " Black Triangles" being left at the completion of restorative treatment.

Loss of papilla can be the consequence of several issues, including periodontal disease, after periodontal therapy, traumatic oral hygiene techniques, poorly contoured restorations and tooth loss.

However despite this knowledge and while various surgical, orthodontic and restorative techniques exist, the maintenance of an interdental papilla and reconstruction once it is lost, remains one of the most challenging and least predictable problems in modern dentistry.

Various factors are known to influence the presence or absence of a papilla, such as the availability of underlying osseous support, periodontal biotype and bioform, tooth morphology and contact points.

Studies by Dennis Tarnow from 1992, for example, have shown that the distance from the crestal bone to the approximal contact of the teeth plays a critical role in determining whether complete regeneration of the papilla is achieved after the restorative treatment is concluded. Tarnow identified that for successful papilla regeneration, the approximal contact should ideally be at a distance of 5mm from the crestal bone - other researchers have

The basic idea of intra-oral application of HA for interdental papilla regeneration is based on the concept that using stabilised, cross-linked HA, like that used extraorally for aesthetic defects in skin tissue, could provide a physical structure to the tissue that was otherwise lacking, acting as a structural support for reconstruction.

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Various techniques have been proposed and this report outlines a new clinical approach, refined by AADFA, called the "Pyramid Technique".

and will resorb over time. However, a life span of 18 months is now being achieved in most cases and addition to improving aesthetics in such cases, HA also stabilises gingival health. In this way, although the material resorbs and the defect will return if further enhancement is not delivered, the condition will never return to the original defect size and further tissue deterioration is not observed.

In 1991, Sobocki examined dental gingival dimensions and realized that vertical height can be accomplished if there is sufficient width of the Attached Gingiva.

In line with this principle, the "Pyramid Technique" aims to create a "wide" base to provide the opportunity for the papilla to regenerate on its own. Cross-linked HA is used for the injection in the region of the connective tissue attachment in order to achieve responsive papilla height by increasing basal width. This technique has been shown to provide greater longevity within the gingival tissues compared to other approaches.

On a histological level, we can see why this happens.

Following injection of crosslinked HA into inflamed periodontal tissues around tooth 48, Fig 3. shows the tissue 1 year later around the injection site. We can see the particles of HA, a high concentration of fibroblasts and a connective tissue free from inflammation.

Comparatively, Fig 4. shows the area 1 cm distal to the site of HA injection, which continues to display destructive inflammatory changes.

In modern aesthetic dentistry a few millimetres mean the difference between success and failure of the "pink aesthetics" in the highly sensitive aesthetic zone.

The pyramid application of HA makes it possible for any dentist in daily practice to easily and safely improve aesthetically compromised cases. It is interesting to note that HA is now being mixed with harvested mesenchymal stem cells and platelet rich plasma by various researchers and it is anticipated that such therapy will lead to even better longevity in the future.

Despite diverse periodontal, surgical and orthodontic treatment options, the gain of those few millimetres can be extremely difficult and unpredictable. HA can provide modern practitioners with an ace up their sleeves!

Long-term success and stability is always the goal of dental practice, yet these materials are temporary

Case 1 A : Defect following resolution of periodontitis B : 18 months after injection with HA

A : Defect left after previous periodontal surgery between the right central and lateral incisors.

B : 25 months after initial injection with HA Case 2 AS SEEN ON :

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Figure 1. Structure of Hyaluronic Acid Figure 2. Papilla Anatomy Figure 3. Creating a wide base results in papilla height

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THE PYRAMID TECHNIQUE STEP 1

STEP 2

STEP 3

Step 1. Creation of a wide platform/base from which to build, via multiple injections of cross-linked HA into the non-attached gingiva Step 2. Volumizing the attached gingiva Step 3. Intra-papillary injection 2-3mm below the highest point of the papilla to stabilse the papilla itself

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