Facial Aesthetics Using Botulinum Toxin and Dermal Fillers

Part 1 - Bruxing and clenching: Treating masseters

Instructors:

Bob Khanna, DDS

Bob Khanna, DDS

Professor Bob Khanna is a Cosmetic and Reconstructive Dental Surgeon. He runs successful clinics in Ascot and Reading and carries out a full spectrum of treatments from Aesthetic Dentistry, Surgical Implantology and bone regeneration procedures to full mouth rehabilitation.

Dr. Khanna demonstrates treatment of the masseters with botulinum toxin

Hi, I'm Dr. Bob Khanna. I'm here in my practice in Reading, United Kingdom and today I'm going to show to treat a masticatory system when it's upset. And by that, I mean when it's overused in a way that we often refer to as power function outside of the norm. So in Samira's case, it's given rise to a squarer jaw form, which of course is not deemed to be as feminine as it could be. And of course Samira is a very beautiful girl and we will want to promote more of that beauty. And a wonderful way of achieving not only alleviation of the symptoms that she's suffering from, but also to actually give rise to better aesthetic appearance. So that's the aim of the treatment today. So let's have a look and see what we can do. So we can see in Samira's case this area of bulk which of course is the masseter. The masseter really is two sets of muscles. You got the anterior fibers which of course more superficial and you go the posterior fibers which run deeper to the anterior fibers. Now in this case, I would like to inject both sets of fibers in a very strategic fashion so that they can gain maximum treatment to those muscles and therefore obtain maximum effect. So what I've done here is define the anterior limit of the masseter muscle and the posterior limit. I've also defined here a line drawn from the tragus through to the oral commissure. And this is a very convenient way of constantly being reminded as to where the upper elevators of the mouth are retained. So in fact, I've got the zygomatic majors, zygomatic minor, levator anguli oris and then course levator labii superioris and levator labii superioris alaeque nasi in that order. And so what I'm going to do here is initiate treatment in this aspect here, this inferior lateral aspect of the jaw. But if I retained a nice margin of at least 2-cm from that line drawn from the oral commissure and tragus then I can be sure that I'm not going to infiltrate inadvertently the upper smile elevators. In this way, I can protect and safeguard against any possible signs of a smile asymmetry postoperatively. The first point you can see here centrally placed into the mastic. Clench for me Samira. Relax. Let me just show you that. Clench. Relax. Clench. You can see my pencil moving very nicely. Relax. Clench. Relax. Clench. Relax. Clench. Relax. Clench. Relax. It's quite interesting to see in fact the direction of the force of contraction on the different sets of fibers. Can you see? Clench. You can see how the pull is actually more posteriorly positioned. And you can have a look at the anterior. Clench. You can see if I pull this towards the anterior. So that confirms for you the different pulling action and the vectors of forces created by the different sets of muscle. It is imperative that you do capture both sets in a case like this because of course both sets of muscles are involved in closing of the jaws and ultimately brining the teeth together. In Samira's case, the reason why they're over belt or hypertrophy or hypertrophic, even better. Maybe in Samira's case they're hypertrophic because of course of over excessive habitual clenching which is very very common in a lot of people. And we're not quite sure why it happens but it often is stress related or in fact certain personality types in fact, certainly. Aggressive personality type actually has been shown to be more prevalent. So a lot of sports people for example are very keen to clenching and what have you. Okay. Injection time. And last but not least. Good. Complete. So Samira's case we place four injection sites of 30 units each sites of Dysport which totals to 120 units per masseter, which has been carefully worked out to take into account the level and the degree of hypertrophy that exist in her case. I would expect to see a resolution of symptoms after two to four weeks. And I would hope to achieve a maximum effect after six to eight weeks, at which point I would take the after photographs and compare to the before shots. I will for sure be able to see as Samira will a tapering effect of her face, less of a more masculine jaw line, and more of a very nicely tapering feminine form.