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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 76-82

Sattler medbeauty seven protocol for compensatory soft-tissue filling in orthodontic class ii patients: Case series


1 Faculty of Dentistry, Department of Orthodontics, Centro Universitário Inga, Uninga, Maringa, PR, Brazil
2 OdontoFaciale Institute, Niteroi, RJ, Brazil

Date of Submission13-Apr-2021
Date of Decision07-Jun-2021
Date of Acceptance15-Sep-2021
Date of Web Publication31-Dec-2021

Correspondence Address:
Celia Marisa Rizzatti-Barbosa
Rua Sousa Reis, 120, Apto 93A, Butanta, Sao Paulo, SP 05586 080
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aihb.aihb_63_21

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  Abstract 


Hyaluronic acid fillers can be used for the correction of facial soft tissue in orthodontics patients instead of orthognathic surgery. These clinical cases show the aesthetic results of Sattler MedBeauty Seven Protocol (SMSP) in five Class II female patients after having undergone orthodontic treatment. They had the lower third of the face filled with cross-linked hyaluronic acid (e.p.t.q. S500®), according to the SMSP. All patients were evaluated before and after treatments through an inquiry on adverse events, a Numerical Visual Scale (NVS), a self-assessment questionnaire (SQ) and the analysis of photographic records (PRs). The results showed oedema, pain and haematoma as the most cited adverse events, a score of 10 in the NVS for all patients, and a good aesthetic effect of chin and mandible in SQ and PR. The results suggest that SMSP is favourable in the aesthetic correction of chin and mandible in class II orthodontic patients using e.p.t.q. S500® for compensatory filling.

Keywords: Cosmetic, filler, hyaluronic acid, orthodontics, orthognathic surgery


How to cite this article:
Rizzatti-Barbosa CM, De Albergaria-Barbosa JR, Sattler S. Sattler medbeauty seven protocol for compensatory soft-tissue filling in orthodontic class ii patients: Case series. Adv Hum Biol 2022;12:76-82

How to cite this URL:
Rizzatti-Barbosa CM, De Albergaria-Barbosa JR, Sattler S. Sattler medbeauty seven protocol for compensatory soft-tissue filling in orthodontic class ii patients: Case series. Adv Hum Biol [serial online] 2022 [cited 2022 Jan 25];12:76-82. Available from: https://www.aihbonline.com/text.asp?2022/12/1/76/334593




  Introduction Top


Orthodontics modify the occlusion of remaining teeth in harmony with the maxillomandibular and facial soft-tissues relationship patterns.[1] Correcting dental occlusion does not always achieve the planned results for soft-tissue aesthetics.[2] In unfavourable cases, orthognathic surgery is necessary, especially if proper aesthetic treatment planning was no consideration at the beginning of treatment.[3]

Both situation, teeth and facial appearance has been a motivation for concern and demand of patients' orthodontics.[4] However, in recent years, the main complaint of patients after orthodontic therapy has been motivated by the aesthetics of the face.[5],[6]

The characteristics responsible for the most pleasant facial appearance have been studied over the years, and it was observed that the components associated with the ideal facial aesthetic are mainly linked to the characteristics of the mandible and soft chin tissues.[7],[8],[9],[10]

Participants with standard orthodontic Class II may present significant aesthetic tegmental alterations, especially in the angles between the lips and nasal base or mentum/labial sulcus and chin. Increased facial convexity, deficiency in neck muscle tone and altered chin-neck angle are observed in these cases.[11],[12],[13],[14] Often, orthodontic correction of teeth is not enough to improve the soft-tissue aesthetics and, in these situations, orthognathic surgeries as a compensatory and complementary therapy to orthodontics, surgically repositioning the maxilla and mandible and modifying the facial pattern for more favourable aesthetic conditions are indicated.[15],[16] However, these surgical procedures, in addition to the high cost, are invasive, irreversible, involve general anaesthesia and hospitalisation, have long time-consuming post-operative procedures, are irreversible and do not always admit the results provided for in the aesthetic proposal.[17],[18]

Minimally invasive aesthetic procedures, especially those that permit correction and reversibility, have increased in recent years. This is probably because they are performed under local anaesthesia, admit greater predictability, require a short period of post-operative recovery, in addition to being much more accessible when compared to orthognathic surgery.[19]

Some minimally invasive treatments have been proposed for compensatory correction after orthodontics, and there are several alternatives of materials and techniques for this purpose.[20],[21] Hyaluronic acid (HA) has been widely studied and used to fill the regions of the face due to its ability to form an elastic and cohesive material. It is known that the HA effectiveness establishes an intimate correlation with its viscoelastic properties under tension, associated with good shear during and after its injection.[22] The HA rheological properties should be considered when used in subcutaneous implantation,[23] because higher viscosity with a more expressive amount of crosslinking is needed to give effective volume to deep soft tissues,[24],[25] mainly in the correction of Class II orthodontic patients. A larger amount of material is necessary for effective filling of the chin and mandible because HA deposits are made in the subperiosteal, subcutaneous and middle dermis regions of the chin and posterior jaw,[26] and some risk conditions may happen in these procedures.

Usually, supraperiosteal HA applications in those regions do not cause major complications. However, subcutaneous and middle dermis large amount of material associated with aggressive procedures performed without anatomic knowledge may result in vascular damage. arterial injury, ischemia, cyanosis, and numbness may occur and should be monitored.[27], [28,[29],[30] The chin region requires some care regarding the mental foramen because it is necessary to avoid injury in the terminal branches of the inferior alveolar nerve and compression or occlusion of blood vessels in this area. The mental foramen is easily localized by palpation or by the definition of an imaginary vertical line between the canine and first premolar tooth or even by external orientation through the mid pupillary line. In the posterior region of the mandible, which comprises the anterior border of the masseter muscle and the angle of the mandible, there is a depression immediately anterior to the masseter muscle in which crosses the facial artery.[27],[28] It is important to be careful in HA applications in this region as well.

Late post-operative complications related to the composition of HA and its metabolic residues may also be associated with mandible filling. BDDE (1.4 butanediol diglycidyl ether) is one of the most used chemical components in the crosslink implementation of AH[28] and may represent an important residue to be reputed in this context.[31]

For this reason, the absence of residual BDDE through the metabolization of HA should be considered as necessary to the procedures proposed, especially in situations that require a higher volume of implanted material.

The e.p.t.q. S500® (JETEMA® EsPetacular TechniQue S500, Hyundae MedTech, South Korea) is a high-crosslinking HA that has been successfully employed in several countries in Western Europe and South Korea. According to the manufacturer, it is presented in ~1.20 mL syringes with 22G or 27G cannulas. It has 24 mg/mL of HA (Lidocaine 3%) and is indicated for applications in subcutaneous and supraperiosteal tissue. Presents MoD (%) 1.89, complex viscosity (0.1 Hz) of 458.2, and degree of cohesiveness of-0.5583. It is produced with homogenization of molecules at pH levels (6.9) and osmolarity (282 mOsmkg) similar to those of the dermis and has the lowest degree of T-Mod (degree of gel modification) among the various formulations of HA available. It presents good extrusion strength (12.9N), and, consequently, good control of tissue modelling during its implantation. Because this property, e.p.t.q S500® is produced with zero endotoxins and BDDE technology, it generates little residue after its metabolisation, low levels of bacterial endotoxin (0.042Eu/mL) and compatible indexes of heavy metals.[32]

This is particularly important when considering that, for compensatory correction of soft tissue after orthodontic therapy, amounts of HA are around 10 mL. It demands an optimal standardization of the amounts injected due to the production of metabolic residues from the material.

Because of characteristics manufacturing and composition, the e.p.t.q. S500® might decrease side effects and control the improvement of filler procedure. In this rationality, ideal use and quantification protocol are necessary to adequately address the needs of diagnosis and indication of the product.

However, no description of e.p.t.q. S500® protocols for soft-tissue correction in Class II orthodontic patients was found in the literature, neither about the use of Sattler MedBeauty Seven Protocol (SMSP) in those clinical cases. Therefore, the main of this series of cases was to present the aesthetic results of SMSP using e.p.t.q. S500® HA in compensatory soft-tissue filling for orthodontic Class II patients.


  Subjects and Procedures Top


Subjects

The work was carried out on five female patients, aged between 24 and 48 years old, presenting soft-tissue characteristics of orthodontic Class II and who had already undergone orthodontic treatment. The patients had similar characteristics for muscle mass, skin thickness and biotype, general and local health, and indication for compensatory filling of facial skin tissues. All received HA implantation for aesthetic reasons and signed the free and informed consent form to participate in the work.

Procedures

All implantation procedures were performed by the same professional (S. S.) using the Sattler Profile MedBeauty protocol, previously defined by the Authors (S. S., JRAB, CMRB). Patients received a total of 7 mL of HA e.p.t.q. S500® (JETEMA® Spectacular Technique S500, Hyundae MedTech, South Korea) in the lower third of the face: 3 mL in the chin region, and 4 mL (2 mL on each side) in the posterior mandible.

Protocol

After the medical records were filled out and pre-operative photographic were done, the antisepsis care was adopted. Local anaesthesia was performed through intraoral blockade of the mental nerve and extraoral infiltration in the mandible with Lidocaine 2% with epinephrine 1: 50,000, and the HA implantation points were defined with a dermal pen. HA was injected into the chin, mandibular branch and pre-jowl regions through a 22G/50 mm cannula. Tower and fan applications were made on the chin from two needle punctures performed at the points of the soft pogonion integumentary, an intersection with the vertical line from the line of right and left columellar side towards the chin [Figure 1]a. The distance between the vertical line and the chin defined the amount of filling needed [Figure 1]b. Treatment volume was determined by the investigator based on the clinical experience.
Figure 1: Intersection with the vertical line from the line of right and left columellar side towards the chin (a). The distance between the vertical line and the chin defined the amount of filling used (b).

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Briefly, the vertical towers were done on these two fixed points of the punctures through HA injection in three successive layers: 0.3 mL supraperiosteal and 0.2 mL in the subcutaneous and medium dermis, with the objective of projecting the chin in an anterior direction, bringing it closer to the true vertical line. After this previous projection, the entire lower peri-labial and the pre-jowl region was restructured with successive retro injections as the following: 0.25 ml in the pre-jowl region, just above 0.15 ml, and 0.1 ml retro-injections complementing each side (right and left) [Figure 2].
Figure 2: Lower peri-labial and pre-jowl region restructured for retro injections (0.25 ml in the pre-jowl, just above 0.15 ml, and 0.1 ml retro-injections complementing each side).

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In the region of the mandible angle (2 cm above and anterior to the mandible angle), after the 0.3 mL supraperiosteal tower, 0.2 ml were injected in the subcutaneous from the same spot. After that, several successive retroinjections were done in the middle dermis forming a fan and totalling 1.5 ml of the mandible body [Figure 3]. Notice that it was not involved in the sagging jowls.

Instructions for home care were given once the HA implantation procedures were completed. Photographic records (PRs) of the immediate post-operative period were made, and the patient received an ice pack for 30 min before being discharged.
Figure 3: Retro injections done in the middle dermis forming a fan (1.5 ml of the mandible body).

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Data evaluations

The patients were evaluated before (baseline) and after 30 days of treatments through an inquiry on adverse events, a numerical visual scale (NVS), a self-assessment questionnaire (SQ), and through the analysis of PR.

Questionnaires were modified from those cited by Arizola et al. (2012),[33] investigating post-operatory adverse events (pain, swelling, skin purplish, skin redness and skin traction); subjective treatment satisfaction degree on an NVS (from 0 to 10, considering 0 the worst result, and ten the best result); and a subjective patient's evaluation regarding the degree of facial changes realised by the patients, according to their own reports by the SQ.

PR was conducted by the same professional (S.S.), always under similar conditions. They were organised on the same screen and compared by two professionals previously calibrated for this purpose (CMRB and JRAB), defining the aesthetic quality of the protocol on a scale of 0–3 (0 = bad, 1 = satisfactory, 2 = good and 3 = excellent).


  Results Top


The data were compiled, grouped into tables, analysed by the team researchers (JRAB and CMRB) and are shown in the following tables. The data on adverse effects are shown in [Table 1].
Table 1: List of adverse events presented by patients after 24 h post-operatorively

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All patients had at least two adverse events, and hematoma, pain or oedema was the most prevalent. Only one patient had allodynia, although she did not report spontaneous pain. The recovery of all adverse events was observed at most 7 days after surgery, with the hematoma being the most persistent.

Patients were unanimous in defining the score 10 for the treatments performed on NVS. All patients approved the treatments and would recommend them to other patients. About subjective patients' evaluation regarding the degree of facial changes regarding the treatment performed, the answers considered scores for each region of the face. The results are shown in [Worksheet 1].



Only one patient reported any aesthetic effect in two areas that were not treated. All patients considered a great or median aesthetic effect in the treated areas. No patient considered the treatment without any aesthetic effect. The best aesthetic effects observed were in the treated areas, that is, in the chin and jaw. Three patients reported improvement in neck aesthetics.

PR defined score of 3 for all cases. The improvement is noticeable in all treated cases and can be shown in [Figure 4].
Figure 4: Improvement observed in the photographic records of clinical cases before (a) and after (b) the treatment.

Click here to view



  Discussion Top


The main of this case series report was to determine whether Sattler MedBeauty Seven Protocol is suitable for complementary aesthetic corrections of soft tissues in Class II orthodontic patients after having undergone orthodontic treatment, using the new AH e.p.t.q. S500®.

HA for tissue augmentation has been widely used among the materials classified as tissue fillers. In this context, the augmentation of the lower third of the face is inserted. This procedure is well indicated for the chin and angle of the mandible when it intends to correct soft-tissue aesthetic. It is usually done by orthognathic surgery. However, orthognathic procedures evoke invasive intervention, which requires hospitalisation, general anaesthesia, high cost, in addition to being irreversible. The soft-tissue augmentation procedures through HA are performed under local anaesthesia, are fully reversible, and less expensive than surgical procedures. Sometimes, only HA soft-tissue augmentation procedures can achieve reasonably good aesthetic results.

However, some limitations can be attributed to HA. Complications and adverse events may happen due to the material or protocol used, such as compression or vascular occlusion, difficulty in shaping the area treated with the filler material, or even late effects due to metabolites of the material components.

These effects can be reduced to the extent that the application protocols obey the knowledge of the local anatomy, and the material of choice is suitable for its indication. For the correction of the soft tissues of the lower third of the face in a situation with a class II appearance, the supra-periosteal filling with a high-density HA allows the augmentation of the chin and mandible. In this protocol, we opted for a highly cross-linked material, where supra-periosteal applications were made on the chin and the mandible angle. However, we opted for subcutaneous supplementation in the lateral regions of the chin and in the pre-jowl and in the middle dermis as a complement of the subcutaneous tower at the projection points of the chin. However, we opted for subcutaneous augmentation in the lateral regions of the chin and in the pre-jowl and in the middle dermis as a complement of the subcutaneous tower at the projection points of the chin. These procedures could be done with a medium-density HA (S300), but its permanence in the tissue and its modelling property would not be adequate. It was verified few adverse events in these five clinical cases, which would be expected since we used a dense material in the shallow regions. However, none of the observed effects persisted for more than a week. The advantage of these procedures is their persistence and their hydrophilic capacity. The e.p.t.q. S500® is an AH with very homogeneous particles, a complex viscosity and a high degree of cohesiveness and extrusion. It gives excellent quality to the material and differentiation regarding its moldability, providing favourable and persistent results. Because it has a remarkably high degree of crosslink, low levels of bacterial endotoxins and compatible indices of heavy metals, the material proved to be safe and reliable in terms of waste production after its metabolization, as well as little tendency to inherent long-term postoperative complications to the material. It is important to observe that excessive and repetitive amounts of HA in the same region can induce bone resorption.[34] Treatment volume of e.p.t.q. S500® used in these clinical cases were determined by the investigators based on clinical experience. Until now, we did not observe any bone resorption due to e.p.t.q. S500® injection.

There was also a report of aesthetic improvement in untreated areas such as nasolabial folds, marionette clines and neck design. It was possibly observed due to the filling close to the pre-auricular region, which evoked a different perception of light and shadow. Or even the new posture of the lower lip by filling in the mental region may have modified this incidence of light. The changes perceived in the neck certainly were because of the new soft-tissue composition and definition of the mandible limits. This was confirmed by the analysis of PR. Scores 3 were defined for all cases. That is, the professionals considered achieved excellent results for all patients.

These aspects by themselves would indicate the use of the Sattler MedBeauty Seven Protocol associated with e.p.t.q. S500® in soft-tissue correction in the lower third of the face. The satisfaction shown by the patients, the low prevalence of adverse events and the positive evaluations defined by the analysis of the photographic images admit to establishing that the works were carried out with criteria and that the material used corresponded to the expectations.

However, transoperative care will continue to be a determining factor for infections or protocol failures to occur. The care of the professional in indicating and executing the procedures correctly, and the patient in-home care, are essential for the success of the treatment. Our team has reinforced the importance of care when performing orofacial harmonisation procedures.

Knowledge of the anatomy of the region as well as the professional's ability can be determining factors to avoid adverse effects and complications. Supraperiosteal applications do not involve great risks of vascular impairment because they are deeper and are performed in different layers from the main blood vessels. However, those that involve injections into subcutaneous tissue require criteria in their application. The region of the lower and anterior third of the face receives vascularisation of the facial artery and vein and branches into the labial and mental areas, which irrigate most of the tissues involved in the procedures adopted in the protocol.

The results of this clinical cases report demonstrated that the steps adopted in the Sattler MedBeauty Seven Protocol are adequate and can be safe when using e.p.t.q. S500®. And also, the forms of evaluation of the results admitted proposing reliability in the computed results. We consider that the ultimate goal of a comprehensive plan is to provide the patient with the most viable options and to have an individualised treatment plan for the patient. Any experienced professional would attest that often only orthognathic surgery/minimally invasive procedure or a combination of both are not sufficient to achieve the best results, but one must be willing to incorporate adjuvant procedures to obtain the best results. The presentation of these clinical cases was aimed to demonstrate the Sattler MedBeauty Seven Protocol admits few adverse effects, good aesthetics results and good acceptance by the patient. However, its effectiveness can be investigated more carefully in clinical trials, where objective parameters of cephalometric analysis of soft tissues and a longer time for patient assessment can be used.[35]

We consider that blind and randomised clinical studies with an adequate number of subjects should be conducted to study the Sattler MedBeauty Seven Protocol using other volumising materials to prove, following these analysis tools, its quality in this indication.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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