Australasian Dentist Issue 92

CATEGORY 66 AUSTRALASIAN DENTIST Flying blind In almost every aspect of modern dental practice, clinical procedures are made safer and more effective through the use of routine imaging. Whether it be digital or conventional film; OPG, bitewing, periapical or CBCT; the use of some reliable method of imaging is considered best practice for all manner of dental treatments, from implants and RCT, through to extractions and simple restorations. Indeed, the failure of a dental practitioner to properly utilize available imaging to aid in everything from patient screening and diagnosis; to actively guiding treatment delivery; and conducting appropriate post-operative evaluation and complication management, would be considered a substantial departure from accepted standards, exposing them to regulatory action and litigation. Essentially, it would be irresponsible and inappropriate to ‘fly blind’ in traditional dentistry and indefensible if you did. Yet, until recently, a blind approach to treatment provision was the only option practitioners had when performing skin rejuvenation therapies, like Botox, Dermal Filler, Fat-dissolving injections and facial Thread Lifting; across the head and neck region and it had become the accepted norm. So, while dental practitioners would never dream of blindly placing an implant into complex anatomy without the aid of imaging; running the risk of not only a poor result but serious complication if inadvertently encroaching on adjacent nervous or vascular structures; those placing Botox, dermal filler, and the like, simply had no other option. This is in large part due to the nature of the tissues being treated. Traditional dentistry, largely, works with hard tissue for which dental x-ray has been around for more than 100 years, with technology developing significantly over time to provide imaging tools of better quality, lower cost, and improved ease of use chairside. Facial soft tissues have been much harder to image directly by treating clinicians with technologies like MRI and CT having only been developed over a much shorter period which, despite significant advances, are still expensive, cumbersome, and inconvenient. Yet, a critical aspect to many facial rejuvenationprocedures (aswith traditional dentistry), is correct anatomical placement. Whether it is depositing dermal filler into a strategic tissue space; aligning thread lifts within specific tissue planes; injecting Botox into individual muscle layers; placing fat-dissolving solution into designated fat compartments; or even achieving the correct depth of micro-needling penetration into the dermis; a failure to achieve correct anatomical orientation will reduce the effectiveness of treatment. More importantly, poorly planned, imprecise, and ill-conceived procedures, when working within the complex and closely related anatomy of the face, have the potential to cause serious complication, ranging from aesthetic asymmetries and irregularities; functional defects, if Botox impacts unintended muscles; through to skin necrosis and blindness if dermal filler inadvertently encroaches on vascular supply. While practitioners tried to mitigate these risks by ensuring they had a comprehensive anatomical knowledge and deployed ‘safer’ materials and techniques, differences in individual patient anatomy and practitioner ability meant that this was far from fool-proof. Ultimately it had to be accepted that flying blind was the norm when performing facial procedures and that even when practitioners were trying to do everything right, complications and poor outcomes could readily occur. This has been particularly difficult for those just starting out and trying to learn theseprocedures, as it requiredasubstantial amount of blind faith, a steep learning curve and an inherent nervousness without the benefit and reassurance brought about by the kinds of accurate imaging and pre- screening they were accustomed to in traditional dentistry. Thankfully, this has LINICAL Chairside Ultrasound – the new standard for Dento-Facial injections By Dr Myles Holt, BDS, LLM (Heath&Medical), MSc (Aesthetic Medicine), FIADFE, AADFA Director & Head Trainer Medico-Legal Advisor, Honorary Lecturer, MSc Aesthetic Dentistry, King’s College London, Dental Surgeon Dr Myles Holt Fig. 1: Portable, wireless, hand-held, point-of-use Ultrasound technology, has set a new standard for patient care and practitioner education in dento- facial procedures.