"I looked weird," she recalled. "I didn't look pretty at all."
Roman suffered from a gummy smile, a condition that is typically corrected with costly and complicated surgery. But her orthodontist invited her to participate in a research study to try a simpler fix: Botox therapy.
At 19, Roman became one of the youngest patients to receive Botox for dental problems. And now, seven years later, she has become a Botox aficionado, returning to her orthodontist every four to six months for more injections.
Botox benefits for teens
Botox is starting to become a substance of choice for the teenybopper crowd. Once viewed primarily as a miracle wrinkle remover in the fight against aging, the neurotoxin is increasingly being embraced by dentists seeking to help their younger patients. Not only are some dentists using the substance to help patients -- primarily girls -- with unsightly gummy smiles, but others are giving Botox injections to help teens with debilitating jaw pain. A few orthodontists, meanwhile, are using it to help keep patients' lower teeth from relapsing after treatment.
It is unclear how many teens get Botox treatments for dental issues. But overall, teen use of Botox is on the rise. Last year, nearly 12,000 teenagers received Botox injections, up 2% from 2008, according to the American Society of Plastic Surgeons.
“It's not like injecting normal saline or a local anesthetic solution. It's quite potent.”
— Mario Polo D.M.D.
Earlier this year, Charice Pempengco, the 18-year-old singer on the hit TV show "Glee," created a stir when she told reporters that she received Botox and a skin-tightening procedure to "look fresh on camera." Later, her publicist clarified that the Botox was not for cosmetic purposes, but rather to deal with jaw pain.
While some teens seek out Botox to enhance their appearances, erroneously believing it can prevent wrinkles from developing, other teens stumble upon the treatment when they go to their dentists, complaining of pain or unsightly smiles.
"Some come in rubbing the side of their jaw or their temple area," said Louis Malcmacher D.D.S., president of the American Academy of Facial Esthetics who also teaches courses on how to inject Botox. "All of a sudden, they have a lot of pain in the masseter muscles or the temporalis muscles," he said. "It often feels like severe TMJ."
For adolescents, complaints about jaw and headache pain are often related to each other and have relatively little to do with stress, Dr. Malcmacher said. The muscle spasms are often due to adolescent growth, he said, with bones in the face growing faster than the occlusion.
Splints don't seem to ease the pain, Dr. Malcmacher said, but he's found that Botox can provide relief.
Every month, he said he treats three or four teenagers with Botox for such pain. Usually, the teens get injections for three to five years, with the pain going away permanently for most by the time they reach age 20.
Botox can also be a great postorthodontia treatment, Dr. Malcmacher said, since many patients have hyperactive mentalis muscles that put pressure on their lower teeth. If teens are treated for a few years with Botox after their braces are removed, it's much less likely that their lower teeth will relapse.
Dr. Malcmacher said he has taught many orthodontists how to reduce the mentalis muscle's strength but not weaken it too much, as the muscle still needs to be used for chewing. But he said he's not sure how many orthodontists are actually using Botox in their practices.
By far, the most popular Botox treatment for teens with dental problems involves correcting gummy smiles. As many as 10 teens a month visit Dr. Malcmacher for the procedure, which costs $250 for each set of injections.
The research on Botox benefits
Mario Polo, D.M.D., an orthodontist in Puerto Rico who treats eight to 12 teens a year, has such a loyal following that patients fly to his office from the mainland U.S.
Dr. Polo, who treated Keyla Roman, said he helped devise the gummy smile treatment in 2001 after seeing so many self-conscious teens. Almost all the teens suffering from the problem are girls, he said, adding that excessive gingival display appears to be gender-linked.
Dentists are using Botox therapy to fix a gummy smile. Images courtesy of Dr. Mario Polo.
With his research, he tested whether the treatment worked (American Journal of Orthodontics and Dentofacial Orthopedics, February 2005, Vol. 127:2, pp. 214-218) and how effective it can be (AJO-DO, February 2008, Vol. 133:2, pp.195-203).
Botox works quite well, but must be handled carefully, he concluded. "It's not like injecting normal saline or a local anesthetic solution," he said. "It's quite potent." Adequate training is needed to inject Botox, and its practice by dentists is a procedure regulated by state dental boards.
Patients can wind up with hematomas or bleeding, he said, adding that the medical literature shows some patients can have trouble swallowing, speaking, or breathing after Botox.
"It's a very tricky procedure," Dr. Malcmacher said. If a dentist injects too much, the patients' "upper lip can hang over their knees."
Dr. Polo says he is currently working on different dosages for Botox therapy for gummy smiles, which will allow dentists to determine how much to inject, based on the severity of the patients' problem. Other dentists say they prefer to gradually administer Botox to patients, making sure that they don't give too much and create lopsided smiles.
Alterative to surgery
For many teens with gummy smiles, the procedure is a godsend. Given that teens' bodies are still growing, most dentists wouldn't consider putting them through the traditional surgical procedures to lengthen crowns. And given their age, teens can feel that the unsightly gums are especially embarrassing.
Keyla Roman became so devoted to Dr. Polo that she flew to his office in Puerto Rico even after she moved to Miami.
She said she would recommend the procedure to any teen who is self-conscious about her smile. "With a little bit of change in your face, you're going to feel better," she said.
Roman still remembers her delight when Dr. Polo first injected one shot of the neurotoxin near each nostril. At first, she didn't see any difference. But when she woke up the next morning and looked at herself in the mirror, she barely recognized herself.
"I looked like a different person," she said. "I loved it."
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