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The ageing process of the face involves a level of bone erosion that generates a morphological change in the main features of a person’s face. Consequently, the muscular structures of facial expression also undergo changes in their functionality. Another important factor that can shift bone ageing in one district over the other is altered mimicry due to altered skeletal growth. The study carried out that led to the standardisation of this technique involves the restoration of the bone gap due to physiological bone ageing and bone compensation in those cases where there is an alteration of normal maxillary and mandibular development and growth. The technique involves supraperiosteal bolus infiltrations of 2-phase hyaluronic acid-based gels with very high cohesiveness for maximum volumetric compensation with a small quantity of product. This functional treatment aims to achieve a dynamic and functional modification of each patient’s subjective physiological muscle contraction. The study was substantiated by a team of specialists who highlighted the changes by means of electromyographic and ultrasound examination and photography. Key words: miofacial function, miofacial treatment, Skeletal anterior open bite, Orofacial myofunctional status, Orofacial myofunctional therapy, Filler, Anthropometry; Facial beauty; Facial measurements; Quantitative analysis.
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Emanuele  Bartoletti
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Annali di stomatologia
Bone level technique: personal technique for miofacial functional treatment
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Original Article
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2023-03-09
2023-03-09
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Ann Stomatol (Roma)
Emanuele  Bartoletti
2023/03/09
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Head of Outpatient Department of Aesthetic Medicine Fatebenefratelli Isola Tiberina-Gemelli, Rome, Italy
1971-1441
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Bone level technique: personal technique for miofacial functional treatment
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                                                                                                      Original Article


Bone level technique: personal technique
for miofacial functional treatment



Francesco Calvani1                                             Introduction
Umberto Torre1
Alessandro Lozza3                                              The ageing process of the face involves a level of bone
Emanuele Bartoletti2                                           erosion that generates a morphological change in the
                                                               main features of a person’s face. Consequently, the
                                                               muscular structures of facial expression also undergo
1
    Calvani Multispecialty Center, street Livorno 25, 00162,
                                                               changes in their functionality.
    Rome, Italy;
                                                               Another important factor that can shift bone ageing in one
    E-Mails: info@centropolispecialisticocalvani.it
    francescocalvani@gmail.com                                 district over the other is altered mimicry due to altered
                                                               skeletal growth. It has been reported several times in the
2
    Head of Outpatient Department of Aesthetic Medicine
                                                               literature that an open bite leads to a more energetic con-
    Fatebenefratelli Isola Tiberina-Gemelli, Rome, Italy;
                                                               traction of certain muscles such as the chin muscle, the
    E-Mail: embartoletti@libero.it
                                                               mouth angle depressor and the buccinator muscle.
3
    MD Care Center for Facial Paralysis and Oral Nerves        The study carried out that led to the standardisation of
    Studio Schiappadori Milan Italy                            this technique involves the restoration of the bone gap
    Corso Vittorio Emanuele 15                                 due to physiological bone ageing and bone compensa-
                                                               tion in those cases where there is an alteration of nor-
Corresponding author:                                          mal maxillary and mandibular development and growth.
Francesco Calvani E-Mail: francescocalvani@gmail.com           The technique involves supraperiosteal bolus infiltra-
                                                               tions of 2-phase hyaluronic acid-based gels with very
                                                               high cohesiveness for maximum volumetric compensa-
Abstract                                                       tion with a small quantity of product.
The ageing process of the face involves a level of             The points we studied are strategic points with an indi-
bone erosion that generates a morphological change             rect dynamic action on the mimic muscles and thus on
in the main features of a person’s face. Consequent-           their balance with an inevitable postural change.
ly, the muscular structures of facial expression also          This effect produces a lifting of the skin, subcutaneous
undergo changes in their functionality.                        tissue and some surrounding structures of the face.
Another important factor that can shift bone ageing            This functional treatment aims to achieve a dynamic
in one district over the other is altered mimicry due          and functional modification of each patient’s subjective
to altered skeletal growth.                                    physiological muscle contraction.
The study carried out that led to the standardisa-             The points standardised by Dr Francesco Calvani have
tion of this technique involves the restoration of             been studied for maximum muscular effect. The study
the bone gap due to physiological bone ageing and              was substantiated by a team of specialists whohigh-
bone compensation in those cases where there is an             lighted the changes by means of electromyographic
alteration of normal maxillary and mandibular devel-
                                                               and ultrasound examination and photography.
opment and growth.
The technique involves supraperiosteal bolus infil-
trations of 2-phase hyaluronic acid-based gels with
                                                               Materials and methods
very high cohesiveness for maximum volumetric                  32 patients were recruited for this study between the
compensation with a small quantity of product.                 ages of 38 and 55. All patients underwent infiltrative
This functional treatment aims to achieve a dynamic            treatment on standardised points.
and functional modification of each patient’s sub-             All patients had natural and complete dentition. 26% had
jective physiological muscle contraction. The study            dental restorations in the posterior sectors.
was substantiated by a team of specialists who high-           All patients had dental alignment with skeletal classes in
lighted the changes by means of electromyographic              first class (12 patients), second class (16 patients) and
and ultrasound examination and photography.                    third class (4 patients).
Key words: miofacial function, miofacial treatment,            No patients underwent orthognathic surgery.
Skeletal anterior open bite, Orofacial myofunctional           All patients had no current orthodontic treatment.
status, Orofacial myofunctional therapy, Filler, An-           All patients underwent infiltrations of supraperiosteal hy-
thropometry; Facial beauty; Facial measurements;               aluronic acid at the points standardised by the technique,
Quantitative analysis.                                         which included 3 mandibular points,2 maxillary transmu-


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     Bone level technique: personal technique for miofacial functional treatment

     cosal points, 2 zygomatic points and 2 fronto-temporal          10 strategic points to restore bone thrust on muscles and
     points, totalling 10 points.                                    tissues
     The points were studied from a bone and vascular point          All patients were treated in one session.
     of view to allow maximum effect with minimum vascular           Bolus infiltration was performed over the standardised
     risk.                                                           bone component. A 27G needle was used at each point.
     Patients were studied by means of electromyography              The most important strategic point especially in patients
     performed in static and dynamic situations with aelec-          with second dento-skeletal classis the point of chin syn-
     tromiography neuromian 2to record potential changes             thesis called chin protuberance or gnathon. These pa-
     before and after treatment. The study mainly involved           tients presented, after sub-muscular infiltration at the
     recording the orbicularis of the mouth, the chin muscle,        level of the chin muscle tendon, a support of the chin
     the mouth angle depressor, the buccinator and ultra-            muscle that produced a reduction in the autonomous
     sound. The ultrasound study (Mindray 23 MHz linear              contraction of the patient’s dento-skeletal hindbrain.
     probe) was conducted in three phases. The first phase           The autonomous contraction is due to the labial incom-
     involved the process of checking and mapping the pa-            petence that the bone gap produces.
     tients to investigate the possible presence of previous         Strategic points were ultrasound-assessed to study their
     treatments that could influence the study. As a matter of       vascularisation and to avoid complications from com-
     fact, patients who had previous treatments with non-ab-         pression or arterial cannulation.
     sorbable fillers and had no memory or knowledge of              The above-mentioned infiltrations produced an improve-
     them were excluded from the ultrasound investigation.           ment reported by the patient as a feeling of relaxation
     In the second phase, anatomical and especially vascular         of the entire face, especially the middle and lower thirds
     ‘full face’ mapping of the patients was carried out in or-      with a change in the functionality of muscle contraction,
     der to highlight any anatomical variants that might have        and with a change of contraction not properly said but
     jeopardised the safety of the study. The third ultrasound       produced by more basal support as we know thatacting
     phase assessed the result of the filler placement in all        on the bone and increasing the physiological resorp-
     points but especially in the functional points both at the      tion of these areas produces a feeling of relaxation and
     chin and jaw level (Calvani point)                              well-being.
     Electromyography was performed before the infiltration          Each point provides a certain type of face dynamics.
     and after the infiltration to record changes at rest and        1 infiltration of the chin area comprising the chin tubercle
     in dynamics with a recording of each patient’s normal           and the chinprotuberance where it anchors into the mus-
     postural and subjective contraction.                            cle of the same name.
     The change in each patient’s postural automatism was            2 Bilateral retro-masseter mandibular angle where the
     highlighted by recording the pre and post results and           greatest mandibular bone resorption occurs due to mus-
     comparing them.                                                 cle stimulation and contraction.
     90% of the patients experienced an improvement in                 3 Calvani point located along an oblique line connect-
     muscle contraction resulting in a reduction in muscle hy-       ing the third/fourth tooth element to the insertion of the
     peractivity after infiltration.                                 zygomatic muscles (major and minor) at the level of the
     The affected areas were ultrasound-mapped, highlight-           antero-inferior margin of the maxillary bone in its lateral
     ing the muscular and vascular structures with precision         portion. A strategic point for the protrusion of the maxil-
     and safety.                                                     lary bone and acting electromyographically on the zygo-
                                                                     matic muscles.
     The technique                                                   4 nasal root point extending mainly from the root of the
                                                                     nasal pyramid to the cartilaginous component
     The technique involves the use of hyaluronic acid in a
                                                                     5 zygomatic point between the junction of the body and
     two-phase gel with high molecular cohesiveness and
                                                                     the zygomatic arch
     high G’.
                                                                     6 lateral supraorbital point above the orbital rim, one
     The product was chosen on the basis of its rheological
                                                                     centimetre lateral to the fronto-orbital suture
     properties. A 1-phase product was not considered be-
                                                                     After infiltration all patients were evaluated by electromy-
     cause of its cohesiveness and duration of firmness. This
                                                                     ography at 3 months.
     technique involves the sole and exclusive use of two-
     phase products because it was discovered that in the
     medium term they leave the most stable and balanced             Discussions
     functional result.                                              The bone level technique involves the infiltration by
     The technique involves the infiltration of hyaluronic acid      2-phase hyaluronic acid of specific bone points for bone
     divided as follows:                                             restoration due to ageing and compensation of those
     - 0.50ml in the chin area                                       bone gaps due to altered growth in the jaw bones.
     - 0.25 ml in the mandibular angle area per side                 The study focused specifically on dynamic and static
     - 0.2 ml inside the supraperiosteal oral cavity on the          muscle changes.
         maxillary bone in areas 1.4and 2.4 respectively             By means of electromyographic examinations, an im-
     - 0.30ml in the dorsal nasal area extending between             provement of these muscular districts involved in com-
         dorsum and tip                                              pensation phenomena (due to a bone deficit either by
     - 0.25 ml at the level of the zygomatic arch per side           physiological resorption due to ageing or due to impaired
     - 0.15 ml in the eyebrow orbital area at 1 cm lateral to        development and lack of maxillofacial and orthodontic
         the fronto-temporal suture per side.                        surgical therapies)was revealed.
     - The variability of the quantity depends on the clinical       Facial expressions and the correlation between chew-
         picture of the patient being analysed.                      ing, swallowing, skeletal class and emotionality of each
     - The total is2,5/ ml of hyaluronic acid                        individual subject is much discussed in the literature.



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F. Calvani et al.




Figure 1. Patient 1 - pre and post. Patient with second dento-skeletal class. Pre and post treatment photos with bone level
technique. Labial incompetence was filled by intramucosal infiltration below the chin muscle and the maxillary muscle.



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     Bone level technique: personal technique for miofacial functional treatment

     Gallerano9 et all in a 2012 article described a myofunc-              result that is not only functional but also aesthetic on
     tional treatment after an orthodontic surgical treatment in           the muscle, tissue and skin29.
     a study of 30 cases, investigating the language ability               The technique we adopted involves a change not of
     of class I,II, III subjects12;14;5 showing that 19 out of 30          contraction but of muscle axis. By changing muscle
     patients after surgery reported improved swallowing,                  axis, a change in the contractile behaviour of the mus-
     correct tongue tone and posture, and re-education                     cle was noted27.
     of the facial muscles. Most of the patients belonged                  James3 et all carried out an important study on muscle
     to a third dento-skeletal class with an anterior open                 pain related to chewing disorders especially in patients
     bite30;32. All these patients were re-educated using                  with an anterior open bite. They identified muscular ex-
     speech therapy sessions for muscular rehabilitation as                ercises to treat this type of disorder, but also showed that
     the muscles underwent a change in axis and posture                    muscle tension especially in the treatment of myofascial
     during the treatment. Of the 19 patients, only 2 were                 pain7;8 of the masticatory muscles can only and exclu-
     ineffective while the rest had a restitutia ad integrum               sively be alleviated by performing muscle stretching and
     with a reduction in the speech disorder they previously               making a change in the dental occlusion, all of which
     had. This makes us realise that inevitably acting on                  results in a change in the axial muscle. Thus changing
     the bone by changing position and volume can have a                   the muscular axis results in a change of contraction33; 36;




     Figure 2. Patient 2 pre and post. Patient with second dento-skeletal class. Pre and post treatment photos with bone level
     technique. Labial incompetence was filled by intramucosal infiltration below the chin muscle and the maxillary muscle. In the
     frontal view, increased volume is evident at the level of the lower middle third of the face without superficial skin infiltration but
     only deep infiltration. The result is achieved by muscular thrust by increasing bone volume and with physiologic resorption of
     the bone



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F. Calvani et al.

25
  . The facial and dental bone component in orthodontic          masseter muscles. When swallowing, this results in an
treatments and maxillofacial surgery change their phys-          increased muscle contractility of the lower third of the
iognomy. A surgical treatment is aimed at changing the           face compared to the upper third.
skeletal relationship between the maxilla and the mandi-         This reinforces the results obtained with our technique.
ble. This shift can have different degrees depending on          Infiltrating under the chin parasymphysis, without involv-
the planned treatment and the alteration to be correct-          ing the muscle of the same name in its structure, creates
ed21;. Orthodontic treatment is aimed at rebalancing the         a support of the same at the tendon level and thus a sup-
correct relationship of the tooth guides. The process of         port for the lip especially in dento-skeletal labial incom-
restoring a malocclusion to first class is a process that        petencies. By means of electromyography with surface
changes the occlusal, masticatory, swallowing and inev-          and intramuscular electrodes, a contractile reduction
itably mimic posture.                                            from 15% to 40% was found. Naturally, the percentage
The aim of the technique involves precisely this, i.e.           increased significantly in dento-skeletal classes II and
changing the muscular axis22;34;10. This is done with deep       III. The significant reduction in contraction is of course
supraperiosteal infiltrations that act on the mimic muscles,     not due to the muscle itself reducing its contraction but
in some cases creating different contraction axes. This          rather to a change in its axis that causes the muscle to
results in a change of contraction automatism that each          contract differently19.
patient possesses that takes time to change. Of course,          It is not possible to standardise the change as the indi-
there are no studies that can translate this effect into a       viduals changed.
functional effect at the swallowing level, but the effect is     The concept of change of contraction is a broad con-
certainly present at the facial mimic and indirectly aes-        cept and each person has a different response, so this
thetic level. All patients in this study experienced a benefit   study only reported improvement in an incorrect posture
translated into generalised facial muscle relaxation. In the     concept.
second classes, on the other hand, the patients reported         Jiaxing Wang2 et all conducted a study also defining
a reduction in the contraction of the chin muscle23;24, orbi-    facial contraction correlated with the individual’s ethnic
cularis of the mouth, lip depressor, risorius and buccinator.    group. It was seen that following muscular exercise, peo-
Hong Hong11 et all in 2021 carried out an important study        ple of different ethnic groups contract correlated muscle
on skeletal growth, showing, by means of electromyo-             groups differently. It is therefore difficult to standardise
graphic examination, the different contraction that oc-          a result, but our observations have always shown an
                                                                 improvement, especially in those areas where there is
curs at the level of the lower third compared to the upper
                                                                 hypertonus4.
third of the face15;16;17.
They showed that in patients with open anterior bite18;20;
a greater anterior facial height and a greater degree of         Third article
incisional protrusion can be found.This study evolved            In a study of 50 patients11;29 with TMD, taking into con-
by correlating electromyography with 18 cephalometric            sideration the contraction of the orbicularis muscle of the
measurements and it was found that there is a differ-            mouth, lips, and masticatory and lingual systems, it was
ence between the contraction of the orbicularis muscles          found that changing the muscle axis by pressure ma-
of the mouth and chin and the anterior temporalis and            neuvers with the hands showed a remaining masticato-




Figure 3. The EMG recording during a maximal effort of 20 seconds shows a global reduction of the amplitude and frequency
of voluntary recruitment in the right and left mental muscle after treatment.
Pre-treatment: A right mental, B left mental
After treatment: C right mental, B left mental


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     Bone level technique: personal technique for miofacial functional treatment

                                                                     study on facial expressions related to food cravings. The
                                                                     article reports the change in contraction and posture due
                                                                     to a specific emotional stimulus. Thus, the emotion in the
                                                                     facial expression can lead to a change in contraction and
                                                                     posture of the whole face depending on the emotionality
                                                                     of the subject. In a subject with a tired face and a re-
                                                                     ceding chin, a change in masticatory posture can there-
                                                                     fore occur. In our technique using electromyography, we
                                                                     noticed a reduction in muscle contraction after the pro-
                                                                     posed treatment, which brought the patient a functional
                                                                     and indirectly aesthetic benefit. This indirectly led to an
                                                                     increase in self-esteem and a rebalanced contraction of
                                                                     all mimic muscles. Less chin and buccinatorcontraction,
                                                                     with evident increase in the volume of the part itself and
                                                                     skin rebalancing13;.
                                                                     Koletzi26 et all in a study of adolescents found that after
                                                                     muscular rehabilitation of the lower third, there was an
                                                                     increase in tongue thrust at the upper and lower incisors.
                                                                     This resulted in an increased contraction of the orbicu-
                                                                     laris muscle of the mouth. Thus, altered orbicular con-
                                                                     traction is also found in the growth phase. Our protocol
                                                                     provides support at the level of the chin muscle, which
                                                                     nevertheless brings help with the function and muscular
                                                                     posture of the lower third.

                                                                     Conclusions
                                                                     In light of the results obtained and the literature in use,
                                                                     we believe that the bone level technique can be an
                                                                     important aid in the contractile processes of the facial
                                                                     muscles. Often the discomfort of patients due to physio-
                                                                     logical skeletal resorption related to advancing age, loss
     Figure 4. Bone level points. Ten points for modulation of       of dental elements or dental and skeletal malocclusions
     muscle contraction.
                                                                     can lead to an alteration of the physiological contractile
                                                                     harmony of the entire face.
                                                                     All patients underwent basic EMG examination with su-
     ry igloo. By acupressure both the lip and the orbicularis       pramaximal voluntary contraction of individual muscles,
     were suspended. This resulted in a masticatory postural         demonstrating full cooperation.
     change28;29.                                                    Y-Solution 720 was infiltrated by needle: this is the only
     After functional rehabilitation by means of targeted            hyaluronic acid-based filler with a high G’ (517 Pa) and
     stretching and speech therapy exercises, a significant          high cohesivity (54 gf ) that simultaneously has the best
     improvement in function was noted. The results after            features of biphasic and monophasic fillers: it is de-
     physiological rehabilitation treatment were exciting26;31.      scribed by its manufacturers as belonging to a new class
     All movements were recorded before and after treat-             of products called Y-phasic.
     ment. The areas most affected were appearance, lip              These characteristics give the gel a high versatility level:
     posture, cheek, tongue and jaw mobility, chewing and            it can be used not only in the classic areas that need
     swallowing functions.                                           volumetric increase, such as cheekbone, chin or man-
     After functional treatment with physiotherapy and speech        dibular profile, but also in areas such as the nose: the
     therapy, it was ascertained that degenerative changes in        gel has a superior lifting capacity, enabling it to withstand
     masticatory dysfunctions due to bone and muscle pro-            external stresses and retain its original shape without
     cesses were alleviated and even stopped. The study              migrating; it has a better lifting capacity that allows it
     shows that poor masticatory posture that inevitably in-         to withstand external stresses and maintain its original
     volves the musculoskeletal system of both mastication           shape without migrating.
     and mimicry can improve if treated.                             After 20 minutes EMG was repeated with the same se-
     With our technique we have proven the fact that by in-          quence (right buccinator, left buccinator and chin mu-
     serting supraperiosteal hyaluronic acid there are no al-        scle).
     terations to the muscles as the muscles are not affected,       The result shows an overall reduction in the amplitude
     but by shifting their axis a valid functional result can be     of the electromyographic trace with both spatial and
     achieved to reduce stress and accentuated contractility         temporal reduction of motor unit recruitment between 25
     especially in very emotional patients with work-related         and 50% compared with the previous condition with the
     stress.                                                         same parameters.
     Emotionality in contraction plays a very important role. A      Only two patients showed a reduction of 3-6%: these
     patient with an altered state of aesthetics will present an     patients had a first dento-skeletal class and a third den-
     altered mimicry just as a patient with muscular contrac-        to-skeletal class, respectively.
     tile alterations will present an altered aesthetics.            Our electromyographic observations showed us how an
     Jennifer Schmidt6 in a 2017 article reported an important       increase in volume at certain strategic points can restore



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F. Calvani et al.

support to the soft tissues, inevitably triggeringa gener-            10. C M de Felício 1, A P M Medeiros, M de Oliveira Melchior
alised muscular contractile rebalancing.                                  Affiliations expand. Validity of the ‘protocol of oro-facialmyo-
A principle that should not be underestimated is maxillary                functionalevaluation with scores’ for young and adult sub-
                                                                          jects. J OralRehabil. 2012 Oct;39(10):744-53.
and mandibular bone resorption. Resorption processes                      doi: 10.1111/j.1365-2842.2012.02336.x.Epub 2012 Aug 1.
play an important role in the contractile capacity of the                 PMID: 22852833 DOI: 10.1111/j.1365-2842.2012.02336.x
face. A face without bone support will inevitably undergo             11. Hong Hong# 1, YueZeng# 1, Xiaomin Chen1 2, CaixiaPeng1 3, Ji-
a change in muscular contractility due to both the down-                  anqingDeng 1 4, Xueqin Zhang 1 3, Lidi Deng1 5, YongjianX-
ward slide of the entire skin muscle system and the in-                   ie 1, Liping Wu 6 Affiliations expand. Electromyographic fea-
evitable change in muscle axis. The muscles will also                     tures and efficacy of orofacial myofunctional treatment for
                                                                          skeletal anterior open bite in adolescents: an exploratory
undergo stretching due to the weight of all the tissue ele-
                                                                          study. Oral Health. 2021 May 7;21(1):242.
ments of the face with an inevitable change in their tone                 doi: 10.1186/s12903-021-01605-0.
especially at the level of the middle third. To rebalance,                PMID: 33962610
therefore, this phenomenon will produce an increase in                    PMCID: PMC8103572
contraction to also support the weight of all the tissues.                DOI: 10.1186/s12903-021-01605-0
By rebalancing and compensating the superficial bone                  12. JanvierHabumugisha1, Bo Cheng1, Shu-Yu Ma1, Min-
                                                                          Yue Zhao1, Wen-Qing Bu1, Gao-Li Wang1, Qiong Liu 1,
volumes with the help of 2-phase hyaluronic acid, it has
                                                                          RuiZou 2, Fei Wang 3Affiliations expand. A non-randomized
been noted that these muscles are able to rebalance                       concurrent controlled trial of myofunctional treatment in the
their contraction. This is the most plausible explanation                 mixeddentition children with functional mouth breathing as-
for the results obtained.                                                 sessed by cephalometric radiographs and study models
                                                                          PMID: 36008795
                                                                          PMCID: PMC9413933
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     Bone level technique: personal technique for miofacial functional treatment

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