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Upper Lip Horizontal Line: Characteristics of a Dynamic Facial Line

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Upper Lip Horizontal Line: Characteristics of a Dynamic Facial Line International Journal of Environmental Research and Public Health Article Upper Lip Horizontal Line: Characteristics of a Dynamic Facial Line 1, 1, 1 1 Alexander D Vardimon y, Nir Shpack y, Atalia Wasserstein , Marilena Skyllouriotou , Morris Strauss 1, Silvia Geron 1, Noa Sadan 1, Shifra Levartovsky 2 and Rachel Sarig 1,3,4,* 1 Department of Orthodontics, the Maurice and Gabriela Goldschleger School of Dental Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; [email protected] (A.D.V.); [email protected] (N.S.); [email protected] (A.W.); [email protected] (M.S.); [email protected] (M.S.); [email protected] (S.G.); [email protected] (N.S.) 2 Department of Oral Rehabilitation, the Maurice and Gabriela Goldschleger School of Dental Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel; [email protected] 3 Department of Oral Biology, the Maurice and Gabriela Goldschleger School of Dental Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel 4 The Dan David Center for Human Evolution and Biohistory Research, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv 6997801, Israel * Correspondence: [email protected]; Tel.: +972-2-640-6569 These authors contributed equally to this work. y Received: 18 August 2020; Accepted: 9 September 2020; Published: 13 September 2020 Abstract: Background: Upper lip appearance received major attention with the introduction of diverse treatment modalities, including lip augmentation, rhinoplasty surgery, and dental treatment designed to support the upper lip. Our objectives were to define the prevalence and characteristics of the upper lip horizontal line (ULHL), which is a dynamic line appearing during a smile, in relation to gender, malocclusions, aging, and facial morphology. Methods: First, the prevalence and gender distribution of ULHL was examined from standardized en-face imaging at full smile of 643 randomly selected patients. Second, cephalometric and dental cast model analyses were made for 97 consecutive patients divided into three age groups. Results: ULHL appears in 13.8% of the population examined, and prevailed significantly more in females (78%). The prevalence of ULHL was not related to age nor to malocclusion. Patients presenting ULHL showed shorter upper lip and deeper lip sulcus. The skeletal pattern showed longer mid-face, shorter lower facial height and greater prevalence of a gummy smile. Conclusions: Female patients with short upper lip, concavity of the upper lip, and gummy smile are more likely to exhibit ULHL. The ULHL is not age-related and can be identified in children and young adults. Therefore, it should be considered when selecting diverse treatment modalities involving the upper lip. Keywords: upper lip; smile; sexual dimorphism; facial morphology; aging; wrinkle 1. Introduction Perceptions of facial beauty are multifactorial, with genetic, environmental, and cultural foundations [1]. Yet, various researchers who analyzed the esthetics of the smile and face revealed some common features of symmetry and harmony. The face can be divided into thirds, with the lips comprising of the key aesthetic feature of the lower third, where the upper lip is shown as having the greatest effect on beauty perception. Traditionally, fuller lips have been considered more beautiful and were associated with voluptuousness, sensuality, and youthfulness. Indeed, in the last century, there has been a gradual increase in the demand for lip prominence [2], starting with dental treatment to support the upper lip through lip Int. J. Environ. Res. Public Health 2020, 17, 6672; doi:10.3390/ijerph17186672 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, 6672 2 of 10 augmentationInt. J. Environ. Res. proceduresPublic Health 2020 and, 17 aesthetic, 6672 plastic surgery [3–6]. Facial wrinkles that appear in2 of the 10 lower third of the face (i.e., nasolabial folds, vertical lip lines (perioral lines), Marionette lines (smile lines), lip through lip augmentation procedures and aesthetic plastic surgery [3–6]. Facial wrinkles that and mental creases (chin lines)) might affect the attractiveness of the face. These wrinkles are affected byappear the orbicularisin the lower oris third and 10of otherthe face circumferential (i.e., nasolabial muscles folds, [vertical7], as well lip aslines changes (perioral in liplines), and skin Marionette lines (smile lines), and mental creases (chin lines)) might affect the attractiveness of the strain [8,9]. Vertical perioral lines in the upper lip develop with aging [10] and are more expressed in face. These wrinkles are affected by the orbicularis oris and 10 other circumferential muscles [7], as women [11]. well as changes in lip and skin strain [8,9]. Vertical perioral lines in the upper lip develop with aging The transverse upper labial crease was recently described to be located in the mid-philtral area [10] and are more expressed in women [11]. belowThe the transverse nose [12]. upper It was labial visible crease both was at restrecently and described during animation to be located or only in the during mid-philtral facial animation, area andbelow was the more nose [12]. apparent It was in visible older both women at rest (> and40). during It was animation suggested or thatonly theduring anatomical facial animation, basis for the formationand was more of this apparent crease isin thought older women to be the( > insertion40). It was of suggested the two depressor that the anatomical septi nasi musclebasis for fibers the into theformation overlying of this skin crease [13]. Atis thought least one to third be the of inse thertion female of volunteersthe two depressor were aware septi ofnasi this muscle upper fibers transverse labialinto the crease, overlying indicating skin [13]. that At this least might one be third of an ofaesthetic the female concern volunteers when we attemptingre aware of to this address upper upper liptransverse appearance labial [12 crease,]. indicating that this might be of an aesthetic concern when attempting to addressTreatment upper lip of a theppearance upper lip[12]. region has received major attention lately, with the introduction of diverseTreatment modalities, of the such upper as injectablelip region has derivative received of ma botulinumjor attention toxin lately, [14 ],with insertion the introduction of filler materials of (e.g.,diverse hyaluronic modalities, acid) such [15as ]injectable or surgical derivative techniques of botulinum (e.g., myotomy toxin [14], of insertion the Levator of filler Labii materials Superioris Muscle(e.g., hyaluronic [16], or lip acid) lift [ and15] or fat surgical grafting) techniques [17]. Although (e.g., myotomy Botox has of beenthe Levator primarily Labii used Superioris in cosmetic treatmentMuscle [16], for or lines lip lift and and wrinkles fat grafting) on the [17]. face, Alt ithough is also Botox of great has valuebeen primarily and interest used for in dentistscosmetic in an attempttreatment to for treat lines functional and wrinkles or aesthetic on the face, dental it is conditions, also of great like value deep and nasolabial interest for folds, dentists radial in lipan lines, attempt to treat functional or aesthetic dental conditions, like deep nasolabial folds, radial lip lines, high lip line, and black triangles between teeth [18]. high lip line, and black triangles between teeth [18]. In the present study, we describe the upper lip horizontal line (ULHL), which is a dynamic line that In the present study, we describe the upper lip horizontal line (ULHL), which is a dynamic line appears only while smiling (Figure1). Although various parameters of the upper lip were analyzed in that appears only while smiling (Figure 1). Although various parameters of the upper lip were theanalyzed past (e.g., in the lip past length, (e.g., naso-labial lip length, angle, naso-labia gummyl angle, smile), gummy no attention smile), no has attention been given has been yet to given the ULHL andyet to it hasthe ULHL not yet and been it has taken not into yet been diagnostic taken into consideration. diagnostic consideration. FigureFigure 1. En-face view of two patientspatients ((a)a,b and) with (b) upper with upper lip horizontal lip horizontal line (ULHL). line (ULHL). (a1,b1 ):(a1),(b1): No presence ofNo ULHL presence at lip of together;ULHL at lip (a2 together;,b2): no presence(a2),(b2): ofno ULHLpresence at rest;of ULHL (a3,b3 at): rest; full (a3),(b3): presence full of ULHLpresence at smile (seeof ULHL arrow). at smile Note (see the arrow). flip of the Note upper the flip lip of during the upper full smile. lip during full smile. WhenWhen aesthetic treatment treatment is isplanned, planned, it is it essent is essentialial to match to match the theexpectations expectations of the of patient the patient by by havinghaving aa completecomplete diagnosisdiagnosis ofof allall relatedrelated parametersparameters andand toto bebe awareaware ofof thethe clinician’sclinician’s abilityability toto affect theaffect results. the results. Even inEven cases in cases in which in which the treatment the treatment plan plan does does not includenot include intervention intervention (e.g., (e.g., gummy smile,gummy facial smile, asymmetry), facial asymmetry), it is important it is important to inform to inform the patient. the patient. SinceSince ULHL is is mainly mainly visible visible during during smiling smiling (dynamic (dynamic line), line), and and in the in light the light of diverse of diverse exposure exposure ofof dentaldental and gingival gingival units units during during smiling smiling [19], [19 it], is it possible is possible that that ULHL ULHL is related is related to a predisposed to a predisposed spatialspatial arrangement of of soft soft and and hard hard tissue tissue in inthe the face. face. Consequently, Consequently, the question the question arises arises whether whether ULHL is a product of aging or a result of anatomical structure arrangement. In order to allow the ULHL is a product of aging or a result of anatomical structure arrangement.
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