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Guidelines to Lip Position in the Construction of Complete Dentures Paul A

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Guidelines to Lip Position in the Construction of Complete Dentures Paul A Prosíhodontics Guidelines to lip position in the construction of complete dentures Paul A. Brunton* / J. Fraser McCord* A variety of philosophies and techniques for the prescription of esthetically and fiinctionally acceptable complete dentures are reviewed. Guidelines for the use of anatomic landmarks are discussed in addition tofimctional determinants of tooth position. The value ofpre-exiraciion records is discussed and suggestions are made as to useful clinical aides lo more appropriate prescription of acceptable dentures. (Ouintessence Int 1994:25:121-124.) Introduction 2. Support from underlying structures, such as the an- terior teeth and associated alveolar bone"'^ It could be postulated that the demand for prosthodon- tic treatment is likely to change; an increased number Ricketts.'' in an attempt to quantify the pereeived of partial dentures may be required, as patients are an- "ideal" lip contour, studied profile photographs of ticipated to retain more of their natural dentition. ' Fur- popular female personalities admired for their beauty. ther, use of techniques appropriate to the older patient, The lips were related to the '"esthetic plane," a line eg, template dentures for the provision of replacement drawn from the end ofthe nose to the chin. He deter- complete dentures, is to be expected.^ The anticipated mined that the lower Up is approximately 2 mm and the increased numbers of elderly patients are expected to upper lip approximately 4 mm posterior to the esthetic be better educated and have more disposable income plane, which is used in orthodontic evaluation and than ever before.-' In consequence, their expectations, treatment planning.' This esthetic plane, because of its particularly with regard to esthetics and function, are great variability, is considered by Ellinger^ to be a poor likely to place increased demands on the prosthodon- reference plane. tist. Knowledge of lip positiotis in the dentate state are Clinical experience suggests that the cumulative ef- useful in the transition from the dentate to the edentu- fects of biologic and chronologic aging will result in in- lous state, and may be used in the prescription of pros- creased numbers of edentulous patients for whom theses for the edentulous patient. Resorptive changes prosthodontic treatment is hkely to be problematic' in alveolar bone following the loss of maxillary teeth The purpose of this article is to review methods to have been studied longitudinally.' " These studies re- restore lip support to edentulous patients. vealed a loss of buccal bone and an associated decrease in ridge height in the anterior region of the maxilla. The net result is that the maxilla decreases in size while, co- Physiologic lip support and contour incidentally, the mandible appears to increase in width In dentate patients, the lips rely on two types of sup- relative to the maxilla.'^ port; To quantify facial profile and help preserve a natural 1. Intrinsic support from muscles, fibrous connective facial contour during the transition from a dentate to tissue, and glands, etc an edentulous state. Scher'^ advocated the use of a den- tofacial profilometer. This measured the nasolabial an- gle, the length of the upper lip and horizontal part of the nose at the pre-extractton phase of dentnre con- ' Department of Restorative Dentistry, University Dental Hospi- struction. Friedman''' recommended the use of facial tal of Manchester, Higher Cambridge Street. Manchester M15 6FH, England. measurements, profile patterns, and photogTaphs to Quintessence International Volutne 25, Number 2/1994 121 Prosthodontics Table ¡ Clinieal indications of excessive and insufficient lip support Signs of excessive lip support Signs of insufficient Up support Tensed, stretched appearance of the lips Perpetuation of the general appearance of collapse around the mouth Tension lines around the moulh Reduction in the size of the vermilion borders of the lips Distortion ofthe philtrum Drooping of the corners of the moulh Obhteration ofthe mentolabial, nasolabial. Deepening of the mentolabial, nasolabial, and labio- and labiomarginal suici marginal sulci Eradieation of the natural contours of the lower part Obliteration of the philtrum of the face that correlate that portion with the upper part ofthe face obtain an index of lip contours and serve as a guide to bone is also important: if the replacement teeth are in positioning the anterior teeth. an unnatural position, it is technically difficult to devel- Physiologic lip support is perceived to be important op a natural contour for the labial flange."^ Further, not only for a natural and pleasing appearance but also variation in the thickness and length of the flange from from a functional point of view.'' The muscles of the lips left to right may be necessary to duplicate facial asym- and cheeks, like al! skeletal muscle, function most effi- metry,'' ciently when maintained and supported at their func- The clinical signs of excessive and insufficient lip tional physiologic length: esthetic considerations in the support, summarized in Table 1, are documented but construction of complete dentures must therefore be not quantifled."'-^ Watt and MacGregor'- stated that assessed not only while the lips are in repose but also the average sagittal angle between the columella and while they are in function.''''^ the lip is approximately a right angle. This angle eould The pattern of résorption in the anterior maxilla is be increased if the anterior teeth are retroclined or if such that placement of the replacement teeth over the the columella is prominent and at a lower levei than the residual alveolar ridge will result in unphysiologic lip ala. If, however, the columella and ala in profile are at support.'" Indeed it has been observed, in some indi- the same level and associated with proclined anterior viduals, that the resultant space between the upper lip teeth, an angle of more than 90 degrees is indicated. It and incisor teeth that oeeurs when the anterior teeth was also suggested that a horizontal nasolabial angle are set too far palatally is responsible for phonetic between 90 and 120 degrees is appropriate. This angle problems such as imparting a whispering quality to would vary according to whether the patient has a nar- speech patterns.'^ row face or a broad face, the broader-faced individual While a natural tooth position on complete dentures requiring a flatter angle and vice versa. is desirable, to further develop natural form and phys- Watt-'' reeommended the constrtiction and use of iologic lip support, a denture must reproduee a natural biométrie trays to prescribe the appropriate depth and anatomy around these teeth to enhance lip support and width of the buecal sulei and hence to facilitate the res- toration of the pre-extraction form of the lips and Tlie labial flange and associated denture base mate- cheeks. rial replace the lost supporting structures of the natural teeth: some workers'*"'" believed that physiologic lip support is provided by the labial flanges and the gingi- Comparison ofthe edentulous and dentate states val two thirds of the anterior teeth. Contouring of the Ismail et aP and Carisson and Ericson''' studied the labial flange to compensate for the loss of alveolar soft tissue profile of subjects prior to the extraction of 122 Quintessence International Voiume 25, Number 2/1994 Prosthodontics their remaining leeth and for 12 months subsequently placed incisors, a sunken, uneosmetie oval profile with .__ and reported a dramatic ehange in the contour of the inverted lips may result,'*' lips following extraetion of the anterior teeth. While A longitudinal study of upper lip length in dentate ~- the prescribed dentures restored the lips to the pre-ex- adults demonstrated that the upper lip lenglh increases traction contour, there was a gradual reduction in the with age.^^Thus, in older patients, it would appear to be vertical and horizontal dimensions of lip contour, more appropriate to site the maxillary incisors level *' which was attributed to the pattern of alveolar résorp- with or superior to the upper lip. This is in agreement tion, Watson and Bhatia,-' however, considered that with Frush and Fisher,-'' who eonsidered that natural the upper lip had changed in character in the edentu- age changes must not be disregarded when dentures lous group with a flattening of the profile, Tallgren et are constructed. Restoration of facial contours beyond a!-^ studied, over a 2-year period, soft lissue profile in those compatible with the patient's physiologic age patients who were to receive immediate complete den- may produce the "denture look,'"" lures and reported a more anterior position ofthe max- One of the most important anatomic features facili- illary lip, which they considered to be a result of the tating positioning of the replacement central incisors is presence of the denture flange. In addition, a decrease the incisive papilla,'"-'"' The average distance from the _^ in the occlusai vertical dimension and an associated an- posterior border of the papilla to the labial surface of terosuperior rotation of the mandible have been re- the central incisors has been reported to be 12,5 ported in other studies,-""-'- This mandibular rotation mm,"**'" Other workers"'-'^''- recommended a distance produces an outward positioning of the upper lip; this of S to 10 mm measured from the middle of the incisive change is greatest during the first 6 months of denture papilla as a biométrie guide to anterior tooth position.
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