Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Prosthesis Using a Sub Nasal Lip Lift

Journal of Dental Health, Oral Disorders & Therapy

Abstract Case Report

Increasing success with endosseous implants in edentulous patients has heightened the interest in using fixed prostheses in this patient population. Volume 5 Issue 1 - 2016 Despite this trend, upper lip support has been a long-standing challenge, especially in patients with a thin elongated upper lip, termed “senile”, where the presence or absence of a flange compromises the esthetic and functional outcomes. Although, 1 the conventional solution to reestablish elevation and support of the upper lip Department of Prosthodontics, Tufts University School of Dental Medicine, USA has been an anterior flange of a removable prosthesis, fixed implant supported 2 prostheses do not incorporate a flange for reasons of hygiene and maintenance. In Department of Head & Neck Surgical Oncology, Micro vascular & Reconstructive Surgery, Oral & Maxillofacial this case report a patient with atrophic maxillary edentulism and upper lip senility Surgery, USA that sought fixed rehabilitation was identified. Following pre-surgical assessment 3Department of Restorative Sciences, University of Alabama at of vertical facial proportions, lip length and morphology, and inter-arch space, a Birmingham, USA surgical upper lip length reduction was performed using the Subnasal Lip Lift 4Department of Oral & Maxillofacial Surgery, University of (SNLL) technique. 6 months after the SNLL, when the lip length stabilized, the Alabama at Birmingham, USA patient received fixed implant supported monolithic zirconia prosthesis without an anterior flange. The desired amount of lip elevation and tooth display in the *Corresponding author: Aikaterini Kostagianni, final prosthesis was achieved. The lip length remained stable at the 1-year follow- Department of Prosthodontics, Tufts University School of up, Subnasal scars were not evident by 2 months, abnormal lip dynamics were not Dental Medicine, Kneeland Street, Boston MA 02111, USA, observed, and improved vermillion eversion was present. Tel: 617-636-0472; Email:

Keywords: Lip support; Fixed implant supported prostheses; Lip lift; Esthetic Received: | Published: facial surgery August 05, 2016 August 25, 2016

Introduction

Patients with acquired maxillary edentulism and atrophy often Additionally,flanges provide the support amount toand a senilethickness lip, theyof material cannot requiredbe employed may present with facial soft tissue changes that limit the restorative limitwith fixedbiomechanical restorations function for reasons [9,10]. of maintenanceHowever, many and hygiene.patients dentist’s ability to fabricate a functional and esthetic prosthesis. Often with age, the upper lip becomes thin and elongated, due to atrophy of muscles, fat, and connective tissue [1] and is termed lipdesire support fixed of implant 412 patients retained with prosthetic differing prostheses solutions butand thin lack “senile”. Interestedly, the age-related changes of lip do not result in adequate soft tissue support without a flange. Calvani evaluated a loss of lip volume, rather the volume is redistributed to increased restorations presented with a horizontal groove in the upper lip length resulting in vermillion inversion and ptosis of the lip [2] [11].lips andThis determined groove, termed 66% a “split of full-arch philtrum implant line”, can supported develop fixedwith One of the negative consequences of the senile lip regards an unpredictable display of oral spaces, such as the buccal corridor support inferior to the nasal base. and smile line [3], with the maxillary incisal display at rest being a fixed implant supported prosthetics when there is inadequate decreased or eliminated [4]. These changes, compounded with Nonetheless, surgical augmentation of the senile upper lip can atrophy of the underlying maxillary skeleton and tooth loss, result maxillary prosthesis for the edentulous maxilla minimizing the approach to provide lip support to this patient population is unwantedfacilitate the effects restoring of atrophy, dentist’s tissue ability thinning, to provide and an loss esthetic, of support. fixed in significant labio-facial changes [5]. The conventional prosthetic Known as a Subnasal Lip Lift (SNLL), it effectively shortens the lip while simultaneously increasing the vermillion display by eversion prosthesiswith a denture into the flange vestibule to reestablish and pushing lip support the lip outward and elevation [7,8] (Figure 1). While the literature supports that the SNLL procedure which[6]. However, alters muscle denture pull flange and supportsubsequent occurs tissue by extensionmovement. of This the has predictable esthetic outcomes to improve age-related changes to the upper lip with intact muscular function, the technique has artificial support pushes the orbicularis oris outward uniformly with meticulous closure, laser resurfacing, or dermabrasion alsoand allowsseems inadequatethe superior in anteriorcorrecting border an inverted of the vermillionflange to develop border also been refined in the past decades to diminish scar formation, andan unaesthetic does not restore Subnasal convexity convexity. to the The philtrum lifting effectcolumns. of the Although flange demonstrate the application of surgical management of maxillary [5,9,12-16]. This technique was employed in this case report to

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J Dent Health Oral Disord Ther 2016, 5(1): 00137 Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Copyright: 2/6 Prosthesis Using a Sub Nasal Lip Lift ©2016 Kostagianni & Hanna et al.

edentulism accompanying a senile upper lip that was restored and philtrum contours for esthetic tooth display and lip support,

The purpose was to elevate the upper lip to an ideal position with a flangeless fixed implant-supported maxillary prosthesis. thereby reducing the need for an anterior flange.

Figure 1: Subnasal lip lift procedure to excise tissue at the Nasal base which is then sutured to shorten the lip and avert the vermillion to increase A B C display.

Clinical Report The Subnasal Lip Lift procedure (SNLL) A 78 year-old female presented to the University of Alabama The planned lip excision was marked with the patient in the at Birmingham School of Dentistry seeking care. She expressed upright position for accurate lip length assessment and prior to dissatisfaction with the function and esthetics of her existing administering local anesthesia to avoid tissue distortion (Figure 4). A bullhorn-type incision in the Subnasal region was designed. maxillary edentulism prosthesis with and moderate sought rehabilitation atrophy, a senile with upper fixed and extends around the ala-facial groove. The inferior incision lipimplant with lack supported of vermillion restorations. display Clinicaland an evaluationunnatural convexity revealed lineThe superiormirrors theincision pattern line superior approximates excision the withnaso-labial a separation junction, of caused by her existing removable prosthesis due to the attempt the excisions at the desired level of lip lift. The incision is made to create an ideal maxillary tooth display (Figure 2). Vertical facial proportions, lip length/morphology and vestibular depth underlying orbicularis oris muscle was not excised because of were assessed. Lip length was measured in repose from the thewith potential a #15 blade for irregular and carried lip dynamics, into the subcutaneous however, some plane. advocate The muscle excision proposing it offers greater stability of the lift

Subnasal to the stomion superius and was found 25mm (Figure interrupted 4-0 Vicryl subcutaneous sutures (Ethicon, Somerville, with3). These prosthetic findings treatment. indicated Thus, that an patient’s interdisciplinary desire for treatment maxillary with less relapse [5,22]. Closure was achieved with meticulous planfixed was implant developed supported to reestablish prosthesis a couldnatural not lip be support achieved with only a combination of prosthetic tooth support and a SNLL procedure. ointment,NJ) and 5-0 applied nylon daily skin for sutures 1 week, taking and care the tonylon avert sutures the wound were Prosthodontic evaluation included a trial diagnostic tooth set-up removededges (Figure in 7 days.5). The Sunblock wound was treatedrecommended with topical for six antibiotic months to avoid any potential for hyper pigmentation. On the same day teeth alone and measure the available restorative space [17,18]. of the SNLL 8 dental implants were placed utilizing a surgical without a flange to judge lip support provided by the prosthetic guide fabricated from the trial teeth set-up (Figure 6). Delayed a realistic pre-surgical assessment of the need for additional lip engagement of the implants was applied due to inadequate supportThe lip contours [19,20]. wereThe teeth visualized were setwithout up to the ideal flange dimensions to determine for a primary stability and a tissue-borne interim denture was inserted interach space [18,21]. This set-up was also utilized as a reference as possible to accommodate the lip elevation and minimize fixed implant supported prosthesis, with approximately 10mm excessiveone week anteriorafter SNLL. tooth The display. anterior It flangeis important was reduced to inform as much the with the surgeon and prosthodontist, an 8 implant-supported patient that the ideal dimensions and esthetics of this provisional screwto evaluate retained the monolithicdesired amount Zirconia of lip restoration reduction. was In finalselected. planning prosthesis may not be feasible during the healing phase. However, if the initial implant stability permits, the denture prosthesis

esthetics.may be immediately converted to a flangeless screw-retained fixed provisional restoration, which will allow for more optimal

Citation:

Kostagianni A, Hanna TC, Givan DA, Louis PJ (2016) Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Prosthesis Using a Sub Nasal Lip Lift. J Dent Health Oral Disord Ther 5(1): 00137. DOI: 10.15406/jdhodt.2016.05.00137 Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Copyright: 3/6 Prosthesis Using a Sub Nasal Lip Lift ©2016 Kostagianni & Hanna et al.

After approximately six months of healing following the prosthesis a screw-retained monolithic Zirconia restoration was fabricated; while the prosthesis replaced teeth and tissue, there provisional restoration was fabricated to reassess tooth position, implant placement and the SNLL, an implant supported fixed demonstrated an increase in vermillion show and elimination of prosthesis. The delay is not only for adequate osseointegration, awas Subnasal no extension bulge for into the anterior upper lip. vestibule. Satisfactory The lip final support outcomes was butlip support, to allow andfor the to serve anticipated as a guide partial for therelapse final of implant the SNLL supported prior to stabilization of the lift length [22]. The patient had a preoperative implant-supported restoration. Philtrum columns and an age- appropriateaccomplished vermillion with the display combination were achieved, of the SNLL (Figure and 8). the At fixed the resection resulting in a 19 mm immediately post-operative. one-year follow up patient expressed high satisfaction with the Atlip 6-months length of 25lip length mm and was underwent found to anbe 821 mm mm Subnasal lip (Figure tissue 7). esthetic results of her treatment, as well as improved function of These measurements were stable at 1-year follow-up, while the her implant-supported prosthesis.

Subnasal scar was inconspicuous by 2 months. For the definitive

Figure 2: A B C D vermillion,Senile and a lip subnasal without convexity. denture flange support noting excessing length, flattening of contours, and vermillion inversion (A). Senile lip with a well-constructed denture flange (B, C and D) which uniformly pushes out the lip with loss of philtrum columns, unnatural fullness, inversion of the

Figure 3: Pre-operative assessment of a senile lip with denture removed.

Citation:

Kostagianni A, Hanna TC, Givan DA, Louis PJ (2016) Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Prosthesis Using a Sub Nasal Lip Lift. J Dent Health Oral Disord Ther 5(1): 00137. DOI: 10.15406/jdhodt.2016.05.00137 Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Copyright: 4/6 Prosthesis Using a Sub Nasal Lip Lift ©2016 Kostagianni & Hanna et al.

Figure 4: Bullhorn-type SNLL marking are made with the patient upright, prior to local anesthesia.

Figure 5: anticipated partial relapse. A Surgical excision of superficial layers without encroachment into the underlying muscle tissue. B. Post-surgical final closure prior to

Figure 6: Surgical guide dublicated from the diagnostic teeth set-up and placemant of 8 dental Implants.

Citation:

Kostagianni A, Hanna TC, Givan DA, Louis PJ (2016) Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Prosthesis Using a Sub Nasal Lip Lift. J Dent Health Oral Disord Ther 5(1): 00137. DOI: 10.15406/jdhodt.2016.05.00137 Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Copyright: 5/6 Prosthesis Using a Sub Nasal Lip Lift ©2016 Kostagianni & Hanna et al.

Figure 7:

6-month postoperative assessment with screw-retained implant supported provisional prosthesis. Note that no flange is incorporated for lip support (A. Lateral high smile view, B. Lateral repose view, C. Provisional prosthesis)

Figure 8: - ic Zirconia screw retained Prosthesis) noting a natural support contour and the presence of age-appropriate philtrum columns and vermillion display. One-year outcome with Zirconia fixed implant supported prostheses (A. Frontal high smile view, B. Frontal repose view, C. Monoloth

Discussion at rest is estimated to range from 18-22 mm [23,24]. However, rather than endorsing a set numeric range to guide the need Inadequate lip support may result from reasons other than for surgical correction, greater emphasis should be placed on maxillary atrophy with a senile lip, and a comprehensive oral and proportional values to account for individual and ethnic variance. facial evaluation should be performed to determine if soft tissue The vermilion follows proportions by division into thirds with the surgical procedures, such as a SNLL, are appropriate rather than upper lip being 1/3 and the lower lip being 2/3 of total vermilion procedures involving hard tissues. To determine the etiology, height [22,26,27]. These proportions believed to be relatively consistent in classical measures of attractiveness. thickness and lip length [10]. The assessment is done with and withoutan assessment patients should existing include dentures the infacial place, height, if available, facial profile,evaluating lip Perenack noted the relative contraindications to an SNLL both the vertical facial proportions of the upper lip, lower lip, are a short lip length, less than 18 mm, or a history of forming and chin as well as the contribution of the vertical dimension hypertrophic scars and keloids, otherwise excellent outcomes of occlusion. Documentation of upper lip length, depth of the vestibule, and height of the anterior maxillary ridge is important approximately 18 mm or less, the lip may be well supported by the to aid interdisciplinary planning for SNLL treatment. The fullness prostheticcould be routinely teeth alone obtained. since their 5 If position the lip and length angulation is found are to the be of the upper lip is assessed by a measure of the nasiolabial angle The changes in lip length associated with orthagnathic surgery are diagnostic lines, such as Burstone’s, Steiner’s, or Ricket’s lines alsomajor well supporting established features whereas of the conventional inferior portion bone of grafting the upper of thelip. [23].(normal Factors range such 85°-105°) as lip thickness, or from morphology measures of against the nasal normal base, atrophic maxilla may provide only minimal success in supporting and presence of facial hair effects the perception of support and the senile lip largely due to the extent of grafting necessary and is challenged with the senile lip. The normal upper lip length does not address the lip length or morphology [27-29]. Evaluation

Citation:

Kostagianni A, Hanna TC, Givan DA, Louis PJ (2016) Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Prosthesis Using a Sub Nasal Lip Lift. J Dent Health Oral Disord Ther 5(1): 00137. DOI: 10.15406/jdhodt.2016.05.00137 Interdisciplinary Treatment for Upper Lip Support with Fixed Implant Supported Copyright: 6/6 Prosthesis Using a Sub Nasal Lip Lift ©2016 Kostagianni & Hanna et al.

of the apical position of the upper lip during maximum smile is 13. also critical. Lip function that provides less gingival display was follow-up of the original technique. Plast Reconstr Surg 112: 671- often deemed more esthetic, and a low lip line is advantageous for 672.Yoskovithch A, Fanous N (2003) Correction of thin lips: a 17-year 14. Ramírez OM, Khan AS, Robertson KM (2003) The upper lip lift using can be visible in high smile patients [30,31]. the bulls horn approach. J Drugs Dermatol 2(3): 303-306. the fixed anterior prostheses, since the tissue-prosthesis junction Summary The described Subnasal lip lift (SNLL) offered a predictable 15. Waldman SR (2007) The subnasal lift. Facial Plast Surg Clin North 16. Am 15(4): 513-516. and esthetic improvement of age-related upper lip changes, effectiveness of the lip lift for treatment of the aging lip: a morphometricPenna V, Iblher evaluation. N, Bannasch Plast Reconstr H, Stark Surg GB 126(2): (2010) 83e-84e. Proving the implant-support prosthetics. Esthetic and functional outcomes wereand allowed enhanced for aby functionally normalizing successful upper lip restoration length, increasing with fixed 17. Ellis E, McFadden D (2007) The value of a diagnostic setup for full vermilion show, increasing tooth display, eliminating a Subnasal 1764-1771. convexity, and reduction of restorative material. Additional factors fixed maxillary implant prosthetics. J Oral Maxillofac Surg 65(9): of expense, multiple staged procedures, and overall treatment 18. time must be considered. Overall, the Subnasal lip lift provided a edentulous maxilla. Br Dent J 201: 261-279. Jivraj S, Chee W, Corrado P (2006) Treatment planning of the highly satisfactory treatment outcome. Preservation of muscular 19. and mandibular central incisor in smiling and physiologic rest of this treatment modality. Choi TR, Jin TH, Dong JK (1995) A study on the exposure of maxillary function and avoidance of an underlying flange are key elements References 20. position.Neves FD, J Wonkwang Mendonç Dent Res Inst 5: 371-379. 1. Perkins SW, Sandel HD (2007) Anatomic considerations, analysis, maxillary implant-supporteda G, Frenandes prosthesis Neto design. AJ (2004) J Prosthet Analysis Dent of 91(3):influence 286-288. of lip line and lip support in esthetics and selection of

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