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

Patients with acquired maxillary edentulism and atrophy often present with facial soft tissue changes that limit the restorative 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 “senile”. Interestedly, the age-related changes of lip do not result in a loss of lip volume, rather the volume is redistributed to increased length resulting in vermillion inversion and ptosis of the lip [2] One of the negative consequences of the senile lip regards an unpredictable display of oral spaces, such as the buccal corridor and smile line [3], with the maxillary incisal display at rest being decreased or eliminated [4]. These changes, compounded with atrophy of the underlying maxillary skeleton and tooth loss, result in significant labio-facial changes [5]. The conventional prosthetic approach to provide lip support to this patient population is with a denture flange to reestablish lip support and elevation [6]. However, denture flange support occurs by extension of the prosthesis into the vestibule and pushing the lip outward [7,8] which alters muscle pull and subsequent tissue movement. This artificial support pushes the orbicularis oris outward uniformly and allows the superior anterior border of the flange to develop an unaesthetic Subnasal convexity. The lifting effect of the flange also seems inadequate in correcting an inverted vermillion border and does not restore convexity to the philtrum columns. Although flanges provide support to a senile lip, they cannot be employed with fixed restorations for reasons of maintenance and hygiene. Additionally, the amount and thickness of material required may limit biomechanical function [9,10]. However, many patients desire fixed implant retained prosthetic solutions but lack adequate soft tissue support without a flange. Calvani evaluated lip support of 412 patients with differing prostheses and thin lips and determined 66% of full-arch implant supported fixed restorations presented with a horizontal groove in the upper lip [11]. This groove, termed a “split philtrum line”, can develop with a fixed implant supported prosthetics when there is inadequate support inferior to the nasal base.