Download Upper Lip Changes and Gingival Exposure on Smiling In

Journal of Babylon University/Pure and Applied Sciences/ No.(7)/ Vol.(22): 2014
Upper Lip Changes and Gingival Exposure on
Smiling In Group With Class I Normal Occlusion.
Issam merrzah Abdullah
University of Babylon/ college of dentistry
[email protected]
Abstract
Our objectives were to evaluate and quantify upper lip soft-tissue changes in the vertical
dimensions both at rest and at maximum smile. Methods thirty three volunteers (15 men, 18 women)
aged 18 to 23 (mean, 21.5 years) were recruited for this study. For each subject, 8 measurements of
upper lip position and maxillary incisor crown height at rest and in maximum smile were recorded.
Results: A statistically significant sexual dimorphism was apparent in most of the measured variables.
Relaxed external upper lip length was 1.8 mm mm shorter in the women than in the men. The mean
maxillary central incisor length was 0.56 mm greater in the men than in the women. A low smile line
was more prevalent in the women, The average smile is more prevalent in male than female.
Conclusions: Data from this study clearly indicate sexual dimorphisms in upper lip length, maxillary
incisor display, and resting external upper lip length. Low smile patterns are more common among
female patients, and also common among male patients while high smile are less common among
female and male patients. The average smile is more prevalent in male than female.
Key words; gingival exposure, smile gingival, upper lips.
‫ﺍﻟﺨﻼﺼﺔ‬
.‫ﺍﻟﻬﺩﻑ ﻤﻥ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺴﺔ ﻫﻭ ﻟﺘﻘﻴﻴﻡ ﻭﺘﺤﺩﻴﺩ ﺘﻐﻴﺭﺍﺕ ﺍﻟﺸﻔﻪ ﺍﻟﻌﻠﻴﺎ ﻓﻲ ﺍﻟﺒﻌﺩ ﺍﻻﻓﻘﻲ ﻟﻠﻭﺠﻪ ﺨﻼل ﻜل ﻤﻥ ﺍﻻﺴﺘﺭﺍﺤﺔ ﻭﺍﻻﺒﺘﺴﺎﻤﺔ‬
‫ ﻗﻴﺎﺴﺎﺕ‬٨ ‫ﺠل ﻟﻜل ﺸﺨﺹ‬‫ ﺴ‬.‫ ﺴﻨﻪ‬٢٣‫ ﺴﻨﻪ ﻭ‬١٨ ‫ ﻨﺴﺎﺀ( ﺘﺘﺭﺍﻭﺡ ﺍﻋﻤﺎﺭﻫﻡ ﺒﻴﻥ‬١٨ , ‫ ﺭﺠﺎل‬١٥) ‫ﺸﻤﻠﺕ ﺍﻟﺩﺭﺍﺴﺔ ﺜﻼﺜﺔ ﻭﺜﻼﺜﻴﻥ ﻤﺘﻁﻭﻉ‬
‫ ﺍﻅﻬﺭﺕ ﺍﻟﻨﺘﺎﺌﺞ ﺒﺎﻥ ﻫﻨﺎﻙ ﻓﺭﻕ‬.‫ﻟﻠﺸﻔﻪ ﺍﻟﻌﻠﻴﺎ ﺨﻼل ﺍﻻﺴﺘﺭﺍﺤﺔ ﻭﺨﻼل ﺍﻻﺒﺘﺴﺎﻤﺔ ﻭﺍﻴﻀﺎ ﺸﻤﻠﺕ ﻗﻴﺎﺱ ﻁﻭل ﺍﻟﻘﺎﻁﻊ ﺍﻟﻤﺭﻜﺯﻱ ﺍﻟﻌﻠﻭﻱ‬
‫ ﻤﻠﻡ ﺍﻗﺼﺭ ﻋﻨﺩ ﺍﻟﻨﺴﺎﺀ ﻤﻥ ﺍﻟﺭﺠﺎل ﻭﻜﺎﻥ‬١.٨ ‫ﻤﻌﻨﻭﻱ ﻓﻲ ﺍﻏﻠﺏ ﺍﻟﻘﻴﺎﺴﺎﺕ ﺒﻴﻥ ﺍﻟﺭﺠﺎل ﻭﺍﻟﻨﺴﺎﺀ ﻓﻁﻭل ﺍﻟﺸﻔﻪ ﺍﻟﻌﻠﻴﺎ ﻋﻨﺩ ﺍﻻﺴﺘﺭﺍﺤﺔ ﻜﺎﻥ‬
‫ ﻭﻜﺎﻨﺕ‬,‫ ﻜﺎﻨﺕ ﺍﻻﺒﺘﺴﺎﻤﺔ ﺍﻟﻤﻨﺨﻔﻀﺔ ﻫﻲ ﺍﻟﺴﺎﺌﺩﺓ ﺒﻴﻥ ﺍﻟﻨﺴﺎﺀ‬.‫ ﻤﻠﻡ ﺍﻁﻭل ﻋﻨﺩ ﺍﻟﺭﺠﺎل ﻤﻥ ﺍﻟﻨﺴﺎﺀ‬٠.٥٦ ‫ﻁﻭل ﺍﻟﻘﺎﻁﻊ ﺍﻟﻤﺭﻜﺯﻱ ﺤﻭﺍﻟﻲ‬
‫ ﺍﻟﻅﻬﻭﺭ ﺍﻟﺸﻔﻭﻱ ﻋﻨﺩ‬,‫ ﺍﻟﺸﻔﻪ ﺍﻟﻌﻠﻴﺎ‬,‫ ﺍﻟﻅﻬﻭﺭ ﺍﻟﻠﺜﻭﻱ‬. ‫ﺍﻻﺒﺘﺴﺎﻤﺔ ﺍﻟﻤﺘﻭﺴﻁﺔ ﺍﻜﺜﺭ ﺸﻴﻭﻋﺎ ﻋﻨﺩ ﺍﻟﺭﺠﺎل ﻤﻥ ﺍﻟﻨﺴﺎﺀ‬: ‫ﺍﻟﻜﻠﻤﺎﺕ ﺍﻟﻤﻔﺘﺎﺤﻴﺔ‬
.‫ﺍﻻﺒﺘﺴﺎﻤﻪ‬
Introduction
The smile is a voluntary facial expression indicating happiness, pleasure, and
greeting. Maxillary gingival exposure during smiling causes interest and concern
among many dental practitioners and plastic surgeons. An excessive gingival display
on smiling, referred to as “gummy smile,” “high lip line,” or “high smile line,” is
often esthetically displeasing and considered undesirable (Ricketts, 1968; Singer,
1974; Jnzen , 1977; Tjan & Miller, 1984; Mack, 1996; Garber & Salama, 2000;
Silberberg et al., 2009). According to Garber and Salama1, the essentials of the
esthetic smile involve the relationship between 3 primary components: teeth, lip
framework, and gingival scaffold. Several etiologic factors have been suggested in the
literature, including skeletal, gingival, and muscular factors that can contribute alone
or in combination to this feature (Garber & Salama, 1996; Silberberg et al., 2009;
Peck et al., 1992; McAlister et al., 1998; Hwang et al., 2009). Several treatment
modalities have been proposed in the literature to diminish the gingival display on
smiling. In patients with clinically short anterior tooth crowns, surgical crown
lengthening or gingivectomy is recommended (Garber & Salama, 1996; Silberberg et
al., 2009). In other patients, whose teeth crowns are proportionally balanced, but
muscular hyperactivity is suspected, injection of botulinum toxin-A to the lip elevator
muscles (Hwang et al., 2009; Polo, 2005; Polo 2008),or a lip repositioning procedure
(Litton & Fouriner, 1979; Miskinyar, 1983; Ezquerra et al., 1999; Rosenblatt &
Simon, 2006) is advocated.
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Journal of Babylon University/Pure and Applied Sciences/ No.(7)/ Vol.(22): 2014
In patients whose gingival display is excessive as a result of maxillary vertical
excess, orthognathic surgery has been suggested (Garber & Salama, 1996; Ezquerra et
al., 1999). Some soft-tissue surgical procedures, especially lip repositioning, lack
wide scientific evidence and long-term follow-ups as do some other surgical
procedures; they can lead to relapse and undesirable side effects such as scar
contraction. The purposes of this study were to evaluate and quantify upper lip softtissue changes in the vertical dimensions at both rest and maximum smile in a group
of sample with class I normal occlusion (Miron & Allon, 2012).
Material and Methods
The sample has been selected randomly from the students of Babylon university
(college of medicine, college of dentistry and college of nursing). Out of 50 persons
only 33 subjects were selected (18-23 years old). The sample was taken in terms of
the following criteria:1. The sample was all of Iraqi Arab in origin.
2. No participants had undergone any maxillofacial surgery or anterior maxillary
tooth prosthodontics rehabilitation.
3. No previous orthodontic treatment.
4. No extracted teeth up to the first molar.
The normal occlusion has been determined by the following criteria(Amasha,
2002; Uysal & Memili, 2005; Vitral et al., 2011; Scavone et al., 2008; Obaidi &
Manar , 2007):
a) Normal buccal segment relationship (class I molar relationship and class I canine
relationship).
b) Class I incisal relationship
c) Normal overjet and overbite(2-4mm)
d) Minor spacing or crowding .
e) No crossbite (anteriorly and posteriorly).
To reach the maximum social smile position, each subject was requested to
present his or her full smile a few times, and measurements were taken when the
subject successfully repeated the full smile pattern. In addition, the age and sex of
each subject were recorded. The measurements and the methods used to obtain these
variables are as follows.
1. Performed both at rest and maximum smiling:
a) external upper lip length, the vertical measurement from the alar base of the nose
(subnasale) to the inferior border of the upper lip (stomion superioris).
b) vermilion height, the vertical measurement from the superior border of the
vermilion at the Cupid’s bow to the inferior border of the upper lip.
c) maxillary central incisor display, the vertical measurement from the inferior border
of the upper lip to the incisal edge of the left central incisor.
2. Performed once in maximum smiling when applicable:
a) gingival display in maximum smiling, recorded in patients whose gingival display
was noticed in the maximum smile.
Two consecutive trials were made in each subject before recording the
measurement to verify the validity of the position. Measurement of hard-tissue
landmarks by estimation over soft-tissue landmarks is a common and acceptable
concept used in various measurements in medicine (e.g., the identification of nasion
and porion with a facebow).
b) Maxillary central incisor height, the vertical measurement of the clinical crown
height of the maxillary left central incisor.
The measurement was made under direct vision at the center of the tooth. Smile
pattern was classified according to the 3 categories defined by Tjan et al,(1984)
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Journal of Babylon University/Pure and Applied Sciences/ No.(7)/ Vol.(22): 2014
relating to the anterior maxillary tooth crown exposure at maximum smile: “low
smile” displaying less than 75% of the clinical crown height of the maxillary anterior
teeth, “average smile” revealing 75% to 100% of the maxillary anterior crown height,
and “high smile” exposing the whole anterior maxillary crown height and a band of
contiguous maxillary gingiva. Independent Student t tests were performed to assess
differences between the sexes.
Results
Means and standard deviations, derived for all measured variables of the
subjects, are reported with some statistical information in table I. Relaxed external
upper lip length was 1.8 mm shorter in the women than in the men (P<0.05).
The mean maxillary central incisor display at rest was 0.42 mm greater in the
women than in the men, it was not statistically significant. The upper vermilion
comprised 35% to 42% of the external upper lip length. Although it was not
statistically significant, the women tended to have a higher percentage of vermilion
display relative to the men, table I. Central incisor clinical crown height was 0.56 mm
shorter in the women compared with the men (P<0.05). The mean maxillary central
incisor display at smiling was more in men (7.36 mm) than in women (5.71 mm).
External upper lip length became shorter by about 23% at maximum smiling in both
genders, table I. High smiles, with exposure of the entire maxillary incisors and a
band of gingiva, were noticed in 12% of the study population and were more
prevalent in men (14%) than in women (11%). Average smiles, noticed in 27 % of the
subjects, were more common in men (33%) than in women (22%). Low smiles were
noticed in 61% of the subjects and were more than in women (67%) than men (53%).
Table II summarizes the smile patterns by genders.
Table I gender differences of study parameters.
Female
Mean
SD
18.81
1.54
0.82
1.59
0.42
0.06
9.10
0.64
14.51
2.14
5.71
2.36
0.78
0.14
Factors
Resting external upper lip length (mm)
Resting maxillary central incisor length (mm)
Resting vermilion/external upper lip length ratio
Maxillary incisor height (mm)
Smiling external upper lip length (mm)
Smiling maxillary central incisor display (mm)
Smiling/resting external upper lip length ratio
P< 0.05
male
Mean
SD
20.69
2.23
0.40
0.84
0.35
0.10
9.66
0.30
15.92
1.73
7.36
2.10
0.77
0.08
t test
-2.64
0.77
2.54
-2.58
-1.78
-1.84
0.01
Table II Smile pattern by gender.
Smile type
Low smile
Average smile
High smile
Total
Female (%)
12 (67%)
4 (22%)
2 (11%)
18 (100%)
Male (%)
8 (53%)
5 (33%)
2 (14%)
15 (100%)
Total (%)
20 (61%)
9 (27%)
4 (12%)
33 (100%)
Discussion
Gingival and tooth exposure during smiling are challenging issues to many
physicians, especially those who deal with smile esthetics. Overexposure of teeth and
gingival tissues is considered by many to be unattractive and usually requires
intervention.(Garber & Salama, 2000; Ricketts, 1968; Singer, 1974; Jnzen 1977Mack,
1996; Silberberg et al., 2009; Rosenblatt &Simon, 2006; Ezquerra et al. 1999; Miron
& Allon, 2012; Landsberg, 2006). Data from this study, similar to other studies,
clearly indicate sexual dimorphism in lip and tooth measurements. These differences
1985
Journal of Babylon University/Pure and Applied Sciences/ No.(7)/ Vol.(22): 2014
are reflections of simple biologic scaling: male subjects are uniformly larger than
equivalent female subjects.
The upper lip at rest was 1.8 mm shorter in the women than in the men (P<0.05),
this comes in agreement with Peck et al,1992 who recorded vertical measurements in
young orthodontic patients (mean age, 15 years), observed that the difference in upper
lip length between the sexes was only 2.2 mm. No difference was observed in
maxillary incisor exposures at rest between the genders this finding came in
disagreement with Miron et al (2012). and this results may be due to sample age and
sample type as in this study the sample was class I normal occlusion while another
study was without classification or malocclusion. The clinical central incisor crown
was 0.5 mm shorter in the women than in the men, slightly less than the difference
observed by Peck et al. (1992). Upper lip vermilion height, defined elsewhere as
upper lip thickness, comprised 42% of the whole upper lip length in women and 35%
in men25. This observation was somewhat similar to other studies.(Desai et al., 2009;
Perenack, 2005). The mean maxillary central incisor display at smiling was different
in both genders and this comes in partially agreement with Peck et al.(1992) and don't
agree with Miron et al (2012), and this may be due to sample age and its orthodontic
classification. The upper lip length was 23% shorter in maximum smiling relative to
the resting position in both genders this comes agreement with Peck et al. (1992) and
Miron et al (2012). Our findings suggest that a low smile pattern can be considered a
female norm(67%), since more than half of the women in this study don't exposed
their gums while smiling, and a low smile pattern can be considered a male norm
(53%). Similar results and female/male ratios were observed by others in slightly
younger population groups. (Tjan et al., 1984; Polo, 2008; Peck et al., 1992).
Although other authors have found a 2:1 ratio of gingival exposure between
female and male subjects, we found of 1 women to 1 man in exposure of gingivae
when smiling.( Tjan et al., 1984; Polo, 2008; Peck et al., 1992) In our opinion, this
might be attributed to the difference between the study groups because of mean age or
ethnic-related features, also this study based on class I malocclusion as the subjects
with different dental arch classes can effects on the position and relation of the lips in
rest and during smile.(Proffit & Fields, 2000). Table III compares smile patterns by
sex between this study and previous studies.
Table III Comparison of smile patterns with other studies
Study
Tjan et al.,1984
Rigsbee et al.,1988
Peck et al.,1992
Current study
Female
High
Low
34 (14%) 31 (12%)
32 (70%) —
25 (54%) 7 (15%)
2 (11%) 12 (67%)
Male
High
Low
14 (7%) 62 (30%)
21 (38%) —
11 (26%) 14 (33%)
2 (14%) 8 (53%)
Conclusions
Data from this study clearly indicate sexual dimorphisms in upper lip length,
maxillary incisor display, and resting external upper lip length. Low smile patterns are
more common among female patients, and also common among male patients while
high smile are less common among female and male patients. The average smile is
more prevalent in male than female.
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Journal of Babylon University/Pure and Applied Sciences/ No.(7)/ Vol.(22): 2014
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