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Gingival smile enhancement for the edentulous patient by using a LeFort I osteotomy
MASSAD, B/tANNIN, AND GOLJAN
Fig. 2. Preoperative close-up view shows excess gingival smile and poor circumoral dental relationships.
Fig. 3. Preoperative, strained appearance in lower face and depressed supramental area with thickened lower lip.
dictable surgical approach to correcting skeletal malrelationships requiring mobilization and repositioning of the inferior maxillary facial skeleton.I Such an approach is a reasonable solution to a poor gingival smile due to maxillary excess that is not correctable by simple procedures.
REVIEW OF THE L I T E R A T U R E A review of the literature covering the past 24 years revesled no published reports citing use of the LeFort I ost,eotomy to correct a nonesthetic gingival smile in the edentulous patient.
TREATMENT PLANNING A 39-year-old-woman had been wearing a maxillary dencure, opposing natural mandibular dentition, since she was 2a years of age. Vertical excess of the inferior third of the
= -/
Fig. 4. Preoperative, significant genial deficiency.
Fig. 5. Papillameter instrument must be placed in contact with median alveolar crest and measurements read with eye perpendicular to calibration scale, while lip is at rest.
maxillae was especially evident when she smiled (Figs. 1 through 8). She also had a significant genial deficiency (Fig. 4). The patient was conscious of her poor gingival smile and deficient chin. She worked as a receptionist and felt that these facial features detracted from her effectiveness. The vertical distance between the median alveolar crest and upper lip line was measured with a Papillameter instrument (Swissedent Corp., San Jose, Calif.) (Fig. 5) and found to be 4 ram. Lip and facial tone both at rest and during animation were within normal limits. Diagnostic casts, frontal and lateral photographs, and a lateral eephalometric radiograph were prepared. Cephalometric soft tissue profile tracings demonstrated the extent of genial hypoplasia (Fig. 6).
AC,'GCS" 2 a 9 2
VOk.Cdv/~£ 6 ~
NU.'vJ£BER :!
LEFORT I OSTEOTOMY FOR SMILE ENHANCEMENT
.
.
.
.
.
.
.
:::: .
.
.
.
.
.
.
.
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Fig. 8. Postoperative close-up shows natural smile line and markedly improved circumoral dental relationships. Fig. 6. Cephalometric soft tissue profile tracings: Left, preoperative, strained lips and coarse profile and right, postoperative, fine definition of lips and enhanced lower face.
Fig. 9. Postoperative, unstrained appearance in lower face and elevated and improved supramental area.
Fig. 7. Postoperative, natural smile line and more relaxed and softer appearance of lower face:
Prosthetic requirements indicated that the maxillae should be intruded 4.5 mm, for a total projected postsurgical Papillameter instrument reading of 8.5 ram. Genial hypoplasia could be corrected with a combination of a 5 mm horizontal chin augmentation implant and autorotation of the mandible resulting from intrusion of the maxillae. The treatment plan was explained to the patient. Because consent to an alteration of facial features represents a major decision for any patient, she was made to understand proposed changes in detail, as well as procedure limitations and potential complications, in a realistic manner.
T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
After seeking a second opinion, the patient consented to the procedures.
SURGERY A new treatment denture was constructed to accommodate anticipated surgical changes, such as reduced vestibular space and mandibular autorotation. The denture was made in a standard manner, including 1 mm peripheral holes in the zygomatic buttress and anterior nasal spines. These holes would be used for wiring the denture to the maxillae, for use of the denture as a postsurgical stent. The patient was hospitalized and a standard LeFort I osteotomy was performed. The lateral maxillary wall was approached by means of a high mucobuccal fold incision from one zygomatic buttress to the other and tunneling
153
MASSAD, BRANNIN, AND GOLJAN
blood vessels was protected. The maxillae were repositioned, with a Papillameter instrument used to verify proper extent of intrusion.Four rigid fixationplates were placed across the osteotomy sites.The maxillae were further stabilizedby wiring of the treatment denture to zygomatic buttresses bilaterallyand to the piriform rim. The chin was horizontally augmented with an alloplasticimplant (Proplast II, Viteck Co., Houston, Tex.) through an incision between the lower lip and alveolar process. The implant was attached to the symphysis with stainlesssteel ligatures. The patient was discharged on the second postsurgical day. She was limited to blender-prepared food for 2 weeks and then softfoods.The wired denture-stent was removed 1 month after the operation.
RESULTS Fig, :10i: Postoperative, significant genial enhancement and natural soft flow to lips and lower face.
A new denture was not made until 3 months after surgery, to ensure vertical stability of the osteotomized segment. The esthetic denture base was successful because of the increased vertical distance between the median alveolar crest and upper lip. The patient was extremely pleased with her general facial profile (Figs. 7 through 10).
REFERENCE 1. Belt WH, Proffit WR, White RP. Surgical correction of dentofacial deforrnaties, vol 1. Philadelphia: WB Saunders Company, 1980:281-95.
m~was fractured d o ~ w ~ d and made freelymobile while: its majo~ b i ~ supply from the greater palatine
Reprint requests to: DR. JOSEPH J. MASSAD 2047 W. EDISON TULSA, OK 74127
Bound v o l u m e s a v a i l a b l e to subscribers Bound volumes of THE JOURNAL OF PROSTHETICDENTISTRYare available to subscribers (only) for the 1991 issues from the publisher at a cost of $50.00 ($63.00 international) for Vol. 65 (January-June) and Vol. 66 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 63 and 64 are also available. Payment must accompany all ordera. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800) 325-4177, ext. 4351. Subscriptions must be in force to qualify. Bound v o l u m e s a r e not a v a i l a b l e in p l a c e of a regular JOURNAL subscription.
Fig. 2. Preoperative close-up view shows excess gingival smile and poor circumoral dental relationships.
Fig. 3. Preoperative, strained appearance in lower face and depressed supramental area with thickened lower lip.
dictable surgical approach to correcting skeletal malrelationships requiring mobilization and repositioning of the inferior maxillary facial skeleton.I Such an approach is a reasonable solution to a poor gingival smile due to maxillary excess that is not correctable by simple procedures.
REVIEW OF THE L I T E R A T U R E A review of the literature covering the past 24 years revesled no published reports citing use of the LeFort I ost,eotomy to correct a nonesthetic gingival smile in the edentulous patient.
TREATMENT PLANNING A 39-year-old-woman had been wearing a maxillary dencure, opposing natural mandibular dentition, since she was 2a years of age. Vertical excess of the inferior third of the
= -/
Fig. 4. Preoperative, significant genial deficiency.
Fig. 5. Papillameter instrument must be placed in contact with median alveolar crest and measurements read with eye perpendicular to calibration scale, while lip is at rest.
maxillae was especially evident when she smiled (Figs. 1 through 8). She also had a significant genial deficiency (Fig. 4). The patient was conscious of her poor gingival smile and deficient chin. She worked as a receptionist and felt that these facial features detracted from her effectiveness. The vertical distance between the median alveolar crest and upper lip line was measured with a Papillameter instrument (Swissedent Corp., San Jose, Calif.) (Fig. 5) and found to be 4 ram. Lip and facial tone both at rest and during animation were within normal limits. Diagnostic casts, frontal and lateral photographs, and a lateral eephalometric radiograph were prepared. Cephalometric soft tissue profile tracings demonstrated the extent of genial hypoplasia (Fig. 6).
AC,'GCS" 2 a 9 2
VOk.Cdv/~£ 6 ~
NU.'vJ£BER :!
LEFORT I OSTEOTOMY FOR SMILE ENHANCEMENT
.
.
.
.
.
.
.
:::: .
.
.
.
.
.
.
.
.,:~
Fig. 8. Postoperative close-up shows natural smile line and markedly improved circumoral dental relationships. Fig. 6. Cephalometric soft tissue profile tracings: Left, preoperative, strained lips and coarse profile and right, postoperative, fine definition of lips and enhanced lower face.
Fig. 9. Postoperative, unstrained appearance in lower face and elevated and improved supramental area.
Fig. 7. Postoperative, natural smile line and more relaxed and softer appearance of lower face:
Prosthetic requirements indicated that the maxillae should be intruded 4.5 mm, for a total projected postsurgical Papillameter instrument reading of 8.5 ram. Genial hypoplasia could be corrected with a combination of a 5 mm horizontal chin augmentation implant and autorotation of the mandible resulting from intrusion of the maxillae. The treatment plan was explained to the patient. Because consent to an alteration of facial features represents a major decision for any patient, she was made to understand proposed changes in detail, as well as procedure limitations and potential complications, in a realistic manner.
T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
After seeking a second opinion, the patient consented to the procedures.
SURGERY A new treatment denture was constructed to accommodate anticipated surgical changes, such as reduced vestibular space and mandibular autorotation. The denture was made in a standard manner, including 1 mm peripheral holes in the zygomatic buttress and anterior nasal spines. These holes would be used for wiring the denture to the maxillae, for use of the denture as a postsurgical stent. The patient was hospitalized and a standard LeFort I osteotomy was performed. The lateral maxillary wall was approached by means of a high mucobuccal fold incision from one zygomatic buttress to the other and tunneling
153
MASSAD, BRANNIN, AND GOLJAN
blood vessels was protected. The maxillae were repositioned, with a Papillameter instrument used to verify proper extent of intrusion.Four rigid fixationplates were placed across the osteotomy sites.The maxillae were further stabilizedby wiring of the treatment denture to zygomatic buttresses bilaterallyand to the piriform rim. The chin was horizontally augmented with an alloplasticimplant (Proplast II, Viteck Co., Houston, Tex.) through an incision between the lower lip and alveolar process. The implant was attached to the symphysis with stainlesssteel ligatures. The patient was discharged on the second postsurgical day. She was limited to blender-prepared food for 2 weeks and then softfoods.The wired denture-stent was removed 1 month after the operation.
RESULTS Fig, :10i: Postoperative, significant genial enhancement and natural soft flow to lips and lower face.
A new denture was not made until 3 months after surgery, to ensure vertical stability of the osteotomized segment. The esthetic denture base was successful because of the increased vertical distance between the median alveolar crest and upper lip. The patient was extremely pleased with her general facial profile (Figs. 7 through 10).
REFERENCE 1. Belt WH, Proffit WR, White RP. Surgical correction of dentofacial deforrnaties, vol 1. Philadelphia: WB Saunders Company, 1980:281-95.
m~was fractured d o ~ w ~ d and made freelymobile while: its majo~ b i ~ supply from the greater palatine
Reprint requests to: DR. JOSEPH J. MASSAD 2047 W. EDISON TULSA, OK 74127
Bound v o l u m e s a v a i l a b l e to subscribers Bound volumes of THE JOURNAL OF PROSTHETICDENTISTRYare available to subscribers (only) for the 1991 issues from the publisher at a cost of $50.00 ($63.00 international) for Vol. 65 (January-June) and Vol. 66 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 63 and 64 are also available. Payment must accompany all ordera. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800) 325-4177, ext. 4351. Subscriptions must be in force to qualify. Bound v o l u m e s a r e not a v a i l a b l e in p l a c e of a regular JOURNAL subscription.