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Journal of Oral Rehabilitation 2006 33 ; 102–109

Influence of lip support on the soft-tissue profile of complete denture wearers

Y. KAMASHITA*, Y. KAMADA* N. KAWAHATA & E. NAGAOKA * Department of Oral and

Maxillofacial Prosthodontics, Field of Oral and Maxillofacial Rehabilitation, Course for Advanced Therapeutics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan, Dentist in private practice, Tenri, Japan and Department of Oral and Maxillofacial Prosthodontics, Field of Oral and Maxillofacial Rehabilitation, Course for Advanced Therapeutics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan

SUMMARY Complete dentures change the soft-tissue profile, although the exact relationship remains unclear. This study examined the relationship between the presence and degree of lip support provided by dentures and the lateral views of the facial appearance of edentulous patients. The sub- jects were five edentulous patients (three men and two women). Their facial appearances with experimental record blocks, with and without their complete dentures, were measured using a three- dimensional laser measuring system. The experimen- tal record block for each subject had different conditions in the anteroposterior direction anteriorly but the same vertical dimensions posteriorly. The lateral digital facial images were displayed on a computer monitor, and the linear and angular

measurements were analysed using image analysis software. The nasolabial angle was smaller and the labial points projected more with excessive lip sup- port versus with deficient support. Moreover, the counter of the nose was affected by the labial flange of the record base, particularly in the facial appearance of one subject with highly atrophic residual ridges. The lip support affected the lower facial soft-tissue profile, including the lower part of the nose; the nasolabial angle and positional relationship between the lips and Ricketts’s esthetic plane (E plane) are useful indexes for examining lip support. KEYWORDS : facial appearance, lip support, complete denture, profile, esthetic plane

Accepted for publication 10 September 2005

Introduction

The lower one-third of the face has a major impact on facial appearance (1, 2). The facial appearance of an edentulous person changes with the loss of lip support and intercuspal position following tooth extractions, but can be restored by complete dentures (3, 4), which provide lip support and an occlusal vertical dimension. For denture wearers to retain a natural appearance, it is important to provide adequate lip support and an appropriate occlusal vertical dimension. Several previous studies have reported on the facial appearance of edentulous patients. These studies com- pared dentate and edentate subjects (5, 6), the differ- ence between with and without dentures (7), the

ª 2006 Blackwell Publishing Ltd

temporal changes over the period of wearing dentures (8, 9), or the differences among old, reconstructed and new dentures (10). Using photographs (7), lateral radiograms (5, 6, 8, 9), traced 35-mm slide projections (10) and digital camera images (11), these previous studies demonstrated that soft-tissue profile analysis is useful for researching the facial appearance of denture patients and is convenient for daily prosthodontic treatment. The soft-tissue profile is affected by the lip support, which is altered by the anterior artificial dental arch and denture flange (12), but the exact relationship between the facial profile and this altered lip support remains unclear. Therefore, we evaluated the influ- ence of the presence and degree of lip support by

102

INFLUENCE OF LIP SUPPOR T O N E D E N T A T E P R O F I L E

dentures on the lateral views of the faces of edentu- lous patients.

Material and methods

Subjects

The subjects were five edentulous Japanese volunteers (three men and two women) who were treated with upper and lower complete dentures at Kagoshima University Dental Hospital. The study was explained and informed consent was obtained. No subjects had any abnormal morphological or functional findings. The subjects had a mean age of 65 Æ8 years (range 54–

78).

Non-contact type

three dimensional

measuring system

(Voxelan)

Image processing

system

(3D-Sphinx)

Analyzing system

3D Measurement 3D Facial image Correcting head posture Lateral view Calculating angular and linear items
3D Measurement
3D Facial image
Correcting
head posture
Lateral view
Calculating angular
and linear items

Fig. 2. Schematic of the diagnostic system.

Conditions of lip support

lip support): incisal edge of occlusion rim (IEOR) 10 mm in front of the center of the incisive papilla (13), (2) R(+5) (excessive lip support): IEOR 5 mm anterior to R(0), (3) R()5) (deficient lip support): IEOR 5 mm posterior to R(0), (4) R( ))B(+) (lip supported by the record base only): without the occlusion rim but with the record base anteriorly, and (5) R( ))B( )) (no lip support): without both the occlusion rim and the record base anteriorly.

Measurement system

To evaluate the effect of wearing complete dentures on the lip support, the soft-tissue profile with and without dentures was investigated. The facial appearances of the subjects were measured in the intercuspal position with their dentures [D(+)] and in the rest position without them [D( ))]. Their dentures were fabricated by experi- enced dentists following standard procedures. Various states of lip support restored by wearing dentures were simulated using experimental record blocks. The experimental record block (Fig. 1), which consists of a cold-cured resin record base and an acrylic occlusion rim, could be divided into a removable anterior part and a fixed posterior part. The posterior part of the occlusion rim was kept constant under the maxillo–mandibular relationship, determined while wearing dentures. The anterior part could be adjusted to give five conditions of lip support: (1) R(0) (standard

a b c
a
b
c

In this study, the facial appearances of the subjects were measured using the three-dimensional (3D) laser meas- uring system (Fig. 2) reported by Nishi et al. (14), because this system improves the accuracy of the analysis by correcting head posture in three dimen- sions. Adjusted lateral views of each subject were obtained after fitting the facial images in three dimen- sions. Three-dimensional facial images obtained using a 3D d laser measuring apparatus* with an accuracy of 0 Æ 5 mm

were reconstructed using an imaging system . When the head posture for the measurement was incorrect,

the 3D image was rotated so that the sagittal plane was

vertical on the frontal view and the Frankfort plane was

e horizontal on the lateral view. The images of each subject were matched in three dimensions by aligning the upper face, which was not affected by the dentures.

Fig. 1. Schematic of the experimental record blocks. (a) R( )5), (b) R(0), (c) R(+5), (d) R( ))B(+), (e) R( ))B( )).

*Voxelan; NKExa, Japan 3D-Sphinx; Medic Engineering, Japan

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33 ; 102–109

103

104 Y. KAMASHITA et al.

The 3D images were projected on the sagittal plane. In the lateral view of the facial image displayed on a computer monitor, the 2D coordinate data of landmarks were obtained by clicking the mouse button using image-processing software . The linear and angular measurements were calculated using the original ana- lysis software.

Landmarks and measured items

The landmarks (Fig. 3) and measured items (Fig. 4) on the lateral view in this study were the same as those in our previous study (11, 15). These items were deter- mined to evaluate lip support and the occlusal vertical dimension in prosthodontic treatment. The definitions of the landmarks followed Martin et al. (16). We used four additional points: cms, cmi, lss and lsi (Figure 3 and Table 1). The data consisted of four angular measurements and 11 linear measurements. Each item is named by hyphenating the symbols of the corres- ponding landmarks. Ricketts’s aesthetic plane (E plane; 17) and the Izard plane (I plane; 18) were used as reference planes for the horizontal linear measurements. When the landmarks were posterior to the reference planes, the measured values were negative. The I plane is the vertical plane through the glabella. A change in these measurements reveals a shift of the respective landmark in the anteroposterior direction.

1. g 2. prn 1 3. cms 4. cmi 15 5. sn 6. lss 7.
1.
g
2.
prn
1
3.
cms
4.
cmi
15
5.
sn
6.
lss
7.
lsi
8.
ls
2 9.
lst
3
5 10.
sto
4
6 11.
lit
7 8 9
12.
li
10
16
13.
labm
11
12
14.
pg
13 ex
15.
14 ch
16.

Fig. 3. Reference points in the lateral view.

Angular measurement 1
Angular measurement
1

Linear measurement

2 3
2
3

4

13 5 7 6 8 9 10 14 11 12 Esthetic plane Izard plane (E
13
5 7
6 8
9
10
14
11
12
Esthetic plane
Izard plane
(E plane)
(I plane)

Symbols of measurements

1. Nasolabial angle

2. ls-ch-sto

3. li-ch-sto

4. ls-ch-li

5. lst - E

6. lit - E

7. prn - I

8. sn - I

9. lst - I

10. lit - I

11. labm - I

12. pg - I

13. ex - ch

14. sn - pg

15. sn-pg / ex-ch

Fig. 4. Items measured in the lateral view.

The vertical linear measurements, upper facial height (ex-ch), lower facial height (sn-pg) and their ratio (sn-pg/ex-ch), were used to evaluate the vertical dimension of occlusion.

Statistical analysis

The paired t -test was used to evaluate the differences between the mean values of measurements with and without dentures. One-way repeated measures analysis of variance (ANOVA ) and Tukey–Kramer multiple com- parison tests were used to evaluate the data on the facial appearances of subjects wearing the experimental

record block under different conditions. The signifi-

cance level for all statistical comparisons was set at

P < 0 Æ05.

Results

Effect of wearing complete dentures

Table 2 shows the mean values and standard deviations

of the measurements and the results of the statistical

analysis of the facial profiles with [D(+)] and without [D( ))]dentures.

The mean nasolabial angle for D(+) (102 Æ5 ) was significantly smaller than that for D()) (120 Æ2 ; paired t -test, P ¼ 0Æ034). The mean value of ls-ch-li for D(+) (39 Æ4 ) was significantly larger than that for D()) (26 Æ7 ). The mean value of lst-E for D(+) ()3Æ 0 mm) was significantly different from that for D())

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 102–109

Table 1. Definitions of the reference points

INFLUENCE OF LIP SUPPOR T O N E D E N T A T E P R O F I L E

105

Reference points

Definition

g

(glabella)

The anterior-most point of the forehead The anterior-most point of the nose The upper end of the linear part of the columella The lower end of the linear part of the columella The turning point between the columella and the upper lip

prn (pronasale)

cms

cmi

sn (subnasale)

lss

The superior point of the straight line under the nose

lsi

The inferior point of the straight line under the nose

ls (labrale superior)

The superior-most point of the upper vermillion

lst

The anterior-most point of the upper vermillion

sto (stomion)

The meeting point of the upper and lower vermilions

lit

The anterior-most point of the lower vermilion

li

(labrale inferius)

The inferior-most point of the lower vermillion

labm (labiomentale)

The deepest point of the concavity of the lower lip

pg (pogonion)

The anterior point on the symphisis of the chin

ex (ectocanthion)

The posterior-most point of the eye

ch (cheilion)

The commissure of the mouth

Table 2. Mean and standard deviations of each measurement with and without dentures and the results of the paired t-test

 

D(+)

 

D())

Paired t-test

Mean

s.d.

Mean

s.d.

P -value

Nasolabial angle ( ) ls-ch-sto ( ) li-ch-sto( ) ls-ch-li ( ) lst-E (mm) lit-E (mm) prn-I (mm) sn-I (mm) lst-I (mm) lit-I (mm) labm-I (mm) pg-I (mm) ex-ch (mm) sn-pg (mm) sn-pg/ex-ch

102 Æ5

6

Æ82

120Æ

2

12Æ67

0Æ

034*

18Æ8

4

Æ87

10Æ

8

6

Æ29

0Æ

055

20Æ6

5

Æ91

15Æ

8

5

Æ09

0Æ

083

39Æ4

5

Æ62

26Æ

7

9

Æ88

0Æ

034*

)3

Æ0

1

Æ99

)10Æ

7

5

Æ55

0Æ

027*

)1

Æ4

1

Æ83

)8Æ

7

6

Æ48

0Æ

077

14Æ7

3

Æ46

13Æ

2

2

Æ90

0Æ

096

0

Æ6

2

Æ31

)4Æ

1

3

Æ69

0Æ

048*

2

Æ3

2

Æ85

)7Æ

2

6

Æ04

0Æ

034*

0

Æ2

3

Æ23

)7Æ

8

5

Æ98

0Æ

065

)5

Æ5

3

Æ17

)10Æ

9

4

Æ79

0Æ

090

)4

Æ5

4

Æ18

)7Æ

2

4

Æ35

0Æ

173

65Æ9

1

Æ20

66Æ

9

2

Æ61

0Æ

207

48Æ5

4

Æ04

47Æ

9

5

Æ55

0Æ

706

0 Æ74

0

Æ06

0Æ

72

0

Æ09

0Æ

587

*Significant difference (P < 0Æ 05)

()10Æ 7 mm). The mean values of sn-I and lst-I for D(+) (0Æ6 and 2Æ3 mm respectively) differed significantly from those for D( )) ()4Æ1 and )7Æ 2 mm respectively).

Influence of the experimental record blocks

The results for the facial profiles with the experimental record blocks are shown in Table 3. The more protru- sive the occlusion rims were, the larger were the horizontal linear measurements and the smaller were

the nasolabial angles. Repeated measures ANOVA for the nasolabial angle and horizontal linear measurements revealed significant differences among the experimen- tal conditions, except for prn-I and pg-I. R(+5) had a significantly smaller nasolabial angle (96Æ 0 ) than did R( )5), R( ))B(+) and R())B( )) (114Æ 4, 114Æ 8 and 119Æ 6 respectively). The mean value of lst-E for R(0) ()3Æ 8 mm) was significantly smaller than that for R(+5) ()0Æ 9 mm) and was significantly larger than those for R())B(+) ()9Æ 7 mm) and R( ))B( )) ()9Æ 9 mm). There was a significant difference in lit-E between R(+5) and R()5) (2Æ 0 and )2Æ9 mm respect- ively). The values for R(+5), R(0) and R()5) differed significantly from those for R())B(+) ()7Æ 2 mm) and R())B( )) ( )6Æ6 mm). Concerning sn-I, there was a significant difference only between R(+5) (1Æ 6 mm) and R( ))B( )) ()2Æ 2 mm). The mean values of lst-I and lit-I for R(+5) differed significantly from those for the other conditions. R( ))B(+) and R( ))B( )) were significantly smaller than the other conditions. The mean value of labm-I for R(+5) ()2Æ 5 mm) differed significantly from those for R() )B(+) and R( ))B()) ()7Æ3 and )6Æ 9 mm respectively), but did not differ from those for R(0) and R()5) ( )5Æ1 and )4 Æ8 mm). The vertical linear meas- urements were similar to each other, and there were no significant differences among the experimental condi- tions. The measurements of items for R(0) were similar to the respective items for D(+). All the horizontal meas- urements for R( ))B()) were smaller than those for

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33 ; 102–109

106

Y. KAMASHITA et al.

Table 3. Mean and standard deviations of the measurements and the results of repeated measures ANOVA

 

R() )B())

R())B(+)

R( )5)

R(0)

R(+5)

ANOVA P -value

Nasolabial angle ( ) ls-ch-sto ( ) li-ch-sto ( ) ls-ch-li ( ) lst-E (mm) lit-E (mm) prn-I (mm) sn-I (mm) lst-I (mm) lit-I (mm) labm-I (mm) pg-I (mm) ex-ch (mm) sn-pg (mm) sn-pg/ex-ch

119Æ 6 (14. 30) a 13Æ 8 (5Æ 59) 17Æ 8 (12Æ 62) 31Æ 7 (16Æ 49) )9Æ 9 (1Æ 87) a )6Æ 6 (2Æ 88) a 14Æ 2 (2Æ 79) )2Æ 2 (1Æ 70) a )4Æ 6 (1Æ 69) a )4Æ 2 (1Æ 54) a )6Æ 9 (2Æ 23) a )4Æ 2 (3Æ 49) 67Æ 4 (3Æ 43) 46Æ 8 (6Æ 40) 0 Æ70 (0Æ 11)

114Æ 8 (8Æ 56) a 14Æ 5 (3Æ 91) 16Æ 9 (8Æ 57) 31Æ 3 (8Æ 71) )9Æ 7 (2Æ 64) a )7Æ 2 (2Æ 64) a 14Æ 2 (3Æ 48) )1Æ 7 (2Æ 63) a,b )4Æ 5 (2Æ 67) a )4Æ 6 (2Æ 34) a )7Æ 3 (2Æ 88) a )4Æ 1 (4Æ 45) 66Æ 4 (0Æ 95) 47Æ 3 (6Æ 25) 0 Æ71 (0Æ 10)

114 Æ4 (7Æ 85) a 13Æ7 (2Æ 30) 18Æ0 (4Æ 33) 31Æ7 (4Æ 19) )5 Æ7 (1Æ 13) b )2 Æ9 (1Æ 22) b 14Æ6 (3Æ 24) 0 Æ2 (1Æ 91) a,b )0 Æ1 (2Æ 59) b )0 Æ6 (2Æ 63) b )4 Æ8 (3Æ 26) a,b )3 Æ3 (4Æ 31) 66Æ0 (1Æ 20) 46Æ2 (5Æ 57) 0Æ 70 (0Æ 09)

107Æ 1 (8 Æ39) a,b 16Æ 4 (2 Æ44) 19Æ 3 (7 Æ59) 35Æ 8 (7 Æ40) )3Æ 8 (1 Æ83) b )0Æ 7 (1 Æ33) b,c 14Æ 3 (3 Æ14) 0Æ 3 (2 Æ12) a,b 1Æ 7 (2 Æ38) b 0Æ 7 (2 Æ63) b )5Æ 1 (2 Æ76) a,b )4Æ 1 (2 Æ94)

96Æ 0 (7Æ 02) b 15Æ 6 (5Æ 40) 25Æ 1 (3Æ 69) 40Æ 8 (5Æ 21) )0Æ 9 (1Æ 58) c 2Æ 0 (1Æ 98) c 14Æ 9 (3Æ 29) 1Æ 6 (2Æ 95) b 6Æ 0 (3Æ 12) c 5Æ 2 (4Æ 12) c )2Æ 5 (3Æ 87) b )1Æ 9 (4Æ 61) 66Æ 9 (2Æ 94) 47Æ 4 (3Æ 83) 0 Æ71 (0Æ 07)

0Æ 004 *

0Æ

720

0Æ

144

0Æ

277

<0Æ

001*

<0Æ

001*

0Æ

284

0Æ

031*

<0Æ

001*

<0Æ

001*

0Æ

002*

0Æ

128

67Æ

2(1Æ 36)

0Æ

531

47Æ 5 (4 Æ97)

0Æ

680

0 Æ71 (0 Æ07)

0Æ

754

* Significant difference ( P < 0Æ 05), mean values with the same superscript letters did not differ significantly (P > 0 Æ05) in the post hoc test. Values are expressed as mean (s.d.).

D()). The angular measurements of the vermilions for R())B( )) were larger than those for D()), while the nasolabial angles were similar.

Profilogram of one subject with a highly atrophic residual ridge

A profilogram was made to examine the change in the profile of one subject whose jaws, particularly the upper jaw, had a highly atrophic residual ridge (Fig. 5). A profilogram is a figure (g-n-prn-sn-ls-sto-li-labm-pg) that connects the eight landmarks (g, prn, sn, ls, sto, li, labm and pg) and the nasion (n) with a line. The coordinate data for the nasion, which was used as the origin for the profilogram, were obtained in the same way as for the other landmarks. The nasion is sometimes hidden by the eyelid on the lateral view in Japanese. In such cases, we obtained the 2D coordinate data on the mid-sagittal cross-section from 3D coordinate data. The seven figures made under the different experimental conditions were superimposed using the nasion. All landmarks, except the glabella, shifted antero- posteriorly and inferosuperiorly according to the lip support condition: D()) was the most posterior and R(+5) was the most anterior. The profilograms for D(+), R()5) and R(0) were similar. The profilograms for R())B( )) and R( ))B(+) were very similar, but sn for R())B(+) was anterosuperior to R())B( )). The posi- tions of ls, sto, li and labm for D( )) were posterior to R())B( )) and R( ))B(+). The positions of prn for D(+),

g n (mm) prn sn ls sto li labm pg
g
n
(mm)
prn
sn
ls
sto
li
labm
pg
of prn for D(+), g n (mm) prn sn ls sto li labm pg Fig. 5.

Fig. 5. The profilograms of one patient with the experimental record blocks, with and without dentures. The nasion was used as the origin and each line connects eight landmarks (g-n-prn-sn-ls- sto-li-labm-pg).

R( )5), R(0), R(+5) and R())B(+) were similar, while the position for D()) was posterior and that for R( ))B( )) was intermediate.

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 102–109

INFLUENCE OF LIP SUPPOR T O N E D E N T A T E P R O F I L E

Discussion

Three-dimensional approaches, such as volume analysis or surface data observations using cross sectional views in any plane, are important, and in another study we are investigating 3D facial analysis of denture wearers. However, the 3D apparatus is too expensive for use in a general practitioner’s clinic. In this study, we focused on profile analysis because soft-tissue profile analysis is very useful and convenient for assessing the facial appearance of complete denture patients before and after treatment. We used a 3D measurement system in this study to allow correction of head posture in three dimensions in order to ensure that facial images with different experimental dentures coincided. We have reported a facial analysis system that uses a digital camera and the same measurement items used in this study (11, 15, 19). In one of our reports (19), we compared young–adult (ages 23–29) and young–old (ages 51–78) Japanese dentate subjects. The mean values of the young–old group were used to discuss the results in this study.

Portion affected by the lip support conditions

The major differences in the linear measurements concerning the vermilions (lst-I, lit-I, lst-E and lit-E) and nasolabial angle between those subjects with and without dentures and between the different conditions of the experimental record blocks indicate the change in the upper and lower lip contours. The significant differences in sn-I and labm-I for the different experi- mental conditions mean that the degree of lip support changes not only the lip contour but also the form of the nasal base and labiomental sulcus. These results are in agreement with Fanibunda et al . (7), who reported a forward shift of the upper and lower lips following the insertion of complete dentures and the dominant effect of maxillary dentures. The profilogram for the subject with marked bone resorption reached the anterior nasal spine (Fig. 5), indicating that the lip support altered the form of the lower half of the nose, including its tip. These results mean that a denture can change the form of the nose.

Measurement items affected by denture conditions

Nasolabial angle The nasolabial angle is a common parameter for evaluating the facial profiles of complete

denture wearers. Watt and MacGregor (13) stated that the nasolabial angle for adequate lip support is approxi- mately 90 in fabricating complete dentures. Brunton and McCord (5) have reported that the nasolabial angle of Caucasian dentate subjects is approximately 110 and that edentulous patient should be given an obtuse nasolabial angle exceeding 90 as a prosthodontic guideline. Owen et al . (20) reported racial differences for the nasolabial angle in the facial appearances of dentate subjects, ranging in age from 18 to 41 years (mean age 26Æ5), from six racial groups, including Japanese. Japanese had a smaller nasolabial angle (97Æ 1 ) than did Caucasians (109 Æ5 ) and Hispanics (105 Æ1 ), but a larger angle than did Koreans (92Æ 9 ), Chinese (92 Æ5 ) and African Americans (90Æ 0 ). The mean nasolabial angle for D(+) (102Æ 5 ), which was significantly smaller than that for D()) (120 Æ 2 ), was similar to that reported by Owen et al. (20) for young–adult groups (97Æ 1 ) and by Kamashita et al . (19) for young–old groups (105 Æ5 in males and 93Æ 1 in females) of dentate Japanese. This suggests that the recovery of lip support with dentures could reduce the larger nasolabial angle that results from the loss of lip support owing to missing teeth to the level of that in dentate groups. The nasolabial angle for R(+5) (96 Æ0 ) was signifi- cantly smaller than that for the other conditions, except R(0) (107 Æ1 ). Therefore, the nasolabial angle is altered by the lip support provided by the anterior teeth, especially excessive lip support by protrusive anterior teeth. The nasolabial angle for D()) was very near that for R())B( )), and that for D(+) was most similar to that for R(0). Therefore, the nasolabial angle is a useful parameter of lip support.

Angular measurements of the vermilion It has been repor- ted that poor lip support reduces the height of the vermilion (12). Three angular measurements (ls-ch-sto, li-ch-sto and ls-ch-li) used to evaluate the upper and lower vermilions were affected by vermilion height and the position of the cheilion. These measurements increased with denture insertion, and the mean ls-ch-li was significantly larger for D(+) (39 Æ 4 ) than for D( )) (26Æ 7 ), but was smaller than that for young–old dentate Japanese (48Æ 6 in males, 59Æ5 in females) as reported by Kamashita et al . (19). These results sugges- ted that the vermilions, which rotated in the inner oral cavity with the loss of lip support from the teeth, were pushed out and enlarged by the insertion of the

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33 ; 102–109

107

108 Y. KAMASHITA et al.

dentures. However, the degree of vermilion height recovered was smaller than that in the young–old (ages 65–74) dentate groups. This may be owing to the atrophy of the vermilions caused by aging and the loss of teeth.

Horizontal measurements referring to the I plane The trends of the changes in lst-I and lit-I with the experimental conditions were the same as those in lst-E and lit-E, except in lit-I for R(+5). The shifts in the positions of in and lit (1 Æ8 and 1Æ 3 mm respectively) from R()5) to R(0) were smaller than those from R(0) to R(+5) (4Æ 3 and 4 Æ5 mm, respectively). The former small shift compared with the latter, which was similar to the anterior arch shift (5 mm), and this probably arose from the difference between slack and stretched soft tissues, as well as the lip position relative to the E plane, as mentioned below. The larger horizontal measurements obtained for R())B( )) compared with those for D()), which mean that positions lst and lit for R( ))B( )) are anterior to those for D()), suggest that the presence of posterior teeth contributes to lip support. The similarity in the measurements of the corres- ponding items for R(0) and D(+) showed the validity of positioning the labial surface of the occlusion rim 10 mm forward from the center of the incisive papilla.

Horizontal lip position referring to the E plane The upper and lower lip positions relative to Ricketts’s E plane (17) are major parameters reflecting the harmony of the facial profile. Ricketts reported that for Caucasians, the upper and lower lips should lay 4 and 2 mm posterior to the E plane respectively (17). Owen et al. (20) reported racial differences for the upper and lower lip positions relative to the E plane. The upper and lower lip positions relative to the E plane for Japanese ()1Æ 9 and )1Æ 2 mm) were posterior to those for African Americans (0Æ 3 and 2Æ 9 mm) and anterior to those for Caucasians ( )7Æ5 and )5Æ 2 mm). The measurements involving the E plane, lst-E ()10Æ 7 and )3 Æ0 mm) and lit-E ( )8Æ7 and )1Æ4 mm) for D()) and D(+), indicated that the upper and lower lip positions relative to the E plane shifted forward (7Æ 7 and 7Æ3 mm respectively) on wearing complete den- tures. However, D(+) ()3Æ 0 mm) had a smaller lst-E than that in the young–old dentate Japanese reported by Kamashita et al . (19) ()0Æ 5 mm in males and 0Æ 6 mm in females) and in young–adult dentate Japanese of

both sexes reported by Owen et al. (20) ()1Æ 9 mm). Conversely, the result for lit-E for D(+) ()1Æ 4 mm) was similar to reported values ()1Æ 9 mm in males and 0Æ 8 mm in females reported by Kamashita et al . (19) and )1Æ 2 mm reported by Owen et al. (20)). These results indicate that atrophy resulting from aging and the loss of teeth could be greater in the upper vermilion than in the lower. There were no significant differences in the values of lst-E and lit-E between R())B( )) and R())B(+), but the more protrusive the anterior arches were, the larger lst-

E and lit-E were. Therefore, these measurements

depend on the altered lip support, but not on the presence of the labial flange in the absence of an anterior artificial dental arch. The shifts in positions lst and lit relative to the E plane from R( )5) to R(0) were 1Æ 9 and 2Æ 2 mm, respectively, and those from R(0) to R(+5) were 2Æ9 and 2Æ 7 mm respectively. These shifts were smaller than those relative to the I plane, as mentioned above. These differences occurred because the E plane itself changed with the shift in the position of the pronasale and pogonion. These measurements for D(+) were similar to those for R(0), which indicates that the standard record block gives lip support equivalent to that of adequate dentures.

From these results, the positions of lst and lit relative

to the E plane were affected by the anteroposterior

position of the artificial dental arch when the posterior artificial dental arch maintained the correct occlusal vertical dimension and supported the cheeks.

Maxillo–mandibular relationship The indexes of the ver- tical dimension of occlusion (sn-pg, ex-ch and sn-pg/ ex-ch), and an index of the horizontal mandibular positions (pg-I) did not differ significantly in the different conditions. These results mean that the max- illo–mandibular relationships and the vertical position of the cheilion (ch) are not affected by the degree of lip support when the mandibular positions are kept con- stant.

Conclusion

The following conclusions can be drawn from the results of this study:

1. The presence and condition of anterior artificial dental arches affected not only the lip contour but also the lower half of the nose.

ª 2006 Blackwell Publishing Ltd, Journal of Oral Rehabilitation 33; 102–109

INFLUENCE OF LIP SUPPOR T O N E D E N T A T E P R O F I L E

2. The nasolabial angle and lip position relative to the E

and I planes are useful indexes for examining lip

support in denture wearers.

3. The standard anterior occlusion rim (10 mm anterior

from the center of the incisive papilla) is useful for fabricating dentures. 4. The presence of posterior teeth contributes to lip support.

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Correspondence: Yuji Kamashita, Department of Oral and Maxillofa- cial Prosthodontics, Field of Oral and Maxillofacial Rehabilitation, Course for Advanced Therapeutics, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kago- shima 890-8544, Japan. E-mail: kamasita@dentb.hal.kagoshima-u.ac.jp

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