Assessing the Lips for Successful Rejuvenation

By Souphiyeh Samizadeh / 01 Dec 2015

Dr Souphiyeh Samizadeh provides an overview of lip-treatment trends and shares advice on clinical evaluation techniques

Lip aesthetics

Throughout human history, we have ornamented our lips in many ways for various reasons, including cultural beliefs, beauty and aesthetics, courtship and social status (Figure 1).1 As well as being one of the key aesthetic units of the face, lips play a significant role in phonation and swallowing, so for practitioners aiming to augment or enhance lips, successful treatment is essential.

Studies examining the profiles of Caucasian female models in the late 20th century found that fuller and more anteriorly positioned lips were more fashionable.3,4 For 65 years from 1930, Nguyen and Turley studied male model profile changes from photographs collected from leading fashion magazines in order to analyse the way that the male profile had changed through time. They reported significant changes in the ideal lip aesthetics, which included:5

  • Increasing lip protrusion
  • Increasing lip curl
  • Increasing vermilion display
As a result, and with the evolution of treatments available, lip augmentation has become progressively popular in recent years, reflecting the cultural trends in youth and beauty. It has been reported that lip augmentation is one of the most popular and requested aesthetic procedure since the introduction of modern dermal fillers.1, 6 
Figure 1: Examples of various ideal lip aesthetics in different cultures and time periods

What makes an ‘ideal’ lip?

Beauty ideals and aesthetic standards vary across eras and cultures. In Western culture, plump and well-defined lips tend to be preferred.1, 7 In the early years of medical aesthetics, despite cultural preferences for plump lips and admiration of models with voluptuous lips, no actual guidelines existed for assessment and enhancement of the lips.8 Following research, however, studies suggest that the ‘ideal lip’ should have the following characteristics:

  • Fullness and volume1
  • Correct balance between the upper and lower lips1
  • Well-defined vermilion border1,8
In my opinion, lips should also be harmonious with other facial features of the individual. Enlarged, full lips in a very petite face will not be aesthetically pleasing as this would be out of proportion with the rest of face. Sexual dimorphism should also be kept in mind when treating lips, as men have a larger mouth width, philtrum width, total lip height, and lip volume compared to women.9,10 Techniques for augmentation and enhancement of the lips have evolved with advances in biotechnology and the various temporary, semi-permanent and permanent fillers and implants available on the market. In order to be able to use these different products and techniques successfully, an understanding of lip anatomy, terminology (Figure 2), assessment and aesthetics is essential.


Figure 2: Lip anatomy and terminology


1. Philtrum
2. Philtrum columns
3. White roll
4. Cupid’s bow
5. Vermillion border
6. Oral commissures
7. Upper incisor teet
8. Upper lip tubercle
9. Cutaneous upper lip



Assessing lips

I advocate examining your patients in their natural sitting position as this is a standardised and reproducible position for upright examination.2,11 It is also important to examine lips while relaxed and during animation in order to assess the natural position of lips and symmetry of muscle movement to detect any asymmetry, and to assess action and hyperactivity of muscle groups.2,12 The position of the lips is closely related to the teeth and alveolar processes,13 yet it is paramount to keep in mind that the lips are only one factor of an attractive smile.

Other factors that contribute to the lower face and smile aesthetic, and those that should be assessed (ideally by a dental professional), include:14

In my opinion, lips should also be harmonious with other facial features of the individual. Enlarged, full lips in a very petite face will not be aesthetically pleasing as this would be out of proportion with the rest of face 

The dentitions, gingivae and alveolar bone:

  • Crown length
  • Crown width
  • Incisor crown angulation
  • Midline
  • Open gingival embrasure
  • Gingival margin
  • Incisal plane
  • Gingiva-to-lip distance

Skeletal components:

  • The relative position of the mandible to maxilla

Soft tissue factors
  • Lip and soft tissue morphology
  • Prominence of chin and nose
Clinical evaluation
Systematic clinical evaluation of the lips with assessment of a number of parameters results in a better understanding of the aesthetics of the lips and a more successful treatment planning. The following systematic evaluation can be followed as suggested by Dr Farhad Naini:2

Lip height:

  • Upper and lower lips
  • Lower lip/chin height
  • Ratio of upper lip to lower lip/chin height
  • Interlabial gap (gaps between the lips at rest)
  • Upper and lower lip vermilion height 
Lip thickness: Lip thickness is an important parameter during analysis as it is directly correlated with lip prominence and can be influenced by ethnic background. Unlike thick lips, thinner lips usually more readily follow the teeth and jaw movements.2 As such, aesthetic effects of loss or movement of teeth in individuals with thinner lips would be more noticeable.

Lip contour: This can be evaluated in frontal and profile views to evaluate lip curvature, lip curl and inclination. Excessive or reduced lip curl could be due to the position and strength of dentoskeletal support for the lips. For example, maxillary dentoalveolar retrusion could result in a flat upper lip.2

Lip inclination: The support of lips is provided by the dentoalveolar. The inclination of the lips provides an indication of prominence of the underlying dentoalveolar. Protrusion or retrusion of the upper and lower incisors will result in protrusion or retrusion of the lips. When upper incisor teeth impinge in the lower teeth, it can result in eversion of the lower lip.2 

Lip posture: Assess lip posture and lip seal in natural head position in repose. The two should be assessed when relaxed with normal muscle tone (without excessive muscular contraction). Each person has a unique characteristic orolabial soft tissue posture (lip posture) and if the lip seal does not occur in the rest position, adaptive postures are used. This means the patient will have a continuous contraction of circumoral musculature.

Lip prominence: In profile, the prominence of the lips can be assessed relative to the prominence of the nose and chin. The prominence of the lip can vary due to soft tissue factors such as lip thickness, dentoalveolar factors such as position of the incisor teeth, or skeletal factors.2 

Lip activity and function: Practitioners should assess the patient for hypertonic (hyperactivity or overactivity) or hypotonic (low muscle tone or underactivity) lips. A hypertonic lower lip, also known as a ‘strap- like’ lower lip may retrocline the lower incisor teeth.2 A hypertonic upper lip levator muscle can result in a gummy smile. Hypotonic upper or lower lips appear flaccid and may result in overstretching of the lips to achieve lip seal. This is common in individuals with increased lower-face height.2

Conclusion

While this article has hopefully provided readers with a detailed overview of considerations to take into account when treating lips, it is also imperative that practitioners understand how lips age and the anatomy of the perioral region. Knowing how, where and when to treat the lips should lead to successful rejuvenation and satisfied patients. 

References

  1. Niamtu J, ‘New lip and wrinkle fillers’, Oral and maxillofacial surgery clinics of North America, 17 (2005), pp.17-28.
  2. Naini FB, ‘Facial Aesthetics: Concepts and Clinical Diagnosis’, Wiley-Blackwell (2011).
  3. Auger T, Turley P, ‘Aesthetic soft-tissue profile changes during the 1990s’, Journal of Dental Research, (1994) pp.368-368.
  4. Auger TA, Turley PK, ‘The female soft tissue profile as presented in fashion magazines during the 1900s: a photographic analysis’, Int J Adult Orthodon Orthognath Surg, 14 (1999) pp.7-18.
  5. Nguyen DD, Turley PK, ‘Changes in the Caucasian male facial profile as depicted in fashion magazines during the twentieth century’, Am J Orthod Dentofacial Orthop, 114 (1998), pp. 208-217.
  6. Morris CL, Stinnett SS, Woodward JA, ‘Patient-preferred sites of restylane injection in periocular and facial soft-tissue augmentation’, Ophthalmic Plastic & Reconstructive Surgery, 24 (2008) p.117-121.
  7. Bisson M, Grobbelaar A, ‘The esthetic properties of lips: a comparison of models and nonmodels’, The Angle orthodontist, 74 (2004) pp.162-166.
  8. Klein AW, ‘In Search of the Perfect Lip: 2005’, Dermatologic Surgery, 31 (2005) pp.1599-1603.
  9. Sforza C, Grandi G, Binelli M, et al., ‘Age- and sex-related changes in three-dimensional lip morphology’, Forensic Sci Int, 182 (2010), p181-187.
  10. Gibelli D,CodariM,RosatiR,etal.,‘AQuantitativeAnalysis of Lip Aesthetics: The Influence of Gender and Aging’, Aesth Plast Surg, 39 (2015) pp.771-776.
  11. Bansal N, Singla J, Gera G, et al., ‘Reliability of natural head position in orthodontic diagnosis: A cephalometric study’, Contemporary Clinical Dentistry, 3 (2012) pp.180-183.
  12. Mani V, ‘Surgical Correction of Facial Deformities’, JP Medical, (2010) p.290.
  13. Turley PK, ‘Evolution of esthetic considerations in orthodontics’, Am J Orthod Dentofacial Orthop, 148 (2015) pp.374-379.
  14. BurrowSJ,‘The impact of extractions on facial and smile aesthetics’, Seminars in Orthodontics: Elsevier, (2012) pp.202-209. 

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