Beyond the Teeth: Framing Your Patient’s Beautiful Smile

Lip and perioral augmentation has increased in popularity in North America. In the 2007 report by the American Society of Plastic Surgeons on data gathered in 2006, minimally invasive cosmetic procedures increased 8%, with more than 9 million performed. Approximately 778,000 patient cases involving the use of injectable hyaluronic acid put this cosmetic procedure in the top 5 for first time.1
Dentistry has evolved beyond just simple fillings and extractions. We have been anointed the cosmetic specialist of the mouth, and rightly so. New advances in noninvasive procedures and products like injectable dermal fillers have facilitated easier and less traumatic augmentation of our patients’ lips and perioral tissue.2 It is therefore inevitable that this new and flourishing area of lip and perioral augmentation merges with cosmetic dentistry. Our expertise as the orofacial experts place us in the unique position to offer patients who are considering lip and perioral augmentation
a full and complete differential cosmetic treatment plan. This includes soft-tissue augmentation, as well as orthognathic, or-thodontic, and restorative/aesthetic dental treatment options.3-6
The following case report demonstrates an example of an additional aesthetic service that the cosmetic dentist can offer to his patient base. Lip and perioral augmentation procedures can be completed in the dental chair as a part of a cosmetic dental reconstruction, or they can be offered separately. These procedures takes anywhere from 30 to 60 minutes of chair time, not including a short 30 minute follow-up appointment one week later.

CASE REPORT

Examination and Consultation

Figure 1a. Patient presenting before lip augmentation.

Figure 1b. Close up of lip and perioral area.

A 35-year-old female presented to our practice for a consult regarding lip augmentation (Figures 1a and 1b). She had heard that our practice incorporated lip augmentation into our cosmetic treatment options and she was interested in what was available to her. Her orofacial examination was normal with an ASA 1 status. During the initial consult, the patient described that she had always had thin lips, especially her top lip. She felt this to be an aesthetic distraction since she was an entertainer.
During the consult, I used a facial caliper to show the patient her lip proportions. This caliper is fixed at a 1.0 to 1.618 relationship, otherwise known as the Golden Proportion7 (Figure 2). Using a proportional caliper serves 2 purposes. During the consult, the patient can realize their physical proportions and the doctor can record and use this information for a pre- and post-augmentational resource. Upon examination, the upper lip presents slightly less in relationship to the lower lip, ac-cording to the caliper (Figure 2). After a complete soft-tissue and hard-tissue examination, it was concluded that this patient’s cosmetic desires would be best achieved by placing a dermal filler into her lips. I suggested to the patient that we add volume and sculpt the upper lip, while adding a slight amount of volume to the lower lip. The material of choice for injectable filler would be a resorbable type such as a crossed-linked hyaluronic acid or collagen.8

Anesthesia Technique

Figure 2. The caliper device shown aids in treatment planning for lip and perioral augmentations. In addition, placing a mirror in front of the patient while one holds up the caliber device will greatly reduce communication problems and increase treatment planning success.

Figure 3. The GMB injection shown here is a modification of the standard infra-orbital, with the deposition of anesthetic bolus slightly mesial and inferior to the infra-orbital canal. This concentrates the anesthetic effect around the lip and perioral area and diminishes unwanted collateral anesthesia of the lateral and superior facial innervations.14

Figure 4. The outlined area is the affected area of anesthesia wanted for lip and perioral augmentation. The GMB, long buccal infiltrate and mental block anesthetic injections will provide sufficient anesthesia for these areas.

The patient was anesthetized using 2 blocks and an infiltrate: the Gordon Modified Block (GMB), a mental block, and a long buccal infiltrate (Figure 3). This sufficiently anesthetized the area marked on the patient’s face (Figure 4) without distorting the muscles of facial expression. I used 2 carpules of 2% xylocaine without epinephrine. Using an anesthetic with epinephrine is not absolutely necessary.9 Rarely does one exceed 40 minutes in the time it takes to perform lip injection procedures, although care must be taken not to rush the augmentation procedure. Rushing the injection of fillers may result in excess bruising, swelling, postoperative pain, and also diminish the aesthetic results.10

Augmentation Materials Needed

Figure 5. Illustrated here is the patient receiving an njection of cross-linked hyaluronic acid (Juvederm) in Zone B.

Figure 6. Illustrated here in the patient receiving an injection of human collagen (CosmoPlast) in Zone A.

Figure 7. Here are the selected injection points around the lips. Notice they are in ZB.

Figure 8. This illustrated classification system is built on an outer ring to inner ring order of augmentational filling. If a patient is undergoing more than just lip augmentation than the areas in the outer ring would need to be addressed first in order of sequence. This prevents unwanted beaking of the lips or overfill potential of the lips.

Figure 9. The lips are broken down into segments and zones. Order and location of augmentation zones are dependent on age, anatomy, and desired effect of patients.

Figure 10a. Illustrated here is the correct needle placement for ZB. This is the body of the lip. Laying the needle on the lips first allows for more accurate needle injection into the lip plane.

Figure 10b. This is immediately after full lip augmentation in segments 1 to 6, ZA and ZB. This is usually the extent of the swelling and should last 4 to 6 hours. Patients are to reduce lip activity for 8 hours.

Figure 11. This is a semi-profile angle that shows the G-K line angle. This is one-week post augmentation. The blue arrows depict the role or line angle that represents a youthful lip projection.

Figure 12. This picture illustrates tenting of the needle after insertion into the desired plane. If the gray of the needle is shown than I am too shallow. If the outline of the needle is not present than I am too deep.

I used a combination of 2 types of resorbable fillers for this patient’s augmentation: a cross-linked hyaluronic acid (alloplast) (Juvederm Ultra [Allergan; Figure 5), and a collagen (allogenic) (CosmoPlast [Allergan];11 Figure 6). Crossed-linked hy-aluronic acid (Juvederm Ultra) is an ideal filler for the lips.12 It was selected because of its soft and textured feel in the lips and placed in Zone B (ZB). Cosmoplast, placed in Zone A (ZA), was used for the vermilion border of the lips due to its ease of flow in this border anatomy.13
Procedural points to keep in mind are as follows: start laterally and move our injection point’s medial; start in ZB then ZA; and stay away from Zone C (ZC). Filling ZC is not needed and can easily obscure the anterior dentition, thereby violating the natural presentation of the teeth. In addition, when filler is placed in this zone, the potential to violate the wet/dry line exist and the patient will feel the filler with his or her tongue due to the thin mucous membrane of the oral cavity.6 On should plan for a minimum of injection points. A total of 8 injection points in the body of the lips (ZB) were planned: 4 in the upper lip and 4 on the lower (Figure 13).

Figures 13a to 13c. Final photos.

Gordon Classification

Depicted in Figure 7 is a classification method constructed for the purpose of teaching, documenting and patient/professional communication regarding lip and perioral augmentation.14 ZA extends from and includes the superior aspect of the vermilion border, to the lower border of the columella nasi of the nose. This zone is wider due to the philtrum that at times is augmented in this zone. ZB is the area midpoint between the inferior border of the vermilion border (ZA) and the superior border of ZC. ZC is the area from the inferior border of ZB to the lower transitional zone (wet/dry line) lip (Figure 8). ZC extends from the transitional zone (wet/dry line) to the border of ZB. ZB extends from the middle of the lip (border of ZB) to the vermilion border of the lower lip. ZA extends from (and includes) the vermilion border and the cleft superior to the metal protuberance of the chin.

Clinical Technique

Upon clinical examination it was evident that this patient did not need any significant sculpting of the lips. As a result, most of the augmentation was focused on adding volume created by adding crossed-linked HA (Figure 10a). To add volume, I began by filling the lips laterally and medially; this avoids “beaking” of the lips. I start in Zone B (Gordon’s classification system) which is essentially the middle of the lips. Filling in this area with a hyaluronic acid will displace tissue and “inflate” the lip to its natural potential. Between the ages of 20 and 39, the lip and perioral tissue will still be relatively taut. Filling in the volume will distend the tissue and normal anatomy will be realized. A slight curvature of the maxillary lip may even occur. This angle, identified by Drs. Glogau and Klein, is referred to as the G-K Line angle.15 (Figure 9).
Placing the needle in ZB will orient the flow of the material into the middle of the lip. After insertion of the needle, I like to tent the tissue up to visualize that I have the needle in the correct plane and depth (Figure 11). When the proper plane and depth is realized, I begin to inject the filler. This will inflate the lips like air in a balloon. Slow injection is the key while carefully observing the flow of the material. I used a minimum of injection points for this patient and worked my way medially. I augmented the upper and lower lip ZB in a similar way (Figure 5). Planning precise injection points and filling the natural planes will reduce postoperative swelling and bruising significantly (Figure 11).
For this patient, I decided to add a little filler in ZA, specifically at the border of A and B. This technique created or accentuated a slight G-K line angle. I selected collagen for this particular injection, due to the softness of the material and ease of flow (Figure 6). In an older patient, this line angle may not be realized quite as easily, and one may wish to select a HA filler to more assertively create this angle. It is important to add volume before sculpting the lips and this is done in ZB before ZA. The point is, there are a significant number of instances where sculpting of the lips in ZA will not be necessary after adding volume in ZB.

CLINICAL RESULTS

This patient showed a remarkable increase in upper and lower lip volume, accomplished by injected filler into ZB in segments 1 to 6. We have also accentuated her G-K line angle by augmenting ZA vermilion border in segments 1 to 3. The augmenter should always be aware of the patient’s wants and general aesthetically pleasing results. This particular patient wanted slightly larger lips. Care must be taken in keeping the ideal proportions and that the patient’s facial framework can accept larger sized lips (Figures 13a to 13c).
I normally schedule all patients for a one-week post-augmentation evaluation. This allows me to correct the augmentation if needed. Options at this point are adding more filler and or messaging current filler placed. This particular patient’s augmentation went well enough that no additional augmentation was required. I proceeded to further document the case with photos and interview the patient on her experience.

DISCUSSION

This augmentation took 2 weeks, from the beginning consult to the one-week postoperative visit. I used a total of 1 syringe of cross-linked hyaluronic acid and one syringe of collagen. The cost to the patient for such a treatment can range from $500 to $800. This depends on demographic location, the practitioner’s skills, and the materials used. The duration of this cosmetic effect can last anywhere from 5 to 7 months, depending on correct-plane placement, type of filler used, and the patient’s metabolism of resorbable filler.16 Placing a patient in a regular 6-month hygiene visit and incorporating a cosmetic re-evaluation time slot will ensure the maintainence of the lip and perioral augmentational cosmetic results.
This is one typical case that practitioners may be presented with in their practice, when one incorporates lip and perioral augmentation. Other options of lip augmentation that may present in a practice may include the following:
Botox(t) Botulinum Neurotoxin: This entails the use of approved toxins in cosmetic injections around the lips (Zone A). This reduces lines, called rhytids, that form around the lips as we age. The cosmetic results are smoother textured lips with a more rejuvenated appearance.17,18
Combination therapy: Botox treatment and filler sequence can be used together to augment the lips.
Perioral augmentation (outer circle Figure 7): This includes the use of fills and Botox treatments. Filler injections reduce smile-line severity for a more youthful appearance. Botox treatment can be used to reduce a “gummy smile,” or “cobble-stoning,” which is the pitting in the chin when it is contracted. Some individuals have an over-developed expression of this, which can be unflattering to the lip plane. Botox can also alleviate the upward lifting of the commisures.19

CONCLUSION

Introducing lip and perioral augmentation into the cosmetic dental practice can result in many benefits: the patient receives a full and comprehensive oral facial cosmetic treatment plan; and augmenting lips—or relieving smile lines for other patients—complements the other treatment that we offer the cosmetic dental patient. In addition, dentists who offer these additional cosmetic procedures to their patients can typically rejuvenate their practice with excitement in providing these services translating throughout the entire staff.
While the introduction of lip and perioral-augmentational procedures requires some additional training, the ability to perform these cosmetic services usually builds upon previously established knowledge and skills for most dentists. As dental health professionals, we are the experts of the lips and perioral area. No other medical specialist has as much didactic, clinical, and everyday hands-on experience in the orofacial arena. We now have the ability to offer optimal cosmetic enhancements within our areas of expertise.


References

  1. American Society of Plastic Surgeons. National Clearinghouse of Plastic Surgery Statistics. Arlington Heights, IL: ASPS; 2007.
  2. Matarasso SL, Carruthers JD, Jewell ML; Restylane Consensus Group. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg. 2006;117(3 suppl):3S-34S.
  3. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53:262-284.
  4. Pogrel MA. What are normal esthetic values? J Oral Maxillofacial Surg. 1991;49:963-969.
  5. Gazit-Rappaport T, Weinreb M, Gazit E. Quantitative evaluation of lip symmetry in functional asymmetry. Eur J Orthod. 2003;25:443-450.
  6. Scott CR, Goonewardene MS, Murray K. Influence of lips on the perception of malocclusion. Am J Orthod Dentofacial Orthop. 2006;130:152-162.
  7. Huntley HE. The Divine Proportion. Mineola, NY: Dover Publications; 1970.
  8. Broder KW, Cohen SR. An overview of permanent and semipermanent fillers. Plast Reconstr Surg. 2006;118(3 suppl):7S-14S.
  9. Goulet JP, Perusse R, Turcotte JY. Contra-indications to vasoconstrictors in dentistry: Part III. Pharmacologic interactions. Oral Surg Oral Med Oral Pathol. 1992;74:692-697.
  10. Lemperle G, Rullan PP, Gauthier-Hazen N. Avoiding and treating dermal filler complications. Plast Reconstr Surg. 2006;118(3 suppl):92S-107S.
  11. Restylane injectable gel [package insert]. Scottsdale, AZ: Medicis Aesthetics, Inc; 2005.
  12. Friedman PM, Mafong EA, Kauvar AN, et al. Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg. 2002;28:491-494.
  13. Klein AW, Glogau RG. Injectable collagen. In: Klein AW, ed. Tissue Augmentation in Clinical Practice. 2nd ed. New York, NY: Taylor & Francis Group; 2006.
  14. Gordon R. Anesthetic. Vermilion Dollar Lips. St Petersburg, FL: Vermilion Dollar Publications; 2008.
  15. Klein AW. The art and architecture of lips and their enhancement with injectable fillers. In: Klein AW, ed. Tissue Augmentation in Clinical Practice. 2nd ed. New York, NY: Taylor & Francis Group; 2006.
  16. Reed RK, et al. Removal rate of [3H]hyaluronan injected subcutaneously in rabbits. Am J Physiol. 1990;259(2 pt 2):H532-H535.
  17. Niamtu J III. Aesthetic uses of botulinum toxin A. J Oral Maxillofac Surg. 1999;57:1228-1233.
  18. Fagien S. Extended use of botulinum toxin A in facial aesthetic surgery. Aesthetic Surg J. 1998;18:215.
  19. Fagien, S. Botox for the treatment of dynamic and hyperkinetic facial lines and furrows: Adjunctive use in facial aesthetic surgery. Plast. Recontstr Surg. 1999; 103:701.

Dr. Gordon is a graduate of Marquette Dental School. He attended a post graduate periodontal internship at the University of Nebraska Medical College and additional training in Oral Maxillo Facial Surgery at Winn Army Hospital Georgia. Dr. Gordon is a NIH Scholar Recipient and is currently working on his PhD at the University of South Florida medical center in the department of Dermatology. He has a passion for art and facial aesthetics as an adjunct to cosmetic dentistry. He lectures on oral/facial augmenters on his classification, diagnostic, and reconstructive lip/perioral augmentation techniques. He published the first textbook exclusively on lip and perioral augmentation for the cosmetic dentist. He can be reached at (877) LIP-FILL (547-3455), or visit his Web site at vermiliondollarlips.com for more information about his book and seminar series.