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PostPosted: Sun Dec 20, 2009 8:09 am 
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Hey, this is my first post here having spent the best part of my day on Google trying to search for answers. So hopefully someone here will have the answer!

In May of this year I had Mandibular Sagittal Split Osteotomy to move my lower forward so that I would have a perfect bite and a more pronounced jaw and chin. My bite is now where it is and there were no complications.
Two weeks before the operation I met with the surgeon to discuss exactly what it was that I expected from the operation and I explained a more pronounced jaw line and chin as well as a good bite. At the time he asked me if I felt I showed too much teeth (some gum) when I smile to, which I said no to but delve further to see the meaning of the question. Essentially it was possible to move my upper jaw upwards to reduce the amount of gum on show when smiling. However after some reconsidering he decided it was actually a case of my upper lip being too short and the additional surgery was not appropriate. A Bimaxillary Osteotomy I believe. I did and do show too much teeth (some gum) when smiling according to the relevant measures but it is not an issue for me.

Soon after the operation I realised that my chin was not as pronounced as I would have liked it to be, it did not lay on the Frankfort Horizontal Line. However I was very happy with the overall improvement and continue to be.

Towards the end of May I met with the surgeon for a post operative review and raised the question of my chin. It was my theory that by pushing my jaw out the soft tissue of the chin had been stretched leading my chin not to be as pronounced as it could be despite having a perfect bite (presumably as indicator of a perfect alignment of my lower jaw/chin too). He agreed and assured me that a chin implant could be performed quite easily to rectify this once my braces had been removed.

On November the 2nd I met with the surgeon for another review and again everything looked very positive. It was a far more rushed affair this time with another person taking the measurements and the surgeon visiting at the end to confirm the positive measurements. Afterwards he said his final farewell at which point I asked about the chin implant. His reply was that my problem lay with having a too small an upper lip and that a chin implant would not help. It was added that the original additional surgery on my upper jaw would not have helped and lengthening my upper lip was not really viable.

This set me back a bit as I had a solid expectation that my chin would finally lay on the Frankfort Horizontal Line, my original criteria for success along with a perfect bite.

On November the 3rd I saw the orthodontist who was satisfied with my bite and removed my braces. In discussion I shared my reservations about the surgeon having told me one thing only to say another subsequently. The orthodontist was very helpful and examined my profile closely. He highlighted that my lips did not meet when relaxed (a large inter-labial gap) something I had never knew to be out of the ordinary previously. The significance being that when my mouth is close my lower lip stretches upwards to meet my upper lip and thus the soft tissue on my chin is stretched. When my lips are relaxed my chin lies nearer to the Frankfort Horizontal Line but still falls short.

At this point it was my belief that my upper lip needed somehow to be lengthened to reduce my inter-labial gap to normal at which point a chin implant could be an option.

In my research I discovered the article “Effect of lip training in children with short upper lip” by Bengt Ingervall and Gun-Britt Eliasson (1982) a “one-year study of the effects of a simple lip exercise on incompetent lips.” It concludes “Upper and lower lip length were increased, and the inter-labial gap reduced.” On my return to the orthodontist on the 10th of November I asked him about such exercises and he said he would email a response having researched them first.

In the meantime I have measured my upper lip, ‘lower lip and chin’ and inter-labial gap. They are as follows:

• Upper lip: 23 mm
• Lower lip and chin: 50 mm
• Inter-labial Gap: 7 mm

Researching how normal these measurements are I have found the following:

Upper lip length is measured from the base of the nose (subnasale) to the inferior part of the upper lip (upper lip stomion). The normal length of an adult male lip is 22 ± 2mm. For a female, it is 20 ± 2mm. Upper lip length is the basis for establishing vertical face dimensions in the lower third of the face since the upper lip length usually is not easily altered. This measurement is the basis for establishing the vertical length of the lower two thirds of the lower third of the face.

‘Oral and Maxillofacial Surgery’ by Raymond J. Fonseca 2002
The length of the lower lip should be about twice the length of the upper lip.

‘Facial plastic and reconstructive surgery’ by Ira D. Papel, John Frodel – 2002

It seems as if my upper lip is perfectly within the norm. My measurements were taken with the guidance of the following diagram.

Image

I am no expert and I have explored whether I have made an error in measurement but I really struggle to find a length below 20 mm (the limit of the normal range). Only if I measure my lip as being from the subnasale to the labrale superius, am I able to find an upper lip length that is shorter than the 20 mm.

With all this in mind I am left with a number of questions.

Firstly does the short upper lip theory have much creditability? It was only put forward when I pressed him further on the “do you think you show too much teeth/gum when smiling?” question. It seems increasingly like it was a white lie.

Here is a picture of my lips/interlabial gap.

Image


Thank you for your help! And reading this far. :)


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PostPosted: Sun Dec 20, 2009 9:23 am 
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Do you have mentalis strain (chin dimpling) when you close your lips?

I have a short upper lip (as well some mild VME and a retrognathic lower jaw) and I've measured my upper lip and its about 20mm, still in the normal range like yours. However, I think if your lips don't meet at rest and you don't have vertical maxillary excess then your upper lip is the issue, even if it's technically a normal length.


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PostPosted: Sun Dec 20, 2009 11:39 am 
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Image

Hey, thank you for replying!

I do have mentalis strain as my lower lip strains to meet the upper. I did some reading too on 'vertical maxillary excess' and it does seem that I fit the description for it. Below is the explanation that I found on Google.

Quote:
Controversy continues about the cause and effect of airway obstruction on facial growth. We do know vertical maxillary excess (a "gummy smile") generally occurs in the presence of blocked nasal airflow and a mouth-breathing (respiratory) habit that is ongoing during childhood when the facial bones are developing.

In this situation, the facial skeleton grows long (vertically) and the appearance demonstrates increased length to the upper jaw "gummy smile" with a large separation (distance) between the upper and lower lips, a deficient (small) lower jaw and a long and retruded chin.


I have been a mouth breather and previous to my operation my lower jaw was smaller than normal. The surgeon also picked up on my 'gummy smile' before too. Below is a picture of me smiling now.

Image


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PostPosted: Sun Dec 20, 2009 12:14 pm 
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You should have had your upper jaw impacted because that would have lowered your upper lip and improved lip competence. A sliding genioplasty would have probably helped as well, bring your lips closer together and improving your chin's projection.

Can you post a picture of your lip closed from the front and side?


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PostPosted: Sun Dec 20, 2009 12:40 pm 
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As requested:

From The Side

Image

From The Front

Image

It seems insane that he would present the question of having my upper jaw impacted (Le Fort 1 Osteotomy?) as simply a matter of do I show too much gum or not.


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PostPosted: Sun Dec 20, 2009 4:25 pm 
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Alrighty well it appears you actually have no mentalis strain but you do have some lip incompetence obviously. This is actually good news in my opinion because plenty of people have lip incompetence but they're bite, chin development and jaw development is normal.

Look into having a sliding genioplasty done. It doesn't require braces and it's relatively easier time to heal from then jaw surgery. Find a skilled doctor who can adequately advance your chin and if necessary, move your chin vertically which would reduce your lip incompetence.

I'm surprised your surgeon didn't do the genio to begin with.


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PostPosted: Mon Dec 21, 2009 7:21 am 
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The reason given by the surgeon for not pursuing a sliding genioplasty was that my upper lip was too short. When my lips are relaxed my chin is exactly where it should be but when my lips are closed then my lower lip has to move that much further to meet my upper lip. The result is that the soft tissue of the chin is stretched and the definition is loss.

To resolve this issue with a sliding genioplasty would lead to my chin being too pronouned when my lips were relaxed the argument went. With this in mind the solution was to lengthen my upper lip, something he did not feel possible.

As it is there are some techniques to lengthening the upper lip but if my upper lip is already of normal length then making it longer may adversely affect my facial symmetry. One step forward, one step back scenario.

So the question is why do I have an interlabial gap of 7mm and not the normal of 4mm? The explanation that my upper jaw is too long and that my teeth sit further below my upper lip seems the most likely.

All the work was undertaken by the NHS so the cosmetic consideration was not so great and it seems to me now that the surgeon was keen on me having the simpler operation than one combined with a Lefort 1.

The great frustration for me is that I could of had the Lefort 1 had I known the full implication of it and gave an instant positive response. :(


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PostPosted: Mon Dec 21, 2009 7:43 am 
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Bowater wrote:
So the question is why do I have an interlabial gap of 7mm and not the normal of 4mm? The explanation that my upper jaw is too long and that my teeth sit further below my upper lip seems the most likely.


I would have to agree. As for interlabial gap in general, isn't the normal perfect lip competence, i.e. 0mm? Why would the normal be 4mm?


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PostPosted: Mon Dec 21, 2009 7:47 am 
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I feel like your having this conversation with your self. I have had a sliding genioplasty done, it did improve my lip competence and my lip position/jaw is very similar to yours.

Like I said, the Lefort probably should have been done, however, your chin is still recessed and you would have benefited from a sliding genioplasty with advancement and height reduction.


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PostPosted: Mon Dec 21, 2009 7:58 am 
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From the Oxford American Handbook of Clinical Dentistry:

Competent lips Lips meet with <2 mm of interlabial gap at rest.
Incompetent lips Lips meet with >2 mm of interlabial gap at rest.

http://books.google.com/books?id=lksG08 ... ap&f=false


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PostPosted: Mon Dec 21, 2009 10:19 pm 
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ReoSity wrote:
I feel like your having this conversation with your self. I have had a sliding genioplasty done, it did improve my lip competence and my lip position/jaw is very similar to yours.

Like I said, the Lefort probably should have been done, however, your chin is still recessed and you would have benefited from a sliding genioplasty with advancement and height reduction.


Hey man, sorry for giving you that impression I just want to give give you information that was given to me without biasing your response in a negative or positive response. This explains my passive replies so as not not to encourage or discourage a certain point of view.


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PostPosted: Mon Dec 21, 2009 10:25 pm 
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GrizzlyB wrote:
From the Oxford American Handbook of Clinical Dentistry:

Competent lips Lips meet with <2 mm of interlabial gap at rest.
Incompetent lips Lips meet with >2 mm of interlabial gap at rest.

http://books.google.com/books?id=lksG08 ... ap&f=false


I have found some estimates that find 3mm to be the average but if it is less than 2mm (the Oxford American Handbook of Clinical Dentistry sounds a reliable source) then that only serves to strengthen my concern.

I have made an appointment with a plastic surgeon and a maxillofacial surgeon over the Christmas period but of course I am impatient for answers beforehand. :)


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PostPosted: Tue Dec 22, 2009 6:48 pm 
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I'm going to chime in on this lip issue too b/c I am wondering as well. I had a Le Fort I and BSSO 6 months ago and although I am generally happy with the results, I wish my upper lip sat "flatter" when my mouth is closed. I do not think my upper jaw should have been impacted more b/c then I don't think I'd show enough teeth when I smile. My teeth show from top to bottom when I smile and when I smile really big, or laughing, maybe a mm of gum shows, which is fine by me. I am wondering is there anything that can be done to the upper lip to stretch it out? I remember in middle school when my dentist used to give me little cotton things too put under my upper lip, to stretch it out, so I'd have a less gummy smile. Should I do that now? It's not even that it really needs to be longer, but stretched out so it will lie flatter when my mouth is relaxed. Oh and I don't want to get a genioplasty or chin implant so if that's the only way, then I can live with it.

_________________
Braces first time 12/96-11/99
Braces second time 12/08-10/09
BSSO & Le Fort I 6/15!
Unwired, in elastics, and on soft foods 6/26!!!
Orthodontic elastics 7/21-8/11
Braces off... OCTOBER 2ND, 2009!


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PostPosted: Wed Dec 23, 2009 10:48 am 
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Hey HokieTay it is interesting that you should reply with the same query as me since I would of have had the exact same treatment as you if I had the Le Fort I also. Maybe a Le Fort I would not help in my case. :?

I have found elsewhere the following treatment being prescribed for someone who had too short of an upper lip:

Quote:
I would recommend seeing a plastic surgeon for this. There is a muscle that goes from the base of your nose to the upper lip. Some length can be gained by releasing this muscle.

Good luck.


http://en.allexperts.com/q/Plastic-Surg ... -short.htm

I enquired further to the same plastic surgeon as to what the likely increase in upper lip length was likely to be but his reply to me was:

Quote:
I cant tell you the exact amount of length gained, but looking at your photo in my opinion I dont believe you have a short upper lip.

Good luck.


http://www.allexperts.com/user.cgi?m=6& ... ID=4839694

However it may be that the treatment is appropriate for you. Try asking on the site with a picture. He replied in less than 2 days for me.


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PostPosted: Fri Jan 08, 2010 7:03 am 
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Hey everyone, thank you for all your advice so far. I went to a second Maxiofacial surgeon today for a second opinion. Firstly he felt the result of my previous surgery was excellent. Good news.

As for the issue of my chin disappearing when my lips meet his judgement was that both my lips are too short for where my jaws are. As such a genioplasty would not be appropriate as my lips would purse even more to meet. He did however suggest a Le Fort I with a 10mm movement of the upper jaw would result in my lips meeting when relaxed without pursing solving the problem of my chin.

He himself is retired from surgery, which is a good indicator of an unbiased opinion. He has promised to send a letter to my previous Maxiofacial surgeon to constructively raise the question of a Le Fort I.

I don’t know for sure but I am presuming it will no longer be an NHS issue but now a private one. My original surgeon does work privately too.

Also one implication of a Le Fort I would be that I would show less of my teeth as my jaw/teeth will be moving up 10mm behind my lip. Has anyone else encountered this? So from this :D to this :)

Thanks for reading. :)


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