Dental Tribune United Kingdom Edition

The aetiology of the extreme high lip line is often multi-fac- torial, a combination of the four main causes. Skeletal deformity often leads to the most difficult cases and they are often associ- ated with another of the main causes, muscular hyper-activity, which can result in an unsatisfac- tory outcome even after orthog- nathic surgery. The other factors are over-eruption which can with difficulty be treated with ortho- dontic intrusion and finally mere- ly a short upper lip which is rare. Treatment modalities for these cases can be divided into non-surgical and surgical. Non- surgical solutions are orthodon- tic intrusion mainly in younger patients but this can be difficult and needs specialist attention. The use of Botulinum Toxin is the other solution and here the use of 40 units, 15 at each corner (for Leavator Labii superiorus aleq- uae nasi) of the nose (Fig 6) and 10 units in the centre (for Depres- sor septi). Whilst good results can be achieved in the muscular hyper-activity group, it appears to wear off in three months and it has been noticed that on further applications the effect may not be as satisfactory. Surgical solutions are orthog- nathic surgery, surgical crown lengthening and finally lip re- positioning surgery. The first requires a specialist team and is generally only suited for the most extreme cases as long-term side effects such as paraesthesia are a possibility. It has also been seen that even after hard tissue correc- tion further soft tissue work (lip re-positioning) may be needed for the desired aesthetics. The last two surgical mo- dalities only need GDP or Peri- odontist skills and are both low risk, low pain solutions although crown lengthening may require extensive dental restorative pro- cesses. They can be used together but the biology must be respected and a minimum of 5mm of at- tached gingiva must be retained (Figs 7 and 8). Case This 26-year-old patient fitted in with the type seen routinely; 95 per cent of the cases seen are young females who all show the same photographs of their smiles when at a social function (un-re- strained and under the influence of alcohol) which they really dis- like to the point of having devel- oped a habit of covering their mouth with a hand when smil- ing hard. Seeing a case or two every week the same features and characteristics are repeated and there is an immense effect on these patients psychologically, with some even having discussed events of bullying. In these cases there is often Fig 2: Another case of straighten and whitenFig 1: Media driven expectation for perfect smile Fig 4: Balance for ideal aestheticsFig 3: Balance upset the extreme high lip line Fig 5b: after orthodontic correction alone on balance after only one monthFig 5a: before orthodontic correction page 23DTß 24 Clinical November 12 - 18, 2012United Kingdom Edition