Original Article

3D Assessment of Facial Contours of Patients Wearing Either Complete

Denture or Implant‑Supported Fixed Dentures
ZB Demirekin, A Günaydın1, K Çavdarlı2, Y Fındık3, S Türkaslan, T Baykul3

Department of Background: Total edentulousness leads to soft tissue changes causing

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Abstract
Prosthodontics, Faculty
of Dentistry, 3Oral and
esthetic problems. Being aware of the significant effects of different treatment
Maxillofacial Surgery, approaches on facial soft tissue can help to obtain more satisfying esthetic
Faculty of Dentistry, results. Aim: The current study’s objective was to evaluate three‑dimensional
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/16/2023

2
Department of Dentistry facial soft tissue changes in edentulous patients rehabilitated with a
Services, Vocational School complete denture (CD) and implant‑supported fixed partial denture (FPD).
of Health Services, Suleyman Material and Methods: Fourteen edentulous patients, mean age of
Demirel University,
Isparta, 1Private Practice,
47.6 years (42–63), were assessed before prosthetic treatments (T0), after
Orthodontist, Eskişehir / CD (T1), and after FPD (T2). 3dMDface System (3dMD LLC) obtained the
Turkey images and transferred them to 3dMD Vultus software (3dMD Vultus software
Version 2.3.0.2). Nine linear, five angular, and one topographical measurement
were performed for facial soft tissue analysis. For statistical analysis of facial
soft tissue, ANOVA was used with a level of significance set at 5% (p ˂.05).
Results: Significant differences were observed in lower lip height (Sto‑Sl)
and nasolabial angle (Prn Sn Ls) with CD. There is no significant difference
with the implant‑supported fixed partial dentures in these measurements when
compared with pretreatment. Significant differences were observed in the lower
lip angle (Chr Li Chl) with the implant‑supported fixed partial dentures. There
is no significant difference with CD in this measurement when compared with
pretreatment. According to the paired comparisons, a significant difference
Received: was observed in philtrum height (Ls‑Sn) between the treatment approaches.
22-Apr-2021; Conclusion: CD and implant‑supported fixed partial dentures, both treatment
Revision: approaches, cause facial soft tissue changes, which may help to improve the
22-Oct-2021; facial esthetic. The effects of these treatment methods on facial soft tissues are
Accepted: not significantly different, except the philtrum height.
13-Nov-2021;
Published: Keywords: 3D facial soft tissue imaging, dentures, implant‑supported fixed
16-Mar-2022 partial denture, stereophotogrammetry

Introduction been widely mentioned in the literature.[1] The use

C omplete dentures have been the most preferred
treatment option for edentulous patients for many
years in terms of cost and time. Nevertheless, it is
not always possible to ensure patient satisfaction with
complete denture treatments due to insufficient stability
and retention in the rehabilitation of edentulous
patients. The introduction of dental implants in
dentistry as a treatment option is a recent development.
Its advantages, especially in total edentulousness, have
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of implants in total edentulous cases has increased,
especially as overdenture retainers, due to their
contribution to retention and stability. Two different
treatments are feasible in implant therapy of edentulous
Address for correspondence: Dr. ZB Demirekin,
Department of Prosthodontics, Suleyman Demirel University,
Faculty of Dentistry, Isparta, Turkey.
E‑mail: dtzeynepbasagaoglu@yahoo.com.tr
This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
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For reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com

DOI: 10.4103/njcp.njcp_1446_21
How to cite this article: Demirekin ZB, Gunaydin A, Cavdarli K, Findik Y,
Turkaslan S, Baykul T. 3D assessment of facial contours of patients wearing
either complete denture or implant-supported fixed dentures. Niger J Clin
Pract 2022;25:286-93.

286 © 2022 Nigerian Journal of Clinical Practice | Published by Wolters Kluwer ‑ Medknow
 Demirekin, et al.: 3D assessment of facial contours with varying prostheses
patients, overdentures and implant‑supported fixed
dentures.
In overdenture prostheses, the soft tissue in terms of
facial contours is supported by the prosthesis. They
are economical because fewer implants are applied and
treatment is completed in a short period. Also, they have
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advantages such as providing esthetics and function,
supporting the lip, and promoting oral hygiene more
easily.[2] However, the removable dentures may not be
fully conceded by patients as psychological or social
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aspects still remain as concerns.
When the implant‑retained fixed partial denture as a
treatment option—besides the stability of prosthetic
treatment—increases, significant improvements occur
in patients’ quality of life who switch from removable
partial dentures to fixed partial dentures. In recent years,
the literature related to developments in dental implants,
the promising success rates of implant‑supported fixed
partial dentures, and high survival rates have been
published.[3]
Besides the functional aspect of the prosthetic approach,
patients demand esthetic solutions as well. The most
promising and preferred approach among the treatment
methods offered to total edentulous patients is full‑arch
implant‑supported fixed partial dentures. However,
fixed partial dentures are short of buccal extensions as
complete dentures which aid to support facial contours.
As the patients’ age progresses, as a result of tooth loss,
crest resorption, decrease in chewing efficiency, facial
contour changes due to muscle imbalance, decrease
in the vertical dimension, and esthetic and phonetic
insufficiency are observed. Besides, implant treatments
for fixed partial dentures include higher surgical risks
and more complicated prosthetic phases, which are
long‑term and more expensive treatment methods.[4]
As a result, while providing retention and stability in
prostheses and giving natural tooth‑like function with
fixed prostheses, problems might occur in the esthetics
of facial contours.[5] One of the aims of prosthetic
treatment is soft tissue support, facial esthetics, and
dominant treatment success.
In the literature, studies are investigating facial changes
in prosthetically treated individuals with cephalometric
radiography,[6,7] two‑dimensional (2D) images,[8,9] and
three‑dimensional (3D) imaging technologies.[10,11]
The evaluation and measurement of facial soft tissues
are very important for orthodontics, maxillofacial
surgery, and prosthodontics. These units obtain the
measurement values of soft tissue and can clearly
define their relationship with hard tissue.[12] Many
non‑invasive methods can be used to measure and
Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022
evaluate soft tissues in three dimensions. The main
techniques are stereophotogrammetry, laser scanning,
structured light techniques, computed tomography,
cone beam computed tomography, magnetic resonance
imaging, 3D ultrasonography, and pulsed holography.[13]
The 3DMDface System is a 3D imaging technique that
combines stereo photography and the structured light
technique.[13]
In the existing research, implant‑supported prosthetic
rehabilitation and soft tissue relationships; differences
of cost, function, occlusion, satisfaction, and chewing
efficiency between complete denture prostheses and
implant‑supported fixed prostheses; and advantages and
disadvantages were investigated in vitro and in vivo,
but no research had used the stereophotogrammetry
technique related to tissue support, esthetic differences,
and changes in facial structure with an exact method.
Estimating the advantages and disadvantages of esthetic
expectations in terms of physicians and patients in
different cases and different patient groups and the
determining method’s results in terms of esthetic results
can be a roadmap for clinicians.
This study aimed to evaluate the soft tissue changes with
3D images recorded before and after applying complete
dentures and implant‑supported fixed partial dentures
in mandibular and maxillary edentulous cases. In this
study, the influence of different prosthetic treatments on
supporting the soft tissue and affecting facial contour is
evaluated.
Material and Methods
The study was conducted on fourteen completely
edentulous patients of the age group between 42 to
63. The individuals who had motor difficulties, evident
deficiencies in everyday actions, or pathological changes
of the face or the alveolar ridges were excluded.
The patients were informed about the study and
were guaranteed that they would not be advantaged/
disadvantaged by accepting/refusing to participate. The
Ethics Committee of Süleyman Demirel University
Faculty of Medicine approved the study (approval
decision no. 215 as of December 04,2015), and each
participant signed a written consent form according to
the World Medical Association's Helsinki Declaration
(2018:189).
The inclusion criteria for the patients were:
• Patient wearing a complete denture for a minimum
of one year and a maximum of four years,
• The complete dentures were free of any defect in
vertical height, centric relation, supporting soft
tissue, anatomic variations.
287
 Demirekin, et al.: 3D assessment of facial contours with varying prostheses
• The patients were included in this study with
satisfying complete dentures and the ones who had a
positive look on fixed partial dentures, affirming the
fixed option is a better one.
The patient group comprised fourteen consecutive
patients treated with implant‐supported fixed partial
dentures without bone graft procedures. At least five
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implants per jaw were inserted in both edentulous
jaws.
Two edentulous patients were not included in this study
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as one was orthodontically Class III, and the other was
not able to attend control appointments.
Information was given about the complete dentures,
implant treatment, and implant‑supported fixed partial
denture strategies. They were asked if they would agree
to undergo any of these treatment strategies without
prior knowledge of which one they would choose.
They filled out a questionnaire taking several criteria
into account if they decided to have treatment with an
implant‑supported fixed partial denture. 3D photos were
recorded (T0) from the patients without wearing their
complete dentures.
The edentulous patient, who was a candidate for
implant‑retained fixed partial denture, was first
rehabilitated with a complete denture or the ones who
were already wearing complete dentures were included
after corrections were accomplished about vertical
height, buccal extension supporting lip and cheek.
Maxillary and mandibular complete dentures were
checked for occlusion, fitting, and ability for mastication.
These complete dentures were used for three weeks, and
3D photos were taken (T1) while patients were wearing
their dentures.
Surgical and prosthetic procedures
Edentulous patients were treated with dental
implants (ITI, Institut Straumann AG, Waldenburg,
Switzerland) after clinic and radiographic controls.
Three months after implant insertion, all implants were
evaluated by using of radiographs and clinically, and
after the osseointegration period, implant‑supported
fixed partial denture procedures were applied.
Implant‑supported fixed partial dentures were
manufactured utilizing the Cr‑Co alloy metal framework
and dental porcelain superstructure. All patients were
evaluated for occlusion, speech, esthetics, retention,
and mastication. Two weeks after cementation of
implant‑supported fixed partial dentures, 3D photos
were taken (T2).
Imaging and data processing
The 3D photogrammetric data were acquired using
the 3dMDface System (3dMD LLC) under clinical
288 Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022
lighting, which provides a measurement of distances,
angles, and volumetric changes between selected
points or areas. Calibration of the System was
performed before every imaging process. The images
were obtained in the natural head position before
treatments (T0), after complete denture (T1), and after
implant‑supported fixed partial dentures (T2). The
captured images were transferred to the 3dMD Vultus
software (3dMD Vultus software Version 2.3.0.2),
and measurements were performed. Studies have
reported that the imaging technique used is valid and
reliable.[14,15]
The soft tissue landmarks and nine linear, five angular,
and one topographical measurement are presented
in Tables 1 and 2 and Figures 1 and 2. To accurately
identify landmarks on the 3D surface, zoom and rotation
tools were used. To determine significant changes
between treatment approaches, repeated‑measures
analysis of variance (ANOVA) was used. The
Bonferroni multiple comparison tests were performed
on the measurements with statistical significance to
determine the groups. An α level of. 05 indicated a
significant difference in scores.
Results
Fourteen facial soft tissue measurements were included in
this study [Table 2], and the differences between groups
are presented in Table 3. Differences were observed in
anterior, upper, and lower facial heights; chin height;
upper lip height; mouth height; soft tissue convexity angle;
total facial convexity angle; upper lip angle; and Sl‑Li
topographical measurement compared to pretreatment
in the treatment approach. There was no statistically
significant difference found in these measurements
between the treatment groups. The changes observed in
the lower lip height and nasolabial angle compared with
Figure 1: Facial landmarks for analysis
 Demirekin, et al.: 3D assessment of facial contours with varying prostheses

Table 1: Landmarks used for 3D facial soft tissue assessment

Landmark Abbreviation Definition
Nasion N The midpoint on the soft tissue contour of the base of the nasal root at the level of the
frontonasal suture
Pronasale Print The most anterior midpoint of the nasal tip
Subnasal Sn The midpoint on the nasolabial soft tissue contour between the columella crest and the upper lip
Common Sto The midpoint of the horizontal labial fissure
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Labiale superiors Ls The midpoint of the vermilion line of the upper lip
Labiale inferious Li The midpoint of the vermilion line of the lower lip
Chellion (Right/Left) Chr/Chl The point located at each labial commissure
Sublabiale Sl The most posterior midpoint on the labiodental soft tissue contour that defines the border
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between the lower lip and the chin

Pogonion Pg The most anterior midpoint of the chin
Gnathion Gn The most inferior midpoint on the chin’s soft tissue contour is located at the level of the 3D
cephalometric hard tissue Mention landmark.

Table 2: Parameters used for 3D facial soft tissue assessment

Measurement Abbreviation Definition
Anterior facial height N‑Gn Distance between N‑Gn
Upper facial height N‑Sto Distance between N‑Sto
Lower facial height Sn‑Gn Distance between Sn‑Gn
Chin Height Sl‑Gn Distance between Sl‑Gn
Philtrum Height (The skin portion of the upper lip) Ls‑Sn Distance between Ls‑Sn
Upper Lip Height Sn‑ Sto Distance between Sn‑ Sto
Lower Lip Height Sto‑Sl Distance between Sto‑Sl
Mouth Height Ls‑Li Distance between Ls‑Li
Mouth Width Chr‑Chl Distance between Chr‑Chl
Upper Lip Angle Chr Ls Chl The angle between Chr Ls Chl
Lower Lip Angle Chr Li Chl The angle between Chr Li Chl
Nasolabial Angle Prn Sn Ls The angle between Prn Sn Ls
Soft Tissue Convexity Angle Ning The angle between N Sn Pg
Total Facial Convexity Angle NPrnPg The angle between N Prn Pg
Sl‑Li Topographical Measurement Sl‑Li Topographical distance between Sl‑Li

Table 3: Morphometric evaluation of prosthodontic treatment approaches

T0 (±S) T1 (±S) T2 (±S) P T0‑T1 T0‑T2 T1‑T2
Anterior facial height (mm) (N‑Gn) 130,94±9,59 134,45±8,66 133,36±8,72 *** *** ** ns
Upper facial height (mm) (N‑Sto) 82,03±6,79 84,45±6,44 84,75±6,08 *** *** *** ns
Lower facial height (mm) (Sn‑Gn) 73,27±6,71 75,42±6,40 74,66±5,83 *** *** * ns
Chin Height (mm) (Sl‑Gn) 31,29±4,61 32,79±4,11 33,12±3,88 *** ** *** ns
Mouth Width (mm) (Chr‑Chl) 52,53±4,36 52±3,83 52,83±3,93 ns ns ns ns
Philtrum Height (mm) (Ls‑Sn) 18,67±2,75 19,77±1,9 18,88±1,96 * ns ns **
Upper Lip Height (mm) (Sn‑ Sto) 22,80±2,91 24,89±2,03 24,41±2,31 *** * * ns
Lower Lip Height (mm) (Sto‑Sl) 17,15±4,24 18,63±3,76 18,14±3,49 *** *** ns ns
Mouth Height (mm) (Ls‑Li) 10,05±1,9 11,48±1,29 11,48±1,68 *** ** ** ns
Soft Tissue Convexity Angle (°) (NSnPg) 169,37±7,17 166,04±6,68 167,11±5,8 *** *** * ns
Total Facial Convexity Angle (°) (NPrPog) 134,52±6,79 131,60±6,77 132,05±6,26 *** *** *** ns
Upper Lip Angle (°) (Chr Ls Chl) 157,88±7,28 156,15±6,91 155,85±6,88 *** * ** ns
Lower Lip Angle (°) (Chr Li Chl) 159,29±7,89 157,47±7,39 157,21±7,62 ** ns * ns
Nasolabial Angle (°) (Prn Sn Ls) 128,22±7,42 125,51±7,14 126,43±6,55 ** ** ns ns
Sl ‑ Li (mm) 13,52±2,94 14,33±2,43 14,40±2,41 ** * * ns
ns: non significant, *P˂.05, **P˂.01, ***P˂.001

pretreatment were significant in the CD group but not in difference observed in the lower lip angle compared with
the implant‑supported fixed partial denture group. The the pretreatment was significant in the implant‑supported

Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022 289

 Demirekin, et al.: 3D assessment of facial contours with varying prostheses
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Figure 2: Lateral view of facial landmarks for analysis
fixed partial denture group but not in the CD prosthesis
group. The changes in mouth width were not significant.
The philtrum height changes compared to the pretreatment
were not significant in both groups, but the difference
between the groups was significant.
Discussion
Soft tissue support is one of the main issues of prosthetic
rehabilitation when treating completely edentulous
patients. In the literature, studies are examining these
esthetic changes in facial contours, hard and soft tissue
using cephalometric radiography,[6,7] 2D photographs,[8,9]
and 3D imaging technologies.[10,11] The 3dMDface
System is a 3D imaging technique combining stereo
photography and the structured light technique.[13]
Researchers who investigated this imaging technique’s
accuracy concluded that it is a reliable and suitable
technique for facial imaging evaluations.[14,15] In the
literature, there are multiple studies on populations,
orthodontics, and surgery with this technique. According
to the literature research we conducted, in the field
of prostheses, no studies have been done with the
3dMDface System conccerning CD and implant
supported‑fixed partial dentures.
In edentulous patients, supporting soft tissues and
improving facial appearance for better esthetics is as
important as function. In the literature, studies evaluate
the effects of CD,[9,10] implant‑supported prosthesis,[11,16]
labial flange effects on facial structure,[17,18] and labial
flange effects on facial esthetic impressions.[19‑21] In the
current study, the effect of CD and implant‑supported
prosthesis on facial soft tissue and the differences
between these treatment methods were evaluated using
the 3dMDface System.
Edentulous patients’ facial appearance is generally
characterized by the sign of changes and closure in the
290 Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022
lower third of the face. This vertical closure affects the
mouth and nose distance dramatically and hence the
entire facial structure.[22] A concave facial profile, nine
prognathic views of the mandible, and pseudo Class III
relationship are present in most adult edentulous
patients.[6,23] The factors that cause this condition
have been reported as a loss of maxillary lip support,
excessive projection of the chin due to aging, changes
in the occlusal vertical dimension, or a combination
of them.[8] These facial profile changes appear more
excessive in patients with protrusive mandibula than
with retrusive mandibula.[22] Patients with a concave
profile might need compensatory support.[16] The
occlusal vertical dimension affects the mandibular
position.[24] The prosthetic treatment causes the posterior
rotation of the mandibula, and a decrease in mandibular
prognathism,[6] and generally, a better facial profile
is obtained with a new prosthesis.[6,9] Bidra reported
that this mandibula movement might help improve the
appearance of a patient with a concave profile. Still,
in patients with convex profiles, this movement of
the mandibula might be a challenging factor.[8] In the
current study, 3D soft tissue findings also support this
view. A significant decrease was observed in the study’s
soft tissue convexity angle and total facial convexity
angle. There were no significant differences between the
treatment approaches in terms of these facial angles.
In their cephalometric study, Çiftçi et al.[6] found an
increase in the vertical facial dimension with dentures
in patients. Kamashita et al.[10] evaluated the effects of
prosthetic treatment in toothless patients in a 3D imaging
study. They reported no change in Ex‑Ch and Sn‑Pg
measurements. Tartaglia et al. reported an increase in
facial heights in their 3D imaging study.[11] The current
study results for facial height changes were consistent
with the results of Tartaglia et al.[11] An increase in the
anterior (N‑Gn), upper (N‑Sto), and lower (Sn‑Gn) facial
heights were observed with both treatment approaches,
and there was no significant difference between the
approaches. In both treatment approaches, the chin
height was one of the soft tissue linear measurements
affected by the increased occlusal vertical dimension.
Facial support is indicated as one of the critical
factors for prosthesis design decisions because the
labial flange of restoration and denture teeth’ position
obtain soft tissue support and facial esthetics.[10,16]
The improvement of lip support is not required for all
edentulous patients.[25] The perception of lip support
is affected by several factors, including anterior tooth
positions,[10,16,23,26] especially their angles;[10] labial flange
borders and thickness;[27] cervical edge contours;[16,28]
amount of alveolar bone resorption;[29] morphology of
 Demirekin, et al.: 3D assessment of facial contours with varying prostheses
the cartilaginous part of the lower nose, nasal septum,
and anterior nasal spine; angulation of the nasal tip and
nasolabial angle; projection of the chin;[25] lip contour;
the form of the nasal base and labiodental sulcus;[10]
and facial hair, including mustache and beard in men.[8]
Zitzmann and Marinello reported that the position of the
upper lip base might vary based on the amount of upper
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lip support provided by a prosthesis.[16] The proper lip
support and occlusal vertical dimension could change
the location of the subnasal and pogonion.[8]
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Dentures can affect the nose’s form, including its tip,[10]
nevertheless, nasolabial angle (Prn Sn Ls) is considered
one of the parameters of lip support. Kamashita
et al.[10] reported a decrease in this angle with complete
dentures, and Tartaglia et al.[11] observed a significant
decrease in this angle with implant‑supported fixed
partial dentures. In our study, a decrease in this angle
was observed in both groups. The decrease in the CD
group was significant compared to pretreatment, but it
was not significant in the implant group. These findings
might be due to factors affecting lip support such as
labial flange, anterior tooth positions, anterior tooth
angles, and the removable restoration’s nasal base shape.
However, according to pairwise comparisons, there
were no statistically significant differences between the
two treatment approaches. Bidra et al.[18] pointed out
that anatomical differences between the labial flange
and flangeless prostheses are minimal and clinically
insignificant. Similarly, in facial esthetics[19] and lip
support evaluations[20] by laypeople, prosthodontists, and
general dentists, the differences have been very small
and clinically insignificant between the prostheses with
and without labial flanges. When patients performed
the facial esthetics evaluation, it was reported that there
was no difference in facial esthetics between these two
prosthetic designs.[21]
Dental prosthesis significantly modified labial
dimensions and positions.[9,11] In the current study, a
significant increase in mouth height was observed,
without significant mouth width differences compared
with the initial treatment value. These results were
similar to the results reported by Tartaglia et al.[11] Rasche
et al.[9] reported an increase in mouth width in their
study with facial anthropometric indexes and pointed
out the more original and natural facial dimensions’
re‑establishment. Due to the lack of dental support,
upper and lower vermillion changes are observed in
edentulous patients.[23] Kamashita et al.[10] reported that
the vermilions were pushed out and enlarged by applying
the dentures. These protrusive movements were the
cause of changes observed in vertical lip measurements
in the current study.
Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022
An increase in the occlusal vertical dimension makes
the perioral area look younger and ensures a younger
appearance of the whole face.[30] A decrease in the
lower and upper lip vermillion height and a relative
increase in the cutaneous part of upper and lower lips
are typical appearances of perioral aging. The mouth
width is seen to increase, which has been reported to
be caused by the upper lip’s sagging.[31] The increased
upper vermillion height provides a more youthful and
attractive appearance.[9] In the current study, in both
treatment approaches, when the philtrum height and
upper lip height were compared to the edentulous
condition together, the significant increase in the upper
lip height was caused by the increase in the upper
vermillion exposure. This result is consistent with the
findings of Raschke et al.,[9] and the esthetic alternation
can be considered especially in female patients.
In the current study, compared to the edentulous
situation, there was a similarity between the effects of
treatment methods in upper lip height and upper lip
angle. The effect of CD on the lower lip height was
statistically significant, whereas the implant‑supported
prosthesis effect was not significant. Additionally, the
lower lip angle change was statistically significant in
the implant‑supported prosthesis group, whereas CD’s
effect was not significant. The labial flange could cause
this result. According to the pairwise comparisons,
there was no significant difference between treatment
methods. Considering the upper and lower lip heights
and angles together in three‑dimensional measurements,
the effects of treatment approaches on the lower lip were
remarkable. This conclusion could be in agreement with
Tartaglia’s findings, who reported that the lower lip was
influenced by the prosthetic treatment more than the
upper lip in these groups of patients.[11] In edentulous
patients, the mean reduction in anterior lower ridge
height was four times greater than in the upper ridge.[29]
The structural modification of the regional facial soft
tissue after this alveolar reduction could affect the lower
lip’s responses. This result might be one reason the lower
lip reactions to the treatment approaches in edentulous
patients were different from those of the upper lip. In
patients with CD, Raschke et al.[9] reported an increase
in the upper lip height but no significant modification
in lower lip height. The reason this result of the current
study was not compatible with that of Raschke et al.
might be the evaluation method.[9]
Facial soft tissue is a complex structure. The estimation
of soft tissue alteration could be difficult.[32,33] The reasons
for this difficulty include various factors such as the
thickness, tonicity, posture, and length of the soft tissue
covering.[32] Many factors such as lip support,[34] high
291
 Demirekin, et al.: 3D assessment of facial contours with varying prostheses
lip line,[35] soft tissue defects,[34‑37] the amount of bone
loss that has occurred,[34,36,37] and the patient’s restorative
history[36] must be taken into account while deciding on
the prosthetic design. There are reports that the labial
flange exposed clinically insignificant differences.[18‑21]
Additionally, some studies reported that the labial flange
significantly ensured lip support.[30,17,34,37] Deciding on
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lip support can be critical for patients who have severe
resorption and are unsatisfied with their appearance.
The thickness of the labial flange in a complete denture
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/16/2023
prosthetic option might more specifically satisfy the
patient’s esthetic requirements.[17,37] In the current study,
according to pairwise comparisons, the only statistically
significant difference between the two treatment methods
was found in philtrum height. A more significant
increase was observed in the CD group. This result
might have been due to the labial flange effect, which
can be considered in patients with short philtrum.
The prediction of soft tissue responses, which is very
important for obtaining facial esthetics, has become
more comfortable due to the development of imaging
technologies. 3D facial scanning is an ideal method for
the evaluation of soft tissue imaging.[38] 3D technologies
had made it possible to evaluate the facial soft tissue and
its changes in volumetric measurements and a coordinate
system. More comprehensive studies assessing the
effects of CD and the implant‑supported prosthesis can
be conducted. In the current study, soft tissue changes
were observed in both treatment approaches applied
to edentulous patients. In the treatment planning,
practitioners should consider the philtrum and the lower
lip in the soft tissue evaluation.
Conclusions
There was no significant difference between CD and
implant‑supported fixed partial denture regarding
anterior, upper and lower facial heights; chin height;
upper lip height; mouth height; soft tissue convexity
angle; total facial convexity angle; upper lip angle;
and Sl‑Li topographical measurement. The results may
advise suggestion of fixed partial dentures to patients
who will receive implant therapy as they are more
natural tooth‑like restorations than complete dentures.
Hence implant‑supported fixed partial dentures are
capable of supporting facial soft tissues, except philtrum
regions, presenting similar facial contours as complete
dentures.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
292 Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022
Clinical Implications
The prosthetic treatment goal is to improve dental
function along with both dental and facial esthetics. The
three-dimensional facial soft tissue assessment ensures
more reliable knowledge about the results of different
treatments. The knowledge about facial soft tissue
changes depend on the dentures and implant-supported
fixed partial dentures and can help to decide treatment
procedures in edentulous patients.
References
1. Misch CE. Contemporary Implant Dentistry. Elsevier Health
Sciences, Global - English; 2007. p. 1‑1120.
2. Eğilmez F, Ergun G, Cekic‑ Nagas I, Bozkaya S.
Implant‑supported hybrid prosthesis: Conventional treatment
method for borderline cases. Eur J Dent 2015;9:442‑8.
3. Feine JS, Carlsson GE, Awad MA, Chehade A, Duncan WJ,
Giani S, et al. The McGill consensus statement on overdentures.
Mandibular two‑implant overdentures as a first choice standard
of care for edentulous patients. Montreal, Quebec, May 24‑25,
2002. Int J Oral Maxillofac Implants 2002;17:601‑2.
4. Real‑Osuna J, Almendros‑Marques N, Gay‑Escoda C.
Prevalence of complications after the oral rehabilitation with
implant‑supported hybrid prostheses. Med Oral Patol Oral Cir
Bucal 2012;17:116‑21.
5. Bergman B, Carlsson GE. Clinical long-term study of complete
denture wearers. J Prosthet Dent. 1985;53:56-61.
6. Çiftçi Y, Kocadereli İ, Canal Ş, Şenyılmaz P. Cephalometric
evaluation of maxillomandibular relationships in patients wearing
complete dentures: A pilot study. Angle Orthod 2005;75:821‑5.
7. Watson RM, Bhatia SN. Tooth positions in the natural and
complete artificial dentitions, with special reference to the incisor
teeth: An interactive on‑line computer analysis. J Oral Rehabil
1989;16:139‑53.
8. Bidra AS. Three‑Dimensional esthetic analysis in treatment
planning for a ımplant‑supported fixed prosthesis in the
edentulous maxilla: Review of the esthetics literature. J Esthet
Restor Dent 2011;23:219‑37.
9. Raschke GF, Eberl P, Thompson GA, Güntsch A, Peisker A,
Schultze‑Mosgau S, et al. Wearing complete dental
prostheses‑ Effects on perioral morphology. Med Oral Patol Oral
Cir Bucal 2016;21:413‑9.
10. Kamashita Y, Kamada Y, Kawahata N, Nagaoka E. Influence of
lip support on the soft‑tissue profile of complete denture wearers.
J Oral Rehabil 2006;33:102‑9.
11. Tartaglia GM, Dolci C, Sidequersky FV, Ferrario VF, Sforza C.
Soft tissue facial morphometry before and after total oral
rehabilitation ımplant‑supported prostheses. Craniofac Surg
2012;23:1610‑4.
12. Kim DI, Lagrave’s MO. Assessing the Correlation between
Skeletal and Corresponding Soft-Tissue Equivalents to
Determine the Relationship between CBCT Skeletal/Dental
Dimensions and 3D Radiographic Soft-Tissue Equivalents. Int J
Dent. 2018;2018:8926314.
13. Kau CH, Richmond S. Three Dimensional Imaging for
Orthodontics and Maxillofacial Surgery. 1st ed. Singapore:
Wiley‑Blackwell; 2010. p. 11‑28.
14. Plooij JM, Swennen GR, Rangel FA, Maal TJ, Schutyser FA,
Bronkhorst EM, et al. Evaluation of reproducibility and reliability
of 3d soft tissue analysis using 3d Stereophotogrammetry. Int J
Oral Maxillofac Surg 2009;383:267‑73.
 Demirekin, et al.: 3D assessment of facial contours with varying prostheses
15. Lubbers HT, Medinger L, Kruse A, Gratz KW, Matthews F.
Precision and accuracy of the 3dMD photogrammetric
system in a craniomaxillofacial application. J Craniofac Surg
2010;21:763‑7.
16. Zitzmann NU, Marinello CP. The treatment plan for restoring
the edentulous maxilla with implant‑supported restorations:
Removable overdenture versus fixed partial denture design.
J Prosthet Dent 1999;82:188‑96.
Downloaded from http://journals.lww.com/njcp by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AW
17. Fortin Y, Sullivan RM, Rangers BR. The Marius implant
bridge: Surgical and prosthetic rehabilitation for the completely
edentulous upper jaw with moderate to severe resorption:
A 5‑year retrospective clinical study. Clin Implant Dent Relat
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/16/2023
Res 2002;4:69‑77.
18. Bidra AS, Zapata G, Agar JR, Taylor TD, Grady J. Differences
in lip support with and without labial flanges in a maxillary
edentulous population. Part 1: Objective analysis. J Prosthodont
2018;27:10‑6.
19. Bidra AS. Manzotti A, Wu R. Differences in Lip support with
and without labial flanges in a maxillary edentulous population.
Part 2: Blinded subjective analysis. J Prosthodont 2018;27:17‑21.
20. Bidra AS. Nguyen V, Manzotti A, Kuo CL. Differences in lip
support with and without labial flanges in a maxillary edentulous
population – Part 3: Unblinded and discriminatory subjective
analysis. J Prosthodont 2018;27:22‑8.
21. Bidra AS, Touloumi F, Wu R. Differences in lip support with
and without labial flanges in a maxillary edentulous population.
Part 4: Patient‑centered analysis. J Prosthodont 2018;27:29‑34.
22. Martone AL. Effects of complete dentures on facıal esthetıcs.
J Prosthet Dent 1964;14:231‑55.
23. Nairn, RI. Interrelated factors in complete denture construction.
J. Pros. Den 1965;15:19‑24.
24. Spear FM. Approaches to the vertical dimension. Adv Ethet
Interdicip Dent 2006;2:2‑12.
25. Bidra AS, Agar JR. A classification system of patients for
esthetic fixed implant‑supported prostheses in the edentulous
maxilla. Compend Contin Educ Dent 2010;31:366‑8, 370, 372‑4.
26. Watt DM. Tooth positions on complete dentures. J Dent
1978;6:147‑60.
27. Besford JN, Sutton AF. Aesthetic possibilities in removable
Nigerian Journal of Clinical Practice ¦ Volume 25 ¦ Issue 3 ¦ March 2022
prosthodontics. Part 2: Start with the face, not the teeth,
when rehearsing lip support and tooth positions. Br Dental J
2018;24:141‑8.
28. Malo P, Nobre Mde A, Lopes I. A new approach to rehabilitate
the severely atrophic maxilla using extra maxillary anchored
implants in immediate function: A pilot study. J Prosthet Dent
2008;100:354‑66.
28. Talgren A. The continuing reduction of the residual alveolar
ridges in complete denture wearers: A mixed‑longitudinal study
was covering 25 years. J Prosthet Dent 1972;27:120‑32.
30. Mohindra NK. Bulman JS. The effect of increasing vertical
dimension of occlusion on facial aesthetics. Br Dent J
2002;192:164‑8.
31. Raschke GF, Rieger UM, Bader RD, Schaefer O, Guentsch A,
Dammeier MG, et al. Perioral aging‑An antropometric appraisal.
J Craniomaxillofac Surg 2014;42:312‑7.
32. Koh CH, Chew MT. Predictability of soft tissue profile changes
following bimaxillary surgery in skeletal class III Chinese
patients. J Oral Maxillofac Surg 2004;62:1505‑9.
33. Konstantonis D, Vasileiou D, Papageorgiou SN, Eliades T.
Soft tissue changes following extraction vs. non‑extraction
orthodontic fixed appliance treatment: A systematic review and
meta‑analysis. Eur J Oral Sci 2018;126:167‑79.
34. Jivraj S, Chee W, Corrado P. Treatment planning of the
edentulous maxilla. Br Dent J 2006;201:261‑79.
35. Nerves FD, Mendonça G, Neto AJF. Analysis of the influence of
lip liner and lip support in esthetics and selection of maxillary
implant‑supported prosthesis design J Prosthet Dent 2004;91:286‑8.
36. Steigman M. Treatment sequencing for the multiunit restoration:
Hard and soft tissue considerations. J Oral Maxillofac Surg
2007;65:53‑63.
37. Bedrossian E, Sullivan RM, Fortin Y, Malo P, Indresano T.
Fixed‑prosthetic implant restoration of the edentulous maxilla:
A systematic pretreatment evaluation method. J Oral Maxillofac
Surg 2008;66:112‑22.
38. Hassan B, Greven M, Wismeijer D. Integrating 3D facial
scanning in a digital workflow to CAD/CAM design and fabricate
complete dentures for immediate total mouth rehabilitation. Adv
Prosthodont 2017;9:381‑6.
293