Analysis of influence of lip line and lip support in esthetics and selection of

maxillary implant-supported prosthesis design

Flávio Domingues Neves, DDS, MS, PhD,a Gustavo Mendonça, DDS, MS,b and
Alfredo Julio Fernandes Neto, DDS, MS, PhDc
School of Dentistry, Federal University of Uberlandia, Minas Gerais, Brazil; Catholic University of
Brasilia, Brasilia, Brazil

The lip line and lip support influence esthetics and selection of implant-supported prosthetic designs for
maxillary edentulous patients. This article describes a procedure to analyze the influence of lip line and lip
support on the esthetics of an existing maxillary complete denture, revealing potential limitations when
planning a fixed implant-supported prosthesis. (J Prosthet Dent 2004;91:286-8.)

C orrect implant placement and restorative design

requires knowledge of prosthetic limitations and patient
expectations.1-3 This is especially true for the maxillary
edentulous patient seeking an implant-supported resto-
ration. There are a number of prosthetic alternatives that
may significantly impact dental and facial esthetics
including: (1) fixed metal ceramic implant-supported
restoration, (2) fixed implant-supported complete
denture, and (3) removable implant-supported com-
plete denture or (4) implant overdenture. The decision
to fabricate a fixed or removable prosthesis selection is
dependent on financial means, bone quantity and
quality, hygiene preference, lip line, and lip support.2
This article describes a technique that allows the patient
to preview the expected esthetic result 3-dimensionally
and to collaborate in the prosthetic design choice.
TECHNIQUE
1. Evaluate the patient’s existing maxillary complete
denture and determine whether the denture is
satisfactory with respect to size, arrangement of
teeth, incisal plane, and lip support.
2. Duplicate the denture with the use of a denture
duplicator (Denture Duplicator; Lang Dental Mfg
Co, Wheeling, Ill). Place irreversible hydrocolloid
(Jeltrate; Dentsply International, York, Pa) in the
lower half of the flask. Place the cameo surface of the
denture into the impression material at a slight
angle. Place the anterior teeth closer to the bottom
of the flask with the posterior teeth positioned
slightly more superior than the anterior teeth. After
the impression material has set, place additional
irreversible hydrocolloid in remainder of the flask.
a
Assistant Professor, Department of Occlusion, Fixed Prosthesis, and
Dental Materials, Federal University of Uberlandia, School of
Dentistry.
b
Assistant Professor, Department of Prosthodontics, Catholic Univer-
sity of Brasilia.
c
Professor and Chairman, Department of Occlusion, Fixed Prosthe-
sis, and Dental Materials, Federal University of Uberlandia,
School of Dentistry.
Carefully place the impression material into the base
of the denture (intaglio surface) in the lower half of
the flask. Place additional impression material into
the upper half of the flask. Close the flask with steady
pressure. Secure the thumb screw and allow
impression material to set. Remove the denture
and fill the impression with autopolymerizing acrylic
resin. Use tooth-colored acrylic resin (Jet Tooth
Shade; Lang Dental Mfg Co, Wheeling, Ill) in the
area of the teeth and clear acrylic (Ortho-Jet; Lang
Dental Mfg Co, Wheeling, Ill) in the area of the
base. After polymerization, remove the duplicate
denture and trim excess resin on the cameo portion
of the duplicate denture. Use a slow-speed hand-
piece with a No. 8 round bur (HP 14844; SS White
Burs Inc, Lakewood, NJ) to prepare the pilot hole in
the resin tooth of the duplicate denture. Condense
gutta-percha (Gutta-percha Hygenic; The Hygenic
Corp, Akron, Ohio) into the holes.
3. Place the duplicate denture intraorally and instruct
the patient to wear this template during the
radiographic examinations. Make radiographs of
the patient with the template in position. Plan the
implant height and location with the aid of the
gutta-percha markers placed to detect the bone
level.
4. Mark the duplicate denture papillae in black with
a fine-point marker (Grip Fine-Point Permanent
Marker, Black; Societe BIC, Clichy Cedex, France),
simulating their absence for the implant-supported
fixed prosthesis (Fig. 1). Place the duplicate denture
intraorally and determine the role of the papillae on
the esthetic result. (Fig. 2).
5. Remove the labial flange above the anterior teeth.
(Fig. 3). Place the duplicate denture intraorally
again, to determine the lip support needs without
the benefit of the anterior flange. (Fig. 4).
6. Prepare the duplicate denture to be used as a surgical
template. Prepare holes in the template with a pear-
shaped acrylic bur (H77-060; Brassler USA, Savan-
nah, Ga), according to the number of implants
selected for the patient. Sterilize the template in

286 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 91 NUMBER 3

NEVES, MENDONÇA, AND FERNANDES NETO
Fig. 1. Papillae area marked with black for lip line analysis.
Fig. 3. Anterior flange removed from duplicate denture for lip
support analysis.
glutaraldehyde 2% solution (Sekucid; Paragerm Lab,
Carros Cedex, France).
DISCUSSION
After demonstrating to the patient a preview of the
dental and facial esthetics, a more informed decision can
be made regarding the limitations of a fixed prosthetic
design. According to Sadowsky,3 a fixed implant-
supported metal ceramic prosthesis may achieve optimal
esthetics, phonetics, and hygiene access for patients with
a minimally resorbed residual ridge. However, there are
important considerations in terms of residual bone, soft
tissue, and implant number. If these criteria are met, and
the patient does not require a flange for esthetics, then
a metal ceramic design may be acceptable. With
moderate to advanced resorption, teeth, as well as hard
and soft tissues, may require replacement. A fixed
implant-supported complete denture can offer a matrix
for a flange, but a high lip line may expose either the
framework or implants. A prosthesis with an acrylic
MARCH 2004
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 2. Frontal view with duplicate denture in position.
Papillae are visible.
Fig. 4. Lateral view with duplicate denture in position. Lip
supported only by teeth.
flange may be needed. Therefore, a high lip line or soft
tissue defects may require either a removable implant-
supported complete denture or an implant overdenture.
SUMMARY
The facial and dental esthetic planning of a maxillary
implant-supported prosthesis is complex. The technique
described involves duplicating the patient’s existing
complete denture and using the duplicate denture as
a template to allow visualization of the impact of the
definitive implant-supported restoration on esthetics,
before beginning treatment. Then both surgical plan-
ning for implant placement and design choice may lead
to a more optimal result.
REFERENCES
1. Desjardins RP. Prosthesis design for osseointegrated implants in the
edentulous maxilla. Int J Oral Maxillofac Implants 1992;7:311-20.
2. DeBoer J. Edentulous implants: overdenture versus fixed. J Prosthet Dent
1993;69:386-90.
3. Sadowsky SJ. The implant-supported prosthesis for the edentulous arch:
design considerations. J Prosthet Dent 1997;78:28-33.
287
THE JOURNAL OF PROSTHETIC DENTISTRY NEVES, MENDONÇA, AND FERNANDES NETO

Reprint requests to: 0022-3913/$30.00

DR FLÁVIO DOMINGUES NEVES SCHOOL OF DENTISTRY Copyright ª 2004 by the Editorial Council of The Journal of Prosthetic
FEDERAL UNIVERSITY OF UBERLANDIA Dentistry
AV. PARÁ, 1720 - BLOCO 2B, SALA 2B01
UBERLANDIA
MINAS GERAIS, CEP: 38400-902
BRAZIL
FAX: 55 (34) 3218-2222
E-MAIL: neves@triang.com.br doi:10.1016/j.prosdent.2003.12.006

Status of teeth adjacent to single-tooth implants

Noteworthy Abstracts Krennmair G, Piehslinger E, Wagner H. Int J Prosthodont
of the 2003;16:524-8.
Current Literature

Purpose. This study evaluated the status of teeth adjacent to single-tooth implants in the anterior and posterior
jaw during a follow-up of more than 3 years.
Materials and Methods. Seventy-eight single-tooth implants and 148 adjacent teeth were followed for a mean
of 58 months. Implant survival rate, peri-implant structures, and prosthetic complication rates were evaluated.
Crowns and periodontal status of adjacent teeth were compared at crown placement and at the last examination.
Horizontal distance from the implant edge to adjacent teeth was calculated and compared for anterior and
posterior regions. The influence of approximal crestal bone resorption of the adjacent teeth was calculated using
multivariate regression analysis.
Results. The clinical findings for implants (one loss), peri-implant structures, and prosthetic complication rates
(three crown fractures) were excellent. There was a high proportion of intact adjacent teeth in both anterior and
posterior regions at crown placement and at the follow-up examination. No adjacent teeth required extraction
or endodontic treatment, and only four required restoration. Comparison of the periodontal status at crown
placement and at follow-up revealed no differences for plaque and bleeding indices or for pocket depth of
adjacent teeth. There was a significant influence of the horizontal distance on approximal bone loss in the closer
distance of the anterior region, but not in the posterior region.
Conclusion. The crown and periodontal status of teeth adjacent to single-implant restorations was excellent.
The approximal bone crest reduction of the adjacent teeth was significantly influenced by the horizontal
distance between the implant edge and neighboring tooth.—Reprinted with permission of Quintessence
Publishing.

288 VOLUME 91 NUMBER 3