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Int. J. Oral Maxillofac. Surg.

2004; 33: 676–682


doi:10.1016/S0901-5027(03)00132-2, available online at http://www.sciencedirect.com

Clinical Paper
Preprosthetic Surgery
D. N. Sutton1, B. R. K. Lewis2,
Changes in facial form relative M. Patel3, J. I. Cawood2
1
Department of Maxillofacial Surgery,
University Hospital Aintree, Liverpool, UK;

to progressive atrophy of the 2


Department of Maxillofacial Surgery,
Countess of Chester Hospital, Chester, UK;
3
Department of Maxillofacial Surgery,

edentulous jaws Withington Hospital, Manchester, UK

D. N. Sutton, B. R. K. Lewis, M. Patel, J. I. Cawood:Changes in facial form


relative to progressive atrophy of the edentulous jaws. Int. J. Oral Maxillofac.
Surg. 2004; 33: 676–682. # 2003 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The surgical and prosthodontic rehabilitation of the edentulous patient


aims to restore oral function and facial form. Planning treatment requires an
understanding of the effect of progressive jaw atrophy, and the concomitant effect
on the soft tissues of the face. This study examined 179 Caucasians at different
stages of jaw atrophy according to the Cawood and Howell classification; various
standard anthropological measurements of the face, according to Farkas, were also
taken. We have demonstrated that changes in the soft tissues are related to the
degree of underlying jaw atrophy. This has important implications when planning
surgical and prosthodontic rehabilitation of the edentulous patient.
Early stages of jaw atrophy (Class II, III & IV) result in the collapse of the
circumoral musculature causing a narrowing of the mouth, loss of lip support,
Key words: jaw atrophy; facial certhetics;
inversion of the lips and contraction of the cheeks. Late changes of jaw atrophy assessment & treatment planning; surgery/
(Class V & VI) result in changes in vertical facial proportion causing a decrease prosthodontics edentulous jaw.
in lower facial height and an increase in chin prominence.
These late skeletal changes accentuate the earlier soft tissue facial effects. Accepted for publication 8 May 2003

The surgical and prosthodontic rehabili- there are changes in the facial muscula- form, using recognised anthropometric
tation of the edentulous patient has two ture and consequently a change in facial measurements according to Farkas, and
main goals, firstly, the restoration of oral morphology2. TALLGREN observed that relate these to the extent of jaw atrophy,
function and secondly the restoration of the greatest proportion of the alveolar using the classification of the edentulous
facial form. The relative importance of bone loss occurs in the first year10, how- jaws described by CAWOOD & HOWELL1.
each of these factors will vary from ever this is a chronic process and bone
patient to patient. Satisfactory planning loss continued over the subsequent 25
Methods
of treatment and need or otherwise for years of her study. In addition it is
bone augmentation for these patients known that the rate of this chronic pro- The study sample consisted of 179 Cau-
requires a full understanding of the cess varies not only between individuals, casian patients, mean age 63 years, range
effect of progressive jaw atrophy not but also within the same individual over 18–97 years with varying degrees of jaw
only on the bones of the jaw but also of a period of time. atrophy. The patients were assigned to
the overlying soft tissues. Relatively little has been published groups according to the stage of jaw atro-
Loss of the natural dentition results in regarding the progressive soft tissue phy, which was established by clinical
gradual resorption of the alveolar pro- changes consequent to the loss of the den- examination. Jaw atrophy was assessed
cess and consequently a change in nat- tition. Accordingly the aim of the study using the classification of CAWOOD &
ural jaw relationship, at the same time was to examine the changes in facial HOWELL (Fig. 1).
0901-5027/070676 + 07 $30.00/0 # 2003 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Changes in facial form relative to progressive atrophy of the edentulous jaws 677

Fig.2. Anthropometric measurements (frontal).

Fig. 1. Cawood & Howell Classification of the edentulous jaws.

The distribution of the patients is height percentage was calculated


shown in Table 1. Each patient had (Table 2 and Figs 2 & 3).
seven standard anthropometric measure- Statistical analysis was carried out
ments carried out according to the meth- using one-way analysis of variance test
ods of FARKAS3,5 and those of KOLAR & using a computer statistical package
SALTER7. The measurements used were (Statistical Package for Social Sciences,
nasolabial angle, commissure width, SPSS) to assess the significance of dif-
upper lip length, alar base width, chin ferences between the various groups Fig. 3. Anthropometric measurements (lateral).
prominence and the total and lower face relative to the anthropometric measure-
heights, from which the lower face ment involved.
and lower face height proportion rela-
tive to the stage of jaw atrophy.
Table 1. To show number of patients accord- Results
Decrease in commissure width and
ing to stage of jaw atrophy (see Fig. 1) The results for each anthropometric increase in the nasolabial angle are
Male Female Total measurement are presented in Table 3 early changes; whereas the decrease in
with appropriate statistical significance lower face height and the increase in
Class I 50 50 100 and graphically (Figs 7, 8, 9, 11). Sta- chin prominence occur as late changes.
Class III 17 13 30 tistical analysis revealed that there were There were no significant changes in
Class IV 17 14 31 significant changes in nasolabial angle, alar base width or upper lip length
Class V 9 9 18
commissure width, chin prominence between the groups.
678 Sutton et al.

Table 2. Anthropometric definitions of measurements used (see also Figs 2 & 3)


Anthropometric Measurement Anthropometric definition
code
SA-43 Nasolabial angle The angle between the surfaces of the columella and the upper lip
SH-13 Commissure width The distance between the cheilions of the closed mouth
SV-27 Upper lip length The height of the upper lip between the subnasale and the stomion
SH-10 Alar base width The distance between the most lateral points on the alae
SV-21 Total face height The distance between the nasion and the gnathion
SV-23 Lower face height The distance between the subnasale and the gnathion
Chin prominence The distance of pogonion from vertical facial profile line

Table 3. Showing mean anthropometric variables relative to degree of jaw atrophy


Alveolar ridge classification
Significance
I III IV V
Nasolabial angle (8)
Male 100 110 112 125 0.001
Female 100 110 110 130
Commissure width (mm)
Male 53 46 44 43 0.001
Female 50 43 40 40
Lower face height proportion (%)
Male 57 57 54 50 0.001
Female 57 56 54 50
Chin prominence (mm)
Male 0 0 1 8 0.001
Female 0 0 1 7
Upper lip length (mm)
Male 23 23 23 22 n.s.
Female 20 21 21 21
Alar base width (mm)
Male 37 36 37 37 n.s.
Female 33 32 34 34

Fig. 4. Dental bulge (Watt & McGregor).


Changes in facial form relative to progressive atrophy of the edentulous jaws 679

Fig. 5. Muscles of facial expression.

Fig. 6. Early effects of jaw atrophy on facial form.

Fig. 7. Decrease in commissure width (early change).


680 Sutton et al.

Fig. 8. Increase in nasolabial angle (early change).

Discussion increased interest in medically asso- Obviously, the complex nature of the
ciated anthropometry. It is recognised facial anatomy has required many more
Anthropometry is the biologic science of that standard facial measurements are measurements than are used in classic
the measurement of the human body. essential to the assessment of congenital anthropometry. To this end Farkas has
The use of direct measurements and or acquired defects and to the planning devoted many years of painstaking study
where appropriate ratios or proportions, when constructing or reconstructing nor- and research. He has defined many more
allow clinical comparisons to be made mal facial appearance. Farkas and his facial reference points as well using
between patients in a way not possible associates have concentrated their efforts these points on thousands of subjects to
with subjective measurements. Over the on investigating the anthropometry of record tabulated data of healthy indivi-
past 40 years there has been an the head and face in medicine. duals as well those with asymmetries3,4.

Fig. 9. Increase in chin prominence (late change).


Changes in facial form relative to progressive atrophy of the edentulous jaws 681

tion of the modiolus is central to the


changes in facial form.
Loss of the dentition and alveolar
atrophy causes the ‘facial curtain’ to
collapse due to the unopposed contrac-
tion of the buccinator and orbicularis
oris muscles (Fig. 6). As a result the
position of the modiolus is altered in
two directions—medially and posteriorly
(Fig. 6). This in turn distorts the muscles
of facial expression which decussate at
the modiolus or interlink with the orbi-
cularis oris muscle (Fig. 5). This change
in muscle orientation have both immedi-
ate and late effects on facial form and
relate directly to the stage of jaw atro-
phy. Early stages of jaw atrophy (Class
III and IV) are associated with a
decrease in commissure width, increase
Fig. 10. Decrease in lower face height caused by clockwise rotation of the atrophic mandible. in the nasolabial angle, inversion of the
lips and hollowing of the cheeks (Fig. 6).
Late stages of jaw atrophy (Class V and
VI) area associated with a decrease in
Its use in this study has allowed the basal bone of the jaws is unpredictable lower face height and increase in chin
quantification of the changes in facial and should be considered pathological. prominence due to the clockwise rotation
form, which follow the loss of the WATT & MACGREGOR described the of the mandible (Figs 10, 11). In addi-
natural dentition, and subsequent jaw facial musculature as a curtain draped tion, there is loss of vermillion show of
atrophy. between the maxilla and mandible, over the lips. Originally the circumferential
The CAWOOD & HOWELL Classification the dental bulge8 (Fig. 4). The facial fibres of the orbicularis oris muscle, sup-
is an internationally recognised9, and muscles are formed by the circumoral ported by the muscles of facial expres-
independently validated6, descriptive muscles, the labial elevator and depres- sion, form a ‘J shape’ which everts the
classification of atrophy of the edentu- sor muscles in the vertical plane, and lips. With progressive loss of dento-
lous jaws. This classification has shown the buccinator/superior constrictor band alveolar support, the lips invert and the
that following tooth loss the pattern of in the horizontal plane (Figs 5 & 6). ‘J shape’ process is lost, causing loss of
atrophy of the alveolar process is pre- These peri-oral muscles decussate at the vermillion show (Fig. 12).
dictable and may be considered physio- modiolus, which lies lateral to the com- The measurement of alar base width
logical, however, any resorption of the missure (Fig. 5). Alteration in the posi- and upper lip length remain unchanged

Fig. 11. Decrease in face height (late change).


682 Sutton et al.

siderations [Review] [10 refs]. Int J Oral


Maxillofac Surg 1991: 20: 75–82.
3. FARKAS LG. Anthropometry of the Head
and Face in Medicine. New York: Else-
vier-North 1981.
4. Farkas LG, Katic MJ, Hreczko TA,
Deutsch C, Munro IR. Anthropometric
proportions in the upper lip-lower lip-
chin area of the lower face in young
white adults. Am J Orthodont 1984: 86:
52–60.
5. Farkas LG, Katic MJ, Kolar J, Munro
IR. The adult facial profile: relationships
between the inclinations of its segments.
Deutsche Zeitschrift fur Mund-, Kiefer-,
und Gesichts-Chirurgie 1984: 8: 182–
186.
6. Fenlon MR, Sherriff M, Walter JD.
Operator agreement in the use of a
descriptive index of edentulous alveolar
ridge form. Int J Oral Maxillofac Surg
1999: 28: 38–40.
7. KOLAR J, SALTER E. Craniofacial Anthro-
pometry. Springfield, Ill: CC Thomas
1997.
8. MacGregor AR, Watt ME, Brown
Fig. 12. Late effects of jaw atrophy on facial form. J. Vertical dimension in edentulous
patients. J Dent 1984: 12: 287–296.
9. Stoelinga PJ, Cawood JI. Report of the
with advancing jaw atrophy (Table 3), phy and the changes in facial form con- International Research Group on Recon-
and this can be explained. The alar base sequent to the loss of the natural denti- structive Preprosthetic Surgery: the his-
lies superior to the alveolar bone and so tion, and shows that these changes are tory of the Consensus Conference on
is not dependent on the alveolus for sup- predictable. Reconstructive Preprosthetic Surgery.
port. In contrast, the upper lip is depen- An understanding of the effects of Int J Oral Maxillofac Surg 1996: 25:
dent on the dentition and bone of the progressive jaw atrophy on facial form 81–84.
10. Tallgren A. The continuing reduction
alveolus for support. As its support is will assist surgeon and prosthodontist in
of the residual alveolar ridges in complete
lost, and the nasolabial angle increases, the assessment and planning of pre- denture wearers: a mixed-longitudinal
together with the loss of vermilion show implant surgery which is indicated in study covering 25 years. J Prosthet Dent
described above, an apparent, rather than the Class IV, V and VI jaw in order to 1972: 27: 120–132.
real, shortening of the lip occurs. restore facial form.
The aim of oral rehabilitation of the
edentulous patient is the restoration of Address:
References
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tors will depend on the individual tion of the edentulous jaws. Int J Oral Countess of Chester Hospital
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preprosthetic surgery. I. Anatomical con- Tel: þ44 1244 263056
tionship between the stage of jaw atro-

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