Lip Travel Reduction

Part 1 - We look at who the three best candidates are for lip travel procedure.

Instructors:

Michael Skinner, DDS

Michael Skinner, DDS

Michael Skinner, DDS, a Board Certified Diplomate of the American Academy of Periodontology, is the founder of The Advanced Institute For Oral Health and is engaged in full time private practice of periodontics and implantology in Brentwood, Tennessee. Dr. Skinner has over 18 years of experience dedicated strictly to periodontology and implantology.

In this continuing education course, Dr. Skinner describes the best type of candidates for the lip travel procedure as well as a breif overview of the lip travel procedure. The lip travel procedure is also called a reverse frenectomy or a vestibular

Hi, I'm Marlene Hilton with HDiQ Dental. Today we go chair side with Dr. Michael Skinner as he demonstrates a lip travel reduction otherwise known as a reverse fernectomy or a vestibular obliteration. Dr. Skinner is a board certified diplomate of the American Academy of Periodentology, he is the founder of the Advanced Institute for Oral Health and he is engaged in full time private practice of periodontics and implantology in Brentonwood, TN. Dr. Skinner has over 18 years of experience dedicated strictly to periodontics and implantology. He is also one of only a handful of dentists selected to provide treatment to patients featured on ABC's hit reality TV show "Extreme Makeover." Now as you'll see in today's presentation even with healthy and beautiful teeth,excessive gingival display can adversely affect the appearance of a smile. The patient we treated today with a lip travel reduction had good proportion and good size of the teeth, good occlusion, basically when she smiled her lip traveled up to high. We did a procedure to obliterate the vestibule and basically reduced the room that the lip had to move so that ideally her lip when she smiles her lip will end up at the margin of the enamel and the gingiva. There are three general broad categories to which excessive gingival display or gummy smile can be grouped, one, people who have disproportionately short teeth and their teeth can be lengthened, clinical crown lengthening, by either soft tissue or combination soft tissue osseous procedure. Then there are people who have aberrant occlusion, super eruption of their teeth and they may still have normal proportion and they can be treated by a combination of shortening the teeth incisally and crown lengthening the teeth apically and gingivally. And then there are patients that have good tooth proportion and good size but still show a lot of gum when they smile and their smile can be improved drastically just by reducing the amount of travel from the lip when they smile. Resting lip posture is usually 2-3 mm from the incisal edge. Ideally when the person smiles the lip would travel 8 mm and the lip position would be at the position of the gingival margin. In some people when they smile their lip travels to far and so we look at Z she actually has about 15 mm of lip travel when she smiles so we need to reduce the amount of lip travel by 3-4 mm so that when she smiles we have a lip position at the gingival margin or at the junction of the enamel and the gingival. To do this we are going to need to reduce the depth of the vestibule twice as much as we need to reduce the lip travel. This procedure is a superficial soft tissue procedure, it doesn't involve any deep tissue attachments so it really doesn't effect the resting lip posture greatly but it obliterates the vestibule and limits the distance the lip can move when a person smiles. Additionally,many of these people have an undercut at the apex of the incisors and in order to not have a concavity for the lip to roll up into many times they will have a characteristic crease above the vermillion border of the lip in order not to have that we harvest a connective tissue graft and place it via a superperiostial sub epithelial tunnel in conjunction with the lip travel. In the case of the patient today we sedated her using IV versed, light sedation, then we acquired infiltration anesthesia to allow us to mark the margins of our anticipated tissue removal with a C02 laser. Initially we give just a small amount of infiltration anesthesia so as to not balloon up the mucosa and distort our design. After we have our design outline then we give more profound anesthesia. The first thing we do in this procedure is acquire some superficial infiltration anesthesia and to make an effort not to balloon the tissue because I want to be able to mark these landmarks for my future de-epithelialization of the lip without distorting the tissue.So we are going to do just a little infiltration anesthesia. Z,you are going to feel just a little tingle. Pardon me. Pardon me. One thing that I evaluate is a line drawn from the chin to the lip to the upper lip to the nose and ideally all of those soft tissue structures would fall in that line and in her case her upper lip is at a deficit and we will definitely do a connective tissue graft in order to eliminate that undercut and also provide a little more support for her upper lip in this feldstrum area. So after we've gained some initial anesthesia without ballooning the tissue excessively then we measure from the depth of the vestibule and we are going to decrease her vestibular depth by approximately 8mm. So I am going to take aC02 laser, which I use to mark my tissue position or the position of my initial incision. We found that to appreciatively affect lip travel that an amount of the vestibular depth roughly twice the amount of lip travel to be reduced needs to be removed. Doing OK Z We're going to graduate this in the premolar area so that we blend in and we don't have a definite juncture or big discrepancy in the mucosal attachment. It really would not effect the lip position much but it might be something that is objectionable if it were noticed by the patient as far as food getting caught in the vestibule cheek area so we're going to graduate that in the premolar area. Using the C02 laser see now we've marked the border of our de-epithelialization and we will proceed with connecting those dots and our goal is to remove approximately one and half mm thickness of epithelium so that we expose connective tissue that will heal with enough collagen content to resist pull of the facial muscles and the lip and stretching the lip back out to the preoperative position. What we are doing now is infiltration anesthesia on the palate for our connective tissue graft. We are going to take our connective tissue graft via trap door access. Doing OK Z Using the C02laser, Dr. Skinner will continue to connect the initial incisions. At this point we have completed the outline where we have marked the extent of the de-epithelialization of the vestibule.