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ORIGINAL ARTICLE
Year : 2022  |  Volume : 25  |  Issue : 3  |  Page : 286-293

3D assessment of facial contours of patients wearing either complete denture or implant-supported fixed dentures


1 Department of Prosthodontics, Faculty of Dentistry, Suleyman Demirel University, Isparta, Turkey
2 Private Practice, Orthodontist, Eskişehir /, Turkey
3 Department of Dentistry Services, Vocational School of Health Services, Suleyman Demirel University, Isparta, Turkey
4 Oral and Maxillofacial Surgery, Faculty of Dentistry, Suleyman Demirel University, Isparta, Turkey

Date of Submission22-Apr-2021
Date of Acceptance13-Nov-2021
Date of Web Publication16-Mar-2022

Correspondence Address:
Dr. Z B Demirekin
Department of Prosthodontics, Suleyman Demirel University, Faculty of Dentistry, Isparta
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_1446_21

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   Abstract 


Background: Total edentulousness leads to soft tissue changes causing esthetic problems. Being aware of the significant effects of different treatment approaches on facial soft tissue can help to obtain more satisfying esthetic results. Aim: The current study's objective was to evaluate three-dimensional facial soft tissue changes in edentulous patients rehabilitated with a complete denture (CD) and implant-supported fixed partial denture (FPD). Material and Methods: Fourteen edentulous patients, mean age of 47.6 years (42–63), were assessed before prosthetic treatments (T0), after CD (T1), and after FPD (T2). 3dMDface System (3dMD LLC) obtained the 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 was observed in philtrum height (Ls-Sn) between the treatment approaches. Conclusion: CD and implant-supported fixed partial dentures, both treatment approaches, cause facial soft tissue changes, which may help to improve the facial esthetic. The effects of these treatment methods on facial soft tissues are not significantly different, except the philtrum height.

Keywords: 3D facial soft tissue imaging, dentures, implant-supported fixed partial denture, stereophotogrammetry


How to cite this article:
Demirekin Z B, 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

How to cite this URL:
Demirekin Z B, 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 [serial online] 2022 [cited 2022 Aug 19];25:286-93. Available from: https://www.njcponline.com/text.asp?2022/25/3/286/339709




   Introduction Top


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


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.
  • 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 implants per jaw were inserted in both edentulous jaws.

Two edentulous patients were not included in this study 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 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 [Table 1] and [Table 2] and [Figure 1] and [Figure 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.
Table 1: Landmarks used for 3D facial soft tissue assessment

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

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Figure 1: Facial landmarks for analysis

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Figure 2: Lateral view of facial landmarks for analysis

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   Results Top


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 pretreatment were significant in the CD group but not in the implant-supported fixed partial denture group. The difference observed in the lower lip angle compared with the pretreatment was significant in the implant-supported 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.
Table 3: Morphometric evaluation of prosthodontic treatment approaches

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   Discussion Top


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],[20],[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 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 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 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]

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.

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 lip line,[35] soft tissue defects,[34],[35],[36],[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],[19],[20],[21] Additionally, some studies reported that the labial flange significantly ensured lip support.[30],[17],[34],[37] Deciding on 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 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 Top


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.


   Clinical Implications Top


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.



 
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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[Pubmed] | [DOI]



 

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