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J Oral Maxillofac Surg70:1174-1176, 2012

Effect of Open Rhinoplasty onthe Smile Line

Reza Tabrizi, DMD, MSc,*

Hoori Mirmohamadsadeghi, DDS, MSc,†

Danadokht Daneshjoo, DDS,‡ and Samira Zare, DDS§

Purpose: Open rhinoplasty is an esthetic surgical technique that is becoming increasingly popular, andcan affect the nose and upper lip compartments. The aim of this study was to evaluate the effect of openrhinoplasty on tooth show and the smile line.

Patients and Methods: The study participants were 61 patients with a mean age of 24.3 years (range,17.2 to 39.6 years). The surgical procedure consisted of an esthetic open rhinoplasty without alarresection. Analysis of tooth show was limited to pre- and postoperative (at 12 months) tooth showmeasurements at rest and the maximum smile with a ruler (when participants held their heads naturally).Statistical analyses were performed with SPSS 13.0, and paired-sample t tests were used to compare toothshow means before and after the operation.

Results: Analysis of the rest position showed no statistically significant change in tooth show (P � .15),but analysis of participants’ maximum smile data showed a statistically significant increase in tooth showafter surgery (P � .05). In contrast, Pearson correlation analysis showed a positive relation betweenrhinoplasty and tooth show increases in maximum smile, especially in subjects with high smile lines.

Conclusion: This study shows that the nasolabial compartment is a single unit and any change in 1 partmay influence the other parts. Further studies should be conducted to investigate these interactions.© 2012 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg 70:1174-1176, 2012

twtcnentrs

pen rhinoplasty is an “open-tip” surgical approachsing a columellar flap that has become popular in theast 20 years.1 The open approach eliminates the

restrictions imposed by the closed approach and hasproved to be a major advance in the management ofcomplex nasal deformities.2 It provides complete an-atomic exposure of the cartilage complex, which al-lows for direct visualization, accurate diagnosis of theunderlying nasal framework, and suturing of cartilagegrafts and decreases the chance of asymmetric carti-

*Associate Professor and Head of Craniomaxillofacial Surgery

Ward, Chamran Hospital, Shiraz University of Medical Science,

Shiraz, Iran.

†Assistant Professor, Community of Oral Health Department,

School of Dentistry, Shahid Beheshti Medical University, Tehran,

Iran.

‡Dentist, Private Practice, Shiraz, Iran.

§Resident, Esthetic and Restorative Dentistry, Shiraz Dental Fac-

ulty, Shiraz, Iran.

Address correspondence and reprint requests to Dr Tabrizi:

Craniomaxillofacial Surgery Ward, Chamran Hospital, Chamran

Ave, Shiraz, Iran; e-mail: Tabmed@gmail.com

© 2012 American Association of Oral and Maxillofacial Surgeons

278-2391/12/7005-0$36.00/0

oi:10.1016/j.joms.2011.03.034

1174

lage cuts.2,3 The current re-emergence of the softissue paradigm has shifted diagnostic thinking to-ard soft and hard tissue interrelations and the ways

hese contribute to the overall facial esthetic. Practi-ally speaking, the amount of tooth show during dy-amic facial animation must be considered in clinicalvaluation.4 The aim of rhinoplasty is to change theasal structure to create better facial harmony, al-hough it influences other facial structures. In mosthinoplasty surgeries, nasal tip elevation occurs andubsequently nasolabial angle increases.5 This study

explored the effects of open rhinoplasty with no alarresection on rest and maximum smile tooth-showchanges.

Patients and Methods

This was a prospective study of 61 patients whounderwent esthetic open rhinoplasty without alar orwedge resection at the alar site. This research wasapproved by the research committee of the medicalethics group of Shiraz Medical University. All patientswere operated on by the first author (R.T.) from 2006through 2009. Participants consisted of 22 men and39 women with a mean age of 24.33 years (range,

17.2 to 39.6 years). Subjects with a history of hard or

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TABRIZI ET AL 1175

soft tissue problems (such as cleft lip or palate), sen-sory or motor nerve dysfunction, and previous hardand soft tissue manipulation were excluded from thisstudy. Adequate pre- and postoperative documenta-tion was completed, and participants were followedfor 1 year. Rest and maximum smile tooth show weremeasured with a ruler (when participants held theirheads naturally) during 2 pre- and postoperative (at 12months) appointments. Patients were informed aboutthese measurements and they did not receive anyother intervention, such as dental restoration or softtissue augmentation, during the follow-up period.

SURGICAL TECHNIQUE

Open rhinoplasty consists of trans-columellar andinfracartilaginous incisions, skeletonization, cephalicresection in the lower lateral cartilages, dorsum mod-ification, medial and lateral osteotomy, modificationof the tip with an interdomal suture, and strut place-ment between the medial crus. The strut was placedin all cases and minimal dissection was done at thecolumellar-lip junction without any resection of de-pressor septi muscles and alar sites. Tip grafts werenot used in any surgical procedures.

STATISTICAL ANALYSIS

Statistical analyses were performed with SPSS 13.0for Windows (SPSS, Inc, Chicago, IL). Scale numericvariables were expressed as mean, range, andstandard deviation. Paired-samples t tests were usedto compare initial and subsequent tooth show means.

Results

Esthetic open rhinoplasties without alar resectionwere performed in 61 patients. Patients were fol-lowed for 1 year after surgery. Based on the pre- andpostoperative documentations, the initial and subse-quent tooth show means in the rest position were1.62 and 1.66 mm, respectively. The difference wasnot statistically significant (P � .15), but the averageooth show for maximum smile increased signifi-antly from 5.75 to 6.41 mm after surgery (P � .05).n contrast, Pearson correlation analysis showed aositive (direct) relation between rhinoplasty andaximum smile tooth show improvement especially

n subjects with a high smile line (Table 1).

Discussion

The influence of rhinoplasty on upper lip functionmust be considered in treatment planning, especiallyfor dentists, because this intervention may causechanges in patients’ tooth show after surgery. A re-view of upper lip muscle anatomy shows a close

relation between upper lip animation and depressor

septi muscles. Previous studies have shown that de-pressor septi muscles can lower the nasal tip andshorten the upper lip on animation.6,7 Rohrich et al8

studied 55 fresh cadavers and showed 3 variations ofthe depressor septi muscle: type I inserted fully intothe orbicularis oris (62%); type II inserted into theperiosteum and partly into the orbicularis oris (22%);and type III had absent or immature depressor septimuscles (16%). The paired depressor septi are notactive in all patients but act as a bridge between thenose and upper lip, so repositioning these muscles inthe septum or upper lip can influence other parts.Some patients with hyperactive depressor nasi mus-cles need intervention to reposition them intraorallyor internasally,8 but this procedure is not effective inll patients because of muscle reattachment.9 Cachay-elásquez10 described the “rhino-gingivolabial syn-

drome of the smile” as hypertrophy of the depressorsepti muscles, drooping of the nasal tip, elevation andshortening of the upper lip, and increased maxillarygingival show. He asserted that resecting depressorsepti muscles and removing some parts of the nasalisand orbicularis oris muscles can improve their appear-ance without any side effects.10 However, Converse11

suggested preservation of these muscles’ function.Nasal tip elevation may produce more tension ondepressor septi and consequently cause an increasedelevating force on the upper lip, particularly duringanimation. In the rest position, depressor septi are nolonger active, so they cannot affect tooth show. Inthis study, patients were asked to prevent active func-tions, such as active smiling or chewing, during thefirst months after operation. This instruction mighthave interfered with the study’s results, becausechanging habits can cause tooth show underestima-tion in maximum smile. After the 1-year follow-upperiod, patients were relieved of pain and edema andthe nasolabial compartment returned to its normalposition. The difference in the amount of tooth-showchange was greater in patients with a high smile line,perhaps because this condition involves more active

Table 1. COMPARISON OF TOOTH SHOW IN RESTPOSITION AND MAXIMUM SMILE BEFORE AND AFTERRHINOPLASTY

Preoperative Postoperative

P ValueMean SD Mean SD

Rest position 1.62 1.05 1.66 1.04 �.05Maximum

smile5.75 1.19 6.41 1.57 �.05

Abbreviation: SD, standard deviation.

Tabrizi et al. Effect of Open Rhinoplasty on Smile Line. J OralMaxillofac Surg 2012.

upper lip muscles to relieve lip incompetency.

1176 EFFECT OF OPEN RHINOPLASTY ON SMILE LINE

The nasolabial compartment is a single unit and anychange in 1 part may influence the others. Furtherstudies should be conducted to investigate these in-teractions.

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