THE INFLUENCE OF THE LIPS ON MANDIBULAR

EDENTULOUS PATIENTS

REST POSITION IN

THOR ARSTAD, L.D.S.*

Oslo University,

Oslo, Norway

of the anatomy and physiology of the temporomandibular joint has

improved considerably. However, the causes of many of the pathologic
changes in the joint are still unknown. The temporomandibular
joint and the
masticatory muscles have been overemphasized while the muscles actuating the
lips, cheeks and chin, and tongue have been neglected as influencing factors on
mandibular position and movement.
This article describes a method of determining the maxillomandibular
interarch distance in edentulous patients and explains the effect of the lips and tongue
upon the position of the mandible.

NOWLEDGE

REMODELING

THE

FACE

The mouth forms the speech and expresses the thoughts and emotions of the
patient. The face changes with the loss of the teeth and the dentist can do much
to remodel the face. Remodeling involves repositioning the lips for esthetics and
also for proper facial movements.
The most opportune time for remodeling the face is at the time of making
the jaw relation records. At that stage, the wax of the occlusion rims can be easily
trimmed or built up.
It is impossible to overstress the need for rigid and closely fitting trial denture
bases that are slightly short at the borders. If the borders of the trial bases impinge upon the vestibular fold and its fibrous bands, the lips will be shortened and
the base may loosen imperceptibly. Many incorrect jaw records result from trial
bases that are overextended at the border or fit loosely.
DEVELOPING

THE

UPPER

OCCLUSION

RIM

The upper occlusion rim is trimmed at a level that is 1.5 mm. below the
relaxed upper lip line because this is the amount of upper teeth usually visible when
the mouth is slightly open. The occlusal surface of the rim is cut parallel to the
interpupillary line in the anterior region. The rim may be adjusted to try to compensate for a lip line that is lower on one side than on the other.
Sagittally, the rims are cut parallel to an imaginary line from external auditory
*Professor,

Odontological

Faculty.
27

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ARSTAD

J. Pros. Den.
Jan..Feb., 1965

Fig. L-Different
inclinations
of the occlusal plane effect the apparent width of the dental
arch. A, The plane is raised posteriorly
and the teeth are less visible during talking and smiling.
B, The plane is lowered posteriorly
and more tooth substance is visible; the mouth seems
broader.

meatus to the lower border of the ala of the nose. Numerous studies show that
the natural occlusal plane approximates this line, but the position of the occlusal
plane forms a part of the personality of the patient. When the patient smiles
broadly or laughs, the observer should see no more of the premotars or molars
than the cuspid. The occlusal plane should be parallel with the upper lip when
the patient smiles broadly and the upper posterior teeth are exposed.
If the occlusal plane is raised posteriorly, the upper premolars and molars
will be less visible when talking and smiling. This procedure is useful when the
upper dental arch is very broad. If the upper jaw is narrow, the premolars are
less visible because they are in the shadows of the cuspids. By lowering the
occlusal plane, the premolars become more visible, and an impression of a broader
dental arch is conveyed. Hence, different esthetic effects can be produced by changing the orientation of the occlusal plane (Fig. 1). Therefore, the position and
movement of the upper lip determine the height of the upper occlusion rim and
its plane of orientation.
DEVELOPING

THE LOWER OCCLUSION

RIM

The height of the lower occlusion rim depends upon the selected interocclusal
distance. Usually a height which places the lower occlusion rim level with the
relaxed lower lip when the mouth is slightly open is the beginning posit-ion. The
lower occlusion rim should extend only from cuspid to cuspid which will afford
sufficient support for the lower lip (Fig. 2). Occlusion rims that extend into the
molar region are cumbersome and interfere with the tongue. The posterior part of
the tongue tends to widen out, with its borders extending over the ridges in the
lower molar region. This action stabilizes a thin trial denture base when the occlu-

MANDIBULAR

29

REST POSITION

Fig. Z.-A lower occlusion rim extending only from cuspid to cuspid supports the lower lip
sufficiently and permits the posterior part of the tongue to spread out over the thin trial denture
base and stabilize it.

Fig. 3 .-The

final recording

is made by a bulk of very soft wax in the lower

with slight or no contact in the front.

premolar

region

sion rim is not extended posteriorly. The final recording is made in a bulk of very
soft wax in the premolar region (Fig. 3).
IMPORTANCE

OF CORRECT INTERARCH

DISTANCE

It is not easy to estimate the interach distance because there are no precise
measurements to follow. An excessive interarch distance creates denture difficulties.
The residual ridges become sore and resorb rapidly. The teeth clatter during speech
or mastication. On the other hand, if the vertical dimension of occlusion is shortened, the patient looks older, the lower half of the face is compressed, the cheek
and lips are slack, and the chin protrudes.
Most denture patients are elderly. The corners of their mouths droop, their
cheeks sag, furrows deepen, wrinkles appear, and the lips become thin. It is
possible to modify signs of age to some extent, mainly by contouring the vestibular

30

ARSTAD

J. Pros. Den.
Jan.-Feb., 1965

portion of the trial denture bases and not by increasing the interarch distance according to some ill-judged rule of thumb.
Much has been written about the harm done to the temporomandibular joint
by an excessive interocclusal distance (reduced interarch distance). Many patients
having dentures that are too short in a vertical direction make no complaint
and have temporomandibular joints that seem to be physiologic. However, even
though knowledge of the mechanism is scant, the task of the dentist is to treat and
to restore. Therefore, an attempt must be made to find the interach distance that is
the most appropriate.

Fig. 4 .-Persons
open, lowering

REST POSITION

with protruding
chins (Angle Class III)
the mandible to reduce the prominence.

tend to hold their mouths slightly

The interocclusal
distance is great.

OF THE MANDIBLE

It is a common belief that the resting position of the mandible is reasonably

stable. Thus, it should not be too difficult to measure from this stabilized position
to some landmark in the cranium. The free-way space (interocclusal distance) between correctly formed occlusion rims averages 2 to 4 mm. with the mandible in
physiologic rest position. Mandibular rest position is the position that the mandible
is in when it is at rest, and supported sufficiently by the elevator muscle fibers in
tonic contraction to counter the gravitational weight of the mandible and the
tonicity of the depressor muscles.
When discussing the mandibular rest position, one presupposes that the lips
are closed. There is also a mandibular rest position when the mouth is open as a
result of the counteraction of the same muscles. Though this mandibular position
has little prosthetic interest, it is preferred by some patients with protruding chins
(Fig. 4).
The mandibular rest position with closed lips varies with the position of the
head, and with the position of the tongue and lips. Some patients raise the posterior part of the tongue into contact with the palate, upper molars, occlusion rim,

NtkEr
;

MANDIBULAR

REST POSITION

31

or residual ridge to keep the mandible stationary (Fig. 5,B). Other patients raise
the anterior part of the tongue to touch the anterior part of the palate (Fig. 6,B),
and still others place the tongue between the teeth. For the same reason many
patients bring the lower lip into contact with the upper teeth or press it lightly
against the upper lip. If the patient is asked to remove the tongue from contact
with the upper dental arch, keeping the lower lip out of contact with the upper
teeth but lightly touching the upper lip, the interocclusal distance will increase.

Fig. 5.-Roentgenograms
indicate the position of the mandible before and after removal of
the natural teeth. A, Before extraction
with the teeth in occlusion; and (B) some time later
with the edentulous mandible in rest position. Practically
no difference can be found in the
position of the mandible between the two. Note that the posterior part of the tongue is kept
in contact with the upper residual ridges in Fig. 5~.

Fig. 6.-Roentgenograms
indicate similar findings as in Fig. 5,B. The mandible is in relatively the same position before and after removal of the natural teeth. Note that the anterior
part of the tongue is in contact with the palate in Fig. 6,B.

J. Pros. Den.
Jan..Feb., 1965

32

Fig.
relaxed
dentures
relation

I.--Left,
When the teeth are lost, the lips fall inward. If the lips are to meet in a
state, they rest closer to the maxillae than when the teeth were present. Right, With
restoring the lip position, the mandible will assume a rest position that is lower in
to the maxillae.

IMPORTANCE

OF LIPS IN ESTABLISHING

REST POSITION

The part played by the lips in determining the maxillomandibular

distance can
be demonstrated as follows. The upper occlusion rim is trimmed to a length approximately 1.5 mm. below the relaxed upper lip, and the lower occlusion rim is cut
level with the relaxed lower lip, as described previously. In most instances, this
produces the correct interarch distance, and requires minor adjustments, if any.
When the mandible is raised to bring the occlusion rims into contact, one should
expect the lips to be apart a distance of 1.5 mm., because the upper lip was that
amount shorter than the upper occlusion rim and the lower lip was the same height
as the lower occlusion rim. However, when the relaxed lips are brought together
with the mandible in rest position, approximately 3 mm. of space will exist between the occlusion rims. The lips, from a relaxed state with the mouth slightly
open, have been elongated 1.5 mm. plus 3. mm. for a total of 4.5 mm. to meet in
a relaxed state with the mandible in rest position. The patient cannot feel this
elongation, and the dentist does not see it. There seems to be no movement of the
lips from their position when the mouth was slightly open until they meet. They
appear to be relaxed during the entire test. However, in fact, they elongate approximately 4 mm.
When a person opens the mouth with the lips slightly parted and then closes
the mouth to bring the mandible to its rest position, the impression is received that

EI%%
1

MANDIBULAR

REST POSITION

33

the lips have not moved. However, they have elongated considerably during this
movement of the mandible. One may detect how little is felt in the lips, when he
starts with the mandible in rest position, with the lips closed, and then occludes the
teeth. This movement raises the mandible about 3 mm. and shortens the lips to the
same extent. When looking in a mirror, only a slight movement of the lower lip
will be detected. In my opinion it is the lips that are decisive for the rest position
of the mandible with closed mouth.
Tallgren showed that, in edentulous patients, the resting mandible assumed a
lower position when dentures were in the mouth. Roentgenograms made with the
natural teeth in occlusion and some time later after removal of all natural teeth
with the mandible in rest position, confirm Tallgrens findings (Fig. 5. and 6). The
lips fall inward when unsupported by natural or artificial teeth or even by occlusion
rims, and the mandible must be raised to bring them into relaxed contact (Fig. 7).
Doubtlessly many dentists have had to change the estimated interarch distance after
building up the vestibular part of the occlusion rims during remodeling of the face
because the lips have changed position.
The influence of the lips upon rest position can also be observed when studying
patients with malocclusion. The mandible is pushed slightly forward to make the
lips meet more easily in an Angle Class II, division 1 jaw relationship. Roentgenograms of the temporomandibular joint with the mandible in rest position indicate
that the condyles are drawn a little anteriorly and the interocclusal distance is small.
In a Class III jaw relationship the patient tends to lower the mandible a little with
the lips slightly separated to minimize the impression of the prominent chin (see
Fig. 4). Roentgenograms made with the mandible in rest position in this situation
will show that the condyles are in their most retruded position and that the interocclusal distance is great.
Great importance is attached to building the occlusion rims so that they support the lips fully in order to give them a harmonious position prior to establishing
the interarch distance. Correct support will encourage movements that are natural
to the patient. The older the patient, the greater is the need for this method. A
semicircular bulk of material in the lower premolar region of the denture is more

Fig. 8.-Increased
bulk of the denture base in the lower premolar region raises the drooping
corners of the mouth and reduces the depth of the adjoining folds in the texture of the skirt.

34

ARSTAD

J. Pros. Den.
Jan.-Feb., 1965

successful in raising the drooping corners of the mouth than an increase of the
interarch distance (Fig. 8).
IMPORTANCE

OF THE

LIPS

IN

MANDIBULAR

MOVEMENTS

The aggregate power of the muscles of the lips, cheek, and chin, together
with the tongue, must influence the movements of the mandible. Sears2 and Campbell3 claim that it is possible to lower the condyles from the glenoid fossae with the
aid of pivots in the molar region. Since all of the elevator muscles are positioned
dorsal to the pivot, and since there are no muscles that can draw the condyles downward without at the same time drawing them forward, it seems that the condyles
cannot be lowered in this way.
Campbell3 states that the horizontal fibers of the temporal muscle which are
attached to the coronoid process can lower the condyles against a pivot. However,
the muscles of the lips, cheek, and chin, acting in conjunction with those of the
tongue, can draw the chin upward, thus pivoting the condyles downward. The
muscles attached to the chin constitute the power of a long lever of the first class.
Martone and Edwards4 give valuable information on the power of these muscles.
More research is required to clarify the influence of the muscles of expression on
mandibular positions and movements.
SUMMARY

The rest position of the mandible with the mouth closed is governed chiefly
by the lips. The elevator and depressor muscles, together with the tongue, maintain
the position. Great importance should be attached to building the vestibular part of
the occlusion rims so that they support the lips fully in order to give them harmonious position and movements prior to establishing the interarch distance. The
rest position with the mouth open is probably governed wholly by the balanced tonus
of elevator and depressor muscles.
REFERENCES

1. Tallgren, A.: Changes in Adult Face Height Due to Aging, Wear and Loss of Teeth and
Prosthetic Treatment, Acta Odont. Scandinavica (suppl. 24) 15:1-122, 1957.
2. Sears, V.: Mandibular Condyle Migrations as Influenced by Tooth Occlusions, J.A.D.A.
45:179-192, 1952.
3. Campbell, J.: Chronic Facial Pain, American Equilibration Sot. Compendium, 1960, p, 132.
4. Martone, A. L., and Edwards, L. F.: Phenomenon of Function in Complete Denture Prosthodontics. Anatomy of the Mouth and Related Structures. Part II. Musculature of
Expression; Part III. Functional Anatomic Considerations, J. PROS. DEN. 12:4-27;
206-219, 1962.
OSLO UNIVERSITY
OD~NTOLOGICAL FACULTY
GEITMYRSVEGEN 69
OSLO, NORWAY