Symmetrical Smile Research Articles

Smile Enhancement Through Periodontal Surgery

Illustrations of the periodontal plastic surgery cases are presented. Results: Standard measures, golden proportions, and symmetry are concepts that mostly applied for guidance of image designing. Nevertheless, aesthetic attainment is possible with the presence of different measures and proportions and symmetry or asymmetry. Specific mathematical measures and symmetry should not be considered as beauty criteria and the violation of computational formulas and asymmetry should not be introduced as inconsistency. Symmetric smile, which follows proved measures, is not necessarily aesthetic. However, measures, proportions, and symmetry are all aspects of beautiful art work but rarely suffice for attaining beauty phenomenon. Conclusions: In modern society, we insist on finding a form that follows determined rules. Medical and periodontics sciences can have rules in repair and reconstruction of the beauty and health by anatomic symmetric smile principles. Nonetheless, physicians may not be able to achieve beauty despite of applying most complete world standards. Countless individual differences in facial features lead to achieving countless outcomes in aesthetic proceedings. Eventually, individual’s kindness and personality can create a wonderful attraction while smiling that is unjustifiable.

The degree of facial movement following microvascular muscle transfer in pediatric facial reanimation depends on donor motor nerve axonal density.

Free functional muscle transfer to the face is a standard of facial animation. The contralateral facial nerve, via a cross-face nerve graft, provides spontaneous innervation for the transferred muscle, but is not universally available and has additional shortcomings. The motor nerve to the masseter provides an alternative innervation source. In this study, the authors compared donor nerve histomorphometry and clinical outcomes in a single patient population undergoing free muscle transfer to the face. Pediatric patients undergoing dynamic facial (re-)animation with intraoperative nerve biopsies and gracilis transfer to the face powered by either the contralateral facial nerve via a cross-face nerve graft or the motor nerve to the masseter were reviewed over a 7-year period. Myelinated nerve counts were assessed histomorphometrically, and functional outcomes were evaluated with the Scaled Measurement of Improvement in Lip Excursion software. From 2004 to 2011, 91 facial (re-)animation procedures satisfied study inclusion criteria. Average myelinated fiber counts were 6757 per mm2 in the donor facial nerve branch, 1647 per mm in the downstream cross-face nerve graft at the second stage, and 5289 per mm in the masseteric nerve. Reconstructions with either innervation source resulted in improvements in oral commissure excursion and smile symmetry, with the greatest amounts of oral commissure excursion noted in the masseteric nerve group. Facial (re-)animation procedures with use of the cross-face nerve graft or masseteric nerve are effective and result in symmetric smiles. The masseteric nerve provides a more robust innervation source and results in greater commissure excursion. Therapeutic, III.

Variations in the perception of the smile line according to examiners from three different social classes

Objective: This study assessed the variations in the perception of the smile line, according to examiners from three different social classes in the City of Cuiaba, Brazil. Materials and Methods: A total of 12 smile photographs were taken of female students. These photographs were then classified according to the smile line profile presented by each volunteer (ideal, straight and reverse smile line). We selected which side of the smile matched the esthetic norms; later, the smile photographs were digitally duplicated and modified to obtain a symmetrical smile. After the changes were made, each volunteer was classified into the appropriate category. According to this classification, we carried out the alterations in the other two types of smile photos and placed them in an album for subsequent evaluation of the three types of smiles by examiners from three different social classes: A, B and C. Results: There was a lower satisfaction of the subjects with regards to the reverse smile for the examiners from Class A. The lowest satisfaction for the Class B examiners was related to the reverse smile. Data of the comparisons among the Class C examiners revealed no statistical difference between groups ( P > 0.05). Conclusion: There was no statistical difference between the ideal and straight smiles.

Facial reanimation utilizing combined orthodromic temporalis muscle flap and end-to-side cross-face nerve grafts.

Individuals with facial paralysis of 6 months or more without evidence of clinical or electromyographic improvement have been successfully reanimated utilizing an orthodromic temporalis transfer in conjunction with end-to-side cross-face nerve grafts. The temporalis muscle insertion is released from the coronoid process of the mandible and sutured to a fascia lata graft that is secured distally to the commissure and paralyzed hemilip. The orthodromic transfer of the temporalis muscle overcomes the concave temporal deformity and zygomatic fullness produced by the turning down of the central third of the muscle (Gillies procedure) while yielding stronger muscle contraction and a more symmetric smile. The muscle flap is combined with cross-face sural nerve grafts utilizing end-to-side neurorrhaphies to import myelinated motor fibers to the paralyzed muscles of facial expression in the midface and perioral region. Cross-face nerve grafting provides the potential for true spontaneous facial motion. We feel that the synergy created by the combination of techniques can perhaps produce a more symmetrical and synchronized smile than either procedure in isolation. Nineteen patients underwent an orthodromic temporalis muscle flap in conjunction with cross-face (buccal-buccal with end-to-side neurorrhaphy) nerve grafts. To evaluate the symmetry of the smile, we measured the length of the two hemilips (normal and affected) using the CorelDRAW X3 software. Measurements were obtained in the pre- and postoperative period and compared for symmetry. There was significant improvement in smile symmetry in 89.5 % of patients. Orthodromic temporalis muscle transfer in conjunction with cross face nerve grafts creates a synergistic effect frequently producing an aesthetic, symmetric smile. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors at www.springer.com/00266 .

A 7-Year-Old Child With Chronic Droopy Eyes, Weakness in Head-Neck Control, and an Abnormal Gait

Our patient is a 7-year-old girl, who presented at the age of 3 years with features of droopy eyes, weakness in head-neck control, inability to hop and jump, and an abnormal gait. She was initially evaluated in an outside hospital (OSH) occupational safety and health and treatment with pyridostigmine with suspicion of myasthenia gravis. She was then referred to our center for further evaluation. At the time of her hospitalization, she was reported to have improvement in her ptosis and stamina with pyridostigmine, without much benefit in her gross motor activities, inability to run and jump, and difficulty in getting up from lying and sitting position. There was no history pain, fever, swallowing, or breathing difficulty. She was born full-term with an uneventful pregnancy, labor, and childbirth and had a previously normal development. There was no history suggestive of hypotonia or weakness in the neonatal period or thereafter. Medical history was not remarkable, and there was no evidence of neurologic, genetic, or rheumatologic disorders in the family. On examination, she was of average weight and built, with an unremarkable general, cardiac, pulmonary, and abdominal examination. Neurologic evaluation showed ptosis in neutral gaze, which disappeared with sustained upward gaze, no ophthalmoplegia, symmetric smile, and normal tongue movement without fasciculation. Axial and appendicular tone was low without any wasting or polyminimyoclonus. Motor strength test was notable for proximal muscle weakness more in the lower extremity compared with the upper, with power in range of 4-5 for most muscle groups. There was areflexia, intact sensation, and gait was of trendelenberg pattern with intact toe

Static support in the facial palsy patient: A case series of 51 patients using tensor fascia lata slings as the sole treatment for correcting the position of the mouth

Although free functional muscle transfer (FFMT) remains the gold standard treatment of facial paralysis to produce a spontaneous, symmetrical smile in response to emotion, there are occasions when this option may not be available. Many patient factors and co-morbidities may result in a poor outcome, with flap and even patient survival being put at risk. The use of tensor facia lata (TFL) slings has been well described and provides a surgeon with a static option which yields acceptable results. We present the results of two surgeons experience using TFL sling as the sole treatment of facial paralysis and include complications, revision rates and outcomes. The results confirm that the use of a TFL sling equips the facial palsy surgeon with an excellent option for the cases where free functional muscle transfer is unavailable.

Gambaran Komponen Senyum Pasien Sebelum Perawatan Ortodonti (Kajian Foto Frontal di Klinik Ortodonti RSGMP FKG UI)

Smile is a non-verbal communication to express spontaneous feelings and emotions. Most patients that come to have orthodontic treatments want to have an attractive smile, but before the treatment smile has not yet been studied. There are eight components to make ideal frontal smile: lip line, smile arc, upper lip curve, buccal corridor, symmetry of smile, occlusal plane, dental and gingival components. This study was descriptive in design, in order to obtain frontal smile description before orthodontic treatment of RSGMP FKG UI patients that were grouped according to facial form, age, and gender. The results of the study show that patient smile before orthodontic treatment frequently exhibits medium lip line and the mean of incisor display at 75% of clinical crown. Most subjects show gingival display of 2 mm or less. On the smile arc, the most common features are straight smile and consonant smile. Equally common smile arc positions are those touching and not touching lower lip. The average buccal corridor is in medium smile, and thus most subjects have straight upper lip curves and symmetric smiles. DOI: 10.14693/jdi.v15i1.80

Reconstruction of Large Defects of the Lips and Commissure Using a Composite Radial Forearm Palmaris Longus Free Flap Associated With a Lengthening Temporalis Myoplasty

We performed a single-stage operation to reconstruct a large defect of the lips and commissure using a composite radial forearm-palmaris longus free flap. To obtain cranial traction and a voluntary smile, independently from any jaw movement, traction was achieved by using a lengthening temporalis myoplasty. The tendon attached to the coronoid process was fixed to the palmaris longus tendon, recreating a new commissure and a "neo-modiolus." Physical therapy was started on the 21st postoperative day to facilitate progress from a "mandibular smile," to ideally a spontaneous and symmetric smile after 3 months of therapy. This procedure was able to obtain good oral continence and a good commissural movement during smile which has not previously been mentioned in the published literature.

THE TERM STRUCTURE OF IMPLIED VOLATILITY IN SYMMETRIC MODELS WITH APPLICATIONS TO HESTON

We study the term structure of the implied volatility in the presence of a symmetric smile. Exploiting the result by Tehranchi (2009) that a symmetric smile generated by a continuous martingale necessarily comes from a mixture of normal distributions, we derive representation formulae for the at-the-money (ATM) implied volatility level and curvature in a general symmetric model. As a result, the ATM curve is directly related to the Laplace transform of the realized variance. The representation formulae for the implied volatility and its curvature take semi-closed form as soon as this Laplace transform is known explicitly. To deal with the rest of the volatility surface, we build a time dependent SVI-type (Gatheral, 2004) model which matches the ATM and extreme moneyness structure. As an instance of a symmetric model, we consider uncorrelated Heston: in this framework, the SVI approximation displays considerable performances in a wide range of maturities and strikes. All these results can be applied to skewed smiles by considering a displaced model. Finally, a noteworthy fact is that all along the paper we avoid dealing with any complex-valued function.

Facial Reanimation of Patients With Neurofibromatosis Type 2

Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome defined by bilateral vestibular schwannomas. Facial paralysis, from either tumor growth or surgical intervention, is a devastating complication of this disorder and can contribute to disfigurement and corneal keratopathy. Historically, physicians have not attempted to treat facial paralysis in these patients. To review our clinical experience with free gracilis muscle transfer for the purpose of facial reanimation in patients with NF2. Five patients with NF2 and complete unilateral facial paralysis were referred to the facial nerve center at our institution. Charts and operative reports were reviewed; treatment details and functional outcomes are reported. Patients were treated between 2006 and 2009. Three patients were men and 2 were women. The age of presentation of debilitating facial paralysis ranged from 12 to 50 years. All patients were treated with a single-stage free gracilis muscle transfer for smile reanimation. Each obturator nerve of the gracilis was coapted to the masseteric branch of the trigeminal nerve. Measurement of oral commissure excursions at rest and with smile preoperatively and postoperatively revealed an improved and nearly symmetric smile in all cases. Management of facial paralysis is often times overlooked when defining a care plan for NF2 patients who typically have multiple brain and spine tumors. The paralyzed smile may be treated successfully with single-stage free gracilis muscle transfer in the motivated patient.

Bilateral Reconstruction of Smile Through Muscular Transplants Neurotized to Masseter Nerves

In recent years, microsurgical transplant of the gracilis muscle has been the most widely used technique in the dynamic rehabilitation of the smile. The most frequently used donor nerve is the seventh cranial nerve, as it allows for the most physiological rehabilitation, including the rehabilitation of spontaneous smile. An exception to this is the case of bilateral facial paralyses, in which there is no contralateral nerve to be used as a donor. In these cases, it is necessary to use other nerves such as the hypoglossal, the accessory nerve, or the masseter branch of the trigeminal nerve. In this article, we describe a case of dynamic bilateral facial rehabilitation with a bilateral transplant of the gracilis muscle neurotized to the masseter nerve to achieve a strong, symmetrical smile, which is properly controlled by the patient.

Parálisis facial: primera microcirugía correctiva en Ecuador mediante técnica de Viterbo (NTL).

La parálisis facial es un trastorno desfigurante con importantes repercusiones psicológicas emocionales y familiares, llevando a estos pacientes al borde del suicidio; es una combinación compleja de degeneración axonal y muscular. En la actualidad con los avances tecnológicos, los mejores resultados se consiguen en combinación con la microcirugía mediante el injerto de nervios facial (Cross Face Nerv Grafting) lográndose una sonrisa armoniosa y simétrica en su facie. Cabe destacar que el tratamiento Microquirúrgico de esta patología anteriormente se realizaban en Estados Unidos, Francia, Brasil, Taiwán, Japón y desde hoy disponible en Ecuador.

A Single Hypoglossal Nerve for Bilateral Smile Reconstruction in Möbius Syndrome

Möbius syndrome is a rare congenital disorder characterized by a variety of cranial nerve defects. Although there are several variants of Möbius syndrome depending on which cranial nerves are affected, the commonest form involves facial and abducens cranial nerve paralysis. Despite several strategies for bilateral smile reconstruction that have been advocated, the condition still presents a challenge to the plastic surgeon. The most acceptable method nowadays is bilateral free neurovascularized muscle transfer. The author represents a new method of using a single hypoglossal nerve to supply both free flaps in a Möbius patient. The procedure is done on 2 stages using both latissimus dorsi muscles and a single hypoglossal nerve. The patient regained a natural symmetric smile 12 months after the first stage. Despite hemilingual atrophy, no tongue morbidity was observed. The author concludes that despite the limitation of the study, the hypoglossal nerve is a good nerve source to supply both free flaps for smile reconstruction in Möbius syndrome.

Facial Reanimation of Patients with Neurofibromatosis Type 2

Background Neurofibromatosis type 2 (NF2) is a tumor suppressor syndrome defined by bilateral vestibular schwannomas. Facial paralysis, from either tumor growth or surgical intervention, is a devastating complication of this disorder and can contribute to disfigurement and corneal keratopathy. Historically, physicians have not attempted to treat facial paralysis in these patients. Objective To review our clinical experience with free gracilis muscle transfer for the purpose of facial reanimation in patients with NF2. Methods Five patients with NF2 and complete unilateral facial paralysis were referred to the facial nerve center at our institution. Charts and operative reports were reviewed; treatment details and functional outcomes are reported. Results Patients were treated between 2006 and 2009. Three patients were men and 2 were women. The age of presentation of debilitating facial paralysis ranged from 12 to 50 years. All patients were treated with a single-stage free gracilis muscle transfer for smile reanimation. Each obturator nerve of the gracilis was coapted to the masseteric branch of the trigeminal nerve. Measurement of oral commissure excursions at rest and with smile preoperatively and postoperatively revealed an improved and nearly symmetric smile in all cases. Conclusion Management of facial paralysis is often times overlooked when defining a care plan for NF2 patients who typically have multiple brain and spine tumors. The paralyzed smile may be treated successfully with single-stage free gracilis muscle transfer in the motivated patient.

Intraoperative Muscle Electrical Stimulation for Accurate Positioning of the Temporalis Muscle Tendon during Dynamic, One-Stage Lengthening Temporalis Myoplasty for Facial and Lip Reanimation

Facial paralysis is a significant functional and aesthetic handicap. Facial reanimation is performed either by two-stage microsurgical methods or by regional one-stage muscle pedicle flaps. Labbé has modified and improved the regional muscle pedicle transfer flaps for facial reanimation (i.e., the lengthening temporalis myoplasty procedure). This true myoplasty technique is capable of producing a coordinated, spontaneous, and symmetrical smile. An intraoperative electrical stimulation of the temporal muscle is proposed to simulate the smile of the paralyzed side on the surgical table. The intraoperative electrical stimulation of the temporalis muscle, employing direct percutaneous electrode needles or transcutaneous electrical stimulation electrodes, was utilized in 11 primary and four secondary cases with complete facial palsy. The duration of the facial paralysis was up to 12 years. Postoperative follow-up ranged from 3 to 12 months. The insertion points of the temporalis muscle tendon to the nasolabial fold, upper lip, and oral commissure had been changed according to the intraoperative muscle stimulation in six patients of the 11 primary cases (55 percent) and in all four secondary (revisional) cases. A coordinated, spontaneous, and symmetrical smile was achieved in all patients by 3 months after surgery by employing speech therapy and biofeedback. This adjunct intraoperative refinement provides crucial feedback for the surgeon in both primary and secondary facial palsy cases regarding the vector of action of the temporalis muscle and the accuracy of the anchoring points of its tendon, thus enhancing a more coordinated and symmetrical smile.

The Term Structure of Implied Volatility in Symmetric Models with Applications to Heston

We study the term structure of the implied volatility in a situation where the smile is symmetric. Starting from the result by Tehranchi that a symmetric smile generated by a continuous martingale necessarily comes from a mixture of normal distributions, we derive representation formulae for the at-the-money (ATM) implied volatility level and curvature in a general symmetric model. As a result, the ATM curve is directly related to the Laplace transform of the quadratic variation of the log price. To deal with the remaining part of the volatility surface, we build a time dependent SVI-type approximation which matches the ATM and extreme moneyness structure. As an instance of a symmetric model, we consider uncorrelated Heston: in this framework, our representation of the ATM volatility takes semiclosed (and easy to implement) form and the time-dependent SVI approximation displays considerable performances in a wide range of maturities and strikes. In addition, we show how to apply our results to a skewed smile by considering a displaced model. Finally, a noteworthy fact is that all along the paper we will deal only with Laplace transforms and not with Fourier transforms, thus avoiding any complex-valued function.

Availability of Latissimus Dorsi Minigraft in Smile Reconstruction for Incomplete Facial Paralysis: Quantitative Assessment Based on the Optical Flow Method

Acute unilateral facial paralysis, such as occurs in Bell palsy and Hunt syndrome, is mostly a benign neurologic morbidity that resolves within a few months. However, incomplete or misdirected return of the affected nerve results in unfavorable cosmetic sequelae in some patients. Although functional problems such as lagophthalmos are rare, facial asymmetry on smiling resulting from a lack of mimetic muscle strength in the cheek is often psychologically annoying to patients. To obtain a more natural smile, the authors transfer latissimus dorsi muscle to assist in cheek movement. A small, thinned muscle (mini-latissimus dorsi) is sufficient for transplant in this situation. In this study, 96 patients with incomplete facial paralysis who underwent mini-latissimus dorsi transfer were examined. In this series, along with evaluation using the grading scale used in previous reports, preoperative and postoperative videos of 30 patients were analyzed for quantitative assessment using newly developed computer software. Temporary deterioration of paralysis was recognized in three cases but did not last more than a few months. Signs of transferred muscle contraction were recorded after 4 to 12 months among 91 patients. No apparent clinical signs of contraction were recognized in one patient, and four patients could not be followed postoperatively. The synchronized ratio of vertical movement and the symmetrical ratio of horizontal movement both in the cheek and in the lower lip between healthy and paralyzed sides among 30 patients were statistically improved. Statistical analysis using newly developed computer software revealed that a more symmetrical smile can be achieved by muscle transfer among patients with incomplete facial paralysis. Mini-latissimus dorsi transfer can avoid postoperative muscle bulkiness of the cheek and can achieve more natural cheek movement.

Dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer for re-animation of established facial paralysis: simultaneous reinnervation of the ipsilateral masseter motor nerve and the contralateral facial nerve to improve the quality of smile and emotional facial expressions

One-stage microneurovascular free muscle transfer is a common surgical procedure for re-animation of established facial paralysis. However, innervation of the transferred muscle by the contralateral facial nerve prevents smile and other facial expressions on one side, and reinnervation requires about 7 months. To overcome these drawbacks, we report a dual innervation method using one-stage reconstruction with free latissimus dorsi muscle transfer. Three patients were treated with the dual innervation method, which is based on the one-stage method with some modifications: the soft tissue present over the ipsilateral masseter muscle and the hilum where the thoracodorsal nerve proceeds into the muscle segment is removed; the muscle is harvested to locate the hilum in the cranial one-third of the segment; and the muscle is transferred to the malar pocket of the paralysed face such that the hilum contacts the masseter muscle. On average, muscle movement was recognised on voluntary biting at 3.4 months and on spontaneous smiling at 5.9 months after surgery. A dual innervation sign was recorded on electromyographs 6.4 months after surgery. The patients developed a spontaneous symmetrical smile and facial expressions on one side with minimum synkinesis after postoperative mirror rehabilitation. The advantages of the dual innervation method include faster reinnervation of the transferred muscle compared to one-stage options; achievement of spontaneous smile and voluntary smile on each side; augmentation of neural signals to the muscle for more symmetrical smiling; minimum synkinesis of the transferred muscle on biting for eyelid closure and emotional facial re-animation through a learning program to enhance cerebral cortical reorganisation.

PR29 MASSETERIC‐FACIAL NERVE COAPTATION – AN ALTERNATIVE TECHNIQUE FOR FACIAL NERVE REINNERVATION

Introduction Facial nerve paralysis can be a disabling condition functionally, psychologically and aesthetically. When there has been an acquired proximal injury to the facial nerve in the presence of previously functional facial musculature, such as in acoustic neuroma surgery, neurotisation of the distal facial nerve is an appropriate choice of management. The hypoglossal nerve is most commonly used. However this is not without its limitations, notably subsequent hemilingual atrophy and facial synkinesis. We present an alternative technique of facial reinnervation utilising a motor branch of the trigeminal nerve, the nerve to masseter. We believe this technique has the potential to overcome problems encountered with use of other extra‐facial nerves.Methods Three patients with acquired facial nerve palsy following tumour resection underwent transfer of the ipsilateral masseteric nerve to facial nerve. In two patients the nerve was directly coapted to the trunk of the facial nerve while the third patient had transfer to the buccal branch.Results By twelve months postoperatively all three patients demonstrated significant improvement in facial muscle tone and symmetry at rest. All patients were able to produce a symmetrical smile with minimal synkinesis. Two of the three patients also had evidence of occasional spontaneous movements.Conclusion Use of the ipsilateral motor nerve to masseter offers an alternative technique for neurotisation of the facial nerve. The advantages of this technique include ease of dissection, constant and reliable anatomy, powerful innervation of the facial muscles, minimal donor site morbidity and the potential for return of spontaneous facial movements.

Use of video self-modelling and implementation intentions following facial nerve paralysis

This research aimed to address smile deficits after long-term facial nerve paralysis (FNP) by implementing two treatments not previously used for FNP: video self-modelling and implementation intentions. Two FNP subjects were studied, who were both experiencing difficulty producing symmetrical smiles, particularly in social situations. Smile types measured were a symmetrical (adapted) smile and an asymmetric (everyday) smile. Treatment involved each subject observing only his or her best adapted smiles on videotape, three times a day for 2 weeks. Time from onset to smile completion was recorded and to assess quality, 20 observers rated randomly ordered smiles. For adapted smiles, there was both a significant post-treatment decrease in time from initiation to completion and a rated improvement on the dimensions of overall smile quality, movement control and symmetry. Therefore, with increased speed, the more symmetrical adapted smile could be used spontaneously during designated social interactions. These case studies suggest that smile symmetry and control can still be improved some years after FNP, and that video self-modelling and implementation intentions warrant further research.