Neutral Smile

• Clinical Definition: A normal relaxed position of the lips.
• Key Function: The neutral lip posture is used by clinicians as a reference point when examining facial symmetry and occlusal (bite) alignment.
• Common Concerns: When patients have an abnormal neutral lip posture, they may present with facial asymmetry, strained facial musculature, and/or inadequate incisor show due to age-related changes or excessive loss of enamel/dentin.
• Restorative Options: The restoration of a patient's neutral lip posture can be accomplished through various methods, including, but not limited to: relocation of the lip(s); orthodontic alignment of the teeth; botulinum toxin injections into facial musculature; and restoring contour to teeth.

The common symptoms noticed in relation to variations in a neutral lip posture are as follows:

• Visual Asymmetry - One side of your mouth is slightly elevated when you're relaxing.
• Incisal Deficiency - Your top front teeth are completely hidden from view (often creating an illusion that you have premature aging of your face).
• Muscle Fatigue - Dull, chronic ache in the muscles on either side of the corners of your mouth (this can be a result of you constantly compensating with excessive tension to get into a comfortable facial position).
• Lip Strain - Painful tightness/pulling sensation at the corners of your mouth when trying to achieve a natural relaxation facial position.

• Sudden Facial Asymmetry - Which resembles nerve damage/paralysis while you're at rest.
• Prolonged, Localized TMJ (Temporomandibular Joint) Pain/Tenderness - While you're passively resting your face.
• Quick Changes - In how your lips fall or how your teeth show after a traumatic injury to your face/dental work.
• Continual Biting - Of the inside of your cheek/lips using the same areas as before, due to your resting muscle tone changing.

• Sudden Facial Asymmetry - Which resembles nerve damage/paralysis while you're at rest.
• Prolonged, Localized TMJ (Temporomandibular Joint) Pain/Tenderness - While you're passively resting your face.
• Quick Changes - In how your lips fall or how your teeth show after a traumatic injury to your face/dental work.
• Continual Biting - Of the inside of your cheek/lips using the same areas as before, due to your resting muscle tone changing.

• Age - As we grow older, our dermal collagen is depleted, which will result in lessened support for the lips.
• Full Mouth Tooth Wear - With no treatment; or bruxism; or loss of posterior teeth.
• History of Chronic Facial Muscle Imbalance - Bell's palsy.
• Stressful Lifestyle - Creating habitual clenched/perioral muscles due to stress and anxiety.

• Relax All of Your Facial Muscles - While standing in front of a mirror in good lighting.
• Look to See Where the Corners of Your Mouth Are Situated - Do they both go down an equal amount or is one corner lower than the other?
• Now Look to See How Much of Your Upper Teeth You Can See When Relaxed - You want to see about 1 – 3 mm of the top edge of your two middle front teeth.
• Next Gently Run Your Fingers Over Your Cheeks and Lips - Looking for tension, sore spots, or anything that seems out of place.

• A Clinical Facial Analysis - Will include visual and digital assessments of: lip drapes, commissures, resting vertical dimension.
• An Occlusal Evaluation - Will include assessments of: bite stability, patterns of tooth wear, arch relationships using articulating paper.
• X-Rays - Will provide panoramic and cephalometric images to help determine the structure supporting the skeletal and dental components of your face.
• Dynamic Video Capture - Includes recording you speaking naturally and switching between different emotions to analyze what happens as you use the muscles involved in expression.

• Grade 1 (Mild) - Asymmetries at rest are minimal or there is a minor reduction in incisor display when compared to youthful appearance; no functional pain exists.
• Grade 2 (Moderate) - Significant lip sagging occurs; moderate muscular strain of the perioral musculature develops and significant loss of resting tooth show can be noticed.
• Grade 3 (Severe) - Facial asymmetry is apparent; marked loss of vertical dimension has occurred; long-term neuromuscular fatigue necessitates multiple disciplines for treatment.

• Minimally Invasive Restorative Bonding - Composite or ceramic bonded to worn-down incisors to produce a youthful-appearing resting tooth display.
• Orthodontic Realignment - Use of clear aligners or fixed braces to correct underlying skeletal and dento-skeletal discrepancies.
• Neuromuscular Modulation - Botulinum toxin is injected into specific areas to modulate hypertonicity of the perioral muscles and improve overall resting symmetry.
• Prosthetic Rebuilding - Full-mouth reconstruction by use of full-coverage crowns and bridges to rebuild lost vertical dimension.

• Diagnostic Consultations - Cost from ₹1,000 to ₹3,000 at a variety of clinics in cities in Kerala.
• Aesthetic Composite Contouring - Is charged by tooth from ₹3,000 to ₹8,000 according to the materials used.
• Orthodontic Corrections - Can range from ₹45,000 to ₹1,20,000 for different levels of complexity with respect to orthodontic appliances.
• Full Mouth Rehabilitation Costs - Are generally ₹1,50,000 to ₹4,50,000+ when all teeth have been fully restored with ceramics.

Insurance Coverage Note - The patient will likely be responsible for the aesthetic portion of their restoration, as insurance only pays for functional wear.

• General Dentist - Best suited for the first screening of your teeth, minor bonding, simple evaluation of bites, etc.
• Prosthodontist - Does most of the advanced full-mouth reconstruction, reconstructs the bite, and creates an aesthetically pleasing smile design.
• Orthodontist - Required to correct any issues with the alignment of the jaws and position of your teeth.
• Maxillofacial Surgeon - Will consult with you if there are severe skeletal asymmetries and/or surgery is needed.

• Elective/Scheduled: Most neutral lip posture asymmetries, along with all other aesthetic concerns, will have scheduled appointments in relation to their non-emergent nature.
• Emergency: Must be evaluated within 24 – 48 hours if resting asymmetry is accompanied by sudden numbness, pain, or obvious signs of nerve dysfunction.

1. I am now missing most of my teeth when I am at rest, what caused this?

The natural process of aging, combined with excessive loss of your dentition due to dental wear has caused a downward pulling of the upper lip posture so that it covers your anterior (front) teeth which previously showed at rest.

2. Is there an option to correct my neutral lip posture on a permanent basis without  undergoing surgical procedures?

Many patients have been treated conservatively through restorative bonded treatments, orthodontic treatment and/or strategically placed muscle relaxing agents.

3. Do eating hard foods such as those found in traditional Kerala cuisine, e.g. crunchy snacks affect how I eat at rest?

Consistently consuming hard foods may promote excessive tooth wear; eventually this process will reduce the patient’s vertical dimension and create changes in the patient's resting lip posture over time.

• Bruxism - The habit of grinding your teeth, which can flatten out your tooth structure and collapse your resting facial height.
• TMJ (Temporomandibular Joint) Disorder - This is when you have dysfunction in one or both of your TMJs that can lead to strain on your muscles and an asymmetrical resting position for your jaw.
• Edentulous - When you have partial or complete tooth loss; this will greatly compromise the support of the lower part of your face.

• Splint Therapy for Occlusion - Custom-made night guard splints are used to protect your teeth from being worn down further by bruxing and help keep the muscles in your jaws stabilized.
• Crown Lengthening Periodontal Surgery - Gum recontouring with a surgical procedure is done so the patient has access to their optimal tooth structure before they receive any restorative work.

The neutral lip posture is a key tool in the evaluation process today. It provides a connection between aesthetic concerns and functional health. Proper vertical dimension can be maintained through good proactive dental care and will prevent early signs of perioral aging and muscle fatigue. Any patients who have experienced structural collapse or asymmetry should schedule a comprehensive evaluation with a qualified restorative specialist to provide long term protection of overall oral health and facial harmony.