J Oral Maxillofac Surg

47:359-366. 1999

Ptosis of the Chin and

Lip Incompetence:
Consequences of Lost Mentalis Muscle Support
BRIAN C. RUBENS, DDS,* AND ROGER A. WEST, DMDt

Ptosis of the chin and lip incompetence are worrisome complications of

surgery in the mandibular symphyseal region. This article relates the nor-
mal anatomy and physiology of the muscles in this region to these com-
plications. It suggests a sequence of surgical planning that can prevent
them and also offers ways of dealing with the problems should they occur.

Introduction izontally and anterolaterally from their bony origin;

the inferior fibers arise from their origin and pass
Oral and maxillofacial surgeons frequently per- nearly vertically downward, whereas lateral fibers
form surgery on the bone and soft tissue of the man- traverse laterally (Fig 2). There are no fibers that
dibular symphyseal region. One of the complica- pass into the lower lip. Contraction compresses the
tions of this type of procedure is unsightly ptosis of skin overlying the chin against the front of the man-
the chin, with or without concomitant lip incompe- dibular symphysis, in turn elevating the soft tissues
tence. This can be further complicated by coexis- of the chin and contiguous lower lip. Although there
tent sensory disturbances. This article deals with is no direct effect on the lower lip, indirectly the
the anatomy and physiology of the region, offers an mentalis muscle provides the major vertical support
approach to surgical planning, and delineates surgi- for the lower lip.
cal techniques that can be used to repair the prob- The mentalis musculature may alter anterior oc-
lem. clusion by elevating the chin and the lower lip, re-
sulting in flaring of the maxillary incisors. Hamula
Anatomy and Physiology experimented with severing the superior mentalis
muscle attachments from the bony symphysis to ef-
The chin musculature is composed of three mi- fect reduction in the labiomental fold and to reduce
metic muscle groups: the mentalis, the obicularis the effects of adverse lower lip function on maxil-
oris, and the depressors. These muscles are inner- lary incisor position following orthodontics ~3 He
vated by the seventh cranial nerve and function as created lip and chin ptosis resulting in a reduction of
an integrated unit.’ The mentalis muscle controls the labiomental fold. He noticed that there was a
the posture of the chin. Muscle fibers originate from concomitant increase in interlabial gap with some
an oval area of bone opposite the roots of the inci- return toward the presurgical position by a year fol-
sors, on the anterior surface of the mandibular sym- lowing surgery.
physis (Fig 1).2 Its fibers fan out in three basic di- The obicularis oris is primarily a sphincteric mus-
rections and penetrate into the integument of the cle with additional fibers from the surrounding ele-
skin. The superior fibers extend approximately hor- vators and depressors contributing to its substance.
Its strength is altered only minimally by changes in
* Former Chief Resident, Department Of Oral and Maxillofa- chin position and is generally not a great surgical
cial Surgery, University Of Washington, Seattle. concern.
t In private practice, Northwest Center For Corrective Jaw The depressors are composed of two muscles, the
Surgery, Seattle, Washington.
Address correspondence and reprint requests to Dr West: depressor anguli oris and depressor labii inferioris.
Providence Professional Bldg, Suite 303, 550 16th Ave, Seattle, The depressors have little effect on chin position
WA 98122. and enter into the integument of the skin and con-
0 1989 American Association of Oral and Maxillofacial Sur- tribute fibers to the obicularis oris. The depressor
geons anguli oris arises from a broad base between the
0278-2391/89/4704-0007$3.00/O mandibular canine-first molar region and enters at

359
360 COMPLICATIONS OF LOST MENTALIS MUSCLE SUPPORT

tion with age.’ The strength of the obicularis oris

also decreases with increasing age.
With progression from the dentulous to the eden-
tulous state, there are neuromuscular changes that
need consideration from a prosthetic standpoint,
brought about by loss of proprioceptive input from
the dentition. Tallgren used (electromyogram) EMG
studies to examine the neuromuscular response of
various facial muscles to the loss of dentition.6 She
evaluated ten patients at 2 to 4 months following the
removal of their posterior dentition and following
the removal of all remaining anterior teeth after the
FIGURE 1. Diagram showing area of attachment of the paired
subjects became accustomed to their prostheses.
mentalis muscle.
Tallgren grouped and studied the buccinator, upper
and lower obicularis oris, mentalis, and masseter,
the corner of the mouth. This muscle may be con- and found that there was unbalanced muscular ac-
tinuous with the platysma and may contribute trans- tivity with increased mentalis and lower obicularis
verse fibers called the transversus menti. The de- oris activity in posterior edentulous individuals.
pressor labii inferioris arises slightly anterior and The obicularis oris and mentalis muscles are appar-
often deep to the depressor anguli oris, entering into ently the most sensitive to changes due to the loss
the obicularis oris more medially. of posterior teeth. She concluded that upper and
Physiologically, the soft tissue of the lower lip lower lips do not act synergistically; the upper lip is
and chin contribute to oral continence. Whereas the more passive in function than the lower lip. Tallgren
mentalis muscle is essential for vertical support, also noted that in the edentulous state there is im-
oral continence is an integrated function of lip sen- provement of the neuromuscular pattern to near
sitivity, obicularis oris strength, and lip curtain normal, with a decrease in mentalis tone and lower
height.4 The lips, in general, help provide oral con- obicularis oris tone, when dentures are placed. Re-
tinence, are an adjunct to eating and communica- moval of dentures results in a return to previously
tion, and aid in providing oral access and mainte- altered neuromuscular patterns. From the stand-
nance of the intraoral milieu. Stranc and Fogel ex- point of the physiology of the lower lip and chin,
amined 44 patients with varying degrees of oral alteration of normal lip parameters as well as aging,
incontinence of differing etiologies.4 Labial sulcus the edentulous state, and the loss of normal ana-
depth was used as an indicator of lip height. Sphinc- tomic relationships lead to abnormal function.
ter power and lip sensitivity via two-point discrim-
ination were measured. They also examined inter- Prosthetic Considerations
commisural distance at rest, during maximal lip
contraction, and maximal lateral lip retraction. It With advancing age and the edentulous state,
was observed that the strength of the obicularis oris bony changes occur affecting profile and coordi-
and preservation of lip sensation play the major role nated muscular function.3*7’8 There is a reduction in
in obtaining acceptable lip seal. Lower lip height both maxillary and mandibular alveolar ridge
was less important except in instances where mouth height, with mandibular loss at a ratio of 4:l com-
closure was not possible. Preservation of lower lip pared with the maxilla. Mandibular basilar bony
sensation was the single most important factor in form affects the rate of resorption. The broader the
maintaining oral continence. Fogel and Stranc also base, the slower the rate of resorption. Mandibular
examined normal lip parameters and noted a linear ridge resorption encroaches on the origin of the
reduction in lip sensitivity to two-point discrimina- mentalis muscle, often necessitating procedures de-
signed to increase vestibular depth or alter pros-
thetic design to improve retention (Fig 3).9 Such
procedures further encroach upon the mentalis
musculature, the support element of the soft-tissue
FIGURE 2. Mentalis muscle chin.
fibers coursing from origin to Many procedures have been performed to in-
attachment in skin integu-
crease sulcus depth. lo-l3 Samit and Popowich, in a
ment.
review article, examined ten modifications of a tra-
ditional skin graft vestibuloplasty technique.14 Ex-
tensive mentalis reflection was found to be common
RUBENS AND WEST 361

mies.“-” The results were unpredictable, often re-

sulting in little change in chin profile. Kawamoto
recognized that chin point ostectomy may produce
FIGURE 3. Chin ptosis sec- ptosis, particularly when smiling.*’ He suggested
ondary to progressive loss of
using a horizontal mandibular osteotomy and non-
mentalis attachment in the
edentulous state. resorbable sutures to reduce postoperative ptosis.
Hohl and Epker” examined 11 patients treated for
macrogenia by either chin point ostectomy or hor-
izontal sliding mandibular osteotomy. Treatment
results suggested poor predictability with chin point
ostectomy and variable results with horizontal slid-
to most procedures. Samit and Kent examined com-
ing mandibular osteotomy. They observed chin pto-
plications seen in 100 skin graft vestibuloplasties.i5
sis when the entire symphyseal region was de-
They noted that excessive dissection in the anterior
gloved. The authors advised against using the chin
vestibule of the mandible produced a postoperative
point ostectomy procedure and advocated main-
loss in lower facial contour. This may be due to
taining the integrity of the periosteum attached to
inversion of the lower lip and flattening of the la-
the inferior segment to improve the predictability of
biomental fold, giving the appearance of pseudoprog-
soft tissue change. They also suggested retaining a
nathism. However, denture support of the lower lip
lingual pedicle of muscle to maintain blood supply
and chin may facilitate satisfactory compensation.
to the inferior segment. Ellis et al investigated the
Quayle, in an article pertaining to labial sulcoplasty,
influence of the lingual soft tissue pedicle on remod-
commented on the occurrence of a “pendulous
eling and resorption of the inferior bone segment in
chin, ’ ’ thought to be secondary to increased atro-
horizontal mandibular osteotomies performed on
phy of the mandible in combination with excessive
Macaca mulatta monkeys.** They observed less
sulcoplasty.‘3 Hillerup” reported on his experience
bony resorption of the most anterior symphyseal
using a vestibular sulcus extension technique on 19
region when a lingual pedicle was maintained. They
patients with severe mandibular atrophy. He found
concluded that the loss of the blood supply was the
a reduction in lower lip height and slight inversion
major factor associated with the bone resorption.
of the vermilion zone. Hillerup suggested that pedi-
The soft tissue change associated with horizontal
cled flaps should be made no broader than one third
sliding mandibular osteotomy has been shown to be
the total distance from the vermilion border to mu-
less predictable when the procedure is used to re-
cogingival junction to avoid inversion. Persistent
duce chin prominence than when used for augmen-
dysesthesia was associated with the technique.
tation purposes. Bell et al examined seven patients
Kethley and Gamble modified Kazanjian’s vestibu-
who underwent sliding mandibular osteotomies to
loplasty technique to avoid periosteal reflection to
treat macrogenia.23 Comparing long-term soft tissue
the inferior mandibular border, preserving the la-
changes to initial bony change, an approximate soft
biomental fold. ** Adawy et al, in a review article
tissue reduction of 58% was found. They suggested
dealing with changes in soft tissue profile following
that the predictability of soft-to-hard-tissue move-
mandibular vestibulolingual sulcoplasty and free
ment could be improved by maintaining the maxi-
skin grafting, evaluated 47 patients 1 to 5 years after
mum amount of soft tissue attachment to the infe-
surgery. I6 They found a mean decrease in height of
rior border and mental symphysis region of the re-
the lower lip of 2.6 mm. A permanent increase in
positioned segment. Noble, in his thesis, studied 30
chin prominence averaging 2.5 mm was apparent
nongrowing patients treated with horizontal man-
within 1 year after operation. They also noted a
dibular osteotomies for reduction genioplasty.24 He
slight anterior repositioning of both lips, averaging
concluded that the ratio of soft-to-hard-tissue hor-
about 1.3 mm for the upper lip and 1.2 mm for the
izontal movement was in the range of 60%. Lower
lower lip.
lip movements were unpredictable, and soft tissue
changes in the vertical dimension were too variable
Orthognathic Considerations to permit accurate prediction of soft tissue changes.
It appeared that the amount of hard tissue move-
Multiple surgical procedures have been devel- ment was the main determinant of soft tissue re-
oped to improve facial esthetics in the chin region. sponse.
Initial genioplasty techniques aimed at reducing Various modifications of the horizontal mandib-
chin prominence involved either ostectomy or os- ular osteotomy have also been used to treat the
teotomy of the prominent chin point, wedge ostec- retrusive chin.25-27 Soft tissue changes are more
tomy, or horizontal sliding mandibular osteoto- predictable with augmentation than with reduction
362 COMPLICATIONS OF LOST MENTALIS MUSCLE SUPPORT

procedures. McDonnell et a127 found a ratio of lips together. Four years earlier, the patient was treated
about 75% long-term soft tissue change to initial for a class II malocclusion and associated mandibular hy-
poplasia with mandibular sagittal osteotomies and a hor-
bony change. Busquets and Sassouni observed a
izontal mandibular osteotomy (augmentation genioplas-
ratio of about 8O%.28 Bell and Gallagher discussed ty). The patient lost support of the lower lip, with result-
the use of the horizontal mandibular osteotomy to ing lip incompetence and associated chin ptosis (Figs 4
correct deficient chin contour and emphasized the and 5). She was able to achieve approximation of the lips,
importance of maintaining maximal soft tissue at- but the lower lip was incompetent in a relaxed position,
tachments to improve the predictability of concom- displaying all of her mandibular incisors. Radiographic
evaluation showed distortion of the gonial angles of the
itant soft tissue movement.26 They noted that chin mandible due to counterclockwise rotation of the proxi-
ptosis and interlabial incompetence with excessive mal fragments following the sag&al osteotomies (Fig 6).
exposure of mandibular teeth may ensue if meticu- This cumulative effect of the decrease in posterior facial
lous care is not taken to preserve soft tissue attach- height, along with chin ptosis, further accentuated an al-
ready steep mandibular plane angle.
ments.
Various treatments were discussed with the patient.
Various soft tissue surgeries may be used as an These included reconstruction of the gonial angles with
adjunct and can be performed simultaneously to alloplastic augmentation and/or correction of the chin
further improve chin contour.8’29‘31 Turvey and Ep- ptosis and lip incompetency. Although the patient was
ker discuss the use of submental lipectomy to cor- unhappy about the loss of contour in the gonial angle
region, her primary concern related to distortion of the
rect ptosis of the chin, a condition they describe as
lower lip and chin. Therefore, a decision was made to
an “exaggerated submental fold due to overabun- correct/improve the chin ptosis and lip incompetency.
dance of soft tissue beneath the chin or exaggerated The corrective procedure was limited to the soft tissues,
submental fat pad. 3o Gonzalez-Ulloa also describes with the objective of surgically repositioning the mentalis
a soft tissue approach to correct ptosis or “witches’ muscle superiorly, to improve the support of the lower lip
and the chin. This procedure involved placing a horizon-
chin.“31 Brennan and Giammanco demonstrated
tal incision in the mucosa halfway between the depth of
the use of the mentopexy procedure to correct chin the vestibule and the superior margin of the lower lip. The
ptosis by repositioning the premental fibrofatty pad mental nerves were identified, and a supraperiosteal dis-
to a more anterior and superior insertion.’ They section was completed to within 5 to 8 mm of the menton.
suggested performing mentopexy with a submental The periosteum was incised and the dissection continued
subperiosteally to the inferior border of the symphysis.
lipectomy, or augmentation mentoplasty when
Releasing incisions were then placed in the periosteum
more chin projection is desired. Sher describes a circumferentially along the inferior border. The perioste-
technique for creating a chin cleft by selective ex- al-mentalis muscle complex was then elevated and su-
cision of mentalis muscle.32 tured to the remaining superior tissue, following the su-
Many authors feel that the horizontal mandibular praperiosteal dissection. Symmetry was confirmed, and
the lifting effect on the sagging chin appeared to be sat-
osteotomy is the surgical treatment of choice for isfactory, with apparent correction of lip incompetence
managing excessive or deficient chin contour. Pre- (Figs 7 and 8). Mucosal tissue was closed in a running
dictability of results depends on meticulous atten- manner with 4-O resorbable suture, and a pressure dress-
tion to detail. Three-dimensional stabilization of ing was applied to support the chin.
bony fragments is necessary to ensure predictability
of soft tissue changes. 17,33Incorrect incision place- Case 2
ment with excessive subperiosteal dissection, and A 27-year-old white woman was evaluated for a com-
improper wound closure, with or without suprahy- plaint of “sagging of the chin” and a change in her oc-
oid myotomy, will all adversely affect treatment clusion (Fig 9). Eighteen months earlier the patient had
results. 26Rowe suggested using a lip incision placed
midway between the depth of the labial vestibule
and the vermilion border of the lower lip.34 Several
authors have recommended maintaining the attach-
ments of the paired genioglossus, geniohyoid, and
anterior bellies of the digastric muscles pedicled to
the interior segment of bone. 17,26*35 Pressure dress-
ings have been suggested to aid in initial soft tissue
FIGURE 4. Preoperative
support and to minimize edema. However, caution chin ptosis in case 1.
must be used to avoid excessive application of
pressure.36
Case Reports

Case 1
This 53-year-old woman presented with a chief com-
plaint of drooping of the chin and difficulty in keeping her
RUBENS AND WEST 363

FIGURE 7. Case 1, profile

view following corrective soft
tissue procedure. It demon-
strates lip competence with
persistent ptosis.

FIGURE 5. Case 1, lip incompetency at rest.

been treated with a bilateral saglttal split mandibular os-

teotomy to correct a skeletal class III pattern of maloc-
clusion. A reduction genioplasty had also been performed
mies, an incision was placed in the mucosal surface of the
in which the symphysis had been surgically excised (Fig lower lip, halfway between the depth of the vestibule and
10). Perioperative orthodontic therapy had not been uti- the superior margin of the lower lip. The mental nerves
lized due to foreshortened root structure from 4 years of were identified and dissected out bluntly. Dissection was
previous orthodontic treatment. Evaluation of study casts continued sharply in the plane of the obicularis oris mus-
showed that dental compensation would preclude satis- cle to the symphysis, paying particular attention to pre-
factory resolution of the malocclusion unless orthodontic serving the maximum amount of soft tissue attachments
coordination was completed presurgically. The esthetic to the remaining symphyseal “stump.” Horizontal sec-
changes in the chin and lip area, as well as the lip incom- tioning was performed, with the cut beveled superiorly.
petency, were felt to be due to the loss of both bone and The symphyseal stump with all attached soft tissues was
muscle support. Therefore, a decision was made to re- advanced antero-superiorly and stabilized by three figure-
construct the bony defect of the symphysis using a mod- of-eight intraosseous wires. Sutures were placed deeply,
ifled horizontal osteotomy along with surgical reduction and the lip position and chin contour reevaluated before
of mandibular length using bilateral mandibular sagittal further closure. The superior change in mentalis position
osteotomies to correct the malocclusion (Figs 11 and 12). eliminated the lip incompetency and chin ptosis. The ad-
These surgical procedures were performed concomi- vanced symphyseal stump had recreated a labiomental
tantly. Following the completion of the sagittal osteoto- fold, thus giving better definition to the chin. The remain-
der of the closure was completed in layers, and a pressure
dressing was applied to support the chin and lip. The
results are shown in Fig 13.

Discussion
When surgery is performed in the chin region, it
is best to avoid a “degloving” procedure. Careful

FIGURE 6. Case 1, postoperative cephalometric radiograph of

initial treatment leading to ptosis of the chin and lost mandibular FIGURE 8. Case 1, lip competence achieved following reposi-
plane angle. tioning of mentalis-periosteal complex.
364 COMPLICATIONS OF LOST MENTALIS MUSCLE SUPPORT

FIGURE 9. Case 2, initial

appearance of soft tissue chin
after symphyseal ostectomy
procedure.

planning and good surgical technique generally

make this possible, thereby minimizing the risk of
postoperative loss of chin and lip support.
FIGURE 11. Case 2, postoperative cephalometric radiography
Dissection through the mucosa of the lower lip is
of horizontal mandibular osteotomy to move symphyseal and
made through an incision midway between the ves- attached mentalis-periosteal complex anterosuperiorly.
tibule and the upper border of the lower lip. This
approach reduces excessive scar retraction and re-
sultant loss of vestibular depth.34,37 The dissection deep sutures to reattach the deeper supporting
is continued inferiorly, paying particular attention structures of the chin, and to eliminate dead space
to preserving the maximum amount of soft tissue superior to the symphyseal fragment. A pressure
attachment to the symphysis, including the inser- dressing will aid in stabilizing the repositioned soft
tion of the mentalis muscle. At the completion of tissue structures and help prevent hematoma forma-
the procedure, the wound is closed in layers, with tion. If the surgeon chooses to achieve a greater
exposure, it must be recognized that this carries a
greater risk of ptosis of both the lip and chin. More
meticulous attention is then necessary to reposition
and secure the soft tissues at the time of closure.
The case reports reflect varying degrees of resid-
ual deformity. In one case, this was further accen-
tuated by surgical excision of bone from the man-
dibular symphysis to accomplish a reduction geni-
oplasty. The soft tissue procedure used to eliminate
chin ptosis and associated lip incompetence in case
1 was designed to recapture the mentalis-periosteal
complex and reposition it superiorly. The supra-
periosteal dissection preserved a segment of sub-
mucosal and periosteal tissue to secure the superi-
orly repositioned mentalis-periosteal complex. De-
spite this, the results were less than optimal (Figs 7
and 8). The use of nonresorbable sutures placed in
bone holes to secure the repositioned soft tissues
may not adequately increase the predictability of
results when the procedure is limited to the soft
tissues. More predictable results may be achieved
by maintaining the soft tissue attachments to the
FIGURE 10. Case 2, postoperative cephalometric radiograph
bony symphysis, sectioning the symphysis verti-
of initial treatment leading to lost definition and ptosis of the cally, and moving the mentalis muscle as part of an
chin, secondary to symphyseal ostectomy procedure. overall bony soft tissue complex. A modification of
RUBENS AND WEST 365

K.H.

FIGURE 14. Sagittal sym-

PRE-OP:-
physotomy used with suffi-
cient symphyseal bone to su-
‘2nd SURGERY periorly reposition the men-
talis-bony-periosteal complex.
POST OP: - - -
(5 MOS.)

A modification of the above procedure was used

in case 2. A horizontal mandibular osteotomy an-
gled to effect movement in an anterior and superior
direction was used. By maintaining the soft tissue
attachment to the symphyseal fragment, a bony and
associated soft tissue movement was accomplished,
giving improved definition and character to the
chin, as well as reducing chin ptosis and lip incom-
petence (Fig 13).
In cases where inadequate symphyseal bone re-
mains a bone augmentation procedure is necessary
to provide soft tissue support, as well as redefini-
tion of the normal chin contours. This, along with
the superior repositioning of the mentalis-periosteal
complex, may or may not be achieved in one pro-
cedure .
Although alternate approaches may be used to
correct residual defects in chin and lip support, it is
clear that isolated soft tissue procedures are not
predictable. Therefore, if the residual bone is ade-
quate, a simultaneous bony-soft tissue procedure
may insure more predictable results. When bone
FIGURE 12. Preoperative and postoperative cephalometric
overlay tracings demonstrating correction of lost chin definition support is inadequate to allow for osteotomy, the
and support. reconstruction of the bony foundation may be nec-
essary, either as a staged procedure or in tandem
the sagittal symphysotomy approach to the chin re- with manipulation of the soft tissue complex.
gion may be used to move the bone and periosteal The most important consideration is to avoid cre-
muscle complex superiorly with wire or screw sta- ating these types of defects, as it is clear that sur-
bilization (Fig 14).38,39 gical procedures designed to correct ptosis of the
chin and lip incompetence are not predictable. Pres-
ervation of the mentalis muscle attachment to the
underlying supporting bone through the periosteal
complex is mandatory.

References

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