2. INTRODUCTION:-
• Lips are soft, movable.
• It serve as the opening for food
intake and in the articulation of
sound and speech.
• The upper and lower lips are
referred to as the "Labium
superius oris" and "Labium inferius
oris", respectively.
The junction where the lips meet the
surrounding skin of the mouth area is
the vermilion border,
3. Development of Lip
•In the sixth week of intrauterine life, two medial nasal
processes merge in midline. This will form intermaxillary
segment which will give rise to center of upper lip.
•In adult, center of upper lip forms philtrum.
•Lateral part of upper lip fissure presents in maxillary
process.
•This may lead to cleft formation if it is not covered
by epithelium and fused.
•Upper lip is thus formed from one third medial nasal process
and two-third maxillary process.
4. Anatomy
• lips are fleshy folds lined by
skin externally and mucous
membrane internally, which
has profuse salivary glands.
• The upper and lower lips
close along the red margin
which represents the
mucocutaneous junction.
5. Classification of Lips Disorders
C O L O R E D L E S I O N S
#WHITELESIONS
• Candidiasis
• Squamous cell papilloma
• Verruca vulgaris
• Condyloma
• Lichen planus
• Lichenoid drugeruption
• Actinic keratosis
• Squamous cell carcinoma
• Snuff dipper's lesion
• Cigarette smoker's lip
• Focal epithelial hyperplasia
#REDLESIONS
• Hemangioma
• Sturge-Weber syndrome
• Thrombocytopenic purpura
• Rendu-Osler-Weber disease (hereditary hemorrhagic
telangiectasia)
• Kaposi's sarcoma
• Contact allergy
#BROWNLESIONS
• Nevus
• Labial melanotic macule
• Melanoma
• Albright's syndrome
• Peutz-Jeghers syndrome
• Addison's disease
• Hemochromatosis
• Kaposi's sarcoma
#YELLOWLESIONS
• Lipoma
• Fordyce's disease
7. Developmental Disorders of Lip
Congenital Lip Pits
It is also called as ‘paramedian lip pit or congenital fistula’.
Etiopathogenesis
• Hereditary
• Notching of lip
• Incomplete union
Clinical Features
• Sex predilection— more commonly seen in females.
• Site—it is common on vermilion border of either side of
midline. It is most commonly seen on lower lip.
• Size—it may be upto 3-4 mm in diameter and may extend
as deep as 2 cm.
• Appearance—lips, some times appear swollen, accentuating
• Palpation—on palpation, sparse mucus secretion may
be visible from the base of the lip-pit which occurs due
to involvement of underlying minor salivary glands.
8. Syndromes associated— vander Woude’s
syndrome (cleft lip, cleft
palate and congenital lip pits).
Diagnosis
Clinical diagnosis—unilateral or bilateral
depression on vermilion border of lip will
diagnose these conditions.
Management
• Surgical excision—it is done for cosmetic
purpose.
9. Commissural Pits
Commissural lip pits are mucosal
invagination occurring
at the vermilion border of lip.
Pathogenesis
They occur due to failure of normal fusion
of embryonal maxillary and mandibular
processes.
It is transmitted as
autosomal dominant transmission.
10. Clinical Features
• Sex distribution—it is more common amongst males and black people are
affected more than white people.
• Site—if it is unilateral, it occurs on the right side of the lip.
• Appearance—commissural pit appears as a unilateral or bilateral pit at the
corner of the mouth on the vermilion surface.
• Size—size ranges from a shallow dimple to a tract measuring 4 mm in
length and tissue slightly raised above the opening.
• Palpation—in squeezing of the lip pit, small amount of saliva can come out.
Differential Diagnosis
• Congenital lip pit—it may be associated with facial or palatal cleft.
Management
• Surgical excision—it is indicated only in severe condition, where salivary
secretion excessive and secondary infection can occur.
11. Double Lip
It is an anomaly characterized by a fold of excess tissue
on the inner mucosal surface of the lip. It may be
congenital or acquired because of trauma to the lip.
Pathogenesis
It occurs in 2nd or 3rd week of gestation due to
persistent of the sulcus between the pars glabrosa and
pars villosa of the lip.
Clinical Features
• Site—it usually occurs on inner aspect of upper lip.
• Cupid bow appearance—when upper lip is tensed,
double lip resembles ‘cupid bow’.
Diagnosis
• Clinical diagnosis—cupid bow appearance is typical.
Management
• Surgical excision
12. Cleft Lip
It occurs along many planes as a result of fault or
defect in the development.
Definition
Cleft lip—it is a birth defect that results in a
unilateral or bilateral opening in the upper lip
between the mouth and the nose. It is also called
as harelip. It is wedge shaped defect resulting
from failure of two parts of the lip to fuse into a
single structure.
Etiology
• Hereditary
• Genetic
• Nutritional disturbances
• Developmental
• Defective vascular supply
• Mechanical disturbances
• Infection
13. Clinical Features
• Sex—it is more common in males as compared to females.
• Site—it is more frequently seen on the left side than on the right
side.
• Teeth— teeth may be missing, deformed, displaced or divided,
thus producing supernumerary teeth.
• There is nasal distortion as lip and nasal tissue pulls towards the
attached side.
• Hare lip—this term is used to apply for only median cleft lip. Hare
lip is derived from the rabbit who normally have cleft in the middle
of their lip.
Diagnosis
• Clinical diagnosis—cleft can be seen clinically on lip and palate.
• Radiological diagnosis—cleft palate involving alveolus is seen
clearly on radiography.
14. Management
The complete rehabilitation of the condition
requires a
multi-disciplinary approach.
• Cheiloplasty
• • Obturator
• • Palatoplasty
• • Bone grafting
• • Orthodontic therapy
• • Cleft rhinoplasty
• • Speech therapy
• • Psychotherapy
• • Feeding plate
15. Cheilitis
It is inflammation of lip.
Various types of cheilitis are Described
Glandular Cheilitis
It is also called as cheilitis glandularis. It is an uncommon
condition in which lower lip becomes enlarged, firm and
finally everted.
Etiology
• Sun exposure
• Hereditary
• Salivary gland inflammation
• Others—dust, tobacco use and emotional disturbances
• multiple, painless, pinhead sized lesions with
central depression and dilated canals are present.
• Superficial suppurative type (Baelz’s disease)—it is
characterized by painless swelling, induration, crusting
and superficial ulceration of lip.
16. Deep suppurative type (cheilitis
glandularis apostematosa
myxadenitis labialis)—
Deep seated infection with abscess and fistula
tract that eventually forms a scar.
Clinical Features
• Age—it is more common in adults but
sometimes, it can also occur in children.
• Site—lower lip is involved more often than the
upper lip.
• Symptoms—enlargement of labial salivary
glands occurs which can be nodular.
• Signs—orifices of secretory ducts are inflamed and
dilated appearing as small red macules over the mucosa.
17. Volkmann’s cheilitis—
It is more severe suppurative form of glandular
cheilitis.
The lip is considerably and permanently enlarged
and is subjected to episodes of pain, tenderness
and increased enlargement.
The surface is covered by crust and scales
beneath which the salivary duct orifice may be
discovered.
18. Malignant transformation—
it is apparently pre-malignant
and epidermoid carcinoma can be associated with it in
18 to 35% of cases.
Diagnosis
• Clinical diagnosis—everted hypertrophic lip with secretion after
pressure on lip.
Management
• Vermilionectomy or lip shaveded.
• Surgical excision
19. Granulomatous Cheilitis or Orofacial
Granulomatosis
It is also called as ‘Miescher’s syndrome’ or
‘cheilitis granulomatosa’.
Etiology
Local causes
• Chronic oral/dental infection
• Embedded foreign material
• Allergy to cosmetics, foods, oral hygiene
products and dental restorative materials.
Systemic causes
• Chronic granulomatous disease
• Crohn’s disease
• Sarcoidosis
• Tuberculosis
20. Clinical Features
• Age and sex—it is seen in adults as well as in children and there is
female predilection.
Symptoms
• There is diffuse swelling of the lips, especially the lower lip
• In some cases, an attack is accompanied by fever and mild
constitutional symptoms including headache and even visual
disturbances.
• Enlarged lip can create cosmetic problems, difficulty during eating,
drinking or speaking.
• Syndrome—it is associated with Melkersson Rosenthal syndrome
which consists of fissured tongue and facial paralysis.
Diagnosis
• Clinical diagnosis—soft swelling of lip with fever,headache and vesicle
can be seen.
21. Differential Diagnosis
• Cheilitis glandularis
• Angioedema
• Sarcoidosis
• Crohn’s disease
• Lymphangioma
Management
• Corticosteroid injection—repeated injection of triamcinolone into
the lips every few weeks may be effective. Before giving steroids,
topical anesthetics gels was applied over the lesion and then
0.1% of triamcinolone acetonide injection is given. This injection
should be given weekly for 7 to 10 weeks.
• Cheiloplasty—surgical stripping of lip can be done.
22. Angular Cheilitis
It is also called as ‘Perleche’, ‘Angular cheilosis’
‘Cheilocandidiasis’.
Causes
• Microorganisms— candida albicans, staphylococci
and streptococci.
• Mechanical factors—overclosure of jaws.
• Nutritional deficiency—riboflavin, folate and iron
deficiency
• Other factors—hypersalivation, Down’s syndrome
Clinical features
• Age—it occurs in young children as well as in adults.
• Symptoms—it is characterized by feeling of
dryness and a burning sensation at the corners
of the mouth.
• Appearance—it is usually a roughly triangular area
of erythema and edema at one or more, commonly
both the angles of mouth.
23. Diagnosis
• Clinical diagnosis—triangular area or erythema with wrinkled
macerated mucosa at angle of mouth.
Management
• Removal of the cause
• Nutritional supplement— vitamin B and iron supplements
• Fusidic acid ointment—it is used in staphylococcal infection.
• Miconazole—miconazole may be preferred, if angular cheilitis is
due to candidiasis (cream applied locally together with an oral gel).
• Gentian violet application—in some cases, it is useful.
24. Eczematous Cheilitis
• The lips are involved secondary to atopic eczema but
possibility of contact dermatitis must also be
considered.
• The management of atopic eczema of the lips is with
emollient and topical steroids.
Contact Cheilitis
Definition
Contact cheilitis is an inflammatory reaction of the
lips provoked by the irritants or sensitizing action of
chemical agents in direct contact with them.
Causes
• Lipsticks
• Lip salves and other medicaments
• Mouth washes and dentifrices
• Dental preparations
• Foods—oranges, mangoes and artichokes are among the
food plants which occasionally cause allergic cheilitis and
dermatitis of the skin around the lips.
25. Clinical Features
• Site—lipstick cheilitis is usually confined to the vermilion borders but more often extends
beyond that.
• Signs and symptoms—there may be persistent irritation and scaling or a more acute
reaction with edema and vesiculation
Management
Topical steroids will give symptomatic relief-- 1% triamcinolone acetonide.
Actinic Cheilitis
It is also called as Actinic cheilosis. Some other terms which use are Farmer’s
lips or Sailor’s lip as these people are more exposing to sunlight.
Definition
It is a pre-malignant squamous cell lesion resulting from long-term exposure
to solar radiation and may be found at the vermilion border of lip as well as
other sun exposed surfaces.
Etiology
• Chronic sun exposure—it is the main cause, so it usually occurs in hot, dry
regions, in outdoor workers and in fair skinned people.
26. Clinical Features
• Site—the lower lip is more commonly
affected than the upper lip.
• Age and sex distribution—it is more
commonly seen in adult’s patient. It is
less common in females.
• Signs—in the early stages, there may
be redness and edema but later on, the
lips become dry and scaly. If scales are
removed at this stage, tiny bleeding
points are revealed. With the passage of
time, these scales become thick and
horny with distinct edges.
27. Diagnosis
• Clinical diagnosis—redness, edema with history of
chronic sun exposure will give clue to diagnosis.
Management
• Topical fluorouracil
• CO2 snow
• Vermilionectomy (lip shaves)
• Laser ablation
• Electrodesiccation
• Prevention
28. Exfoliative Cheilitis
It is also called as Factitious cheilitis. It is a chronic superficial
inflammatory disorder of the vermilion border of lips
characterized by persistent scaling and flaking.
Causes
• Chronic injury— due to repeated lip sucking, chewing or
other manipulation of the lips.
• Personality disorders—emotional disturbance, psychological
difficulties and stress.
Clinical Features
• Age and sex distribution—age of occurrence is seen in
younger group. Most cases occur in girls.
• Site—the process starts in the middle of the lower lip and
spreads to involve the whole of the lower lip or both the lips.
• Symptoms—the patient complains of irritation or burning and
can be observed frequently on biting or sucking the lips.
• Signs—it consists of scaling and crusting, more or less
confined to the vermilion borders and persisting in varying
severity for months or years.
29. Diagnosis
• Clinical diagnosis—Scaling, crusting with perioral
skin erythema will aid to diagnosis.
Management
• Reassurance and psychotherapy
• Topical steroids—hydrocortisone cream
• Combination—hydrocortisone can be combined with
iodoquinol (antibacterial and antimycotic) cream can
be used in chronic cases of exfoliative cheilitis.
• Others therapy—it includes topical silver nitrate,
salicylic acid, antibacterial and antifungal formulation.
30. Plasma Cell Cheilitis
It is an idiopathic benign inflammatory condition characterized by
dense plasma cell infiltrate in the mucosa close to the body orifice.
Clinical Features
• Site—it can affect penis, vulva, lips, buccal mucosa, palate, gingiva,
tongue, epiglottis and larynx.
• Sign—it presents as circumscribed patches of erythema , usually on
the lower lip in elderly persons.
Diagnosis
• Clinical—not possible.
• Laboratory—on histopathological examination plasma cell can be
seen.
Management
It responds to topical application of powerful steroids or to intradermal
injection of triamcinolone.
Drug-induced Cheilitis
Cheilitis can occur as an isolated feature of a drug reaction- either as
a result of allergy or a pharmacological effect.
The aromatic retinoids, etretinate and isotretinoin cause
dryness and cracking of lips in most patients.
31. Carcinoma of Lip
Squamous cell carcinoma is the commonest malignancy to affect the
vermilion zone. It occurs in light skinned people who have chronic
exposure to sunlight.
Clinical Features
• Age and sex distribution— 6th and 7th decade of life. It is more
common in males
• Site—it is most common on the lower lips of fair skinned people
• Onset—it usually begins on vermilion border of the lip to one side
of the midline and it may be covered with crust due to absence of
saliva.
• Symptoms—patient may complain of difficulty in speech, difficulty
in taking food and inability to close the mouth.
There is also pain, bleeding and paresthesia.
Signs -- It often commences as a small area of thickening, induration
and ulceration or irregularity of the surface
• In some cases, it commences as a small warty growth or fissure on
the vermilion border of the lip.
• As the lesion enlarged, it takes papillary or an ulcerative form.
• In untreated cases, there is total destruction of lip and invasion of
cheek, the gums and the mandible.
32. Diagnosis
• Clinical diagnosis—ulcerative growth with
destruction of lip is present.
• Laboratory diagnosis—it is mainly well differentiated
malignancies.
Management
• Surgical—prognosis is good if the treatment is done
before metastasis.
• The best results are seen when being obtained
when the entire lip mucosal field is removed for early
lesion.
33. Miscellaneous Disorders
Chapping of the Lips
It is a reaction to adverse environmental conditions in
which keratin of the vermilion zone loose its plasticity.
• Causes—it is caused by exposure to freezing cold
or to hot, dry wind, but acute sunburns can cause
very similar changes.
• Clinical features—lip becomes sore, cracked and
scaly. The affected subjects tend to lick the lips or
to pick at the scales which make conditions worse.
• Management—Management is by application of
petroleum jelly and avoidance of the causative
environmental conditions.
34. Actinic Elastosis
It is also called as ‘Solar elastosis’ or ‘Senile elastosis’.
Causes
• Sunlight exposure—it is caused by prolonged exposure to UV
light. UV radiation can produce collagen degeneration in the dermis
and extent of this effect is dependent upon factors such as the
thickness of stratum corneum, melanin pigment, clothing or
chemical sunscreens.
Clinical Features
• Site—it is seen on the labial mucosa exposed to sun.
• Age—it occurs in elderly population.
• Signs—white area of atrophic epithelium develops with underlying
scarring of the lamina propria.
• Appearance—it includes leathery appearance, laxity with wrinkling
and various pigmentary changes.
• Clinical types—clinically, it is manifested in three forms:
• Cutis rhomboidalis—thickened skin with furrow giving an
appearance of rhomboidal network.
• Dubreuilh’s elastoma—diffuse plaque like lesions.
• Nodular elastoidosis—nodular lesion.
35. Caliber Persistent Artery
A caliber persistent artery is defined as an artery with a diameter
larger than normal near a mucosal or external surface. In this
condition, main arterial branch extends upto the superficial tissue
without reduction in the diameter is present.
Clinical Features
• Age and sex distribution—it is more commonly seen in adults.
Site—either lip can involve or some patients have bilateral lesion.
• Appearance—the lesion present as linear, arcuate or papular
elevation on the lip.
• Ulcer formation—such artery in the lip may cause chronic
ulceration which can be mistaken for squamous cell carcinoma.
The ulcer is attributed to continual pulsation from the large artery
running parallel to the surface.
• Signs—pulsation can be seen in the lesion. Pulsation is present
in lateral direction.
Management
• No treatment is necessary and some time, biopsy is done to
avoid the misdiagnosis of the lesion.
36. References :-
• Burket’s oral medicine 11th edition
• Oral and maxillofacial medicine second
edition – crispian scully
• Textbook of oral medicine by anil
govindrao ghom
• Differential diagnosis of oral and
maxillofacial lesion
Norman k. wood & Paul w. goaz
