Assessment of Anterior-posterior position of Lips: E-Line-S-Line

ASSESSMENT OF ANTERO-POSTERIOR POSITION OF

LIPS: E-LINE- S-LINE
1

SAAD ASAD, FCPS (Orthodontics), Invisalign Certified Orthodontist

2
FARHAT KAZMI, M.Phil Oral Pathology, PhD Trainee
MUHAMMAD MUMTAZ, MDS Oral Surgery, PhD Trainee
4
AAQIL MALIK, MSc Implant Dentistry

RIZWAN RAZ BAIG, BDS

ABSTRACT
In cephalometric and photographic analysis, several reference lines have been used to assess
anteroposterior position of the upper and lower lips: E-Line and S-Line being the most commonly used
reference lines Aim of this study was to find out the antero-posterior position of lips on photograph using
E-line and S-line in patients with orthognathic profile and to establish correlation between lip
prominence judged by E-Line and S-Line. The study was conducted on 90 subjects, with orthognathic
profile as judged in consensus by orthodontist, prosthodontist, Oral Surgeon, Oral Pathologist and
General Dentist and confirmed by lateral cephalogram (ANB 0-40, Wits Value 0,-1mm) with age range
of 12-30 years. E-Line & S-Line were drawn on photograph to assess the prominence of upper Lip and
lower lip. SPSS 16.0 was used for statistical evaluation. Antero-posterior position of upper and lower
lip with reference to E-line was -1.9+3.33 mm -0.4+3.24 mm respectively and Antero-posterior position
of upper and lower lip with reference to S-line was 3.72+2.85 mm and 1.18+3.23 mm respectively.
Moreover statistically significant correlation was found r=0.509 between Upper lip to E-Line and Upper
Lip to S-Line andm r= 0.861 between Lower lip to E-Line and Lower lip to S-Line.
Keys: Lip Prominence, E-Line, S-Line
INTRODUCTION
In the recent past diagnosis & treatment planning
in orthodontics has been shifted towards facial planning.1 Macro-esthetics, mini-esthetics & micro-esthetics have been emphasized and orthodontic ethics has
been linked to improving the nose-lip- chin balance.2
Lip balance in three planes has been one of the major
determinants in treatment planning: Lip Incompetence, Lip Prominence, Lip Fullness, Lip Strain, Short
Philtrum height, Acute Nasio-labial angle & Acute
Labio-mental angles shift treatment option towards
extraction in Borderline cases (arch length discrepancy=5-9 mm).3
1

In cephalometric and photographic analysis, several reference lines have been introduced to assess
anteroposterior position of the upper and lower lips.
Ricketts E line4, Steiners S line5, Holdaways H line6,
Burstones B line7, and Sushners S22 line8 are
common lip assessment lines used by Orthodontists in
diagnosis and treatment planning. Orthodontists however have their individual preferences of a reference
line in judging lip positions in patients.
E-Line and S-Line are most commonly used reference lines in orthodontic diagnosis and treatment
planning. E-Line is drawn from Pronasale (Pn) to soft
tissue pogonion (Pog) and lip prominence with refer-

Correspondence: Assistant Professor, Department of Orthodontics, Head of Oral Biology & Tooth Morphology, The University College of Dentistry, The University of Lahore. E-mail: saad2609@yahoo.com, Cell No:
0300-4079491
Assistant Professor & Head of Oral Pathology, University College of Dentistry, The University of Lahore.
E-mail: drfarhatkazmi@gmail.com, Cell No: 0321-8859705
Assistant Professor Oral & Maxillofacial Surgery, University College of Dentistry, The University of Lahore.
E-mail:maxfacmumtaz@gmail.com, Cell No: 0300-4554790
Assistant Professor, Department of Implant Prosthesis, University College of Dentistry, The University of
Lahore. E-mail: aaqilmalik@gmail.com, Cell No: 0332-3274621
Demonstrator Department of Operative Dentistry, University College of Dentistry, The University of Lahore.
E-mail: rizwan_dentist@hotmail.com, Cell No: 0300-8034191

Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

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Assessment of Anterior-posterior position of Lips: E-Line-S-Line

ence to this line is assessed. Upper lip to E-Line =-1mm

and Lower lip to E-line = 0 mm. This means that upper
lip is slightly behind E-line & lower lip touches E-line
in balanced face.

or congenitally missing teeth, already undergoing with

orthodontic treatment and Syndromes, were excluded
from the study. Sample was collected using the nonprobability convenience sampling technique.

S-Line is drawn from midpoint between subnasale

(Sn) and Pronasale (Pn) to soft tissue pogonion (Pog)
and lip prominence with reference to this line is
assessed. S-line though has been used cephalometrically
but it has not been used on photograph to assess lip
prominence. Its cephalometric norms are as follows:
Upper lip to S Line (02mm), Lower lip to S Line
(02mm). Steiner used S-Line with the idea that E-Line
is affected by nose length.

Profile Photograph was taken for each selected

subject and landmarks were listed as shown in Figure
1.E-Line & S-Line were drawn as shown in figure 2,
linear distances from upper & Lower Lip to E-Line and
S-Line are determined to assess the prominence of
upper Lip and lower lip.

Aim of this study was to find out the anteroposterior position of lips on photograph using E-line
and S-line in patients with orthognathic profile and to
establish correlation between lip prominence judged by
E-Line and S-Line.
METHODOLOGY
The study was conducted on 90 subjects (45 females, 45 males) with age range of 12-30 years, who
reported at Faculty of Dentistry, The University of
Lahore. Subjects having orthognathic profile as judged
in consensus by orthodontist, prosthodontist, Oral
Surgeon, Oral Pathologist and General Dentist were
selected and lateral cephalogrm was taken. Those
patients having ANB 0-40 and Wits Value 0,-1mm were
included in the study. Patients having supernumerary

SPSS 16.0 was used for statistical evaluation.

Mean, Standard Deviation, Variance, Minimum &
Maximum value and Range were calculated for each
variable for each subject. Correlation coefficients(r)
between lip protrusion as assessed by E- Line & S Line
was determined.
RESULTS
The study was conducted on 90 subjects (45 females
& 45 males) with mean age 18.5+3.89. Descriptive
Statistics were calculated for each variable for each
subject. Mean value for upper lip and lower lip anteroposterior position in patients as judged with E-Line &
S-Line with orthognathic profile was determined as
shown in table I.
Statistically significant co-relation was found between upper lip and lower lip prominence as assessed
by E-Line & S-Line (table 2 and figure 3)

TABLE 1: ASSESSMENT OF ANTERIOR-POSTERIOR LIPS POSITION BY E-LINE AND S-LINE

Descriptive Statistics
Range

Minimum

Maximum

Mean

SD

Upper Lip to E-Line

13.00

-7.00

6.00

-1.90

3.33

Lower Lip to E-Line

15.00

-8.00

7.00

-4.00

3.24

Upper Lip to S-Line

15.00

-7.00

8.00

.37.22

2.85

Lower Lip to S-Line

18.00

-9.00

9.00

1.18

3.23

TABLE 2: CO-RELATION BETWEEN E-LINE AND S-LINE LIP ASSESSMENTS

Correlations
Upper Lip to E-Line

Lower Lip to E-Line

Upper Lip to S-Line

Lower Lip to S-Line

.714**

.509**

.538**

.645**

.861**

Lower Lip to E-Line

Upper Lip to S-Line
Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011)

.743**
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Assessment of Anterior-posterior position of Lips: E-Line-S-Line

Fig 1: Profile Photograph showing Soft Tissue Landmarks used in this study: Pn (Pronasale), Sn
(Subnasale), Ls (Labius Superiorus), Li (Labius
Inferiorus), Pog (Soft Tissue Pogonion)

Fig 2: E-Line (Pn-Pog), Upper Lip to E-Line (Ls-ELine), Lower Lip to E-Line (Li-E-Line), S-Line
(Sn-Pog), Upper Lip to S-Line (Ls-S-Line),
Lower Lip to S-Line (Li-S-Line),

Fig 3: Co-relation between E-Line & S-Line Lip Assessments

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Assessment of Anterior-posterior position of Lips: E-Line-S-Line

DISCUSSION
Shift of paradigm from Angle to soft tissue and
concepts of facial planning in orthodontics have stressed
on significance of nose-lip and chin evaluation9 with
emphasis on assessment of lip prominence. Different
reference lines have been used cephalometrically and
photographically to assess antero-posterior position of
lips: E-Line and S-Line being the most commonly used
reference lines.
Photographically upper lip to E-Line is -1 mm and
lower lip to E-Line is 0mm. E-Line to upper lip is 3+2mm and lower lip to E-Line is -2+0 mm as suggested
by Ricketts4 in his cephalometric analysis. S-Line5 to
upper lip is (02mm) and, S Line to lower lip is
(02mm). Erbay EF et al in their study on ninety-six
adults (55 females, mean age, 21.63 years; 41 males,
mean age, 22.45 years) with Angle Class I occlusal
relationships investigated cephalometrically the horizontal lip position of Anatolian Turkish adults and
concluded that the upper and lower lips were retrusive
according to the norms of Steiner and Ricketts.10 Naidu
D. L11 in an other study assessed photographs &
cephalograms of one hundred 17-25 years old mixed
Indian student population with attractive facial profiles, as judged by the investigators and concluded that
B line was found to be the best in terms of consistency
and sensitivity followed by the E line & S-Line in terms
of consistency but not sensitivity. Lip prominence
however was dependent on nasal and chin position.12-14
In this study E-Line to upper lip was -1.9+3.33 mm
and Line to lower lip was -0.4+3.24 mm while upper
lip to S-Line was 3.72+2.85 mm and lower lip to
S-Line was 1.18+3.23 mm, results were comparable to
norms.

mm and 1.18+3.23 mm respectively. Moreover statistically significant correlation was found r=0.509 between
Upper lip to E-Line and Upper Lip to S-Line and r=
0.861 between Lower lip to E-Line and Lower lip to SLine.
REFERENCES
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Sarver DM, Proffit WR, Ackerman JL. Evaluation of facial soft

tissues. In: Proffit WR, White RP Jr, Sarver DM, editors.
Contemporary treatment of dentofacial deformity.4th ed.
Elsevier: Mosby; 2008. p. 92-126

Malki M et al.The impact of extractions on profile esthetics: a

statistical study. Int Orthod. 2009; 7(1):31-54.

Ricketts R.M. Esthetics, environment, and the law of lip

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Steiner C.C. The use of cephalometric as an aid to planning and

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Holdaway R.A. A soft tissue cephalometric analysis and its use

in orthodontic treatment planning. Part I. Am J of orthod 1983;
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Burstone C.J. Lip posture and its significance in treatment

planning. Am J of orthod 1967; 53: 403-413.

Sushner NJ. A photographic study of the soft-tissue profile of

the Negro population. Am J of orthod 1977; 72: 373-85.

Su YY et al. Influence of chin prominence on anteriorposterior lip positions of facial profile.

2008;17(6):598-602.

10

Erbay EF et al. Soft tissue profile in Anatolian Turkish adults:

Part I. Evaluation of horizontal lip position using different soft
tissue analyses. Am J of Orthod Dentofacial Orthop 2002;
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11

Naidu D. L. Comparisons of the Consistency and Sensitivity

of Five Reference Lines of the Horizontal Position of the
Upper and Lower Lip to Lateral Facial Harmony. Orthocj.com
/2010/11

12

Oh HS et al, Correlations between cephalometric and photographic measurements of facial attractiveness in Chinese and
US patients after orthodontic treatment. Am J Orthod
Dentofacial Orthop. 2009 Dec;136(6):762.e1-14; discussion
762-63

CONCLUSIONS

13

Antero-posterior position of upper and lower lip

with reference to E-line was -1.9+3.33 mm -0.4+3.24
mm respectively and Antero-posterior position of upper and lower lip with reference to S-line was 3.72+2.85

Hsu BS. Comparisons of the five analytic reference lines of the

horizontal lip position: their consistency and sensitivity.Am J
Orthod Dentofacial Orthop. 1993;104:355360.

14

Cala L, et al Facial profile preferences: differences in

the perception of children with and without orthodontic history. Am J Orthod Dentofacial Orthop. 2010;138(4):
442-50.

Co-relation between E-Line and S-Line in assessing upper and lower lip was established in this study
and statistically significant correlation was found

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