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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 3 RIZWAN RAZ BAIG, BDS 5 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 2 3 4 5 In cephalometric and photographic analysis, several reference lines have been introduced to assess anteroposterior position of the upper and lower lips. Ricketts’ ‘E’ line4, Steiner’s S line5, Holdaway’s ‘H’ line6, Burstone’s ‘B’ line7, and Sushner’s ‘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: [email protected], Cell No: 0300-4079491 Assistant Professor & Head of Oral Pathology, University College of Dentistry, The University of Lahore. E-mail: [email protected], Cell No: 0321-8859705 Assistant Professor Oral & Maxillofacial Surgery, University College of Dentistry, The University of Lahore. E-mail:[email protected], Cell No: 0300-4554790 Assistant Professor, Department of Implant Prosthesis, University College of Dentistry, The University of Lahore. E-mail: [email protected], Cell No: 0332-3274621 Demonstrator Department of Operative Dentistry, University College of Dentistry, The University of Lahore. E-mail: [email protected], Cell No: 0300-8034191 Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 84 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 (0±2mm), Lower lip to S Line (0±2mm). 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** 85 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 Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 86 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 (0±2mm) and, S Line to lower lip is (0±2mm). 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 1 Sarver DM, Proffit WR. Special considerations in diagnosis and treatment planning. In: Graber TM, Vanarsdall RL Jr, Katherine WL, editors. 4th ed. Elsevier: Mosby; 2005.p. 3-70 2 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 3 Malki M et al.The impact of extractions on profile esthetics: a statistical study. Int Orthod. 2009; 7(1):31-54. 4 Ricketts R.M. Esthetics, environment, and the law of lip relation. Am J of orthod 1968; 54: 272-289. 5 Steiner C.C. The use of cephalometric as an aid to planning and assessing orthodontic treatment. Am J of orthod 1960; 46: 721-35. 6 Holdaway R.A. A soft tissue cephalometric analysis and its use in orthodontic treatment planning. Part I. Am J of orthod 1983; 84(1): 1- 28. 7 Burstone C.J. Lip posture and its significance in treatment planning. Am J of orthod 1967; 53: 403-413. 8 Sushner NJ. A photographic study of the soft-tissue profile of the Negro population. Am J of orthod 1977; 72: 373-85. 9 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; 121(1):57-64. 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;104:355–360. 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 Pakistan Oral & Dental Journal Vol 31, No. 1 (June 2011) 87