Lip posture and its significance in

.
treatment plannin g

C H A R L E S J . B U R S T O N E , D . D . S ., M . S .
Indiamapoli. , Ind.

SIN CE malocclusion, tooth stability, and facial esthetics are influenced in part
by the total mass, position in space, and general activity of the sof t-tissue struc-
tures, the orthodontist is vitally concerned with sof t-tissue morphology and the
posture of the lips. The present article will consider the role and significance of
lip posture in orthodontics, particularly as applied to treatment planning.
Normally, two postural positions of the lips can be observed. In the relaxed-
lip position, the lips are relaxed, apart, and hanging loosely with no effort made
at lip contraction. In the closed-lip position, the lips are lightly touching in
order to produce an anterior seal of the oral cavity. The closed"lip position is
characterized by minimal contraction in the effort to eff ect this anterior closure.
In the Class II, Division I case in which there is a significant overjet, the closed-
lip position is interpreted as that position in which light contact exists between
the lower lip and the maxillary incisor. As will be shown, a great deal of
confusion can arise if one does not diff erentiate between the relaxed-lip and
closed-lip positions in the evaluation of dental and facial abnormalities. For
that reason, a detailed description of the relaxed-lip and closed-lip positions
will be presented. Certainly, before an attempt is made to describe the more
complicated types of lip activity seen in swallowing, mastication, or speech, it
would seem advantageous to consider the role of lip posture in subjects with
normal occlusion as well as those with malocclusion.
The research on lip posture has been remarkably sparse and, with few excep-
tions, has been ignored by American investigators, who have been primarily
interested in dentoskeletal variation. To he sure, Brodie 1 and others have alluded
to the wrap-around muscle sheath as a restraint against forward migration of
the dental arches. Furthermore, differences in lip posture in which the lower lip
may lie either anterior or posterior to the maxillary incisors have been discussed
as etiologic factors in the development of the Class II malocdusion . .Schlossberg,2
employing an electromyographic technique, has gone one step further and has
attempted to anal yze the muscle areas and their sequence of contraction as the
262
Volume 53 Lip posture 263
Numb.er 4

lips move from the relaxed to the closed position. With this approach, the greater
role of mentalis action in producing an anterior seal in Class II, Division 1cases
was noted.
The British school has intensively studied lip posture during both normal
and abnormal swallowing. 3• 4 Tulley,5 for instance, has attempted to evaluate the
relative amount of tongue and perioral muscle activity by means of an electro-
myographic technique. Collaborating previous observations, he found greater
perioral concentration in abnormal swallowers. The term lip incompetence is
widely discussed in the British literature, which shows an awareness of the
importance of lip length in case analysis.
RELAXED-LIP POSITION

In theory, the relaxed-lip position represents a state in which there is no

contraction of lip musculature. Prom a clinical standpoint it may appear that the
problems encountered in trying to obtain a reliable record of this position are
insurmountable unless an electromyographic technique is employed. This, how-
ever, should not discourage us from using such a position if it affords information
that is helpful at the clinical level. It might be pointed out that determination of
rest position of the mandible is likewise not highly reproducible or easily
obtained. Yet this concept is quite helpful and usef ul in dental and orthodontic
procedures.
The technique for obtaining the relaxed-lip position is standardized in the
following way. The patient is placed with the F'rankfort horizontal plane parallel
to the floor. Although there may be certain advantages to positioning the head
along a postural horizontal plane, head position in this study was determined
by the cephalostat rather than the natural upright posture of the subject. Three
methods have been successf ully utilized for relaxing the upper and lower lips.
1. The mandible may be lightly jiggled in an opening and closing
manner, as if one is attempting to establish centric occlusion. During this
procedure the patient is encouraged to relax the mandible so that its
movement is accomplished entirely by the operator. The amount of space
between the upper and lower lips is carefully checked when the teeth
lightly touch during successive elevations of the mandible. In attempting
to relax the mandible, the patient usually simultaneously relaxes the lips.
The opening and: closing movement of the mandible serves a dual func-
tion, since it tends to block those reflexes which normally maintain an
anterior lip seal under most circumstances.
2. The upper and lower lips, particularly the lower lip, may be
lightly stroked with the fingers. In many instances, as the stroking con-
tinues, it will be seen that the lips relax and a space forms between the
upper and lower lips.
3. Perhaps the least reliable method of producing a relaxed-lip
posture is that of instructing the patient to relax his lips. Suggesting
that the subject relax his lips will frequently produce an abnormal lip
posture, for in attempting to achieve a relaxed-lip position the patient
may curl the lips away from the teeth. Therefore, although verbal instruc-
264 Rurstonc A n1 . .I O r t hodont ics
I /ll'il 1 9G 7

tions may be helpful in establishing a relaxed-lip position, t his should

not be used as the only method in establ ishing lip post ure.
How reproducible is the relaxed-li p position? 'l'o study the possibility of
error in positioning the patient, as well as in tracing and measuring the head-
plate, ten subjects with malocclusions were selected at random. Pour different
operators took four headplates of each subject with the lips relaxed and the
mandible in centric occlusion. Tracings were made from the lateral headplate,
and the shortest distance between the upper and lower lips was measured with
a millimeter rule. Since this distance is fairly representative of the type of
measurement that can be made in the relaxed-lip position it was considered
typical in determining the amount of experimental error. The four readings for
each subject were averaged, and the deviation was determined for each variable
in the sample. The mean deviation was then calculated for the entire group of
forty deviations. The mean deviation for the sample was 0.5 mm., which
represents the total error on the average produced by tracing measurement and
positioning of the patient. The greatest deviation was seen in one patient with a
Class II, Division 1 malocclusion and a strong tendency toward mentalis con-
traction. In this subject, one deviation as high as 2.7 mm. was observe<l At the
other extreme, many of the subjects demonstrated no discernible diff erence in
the linear distances measured from headplates taken by different operators. It
might be anticipated that if the sample were made up of persons with fairly
normal dental and lip relationships, the deviation would be considerably less.
Likewise, a single operator or clinician would be expected to have less variation
in his attempts to record a relaxed-lip position.

Fig. 1. Normal interlabial gap. Relaxed-lip position showing small sj)(lce or gap between
upper and lower lips.
Volume 53 Lip posture 265
Number 4

If lip posture is to be evaluated, it is well to standardize the vertical dimen-

sion of the jaws. The simplest procedure is to have the mandible elevated with
the teeth together in occlusion. However, in certain conditions, such as marked
overjet, it is possible that in centric or maximum occlusion the lower lip may be
deflected by the maxillary incisors. In such cases it is desirable to open the
mandible to rest position or beyond so that a truer picture of lower lip posture
may be achieved.
Relaxed-lip posture, like body posture, is a muscle-determined position.
Therefore, it cannot have the reproducibility that is associated with measurements
on hard structures. The recording of lip posture is further complicated by the
fact that we are dealing with muscles innervated by the seventh cranial nerve.
The seventh nerve is closely associated with the autonomic nervous system and
has connections at a higher level with the hypothalamus, which means that
emotional states can strongly influence the contraction or lack of contraction of
the muscle fibers of the lip. With care, however, the investigator or clinician
can obtain records of the relaxed-lip position that are relatively reproducible.
VERTICAL CHARACTERISTICS. If the lips are relaxed there is normally a space
between the upper and lower lips ( Fig. 1) . This space, known as the interlabial
gap, represents the shortest linear dimensions between the inferior surface of the
upper lip and the superior surface of the lower lip. In a sample composed of
adolescents with acceptable faces,* the average gap is 1.8 mm. in centric occlusion
and 3.7 mm. in rest position of the mandible. The standard deviations are,
respectively, 1.2 and 1.6 mm. It can be seen that the interlabial gap is quite
small in both centric occlusion and rest position of the mandible and that it does
not increase proportionately with the opening of the mandible. Although
normally variation is small, considerable variation can be seen in the interlabial
gap in persons who have either malocclusions or facial disharmonies. Extreme
conditions in which there is excessive space or lack of space between the upper
and lower lips can commonly be observed.
Inadequacies of lip length relative to the vertical dimension of the lower face
are characterized by large interlabial gaps; conversely, if there is a redundancy
of lip tissue in relation to the existing vertical dimensions, no interlabial gap is
present. Fig. 2 shows three patients with lip-length inadequacies and subsequent
large interlabial gaps. In Fig. 2, A there is an interlabial gap of 7.0 mm., with
the lips closely adapted to the upper and lower incisors. Fig. 2, B illustrates a
similarly large interlabial gap, with the lips away from the labial surfaces of the
teeth. The largest interlabial gap of the group (12.0 mm.) is shown in Fig. 2, C.
When the lips are long in relation to the vertical dimension of the lower part
of the face (lip-length redundancy) , the lips are in contact and tend to bulge
forward away from the teeth ( Fig. 3) .
A number of factors can be responsible for variation in interlabial gap.
Inthe first place, there may be differences in length of either or both lips. Inthe
*Thirty-two boys and girls, 13 to 15 years of age, selected on the basis of facial
appearance from a group of 3,000 Caucasian children by nonorthodontists (teachers,
artists, and housewives). Throughout the remainder of the present article, these
subjects will be ref erred to as the normal adolescent sample.
2 66 Burstone t 1u . J ( Jr t hodont ies
cl pril 1 % 7

Fig. 2. Excessive interlabial gap. 'rh reo trae.i ngs am show n i n w li i<'li l i p length is short rela-
tive to the vertical dimension. A, 7 mm. ; ll, \J mm.; C, l'.! mm. I ga p m('asurements).

Fig. 3. Lip-length redundancy. Because of excessive lip length, n o i ntcrlabial gap is present.
Note space between incisors and lip.

second place, there may be a variation in skeletal height in the anterior portion
of the face. In view of the great amount of variation in interlabial gap, it is
apparent that there must be a lack of correlation between vertical height of the
skeleton and vertical length of the lips. In order to gain some insight into the
last factor, a number of lip-length measurements were made. When one attempts
to evaluate the relative length of the upper and lower lips, it is convenient to
divide the lower face into two portions. The upper portion, representing the
upper lip, is measured from subnasale to stomion (lowest point on the upper lip ) .
Volume 53 Lip posture 2 67
Number 4

STOMION-GNATHION

Fig. 4. Vertical measurements of lip. Upper lip length (subnasale-stomion) and lower lip
length (stomion-gnathion).

The lower portion, which encompasses the lower lip and the chin, is measured
from stomion ( highest point on the lower lip ) to gnathion ( Fig. 4) . In order to
establish soft-tissue gnathion, a line perpendicular 1:-0 the palatal plane is dropped
from the lowest point of the outline of the mandibular symphysis to the sof t
tissue of the chin. The linear measurement of upper lip length as well as the
lower lip-chin dimension is measured perpendicular to the palatal plane.
Significant differences in length of the upper lip were noted between boys
and girls in the normal adolescent sample; hence, the means and standard devia-
tions are listed by sex ( Table I) . Approximate average lengths for the upper
lip as measured from the lateral headplate are 24 mm. for boys and 20 mm. for
girls. In a typical sample of malocclusions, considerably greater variation in lip
length is usually to be expected. The type of variation that can be seen in
adolescent girls with Class II, Division 1 malocclusions is shown in Fig. 5. The
shortest lip is observed in Fig. 5, A where the vertical dimension from subnasale
to the lower border of the upper lip is 16 mm. Fig. 5, B shows a more typical
lip, which is 20 mm. in length. At the other extreme ( Fig. 5, G) is an exceedingly
long lip, with a dimension of 26 mm.
It has been suggested that the length of the upper lip tends to be shorter in
persons with Class II, Division 1malocclusion than in those with normal faces or
occlusions. For purposes of comparison with the normal sample, a group of Class
II, Division 1 patients with full-cusp distoclusions were selected.• However, no
significant differences in length of the upper lip between the two samples could
be found with the use of the "t" test.

*The Class II, Division 1 sample was composed of a group of f ull-cusp distoclusions
selected at random from the clinic at the Indiana University School of Dentistry.
The sample i :made up of twenty boys and girls in the age range of 12 to 14 years.
26 8 B1irst one A m. ,/. "r t hodontfr :.•
A p ri.1 1 967

Table I. Lip length in norrnal ad olesce nt. sampl e

Mean ( mm.) S.D. (mm.)
Boys
Upper lip length 2:u: 21.5 to 36.0
Lower lip length 49.9 43.0 to 58.0
Lower lip length
Ratio - - -- -
- -- - 2.1
Upper lip length
Girls
Upper lip length 20.1 l.9 17.0 to 23.0
Lower lip length 46.4 3.4 38.0 to 52.0
Lower lip length
Ratio - - -- -
- -- - 2.3
Upper lip length

A B c
Fig. 5. Variation in upper lip length. Length from subnasale to stomion : A, 16 mm.; B, 20
mm.; C, 26 =· All three cases are Class II, Division 1 malocclusions.

Another method of evaluating the relative length of the lip is to measure

the distance from the inferior border of the upper lip to the tip of the incisal
edge. This vertical measurement between stomion and incision is made at a right
angle to the palatal plane. In the normal face the maxillary incisor projects
inferiorly 2.3 mm. to the lower border of the upper lip, with a standard deviation
of 1.9 mm. A significant difference between the adolescents with normal faces
and those with Class II, Division 1 malocclusions was noted in the stomion-
incision measurement ( 0.1 per cent level of confidence) . Since lip length, on the
average, tends to be normal in the Class II, Division 1 case and yet the stomion-
incision measurement is smaller than normal, it would appear that the maxillary
incisor is supraerupted in the Class II malocclusion. This is not to imply that
there is not eonsiderable variation in the stomion-incision measurement in Class
II malocclusions. The range of variation can be demonstrated by the two tracings
shown in Fig. 6, in which both A and B show upper lips of patients with full-cusp
distoclusions and marked overjet. The distance between the lower border of the
lip and the incisal edge is 2 mm. in A and 8 mm. in B.
From an esthetic point of view, tlie relative length of the upper lip and the
position of its lower border to the incisal edge of the maxillary incisor has con-
siderable clinical significance. If only the appearance of the dentition is con-
sidered, the stomion-incision measurement may be somewhat useful in deter-
Volume 53 Lip posture 269
Number 4

A B
Fig. 6. Variation in position of upper lip line in two Class II, Division 1 cases. Stomion-
incision distances: A, 2 mm.; B, 8 mm. Lips are in relaxed position.

mining the anterior end of the occlusal plane. The position of the maxillary
incisor may be quite precarious in a Class II, Division 1 case, since a high
percentage of these patients have a greater than average stomion-incision mea-
surement before treatment. Poor mechanics, such as indiscriminate use of Class
II elastics, may cause added eruption of the maxillary incisors and thus further
increase this dimension. A "treated look" is produced, with both tooth and
gingiva showing.
Not only can the absolute length of the upper lip be measured and compared
to the position of the maxillary incisor, but it can also be related to the length
of the lower lip and chin. If a measurement is made between stomion and
gnathion perpendicular to the palatal plane ( Fig. 4) , and if a ratio is made
between this dimension and the length of the upper lip, it will be found that in
the normal face there is a ratio of 2 to 1 in favor of the stomion-gnathion
dimension. Some facial disharmonies are vertical in nature and are associated
with a disproportion in the ratio between the upper lip and the area comprising
the lower lip and chin.
It is thus that the interlabial gap is determined by a number of f actors,
including anterior skeletal height, dental protrusion, inherent lip length, and
lip posture.
HORIZONTAL CHARACTERISTICS. In any discussion of lip posture, it is necessary
to consider not only the vertical posture but also the horizontal or anteroposterior
posture of the lip. A useful plane for evaluating the relative protrusion or
retrusion of the lips is one connecting subnasale and soft-tissue pogonion.
Practically, the plane is established by dropping a tangent to the chin area from
subnasale ( Fig. 7). Subnasale is that landmark where the upper lip meets the
inferior border of the nose. In some lip contours, a definite point cannot be
located at the juncture of the lip and nose and, for convenience of reproducibility,
the deepest point relative to a 45 degree angle to the palatal plane is then used
as subnasale. Lip protrusion or retrusion is measured as a perpendicular linear
distance from the subnasale-pogonion plane to the most prominent point on the
upper and lower lips.
The subnasale-pogonion plane has been selected as a plane of minimal varia-
tion in the area of the face. If tracings of nongrowing persons are superposed
before and af ter treatment, subnasale and pogonion will not show a radical
change, provided that the headplate is taken in the relaxed-lip position. Ricketts7
has suggested the use of an esthetic plane joining points on the nose and the chin.
27 0 Burstone A.m . ./ . Or t hodonti.cs
A pri.1 1967

Pg

Fig. 7. Horizontal lip posture. Lip protrusion is measured perpendicular to subnasale-pogonion

plane.

Table IL Lip line (incision-stomion) in normal ad olescent sample

Meam. (mm.) S.D. (mm.) Range (mm.)
2.3 1.9 0.3 to 9.0

The question arises whether the selection of the point of the nose as a landmark
brings into play an area that will vary more than the one we are interested in
measuring, that is, the lips. To investigate the variation of nose length, two
perpendicular lines were dropped to the palatal_ plane from subnasale and the tip
of the nose ( Fig. 8) . The pertinent statistics from the normal adolescent sample
are given in Table III. Of particular interest is the magnitude of the standard
deviation, which is approximately twice as great as the standard deviations that
are estimates of variation in lip protrusion ( Table IV ) . For this reason, it was
deemed desirable to avoid the area of the nose in any attempt to evaluate the
protrusion or retrusion of the upper and lower lips. This is not to suggest, how-
ever, that the nose is not a factor to be considered in orthodontic Cas€ analysis.
In the normal adolescent sample, the upper and lower lips fall forward of
the subnasale-pogonion plane. On the average, the upper lip is 3.5 mm. anterior
to the line and the lower lip lies 2.2 mm. anteriorly. It can be seen that the upper
lip projects slightly more than the lower lip relative to this line. The standard
deviations and the range of variation are given in Table IV. No significant.
Volume 53 Lip posture 271
Number 4

Fig. 8. Measurement of nose length. Perpendicular lines are dropped from subnMale and tip
of nose to palatal plane. Nose length is measured between these two intersections along palatal
plane.

Table III. Nose length in normal ad olescent sample

Mean (mm.) S.D. (mm.) Range (mm.)

15.5 2.8 12.0 to 20.0

Table IV. Lip protrusion in normal ad olescent sample

Dimensions Mean S.D. Ramge

Upper lip to Sn-Pg 3.5 mm. 1.4 1.0 to 6.0 mm.

Lower lip to Sn-Pg 2.2 mm. 1.6 -0.5 to 6.0 mm.
Upper lip inclination to palatal plane 97.5° 9.3 87.5° to 113.6°
Nasoiabial angle 73.8° 8.0 60.0° to 90.0°

differences in lip protrusion were found between male and female subjects in
this sample. As might be expected in malocclusion groups, there may be con-
siderable variation in the protrusion of the upper lip, the lower lip, or both lips.
The variation that can be found in lip protrusion is demonstrated by four maloc-
clusions in Fig. 9. A bimaxillary protrusion with an anterior cross-bite is seen in
Fig. 9, A. Here, instead of minimal projection of lips beyond the subnasale-
pogonion plane, the upper lip is 9 mm. forward and the lower lip 12 mm. forward
of this plane. 'The lip posture in the Class II, Division 1case shown in Fig. 9, B
is different in that the lips do not hug the teeth and hence contribute more to
2 72 Burstone A m .f O r l hod()ntics
4 pr il 191l7

A B c D

Fig. 9. Variation of horizontal lip posture (relaxed-lip position). A, Bimaxillary protrusion;

B, bimaxillary protrusion; C, upper lip protrusion and lower lip retrusion; D, retrusion of
upper and lower lips. Plane of reference is subnasale-pogonion.

the measured protrusion in the relaxed-lip position. Both the upper and the
lower lips lie 9 mm. in front of the subnasale-pogonion plane. The Class II,
Division 1 case shown in Fig. 9, (] demonstrates another type of variation that
can be observed in the anteroposterior lip posture in cases of overjet. The upper
lip lies 6 mm. anterior to the reference plane, while the lower lip lies on the plane.
Finally, in the Class II, Division 2 case shown in Fig. 9, D both upper and lower
lips are abnormally retrusive, particularly the lower lip. The upper lip lies
1.5 mm. forward of the subnasale-pogonion plane. The lower lip, however, is
quite retrusive, lying 3 mm. behind the plane.
Planes of reference other than subnasale-pogonion may be used to evaluate
the protrusion or retrusion of the upper lip. For instance, an angular reading
can be employed to measure upper lip protrusion ( upper lip inclination ). The
upper lip inclination ( Fig. 10) is measured by the intersection of the line
subnasale-labrale superius with the palatal plane. Normally, the lip is slightly
flared, forming an angle of 97.5 degrees with the palatal plane. It should not be
particularly surprising that the upper lip was found to be significantly flared
when the Class II, Division 1 sample was compared with the normal sample
(0.1 per cent level of confidence ) . This is not to imply that in all Class II,
Division 1 cases the upper lip is flared, for considerable variation in the inclina-
tion of the upper lip can be observed in these malocclusions. For instance, two
upper lips from Class II, Division 1cases are shown in Fig. 11. In Fig. 11, A an
angle of 90 degrees is formed between the lip and the palatal plane, while in Fig.
11, B the upper lip is in protrusion, with an angle of 111 degrees. The protrusion
of the upper lip in the Class II case is not only produced by the flared upper
incisors but may also be influenced by how closely the upper lip is adapted to
the incisor as well as by the thickness of soft tissue in the area of subnasale.
From an esthetic viewpoint, it may be somewhat useful to measure the
Volume 53 Lip posture 273
Number 4

Fig. 10. Angular readings of upper lip protrusion. A, Upper lip inclination angle; B, naso·
labial angle. Horizontal line is palatal plane.

\•
'
A B
Fig. 11. Variation in upper lip inclination in two Class II, Division 1 cases: A, 90.0 degrees;
B, 111.0 degrees. Lips are in relaxed position.

protrusion of the upper lip relative to the inferior border of the nose. This is
done by the nasolabial angle ( Fig. 10), which is formed by the intersection of
a line, originating at subnasale, tangent to the mean of the lower border of the
nose and a line from subnasale to labrale-superius. A typical nasolabial angle
is approximately 74 degrees. Clinically, the nasolabial angle may be significant,
since the layman is likely to evaluate upper lip protrusion in relation to the nose.
Class II, Division 1cases which, before treatment, have obtuse nasolabial angles
are particularly difficult. Following retraction of the anterior teeth, the obtuse-
ness may increase to the point of deformity. The patient may then have a typical
"orthodontic look," with a sunken-in upper lip.
Observing the variation in the anteroposterior positioning of both upper and
lower lips, one may ask what factors determine the relative position of these lips
in a horizontal plane. Certainly, the variable of lip thickness must be considered
one major factor which can influence the amount of protrusion or retrusion of
the lips. The question of the role of tooth position in lip protrusion has still to be
answered. Do the teeth push the lips out into varying positions Or do the lips
have a posture of their own independent of tooth position In an effort to answer
this question, a sample of young adult edentulous patients was selected.8 Special
bite rims were constructed to maintain the vertical dimension, which was
previously established by a phonetic method. The anterior portions of the bite
2 74 Burst one A n1 . • f . ntf hodontics
4 pri.l l96 7

A II /1

Fig. 12. Bdentulous series ( relaxed-li p position) . A, Subject I ; uonnal profile wit h typi<'al
interlabial gap. B, Subject 2 ; slight protrusion of lips. C, Subject il; bimaxillary protrusion of
lips. Note laek of support from bone or teeth. D, Subject 4 ; li ps are slightly rntrusi ve. E ,
Subject 5; marked lip retrusion, particularly of lower lip ( 5 mm. behind Sn-Pg plane) . F.
Subject 6 ; mild lip redundancy. G, H , I , aml .r, Subjects 7 th rough 10 exhibit increasing
redundancy of lip length. Note protrusion of lmver lip (9 mm. antPrior to Sn-Pg plane) in
Subject 10.

rims were radically cut away to make certain that they afforded no lip support.
It was thus possible to study the horizontal posture of the lips without any
tooth or alveolar process support ( in several subjects some alveolar process was
present) . The horizontal posture of the lips in a relaxed state, as observed in the
edentulous sample, is reported below.
Subject 1 illustrates a fairly normal type of sof t-tissue profile ( Fig. 12, 11) .
Both the interlabial gap and the lip protrusion are fairly typical. It can be seen
that, even without the support of the teeth, the lips have remained in a fairly
normal position and have not fallen back to the level of the bite blocks. The bite
blocks have served a dual function. First, they have maintained the proper
vertical dimension for the patient and, second, they have prevented the tongue
from coming forward and adding to the lip support.
In Subject 2 (Fig. 12, B ) the lips are slightly protrusive in relation to the
Volutne 53 Lip posture 275
N11mb.er 4

subnasale-pogonion plane; yet this protrusion occurs without the support of the
upper and lower incisors. Subject 3 ( Fig. 12, C ) demonstrates even greater lip
protrusion without dental support. In this case both upper and lower lips lie
5 mm. in front of the subnasale-pogonion plane. Once again, the lack of dental
support should be noted.
In Subjects 4 and 5 ( Fig. 12, D and E ) the lips are found to be more re-
trusive than normal; however, they still have not fallen back to approximate the
labial surfaces of the bite rims. The lower lip of Subject 5 lies 5 mm. behind the
subnasale-pogonion plane. It is interesting to compare Subjects 3 and 5, since
both patients exhibit retrognathic skeletal patterns, that is, the mandible lies
posterior to the maxilla. In Subject 3, however, the lower lip is postured pro-
trusively, and in Subject 5 it maintains a retrusive position.
The edentulous patients presented up to this point have been characterized
by fairly typical interlabial gaps. In the next series, the patients are lacking an
interlabial ga.p and demonstrate the effect of lip redundancy on the general
posture of the lips. In the headplates shown from Fig. 12, F through 12, J, atten-
tion is called to the support that the upper and lower lips give to each other.
In Subjects 9 and 10 the excess lip length has forced the upper and lower lips
into a state of protrusion. The lower lip of Subject 10 is bulged forward of the
subnasale-pogonion plane by 9 mm. ( Fig. 12, J ) .
A careful study of the edentulous sample suggests that there is a relaxed-lip
position that is independent of teeth and the supporting alveolar process. In this
group with loss of dental-alveolar support, the lips did not fall back routinely
into retrusive positions. It is interesting to note that this group of young adult
edentulous patients did not exhibit the facial concavity which is usually associated
with an older age group. Perhaps other changes, including age changes, in the
sof t-tissue mass of the lips may be responsible for this difference.
The point might be raised that, even though the teeth have been extracted,
the upper lip may be supported by the apical base area of bone or by the remain-
ing alveolar process. In most of the cases which have been studied, the remaining
area of bone in the maxilla is apical to that bone which is most dramatically
changed during routine orthodontic tooth movement. On the other hand, the
lower lip appears relatively free and away from the bony support of the mandible
in this group.
Although common experience tells us that lip posture can be influenced by
tooth movement, it can now be postulated that there is a relaxed postural position
of the lips which is independent, or partially independent, of tooth position. As
observed in the edentulous sample, there is considerable variation in an antero-
posterior direction in the relaxed position of these lips. In some persons the lips
are postured in a relatively protrusive manner, while in others they maintain
a retrusive posture. In the same person there may be different degrees of pro-
trusion and retrusion between the upper and lower lips.
CLOSED-LIP POSITION

Even though an understanding of the relaxed-lip position is essential to an

appreciation of lip function, the patient normally does not assume this pose in
2 76 Bnrstone Am. ./. Ortho(lontic8
A p'd7 1 !Hi7

Fig. 13. Normal closure from relaxed-lip position. Minimal contraction is required. Lower lip
contributes more to eff ect anterior seal. Larger than average interlabial gap is shown.

his daily activity. Rather, he maintains an effective lip seal which facilitates
swallowing, protects the teeth and the gingivae, and adds eertain retaining forces
to maintain the position of the anterior teeth.
In the normal person, minimal muscular contraction is required to move the
lips from their relaxed position to one of light closure ( Fig. 13) . Since the
interlabial gap is small, this is to be expected . During typical contraction the
lower lip contributes more movement to the closure of the interlabial gap than
does the upper lip. Simultaneously, both upper and lower lips flatten against the
incisors. There may or may not be a small amount of flattening in the area of
the chin which is associated with contraction of the mentalis muscle. Typically,
this flattening is extremely small or nonexist ent.
It is difficult not to be impressed by the great amount of variation in the
manner of lip closure during the change from the relaxed to be closed-lip position
in persons with dentofacial disharmonie.<>.
Two cases are used to illustrate the variation that can be observed. Fig. 14, A
shows a Class II, Division 1 malocclusion with an 11 mm. interlabial gap. In
order to effect closure, the patient must elongate the upper lip, which increases
in length during contraction by 6 mm., and at the same time he must project the
lower lip upward and forward by contraction of the mentalis muscle. During
this process the upper lip is flattened against the upper incisor, which eliminates
the normal contour of the maxillary sulcus. The contraction of the mentalis
muscle flattens the chin area and moves the inferior sulcus upward and forward.
By this action, the lower lip appears to be reaching for the upper lip and, in a
sense, is attempting to avoid the maxillary incisor.
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Number 4

B
Fig. 14. Abnormal path of closure from relaxed-lip position. A, Class II, Division 1case. Upper
lip flattens and elongates; lower lip moves upward and forward with flattening of chin area.
B, Class III case. Normal upper lip response; lower lip moves upward and backward.

'l'he typical manner of lip closure in the Class III case is somewhat different.
For example, the Class III malocclusion patient shown in Fig. 14, B elevates the
lower lip in an upward and backward manner. He must close an interlabial gap
of 6 mm. in order to produce a lip seal. 'l'he lower lip contributes the most to this
closure, as it rises 5 mm. The upper lip elongates 1 mm. as it retrudes and
flattens against the upper incisor.
ANTEROPOSTERIOR POSITION OF THE DENTITION. One of the central problems in
orthodontic treatment planning is the determination of the anteroposterior posi-
tion of the incisors. Some orthodontists prefer to solve this problem by the
arbitrary use of cephalometric standards based upon dentoskeletal landmarks.
Perhaps an added dimension for establishing the position of the incisors is
available if one considers soft-tissue morphology and lip posture. It is generally
agreed that one of the objectives of orthodontic treatment is improvement of
facial form. There are dangers, however, in using average profile readings of
teeth, skeleton, or soft tissue as guides or objectives for a given patient. Fig. 15
shows two dental bimaxillary protrusions. In the first (Fig. 15, A) , the lips are
relatively short in comparison with the vertical dimension, and hence the patient
has a great deal of difficulty in effecting lip closure. In the other patient, on the
other hand, lip length is quite adequate and the patient experiences no difficulty
in maintaining contact of the upper and lower lips ( Fig. 15, B ) . Should the
orthodontic treatment objectives be the same for both cases? In the first instance
a facial disharmony is produced for, when the patient attempts to close his lips,
the upper lip is flattened, the mandibular sulcus is raised, and the chin area is
flattened. For esthetic reasons alone, it would be desirable in this type of case
to reduce the dental protrusion and, therefore, to make it easier for the patient
to effect anterior lip seal. The second bimaxillary protrusion presents a slightly
2 7 8 Burst01w J m_ ./. f Jr l hodontic.
A ·pril 1 967

/;

Fig. 15

Fig. 16

A fl

Fig. 15. Two pati ents with bimaxilla ry prot rusion. A, Lip- length i nadequacy with large
interlabial gap. B, Lip-length redundany.
Fig. 16. Lip posture in two Class II, Division 1 1•ases. A, Lower lip tight tLnd rctruded against
lower incisors. B, Lower lip flaccid and away from teeth.

different problem ( Fig. 15, B ) . Here lip length is adequate and the protrusion
of the anterior teeth does not affect the ease of lip closure. Even though, for
esthetic reasons, it would be desirable to retract the upper and lower lips, it is
questionable whether the lips would retract following retrusion of the anterior
teeth since a redundan cy of lip length does exist. From the standpoint of sof t
tissue, all bimaxillary protrusions do not present the same problems .
Volume 53 Lip posture 279
Number 4

Not only might the degree of interlabial gap be helpful in determining the
position of the anterior teeth, but the horizontal posture of the lips might be
suggestive as well. As was seen in the edentulous sample, the relaxed-lip posture
is retrusive in some patients while in others it may be protrusive. Although
positive proof cannot be given at this time, it may be well to formulate the
following working hypothesis, which needs further clinical testing, as a guide
for planning the final anteroposterior positioning of the incisors.
Myometric studies by Winders9 and others have shown that stable normal
occlusions and malocclusions have minimal lingually directed pressures against
the incisors. It is also known that relatively small forces can produce lingual
tipping of the incisors. 10 Stability of the incisors is dependent on an equilibrium
of forces on the crowns of the teeth, since thresholds for bony resistance in simple
tipping movements are very low. This equilibrium is time-linked and perhaps is
best described as an "energy" equilibrium.
An anterior component of forces on the incisors can be produced: by the
tongue, the occlusion (normally the upper incisors have an anterior component
and the lower incisors a posterior component) , and the total resista:iice of the
dental arch. The lips and occlusion supply the posterior component of force.
Lip posture should be considered an important element, if not the most important
element, in determining a stable position for the incisors.
The starting place for evaluating lip posture is the relaxed-lip position. A
retruded lip pressed against a lower incisor is less suggestive of the desirability
of protruding the lower incisor during treatment than a lip that is protruded
and lying away from the incisor. Normally, a relaxed lower lip will contact the
lower incisor at the junction of its incisal and middle thirds. This can be used
as a rough guide in evaluating the relative inherent protrusiveness of the lip
in its relaxed state.
The closed-lip position for the patient should next be evaluated. If,the inter-
labial gap is small and the position of the teeth typical, lingually directed forces
( the posterior component of force ) will increase only slightly as the lower lip
moves posteriorly from the relaxed to the closed-lip position. If the interlabial
gap is large, the patient will markedly increase the posterior component of
force as he attempts to close the lips. This implies that even if the lips are pos-
turally protrusive, protrusion of the teeth may not be stable if the interlabial
gap is large. In this type of situation, an overly protruded dentition may be
stable if the patient adapts by using the relaxed-lip position as his habitual lip
posture. If closure by the mentalis muscle is used to seal the lips, the lower lip
is brought forward, which minimizes pressures on the incisors. Esthetically and
functionally, the use of the mentalis muscle in this way is not desirable, even
though the reduced posterior component of force may aid stability.
Thus, the desirability of maintaining the lower incisor in its original position
or retruding or protruding it may be influenced by the postural position of the
lower lip. For example, both of the Class II, Division 1 cases shown in Fig. 16
are characterized by an overjet, but there is a striking difference in the lower
lip postures. In Fig. 16, A the lower lip is in close apposition to the lower in-
cisor ( retruded posture) , whereas in Fig. 16, B the lower lip is protruded from
the incisor ( protruded posture) . It should be remembered that the foregoing
280 Burstonc .'lm. .f . Or t hodontics
.1pril 1967

statements which imply that the lower l ip may be used as a guide for position-
ing the incisors should be tempered by the fact that other variables hcsides the
posture of the lower lip can influence the position of the maxillary incisor.
It should also be pointed out that the lips have a striking abil ity to adapt
to the teeth, whether they be protrusively or retrusively placed. In certain bi-
maxillary protrusions, the lips appear actually to reach to a more forward po-
sit.ion to cover the teeth with minimal lingual pressures on the incisors.9 This
adaptability of the lips to different tooth positions in the same person suggests
that there may be multiple positions of stability for a given patient. It should
be remembered that the starting position for the lips as they begin to effect an
anterior oral seal is a relaxed position and that this position is fundamental to
an understanding of the posture of the lips when they are closed.

PREDICTION OF FACIAL CHANGES

If we are interested in answering the question of how far forward or back-

ward the lips will move following orthodontic treatment, the relaxed-lip-position
headplate is the most usef ul. Attempts to predict sof t-tissue changes on the basis
of the closed-lip position are complicated by the fact that the lips may be overly
stretched and flattened in their effort to eff ect lip closure.
Forgetting about the influence of growth, the most dramatic facial changes
following the retrusion of teeth arc seen in those cases in which there is a large
or normal interlabial gap. If a redundancy or a potential redund;mcy of lip
tissue exists, most likely the lips will not fall back following retrusion of the
teeth ( Fig. 17) . The treated case pictured in Fig. 18 shows the effect of lip-
length redundancy on the fall-back of the lip following retraction of the maxil-
lary incisors. The maxillary incisor has been retracted a considerable distance,
and yet the posture of the upper and lower lips in the closed position is ap-
proximately the same. Lip contact because of the redundancy tissue has main-
tained the lips in a more protrusive position than normal. It can also be noted
that there is an area of space between the upper and lower lips and the labial
surfaces of the incisors. If one considers malocclusions, with and without inter-
labial gap, it appears that no simple formula can be given for predicting the
amount of lip displacement following retraction of the incisors.8

LIP POSTURE AS A N E'f IOLOGIC FACTOR

One could theorize about the relationship betwetin lip posture and the po-
sition of the teeth as well as the development of different types of malocclusion.
The possibility exists that in persons of certain types who have large interlabial
gaps, strong lingual forces are directed against the incisors in an effort to effect
lip closure, producing a dental retrusion. In other persons who also have large
interlabial gaps, there may be no attempt to produce lip closure, with the result
that the teeth may move into a position of bimaxillary protrusion. Although
these possibilities may reasonably explain certain bimaxillary retrusion and
protrusion malocclusions, little documentation is available as yet.
The British investigators have attempted to associate lip incompetence or
large interlabial gaps with abnormal swallowing patterns. They believe that in
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Number 4

Fig. 18

Fig. 17. Class II, Division 1 case demonstrating long lip length. Following retraction of upper
incisor, lip-length redundancy is expected.
Fig. 18. Lip-length redundancy bef ore (A ) and af ter (B) treatment. Lips have not retruded,
even though upper incisor has been retracted a considerable distance. Note space between lips
and teeth following treatment (B).

order to produce an anterior oral seal, the patient may project the tongue be-
tween the upper and lower lips and thereby initiate a more infantile type of
swallowing response.
One can also theorize about the horizontal relaxed-lip posture and its rela-
tionship to retrusive and protrusive dentitions. l£ the interlabial gap is small,
are dentitions more protrusive in those persons who have a protrusive relaxed-