READERS' FORUM
Letter to the editor
Relationship between the position of the
maxillary incisor and upper lip
W e read with great interest the article by El Asmar
et al in the August 2020 issue evaluating the ideal
position of the maxillary incisor relative to the thickness
of the upper lip (El Asmar R, Akl R, Ghoubril J, El Khoury
E. Evaluation of the ideal position of the maxillary
incisor relative to upper lip thickness. Am J Orthod
Dentofacial Orthop 2020;158:264-72). The authors
explored the factors influencing profile evaluation
from various perspectives. However, we would like to
raise a few questions regarding the article.
In Table I, which showed the distribution of the sam-
ples, one of the important indicators was the thickness of
the lip; lips were divided into 2 groups according to this
variable, but the scope of each group was not given. This
could be important for future research.
To reduce the biases that may be encountered in
the judgment process, we very much agree with the
author’s practice of cropping photographs and adjust-
ing skin tone, especially in Figure 2, where Pog was
removed to avoid the influence of the chin. However,
the tip of the nose was still retained within the scope
of the photograph. The position of the tip of the
nose, especially the relative relationship between the
tip of the nose and the upper lip, is closely related to
the esthetic evaluation of the profile. When our pur-
pose is to evaluate the effect of tooth position and
lip thickness on the appearance of the profile, it may
be more reasonable to narrow the evaluation to the
inferior nasal point to below point B.
The different taper of the upper lip, even if the maxil-
lary incisors are in a different anteroposterior position,
may have a similar response to the soft tissue profile. It
may be necessary to consider the effect of upper lip taper
in future studies.
We look forward to a response from the authors to
help us better interpret the results of this study.
Tao Shen
Hui Shi
Nanchang, Jiangxi, China
Am J Orthod Dentofacial Orthop 2021;159:705
0889-5406/$36.00
Ó 2021.
https://doi.org/10.1016/j.ajodo.2021.03.004
Authors’ response
T hank you for your interest in our article.
In this study, the right measure that can determine if
the upper lip is thick or not is based on the study of Berg-
man1 in 2014, as mentioned in our article, who
measured the thickness among kids and young adults
aged from 6 to 18 years. This study is the most recent
one concerning the thickness of the upper lip and the
only one to have followed patients through the years.
They found that the mean thickness of the upper lip
increased from 11 mm at age 6 years to 13 mm at age
18 years in males and from 11 mm at age 6 years to
12 mm at age 18 years in females.1 This means that if
the thickness of the upper lip was lower than these
numbers, the patient was considered to have a thin lip.
However, if the thickness was equal to or greater than
these numbers, the patient was considered to have a
normal or thick lip.
We agree with what you are saying, but our study is
based on the opinion of evaluators. It is true that this
study has an objective side, but the conclusions that
we are making are based on subjectivity. So, if we crop
the nose and chin and only keep the upper and lower
lip, the evaluation will not be general and will only
take into consideration a little part of the profile, and
this does not answer our problem. In addition, the naso-
labial angle and the angle of the upper lip reflect the
position of the maxillary incisors and the soft tissues
covering those teeth. Therefore, they have considerable
importance and must be visible when evaluating the
profile on pictures, as mentioned in your question,
“especially the relative relationship between the tip of
the nose and the upper lip are closely related to the
aesthetic evaluation of the profile.”2,3 The chin is indeed
a disorienting factor considering its very inconsistent
position, but the tip of the nose is directly related to
the upper lip. Furthermore, the small part of the nose
that is showing gives an added value and can lead us
to determine the anteroposterior position of the upper
lip, knowing that if only the upper and lower lips are
showing, the evaluator will lose his references and will
not be able to visualize and place the lips in a profile
context.
In our study, we demonstrated that even if a patient
is in a skeletal Class I relationship and the maxillary in-
cisors are in an ideal position, depending on the
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