Esthetics, environment, and

the law of lip relation

H 0 H F’i K T M . R I C’J Ii F 1 ‘1’ ‘I’ ,S , I).l).S., M.S.

Pacific Palisades, Calif.

ASALPSIS, by definition, means reduction to component parts in order to

discover the interrelationships that exist. Diagnosis often implies an inquiry
into the cause of a condition and its characteristics. Although orthodontic analy-
sis is descriptive, diagnosis must include the fourth dimension of time and must
encompass a consideration of the biologic phenomenon of gr0wt.h. In addition,
personality type or the patient’s acceptance or rejection of fullness or promi-
nence of the denture on a temperamental basis is another biologic consideratio’tl.
It is, therefore, incumbent on the diagnostician to imagine a. morphologic
condition from its beginning, visualize its present status in a sequence of de-
velopmental behavior, and conceive the possible future behavior in order ts
make a knowledgeable, qualified opinion regarding its prognosis. Thus, tb
esthetic factor is a longitudinal and biologic proposition as well as a structural
and functional problem.
In 1965, I published two paper& ” which dealt with some of the functional
or muscular factors involved in esthetic considerat,ions. This work dealt specifi-
cally with the chin, the lower alveolus, and environmental conditions. I called
these three structures the “keystone triad” and listed several anatomic, physi-
ologic, and growth factors which should be considered in this complex longi-
tudinally.
To extend this concept further, attention should be given the area of tongu;
and lip balance. Research in muscular phenomenon has usually followed the
physical aspect, but, as a matter of organization in a concept of contemporary
orthodontic analysis and diagnosis, let us review some of the many factors to
be considered in the evaluation of equilibrium or imbalance states between lips
and tongue as a background for the interrelationship between esthetic and
functional considerat.ions.

Presented at the annual meeting of the Great Lakes Society of Orthodontists,

Oct. IO to 19, 1966.

272
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Esthetics, environment, and law of lip relatioqa 273

FACTORS TO CONSIDER IN ANALYSIS OF ORAL SOFT TISSUES

Nine pertinent distinctions can be recognized as basic to analysis:

1. A correlation of morphology and function is implicit in most
conditions of lip relations; what looks good usually works well.
2. The tongue interacts with the Zills in all functions, such as masti-
cation, speech, deglutition, and even in tonicity at physiologic
rest.
3. Lip and tongue function is read from the cephalometric x-ray
film (Fig. 1).
4. It is recognized that the lips are influenced by the teeth or that,
conversely, the teeth are influenced by the lips.
5. The lips are viewed in perspective or considered in multiple di-
mensions.
6. A distinction is made between mouth disharmonies and lip im-
balances.
7. Combinations of conditions are recognized in the context of pat-

Fig. 1. Roentgenogram of patient during act of swallowing barium (Microtrast prey)ara-

tion). Note that teeth are parted, tongue is propped between teeth and mouth, and lips
are pursed in antagonistic contraction against function of “thrust” tongue during deg ,luti-
ttl~n. This represents interaction of tongue and lips as reciprocal organs; therefore, il ifor-
m&ion relative to tongue function can be gained from careful observation of m outh
externally.
274 Ricketts

as conditions are isolatccl am1 calassifie(l iirltl t Ilcn c:orrt~lutcd

terns, info
patterns for intelligent understantling.
8. Lip and mouth conditions arc considered longitudinally hccausc~
more lip prominence or mow rcccssivc mouth c~lraractcristiw may cl+
velop as the patient, grows.
9. A flamboyant, gregarious, outgoing personality frequently will
accept a more prominent and “forward” denture, and it is possible that
recessive dentures are more suitable for withdrawn persons, although
these ideas are not totalljT applicabk.
Thus, it is the job of the sckntist or the purpose of the diagnostic clinician
to isolate specific conditions, study the integrated pattern that combinations
form, and fit them into the total picture of analysis in the understanding of
the individual situation.

Fig. 2. Drawings representing research on the esthetic plane (line from end of nose to
chin). Middle drawing represents ideal well-formed face in normal 26-year-old woman;
mouth is in good harmony, lips are in good balance, and chin is prominent. Note cheek
plane (line from cheek soft-tissue prominence to chin); distance between these poinls
represents effective length of nose. Holdaway’s line (dotted) through upper lip aIrno&
bisects E plane and C plane. Note that lower lip is slightly closer to E plane than uppes
lip for best balance of lips. Drawing at left represents lower end of range in normal 30.
year-old man. Note length of nose, recessive cheek, concave profile, and recessive type @
mouth. Chin is dominant in face and, although lips are not most attractive part of
denture occlusion is superb. Drawing at right represents protrusive end of range. In
this particular patient shows slight strain because of long face. Note fullness of low
approaching E line, shortness of nose, and prominence of cheek. This face accepted
fullness of denture with much grace and harmony. Distance of lower lip ahead of C
is partly due to above-average thickness of lower lip. t
Volume 54 Esthetics, environment, and law of lip relation 275
Number 4

CLASSIFICATION OF LIP RELATIONS

In about 1953, this area attracted my scientific interest and study, and I
made some preliminary attempts at description and classification of lip rela-
tions.3-5
No single ideal but a range of normal relations was recognized. As a start,
a line was drawn from the nose to the chin simply to assist in the description of
mouth relations to adjacent structures. This line was called the esthetic plane
or E plane (Fig. 2). It was recognized that the mouth also should be related
to the cheek bones for total perspective, but it was not mentioned quantita-
tively.
From publications of others and from common experience with the lay
public and with some artists, it was noted that most people object to lips that
protrude beyond the E plane. Lip prominence seemed to be an undesirable trait
and an unacceptable situation, particularly in adults.6 However, fullness of the
lips and mouth prominence are characteristics of the young. Many women ob
ject to excessively flat mouths or puckered lips later in life because the promi-
nent denture and the full mouth constitute a mark of youth, whereas flat
mouths suggest old age.
The lower lip position in a significant sample of adults was found to be
located a mean distance of 4 mm. posterior to the line, with a standard devia-
tion of f 3 mm. It was also located on a plane ahead of the root of the nose, or
alar cartilage. Holdaway described lip objectives to be a line from the chin
through the upper lip to extend to a point near the center of the nares. Our
range was greater in men, and the line from the tip of the lower lip could
extend backward almost as far as the alar cartilage. Even though flat or re-
cessive types are natural in some patients, the mouth of such a patient is not
esthetically attractive by lay standards, Other features for beauty are conse-
quently more attractive in these faces (for example, the strong “noble” chin,
the eyes, a well-contoured nose, or skin complexion, etc.). As a working hy-
pothesis for an objective of the lower lip in treatment of patients of pubertal
age or for the typically finished case at the age of 12 to 14 years, a mean was
adopted to be -2.0 mm. with a standard deviation of f 3.0 mm. for the lower
lip behind the E plane. That yields an orthodontic working range from -5 to
+1 mm.
At the start of these scientific investigations, both the upper and lower
lips were considered.8 Because the curl of the lower lip and its position were
determined by the upper incisors in the first place, it was considered unneces-
sary to measure the upper lip. The upper lip finally was related only to the
lower lip as the lower lip became the basic reference.
After many years of clinical use, I finally brought the work on the E
plane to its culmination with the formulation of a law which I called the
*‘law of lip relationship.” It was essentially as follows: “In the normal white
person at maturity, the lips are contained within a line from the nose to the
chin, the outlines of the lips are smooth in contour, the upper lip is slightly
posterior to the lower lip when related to that line, and the mouth can be closed
rith no strain.”
 filthough adCquate fol’ (~onSitl(‘l’ati(Jrl ill th: Saggitd [Jhc. this hi\\’ \vas

not quite complete becaust 0-f the ncecI l’or tllrcc~-dimc~i1sic,nalplanes of concern.
Subsequent to the use of the esthetic, plane? it was recognized in 1958” that
mouth width, or the frontal dinlension, was also iln important variable. The
first problem was to dcvisc> a mans 01’ establishing ~)rol,ortioncllit:lJ. Refercnw
lines in the frontal plant (‘or function and esthetic value also were needed.
By drawing a line through the innc~r and outer c~~nthns of each eye and by
dropping perpendiculars through the pupils of’ the ctyc~s,rei’c~rcnce lines were
erected. These were called the l)ul~,i/ lJcr?zes.It \riIs rc>cognizctl that usually the
angles (or “corners”) of the mouth fell almost halfway- bctwcen this line and
the outer limits of the alar portions 01’ the nos(’ in l’a(aeswith the most, har-
monious proport,ions. The width of the mouth was n~~surcd from the angles.
Therefore, an “interangular dirncnsion ” was obtainccl in photographs corrected
to true life size. In patients with the tmrrowest mouths, the interangular di-
mension approached the width of the nostrils. Wide corners of the mouth were
observed to extend to a width directly below the ccntcrs of the pupils of the
eyes. A rating scale was thus cstnhlishcd from 1 to .?. The most narrow mouth
was rated 1, 3 was typical, and 5 was the widest.

OBLIQUE CONSIDERATIOS

In order to evaluate mouth balance completely, a third plane was found

useful. Photographs of ct,hnie and facial types were studied, and the cheek-boBe
prominences were noted. In the final analysis, the mouth, in animation, related
to the chin, nose, and chctks. A line was therefore drawn on the lateral film
from the cheek prominence to the chin. This was called the cheek plase, or
C plane.
It was observed that prominent cheeks deserved more prominent lips and
that recessive cheeks might be better served by flatter mouths. In life, the face
is not constantly observed in direct frontal and lateral perspective. Therefore,
a “cold” or “hard” static view is tempered with the realization of the total
physical experience in making the diagnosis and planning treatment.
Eye width, of course, varies in the human population, as do all phenotype

Fig. 3. Type I, mouth protrusion. Note that lower lip extends 5 mm. beyond E: plane and
full lip thickness ahead of C plane (d,ashed line). Patient’s occlusion was good, but parents
sought treatment for esthetic reasons. Mouth width in frontal dimension at outside limits
falls at 5 on rating scale. Sate that mouth is as wide as pupil planes. Face will, there-
fore, accept wide arch and fuller denture. Patient was treated by extraction technique and
breadth was introduced in arch form for “happy” conclusion.
Fig. 4. Type II, mouth retrusion with overretraction of denture. ?iote violation of law of
lip relation. Lower lip is farther awav from E plane than upper, and lower lip is entirely
posterior to C plane. Chin is too prominent. and full cheek could take more prominellt
lip. Note, in frontal view, that average mouth width of about 3 on rating scale is preseti.
(Dotted lines at angles of mouth are about centered between ala of nose and P planes or
pupil planes.)
Volume 54 Esthetics, ewvironment, and law of lip relation 277
Nuns 3er 4

Fig. 9

BILABIAL PROTRUSION

BILABIAL RErRUSION

pligs. 3 and 4. For legends, see opposite page.

278 Ricketts

traits. The three reference lines serve as a means of description and classifica-
tion. Lip problems strike at the very heart of orthodontic analysis. The esthetic
plane, pupil planes, and cheek plano yield basic lines for observa.tion and com-
munication where formerly nothing but subjectivity was available.

FINDINGS IN MOUTH DISHARMONIES

If the upper lip is rightly related to the lower lip, the lips might be said
to be in balance. However, if both lips are beyond the esthetic plane to a marked
degree, the whole mouth is unharmonious or overproportioned with respect to
other facial structures. Mouth protrusion or “double prot,rusion,” t.herefore, con-
stitutes Type I (Fig. 3).
Conversely, if the mouth is retracted, not supported by the teeth, and the
lips are flat or ‘(sunken in” because of a retruded denture, there is a disharmony
of the opposite kind in the face. This is Type II, or bimaxillary retraction
(Fig. 4). The mouth now does not occupy as prominent a role in the face as
desirable and is out of proportion to the nose, chin, and cheeks, which become
the more dominant features in the face. Therefore, bimaxillary lip protrusion
(Type I) and bimaxillary lip retrusion (Type II) are classified as disharmonies

VPPER PROVERSION

Fig. 5. Type III, imbalance, upper lip proversion. Note undesirable fullness of upper lip,
which is closer to E plane than lower lip. Lower lip is good in its relation (almost bise&
ing E and C planes). Imbalance in lips is due to forward version of upper lip. This fr
typical of Class II, Division 2 lip relation, although this patient has mild Division f
relation. In frontal view, lips would be rated 4 in width, that is, slightly wider thair
average (dotted lines).
Yolzlme 54 Esthetics, environment, and law of lilp relation 279
Number 4

Distinctions and correlations should be made in the frontal view with re-
spect to conditions in the lateral view. Protrusion with flaccidity of the lips and
a wide mouth is an entirely different situation than protrusion with a narrow
mouth and tight lips. Fullness of the lips with a wide mouth together with lip
flaccidity, is esthetically quite acceptable. Lip prominence accompanied by
short lips is objectionable because of the pursing and unattractive compensation
necessary in mouth closure (the “gummy smile”).
The same idea applies to the retracted mouth. The face with retracted lips
in addition to a narrowed mouth is severely handicapped when facial beauty is
considered.
The face with wide, full lips that can function without lip strain, together
with a normal occlusion and ideal oral health, is a remarkably beautiful struc-
ture to behold. Normal occlusion, together with good lip and mouth harmony,
will overcome ugliness in a face that otherwise might be quite deficient in
beauty.

LIP IMBALANCES

Another issue is frequently raised regarding lip posturing. Since the be-
ginning of my clinical practice, I have believed it necessary, for several reasons,

LOWER EVERSION

1plg. 6. Type IV, imbalance, lower lip ever&on. Lower lip is too far forward of upper
lip, or out of balance. Note that lower lip is extended beyond E plane and that full
$$iokness of lip is almost ahead of C plane. Wide mouth was present in frontal view,
with rating of 4.
to obtain bot,h a plrotograI)lr ant1 il I’oc~rrtgcnog~arrr wit II the, IWI It clcrrchcd in
the position of masimum irltc~L’cllsil);rtiorr,OL’in the paticllt ‘s centric* ocdclusion. and
with the lips closctl as nrarly as possibl(l. \Vith the teeth ilrrtl ja\vs in this posi-
tion, the strain and the conditions imposed 1)~ the tccsth for the rrat~ural closure
of t,hc lips and for the swallowing fun&m could be obsc~\-etl. .\n insight into
the patient,% needs with r~?gar*d to tltc mnsculatur~c ~oultl bc gained in a much
more critical manner than it’ the l)irtirrrt were simply ptarmittcd to ~cpose in an
aequircd position.
When the jaws are together and t.he lips closed, therefore, strained condi-
tions appear to be more obvious and arc recordctl in the l~oc~ntge~l0~i'alrl. Photo-
graphs produced in this manner and enlarged to full lift size have pt’rmittetl
a classification of lip relations and in&nlanccd statf,s which has provrd ot
analytic value in diagnosis, prognosis, and treat,ment l)lanning in the individual
situation.
As stated in the “Law,” the upper lip should be slight1.v behind the lower
lip when related to the E plane. When the upper lip extends ahead of the
lower, the condition also is undesirable and will sometimes bring objections
from laymen. This is a condition characteristic of Class II, Division 2 and may

SHOWLLPS
Fig. 7. Type V, imbalance, lip incongruity. Even in this short face, lips are too short for
intermaxillary distance. Inherent lip shortness or lip atrophy due to malfunction is
prob.ably quite common in Class II, Division 1 malocclusion. Although upper lip appeW
foreshortened, this problem is common to both lips with compensatory elevation of ~OWVSS
lip under upper incisors to mask its shortness. Frontal view shows normal width of mou&
(3 rating), but compensatory lip positioning is present.
volume
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Esthetics, environment, and lan! of lip relation 28 1

be produced in extraction cases if the lower denture is retracted excessively.

This condition is classified as proversion (of the upper lip) (Fig. 5).
The opposite to upper lip proversion is lower lip eversion. This also is a
condition of lip imbalance, but one in which the lower lip is too far forward.
This is a most marked characteristic of the patient who has been operated upon
for cleft palate but it also is present in some persons with anterior cross-bite.
Certain bimaxillary protrusions may cause the lower lip to be everted. In this
condition, the lower lip is rolled forward and excessive mucous membrane of
the lower lip is exposed. In the summer and in sunny climates, the lips of these
patients are often burned extensively, which may complicate orthodontic treat-
ment (Fig. 6).
One of the basic considerations in the evaluation of an orthodontic case is
the lip length or inherent size characteristic of the lips. It is easy to recognize
a short and atrophic upper lip, but the shortened lowe,r lip frequently is over-
looked in these conditions. Therefore, one of the primary considerations in
abnormal lip relationship is inherent lip shortness or lip length in both the
upper and lower lips. It becomes a matter of basic incongruity of lip structure
with the basic skeletal pattern (Fig. 7).

Fig. 8. Type VI, lip imbalance, lip strain. Adequate lip length is available in contrast to
Type V, but protrusive denture requires pursing and straining to accomplish lip closure.
Note protrusive quality of both lips and irregularity of contours in violation of law. A
good 4 rating is present in frontal view, but lower lip is caught under upper incisors.
(See also Fig. 3.)
 In problems of this natur(h, t’wid hc~ight must ids0 IW
actual length of the lip might be adcqr~atc for one person
that
tht,
consiflf~ivd,
but, I'or
lwause
of
structural height of the face, pro\.e to I)e inauficirnt in anot,her. Proportional
lip length, therefore, is a primary critic.al consideration in lip imbalanccu, and
the upper incisors may need to btl intt’u(lrtl to harmonize with the lip omhrasurc.
Another classification of lip relation assumcls that natural adequate lip
length is available. However, as a result, of basic protrusion of the
cisors during function, the lips are pursed and the angles of the mouth will be
in- upper
drawn forward in strain (Fig. 8). This condition may or may not> be accom-
panied by furrowing in the area of the lateral contour of the nose down to t,htl
angle of the mouth, which I have termed “caninus furrowing.” The most com-
mon type of problem in malocclusion is the mentalis habit classification. It is
easily recognized as a severe manifestation of bilateral and peripheral lip strain
accompanied by mentalis function and elevation of the integument of the chin.
Mentalis habits are severe manifestations of strain (Fig. 9). It is associated with
either isolated conditions of a protrusive denture, inadequate lip length, and
a long or retrognathie type of face. The patient must exert maximum effort to
close the lips. Tt can occur in a mild combination of all three factors. It fre-

MtNTALIS HABIT

Fig. 9. Type VII, imbalance, mentalis habit. Mentalis is manifestation of severe lia,
strain. Long face, short lips, and protrusive denture combine to cause chronic men@&
contraction and soft-tissue chin elevation. Note protrusion of lower lip fully ahead ofC
plane and both lips ahead of E plane. Pursing is manifested in frontal view, with
rating about 3 in width. Treatment should include effort to reduce skeletal facial he
and increase lip length.
Volume
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Esthetics, environment, arnd 7,uw of lip reMion 283

quently results in a very unpleasant appearance of the lips and the illusion of
a weak chin, and it actually is a source of embarrassment to many patients.
Then next classification is that of sucking of the lower lip or, sometimes,
lower lip biting (Fig. 10). The lower lip is pulled under the upper incisors to
create a seal during the swallow. There might also be a slight pursing of the
lips but, in severe types, particularly if the habit persists, there is a contraction
of the risorius muscles on each side. The corners of the mouth also may be pulled
downward and backward. These patients frequently display deep overbites and
severe overjets of the teeth, but their molar or jaw relations may or may not be
Class II.
A classification that is often misdiagnosed is the sublabial contraction
(Fig. 11). These patients usually display a prominent chin or a “button.” Al-
though one might conclude, on first inspection, that these patients possess strong
mentalis habits or that the problem is chiefly with the mentalis muscle, the
condition actually is recognized by hypertrophy of tissue in the area immedia-
tely above the chin and below the lip. It has been postulated that this condition
of furrowing below the lower lip might be due to an anatomic joining of the
two quadratus labii inferioris muscles uniting across the midline. This would
form a band of tight tissue and could account for the condition, although the
exact reasons are obscure. At any rate, this type of patient usually will display

LIP SUCKING

Fig. 10. Type VIII, lip imbalance and lower lip sucking. Some patients may place lower
lip under upper incisors as compensatory action, but others actually suck on lower lip as
‘a habit, as exhibited here. Note complete retraction of lower lip behind C plane with
lower lip almost disappearing in frontal perspective. Tongue is also retracted as evidence
of double chin outline; patient was transitory-type thruster.
2 X4 Rick&s

an exceedingly powerful lowf~r lip in1(1, quite often, JII~IJ-be itlent ifietl as having
a I~ivision 2 type of malocclusion. The lower lip may 1~ adequate in length and,
being so, would reach high enough to envelop the upper incisor teeth. Drawn
backward by the tight lower lip, the upper anterior tec*th ilre directed inward
and their roots subsequently arc tipped labially 1)~ oeelttsal l’nnction or because
the upper lip also is adequate in length.
The last classification is that of pcrioral contraction ( Fig. 12 1. This concli-
tion of the caninus, together with sublabial furrowing, is characteristic of thch
tongue-thrust syndrome and almost diagnostic of it. The attempt to oppose tllc
tongue causes extensive circumol.bicnlar,is action, and the whole complex 1~
comes strained. The buccinator-caninus-triangularis muscle complex helper
trophies. This is also diagnostic of some cases of temporomandibular joint ab-
normality with at,rophy of the musclrs of mastication. It has been observed in
patients with poliomyelitis of the masticatory muscles. The patient may 11s~
the lip and fa.ce muscles for closing the mandible in the absence of other J11lW
cles. (‘omplete perioral contraction constitutes a gripping of the muscles around
the entire denture.

Fig. 11. Type IX, lip imbalance, sublabial contraction. In contrast to Type VIII (lip
sucking), sublabial contraction occurs at lower level than tip of lip. This is more COB%-
monly associated with thick, hypertrophied band of muscle crossing midline. Lower
may exhibit forward roll, but deep sublabial furrow is evident and sometimes chro
ischemic dermatitis is present. Mouth width in frontal view is a good 4 rating as fur*
shows. This is not a mentalis habit condition but may be confused with one.
Volume 54 Esthetics, environment, ad law of lip relation 285
Number 4

THE TONGUE PARAMETER

As stated previously, lip function cannot be divorced from tongue function

because the two work reciprocally. Nothing in orthodontics has been more con-
troversial in the past decade than the function and characteristics of the tongue.
More than 10 years ago, a wave of interest, particularly in the role of degluti-
tion in the cause and cure of malocclusion, swept the profession. Crests of
hysterical proportion developed in different areas throughout this country and
the world. In some areas the climate has calmed, but the storm has left lasting
havoc. In the wake of the st,orm some stood fast; in fact, it could be said that
they slept through the tempest. Many, however, were buffeted uncontrollably
and were thrown high on the beach in dazed confusion. These were principally
those who were essentially disciplined only to oral habits as the primary etio-
logic factor in malocclusion. Tongue-thrust became a boon to their existence.
Ironically, the tongue and faulty deglutition were grasped almost simul-
taneously by clinicians on both sides of the extraction issue. Open-bite and
relapses were explained by the preservists as being due to faulty deglutition,
while the extractionists, looking for answers to relapse, for developing deep
bites, or for spacings in the denture, fell upon tongue training almost as a
panacea for all orthodontic ills. Everything from long nipples to no nipples, or

PENORAL CONTiACTION

Fig. 12. Type X, imbalance, perioral contraction. Very frequent outward manifestation of
tongue-thruster in deglutition. Deep furrows develop in caninus muscle are.as. Note that
lips in lateral view are well balanced and nicely within E plane but are not smooth in
Fontour in frontal view, although a rating of 3 is present. This young lady was strikingly
deeutiful and won beauty contests after orthodontic expansion and correctional tongue
‘Merapy for habitual type of tongue-thrust.
 286 Ricketts

K.C.
7- IO

Fig. 13. Tongue atavism (habitual thruster). Failure of tongue and laryngeal pharynx to
descend normally. Note that hyoid bone is high and tongue is upward and forward,
filling entire oral cavity. Teeth erupted labially and spaced in both arches under influence
of malpositioned tongue. Because tongue was chronically between teeth, habitual thrust
could not be avoided. Therapy must include infrahyoid contraction and care of entire
hyoid complex. Same postural problem of tongue may occur in thumb-suckers secondary
to open-bite.
Fig. 14. Glossoptosis (transitory thruster). Drooping of entire oral and laryngeal pharynx
withdraws tongue from influencing teeth, and denture may appear “crushed.” Ironically,
tongue may be thrust violently upward and forward during act of deglutition and be
braced between arches of teeth for short duration, resulting in transitory or intermittent
type of thust which is difficult to detect.

PO.
LI 6-6 4. 6-10
7.0

Fig. 15. Adaptive or secondary thrusters. Respiratory obstruction of variety of charac-

teristics can affect deglutition as compensatory factor. A, Adaptive thrusting of tongue
and open-bite or cross-bite have been observed to be consistent with large tons& in some
patients. B, Adenoid or other respiratory factors also influence tongue posture. Lined area
was removed by tonsillectomy and adenoidectomy. Dark area represents relative elevation of
tongue. Pattern of deglutition was also changed, as well as habitual posture of mandible.
Volume 54 Esthetics, environment, and law of lip relation 287
Number 4

from anesthetic throat to sore tonsils, was held to be the root of the problem.
Many unqualified speech therapists or undisciplined opportunists were brought
‘into the clinical field, and undocumented claims were extensive. The task of
diagnosis was often handed to untrained, unsophisticated, and incompetent
speech personnel.
Realizing the need for a clarification of the tongue-thrust syndrome, we at-
tempted to classify the tooth-apart swallow and to organize our own observa-
tions. It was recognized that all patients swallowing with the tongue between
the teeth did not do so in the same sequence, with the same degree, frequency,
or duration of the activity, or from the same base. This precipitated a study”
in which three different types of swallowing problem were demonstrated and
a relationship between morphology and function was suggest,ed.
Out of the confusion and heat on the subject, a few clear-cut and untainted
facts were uncovered :
1. Problems of the tongue and deglutition are truly primary prob-
lems in orthodontics and, in some patients, appear to be acquired during
treatment. Patients refusing to settle almost always swallow with the
tongue between the teeth, and slight open-bites prevail in retention in
these cases.
2. Although open-bite and lack of cuspid function are commonly as-
sociated with tongue problems, posterior open-bite, cross-bite, and deep-
bite in the anterior area also are influenced by tongue conditions and
by faulty deglutition.
3. Not all deglutition problems are alike. Some patients have habit-
ual or chronic postural problems with tongue positions constantly oc-
cupying the space between the teeth (Fig. 13, atavism). Others thrust
the tongue forward only intermittently but vigorously from a drooped
or ptosis position far downward. Cases of true glossoptosis can be ob-
served with severe crowding of the denture, yet the patients can still
be tongue-thrusters (Fig. 14, transitory). Third, the positioning of the
tongue between the teeth may be acquired secondarily as a result of
other primary factors (Fig. 15). Respiratory obstructions occur from
a variety of causes and result in the mandible’s being dropped. Even pain
in the teeth is lessened by the cushioning effect of the soft tongue during
deglutition. All of these factors result in acquired tongue habits which
are adaptive in nature.
4. Tongue-thrusting includes a growth phenomenon. It is observed
with far greater frequency in children than in adults, but it still is
found in adults! It also extends into the retention period in orthodontic
practice. If it is to be handled simply as a ma.rk of immaturity on a
clinical management basis, why do not all children outgrow it?
5. The inability to cope with the severe tongue-thrust syndrome sug-
gests that the condition is related to some deep underlying structural,
neurologic, or even genetic problem in some patients. For instance, the
tongue-thrust in the severely dolichofacial person with short lips must
be strictly compensatory to the structural relations, which have been
388 Kick&s

died akelettsl open-bites. In other patients no Iypc oi trentmcnl I plrl~G~-

therapy or mechanical or psythologic trclatmG,nt ,i. SWINGSto produ~
lasting results. The work of Konr;ld liorenz ‘I ILas suggested lhitt b1)-
havioral patterns are genetically transmittcld, and the rcsistancdc of some
patients to therapy leads one to think that the pattc~rn may hc irrc:\,rrsi-
hle in some. The dominance of ihis kind of phenomenon Jvarrants iI
fourth class of tongue parameter, which is nezlrologic.
6. Although the tongue-thrust s,vndromr is rccognixed and the dc-
scription and classification of problems has been verified, the etiology of
many of these tongne problems still is not proved. The hypothesis most
acceptable to those working closest to the field has implic.ated respira-
tion as a primary concern, The growth of the nasal cavity ant1 the CS-
t,ent of ventilation through the nose are points of interest that hare been
the subjects of very little research. If a patient (*annot breathe easily
through the nose, t,he mouth is employed as the airway. The jaw is
dropped downward and held forward. This phenomenon was not,ctl by
me in 1950 as observed from rest-position studies. Nature, conservative
t,hat she is, does not wast,e energy for the swallow. The tongue is em-
ployed simply for stabilization and fixation of the> mandible for the
swallow, and hence the tooth-apart, tongue-thrust swallow is the result.
7. Under t,he above hypothesis, investigators have been led to anoth(Ar
phenomenon that is not commonly known. Important. observations di-
rected attention to bottle feeding. Straub noted that the incidence of
t,onguc-thrust was significantly higher in children who had been hottl(>
fed. At first inspection, the larger or leaky mechanical nipple or thca
postural problems encountered in feeding from a hottlr were considered
as causes of tongue-thrusting. However, another ct\-(xn greater etiologic
factor is speculative-the infant’s sensitization to cow’s milk. Com-
munication with pediatricians, as well as some preliminary research,
has suggested that mild allergy or sensitization to unnatural milk is
commonplace and could conceivablp incite a lasting phenomenon.”
Almost t.he first systemic eft’ects of allergy are observed in the nasal
membranes and affect breathing. Theoretically, the lower ja.w and tongue
may acquire a forward functioning position as a conipcnsatory mocha-
nism. The question remains, could this habituall)- arquircd contlition
constit,ute a lasting conditioned rcflcs pattern for the swallow? The oral
environment, therefore, is altered b?. respiratory obstruction of a direct
and indirect, chronic, or intcrruptrd nature.

DISCUSSION AND STJMMARY

Orthodontists rightly emphasize lips and mouth relations in analysis and

diagnosis. In the sclcction of treatment methods, however, many arc inclined to
consider only immediate esthetic goals. Although it. would appear that, functional
equilibrium and esthetic considerations would be the first area of clinical re-
search, a review of the literature reveals that sophisticated, qualitative, over-
all diagnostic criteria have not been available and that paramrters have been
Volume 54 Esthetics, environment, and law of lip relation 289
Number 4

loose and nondescriptive. Further, purely subjective evaluations are often em-
ployed clinically.
The attempt was made to organize, clarify, and classify lip conditions for
analytic value. As background for consideration, however, growth and be-
havioral characteristics, sex, and ethnic type are basic to etiology in the total
frame of heredity and environment in a biologic sense.
Research on normal values has been described, and a “law of normal lip
relations” has been proposed. This law, including both functional and esthetic
considerations, stated essentially that the lips in white adults are contained
within a line from the nose to the chin, the lower lip is closer to the line than
the upper, the lips are smooth in contour, and the mouth is closed with no strain.
Ten conditions of the mouth and lips as opposed to four types of tongue
problem have been described. The functional balance or homeostatic position of
the denture is produced by combinations of t,hese lip and tongue conditions,
which must be considered on a longitudinal basis by the sophisticated clinician.

REFERENCES
1. Ricketts, R. M.: The Keystone Triad. I. Anatomy, Phylogenetics, and Clinical Refer-
ences, AM.J. ORTHODONTICS50: 244-264,1964.
2. Ricketts, R. M.: The Keystone Triad. II. Growth, Treatment, and Clinical Significance,
AM. J. ORTHODONTICS50: 72%750,1964.
3. Ricketts, R. M.: Facial and Denture Changes During Orthodontic Treatment as Ana-
lyzed From the Temporomandibular Joint, AM. J. ORTHCDONTICS41: 163, 1955.
4. Ricketts, R. M.: The Role of Cephalometrics in Prosthetic Diagnosis. J. South. Cali-
fornia D. A. 24: 19-30, 1956.
5. Ricketts, R. M.: Planning Treatment on the Basis of the Facial Pattern and an Esti-
mate of Its Growth, Angle Orthodontist, 27: 14, 1957.
6. Ricketts, R. M.: Cephalometric Analysis and Synthesis, Angle Orthodontist 31: 141,
1961.
7. Holdaway, R.: Presentation, Jarabak Society Meeting, February, 1963.
8. Ricketts, R. M.: A Foundation for Cephalometric Communication, AM, J. ORTHODONTICS
46: 330, 1960.
9. Ricketts, R. M.: The Functional Diagnosis of Malocclusion, Tr. European Orthodont.
SOL?. pp. l-21, 1958.
10. Ricketts, R,. M.: Clinical Research in Orthodontics in Vistas in Orthodontics, edited by
Kraus and Riedel, Philadelphia, 1962, Lea & Febiger, Znc.
11. Lorenz, K. Z.: The Evolution of Behaviour, Scientific American, December, 1958.
12. Marks, M. B.: Allergy in Relation to Orofacial Dental Deformities in Children; A
Review, J. Allergy 36: 293-302, 1965.

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