Evaluation Of Lip Esthetics By Changing The Vermillion Height As Perceived By Orthodontists, Orthodontic Residents And Patients

Hafiz Taha Mehmood1                         BDS

Imtiaz Ahmed2                                       BDS, FCPS, M.Orth

Gul-e-Erum3                                            BDS, FCPS, M.Orth

Hana Pervez4                                           BDS

OBJECTIVE: To evaluate lip esthetics by changing in the vermillion height as perceived by orthodontists, orthodontic resident and patients.

METHODOLOGY: The Images were constructed by increasing and decreasing the vermillion heights in the increments of 0.5mm from -2.0mm to +2.0mm from average vermillion height. Overall 9 images were constructed and rated by 10 orthodontists, aged 32 to 45 years, 31 orthodontic residents, aged from 25 to 35 years, and 46 orthodontic patients, aged from 15 to 35 years, on visual analogue scale.

RESULTS: There were variations among the three groups; orthodontist, orthodontic residents and orthodontic patients in the median esthetic scores, assigned to nine vermillion heights. The participants found images -0.5mm, 0mm and +0.5mm most attractive and the images -2mm, -1.5mm and +2mm least attractive.

CONCLUSIONS: Images with or near the average vermillion height was considered to be attractive by orthodontist, orthodontic residents and patients. The ranges of vermillion heights preferred by orthodontists and orthodontic patients were similar. Majority of male preferred 0mm while female respondents showed a broader tolerance for vermilion height.

KEY WORDS: Lip esthetics, Vermillion height, Pakistani.

HOW TO CITE: Mahmood HT, Ahmed I, Erum G, Pervez H. Evaluation of lip esthetics by changing the vermillion height as perceived by orthodontists, orthodontic residents and patients. J Pak Dent Assoc 2015;24(3):140-144.

Received: May 11 2015, Accepted: October 26, 2015


The esthetics of the lips and their role in providing the completeness of the face are very important as they are one of the most integral components of facial aesthetics.The lips have been compared to a frame that sets off the image of smile, encompassing teeth and gums.The plump and well defined lips are the symbol of beauty and they are unavoidable for the youth, attraction, fertility, sex appeal and femininity.1 People having less attractive faces tend to be detached from the surroundings2 and are more likely to face isolation. Upper and lower lips are important facial features and their rolein determining the facial esthetics is inevitable.3

Lip esthetics is one of the major reasons why many patients seek orthodontic treatment. Albino et al1  proposed that 80% patients have undergone orthodontic treatment for esthetic concerns.Enhancing or correcting the shape, fullness and symmetry of your lips can make your smile seems fuller. Studies have suggested that thick, prominentand plump lips are considered to be more beautiful and youthful5,6,7 and thin and loose lips are the signs of agedness.8,9 Therefore youthful and plump appearance of the lips strengthens the youth and health on our face. People with less prominent lower lips often opt for lip enhancement surgeries.10 Lip esthetic surgeries, being performed, many of which produce more prominence in lips.11

Improving smile esthetics, a component of orthodontic treatment, is always of great concern for orthodontists and orthodontic patients. In determining smile esthetics, vermillion height is one of the key factors.12 Among the various lip esthetics parameters, we used vermilion height in our study anddeterminedthe orthodontists’ and patients’ perception of lip esthetics byusing images in which vermillion heights were adjusted incrementally. Vermilion height is defined as the length between superior vermillion border and inferior vermillion border.

The study was conducted in order to obtain answers for the questions: (i) among the following images which vermillion height is considered to be more attractive by orthodontist, residents and patients? (ii)Do orthodontist, orthodontic residents and patients have similar perception of lip esthetics? (iii) Is there any significant difference exist between orthodontist and residents in the perception of lip esthetics? (iv)Overall difference in male and female judgesin evaluation of lip esthetics?


The study was conducted from March 2014 to August 2014 in multiple universities, hospitals and private clinics.


To evaluate lip esthetics, anextra-oral frontal view photograph from a volunteer was taken exposing

the lower third of the face. The average vermillion heights were measuredusing vernier caliper clinically and it was found for upper lip from labralesuperius and crista philtri 8.2mm and 9.3mm respectively, and for lower lip from labraleinferius 9.2mm. Labralesuperius is the highest point of vermilion on upper lip and labraleinferius is the lowest point of vermillion in lower lip. The crista philtri is the point on each elevated margin of philtrum just above the vermillion line. The image was modified using Adobe CS5.The average vermillion height was increased and decreased 0.5mm incrementally from -2.0mm to +2.0mm. Overall 9 images were constructed and titled capital alphabetical letters and arranged at random. The images were printed and displayed on separate cards and the respondentswere shown single image at a time to limit the comparison. (Figure 1)

Visual Analogue Scale

Visual analogue scale has been used for assessment of pain intensity.13,14 The respondentswere asked to enter their name, gender and age, prior to viewing the images on the data forms and thenrate the images using visual analogue scale.In the given scale, 0 being the minimum and 10 being the maximum esthetic score for each image. The VAS was used to allow the individual to show their personal evaluation in rating the images. VAS has already been used for evaluation of smile and lip esthetics.15,16,17(Figure 2).

Groups Distribution

The raters are divided among three groups. Group 1 involves orthodontists from different dental universities and private clinics of Karachi, Pakistan and includes7 males and 3 females, aged 32 to 45years. Group 2 involves orthodontic residents from three universities of Karachi, Pakistan including Ishrat-ul-Ebad Khan Institute of Oral Health Sciences (Dow University of Health Sciences), Altamash Institute of Dental Medicine and Karachi Medical and Dental College (Karachi, Pakistan) and includes 10 males and 21 females, aged 25 to 35 years. Group 3 involves orthodontic patients from Ishrat-ulEbad Khan Institute of Oral Health Sciences, DUHS Karachi, Pakistan and includes 15 males and 31 females, aged 15 to 35 years.

Sample Size Calculation

Using PASS version 11.0, one-way ANOVA power analysis with 95% confidence interval, sample sizes were calculated for each group separately, depending on our pilot study. The effect size was estimated at 0.5860. For group 1 we needed7 individuals and for group 2 and 3, we needed 30 individuals.  The total sample would be 67 subjects achieved 99% power to detect differences among the means versus the alternative of equal means using an F test with a 0.05000 significance level. The size of the variation in the means is represented by their standard deviation which is 0.95. The common standard deviation within a group is assumed to be 1.615. The group allocation ratio for group 1 would be 0.25 and for group 2 and 3 would be 1.0.

Statistical Analysis

Statistical analyses were done using Statistical Package for the Social Sciences (SPSS for windows version 21). To evaluate the median of the esthetic scores given by the respondents, Kruskal-Wallis was performed for nine different images for each group separately at 95% level of significance. Mean with standard deviation were also calculated.


Group 1 included 10 orthodontists, group 2 composed of 31 residents and group 3 had 46 patients. The participants found images -0.5mm, 0mm and +0.5mm most attractive and the images -2mm, -1.5mm and +2mm least attractive.

The Kruskal-Wallis test showed that there were significant differences among the three groupsin the median esthetic scores. The median esthetic scores for each vermilion height are shown in figure 1.

Figure 1: The median esthetic scores for each vermillion height among the three groups.(O represents Orthodontists; OR, Orthodontic Residents and OP, orthodontic Patients)

Among orthodontists, the Kruskal-wallis test showed the significant differences (p<0.05) in the median scores for the nine vermillion heights. (Figure 1)

Figure 2: The median esthetic scores for each vermillion height in overall male judges.

Figure 3: The median esthetic scores for each vermillion height in overall female judges.


Aging is a complex procedure and many changes occur in the soft tissues with aging than in hard tissues of the face.18  The change most significant to orthodontist is the lips that sag downward relative to the teeth, with the resultant decrease in exposure of the upper incisors, and increase in exposure of the lower incisors.19 Lip thickness reaches its maximum width during adolescent period, and then gradually decreases, to an extent that some women seek treatment. So, if an adolescent patient is undergoing orthodontic treatment, then leaving the lips somewhat prominent will likely to appear ideal as a result of aging.

Due to the ongoing trend of having more prominent and thick lips20, we might have expected that the respondents would find thick lip images more acceptable. The results of this study suggested that the images within or near the average ranges were found to be attractive to the respondents. According to the results of our study, from the series of nine images; orthodontist, orthodontic residents and orthodontic patients found images -0.5mm, 0mm and +0.5mm most attractive and the images -2mm, -1.5mm and +2mm least attractive.The results of this study were consistent with the findings of Hideki loi et al21 , the ranges of vermillion heights preferred by orthodontists and orthodontic patients were similar to our results.In our study, orthodontist and patients had similar perception as neither thick nor thin lips were preferred. We therefore propose that the results of orthodontic treatment mayliewithin the range of -0.5mm to +0.5mm vermillion heights.

The orthodontists and orthodontic residents have difference in their perception of lip esthetics. The orthodontists assigned highest esthetic score to 0mm and +0.5mmvermillion heights and orthodontic residents to -0.5mm vermillion heights. (Figure 4)

Figure 4: Line with markers showing the significant differences in the scores between the three groups. (O represents Orthodontists; OR, Orthodontic Residents and OP, orthodontic Patients)

There was gender difference in the perception of lip esthetics. Male respondents favored narrow and distinct range, while the female respondents favored relatively broader tolerancein vermillion height changes in evaluationof vermillion heights. 0mm average vermillion height was found to be attractive for overall male respondents while a range from -1mm to +0.5mm was attractive for overall female respondents.

There were some limitations in the study. The sample size for orthodontists was small, owing to the fact that there are only few orthodontists in Karachi. We tried to include all of them, but due to the unavailability at the time of research being conducted, the sample size remained small. The images were computer generated and there were some degrees of human error. The images were only one individual, and we have included only one variable for the assessment of lip esthetics, vermillion height and showed only the lower third of the face. Another limitation is that the respondents have perceived the lip esthetics, when the lips were in rest position only.


  • Images with or near the average vermillion height was considered to be attractive by orthodontist, orthodontic residents and patients.
  • The ranges of vermillion heights preferred by orthodontists and orthodontic patients were similar. . Majority of male preferred 0mm as more attractive while female respondents showed broad tolerance for vermillion height.

Author Contribution: IA and GE convinced the idea, HTM and HP collected the data and wrote the manuscript, IA and GE revised and gave final approval.

Disclosure: None disclosed


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1. Department of Orthodontic DIKIOHS, Karachi, Pakistan

2.Associate Professor, Head of Department of Orthodontic, DIKIOHS, Karachi, Pakistan.

3. Assistant Professor, Department of Orthodontic, DIKIOHS, Karachi, Pakistan.

4.Department of Orthodontic, DIKIOHS, Karachi, Pakistan.

Corresponding author: “Dr Hana Pervez” < hinaprervez951@gmail.com >