An evaluation of the nasolabial angle and the relative

inclinations of the nose and upper lip

Jay P. Fitzgerald, DDS, MS," Ram S. Nanda, DDS, MS, PhD, b and
G. Frans Currier, DDS, MSD, MEd ~
Oklahoma City, Okla.

The purpose of this study was to develop a consistent and reproducible method of constructing a
nasolabial angle that would also permit an evaluation of the relative inclination of the lower border of
the nose and the upper lip, as well as their relationship to each other. Comparison of repeated
individual measurements of soft tissue profile landmarks on 15 subjects, as completed by four
orthodontists, revealed that the proposed method of constructing the nasolabial angle was consistent
and reproducible by the same orthodontist and among different orthodontists. Normative data for the
three nasolabial parameters were produced from a sample of 104 young white adults determined by
the authors to have well-balanced faces. Mean and standard deviation values from this pooled
sample demonstrated a lower border of the nose to Frankfort horizontal plane angle at 18~ +_ 7 ~
upper lip to Frankfort horizontal plane angle 98 ~ __. 5 ~ and nasolabial angle 114 ~ +_ 10~ No
statistically significant difference was demonstrated between the values for men and women in this
study, but the women did have a slightly larger nasolabial angle. A linear comparison of the three
nasolabial parameters with six skeletal measurements revealed no significant relationship between
the soft tissue profile of. the nasolabial region and the underlying skeletal relationships. (AMJ
ORTHOD DENTOFACORTHOP 1992;102:328-34.)

A recent study by CzameckP on facial pro-

files determined that the nose-lip-chin relationships are
exceedingly important in determination of facial es-
thetics. A frequently used soft tissue parameter in ortho-
dontic diagnosis is the nasolabial angle; which is
formed by a line from the lower border of the nose to
one representing the inclination of the upper lip. How-
ever, the structure of this region is so variable that the
nasolabial angle has been drawn differently by various
investigators. 2-9 In addition, the nasolabial angle mea-
surement may not accurately describe variations in the
soft tissue profile. For example, angular measurement
of a patient may be within normal range, and yet there
is presence of protrusion of the maxillary incisors and
the upper lip. The reason for the normal nasolabial angle
is an upturned nose. Combinations of such variations
may lead to erroneous conclusions in orthodontic di-
agnosis.
The purpose of this article is to establish a standard
reliable and reproducible method for measuring the na-
From the Department of Orthodontics, University of Oklahoma College of
Dentistry, Oklahoma City, Okla.
Based on a thesis submitted to the Graduate College of the University of
Oklahoma in partial fulfillment of the requirements for the degree of Master
of Science.
"Graduate Student.
bProfessor and Chairman.
CAssociate Professor.
811131133
328
solabial angle and its components. With this method,
normal values for soft tissue measurements of the lip
and nose were elucidated.
LITERATURE REVIEW
Comprehensive orthodontic diagnosis and treatment
include facial harmony as a primary goal. Angle t~ sug-
gested that if the dentition was intact and arranged in
an optimum occlusion, the soft tissue would then as-
sume a harmonious position. However, Hellman"
pointed out that variations from normal occur in the
soft tissue even in the presence of a normal occlusion.
Tweed ~2 proposed the use of a hard tissue diagnostic
triangle in diagnosis and treatment planning with the
assumption that an upright mandibular incisor over the
basal bone was stable and esthetic. ReideP 3 stated that
the ultimate goal of orthodontics is perfection, and this
includes ideal function, ideal esthetics, and mainte-
nance of these ideals.
Orthodontic treatment planning has evolved from
considering previously good occlusion toward the as-
sessment of the soft tissues as well. Several authors
have provided methods of examining the soft tissue
profile and have proposed standards for an esthetic fa-
cial profile, t4z~ Soft tissue assessments were initially
subjective evaluations but have evolved into studies of
the normal soft tissue profile, as well as soft tissue
changes, with growth 2z'29 and treatmentfl ~
The complexity of predicting changes in the soft
vol,,,,,,+102
Nt,nbcr 4
/ S G n , I~
Fig. 1. Six skeletal angular measurements,excludingnasolabial parameters, included: facial angle,
angle of convexity, ANB, SGnlFH, SGnlSN, and FMA.
tissue profile over time with or without treatment is
difficult. Many factors may contribute to these changes,
including orthodontic tooth movement, orthognathic
surgery, and growth o f the hard and soft tissues. Soft
tissue changes relative to dental or skeletal movement,
as well as with those associated with growth, must be
anticipated if the best possible facial esthetics are to be
achieved. Therefore it is vital to have methods o f eval-
uating the soft tissue profile and establishing normal
ranges for soft tissue parameters.
MATERIAL AND METHODS
This study used the cephalometric radiographs of 104
white adults, 80 men and 24 women. All exhibited Class 1
occlusions with good facial balance. There was no history of
orthodontic treatment or facial surgery. All 28 permanent teeth
were intact excluding the presence of third molars. The mean
Evahcation of nasolabial angle 329
Feclld
Angle ANB
;An~, ol
! Convexity
age of the sample was 24 years with a range from 22 years
4 months to 32 years 10 months.
All ccphalometric radiographs were taken with the lips
relaxed, which is a more natural position and allowed a more
accurate structure of the lip, ~ and were traced on 0.003-inch
matte acetate tracing paper. Nine reference points were lo-
cated on the cephalometric tracings and entered into a Corn-
plot 2000 computer digitizer system. Six skeletal angular
measurements, excluding the nasolabial parameters, were
recorded: facial angle, angle of convexity, ANB angle,
SGn/FH, SGn/SN, and FMA. (See Fig. I.) Dental mea-
surements were not included since all subjects used in this
study presented with balanced faces.
Because there has been no uniform method for drawing
the nasolabial angle, it was necessary to develop a new, re-
liable and reproducible method. A three-step approach was
derived. (See Fig. 2.) The most posterior point of the lower
border of the nose at which it begins to turn inferiorly to
330 -, 6 -r;tz~ Nanda, and Ctcrrier am. J. Orthod. Dentoftzc. Orthop.
October 1992

Fig. 2. Cephalometric landmarks: sella (S), nasion (N), porion (P), orbitate (Or), subspinale (A), su-
pramentale (B), pogonion (Pog), posterior columella point (PCm), and labrale superius (Ls). The soft
tissue angular measurements used in this study: lower border of the nose to Frankfort horizontal plane
angle or NIFH, upper lip to Frankfort horizontal plane angle or LIFH, and nasolabial angle.

merge with the philtrum of the upper lip was located and
called posterior cohonella point, or PCm. A tangent was
drawn from PCm anteriorly along the lower border of the
nose at its approximate middle third and called PCm tangent.
The posteroinferior angle of this line extending anteriorly and
intersecting the Frankfort horizontal plane was considered the
relative inclination of the nose and termed the lower nose to
Frankfort horizontal plane angle, or N I F H . If this line rep-
resenting the lower border of the nose was parallel to the
Frankfort horizontal plane, it was measured as 0 ~ Occasion-
ally, a patient had a nose that was turned so far down that a
plane parallel to the lower border of the nose intersected the
Frankfort horizontal plane posterior to the soft tissue profile.
In this case, the anteroinferior angle formed at this intersection
was reported as the N / F H angle with a negative value.
The line drawn from PCm to labrate superius (Ls) was
termed the PCm-Ls line. When extended superiorly, it inter-
sects the Frankfort horizontal plane. The anteroinferior angle
formed at this intersection was considered the relative incli-
nation of the upper lip and was termed the upper lip to Frank-
fort horizontal plane angle, or L/FH.
The anteroinfcrior angle formed by the intersection of
PCm tangent and the PCm-Ls line was the nasotabial angle.
This angle is the sum of the angles N/FH and L/FH or is
the complement of the triangle formed by these two lines with
the Frankfort horizontal plane.
Fifteen cephalometric radiographs were selected by the
primary examiner from a sample of over 200 radiographs to
demonstrate various configurations of nose-lip profiles. These
various configurations included protrusive lips, recessed lips,
up- and down-turned noses, and combinations of these to
evaluate the reproducibility of this method on the different
cases a practitioner might experience. Each radiograph was
traced, and exact duplicates were made of each tracing. This
was done for all 15 subjects. Ten copies of each tracing (a
total of 150) were randomly distributed to each of four ortho-
dontists who were to draw the angles according to the written
instructions provided to them. From each of the 10 copies, a
mean and a standard deviation for the N/FH angle, the
L/FH angle, and the nasolabial angle were derived.
The coefficients of reliability (r) are representative. It was
found that the r value for the L/FH angle was 0.84, which
was the smallest coefficient of reliability. The N/FH angle
had a coefficient of reliability of 0.98, and the nasolabial
angle had the largest coefficient of reliability of 0.99. It was
concluded from this statistical analysis that the construction
of the three nasolabial parameters is consistent and repro-
ducible.
The mean standard deviation as determined from the stan-
dard deviation produced by the four examiners for each angle
over the entire sample of 15 subjects and their replicates was
also calculated to provide a comparison of the reproducibility
among each of the three nasolabial parameters.
Error of method. To estimate the error of tracing, the
Vo/ume 102 Evaluation of nasolabial angle 331
Number4

location of landmarks and measurements, and thus the in- Table I. The mean, standard deviation, and
herent deviation within the study, all the 104 cephalomctric range for all o f the angular measurements in
radiographs were retraced at random by the primary examiners degrees based on a sample o f 104 normal,
and redigitized after a 7-day period. The means and standard white young adults
errors were calculated for the differences between the two
recordings. The mean error averaged less than 1.0~ for the Variable I Mean and SD I Range
entire sample. For purposes of this study, the average of the
Facial angle 87.85 ~ - 1.71 ~ 8 0 . 8 9 ~ to 8 9 . 9 8 ~
first and second measurements was used.
Angle of convexity 0.65 ~ _ 5.30 ~ - 7 . 4 0 ~ to + 8 . 1 3 ~
Statistical analysis. The measurements recorded from the ANB 2.18 ~ • 1.97 ~ - 2 . 5 7 ~ to + 5 . 9 7 ~
sample of 104 cephalometrie radiographs were tabulated. The SGn/FH 5 7 . 5 2 ~ .4- 3 . 3 2 * 4 7 . 7 9 ~ to 6 5 . 7 9 ~
mean and standard deviation were calculated for each mea- SGn/SN 66.32 ~ • 4.14 ~ 5 6 . 7 4 ~ to 7 5 . 3 2 ~
surement to establish normative data. FMA 20.54 ~ • 5.59 ~ 1 0 . 5 3 ~ to 3 1 . 8 3 ~
To determine if the nasolabial parameters had a linear N/FH 17.76~ • 7.40 ~ 0 . 4 5 " to 3 2 . 3 0 ~
correlation with the skeletal measurements in this sample, L/FH 9 7 . 8 5 ~ --- 5 . 2 6 ~ 9 0 . 0 6 ~ to 1 1 7 . 6 8 ~
pair-wise correlation coefficients were calculated from a linear Nasolabial angle 114.08 ~ • 9.58 ~ 9 1 . 4 0 ~ to 1 3 8 . 9 7 ~

regression analysis between the six skeletal measurements and

the three nasolabial parameters. Any linear correlation would
reveal a possible cause-and-effect relationship between these
parameters.
The three nasolabial parameters were also compared with
each other in a similar manner to determine the extent of
linear correlation within the three nasolabial parameters.
To determine if a linear correlation existed between the
nasolabial parameters and a grouping of the skeletal mea-
surements for each of the three nasolabial parameters, a back-
ward multiple step linear regression analysis was performed
with the seven skeletal measurements.
RESULTS
The largest standard deviation for any individual
orthodontist within any case was • 2.85 ~ and that was
for the L / F H angle by orthodontist C. The smallest
standard deviation for any individual orthodontist was
• ~ for the L / F H angle by the same person.
To assess the reproducibility o f constructing the na-
solabial parameters among orthodontists, coefficients
of reliability (r) were calculated on the individual mea-
surements for each angle, (15 persons with I0 replicates
each evaluated by four orthodontists for a total 600
measurements for each angle, or 1800 for all three
angles).
The nasolabial angle had the largest average stan-
dard deviation with +_ 1.07 ~ and the L / F H angle the
smallest at ___0.78~ The N / F H angle had a slightly
higher average standard deviation o f • ~. Each of
the nasolabial parameters is reProducible as the greatest
difference between the average standard deviations was
less than 0.25 ~.
The normative data o f 104 normal, white young
adults is presented in Table I. The mean value o f the
nasolabial angle was 114.08 ~ • 9.58 ~ with men at
113.55 ~ --- 9.44 ~ and women at 116.19 ~ This differ-
ence was found to be statistically insignificant.
The N / F H angle had a mean value of 17.76 ~ and
a standard deviation o f _+ 7.40 ~ The men had a mean
value o f 17.54 ~ -+ 7.28 ~ and the women 18.61 ~ •
7.96 ~ with no statistically significant difference between
them.
The mean value o f the L / F H angle was found to
be 97.85 ~ • 5.26~ The men demonstrated a mean
value o f 97.73* - 5.11 ~ and the women 98.33 ~ _
5.91 ~ with the difference being statistically insignif-
icant.
Separation o f the data between men and women
revealed no significant statistical difference, so the data
were pooled. The Pearson coefficients o f correlation
and p values for the correlations between the soft tissue
and skeletal measures and the three nasolabial param-
eters are presented in Table II. The coefficients of cor-
relation demonstrate that no significant relationship ex-
isted between any o f the skeletal parameters and any
o f the three soft tissue measurements o f the nasolabial
region.
A linear regression analysis and determination o f
Pearson coefficients o f correlation (r) were used to eval-
uate any possible dependent relationships that might
exist between the skeletal measurements and the na-
solabial parameters. The nasolabial parameters were
a l s o compared with each other to determine the extent
of linear correlation within the nasolabial parameters.
As expected, both the N / F H and the L / F H angles
had identical and significant p values when compared
with the nasolabial angle. The N / F H angle and the
nasolabial angle had a significant correlation value o f
0.68. The L / F H angle had a smaller, but still significant
correlation value o f 0.59. There was no significant cor-
relation between the N / F H and the L / F H angles.
A backward multiple step linear regression analysis
revealed no significant correlation between the naso-
labial parameters and any group o f the skeletal mea-
Surements. This analysis linearly compared each na-
solabial parameter with the six skeletal measurements
as a group. Each skeletal measurements was sequen-
tially removed from the comparison until the compar-
332 _. o ._r;tzoeraldN, a n d a , a n d C u r r i e r Am.J. Orthod. Dentofac. Orthop.
October 1992

Table II. Pearson coefficients of correlation, as determined from a linear regression analysis for the three
nasolabial parameters when compared with skeletal parameters
NIFH LIFH Nasolabial angle

r [ p vahte p value r [ p value

I I
Facial angle 0.032 0.745 0.034 0.730 0.009 0.927
Angle of convexity 0.463 0.641 0. I 12 0.260 0.246 0.115
ANB 0.116 0.240 0.022 0.825 0.070 0.482
SGn/FH 0.202 0.040 0.172 0.080 0.042 0.672
SGn/SN 0.036 0.720 0.194 0.049 0.122 0.218
FMA 0.087 0.378 0.085 0.391 0.010 0.921
N/FH 1.000 0.000" 0.013 0.893 0.685 0.000"
L/FH 0.013 0.893 1.000 0.000" 0.594 0.000"
Nasolabial angle 0.685 0.000" 0.594 0.000" 1.000 0.000"

*p < 0.01.

ison was complete. There was no correlation between
the nasolabial parameters and any grouping of the skel-
etal measurements.
DISCUSSION
The evaluation of the soft tissue profile is vital
in the diagnosis and the treatment planning of the
orthodontic patient. Soft tissue changes have been
shown to accompany growth, as well as orthodontic
treatment. 2~'37 Although the soft tissue changes with
orthodontic treatment are variable, the direct effect of
orthodontic treatment on the soft tissue profile is usually
apparent. Even more dramatic are the changes in the
soft tissue profile that may be induced by orthognathic
or plastic surgery. It is for these reasons that the soft
tissue profile must be carefully examined before a de-
cision regarding orthodontic treatment and/or orthog-
nathie surgery can be made.
Review of the nasolabial soft tissue is important
when contemplating orthodontic treatment. Movement
of the maxillary incisors in any of the three planes of
space influences this area. 3~ However, consistent and
reproducible methods of evaluating the nasolabial re-
gion are lacking.
The nasolabial angle is formed by two lines, one
from the nose, another from the upper lip, .and both
independent of each other. The angular measurement
described by these two lines is a resultant of their in-
dividual inclinations. The nasolabial angle of a person
may be within normal range, small, or large. The mea-
surement of this angle alone provides inadequate in-
formation as it does not reveal which component is
responsible for the variability. It could be the nose, the
lip, or both. Therefore it is important to analyze each
component of this angle to assist in the diffe~'ential
diagnosis of normal from its variation. This study was
planned not only to suggest consistent and reproducible
criteria in drawing this angle on a lateral cephalometric
radiograph, but also to evaluate and to develop standards
for the inclination of the nose and the upper lip.
The proposed method of locating the posterior col-
umella point onto which a tangent was drawn to the
lower border of the nose, as well as the line from this
point to labrale superius, proved to be a reliable tech-
nique for constructing the nasolabial angle. The pos-
teroinferior angle formed by the intersection of the
Frankfort horizontal plane with the line drawn tangent
to the lower border of the nose provided a representative
inclination of the nose. The anteroinferior angle formed
by the intersection of the Frankfort horizontal plane
with the line drawn from the posterior columella point
tangent to labrale superius provided a representative
inclination of the upper lip.
The error of measurement was minimal and typical
of measurement error for other cephalometric radio-
graphic parameters. When the individual measurements
of the three nasolabial parameters, as recorded by four
orthodontists, were statistically evaluated by a single
factor repeated measure analysis of variance, a very
high coefficient of reliability was revealed for the
N/FH angle, the L/FH angle, and the nasolabial angle.
This indicated that any orthodontist who was randomly
chosen could evaluate the nasolabial region using this
method, with a high degree of reliability.
The reproducibility among the three nasolabial pa-
rameters was also examined. This was accomplished
by calculating a mean standard deviation of the indi-
vidual measurements produced by the four examiners
for each of the three angles throughout the sample. The
greatest difference between the average standard de-
viations for the three angles was less than 0.25 ~. This
suggested that all of the three nasolabial parameters
were equally reproducible.
The mean value of'the nasolabial angle in this sam-
Volume 102
Number 4
pie was similar to the one reported for female subjects
by Nanda et al. 39 They reported that the nasolabial angle
decreased slightly from 7 to 18 years o f age in both
sexes with the mean at 7 years at 107.8 ~ ___ 9.4 ~ for
boys and 114.7 ~ • 9.5 ~ for girls. At 18 years, their
means were 105.8 ~ • 9.0 ~ for men and 110.7 ~ •
10.9 ~ for women. These growth changes were small
considering the large standard deviation. The nasolabial
angle proposed by Owen 7 had a slightly smaller normal
value o f 105 ~ • 8 ~ as compared with the results o f
this study. This may be due to the different locations
o f the vertices o f the two nasolabial angles. Their ver-
tex, subnasale, was constructed by bisecting tangents
to both the columella o f the nose and the upper lip.
This placed the vertex considerably posterior to the
posterior columella point.
The upper L / F H angle had the lowest variability of
the three angles measured. The mean value for this
angle was similar to the nasolabial angle described by
Hunt and Rudge. 6 Their angle was formed by the in-
tersection o f the Frankfort horizontal plane and a line
drawn tangent to the upper lip passing through sub-
nasale with a normal approximating 90 ~ The difference
between the normal values may be explained again by
the more posterior location o f subnasale as compared
with the posterior columella point.
Controversy about the soft tissues of the facial in-
tegument being independent in their thickness and size
from underlying facial skeleton is evident from review
o f the literature. '5'2s'38 The concept o f independence of
relationships between soft tissue structures from the
skeletal relationships in the well-balanced face is sup-
ported here. If the thickness o f the soft tissue drape is
independent from its underlying skeletal relationships,
greater emphasis needs to be placed on its evaluation
in formulating treatment plans for dentofacial dishar-
monies.
SUMMARY AND CONCLUSIONS
A method o f constructing the nasolabial angle was
developed that provides a method o f determining the
relative angulations o f the nose and the upper lip, as
well as their relationship to each other. Statistical anal~-
ysis o f measurements for the nasolabial parameters pro-
duced by four orthodontists using this technique re-
vealed that this method o f evaluating the nasolabial
region is consistent and reproducible.
The correlation between the soft tissue profile and
the six facial skeletal relationships were evaluated. The
six skeletal measurements were the facial angle, angle
of convexity, A N B , S G n / F H , S G n / S N , and F M A .
Correlation coefficients derived from a linear regression
analysis revealed no positive correlation between the
Evaluation of nasolabial angle 333
soft tissue measures and the skeletal measurements in
the well-balanced profile.
The findings o f this investigation o f the nasolabial
region reveal the following conclusions:
1. A reliable method o f constructing the nasolabial
angle has been devised that includes angulations
o f the lower border o f the nose and the upper
lip. These measurements were consistent and
reproducible within and among the orthodontists
studied.
2. The mean and standard deviation, from a sample
of 104 young white adults, for the three naso-
labial parameters were 18 ~ ___ 7 ~ for the N / F H
angle, 9 8 ~ ~ for the L / F H angle, and
114 ~ • 10 ~ for the nasolabial angle.
There was no statistically significant difference
between men and women.
3. No correlation was demonstrated between these
soft tissue profile measurements o f the nasolabial
region and the six skeletal relationships exam-
ined in this sample o f well-balanced faces.
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Reprint requests to:
Dr Jay P. Fitzgerald
Department of Orthodontics
University of Oklahoma
College of Dentistry
P.O. Box 26901
1001 Stanton L. Young Blvd.
Oklahoma City, OK 73190

AAO MEETING CALENDAR

1993--Toronto, Canada, May 15 to 19, Metropolitan Toronto Convention Center
1994--Orlando, Fla., May 1 to 4, Orange County Convention and Civic Center
1995--San Francisco, Calif., May 7 to 10, Moscone Convention Center
(International Orthodontic Congress)
1996--Denver, Colo., May 12 to 16, Colorado Convention Center
1997--Philadelphia, Pa., May 3 to 7, Philadelphia Convention Center
1998--Dallas, Texas, May 16,to 20, Dallas Convention Center
1999--San Diego, Calif., May 15 to 19, San Diego Convention Center