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Reviewed July 13, 2026
What is ricketts e-line?
The Ricketts E-line, also known as the esthetic line in orthodontic literature, is the most cited soft-tissue profile reference in orthognathic surgery. It runs from the tip of the nose (pronasale) to the chin (soft-tissue pogonion). Both lips should sit slightly behind this line, with the upper lip further behind than the lower.
How It's Measured
How is the Ricketts E-line measured?
The Ricketts E-line is a straight reference plane drawn between two soft-tissue landmarks on the side profile (Naini, 2022). Once the plane is set, the lips are measured as signed perpendicular distances from it:
Pronasale (Prn): the most projecting point of the nasal tip in profile.
Pogonion (Pog'): the most projecting point of the soft-tissue chin.
Labrale superius (Ls): the upper-vermilion midline point. Its distance from the E-line is the upper-lip value.
Labrale inferius (Li): the lower-vermilion midline point. Its distance from the E-line is the lower-lip value.
Negative values mean the lip sits behind the line. Positive values mean the lip protrudes past it. Almost every published norm puts both lips slightly negative.
Ricketts' E-line drawn from pronasale to soft-tissue pogonion. The annotation traces the perpendicular distance from the upper lip (labrale superius) to the line, which on this subject reads -2 mm. A negative value means the lip sits slightly behind the E-line, which is what most published norms describe as ideal.
Why It Matters
Why does the Ricketts E-line matter?
The Ricketts E-line is the single most-used profile reference in clinical orthodontics. Orthodontists, oral surgeons, and rhinoplasty planners default to it because both anchor points (nose tip and chin) are easy to identify on a lateral cephalogram and a clinical photograph, and the lip positions read off it map directly to incisor angulation and dentoalveolar protrusion (Naini, 2022). Treatment plans that retract or advance the maxillary incisors are routinely tracked by how the upper lip moves relative to the esthetic line.
The clinical interpretation is straightforward but tightly demographic. In white Caucasian samples the canonical norms are -4 to -6 mm for the upper lip and -2 to -4 mm for the lower lip (Naini, 2022). Lips that sit forward of those bands are called bimaxillary protrusive; lips that sit further back are retrusive. Both states drive different surgical decisions: premolar extraction with incisor retraction for protrusion, bimaxillary advancement or genioplasty for retrusion.
The E-line is highly sensitive to its endpoints. A small change in nasal tip projection or chin advancement shifts the entire reference plane, which in turn shifts how every lip number reads. That sensitivity is also the reason the E-line is not a free-standing aesthetic ideal. It works as a clinical compass for incisor planning, not a universal beauty rule. Studies on lip aesthetics in non-Caucasian populations consistently show more anterior lip positions without those patients being judged less attractive (Sci Rep, 2023).
-4 mm to -6 mm
Upper lip (Ls)
-2 mm to -4 mm
Lower lip (Li)
-4 mm to -2 mm
Typical Range
Fig 2. These values are the white-Caucasian reference set published by Ricketts and reproduced across orthodontic textbooks. Norms shift with demographic background.
Demographic Variants
Ideal Ricketts E-line values by demographic
Ricketts E-line norms shift meaningfully with population. Upper-lip and lower-lip distances both run more anterior in African and East Asian samples than in the original Caucasian reference set. Each row links to the published normative paper for that group.
Demographic | Upper-lip distance to E-line | Lower-lip distance to E-line | Source |
|---|---|---|---|
White Caucasian adults | -4 mm to -6 mm | -2 mm to -4 mm | |
African / African American adults | More anterior than the Caucasian norm | More anterior than the Caucasian norm | |
East Asian adults | Closer to the line, sometimes positive | Closer to the line, sometimes positive |
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Your Questions
Frequently asked questions
The Ricketts E-line (esthetic line) is a soft-tissue reference plane drawn from the tip of the nose (pronasale) to the most projecting point of the chin (soft-tissue pogonion). It was introduced by orthodontist Robert M. Ricketts in 1968 and became the standard cephalometric reference for assessing lip position in side profile (Naini, 2022).
The Ricketts E-line is drawn between pronasale and soft-tissue pogonion on a lateral photograph or cephalogram taken in natural head position. The signed perpendicular distance from labrale superius (upper lip) and labrale inferius (lower lip) to that line is then recorded in millimetres. Negative numbers indicate the lip sits behind the line; positive numbers indicate protrusion past it (Naini, 2022).
In white Caucasian adult samples the canonical Ricketts E-line norms are -4 to -6 mm for the upper lip and -2 to -4 mm for the lower lip behind the line (Naini, 2022). Children sit closer to the line at age 10 and gradually retreat behind it as the nose and chin continue to grow into adulthood.
Yes, and the difference is substantial. African and East Asian populations consistently show more anterior lip positions relative to the Ricketts E-line than the Caucasian reference set, without that being read as unattractive in their own populations. Cross-cultural studies on lip aesthetics confirm that a single universal E-line target is not clinically appropriate (Heidekrueger et al., 2017).
Yes. Premolar extraction with incisor retraction is the standard orthodontic approach to reduce bimaxillary protrusion and pull the upper lip back toward the Ricketts E-line. Bimaxillary advancement or genioplasty is the orthognathic option for severe lip retrusion or chin deficiency. Lip position relative to the esthetic line is one of the primary outcome measures tracked in both treatment plans (Naini, 2022).