RESEARCH AND EDUCATION

Selecting maxillary anterior tooth width by measuring certain

facial dimensions in the Kurdish population
Neda AL-Kaisy, BDS, MSc, PhDa and Balkees Taha Garib, BDS, MSc, PhDb

To achieve a successful com- ABSTRACT

plete denture esthetic restora- Statement of problem. One of the most difficult aspects of complete denture fabrication is
tion, the hard and soft orofacial selecting appropriately sized maxillary anterior teeth that will harmonize with the face. There are no
components should be evalu- generally accepted or naturally observed principles to guide dentists in this selection.
ated together.1 The position of
Purpose. The purpose of this study was to determine whether a relationship exists between various
the lips and the smile index are facial measurements and the different single or combined mesiodistal widths of maxillary anterior
considered important compo- teeth in a Kurdish population.
nents in determining the pros-
Material and methods. A total of 65 Kurdish dental students participated in this study. Two
thodontic outcome.2 The
standardized digital photographs of the face (relaxed and smiling capture) were recorded. The
amount of anterior tooth sur- interpupillary distance (IPD), inner canthal distance (ICD), interalar distance (IAD), and width of the 2
faces visible with the lips at central incisors were determined by Image J software. The mesiodistal width and the combined
rest2 or with increased occlusal straight-line width of the centrals, laterals, and canines were measured directly from the casts of the
vertical dimension3 has been participants with digital calipers. A simple linear regression and the Pearson correlation coefficient
investigated to improve the were used to investigate the relationship between the particular facial measurement and the widths
facial esthetics of patients with of the anterior teeth (a=.05).
complete dentures. However, Results. Significant correlations existed between the IPD and different tooth measurements; the
selecting the appropriate size of highest was with the mean width of the canines (r=0.55). The proposed proportion between the IPD
maxillary anterior teeth re- and the central incisor width was 6.93. The golden proportion of the ICD to the width of the central
incisors and of the IAD to the straight-line width of the 6 anterior teeth could be used as a
mains the most difficult step in
dependent parameter in Kurdish men.
complete denture fabrication,
especially in the absence of Conclusions. The IPD can be used to predict the width of anterior teeth in both sexes. In men, the
preextraction records.4 width of the central incisors may be estimated from the ICD and the straight-line width of the 6
anterior teeth from the IAD. (J Prosthet Dent 2016;115:329-334)
The maxillary central in-
cisors hold a prominent posi-
tion in the smile, and it has been suggested that each of the To achieve a good esthetic result for patients with
anterior teeth portrays a different aspect of a person.5,6 The complete dentures, the size of the maxillary anterior teeth
central incisors may reflect a patient’s age, the lateral in- should be in proportion to facial measurements. Various
cisors may coincide with a patient’s sex, and canines may attempts have been made to guide the appropriate se-
display patient vigor.6 Furthermore, the width of the lection of the size of maxillary anterior teeth in edentu-
anterior teeth is considered to be more critical than lous patients.10 Researchers have used more than
the length because they are the most prominent teeth in one facial measurement to predict the maxillary anterior
the arch when viewed from the front.7 Age has not been tooth width. These include the interpupillary width,
shown to be significant with respect to mean mesiodistal interalar width, inner canthal distance (ICD), and
incisor width.8,9 intercommissural width.4,11-13
a
Lecturer, Department of Prosthodontic, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani, Sulaimani, Kurdistan Region, Iraq.
b
Professor and Chairman, Department of Oral Pathology, School of Dentistry, Faculty of Medical Sciences, University of Sulaimani, Sulaimani,
Kurdistan Region, Iraq.

THE JOURNAL OF PROSTHETIC DENTISTRY 329

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Clinical Implications
Certain horizontal facial parameters could be used
to select maxillary anterior teeth during oral
rehabilitation. This selection approximately matches
the natural individual tooth dimensions.
The interpupillary distance (IPD) remains constant
throughout life,14 and the mean mesiodistal incisor width
showed no significant changes with age.8,9 Therefore,
proportions between it and the width of the maxillary
anterior teeth should remain constant. The proportional
relationship between the IPD and maxillary anterior
tooth widths has been shown to differ according to race
and sex.13,14 Some researchers found a positive correla-
tion between the IPD and both the straight canine tip
distance (r=0.426)15 and mesiodistal width of maxillary
central incisors (r=0.468).16 Others did not consider the
IPD to be a reliable predictor for selecting maxillary
anterior tooth widths for edentulous patients.17
The interalar distance (IAD), however, has been
shown to be equal to the straight distance between the
tips of the canines and varies with sex and ethnic
group.4,18 Scandrett et al19 suggested that extending
parallel lines from the lateral surfaces of the ala of the
nose onto the labial surface of the maxillary occlusion rim
to estimate the intercanine cusp tip. Others used distal
surface intercanine distance rather than canine tip dis-
tance to evaluate the position of canines and correlate it
with the IAD.15,20 Hoffman et al4 suggested that multi-
plying the interalar width by a factor of 1.31 can help in
estimating the combined width of the maxillary 6 anterior
teeth, while Abdullah et al21 found this factor was equal
to 1.26. However, Qmamar et al22 found the interalar
width is not a reliable tool for selecting the width of
maxillary anterior teeth.
The use of the ICD has also been considered in
determining the width of the maxillary anterior teeth for
edentulous patients.23,24 The maturity of this parameter
is reached between 8 and 11 years,25 and the normal
dimension ranges between 28 and 35 mm, with no dif-
ferences related to sex,26 race,27 or age.21 Therefore, the
ICD is considered a reliable anatomic dimension that
may provide a valid approach to anterior tooth selection.
Moreover, the golden proportion concept was used in
relation to the ICD measurements after using the formula
[(ICD×0.618)/2] to predict the width of the central in-
cisors.12,21 The rule of golden proportion in its original
form was not recommended for treatment planning
without observing individual modifying factors like the
ethnicity and race of the population.28
The purpose of this study was to determine a rela-
tionship between 3 facial measurements (ICD, IPD, and
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 115 Issue 3
Figure 1. Standardization of participant for photography with extraoral
measurements.
IAD) and the width of maxillary anterior teeth (single and
combined width) in a sample from a Kurdish population.
MATERIAL AND METHODS
A total of 65 adult Kurdish participants (38 men and 27
women, aged 21 to 32 years) participated in this study.
They were predoctoral students of Sulaimani School of
Dentistry. All were required to have permanent, well-
aligned, natural maxillary anterior teeth with no attri-
tion. Students were excluded if they had a history of
orthodontic treatment, asymmetry of the face, anterior
spacing, overlap, anterior restorations, or a fixed anterior
dental prosthesis. Informed consent was obtained from
each participant before participation. This study was
approved by the Medical Ethics Committee, Faculty of
Dentistry, University of Sulaimani.
Two standardized full-face digital photographs of the
participants viewed from the front were recorded. The
participant was seated upright and looked straight
ahead. One image was in the relaxed rest position, and
the image had the subject smiling to reveal the maxillary
anterior teeth, allowing the measurement of the com-
bined width of the central incisors. The participant’s
head was supported by the chin rest of a panoramic
radiograph machine (Proline 2002 CC; Planmaca). The
distance between the tip of the nose and the lens of the
camera (Lumix DMC-FS20; Panasonic) was fixed at 100
cm to ensure distortion-free images. Two steel metric
rulers held perpendicular to each other were used as
frames bordering the face for calibration of the
measurements.29
ImageJ software (Image Processing and Analysis in
Java; US National Institutes of Health)30 was used to
AL-Kaisy and Garib
March 2016 331

70
Total
Men
60 Women

50

Dimensions (mm)
*
40

30

20

10

0
IPD IAD ICD
Facial Measurements
Figure 3. Mean and standard deviation values of IPD (interpupillary
distance), IAD (interalar distance), and ICD (inner canthal distance) in
total sample and according to sex. *Significantly different at P<.05, in-
Figure 2. Straight-line dimensions on cast. dependent t test, men versus women.

determine the IPD, ICD, IAD, and the combined

A scatter plot of the data was drawn to find the relation
mesiodistal width of 2 centrals (Ph2A). The calibrating
between each facial and tooth variable. The resultant
scale of the software was adjusted to the metric ruler in
slope was delineated, and the simple linear regression
the photograph (Fig. 1).
equation (y=B0+B1x) was estimated. x represented the
An impression of the maxillary arch for each partici-
facial measurement as an independent variable. Each
pant was made with alginate impression material
anterior tooth measurement was identified as a depen-
(Hydrogum; Zhermack), and casts were poured in Type
dent variable (y). The constant (B0) and regression coef-
IV dental stone (Elite stone; Zhermack). A digital caliper
ficient (B1) values were calculated and used to construct
read to the nearest 0.01 mm was used to record the
the equation. The r and r2 values, the ANOVA test, and
maximum mesiodistal widths of the individual maxillary
the linear regression test (s-stat test) specified the cor-
anterior teeth. These records included the right and left
relation significance. The precision of prediction for each
central incisors (C1 and C2), right and left lateral incisors
single observation was evaluated by fitting the simple
(L1 and L2), and right and left canines (Ca1 and Ca2). In
linear regression model to all but one of the sample
addition, the straight-line width of the distal surfaces of
observations. This procedure was repeated for all obser-
the central incisors (2A), the lateral incisors (4A), and the
vations in the sample.
canines (6A) were measured directly from the casts
The predicted width of the central incisors was also
(Fig. 2). Each parameter was measured and recorded 3
estimated from the ICD measurement by following the
times by 1 operator (N.M.J.), and the average value was
concept of the golden proportion.12,21 A t test was applied
calculated.
to compare the differences between the predicted and real
The data were analyzed with statistical software (SPSS
measured values and between the IAD and the straight-
for Windows v.16; SPSS Inc). The descriptive statistical
line width of the distal surfaces of the canines (6A) (a=.05).
(mean, SD) values of the variables were measured for each
parameter in the total sample and both sexes. An inde-
RESULTS
pendent t test was used to ascertain the significance of
differences in the mean of the measured parameters be- The facial measurements of the young Kurdish partici-
tween the sexes and the mesiodistal width of individual pants were characterized by 58.59 ±3.8 mm for IPD, 35.9
anterior teeth on the left and right side. The differences in ±2.5 mm for IAD, and 28.58 ±2.8 mm for ICD. Women
the ratio of the IPD to the mean width of the central in- had a significantly smaller IAD than men (34.63 mm
cisors (Mean1) was tested after exploring the normality of versus 37.17 mm, P=.013) (Fig. 3). In the total sample, the
the distribution of ratios. ratio between the facial measurements indicated that
A simple linear regression and its corresponding the IPD was equal to 1.64 ±0.1 of the IAD and 2.06 ±0.15
correlation coefficient (Pearson correlation, r) were used of the ICD, while the ratio of the IAD to ICD was 1.26:1.
to investigate the relationship between the widths of The width between identical anterior teeth on the
individual anterior teeth and each facial measurement. right and left sides showed no statistical significance

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332 Volume 115 Issue 3

Table 1. Mean and SD values of width of right and left anterior teeth Table 2. Width dimension of anterior teeth from cast and photograph
by sex Total Female Male
Total Female Male Characteristic Mean SD Mean SD Mean SD t Test P
Variable Mean SD P Mean SD Mean SD t Test P Ph2A 16.48 0.77 16.38 0.75 16.58 0.80 -0.627 .537
C1 8.48 0.51 .769 8.30 0.53 8.65 0.44 -1.74 .096 Sum2 16.61 0.89 16.36 0.94 16.86 0.81 -1.362 .187
C2 8.44 0.429 8.33 0.44 8.55 0.39 -1.28 .214 Sum4 28.28 1.67 28.12 1.60 28.42 1.80 -0.440 .664
Mean1 8.46 0.468 8.32 0.46 8.60 0.40 -1.60 .122 Sum6 44.53 2.48 43.87 2.47 45.18 2.41 -1.317 .201
L1 6.38 0.49 .889 6.33 0.58 6.47 0.53 -0.59 .561 2A 16.92 0.90 16.64 0.92 17.21 0.81 -1.596 .125
L2 6.40 0.55 6.37 0.49 6.39 0.51 -0.06 .946 4A 29.72 1.70 29.36 1.85 30.08 1.53 -1.032 .313
Mean2 6.39 0.51 6.36 0.53 6.43 0.48 -0.34 .733 6A 37.39 2.36 37.10 2.42 37.66 2.37 -0.570 .574
Ca1 7.4 0.475 .978 7.25 0.35 7.54 0.53 -1.55 .134 Ph2A, combined mesiodistal width of 2 centrals on photograph; Sum2, summation of 2 central
Ca2 7.4 0.470 7.25 0.42 7.55 0.48 -1.65 .113 incisors width; Sum4, summation of 4 incisors width; Sum6, summation of 6 anterior teeth
width; 2A, straight-line width of distal surfaces of central incisors; 4A, straight-line width of
Mean3 7.4 0.467 7.25 0.38 7.55 0.50 -1.62 .118
distal surfaces of lateral incisors; 6A, straight-line width of distal surfaces of canines.
C1, width of right central incisor; C2, width of left central incisor; L1, width of right lateral
incisor; L2, width of left lateral incisor; Ca1, width of right canine; Ca2, width of left
canine; Mean1, mean width of right and left central incisors; Mean2, mean width of right and
left lateral incisors; Mean3, mean width of right and left canines; statistical difference at 2]12,21 can be used to estimate the width of central in-
P<.05.
cisors, particularly in men. Caution should be taken in
female patients (Table 5).
Finally, this study showed that the IAD should not be
(for centrals P=.796, laterals P=.889, and canines P=.978).
used as a dependent parameter to estimate the width of
Thus, the mean width of each tooth set was considered to
6A in the total studied sample. Nevertheless, it can be
be the final representative value. The participants had a
used to estimate the width of 6A in men (Table 6).
mean central incisor width of 8.46 ±0.46 mm, mean
lateral incisor width of 6.39 ±0.51 mm, and mean canine
DISCUSSION
width of 7.4 ±0.46 mm, with no significant sex differences
(Table 1). The selection of the appropriate size of anterior teeth for
The mean and SD of tooth measurement on the cast edentulous patients is a difficult procedure, especially in
(summation and straight-line dimensions) and the digital the absence of preextraction records such as casts, pho-
photograph are shown in Table 2. Different measured tographs, or extracted teeth. Currently there is no uni-
values for the central incisors were recorded as follows: versal agreement on an accurate method of determining
the mean value for the summation of 2 central incisors this selection.
width (Sum2) was 16.61 ±0.89. The width of the distal The sample was selected from 1 ethnic group (Kurdish)
surfaces of the centrals (2A) was 16.92 ±0.9. The com- to verify the proper anterior teeth measurements related to
bined width of the central incisors measured on this population because these measurements vary with the
the digital photograph (Ph2A) was 16.48 ±0.77. No sig- ethnicity of studied populations.13,14 Differences in sample
nificant differences were found among these tooth size and measuring techniques should be considered when
measurements (f=1.71, P=.192). All summation and the findings are compared with previous studies.
straight-line dimensions of tooth measurement showed All participants had well-aligned, permanent, fully
no sex differences (Table 2). erupted maxillary anterior teeth. In accordance with
The Pearson correlation coefficient between the facial previous studies,3,8,15-18,20,29 young participants (aged 21
and different tooth measurements showed that the mean to 32 years) were selected so that the measurements of
central (Mean1), mean canine (Mean3), 2A, summation the anterior tooth widths would made after full muscu-
of 6 anterior teeth width (Sum6), and 6A were only loskeletal development.8,9 Anyone with a tooth-
significantly correlated with the IPD. The highest corre- distorting condition (orthodontic treatment, asymmetry
lation value was reported with Mean3 (r=0.55). The of the face, anterior spacing, overlap, anterior restora-
simple linear regression fit model was performed on the tions, or a fixed anterior dental prosthesis) was excluded.
significant results (with IPD). The other weak correlations In agreement with several studies in different pop-
(with IAD and ICD) were neglected. Accordingly, the ulations, no difference was found in the width mea-
equations were calculated, and the real and the expected surement of identical teeth on the right and left sides.23,28
values showed no significant differences (Table 3). The mean width of the central incisors (8.46 mm) was
The proposed proportion between the IPD and cen- similar to that reported by Scandrett et al19 (8.50 mm)
tral incisor width in the Kurdish population anticipated and less than that registered by Abdullah12 (8.77 mm)
by other researchers14,19 was found to equal 6.93 ±0.45, and Woodhead26 (9.00 mm).
with no significant sex variations (Table 4). Furthermore, sexual dimorphism did not exist in the
The golden proportion concept, which uses the ICD tested sample for all measured tooth variables and the
to predict the width of the central incisor [(ICD×0.618)/ 2 facial dimensions (IPD and ICD). This result is in

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March 2016 333

Table 3. Significant correlation coefficient (r) and estimated fitted simple linear regression between facial (IPD) and teeth measurement
(cast and photograph)
IPD 95% Confidence Interval Real Value Expected Value
Characteristic r SLR t Test P Lower Bound Upper Bound Mean SD Mean SD t Test P
Mean1 0.427 y=0.0499x+5.5403 2.217 .037 0.003 0.097 8.46 0.45 8.456 0.216 0.092 .927
Mean3 0.550 y=0.0665x+3.504 3.077 .006 0.022 0.111 7.40 0.47 8.813 7.01 -0.983 .336
2A 0.426 y=0.0915x+11.254 2.207 .038 0.006 0.194 16.61 0.90 16.879 0.455 0.237 .814
Sum6 0.469 y=0.3031x+26.767 2.490 .021 0.051 0.556 44.53 2.49 44.478 1.282 0.087 .931
6A 0.406 y=0.2492x+22.783 2.080 .049 0.001 0.498 37.39 2.36 37.352 1.083 0.062 .951

IPD, interpupillary distance; Mean1, mean width of right and left central incisors; Mean3, mean width of right and left canine; 2A, mean width of right and left canines; 2A, straight-line width of
distal surfaces of central incisors; Sum6, summation of 6 anterior teeth widths; 6A, straight-line width of distal surfaces of canines; SLR, simple linear regression (y, dependent variable; x, in-
dependent variable).

Table 4. Ratios of IPD to mean central incisor width by sex Table 5. Predicted width of maxillary central incisor from ICD by
Ratio IPD/Mean1 applying golden proportion concept [(ICD×0.618)/2] in relation to sex
Sex Mean SD t Test P Predicted Value Real Value
Female 6.92 0.37 -0.116 .922 Sex Mean SD Mean SD t Test P
Male 6.94 0.53 Female 8.97 0.51 8.32 0.46 -3.25 .004*
Total 6.93 0.45 Male 8.69 1.13 8.64 0.40 0.14 .807
Total 8.83 0.87 8.46 0.45 1.83 .073
IPD, interpupillary distance.
ICD, inner canthal distance.
*Significantly different at P<.05, independent t test, men versus women.

agreement with some previous studies24,28 but in contrast

with others in which significant differences were found in Table 6. Comparison of interalar distance and straight-line distance
the majority of measurements between the sexes.12,23 between distal contacts of canines
Nevertheless, Kurdish men had a significantly wider IAD 6A
IAD than women. Sex Mean SD Mean SD t Test P
Of the 3 measured facial dimensions, only the IPD Female 34.63 2.01 37.10 2.42 -2.72 .012*
showed significant correlations with 5 anterior tooth Male 37.17 2.28 37.66 2.57 -0.51 .621
measurements. The predicted values did not significantly Total 35.90 2.52 37.38 2.36 -2.01 .041*
differ from the real measurements. Thus, applying these IAD, interalar distance; 6A, straight-line width of distal surfaces of canines.
regression equations using the IPD will be valuable in *Significantly different at P<.05, independent t test, men versus women.

predicting the width of the artificial anterior teeth of

complete dentures for the Kurdish population. However,
in a study conducted on a Malaysian sample,29 significant
correlations were found between the width of anterior
teeth and both the IPD and IAD.
In previous studies,14,19 the proportional ratio of the
IPD with central incisor width was indicated to be
6.6 mm, a value close to the result obtained in the current
study (6.9 mm). However, it is less than that reported by
Hasanreisoglu et al18 (7.7 mm for men and 7.5 mm for
women).
However, other authors have determined the possi-
bility of using the ICD as a guide for selecting central
incisor width in different populations.12,21 The width of
the central incisor is calculated by multiplying the ob-
tained facial value (ICD) by the coefficient of a geometric
progression of the golden proportion (0.618), then
dividing the result by 2. This method may be useful
when estimating the width of central incisors in Kurdish
men but not with Kurdish women because the calculated
value was significantly smaller than the actual
measurement.
Canine position provides tissue support at the corner
of the mouth and is in the turning point of the dental
arch.15,20 Concerning the relation of the IAD with canine
position, the straight-line width of the distal surfaces of
the canines (6A) was nearly equal to the width of the IAD
in men but not in women. This result is in agreement
with Hussain et al17 but contradicts the results obtained
by Sinavarat et al20 and Latta et al.13
Other studies should be conducted with a larger
sample size to define an acceptable biometric ratio of
such facial measurements for estimating anterior tooth
width for a wider base.
CONCLUSIONS
In this sample from the Kurdish population, the width of
the centrals (Mean1) and canines (Mean3), the straight-
line width of 2 centrals (2A) and 6 anterior teeth (6A),
as well as the summation of 6 anterior teeth widths
(Sum6) were all significantly correlated with the IPD.
These tooth measurements could be predicted by
applying the suggested regression formula.
The ratio between the IPD and central incisor width
in the Kurdish sample was 6.93, with no significant sex
variation. The use of the ICD as a dependent parameter

AL-Kaisy and Garib THE JOURNAL OF PROSTHETIC DENTISTRY

334
to estimate the width of the central incisors and the use
of the IAD for the straight-line width of the distal
surfaces of the canines (6A) were applicable only to
men.
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Corresponding author:
Dr Neda Al-Kaisy
University of Sulaimani, Faculty of Medical Sciences
School of Dentistry Department of Prosthodontic
Kani Askan st3 zone 205
Kurdistan Region
IRAQ
Email: neda_kaisy@yahoo.com
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
AL-Kaisy and Garib