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N 4 Oct.95

THE RELATIONSHIP BETWEEN FACIAL REFERENCES ANDMESlODlSTAL WIDTH OF MAXILLARY ANTERIOR TEETH AMONG

SAUDI PATIENTS

a lid A l ~ a z n a n * , b du lla h A l aida an**, E:btissam M. A1 ~ a d i * * * , bdulaz iz Al Mufarj ****

development of contribution from each one ofthem. This method was based on the rat io ofSelection of the maxil lary anterior artif icial 1 16 Maxi l lary incisor width to Bizygom aticespecially the c entra l incisors, represents width (facia l width ), and of 1 3.3 Maxillary ante-primary concern in denture esth etics( '). Their rior teeth width to bizygoma tic width('). Trubytetooth indicator instrument (DentsplyIWork Divi-sion, Dentsply Int'l. Inc., Work, Pa, USA) weree teeth width is con side red to be m ore critical designed based on this method.length(')

It is very difficult task to select the properze of anterior tee th for ede ntulous p atients

This method is based on the work of Ber-~ i l l i a m s ( ~ )nd House ( 6 3 7 ) as transitionalLecturer, Department of Restorative DentalSciences King Saud Univers~ ty, College ofDentistry Riyadh, Saudi ArabiaResident, Minis try of Health R iyadhm, SaudiArabia.

* ' College of Den tistry, King Saud Un iversity ,Riyadhm, Saudi Arabia.Chief Dentist, King Abdulaziz University Hospital,Riyadh, Saudi Arabia

Some clinicians have questioned the validityof this m ethod('). La Vere et a1(' '1 ' ' 1 presentedthe work of the student on each other wheremeasurements ' of teeth were made on thestone casts of the subject. Trubyte tooth indica-tor was used to measure the byzygomat icwidth. They foun d that only 2 3% of the subjectha d the 1:16 ratio and m ajority of the subject,53%, had facial width smaller than the centralincisor. Ho weve r, majority of the tee th selectedwere within a 1 m m difference width of the natu-ral tooth dimensions.ln terpup i l la ry w id th :

This method is based on the relationship be-tween the interpupillary distance and the mesio-dista l width of the maxil lary cen tral incisor assuggested and evaluated by Cesario and Lat-t a ( l 2 ) .They divided the subjects into four cater-

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T H E R E L A TI O N SH I P B E T W E E N F A C I A L R E F E R E N C E S A N D M E S l O D lS T A L W I D T H O FM A X I L L A R Y A N T E R I O R T E E T H A M O N G S A U D I P A T I E N T S

gories: white male an d female, and b lack maleand female. They found that the ratio of 1 6.6was ful l within the 95% of three of the four-roups while the fourth (black male) the ratiowas found to b e 1.7.lnteralar w idth :

Several authors(13 -15) have referred to th ewidth of the nose to be used as a guide to se-lect m axillary an terior teeth.

This method is based on locating the tip ofthe maxil lary canine by extending parallel l inesfrom the lateral surface of the alae of the n oseon the labial surface of the upper occlusalrim (8* 14 f15 ). arb et a((') criticized, this methodsince it is not sufficiently reliable for use as themea n for f inal tooth selection. s mith (16) investi-gated the validity of this metho d by using acombination of clinical and radiographic exami-nation of the interalar width an d a stone cast forthe teeth width. He found no significant relation-ship be tween intercanine (t ip to t ip) distanceand interalar width. Mauroskoufix and Ritch-ie(17) found no relationship between nasal widthand the four maxil lary incisors. However, theyfound that 56% of the males and 53% of the fe-males had differences between the intercanine(t ip to t ip) width and interalar to be less than2mm.M ou th w id th :

This me thod is bas ed on the hypothesis thatthe distal surface of the maxi l lary caninesshould be approximately located at the corne rsof the mouth. The traditional cl inical approachwas to mark the upper occlusal rim at the cor-ners of the mouth while the patient lips are re-laxed. The distance between the two marks,mea sured by fixible ruler and the maxillary a nte-

r ior teeth was chose n a ccordingly(8). Si lver-man('') indicated that the distal surface of max-illary canines w ere 4m m distal or medial to themouth commissures.

Latta et al( I9 ) evaluated the relationship be-tween these four facial measurem ents in eden-tulous patients. They found no correlation be-tween the widths of the subjects as a whole, norwhen the subject were subdivided into race andsex groups.

'This study eva luate d the relationsh ip be -tween these four facial references and the m e-siodistal width of the maxil lary anterior teethamong Saudi patients.Materia ls an d Methods:

A total of 439 Saudi patients from RiyadhSaudi Arabia of which 202 (46%) were malesand 237 (54%) were females, were randomlyselected from the outpa tient dental clinic of Col-lege of D entistry and King Abdu laziz UniversityHospital at King Saud University. Age range ofthe patients was between 20 a nd 60 years old,all of who m had m axillary anterior teeth presentwith no caries, restoration, or severe attrit ion.Patients with congenital or surgical facial de-fects we re excluded.

Greatest bizygomatic width of each patientwas measured by using a face bo w and m ill ime-ter ruler as suggested by Zarb et al('). Th e restof the m easu remen ts were d one with a Boleygauge to the nearest tenth of a millimeter. Thelnterpupil lary distance was measured from m id-pupil to midpupil, and interalar width was mea s-ured by bringing the gauge beak just in contactwith the outer surface of the widest point of thealae while the patient was in a relaxed state.The width of the mouth was determined by

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ADJ: V01.20 N 4 Oct.95measuring the lip'vermillion from commissure to 43 to 82mm, interalar width ranged from 24 tocommissure while patient's lip was relaxed. 62mm, and the width of the mouth meas-

ured from 31 to 75mm. Variations remainedAll teeth measurements were made intraor- high even when the population was divided ac-ally by using a modified Boley gauge of which- cording to sex.the beak was pointed to fit the embrasures. Themesiodistal measurements of the maxillary an- The correlation test was done between theseterior teeth were recorded at the widest point four facial distances and four maxillary anterior(contact area). teeth measurements. These four teeth meas-

urements were the mean of the two central inci-Three readings for each measurements sors, the total width of the two central incisors,were taken and the mean of these readings was the totaLwidth fo the four incisors (lateral to lat-recorded. The recorded data were statistically erall. and the total width of the six anteriorsanalyzed. ,,(canine to canine). The later three measure-Results: ments was obtained by adding the individual'smeasured width together.Table 1 shows that the mean value of the

measurements are greater for men than women The correlation test demonstrated no rela-which suggested differences in sex. tionship between the four facial distances and

any of the four teeth measurements (Table 1 1 ) .The facial anatomical references varied There was no relationship existed even whengreatly. The biz~gOmaticwidth ranged from 99 the population was divided according to sex.to 170mm, interpulpillary distance ranged fromTable I

Means Values and Range of Measurements (mm)

Maximum1708 26 275135 12269

Minimum99432431

6.5122230

Woman125.81f .9860.13 f .9136.1 1f .1348.68f .466.30 f .6016.39f 1.6028.99 f 2.5743.93 t- 3.22

BizygomaticlnterpupillarylnteralarMouthCentral incisorTwo CentralsInterlaterallntercanine

All Subjects128.38 f .9760.92 f .6337.59 f .8550.79f .09

8.42 f .8316.85f 1.5629.93 f .6645.16 f .28

Men131.78 1 8.9361.91 f .0239.50 f .0753.51 +_ 4.56

8.61 + 0.6517.21f 1.4730.62 f .7745.16 t- 3.52

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T H E R E L A T IO N S H I P B E T W E E N F A C I A L R E F E R E N C E S A N D M E S l O D l S T A L W I D T H O FM A X I L L AR Y A N T E R I O R T E E T H A M O N G S A U D I P A T I E N T S

Table IICorrelation Matrix between Facial References and Teeth Measurements(All Subjhects)

(.) = P-value for r (correlation)

Bizygomatic

lnterpupillary

lnteralar

Mouth

Discussion: anteriors (interlateral distance) and, the totalwidth of the six anterior teeth (intercanine dis-When the re is no pre-extraction record. the tance),select ion of the maxi l lary anterior teeth foredentulous patient wil l be more diff icult. Among Bizygomatic width:

Central Incisor-0.0285(0.5530)-0.0158(0.741 2)-0.0333(0.4866)-0.0789(0.1222)

the solutions to this problem is the use of ana-tomical facial references, such as the bizygo-matic width, interpupil lary distance, interalarwidth, and the corners of the mouth. Presentday dentists are uncertain about the true valueof these methods((10s16319).arb et ad8) stated,with respect to interalar width, that "this is notsufficiently reliable for us e as the means for thefinal selection". In this study, there was no cor-relation found b etween the above mentioned fa-

There was no correlation between the Bizy-gomatic width and the central incisor width.Only 18% of the subjects had 1 16 proportion,and m ajority of them (67%) ha d the bizygomaticwidth smaller than the width of the central inci-sors. This result8 are in agreement with La Vereet al(lOgl ' 1 who found that 23% of the subjectshad the 1.16 ratio and the 5 3% had smaller bi-zygomatic width.

cia1 widths and the fou r m easurem ents of the 'These results suggested that using facialmaxil lary anterior teeth which are the mean of width as a guide for central incisor selectionthe two central incisors, the total width of the may result in selecting a larger central incisor.two central incisors, the total width of the four Howe ver, the majority (59%) of the teeth select-

lntercanine-0.1125(0.5189)-0.1131(0.0180)-0.0359(0.4535)-0.0287(0.5496)

The two centrals-0.0285(0.5530)

--0.0158(0.7412)-0.0333(0.4866)-0.0789(0.1222)

Interlateral-0.0332(0.4898)-0.0286(0.5513)-0.0557(0.2444)-0.0738(0.1231)

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ADJ: V01.20 N 4 Oct.95ed was within 1mm of the width of the naturaltooth and this is also in agreem ent with La Ve reet al('O-'').lnterpupil lary distance :

Cesario and ~ a t t a ( l ~ )ound that the ratio1:' 6.6 of central incisor to interpupillary fallswitnin the 95% confidence interval of the m eanfor three groups out of the four group subjects.In the present study, no such co rrelation wasfound. However, 57% was within 1mm of natu-ral tooth width if this,metho d used.lnteralar width :

In concurrence with Mavroskaufis and Ritch-ie(17), there was no correlation betw een the in-tralar width and the four maxillary anterior(lateral to latera l).

distance within 1mm of the interalar, sm ith(16)found 19% of the subjects were w ithin 0.5mm.Wid th o f the mouth :

~ i l v e r m a n ( l ~ )tated that "the distal surfaceof the maxillary cuspid is + 4mm d istal or medialto the commissure of the mouth". Only 40% ofthe subjects in this study had the intercaninedistance-within 4mm of the width of the mouthwhich was determined by m easuring the m axil-lary lip vermillion from com missure to co mm is-sure.

The results of this study showed that the fourinvestigated facial distances w ould not be a reli-able guide for selectjng the maxillary anteriorteeth. Ho wever, they ca n b e used as inital ten-tative step, or in com bination with each other orwith the o ther means of too th selection and the

sm ith(16 ) found no significant relationship final decision should be m ade during the try-inbetween interalar width and the intercanine dis- stage of the denture and to be confirmed by thetance. On the other hand. Mavroskaufis and patient.FIitchie(l7) found some demo nstrable relation- References:ship where the d ifference between the interalarwidth and intercanine distance was within 2mm 1 Young H.A.: Denture esthetics. J. Prosthetin 56% of the men and 53% of the wom en. In Dent., 1956; 6: 748-55.both studies the intercanine distances yeremeasured from tip of the canine to tip of the

C -canine . This should help in arranging the teethrather than se lecting them. The suggestion wasto position the tips of the canines o n the twoperpendicular lines drawn from the outer sur-face of the alae.

In the presen t study the intercanine distanc-es were measured from distal surface to distalsurface of the can ines .

~ e e ( l ~ )ndicated that the interalar width wasequal to intercanine distance. In the presentstudy only 70 of the sub jects had intercan ine

2- Kra jicek D.D.: Natu ral appearance for the in-dividual denture patient. J. Prosthet Dent.,1960 ; 10: 205-14.

3- Lombardi R.E.: The principles of visual per-ception and their clinical application to den-ture esthetic. J. Prosthet Dent., 1973' 29:358-82.

4- B erry F.H.: Is the theory of temperaments thefoundation of the study of prosthetic art?Dentists' Mag. 1905 -6; 1 405-1 1.

5- Williams J.L.: A new classification of hum antooth form with special reference to a new

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THE RELATIONSHIP BETWEEN FACIAL REFERENCES AND MESlODlSTAL WIDTH OFMAXILLARY ANTERIOR TEETH AMONG SAUDI PATIENTS

system of artificial teeth. Dent. Cansmos,1914; 56: 627-28. 14- Lee J.H.: Dental aesthetics. The pleasing

6- House M.M.: Art - a fundamental in denture appearance of artificial dentures. Bristol,prosthesis. JADA 1937; 24: 406-22. John Wright & Sons Ltd., 1962.

7- House M.M.: Form and color harmony in 15- Wehner P.J., Hickey J.C., Boucher Co.: Se-denture art. Whittier. C.A., House & Loop, lection of artificial teeth. J. Prosthet Dent.,1939. 1967; 18: 222.

8- Zarb G.A., Bolender C.L., Hickey J.C., Carl-son G.E.: Boucher's prosthodontic treatmentfor edentulous patients (10ed). St. Louis.The C.V. Mosby Co., 1990; pp. 333.

9- Young H.A.: Selecting the anterior toothmold. J. Prosthet Dent., 1954; 4: 748-60.

10- La Vere A.M., Marcrofl K.R., Smith R.C.,Sarka R.J.: Denture tooth selection; an anal-ysis of the natural maxillary central incisorcompared to the length and width of theface: Part I, J. Prosthet Dent., 1992; 67: 661-63.

11 La Vere A.M.. Marcroft K.R., Smith R.C.,Sarka R.J.: Denture tooth selection; an anal-ysis of the natural maxillary central incisorcompared to the length and width of theface: Part II. J. Prosthet Dent., 1992; 67:810-12.

12- Cesario V.A., Latta G.H.: Relationship be-tween the mesiodislal width of the maxillarycentral incisor and interpupillary distance. J.Prosthet Dent., 1984; 52: 641-43.

13- Scctt J. E.: The scott system of precision ar-ticulation in three dimensional occlusion. J.Pros:het Dent., 1952; 2:362- 80.

.16-Smith B.J.: The value of the nasal width asan esthetic guide in prosthodontics. J. Pros-thet Dent., 1975., 34: 562-73.

17- Mavroskoufis F., Ritchie G.M.: Nasal widthand incisive pupilla as guides for the selec-tion and arrangement of maxillary anteriorteeth. J. Prosthet Dent., 1981; 45: 592-97.

18- Silverman S.I.: Physiologic factors in com-plete denture esthetics. Dent clin North Am.,March 1967; 115-22.

19- Latta G.H., Weaver J.R., Conkin J.E.: Therelationship between the width of the mouth,interalar width, bizygomatic width, and inter-pupillary distance in edentulous patient. J.Prosthet Dent., 1991; 65: 250-54.

Summary:A total of 439 Saudi patients were examined

to determine if there is a correlation betweenthe widlh of the maxillary anlerior: teeth and fouranatomical facial references. The bizygo~naticwidth, interpupillary distance, intraalar width andthe widlh of the mouth. All measurements doneby using a modified Boley gauge except the bi-zygomatic which was done by using a face bow.No correlation was found between the measure-ments for the population as whole, nor when thepopulation was divided accordingly to sex.

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V01.20 N 4 Oct.95

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