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 Table of Contents  
REVIEW ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 57-63

Conventional methods for selecting form, size, and color of maxillary anterior teeth: Review of the literature


1 Department of Prosthodontics, Faculty of Dentistry, Bezmialem Vakif University, Istanbul, Turkey
2 Department of Prosthodontics, Faculty of Dentistry, Istanbul University, Istanbul, Turkey

Date of Web Publication29-Sep-2015

Correspondence Address:
Dr. Aysegul Kurt
Department of Prosthodontics, Faculty of Dentistry, Bezmialem Vakıf University, Adnan Menderes Bulvarı Vatan Caddesi 34093 Fatih, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-4610.166184

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  Abstract 

One of the most confusing and difficult aspects of complete denture prosthodontics is the selection of appropriately maxillary anterior denture teeth when no preextraction records are available. Dental literature indicates that varied methods have been proposed for artificial tooth selection. The aim of this article is to review the conventional methods for maxillary anterior tooth selection and their reliabilities. A search of the dental literature in PubMed was completed for the years 1955–2015 with an emphasize on peer-reviewed dental journals limited to studies in the English language and using tooth selection and complete denture as keywords. The study works on three aspects of tooth selection: (1) Form, (2) size, and (3) color. This review of the literature demonstrates no universally reliable method of determining form and color for maxillary anterior denture teeth. But, interalar distance, interpupillary distance, and distance between the medialis angles of the eyes appear to be a reliable guide for selecting the size of maxillary anterior teeth. Information of racial differences may help identify esthetic modifications to treatment plans to include the multiple racial groups within modern societies.

Keywords: Denture, maxillary anterior tooth, tooth selection


How to cite this article:
Kurt A, Isik-Ozkol G. Conventional methods for selecting form, size, and color of maxillary anterior teeth: Review of the literature. Eur J Prosthodont 2015;3:57-63

How to cite this URL:
Kurt A, Isik-Ozkol G. Conventional methods for selecting form, size, and color of maxillary anterior teeth: Review of the literature. Eur J Prosthodont [serial online] 2015 [cited 2019 Apr 18];3:57-63. Available from: http://www.eurjprosthodont.org/text.asp?2015/3/3/57/166184


  Introduction Top


The restoration of the edentulous patient by denture has an important psychological effect. Once properly restored, the patient's self-esteem and self-confidence are often improved, which is also a goal of the oral rehabilitation.[1],[2] One of the primary considerations in manufacturing a denture is the selection of the maxillary anterior artificial tooth.[3] Biometric measurements or assumptions, usual choices made by the dentist, and the preferences of the patient are the most frequently used considerations. They are all utilized to help the dentist find a mold similar to the missing natural teeth, which may be difficult if no records of the dimensions, shape, or color of the natural teeth are available.[4] A review of the dental literature shows that several factors have been proposed as aids for artificial tooth selection, and numerous methods have been devised to find reliable factors in determining artificial tooth form, size, and color.[5] Although many attempts have been made to quantify the selection of anterior teeth for complete dentures, little consensus on effective methods has been reached.[6] The aim of this article is to review the conventional methods for maxillary anterior tooth selection and their reliabilities.


  Method of Literature Search Top


Search of the dental literature in PubMed was performed for the years 1955–2015 with an emphasis on peer-reviewed dental journals limited to studies in the English language using tooth selection and complete denture as keywords. This review evaluates three aspects of tooth selection: (1) Form, (2) size, and (3) color.


  Form Evaluation for Tooth Selection Top


Tooth form evaluation is usually made according to gender, age, and face form.

Gender and tooth form relationship

Frush and Fisher built a theory called "dentogenic theory" in the 1950s as a result of a series of articles. The theory claims that there is a relationship between the gender of a person and his or her tooth shape. It is believed that roundness, smoothness, and softness are feminine characteristics, while vigor and boldness are masculine characteristics.[7] Other authors also corrected the correlation between the gender and tooth shape in several studies; while one of these studies shows significant dimorphism of the upper and lower canine teeth,[8] there are also other studies that show this correlation in natural maxillary central incisor.[9],[10],[11]

However, the literature demonstrated that positive sexual dimorphism in the natural dentition was limited.[12],[13],[14],[15],[16],[17] Berksun et al. carried out a study with 13 prosthodontists that evaluated male or female gender with 60 black-and-white photographs that showed the upper front teeth. The photographs that were evaluated correctly were established by the "dentogenic theory" and the photographs that were evaluated wrongly were perceived as belonging to the other gender.[13] In a similar study completed by Wolfart et al., a significant correlation could not be shown between the tooth shape and gender.[14] Hyde et al. studied that size, position, and angulations of maxillary anterior teeth were evaluated regarding the sex of the patients with stone casts of natural teeth, which were assessed by experts. It was concluded that the experts could not distinguish sex by the visual assessment of maxillary anterior teeth on casts alone.[15]

There is little consistency in the selection of the anterior teeth appropriate for the sex of the individual by the dentist.[18] If the clinicians want to make tooth selection according to gender, they must consider the whole set of teeth instead of just focusing on one. Also, teeth form, their position, angulations, and the proportion of sizes are factors that need to be considered for suitable prosthesis for each gender.[13],[14]

Age and tooth form relation

In the dentogenic theory, artificial teeth are chosen according to the patient's age.[7] Interproximal wear of teeth is a normal aging change and makes them appear smaller.[19] Most of the dentists know the changes in teeth that occur with age and they aim to create a natural appearance while selecting teeth. By studying patients with three different age groups (young, middle age, and old) having natural dentition, Sellen et al. asked 50 dentists to choose the correct teeth by only observing the patients' face. The results of the study reported that clinicians more frequently select suitable anterior teeth for the elderly than for other age groups.[18] Several authors have attempted to predict patient age by reviewing denture tooth arrangements or oral photographs.[17],[18],[20] These studies failed to evaluate the teeth from an extraoral perspective. Frush and Fisher noted that a restoration can only be evaluated in the mouth.[7]

There is a little consistency in the selection of the anterior teeth appropriate for the age of the individual by the dentist. The development and implementation of an esthetic pro forma to guide the dentist and patients through the process of choosing a tooth mold based on age may be helpful.[18]

Face form and tooth form relation

A method of selecting teeth according to the "law of harmony" is popularly used at the present time. This method is based on a relationship existing between the face form and the form of the maxillary central incisor in the most people and that this relationship should be taken into account in the tooth selection procedure. It is described as three "basic" forms of teeth shape: Tapering, ovoid, and square.[16] Combination forms were rationalized to make selection easier, resulting in six combination forms in both square and tapering and four combination forms in ovoid. From these classifications, lateral incisors and canines that harmonized with each classification were selected.[21]

Only a limited number of studies on this subject have been published over the past 50 years, describing a relationship between the shape of the maxillary incisor and the face form. Some studies supported that the face form was helpful to select the tooth form.[5],[22],[23],[24] Whereas others did not support the relationship between the face and tooth shape.[12],[16],[25],[26] Wright found identical face and tooth forms in only 13% of 600 subjects.[27] Sellen et al., Ibrahimagic et al., and Wolfart et al. found similarities between forms in about 30% of cases.[10],[14],[22] The greatest percentage of correspondence was 51.3%, found by Berksun et al.[13] The similarity with the border reversing the central incisor and the face shape from the chin margin to the hairline is greater than that of the face shape from the chin margin to the eyebrow line.[16] Another study consisting of 100 patients supported that the face shape from the chin margin to the eyebrow line produced a better match than the one from the chin to the hairline.[28]

An important fact is that most of those studies were conducted in white population samples. Varjão et al. studied a total of 160 subjects (40 whites, 40 mulattos, 40 blacks, and 40 Asians) and found that a correspondence between tooth and face forms was found in 23.75% of all cases.[29]

Pound did not only evaluate the outline form of the face in the frontal plane, but also in the sagittal plane. This assessment then was related to the labial surfaces of the artificial teeth in the frontal and sagittal views to determine whether the patient has a convex, straight, or a concave profile.[30]

Suggestions have been made for alternative expedient guides for anterior tooth selection, such as facial contours in different planes and anatomic landmarks.[10],[30],[31]


  Size Evaluation for Tooth Selection Top


There are some mathematical proportions for predicting the width of the maxillary anterior teeth: Nasal width, intercommissural width, interpupillary width, distance between the medialis angles of the eyes, and incisive papilla.

Nasal width and tooth size relation

Several authors stated that the distance between the outer surfaces of the alae of the nose seems to be the same as that between the tips of the canines.[6],[32],[33],[34],[35] Kern made measurements on 509 dried skulls and found that most of his measurements of nasal width were equal to or ±0.5 mm of his measurements of the four maxillary incisors.[36] Mavroskoufis found that interalar nasal width is a reliable guide for selecting the mold of anterior teeth. The mesiodistal width of the set of anterior teeth (four incisors and the mesial halves of the canines) can be determined by adding 7 mm to the patient's nasal width.[37] Hoffman et al. studied 340 North American subjects to investigate whether the interalar width could be used as a reliable guide for the selection of suitable anterior teeth when constructing dentures. The authors found that the mean of the distance between the tips of the maxillary canines was 3% bigger than the mean of interalar width and that the mean of the distance between the distal surfaces of the maxillary canines was 31% bigger than the mean of the interalar width.[6] Gomes et al. studied 81 Brazilian people and showed that the interalar width was significantly correlated to the mesiodistal width measured on a photo, both between the tips of the maxillary canines and between the distal surfaces.[38] In another study by the same authors, it was found that a ratio of 1.31 can be calculated when the circumferential distance between the distal surfaces of the maxillary canines was compared with the interalar width.[35] Ellakwa et al.[39] and Tripathi et al.[40] showed that interalar width provided the strongest predictive relationship with anterior maxillary teeth. In 1975, Smith also studied the relationship between nasal width and intercanine distance by using a combination of clinical and radiographic methods for the recording of the interalar fold width of the noise and stone cast with modified canine cusps for the tooth measurements. No demonstrable relationship between intercanine distance and either interalar width, or interalar fold width, or skeletal nasal aperture was found.[41] Hasanreisoglu et al. studied with 100 Turkish subjects and they found that interalar width may be used as a guide for selecting maxillary anterior teeth, particularly in women.[42] In a study by Latta et al., the relationships among the width of the mouth, the interalar width, the bizygomatic width, and the interpupillary distance were evaluated. It was concluded that these relationships might be used as references if applied in combination.[3] According to most studies, interalar width can be used as a reliable guide for maxillary anterior teeth selection.

Intercommissural width and tooth size relation

The curve distance between the corners of the mouth, which supposedly represents the curve distance between the distal surfaces of the maxillary canines, is often used as a method for selecting the maxillary anterior denture teeth.[21],[43] Sinavarat et al. also studied 100 Thai subjects and found a correlation between the intercommissural width to the intercanine tip width and the width of the distal surface of the canine.[44] But, Varjão and Nogueira reported a weak correlation with the distance between the canines and the distance between the corners of the mouth in four racial groups. They reported that using the corners of the mouth for the selection of the artificial teeth width would lead to, in general, the selection of narrower teeth than the natural teeth.[45] In addition, Latta et al., Scandrett et al., and Lieb et al. also found inadequate correlation between the intercanine width and intercommissural measurements.[3],[19],[46] There is little consistency in the selection of the anterior teeth appropriate for the intercommissural width of the individual by the dentist.

Interpupillary distance and tooth size relation

Certain authors have proposed a relationship between the width of the maxillary central incisor and the interpupillary distance.[6] The relationship between the interpupillary distance and mesiodistal width of maxillary central incisors was suggested and evaluated by Cesario and Latta's study of 100 American subjects. A ratio of 1:6.6 occurred in 95% of white and black female patients in the sample group tested. In black male patients, the ratio was 1:7.[47] Hasanreisoglu et al. studied 100 Turkish subjects and found a ratio of 1:7.7 and 1:7.5 for men and women, respectively.[42] Gomes et al. studied 81 Brazilian people by using dental casts and found that the highest probability correlation between the sum of mesiodistal width of the six teeth and interpupillary distance.[38] Isa et al. studied 60 Malaysian subjects to investigate the relationships between some facial dimensions and widths of the maxillary anterior teeth. It has been reported that the width of the central incisors was highly correlated to the interpupillary distance, while the widths of the lateral incisors and canines were highly correlated to a combination of interpupillary distance and interalar distance.[48] According to the studies, the interpupillary distance appears to be a reliable guide for selecting maxillary anterior teeth.

Distance between the medialis angles of the eyes and tooth size relation

Intercanthal distance (ICD) is the distance between the medialis angles of the palpebral fissure bilaterally.[2],[38],[49],[50],[51] ICD is considered normal at a dimension of 28–35 mm between 8 and 11 years and ICD of 93% growth has been achieved approximately at 5 years of age.[52],[53] No differences related to sex, race, or age have been shown in the ICD.[52],[54] This makes ICD a reliable anatomic dimension that may provide a valid approach to anterior tooth selection.[49],[51] Gomes et al.[38] and Lucas et al.[55] indicated that ICD showed a correlation to the distance between the tips and the apparent distal surface of the maxillary canines. Abdullah has stated that ICD, when multiplied by a decreasing function value of the geometric progression term 0.618 and divided by 2, was a reliable predictor of maxillary central incisor.[50] According to Al Wazzan, ICD is correlated to the dental widths, the mean widths of the central incisor, and the combined widths of the six upper anterior teeth. The biometric ratios of 1:0.267 and 1:1.426 could be used to estimate the central incisor width and the combined width of the six anterior teeth, respectively.[2] According to the studies, ICD appears to be a reliable guide for selecting maxillary anterior teeth.

Incisive papilla and tooth size relation

The incisive papilla has been used as an anatomic landmark in the positioning of maxillary anterior teeth because it is known as a reliable and relatively stable anatomic landmark.[4],[30],[37] A line drawn at a right angle to the midline passing through the center of the incisive papilla passes through the tips of the maxillary canines.[37],[56],[57],[58],[59] However, it cannot always be pronounced as a definitive method. The data obtained for a representative sample of 298 young Jordanians from measurements made on dental stone casts showed that the transversal line that connects to the cusp tips of the maxillary canines passed within 1.2 mm anterior and posterior to the midpoint of the incisive papilla in about 50% of subjects.[60] There was also a recommendation made by Varjão et al. for the use of the center of the incisive papilla as a guide for the selection of the proper width of maxillary dentures in four racial groups (white, black, mixed, and Asian subjects). In all studied racial groups, there was no coincidence between the center of the incisive papilla and the canine line. The utilization of the center of the papilla would lead to the selection of wider artificial teeth.[61]

The incisive papilla method is used as a conventional method by dentists but the relationship between natural teeth width and artificial teeth width cannot be predicted clearly by this method. Racial differences were detected when anatomic measurements were evaluated individually and more than one anatomic reference is needed to predict the width of maxillary anterior teeth.[3],[19]


  Color Evaluation for Tooth Selection Top


Selection of an appropriate tooth color for edentulous patients is an important part of complete denture fabrication. It has been shown that proper color selection has a positive impact on the patients' perception of esthetics.[62] In dentistry, comparison with the remaining teeth is frequently used to select the color of artificial teeth.[63] Clinicians providing edentulous patients with complete dentures are often confronted with the problem of not knowing the patient's natural tooth color. For choosing the color of the tooth in edentulous patients, preextraction records, a photograph of patients, the idea of relatives, and reminding the patient of their own natural teeth color are beneficial.[33] If they are not usable, some reference factors are assessed. It would be valuable to determine this from other personal features such as gender, age, eye color, hair color, and skin color.[64]

Hassel et al. concluded that while some of the factors investigated, namely hair and eye color and gender were significantly associated with tooth color, facial skin complexion was not. Lighter colors were associated with lighter eye color and with female gender. More yellow/green than yellow/red values were associated with hair colors other than black and with female gender.[64]

A supported study of African-American subjects from 21 to 69 years of age found that facial skin complexion was not significantly correlated with tooth color. It was also found that facial skin complexion did not correlate significantly with tooth color and was only a poor predictor of gingival pigmentation.[65] Esan et al. indicated that there was no significant relationship between facial skin color and tooth color.[66] Jahangiri et al.'s study has been conducted to assess the relationship between tooth color and skin color. Persons with medium-to-dark skin tones were more likely to have teeth with higher values (lighter), whereas individuals with lighter skin tones tended to have teeth with lower values (darker), regardless of gender or age. They showed that tooth color and skin color were inversely related for different races.[67] Hassel et al. reported significant differences, with the teeth of women being slightly more yellow, lighter, and less saturated.[64] Gozalo-Diaz et al. and Esan et al. also found that women subjects had lighter and less yellow central incisors than men.[66],[68] This result is inconsistent with the findings of Jahangiri et al. who reported that there was no significant relationship between tooth color and gender.[67]

Age is highly correlated with the natural color of teeth. The color of natural teeth becomes darker, more reddish, and more yellow with increasing age because of deposition of secondary dentin, wearing a way of enamel, and external staining.[17],[33],[69] Hasegawa et al. found that the older the subject, the darker and more yellow the color at the center site of the natural tooth becomes. Both reddish and yellowish colors of the natural teeth tend to increase from the incisal to cervical whereas translucency decreases.[70] Goodkind and Schwabacher found that 2,830 natural anterior teeth darkened after the age of approximately 35 years by the formation of secondary dentine.[71] The age factor in the dentogenic theory was accomplished by using lighter colors for younger patients and darker colors for older patients.[7] Young et al. indicate that the color of resin teeth selected for complete dentures tends to be relatively independent of the patient's age, although natural teeth darken with age.[72]

The colors of teeth before extraction, when available, usually are the "color of choice" for the artificial teeth. However, the color must be selected with the tooth in its normal environment. If no such records are available, the selection of color is based primarily on the overall complexion as modified by the age of the patient.[33]


  Conclusion Top


One of the most confusing and difficult aspects of complete denture prosthodontics is the selection of appropriately maxillary anterior denture teeth when no preextraction records are available. This review of the literature demonstrates no universally reliable method of determining form, and color has been found for maxillary anterior denture teeth. But, interalar distance, interpupillary distance, and distance between the medialis angles of the eyes appear to be a reliable guide for selecting the size of maxillary anterior teeth. There can be racial differences in the characteristics of anterior teeth and these must be borne in mind during anterior tooth selection for various racial groups. Knowledge of racial norms may help specify certain esthetic and functional modifications to treatment plans to accommodate the multiple racial groups within modern societies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Introduction
Method of Litera...
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