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Reliability of intercommissural width in the determination of width of

maxillary anterior teeth in Indian and Malaysian population

Article  in  Drug Invention Today · April 2018

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 Research Article

Reliability of intercommissural width in the determination

of width of maxillary anterior teeth in Indian and
Malaysian population
J. Lakshmi Prabha, Ashish R. Jain*

ABSTRACT

Aim: The aim of this article was to assess the reliability of intercanine distance and intercommissural width in determining
the width of maxillary anterior teeth in Indian and Malaysian populations. Materials and Methods: The study included
39 dentate subjects with Angles Class I molar and canine relationships. The patients who visited a private dental college
were selected for this study, and an informed consent was obtained from these patients who were included in this study.
The exclusion criteria for this study were patients with malocclusions, those who have undergone orthodontic treatments,
periodontally compromised patients, missing teeth, or any gross skeletal or facial deformities. The intercommissural width
was measured in mm with the patient seated on dental chair in a relaxed posture with a divider and scale. The intercanine
distance was measured in mm using stone models poured with a non-elastic thread and scale. Results: This study showed
that the mean value for intercanine width (55.4 mm and 54.3 mm) and intercommissural width (53.4 mm and 55.4 mm) for
Indian and Malaysian populations, respectively, was determined and was found to be comparatively equal. The Pearson’s
coefficient index “r” was calculated which showed a positive correlation between the two parameters in both the populations.
The r value for intercanine distance and intercommissural width for Indian and Malaysian population was found to be 0.8514
and 0.8136, respectively. Conclusion: Anterior teeth selection plays a major role in the fabrication of complete denture. The
major difficulty lies in the selection of anterior teeth when pre-extraction records are not available. Hence, this study was
done to emphasize the importance of intercommissural width in the determination of width of anterior teeth.

KEY WORDS: Anterior teeth selection, Intercanine distance, Intercommissural width, Maxillary teeth

INTRODUCTION and extracted teeth. A  major hurdle in achieving a

pleasing esthetic smile is the selection of anterior teeth
Replacement of missing teeth is of major concern in the absence of pre-extraction records.[2] In this case,
to restore esthetics and function. In case of a various other parameters such as bizygomatic width,
completely edentulous patient, complete denture is interpupillary distance, interalar width, intercanthal
essential to prevent atrophy of muscles and to help distance, and intercommissural width were used for a
in mastication.[1] Fabrication of complete denture systematic approach of anterior teeth selection.[1,3] To
depends on various parameters which determine achieve functional and physical rehabilitation of the
its success. One such parameter is anterior teeth patient, the proper choice objective parameter should
selection which plays a major role in determining be established. This helps in reconstructing an optimal
the esthetics. Dentists use various parameters and occlusion for the edentulous patient.[4]
indicators for anterior teeth selection in day-to-day
Smile design and anterior teeth selection of artificial
practice. Pre-extraction records which help in anterior
teeth are of key importance in producing proper
teeth selection for edentulous patients include pre- occlusal reconstruction in the prosthetic management
extraction photographs, radiographs, stone models, of edentulous patients.[4] In most cases, the chief
complaint of the patient remains specifically anterior
Access this article online tooth esthetics which is primarily based on the width
Website: jprsolutions.info ISSN: 0975-7619
of central incisors and anatomical variations of
this cause unpleasing appearance.[1] Anterior teeth

Department of Prosthodontics, Saveetha dental college, Saveetha University, Chennai, Tamil Nadu, India

*Corresponding author: Dr.  Ashish R. Jain, Department of Prosthodontics, Saveetha Dental College and Hospital,
Saveetha University, Ponamalle High Road, Chennai – 600  127, Tamil Nadu, India. Phone:+91-9884233423.
E-mail: dr.ashishjain_r@yahoo.com

Received on: 18-02-2017; Revised on: 26-03-2018; Accepted on: 28-04-2018

506 Drug Invention Today | Vol 10 • Issue 4 • 2018

 J. Lakshmi Prabha and Ashish R. Jain

selection depends on teeth visibility, positive incisal anterior teeth was selected by dividing transverse
line, and size and color which helps in physiognomic. circumference of the head by 13 or by dividing the
They help in restoring functional and physical bizygomatic width by 3.3. According to Sears study,
rehabilitation to the edentulous patients. Factors tooth length was compared to the length of the
which help in teeth selection are patients’ age, gender, face.[9,12] Hence, it is concluded by various researchers
facial type, and harmony between size, shape, and that anthropometric analysis done within similar
color of the teeth.[4] Teeth size is determined based population groups and their interrelationship with
on the “Golden Proportion” which is universally the natural teeth measurements using pre-extraction
excepted proportion of incisal and canine widths first records help in better determination of anterior teeth
proposed by “Lombardi.” However, several studies selection for edentulous patients.[4,9]
have stated that the esthetic smiles are not designed
using this golden proportion, and hence, this topic Various studies report variations in the result based
remains controversial.[4,5] Hence, to achieve esthetic on various characteristics and ethnicity. Thus, this
outcome and patient acceptance, there has to be an study was aimed at determining the reliability of the
understanding between the physical and biological width of Intermaxillary commissure in comparison to
factors which are directly related to the patient’s intercanine width for anterior teeth selection in two
individual features.[1] different populations.

Several studies have been done to estimate and MATERIALS AND METHODS
correlate the use of various extraoral and intraoral
landmarks to determine the anterior teeth in In this study, 39 dentate subjects were selected from
edentulous patients. This study was conducted based a private dental institution, of which 25 subjects were
on the hypothesis that intercanine distance is used Indians and the rest 14 subjects were Malaysians.
for the measurement of anterior teeth as the distal The inclusion criteria included subjects interested
surfaces of the canines are seen to correspond to the in participating in the study, patients above 18 years
commissures of the mouth. A  study by Silverman of age for whom the growth phase is completed,
showed that intercanine was ± 4  mm from the and patients with complete arch without orthodontic
commissures, but another study showed that there findings and good periodontal health.[1] Exclusion
was no significant correlation between intercanine criteria included history of orthodontic treatment, gross
distance and intercommissural width in anterior teeth facial asymmetry, signs of inflammation, congenital
selection.[3,6,7] Another study by Baer and Reynold or surgical defects or any conservative restorations,
showed that the patients prefer the lesser width of paediatric patients, and patients with growth
artificial teeth in prosthesis when compared to the deformities. An informed consent was obtained from
width of their natural teeth.[8] However, there are the participants of this study.[2,4,9] The two parameters
little data in literature stating the accurate guidelines compared in this study were intercanine distance and
for anterior teeth selection. This shows that more intercommissural width.[3]
than one parameter should be assessed for accurate
prediction of the width of anterior teeth in determining This study was designed to evaluate the use and
teeth selection.[4] Certain authors believe the use of accuracy of intercanine width and intercommissural
facial measurements provides better accuracy in width in the selection of anterior teeth. The
teeth selection. These measurements are made with intercommissural width was measured extra orally with
the help of easily located constant reference points the patient’s mouth in the rest position [Figure 2]. The
usually facial landmarks and are compared with the patient was made to sit comfortably in the dental chair
width of anterior teeth. These measurements are in erect posture. Phonetics method was used to keep
seen to be similar in same population groups and are the patients’ mouth relaxed and in the rest position.
seen to show varied results across foreign population The intercommissural width was measured using a
groups.(3) “Biometric ratio method” devised by divider and scale, and the values were tabulated. The
Berry stated that dimensions of central incisors were intercanine width was measured on stone casts made
found to be one-sixteenth of the face width and one- from irreversible hydrocolloid impression material
twentieth of the face length.[9,10] House and Loop taken in stock trays. The casts were then trimmed, and
stated in their study the relation between width of the inter canine width was measured using a non-elastic
maxillary central incisor and bizygomatic width as thread measuring from the distal end of one canine to
one-sixteenth of greatest bizygomatic width equal the distal end of another canine [Figure 1]. The thread
to the width of maxillary central incisors. It was also was fixed to the smooth and highest circumference of
found that this value when divided by 3.3 gives the the cast, and the markings were made on both sides
maximum dimension of the overall width of anterior of the distal margin of canine. The distance between
teeth in maxilla.[9,11] Sears proposed a similar method the thread marks was measured using a scale, and the
using “Anthropometric Cephalic Index” in which readings were tabulated.[3,9]

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 J. Lakshmi Prabha and Ashish R. Jain

Both the parameters were measured 3  times, and teeth selection over conventional technique of using
the average value was considered for the study. All intercanine distance [Graphs 3 and 4].[2,3]
the data recorded were compiled and entered in a
spreadsheet using Microsoft Excel software, and the DISCUSSION
coefficient value was calculated using a “r” value
calculator. The value of coefficient of determination It is scientifically proven that there is no reliable
“r2” was also determined, and the readings were method of accurately assessing the selection of anterior
tabulated.[3,4,9] teeth in the absence of pre-extraction records. There is
increased difficulty in teeth selection for edentulous
RESULTS patients in case of absence of these records. Hence,
discussions on this are based on various studies and
The readings were tabulated and the mean was taken reviews conducted to assess the reliability of different
as shown in tabulation Table 1 and Graph 1. The mean parameters used for teeth selections using different
value for intercanine width (55.4 mm and 54.3 mm) methodology.[4,13]
and intercommissural width (53.4 mm and 55.4 mm)
for Indian and Malaysian populations, respectively, This study is done to present the reliability of one
was determined and was found to be comparatively such parameter, namely, the intercommissural width
equal. Then, the Pearson’s coefficient index “r” was in assessing the anterior teeth selection in comparison
calculated to determine the correlation between the
intercanine distance and intercommissural width of
both Indian and Malaysian populations, respectively,
and the Graph 2 was plotted. The value of r was found
to be 0.8514 and 0.8136 for intercanine distance and
intercommissural width, respectively. This showed
that there is a positive correlation between intercanine
distance and intercommissural width in anterior
teeth selection and is reliable across both races. The
coefficient of determination “r2” was 0.7249 and
0.6619 for intercanine distance and intercommissural
width, respectively. These data were analyzed and
compared with the previous studies to check the
reliability of intercommissural width in anterior

Graph 3: X and Y values for Indian population

Graph 1: Mean values of Indian population

Graph 2: Mean values of Malaysian population Graph 4: X and Y values for Malaysian population

508 Drug Invention Today | Vol 10 • Issue 4 • 2018

 J. Lakshmi Prabha and Ashish R. Jain

Table 1: Mean values and r values for Indian and Malaysian populations
Parameter n Sum of X values Sum of Y values  Mean of X Mean of Y r values r2
 (intercanine distance) (intercommissural width) values values values
Indian 25 1386 1335 55.4 53.4 0.8514 0.7249
population
Malaysian 14 760 776 54.3 55.4 0.8136 0.6619
population

in measurements of intercanine width due to wear and

inability to maintain the same arc of greatest curvature
around the maxillary cast used for the measurement of
intercanine distance.[1,16] Since the correlation between
the parameters were weak in their study, it proved that
no single parameter can be a reliable measurement for
anterior teeth selection and it also made emphasizes on
the use of pre-extraction records for teeth selection.[1] A
study by Glynis and Mariette suggested measurement
of intercanine width as a straight line measurement to
avoid errors caused by proclination or retroclination
Figure 1: Measurement of intercanine distance or the level of circumferential measurement.[2] This
study states linear measurement as a reliable method
which is in accordance with the study by Ahn et al.[2,17]
Deogade et al. in their study stated that variations
in the values may occur due to different measuring
techniques used and the various population groups
involved in the study. This study also showed a strong
positive correlation between the parameters which is
in accordance with the present study.[3,18]

With the small number of subjects analyzed in this

study, efforts to standardize the measurements were
made. However, still the question of a generalized
method which can be used for anterior teeth selection
persists.[9] The main limitations of this study are
that it does not assess gender-based variations and
includes only two population groups. Thus, the future
prospective of the study is that it has to be carried out
Figure 2: Measurement of intercommissural width
across other population groups and subgroups with an
increase in sample size.

to the conventional intercanine distance. The study CONCLUSION

showed a strong positive correlation between the
two parameters which emphasizes the fact that in the Anterior teeth selection plays a major role in the
absence of pre-extraction records, and anterior teeth fabrication of complete denture.[19] The major
selection can be done using intercommissural width of difficulty lies in the selection of anterior teeth when
the patient at rest. This is in accordance with the study pre-extraction records are not available.[20] It is
conducted by Waseemand Raisa in estimating the concluded from this study that the intercommissural
dimensions of anterior teeth in Kashmiri population. width is a reliable parameter in anterior teeth selection
Although there was a weak but significant correlation records are unavailable or intercanine width cannot
between the intercommissural width and anterior teeth be determined.[21] Hence, this study was done to
dimensions which is contradictory to this study results, emphasize the importance of intercommissural width
there is a strong positive correlation between the in the determination of width of anterior teeth within
parameters.[9] However, the study conducted by Kini certain limitations which can be reevaluated in the
and Angadi showed similar results with this study and future studies. However, this study was conducted in
established a significant positive correlation between a smaller population, and within only two races, it can
the parameters.[9,14] Ellakwa et al. stated the importance be further investigated in a larger population across
of intercanine width for anterior teeth selection in their different population groups and subgroups for better
study.[1,15] Their results showed variability and difficulty knowledge.

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 J. Lakshmi Prabha and Ashish R. Jain

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Source of support: Nil; Conflict of interest: None Declared

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