J Indian Prosthodont Soc (Oct-Dec 2013) 13(4):473–477

DOI 10.1007/s13191-012-0234-6

ORIGINAL ARTICLE

Acceptable Deviation between Facial and Dental Midlines

in Dentate Population
N. S. Jayalakshmi • S. Ravindra • K. R. Nagaraj •

P. L. Rupesh • M. P. Harshavardhan

Received: 5 February 2012 / Accepted: 14 December 2012 / Published online: 5 January 2013
Ó Indian Prosthodontic Society 2012

Abstract The success of the dental restorations largely population showed deviation between facial midline and
depends on its esthetics, although various literature reviews anterior teeth midline within the range of 0–1 mm.
recommend that anterior teeth midline be placed coinciding
the facial midline, the amount of acceptable deviation Keywords Facial midline  Dental midline 
between facial and dental midline has not been fully inves- Acceptable deviation
tigated. To observe the acceptable deviation between the
dental and facial midline. Facial photographs of 200 students
aged about 18–30 years of both sexes, without any missing Introduction
teeth, with complete alignment of anterior teeth, were selected
and scanned on to computer screen. Using specialized pro- The term ‘‘Esthetic’’ is used to connote that some thing seen
gramme, the crown width of the central incisor in the mouth is pleasant. Over the centuries as artists have developed the
and on photograph was ensured constant. The distance management of esthetic process into principles of visual
between the facial midline, (obtained by bisecting intercanthal perception, they have enabled to create scenes of intense
line) and the mesial surfaces of the central incisors were read vitality, beauty, depth and realism all on a 2D canvas [1]. As
on the computer. 44.4 % Boys and 55 % of Girls showed dental restorations are subjected to the same perceptual
deviation between dental and facial midline in the range of process, understanding of perceptual principle can eliminate
0–1 mm. while, 54 % of boys and 33 % of girls showed confusion in achieving the realm of esthetics and main-
deviation of the dental and facial midline in the range taining esthetic harmony [1, 2]. Dentist who understands the
1–2 mm. 37 % of boys and 8 % of girls showed deviation of principles of visual perception can fabricate the restoration
dental midline with facial midline with the range of 2–3 mm. with confidence to meet, the esthetic demands subtly and
80 % of the study population showed maxillary and man- wisely without violating the principles of reality [3, 4].
dibular dental midlines never coincide. Majority of the study The study of the relationships existing between different
objects is made visible by the contrast in color, line and
Electronic supplementary material The online version of this texture. This is called Composition [1]. The ordering of, a
article (doi:10.1007/s13191-012-0234-6) contains supplementary part of composition to give the individual total effect of the
material, which is available to authorized users. ‘‘whole’’ is called Unity. Unity exists in two types: Static
unity and dynamic unity. The regular geometric shapes, such
N. S. Jayalakshmi (&)  P. L. Rupesh  M. P. Harshavardhan
Department of Prosthodontics, Coorg Institute of Dental as snowflakes and crystals, exhibit static unity [1]. Plants
Sciences, Virajpet, India and animals exhibit dynamic unity. Repetitions of shape,
e-mail: drnsjai@gmail.com color and line are cohesive forces [1]. Success of a dentist
P. L. Rupesh lies in making use of these static cohesive forces to fabricate
e-mail: rupeshpl@yahoo.com prosthesis, to suit a living dynamic human being [5]. Con-
sider an instance, where anterior teeth placement is done on
S. Ravindra  K. R. Nagaraj
Department of Prosthodontics, The Oxford Dental College and the unchanging curve of a circle [1]. The resulting denture
Hospital, Bangalore, India gives a dull dead appearance, immediately noticeable in a

123
474 J Indian Prosthodont Soc (Oct-Dec 2013) 13(4):473–477

living dynamic mouth as something abnormal [5]. The Composting, which means various measurements can be
objective of a dentist is to provide dynamic and not static made using the image without hampering the image qual-
unity. Dentogenic factor helps us in achieving this [6–8]. ity. Microsoft office suite and Corel word perfect, to record
The term ‘‘Dentogenic’’ means, the art, practice and and analyze the result.
techniques used to achieve esthetic goals in dentistry [8, 9]. Canon—A620 digital camera with the following speci-
Lombardi noted that proper location of the dental midline fications were used for the study. A minimum of 5 Mega
was necessary for stability of the dental composition as Pixels is recommended for dental/medical photography
improper placement of the midline would produce tension [15–18]. The camera used in the study was of the resolution
that make the viewer feel that the line must move to its 7.1 Mega Pixels. It had a color monitor with 200 LCD,
proper place to produce stability & permanence [3, 5]. which could be turned up to 270° that helped to view tall
Various complete denture textbooks [3, 7, 9, 10] recommend objects of interest, without lifting the camera above the
that the mesial surfaces of maxillary central incisors be in head. Camera had optical zoom 49 for better the image
contact with the imaginary vertical line that bisects the face. quality. Recommended optical zoom for dental/medical
Anatomical landmarks like, incisive papilla, labial frenum, photography is 39. Lens specifications of the camera were
tubercle of upper lip have been used to estimate the position 7.3–29.2 mm, which produces images equivalent to the
of the central incisor for complete denture prostheses. Using lens of 35–140 mm [15, 18, 19]. Minimum lens specifi-
tubercle of the upper lip as the midline of the face, Latta [11, cation recommended at international conferences to pro-
12] found that in 70 % of 100 patients the average distances duce image of adequate accuracy [15, 17, 18], is 35 mm.
of the mid-palatal suture, nasopalatine papilla and labial
frenum were less than 1 mm from the midline and the range
may vary as much as 5.5 mm. Tjan [13] suggested that, an Method
imaginary line dividing the middle lobe of the upper lip
could be used to establish the facial midline, as it is closer to Around 200 students were selected for the study conducted
the mouth compared to other landmarks. Miller [13] sug- in, The Oxford Dental College and Hospital. The consent
gested that center of the philtrum should be considered as from the ethical committee from the same institution was
the most reliable guide to the facial midline. obtained. Exclusion criteria for the study sample include,
Because no human face is symmetrical, there can be no students with restorations in the anterior teeth region, clin-
hard and fast rule for determining the facial midline [14]. ical evidence periodontal disease, misalignments of teeth
The artistic judgment of the individual clinician therefore like rotations, spacing in the anterior region, congenital
must be used. Since the amount of deviation of the anterior deformities of head and neck region. Students with ideal
tooth midline from the facial midline that is noticeable to a alignment of anterior teeth aged in the range of 18–30 years
viewer is unknown, the purpose of this investigation was to were selected. Each student was seated on a chair at a fixed
determine the observable deviation between the anterior position in relation to the camera lens. Reference points
tooth and facial midlines in a limited sample of dentate were anterior border of the ear lobe to the camera lens. This
subjects confining to a specific area and age group. placed the eye of the subject in straight line with the lens.
Thus, the position of the subject in relation to the camera
lens was standardized at a fixed distance of 130 cm. All the
Materials students were asked to remove their spectacles while
shooting the photographs. Students head position was fixed
The HP Pavilion Laptop had the Following on the cephalostat with help of zygomatic clamps and was
Configurations asked to rest his/her chin on the chin rest. Cheek retractor
was fixed to the student and they were instructed to close
Hardware their mouth at the maximum intercuspation of their teeth and
to look at the camera lens while shooting the photograph.
HP Pavilion laptop model-dv6000, with 1,024 MB of random The width of the central incisor in the mouth and on the
access memory. Optical drive and other generic input devices photographs was measured in millimeters. Camera was
like keyboard and mouse. A graphics card that supports a preset to its reproduction ratio 1:2 where in the image size
SXGA high-resolution display and 1500 LCD color monitor. was half as that of the object. Minimum recommended ratio
is 1:10 for portrait views [15–18]. Each photograph was
Software edited using Adobe Photoshop V7.0.
Photographs were aligned with interpupillary line par-
Windows XP Professional. Adobe Photoshop Version 7.0 allel to the frame of the screen. Image was magnified using
is an authentic photo editing software with Advanced zoom tool such that width of the central incisor on the

123
J Indian Prosthodont Soc (Oct-Dec 2013) 13(4):473–477 475

the facial midline and mandibular dental midline was noted

in millimeters as depicted in Photo 3. The difference
between the maxillary and mandibular dental midline was
obtained by subtracting the later reading from the former in
millimeters. The images were stored in JPEG format.

Results

Statistical Methods

Student t test has been used to find the significance of study

parameters between male and female. Reference interval
Photo 1 Inter canthal distance, computation of facial midline has been calculated using Non-parametric (Percentile)
(36 mm) method [20, 21].
? Suggestive significance 0.05 \ P \ 0.10.
* Moderately significant 0.01 \ P B 0.05.
** Strongly significant P B 0.01.
Results as tabulated in the Table 1 and pictorial presen-
tation in graph 1, proved that, about 55 % of women and
48 % of men showed deviation in the range of 0–1 mm,
37 % of women and 50 % of men showed deviation in the
range of 1–2 mm and 8 % of women and 3.7 % of men
showed the deviation in the range of 2–3 mm. Standard
deviation of the above results were insignificant as P values
ranged from 0 to 3 for women and 0–4 for men.
Photo 2 Deviation of facial midline with maxillary teeth midline on
computer screen (3 mm)
Discussion

The midline is the most important focal spot in an esthetic smile.

An off- center midline is readily recognized by the patient [4,
22]. Boucher recommends that the long axis of central incisors
should be parallel to the long axis of the face and the midline of
the dental arch should be located near the middle of the face [7,
23]. The means of the distances from the facial midline to the
upper dental midline was found to be 1.62 ± 0.43 mm in males
and 1.32 ± 0.16 mm in females and is statistically insignificant,
Even when segregated into male and females, mean distances
remained less than 2 mm. The means of the distances between
upper and lower dental midline is found to be 1.45 ± 0.88 mm
Photo 3 Deviation of maxillary & mandibular teeth midlines on
computer screen (2 mm) in males and 1.26 ± 0–83 mm in females. The upper and lower

student co-incide with that on the image. Two points were Table 1 Comparison of deviation of facial midline with maxillary
marked on inner canthus of the eye at the medial border of teeth between male and female population
the punctum using the ‘Pen tool’. Guidelines were drawn Deviation with maxillary Male Female Total
on these points. The distance between the two points was teeth (n = 108) (n = 100) (n = 208)
measured and noted in millimeters as depicted in Photo 1.
Up to 1.0 mm 48 (44.4 %) 55 (55.0 %) 103
Facial midline was obtained by dropping the perpendicular
(49.5 %)
to bisect the inter-canthal distance. Dental midline between
1.00–2.00 mm 54 (50.0 %) 37 (37.0 %) 91 (43.8 %)
the upper central incisors was obtained using the guide
2.00–3.00 mm 4 (3.7 %) 8 (8.0 %) 12 (5.8 %)
tool. The deviation between the facial midline and the
Mean ± SD 1.29 ± 0.72 1.17 ± 0.67 1.23 ± 0.69
maxillary dental midline was noted in millimeters as
(min–max) (0–4.0) (0–3.0) (0–4.0)
depicted in Photo 2. In the same manner deviation between

123
476 J Indian Prosthodont Soc (Oct-Dec 2013) 13(4):473–477

dental midlines never coincide in almost 80 % of the population References

[24–26]. However, the standard deviation in the current study
found to be statistically insignificant. 1. Lombardi RE (1973) The principal of visual perception and their
clinical application to denture esthetics. J Prosthet Dent 29:
Although approximately 63 % of all measurements fall
358–382
within this narrow band, clinical significance may only be 2. Kern BE (1967) Anthropometric parameters of tooth selection.
minimal because the range varied as much as 4.2 mm. J Prosthet Dent 17:431–437
Surely, a midline discrepancy this large would result in an 3. Charles M, Heartwell JR, Rahn AO (1986) Syllabus of complete
denture, IV edn. Lea & Febiger, Philadelphia, pp 256–260
unacceptable esthetic placement for artificial teeth [27, 28].
4. Frush JP, Fisher RD (1956) How dentogenics interpret the per-
Another interesting finding was neither the facial nor the sonality factor. J Prosthet Dent 6:441–449
anatomic measurements changed significantly with age [2, 5. Krajicek DD (1962) Simulation of natural appearance. J Prosthet
28, 29]. The above findings are quite possible to play an Dent 12:28–33
6. Sharry JJ (1969) Complete denture prosthodontics, 2nd edn. Mc
important role in prosthetic tooth selection and arrange-
Grane, New York, p 235
ment in complete and removable partial denture prostho- 7. Boucher CO, Hickey JC, Zarb GA (1975) Prosthodontic treat-
dontics [24, 30]. Statistical data obtained from similar ment for edentulous patients, IV edn. C.V. Mosby Co., St. Louis,
studies may provide a good starting point for contouring pp 387–388
8. Wright SM (1974) Prosthetic reproduction of gingival pigmen-
wax occlusion rims. The data can also be used as a reliable
tation. Br Dent J 136:367–372
guide for setting the maxillary central incisors for esthetic 9. Goldstein RE (1969) Study of need for esthetics in dentistry.
and phonetic requirements in the trial wax denture [25, 26, J Prosthet Dent 21:589–598
31]. In this study some photographs where exact alignment 10. Culpepper WD, Mitchelle PS, Blass MS (1973) Esthetic factor in
anterior tooth restoration. J Prosthet Dent 30:576–582
of the interpupillary line to the frame of the screen when
11. Latta GH Jr (1988) The midline and its relation to anatomic
not possible were discarded. landmarks in the edentulous patient. J Prosthet Dent 59:681–683
The results of this study when compared with that of 12. Cesario VA Jr, Latta GH Jr (1984) Relationship between the
another similar study proved to give similar results [32]. In mesiodistal width of the maxillary central incisor and interpu-
pillary distance. J Prosthet Dent 52:641–643
arrangement of artificial teeth, the mid line may be placed in
13. Tjan AH, Miller GD, Josephene GP (1984) Some esthetic factors
precision with facial mid line or at a slight variance from the in a smile. J Prosthet Dent 51:24–28
facial midline (not [ 2 mm) with no loss in natural appear- 14. Pound E (1954) Lost-fine arts in the fallacy of the ridges.
ance [14, 33]. The most reliable guide in making this decision J Prosthet Dent 4:6–16
15. Bengel W (2006) Mastering digital dental photography: 9–55
would be the patient’s natural tooth prior to extraction [4, 5].
16. Sharland MR (2004a) Dental imaging for the general dental
In the absence of pre-extraction records, it would be most practitioner: 3 extra oral imaging. Dent Update 31:385–390
prudent to place the maxillary midline in the exact middle of 17. Sharland MR (2004b) Dental imaging for the general dental
the mouth using the interpupillary line as a guide [26, 27]. practitioner: 2 intra oral imaging. Dent Update 31:328–332
18. Mckenow HF, Murray AM, Sandler PJ (2005) How to avoid
common errors in clinical photography. J Orthod. 32:43–54
19. Doldo T, Fiorelli G, Patane B (1999) A comparison of three
Limitation digital cameras for internal photography. J Clin Orthod 33:
588–593
The study was conducted on photographs of subjects, 20. Rosner B (2000) Fundamentals of biostatistics, 5th edn. Ameri-
can Public Health Association, Washington, pp 112–114
which is a 2D substitute for 3D object (face), future scope
21. Venkataswamy MR (2002) Statistics for mental health care
of this study lies in using advanced imaging techniques to research. J Econ Hist 58:432–467
obtain 3D image of the individual [18, 34]. A recent study 22. Ortman HR, Tsao DH (1979) Relationship of the incisive papilla
conducted on students of five different Brazilian universi- to the maxillary central incisors. J Prosthet Dent 42:492–496
23. Lyun BD (1964) The significance of anatomic landmarks in
ties concluded, that there exists no significant co relation
complete denture service. J Prosthet Dent 14:456–459
between maxillary dental midline and the bisector of 24. Beder OE (1971) Esthetics—an enigma. J Prosthet Dent 25:
interpupillary line [35]. Similar results of the above study 588–591
are yet to be assessed in Indian population. 25. Mack MR (1996) Perspective of facial esthetics in dental treat-
ment planning. J Prosthet Dent 75:169–176
26. Morley J (1997) Smile design specific considerations. J Calif
Dent Assoc 25:633–637
Conclusion 27. Peck H, Peck S (1970) A concept of facial esthetics. Am J Orthod
40:284–317
Overall means of the deviations between facial midline and 28. Levin E (1978) Dental esthetics and the golden proportion.
upper dental midlines were less than 2 mm. This study con- J Prosthet Dent 40:244–252
29. Cox NH, van der Linden FP (1971) Facial harmony. Am J Orthod
cludes to state, while arranging artificial teeth for the dentures, 60:175–183
the midline may be placed coinciding with facial mid-line or 30. Lombardi RE (1974) A method for the classification of errors in
slightly at a variance from it and not to exceed 2 mm. dental esthetics. J Prosthet Dent 32:501–513

123
J Indian Prosthodont Soc (Oct-Dec 2013) 13(4):473–477 477

31. Collett HA, Briggs DL (1954) Personality factors relating to over 34. Christensen GJ (2005) Important clinical uses for digital pho-
adaptation to dentures. J Prosthet Dent 4:269–273 tography. J Am Dent Assoc 136:77–79
32. Cardash HS, Ortmanier Z, Laufer BZ (2003) Observable devia- 35. Eskelsen E, Ferandes CB, Pelogia F, Cunha LG, Pallos D, Neisser
tion of the facial and anterior tooth midlines. J Prosthet Dent MP, Liporoni PC (2009) Concurrence of maxillary dental midline
89:282–285 and bisector to the interpupillary line. J Esthet Restor Dent
33. Mashid M, Khoshvaqhti A, Varshosaz M, Vallaei N (2004) 21:37–41; discussion 42
Evaluation of golden proportion in individuals with an esthetic
smile. J Esthet Restor Dent 16:185–192; discussion 193

123