Relationship of denture cast

measurements to width of maxillary

anterior teeth
Philip S. Baker, DDS,a Walter J. Morris, DMD,b Carol A.
Lefebvre, DDS, MS,c George A. Price, MSd and Stephen W.
Looney, MS, PhDe
Medical College of Georgia, Augusta, Ga; Veterans
Administration Dental Service, Birmingham, Ala; Sylvan Learning
Center, Augusta, Ga
Statement of problem. When making complete dentures, clinicians may have difficulty with selection of properly sized
denture teeth.

Purpose. The purpose of this study was to determine if there are specific measurements made on an edentulous cast
that could be useful to clinicians for selection of proper maxillary anterior denture tooth width.

Material and methods. Following Institutional Review Board approval, measurements were made on 50 maxillary and
mandibular sets of complete denture casts and their marked and contoured occlusion rims and record bases consecu-
tively submitted to a dental laboratory. The following 6 measurements were recorded for each set of casts: left mid-
maxillary to right mid-maxillary, representing the distance between the respective residual ridge crest points adjacent
to each canine eminence; left retromolar pad to right retromolar pad; incisive papilla to left hamular notch; incisive
papilla to right hamular notch; left hamular notch to right hamular notch; and incisive papilla to vibrating line. These
measurements were statistically compared with the control, the canine-to-canine distance as marked on the con-
toured maxillary occlusion rim to indicate the relaxed commissures. The casts were also classified as small, medium or
large based upon the tooth width specified by the commercial mold guide for their respective canine-to-canine control
measurement. The estimation bias was determined for each of the 6 measurements, and for those measurements for
which the bias was significantly different from zero, a bias-correction was applied. St. Laurents coefficient was used to
describe the agreement between each (bias-corrected) measurement and the canine-to-canine control. A commercial
guide was used to determine the accuracy of each of the 6 bias-corrected measurements in classifying denture teeth
width as small, medium or large as compared to the same classification using the canine-to-canine control.

Results. The bias-corrected measurement from the left hamular notch mark to the right hamular notch mark, ob-
tained by adding 10 mm, exhibited the greatest degree of agreement with the control. This measurement was also the
only one of the 6 that correctly classified more than 50% of both the medium and large casts. None of the 6 measure-
ments classified more than 30% of the small casts correctly.

Conclusions. Of the 6 measurements considered here, the bias-corrected measurement from left hamular notch mark
to right hamular notch mark was preferred for selecting denture teeth width. (J Prosthet Dent 2010;105: 44-50)

Clinical Implications
Based on the results of this study, use of the right hamular notch
to left hamular notch measurement plus 10 mm provides a useful
method for determining the width of the 6 maxillary anterior teeth
for complete denture patients with medium and large cast sizes.

a
Associate Professor, Department of Oral Rehabilitation, Medical College of Georgia, School of Dentistry.
b
Staff Prosthodontist, Veterans Administration Dental Service.
c
Professor, Departments of Oral Rehabilitation and Oral Biology, Medical College of Georgia, School of Dentistry; and Professor,
Department of Graduate Studies School of Graduate Studies, Medical College of Georgia, School of Dentistry.
d
Mathematics Instructor, Sylvan Learning Center.
e
Professor, Departments of Biostatistics and Oral Health and Diagnostic Sciences, Medical College of Georgia School of Dentistry.
The Journal of Prosthetic Dentistry Baker et al
January 2011
When making complete dentures
for edentulous patients, clinicians
may have difficulty with selection
of the properly sized denture teeth.
Since the patient has no teeth remain-
ing and often no records to serve as a
guide, it is necessary to make a clini-
cal decision based upon other infor-
mation or techniques. Many methods
are presented to aid in tooth selec-
tion, but these are not specific.1-17
Young reviews 21 techniques, span-
ning 1700 to 1951. Despite the variety
of methods, he concludes that none
is satisfactory, and recommends the
cultivation of the operators esthetic
sense as the most effective tooth se-
lection technique.18 For the beginning
dentist, this approach is impractical.
Three methods are commonly used
today for selecting the width of the 6
maxillary anterior teeth: The first is
Berrys biometric ratio method, which
is based on the 1:16 maxillary central
incisor width to bizygomatic width ra-
tio introduced in 1905.19 Several man-
ufacturers have created tooth molds
extrapolating this measurement into
complementary lateral incisor and ca-
nine widths to create matched sets to
further simplify selection. The Trubyte
Tooth Indicator (Dentsply Trubyte,
York, Pa) is a commercial aid based
on the biometric ratio, and can be
used for estimating the width, length,
and outline and profile forms of the
maxillary anterior. Secondly, interalar
width measurement is also used as a
method to determine denture tooth
1 Canine-to-canine distance determination.
Baker et al
width. An estimate of the cusp tip
location of the maxillary canines can
be made by extending parallel lines
from the ala of the nose onto the la-
bial surface of the contoured occlu-
sion rim, and measuring the distance
between the marks on the facioincisal
of the rim along the curve with a flex-
ible ruler. Mavroskoufis and Ritchie,6
however, found that this method un-
derestimated the intercanine cusp tip
width by approximately 7 mm. They
suggested adding this amount to the
measurement of the individuals nasal
width to provide a more harmonious
length of arc. A commercial guide, the
Ivoclar Vivadent BlueLine Form Selec-
tor (Ivoclar Vivadent, Amherst, NY),
features a caliper, called the Facial
Meter, for correlation of the patients
interalar dimension with tooth mold
width. Thirdly, the distance between
the marks indicating the relaxed cor-
ners of the mouth, measured along
the incisal curvature of the contoured
occlusion rim with a flexible ruler
(Figure 1), represents an appropri-
ate width for the 6 maxillary ante-
rior teeth.20 This method, called the
canine-to-canine distance determina-
tion, is considered to be the control
for the present investigation, since it
has been shown to have the highest
correlation with the width of the nat-
ural maxillary anterior teeth in previ-
ous studies.21,7
An experienced dentist or labora-
tory technician can frequently assess
cast size, and from that determine the
45
size of denture teeth needed without
direct intraoral examination. For the
inexperienced clinician, some dimen-
sion of casts of edentulous patients
that can be used to select accurately
the appropriate size of denture teeth
would be helpful. The purpose of this
study was to determine if there are
specific measurements made on an
edentulous cast that could be useful
to clinicians for selection of proper
denture tooth size. The null hypoth-
esis tested was there would be no spe-
cific cast measurement that would be
useful to clinicians to determine den-
ture tooth size.
MATERIALS AND METHODS
Following approval from the Insti-
tutional Review Board of the Medical
College of Georgia (MCG), measure-
ments to the nearest tenth of a milli-
meter (mm) were made on 50 maxillary
and mandibular complete denture casts
and their marked and contoured occlu-
sion rims and record bases consecu-
tively submitted to the MCG School
of Dentistry Removable Prosthodontic
Laboratory for tooth arrangement. An
adequate sample size was based on the
desired confidence interval width rath-
er than power.
The maxillary occlusion rims were
fabricated to the following standard-
ized dimensions, which normally pro-
vide a slight excess of wax for final
contouring. The anterior region is 22
mm in height, as measured from the
notch formed by the labial frenum to
the occlusal plane. The labial surface
is inclined 15 degrees facially from the
record base to provide lip support,
and the labioincisal positioned 8 mm
anterior to the middle of the incisive
papilla. The posterior region is 12 mm
in height, from the record base at the
residual ridge crest in the tuberosity
area to the occlusal plane. The occlu-
sion rim extends posteriorly to a point
8 mm from the posterior edge of the
record base, and slopes anteriorly to-
ward the occlusal at a 45-degree an-
gle. The occlusal plane is established
parallel to the residual ridge crest and
46
the base of the definitive cast. The
width of the occlusion rim is 6 to 8
mm anteriorly, and 8 to 10 mm poste-
riorly, and tapers toward the occlusal
plane to form these widths.22
The following sequence was used for
modification of the record bases and
occlusion rims for each patient.23After
initial fitting procedures, the maxil-
lary record base and occlusion rim
were placed intraorally and the la-
bial inclination of the rim modified
for adequate lip support. Because
the contour of the labial surface of-
ten directly affects the incisogingi-
val position of the upper lip, it was
established first. Lip support was
considered appropriate according to
the following guidelines: reasonable
exposure of the lip margin; preserva-
tion of the labial philtrum; adequate
support of the nasolabial folds; lack
of either a strained appearance due
to over support, or collapsed appear-
ance due to undersupport; and satis-
factory mobility of the upper lip.
Next, the lip length was evaluated.
The maxillary record base and occlu-
sion rim were removed from the mouth
and the tip of the operators index fin-
ger placed on the crest of the residual
ridge in the anterior region. The upper
lip was allowed to rest over the finger
with the facial muscles relaxed. The
thumb of the same hand was placed
at the edge of the upper lip, and the
amount of the index finger covered by
the lip noted as a rough indication of
the lip length in relation to the maxil-
lary residual ridge. If the lip ended al-
most level with the crest of the residual
ridge, the lip was considered short. If
the lip projected 4-5 mm below the
crest, it was average in length. If the
edge of the lip was 6mm or more be-
low the crest, it was considered long.
Once the lip length was deter-
mined, the amount of visible central
incisor with relaxed facial muscula-
ture was established. If the lip was
short, some of the occlusion rim
(and later, the teeth) should be visible
when the patients face is at rest. If the
lip was long, the occlusion rim may
not extend the full length of the lip.
The Journal of Prosthetic Dentistry
If the upper lip was of average length,
then the rim often extends just below
(1-2 mm) the resting length of the
lip. Depending upon the patient, the
amount of occlusion rim and even-
tually denture teeth that are visible
when the patient is at rest may vary
from not being visible to being visible
4 mm or more.
With the maxillary occlusion rim
and record base in the mouth, a mark
was made in the anterior region to
indicate the estimated length of the
teeth, and this mark extended hori-
zontally to parallel the interpupillary
line. The incisal plane of most anterior
teeth is in harmony with the interpupil-
lary line, however this was considered
only a guide. The occlusion rim and
eventually the denture teeth must be
in harmony with the patients smile.
This may mean that the plane may not
exactly parallel the interpupillary line.
The occlusion rim was then marked
posteriorly, so that the occlusal plane
was parallel with a line from the ala
of the nose to the tragus of the ear
(Campers plane).
The plane of occlusion was then
established on the occlusion rim by
shortening the wax to the anterior
and posterior marks, and testing the
rim intraorally for parallelism with the
interpupillary line, Campers plane
and esthetics. This initial plane of oc-
clusion was tentative, however, and
may have required revision as the
mandibular record base and occlu-
sion rim are adjusted.
The midline of the face was then
determined and transferred to the
maxillary occlusion rim as a 6 mm
long, narrow groove extending superi-
orly from the occlusal surface. A hori-
zontal line was then marked across the
midline groove, corresponding to the
edge of the upper lip in the highest
smiling position. In the authors opin-
ion, this generally indicates the mini-
mum tooth length for good esthetics
for medium and long lip lengths. For
a patient with short lip length, expo-
sure of the gingiva may occur with just
a half-smile, or with the lip at rest in
extreme situations, even with the lon-
Volume 105 Issue 1
gest tooth mold selected. The patient
should be informed of this prior to
setting the teeth.
Next, lines were scribed on the
labial surface of the occlusion rim,
corresponding to the commissures of
the lips at rest. The canine-to-canine
measurement, treated as the control,
was made by using a flexible ruler to
measure the distance between the
marks indicating the relaxed corners
of the mouth on the contoured max-
illary occlusion rim. The following 6
measurements (Figs. 2 and 3), made
using a Boley millimeter gauge cali-
per (Hu-Friedy, Chicago, Ill), accurate
to 0.1 mm, were evaluated for their
usefulness in helping clinicians select
denture teeth of a specific width: 1)
from the left mid-maxillary mark to
the right mid-maxillary mark, indi-
cated by the respective residual ridge
crest point adjacent to the canine emi-
nence, 2) from the left retromolar pad
to the right retromolar pad, 3) from
the incisive papilla to the left hamular
notch mark, 4) from the incisive pa-
pilla to the right hamular notch mark,
5) from the left hamular notch mark
to the right hamular notch mark, and
6) from the incisive papilla to the vi-
brating line mark. These measure-
ments were collectively referred to as
the 6 measurements. One evaluator
made all measurements.
Descriptive statistics were calcu-
lated for each of the 6 measurements
as well as for the canine-to-canine
measurement. The estimation bias for
each of the 6 measurements was de-
termined by first subtracting the mea-
surement from the canine-to-canine
value for each cast, and then calculat-
ing summary statistics for the mea-
surement differences. If the differences
were found to be non-normally distrib-
uted using the Shapiro-Wilk test, the
median and a non-parametric confi-
dence interval were used to estimate
the bias. Otherwise, a confidence in-
terval based on the t-distribution was
used. For those measurements for
which the bias was significantly dif-
ferent from zero, a bias-corrected ver-
sion was obtained by adding the ap-
Baker et al
January 2011 47
so that the width of the confidence
interval would be no greater than
0.30 when all casts were considered.
The previously mentioned statistical
analyses were performed using statis-
tical software (SAS 9.1; SAS Institute,
Inc, Cary, NC; StatXact-7; Cytel, Inc,
Cambridge, Mass; and PEPI V.4.0;
Sagebrush Press, Inc, Salt Lake City,
Utah). A confidence coefficient of 95%
was used throughout.

RESULTS

2 Maxillary definitve cast with points and lines of mea- Based on the Shapiro-Wilk test re-
surement shown. Point A- center of incisive papilla; points sults, only the measurements from the
B- right, and C- left mid-maxillary marks, indicating re- left mid-maxillary mark to the right
spective residual ridge crest points at the canine eminence; mid-maxillary mark (P=.003) and
point D- right hamular notch; point E- left hamular notch
from left hamular notch mark to right
mark; point F- midsagittal vibrating line mark. Line G- dis-
hamular notch mark (P=.001) were
tance from incisive papilla to vibrating line mark; line H-
distance from incisive papilla to right hamular notch; line non-normally distributed. Therefore,
I- distance from incisive papilla to left hamular notch; line the median was used rather than the
J- distance from right to left mid-maxillary marks; line K- mean as a summary statistic for those
distance from right and left hamular notch. (Figure from 2 measurements (Table I). On aver-
Rahn AO, Ivanhoe JR, Plummer KD, editors. Textbook age, the 50 casts included in this study
of complete dentures. 6th ed. Reprinted with permission were in the medium-to-large range, as
from Peoples Medical Publishing House.) determined by the summary statis-
tics for the canine-to-canine control
(Table I). Based on the Shapiro-Wilk
test results, only the difference be-
tween the control and the measure-
ment from the incisive papilla to the
left hamular notch mark was non-
normally distributed (P=.027). There-
fore, the median was used rather than
the mean as a summary statistic for
these differences (Table II). Four of
the 6 measurements demonstrated
significant bias in estimating the ca-
nine-to-canine control; the lone ex-
ceptions were the measurements from
3 Mandibular definitive cast with points and lines of
the incisive papilla to the left and right
measurement shown. Line L indicates distance between
hamular notch marks (Table II). Of
centers of left and right retromolar pads.
the 4 measurements with significant
propriate estimate of the bias (either the 6 (bias-corrected) measurements bias, 3 were positively biased and one
the mean or the median) to each val- in classifying denture teeth width as was negatively biased in its estimation
ue of the measurement. St. Laurents small (45.5 mm to 48.0 mm in me- of the control (Table II). A bias-cor-
coefficient24, along with a 95% confi- siodistal width), medium (48.5 mm rected version of each of these 4 was
dence interval, was used to describe to 51.0 mm), or large (51.5 mm to created by adding the estimated bias
the agreement between each (bias- 56.0 mm), as compared to the same (rounded to the nearest whole mm)
corrected) measurement and the ca- classification using the canine-to-canine to the original measurement. The 4
nine-to-canine control. In addition, control. Exact confidence intervals for bias-corrected measurements, along
an Ivoclar Vivadent Mold Chart (Ivo- the proportion correctly classified were with the 2 that were not bias-corrected,
clar Vivadent, Amherst, NY) was used calculated using the binomial distribu- indicated fair-to-good agreement with
to determine the accuracy of each of tion. A sample size of 50 was chosen the control, as measured by St. Lau-
Baker et al
48 Volume 105 Issue 1

Table I. Summary statistics (mm) for canine-to-canine control and other measurements (n=50)
Measurement Mean (SD) Median (IQR) 95% CI

Canine-to-canine 51.7 (2.7) (50.9, 52.4)

Left mid-maxillary mark to right mid-maxillary mark* 38.2 (3.9) (37.4, 38.9)

Left retromolar pad to right retromolar pad 54.6 (3.6) (53.5, 55.6)

Incisive papilla to left hamular notch mark 52.1 (4.5) (50.8, 53.3)

Incisive papilla to right hamular notch mark 52.1 (4.3) (50.8, 53.3)

Left hamular notch mark to right hamular notch mark* 41.0 (4.4) (40.5, 43.2)

Incisive papilla to vibrating line mark 46.0 (3.9) (44.9, 47.1)

IQR: Inter-quartile range.

*Measurements are non-normally distributed.

Table II. Summary statistics for estimated bias (in mm) for each measurement (n=50)
Measurement Mean (SD) Median (IQR) 95% CI

Left mid-maxillary mark to right mid-maxillary mark 13.7 (4.4) (12.4, 14.9)

Left retromolar pad to right retromolar pad 2.9 (3.7) (3.9, 1.8)

Incisive papilla to left hamular notch mark* 1.4 (7.3) (2.8, 0.5)

Incisive papilla to right hamular notch mark 0.4 (4.2) (1.6, 0.8)

Left hamular notch mark to right hamular notch mark 9.8 (3.2) (8.9, 10.7)

Incisive papilla to vibrating line mark 5.7 (3.6) (4.6, 6.7)

IQR: Inter-quartile range.

*Differences from control are non-normally distributed.

Table III. St. Laurents coefficient of agreement between each measurement

and the canine-to-canine control (n=50)

Measurement rg 95% CI

Left hamular notch mark to right hamular notch mark + 10 mm 0.65 (0.54, 0.75)

Incisive papilla to vibrating line mark + 6 mm 0.60 (0.49, 0.70)

Left retromolar pad to right retromolar pad 3 mm 0.59 (0.49, 0.70)

Incisive papilla to left hamular notch mark 0.54 (0.44, 0.65)

Incisive papilla to right hamular notch mark 0.54 (0.44, 0.65)

Left mid-maxillary mark to right mid-maxillary mark + 14 mm 0.52 (0.42, 0.63)

rg: St. Laurents coefficient

The Journal of Prosthetic Dentistry Baker et al
January 2011 49

Table IV. Results for each measurement in classifying size of denture teeth (n=50)
Proportion Correctly Classified
(95 % CI)

Measurement Small (n=7) Medium (n=18) Large (n=25)

Left hamular notch mark to right hamular notch 0.14 0.67 0.60
mark + 10 mm (0.00, 0.58) (0.41, 0.87) (0.39, 0.79)

Incisive papilla to vibrating line mark + 6 mm 0.29 0.33 0.64

(0.04, 0.71) (0.13, 0.59) (0.43, 0.82)

Left retromolar pad to right retromolar 0.29 0.39 0.72

pad 3 mm (0.04, 0.71) (0.17, 0.64) (0.51, 0.88)

Incisive papilla to left hamular notch mark 0.29 0.11 0.64

(0.04, 0.71) (0.01, 0.35) (0.43, 0.82)

Incisive papilla to right hamular notch mark 0.29 0.17 0.60

(0.04, 0.71) (0.04, 0.41) (0.39, 0.79)

Left mid-maxillary mark to right mid-maxillary 0.29 0.33 0.52

mark + 14 mm (0.04, 0.71) (0.13, 0.59) (0.31, 0.72)

rents coefficient (Table III). The bias-
corrected measurement from the left
hamular notch mark to the right ham-
ular notch mark exhibited the great-
est degree of agreement. This mea-
surement was also the only one of the
6 that correctly classified more than
50% of both the medium and large
casts (Table IV). None of the 6 mea-
surements classified more than 30%
of the small casts correctly; however,
the low number of small casts (n=7)
in the sample prevented any definitive
conclusions from being drawn.
DISCUSSION
Based upon the results of this
study, the null hypothesis was re-
jected. The results in Tables III and
IV indicate that if one measures the
distance from the left hamular notch
mark to the right hamular notch mark
in mm using a Boley gauge, and then
adds a bias correction of 10 mm, the
resulting value will provide reasonable
results if used to determine the width
of maxillary anterior denture teeth for
medium and large casts. However, for
Baker et al
small casts, additional research is re-
quired to identify a valid method for
determining the appropriate size of the
denture teeth. Advantages of the pro-
posed method are that it requires only
a commonly used dental instrument
for measurements, and enables even
the inexperienced dentist to select an
appropriate width of maxillary ante-
rior tooth mold for patients using eas-
ily identified anatomical landmarks. In
contrast to methods that determine
an intercanine cusp tip dimension or
width of a single tooth, the technique
presented here directly calculates the
total width of the maxillary anterior
teeth as measured on the curvature
of the arch, a dimension commonly
listed by denture tooth manufactur-
ers in their printed mold guides. For
dentists preferring a different tech-
nique for tooth width determination,
the proposed method can be used to
verify appropriate width selection.
Limitations of this study include the
low number of small casts available,
and the possible effects of gender and
ethnicity upon the results. showed fair-to-good agreement with
CONCLUSIONS
Within the limitations of the pres-
ent study, the following conclusions
were drawn:
1. The bias-corrected measure-
ment from the left hamular notch
mark to the right hamular notch mark
was shown to provide the greatest
degree of agreement with the control
canine-to-canine measurement for se-
lecting denture teeth for all cast sizes.
2. The bias-corrected left hamular
notch mark to right hamular notch
mark measurement was the only one
that classified more than 50% of both
medium and large casts correctly.
3. The 4 bias-corrected measure-
ments (left hamular notch mark to
right hamular notch mark, incisive
papilla to vibrating line mark, left ret-
romolar pad to right retromolar pad,
left mid-maxillary mark to right mid-
maxillary mark) and 2 uncorrected
measurements (incisive papilla to
left hamular notch mark, and incisive
papilla to right hamular notch mark)
the control for all cast sizes.
50
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Corresponding author:
Dr Philip S. Baker
School of Dentistry
Medical College of Georgia
AD-3114A
1459 Laney Walker Boulevard
Augusta, Georgia 30912-1260
Fax: 706 721-8349
E-mail: pbaker@mail.mcg.edu
Acknowledgment
The original idea and all measurements for
this manuscript came from our beloved friend,
talented mentor and tireless scholar, John R.
Ivanhoe, DDS, Professor Emeritus, who passed
away in August 2008. This work is dedicated
to his memory.
Copyright 2010 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Baker et al