The face-form as a guide for the selection of maxillary

central incisors
F. Mavroskoufis, D.D.S., M.Sc.,* and G. M. Ritchie, M.D.S., L.D.S.R.C.S.*
University College Hospital Dental School, London, England

lh e se1ection of maxillary anterior teeth for theory” with anthropologic arguments, formulated
complete dentures has long posed a problem in and publicized a method called the “law of harmo-
clinical practice, and a controversy about the best ny” which is still widely used at the present time.
method to employ still exists. Several methods are of Williams believed that a relationship exists between
questionable validity, and many dentures have an the face-form and the form of the maxillary central
obviously artificial appearance. As no universally incisor in most people and that this relationship
accepted method for selection of teeth has yet been should be taken into account in the tooth selection
established, dentists seek guidance from a variety of procedure. He described three “typal” or “basic”
techniques using their clinical experience and esthet- forms of teeth (tapering, ovoid, and square) and
ic sense to attain what is hoped will be an acceptable some intermediate and composite forms. Many later
result. Some methods aim to establish the size or guides to tooth selection were based on simplified
width of groups of teeth comprised of either the six versions of Williams’ hypothesis. Although this
anterior teeth, four incisors, or just the two central method or variations of it have been widely used for
incisors. Others try to predict the size or form of tooth selection, it cannot claim to achieve entirely
individual teeth, usually the upper central incisor. satisfactory esthetic results.
This article assesses the forms of replacement One of the methods introduced by the Dentists’
maxillary central incisor teeth since it is generally Supply Company*, 9. I3 employed an “indicator”
believed that incorrect choice of these teeth is often instrument for establishing the patient’s facial out-
responsible for poor denture esthetics.1-Y line. The “indicator” was made of clear plastic and
had a triangular cut out to allow for the nose. There
REVIEW OF THE LITERATURE were “eye slots,” a median line for centering with the
A method of selecting teeth according to the eyes and the median line of the face, and parallel
“temperament of the patient” was popularly accepted vertical lines. By comparing these vertical lines with
during the second half of the nineteenth and early the sides of the patient’s “apparent face,” one could
twentieth century.‘” This method was based on a fifth assess the individual face-form.
century B.C. concept attributed to Hippocrates con- Another technique, suggested by the Austenal
cerning a simple way of classifying illness according to Company, using the “Automatic Instant Selector
the macroscopic symptoms. The temperamental theo- Guide”“, ’ correlated form, size, and appearance so
ry became a complex system for classifying people that only one reading was needed for the selection of
according to their physical characteristics and related the “correct” tooth. However, no information could
to their supposed susceptibility or immunity to various be found which explained the details of this tech-
conditions. These physical characteristics were nique.
employed as a basis for tooth selection. Wright” suggested the use of old photographs of
White and Berry” indicated that harmony the patients’ natural teeth. Krajicek” I6 and others
appeared to exist between the proportions of the proposed methods involving the duplication of the
teeth and those of the face. However, it was Wil- patients’ natural teeth either before or after extrac-
liamsle5 who, after rejecting the “temperamental tion. Klein,‘? Hayward,” and Kafandaris and Theo-
dorou’g suggested incorporating the patients’ natural
*Dental Prosthetics Department. teeth in the denture and recorded techniques to

OOZ-3913/80/050501 + 05$00.50/O 0 1980 The C. V. Mosby Co THE JOURNAL OF PROSTHETIC DENTISTRY 501

Fig. 1. Outline form of a maxillary central incisor for
projection to be superimposed on the face-forms.
overcome the bonding problems between natural
teeth and denture base materials.
The common characteristic of these methods is
that they do not rely on guidance for the selection of
artificial teeth but employ the natural teeth or try to
match or reproduce their natural forms.
Frush and Fisher,*O*21in a series of articles under
the title “Dentogenic Dentures,” tried to establish a
new concept in denture esthetics by combining tooth
selection stages with a further individualization of
the teeth according to sex, personality, and age.
They claimed that if these three qualities were
correctly interpreted, the dentures would have a
natural appearance.
Lee’P ideas on denture esthetics were based on
Williams “law of harmony” but elaborated further
by consideration of additional anatomic features and
suggested modification of the incisal edges and
cervical dimensions according to the related widths
of the forehead and the mandible.
INVESTIGATION
An investigation was made using 70 dental
students, predominantly white, to assessthe validity
of the method based on Williams “law of harmony”
for the selection of upper central incisor teeth.
502
Though Williams1-5 and Clapp6, 7 had used the
“apparent” face for their correlations, it was thought
that a reevaluation of the method would be more
complete if the teeth forms were compared with both
the “apparent” and the “actual” face of the
subject.
The “apparent” face is defined as the portion of
the face that extends from the “adolescent hairline”
to the gnathion, and it is divided into upper, middle,
and lower thirds by the glabella and the subnasion.
Sears24-26 defined the “actual” face as extending from
the glabella to the gnathion and divided into upper
and lower halves by the subnasion. The “actual”
face undergoes fewer changes than the “apparent”
face and therefore can be considered more constant
for reference,*? but the “apparent” face is more valid
esthetically since it represents the visible face.
DeVan** believed that a prosthesis should estab-
lish the best possible appearance of a patient at the
moment of treatment and therefore logically the
“apparent” face should be employed.
METHOD
Two photographs of each student were made, one
full face and the other an intraoral view of the two
maxillary central incisors. The standardized full-face
photographs were made with the head of the subject
positioned so that the face was parallel to the
perpendicular and the facial outline undistorted by
an artificial double-chin effect or cheek pouching.
The hair did not cover any part of the “apparent”
face and the teeth of all subjects were in centric
occlusion.
The lens of the camera was prefocased at the
beginning of the procedure so that all photographs
were made with a fixed distance between face and
film. The position of the camera was also standard-
ized so that it was parallel to the face to avoid
distortion.
The slides were projected onto a white screen and
the outline forms first of the “actual” and then of the
“apparent” face were drawn approximately life size
on thin white paper of appropriate translucency. On
the “actual face” outline, a straight line joined the
highest points of the eyebrows, the ends of it then
bending downward (following the direction of the
eyebrows) to meet the most lateral visible point of
the zygomatic arch. From there, each line continued
downwakd by following the outer lines of the cheeks
and chin, until meeting in the region of the symphe-
sis menti.
When recording the “apparent” face, the upper
portion of the outline was drawn to follow the
MAY 1980 VOLUME 43 NUMBER 5
FACE-FORM GUIDE IN MAXILLARY CENTRAL INCISORS

Fig. 2. Correlation of tooth outline with that of the “apparent” face. A, Identical forms. 8,
Similar forms. C, Dissimilar forms.

Table I. Relation of face-forms to maxillary central incisor tooth form

Tooth forms

Identical Similar Dissimilar

“Apparent” face Left2 Left 17 Left 51

Right 6 I 8 (5.7%] Right 19 I 36 (25.6%) Right 45 I 96 (68.7%)
“Actual” face Left 0 Left 10 Left 60
Right 2 2 (1.45%) Right 12 I 22 (15.75%) Right 56 116 (82.8%)

hair-skin border line, thus including the forehead of grammatic representation of the face-forms for com-
the subject into the face-form. parison (Fig. 1).
The slide projector was positioned on a mobile The difference in length between the compared
table, so that it could be moved forward or back- forms was then measured and expressed as a percent-
ward, thus making changes of magnification possi- age in relation to the length of the face-form and this
ble. The “actual” face form was attached to the was employed to express .the degree of dissimilarity.
screen, and the tooth form was projected on it so that The following formula was devised for assessing the
the margins of the tooth were made to coincide as comparability of face-forms and tooth forms:
closely as possible with the outline of the face-
form.
Subsequently the projected outline forms of the
maxillary central incisors were drawn on the dia- L, was the length of the recorded face-form, and L,

THE JOURNAL OF PROSTHETIC DENTISTRY 503

 Fig. 3. Correlation of tooth outline with that of the “actual” face outline form. A, Identical
fo;ms. B, Dissimilar forms.
was the projected length of the tooth form drawn on
the face diagram. The tooth slide magnification
ranged between 13 X and 15 X . When D did not
exceed l%, which implied a negligible difference in
length, the related forms were considered identical.
When D ranged between 1% and 7%, the compared
forms were designated as “similar.” When any value
exceeded a 7% difference, the forms were considered
“dissimilar.”
The same procedure was employed for compari-
sons with both “actual” and “apparent” face-forms
and with both left and right maxillary central incisor
forms, because previous work by Mavroskoufis and
Ritchie”, 3o had shown that only a minority of
people have identical form of these teeth.
RESULTS
The comparison of 70 “apparent” face-forms with
the outline forms of the 140 maxillary central inci-
sors (70 left and 70 right) showed that for eight
students (5.7%) the correlated forms,were identical,
and for 36 students (25.6%) they were similar but not
identical (Table I). However, for 96 students (68.7%)
there was a dissimilarity between the tooth and
face-forms (Fig. 2). In the comparison between tooth
forms and the respective “actual” face form the
dissimilarity was even more pronounced, revealing a
dissimilarity in 116 subjects (82.8%). Twenty-two
subjects (15.75%) were “similar,” but there were only
two identical situations (1.45%) (Fig. 3).
CONCLUSIONS
From the collated results it is apparent that there
is no evidence for coincidence of face-form and
maxillary central incisor tooth form and that the
selection of teeth based on the supposed “law of
504
harmony” has no validity. These observations show
that there is a much greater percentage of dissimilar-
ity between incisor and face-form, both “actual” and
“apparent” than similarity.
It is interesting to note that where there was a close
conformity of face-forms and tooth forms there was
also a close similarity or identical tooth forms of both
left and right maxillary central incisors.
In patients with similarity of “actual” face-form
and tooth form, the teeth were either short, square,
or very wide. Similarity of “apparent” face-form and
tooth form occurred from long, narrow teeth.
Although the observation is subjective, this apparent
coincidence did not produce the expected pleasing
appearance. The more esthetically pleasing appear-
ances were noted where there was dissimilarity of
face-form and tooth form.
SUMMARY
The outline forms of both maxillary central incisor
teeth were compared with the “actual” and “appar-
ent” face-forms in 70 subjects, to determine whether
a close similarity of face-forms and tooth forms
exists, which would support the “law of harmony”
method for the selection of replacement of teeth.
The results of the investigation do not support the
contention of Williams but rather invalidate this
method of teeth selection because more than two-
thirds of the individuals showed no similarity
between face-form and incisor tooth form.
We would like to thank Mrs. Rosemary Clifford, MA. for
statistical advice and Mr. Charles Day for the photographs.
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MAY1980 VOLUME 43 NUMBER 5
FACE-FORM GUIDE IN MAXILLARY CENTRAL INCISORS

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(Submitted for publication.)
Reprint requeststo:
DR. G. M. RITCHIE
UNIVERSITY COLLEGE HOSPITAL
DENTAL SCHOOL
MORTIMER MARKET
LONWN WClE 6JD, ENGLAND

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