RESEARCH AND EDUCATION

Comparison of maxillary anterior tooth width and facial

dimensions of 3 ethnicities
Ewa C. Parciak, DDS, MS,a Ankur T. Dahiya, BDS, MDS, MSD,b Hamad S. AlRumaih, BDS, MSD,c
Mathew T. Kattadiyil, BDS, MDS, MS,d Nadim Z. Baba, DMD, MSD,e and Charles J. Goodacre, DDS, MSDf

ABSTRACT
Statement of problem. As the cosmetic demands of patients increase, determining the appropriate dimensions of the maxillary anterior
teeth has become increasingly relevant. The relationship between facial measurements and tooth size provide guidance for maxillary anterior
tooth size selection. However, most publications on this topic have focused on the white population, and more data for tooth sizes and their
proportions in other ethnicities are needed.
Purpose. The purpose of this observational study was to investigate the relationship between the mesiodistal dimensions of the 6 maxillary
anterior teeth and the bizygomatic width, interpupillary distance, intercanthal distance, interalar width, and intercommissural width of
individuals of Asian, African-American, and white ethnicities.
Material and methods. Standardized digital images of 360 participants (120 Asian, 120 African-American, and 120 white) were used to measure
facial segments. Individual dimensions of the 6 maxillary anterior teeth were measured using stone casts with digital sliding caliper. The
combined width of the 6 maxillary anterior teeth on a straight line corresponded to the sum of the anterior tooth width. The means and
standard deviations from descriptive measurements were calculated and analyzed for face and maxillary anterior tooth ratios and
correlations. Statistical analysis was done using the Kruskal-Wallis procedure to compare facial and tooth parameters among the 3 ethnicities.
Appropriate post hoc comparisons that adjusted for multiple testing were conducted when warranted (a=.05). The Spearman rho correlation,
a nonparametric correlate of the Pearson correlation, was used to associate the facial and tooth parameters within the strata of sex and ethnicity.
Results. No consistent ratios were found among the examined facial dimensions and the mesiodistal dimensions of the 6 maxillary anterior
teeth among the 3 ethnicities, except for the central incisor width-to-bizygomatic width ratio. No correlations were found between the facial
dimensions and mesiodistal dimensions of the 6 maxillary anterior teeth among the 3 ethnicities except in Asian women. For Asian women,
the intercommissural width correlated with the width of the central incisor (P=.001), the width of 2 central incisors (P=.001), the width of 4
incisors (P=.003), and the width of 6 maxillary anterior teeth (P=.005).
Conclusions. No facial proportions by which the exact width of maxillary anterior teeth could be predicted were found in Asian, African-
American, or white populations. (J Prosthet Dent 2017;-:---)

Dental esthetics and facial appearance have become
important to this current generation, resulting in an
increased interest in achieving optimal treatment out-
comes.1 In addition, the generation approaching 70 years
of age recognizes that maintaining their natural dentition
improves appearance and smile and serves as a visible
sign of successful aging.2
Lombardi3 stated that the proportion of selected tooth
molds should be balanced with facial anatomy. Levin4
indicated that the golden proportion gives the most

Supported by a research grant from Loma Linda University. This research was completed in partial fulfillment of the requirements for the degree of Master of
Science in Prosthodontics (E.C.P.). Presented at the Pacific Coast Society for Prosthodontics 80th Annual Scientific Meeting, June 2015 in Deer Valley, Utah.
a
Prosthodontist, Private practice, Loma Linda, Calif.
b
Prosthodontist, Private practice, Austin, Texas.
c
Resident, College of Dentistry, University of Dammam, Dammam, Saudi Arabia.
d
Professor and Director, Advanced Specialty Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.
e
Professor and Director, Hugh Love Center for Research and Education in Technology, Loma Linda University School of Dentistry, Loma Linda, Calif.
f
Distinguished Professor, Advanced Specialty Education Program in Prosthodontics, Loma Linda University School of Dentistry, Loma Linda, Calif.

THE JOURNAL OF PROSTHETIC DENTISTRY 1

2 Volume
Clinical Implications
The anterior tooth width on a straight line emerged
as the most relevant information that clinicians
could use to select appropriate anterior tooth size
based on ethnicity and sex.
harmonious teeth ratios, but Preston5 observed that
natural tooth ratios rarely follow the golden proportion.
A Web-based study evaluating dentists’ preferences for
anterior tooth proportion also found minimal correlation
between beautiful smiles and the golden proportion.6
Instead, the authors introduced the concept of the
recurring esthetic dental proportion, stating that clini-
cians could use their own preference when establishing
the proportion, as long as it remained consistent.
When pre-extraction records are unavailable, select-
ing the appropriate size of the anterior teeth becomes
somewhat arbitrary. Different anatomic landmarks have
been proposed to aid in determining the correct size of
the anterior teeth, including bizygomatic width, inter-
pupillary distance, intercanthal distance, interalar width,
and intercommissural width.3-20
Berry7 reported that the ratio of the maxillary central
incisor width to the bizygomatic width was 1:16. House
and Loop8 found a range of ratios between 1:13 and 1:19
and stated the bizygomatic width may not be a reliable
guide for estimating the width of maxillary central in-
cisors. In a later study, Scandrett et al9 also concluded
that bizygomatic measurements might not be a reliable
means of selecting the width of maxillary central incisors.
When eye measurements were evaluated, Cesario and
Latta10 found that a factor of 1:6.6 existed between the
mean interpupillary distance and the mean mesiodistal
width of the maxillary central incisor. According to Al
Wazzan,11 the intercanthal distance is correlated with the
mean width of 2 central incisors, the combined width of the
central incisors, the combined width of the 4 incisors, and
the total width of the 6 maxillary anterior teeth. Abdullah12
found the intercanthal distance to be in golden proportion
to the combined width of the maxillary central incisors.
Krajicek,13 using a human skull study, found the
width of the 4 maxillary incisors equaled the nasal width
when measured in the skulls; however, on soft tissue, the
interalar width was correlated more with the width of the
6 maxillary anterior teeth, as shown by Mavroskoufis and
Ritchie.14 Hoffman et al15 noted that the interalar width
when multiplied by 1.31 gave the combined width of the
maxillary 6 anterior teeth. Smith,16 in contrast, found that
neither nasal width nor interalar width correlated with
the width of the 6 maxillary anterior teeth.
Clapp and Tench17 determined the distal surfaces of
the maxillary canines to be located at the commissures of
THE JOURNAL OF PROSTHETIC DENTISTRY
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the mouth at rest. Silverman18 found that the distal
surface of maxillary canines was within 4 mm of the oral
commissures while another study by Al Wazzan et al19
found no correlation between the width of the mouth
and the mesiodistal width of the maxillary 6 anterior
teeth. Several studies proposed that more than one
measurement of the face may be needed to obtain the
best decision for maxillary anterior tooth width.9,19,20
Johnson21 reported that knowledge of the facial
appearance of people of different ethnicities might aid
practitioners, as the treatment provided would be in
balance with their facial appearance. However, few
studies have reported tooth size variation between and
within different ethnic groups. Keene22 reported that
tooth sizes among African-Americans were slightly larger
than those in whites. Turner and Richardson23 also
observed that teeth in Kenyan individuals were signifi-
cantly larger than their Irish counterparts. In another
related study, Bishara et al24 compared the mesiodista1
and buccolingual crown dimensions of the permanent
teeth in 3 ethnic groups from Egypt, Mexico, and the
United States. They found significant differences in the
mesiodistal dimensions among the 3 populations.
Rosenstiel and Rashid,25 in their Web-based study,
determined the public’s preferences for esthetics with
recognition of sex, country of residence, and ethnicity.
The strongest preferences were recorded for midline
diastema and discrepancies in midline shift whereas the
weakest preferences were for tooth whiteness and tooth
proportion. Vig and Brundo26 reported on the various
amounts of anterior tooth exposure in African-Americans
and Asians compared with whites.
In today’s American society, Asian, Hispanic, and
African-American segments of the population are
growing at a much faster rate than the white section.
Hispanic and non-white populations will double in size
by the year 2020 to 115 million, although overall popu-
lation numbers will be constant.27
A search of English language peer-reviewed reports
was undertaken using PubMed and MEDLINE, using the
following keywords: ethnicity; anterior teeth proportions.
The results showed 95 articles, of which only 6 were
relevant to this subject.28-33 Each of those articles
measured tooth parameters in the specific ethnic group.
None of the studies reported a large sample size and
compared anterior tooth proportions among multiple
ethnicities with even sex distribution.
Therefore, the purpose of this study was to collect
data to establish guidelines for predicting the anterior
tooth dimensions based on facial proportions in partici-
pants from 3 ethnicities (Asian, African-American, and
white). The null hypotheses were that no consistent ratio
and correlation would be found between the facial
measurements and mesiodistal dimensions of the 6
maxillary anterior teeth among 3 ethnicities.
Parciak et al
- 2017 3

Figure 1. Standardized photographs with ruler. A, Frontal view. B, Frontal view with facial measurements.

MATERIAL AND METHODS

After receiving Institutional Review Board and partici-
pants’ approval, a total of 360 participants from 3
ethnicities (120 Asians, 120 African-Americans, 120
white) were enrolled in the study. Only participants
whose parents were from the same ethnic group were
enrolled. No participants of known mixed ethnic origin
were included in the study. Each ethnic group was
represented by 60 men and 60 women. The participants
were at least 18 years of age and had all their maxillary
teeth. These teeth were without dental restorations that
could affect the width of the teeth, were in good align-
ment, and were without major crowding or spacing. The
exclusion criteria were history of trauma, congenital or
acquired defects in the head and neck region, history of
maxillofacial surgery, obvious asymmetry of the face,
history of orthodontic treatment, and mixed ethnic
origin.
Two standardized color photographs of each partici-
pant were made at the rest vertical dimension from a
frontal and a profile view (Fig. 1A, B). The photographs
were made with a Nikon D90 camera (Nikon Inc)
equipped with an 18- to 105-mm lens and a SB700
Speedlight (Nikon) flash mounted at the 12 o’clock po-
sition. The camera aperture setting was f25. A meter ruler
was mounted on a background wall and aligned
perpendicularly to the floor and to the left of the par-
ticipant’s head. All photographs were made with the
participant’s head in close proximity to the wall. The
frontal parameters bizygomatic width, interpupillary
distance, intercanthal distance, interalar width, and
intercommissural width were measured on each frontal
view photograph.
The images were entered into image processing
software (AutoCad 2006; Autodesk, Inc) that allowed the
photographs to be calibrated and facial parameters to be
measured with digital caliper. Impressions of the maxil-
lary arches were made with irreversible hydrocolloid
Figure 2. Maxillary cast.
impression material (Jeltrate; Dentsply Intl) and poured
in Type IV dental stone (Prima-Rock; Whip Mix Corp)
(Fig. 2).
The measurements of the teeth were made on a
maxillary cast using digital sliding caliper (Mitutoyo CD-6
inches CSX; Mitutoyo Corp). The width of each anterior
tooth was recorded, and the combined width of the 6
anterior teeth on the straight line was calculated. Each
measurement was considered to be continuous and was
made 3 times; the average of the 3 measurements was
used descriptively and for testing hypotheses. All mea-
surements were made by one person (EP).
All tests of hypotheses were 2-sided (a=.05). The
Kruskal-Wallis procedure, a nonparametric correlate of
the 1-way analysis of variance, was conducted to
compare facial and tooth parameters among the 3 eth-
nicities. Appropriate post hoc comparisons that adjusted
for multiple testing were conducted when warranted. The
Spearman rho correlation, a nonparametric correlate of
the Pearson correlation, was used to associate the facial
and tooth parameters within the strata of sex and
ethnicity.

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Table 1. Descriptive statistics for facial parameters (N=60) Table 2. Descriptive statistics for tooth parameters (N = 60)
Sex Measurement Ethnicity Mean (mm) ±SD 95% CI Width
Female BW Asian 168.7 10.43 166.04 171.44 Sex Measurement Ethnicity Mean (mm) ±SD 95% CI

African American 167.3 10.77 164.52 170.08 Female MRC Asian 7.8 0.46 7.72 7.96

White 166.4 10.63 163.65 169.14 African American 7.9 0.50 7.78 8.04

IPD Asian 74.0 5.27 72.61 75.33 White 7.7 0.44 7.61 7.84

African American 77.6 5.57 76.11 78.99 MRLI Asian 7.0 0.58 6.87 7.17

White 74.8 5.53 73.41 76.27 African American 7.2 0.63 7.08 7.41

ICD Asian 41.9 4.51 40.76 43.09 White 6.8 0.57 6.65 6.95

African American 40.7 4.11 39.65 41.77 MRCI Asian 8.5 0.57 8.37 8.67

White 39.3 3.98 38.26 40.31 African American 9.1 0.64 8.91 9.24

IAW Asian 45.6 3.97 44.58 46.63 White 8.6 0.50 8.42 8.68

African American 52.0 4.57 50.83 53.19 MLCI Asian 8.5 0.57 8.30 8.60

White 43.9 4.43 42.80 45.08 African American 9.1 0.70 8.89 9.25

ICW Asian 57.4 4.50 56.23 58.55 White 8.5 0.51 8.40 8.66

African American 64.7 4.98 63.41 65.99 MLLI Asian 7.0 0.58 6.82 7.12

White 60.5 4.97 59.19 61.76 African American 7.2 0.62 7.06 7.38

Male BW Asian 180.4 12.15 177.25 183.53 White 6.8 0.55 6.68 6.96

African American 178.9 14.52 175.16 182.66 MLC Asian 7.8 0.49 7.69 7.94

White 175.0 10.65 172.28 177.78 African American 7.9 0.47 7.75 7.99

IPD Asian 78.3 5.56 76.85 79.73 White 7.7 0.42 7.57 7.78

African American 82.7 6.59 81.03 84.43 Male MRC Asian 8.2 0.51 8.10 8.37

White 77.4 5.46 75.96 78.78 African American 8.5 0.57 8.35 8.64

ICD Asian 44.9 5.03 43.63 46.23 White 8.1 0.46 7.98 8.22

African American 44.4 4.57 43.20 45.56 MRLI Asian 7.3 0.50 7.19 7.45

White 40.3 3.96 39.32 41.36 African American 7.3 0.64 7.17 7.50

IAW Asian 50.1 3.83 49.08 51.06 White 7.0 0.53 6.84 7.11

African American 59.0 6.18 57.44 60.63 MRCI Asian 8.9 0.48 8.76 9.01

White 48.9 4.26 47.78 49.98 African American 9.4 0.57 9.22 9.52

ICW Asian 60.2 5.16 58.90 61.57 White 8.9 0.51 8.79 9.05

African American 69.4 6.48 67.74 71.08 MLCI Asian 8.9 0.51 8.75 9.01

White 64.7 5.30 63.30 66.03 African American 9.3 0.59 9.18 9.48
White 8.8 0.44 8.71 8.94
BW, bizygomatic width; IAW, interalar width; ICD, intercanthal distance; ICW,
intercommissural width; IPD, interpupillary distance. MLLI Asian 7.8 0.46 7.72 7.96
African American 7.9 0.50 7.78 8.04
White 7.7 0.44 7.61 7.84
RESULTS MLC Asian 7.0 0.58 6.87 7.17
African American 7.2 0.63 7.08 7.41
The descriptive statistics, including measurements of White 6.8 0.57 6.65 6.95
central tendency and dispersion, for facial and tooth
MLC, maxillary left canine; MLCI, maxillary left central incisor; MLLI, maxillary left lateral
measurements made among Asian women, Asian men, incisor; MRC, maxillary right canine; MRCI, maxillary right central incisor; MRLI, maxillary
African-American women, African-American women, right lateral incisor.

white women and white men are listed in Tables 1 and 2. Table 3. Descriptive statistics for 6 maxillary anterior teeth (N=60)
The most constant measurements for facial parameters Sex Measurement Ethnicity Mean (mm) ±SD 95% CI
were bizygomatic width and intercanthal distance among Female MRC-MLC Sum Asian 46.6 2.70 45.92 47.31
Asian, African-American, and white women. The differ- African American 48.4 2.78 47.67 49.11
ences for bizygomatic width were less than 2.4 mm and White 46.1 2.38 45.47 46.70
less than 2.7 mm for intercanthal distance. Male MRC-MLC Sum Asian 48.9 2.22 48.33 49.48
From the descriptive tooth measurements, the largest African American 50.4 2.71 49.74 51.14
teeth were maxillary central incisors in African-American White 47.8 2.27 47.18 48.35
men and women, and the smallest teeth were lateral MLC, maxillary left canine; MRC, maxillary right canine.
incisors in white men and women.
The mean distance between the distal surfaces of the than in the other ethnicities, which was primarily a result
maxillary canines, which is the most relevant distance for of the increased width of the central incisors. The same
anterior tooth selection in establishing the proper tooth results were seen for the men. In African-American men,
size for edentulous patients, for the groups is presented the measurements were also at least 2 mm wider than
in Tables 3 and 4. In African-American women, the the other ethnicities, again primarily because of the
combined width measurements were at least 2 mm wider increased width of the central incisors.

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Table 4. Multiple comparisons (Bonferroni) for 6 maxillary anterior teeth

Sex Dependent Variable Ethnicity Ethnicity Mean Difference ±SE 95% CI
Female MRC-MLC Sum Asian African American -1.77 0.48 -2.93 -0.61
White 0.53 0.48 -0.63 1.68
African American Asian 1.77 0.48 0.61 2.93
White 2.29 0.48 1.14 3.46
White Asian -0.53 0.48 -1.68 0.63
African American -2.29 0.48 -3.46 -1.14
Male MRC-MLC Sum Asian African American -1.53 0.44 -2.60 -0.47
White 1.14 0.44 0.08 2.21
African American Asian 1.53 0.44 0.47 2.60
White 2.68 0.44 1.62 3.74
White Asian -1.14 0.44 -2.21 -0.08
African American -2.68 0.44 -3.74 -1.62

MLC, maxillary left canine; MRC, maxillary right canine. Mean significant difference (P<.05).

Table 5. Central incisor width-to-bizygomatic width ratio (N=60) .070

Sex Ethnicity Mean ±SD
Female Asian 0.050 0.004 1/16
.060
African American 0.054 0.005
White 0.051 0.004 MRCI_BZW 1/19
Male Asian 0.049 0.004 .050 1/20
African American 0.052 0.005
White 0.051 0.003
.040

Multiple comparisons (Bonferroni test) for the 6
maxillary anterior teeth showed that the sum of the width
of the 6 maxillary anterior teeth was statistically different
among the ethnicities for both women and men (Kruskal-
Wallis procedure, P<.001). Specifically, the sum was
statistically larger among women for African-Americans
than Asians (P=.001) and for African-Americans than
whites (P<.001). The sum was also statistically larger
among men for African-Americans than Asians (P=.002)
or whites (P<.001).
The central incisor width-to-bizygomatic width
(CI/BZ) ratio was variable among African-Americans,
Asians, and whites for both men and women. Howev-
er, similarity in the CI/BZ ratio was observed between
the sexes for Asians and whites only. Based on the
results, the CI/BZ ratio was 1:18 for African-American
women, 1:19 for African-American men, and 1:20 for
Asian men and women. For whites, the CI/BZ ratio was
closer to 1:19 for women and 1:20 for men (Table 5,
Fig. 3).
The Spearman rank correlation coefficient or Spe-
arman rho was used for a nonparametric measure of
statistical dependence between 2 variables.34 Correlation
analysis using Spearman rho showed a strong and
positive correlations between the width of the central
incisor, width of the 2 central incisors, width of the 4
incisors, and width of the 6 maxillary anterior teeth
to the intercommissural width among Asian women
(Fig. 4).
Ethnicity Asian African American White
.030
F M
Sex
Figure 3. Central incisor width-to-bizygomatic width ratio. BZW,
bizygomatic width; MRCI, maxillary right central incisor.
DISCUSSION
The null hypotheses were accepted. No consistent ratio
and correlation between facial dimensions and mesio-
distal dimensions of the 6 maxillary anterior teeth was
found among the 3 ethnicities.
The maxillary central incisor width-to-bizygomatic
width ratio of 1:16 as reported by Berry7 was not found
in this study, which was closer to the findings of House
and Loop8 (1:13 to 1:19). In this study, the widest
dimension of the face was used as the bizygomatic
measurement. Asian individuals usually have smaller
teeth and wider faces, which might also indicate why the
ratio was higher for this population. The factor of 6.6
between the interpupillary distance and the width of the
maxillary central incisor, as determined by Cesario and
Latta,10 was not correlated in this study.
No stable ratio and correlation were found between
the width of central incisor, 2 central incisors, and 4
maxillary incisors to the intercanthal distance. This is not
in agreement with the findings of Al Wazzan.11 In that
study, intercanthal distance was measured using a Boley

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6 Volume - Issue -

70.00 70.00

65.00 65.00
ICW (mm)

ICW (mm)
60.00 60.00

55.00 55.00

50.00 50.00

45.00 45.00

7.00 7.50 8.00 8.50 9.00 9.50 10.00 14.00 16.00 18.00 20.00
MRCI Width A MRCI and MLCI Width B

70.00 70.00

65.00 65.00
ICW (mm)

ICW (mm)
60.00 60.00

55.00 55.00

50.00 50.00

45.00 45.00

27.50 30.00 32.50 35.00 37.50 40.00 45.00 50.00 55.00 60.00
MRLI - MLLI Width C MRC - MLC Width D
Figure 4. A, Correlation of width of right maxillary central incisor to intercommissural width in Asian women (Spearman rho=.422 [P=.001]).
B, Correlation of width of maxillary central incisors to intercommissural width in Asian women (Spearman rho=.440 [P=.001]). C, Correlation of width of
maxillary central and lateral incisors to intercommissural width in Asian women (Spearman rho=.379 [P=.003]). D, Correlation of width of maxillary
incisors to intercommissural width in Asian women (Spearman rho=.357 [P=.005]). ICW, intercommissural width; MLCI, maxillary left central incisor;
MRCI, maxillary right central incisor.

gauge to the nearest tenth of a millimeter, and mea-
surements of the maxillary anterior teeth were also
completed intraorally using a Boley gauge. The mea-
surement methodology was different in the present
study, where photographic images with image processing
software and actual casts for measurements were used.
This change in methodology could have resulted in the
discrepancy in findings between the 2 studies.
The combined width of the maxillary central incisors
was not found to be in the golden proportion to the
intercanthal distance, which is not in agreement with the
findings reported by Abdullah.12
Krajicek13 reported a stable ratio between the width of
the 6 maxillary anterior teeth and interalar width as
measured on the soft tissue of cadavers. Our study,
performed on live participants, did not agree with those
results.
In our study, the interalar width, when multiplied by
factor of 1.31 did not equal the combined width of the
anterior segment of the maxilla and did not agree with the
findings of Hoffman et al.15 However, the findings of this
study were in agreement with those of Smith,16 who stated
that neither the nasal nor the interalar width correlated
with the width of the distance from canine to canine. The
distal surfaces of the canines in this study were not located
at the commissures as shown by Clapp and Tench.17
No stable ratio was found between the combined
width of the 6 maxillary anterior teeth and inter-
commissural width in white men and women in the
study by Al Wazzan.19 Our study is in agreement with
these findings with the exception of the Asian female
population. In Asian women, our study found a corre-
lation between the width of a central incisor, the com-
bined width of central incisors, the combined width of all
incisors, and the combined width of the 6 maxillary
anterior teeth to the intercommissural width.
The findings from the present study were not in
agreement with any particular study but did have some

THE JOURNAL OF PROSTHETIC DENTISTRY Parciak et al

- 2017
areas of similarity, providing an interesting perspective
on this discussion. Differences in measurement meth-
odologies and population studied could have had a sig-
nificant effect on these differences.
CONCLUSIONS
Within the limitations of this study, the following
conclusions were drawn:
1. No consistent ratio was found between the facial
dimensions and mesiodistal dimensions of the 6
maxillary anterior teeth among the 3 ethnicities. The
only nearly identical stable ratio identified in this
study was the width of the central incisor and
bizygomatic width, which was 1:19 for African-
American men and women, and 1:20 in Asian
men and women. For Whites, this ratio was closer to
1:19 for women and 1:20 for men.
2. No correlation was found between the facial
dimensions and mesiodistal dimensions of the 6
maxillary anterior teeth among the 3 ethnicities
except in Asian women, where the inter-
commissural width correlated with the width of the
central incisor, the width of the 2 central incisors,
the width of the 4 incisors, and the width of the 6
maxillary anterior teeth.
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Corresponding author:
Dr Ewa C. Parciak
Loma Linda University
Graduate Prosthodontics
11092 Anderson St
Loma Linda, CA 92350
Email: eparciakdds@gmail.com
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
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