Received: 26 November 2019 Revised: 18 May 2020
DOI: 10.1111/jerd.12606
REVIEW ARTICLE
Evaluation of influence factors on the width, length, and width
to length ratio of the maxillary central incisor: A systematic
review and meta-analysis
Yingying Wang BDS1,2†
1,2
Chun Xu DDS, PhD
1
Department of Prosthodontics, Shanghai
Ninth People's Hospital, College of
Stomatology, Shanghai Jiao Tong University
School of Medicine, Shanghai, China
2 sides, gender, measuring method, and ethnicity have influences on width (W), length
Shanghai Key Laboratory of Stomatology &
Shanghai Research Institute of Stomatology ,
Shanghai, China
Correspondence
Chun Xu, Department of Prosthodontics,
Shanghai Ninth People's Hospital, College of
Stomatology, Shanghai Jiao Tong University
School of Medicine, Shanghai, China.
Email: imxuchun@163.com
†
These authors contributed equally to this work.
This work was supported by Shanghai Municipal Health Commission (grant number 201940009).
J Esthet Restor Dent. 2020;1–13.
Accepted: 19 May 2020
| Yingshuang Song BDS1,2† | Qi Zhong BDS1,2 |
Abstract
Objectives: The aim of this study was to analyze whether symmetry of left and right
(L), and width to length ratio (W/L) of the maxillary central incisor (MCI) and provide a
reference for dental treatment planning in the esthetic zone.
Materials and Methods: An electronic search was conduct of the dental literature.
Studies reporting data about measurements were included. Data were extracted and
analyzed for the differences between left and right, male and female, different mea-
suring methods, and ethnicities by Review Manager and Stata statistical software.
Results: Seventeen studies were included. There were no differences between mea-
surement of the left and right groups, perceived and actual measuring groups. How-
ever, differences were found between genders in MCI's W and L but no difference in
W/L. Differences were also found between Asians and Caucasian subjects in MCI's
W, L, and W/L.
Conclusions: The results of this meta-analysis suggest that symmetry of left and right
sides and measuring method do not influence MCI dimension. Gender and ethnicity
are found as influence factors for MCI dimension. We believe these findings can be
helpful for dentists to decide and design the dimensions of the restorations for maxil-
lary anterior teeth in clinical practices.
Clinical significance
1 In the process of designing maxillary anterior teeth for implantation, the contralat-
eral MCI can be helpful to create a symmetrical esthetic restoration. For patients
with maxillary anterior tooth loss or diastemas, dentists should divide the left and
right space equally and keep the MCI contact area aligned with the midline.
2 Dentists should take face size and gender into consideration when making treat-
ment plans for the MCI. Facial parameters as well as the size ratios of the previous
teeth can be evaluated and may influence the size and shape of the teeth.
3 When measuring anterior teeth or facial dimensions for esthetic evaluation, the
recommended method is to measure the perceived sizes of a facial view image
wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals LLC 1
2 WANG ET AL.
created by a digital camera. Slight discrepancies may exist between the actual and
measured values due to the curvature of the arch and the angle in which the pho-
tograph was taken.
KEYWORDS
ethnicity, gender, maxillary central incisor (MCI), measuring method, symmetry, width/length
ratio
1 | I N T RO DU CT I O N
1
It was reported by Shaw et al. that the social attractiveness of young
adults could be influenced by their dental-facial appearance. Today, more
and more patients seek dental treatments to solve their concerns about
dental appearance. In the practice of esthetic dentistry, it is common to
see patients with multiple missing anterior teeth or tooth defects. It is
very important to decide the dimensions of the restorations for these
anterior teeth, especially the maxillary central incisor (MCI), for a success-
ful esthetic treatment. A precise knowledge of the esthetics of natural
anterior teeth is necessary for dental treatments in the esthetic zone.
Dental esthetics were assessed by viewing patients from the front
in specific dynamic states like during conversation, with certain facial
2
expressions and while smiling. A checklist for dental esthetic restor-
ative success was firstly presented by Belser et al.3,4 in 1979 and
updated by Magne et al.5 in 2003. This checklist encompassed objec-
tive and subjective parameters, and the appearance of anterior teeth
was considered as an important objective criterion within the esthetic
checklist.4 MCI was most dominant in anterior teeth when smiling.2 As
for the subjective esthetic standard, different people have different
2
evaluation indicators. It was reported by Ku et al. that the natural
observed MCI size was often different from the esthetic MCI size that
people prefer. Therefore, in this article, we chose to study the objective
esthetic standard of MCI to help in clinical treatment. Studying the nat-
ural MCI size is a reliable and direct way for this aim.
A number of articles have reported factors influencing the MCI's
dimension, including symmetry of left and right sides, gender, measur-
ing method, and ethnicity; but, different articles conveyed different
opinions about how these factors influenced the MCI's dimension. In
the present article, these previous studies were systematically
reviewed, and a meta-analysis was conducted by pooling the data of
these individual studies together, to get a more specific conclusion
about the factors influencing the MCI's dimension.
One potential factor which could influence MCI dimension was
the symmetry of MCI at the left side and the right side. Some authors
reported discrepancies of the dimensions of right and left MCI in hori-
6
zontal and vertical measurements, whereas others found no signifi-
cant differences.7,8
Another factor is gender, which is usually thought to be a major
potential influence factor on the dimension of MCI. There were many
gender-related papers. Most of them reported significant difference
between male and female on the MCI dimension,9,10 and only a few
reported opposite results.2
Two different methods were employed to calculate the dimen-
sions of MCI. Direct measurements on the teeth with a caliper were
used in some studies.11 Others used an indirect technique in which
the dimensions were measured on the photograph and then
converted mathematically to the 2D frontal image size of the mouth
or cast.12 If measuring directly, there were potential sources of mea-
surement error as reported by Farkas et al.13 such as improper identi-
fication of landmarks and problems with measuring instruments. If
indirectly measuring photographs, slight discrepancies may exist
between the actual and measured values due to curvature of the arch
and the angle in which the photograph was taken.2 However, errors
from the quality of the impression or cast or of the materials and
mixing protocol were also reported.14-16 In this article, the measuring
methods for the MCI size were divided into two groups, perceived
MCI size and actual MCI size, no matter whether they were measured
directly or indirectly (Figure 1). The perceived group meant MCI was
observed in front of patients including measuring front photographs
and frontal projection of casts.17,18 The actual group meant measuring
MCI's physiological dimensions including directly measuring teeth on
patients or casts with a caliper.19 In this article, the difference
between these two measuring methods was analyzed to determine
which method is more predictable and accurate for the measuring of
the MCI size.
Ethnicity was also considered as a potential influence factor on
the dimension of MCI. However, only a few studies compared the
MCI dimensions of different ethnicities, and these results were not
uniform.20,21
Various investigations about MCI size have been done. However,
most related studies were limited by an unequal distribution of
genders,14 and some poorly stated inclusion and exclusion criteria
resulting in discounting the effect of some important factors to MCI
measurements such as incisor's wear and gingival alteration on crown
height measurements.5,22 The majority of the studies were of the
Caucasian population. Whether the data complied with Asians or not
was unknown. A more comprehensive analysis which took these
abovementioned factors into consideration should be done.
The null hypothesis was there would be no differences in these
studies between right and left side, between male and female,
between the two measuring methods, and between Asian and
WANG ET AL.
FIGURE 1 Measurement of the width, length, and width to length ratio of maxillary central incisor
Caucasians subject on the width (W), length (L), and width to length
ratio (W/L) of the MCI. The results would be helpful for dentists to
design the sizes and proportions of restorations of maxillary anterior
teeth that are pleasing to their patients.
2 | MATERIAL AND METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-
analysis (PRISMA) statement was followed and consulted during the
whole process.
2.1 | Systematic literature search
Systematic electronic and manual searches were conducted in several
databases including MEDLINE (PubMed), EBSCO, Web of Science,
and CNKI. Electronic search was complemented by manual searching
and conducted to identify randomized clinical trials, case series, and
prospective and retrospective cohort studies. Studies before April
7, 2020 in these literature databases were included. Terms used in the
search included “anterior teeth,” “incisor,” “esthetic,” “ratio,” and
“Maxilla.” The relevant articles were from databases' recommended
articles. Full texts of all potentially related articles were obtained from
available sources on the internet. In particular, the strategy of litera-
ture search was as the following: ((((((proportion[Title/Abstract])) AND
((aesthetic*) OR esthetic*)) AND Maxilla*[Title/Abstract]) AND ((ante-
rior teeth[Title/Abstract]) OR incisor[Title/Abstract]))) OR (((((ratio
[Title/Abstract])) AND ((aesthetic*) OR esthetic*)) AND Maxilla*[Title/
Abstract]) AND ((anterior teeth[Title/Abstract]) OR incisor[Title/
Abstract]). In total, 23 separate searches have been run to identify an
initial set of studies (659). After removing duplicates, the selected
studies (441) were screened based on information contained in titles,
abstracts, and full texts. The selected studies (77) for qualitative
3
synthesis were further reduced to 23 papers, which represent the
pool of studies that provide information required for a quantitative
analysis.
2.2 | Study selection and data extraction
Articles selected for inclusion were based on the following inclusion
criteria: (1) articles published dating before April 7, 2020; (2) studies
conducted on participants with normal oral function and appearance
and with no excessive wear of upper anterior teeth; (3) publications
including the measurements of MCI; (4) studies reporting data includ-
ing mean and SD of W, L, or W/L; (5) a clear report of the measuring
method. The following exclusion criteria were also agreed: (1) sum-
mary, editorials, letters, or case reports; (2) repeated or non-full-text
articles; (3) the research object does not meet the standard; (4) studies
that did not follow the inclusion criteria.
These studies were evaluated independently, based on the inclusion/
exclusion criteria, by both reviewers (Yingying Wang and Yingshuang
Song). Any disagreement between authors was resolved by discussion
with a third reviewer (Chun Xu). Figure 2 provided an overview of the lit-
erature search and article selection in the form of a flow diagram.
2.3 | Quality assessment
A methodological quality assessment was performed according to the
standards described in the Cochrane Handbook for Systematic Reviews
of Interventions (v5.1.0).23 Two reviewers (Yingying Wang and
Yingshuang Song) evaluated the selected trials independently, and dis-
agreements were resolved through discussion or consultation with a
third reviewer (Chun Xu). The methodological quality assessment of
prospective and retrospective design was evaluated by the Case Series
Critical Appraisal Tool from the Joanna Briggs Institute (JBI).24 In the
4 WANG ET AL.
JBI Case Series Critical Appraisal Tool, there were more than six specific
areas with “yes” answers, reflecting the good methodological quality of
the studies. In addition, the different classifications included were the
groups comparable, were cases and controls matched appropriately,
were the same criteria used for identification of cases and controls, was
exposure measured in a standard, valid, and reliable way, was exposure
measured in the same way for cases and controls, and were con-
founding factors identified (Table 1, Figure 3).
2.4 | Statistical analysis
Information was extracted from each included study on the following
characteristics: year of publication, study design, number of
F I G U R E 2 Flow diagram
summarizing literature search and
article selection
participants, and W, L, and W/L measurements of MCI including mean
and SD. In addition, the different classifications including left or right,
male or female, measuring methods, and ethnicities were also
collected.
The data were subsequently entered into the meta-analysis
software of the Cochrane Collaboration (RevManv5.3.5). Using the
random-effects model, forest plots were drawn, and significance
tests were carried out (calculating P values) comparing the following
items: left and right; male and female; actual and perceived; Asians
and Caucasian subjects. Statistical heterogeneity between all the
studies included in this systematic review was not assessed because
all the studies had a different number of participants, measuring
methods, and descriptive methods, making a comparison nearly
impossible.
TABLE 1 Evaluation of article quality by JBI

(1) Were the

groups
WANG ET AL.

comparable
other than the (8) Were
presence of (3) Were the (4) Was (5) Was outcomes (9) Was the
disease in (2) Were same criteria exposure exposure (7) Were assessed in a exposure (10) Was
cases or the cases and used for measured in a measured in (6) Were strategies to standard, valid period of appropriate
absence of controls identification standard, valid the same way confounding deal with and reliable interest long statistical
disease in matched of cases and and for cases and factors confounding way for cases enough to be analysis Total
Author Year controls? appropriately? controls? reliable way? controls? identified? factors stated? and controls? meaningful? used? score
Yin, W. C. et al. 2010 Y Y Y Unclear Y N N Y Unclear Y 6
Parnia, F. et al. 2010 Y Y Y Y Y Unclear N Y Unclear Y 7
George, S. et al. 2010 Y Y Y Y Y Unclear Y Y Unclear Y 8
Tsukiyama, T. 2012 Y Y Y Y Y Y Unclear Y Unclear Y 8
et al.
Ku, J. E. et al. 2012 Unclear Unclear Unclear Unclear Y Unclear N Y Unclear Y 3
Al-Marzok, M. I. 2013 Y Y Unclear Y Y N N Y Y Y 7
et al.
Calcada, D. 2014 Y Y Y Y Y N N Y Unclear Y 7
et al.
Zhao, Q. et al. 2015 Y Y Y Y Y Y Y Y Unclear Y 8
Sandeep, N. 2015 Y Y Y Y Y N N Y Unclear Y 7
et al.
Rokaya, D. et al. 2015 Y Y Y Y Y N N Y Unclear Y 7
Orozeo-Varo, A. 2015 Y Y Y Y Y Y Y Y Unclear Y 9
et al.
Jain, S. et al. 2015 Y Y Y Unclear Y N N Y Unclear Y 6
Radia, S. et al. 2016 Y Y Y Y Y Y Y Y Y Y 10
Kaisy N. A. L. 2016 Y Y Y Y Y Unclear N Y Unclear Y 7
et al.
Parciak, E. C. 2017 Y Y Y Y Y Unclear N Y Unclear Y 7
et al.
Oh, Y. A. et al. 2017 Y Y Y Y Y Unclear N Y Y Y 8
Shetty, T. B. 2017 Y Y Y Y Y Y Y Y Unclear Y 9
et al.
Bali, Poonam, 2013 Y Y Y Y Y Y Y Y Unclear Y 9
et al.
Hemalatha, 2018 Y Y Y Y Y Y Y Y Unclear Y 9
Kumaravel,
et al.
5

(Continues)
 6 WANG ET AL.

3 | RE SU LT S

score
Total

9
9

9
9
Electronic and manual search yielded a total of 659 abstracts. Of note,

appropriate
364 articles were excluded because they did not meet the inclusion

statistical
(10) Was

analysis
criteria. In the second phase of study selection, full-text analysis was

used?
performed for 77 articles, resulting in 23 meeting the inclusion criteria

Y
Y

Y
Y
and was, therefore, included in this systematic review (Figure 2). This

enough to be
interest long
review of the literature is based on 23 articles published from March
meaningful?
(9) Was the
exposure
period of

20, 2010, to July 25, 2019.2,8,9,17,18,20,21,25-34 In all, data from 3603

Unclear
Unclear

Unclear
Unclear
participants were recorded. Data collected was reported from each
study. The details of these studies are described in Table 2.
standard, valid

Using the risk-of-bias analysis (Table 1, Figure 3), 16 studies were

way for cases
and controls?
assessed in a

and reliable

classified as having low risk of bias, 1 study was classified as having a

outcomes
(8) Were

high risk of bias. High risk of bias was caused by the incorrect measur-
ing method for “MEDIA” group.2 In the following analyzation, data
Y
Y

Y
Y

from “MEDIA” group was not used.

factors stated?
confounding
strategies to

Nine papers were included for investigation of the effect of the

deal with
(7) Were

symmetry of left side and right side on the W, L, and W/L of MCI.
Results showed no difference between left and right on W, L, and
Y
Y

Y
Y

W/L of MCI and no heterogeneity in the included literatures

confounding

(Figure 4).
identified?
(6) Were

Eleven articles were included for analyzing the influence of gen-

factors

der on W of MCI, whereas six articles and another six articles were
Y
Y

Y
Y

included for analyzing the influence of gender on L and W/L of MCI,

the same way

respectively (Figure 5). The result showed statistical differences

for cases and
measured in

between males and females on W of MCI, and there was high hetero-
exposure

controls?
(5) Was

geneity in the included literature. Males had wider MCI than females,
and the difference was about 0.36 mm. There was also a statistical
Y
Y

Y
Y

difference between the two gender groups on L, and there was low
standard, valid
measured in a

reliable way?

heterogeneity in the included literature. Males had longer MCI than

exposure

females, and the difference was about 0.42 mm. However, the results
(4) Was

showed there was no statistical difference between the gender

and

Y
Y

Y
Y

groups on W/L.
The data was further subdivided into different groups by measur-
identification
same criteria
(3) Were the

of cases and

ing methods (Figure 5). The result showed no statistical difference

controls?
used for

between two subgroups (“perceived” or “actual”) on W, L, and W/L of

MCI. The data of the “actual” subgroup contained high heterogeneity
Y
Y

Y
Y

as for both W and L of MCI. Although the “perceived” subgroup

appropriately?

showed low heterogeneity as for W and L of MCI.

cases and
(2) Were

matched
controls

Concerning the influence of ethnicity on the MCI size, the data

were divided into two groups: Asian group and Caucasian subject
Y
Y

Y
Y

group. Eighteen papers were included for analyzing W, 11 papers for

other than the

analyzing L, and 12 for W/L (Figure 6). All these included data were
(1) Were the

cases or the
presence of
comparable

absence of
disease in

disease in
controls?

about 1:1 of male to female. The result showed there were statistic
groups

differences between these two groups on W, L, and W/L. Data con-

Y
Y

Y
Y

tained high heterogeneity as for W, L, and W/L.

(Continued)

2018
2019

2019
2014
Year
Rokaya, D. et al.

4 | DI SCU SSION
Kumar, et al.
Aldegheishem,

Melo, M. et al.
Sah, Sanjay
A. et al.
TABLE 1

After reading relevant articles, we selected symmetry of left and right

Author

sides, gender, measuring methods, and ethnicity as potential influence

factors for MCI and chose W, L, and W/L of MCI as indicators.
WANG ET AL. 7

FIGURE 3 Risk of bias graph

TABLE 2 Characteristics of included studies

Number Author Year Ethnicity Total number of Constituent ratio Method

1 Oh, Y. A. et al. 2017 Korea (Asian) 31 16 males:15 females Perceived
2 T. B. Shetty et al. 2017 India (Asian) 100 50 males:50 females Perceived
3 Parciak, E. C. et al. 2017 Asian, American (Asian, 360 80 males:180 female Perceived
African, and White)
4 Radia, S. et al. 2016 London (White) 149 73 males:76 female Perceived
5 A. L. Kaisy N et al. 2016 Kurdish (White) 101 38 males:27 females Cast
6 Zhao, Q. et al. 2015 Chinese (Asian) 101 63 males:38 females Cast
7 Sandeep, N. et al. 2015 India (Asian) 240 20 males:120 female Perceived and cast
8 Rokaya, D. et al. 2015 Nepal (Asian) 150 52 males:98 females Perceived and cast
9 Orozco-Varo, A. 2015 Spain (White) 412 62 males:250 female Cast
10 Jain. S. et al. 2015 India (Asian) 100 50 males:50 females Perceived
11 Calcada, D. et al. 2014 Portuguese (White) 50 20 males:30 females Perceived
12 Al-Marzok, M.I. et al. 2013 Chinese (Asian), India 49 Unclear Perceived
(Asian), Malasian (Asian)
13 Tsukiyama. T. et al. 2012 Asian and White 43 Unclear Perceived
14 Ku, J. E. et al. 2012 Korea (Asian) 80 40 males:40 females Perceived
15 Yin, W. C. 2010 Chinese (Asian) 41 25 males:46 females Cast
16 Parnia, F. et al. 2010 Iran (Asian) 100 50 males:50 females Perceived
17 George, S. et al. 2010 India (Asian) 300 44 males:156 female Cast
18 Bali, Poonam. et al. 2013 India (Asian) 250 21 males:129 female Actual
19 Hemalatha, Kumaravel. et al. 2018 India (Asian) 100 40 males:60 females Perceived
20 Rokaya, D. et al. 2018 Nepal (Asian) 200 68 males:132 females Cast
21 Aldegheishem, A. et al. 2019 Saudi (White) 61 25 males:36 females Perceived
22 Melo, M. et al. 2019 Spain (White) 384 78 males:206 female Cast
23 Sah, Sanjay Kumar. et al. 2014 Chinese (Asian) 147 65 males:82 females Cast

The first factor is the symmetry of left and right MCI. When
reviewing related articles, it was found that data of MCI dimension
were often divided into left and right sides. In this meta-analysis, the
result demonstrated that there was no difference between the sizes
of the left MCI and the right one, which meant no need to divide the
MCI dimension data into these two groups. Studies by Mavroskoufis
et al.6 and Gillen et al.35 pointed out the same results with ours. This
result is in conformity with the esthetic principle of symmetry. There-
fore, following this principle of clinical treatment helps patients
achieve a natural dental appearance. For example, in treating a patient
with a single upper anterior tooth missing due to trauma or other rea-
sons by implantation, according to the principle of symmetry, consult-
ing the size and shape of the contralateral MCI will be helpful for the
esthetic outcome of the restoration. For patients with anterior teeth
8 WANG ET AL.

F I G U R E 4 Forest plots summary of comparison between MCI left side and right side. Diamond symbol represents overall mean and 95%
confidence interval for each group of comparisons. P < 0.05 or mean including 0 represents 2 measurements not statistically, significantly
different. Positive values of mean indicate MCI left side measurement larger than right side measurement; negative values of mean indicate MCI
left side measurement smaller than right side measurement

loss or diastema, dentists should divide left and right edentulous
spaces equally and keep MCIs' contact area aligned with the face
midline.
Next is gender. Previous investigators like Lavelle et al.,36 Cesario
11,37,38 35 39
et al. Gillen et al. and Sterrett et al. reported that males had
wider and longer MCI than females. These results were consistent
with the present meta-analysis. One hypothesis about this result is
that there is a relationship between face size and teeth size. Because
males usually have larger faces than females, their teeth are usually
larger than females. Teeth size to face size ratio has commonly been
used to aid denture teeth selection for edentulous patients. Berry
et al.40 proposed the 1:16 MCI W to bizygomatic W ratio firstly, and it
41
was confirmed by House et al., whereas this ratio was not recon-
firmed exactly by Radia et al. and Hasanreisoglu et al.8,38 Radia et al.8
found an approximate 1:15 proportional relationship between MCI W
and bitemporal W and suggested an approximate proportion of 1:18
for MCI L to total face L and 1:12 for MCI W to face W; but, poor cor-
relation was found between MCI W/L ratio with face W/L ratio.
Although there was no unified ratio for the MCI size and face size,
these studies told us that face size was correlative with MCI size and
confirmed that bigger face usually matched bigger MCI. Dentists
should take face size and gender into consideration when making
treatment plan for MCI. In addition, more potential MCI-related
parameters of face should be investigated and previous ratios should
be verified repeatedly.
As for MCI W/L ratio of male and female, some reported that the
W/L ratio of MCI was not affected by gender,35 which was consistent
with the results of the present meta-analysis. However, there were
also reports showing that significant difference existed between males
and females on the W/L ratio of MCI.42,43 This discrepancy might be
contributed to two possible reasons. First, the sample size of the later
articles was much smaller than that of the former ones, which might
weaken the power of their conclusions.35,42,43 Second, measuring
methods of the MCI size were inconsistent among these studies,
which might lead to different outcomes. Therefore, the conclusion
that gender does not affect the W/L ratio of MCI from the present
meta-analysis should be reliable. The result of the meta-analysis also
suggests that the esthetic W/L ratio of MCI might vary in a range. In
WANG ET AL. 9

F I G U R E 5 Forest plots summary of

comparison between male and female & two
measuring methods. Diamond symbol
represents overall mean and 95% confidence
interval for each group of comparisons. P < 0.05
or mean including 0 represents 2 measurements
not statistically, significantly different. Positive
values of mean indicate male measurement
larger than female measurement; negative
values of mean indicate male measurement
smaller than female measurement. Test for
subgroup shows P < 0.05 or mean including
0 represents 2 measurements not statistically,
significantly different. Positive values of mean
indicate perceived measurement larger than
actual measurement; negative values of mean
indicate perceived measurement smaller than
actual measurement. The letter after study ID
means different group data from a same paper

the present meta-analysis, the average W/L ratio of MCI was
0.85-0.86. The average W/L ratio of MCI in the Caucasian population
8
was 0.75-0.8 in a British study. In other studies, it has been reported
between 0.72 and 1.24.35,39,44 W/L is an important parameter for
esthetic evaluation of MCI. A higher W/L ratio means a squarer tooth,
and a lower ratio indicates a longer appearance. Some authors empha-
sized the importance for achieving Golden Proportion (GP) of W/L
ratio before,9 which was considered the ideal W/L proportion and was
commonly used before.45 But new studies contradicted this theory.46
GP established the value of 1:1.6181, 47,48
about 0.618 which is far
different from the present meta-analysis result (0.85-0.86). GP is not
suitable to be regarded as the standard objective esthetic W/L ratio.
The majority of surveyed dentists selected the esthetic W/L ratio as
close to a value between 0.75 and 0.78 as possible.49 Further studies
are needed in this area.
Suitable measurement is the basis for the study of MCI dimension
and other dental-facial measurements. The results of the present
study showed that there was no statistic difference between two
groups with different measuring methods for the W and L of MCI; but,
the subgroup “actual” on W contained high heterogeneity. Hunter
et al. and Priest et al.15,16 found a 0.1 mm difference between cast-
derived and intraoral-measured MCI W, in other words, between “per-
ceived” and “actual” measurements. We found a 0.09 mm difference
between perceived and actual MCI W and 0.14 mm difference
10 WANG ET AL.

F I G U R E 6 Forest plots summary of comparison

between Asians and Caucasian subjects. Diamond symbol
represents overall mean and 95% confidence interval for
each group of comparisons. P < 0.05 or mean including
0 represents 2 measurements not statistically, significantly
different. Positive values of mean indicate Asians
measurement larger than Caucasian subjects' measurement;
negative values of mean indicate Asians measurement
smaller than Caucasian subjects' measurement. The letter
after study ID means different group data from a same
paper
WANG ET AL.
between the MCI L values of these two groups. There was high het-
erogeneity between actual group members. This high heterogeneity
reminded that actually measuring the patient's MCI might lack consis-
tency and repeatability. Besides, although the absolute value of the
difference was small, it was significant for MCI with a size of only sev-
eral millimeters. Measuring actual patient's MCI size as a suitable
method for the esthetic evaluation needs more consideration. In con-
trast, reliability and accuracy of using digital images for teeth mea-
surements have been proved.11,50,51 In all, the method to measure
perceived tooth or face size using digital images showed consistency
and repeatability. This method also allows a larger sample size and
shorter patient visit time. Therefore, it is more recommended in fol-
lowing studies on esthetic evaluation of MCI.
The last is ethnicity. A homogeneous comparison between two
20
ethnic groups by Tsukiyama et al. showed that Caucasian population
had larger W/L ratio of MCI than Asians.20 Significant difference
between MCI size of different ethnic groups was also reported by
Muller et al.52 Owens et al.53 measured MCI W in several racial groups
and reported variation in most of them. Our results confirmed the
influence of ethnicity on the dimension of MCI, showing that Cauca-
sian population showed larger W, L, and W/L ratio than Asian popula-
tion. However, high heterogeneity existed in both Asian and
Caucasian groups. As only a few papers contained data for more than
two ethnicities, the meta-analysis could not exclude confounders such
as different measuring methods, sample size, and gender distribution.
A uniformed measuring method and a clear statement about gender
distribution are needed in the future studies about the effect of eth-
nicity on MCI dimension. In the following clinical practices, taking eth-
nicity into consideration of anterior teeth esthetic restoration design
is necessary.
When analyzing MCI dimension, most of the studies focused on
the relationship between W and L. MCI W/L ratio influenced not only
teeth appearance but also periodontal tissue. Muller and Eger evalu-
ated the correlation between tooth form and periodontal phenotype
52
in the Caucasian and Asian population. Results showed that the
Asians seem to have a thinner biotype and more slender MCI than
Caucasians.52 Other studies also reported that the tooth form was
related to the thickness of the gingiva and surrounding bone.54-58 This
relationship was important for the implant restoration plan at the MCI
site. For example, if the patient exhibits a thin biotype, dentists should
choose a more slender crown which also means a smaller transgingival
diameter. Further studies are needed to be done on the relationship
between MCI W/L ratio and the biotype of the periodontal tissue.
Unified measuring methods, evenly distributed gender and ethnicity
should be considered in data collecting and clearly stated in papers.
Beside the above-mentioned factors, there are still some other
subjective elements which could influence dental esthetic evaluation.
One of them is media. Currently, the perception of attractiveness is
heavily influenced by the media. A beautiful face seems to be an
important prerequisite for a successful career.1,59,60 In a study by
Brisman et al.,61 the W/L ratio of 0.75 for MCI was preferred by den-
tal students and patients through a questionnaire investigation. An
investigation for the celebrities showed similar result to this esthetic
11
criterion.2 Study by Ku et al.2 divided participants into two groups,
one was MEDIA group made up by celebrities whose frontal photo-
graphs was obtained from the Internet, and the other was NON-
MEDIA group made up by dental students. It appeared that MCI of
the NON-MEDIA group had a more square-like-form than those of
MEDIA group.2 Understanding the public preference for a smaller W/
H ratio of the MCI than is commonly observed in nature, could aid in
better decisions regarding tooth sizes during treatment planning.
This meta-analysis had several limitations. First was the small
number of included studies. Second, only data of MCI were collected
and analyzed, although we know all anterior teeth were important for
facial appearance. Further investigations about the relationship
between periodontal biotype and tooth form/shape and the relation-
ship between the form/shape of face and tooth are necessary.
5 | CONC LU SIONS
Despite the limited number of available studies, the results of this
meta-analysis suggested that left or right and measuring methods
showed no significant influence on MCI W, L, and W/L. Gender and
ethnicity were found as influence factors on MCI dimension. Dentists
should pay more attention to the principle of the symmetry in clinical
treatment for MCIs. Measuring perceived tooth or face sizes is more
accurate and repeatable when using digital photos. Dentists should
take face size, gender, and ethnicity into consideration when making
dental treatment plan for MCIs. In addition, more potential MCI
related parameters of the face should be investigated, and previously
ratios should be verified.
ACKNOWLEDG MENTS
None.
CONFLIC T OF INT ER E ST
The authors declare that they have no conflict of interests and all
authors have read and approved the final draft.
OR CID
Yingying Wang https://orcid.org/0000-0001-5621-1171
RE FE RE NCE S
1. Shaw WC. The influence of children's dentofacial appearance on their
social attractiveness as judged by peers and lay adults. Am J Orthod.
1981;79:399-415.
2. Ku JE, Yang HS, Yun KD. A morphometric analysis of maxillary central
incisor on the basis of facial appearance in Korea. J Adv Prosthodont.
2012;4:13-17.
3. Belser UC. Esthetics checklist for the fixed prosthesis. Part II: Biscuit-
bake try-in. Chicago: Quintessence; 1982:188-192.
4. Carlsson GE, Johansson A, Johansson AK, Ordell S, Ekback G, Unell L.
Attitudes toward dental appearance in 50- and 60-Yearold subjects
living in Sweden. J Esthet Restor Dent. 2008;20:46-55.
5. Magne P, Gallucci GO, Belser UC. Anatomic crown width/length
ratios of unworn and worn maxillary teeth in white subjects.
J Prosthet Dent. 2003;89:453-461.
12
6. Mavroskoufis F, Ritchie GM. Variation in size and form between left
and right maxillary central incisor teeth. J Prosthet Dent. 1980;43:
254-257.
7. Vadavadagi SV, Hombesh MN, Choudhury GK, Deshpande S,
Anusha CV, Murthy DK. Variation in size and form between left and
right maxillary central incisor teeth. J Int Oral Health. 2015;7:33-36.
8. Radia S, Sherriff M, McDonald F, Naini FB. Relationship between
maxillary central incisor proportions and facial proportions. J Prosthet
Dent. 2016;115:741-748.
9. George S, Bhat V. Inner canthal distance and golden proportion as
predictors of maxillary central incisor width in south Indian popula-
tion. Indian J Dent Res. 2010;21:491-495.
10. Wolfart S, Menzel H, Kern M. Inability to relate tooth forms to face
shape and gender. Eur J Oral Sci. 2004;112:471-476.
11. Abdullah MA. Inner canthal distance and geometric progression as a
predictor of maxillary central incisor width. J Prosthet Dent. 2002;88:
16-20.
12. Al Wazzan KA. The relationship between intercanthal dimension and
the widths of maxillary anterior teeth. J Prosthet Dent. 2001;86:
608-612.
13. Whitaker LA. Anthropometry of the head and face in medicine. Plast
Reconstr Surg. 1983;71:144-145.
14. Zlataric DK, Kristek E, Celebic A. Analysis of width/length ratios of
normal clinical crowns of the maxillary anterior dentition: correlation
between dental proportions and facial measurements. Int J Pros-
thodont. 2007;20:313-315.
15. Hollinger JO, Lorton L, Krantz WA, Connelly M. A clinical and labora-
tory comparison of irreversible hydrocolloid impression techniques.
J Prosthet Dent. 1984;51:304-309.
16. Hunter W, Priest WR. Errors and discrepancies in measurement of
tooth size. J Dent Res Dent Clin Dent Prospects. 1959;39:405-414.
17. Sandeep N, Satwalekar P, Srinivas S, Reddy CS, Reddy GR, Reddy BA.
An analysis of maxillary anterior teeth dimensions for the existence of
Golden proportion: clinical study. J Int Oral Health. 2015;7:18-21.
18. Shetty TB, Beyuo F, Wilson NHF. Upper anterior tooth dimensions in
a young-adult Indian population in the UK: implications for esthetic
dentistry. Br Dent J. 2017;233:781-786.
19. Gomes VL, Goncalves LC, Costa MM, Lucas BL. Interalar distance to
estimate the combined width of the six maxillary anterior teeth in oral
rehabilitation treatment. J Esthet Restor Dent. 2009;21:26-35.
20. Tsukiyama T, Marcushamer E, Griffin TJ, Arguello E, Magne P,
Gallucci GO. Comparison of the anatomic crown width/length ratios
of unworn and worn maxillary teeth in Asian and white subjects.
J Prosthet Dent. 2012;107:11-16.
21. Parciak EC, Dahiya AT, AlRumaih HS, Kattadiyil MT, Baba NZ,
Goodacre CJ. Comparison of maxillary anterior tooth width and facial
dimensions of 3 ethnicities. J Prosthet Dent. 2017;118:504-510.
22. Morrow LA, Robbins JW, Jones DL, Wilson NH. Clinical crown length
changes from age 12-19 years: a longitudinal study. J Dent. 2000;28:
469-473.
23. Varjao FMNS. Nasal width as a guide for the selection of maxillary
complete denture anterior teeth in four racial groups. J Prosthodont.
2006;15:353-358.
24. Moola S, Munn Z, Tufanaru C, et al. Chapter 7: Systematic reviews
of etiology and risk. In: Aromataris E, Munn Z, eds. Joanna Briggs
Institute reviewer's manual. Adelaide, South Australia: The Joanna
Briggs Institute; 2017. Available from. https://reviewersmanual.
joannabriggs.org/.
25. Yin WC, Zheng YL, Xu QL, Ji PH. A preliminary analysis of the ratio
between the upper and lower anterior teeth. Shanghai Kou Qiang Yi
Xue. 2010;19:41-44.
26. Parnia F, Hafezeqoran A, Mahboub F, et al. Proportions of maxillary
anterior teeth relative to each other and to golden standard in Tabriz
dental faculty students. J Dent Res Dent Clin Dent Prospects. 2010;4:
83-86.
WANG ET AL.
27. Al-Marzok MI, Majeed KR, Ibrahim IK. Evaluation of maxillary anterior
teeth and their relation to the golden proportion in Malaysian popula-
tion. BMC Oral Health. 2013;13:9.
28. Calcada D, Correia A, Araujo F. Anthropometric analysis of anterior
maxillary teeth with digital photography - a study in a Portuguese
sample. Int J Esthet Dent. 2014;9:370-380.
29. Zhao Q, Li N, Cao J. Morphological features of maxillary ante-
rior teeth in a sample of Chinese population. Homo. 2015;66:
448-454.
30. Rokaya D, Kitisubkanchana J, Wonglamsam A, Santiwong P,
Srithavaj T, Humagain M. Nepalese esthetic dental (NED) proportion
in Nepalese population. Kathmandu Univ Med J (KUMJ). 2015;13:
244-249.
31. Orozco-Varo A, Arroyo-Cruz G, Martinez-de-Fuentes R, Jimenez-
Castellanos E. Biometric analysis of the clinical crown and the
width/length ratio in the maxillary anterior region. J Prosthet Dent.
2015;113:565-570.
32. Jain S, Reddy M, Raghav P, et al. Assessment of tooth proportions in
an esthetically acceptable smile. J Clin Diagn Res. 2015;9:1-4.
33. A. L. Kaisy N, Garib BT. Selecting maxillary anterior tooth width by
measuring certain facial dimensions in the Kurdish population.
J Prosthet Dent 2016; 115:329–334.
34. Oh YA, Yang HS, Park SW, Lim HP, Yun KD, Park C. Analysis of the
width ratio and wear rate of maxillary anterior teeth in the Korean
population. J Adv Prosthodont. 2017;9:93-98.
35. Gillen RJ, Schwartz RS, Hilton TJ, Evans DB. An analysis of
selected normative tooth proportions. Int J Prosthodont. 1994;7:
410-417.
36. Lavelle CL. Maxillary and mandibular tooth size in different racial
groups and in different occlusal categories. Am J Orthod. 1972;61:
29-37.
37. Cesario VA Jr, Latta GH Jr. Relationship between the mesiodistal
width of the maxillary central incisor and inter pupillary distance.
J Prosthet Dent. 1984;52:641-643.
38. Hasanreisoglu U, Berksun S, Aras K, Arslan I. An analysis of maxillary
anterior teeth: facial and dental proportions. J Prosthet Dent. 2005;
94:530-538.
39. Sterrett JD, Oliver T, Robinson F, Fortson W, Knaak B, Russell CM.
Width/length ratios of normal clinical crowns of the maxillary anterior
dentition in man. J Clin Periodontol. 1999;26:153-157.
40. Berry F. Is the theory of temperaments the foundation of the study
of prosthetic art? Dent Mag. 1905;1:405.
41. House MM, Loop JL. Form and color harmony in the dental art. Whit-
tier. 1939;2:16-22.
42. Iscan MY, Kedici PS. Sexual variation in bucco-lingual dimensions in
Turkish dentition. Forensic Sci Int. 2003;137:160-164.
43. Sherfudhin H, Abdullah MA, Khan N. A cross-sectional study of
canine dimorphism in establishing sex identity: comparison of two
statistical methods. J Oral Rehabil. 1996;23:627-631.
44. Cooper GE, Tredwin CJ, Cooper NT, Petrie A, Gill DS. The influence
of maxillary central incisor height-to-width ratio on perceived smile
esthetics. Br Dent J. 2012;212:589-599.
45. Preston JD. The golden proportion revisited. J Esthet Dent. 1993;5:
247-251.
46. Pini NP, de Marchi LM, Gribel BF, Ubaldini AL, Pascotto RC. Analysis
of the golden proportion and width/height ratios of maxillary anterior
dentition in patients with lateral incisor agenesis. J Esthet Restor Dent.
2012;24:402-414.
47. Ricketts RM. The biologic significance of the divine proportion and
Fibonacci series. Am J Orthod. 1982;81:351-370.
48. Wolfart S, Thormann H, Freitag S, Kern M. Assessment of dental
appearance following changes in incisor proportions. Eur J Oral Sci.
2005;113:159-165.
49. Rosenstiel SF, Ward DH, Rashid RG. Dentists' preferences of anterior
tooth proportion - a web-based study. J Prosthodont. 2000;9:123-136.
WANG ET AL.
50. Nalcaci R, Topcuoglu T, Ozturk F. Comparison of Bolton analysis and
tooth size measurements obtained using conventional and three-
dimensional orthodontic models. Eur J Dent. 2013;7:S66-70.
51. Zilberman O, Huggare JA, Parikakis KA. Evaluation of the validity of
tooth size and arch width measurements using conventional and
three-dimensional virtual orthodontic models. Angle Orthod. 2003;73:
301-306.
52. Muller HP, Eger T. Masticatory mucosa and periodontal phenotype: a
review. Int J Periodontics Restorative Dent. 2002;22:172-183.
53. Owens EG, Goodacre CJ, Loh PL, et al. A multicenter interracial study
of facial appearance. Part 2: a comparison of intraoral parameters. Int
J Prosthodont. 2002;15:283-288.
54. Sanavi F, Weisgold AS, Rose LF. Biologic width and its relation to
periodontal biotypes. J Esthet Dent. 1998;10:157-163.
55. Weisgold AS. Contours of the full crown restoration. Alpha Omegan.
1977;70:77.
56. Arnoux JP, Weisgold AS, Lu J. Single-tooth anterior implant: a word
of caution Part II. J Esthet Dent. 1997;9:285-294.
57. Schluger S. Periodontics today: dentistry tomorrow. J Dist Columbia
Dent Soc. 1977;1:6-8.
13
58. Steiner GG, Pearson JK, Ainamo J. Changes of the marginal per-
iodontium as a result of labial tooth movement in monkeys.
J Periodontol. 1981;52:314-320.
59. Kokich VO, Kokich VG, Kiyak HA. Perceptions of dental professionals
and laypersons to altered dental esthetics: asymmetric and symmetric
situations. Am J Orthod Dentofacial Orthop. 2006;130:141-151.
60. Johnson N, Sandy J. An esthetic index for evaluation of cleft repair.
Eur J Orthod. 2003;25:243-249.
61. Brisman A. Esthetics: a comparison of dentists' and patients' con-
cepts. J Am Dent Assoc. 1980;100:345-352.
How to cite this article: Wang Y, Song Y, Zhong Q, Xu C.
Evaluation of influence factors on the width, length, and width
to length ratio of the maxillary central incisor: A systematic
review and meta-analysis. J Esthet Restor Dent. 2020;1–13.
https://doi.org/10.1111/jerd.12606