Gender differences in the form of

maxillary central incisors analyzed using

AutoCAD software
Juliana Brunetto, MMD,a Mirian Marly Becker, DMD,b and
Claudia A. Maziero Volpato, DMDc
School of Dentistry, Federal University of Santa Catarina,
Florianópolis, Brazil

Statement of problem. Female teeth are considered more rounded and male teeth more quadrangular. Although
lacking in scientific support, this theory helps in selecting the mold of artificial teeth for dentures. Parameters that are
more reliable are sought to determine gender differences in tooth form.

Purpose. The purpose of this study was to assess possible differences between genders in terms of tooth form: oval,
triangular, or quadrangular.

Material and methods. The sample comprised 433 subjects with a mean age of 15 years selected from a population
of Brazilian high school students. The maxillary right central incisor (MCI) of each subject was photographed. The im-
ages were adjusted to standardize the long axis of the tooth in the vertical position. The AutoCAD computer program
was used to analyze graphically the geometric form of the tooth. According to analysis results, form was classified as
oval, triangular, or quadrangular. Intraexaminer consistency was analyzed by using linear correlation coefficient and
Bland Altman analysis. The relationship between gender and tooth form was analyzed by chi-square and linear regres-
sion (α=.05).

Results. In women, the form was 57.73% (n=127) oval, 23.54% (n=52) triangular, and 18.64% (n=41) quadrangular;
while in men, the form was 54.93% (n=117) oval, 36.15% (n=77) triangular, and 8.92% (n=19) quadrangular (P<.001).

Conclusions. The oval form was the most prevalent in both genders. However, the triangular form was more com-
mon in men than in women, and the quadrangular form more frequent in women than in men. (J Prosthet Dent
2011;106:95-101)

Clinical Implications
Selecting a suitable mold for anterior teeth has an important role in
prosthetic rehabilitation esthetics. Gender should be considered in
the process of selecting artificial teeth.

The shape of artificial teeth is se-
lected to imitate natural dentition.
However, records of patients’ natural
dentition, such as photographs, ar-
chived casts, or existing natural teeth
are not always available. In these situ-
ations, choice is guided by theories on
the selection of artificial teeth.1
The first tooth selection tech-
niques emerged in the late 19th cen-
tury and were influenced by the The-
ory of the 4 Temperaments,2,3 based
on the observation of physical and
emotional characteristics. Individuals
were classified into one of the follow-
ing temperaments: sanguine, phleg-
matic, choleric, or melancholic. Dif-
ferent tooth forms corresponded to
each temperament.4 However, based
on the work of Williams,5 the Theory
of Temperaments was discredited by
the scientific community.
The form of the maxillary central
incisor (MCI) was classified into 3
categories: oval, triangular, and quad-
rangular.5 Form choice came to be
guided by comparison with the invert-
ed shape of the face. Other physical
and emotional characteristics were
not considered.5-6 Nelson7 also ad-

a
Postgraduate student, Department of Prosthodontics.
b
Clinical Professor, Department of Prosthodontics.
c
Clinical Professor, Department of Prosthodontics.
Brunet to et al
96
vanced a theory that linked the dental
arch form of edentulous patients to
tooth form. Researchers tried to verify
the validity of the method that associ-
ated MCI with face shape and found
no relationship between them.8-14
By 1950, physical and emotional
aspects in the selection of artificial
teeth again became popular. A dento-
genic theory was described, according
to which 3 key factors governed the
choice of artificial teeth: gender (male
or female), personality (vigorous, av-
erage, or fine), and age (young, adult,
or elderly).15 Dentogenic theory was
based on the principle that the more
delicate and feminine personalities
are associated with rounded teeth.
Conversely, bolder, more masculine,
personalities are associated with ir-
regular or square teeth.16
Dental differences between the
genders remain unclear to this day.
Evidence suggests that there are dif-
ferences in tooth dimensions.17 Men’s
teeth seem to be larger than wom-
en’s.18-20 Regarding form, findings
are controversial since some authors
argue that a difference in tooth form
between genders does exist,21 while
others report it as nonexistent.11,12,22
Therefore, gender-based tooth se-
lection lacks scientific support and
adequate reliability. Nevertheless,
this criterion is currently one of the
primary references used to select the
form of artificial teeth.12,23 However,
dental appearance has been shown to
be equally relevant for both genders.24
At first, selection of tooth form
was geared towards the fabrication of
complete dentures. Currently, a wide
array of systems and materials are
available for dental restoration. As a
result, this procedure is more exten-
sively applied, covering a variety of
prostheses and esthetic procedures,
including conventional fixed pros-
theses, and prostheses supported by
implants and veneers25 that further
underscores the relevance of appro-
priate tooth form selection.
Initially, studies were undertaken
on dry skulls and with scant techno-
logical resources.4-8 In contrast, cur-
The Journal of Prosthetic Dentistry
rent accessibility to scanned images
and computerized graphics facilitates
the process of identifying and evalu-
ating tooth form in in vivo observa-
tions.12,20,21,23
Therefore, the purpose of this
study was to evaluate a possible dif-
ference between men and women in
terms of MCI tooth form (triangular,
quadrangular, or oval) in adolescents
attending the first year of public high
school in Florianópolis, Santa Cata-
rina State, Brazil. The null hypothesis
was that no difference exists between
genders in terms of MCI tooth form.
Material and Methods
The form of the right MCI was
evaluated in vivo using dental pho-
tographs of high school students in
Florianópolis. The teeth were pho-
tographed and digitized images were
analyzed graphically by AutoCAD
(AutoCAD 2008; Auto Desk Inc, San
Rafael, Calif ) to classify the right MCI
into the following forms: oval, trian-
gular, or quadrangular. The preva-
lence of each form was related to gen-
der.
The study was approved by the
Ethics Committee in Research of
Santa Catarina Federal University. An
informed consent form was signed
by the subjects’ parents and/or legal
guardians. From the population of
students attending the first year of
high school in Florianópolis, Santa
Catarina, Brazil (N = 4758), a mini-
mum sample size (n = 369) was ob-
tained. To this was added approxi-
mately 40% to make up for any losses
due to exclusion factors. In total, 528
subjects were photographed. This
sample (n=528) was stratified across
28 participating schools. The same
number of male and female subjects
was photographed in each school.
Students who were not wearing
fixed appliances on maxillary anterior
teeth were selected for the study. Ex-
clusion criteria were intraoral features
regarded as unsuitable for the study
and being over 30 years of age. The
following intraoral features associat-
Volume 106 Issue 2
ed with the right MCI were considered
unsuitable: missing teeth, develop-
mental anomaly with abnormal tooth
form, marked tooth wear, crowding,
caries or restoration, fracture, tooth
malposition relative to the basal
bone, eruption alterations, gingival
swelling, gingival recession, presence
of dentures or thick dental plaque,
and a history of esthetic periodontal
surgery.
The subjects were instructed to
brush their teeth. The proximal sur-
faces of the right MCI were flossed to
reduce plaque and enhance the vis-
ibility of details and tooth contour.
An intraoral physical examination was
performed to evaluate the exclusion
factors.
Subjects were instructed to lie on
a reclining chair (Bel Fix, Curitiba,
Paraná, Brazil) so that Camper’s
plane would be perpendicular to the
ground. During the examination and
photography, the chair was fully re-
clined with the subject lying down.
Lip retractors (Indusbello; Londri-
na, Paraná, Brazil) were placed intra-
orally. Photographs were made with
a frontal view, perpendicular to the
buccal surface of the MCIs (Fig. 1).
The MCIs were centered in the photo-
graph, with the midline centered and
perpendicular to the incisal plane.12 A
digital camera (D80; Nikon, Tokyo,
Japan) was positioned so that the
lens (F2.8 EX DG; Sigma Corpora-
tion of America, Ronkonkoma, NY)
was parallel to the buccal surface of
the MCIs.14 The camera settings were
standardized for all images, with the
following characteristics: speed 200,
aperture 32, 1/32 flash (EM-140; Sig-
maCorporation of America) adjusted
manually, lens (F2.8 EX DG; Sigma
Corporation of America) with fixed
1:2 focus (to standardize the distance
between focus and target) and fine
JPEG file format.
The photographic images were
transferred to a computer running
software (Windows XP; Microsoft,
Redmond, Wash) with 2GB RAM
(Dane-Elec, Bagnolet, France). The
filename of each image was stored,
Brunet to et al
August 2011
1 Frontal view photograph, perpendicular to MCI.
2 Adjustment in vertical position of long axis, showing
right MCI, cropped and ready to be centered in image.
3 Tooth outline.
with the name of the photographed
subject, in JPEG format. The images
were then duplicated and the du-
plicate file names were replaced by
sequential file numbers by another
examiner. This ensured that the subse-
quent analysis was performed blindly.
Prior to examining tooth forms,
Brunet to et al
the images were adjusted so that the
right MCIs remained centered in the
image, with the long axis set vertically,
with the use of image-editing software
(Adobe Photoshop 8.0.1; Adobe Sys-
tems, San Jose, Calif ). The image file
was opened into the program and
the following procedures were per-
97
formed: select the function “rotate
canvas” in “arbitrary” mode; change
image angle (in degrees) clockwise or
counterclockwise, as needed, to di-
rect the long axis of the right MCI to
a vertical position; crop the image by
selecting the right MCI (Fig. 2); and
confirm cropping.
The dental ratio of the right MCI
was calculated to identify the form.
Dental ratios were calculated by di-
viding the tooth width in the cervical
region by the greatest width of the
tooth. For this calculation, the trac-
ings were used according to the meth-
odology of Wolfart et al.14 A new soft-
ware-aided graphical evaluation was
proposed and performed by a single
examiner. AutoCAD (AutoCAD 2008;
Auto Desk Inc) is a computer-aided
design (CAD) program used primar-
ily for preparing technical drawings in
2 dimensions (2-D). As a result, the
program was chosen to assist in the
tracings and calculation of the right
MCI form.
The image file was opened in the
program and the following procedures
were performed: trace tooth contour
(Fig. 3); removal of photographic im-
age; tracing of 2 vertical lines tangen-
tial to the mesial and distal contours;
tracing of 2 horizontal lines (one on
the lower intersection of the mesial
tangent with the tooth contour, and
another on the upper intersection of
the distal tangent with the tooth con-
tour); tracing a line equidistant to the
2 previous lines (line B), represent-
ing the largest tooth width; the verti-
cal midline drawn from the center of
line B; and the height of the midline
(from line B) which was divided into 5
parts; a horizontal line was traced on
top of the upper fifth part of the divi-
sion, which represented cervical width
(Fig. 4).
To obtain the dental ratio the ex-
tent of line A was divided by the extent
of line B. According to the numerical
values that were obtained (unitless ra-
tios), dental forms were classified as
triangular (≤ 0.61), oval (> 0.61 and
<0.70), or quadrangular (≥ 0.70).
This was a cross-sectional, observa-
98 Volume 106 Issue 2
tional study. To calculate the minimum
sample size, the following factors were
considered: unknown prevalence of
the phenomenon (tooth form) in the
population, 95% level of confidence,
and 5% tolerable sampling error. The
dependent variables were assessed in
numerical format (dental ratio) and
categorical form (oval, triangular, and
quadrangular tooth forms). The inde-
pendent variable was categorical: male
and female genders.
The data were saved as a spread-
sheet (Excel 2007; Microsoft). The
4 Preparation of images for measurement. Tracing of vertical tangents chi-square test was used to compare
on mesial and distal sides of MCI (upper left). Tracing of horizontal line categorical form percentages. The
on upper intersection of distal tangent with outline (upper right). Trac- relationship between the numerical
ing of line equidistant to the 2 previous lines (line B), representing larg- ratio and the variables of age and
est tooth width (lower left). Tracing of horizontal line (line A), represent- gender was assessed using simple lin-
ing width of cervical region, (lower right) ear regression. Since no association
was found between age and numeri-
20 cal ratio, multiple linear regressions
were not performed. The relationship
Male Female between gender and numerical ratio
was expressed by the mean difference
15
of the numerical ratio between the
Percentage (%)

gender and their respective 95% con-

fidence interval (CI = 95%).
10 To test intraexaminer consistency,
40 dental images were reassessed. The
result was analyzed using Pearson’s
correlation coefficient and Bland-Alt-
5 man analysis. All significance prob-
abilities (P values) were 2-tailed. Data
were analyzed with statistical soft-
ware (STATA/SE 9.2; StataCorp LP,
0
0.5 0.6 0.7 0.8 0.5 0.6 0.7 0.8 College Station, Texas).
Numeric Ratio
5 Histogram of numerical ratio values obtained from dental RESULTS
calculations for each gender
Of the 528 subjects who con-
0.9 sented for the study, 95 were exclud-
ed. Thus, the final sample consisted
of 433 subjects. The mean age was
Numerical Format

0.8 15.92, standard deviation 1.72.

Distribution of the numerical ra-
0.7 tio, obtained by calculating the dental
ratio, is depicted in Fig. 5, as well as
percentages equivalent to 25%, 50%,
0.6 and 75% (Fig. 6). A significant differ-
ence was found in the numerical ratio
0.5 (numerical format) between the gen-
Male Female ders (P<.001).
The numerical ratios were con-
6 Box Plot of numerical ratio (numerical format), according to gender.
verted into categories (oval, triangu-
The Journal of Prosthetic Dentistry Brunet to et al
 August 2011
Table I. Percentage and absolute values of dental forms, according to gender.
Geometric
Form
Triangular
Oval
Quadrangular
Total
0.85
0.80
0.75
Measurement 2
0.70
0.65
0.60
0.55
0.55 0.60 0.65 0.70
Measurement 1
7 Scatter plot and linear regression of first and second
measurements of tooth form.
lar, or quadrangular). The percentage
found in each category according to
gender is detailed in Table I. A statisti-
cally significant difference was found
between the genders in the prevalence
of tooth form categories (P=.001).
In considering each category sep-
arately, significant differences were
found between the genders for the tri-
angular (P=.004) and quadrangular
forms (P=.003) but not for the oval
form (P=.557). The linear regression
coefficient of the numerical ratio ac-
cording to age was -0.0017 (P=.266),
indicative of no association.
Forty teeth were randomly select-
ed by simple sort without replace-
ment, and adjustment and measure-
ments, procedures were repeated. A
high correlation was found between
values obtained in 2 measurements,
which could be observed by means of
simple linear regression (Fig. 7) and
the Bland-Altman plot (Fig. 8). Mean
difference between measurements
Brunet to et al
Gender
Male
36.15% (n=77) 23.64% (n=52)
54.93% (n=117) 57.73% (n=127)
8.92% (n=19) 18.64% (n=41)
100% (n=213) 100% (n=220)
Measurement 1 – Measurement 2
0.75 0.80 0.85
8 Bland-Altman plot of first and second measurements
of tooth form.
was -0.0009. The 95% confidence in-
terval ranged from -0.012 to 0.010.
DISCUSSION
In this study, a significant differ-
ence was found between genders in
terms of right MCI form. Therefore,
the null hypothesis was rejected. Such
results are not in agreement with those
of Wolfart et al,12 who noted there
was no significant difference between
the genders for the same categories
of MCI form. Another difference is
that in their study, the triangular form
was the least prevalent. In the current
study, the quadrangular form was the
least prevalent. These differences may
be due to population variability and
greater software accuracy.
In comparing each tooth category
between the genders, significant dif-
ference was found in the triangular
and quadrangular categories. The
oval category was the most prevalent,
99
Female Total
29.79% (n=129)
56.35% (n=244)
13.86% (n=60)
100% (n=433)
0.10
0.05
0.01
0
–0.01
–0.05
–0.10
0.55 0.60 0.65 0.70 0.75 0.85
Mean of Measurement 1 and Measurement 2
with similar percentages between the
genders. Therefore, no significant dif-
ference was found. Accordingly, the
oval form was the most prevalent in
the work of Broaldbelt10 and Wolfart
et al.12 A higher percentage of the
quadrangular form in women (com-
pared to men) and triangular form in
men (compared to women) also was
found by Wolfart et al.12 However, the
authors did not interpret such differ-
ence as significant.
Regarding numerical ratio (nu-
merical format), the range of values
observed in the current study was
greater in women (Fig. 6). Thus, there
may be greater variability of right MCI
forms in women. This finding is in-
consistent with the study of Lindeman
et al,21 who observed greater MCI
form variability in men. Regarding
tooth size, this greater diversity was
observed in men.17 This variation may
be due to different evaluation meth-
ods across studies, as well as possible
100
variations in population.
Objective observation of tooth
form, as is the case with graphical
analysis, tends to be more consistent
than subjective analysis. Low inter
and intraexaminer agreement is in-
dicative of high dependence on the
observer variability inherent in sub-
jective assessment.14 The high intraex-
aminer consistency observed in the
present study confirms the reliability
of the method. Nevertheless, further
interexaminer studies are needed.
Although the method of selecting a
dental form according to gender is
widespread, dentists seem not to be
able to identify such differences.11
The authors attempted to clarify
the differences in the form of the right
MCI between the genders. It was not-
ed that male MCIs tend to be more
triangular in form. Female MCIs,
however, tend towards a quadrangu-
lar form. Opting for a quadrangular
form for men is statistically more like-
ly to result in a mismatch. The 3 tooth
forms were observed in both genders,
with a higher prevalence for the oval
form. Arguably, choosing the oval
form has a better chance of match-
ing the original tooth, regardless of
gender. The results suggest prevalence
data only, but not a rule. This study,
however, does not provide grounds to
assert that these differences are read-
ily perceptible to a casual observer.
The theory that female teeth should
be more rounded and male teeth
more quadrangular has been rejected.
Tooth selection theories are general-
ly inaccurate. Aspects of tooth position-
ing and color are more easily perceived
than shape. Consequently, less impor-
tance has been given to shape selection.
However, the availability of a wide range
of artificial tooth models and commer-
cial brands may raise doubts at the time
of choosing. Theories of artificial tooth
selection can serve, at best, as guidance,
not as rules. Furthermore, the popular-
ity of bleaching, porcelain laminates,
and bleached shades for artificial teeth
indicates that a significant population
wants to change what they originally
had. Choosing a different shape from
The Journal of Prosthetic Dentistry
what the subject originally had may not
necessarily compromise esthetics. Stud-
ies involving the esthetic perception of
different tooth shapes may help to as-
sess whether there are esthetic prefer-
ences for different shapes.
All assessments were performed
blindly by the same examiner using Au-
toCAD, an accurate and reliable com-
puter program. The AutoCAD program
is traditionally used for calculations and
design in architecture and engineering.
However, there are no reports of its use
for calculating tooth form or size. There-
fore, the authors proposed a new as-
sessment method. Conducting a study
has helped to establish an appropriate
methodology. Furthermore, the analy-
sis was performed in vivo, prospectively
and in a broad sample. All invited in-
stitutions agreed to participate in the
study and the results showed statistical
significance.
The results were not fully in agree-
ment with previously published find-
ings.10,12,17,21 Several factors may have
contributed to this difference: many
studies evaluated tooth size and not
tooth form; the teeth assessed were not
always the same; tooth size variability
might have been different from form
variability; the genetic variability of dif-
ferent populations may have exerted
some influence; the manner in which
form classification was conducted var-
ied among studies since it is difficult to
standardize, especially through subjec-
tive evaluation; and the present investi-
gation focused on a specific population.
The study area features a wide ethnic
diversity resulting from Portuguese, Ital-
ian, German, and African immigration,
among others. Therefore, the popula-
tion studied consisted of a mixture of
these different ethnicities. Thus, further
studies with a similar methodology to
the one used in this study are needed
to assess the reproducibility of results in
different populations.
Despite objective assessment, diffi-
culties in standardizing tooth position-
ing prior to evaluation is a shortcoming.
This limitation is not unique to this
study since currently n o foolproof
method exists to position teeth. Effort
Volume 106 Issue 2
was made to maintain the long axis
of the right MCI in a vertical position.
This minimized variability between
subjects’ dental inclinations. Stan-
dardizing the tracing of tooth contours
posed yet another challenge. Minor in-
ter and intraexaminer variations may
have occurred during this tracing. Nev-
ertheless, the procedure performed
with the aid of AutoCAD seems more
accurate than that afforded by earlier
methodologies.10,12 Further interexam-
iner studies are required.
CONCLUSIONS
Within the limitations of this study,
the percentages of oval, triangular,
and quadrangular forms were differ-
ent between the genders in this popu-
lation. The oval form was the most
prevalent in both genders, exhibiting
similar percentages. The quadrangu-
lar form was the least prevalent and
was found more often in women than
men. The opposite was true of the tri-
angular form, which was more preva-
lent in men than women.
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Corresponding author:
Dr Juliana Brunetto
Rua Auroreal 156 Campeche
Florianópolis – Santa Catarina
88063-201
BRAZIL
Fax: +48-32285007
E-mail: julianabrunetto@yahoo.com.br
Copyright © 2011 by the Editorial Council for
The Journal of Prosthetic Dentistry.

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Brunet to et al