Original Article Evaluating the reliability of the interalar width

and intercommissural width as guides in

selection of artificial maxillary anterior teeth:
Aclinical study
Glynis Anita Miranda, Mariette DSouza1
Department of Prosthodontics, AJ Institute of Dental Sciences, Mangalore, 1Private Practitioner, Udupi,
Karnataka,India

Address for correspondence: Dr.Glynis Anita Miranda, Email:glynismiranda@yahoo.com

ABSTRACT
Objective: Oral rehabilitation of a completely edentulous patient is essential to improve the patients selfesteem and selfconfidence
through the fabrication of conventional or implant supported overdentures. To achieve this, there is a need to restore the
natural appearance of the patient through appropriate anterior tooth selection which requires reliable guidelines. Thus,
the objective of this study was to determine the correlation and evaluate the reliability of the interalar width to intercanine
distance and intercommissural distance to the distal aspects of the canines in the selection of maxillary anterior teeth.
Materials and Methods: Twohundred individuals who satisfied the inclusion and exclusion criteria were selected. The four
parameters such as interalar width, intercanine distance, intercommissural width, and distance between distal aspects of canines
were measured. The data obtained were statistically analyzed. Results: The results revealed that the mean values for interalar
width and intercanine distance in males were 3.852 and 3.538cm, respectively, and in females, it was 3.396 and 3.402cm,
respectively. In addition, the mean values for intercommissural width and distance between the distal aspects of canines were
4.921 and 3.913 cm in males, respectively. In females, it was 4.590 and 3.740cm, respectively. In males and females, the
correlation between interalar width and the difference between the intercanine distance and interalar width is statistically
highly significant (in males r=0.707, in females r=0.619). Correlation of difference of intercommissural width and the
distance between the distal aspects of the canines with the average of intercommissural width is statistically significant(in males
r=0.777, in females r=0.712). Conclusion: A correlation was observed between the interalar distance and the intercanine
distance and also between the intercommissural distance and the distance between the distal aspects of canines.

CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY

I t is the dentists responsibility to preserve the natural dignity of advancing age while fabricating a complete denture
prosthesis, with appropriate and careful selection and arrangement of teeth
As it is difficult to determine the dimensions of the maxillary anterior teeth for an edentulous patient when preextraction
records are not available, other guidelines must be taken into consideration and the development and implementation
of an esthetic proforma to guide the dentist and patient may be essential
One area of prime concern may be to determine correlations and relationships between interalar width and intercommissural
width with the mesiodistal width of upper anterior teeth which can be interpreted as a useful guide in clinical practice.

Key words: Anterior teeth selection, esthetics, interalar width, intercanine distance, intercommissural width

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How to cite this article: Miranda GA, D'Souza M. Evaluating the

DOI: reliability of the interalar width and intercommissural width as guides in
10.4103/2229-5194.197665 selection of artificial maxillary anterior teeth: A clinical study. J Interdiscip
Dentistry 2016;6:64-70.

64 2016 Journal of Interdisciplinary Dentistry|Published by Wolters KluwerMedknow

 Miranda and DSouza: Use of interalar width and intercommissural width as reliable guides
INTRODUCTION
A complete denture is perceived esthetically
pleasing and functionally acceptable when the
teeth are placed and arranged in a biologic harmony with
the surrounding tissues.[1] The arrangement and alignment
of anterior teeth have always remained as a challenging
experience to the dentist since phonetic values, esthetics,
and also function have to be considered simultaneously.
The denture bases and the selection of the artificial teeth
should be in harmony with the facial musculature as well
as the shape and size of the head.[2] Moreover, Boucher
had averred that the correct positioning of an artificial
tooth is actually the one in which it was placed by nature.[3]
Preextraction records such as photographs, radiographs,
and extracted teeth do play an important role in the
selection of teeth with reference to shape, size, and
color. With no preextraction records available, selecting
the proper anterior teeth size for edentulous patients
can be arduous.[4,5] Therefore a systematic approach
is needed in such situations; consequently, several
anatomic measurements have been suggested including
bizygomatic width, intercommissural width, interalar
width, and interpupillary distance. [6,7] The socalled
denture look will be reflected on the face when these
guidelines have been failed to be used though it may have
a satisfactory appearance on the articulator. Furthermore,
one of the critical factors is the position of the canine
in denture teeth arrangement since it provides tissue
support at the corner of the mouth and its position is in
the turning point of the dental arch.[8] Nasal index, a
popular guide in selection of anterior teeth, is actually an
index that relates the interalar width to the space available
for setting upper anterior teeth and, by implication, the
width of teeth when selecting a tooth mold.[9] The interalar
distance supposedly represents the distance between the
cuspid tips. The intercommissural method is based on the
hypothesis that the distal surface of the maxillary canines
should be located approximately at the commissures of
the mouth.
The rationale behind this research depends on the
acceptance of the postulate that artificial anterior teeth
should be arranged in the same position as their natural
predecessors and also be analogous in size and shape.
Hence, an investigation of the relation between the width
of the nose, intercommissural width, and the natural teeth
was undertaken.
MATERIALS AND METHODS
The study was conducted to compare and evaluate the
relationship between the interalar width to the intercanine
distance and the intercommissural width to the distance
Journal of Interdisciplinary Dentistry / May-Aug 2016 / Vol-6 / Issue-2
between the distal surfaces of the maxillary canines in the
male and female groups.
A total of 200 dentulous individuals were chosen for this
study. The sample comprised 100males and 100females
ranging in age from 20 to 30years. The sample was
grouped by gender to determine the effect of this factor
on the correlations of the measurements.
Selection of individuals was based on the following criteria:
Inclusion criteria:
1. All cases were above 18years of age so that
growth of the face was essentially complete
2. Cases who had nor mal occlusion with full
complement of natural teeth.
Exclusion criteria:
1. Individuals with proximal restorations on the
distal surfaces of canine that could grossly affect
the width of maxillary anterior teeth
2. Individuals who had spacing or crowding of
maxillary anterior teeth were excluded
3. Individuals with congenital or developmental
deformities(abnormal or altered nose) and had
undergone any surgical repair in the orofacial
region
4. Individuals treated orthodontically or proximal
stripping were excluded
5. Individuals with developmental anomalies of the
maxillary anterior teeth and deciduous canines
were excluded
6. No individuals were included with atypical
condition such as traumatized lips and mobile
anterior teeth.
The individual should have an apparently normal face
form as determined by the vermilion border of lips, the
nasolabial fold, the philtrum, and the labiomental fold.
By normal it is meant that these factors did not by
themselves bring undue attention to the individual.
A proforma specially designed for the project was filled
out for each individual. Both extraoral and intraoral
examinations were done. Informed consent was taken for
using their data in the research.
PROCEDURE
The individual was seated on the dental chair
comfortably, in a relaxed state and upright position. The
proforma was filled out for each individual and selection
was done according to the criteria laid down for the
study. The interalar width and the intercommissural
distance were measured using a Vernier Caliper. An
impression of the maxillary cast was made and the
65
 Miranda and DSouza: Use of interalar width and intercommissural width as reliable guides
cast was poured. On the cast, the intercanine distance
and the distance between the distal aspects(distal
contact point) of the canines in a straight line were
measured. These measurements were done on accurate
stone casts instead of directly in the mouth because
measurements can be repeated more conveniently on
casts than in mouth. The results obtained were then
compared to find out the accuracy of maxillary artificial
anterior teeth selection.
Recording the interalar width
The individual was seated on the dental chair in a
relaxed state and in an upright position. Two points
were marked on either side of the nose with a fine
tipped marking pen indicating widest points on the
outer surfaces of the alae of the nose. The distance
between the two points marked on the alae of the nose
was recorded using a pair of Vernier Calipers by bringing
the recording parts of the gauge just in contact with
the outer surfaces of the alae, without any pressure
being applied[Figure1]. While measuring, the patient
was asked to stop breathing momentarily to avoid any
change in shape of the nose. The readings on the Vernier
scale were noted down to the fraction of one tenth of
a millimeter. The readings were repeated three times
and the mean was recorded.
Determination of intercommissural width
With the individual in a relaxed state, the distance
was measured between the two points marked at the
commissure in its passive state with a pair of Vernier
Calipers[Figure 2]. Extreme care and attention were
given to prevent any change in position of commissure
consequent to changes in facial expression. The readings
on the Vernier scale were noted to the fraction of one
tenth of a millimeter. Three such recordings were made
to arrive at an average value.
Figure 1: Recording the interalar width at the widest dimension of
the nose
66
Preparation of maxillary cast
A perforated stock metal tray of an appropriate size was
selected to record the complete complement of natural
maxillary teeth. An irreversible hydrocolloid impression
material was used as per the manufacturers instructions.
The impression obtained was inspected and if found
suitable, was thoroughly washed under running water
and then poured immediately with dental stone. To avoid
inaccuracies, the same make of stone and waterpowder
ratio was used. Care was taken to prevent incorporation of
air bubbles using a mechanical vibrator to pour the casts.
Measurement of intercanine distance and
the distance between the distal aspects of
the canines
A small dot was marked on the tips of the canines.
AVernier Caliper was used to check the distance between
the dots. Thus, the intercanine distance, a straight
distance between the tips of the canines, was measured
to the fraction of onetenth of a millimeter[Figure3]. In
individuals where a distinct cusp tip was not noticeable
due to attrition, the midpoint of the wear facet was
taken for recording the intercanine width. Each dot
was equidistant from the mesial and distal margins and
from the buccal and palatal margins. Three readings
were recorded and the average value was taken as the
final intercanine distance. To determine the distance
between the distal surfaces of the canines, the recording
parts of the Vernier Caliper were placed on the distal
surfaces of the canines at the contact point and this
distance was measured to the fraction of onetenth of a
millimeter[Figure4]. Each recording was repeated three
times to standardize the measurements.
For sake of consistency, the same examiner made all of the
records, performed all of the measurements, and recorded
all of the information.
Figure 2: Recording the intercommissural width
Journal of Interdisciplinary Dentistry / May-Aug 2016 / Vol-6 / Issue-2
 Miranda and DSouza: Use of interalar width and intercommissural width as reliable guides

A statistical evaluation was done on the basis of the data In males and females, the correlation between interalar
that was obtained from the 200samples. width and the difference between the intercanine distance
and interalar width is statistically very highly significant. In
males, r value is 0.707 and Pvalue is 0.001. In females,
RESULTS the r value is 0.619 with Pvalue of 0.001 that is highly
significant. In addition, the correlation value between
Measurements obtained from the 200 individuals were the intercommissural width and the difference between
tabulated. In this study, a statistical significance was
the intercommissural width and the distance between
determined using the ttest. There was a statistically
significant difference in the values of the measured
parameters between the male and female individuals.
The investigated parametric interconnection was
analyzed by linear correlative analysis(Pearsons analysis)
and numerically presented by the linear correlation
coefficient(r). The present sample revealed increased
values of interalar width and intercommissural width
values for males than females[Graph1]. Equivocal reports
also exist in literature.[10,11] Thus, it appears that men
have wider noses and greater intercanine distances than
women. The parameters when compared between the
gender groups were found to be statistically very highly
significant(P=0.001) as shown in Tables1 and 2.

The mean values for interalar width and intercanine

Figure 3: Recording the intercommissural width
distance in males were 3.852 and 3.538cm, respectively,
and the mean values for intercommissural width and
distance between the distal aspects of canines were 4.921
and 3.913cm, respectively. In females, the mean values
for interalar width, intercanine width, intercommissural
width, and distance between the distal aspects of canines
were 3.396, 3.402, 4.590, and 3.740cm, respectively.

The coefficient of correlation r was calculated to determine

the relationship between the following[Tables3a and b]:
Interalar width and the difference between the
interalar width and the intercanine distance
Intercommissural width and the difference between the
distal aspects of canine and intercommissural width.

Table 1: Comparison of the various parameters with Figure 4: Recording the distance between the distal aspects of the
gender using Descriptive statistics and Students canines
unpaired ttest
Sex MeanSD* t P 5
Interalar width 4.5
4
Males 3.8520.298 13.03400 0.001 (VHS) 3.5
females 3.3960.184 3
2.5
Intercanine distance 2
1.5
Males 3.5380.215 4.72300 0.001 (VHS) 1
Females 3.4020.194 0.5
0
Intercommissural width Interalar width Intercanine Intercommisural Distance
Males 4.9210.332 7.54500 0.001 (VHS) distance width between distal
Females 4.5900.286 aspects of
canines
Distance between distal
aspects of canines Male Female
Males 3.9130.220 5.70300 0.001 (VHS)
Females 3.7400.209 Graph 1: Comparison of the mean values between male and female
*SD=Standard deviation. VHS=Very highly significant groups

Journal of Interdisciplinary Dentistry / May-Aug 2016 / Vol-6 / Issue-2 67

 Miranda and DSouza: Use of interalar width and intercommissural width as reliable guides

Table 2: Mean difference of the various parameters in males and females

Sex I II Mean difference (III) (cm) P
Males Interalar width Intercanine distance 0.3137 0.001 (VHS)
Distance between distal aspects of canines 0.060 0.115 (NS)
Intercanine distance Intercommissural width 1.38 0.001 (VHS)
Intercommissural width Distance between distal aspects of canines 1.006 0.001 (VHS)
Females Interalar width Intercanine distance 0.006 0.848 (NS)
Distance between distal aspects of canines 0.344 0.001 (VHS)
Intercanine distance Intercommissural width 1.19 0.001 (VHS)
Intercommissural width Distance between distal aspects of canines 0.8501 0.001 (VHS)
VHS=Very highly significant, NS=No significant

In this study, the interalar width of the nose, a standard

Table 3a: Correlation of the difference of interalar
anthropometric measurement, was measured at the
width and intercanine width with average of
widest points between the outer surfaces of the alae of the
interalar width
nose. The intercommissural width was measured between
Males Pearson correlation r 0.707
the corners of the mouth. The intercanine distance and the
Significant (twotailed) 0.001
n 100 distance between the distal surfaces of the canines were
Females Pearson correlation r 0.619 obtained from stone casts.
Significant (twotailed) 0.001
n 100 Hoffman etal.[12] and Scandrett etal.[5] measured the
distance between the distal surfaces of the canines in a
circumferential arc. This is probably because the anterior
Table 3b: Correlation of difference of intercommissural teeth are classified by the distance from the distal surface
width and the distance between the distal aspects of the of one maxillary canine to the distal surface of the
canines with average of intercommissural width opposite canine. However, the present study measured
Males Pearson correlation r 0.777 the distance between the distal surfaces of canine in
Significant (twotailed) 0.001
a straight line. Proclination and retroclination of the
n 100
Females Pearson correlation r 0.712
anteriors may have an influence on the circumferential
Significant(twotailed) 0.001 measurement whereas a linear measurement would be
n 100 more reliable. Moreover, the mesiodistal measurement
may be dependent on the level at which the measurement
the distal surfaces of the canines in males is found to be was made, i.e.,circumferential measurement made
statistically highly significant(r=0.777, P= 0.001). In at a cervical level or incisal level may be more or less
females, the r value for correlating intercommissural depending on the angulation of teeth. The variations
width to the dif ference between distal surfaces of noted in the values of the intercommissural widths and
canines and the intercommissural width is statistically distal surfaces of canines, in this study, may be attributed
significant(r=0.712, P=0.001). to the distopalatal rotation of the canine that is inherent
in most natural dentitons. Mavroskoufis and Ritchie[9] and
Ahn etal.[17] in their study also measured the intercanine
DISCUSSION distance in a straight line.

Many techniques of anterior teeth selection exist, but little
consensus on an effective and valuable method has been
attained. This study was therefore done to ascertain the
validity of interalar width and intercommissural width as
guides in the selection of upper anterior teeth. Literature
has shown that the distance between the outer surfaces of
the alae of the nose nearly corresponds to that between
the tips of the canines.[1216]
Of several methods, the mesiodistal dimension of anterior
teeth can be related to the distance between the corners
of the mouth as pointed out by Silverman and also to the
width of the nose as suggested by Lee.[13]
The current study revealed an average interalar width as
3.852 cm in males and 3.396 cm in females. The values
showed that the interalar width was lesser in females by
0.456 cm(4.56 mm), revealing an influence of sex factor
and this finding is in conformity with concepts of Frush and
Fisher.[18] Smith,[19] Dharap and Tanuseputro,[20] Keng,[11] and
Ahn etal.[17] in their studies had also observed an influence
of sex factor. Their results also showed that males have
wider noses than females.
The average intercanine distance in males was 3.538 cm
and in females was 3.402 cm. This revealed that the
intercanine distance was less in females by 0.136 cm. This

68 Journal of Interdisciplinary Dentistry / May-Aug 2016 / Vol-6 / Issue-2

 Miranda and DSouza: Use of interalar width and intercommissural width as reliable guides
may be due to the differences in the size of the arch and
teeth in the two genders.
The intercommissural width in males was 0.331 cm greater
than in females. The mean intercommissural measurement
for males was 4.921 cm and for females 4.590 cm. Lieb
etal.[21] in their study showed that the average distance
through the commissures was 5.27 cm. In their study, the
variations in measurements can be attributed to ethnicity.
The distance between the distal surfaces of the canines was
also greater in males by 0.173 cm(1.73 mm), indicating
that males have wider arches than females.
In the current study, all measurements are greater in males
revealing the influence of sex factor in accordance to the
dentogenic concept.
Many are of the belief that the interalar width is
comparatively similar to the intercanine distance and
this decisive factor is one of the criteria for the selection
and placement of the upper six anterior teeth. However,
this standard approach is not always to be followed as
a general rule because sometimes there is variance in
the measurements between the variables compared in
some individuals. In the present study, from the mean
values estimated, the average interalar width in males
was more nearer to the measurement of the distance
between the distal surfaces of the canines, rather than
to the intercanine distance. However, in females, the
interalar width value was found to be nearer to the
intercanine distance.
In studies where clinical measurements are considered,
comparison of a new measurement technique with an
established one is often indispensable to see whether they
agree or correlate sufficiently for the new technique to
replace the old one. Using correlation coefficient, notably,
these investigations are often analyzed inappropriately.
The correlation coefficient r measures the degree of
association or strength of linear association between two
quantities and not how strongly they agree.[22] Therefore,
when comparing a new method of measurement with an
established one, we need to know whether the difference
between the two methods is related to the magnitude
of measurement and thus a plot of difference against
standard measurement when carried out will show
whether there will be a true association or not, between
the difference and the magnitude.
In this study, when dif ference was plotted against
the average of the standard measurement, a positive
correlation was observed between the variables that
were compared in both groups indicating that they can
be used as useful guides. Keng[11] in his study found no
Journal of Interdisciplinary Dentistry / May-Aug 2016 / Vol-6 / Issue-2
demonstrable correlation between interalar width and
intercanine distance. He concluded that men had wider
noses and slightly greater intercanine distances compared
to women. The results of this study were in conformity
with the latter findings of Keng. Lieb etal.[21] observed
some correlation between intercanine distance and
intercommissural width, but certainly not high enough to
be used as a predictive factor. The correlation coefficient
was+0.45 and they concluded that the cuspid tooth does
not have any consistent pattern of relationship to anatomic
facial features. Scandrett etal.[5] opined in their study that
intercommissural width had the greatest correlation, 0.44,
with the width of the maxillary anterior teeth.
Further studies can be carried out on dentulous individuals
of different age groups, i.e.,middleaged and older, to
compare the clinical findings. The results of this study may
not be applicable to all age groups. Smith from his study
concluded that there is an increase in the interalar width
with age in both men and women.
As age advances, tissues get laxed and this loss in tonicity
of muscles leads to erroneous values, i.e.,interalar width
is seen to increase generally but that does not indicate
bigger teeth for older individuals. Aged dentitions also
show physiologic or pathologic drifting of teeth that may
cause a difference in values. Therefore, much emphasis
on the importance of preextraction records is essential, to
facilitate anterior tooth selection during complete denture
fabrication.
CONCLUSION
From the results of this study, the following conclusions
can be drawn:
All the measurements made were more in males than
females, thus indicating an influence of gender factor
In males, there was a tendency of interalar width being
greater than the intercanine distance while the reverse
situation existed in females where the intercanine
distance tended to be greater than the interalar width
A correlation between the interalar width and
intercanine distance was observed in both gender
groups
A correlation was also observed between the
intercommissural width and the distance between
the distal surfaces of the canines in both groups.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
69
 Miranda and DSouza: Use of interalar width and intercommissural width as reliable guides
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