CLINICAL RESEARCH

Determining of canine position by multiple facial landmarks to

achieve natural esthetics in complete denture treatment
Natchalee Srimaneekarn, DDS, MSc, PhD,a Tawepong Arayapisit, DDS,b Ornnicha Pooktuantong, DDS, MSc,c
Holland R. Cheng, PhD,d and Pan Soonsawad, DDS, PhDe

Patients who have lost their ABSTRACT

teeth experience not only
compromised mastication and
pronunciation but also the
emotional damage of losing
their natural physical appear-
ance.1 Thus, the goal of a
complete denture includes
helping the patient to regain
confidence in their appear-
ance. This requires knowledge
and understanding of both the
physical and biologic factors.2
The best way to select artifi-
cial teeth is from pre-
extraction records, including
diagnostic casts, radiographs,
and recent images showing a
natural smile. Patients without
pre-extraction records will
present a more challenging
tooth selection process.2-4 Er-
ror in the selection of the
artificial teeth will affect correct
tooth alignment.3,5 Conse-
quently, this will potentially
compromise the patient’s
Statement of problem. Anterior tooth selection is an important step in complete denture
treatment as it plays a pivotal role not only in esthetics but also in mastication and
pronunciation. However, conventional methods for tooth selection are not well established and
rely on facial measurements and proportions, which vary among different ethnicities.
Purpose. The purpose of this clinical study was to investigate the relationship between interalar
width and intercanine distance and to compare different clinical methods for determining the
position of the canine tooth.
Material and methods. Two hundred Thai participants (100 men and 100 women) aged 18 to 25
years with 6 full maxillary anterior teeth were enrolled in this study. The interalar width and
intercanine distance were measured with digital vernier calipers and compared by using the
paired-samples t test. To determine the canine position, 2 reference linesdthe alar line (A line)
and the inner canthus of the eye to alar line (IA line)dwere drawn through the canine on both
sides. The horizontal distances from each reference line to the canine cusp tip and distal contact
point were evaluated and then analyzed using the 1-sample t test.
Results. All measurements were significantly different between men and women (P<.01). Interalar
width was greater than intercanine distance in both sexes. In men, the A line coincided with the
canine distal contact point (P>.05). In contrast, the IA line was distal to the canine distal contact
point by 3.5 ±3.6 mm on the left side and by 3.9 ±3.4 mm on the right side. In women, the A
line was situated between the canine cusp tip and distal contact point. It was mesial to the
distal contact point by 2.0 ±2.0 mm on the left side and by 1.8 ±2.0 mm on the right side. The
IA line was distal to the canine distal contact point by 1.2 ±2.6 mm on the left side and by 1.6
±2.7 mm on the right side.
Conclusions. The interalar width is greater than the intercanine distance in both sexes. The A line is
more clinically relevant than the IA line for predicting canine position. The A line can directly
determine the distal contact point of the canine in edentulous male patients. However, in
women, a distance of approximately 2 mm should be added distal to the A line to locate the
distal contact point of the canine on both sides. (J Prosthet Dent 2020;-:---)

Support provided by National Institute of Health [grant numbers AI095382, EB021230, CA198880]; and National Institute of Food and Agriculture [grant number CA-D*-
MCB-7399-H].
a
Assistant Professor, Department of Anatomy, Faculty of Dentistry, Mahidol University, Bangkok, Thailand.
b
Assistant Professor, Department of Anatomy, Faculty of Dentistry, Mahidol University, Bangkok, Thailand.
c
Lecturer, Department of Anatomy, Faculty of Dentistry, Mahidol University, Bangkok, Thailand.
d
Professor, Department of Molecular and Cellular Biology, University of California Davis, Davis, Calif.
e
Lecturer, Department of Anatomy, Faculty of Dentistry, Mahidol University, Bangkok, Thailand.

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Clinical Implications
The clinical canine cusp line methods, which rely on
facial landmarks to determine the position of the
canine cusp tips, are inaccurate for use in Asian
patients. When using the alar line method, the line
should match with the canine distal contact point in
men; in women, it should be moved 2 mm distally
to reach the canine distal contact point.

appearance and ability to form natural facial expressions,

damage the remaining gingival line, and impair their
ability to pronounce words correctly.5,6
In patients without pre-extraction records, clinicians
may measure the nose to estimate the distance between
the maxillary canines. This is based on the observation
that during embryogenesis of the face, the premaxilla
that supports the anterior maxillary teeth and the alar of
the nose develop from the same region.7,8 Therefore, Figure 1. Measurements of 2 distances. A, Widest part of nose (interalar
theoretically, the interalar width and intercanine distance width). B, Distance between maxillary canine cusp tips (intercanine
distance), without accounting for curvature of face.
should be related.
Hoffman et al9 reported that the intercanine distance
is approximately 3% greater than the interalar width.
points of the left and right canines is used for artificial
While the intercanine distance and interalar width were
tooth size selection from a tooth mold chart,5 the clinical
highly correlated in an Indian population,10,11 studies
relevance point in the tooth selection step should ideally
conducted in Brazil, England, and the United States re-
not be the canine CT but the CD.
ported that these 2 measurements were not significantly
Therefore, in view of the ambiguity of these concepts
related and that using this relationship may result in
and the difference in results among different ethnicities,
misaligned teeth.12-14 This lack of correlation can be
the present study aimed to analyze the difference be-
observed in different ethnicities, sexes, ages, and
tween interalar width and intercanine distance quanti-
geographical regions.15 In a Thai cohort, the interalar
tatively and to determine whether the A line or IA line
width was reported to be greater than the intercanine
can be used to estimate the position of the canine CT and
distance by 3.14 ±3.00 mm in men and by 2.61 ±2.54 mm
CD. The research hypothesis was that the A line or the IA
in women.16 In another study of a Thai cohort, a low but
line can be used to estimate the position of the canines. A
statistically significant level of correlation was found be-
better understanding of the most appropriate methods of
tween the distance of the canine distal contact points
selecting and positioning canine teeth will aid in fabri-
(CDs) and the interalar width (r=0.271, P<.001).17
cating dentures for edentulous patients.
Two traditional methods have been used clinically to
determine the position of the maxillary canine cusp tips
MATERIAL AND METHODS
(CTs). The first method uses an imaginary vertical line
perpendicular to the floor starting from the widest part of This study was approved by the Institutional Review
the ala of the nose and then straight down to the Board of Mahidol University (certificate No. MU-IRB
maxillary occlusal rim3,18dcalled the alar line (A line). The 2009/134.2506). A total of 200 adult Thai participants
second method uses an imaginary diagonal line that (100 men and 100 women; age 18-25 years) were
begins at the inner canthus of the eye and passes through enrolled in this study. Participants from this age group
the widest part of the ala of the nose to the upper were enrolled because no significant developmental facial
occlusal rim19dcalled the inner canthus to alar line (IA changes have been reported to occur after approximately
line). Although these 2 methods draw different lines on 17 years of age.20 All participants had 6 completely
the face, both estimate the same location as the canine erupted natural maxillary anterior teeth with a vertical
CTs or midline vertical axis of the canine. However, the 2 overlap of 1 to 3 mm, a horizontal overlap of approxi-
approaches may lead to confusion among dentists in the mately 20% to 30% of the height of the mandibular in-
selection of the appropriate treatment method. Never- cisors, and an occlusion classified as Angle Class I. Their
theless, because the distance between the distal contact teeth had no cracks, artificial crowns, proximal

THE JOURNAL OF PROSTHETIC DENTISTRY Srimaneekarn et al

- 2020
Figure 2. Demonstration of 2 reference lines. A, Alar line (A line). B, Inner canthus to alar line (IA line).
restorations, crowding, rotation, or malalignment. Par-
ticipants who had previously undergone orthodontic
treatment or who had a facial abnormality (congenital,
traumatic, or surgical) were excluded from the study.
Each participant sat face-forward in a relaxed posi-
tion, and 2 horizontal facial lines were measured by using
digital vernier calipers with a resolution of 0.01 mm
(Mitutoyo Corp) without accounting for the curvature of
the face. The first linedthe interalar widthdwas the
widest part of the nose (Fig. 1A). The second linedthe
intercanine distancedwas the distance between the
maxillary canine CTs (Fig. 1B).
To determine the relative position of the A lines with
regard to the position of the maxillary canine, a stainless
steel rod was set perpendicular to the floor and passively
placed against the edge of the widest part of the ala of the
nose to represent the A line (Fig. 2A). The distances
between the rod and the 2 landmarks, the canine CT and
the CD, were measured on the left and the right sides
separately with digital vernier calipers. When the rod was
in line with the target landmark, the measurement was
considered as 0. When the rod was aligned distal to the
landmark, the measurement was considered a positive
value and negative value when aligned mesial to the
landmark (Fig. 3).
To evaluate the IA line and the maxillary canine, the
position of the stainless steel rod was changed such that
its slope provided a reference IA line which connected
the inner canthus of the eye to the widest part of the ala
of the nose (Fig. 2B). The horizontal distances between
the rod and the 2 landmarksdthe CT and CDdwere
examined using the same criteria as those used to
Srimaneekarn et al
3
measure the A line. All measurements were made by 2
investigators (N.S., T.A.), and the mean values were
calculated.
The paired-samples t test was used to compare the
interalar width and the intercanine distance, while the
independent-samples t test was used to analyze the
differences between men and women for each mea-
surement (a=.05). For the measurements of the A and IA
linesetoeCT or A and IA linesetoeCD positions, the 1-
sample t test, adjusted with the Bonferroni correction,
was analyzed with the 0 value to evaluate the coincidence
of facial landmarks with the canine position, and a 2-way
repeated measures ANOVA was applied to compare the
data between men and women. Moreover, the interrater
reliability was tested using an intraclass correlation co-
efficient (a=.05).
RESULTS
The intraclass correlation coefficient was 0.92, indicating
a high interrater reliability. A significant difference was
found between the sexes in all measurements (Tables 1-
3), which indicated that men and women needed to be
analyzed separately. The results indicated that the in-
teralar width was significantly larger than the intercanine
distance in both sexes (P<.001).
For the A lineetoecanine position, a statistically sig-
nificant difference was found in the A lineetoeCT mea-
surements on both the left and right sides in both sexes
(P<.001). All A lineetoeCT measurements were signifi-
cantly positive values, which indicated that the A line was
positioned distally to the canine CT in both sexes (Table 2).
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4 Volume
Figure 3. Measurement of distance from reference line to 2 positions of canine. A, To cusp tip (CT). B, To canine distal contact point (CD).
Table 1. Relationship between interalar width and intercanine distance (mm)
Interalar Width Intercanine Distance
Sex Mean ±SD Mean ±SD
Men 40.2 ±2.4 36.4 ±2.0
Women 36.6 ±2.2 35.5 ±2.0
P# <.001 .002
CI, confidence interval; LB, lower bound; SD, standard deviation; UB, upper bound. Difference, mean difference between interalar width and intercanine distance. P*, P value of paired-sample
t test for comparison of interalar width and intercanine distance. P#, P value of independent-samples t test for comparison between men and women.
However, the A lineetoeCD measurements differed be-
tween the sexes. In women, the A lineetoeCD measure-
ments on both the left and right sides were significantly
negative values, which indicated that the A line passed
mesial to the CD on both the left and right sides (P<.001).
However, in men, the A line was coincident with the CD
on both the left (P=.287) and right sides (P=.352).
With regard to the relation of the IA lineetoecanine
position, the results of statistical analysis revealed that
the measurements of the IA lineetoeCT or IA lineetoeCD
yielded significant positive values in both sexes on both
sides, which indicated that the IA line was positioned
distally to the canine CT and the CD (Table 3).
DISCUSSION
From the present results, the research hypothesis was
rejected. The interalar width was significantly larger than
the intercanine distance. Neither the A nor the IA line
can accurately estimate the position of the CT in either
sex. However, the A line could determine the CD in men
but was located on average 2 mm mesial to the CD in
women. These findings will be beneficial for tooth se-
lection when complete denture treatment is undertaken
for individuals without pre-extraction records.
Artificial teeth should replicate the size and positional
arrangement of the natural teeth. Methods for selecting
the artificial teeth have been investigated,9-14,16,17
including the estimation of tooth size from the interalar
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95% CI of Difference
Difference
Mean ±SD LB UB P*
3.8 ±3.1 3.2 4.4 <.001
1.1 ±2.6 0.6 1.6 <.001
d d d d
width. Most of these studies focused on the association
between the interalar width and intercanine width.
However, the authors are unaware of a previous study
that scrutinized the direct relationship between the po-
sition of the ala of the nose and the canine tooth, as was
performed in the present study, rather than the pro-
portions of the facial measurements.
This present study revealed that both the intercanine
distance and the interalar width was significantly greater
in men than in women, which was consistent with pre-
vious studies.9,10 The differences between male and fe-
male participants were because of the differences in facial
proportions, and therefore, the data for men and women
were treated separately. The interalar width was found to
be larger than the intercanine distance in the present
study, which is consistent with the findings of Miranda
and D’Souza.11 However, Hoffman et al9 reported that
the interalar width was shorter than the intercanine
distance. These conflicting results might be attributed to
ethnic differencesdan Asian cohort was used in the
present study, as well as in that of Miranda and D’Souza,
whereas Hoffman et al used a white cohort. Therefore,
the data from 1 ethnicity should not be generalized to
other ethnicities. Rather, studies for specific ethnicities
should be encouraged to improve satisfaction in both the
esthetic and functionality of complete denture therapy in
each population.
The combined width of the anterior maxillary teeth
from the distal contact point of the canine to that of the
Srimaneekarn et al
- 2020 5

Table 2. Analysis of coincidence between A line and canine position (mm)

A Line To CT A Line To CD
Left Right Left Right
Sex Mean ±SD (95% CI) P* Mean ±SD (95% CI) P* Mean ±SD (95% CI) P* Mean ±SD (95% CI) P*
Men 3.8 ±2.8 (3.2, 4.3) <.001 4.1 ±2.6 (3.6, 4.6) <.001 −0.3 ±2.4 (−0.7, 0.2) .287 −0.2 ±2.6 (−0.7, 0.3) .352
Women 1.8 ±2.1 (1.4, 2.2) <.001 2.1 ±2.2 (1.6, 2.5) <.001 −2.0 ±2.0 (−2.4, −1.6) <.001 −1.8 ±2.0 (−2.2, −1.4) <.001
P# <.001 <.001
A line, alar line; CD, canine distal contact point; CI, confidence interval; CT, cusp tip; SD, standard deviation. P*, P value of 1-sample t test for comparison between distance and 0 value. P#, P
value of 2-way repeated measures ANOVA for comparison between men and women.

Table 3. Analysis of coincidence between IA line and canine position (mm)

IA Line-To-CT IA Line-To-CD
Left Right Left Right
Sex Mean ±SD (95% CI) P* Mean ±SD (95% CI) P* Mean ±SD (95% CI) P* Mean ±SD (95% CI) P*
Men 7.5 ±3.9 (6.7, 8.2) <.001 8.0 ±3.7 (7.3, 8.8) <.001 3.5 ±3.6 (2.8, 4.2) <.001 3.9 ±3.4 (3.3, 4.6) <.001
Women 4.7 ±2.7 (4.2, 5.3) <.001 5.2 ±2.9 (4.7, −5.8) <.001 1.2 ±2.6 (0.7, 1.7) <.001 1.6 ±2.7 (1.1, 2.2) <.001
P# <.001 <.001

CD, canine distal contact point; CI, confidence interval; CT, cusp tip; IA line, inner canthus to alar line; SD, standard deviation. P*, P value of 1-sample t test for comparison between distance
and 0 value. P#, P value of 2-way repeated measures ANOVA for comparison between men and women.

contralateral canine is required for selecting artificial recommended to improve complete denture
teeth from a denture tooth mold chart.19 However, many prosthodontics.
studies have only made evaluation between the interalar
width and the intercanine distance.9-13,16,17 In addition, CONCLUSIONS
Mavroskoufis and Ritchie14 recommended that the
Based on the findings of this clinical study, the following
addition of 7 mm to the interalar width is necessary to
conclusions were drawn:
estimate the combined 6 anterior maxillary teeth,
whereas McCord and Grant19 recommended the addi- 1. Among Thai people, the interalar width was greater
tion of 8 to 10 mm to the nasal width to obtain the than the intercanine distance in both sexes.
distance between the distal surfaces of the canines. 2. However, both the A and IA lines failed to deter-
Consequently, the present study aimed to examine the mine the canine CT location, which was contrary to
direct association between the ala of the nose not only conventional complete denture teaching.
with the canine CT but also with the CD. 3. The A line is more clinically relevant than the IA line
The results of the present study showed that both the to predict canine position.
A and IA lines failed to estimate the position of the 4. The perpendicular line from the ala of the nose can
canine CT, which was contrary to conventional complete directly determine the distal contact point of the
denture teaching.3,18,19 The IA line was located distally to canine in male edentulous patients.
the distal contact point of the canine in both sexes, which 5. In women, approximately 2 mm should be added
indicated that this line was not suitable for estimating the distally to the A line to locate the distal contact
position of the canine tooth. In contrast, the results of point of the canine on both the left and right
statistical analysis supported the observation that the A sides.
line coincided with the distal contact point of the canine
in men; however, it was located approximately 2 mm
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Corresponding author:
Dr Pan Soonsawad
Department of Anatomy
Faculty of Dentistry
Mahidol University
6 Yothi Rd
Ratchathewi
Bangkok 10400
THAILAND
Email: pan.soo@mahidol.ac.th
CRediT authorship contribution statement
Natchalee Srimaneekarn: Conceptualization, Methodology, Investigation, Data
curation, Validation, Formal analysis. Tawepong Arayapisit: Conceptualization,
Methodology, Investigation, Visualization, Writing - review & editing. Ornnicha
Pooktuantong: Methodology, Investigation. Holland R. Cheng: Funding
acquisition. Pan Soonsawad: Writing - original draft, Project administration.
Acknowledgments
The authors thank the funding support from National Institute of Health and
National Institute of Food and Agriculture. The authors also thank Dr Char-
oonpatrapong, Ms Booncharoensombat, Ms Nguyen and Mr Sabai for their
valuable and constructive suggestions in manuscript composition.
Copyright © 2020 by the Editorial Council for The Journal of Prosthetic Dentistry.
This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.prosdent.2020.11.022
Srimaneekarn et al