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Q U I N T E S S E N C E I N T E R N AT I O N A L

The center of the incisive papilla for the selection

of complete denture maxillary anterior teeth
in 4 racial groups
Fabiana Mansur Varjão, DDS, MS, PhD1/
Sergio Sualdini Nogueira, DDS, MS, PhD2/
João Neudenir Arioli Filho, DDS, MS, PhD3

Objectives: To evaluate the use of the center of the incisive papilla as a guide for the selec-
tion of the proper width of maxillary dentures in 4 racial groups. Method and Materials:
One hundred sixty stone casts were obtained from impressions of the maxillary arch of
white, black, mixed, and Asian subjects. The occlusal surfaces of the casts were photo-
copied and the images placed on a digitizer. The most anterior and posterior points of the
papilla and cusp tips of the canines were digitized. Dentofacial Planner Plus software was
used to calculate the distance from a line passing through the cusp tips of the canines to the
center of the papilla, defined as the midpoint of the anterior and posterior points of the papilla.
The selection error (in millimeters) due to the clinical application of the method of the incisive
papilla was calculated and analyzed. Results: In all studied racial groups, there was no coin-
cidence between the center of the incisive papilla and the canine line. The utilization of the
center of the papilla would lead to the selection of wider artificial teeth. In 24.9% of the white,
19.3% of the mixed, 32.9% of the black, and 15.5% of the Asian populations, errors greater
than 4 mm would be present with the utilization of the papilla. Conclusion: The method of
the center of the incisive papilla is not accurate, but may aid in initial artificial teeth selection
for the racial groups studied. (Quintessence Int 2008;39:841–845)

Key words: artificial teeth, complete denture, dental esthetics, race

Selecting and arranging artificial teeth for
edentulous patients is difficult when pre-
extraction records are not available. Errors at
this stage can often result in patient rejection
of otherwise well-constructed, comfortable,
and efficient dentures.1–5 In an effort to solve
this problem, various guidelines have been
suggested for determining the width of the
maxillary anterior teeth.
The incisive papilla has been used as an
anatomic landmark in the positioning of max-
illary anterior teeth because it is known as a
1
Assistant Professor, Department of Comprehensive Care, Case
Western Reserve University, Cleveland, Ohio, USA.
2
Associate Professor, Department of Dental Materials and
Prosthodontics, Araraquara Dental School, São Paulo State
University, Araraquara – SP – Brazil.
3
Assistant Professor, Department of Dental Materials and
Prosthodontics, Araraquara Dental School, São Paulo State
University, Araraquara – SP – Brazil.
Correspondence: Fabiana Mansur Varjão, Case Western Reserve
University School of Dental Medicine, 10900 Euclid Avenue,
Cleveland, Ohio 44106. E-mail: fabiana.varjao@case.edu
reliable and relatively stable anatomic land-
mark.3,6–8 In 1964, Schiffman9 pointed out
that a line drawn at a right angle to the mid-
line passing through the center of incisive
papilla passes through the tips of the maxil-
lary canines. To select the correct size of the
6 maxillary anterior artificial teeth, the dis-
tance between the canine marks projected to
the buccal surface of the upper occlusal rim
is measured around the curve of the rim with
a flexible rule.9 Because tooth mold charts for
anterior teeth give dimensions from the distal
surface of 1 canine to another, 8 to 10 mm
should be added to that value to obtain the
distance between the distal surfaces of the
canines.10
Previous studies attempted to evaluate the
relation between the incisive papilla and the
position of maxillary canines. In 1975, Ehrlich
and Gazit11 found that 57.6% of intercanine
lines passed through the center of the papilla.
In 1977, Sawiris12 found that in 64% of 50
Caucasian subjects, the intercanine line

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VOLUME 39 • NUMBER 10 • NOVEMBER/DECEMBER 2008 841

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Q U I N T E S S E N C E I N T E R N AT I O N A L
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passed by ± 1 mm from the center of the
papilla. In 1981, Mavroskoufis and Ritchie3
found that in 93.4% of 64 Caucasian sub-
jects, the discrepancy between the inter-
canine line and the center of the incisive papilla
was less than 2 mm. In 1993, Lau and Clark13
found that the intercanine line passed
through the middle third of the incisive papilla
in 57.3% of 82 Chinese subjects.
However, most of these studies were con-
ducted in Caucasian population samples
and the findings extrapolated to other ethnic
groups. In 1992, Johnson14 pointed out that
the prosthodontic literature seemed to per-
tain to only the Caucasian race with little
noted about other races and reported how
knowledge of racial norms for facial appear-
ance might aid practitioners: Treatment ren-
dered would then be harmonious with the
facial appearance for patients of different
races.
The Brazilian society constitutes a diverse
mix of races: Some groups remain racially
pure, while others have mixed with different
races. The aim of this article is to evaluate the
use of the center of the incisive papilla as
a guide for the selection of proper-width max-
illary dentures in 4 racial groups of the
Brazilian population.
METHOD AND MATERIALS
The research plan was prepared in accor-
dance with the guidelines appropriate to
research involving human subjects, as set
down in Resolution 196/96 of the National
Health Council, and approved by the
Research Ethics Committee of São Paulo
State University.
One hundred sixty Brazilian subjects (40
whites, 40 blacks, 40 mixed [descendents of
white and black parents], and 40 Asians
[Japanese and Chinese]) of mixed sex and
age (ranging from 18 to 33 years) were
selected for this study. The subjects had all
natural permanent maxillary teeth with no
history of orthodontic treatment or extrac-
tion; canines and incisors were in good align-
ment without drifting or attrition in more than
one-third of the incisal edge of the canines;
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842 VOLUME 39 • NUMBER 10
and they had no congenital or surgical facial
defects.
Before carrying out any procedures, each
subject received detailed information about
the research and was asked to sign a Free
and Clarified Consent Form.
Artificial stone casts (Rock Plus;
Polidental) were made from irreversible
hydrocolloid (Jeltrate; Dentsply) impressions
of the maxillary arch taken in perforated
stock trays. The following anatomic land-
marks were marked with a lead pencil on the
casts: the outline of the incisive papilla and
the maxillary right and left canine cusp tips.
The original crown tip was considered to
have been at the intersection of a line drawn
along the mesial and distal cutting edge and
a line drawn along the buccal and lingual
long axis of the tooth.
The casts were placed on a photocopy
machine (Xerox Document Center 332ST;
Xerox) with a meter ruler positioned along-
side them. A black-and-white photocopy was
obtained from the occlusal surface of each
cast. The ruler in the photocopy was used as
a guide to detect distortions in the image. If
any distortion was detected, the photocopy
was excluded and the procedure repeated.
The right and left canine cusp tips and the
anterior and posterior points of the incisive
papilla were marked on the photocopies with
a sharp pen.
The photocopies were then fixed on a
digitizing table (Numonics), and the following
points related to the application of the
method of the center of the incisive papilla
were digitized: the most anterior and posterior
points of the incisive papilla and the maxillary
right and left canine cusp tips. An electronic
crosshair pointer was employed for location
and registration of the points marked on the
photocopy. Each point was digitized 2 times
to obtain a mean value. Dentofacial Planner
Plus software (version 2.02; Dentofacial
Software) was utilized to transfer the data
from the digitizing process to a computer.
The software then calculated the linear dis-
tance from a line passing through the cusp
tips of the canines to the center of the incisive
papilla (Fig 1). The center of the papilla cor-
responded to the midpoint of the anterior
and posterior points of the incisive papilla.
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Fig 1 Linear distance (D) of a line passing through the cusp tips of the
canines to the center of the incisive papilla.

If the referred distance was not 0, it was
determined that there was no coincidence
between the center of the incisive papilla
and the line passing through the cusp tips of
the canines. One-way analysis of variance
(ANOVA) was used to determine whether
this distance was significantly different
among races (P < .05).
The selection error due to the application
of the method of the center of the incisive
papilla was determined, in millimeters,
defined as the difference between the real
width of natural teeth and the width of the
teeth estimated by the incisive papilla. This
error was calculated by multiplying the value
of the distance from the canine line to the
center of the incisive papilla by 2, because
according to the clinical application of the
method, this distance would be observed on
both sides of the occlusal rim.
In addition, a prediction was made of the
percentage of subjects of the white, black,
mixed, and Asian populations (using a 95%
confidence interval) in which the selection
error would be within 0 and 2 mm, within 2
and 4 mm, and greater than 4 mm.
RESULTS
There was no coincidence of the center of
the incisive papilla with the line passing
through the cusp tips of the canines. Within
each racial group studied, the mean value of
the distance from the canine line to the
center of the incisive papilla was positive.
This indicates that the line was, on average,
anterior to the center of the papilla (Table 1).
There was no statistically significant differ-
ence (P < .05) among the distances from the
center of the incisive papilla to the line pass-
ing through the cusp tips of the canines for
the 4 races (P = .4302).
The percentage of subjects of each racial
group in which the canine line was anterior
or posterior to the center of the incisive papilla
is presented in Table 2.
Table 3 contains information regarding
the selection errors due to the use of the
center of the incisive papilla for the selection
of the width of the 6 maxillary anterior teeth.
In all studied racial groups, the utilization of
the center of the papilla would lead to the
selection of wider artificial teeth.
DISCUSSION
The mean distances from the line passing
through the cusp tips of the canines to the
center of the incisive papilla were 0.56 mm in
the white group, 0.27 mm in the mixed
group, 0.74 mm in the black group, and 0.22
mm in the Asian group, with no statistically
significant difference among them, indicat-
ing that this parameter is not dependent
upon race. Because the overall mean values
were positive, the canine line was anterior to
the center of the papilla.

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Ta b l e 1 Values (in millimeters) of the linear distance from the line passing
through the tips of the canines to the center of the incisive papilla

White Black Mixed Asian

Largest posterior distance –2.00 –3.75 –3.15 –3.40

Largest anterior distance 5.00 5.40 3.25 3.90
Mean 0.56 0.74 0.27 0.22
SD 1.64 1.90 1.51 1.39
The minus sign (–) demonstrates that the line was located posterior to the papilla.

Ta b l e 2 Location of the line passing through the tips of the canines to the center of
the incisive papilla in the subjects of the 4 racial groups: Percentage of cases
White Black Mixed Asian

Anterior to the center of papilla

D < 1 mm 17.5 20 27.5 37.5
1 ≤ D < 2 mm 22.5 25 22.5 15
D > 2 mm 15 20 10 7.5
Total 55 65 60 60
Posterior to the center of papilla
D < 1 mm 35 17.5 25 20
1 ≤ D < 2 mm 10 10 7.5 17.5
D > 2 mm 0 7.5 7.5 2.5
Total 45 35 40 40
D, distance from the canine line to the center of the papilla.

Ta b l e 3 Selection errors (in millimeters) due to the use of the center of the incisive
papilla for the selection of the width of the 6 maxillary anterior teeth
White Black Mixed Asian

Error statistics
Largest error for narrower teeth –4.00 –7.50 –6.30 –6.80
Largest error for wider teeth 10.00 10.80 6.50 7.80
Mean 1.13 1.48 0.55 0.44
SD 3.27 3.81 3.03 2.78
Prevision of error (%)
Within 0 and 2 mm 43.60 37.40 48.50 52.30
Within 2 and 4 mm 31.60 29.70 32.20 32.20
Higher than 4 mm 24.90 32.90 19.30 15.50
The minus sign (–) demonstrate the selection of narrower teeth.

The findings for the white group coincide
with those of Mavroskoufis and Ritchie,3 who
reported that the mean distance from the line
passing through the tips of the canines to the
center of the incisive papilla in Caucasians
was 0.6 mm. They also found that in 93.4%
of subjects, the discrepancy between the
intercanine line and the center of the incisive
papilla was less then 2 mm. In our sample,
85% of white subjects showed this discrep-
ancy (Table 2). Sawiris12 found that in 64% of
Caucasian subjects, the intercanine line
passed by ± 1 mm from the center of the
papilla. In this study, the intercanine line was
found to pass by ± 1 mm from the center of the
papilla in 52.5% of white subjects (Table 2).
In the Asian group, the intercanine line
was within an area 1 mm anterior and poste-
rior to the center of the papilla in 57.5% of
subjects. This result is similar to the findings
in the Lau and Clark’s13 study, in which the
canine line lay within 1.18 mm (both anterior
and posterior) to the center of the papilla in
57.3% of cases.

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The percentages of subjects in which the
intercanine line was within an area 1 mm
anterior and posterior to the center of the
papilla for all racial groups studied (Table 2)
indicates that the results are different from
those of Schiffman’s9 study, in which 92% of
cases were found to have an intercanine line
within an area 1 mm anterior and posterior to
the center of the papilla.
Mean selection errors due to the applica-
tion of the method of the center of the inci-
sive papilla were similar in the 4 races (Table
3). Positive mean values indicate that the
canine line was anterior to the papilla, signify-
ing that the tips of natural canines were in a
more anterior position than the position indi-
cated by the method of the center of the inci-
sive papilla. Thus, utilization of this method
would lead to the selection of wider (on aver-
age) artificial teeth.
The prediction of the percentage of sub-
jects of each race in which the selection error
would be within 0 and 2 mm, within 2 and 4
mm, and greater than 4 mm showed that
errors greater than 4 mm would be present in
24.9% of whites, 19.3% of mixed, 32.9% of
blacks, and 15.5% of Asians. These results
suggest that the method of the center of the
incisive papilla, although not accurate, may
aid in an initial selection of the width of the
artificial anterior teeth for the racial groups
studied, rendering the best results for the
Asian group.
CONCLUSIONS
Within the limitations of this study, the follow-
ing conclusions were drawn:
1. For all the studied racial groups, there was
no coincidence between the center of the
incisive papilla and the line passing
through the cusp tips of the canines.
2. The method of the center of the incisive
papilla is not accurate but may aid in an
initial selection of the width of the artificial
maxillary anterior teeth for the 4 racial
groups studied.
COPYRIGHT © 2008 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO
PART OF THIS ARTICLE MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER
VOLUME 39 • NUMBER 10 • NOVEMBER/DECEMBER 2008
Q U I N T E S S E N C E I N T E R N AT I O N A L
M a n s u r Va r j ã o e t a l
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