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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 1  |  Page : 298-302  

Evaluation of esthetics of incisor position in relation to incisive papilla to replicate in the denture prosthesis


1 Department of Prosthodontics, Army College of Dental Sciences, Hyderabad, Telangana, India
2 Department of Prosthodontics, CKS Teja Institute of Dental Sciences and Research, Tirupathi, Andhra Pradesh, India
3 Department of Prosthodontics, Proddatur, Andhra Pradesh, India
4 Department of Prosthodontics, MNR Dental College, Sangareddy, Telangana, India

Date of Submission14-Sep-2019
Date of Decision28-Oct-2019
Date of Acceptance04-Dec-2019
Date of Web Publication28-Jan-2020

Correspondence Address:
Dr. K V. Guru Charan Karthik
Department of Prosthodontics and Crown and Bridge, 8-7-79/12, Near HAL Park, Srinagar Enclave, Old Bowenpally, Secunderabad, Telangana - 500 011
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jfmpc.jfmpc_772_19

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  Abstract 


Background: The distance between the central incisor to incisive papilla (CI-IP) is constant and regarded as one of the landmarks for the placement of artificial teeth in the prosthesis. Earlier studies were done in relation to anterior border of papilla but after extraction the incisive papilla recedes changing the position of anterior border. Materials and Methods: In this study, 100 dentulous subjects were divided into two groups (males and females) with 50 in each group. Maxillary alginate impressions were made and base poured using levelling instrument to standardize all casts and surveyed on the surveyor for uniformity of the casts. The measured distances were analyzed using Student t-test analysis. Results: The ovoid arch was the commonest arch form found in both males and females with slightly more prevalent in females. Analysis was done using Student t-test analysis and found that the mean distance from CI-IP was found to be at 12.85 mm and 12.39 mm in males and females, respectively. Conclusion: When square arch form (both male and female) mean CI-IP was compared with the total sample mean CI-IP, the mean CI-IP of square arch form was less than that of total sample with greater significance (P < 0.05). When ovoid arch form (both male and female) mean CI-IP was compared with the square arch form (both male and female) mean CI-IP, the mean CI-IP of ovoid arch form was greater than that of square arch form with greatest significance (P = 0).

Keywords: Arch forms, central Incisor, CI-IP distance, incisive papilla


How to cite this article:
Karthik K V, Padmaja B I, Babu N S, Haritha J, Nikhil M, Priya K S. Evaluation of esthetics of incisor position in relation to incisive papilla to replicate in the denture prosthesis. J Family Med Prim Care 2020;9:298-302

How to cite this URL:
Karthik K V, Padmaja B I, Babu N S, Haritha J, Nikhil M, Priya K S. Evaluation of esthetics of incisor position in relation to incisive papilla to replicate in the denture prosthesis. J Family Med Prim Care [serial online] 2020 [cited 2020 May 27];9:298-302. Available from: http://www.jfmpc.com/text.asp?2020/9/1/298/276776




  Introduction Top


Esthetics has become increasingly important in the practice of modern restorative dentistry and is synonymous with a natural, harmonious appearance. An attractive or pleasing smile clearly enhances the acceptance of an individual in our society, by improving the initial impression in interpersonal relationships.

With knowledge comes the idea of beauty which is esthetics. Hence, as a prosthodontist we need to know the proper placement and position of the teeth from the reliable landmarks to provide an acceptable esthetics for the patients. Reliable and stable land marks are essential, as these landmarks should not be associated with changes in tooth removal and serve as a guide for the proper positioning and placement of teeth.


  Materials and Methodology Top


Materials used

Alginate, Type II dental stone. Type III dental stone and sticky wax.

Armamentarium

Stock trays, levelling instrument, digital calliper, base former, rubber bowl, plaster spatula (curved and straight), surveyor, protractor, and lead pencil [Figure 1]a.
Figure 1: (a) Armamentarium and (b) Arch Forms

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Methodology

Collection of data

In this study, 100 dentulous subjects in the age group of 20--35 years were selected.

Exclusion criteria are:

  1. Subjects having horizontal and vertical overlap of maxillary central incisors >2 mm.
  2. Over erupted teeth in maxillary arch.
  3. Maxillary or mandibular midline diastema.
  4. Any degree of crowding in maxillary and mandibular dentition.
  5. Visible attrition of maxillary central incisor involving incisal edges.
  6. Rotation of maxillary or mandibular central incisors.
  7. Maxillary and mandibular dentition exhibiting pathological migration and grade II or III mobility.
  8. History of previous orthodontic treatment.
  9. Diseases of oral mucosa including infective and non-infective lesions and edentulous lower arch.


After selection, the subjects were divided into two groups as follows:

Group 1: In this group, 50 male subjects of 20--35 years were selected.

Group 2: In this group, 50 female subjects of 20--35 years were selected.

For these subjects, maxillary alginate impressions were taken and casts were poured. Bases were prepared using base former and levelling instrument [Figure 2]a. [Figure 2]b and [Figure 2]c shows the samples of both male and female together.
Figure 2: (a) Standardization of casts using levelling instrument (b) Total male sample casts (c) Total female sample casts

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The cast was then mounted on the surveyor. The horizontal distance between vertical pin of the surveyor and the mesial edges of the maxillary central incisors were measured by placing protractor in such a way that its 90° marking was almost superimposing the vertical pin of the surveyor which at this stage was touching the posterior border of the incisive papilla [Figure 3]a.
Figure 3: (a) Standardizing the cast on surveyor (b) and (c) Measuring the distance using Vernier Calliper

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After securing protractor in this manner, sticky wax was applied to protractor and the vertical pin to stop any unwanted movement. Horizontal distance was measured on the calibrated transparent protractor by using caliper device placed at one end coinciding with the vertical pin and the other end on the incisal edges [Figure 3]b and [Figure 3]c.

The measured values were analyzed using Student t-test analysis.

Observations

The following observations were derived from the obtained results.

  1. The ovoid arch was the commonest arch form found in both males and females (58% and 60%) with slighter prevalence more in females and next most common arch form found was square type (34% and 32%) and least form was tapering (8% each) in both the genders [Table 1].
  2. The mean distance from CI-IP was found to be at 12.85 mm and 12.39 mm in males and females, respectively [Table 1].
  3. When ovoid arch form was taken into consideration, the mean CI-IP of males was slightly more than that of females with no significance (P > 0.05) [Table 1].
  4. When square arch form was taken into consideration, the mean CI-IP of females is more than that of males with slight significance (P = 0.05) [Table 1].
  5. When tapered arch form was taken into consideration, the mean CI-IP of males was almost equal to that of females with no significance (P > 0.05) [Table 1].
  6. When ovoid arch form (both male and female), mean CI-IP was compared with the total sample mean CI-IP, the mean CI-IP ovoid arch form was more than that of total sample with greater significance (P < 0.05) [Table 2].
  7. When square arch form (both male and female), mean CI-IP was compared with the total sample mean CI-IP, the mean CI-IP of square arch form was less than that of total sample with greater significance (P < 0.05) [Table 2].
  8. When tapering arch form (both male and female), mean CI-IP was compared with the total sample mean CI-IP, the mean CI-IP of tapering arch form was nearly equal to that of total sample with no significance (P > 0.05).
  9. When ovoid arch form (both male and female), mean CI-IP was compared with the square arch form (both male and female) mean CI-IP, the mean CI-IP of ovoid arch form was greater than that of square arch form with greatest significance (P = 0) [Table 2].
  10. When ovoid arch form (both male and female), mean CI-IP was compared with the tapering arch form (both male and female) mean CI-IP, the mean CI-IP of ovoid arch form was greater than that of tapering arch form with no significance (P > 0.05).
  11. When square arch form (both male and female), mean CI-IP was compared with the tapering arch form (both male and female) mean CI-IP, the mean CI-IP of square arch form was less than that of tapering arch form with no significance (P > 0.05).
Table 1: Total sample mean and P value with individual arches

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Table 2: Comparisions with clinical significance

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  Discussion Top


Geriatrics, or geriatric medicine, is a specialty that focuses on healthcare of elderly people. It aims to promote health by preventing and treating diseases and disabilities in older adults. After the loss of natural teeth, provision of prosthodontic services becomes necessity in the present day living. To provide effective mastication, teeth have peculiar forms. To make it more efficient both functionally and biologically, they are arranged in particular geometric manner referred to as dental arch.[1]

The primary care for geriatric patients is his nutrition and speech. With the loss of teeth, the nutrition speech is affected a lot and hence it is imperative that the edentulous state should be restored. Knowing the proper positioning of the teeth helps in arranging in its position, thereby restoring the function and speech.

The esthetic relation of edentulous condition varies with different arch forms [Figure 1]b. Earlier researchers have described different arch forms as square, ovoid, and tapered. Combinations of these forms are well recognized in prosthodontics [Figure 1]b.[2] In the treatment of edentulous patients, effective relocation of anterior artificial teeth in pre-existing natural position is of utmost importance. Prosthodontists agreed upon the fact that dental prostheses should represent approximately the same amount of tissue in the same position from where it was lost.[3] Prostheses could not be exact substitute of natural teeth; however, if prepared properly based upon some measurable parameters, then they were not only functionally stable but also biologically and esthetically viable.[3],[4] These results could be achieved effectively with the help of some anatomical landmarks as given below: [5]

(1) The maxillary labial vestibule, (2) the incisive papilla, (3) the mandibular labial vestibule, (4) the maxillary tuberosity, (5) retro molar pad, and (6) palatal gingival margin.[6],[7]

The incisive papilla is an important landmark, as it is an immobile structure and usually does not shift in adult life.[8],[9] The researchers have used incisor to incisive papilla distance as a biometric guide.[7],[10] However, no significant published work has been sighted so far on this subject in our country. The present study aims at knowing this distance, with different arch forms in the people. This would reduce the dentist's chair side effort and patient's time by allowing the dental laboratory technicians to reproduce the relationship established between the natural teeth and the orofacial investing tissues,[11] especially in the absence of pre-extraction records.

One guide to the anterioposterior arrangement of the anterior teeth is the relation to the incisive papilla which is a reliable and relatively stable anatomic land mark based on Caucasian norms, which place the maxillary central incisors 8--10 mm anterior to the center of the papilla.[12]

Watt et al. pointed out that as a result of morphological changes in the denture bearing area (alveolar ridge resorption) following the extraction of maxillary teeth, the papilla slightly moved forward, about 1.6 mm and 2.3 mm upward. As a result of bone remodeling, the relationship between the incisive papilla and the incisive fossa changed slightly so that the fossa lies slightly posterior to the papilla in the edentulous mouth. To compensate for this alteration, they suggested the use of posterior border of the papilla and the positioning of the maxillary canines in a coronal plane passing through the posterior border rather than the middle of the papilla.[12]

John Yanderpool, stated that: “Rules have been laid down by which an ideal standard has been sought to be fixed, the deviation produced by age and sex being considered; and while such standards are more or less artificial and not to be slavishly followed to the extent of producing an unnatural uniformity, they certainly are invaluable as expressing a mean which cannot be deviated to more than a limited extent without transgressing the laws of nature and producing deformity.”[13]

Several well-known authorities in art state that the anterior teeth are arranged in the arc of a circle. It is assumed in our profession that the teeth are arranged in the form of a parabolic curve.[13] To provide effective mastication teeth have peculiar forms. To make it more efficient both functionally and biologically, they are arranged in particular geometric manner referred to as dental arch.[1]

Nelson has found that there was a distinct relationship between face form, tooth form, arch form and teeth alignment form in nature, and in edentulous patients he has noted that there was a distinct relationship between face form and arch form, especially as related to the upper arch. This being true, it necessarily followed that to produce harmony in edentulous cases, we must have the same relationship among all four that we have in nature; that is to say, we must use the proper tooth form and arrange the teeth in the proper alignment to produce this degree of harmony.

Nelson has been able to distinguish three classes of arches and alignment; the same way faces could be classified. They were the square, the tapering, and the ovoid.[13] In the square arch, the palate was usually broad and shallow, and the mandibular ridge was broad in the anterior portion, with a very slight curve from one cuspid to the other cuspid. In the tapering arch, the palate was usually high and inverted V-shaped. The mandibular ridge was very narrow in the anterior portion and presents a decided V-shape. In the ovoid arch, the palate was medium high and rounded in the anterior portion of the vault.

It was necessary to find a stable landmark and also to know about the reliability of using that landmark in all patients with ease and good operator access. One such land mark was incisive papilla (IP). Its location was easy to access and easy to identify. Its location in the center and coincidence with the facial midline making it a perfect landmark.

The IP otherwise known as palatine papilla is a small pear or oval-shaped mucosal prominence situated at the midline of the palate, posterior to the palatal surface of the central incisors. It was observed that in dentulous patients, various forms either discrete or continuous with the interdental papilla of the upper central incisors and in edentulous maxilla it presents itself as round, located behind the crest of the residual ridge or on the tip of the ridge.

In the treatment of the edentulous patient, it is essential that the dentist must possess sufficient diagnostic data to enable him to locate the spatial planes on which the incisal edge of a first incisor and the occlusal surfaces of several maxillary posterior teeth rested in the natural dentition. Three planes were involved: (i) the vertical planes of the labial surface of the first incisor and the buccal surfaces of the posterior teeth; (ii) the horizontal planes of the incisal edges of the first incisors and of the occlusal surfaces of the posterior teeth at the points where they intercept their respective vertical planes, and (iii) the sagittal plane in its relation to the mesial surface of the first incisor.[14]

There was a definite relationship of these planes to the planes of other maxillary parts visible in the edentulous individuals. With the use of these mechanical planes, parallel and perpendicular measurements could be made. The relationship of the planes of the teeth to the planes of the stable parts could be recorded. Thus, in the treatment of the edentulous patient, the artificial teeth could be placed in natural positions by setting them on the denture as recorded by the mechanical planes.[1]

This study stated that the mean CI-IP was 12.62 ± 1.60 mm which was closer to that of the Caucasian studies. Hence, above measurements may be used while considering general population.

When individual ovoid arch form was considered which has a mean CI-IP of 13.18 ± 1.45 mm with a greater significance than general population (P < 0.05), it suggests that ovoid arch form may be considered while arranging the teeth. Hence, there was a need to arrange teeth a bit farther in ovoid arch forms than in the general population.

It was also noted that the ovoid arch was the most frequent arch form in the population. Similarly, teeth should be arranged a bit shorter for square arch form than in general population.

Zia. M. et al. has performed a study on 150 dentulous subjects ranging from 20 to 40 years and found that the mean CI-IP distance to 11.2 mm, 10.5 mm, and 13 mm for ovoid, square, and tapered arch forms, respectively.[1] The differences between Iraqi and Yemenian scores (distance from the labial surface of maxillary central incisors to the mid-point and posterior border of incisive papilla in addition to the scores of inter canine distance) were statistically significant (P < 0.05). Gender had no significant effect on the relationship of the incisive papilla to the maxillary anterior teeth in both Iraqi and Yemenian samples.[15]

There are studies measuring the inter-canine width with utilizing the inter-condylar distance but requires additional radiographs and the exact location with reference to intra-oral landmarks are not obtained.[16]

Few studies give the relation between the inter-alar width and inter-canine width but it gives the rough idea of the width rather than position. The latter is more important for speech and function where the prior one can define the size of the teeth to be placed.[17]

Hence, the above study emphasizes the need for study in different ethnic groups in greater number and which was tried in our research.


  Conclusion Top


Within the limitations of the study, the following conclusions were drawn:

It was found that when square arch form mean CI-IP was taken into consideration, the mean of females is more than that of males with slight significance (P = 0.05).

When square arch form (both male and female) mean CI-IP was compared with the total sample mean CI-IP, the mean CI-IP of square arch form was less than that of total sample with greater significance (P < 0.05). When ovoid arch form (both male and female) mean CI-IP was compared with the square arch form (both male and female) mean CI-IP, the mean CI-IP of ovoid arch form was greater than that of square arch form with greatest significance (P = 0).

Hence, there is a need to arrange the teeth at a specific distance for different arch forms to obtain better aesthetics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zia M, Azad AA, Ahmed S. Comparison of distance between maxillary central incisors and incisive papilla in dentate individuals with different arch forms. J Ayub Med Coll Abbottabad 2009;21:125-8.  Back to cited text no. 1
    
2.
Pound E. Applying harmony in selecting and arranging teeth. Dent Clin North Am 1962;241-58.  Back to cited text no. 2
    
3.
Nagda SJ. Good laboratory practice in prosthodontics. J Indian Prosthodont Soc 2006;6:3.  Back to cited text no. 3
  [Full text]  
4.
Roraff AR. Arranging artificial teeth according to anatomic landmarks. J Prosthet Dent 1977;38:120-30.  Back to cited text no. 4
    
5.
Watt DM, Durran CM, Adenubi JO. Biometric guides to the design of complete maxillary dentures. Dent Mag Oral Top 1967;84:109-11.  Back to cited text no. 5
    
6.
Demirel F, Oktemer M. The relations between alveolar ridge and the teeth located in neutral zone. J Marmara Univ Dent Fac 1996;2:562-6.  Back to cited text no. 6
    
7.
Schiffman P. Relation of the maxillary canines to the incisive papilla. J Prosthet Dent 1964;14:469-72.  Back to cited text no. 7
    
8.
Ehrlich J, Gazit E. Relationship of the maxillary central incisors and canines to the incisive papilla. J Oral Rehabil 1975;2:309-12.  Back to cited text no. 8
    
9.
Huang SJ, Chou TM, Lee HE, Wu YC, Yang YH, Ho CD, et al. Exploring the distance between upper central incisor edge and incisive papilla in Taiwanese population. Taiwan J Oral Med Health Sci 2004;20:4-10.  Back to cited text no. 9
    
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Ortman HR, Tsao DH. Relationship of the incisive papilla to the maxillary central incisors. J Prosthet Dent 1979;42:492-6.  Back to cited text no. 10
    
11.
Mersel A, Ehrlich J. Connection between incisive papilla, central incisor and rugae canine. Quintessence Int 1981;12:1327-9.  Back to cited text no. 11
    
12.
Ryge G, Fairhurst CW. The contour meter. J Prosthet Dent 1959;9:676-82.  Back to cited text no. 12
    
13.
Nelson AA. The esthetic triangle in the arrangement of teeth. Nat Dent Assoc 1922;9:392-401.  Back to cited text no. 13
    
14.
Harper RN. The incisive papilla. J D Res 1948;27:661-8.  Back to cited text no. 14
    
15.
Khalaf HA. Evaluation of the incisive papilla as a guide to the maxillary central incisors and canine teeth position in Iraqi and Yemenian samples. J Fac Med Baghdad 2009;51:146-50.  Back to cited text no. 15
    
16.
Shrestha S, Pandey KK, Verma AK, Ali M, Katiyar P, Gaur A, et al. Comparison of relationship between intercondylar width and maxillary inter-canine width. Int J Res Rep Dent 2019;2:1-6.  Back to cited text no. 16
    
17.
Maskey S, Shrestha R, Yadav R, Yadav N. Relation between Inter alar width and inter canine distance in aid for the replacement of artificial maxillary anterior teeth. JMSCR 2018;6:624-8.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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