ARAŞTIRMA (Research)
Hacettepe Dişhekimliği Fakültesi Dergisi
Cilt: 30, Sayı: 4, Sayfa: 25-32, 2006
Interarch Tooth-Size Relationships of
Normal Occlusion and Class II
Division 1 Malocclusion Patients in a
Turkish Population
Türk Populasyonunda Sınıf II Divizyon 1
Maloklüzyon ve Normal Okluzyonlu Bireylerde
İnterark Diş Boyutu İlişkileri
*Semra CİĞER DDS, PhD, *Müge AKSU DDS, PhD,
*Banu SAĞLAM-AYDINATAY DDS, PhD
*Hacettepe University, Faculty of Dentistry, Department of Orthodontics
ABSTRACT
ÖZET
Introduction: Several studies were published describing the importance of a correct tooth size proportion between the arches.
Objective: The aims of this study were to compare
the tooth size ratios of a Turkish population to the
Bolton ratios, determine sex differences in tooth-size
ratios, identify the teeth that most affect the interarch
relationship and determine whether there is a difference in intermaxillary tooth-size discrepancies for
malocclusion subjects. Subjects and Methods: This
study consisted of 125 subjects with normal occlusion
and 71 patients with Class II, division 1 malocclusion.
For statistical evaluation, 2-way ANOVA, independent samples t-test and stepwise multiple linear regression analyses were performed.
Results: Significant differences were found only in
overall ratio among the normal occlusion and Class
II, division 1 malocclusion groups (p <.05). The tooth
most closely related with the overall ratio in Class II,
division 1 malocclusion group was the mandibular
second premolar.
Conclusion: The results of this study show that the
overall and anterior Bolton ratios can be applied to a
Turkish population. There is a tendency of maxillary
tooth size excess in the Class II, division 1 malocclusion patients of the same population.
Giriş: Maksiller ve mandibuler dişler arasındaki
diş boyut oranlarının önemi hakkında araştırmalar
mevcuttur.
Amaç: Bu çalışmanın amacı Türk populasyonundaki
diş boyut oranlarını Bolton oranlarıyla kıyaslamak,
diş boyut oranlarındaki cinsiyet farklılıklarını belirlemek, interark diş ilişkilerini en çok etkileyen dişleri
tanımlamak ve maloklüzyonlu bireylerde intermaksiller diş boyut uyumsuzluklarındaki farkları belirlemektir.
Bireyler ve Yöntem: Çalışmamızda 125 normal
okluzyonlu ve 71 Sınıf II, bölüm 1 maloklüzyonlu
birey incelenmiştir. İstatistiksel değerlendirme 2yönlü ANOVA, bağımsız gruplarda t-testi ve çoklu
regresyon analizi kullanılarak yapılmıştır.
Bulgular: Sadece normal oklüzyonlu ve Sınıf II,
bölüm 1 maloklüzyonlu bireylerin tüm dişler oranlarında istatistiksel olarak anlamlı fark bulunmuştur
(p <.05). Sınıf II, bölüm 1 maloklüzyon grubunda
tüm dişler oranını en çok etkileyen dişin mandibuler
ikinci premolar olduğu belirlenmiştir.
Sonuç: Bu çalışmanın sonuçları Bolton’un anterior
ve tüm dişler oranlarının Türk populasyonunda
uygulanabileceğini göstermiştir. Aynı populasyondaki Sınıf II, divizyon 1 maloklüzyonlu bireylerde
maksiller diş boyutlarında bir fazlalık mevcuttur.
KEYWORDS
Tooth size ratio; Class II, division 1 malocclusion;
Bolton ratio; Interarch relationship
ANAHTAR KELİMELER
Diş boyut oranı; Sınıf II, divizyon 1 malokluzyon;
Bolton oranı; İnterark diş ilişkileri
26
INTRODUCTION
A proper relationship of the total mesiodistal
width of the maxillary dentition to the mesiodistal width of the mandibular dentition is necessary
in order to obtain an optimal occlusion, overbite
and overjet in the finishing stage of comprehensive orthodontic treatment. A significant variation in this relationship should be detected and
considered during initial diagnosis and treatment
planning. If a tooth size discrepancy exists, the
treatment plan should include compensating
procedures such as stripping, extraction, esthetic
bonding or prosthetic reconstruction. Otherwise
the final result of orthodontic treatment and its
stability may be compromised.
Several studies were published describing the
importance of a correct tooth size proportion
between the upper and lower arches. However,
some methods such as Howes’ ratio1 and Neff’s
anterior coefficient2,3 are not widely used.
In 1958, Bolton4 published his now classical work on interpreting mesiodistal tooth-size
dimensions and their effect on occlusion.He selected 55 cases with ‘’excellent” occlusion and
compared the sums of the mesiodistal widths
of the maxillary and mandibular teeth. Using
the mesiodistal width of 12 teeth, he obtained
an overall ratio of 91.3% + 1.9%; using the 6
anterior teeth, he obtained an anterior ratio of
77.2% + 1.65%. Stifer5 repeated Bolton’s study in
Class I dentitions and arrived at similar results.
More recently the accuracy and dependability of Bolton analysis have been challenged.6,7 It
has been reported in the literature that tooth size
differs among genders as well as various ethnic
groups6,8-15. Since differences in tooth sizes are
not systematic16, different interarch relationships
might be expected between genders and different populations.
Several authors have obtained the normal
values of Bolton analysis of different races.1721
These studies suggest that race and ethnicity should be taken into consideration where
Bolton analysis is concerned. There are only a
few studies establishing Bolton values in Turkish population. Uysal and Sari20 analyzed dental casts of 150 Turkish subjects with normal
occlusion. They obtained an overall ratio of
89.88% + 2.29% and an anterior ratio of
78.26% + 2.61%. A significant sex difference in
the overall ratio was reported in their study. Nur
et al.21, however, reported significant sex differences in the anterior ratio whereas no difference
was found between genders in the overall ratio.
Furthermore, the values for anterior and overall
ratios, which they obtained from the normal occlusion group of 120 subjects, were higher for
both of the genders than the values reported by
Uysal and Sari20 and Bolton4.
Since Lavelle11 stated that tooth size and proportion have an important role in malocclusion,
the relationship between tooth-size discrepancy
and Angle classification have been studied as well.
Nur et al21 analyzed dental casts of 600 Turkish
subjects divided into 5 groups including all malocclusions and reported significant differences
in overall ratios between normal occlusion and
Class II, division 1 and 2 malocclusions. However differences in the anterior ratio between
Class III and Class II, division 1 malocclusions
were reported only in girls.
Crosby and Alexander22 and Laino et al.23
studied orthodontic patients with varying malocclusions and found no evidence of any predisposition for a tooth-size discrepancy in any of the malocclusion groups. However Nie and Lin24 compared normal occlusion subjects with malocclusion subjects and found significant differences for
all the ratios between malocclusion groups. They
also reported that there were no significant differences between subcategories of malocclusion.
Araujo and Souki25 investigated the prevalance of anterior tooth size discrepancies among
the malocclusion groups in the Brazilian population and reported that subjects with Angle Class
I and III malocclusions show significantly greater
prevalance of tooth size discrepancies than do
individuals with Class II malocclusions.
Uysal et al.26 studied 560 subjects divided into
4 different malocclusion groups and 150 normal
27
occlusion subjects and they found that all malocclusion groups had higher overall ratios than the
normal occlusion group. However no significant
differences among malocclusion groups were reported.
Although many studies have compared the
Bolton ratio among malocclusion groups, there
is only one study in literature that investigated
the individual teeth which affect interarch relationships6. In order to predict the final occlusion
after comprehensive orthodontic treatment, it is
necessary to know which teeth are responsible
from the intermaxillary tooth-size discrepancy.
The aims of this study were:
1) to determine if there is a difference between
the tooth size ratios of a Turkish population
and the ratios available from the Bolton analysis,
2) to compare the tooth size ratios of males and
females,
3) to identify the individual teeth that most affect
the interarch relationship,
4) to determine whether there is a difference for
intermaxillary tooth-size discrepancies represented by anterior and overall ratios of Bolton
for Class II, division 1 malocclusion subjects.
SUBJECTS AND METHODS
The data for this study were obtained from
records taken at Hacettepe University, Faculty of
Dentistry, Department of Orthodontics; where a
Bolton tooth-size analysis is performed routinely
on all patients accepted into treatment. Since
tooth size is not related to age, the sample selection was based on dental age and the presence
of a fully erupted permanent dentition. The final
sample included 125 subjects with normal occlusion and 71 patients with Class II, division 1
malocclusion.
In the normal occlusion group, dental casts
of 125 Turkish subjects (55 males, 70 females)
with ideal occlusion were analyzed. The following selection criteria were used:
1) Turkish with Turkish parents
2) A fully erupted permanent dentition from first
molar to first molar.
3) Ideal overjet and overbite
4) Angle Class I molar occlusion
5) Well-aligned upper and lower dental arches
6) Good quality study models.
The malocclusion group consisted of 71 patients (31 males, 40 females). The skeletal pattern was assessed by the Steiner cephalometric
analysis and the following selection criteria were
used:
1) Good quality pretreatment study casts
2) A fully erupted permanent dentition from first
molar to first molar.
3) Increased overjet
4) Angle Class II molar occlusion
5) Skeletal Class II, division 1 malocclusion
(ANB >5°)
Rejection criteria included
1) Prosthetic, amalgam or composite restorations that affect the tooth’s mesiodistal diameter.
2) Obvious mesiodistal and occlusal tooth abrasion
3) Congenital defects or deformed teeth (eg,
conic-form lateral incisor teeth)
The same investigator performed all measurements. A digital caliper accurate to 0.01 mm
was used. Largest mesiodistal diameter of each
tooth except the second and third molars was
measured from its mesial contact point to its
distal contact point at the greatest interproximal
distance. The individual tooth diameters were
added to determine the length of anterior and
overall arch segments. These values were used
to define the anterior ratio (Σ width of six lower
anterior incisors/ Σ width of six upper anterior
incisors X 100) and the overall ratio (Σ width of
lower 12 teeth/ Σ width of upper 12 teeth X
100) according to Bolton4.
28
2-way ANOVA was used to evaluate gender
differences. Independent samples t-test was used
to compare the prevalance of anterior and overall tooth-size discrepancies among the normal
occlusion and malocclusion groups. Statistical
differences were determined at the 95% confidence level (p <.05). Stepwise multiple linear regression analysis was used to identify the individual teeth that were most closely associated with
the overall interarch ratio. The software of above
statistical analyses was SPSS (version 10.0).
Measurements were repeated in 55 randomly
selected patients twice within a 4 week interval.
Method error was calculated using the following
Formula of Dahlberg27:
Method Error = √ (Σ /2n)
2
RESULTS
Replicate analysis of 55 patients (30 normal
occlusion, 25 Class II, division 1 malocclusion)
showed that method errors of the mesiodistal diameter for the individual teeth ranged between
0.08 mm and 0.56 mm.
The results are summarized in Tables I to VI.
Table I shows the mean, range and standard deviation of the width of the maxillary and mandibular teeth in the male and female subgroups
of normal occlusion and Class II, division 1 malocclusion groups.
Table II shows the descriptive statistics of the
tooth-size ratios observed in the normal occlusion and Class II, division 1 malocclusion groups.
The mean values for the anterior and overall
ratios for male and female subjects did not differ significantly (p >.05, Table III and IV). Since
no significant sexual dimorphism was observed
between groups, the sexes were combined for
each group. Thus, the norm values for the Turkish population would be 77.95 + 2.35 for the
anterior ratio and 91.95 + 2.20 for the overall
ratio (Table V). Independent samples t-test demonstrated that there was no statistically significant difference among the malocclusion groups
for anterior ratios. Significant differences were
found only in overall ratio (p <.05) (Table V).
Finally, multiple regression analysis was used
to identify the individual teeth that most affect
the interarch relationship in the Class II, division
1 malocclusion group. Table VI shows the teeth
most closely associated with individual differences in the overall ratio. According to the regression analysis, the tooth most closely related with
the overall ratio was the lower second premolar.
Upper first molar were the second most important teeth explaining variation in the overall arch
ratio, followed by the lower first molars and upper second premolars respectively. Lower central
incisors and canines were least likely to explain
individual differences in the overall ratio.
DISCUSSION
The importance of tooth-size discrepancy is
widely debated in orthodontic literature. Many
investigators claimed that mesiodistal tooth-size
discrepancy is a very important element in diagnosis, which should be measured in each orthodontic patient before the start of orthodontic
treatment8,20-22,25,26. On the other hand Heusdens et al.7 suggested that the effect of generalized tooth-size discrepancy on occlusion is limited. Since conflicting results are present in the
literature, the present study was planned to determine if there is a difference for intermaxillary
tooth-size discrepancies represented by anterior
and overall ratios of Bolton for Class II, division
1 malocclusion subjects.
The results from the present study showed
no statistically significant differences in the incidence of tooth-size discrepancies among the
genders. The tooth size data reported by Moorrees et al.16, and Uysal and Sari20 imply gender
differences in the overall ratio. Other studies suggest that gender differences in the overall ratio
may be population specific12,20,26. On the other
hand, Nur et al.21 reported that there were no
differences in tooth dimension ratios between
genders in malocclusion cases whereas significant statistical differences were found in the anterior ratio as a function of gender in the normal
occlusion group. Our findings are in agreement
with those reported by other investigators and
29
TABLE I
Mean, Range and Standard Deviation of Permanent Tooth Widths for the Turkish Samplea
Normal occlusion
Male
Tooth
Class II, divison 1 malocclusion
Female
Male
Female
Mean
(mm)
SD
Range
Mean
(mm)
SD
Range
Mean
(mm)
SD
Range
Mean
(mm)
SD
Range
I1
8.73
0.50
7.6-9.7
8.38
0.54
7.3-9.6
8.72
0.53
7.7-9.5
8.75
0.47
7.6-9.9
I2
6.66
0.45
6.0-8.1
6.45
0.45
5.4-7.5
6.95
0.52
5.9-8.3
6.84
0.57
5.4-8.0
C
7.91
0.43
7.0-8.8
7.43
0.40
6.4-8.4
7.92
0.41
7.0-8.5
7.83
0.42
6.9-8.5
P1
6.90
0.39
5.9-7.7
6.66
0.35
5.7-7.7
7.12
0.46
6.4-8.4
7.15
0.42
6.1-8.0
P2
6.66
0.39
5.7-7.5
6.44
0.33
5.5-7.5
6.88
0.49
6.0-7.8
6.93
0.49
5.8-8.0
M1
10.53
0.60
9.3-11.6
10.19
0.43
9.0-11.0
10.47
0.68 9.3-12.24
10.32 0.62
9.0-11.8
I1
5.40
0.32
4.6-6.0
5.21
0.34
4.5-6.0
5.51
0.45
4.4-6.20
5.51
0.32
5.0-6.2
I2
5.94
0.38
4.9-6.8
5.73
0.33
5.1-6.5
6.02
0.38
5.3-7.2
6.03
0.36
5.5-7.1
C
6.96
0.37
5.9-7.7
6.48
0.32
5.7-7.2
6.88
0.44
6.0-7.8
6.75
0.40
6.1-7.8
P1
6.95
0.46
6.2-8.0
6.75
0.38
5.9-7.5
7.18
0.36
6.2-8.0
7.02
0.45
6.4-8.2
P2
7.20
0.51
6.1-8.3
6.95
0.39
5.9-7.8
7.21
0.37
6.5-7.9
7.37
0.46
6.4-8.5
M1
11.14
0.71
9.5-12.7
10.75
0.50
9.0-11.7
11.19
0.56
9.6-12.1
11.03 0.58
9.7-12.2
Maxillary
Mandibular
I1 indicates central incisor; I2, lateral incisor; C, canine; P1, first premolar; P2, second premolar; and M1, first molar.
a
TABLE II
Tooth-Size Ratios of Male and Female subjects in Normal Occlusion and Class II, Division 1 Malocclusion Groupsa
Male
Female
X
SD
SE
Range
X
SD
SE
Range
AR
78.62
2.24
0.57
72.89-82.91
78.43
2.41
0.29
71.15-83.54
OR
91.97
1.65
0.33
88.74-95.44
91.82
1.99
0.74
86.65-96.30
AR
77.94
2.46
0.25
70.97-83.15
78.11
2.65
0.32
70.42-84.42
OR
90.54
3.40
0.27
80.67-94.87
91.05
4.24
0.50
76.77-98.56
Normal Occlusion
Class II, division 1
malocclusion
AR indicates anterior ratio; OR, overall ratio; X, mean; SD, Standard deviation; SE, Standard error.
a
30
TABLE III
Results of Analysis of Variance for Bolton’s Anterior Ratio Among Malocclusion Groups and Gender
F
P
Gender
0.09
.762
Nonsignificant
Classes
0.01
.922
Nonsignificant
Gender x Classes
0.482
.943
Nonsignificant
TABLE IV
Results of Analysis of Variance for Bolton’s Overall Ratio Among Malocclusion Groups and Gender
F
P
Gender
0.08
.315
Nonsignificant
Classes
2.65
.031
Significant
Gender x Classes
0.06
.490
Nonsignificant
TABLE V
Comparisons of Anterior and Overall Tooth-Size Ratios Among Normal Occlusion and Class II, Division 1 Malocclusion Groups.a
Tooth-Size
Normal occlusion
X
SD
SE
Range
77.95
2.35
1.22
71.15-83.54
AR
NS
Class II, division 1 malocclusion
77.83
2.58
1.36
70.42-84.42
Normal occlusion
91.95
2.20
2.08
86.65-96.30
Class II, division 1 malocclusion
89.94
3.80
2.42
76.77-98.56
OR
a
P
*
AR indicates anterior ratio; OR, overall ratio; X, mean; SD, Standard deviation; SE, Standard error; NS, not significant.
* P <.05.
did not substantiate the need for sex-specific
standards15,18,19,24,25.
It has been suggested that the generalized
use of the Bolton analysis might not be valid for
other populations6,8-15. On the other hand, studies suggesting that Bolton’s analysis is applicable
to other populations are present as well19. In our
normal occlusion group, the anterior ratio was
found to be 77.95 + 2.35, and the overall ratio
was found to be 91.95 + 2.20. Other investigators who studied the same population reported
different findings and concluded that it is appropriate to use Turkish norms in orthodontic prac-
tice for Turkish patients20,21. However, our values
fell within the 1 standard deviation confidence
interval of Bolton. Since the data from this Turkish sample are similar to Bolton’s original data,
the generalized application of the Bolton analysis to a Turkish population seems possible.
A number of studies examined the tooth-size
ratios in patients with malocclusions requiring
orthodontic treatment and reported different
findings. Some studies found no evidence of
any predisposition for a tooth-size discrepancy
in any of the malocclusion groups22,23. Ta et al.18
reported statistically significant differences in
31
TABLE VI
Stepwise Multiple Regression Showing Teeth Most Closely Associated with Individual Differences in the Overall Ratio in Class
II,Division 1 Malocclusion Groupa
Regression step
Tooth
t
Significance
SE
1
L5
3.37
0.001
1.26
2
U6
3.35
0.001
0.71
3
L6
2.46
0.017
0.80
4
U5
1.99
0.051
1.17
5
U4
1.03
0.305
1.28
6
U2
0.78
0.438
0.85
7
U3
0.64
0.523
1.34
8
L2
0.45
0.648
1.51
9
U1
0.32
0.747
1.09
10
L4
0.30
0.762
0.49
11
L1
0.29
0.770
1.39
12
L3
0.22
0.825
1.51
L6 indicates mandibular first molar; L5, mandibular second premolar L4, mandibular first premolar; L3, mandibular canine; L2,
mandibular lateral incisor; L1, mandibular central incisor; U6, maxillary first molar; U5, maxillary second premolar U4, maxillary
first premolar; U3, maxillary canine; U2, maxillary lateral incisor; U1, maxillary central incisor.
a
the overall ratio between the Bolton Standard
and the Class II occlusion group. Uysal et al.26
reported higher overall ratios in all malocclusion
groups when compared with the normal occlusion group. However no significant differences
among malocclusion groups were reported.
In the present study, only the overall ratio
showed a statistically significant difference between the Class II, division 1 malocclusion and
the normal occlusion groups whereas the anterior
ratio showed a similar pattern of distribution in
both groups. The overall ratio was 89.94 + 3.8
in the Class II, division 1 malocclusion group and
this value was significantly lower than the overall ratio in the normal occlusion group. Nie and
Lin24 also found that maxillary dentition showed
a tendency for maxillary tooth size excess in Class
II malocclusion. Our results suggest that maxillary teeth are larger than the mandibular teeth in
Class II, division 1 malocclusion patients. In order
to establish an ideal occlusion in Class II, division
1 malocclusion patients where there is a clinically
significant tooth-size discrepancy, stripping or extraction in the maxillary arch may be necessary.
Our results also showed that specific teeth
can explain differences in the overall interarch ratio. The mandibular second premolars explained
most of the observed difference in the interarch
discrepancy, followed by the maxillary first molars, mandibular first molars and maxillary second
premolars. Doris et al.10 showed that the maxillary lateral incisors, maxillary second premolars,
mandibular second premolars, and mandibular
canines were the most variable and displayed
the most pronounced group differences. On the
other hand, Santoro et al.15 showed that the maxillary first molars, followed by maxillary central
incisors and maxillary lateral incisors were the
most variable teeth. Crosby and Alexander22 suggested that the greatest variability in mesiodistal
tooth width occurs in the anterior region.
Our findings suggest that posterior teeth are
mostly responsible for incongruity in the overall ratio in the Class II, division 1 malocclusion
32
group and, should be examined clinically at the
beginning of treatment to detect any major size
and shape variation. It is not uncommon for a clinician to correct the skeletal Class II malocclusion
succesfully but still see a Class II canine occlusion
and increased overjet. In such cases, if stripping
is the treatment of choice, it should be carried out
in the posterior section of the maxillary arch according to the results of the present study.
CONCLUSION
Our results showed that the overall and anterior Bolton ratios can be applied to a Turkish
population and that there is a tendency of maxillary tooth size excess in the Class II, division 1
malocclusion patients. Since mandibular second
premolars, maxillary first molars, mandibular first
molars, maxillary second premolars and maxillary first premolars explain most of the variation
in the interarch discrepancy in the Class II, division 1 malocclusion group, they should be examined clinically at the beginning of treatment.
Further studies are needed to clarify the clinical
significance of these findings.
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CORRESPONDING ADDRESS
Banu SAĞLAM AYDINATAY
Hacettepe University, Faculty of Dentistry, Department of Orthodontics, Sıhhiye Ankara, 06100 TURKEY
Business: +90 312 311 64 61 Home: +90 312 225 16 09 Fax: +90 312 309 11 38 e-mail: banusaglam@hotmail.com