Download Mesiodistal Crown Width Digital Ratio for Kerala Population: A

JIOS
ORIGINAL RESEARCH
10.5005/jp-journals-10021-1281
Mesiodistal Crown Width Digital Ratio for Kerala Population:
A Cross-sectional Survey
Mesiodistal Crown Width Digital Ratio for
Kerala Population: A Cross-sectional Survey
1
Sashi Bhushan Ekka, 2Koshi Philip, 3Chandresh Shukla, 4Rajesh Balani, 5Kartik Swamy
ABSTRACT
Source of support: Nil
Introduction: The orthodontic examination may be incomplete
without a careful analysis of the patterns of mesiodistal crownsize relationships. No published data are available regarding
tooth size—arch length discrepancy (Bolton values) for Kerala
population.
Conflict of interest: None
Aim: To establish Bolton’s values specific to Kerala population.
Thus, this was done in order to determine Bolton’s anterior and
overall and posterior ratio between males and females specific to
Kerala population and compare it with Bolton’s values. Secondly
to determine the values outside of 1 standard deviation (SD)
and 2SD.
INTRODUCTION
Materials and methods: The sample for the present study
consisted of 160 pretreatment study casts (Group A—75 male
patients and Group B—85 female patients). Digital vernier
caliper (Standard Digital Caliper Series: EC16) with a
0.01 mm resolution, ±0.02 mm accuracy and 0.01 mm
repeatability, manufacturer specification) was used to measure
the mesiodistal width of the teeth.
Result: Mean anterior, overall and posterior ratios were found to
be 77.32 ± 6.67; 91.78 ± 7.43; 1.07 ± 0.06 respectively. 93.8%
of the sample had anterior ratio in 1SD and 3.8% in 2SD. 94.4%
were in 1SD and 2.5% in 2SD for overall ratio.
Conclusion: Although the means were nearly identical with
those of Bolton’s study, ranges and SDs were significantly
larger. This study indicates that the Bolton’s analysis can also be
used on Indian or at least Kerala population but with increased
standard deviation.
Keywords: Bolton’s ratio, Kerala population, Digital vernier
caliper, mesiodistal crown-size.
How to cite this article: Ekka SB, Philip K, Shukla C, Balani
R, Swamy K. Mesiodistal Crown Width Digital Ratio for Kerala
Population: A Cross-sectional Survey. J Ind Orthod Soc
2014;48(4):375-381.
1,3,4
Senior Lecturer, 2Professor and Head, 5Reader
1,3,4
Department of Orthodontics and Dentofacial Orthopedics
People’s College of Dental Science and Research Centre
Bhopal, Madhya Pradesh, India
2
Department of Orthodontics and Dentofacial Orthopedics
Government Dental College, Kottayam, Kerala, India
5
Department of Orthodontics and Dentofacial Orthopedics
Kothiwal Dental College and Research Centre, Moradabad
Uttar Pradesh, India
Corresponding Author: Sashi Bhushan Ekka, Senior Lecturer
Department of Orthodontics and Dentofacial Orthopedics
People’s College of Dental Science and Research Centre
Bhopal, Madhya Pradesh, India, Phone: 07554078030, e-mail:
[email protected]
Received on: 2/2/14
Accepted after Revision: 24/2/14
A task of the orthodontist is the alignment of teeth to improve
the masticatory efficiency as well as the appearance of
the face and the dental arches. For an ideal occlusion, the
mesiodistal crown diameters of the teeth in both arches
should correspond. Such a task may become frustrating in
the presence of crown-size discrepancies. Research in this
area has been limited to the determination of ratios indicative
of how large the maxillary teeth should be in relation to
their lower counterpart, which is further different for each
population under examination.
The orthodontic examination may be incomplete without
a careful analysis of the patterns of mesiodistal crown-size
relationships. Mesiodistal crown-size relationships are
decisive variables in the search for (1) factors associated with
the development of occlusal and facial irregularities, (2) the
possible effects of discrepancies upon interdigitation during
and after orthodontic treatment, and (3) the isolation of
discrepant teeth of minor malocclusions that may be treated
in part by selective mesiodistal grinding and minor tooth
movement. To accomplish this task, the clinician should be
able to analyze the largest possible number of crown-size
relationships; that is, the relative size differences between
a single tooth or groups of teeth regardless of their location
in the dental arches.
Although, in recent studies, variables, such as incisor
incli­nation (Tuverson), upper incisor thickness (Halazonetis,
Rudolph et al) and arch form (Braun), have been described
as important factors to be considered in achieving an optimal
occlusal relationship and efforts have been made to adopt
Bolton’s analysis to these variations. The Bolton’s analysis
is still a robust guideline for assessing the relationship of
the upper to lower dentition.
REVIEW OF LITERATURE
One of the first investigators to become interested in the
subject of tooth size was GV Black,1 he set up tables of mean
The Journal of Indian Orthodontic Society, October-December 2014;48(4):375-381
375
Sashi Bhushan Ekka et al
figures which are still important references today. Gilpatric2
(1923), Ballard3 (1944), Griewe4 (1949) also investigated
on mesiodistal tooth dimension. Neff5 in 1949 arrived at
an ‘anterior coefficient’ by dividing the sum of six anterior
mandibular sum into six anterior maxillary sum. The range
was 1.17 to 1.41.
Bolton’s6,7 introduction of his analysis in 1958 included
comparisons of total mesiodistal widths of dental arches up
to the distal surfaces of the first molars, as well as segments
of the arches. Bolton evaluated 55 cases with ‘excellent’
occlusions; 44 had been treated orthodontically without
extractions and 11 were untreated. The following ratios were
established by Bolton:
Overall ratio =
Sum of mandibular ‘12’ × 100
Sum of maxillary ‘12’
Anterior ratio =
Sum of mandibular ‘6’ × 100
Sum of maxillary ‘6’
The overall ratio was calculated from the greatest
mesiodistal measurements of the teeth in each arch. The
anterior ratio was calculated from the greatest mesiodistal
measurements of the six anterior teeth in each arch. He
obtained an overall ratio of 91.3% ± 1.91% and an anterior
ratio of 77.2% ± 1.65%. From Bolton’s results, it can be
seen that there is a relatively small range in which tooth
size ratios should fall to be able to achieve optimal occlusal
relationships.
Although his tables for anterior and overall tooth-size
ratios are still used today, the Bolton method has some
limitations.8,9 First, Bolton’s estimates of variation were
underestimated because his sample was derived from perfect
Class I occlusions. Second, although it was speculated
that overbite, overjet, tip, torque, interincisal angle, and
incisor thickness influenced ideal tooth-size relationships,
no definite conclusions have been drawn regarding the
effect of overbite, overjet, tip, interincisal angle, and incisor
thickness on the accuracy of Bolton’s analysis. Third, the
population and sex composition of Bolton’s sample were
not specified. Fourth, the Bolton’s analysis cannot be used
in extraction treatment. Because the ratio between arches of
unequal lengths would not remain constant when premolars
of approximately equal size are removed from each arch,
Bolton’s overall ‘12’ ratio should not be used for predicting
occlusion after removing four premolars.
Beside this, other investigators who also investigated
Bolton’s ratio are Stifter et al.10-48
Group B—85 female patients), belonging to the patients
who were reported to the Government Dental College for
treatment and clinically having full complement of teeth till
the second permanent molars. The sample of 160 subjects for
the study was selected as per the criteria laid down as follows:
(1) All the permanent teeth till second permanent molar
should be present, (2) no history of any previous orthodontic
treatment, (3) all the teeth which are to be measured should
be fully erupted and free of interproximal restoration,
distortion, fractures and caries, (4) all the teeth which are
to be measured should be free of occlusal or proximal
attrition, (5) there should not be any form, size or number
alterations present with the teeth, (6) all the subjects which
are selected for the study range from 14 to 24 years and
(7) Class I occlusion with mild or no crowding.
Armamentarium used in the study: (1) 160 study models,
(2) Fine tip marking pen and (3) Digital vernier caliper
(Standard Digital Caliper Series: EC16) with a 0.01 mm
resolution, ±0.02 mm accuracy and 0.01 mm repeatability,
manufacturer specification) was used to measure the
mesiodistal width of the teeth.
The mesiodistal width of the teeth was measured with
a digital vernier caliper adjusted to the greatest mesiodistal
diameter (contact points) of teeth, parallel to the occlusal
surface and perpendicular to the long axis16 (Figs 1 and 2).
Overall and anterior ratios were determined as per the
method introduced by Bolton. The posterior mandibular
arch segment was divided by the posterior maxillary arch
segment to obtain ‘posterior ratio’. Only 8 to 10 pairs of
models were measured each day to prevent visual fatigue.49
For method error evaluation, 20 casts were selected at
random, four weeks after the original measurements. The
teeth were remeasured on these casts. The first and second
measurements were compared statistically.
Data were analyzed using computer software, statistical
package for social sciences (SPSS) version 10. Data were
expressed in its frequency and percentage as well as mean
and SD. To elucidate the associations and comparisons
between different parameters, Chi-square (χ2) test was
used as nonparametric test. Unpaired student’s t-test was
used to compare mean values between two gender groups.
Paired t-test was employed to compare left and right side
dimensions of tooth within each gender group. For all
statistical evaluations, a two-tailed probability of value,
< 0.05 was considered significant.
RESULTS
MATERIALS AND METHODs
The sample for the present study consisted of 160
pretreatment study casts (Group A—75 male patients and
376
Error analysis showed no statistically significant values
(p > 0.05) in measurement of initial and after a period of
4 weeks. When tooth size measurements were compared
JIOS
Mesiodistal Crown Width Digital Ratio for Kerala Population: A Cross-sectional Survey
Fig. 1: Digital vernier caliper
Fig. 2: Measurement of mesiodistal crown width
(Tables 1 and 2) as a function of gender among the whole
sample, there was no significant difference in male and
female. Teeth measurements were most variable in maxillary
arch than in mandibular arch and more variability was
found in males than females. Bolton’s ratios were compared
in males and females. The results (Table 3) showed no
statistically significant difference in the mean Bolton’s
anterior and overall ratios between males and females.
Mean anterior ratios in the present study were found to
be 77.44 ± 2.84 and 77.22 ± 8.64 for male and female
respectively. Since no sexual dimorphism is evident, new
anterior ratio calculated was 77.32 ± 6.67. Mean overall
ratios in the present study were found to be 91.83 ± 2.49 and
91.74 ± 9.95 for male and female respectively. New overall
ratio calculated was 91.78 ± 7.43. Mean posterior ratios in
the present study were found to be 1.08 ± 0.06 and 1.06 ±
0.05 for male and female respectively. New posterior ratio
calculated was 1.07 ± 0.06. Results from Table 4 showed that
overall ratio is related to both anterior and posterior ratios
with correlation coefficient of 0.904 and 0.183 respectively.
This suggests that overall ratio is affected mainly by anterior
ratio than posterior ratio. The second part of the study was
done to find the values outside 1SD and 2SD (Table 5). Most
subjects in all the groups had overall, anterior and posterior
ratios within 1SD interval. It was found that 93.8% of the
sample had anterior ratio in 1SD and 3.8% in 2SD. For
overall ratio, 94.4% were in 1SD and 2.5% in 2SD.
DISCUSSION
It has been widely accepted that a correct maxillary and
mandibular mesiodistal tooth size relationship is important
for the achievement of proper occlusal interdigitation in
Table 1: Mesiodistal width of maxillary teeth comparing male and female population
Parameters
of maxilla
Mean
(mm)
±SD
Variance
Mean
(mm)
±SD
Variance
Mean ±SD
(mm)
Variance
p-value
t-value
(comparing
sex)
8.81
0.49
0.24
8.32
0.43
0.18
8.55
0.52
0.27
6.752
< 0.001
Left
8.79
0.44
0.19
8.28
0.46
0.21
8.52
0.51
0.26
7.181
< 0.001
Right
7.08
0.46
0.22
6.87
0.51
0.26
6.97
0.50
0.25
2.666
< 0.01
Left
6.88
0.45
0.20
6.72
0.56
0.31
6.80
0.52
0.27
2.031
< 0.05
Right
7.77
0.51
0.26
7.45
0.49
0.24
7.60
0.52
0.27
4.123
< 0.001
Left
7.67
0.49
0.24
7.40
0.45
0.21
7.53
0.49
0.24
3.665
< 0.001
Right
7.06
0.40
0.16
6.84
0.46
0.22
6.94
0.45
0.20
3.081
< 0.01
Left
7.12
0.37
0.14
6.85
0.49
0.24
6.98
0.46
0.21
3.935
< 0.01
Side
Central incisor Right
Lateral incisor
Canine
First premolar
Second
premolar
First molar
Male
Female
Total population
Right
6.67
0.39
0.15
6.54
0.44
0.19
6.60
0.42
0.18
2.069
< 0.05
Left
6.59
0.43
0.18
6.48
0.45
0.20
6.53
0.44
0.19
1.606
> 0.05
Right
10.00
0.53
0.28
9.83
0.57
0.33
9.91
0.56
0.31
1.966
< 0.05
Left
9.91
0.57
0.33
9.77
0.63
0.40
9.84
0.60
0.36
1.388
> 0.05
Unpaired Student’s t-test was used to calculate the p-value
The Journal of Indian Orthodontic Society, October-December 2014;48(4):375-381
377
Sashi Bhushan Ekka et al
Table 2: Mesiodistal width of mandibular teeth comparing male and female population
t-value
(comparing
sex)
p-value
Variance
0.38
0.14
4.131
< 0.001
5.37
0.33
0.11
3.991
< 0.001
0.16
5.86
0.40
0.16
3.665
< 0.001
0.39
0.15
5.87
0.39
0.15
2.922
< 0.01
6.49
0.48
0.23
6.60
0.46
0.22
3.182
< 0.01
0.16
6.50
0.40
0.16
6.63
0.42
0.18
4.406
< 0.001
0.45
0.21
6.92
0.44
0.19
7.01
0.45
0.21
2.698
< 0.01
0.45
0.20
6.91
0.50
0.25
6.97
0.48
0.23
1.629
> 0.05
Right 7.08
0.51
0.26
6.89
0.51
0.26
6.98
0.52
0.27
2.329
< 0.05
Left
0.52
0.27
6.93
0.53
0.29
6.99
0.53
0.28
1.575
> 0.05
Right 10.92
0.77
0.59
10.79
0.68
0.46
10.85
0.72
0.52
1.164
> 0.05
Left
0.67
0.45
10.72
0.80
0.64
10.84
0.75
0.56
2.247
< 0.05
Parameters
of mandible
Side
Male
Central
incisor
Right 5.50
Left
Mean
(mm)
±SD
Female
Variance
Mean
(mm)
0.34
0.12
5.26
5.47
0.31
0.09
Lateral
incisor
Right 5.98
0.36
Left
5.96
Canine
Total population
Variance
Mean
(mm)
0.37
0.14
5.37
5.28
0.32
0.10
0.13
5.75
0.40
0.37
0.14
5.79
Right 6.72
0.42
0.18
Left
6.78
0.40
First
premolar
Right 7.11
Left
7.04
Second
premolar
First molar
7.06
10.99
±SD
±SD
Unpaired student’s t-test was used to calculate the p-value
Table 3: Mean, standard deviation and coefficient of variance comparing male and female population
Parameters
Male
Female
Total population
p-value
Mean
±SD
Variance
Mean
±SD
Variance
Mean
±SD
Variance
t-value
(comparing
sex)
Posterior ratio
1.08
0.06
0
1.06
0.05
0
1.07
0.06
0
1.901
> 0.05
Anterior ratio
77.44
2.84
8.09
77.22
8.64
74.65
77.32
6.57
43.21
0.213
> 0.05
Overall ratio
91.83
2.49
6.18
91.74
9.95
98.96
91.78
7.43
55.16
0.071
> 0.05
Unpaired student’s t-test was used to calculate the p-value
Table 4: Multivariate Pearson’s correlation analysis of different
parameters for total population
Parameters
Posterior
ratio
Anterior
ratio
Posterior ratio
1
Anterior ratio
0.117
1
Overall ratio
0.183*
0.904**
Overall
ratio
1
*p < 0.05; **p < 0.01
the finishing stages of orthodontic treatment. Al Tamimi
and Hashim50 also found no sexual dichotomy in Bolton’s
ratios in a relatively small sample of 65 Saudi subjects. In
contrast, Smith et al8 found that the males had larger Bolton’s
ratios than females. However, these differences were small
being much less than one standard deviation from Bolton’s
sample. The sample was selected according to Angle’s Class
I occlusion with mild or no crowding. It is demonstrated that
clinically significant measurement errors can occur when
Bolton’s tooth-size analysis is performed on casts that have
more than 3 mm crowding.34 All the patients were Keralites,
and between the ages of 14 and 24 years old. This age group
was chosen to minimize the alterations of mesiodistal tooth
dimensions of attrition, restoration or caries.36 Vernier
caliper was selected as a measuring tool because it was
378
proved to be the most accurate method34,43,51 for measuring
mesiodistal width of tooth on models. To minimize random
and systematic errors, all measurements were performed
by a single examiner. The results (Tables 1 and 2) showed
that males had larger teeth than females. These results are
in agreement with Richardson and Malhotra,12 Merz32
who found this in their study on Black North Americans.
However, the findings did not substantiate the need for sexspecific standards. Maxillary tooth material was 8.31 mm
larger than mandibular tooth material, which is in agreement
with Gilpatric2, who calculated that total mesiodistal tooth
diameters in the maxillary arch exceeded that in mandibular
arch by 8-12 mm. The sum of the six maxillary anterior teeth
exceeded the sum of the mandibular teeth by 10.25 mm. The
mesiodistal dimensions obtained for the present sample were
less than the data available from Dominician Americans,41
North American Caucasians8 and Negro.28
Bolton’s ratios were compared in males and females. The
results (Table 3) showed that there is no statistically significant
difference in the mean Bolton’s anterior and overall ratio
between males and females. These results are in agreement with
studies of Richardson and Malhotra,12 Nie and Lin,36 Araujo
and Souki,43 Al-Tamimi and Hashim,50 Basarana et al,51 Paredes
JIOS
Mesiodistal Crown Width Digital Ratio for Kerala Population: A Cross-sectional Survey
Table 5: Percentage distribution of posterior, anterior and overall ratio outside of SD
Parameters
–Outside SD (%)
–SD 2 (%)
–SD 1 (%)
Mean (%)
SD 1 (%)
SD 2 (%)
Outside SD (%)
Posterior ratio
0
15 (9.4)
69 (43.1)
16 (10.0)
40 (25.0)
15 (9.4)
5 (3.1)
Anterior ratio
1 (0.6)
2 (1.3)
72 (45.0)
2 (1.3)
78 (48.8)
4 (2.5)
1 (0.6)
Overall ratio
1 (0.6)
1 (0.6)
70 (43.8)
3 (1.9)
81 (50.6)
3 (1.9)
1 (0.6)
et al,47 and in disagreement with studies of Arya et al,24 Keene,28
Santoro et al41. It is important to note that the possibility of
gender differences in tooth size discrepancies is different from
differences in absolute tooth size. Lavelle11 showed that the
total and anterior ratios were both greater in males than females.
However, these sex differences were small, all being less than
1%. Smith et al8 found that males had larger ratios than females.
However, these differences were small being much less than
1SD from Bolton’s sample. From the results of this study,
similar ratios for males and females suggested that a gender
difference in Bolton’s ratio is population specific.
Since there was no sexual dimorphism evident in mean
anterior and overall ratios, samples of genders were pooled
together to form a single group with n = 160.
Mean anterior ratios in the present study were found
to be 77.44 ± 2.84 and 77.22 ± 8.64 for male and female
respectively. Since no sexual dimorphism was evident,
new anterior ratio calculated was 77.32 ± 6.67. The mean
anterior ratio closely resembles Bolton6,7 mean of 77.2 and
Crosby and Alexander27 of 77.5. The anterior ratio was not
in agreement with Smith8 (79.6%) in White Americans,
Paredes47 (78.32%) in Spanish population, Smith et al8
(80.5%) in South Americans, Smith et al8 (79.3%) in
blacks, Santoro et al41 (78.1%) in Dominician Americans,
Bernabe et al44 (78.09%) in Peruvians, Uysal and Sari46
(78.26%) in Turkish population. These results suggested
that mean anterior ratio was least in Southern Kerala
population followed by black, white and significantly larger
in Hispanics.
Mean overall ratios in the present study were found
to be 91.83 ± 2.49 and 91.74 ± 9.95 for male and female
respectively. New overall ratio calculated was 91.78 ± 7.43.
Mean overall ratio as found in various studies, Bolton6,7
(91.3%), Crosby and Alexander27 (91.4%), Smith8 (92.3%)
in White Americans, Paredes 47 (91.97%) in Spanish
population, Smith et al8 (93.1%) in South Americans,
Smith et al8 (93.4%) in blacks, Santoro et al41 (91.3%) in
Dominician Americans, Bernabe et al44 (90.79-91.33%) in
Peruvians, Uysal and Sari46 (89.88%) in Turkish population.
These results suggest that mean overall ratio was least in
Southern Kerala population followed by white, Hispanics,
and largest in black. Mean posterior ratios in the present
study were found to be 1.08 ± 0.06 and 1.06 ± 0.05 for male
and female respectively. New posterior ratio calculated was
1.07 ± 0.06. The posterior ratio demonstrated the greatest
population differences. The mean of present study resembles
with black while white and Hispanics had lesser value of
1.04 and 1.05 respectively.
The second part of the study was done to find the values
outside 1SD and 2SD (Table 5). Studies defined the ratios
outside 2SD from the Bolton’s mean as values indicating
clinically significant tooth size discrepancies.21,32,44 While
some other studies defined the ratios outside 1SD from
Bolton’s mean44,52 because Bolton7 suggested that a value
greater than 1SD from his mean indicated a possible
treatment need. In the present sample, the frequency of tooth
size discrepancy outside 1 or 2SDs from Bolton’s mean
values was used to determine the clinical significance of
tooth size imbalance. Most subjects in all groups had overall,
anterior and posterior ratios within a 1SD interval. It was
found that 93.8% of the sample had anterior ratio in 1SD
and 3.8% in 2SD. For overall ratio, 94.4% were in 1SD and
2.5% in 2SD. In other studies, percentage values of 9.553,
1141, 13.434, and 15.346 for overall ratio and of 21.346, 22.927,
23.753, 2841 and 30.634 for anterior ratio have been reported
in different patient population. Crosby and Alexander27 and
Freeman et al34 defined a significant discrepancy as a value
of more than 2SDs from Bolton’s mean. On the contrary,
Othman and Harradine54 stated that Bolton’s SDs were not
a good guide to the prevalence of a clinically significant
tooth size discrepancy.
For both overall and anterior ratios in the present study,
means were nearly identical with those of Bolton’s study,
although the ranges and SDs were significantly larger.
This finding was consistent with the results of Crosby and
Alexander,27 Freeman et al34 and Santoro et al41 and Arauzo
and Souki43 used the ratios outside one standard deviation
from Bolton’s mean as tooth size discrepancy. Crosby and
Alexander27 used the ratios outside two standard deviations.
Nie and Lin,36 Smith et al8 and Al-Omari et al53 means and
SDs in their studies were larger than in Bolton’s study.
The probable reason for these findings may be the types of
population that constituted the samples.
CONCLUSION
In general, male crown measurements were slightly larger and
showed a higher variability than the female measurements.
The Journal of Indian Orthodontic Society, October-December 2014;48(4):375-381
379
Sashi Bhushan Ekka et al
A higher variability was found in the maxillary teeth as
compared to the mandibular teeth. Significant sexual
dimorphism for anterior, overall and posterior ratios did not
exist when they were compared among the whole sample.
Mean anterior, overall and posterior ratios were found to
be 77.32 ± 6.67; 91.78 ± 7.43 and 1.07 ± 0.06 respectively.
93.8% of the sample had anterior ratio in 1SD and 3.8%
in 2SD whereas 94.4% were in 1SD and 2.5% in 2SD for
overall ratio. Although the means were nearly identical with
those of Bolton’s study, ranges and SDs were significantly
larger. This study indicates that the Bolton’s analysis can
also be used on Indian or at least Kerala Population but
with increased SD.
In clinical practice, attention should be paid to tooth
size discrepancies between the maxillary and mandibular
teeth and that Bolton’s analysis is important for orthodontic
diagnosis and treatment planning that would improve
achieving optimal occlusion, overbite and overjet. It should
also be borne in mind that Bolton tooth size analysis might be
of assistance in the finishing phase of orthodontic treatment,
especially in increasing the stability of the treatment result.
Although such an analysis in some instances may appear
to be time-consuming, the benefits would seem to be
significant.
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