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Comparison of dental and alveolar arch widths ORTHODONTICS ORIGINAL ARTICLE COMPARISON OF DENTAL AND ALVEOLAR ARCH WIDTHS IN CLASS I AND CLASS II DIVISION 1 MALOCCLUSION NADIA BHUTTA, BDS, FCPS JUNAID ISRAR BDS, DDCS, MFDS RCSENG, FCPS (Orth) 3 ABIDA IJAZ BDS, D.Orth, MCPS, MS, FPFA, FICD 1 2 ABSTRACT The objective of this study was to compare transverse dimensions of the dental arches and alveolar arches in the canine, premolar and molar regions of Class I and Class II div 1 malocclusion groups. This cross sectional study was performed at Lahore medical and dental college, from January 2011 to November 2011, using measurements on dental casts of 30 Class I and Class II div 1 adult female subjects. Twelve dental and alveolar arch width measurements were recorded from dental casts using a dial caliper. Descriptive analysis and paired sample t- test were carried out for significance (P < 0.05). Statistically significant differences were found in two of the twelve measurements. Mandibular canine alveolar width & mandibular premolar alveolar width in Class II div1 group were significantly narrower than Class I group. Rest of the variables did not show any significant difference. The results of our study suggest that Mandibular intercanine and interpremolar alveolar width measurements were narrower in Class II subjects and there is a tendency towards lingual cross bites in that malocclusion group. Key Word: Dental arch width, Alveolar arch width, Class I malocclusion, Class II div 1 malocclusion. INTRODUCTION Improving patient esthetics is one of the main goals of orthodontic treatment. This cannot be achieved without thorough diagnosis of the case. Orthodontic diagnosis involves investigations of the face in all three dimensions both clinically and radiographically. Intra oral and extra oral measurement of face and dental arches is a routine procedure during orthodontic diagnosis. 1 2 3 Assistant Professor, Orthodontic Department Lahore Medical & Dental College, Lahore. Assistant Professor, Orthodontic Department Lahore Medical & Dental College, Lahore. Professor & Head of Orthodontic Department Faryal Dental College, Faizpur Interchange Corresponding Author and Reprint request to: Dr. Junaid Israr SD 39, Street 3, Block 2, Askari III Officers Colony, Bedian Road, Lahore Cantt. Lahore. 54792 Tel No: 0322-4729367 E-mail: [email protected] www.orthozone.pk Mobile: 00962-777515170 Received for Publication: Accepted: July 8, 2013 July 16, 2013 Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) The size and shape of the arches have significant implications in orthodontic diagnosis and treatment planning, affecting the space available, dental esthetics, and stability of the dentition1. Arch width has been a subject of interest among investigators studying the growth of arches.4-8 Transverse component of growth is of great importance as it is the first dimension in which growth ceases.2 Arch width dimensions in addition to causing transverse discrepancies also contribute to anteroposterior and vertical plane malocclusions. Class II malocclusion is reported as the most frequently seen skeletal disharmony in orthodontic population.13-19 Graber reported that many class II malocclusions have a strong transverse component in addition to sagittal and vertical problems.3 Transverse component of skeletal Class II patients has considerable importance while planning and executing treatment of these individuals. 289 Comparison of dental and alveolar arch widths In search of etiology and treatment planning in different malocclusions, various studies have been conducted to compare widths of adult subjects with normal occlusion to those of different malocclusion samples.4-12 However, there is considerable controversy among the results presented in the literature. Some of the authors evaluating transverse dimensions had reported that maxillary arch was narrower in patients with Class II, division 1 malocclusion, and an expansion was needed during or before treatment.20-24 Review of literature in this regard indicates that knowledge of dental arch and dentoalveolar width associated with class I and Class II, Division 1 malocclusion would be helpful to establish a good differential diagnosis in order to adopt the treatment that will achieve the greatest efficiency and the most stable results possible. Skeletal constriction, dentoalveolar constriction and dental constriction must therefore be differentiated, as each requires different treatment with different orthodontic appliances. The aim of this study was to find possible dental and alveolar transverse differences between class II div I and Class I malocclusion. This study will aid in diagnosis of the possible site & cause of arch constriction. The resulting information could help determine the mode of expansion to be planned for a typical malocclusion. METHODOLOGY This study was conducted at department of orthodontics, Lahore medical and dental college. The study was performed using initial lateral cephalograms and 60 dental casts (30 Class I malocclusion and 30 class II div 1 malocclusion) female patients that reported to department of orthodontics from January 2011 to November 2011. Age of the subjects ranged from 16-25 years. The mean and standard deviations of ages of class I and class II patients were 20.9 + 2.58 and 21.2 + 2.14 years respectively. All subjects had adult dentition and none of them had undergone orthodontic treatment previously. A total of twelve dental and alveolar arch width measurements were recorded to the nearest 0.1 mm from each patient’s dental casts using a dial caliper. Following criteria was used: Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) CLASS I MALOCCLUSION SAMPLE Dental casts of 30 adult female with Class I malocclusion were selected. All subjects were skeletally class I, as diagnosed with the help of lateral cephalograms and had bilateral class I canine & molar relationship, all permanent teeth from first molar to first molar fully erupted and present, no ectopic eruptions, no anterior and posterior cross bites, no impactions, good facial symmetry determined clinically, mild to moderate crowding in either or both arches and no history of trauma. CLASS II MALOCCLUSION SAMPLE Dental casts of 30 adult females with class II div I malocclusion were selected. All subjects were skeletally class II div 1 as determined by lateral cephalograms and had bilateral class II canine & molar relationship, excessive overjet (more than 5mm), all permanent teeth from first molar to first molar fully erupted and present, no ectopic eruptions, no anterior and posterior cross bites, no impactions, good facial symmetry determined clinically, mild to moderate crowding in either or both arches and no history of trauma. The landmarks on the casts that were used in this study are shown in Figure 1 & 2 and explained in Table 1. RESULTS Four weeks after the first measurements, a second set of measurements was done. Method error was calculated and found to be negligible. Descriptive statistics (Minimum, Maximum, Mean Standard deviation) and statistical comparisons of dental & alveolar width measurements for dental casts of the two groups identified (Class I & Class II Div 1) are shown in Table 2, 3, & 4. Statistically significant differences were found in two of the twelve measurements. Mandibular canine alveolar width in Class II was significantly narrower than Class I subjects (P < .005). Similarly, mandibular premolar alveolar width was significantly narrower in Class II subjects as compared to Class I (P < .05). Rest of the variables did not show any significant difference. 290 Comparison of dental and alveolar arch widths DISCUSSION This study was carried out to compare the dental arch and alveolar base widths of Class I and Class II div1 malocclusion patients. Width measurements described in this article will help clinicians diagnose and plan the treatment of patients with Class I and Class II division 1 malocclusions and to device expansion protocols for the target area. Investigators who studied growth changes in the transverse arch width found that molar and canine arch widths did not change after age 13 in female subjects and age 16 in male subjects.25-28 Inter canine width has been of particular interest to the researchers who have been working on transverse width measurements of dental arches.6,7,8,22,35 In TABLE 1: MAXILLARY AND MANDIBULAR DENTAL AND ALVEOLAR WIDTH MEASUREMENTS USED IN THE STUDY Abbreviation Explanation UC-C Distance between cusp tip of right and left canines OR the centre of wear facets in cases of attrition. Distance between two points at the mucogingival junctions above the cusp tips of the maxillary right and left canines. Distance between cusp tip of right and left 1st premolars OR the centre of wear facets in cases of attrition. Distance between two points at the mucogingival junctions above the Interdental contact point of the maxillary first and second premolars. Distance between mesiobuccal cusp tip of right and left 1st molars OR the centre of wear facets in cases of attrition. Distance between two points at the mucogingival junctions above the mesio buccal cusp tips of the maxillary right and left 1st molars. Distance between cusp tip of right and left canines OR the centre of wear facets in cases of attrition. The projection of UAC-C point in lower arch. Distance between cusp tip of right and left 1st premolars OR the centre of wear facets in cases of attrition. The projection of UAP-P point in lower arch. Distance between most gingival extensions of buccal grooves on the right and left 1st molars. The projection of UAM-M point in lower arch. UAC-C UP-P UAP-P UM-M UAM-M LC-C LAC-C LP-P LAP-P LM-M LAM-M TABLE 2: DESCRIPTIVE ANALYSIS CLASS I Variables N Minimum Maximum Mean Std. Dev UCC UACC UPP UAPP UMM UAMM LCC LACC LPP LAPP LMM LAMM 30 30 30 30 30 30 30 30 30 30 30 30 30.00 31.00 31.00 40.00 38.00 52.00 20.00 29.50 25.00 39.00 44.00 50.00 40.00 42.00 49.50 54.00 54.50 61.00 31.00 48.00 42.00 49.50 59.50 61.00 34.0667 36.0333 40.2500 47.4000 50.2000 56.0167 26.4500 34.3000 33.8167 45.3167 50.0833 54.8833 2.39516 2.90046 3.56649 3.37179 2.94373 2.23793 2.51324 3.42053 3.10029 2.63427 3.26972 2.82136 Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 291 Comparison of dental and alveolar arch widths TABLE 3: DESCRIPTIVE ANALYSIS CLASS II Variables N Minimum Maximum Mean Std Dev UCC UACC UPP UAPP UMM UAMM LCC LACC LPP LAPP LMM LAMM 30 30 30 30 30 30 30 30 30 30 30 30 29.00 34.00 35.00 45.00 42.00 51.50 22.00 26.00 29.50 31.00 47.00 49.50 42.50 44.00 47.00 56.00 57.00 66.00 31.00 44.00 41.00 51.00 60.00 64.00 34.4167 37.2500 39.7167 48.4833 50.4833 56.9000 26.3500 31.5333 33.6667 43.4000 50.9000 53.6833 2.68804 2.67411 3.14775 2.87823 3.42527 3.58252 2.34576 3.66938 2.80803 3.64692 3.50714 3.31788 TABLE 4: PAIRED SAMPLES STATISTICS Paired Variable Mean N Std Dev Std Error Significance UCC1UCC2 UACC1UACC2 UPP1UPP2 UAPP1UAPP2 UMM1UMM2 UAMM1UAMM2 LCC1LCC2 LACC1LACC2 34.066734.4167 36.033337.2500 40.250039.7167 47.400048.4833 50.200050.4833 56.016756.9000 26.450026.3500 34.300031.5333 30 30 30 30 30 30 30 30 2.395162.68804 2.900462.67411 3.566493.14775 3.371792.87823 2.943733.42527 2.237933.58252 2.513242.34576 3.420533.66938 .43729.49077 .52955.48822 .65115.57470 .61560.52549 .53745.62537 .40859.65408 .45885.42828 .62450.66993 .599 .111 .517 .204 .724 .215 .868 .005** LPP1LPP2 LAPP1LAPP2 LMM1LMM2 LAMM1LAMM2 33.816733.6667 45.316743.4000 50.083350.9000 54.883353.6833 30 30 30 30 3.100292.80803 2.634273.64692 3.269723.50714 2.821363.31788 .56603.51267 .48095.66583 .59697.64031 .51511.60576 .838 .031* .358 .090 UAP-P LAP-P UAC-C LAC-C LC-C UC-C LP-P UP-P UM-M UAM-M LM-M LAM-M Fig 1: Maxillary dental cast measurements (modified from Uysal, Memili, Usumez, Sari) Fig 2: Mandibular dental cast measurements (modified from Uysal, Memili, Usumez, Sari) Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 292 Comparison of dental and alveolar arch widths our study, when we compared the intercanine widths of class I and class II div I malocclusion patients, it was found that mandibular canine alveolar width in Class II was significantly narrower than Class I subjects (P < .005). Similarly, mandibular premolar alveolar width was significantly narrower in Class II subjects as compared to Class I (P < .05). These results were in accordance with the work done by Uysal T et al35 who concluded that that mandibular intercanine and interpremolar widths were narrower in class II div I individuals. However, our results did not match other studies such as Fröhlich6, who compared intercanine widths of both arches from 51 children with Class II malocclusion from data collected by Moorrees11 of children with normal occlusion and found that absolute arch widths of the Class II children did not differ appreciably from those of children with normal occlusion. Sayin and Turkkahraman7 concluded that mandibular intercanine widths were significantly larger in Class II, division 1 group than Class I group, whereas no significant differences were found between maxillary canine width measurements of the two groups. They further found no differences between groups in maxillary and mandibular interpremolar widths. Intermolar widths are the most commonly evaluated measurement in previous studies.30,31,32 In our study, we did not find any significant differences of maxillary and mandibular intermolar dental and alveolar widths in the two population samples. This result was in accordance to Fröhlich6 who found no difference in molar widths between normal and Class II subjects. Bishara et al20 found no significant differences in the female comparisons of the intermolar width measurements. Staley et al8 reported that subjects with normal occlusion (Class I) had larger maxillary and mandibular intermolar width differences than subjects with malocclusion. While evaluating alveolar widths, they reported that maxillary alveolar widths and mandibular alveolar widths of the males were larger in the Class I group. siobuccal cusp tips & central fossa respectively) were significantly larger in Class I group than Class II, division 1 group (P, .01). However, mandibular intermolar widths I and II (from left and right mesiobuccal & distobuccal cusp tips respectively) did not differ significantly between groups. Slaj M et al29 in their study on virtual 3D models concluded that the dimensions of the dental arches are related to gender and to dentoalveolar class. Class I and II subjects have similar dimensions of maxillary dental arch, but Class II subjects have a transverse deficit in the mandible. Different suggestions have been put forth in literature to treat the transverse deficiencies of various malocclusions depending on the etiology. Sayin and Turkkahraman7 concluded that transverse discrepancy in Class II division 1 patients originated from upper posterior teeth and not from the maxillary alveolar base, therefore, they suggested slow maxillary expansion rather than rapid maxillary expansion may be considered before or during the treatment of Class II division 1 patients. Interestingly, Uysal T35 suggested quite the opposite i.e., the maxillary molar teeth in subjects with Class II division 1 malocclusions tend to incline to the buccal to compensate for the insufficient alveolar base. For that reason, rapid maxillary expansion rather than slow expansion may be considered before or during the treatment of Class II division 1 patient. Our study was unable to find any significant difference in the two comparative groups. Dental and alveolar widths in the maxillary canine, premolar and molar regions were insignificantly different form one another. CONCLUSION According to Sayin and Turkkahraman7 maxillary intermolar widths I and II (from left and right me- It was concluded from this study that no dental and alveolar differences exist between the two malocclusion samples except that the mandibular intercanine and inter premolar alveolar widths are significantly narrower in class II samples. The variation in results in our study sample can be attributed to ethnic differences. As a recommendation, we suggest that in Pakistani populations the expansion of maxillary arches in the class II div I groups can be done by any appliance Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 293 Comparison of dental and alveolar arch widths depending on the severity of the initial situation and proper diagnosis of the case. 19 Lauc T. Orofacial analysis on the Adriatic islands: an epidemiological study of malocclusions on Hvar Island. Eur J Orthod. 2003; 25: 273-278. REFERENCES 20 Bishara SE, Bayati P, Jakobsen JR. 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Clin Oral Investig. 2001; 5: 220-226. 18 Silva RG, Kang DS. Prevalence of malocclusion among Latino adolescents. Am J Orthod Dentofacial Orthop. 2001; 119: 313-315. Pakistan Oral & Dental Journal Vol 33, No. 2 (August 2013) 294