Changes in tooth si ze-arch length relationships from

the deciduous to the permanent dentition: A

longitudinal study
Samir E. Bishara, BDS, D. Ortho., DDS, MS," Paymun Khadivi, DDS, ~ and
Jane R. Jakobsen, BA, MA
Iowa Ci~ Iowa, and Pittsfield, Mass.
The purpose of this investigation is to determine the changes in the maxillary and mandibular tooth
size-arch length relationship (TSALD) after the complete eruption of the deciduous dentition
(,X age = 4.0 years) to the time of eruption of the second molars (X age = 13.3 years). In addition,
an attempt was made to determine whether TSALD in the permanent dentition can be predicted
in the deciduous dentition. Records on 35 male and 27 female subjects were evaluated. Each
subject had a clinically acceptable occl usi on-t hat is, a normal molar and canine relationship, at the
time of eruption of the deciduous and permanent teeth. In addition, each subject had a complete
set of data at the two stages of dental development. These selection criteria limited the number of
subjects in this investigation to 62. The mesiodistal diameter of all deciduous teeth and their
permanent successors, as well as various dental arch width and length parameters, were measured
in the deciduous and permanent dentitions. A total of 68 parameters were measured or calculated.
Student t tests were used to determine whether significant differences were present between the
right and left sides for both male and female subjects. Correlation coefficients r were performed
between the deciduous and the corresponding permanent teeth and also for the arch length
parameters, as well as TSALD in the two dentitions. Significance was predetermined at the 0.05
level of confidence. Stepwise regression analysis (R 2) was used to determine which of the variables
in the deciduous dentition could be included in a regression model to determine associations
between maxillary and mandibular TSALD in the permanent dentition. The results of the correlation
coefficients (r) indicate that there are a number of significant correlations between the various
variables in the deciduous and the permanent dentitions, but most of these correlations were
relatively low (<0.7), with the exception of those for the incisors, in the female subjects. The
Multiple Regression Analysis did not significantly improve the predictive abilities. Discriminant
Analysis indicated that the predictive accuracy, i.e., the percentage of cases correctly classified by
the prediction equations were, in general, relatively low. In conclusion, the changes in the alignment
of the teeth were primarily the result of a decrease in the available arch length in both the maxillary
and mandibular arches. The correlations between the various deciduous and permanent
parameters are of such a magnitude that does not allow an accurate prediction of the TSALD in the
permanent dentition from the available dental measurements in the deciduous dentition. The clinical
implications of the findings were discussed. (AM J ORTHOD DENTOFAC ORTHOP 1995;108:607-13.)
One of the most perplexing phenomenon
in orthodontics is the crowding of anterior teeth
before, as well as after the completion of orthodon-
tic treatment.
Incisor crowding can be observed in both the
young and adult dentitions. Van der Linden 1 clas-
sifted crowding on the bases of its cause as primary,
aProfessor. Orthodontic Department, College of Dentistry, University of
Iowa.
bResearch Associate; Currently in private practice.
CAssistant Professor, Department of Preventive and Community College
of Dentistry, College of Dentistry, University of Iowa.
Copyright 1995 by the American Association of Orthodontists.
0889-5406/95/$5.00 + 0 S/1/56506
secondary, and tertiary. He defined primary crowd-
ing as an inherent discrepancy between tooth size
and the available arch length, mainly of genetic
origin. Secondary crowding is caused by environ-
mental factors influencing the dentition, such as
caries and extractions. Tertiary crowding or late
crowding occurs in the postadolescent period.
The incidence of mandibular incisor crowding
was found by Barrow and White 2 to increase from
14% at age 6 to 51% at 14 years of age. Cryer 3
found the incidence to be 62% in 1000 school
children aged 14 years. This trend toward an in-
creased incidence of mandibular incisor crowding
with age in untreated persons has been reported by
607
608 Bishara, Khadivi, and Jakobsen American Journal of Orthodontics and Dentofacia( Orthopedics
December 1995
others. .1 Sinclair and Little 6 quantified the dis-
pl acement in t he mandi bul ar incisor contact points
and found it significantly increase from 9 to 29
years. Fost er et al. 7 report ed a peak at 14 years;
Sinclair, 5 Moorrees, ~ and Bi shara et al. 9 report ed a
cont i nued increase into young adulthood. Bi shara
et al. ~ observed an additional increase bet ween 25
and 45 years of age in bot h mal e and femal e
subjects. They observed t hat t oot h size-arch length
discrepancy from early adol escence (13 years of
age) to mi d-adul t hood (45 years of age) increased
significantly in bot h the maxillary and mandi bul ar
arches. The increases were calculated to be 1.9 mm
in mal e subjects and 2.0 mm in femal e subjects in
the maxillary arch, whereas the correspondi ng
changes were 2.7 and 3.5 mm in the mandi bul ar
arch.
Sinclair 5 observed t hat incisor crowding in nor-
mal unt reat ed per sons occurs at a rat e t hat is about
one third t hat of t reat ed persons. The changes in
the latter group were consistent despite widely
varying initial and final crowding indices. This
seems to indicate t hat t he changes are i ndependent
of the initial malocclusion or t he "success" of the
t r eat ment rendered.
Vari ous investigators at t empt ed to det ermi ne
the relationship bet ween crowding and ot her
dentofacial paramet ers. Moorrees et al. 1~ suggested
that a decrease of the incisor-canine ci rcumference
not ed from 13 to 18 years of age was associated
with a decrease in arch length rat her t han a nar-
rowing in arch width. Similar observations were
made by DeKock 12 who quantified the average
reduct i on to be 10%. Car men ~3 found no significant
rel at i onshi p bet ween incisor crowding, gender, and
Angl e classification. Changes in arch length and
i nt ercani ne and mol ar widths may partly cont ri but e
to a multifactorial relationship that is associated
with crowding. 9
Al t hough several investigators 4'~42 suggested
t hat t he amount and direction of facial growth may
be partially responsible for t he changes in the
mandi bul ar incisor position, ot hers 6'9 did not find
significant associations bet ween the skeletal rela-
tionships and dental changes.
Sanin and Savara 21 found a correl at i on bet ween
mandi bul ar incisor crowding and the size of the
first molars, as well as the angle formed by the long
axis of the mandi bul ar incisors and molars. They
devel oped a probability table t hat was used to
predi ct t he incisor crowding at age 14 years from
variables measured at age 8 years, with a 15%
est i mat e of error. On the ot her hand, Howe et al., z2
as well as Sinclair and Little, 6 found no clinically
significant associations bet ween various mandi bul ar
par amet er s and incisor crowding, and they con-
cluded that no predictive equat i on can accurately
forecast t he nat ure and extent of the changes in
lower incisor crowding.
The literature review indicates that clinicians
and researchers are i nt erest ed in predicting the po-
tential for a t oot h size-arch length discrepancy in
their growing patients. If accurat e predictions can be
made while the pat i ent is in t he deciduous dentition,
clinicians might want to explore the feasibility of
various approaches to i nt ercept these developing
malocclusions. On the ot her hand, if such discrepan-
cies cannot be accurately predi ct ed one will have to
question the advisability of such procedures.
The purpose of this study is to det ermi ne the
changes in the maxillary and mandi bul ar t oot h
size-arch length discrepancies (TSALD) at the time
of t he compl et e erupt i on of the deciduous denti-
tion (X age -- 4.0 years) to t he time of eruption of
t he second mol ars (X age = 13.3 years). In addi-
tion, an at t empt was made to det ermi ne whet her
TSALD in the early per manent dentition can be
predi ct ed from various par amet er s measured at t he
deciduous dentition stage.
MATERIALS AND METHODS
Subjects
Records of 35 male and 27 female subjects who were
participants in the Iowa Longitudinal Growth Study were
evaluated. 23'24 Each subject had a normal occlusion at the
time of eruption of the deciduous teeth, no apparent
facial disharmony, none had congenitally missing teeth or
had undergone orthodontic therapy throughout the pe-
riod of study. Normal occlusion was defined as having a
flush terminal plane or a mesial step between the distal
surfaces of the opposing second deciduous molars, 0% to
50% overbite and 0 to 3 mm of ovejet.
Each subject had complete dental casts at two stages
of dental development, namely, at the time of complete
eruption of the deciduous dentition and at the time of
eruption of the permanent second molars. These selec-
tion criteria limited the number of subjects in this inves-
tigation to 62, 35 males and 27 females.
Parameters measured
A. Arch length: The mesiodistal length of the fol-
lowing arch segments were measured in the max-
illary and mandibular arches for the right and left
sides; ~'2S (1) Anterior segments, between the me-
American Journal of Orthodontics and Dentofacial Orthopedics Bishara, Khadivi, and Jakobsen 609
Volume 108, No. 6
sial contact points of the central incisors and the
points between the lateral incisors and canines,
(2) posterior segments, between the contact
points of the lateral incisors and canines and the
distal of the second deciduous molars or the
mesial of the first permanent molars. The total
arch lengths was also calculated.
B. Tooth size measurements: The mesiodistal widths
of the maxillary and mandibular deciduous and
succedaneous teeth were measured. These mea-
surements were obtained from casts in which the
dentitions were complete and in good condition.
Crown diameters were taken as the distance be-
tween the anatomic contact points. 26'27
C. Tooth size-arch length discrepancy (TSALD):
Two types of TSALD were calculated, total
TSALD mesial to the second deciduous molars or
permanent first molars, and anterior TSALD be-
tween the two canines. The TSALD was calcu-
lated for both the maxillary and mandibular
arches by subtracting the sum of the mesiodistal
diameter of the appropriate teeth from the avail-
able arch length.
Approximately 68 different variables were either
measured or calculated from the various measurements.
All measurements were performed by two investiga-
tors working independently. Each investigator performed
each measurement twice on different occasions. Intrain-
vestigator and interinvestigator discrepancies were pre-
determined at 0.25 ram.
Statistical analysis
Descriptive statistics, including the mean, standard
deviation, minimum and maximum values, were calcu-
lated for the various measurements.
Student t tests were used to determine whether
significant differences were present between the right
and left sides for both the male and female subjects.
Correlation coefficients "r" were performed between the
deciduous and corresponding permanent teeth and also
for the arch length and width parameters, as well as
tooth size-arch length relationships in the two dentitions.
Significance was predetermined at the 0.05 level of con-
fidence.
Stepwise regression analysis (R 2) was used to deter-
mine which of the variables could be included in a
regression model, i.e., to determine associations between
maxillary and mandibular TSALD arches in the perma-
nent dentition. This procedure is useful in isolating a
subset of predictor variables that best explain the varia-
tion of the dependent variableY
Discriminant analysis was used to supplement the
findings from the regression analysis since it provides a
mean of assessing the predictive accur acy- t hat is, the
percentage of cases correctly classified by the prediction
equation. 29
RESULTS
Right - left side comparisons: The results of t he
St udent t tests i ndi cat ed t hat t he mesi odi st al di am-
et ers of t he ant i meres, as well as ant eri or and
post eri or arch lengths, wer e not significantly differ-
ent bet ween t he right and left sides. Thi s was t rue
for bot h t he maxillary and mandi bul ar arches.
Male -female comparisons: St udent t tests indi-
cat ed t hat mal e subjects wer e l arger t han f emal e
subjects in a number of dent al arch par amet er s, as
well as in t he mesi odi st al crown di amet ers. As a
result, t he findings for mal e and femal e subjects are
pr esent ed separat el y.
Correlations (r) between the mesiodistal diameter
of the deciduous and succedaneous teeth (Table I):
Wi t h t he except i on of t he maxillary second molars,
all deci duous t eet h were significantly cor r el at ed t o
t hei r per manent successors. All t he correl at i ons
wer e l ower t han 0.7 with t he except i on of t he
f emal e correl at i ons bet ween t he maxillary cent ral
incisors (r = 0.81 and 0.78) and t he mandi bul ar
cent ral (r = 0.78 and 0.76) and lateral (r = 0.76
and 0.70) incisors.
Correlations (r) between the deciduous and per-
manent arch length segments (Table II): All arch
segment s wer e significantly cor r el at ed in t he de-
ci duous and per manent dent i t i ons except for t he
mandi bul ar ri ght and left ant eri or segment s. All
t he significant correl at i ons were bel ow 0.7 except
for t he maxillary post eri or segment s (r = 0.73 and
0.79) in mal e subjects.
Correlations between total tooth size-arch length
discrepancies (TSALD) in the deciduous and perma-
nent dentitions (Table III). All correl at i ons were
significant but bel ow 0.7.
Multiple Regression Analysis: The previ ousl y
ment i oned findings i ndi cat ed t hat in general , t her e
wer e significant correl at i ons (r) in t oot h size, arch
length, and TSALD bet ween t he deci duous and
per manent dent i t i ons. The maj ori t y of t hese corre-
lations wer e bel ow 0.7. As a result, mul t i pl e regres-
sion analysis (R 2) was used to det er mi ne whet her
t he addi t i on of ot her vari abl es can i mprove t he
ability t o predi ct t he TSALD in t he per manent
dent i t i on. The results of t he Mul t i pl e Regr essi on
Anal ysi s (Tabl e IV) i ndi cat ed t hat t he scores for R 2
r anged bet ween a low of 0.1737 for Tot al Mandi bu-
lar TSALD in femal e subjects t o a high of 0.7474
for Tot al Maxillary TSALD in mal e subjects. The
Di scri mi nant Anal ysi s (Tabl e IV) was used to de-
t er mi ne how accurat el y t hese predi ct i on equat i ons
610 Bishara, Khadi vi , and Jakobsen American Journal of Orthodontics and Dentofacial Orthopedics
December 1995
Table I. Correlation coefficients (r) bet ween the mesiodistal tooth size of the deciduous and succedaneous
permanent t eet h
Maxillary
D1 D2
T4 T5
Mal es 0.33 0. 41' *
Femal es 0.11 0.60**
D3
T6
D4 D5
T7 T8
D6
T9
D7
TIO
D8
Tl l
D9 DIO
T12 T12
0.11 0.44** 0.45** 0.65** 0.49** 0.45** 0.53* 0.22
0.57** 0.45** 0.78** 0.81"* 0.54** 0.73** 0.75** 0.41"
*p _< 0.05; **p -< 0.01.
D1-DIO, maxillary deci duous t eet h from right to left.
T4-T12, maxillary per manent succesdaneous t eet h from right to left.
Dl l -D20, mandi bul ar deci duous t eet h from left to right.
T20-T29, mandi bul ar per manent succedaneous t eet h from left to right.
Tabl e II. Correlation coefficients (r) bet ween the
deciduous and per manent arch
length segments
R Post R Ant L Ant L Post
Maxillary
Mal es 0.73** 0.63** 0.66** 0.79**
Femal es 0.49** 0.60** 0.39* 0.52**
Mandi bul ar
Mal es 0.56** 0.22 0.21 0.54**
Femal es 0.62** 0.47** 0.53** 0.59**
L = Left; R = right; Ant = anterior; Post = posterior; *p _<
0.05; **p -< 0.01.
can correctly classify the expect ed TSALD in the
permanent dentition for each person. The results
of the Discriminant Analysis for correctly classify-
ing individual subjects ranged bet ween a low of
40.8% to a high of 77.8%.
DI SCUSSI ON
One of the ultimate goals of attempting to
quantify the changes in t oot h size-arch length dis-
crepancy bet ween the deciduous and per manent
dentitions is prediction. The results of the correla-
tion coefficients (r), indicate that t here are a num-
ber of significant correlations bet ween the various
variables in the deciduous and permanent denti-
tions, but these correlations were relatively low
( <0. 7) with the exception of the incisors in fe-
males. The Multiple Regression Analysis (R 2) did
not significantly improve the predictive abilities. In
addition, the Discriminant Analysis indicated that
the percent age of cases correctly classified by the
prediction equations were, in general, relatively
low.
Horowi t z and Hixon 3 have stated that correla-
Table I I I . Correlations coefficients (r) bet ween
total t oot h size and arch length
discrepancies in the deciduous and
permanent dentitions
Males Females
Maxillary 0.47"* 0.69"*
Mandi bul ar 0.46"* 0.48"*
**p _< 0.01.
tion coefficients of less t han r = 0.7 or r = 0.8 have
little predictive value when applied to a person. A
correlation coefficient of r = 0.7 means that less
than half of the total variation can be eliminated in
prediction. When the guidelines of Horowitz and
Hixon 3 were applied to the present data, few of
the correlations were sufficiently high to be useful
for prediction. Furt hermore, the results did not
follow a detectable pat t ern bet ween male and fe-
male subjects, bet ween the maxillary and mandibu-
lar arches, as well as bet ween the total and anterior
TSALD.
In previous studies, 213 increases in the TSALD
bet ween early adolescence and early adulthood
have been consistently observed. These changes
were primarily the result of a decrease in the
available arch length bot h anteriorly and posteri-
orly. 2-13 The changes in maxillary and mandibular
TSALD in the per manent dentition were not found
to have a strong association with ot her dental arch
variables in the deciduous dentition. 6'9
The present findings and that of others 31-33 have
poi nt ed to the difficulty of predicting the eventual
TSALD in the per manent dentition from dental
arch measurement s in the deciduous dentition. On
the ot her hand, predicting TSALD in the mixed
American Journal of Orthodontics and Dentofacial Orthopedics Bi shara, Khadi vi , and Jakobs en 611
Volume 108, No. 6
Mandibular
Dl l
T20
D12
T21
D13 D14
T22 T23
D15
T24
D16
T25
0.51"* 0.36* 0.43** 0.50** 0.56** 0.51"*
0.53** 0.58** 0.46** 0.76** 0.78** 0.76**
D17 D18
T26 T27
0.45** 0.38*
0.70** 0.49**
D19 D20
T28 T29
0.46** 0.52**
0.44* 0.42*
Table IV. Results of the stepwise regression analysis indicating the various significnat variables that
contribute to R 2 with TSALD of various arch segments as the independent variable
Variable Portal R 2 Variable Portal R 2
Mal es R 2 = 0.7474
Di fference bet ween t he size of t he maxillary
deci duous and per manent t eet h
Maxillary total arch l engt h
Sum of maxillary deci duous t eet h
Change in mandi bul ar mol ar wi dt h
Di scri mi nant analysis
Mal es R 2 = 0.5532
Mandi bul ar deci duous t eet h
Sum of mandi bul ar deci duous per manent t eet h
Tot al mandi bul ar arch l engt h
Change in mandi bul ar mol ar width
Di scri mi uant analysis =
Mal es R 2 = 0.3238
Maxillary deci duous arch l engt h
Sum of maxillary deci duous t oot h size
Di fference in size of maxillary deci duous and
per manent t eet h
Di scri mi nant analysis =
Mal es R 2 = 0.5608
Mandi bul ar deci duous t oot h size
Di fference bet ween mandi bul ar deci duous and
per manent t oot h size
Mandi bul ar deci duous arch l engt h
Mandi bul ar i nt ermol ar width
Di scri mi nant analysis =
Total maxillary TSALD
Femal es R z = 0.1245
0.1325 Mandi bul ar i nt ercani ne width
0.1627
0.4030
0.0493
68.5%
Total mandi bu&r TSALD
0.1020
Femal es R e = 0.1737
Vari at i ons bet ween t he di fferences in maxillary
and mandi bul ar t oot h size from t he deci duous
to t he per manent dentitions
0.1229
0.2286
0.0996
69.0%
Anterior maxillary TSALD
Femal es R 2 = 0.7267
0.1200 Change in mandi bul ar i nt ercani ne width
0.0803 Change in maxillary i nt ercani ne wi dt h
0.1235 Maxillary deci duous t oot h size
0.1245
50.8%
0.1737
40.8%
0.2456
0.1470
0.0972
Mandi bul ar deci duous arch l engt h 0.1362
Di fference bet ween maxillary and mandi bul ar 0.0604
t oot h size
Maxillary deci duous arch l engt h 0.0403
59.1% 77.8%
Anterior mandibular TSALD
Femal es R 2 = 0.4003
0.2485 Change in mandi bul ar mol ar width 0.1266
0.1143 Change in maxillary cani ne width 0.2738
0.0946
0.1034
77.3% 51.9%
dentition can be performed with much greater
accuracy. 34 This is because the dental arch dimen-
sions, particularly in the mandible, are established
by the time the mandibular incisors have erupted.
Added to that is the fact that a number of accurate
prediction equations have been developed that can
accurately estimate the mesiodistal diameters of
the unerupted premolars and canines. 35-36
612 Bishara, Khadivi, and Jakobsen American Journal of Orthodontics and Dentofacial Orthopedics
December 1995
Ther ef or e clinicians who are i nt erest ed in earl y
t r eat ment shoul d base t hei r di agnost i c decisions on
t oot h si ze-arch l engt h analyses per f or med in t he
mi xed dent i t i on and not in t he deci duous dent i t i on.
Accur at e est i mat es of space di screpanci es will in
t urn allow t he clinician t o deci de whet her t he
pat i ent woul d benefi t f r om a gui dance of erupt i on
pr ocedur e or serial ext ract i ons i ncl udi ng t he re-
moval of first premol ars.
The pr esent and previ ous findings 5'1'13 indi-
cat ed t hat t he changes in t he dent ofaci al st ruct ures
are compl ex and t hat t he processes t hat i nt erpl ay t o
i nfl uence t he rel at i onshi p among t he teeth, t he
dent al arches, and t he face, al t hough identifiable,
are not yet compl et el y under st ood or predi ct abl e.
Ther ef or e bot h clinicians and par ent s need t o
accept t he fact t hat for t he present time, it is
difficult duri ng t he deci duous dent i t i on stage to
predi ct t he magni t ude of t he fut ure TSALD. Earl y
mechani cal i nt ervent i on in t he deci duous dent i t i on
of a phe nome non t hat cannot be accurat el y diag-
nosed or predi ct ed in a part i cul ar per son is t here-
fore not r ecommended. This deci si on has t o be
post poned until t he mi xed dent i t i on aft er t he erup-
t i on of t he per manent incisors.
It has also been suggest ed t hat post r et ent i on
changes in t oot h si ze-arch l engt h rel at i onshi p are,
at least in part , rel at ed t o t he "nor mal " devel op-
ment al changes and shoul d be expect ed in most
persons whet her or not t hey have under gone ort h-
odont i c t r eat ment . The pat i ent , and t he par ent s of
persons seeki ng or t hodont i c t r eat ment , shoul d be
made aware of this phenomenon.
Accor di ng t o Hor owi t z and Hixon37:
The significant point is that orthodontic therapy may
temporarily alter the course of these physiologic changes
and possibilities, for a time, even reverse them; however,
following mechanics-therapy and the period of retention-
restraint the developmental maturation process resumes.
It needs t o be r emember ed t hat t he changes in
arch di mensi ons as well as t oot h posi t i on and
i ncl i nat i on are, in part , compensat or y mechani sms
t hat serve t o mai nt ai n t he bal ance among t he
vari ous funct i onal and st ruct ural demands pl aced
on t he face and dent i t i on. Many of t hese changes
are difficult t o predi ct in t he deci duous dent i t i on
stage.
CONCLUSI ONS
Al t hough it is of t en suggest ed t hat post t reat -
ment and post r et ent i on mandi bul ar incisor crowd-
ing are rel at ed t o i nadequat e or t hodont i c diagnosis
and t r eat ment pl anni ng, this investigation i ndi cat es
t hat addi t i onal fact ors are involved and shoul d be
consi der ed in explaining this phenomenon. These
fact ors are pr esent in most per sons whet her or not
t hey have a mal occl usi on or have under gone ort h-
odont i c t reat ment .
The changes in t he al i gnment of t he t eet h are
pri mari l y t he result of a decr ease in t he available
arch l engt h in bot h t he maxillary and mandi bul ar
arches. The Regr essi on Anal ysi s i ndi cat es t hat t hese
changes are rel at ed in part , t o t oot h size as well as t o
arch l engt h and arch wi dt h changes. The correl a-
tions bet ween t he vari ous deci duous and per manent
TSALD are of such a magni t ude t hat does not allow
an accurat e predi ct i on of di screpanci es in t he per-
manent dent i t i on f r om t he available dent al mea-
surement s in t he deci duous dent i t i on.
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Reprint requests to:
Dr. Samir E. Bishara
Department of Orthodontics
College of Dentistry
University of Iowa
Iowa City, IA 52342