29

CASE STUDY

The Inter-arch anterior tooth size discrepancy in

different malocclusion groups
Dr. Jamshaid Ali Imran1,2, Dr. Ambreen Afzal3
Dr. Zeeshan Sheikh4,5,6 Dr. Sahar Jamshaid Ali7
1

Resident
Department of Orthodontics
Karachi Medical and Dental College/Altamash
Institute of Dental Science, Karachi, PAKISTAN
2

Senior Registrar
Ziauddin College of Dentistry
Ziauddin University, Karachi, PAKISTAN
3

Professor & Head

Department of Orthodontics
Altamash Institute of Dental Science
Karachi, PAKISTAN
4

PhD Scholar
Faculty of Dentistry, Biomedical Sciences
McGill University, Montreal, Quebec, CANADA
5

Post-Doctoral Fellow
Faculty of Dentistry, Matrix Dynamics Group,
University of Toronto, Ontario, CANADA
6

Associate Professor
Department of Material Sciences & Preclinical
Dentistry, Altamash Institute of Dental Medicine
Karachi, PAKISTAN
7

Private Dental Practitioner

Corresponding Author
Dr. Jamshaid Ali Imran
E mail: jamshaid_alii@hotmail.com
Phone: +1 647 4701537
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Article Code: IDJSR 0133

Quick Response Code

Abstract
Objectives: The present study was aimed to
investigate the correlation between anterior tooth
size discrepancies and Angles class I, II, and III
malocclusions and to assess their prevalence in the
Pakistani population from the metropolitan city,
Karachi.
Study design: A Cross sectional, comparative
study.
Place and duration of study: Out-patient
department (OPD) of Orthodontics division at
Karachi Medical and Dental College. Six months.
Subjects and methodology: Total 90 subjects.
(Angles class I: 30, Angles class II: 30 and
Angles class III: 30) with an age range of 15-25
years were included n the study. Equal distribution
of male and female subjects was maintained. The
comparison of male and female subjects was done
regardless of body height and weight. Nonprobability, purposive type of sampling technique
was done for data collection. The mesiodistal tooth
width was measured from first molar to first molar
on 90 mandibular and 90 maxillary plaster models
with a vernier caliper. Analysis of variance was
used to compare the mean Bolton anterior tooth
size ratios as function of Angle classification and
gender. Statistical differences were determined at
the 95% Confidence level (P < 0.05).
RESULTS: When Comparing mean anterior ratio
of class I (mean=79.8), class II (mean =79.9) and
class III (mean =85) in 90 casts, significant
difference were found among all three
classification (P=0.008).The results showed that
significant difference found in mean anterior ratio
when comparing different malocclusion groups.
Significant difference was found in females when
comparing mean anterior ratio among males and
females in class III malocclusion group. When
multiple comparison was done of anterior ratios
between malocclusion groups there was no
significant difference found between class I and II
while class III malocclusion group was
significantly different from class I and class II
(P=0.007).
Conclusions: Significant difference found in mean
anterior ratio
when comparing different
malocclusion groups. Subjects with an Angle class
III malocclusion had a significant greater
probability of tooth size discrepancies than those
with class I and class II malocclusions.
Key words: Tooth size discrepancy; Bolton
analysis; Bolton ratio; Tooth size analysis;
malocclusion.

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Introduction
The presence of a tooth size discrepancy [TSD]
prevents the achievement of an ideal occlusion. A
high percentage of finishing phase difficulties
arises because of tooth size imbalance that could
have been detected and considered during initial
diagnosis and treatment planning. In some
situations, tooth size discrepancy is not observed at
the initial examination and could result in poor
contacts, spacing, crowding, and an abnormal
overjet and overbite.
The etiology of malocclusion can be broadly
categorized under either hereditary, environmental,
or a combination of both factors.1Exploring the
etiology of malocclusion is imperative for selecting
the most appropriate treatment approach as well as
the most appropriate retention device.1,2Crowding
and spacing are considered the most common
manifestations of malocclusion3 and can occur as a
result of either a shortage of the space required for
tooth alignment or an excess of available space.
The tooth size measurements of Wheeler4also are
frequently used. As significant tooth size
discrepancies prevent an ideal occlusion being
produced at the end of orthodontic treatment, the
absence of a TSD is the seventh key for an ideal
occlusion.5
On a clinical level, mesiodistal tooth width is
correlated to the arch alignment and large teeth are
associated with crowded dental arches.6-8Patients
with inter arch tooth size discrepancies require
either removal (e.g. interdental stripping) or
addition (e.g. composite buildups or porcelain
veneers) of tooth structure to open or close spaces
in the opposite arch, it is important to determine the
amount and location of a tooth size discrepancy
before starting treatment.9Bolton developed a
method of analyzing the mesiodistal tooth size ratio
between maxillary and mandibular teeth.10
Among patients undergoing orthodontic treatment,
the prevalence of an overall TSD has varied from
4% 11%.11 Anterior TSDs, however, have
prevalence between 17% and 31% among
orthodontic patients.12The anterior tooth size ratio
was higher for Hispanics (80.5%) than for Black
people (79.3%). Despite these findings, Othman
and Harradine13 noted that the trend to larger
overall tooth size ratios in Black populations is
unlikely to be clinically relevant. Significant
discrepancies in the overall and anterior tooth size
ratios have been found in Japanese, Iranian-Azari,
Spanish, and Brazilian subjects.14-17
Much work has been done internationally, however
no study has been done in our population to set the
norms for mesiodistal crown dimension and
interarch tooth size ratios. Study of these lines
would greatly improve the quality of orthodontic
finish in our population and lead to a more sound
understanding of one of the most complex variables
affecting orthodontic malocclusion. Trends have

been identified in the prevalence of TSDs among

the malocclusion groups. TSDs are more common
in Class II division 1 malocclusions and in Class III
malocclusions.18-21
The purpose of the study is to set a baseline data to
encourage the research of this region to carry out
more research on this subject in Pakistani
population. The objective of the current study was
to determine any difference in intermaxillary tooth
size discrepancies represented by anterior ratios
when comparing Class I, Class II and Class III
cases in a Pakistani population. Study of these lines
would greatly improve the quality of orthodontic
finish in our population and lead to a more sound
understanding of one of the most complex variables
affecting orthodontic malocclusion.

Materials and Methods

The data for this study was obtained from the
records of the Karachi Medical & Dental College,
Dept of Orthodontics. Considering that tooth size is
not related to age, the sample selection procedure
was based on dental age and the presence of a
permanent dentition defined by the presence of all
teeth at least from first molar to first molar. The
subjects were randomly selected and assigned to
three malocclusion groups according to the Angle
classification classes I, II, and III. Total 90 subjects
(30 pairs of Angles Class I, 30 pairs of Class II
and 30 pairs of Class III malocclusion). Sampling
Technique was Non-Probability, purposive type.
The selection criteria adopted were
anterior
permanent teeth erupted in the upper and lower
arches; good-quality study casts; absence of tooth
deformity; no record of restoration or stripping of
incisor and canine teeth age range of 15 to 25 years
of age. Exclusion criteria were: Patients exhibiting
incisal or cuspal attrition, fractures of teeth or
ectopically erupted teeth, patients with anomalies
of tooth size (e.g. microdontia, macrodontia; peg
laterals etc), patients with anomalies of tooth
number (e.g. hyperdontia, hypodontia, cases of
fusion of teeth and gemination), patients with
history of previous orthodontic treatment, patients
with craniofacial syndrome or anomalies.
A stainless steel Boley Gauge vernier caliper
(Odontomed2011, product ref # 16140) was used to
measure the mesiodistal width to the nearest 0.1
mm. The width of each tooth was measured from
its mesial contact point to its distal contact point at
its greatest interproximal distance. Bolton anterior
(canine to the canine) ratios were calculated with
the following formulae:
Sum mandibular 6 X 100 = anterior ratio (%)
Sum maxillary 6
Statistical analysis was performed on data using the
software: IBMSPSS (v. 20, IBM SPSS Inc.,
Chicago, IL). For all continuous variables including
age and malocclusion, mean (X) and standard
deviation (SD), values were calculated for each

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31
measurement. To compare the means of anterior
ratio in different malocclusion groups analysis of
variance (ANOVA) statistical significance level
was taken at 0.05.

Results
Out of 90 cast, 30 pairs of angle class 1, 30 pairs of
angle class II and 30 pairs of angle class III. The
age distribution is 15-25 where 55% are between
15-19 years, 43% in between 20-24 years and rest
are above 24 year as shown in fig 1. When
comparing mean anterior ratio of class I (mean
=79.8), class II (mean = 79.9) and class III (mean =
85) in 90 casts, significant difference were found
among all three classification (p=0.008) as shown
in table 1.When multiple comparison was done of
anterior ratios between malocclusion groups there
was no significant difference found between class I
and class II. The class III malocclusion group was
significantly different from class I and class II (p =
0.007) as shown in table 2.
Table 1. Comparison of means of anterior ratio in different
malocclusion groups (n=90).

I
(n=30)
II
(n=30)
III
(n=30)

Range

Mean

69 89.9
68.5
105.19
66.6
107.7

79.8
79.9
85

SD

4.97
7.04
9.1

*By applying ANOVA (Analysis of Variance).

95%
CI
77.9
81.6
77.2
82.5

Pvalue*

Classes

P-Values

Class-I and Class-II

0.977

Class-III and Class-I

0.007*

Class-III and Class-II

0.007*

*By LSD test (used t-test to perform all pair wise comparisons)
* Class-III is significantly different from class I and II

Class-I = The triangular ridge of the mesiobuccal

cusp of the maxillary first permanent molar
articulates in the buccal groove of the mandibular
first molar.
Class-II= The mesial groove of the mandibular first
permanent molar articulates posteriorly to the
mesiobuccal cusp of the maxillary first permanent
molar.
CLASS III= The mesial groove of the mandibular
first permanent molar articulates anteriorly to the
mesiobuccal cusp of the maxillary first permanent
molar.
Figure 1.Age distribution of patients (n = 90)
30

20

81.6 88.46

22

22
19

0.008
Number of Patients

Classes

Table 2. Multiple comparisons of anterior ratio between

different malocclusion groups.

Class-I = The triangular ridge of the mesiobuccal

cusp of the maxillary first permanent molar
articulates in the buccal groove of the mandibular
first molar.
Class-II=The mesial groove of the mandibular first
permanent molar articulates posteriorly to the
mesiobuccal cusp of the maxillary first permanent
molar.
Class III= The mesial groove of the mandibular
first permanent molar articulates anteriorly to the
mesiobuccal cusp of the maxillary first permanent
molar.

13

13

22.0

24.0

10

0
16.0

18.0

20.0

26.0

Age in Y ears (Mid v alues)

Mean SD = 17.32 3.94 (years)

Range = 15 25 Years

Figure 2.Boley Gauge Vernier Caliper, stainless steel

(Odontomed2011, product ref # 16140)

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Discussion
A tooth-size discrepancy is defined as a lack of
harmony between the mesiodistal widths of
individual teeth or groups of teeth when related to
their functional counterparts of the opposing arch.
Any discrepancy will result in either spacing in 1
arch or a compromise in functional relationships.
To achieve good occlusion with the correct
overbite and overjet, the maxillary and mandibular
teeth must be proportional in size to each other.22
Tooth size discrepancies are considered an
important variable especially in the anterior
segment. Lavelle23 stated that although tooth size
and proportion have an important role in
malocclusion. Genetic influences have been
considered important in the determination of tooth
dimensions, and the first reports were related to
clinical observations within families. Studies on
twins, however, helped in understanding the
genetic contribution of tooth size in that a greater
tooth size correlation was found in monozygotic
twins.24,25Other investigators de-emphasized the
genetic
contribution
and
described
the
determination of tooth size as multifactorial, with
the environment playing an important role.26
Teratogenic and nutritional factors have been
associated with the mechanism of tooth
formation.26Space limitations and nutrition have
been described as important in the development of
a healthy tooth germ and have been related to
alterations in number, shape and form of permanent
teeth.26 Although it is widely accepted that both
genetic and environmental variables affect tooth
development, it is virtually impossible to identify
and describe the role each of these variables play in
the determination of tooth size.
Several studies were published describing the
importance of a correct tooth size proportion
between the upper and lower arches. Lundstrm27
studied the relationship between the mandibular
and the maxillary anterior sum and named it the
anterior index. For an ideal overbite, the optimal
ratio was found to be from 73% to 85%, with a
mean of 79%.
Bolton10,28evaluated 55 cases with excellent
occlusion. After considering tooth sizes from
canine to canine in the maxillary and mandibular
arches, Bolton established an ideal anterior ratio
with a mean value of 77.2% and standard deviation
(SD) of 1.65%. It would be very difficult to obtain
an excellent occlusion in the finishing phase of
treatment without a correct mesiodistal tooth size
ratio. Orthodontists should be concerned with tooth
size discrepancies because of the high incidence in
orthodontic patient populations. Bolton10,28reported
tooth size discrepancies greater than 1 SD in 29%
of the patients studied in his private practice, and
Richardson and Malhotra29 reported similar
discrepancies in 33.7% of their patients. Crosby
and Alexander30 stated that a tooth size discrepancy

had to be greater than 2 SD, e.g., two to three mm

of deviation, to influence the course of orthodontic
treatment. In studies involving 109 individuals,
22.9% showed anterior ratios that significantly
deviated from the Bolton analysis mean (greater
than 2 SD).
Sassouni31 was the first to report that individuals
with a Class III facial type and deficient maxillary
growth showed a greater prevalence of alterations
in shape of the anterior teeth as well as a greater
incidence of agenesis. In more recent articles, other
variables such as incisor inclinations,32upperincisor thickness,33,34and arch form33,35 have been
described as important to consider in achieving
optimal occlusion relationships. Efforts have been
made to adapt the Bolton analysis to these
variations. Cua-Benward et al36 studied the
prevalence of missing teeth in different
malocclusion groups, relating their findings to
Mosss functional matrix concept. They found a
greater prevalence of tooth deformities in the
maxilla in Class III individuals, whereas they found
more tooth deformities in the mandible in Class II
individuals. Hashim HA37 evaluated mesiodistal
crown width in different malocclusion groups
(class I, class II and class III) and found no
statistical difference between them. Discrepancies
in tooth size should be known at the initial
diagnosis and treatment planning stages if perfect
results in orthodontic finishing are to be achieved.
Tooth size discrepancies are considered an
important variable, especially in the anterior
segment. Araujo and Souki38 reported that the mean
anterior tooth size discrepancy for Angle Class III
subjects was significantly greater than that for
Class I and Class II Subjects.
A comparative study between Jordanians, Iraqi,
Yemenites, and Caucasians reported that
Jordanians and Iraqi had larger teeth than the other
populations.39 The later study, however, did not
discuss the differences in tooth size between
different malocclusions. Correct tooth size
relationship between maxillary and mandibular
teeth is an important factor to achieve a proper
occlusal interdigitation during the final stages of
orthodontic treatment.10,40The importance of correct
tooth size proportions between the upper and lower
arches has been demonstrated. Neff 40developed an
anterior coefficient, which was a proportion for the
width dimension of the teeth. A ratio of 1.20 1.22
when the maxillary mesio-distal sum was divided
by the mandibular mesio-distal sum would result in
an optimal overbite. Several methods have been
described to evaluate interarch tooth size
relationship such as Neffs anterior coefficient40,41
and Boltons ratios for the six anterior teeth and the
overall ratio for the 12 teeth.10,28
Many factors such as heredity, growth of the bone,
eruption and inclination of the teeth, external
influences, function, and ethnic background would

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33
affect the size and shape of the dental arches.4245
However, Gilmore and Little46 found that,
although there was a tendency for incisors with a
greater mesiodistal dimension to be associated with
crowding, the association was so weak that
reduction of the widths of incisors to fit a specific
range cannot be expected to produce a stable
alignment. Theories proposed to explain the cause
of dental crowding vary widely, embracing
concepts of evolution, heredity, and environmental
effects.
In a more recent study, Santoro et al47 reinforced
the findings of Crosby and Alexander30 observing
that 28% of 54 Dominican Americans presented a
discrepancy greater than 2 SD. Lavelle23 studied
160 subjects for anterior tooth sizes and showed a
tendency for Angle Class III individuals to present
smaller upper teeth compared with subjects
classified as Class II or I. Moreover, Lavelle23
stated that teeth in the lower arch are larger in Class
III than in Classes II and I, with the inference that a
Bolton discrepancy is greater in Class III cases than
in the other malocclusion groups. In this study, the
mesiodistal tooth size and Bolton ratio were
compared in Class I, Class II and Class III in a
Pakistani sample.
In our study anterior ratio showed tendency
towards large Bolton ratio in class III malocclusion
group which is most similar to the studies done in
Chinese population.48,49The difference in the results
between this study and the other investigations
might be attributed to the sample size, method of
analysis and large standard deviation found in this
study.Crosby and Alexander 30 also compared the
tooth size ratios among different malocclusion
groups, as in this study. They found that there were
no significant differences among Class I, Class II
division 1, Class II division 2, and Class II surgery
groups. This study also found no significant
difference between these groups. In this study we
compared the tooth size ratios among Angles class
I, class II and class III malocclusion groups and
found significant difference in mean anterior ratios
of class III malocclusion group.
Crosby and Alexander 30 also compared the tooth
size ratios among different malocclusion groups but
did not included class III malocclusion group, as in
the current study. They found that there was no
significant difference among Class I; Class II,
division 1; Class II, division 2; and Class II surgery
groups. In the present study, three malocclusion
groups were compared, and no statistically
significant difference was found among them in
overall ratio and statistical difference in anterior
ratio. For patients with Class III malocclusion, the
present findings were in accordance with Nie and
Lin48 and Lavelle.23
The subjects in the present investigation all had
malocclusions sufficiently severe to warrant
treatment and it is possible that this is contributed

to the larger percentage of tooth size discrepancies,

especially in the anterior region. This could be
explained by the fact that anterior teeth, especially
the incisors, have a much greater incidence of tooth
size deviations, that is, the greatest variables in
mesiodistal tooth width occur in the anterior region.
The findings that individuals with a Class III
malocclusion have a significantly greater mean
anterior ratio than the other groups may confirm the
results of Lavelle23 that Class III individuals have
disproportionately smaller maxillary teeth than
Class I and Class II subjects. However, a small size
of the maxillary teeth was not found in the present
study. Therefore, the Bolton discrepancy in the
Class III sample must either be attributed to an
increase in the width of the anterior mandibular
teeth or the accumulation of minor discrepancies of
individual teeth.
The results obtained by Nie and Lin48 using
Angles classification as a variable in analyzing
360 Chinese individuals for tooth size
discrepancies are in agreement with the present
findings that Class III patients demonstrate a
greater tooth size discrepancy when compared with
Class II and I patients. Crosby and Alexander30
tried to verify the presence of a tooth size
discrepancy in 109 patients divided into four
malocclusion groups, but not including Class III
subjects. They compared the average of the anterior
and overall Bolton indices but did not find any
statistical difference in the incidence of the tooth
size discrepancy among the groups (Class I, Class
II divisions 1 and 2, and surgical Class II). Some of
the findings in the present investigation were
similar to their results with respect to the absence
of statistically significant differences when
comparing Class I and Class II malocclusion
groups. Since they did not include subjects with a
Class III malocclusion in their investigation, they
could not find any difference between normal
occlusion and malocclusion groups coinciding with
the Bolton indices, while in the present study, a
large part of the differences in the Bolton indices
were attributed to the presence of a Class III
malocclusion.
Several authors50 proposed new methods to study
tooth size discrepancies. However, these proposals
need to be tested in clinical studies and, for now,
the Bolton analysis prevails as an efficacious
clinical tool for appraising various relationships of
upper to lower dentitions. The high prevalence of
anterior TSDs in Irish orthodontic population51
suggests that a tooth size analysis should be
conducted at the treatment planning stage. Where
significant TSDs are detected, this is normally
accommodated by the reduction or augmentation of
tooth tissue.
Further studies are needed to clarify whether a
correlation exists between increased mandibular
growths (as in Class III malocclusions) with

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34
increased mesiodistal dimensions of lower anterior
teeth. The possible interaction of genetic factors
could determine mandibular size while affecting
the mesiodistal dimensions of lower mandibular
teeth in the same way.

Conclusion
Subjects with an Angle Class III malocclusion had
a significantly greater probability of tooth size
discrepancies than those with Class I and Class II
malocclusions.The mean anterior tooth size
discrepancy for Angle Class III individuals was
significantly greater than that in Class II and Class
I malocclusion.The Orthodontist who is aware of
these possible discrepancies will be better prepared
to diagnose and plan treatment with a more
accurate certainty for patients of varied population
mix. These conclusions could greatly influence
clinical decision making and further studies should
be undertaken in this field.

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INTERNATIONAL DENTAL JOURNAL OF STUDENTS RESEARCH| January 2015 | Volume 2| Issue 4