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European Journal of Orthodontics 31 (2009) 584–589 © The Author 2009. Published by Oxford University Press on behalf of the European Orthodontic Society.
doi:10.1093/ejo/cjp013 All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org
Advance Access Publication 1 April 2009
Introduction
A correct maxillary to mandibular tooth size ratio is
important for the achievement of correct occlusal
interdigitation, overjet, and overbite. Without an appropriate
relationship of mesiodistal (MD) tooth dimensions of the
maxillary and mandibular teeth, coordination of the arches
would be diffi cult with consequences on the fi nal orthodontic
treatment result and its stability ( Ballard, 1944 ; Neff, 1957 ;
Bolton, 1958 , 1962 ).
Bolton (1958) studied tooth size dimensions and their
effect on occlusion. Stifter (1958) replicated the Bolton
study in Class I dentitions and reported similar results.
Previously published indices ( Pont, 1909 ; Howes, 1947 ;
Rees, 1953 ; Neff, 1957 ; Lundström, 1981 ) have been used
to assess the relationship that exists between tooth
dimensions and supporting bone as well as to predict fi nal
tooth positions.
Bolton (1958 , 1962 ) suggested that a ratio greater than 1
standard deviation (SD) from the mean values indicated a
need for diagnostic consideration and possible treatment.
Other authors ( Crosby and Alexander, 1989 ; Freeman et al. ,
1996 ) have defi ned a signifi cant discrepancy as a value
outside 2 SD from Bolton’s mean. Araujo and Souki (2003)
also found a high proportion of patients with anterior tooth
size discrepancies, but they defi ned a discrepancy as greater
than ± 1 SD from Bolton’s mean ratio. Because different
tooth sizes have been associated with ethnicity ( Moorrees,
et al. , 1957 ; Lavelle, 1972 ; Buschang et al. , 1988 ; Smith
et al. , 2000 ), it is logical to expect that differences in tooth
widths can directly affect tooth-widths ratios. Since gender
tooth size differences are not systematic across all teeth
( Garn et al. , 1967 ; Lavelle 1972 ; Bishara et al. , 1989 ),
different interarch relationships might be expected. The
relationships between different malocclusion groups and
tooth size discrepancy have been reported previously
(Lavelle, 1972; Crosby and Alexander, 1989 ; Freeman
et al. , 1996 ; Ta et al. , 2001 ; Fatahi et al. , 2006 ; Puri et al. ,
2007 ).
The aims of the current study were to determine (1)
whether there is a difference in the incidence of tooth size
discrepancies among different malocclusion groups,
classifi ed according to Angle, which coincided with skeletal
categories (Class I, Class II, and Class III) represented by
anterior, overall, and posterior ratio; (2) the percentage of
tooth size discrepancies outside 2 SD from Bolton ’ s means
for tooth ratios in each malocclusion group and in the overall
sample; and (3) whether gender dimorphism exists for tooth
size ratios.
Materials and methods
Dental casts and lateral cephalometric radiographs of
Croatian subjects aged 13 – 22 years (mean age 16.86 ± 2.93
years) was collected from the archives of the Department of
Orthodontics, University of Zagreb, Croatia. The selection
Tooth size discrepancy in orthodontic patients among different
malocclusion groups
Mihovil Struji ć , Sandra Ani ć -Milo š evi ć , Senka Me š trovi ć and Mladen Š laj
Department of Orthodontics, School of Dental Medicine, University of Zagreb, Croatia
SUMMARY An appropriate relationship of the mesiodistal (MD) widths of the maxillary and mandibular
teeth favours optimal post-treatment results. The aims of this study were to determine whether there is a
difference in the incidence of tooth size discrepancies among different skeletal malocclusion groups and
if gender dimorphism exists.
The dental casts and lateral cephalometric radiographs of 301 Croatian subjects (127 males and 174
females, mean age 16.86 ± 2.93 years) were selected from a larger sample of records of the archives of the
Orthodontic Department, School of Dental Medicine, University of Zagreb, Croatia. The subjects were from
malocclusion groups according to Angle classifi cation, with the corresponding skeletal characteristics.
The MD dimensions of all teeth from fi rst molar to fi rst molar were measured on the dental casts using
digital callipers. Statistical analysis was undertaken using Kolmogorov – Smirnov, t , and Scheffé ’ s tests
and one-way analysis of variance.
A statistically signifi cant gender difference was found in anterior ratio ( P = 0.017). A signifi cant
difference in the overall and posterior ratio was observed between Class II and Class III subjects. There
was a tendency for mandibular tooth size excess in subjects with an Angle Class III malocclusion and
for maxillary tooth size excess in those with an Angle Class II malocclusion. The percentage of subjects
more than 2 standard deviations from Bolton ’ s means for anterior and overall ratios was 16.28 and 4.32,
respectively.
585
TOOTH SIZE DISCREPANCY IN DIFFERENT MALOCCLUSION GROUPS
criteria for the dental casts were (1) all permanent teeth
erupted and present from right to left fi rst molar to permit
measurement of the MD crown dimensions, (2) no severe
tooth abrasion or large restorations that could compromise
the MD dimension of a tooth and no teeth with anomalous
shapes or deformity, and (3) pre-treatment casts of subjects
with no previous orthodontic treatment.
A total of 301 casts (127 males and 174 females) met the
criteria. The mean age for males was 16.5 ± 3.1 and for
females 17.1 ± 2.8 years. Occlusional categories of all
subjects, classifi ed according to Angle, coincided with
skeletal categories. Skeletal types were assessed by ANB
from cephalometric analysis. ANB was set at 0 – 5 degrees
for Class I, greater than 5 degrees for skeletal Class II, and
less then 0 degrees for skeletal Class III ( Mureti ć , 1984 ).
One hundred and eleven subjects (36.87 per cent) were
Class I, 109 (36.21 per cent) Class II, and 81 (26.91
per cent) Class III ( Table 1 ).
The MD dimensions of all teeth on each cast from fi rst
molar to fi rst molar were measured with digital callipers
(Levior S.R.O., Kokory, Czech Republic) accurate to
0.1 mm. The MD dimension of each tooth was measured
according to the method described by Moorrees et al.
(1957) , from its mesial contact point to its distal contact
point at its greatest interproximal distance. All measure-
ments, carried out under natural light, were performed by
the same author (MS), who did not exceed more then seven
casts per day in order to avoid eye fatigue and to minimize
the possibility of subjective error.
Bolton ’ s analysis was performed on each set of models,
when the teeth of all 301 subjects had been measured. The
‘ overall ratio ’ was determined using the formula:
overall ratio =↔
↔×
∑
∑
()
()
.
36 46
16 26 100
For the ratio between the maxillary and mandibular anterior
teeth, the same method was used. The ratio between the two
is the percentage relationship of mandibular anterior width to
maxillary anterior width, referred to as ‘ anterior ratio ’ :
anterior ratio =↔
↔×
∑
∑
()
()
.
33 43
13 23 100
Furthermore, the posterior ratio and both anterior and
posterior discrepancy in the upper arch were calculated
from the formula:
posterior ratio =↔↔
↔↔
×
∑
∑
(, )
(, )
.
36 34 44 46
16 14 24 26 100
Measurement error
Intraexaminer error was determined by one author (MS),
who measured 30 pairs of casts after an interval of 24 hours
and interexaminer calibration was carried out by another
author (SM), who also measured the 30 pairs of casts twice
separated by 24 hours. If the difference was less than 0.2 mm,
the fi rst measurement was registered. If the second
measurement differed by more than 0.2 mm from the fi rst,
the tooth was measured again and only the new measurement
was registered.
The reproducibility of the measurements was analysed
using Dahlberg (1940) formula. The error was calculated
from the equation: ME =dn
22/ , where d is the difference
between duplicated measurements and n is the number of
replications.
The results showed no signifi cant difference between the
two measurements. Intraclass correlation coeffi cients were
0.979 ( P < 0.001), 95.79 per cent, ME = 0.17 (range 0 – 1.45)
for interexaminer calibration and 0.987 ( P < 0.001), 97.35
per cent, ME = 0.14 (range 0 – 0.6) for intraexaminer
calibration.
Statistical analysis
The subjects were divided by gender and by skeletal Class.
Statistical calculations were carried out using the Statistical
Package for Social Sciences version 13.0 (SPSS Inc.,
Chicago, Illinois, USA). The results are summarized in
Tables 1 , 2 , 3 , and 4 . After measurement of the MD widths
of all maxillary and mandibular teeth (excluding the second
and third molars), their distribution was evaluated with the
Kolmogorov – Smirnov test to see whether the sample was
normally distributed. To determine whether there was
gender dimorphism in the incidence of tooth size
discrepancies, a Student ’ s t -test was performed. For each
malocclusion group, the level of signifi cance was set at
0.05. In order to compare intermaxillary tooth size
discrepancies among different malocclusion groups, one-
way analysis of variance (ANOVA) was performed. To test
which means were different, Scheffé ’ s test was used that
extends the post hoc analysis possibilities to include linear
differences as well as comparisons between specifi c means.
In order to determine the percentage of tooth size
discrepancies in the different malocclusion groups, each
group was compared with the results from Bolton’s study.
Measurements outside 2 SD were defi ned as exhibiting a
clinically signifi cant tooth size discrepancy suffi cient to
Table 1 Number and percentage distributions of the subjects
among the different malocclusion Classes with the mean age of the
sample.
N
(males)
N
(females)
N
(m + f)
% Mean age
(years)
Class I 42 69 111 36.87 17.02
Class II 49 60 109 36.21 16.70
Class III 36 45 81 26.91 16.81
M. STRUJI Ć ET AL.
586
warrant treatment because this represents a 2 – 3 mm tooth
size discrepancy (Crosby and Alexander, 1989; Freeman
et al. , 1996). The number of patients with a tooth size ratio
outside 2 SD was divided by the total number of patients in
the group. To determine the percentage of tooth size
discrepancies within each of the malocclusion groups, this
number was multiplied by 100 ( Figures 1 and 2 ).
Results
The Kolmogorov – Smirnov test demonstrated that the
sample came from a normally distributed population ( P >
0.20); therefore, parametric tests were used. The numbers
and percentage are presented in Table 1 . Descriptive
statistics for anterior, posterior, and overall ratios between
the genders and t -test for independent samples for gender
are shown in Table 2 . Because statistically signifi cant gender
differences were found in anterior ratio, ANOVA for the
differences regarding Classes was performed separately for
each gender. The differences for skeletal Classes were
calculated for posterior and overall ratio. ANOVA
demonstrated signifi cant differences for posterior and
overall ratios ( Table 3 ).
Scheffé ’ s p ost hoc test showed signifi cant differences ( P <
0.05) in posterior ratios. For overall ratio, signifi cant
differences were found between Class I and Class II and
between Class II and Class III malocclusion groups ( Table 4 ).
Discussion
The age range of the subjects was 13 – 22 years. The mean
age for males was 16.5 and for females 17.1 years. This
young age group was chosen in accordance with the study
of Doris et al. (1981) to minimize the alteration of the MD
dimensions due to attrition, restorations, or caries.
Consequently, the effect of these factors on actual MD tooth
widths was minimal. The subjects in the current study were
all randomly selected Caucasians and thus proportionately
representative of malocclusion type.
Comparison with Bolton’s sample
The descriptive statistics for anterior, posterior, and overall
ratios between genders in each malocclusion group are
shown in Table 2 . The means of the tooth size ratios of the
subjects were similar to Bolton ’ s measurements as well as
with those of Crosby and Alexander (1989). The only
difference was in the higher SD in the present study as
compared with Bolton ’ s standards that could be attributed
to the difference in the sample size. The Class I anterior
ratio SD was 2.58 compared with Bolton´s SD of 1.65,
while the overall ratio SD showed no difference. When
comparing other malocclusion groups with Bolton´s
measurements, similar trends were found. While the means
were very close, the SD were higher in the present study
( Table 3 ). Although Bolton’s analysis is useful in a clinical
setting, some limitations still exist (Lundström, 1981;
Crosby and Alexander, 1989; Freeman et al., 1996). Bolton ’ s
sample was obtained from the models of 55 subjects with
perfect Class I occlusions (Bolton, 1958; 1962). The
population and gender composition of that sample was not
specifi ed, the grouping criteria were not explained in detail,
and it was unclear as to how many were treated or untreated,
which implies potential selection bias. In the present
Table 2 Mean, standard deviation (SD), standard error (SE), and
independent t -test for anterior, posterior, and overall ratios for
males (M) and females (F).
Gender N Mean SD SE P value
Anterior ratio M 127 78.39 2.87 0.25 0.017 *
F 174 77.81 2.36 0.18
Total 301 78.06 2.60 0.15
Posterior ratio M 127 104.74 3.20 0.28 0.340
F 174 104.99 2.96 0.22
Total 301 104.88 3.06 0.18
Overall ratio M 127 91.71 2.00 0.18 0.730
F 174 91.60 2.06 0.16
Total 301 91.64 2.03 0.12
* P < 0.05.
Figure 1 Percentage of subjects with anterior tooth size ratios compared
with Bolton ’ s standard.
Figure 2 Percentage of subjects overall tooth size ratios compared with
Bolton ’ s standard.
587
TOOTH SIZE DISCREPANCY IN DIFFERENT MALOCCLUSION GROUPS
investigation, with a sample size of 301, and pre-treatment
casts of patients treated orthodontically, skeletal categories
were taken into account, and the subjects were selected by
the criteria of occlusal categories coinciding with skeletal
categories.
Tooth size discrepancies in different malocclusion classes
The results of the present study showed signifi cant
differences for overall and posterior ratios among the
different malocclusion groups ( Table 3 ). However, the SDs
were larger than expected. The Class I group had the
smallest SDs, but only for posterior ratios, when compared
with the other malocclusion groups. Tooth size ratios among
different malocclusion groups have been compared by
Sperry et al. (1977) and Crosby and Alexander (1989).
Crosby and Alexander (1989) analyzed Bolton ratios and
tooth sizes for different occlusal categories, but did not
include Class III patients or differentiate between the
genders. The relationship between malocclusion and skeletal
pattern was not mentioned. No statistically signifi cant
differences in the incidence of tooth size discrepancy among
different malocclusion groups were found. Sperry et al.
(1977) analyzed Bolton ratios for groups of Class I, II, and
III cases. The subjects were not differentiated by gender and
the skeletal patterns were not mentioned. The overall ratios
showed that there was mandibular tooth size excess for the
Class III patients similar to the fi ndings in the present study.
Nie and Lin (1999) reached a similar conclusion; however,
they included not only Class III but also Class III surgery
patients. Although Class III surgery and non-surgery patients
were included in the present study, similar results were
found. The overall ratio of Class III patients was highest
among the different malocclusion groups, with the largest
difference between Class II and Class III subjects ( Tables 3
and 4 ). This statistically signifi cant trend to larger ratios in
Class III patients was also reported by Ta et al. (2001) in
southern Chinese, Alkofi de and Hashim (2002) in Saudis,
Araujo and Souki (2003) in Brazilians, and Fatahi et al.
(2006) in Iranians. While Uysal et al. (2005) found no
differences between malocclusion types, all malocclusion
groups had signifi cantly higher average ratios than the
subjects with untreated normal occlusions. Lavelle (1972)
showed that the sizes for maxillary teeth in Class III subjects
were smallest and mandibular teeth the largest among
different malocclusion groups. In that study, only a type of
descriptive statistical result was presented, with no
comparison of ratios, which stated the mean size of each
tooth of male patients for each malocclusion group and
mentioned a pattern of contrast.
Tooth size discrepancy and gender
Bishara et al. (1989) found that males had larger teeth than
females; however, the tooth size discrepancy ratios were not
measured. It is important to note that the possibility of
gender differences in tooth size discrepancy varies from
differences in absolute tooth size (Othman and Harradine,
2006).
No differences in the mean Bolton ratios were found
between the genders (Al-Tamimi and Hashim, 2005). In
studies where differences have been found, they have been
small, with males having slightly larger ratios (Lavelle,
1972, Richardson and Malhotra, 1975; Smith et al., 2000).
Gender differences ( P = 0.017) were found in the present
study but only for anterior ratio, similar to fi ndings of Fatahi
et al. (2006).
Prevalence of tooth size discrepancy
According to Bolton (1958), there is a relatively small range
in which tooth size ratios should fall to be able to achieve
optimal occlusal relationships. Stifter (1958) reached a
similar conclusion, while Crosby and Alexander (1989)
found that a large number of orthodontic patients presented
with a signifi cant Bolton tooth size discrepancy. When all
patients in the current study were combined, 16.28 per cent
had an anterior ratio with a signifi cant deviation from
Bolton ’ s mean (greater than 2 SD; Figure 1 ). A signifi cant
discrepancy, higher than Bolton ’ s mean, was found in
anterior ratio in 21 per cent of Spaniards ( Paredes et al. ,
Table 4 Scheffé ’ s post hoc test (the level of signifi cance was P <
0.05).
Class Class I Class II Class III
Posterior ratio I 0.237 0.384
II 0.237 0.014
III 0.384 0.014
Overall ratio I 0.035 0.969
II 0.035 0.031
III 0.969 0.031
Table 3 Mean, standard deviation (SD), standard error (SE), and
analysis of variance for anterior, posterior, and overall ratios
regarding different malocclusion groups.
Class N Mean SD SE P value
Anterior ratio I 111 78.25 2.58 0.25 0.252
II 109 77.73 2.42 0.23
III 81 78.23 2.82 0.31
Total 301 78.06 2.60 0.15
Posterior ratio I 111 104.97 2.66 0.25 0.013 *
II 109 104.28 3.37 0.32
III 81 105.58 3.00 0.33
Total 301 104.88 3.06 0.18
Overall ratio I 111 91.81 1.99 0.19 0.004*
II 109 91.14 2.14 0.21
III 81 92.08 1.82 0.20
Total 301 91.64 2.03 0.12
* P < 0.05.
M. STRUJI Ć ET AL.
588
2006 ) as well as in the samples of Crosby and Alexander
(1989) 22.9 per cent, Freeman et al. (1996) 30.6 per cent,
Santoro et al. (2000) 28 per cent, Bernabé et al. (2004) 20.5
per cent, and Othman and Harradine (2007) 17.4 per cent. A
discrepancy in overall ratio outside 2 SD from Bolton’s
mean ( Figure 2 ) was found in 4.32 per cent of the present
sample, similar to the fi ndings of 5 per cent by Bernabé et al.
(2004), Paredes et al. (2006) , and Othman and Harradine
(2007), but lower than that of Freeman et al. (1996) of 13.5
per cent and Santoro et al. (2000) of 11 per cent. Fernández-
Riveiro et al. (1995) found greater anterior and overall
ratios in their study, but they considered values outside 1
SD to be signifi cant. In the present investigation, a tendency
was found to mandibular tooth size excess in Angle Class
III malocclusion subjects and maxillary tooth size excess in
Angle Class II malocclusion subjects, in agreement with the
fi ndings of Nie and Lin (1999).
Regarding studies reporting the MD dimensions of lower
teeth to be larger in Class III subjects when compared with
Classes I and II ( Lavelle, 1972 ; Sperry et al. , 1977 ), Fatahi
et al. (2006) speculated that these greater means in Bolton’s
ratio might be due to aetiological factors that lead to
mandibular prognathism and may also be associated with
increased MD dimensions of upper anterior teeth in Class II
subjects that lead to maxillary prognathism. Further studies
are needed to clarify whether a correlation exists between
increased growth of the jaws and increased MD dimensions
of anterior teeth. A large individual cultural variability
might have existed in the growth pattern of the subjects
( Akyalçin et al. , 2006 ).
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 fi nishing phase of orthodontic
treatment, especially in increasing the stability of the
treatment result (Araujo and Souki, 2003). Although such
an analysis in some instances may appear to be time-
consuming, the benefi ts would seem to be signifi cant.
Conclusions
1. Tooth size discrepancy was found to be more frequent
in the anterior region with respect to gender.
2. A tendency was found for mandibular tooth size excess
in Angle Class III malocclusion subjects and maxillary
tooth size excess in those with an Angle Class II
malocclusion. Posterior and overall ratios were greater
in Class III malocclusion subjects than in other occlusal
categories.
3. The percentage of subjects with more than 2 SD from
Bolton ’ s means for anterior and overall ratios was16.28
and 4.32, respectively.
Address for correspondence
Mihovil Struji ć
Department of Orthodontics
School of Dental Medicine
University of Zagreb
Gunduli ć eva 5
10000 Zagreb
Croatia
E-mail: strujic@sfzg.hr
Funding
Croatian Ministry of Science, Education and Sport ( 065-
0650444-0436 ).
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