JOURNAL OF DENTAL SCIENCES
Volume 2 Issue 1
ASSESSMENT OF DENTAL CROWDING IN MANDIBULAR ANTERIOR REGION BY THREE DIFFERENT METHODS
Dr. Ronak Panchal
Abstract Little Irregularity index should be used along with Careys arch length analysis in routine orthodontic practice as Little Irregularity index considers the labio-lingual displacement of teeth, which may be found responsible for giving crowded appearance to the arch even though there is no space problem Keywords: Little Irregularity Index, Careys Archlength Analysis, Analysis of Merrifield Introduction Dental arrangement has a significant influence on the perceived beauty and success of the persons.1 Appearance of the teeth tops the rank order of the reasons for seeking orthodontic treatment. Also mal alignment was observed to be significant predictor of the parent report of the child being teased. Even mild forms of facial deviation, such as malocclusion, can predispose toward psychological distress and anxiety, which may increase the desire for orthodontic correction in either children or their parents. Perception of malocclusion found that adults were generally more aware of the arrangement of anterior occlusal traits than buccal segments. Amongst anterior occlusal traits in adults anterior crowding, rotations, and overjet were of major concern.2 Anterior dental crowding is perhaps the most frequently occurring characteristic of malocclusion. Patients, parents, the public and the profession are unquestionably aware of and concerned with dental crowding and seek its correction. Terms such as dental irregularity, overlap and crowding are subjective, nonquantitative terms which can represent a diversity of clinical meaning. Adjectives such as mild, moderate, severe, significant, etc. are descriptively helpful but still allow a wide range of interpretation. In the literature we find different methods suggested by various workers to assess the mandibular crowding by the methods derived by them. Therefore the present study was carried out using Careys Arch length Analysis, Little Irregularity Index 3 and Analysis of Merrifield. Aims and objectives 1. To assess the degree of severity of crowding as shown by three different methods in males and females. 2. To assess the correlation amongst the three different methods in males and females. 3. To assess the relationship between the severity of crowding and the anterior tooth material in males and females. 4. To assess the relationship between the severity of crowding and the premolar tooth material in males and females. To assess the relationship between the severity of crowding and the arch width in premolar and molar region in males and females. Materials & methods For the present study, 98 subjects (49 females, 49 males) having complaint of crowded and / or mal-alignment of anterior teeth were randomly selected. The criteria for selecting the subjects were as follows: 1. Each individual must have fully erupted permanent dentition up to second molar tooth. 2. No history of decayed tooth / restorations in deciduous dentition. 3. No supernumerary tooth / supplementary tooth / missing tooth / impacted tooth. 4. No restorations in permanent tooth. 5. No history of trauma to the dento-facial structures. 6. No history of previous orthodontic treatment. 7. The age of the patients ranged between 14-18 years. After selection of the patients on the basis of criteria cited above, upper and lower alginate impressions with maximum displacement of soft tissues, created by maximum extension of the impression were taken and poured with dental stone to prepare the study models. Each patients lower casts was then analyzed using Careys arch length analysis, Little irregularity index and Analysis of Merrifield for assessment of crowding in lower anterior region as described below: Careys Arch length Analysis: There are two steps in calculating the Careys arch length analysis. First on the study model, the mesio-distal dimensions of crowns of each of the ten teeth from second premolar of one side to the second premolar on the other side were measured with at least 0.1 mm accuracy with the help of a dial caliper. Summing up all the ten values gives us the total tooth material from premolar to premolar in the mandibular arch of a particular case. Then after, the space available in the mandibular arch for these ten teeth (Available arch length ) was measured on the study model, by adapting a malleable brass wire from mesial surface of first permanent molar on Address for Correspondence : Dr. Ronak Panchal Department of Orthodontics & Dentofacial Orthopaedics Faculty of Dental Science, Dharmsinh Desai University, Nadiad - 387 001. GUJARAT 9 5.
Lecturer Department of Orthodontics & Dentofacial Orthopaedics, Faculty of Dental Science, Dharmsinh Desai University, NADIAD - 387 001. GUJARAT
JOURNAL OF DENTAL SCIENCES
one side to the mesial surface of first permanent molar on the other side, shaped over the alveolar crest, then straightened and measured. The difference in these two parameters (Available arch length Total tooth material) was recorded as Careys arch length discrepancy which suggests the severity of crowding in that particular case. Each case was categorized into one of the following four groups as per the amount of discrepancy. Discrepancy = >0 = No crowding Discrepancy = 0.0 to -2.5 = Mild crowding Discrepancy = -2.5 to -5.0 = Moderate crowding Discrepancy = <-5.0 = Severe crowding Analysis of Merrifield: There are two steps in calculating the Analysis of Merrifield. First on the study model, the mesio-distal dimensions of crowns of each of the six teeth from permanent canine of one side to the permanent canine on the other side were measured with at least 0.1 mm accuracy with the help of a dial caliper. All the six values give us the total anterior tooth material from canine to canine in the mandibular arch of a particular case. Then after, the space available in the mandibular arch for these six anterior teeth (Available anterior arch length) was measured on the study model, by adapting a malleable brass wire from mesial surface of first premolar on one side to the mesial surface of first premolar on the other side, shaped over the alveolar crest, then straightened and measured. The difference in these two parameters (Available anterior arch length Total anterior tooth material) was recorded as discrepancy in the anterior region as per Analysis of Merrifield, which suggests the severity of crowding in that particular case. Each case was categorized into one of the following four groups as per the amount of discrepancy. Discrepancy in anterior region = >0 = No crowding Discrepancy in anterior region = 0 to -2 = Mild crowding Discrepancy in anterior region = -2 to -4 = Moderate crowding Discrepancy in anterior region = -4 to -6 = Severe crowding Little Irregularity Index: It is done by measuring the linear displacement of the anatomic contact points (as distinguished from the clinical contact points) of each mandibular incisor from the adjacent tooth anatomic point on the study model with the help of a dial caliper calibrated to at least tenths of a millimeter. This gives in total five reading and the sum of these five displacements represents the relative degree of anterior irregularity. Care should be taken that the caliper is held parallel to the occlusal plane while the beaks are lined up with the contact points to be measured to ensure that the displacement only in the horizontal direction is recorded. After five measurements are obtained total of all measurements is done. Perfect alignment from the mesial aspect of left canine to mesial aspect of the right canine would have a score of 0, with the increased crowding represented by greater displacement and, therefore a higher score. The severity of crowding is graded into five categories as follow: 0 - No crowding
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1 - 3 Mild crowding 4 - 6 - Moderate crowding >7 - Severe crowding It is also known that not only the size of the arch but the form (shape) of the arch also influences the proper alignment of the teeth in the arch. Any variation in the arch form (narrowing / widening) is known to influence the teeth positioning and proper alignment. Hence to estimate the discrepancy in the mandibular arch width at the molar and pre-molar region, to obtain the measurement of actual arch dimensions and required arch dimensions, Ponts index were used. To estimate the ideal or required arch width at these levels Ponts formula with Tomes correction was used as shown in the equations below: Ideal Pre-molar width = [(sum of max. incisors)] X 100/80 (Ponts Formula) That is = [(sum of mandibular incisors X 4/3) + 0.5] X 100/80 (Tomes correction) Ideal Molar width = [(sum of max. incisors)] X 100/64 (Ponts Formula) That is = [(sum of mandibular incisors X 4/3) + 0.5] X 100/64 (Tomes correction) From the values of the estimated arch width and the actual arch width the discrepancy in the molar and premolar region in the arch width as per Ponts is recorded for each subject in both males and females. Thus as shown above, the degree / severity of crowding of each case was assessed by the three different methods for all 49 females and 49 males. The attempt was made to understand the pattern of distribution of the sample into the various categories by the different methods in both the males and females. Also the three different methods were correlated with one another. An attempt was also made to find out the relationship between the severity of crowding and the size of anterior teeth and premolars in males and females. Also the relationship between the severity of crowding and arch form was estimated in males and females. Discussion Methods used for assessment of crowding can be categorized in to subjective and objective / quantitative methods. The former methods were having problems of intra examiner and inter examiner variability; the later methods are more accurate and efficient for the assessment of crowding. It is important to quantitatively determine the severity of anterior dental crowding as it influences the treatment planning and the post treatment stability. In the past very few had tried to compare the effectiveness and accuracy of different methods in the assessment of such condition. Here the three methods which are used to categorize the severity of crowding are based on different fundamental principles. The Careys arch length analysis tries to assess the relationship between the mesio distal size of the mandibular teeth including premolars and the available space in the arch for their placement. Thus, this gives more stress on the mesio distal anomalies between the teeth size and jaw proportion. This may also get influenced by the width of the arches. The 10
JOURNAL OF DENTAL SCIENCES
Analysis of Merrifield is also assesses the similar relationship but only include the canine to canine segment of the arch. In both these methods the labiolingual displacement of the teeth which also gives and exaggerates the crowded appearance of the arches was not taken in to consideration. On the other hand the Little Irregularity Index assesses labiolingual displacement of the teeth which are responsible for giving crowded appearance to the arch. Due to this basic difference in the above three modes of assessment we find variation in the numbers of distribution into different categories. Comparing above findings between males and females it was found that in both of them highest correlation was found between Analysis of Merrifield and Little Irregularity Index (One considering the mesio distal dimension of the anterior teeth, correlating it with the available space in the arch and the other considering labiolingual displacement of the teeth in addition to the mesio distal displacement irrespective of the relationship to the size of the teeth and available basal space). As regards to minimum correlation (though significant) was found between Careys Arch length analysis and Analysis of Merrifield in females, while between Careys arch length analysis and Little Irregularity Index in males. Greater tooth dimension and excessive narrowing of the arches in both premolar and molar regions are responsible for increase in the severity of crowding in females. While in males, only significant increases in the dimension of the teeth are main responsible factor to increase the level of crowding. That greater tooth dimension and excessive narrowing of the arches in both premolar and molar regions are responsible for increase in the severity of crowding in females. While in males, no significant difference in the dimension of the teeth was recorded while a highly significant difference was found for the parameter, narrowing of arch width in premolar and molar region dimension and excessive narrowing of the arches in both premolar and molar regions are responsible for increase in the severity of crowding in both males and females. Conclusions 1. Significant correlation was found amongst all the three methods to categorize the level of crowding into four different stages of severity of malocclusion which suggest that all the three methods are good enough to differentiate the non crowded case from the crowded case and can be of clinical use in orthodontic practice. 2. The highest correlation value was found between Analysis of Merrifield and Little Irregularity index in both males and females. 3. Though significant the minimum value for correlation coefficient was between Careys arch length analysis and Analysis of Merrifield in females, and between Careys arch length analysis and Little Irregularity index in males. 4. The greater percentages of cases were characterized as non crowded by Analysis of Merrifield while it was not so for the Careys arch length analysis and Little Irregularity Index. This is because Analysis of Merrifield is restricted to the discrepancy between the anterior tooth M material and the available basal arch for these six teeth. It does
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not include the conditions in the premolar region nor does it consider the labio lingual displacement of the anterior teeth. 5. On comparing non crowded and severely crowded category in males and females as per Careys arch length analysis it was found that greater tooth dimension and excessive narrowing of the arches in both premolar and molar regions are responsible for increase in the severity of crowding in females. While in males, only significant increase in the dimension of the teeth is main responsible factor to increase the level of crowding. 6. On comparing non crowded and severely crowded category in males and females as per Analysis of Merrifield it was found that greater tooth dimension and excessive narrowing of the arches in both premolar and molar regions are responsible for increase in the severity of crowding in both males and females. 7. On comparing non crowded and severely crowded category in males and females as per Little Irregularity Index it was found that greater tooth dimension and excessive narrowing of the arches in both premolar and molar regions are responsible for increase in the severity of crowding in females. While in males, only narrowing of arch width in premolar and molar region was found main responsible factor to increase the level of crowding. 8. By statistically comparing differences of mean between values males and females sample it was found that males have over all greater severity of crowding as compared to females as per Little Irregularity index. 9. On comparing the values for the anterior tooth material, premolar tooth material and narrowing of arch width in premolar and molar region for all the females and all the males samples it was found that males have larger tooth size as compared to females. Thus, from the above finding it is concluded that Little Irregularity index should be used along with Careys arch length analysis in routine orthodontic practice as Little Irregularity index considers the labio lingual displacement of teeth, which may be found responsible for giving crowded appearance to the arch even though there is no space problem. References 1. Kerosuo H, Hausen H, Laine T, Shaw WC. : The influence of incisal malocclusion on the social attractiveness of young adults in Finland. Eur J Orthod. 1995 Dec;17(6):505-12. 2. Pauli V.J. et al : Anterior tooth position and motivation for early treatment. The Angle Orthodontist: Vol. 63, No. 3, pp. 171174 3. Little : The Irregularity Index: A quantitative score of mandibular anterior alignment. Am J Orthod, Nov. 1975; 68(5): 554-63
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