You are on page 1of 4

Frequency of Bolton tooth-size discrepancies among

orthodontic patients
John E. Freeman, DDS, a A. J. Maskeroni, DDS, b and Lewis Lorton, DDS, MSD c

Fort George G. Meade, Md.


The purpose of this study was to determine the percentage of orthodontic patients who present
with an interarch tooth-size discrepancy likely to affect treatment planning or results. The Bolton
tooth-size discrepancies of 157 patients accepted for treatment in an orthodontic residency program
were evaluated for the frequency and the magnitude of deviation from Bolton's mean.
Discrepancies outside of 2 SD were considered as potentially significant with regard to treatment
planning and treatment results. Although the mean of the sample was nearly identical to that of
Bolton's, the range and standard deviation varied considerably with a large percentage of the
orthodontic patients having discrepancies outside of Bolton's 2 SD. With such a high frequency of
significant discrepancies it would seem prudent to routinely perform a tooth-size analysis and
incorporate the findings into orthodontic treatment planning. (Am J Orthod Dentofac Orthop
1996;110:24-7.)

O n e of the goals in comprehensive orthodontic treatment is to obtain an optimal final occlusion, overbite, and overjet. There are many factors that will influence the attainability of this goal,
one of which is the relationship of the total mesiodistal width of the maxillary teeth to that of the
mandibular teeth. A significant variation in this
relationship should be compensated for in the
treatment planning by considering esthetic bonding, prosthetic recontouring, stripping of enamel,
extraction, leaving spaces, or changing the desired
anterior overjet or overbite. The alternative to not
doing any of these may result in compromising the
occlusion in the buccal segments, an undesirable
result.
There has long been an understanding that a
certain maxillary-to-mandibular tooth size relationship was important for proper occlusal relationships. Over the years many investigators have attempted to quantify this relationship. In 1923 Gilpatric calculated that the total mesiodistal tooth
diameters in the maxillary arch exceeded that in
the mandibular arch by 8 to 12 ram. a Ballard, in
1944, evaluated 500 sets of models of orthodontic
patients and found that 90% possessed mesiodistal
From the U.S. Army Orthodontic Residency Program, Fort Meade, Md.
The views expressed in this article are those of the authors and do not
reflect the official policy of the Department of Defense or other Departments of the United States Government.
aLieutenant Commander, Dental Corps, United States Navy; Senior
Resident.
bCommander, Dental Corps, United States Navy; Clinical Instructor.
CConsultant, Statistics and Research Design.
Reprint requests to: Dr. John E. Freeman, Dental Department, U.S.
Naval Hospital, Great Lakes, IL 60088.
8/1/58926

24

crown discrepancies of at least 0.25 mm between


one or more pairs of teeth from opposite sides of
the arch, whereas 80% revealed discrepancies of at
least 0.5 mm. 2 In 1949, Neff developed the "anterior coefficient,''3 a method to compare the widths
of the anterior teeth in opposing arches. Neff
concluded, "that everything else being normal an
orthodontic or nonorthodontic normal will settle to
the degree of overbite indicated by the anterior
coefficient.''3 Ballard reported in 1956 that, in a
study of 400 orthodontic cases, over 50% revealed
an excess of at least 2 mm of mesiodistal tooth
width in the mandibular anterior segment when
compared to the maxillary anterior teeth. 4
Bolton's introduction of his analysis in 1958
included comparisons of total mesiodistal widths of
dental arches up to the distal surfaces of the first
molars, as well as segments of the arches. 5 Bolton
evaluated 55 cases with "excellent" occlusions; 44
had been treated orthodontically without extractions and 11 were untreated. The following ratios
were established by Bolton:
Overall ratio =

Sum mandibular "12"


100
Sum maxillary "12"

Anterior ratio =

Sum mandibular "6"


x 100
Sum maxillary "6"

The overall ratio was calculated from the greatest


mesiodistal measurements of the teeth in each arch
from first molar to first molar. The anterior ratio
was calculated from the greatest mesiodistal measurements of the six anterior teeth in each arch.
The results of Bolton's study are summarized in
Tables I and II. From Bolton's results it can be

American Journal of Orthodontics and Dentofacial Orthopedics


Volume 110,No. 1

Freeman, Maskeroni, and Lorton

25

Table I. Statistical comparison Bolton study versus Fort Meade study. Overall "12" ratio

Sample size
Mean
Median
Range
Standard deviation
Standard error of mean
Coefficient of variation

Bolton

Fort Meade

55
91.3
Not available
87.5-94.8
1.91
0.26
2.09%

157
91.4
91.3
82.8-99.4
2.57
0.21
2.81%

Table II, Statistical comparison Bolton study versus Fort Meade study. Anterior "6" ratio

Sample size
Mean
Median
Range
Standard deviation
Standard error of mean
Coefficient of variation

seen that there is a relatively small range in which


t o o t h size ratios should fall to be able to achieve
optimal occlusal relationships, stirrer evaluated
Bolton's study and arrived at similar results. 6
Crosby and A l e x a n d e r f o u n d a large n u m b e r of
o r t h o d o n t i c patients p r e s e n t e d with a significant
B o l t o n tooth-size discrepancy. 7
T h e p u r p o s e o f this study was to evaluate the
p e r c e n t a g e of patients w h o p r e s e n t e d with a significant tooth-size discrepancy at the U.S. A r m y
O r t h o d o n t i c Residency P r o g r a m at F o r t G e o r g e G.
Meade, Md. A significant discrepancy was defined
as o n e whose value was outside of 2 SD from
Bolton's mean, 7' 8 as approximately 95% o f Bolton's
cases w e r e within this range. F o r the overall "12"
ratio, a significant discrepancy is therefore defined
as a ratio below 87.5 or above 95.1, with ratios
in-between falling within 2 SD of Bolton's mean.
Likewise, any ratio below 73.9 or above 80.5 is
considered to be a significant discrepancy for the
anterior " 6 " ratio.
MATERIALS AND METHODS

The data for this study were obtained from records


taken at the Ft. Meade Residency Program, where a
Bolton tooth-size analysis is performed routinely on all
patients accepted into the program. Only records of
those patients with permanent dentitions were considered for evaluation to eliminate errors that may be
incorporated from the prediction of sizes of unerupted
teeth. Those with any significant attrition or those missing any permanent teeth other than second or third
molars were not considered. A total of 459 records were
evaluated at random, and 157 met the established criteria
and were used for this study.

Bolton

Fort Meade

55
77.2
Not available
74.5-80.4
1.65
0.22
2.14%

157
77.8
77.9
68.4-87.9
3.07
0.25
3.95%

The 157 records all contained a Bolton tooth-size


analysis previously completed by a Fort Meade resident.
The analyses had been completed by 24 different residents. The sample consisted of 89 female and 68 male
patients. There were 115 white patients, 27 black patients, and 15 patients of other ethnic origins.
The Bolton tooth-size analysis performed at Fort
Meade consists of two parts as described in Bolton's
publication. 5 The first part is the individual mesiodistal
measurements of all teeth from the first molars mesially.
Tooth-size measurements were typically taken with
sharp-pointed Boley gauges, measuring the widest mesiodistal dimension of each tooth as described by Bolton.
The second part is the calculation of arch length comparisons and determination of tooth-size discrepancy
according to the method outlined by BoRon? This discrepancy includes a comparison of the overall arches (up
through first molars) and also a comparison of the
anterior segments.
The data collected from the records were evaluated
to determine the percentage of patients who had toothsize discrepancies which were within one, within two, or
greater t h a n two standard deviations from Bolton's
mean. A mean, median, range, standard deviation, standard error of the mean, and coefficient of variation were
calculated for both the overall "12" ratio and anterior
"6" ratio. The normality of the variables was investigated
by calculating the skewness and kurtosis of the variables.
In addition, a Pearson's correlation between the variables was performed.
RESULTS

T h e m e a n overall "12" ratio for the o r t h o d o n t i c


patients was f o u n d to be 91.4 (Table I), with a
s t a n d a r d deviation of 2.57. T h e values r a n g e d f r o m

26

Freeman, Maskeroni, and Lorton

American Journal of Orthodontics and Dentofacial Orthopedics


July 1996

FORT MEADE ORTHODONTICCASES


No, of Cases
50
40

20
19

~!~ l

< 87.5

87.5-89.3 89.4-91.2

91.3

91.4-93.2 93.3-95.1

> 95.1

OVERALL "12" RATIO


91.3 = Bolton's mean.
89.4-91.2 and 91.4-93.2 are within 1 standard deviation.
87.5.89.3 and 93.3-95.1 are outside 1 standard deviation, but within 2
standard deviations.
< 87.5 and > 95.1 are outside 2 standard deviations.

Fig. 1. Fort Meade orthodontic cases. Overall " 1 2 " ratio: 91.3 = Bolton's mean. 89.4 to 91.2 and
91.4 to 93,2 are within 1 SD. 87.5 to 89.3 and 93.3 to 95.1 are outside 1 SD, but with 2 SD. <87. 5
and >95.1 are outside 2 SD.

FORT MEADE ORTHODONTICCASES


No. of Cases

< 73.9

73.9-75.4

75.5-77.1

7;~.2

77.3-78.8 78.9-80.5

>

80.5

ANTERIOR "6" RATIO


7z2 = Bolton's mean.
75.5-7Z 1 and 7Z3-78.8 are within I standard deviation.
73.9.75.4 and 78.9-80.5 are outside I standard deviation, but within 2
standard deviations.
< 73.9 and > 80.5 are outside 2 standard deviations.

Fig. 2. Fort Meade orthodontic cases. Anterior " 6 " ratio: 77.2 = Bolton's mean. 75.5 to 77.1 and
77.3 to 78.8 are within 1 SD. 73.9 to 75.4 and 78.9 to 80.5 are outside 1 SD, but within 2 SD. < 73.9
and >80.5 are outside 2 SD.and >95.1 are outside 2 SD.

a low of 82.8 to a high of 99.4, and the median was


91.3. The standard error of the mean was 0.21 and
the coefficient of variation was 2.81%. Of the 157
cases, 21 (13.4%) had overall "12" ratios outside of
2 SD from Bolton's mean (Fig. 1).
The mean anterior "6" ratio for the orthodontic
patients was found to be 77.8 (Table II), with a
standard deviation of 3.07. The values ranged from
68.4 to 87.9, and the median was 77.9. The standard
error of the mean was 0.25 and the coefficient of
variation was 3.95%. Forty-eight (30.6%) cases had
anterior "6" ratios that fell outside of 2 SD from
Bolton's mean value (see Fig. 2).
The correlations were high and statistically significant but there is the indication that the overall

"12" ratio and anterior "6" ratio would not predict


the other consistently. Both graphing the data and
measuring the skewness and kurtosis indicated that
the data sets were not normally distributed and
thus the use of 2 SD units to indicate the "normal"
range is not appropriate.
DISCUSSION

Although the means of the orthodontic patients


in this study and those of the Bolton study are
nearly identical, the ranges and standard deviations
of the orthodontic patients are significantly larger.
Similar findings were found by Crosby and Alexander in evaluating orthodontic patients in a civilian practice? If those cases with ratios greater than

Freeman, Maskeroni, and Lorton 27

American Journal of Orthodontics and Dentofacial Orthopedics


Volume 110, No. 1

2 SD away from Bolton's means truly represent a


significant discrepancy, then a large percentage of
orthodontic patients present with relative tooth
sizes that could potentially cause problems in attaining an optimal occlusal relationship. While
13.5% of the orthodontic cases presented with a
significant discrepancy of the overall "12" ratio,
30.6% presented with a significant anterior "6"
discrepancy. The overall discrepancy was equally
likely to be a n excess in the maxilla or the mandible, whereas the anterior discrepancy was nearly
twice as likely to be a mandibular excess (19.7%)
than a maxillary excess (10.8%).
A possible source of error may be introduced by
using the m e a s u r e m e n t s found by 24 different examiners. O f the 157 records used in this study the
most from any single examiner was 15, thus the
impact from erroneous data from any one person
would be minimal. It was not feasible to test
individual error as the examiners are now at various locations around the world. A n alternative
option in this study would have been for one person
to do all of the measurements, then if there was any
consistent error, it would have b e e n demonstrated
throughout the data.
CONCLUSIONS

These findings suggest that a large number of patients presenting for orthodontic treatment possess a
Bolton tooth-size discrepancy that may influence treatment goals and results. This study found 30.6% of
orthodontic patients to have a significant anterior toothsize discrepancy compared with the 22.9% found by
Crosby and Alexander. 7 Perhaps the difference may be
explained by the patient selection process in a military

residency program versus a private practice. Because of


limited resources, patients in military orthodontic programs are typically those with the more severe malocclusions, even though those refused treatment could very
often derive benefits if they were to be treated. It is also
possible that the population of patients may be more
diverse in the military practice with regard to race and
ethnic background. Thus, it would seem logical that the
percentage of patients with significant discrepancies may
be somewhat dependent on the selection process or the
characteristics of the population from which the patients
are drawn.
As a result of our findings, it would seem prudent for
clinicians to routinely include a tooth-size analysis in
their initial case workup. Identifying such a discrepancy
before final tooth alignment would prove beneficial in
both treatment planning and final expectations of both
the clinician and the patient. Although such an analysis
may appear to be time-consuming, the benefits would
seem to outweigh this minor inconvenience by allowing
more efficient diagnosis of problems, more specificity in
treatment planning, and a higher success rate in achieving optimal occlusions, overbite, and overjet.
REFERENCES
1. Gilpatric WH. Arch predetermination-is it practical? J Am Dent Assoc, July,
I923:553-72.
2. Ballard ML. Asymmetry in tooth size: a factor in the etiology, diagnosis and
treatment of malocclusion. Angle Orthod 1944;14:67-71.
3. Neff CW. Tailored occlusion with the anterior coefficient. Am J Orthod 1949;35:
309-13.
4. Baltard ML. A fifth column within normal dental occlusions. Am J Orthod
1956;42:116-24.
5. Bolton WA. Disharmony in tooth size and its relation to the analysis and treatment
of malocclusion. Am J Orthod 1958;28:113-30.
6. Stifter J. A study of Pont's, Howes', Rees', Nefffs and Bolton's analyses on class I
adult dentitions. Angle Orthod 1958;28:215-25.
7. Crosby DA, Alexander CG. The occurrence of tooth size discrepancies among
different malocclusion groups. Am J Orthod Dentofac Orthop 1989;95:457-61.
8. Thurow RC. Atlas of orthodontic principles. 2nd ed. St Louis: CV Mosby,
1977:373-5.