1/4/2019 A CBCT evaluation of root position in bone, long axis inclination and relationship to the WALA Ridge- ClinicalKey

ARTÍCULO

A CBCT evaluation of root position in bone, long axis inclination

and relationship to the WALA Ridge
Timothy R. Glass, Timothy Tremont, Chris A. Martin y Peter W. Ngan
Seminars in Orthodontics, 2019-03-01, Volumen 25, Número 1, Páginas 24-35, Copyright © 2019

Abstract
Correct tooth position in all planes of space while respecting the boundaries of the underlying bone is important
for stability of teeth after orthodontic treatment as well as the health of the supporting periodontium. 1 2 The aim
of this study was to determine: 1) if mandibular posterior teeth are more centered over basal bone when they are
more upright or close to WALA Ridge norms proposed by Andrews 3 ; 2) if mandibular posterior teeth are more
centered in alveolar bone when they are more upright or close to the WALA Ridge norms; 3) if the estimated
center of resistance mandibular posterior teeth is most often centered in alveolar bone; and 4) if the WALA Ridge
is located at or near the estimated center of resistance of mandibular posterior teeth. A sample of 34 pre-
treatment CBCT scans and mandibular casts of patients ages 12–18 were included in the study. CBCT scans were
digitized and analyzed using the Carestream 3D Imaging Software Version 3.5.7. Casts were digitally scanned
using the Ortho Insight 3D scanner. The WALA Ridge horizontal measurements were made using the Six
Elements™ software (MotionView, Chattanooga, TN). The WALA Ridge vertical measurements were obtained
from the casts using a digital caliper. Coronal CBCT images were used to measure tooth positions of pre-
treatment mandibular posterior teeth relative to surrounding bone. Centeredness of teeth within the bone was
quantified and compared to their inclination and to the WALA Ridge location: D1, D2, D3 and D4. Data were
analyzed using the JMP version 10 SAS Software. Descriptive statistics were used to calculate the mean, standard
deviation, minimum, and maximum values for the distance between WALA Ridge vertical and CR, D2, D3 and D4
for each of the posterior teeth. Single linear regression analysis was performed to evaluate the relationship
between both the long axis inclination and WALA Ridge variables compared to the D1, D2, D3, variables. No
statistical significance was found for centeredness of mandibular posterior teeth over basal bone when they were
more upright or approached WALA Ridge norms. No statistical significance was found for centeredness of
mandibular posterior teeth in alveolar bone when they were more upright or approached the WALA Ridge norms.
Significant differences were found for the mandibular posterior teeth center of resistance being centered in the
alveolar bone regardless of the long axis inclination or WALA Ridge norms (p-value <0.05). Significant
differences were also found for the Wala Ridge being located at or near the center of resistance of mandibular
posterior teeth (p-value <0.05). 1) More upright mandibular posterior teeth based on long axis inclination or
mandibular posterior teeth more closely related to the WALA Ridge landmark are not more centered over basal
bone. 2) More upright mandibular posterior teeth based on long axis inclination or teeth more closely related to
the WALA Ridge landmark are not more centered in alveolar bone. 3) The center of resistance of all mandibular
posterior teeth can most often be found in the center of the alveolar bone regardless of inclination. 4) The WALA
Ridge is located at or near the center of resistance for all mandibular posterior teeth. 5) The WALA Ridge may be
a useful landmark for customizing mandibular arch form if teeth are tipped to an upright position.

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Introduction
Correct tooth position in all planes of space while respecting the boundaries of the underlying bone is important
for stability of teeth after orthodontic treatment as well as the health of the supporting periodontium. 1 2 Despite
all the research over many decades, clinicians are still divided, leading to debate on extraction versus non-
extraction. 3 It is generally believed that when tooth mass is too small relative to basal bone, interdental spacing
or diastemas will likely occur. Conversely, if the basal bone in the body of the mandible is too small relative to
tooth mass, teeth will be crowded. To this point, successful alignment of the teeth, among other factors, is
dependent on the size of the basal bone in relation to the tooth mass. 4 Does this mean that teeth should be
centered over basal bone?

The term “basal bone” has been used loosely for decades to describe the bone over which teeth should be
positioned to obtain stability for both function and health. According to several authors, basal bone is the bone
that underlies, supports, and is continuous with the alveolar process. 5 The term “apical base” was first
introduced by Lundstrom in 1923 but failed to stimulate a sufficient response until Tweed presented the concept
again in 1944 as “basal bone”. 6 Tweed defined basal bone as the bony ridge over which the mandibular central
incisors must be situated to produce permanence of orthodontic results. The focus of Tweed's research was to
find the most stable lower incisor position relative to the underlying basal bone to prevent post orthodontic
relapse.

Lundstrom (1925) theorized that the apical base did not change to fit the normal occlusion but rather the
establishment of normal occlusion was controlled by the apical base. 7 In contrast Damon 8 (2005) suggested
that the use of light continuous orthodontic force could be used in crowded cases to expand the alveolar bone and
maintain its integrity. Previous studies including Howes 9 (1947) and Downs 10 (1948) have attempted to locate
basal bone with little consensus. Not surprisingly, confusion still exists among clinicians and researchers as to the
location of basal bone and its true relevance to stable clinical orthodontic treatment.

The Six Elements of Orofacial Harmony™ developed by Andrews presents a set of parameters and guidelines to
aid in obtaining optimal goals for the teeth, arches, and jaws. 11 Element I states that an optimal arch exists when
teeth are centered over basal bone and the clinical crowns are optimally inclined so that the occlusal surfaces can
interface and function ideally with the teeth in the opposing arch. 12 Andrews proposed using the WALA Ridge
to serve as a landmark for assessing mandibular arch form (size and shape) which in turn can provide a template
for the maxillary arch form. The WALA Ridge is a band of soft tissue immediately coronal to the mucogingival
junction of the mandible and suggested to be at or near the level of the center of resistance of the teeth ( Fig.1
(fig0001) ). 12 This landmark aids the clinician in establishing the correct arch form leading to the most ideal
tooth position in the mandible relative to the basal bone. 12

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Figure1
Schematic depicting WALA Ridge, FA Point, Center of Resistance, and Basal Bone.

The objectives of this study were to investigate 1) if mandibular posterior teeth are more centered over basal bone
when they are more upright or close to the WALA Ridge norms; 2) if mandibular posterior teeth are more
centered in alveolar bone when they are more upright or close to the WALA Ridge norms; 3) if the estimated
center of resistance of mandibular posterior teeth is most often centered in alveolar bone; and 4) if the WALA
Ridge is located at or near the estimated center of resistance of mandibular molar and premolar teeth.

Methods and materials

IRB exemption was obtained from the West Virginia University Institutional Review Board prior to the start of
this study (#1506708605). Pre-treatment orthodontic records including CBCT scans and mandibular casts were
obtained from the orthodontic practice of Dr. CR. The inclusion criteria include patients 12–18years of age in the
permanent dentition with no previous orthodontic treatment, who had a pretreatment cone beam computed
tomography scan, and a mandibular study cast taken prior to orthodontic treatment. The exclusion criteria
included presence of any craniofacial anomalies; absence of mandibular first and second molars; absence of
mandibular first and second premolars; abnormal root morphology; and any previous orthodontic treatment.

The CBCT scans were digitized and analyzed using the Carestream 3D Imaging Software Version 3.5.7.
Mandibular casts were digitally scanned using the Ortho Insight 3D scanner (MotionView Software, Chattanooga,
TN). The WALA Ridge horizontal was measured using the Six Elements of Orofacial Harmony™ software
(MotionView Software, Chattanooga, TN). Coronal CBCT images were used to measure tooth positions of pre-
treatment molars and premolars.

WALA ridge vertical measurements

The WALA Ridge landmark according to Andrews was identified on each cast and marked with red pencil ( Fig.2
(fig0002) ). A stainless steel endodontic ruler (Miltex by Integra, Patterson Company, Saint Paul, MN) was then
laid across the occlusal surface of each second molar (M2), first molar (M1), second premolar (P2), and first
premolar (P1) and its contralateral counterpart ( Fig.3 (fig0003) ). A digital caliper was used to measure the
distance in millimeters from the top surface of the ruler to the WALA Ridge on each tooth ( Fig.4 (fig0004) ). To
account for the ruler thickness, 0.5 mm was subtracted from each measurement.

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Figure2
WALA Ridge was identified on a cast with a red pencil. (For interpretation of the references to colour in this figure legend, the
reader is referred to the web version of this article.)

Figure3
A stainless steel endodontic ruler was laid across the occlusal surface of each posterior tooth for vertical measurements from the
ruler to the WALA Ridge.

Figure4
Digital caliper was used to measure the distance from the ruler to the WALA Ridge or WALA Ridge vertical (WV).

WALA ridge horizontal measurements

The WALA Ridge horizontal was measured using the Six Elements™ software ( Fig.5 (fig0005) ). The digital models
were calibrated, and landmarks were identified according to the software specifications. WALA Ridge horizontal
measurements (WH) of the second molars (M2), first molars (M1), second premolars (P2), and first premolars
(P1) were obtained. Once the measurements were made, each of the values were subtracted from the norms
proposed by Andrews ( Table1 (tbl0001) ). 3 This new value, DWALA, represents the difference between the actual
values and the norm (DWALA = WALA Ridge horizontal measurement – norm value).

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Figure5
WALA Ridge using the 6 Elements software.
Table1
WALA ridge horizontal norms per Andrews 3

Tooth Type WALA Horizontal Norms (mm)

First Premolar 0.8

Second Premolar 1.3

First Molar 2.0

Second Molar 2.2

Measurements from CBCT scans

All CBCT DICOM files were de-identified and downloaded onto the Carestream 3D Imaging Software Version
3.5.7 for data collection. Table2 (tbl0002) shows the data points and reference line descriptions. Table3 (tbl0003)
shows the CBCT variables included in the study. The following measurements were made for each of the posterior
teeth including the second molar (M2), first molar (M1), second premolar (P2) and first premolars (P1).

Table2
Data points & reference lines

Points Description

ROP Reference Occlusal Plane

CR Center of Resistance

ABC2 Alveolar Bone Center at level of Center of Resistance Location

ABC1 Alveolar Bone Center at level of Apex Location

APA Apex Point Alveolar Bone

APB Apex Point Basal Bone

BBC Basal Bone Center

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Points Description

IBB Most Inferior Basal Bone Border

LAI Tooth Long Axis Inclination (degrees)

WV WALA Vertical

WH WALA Horizontal

Table3
CBCT variables

Variable Definition

D1 Distance from ABC2 to CR

D2 Distance from ABC1 to APA

D3 Distance from BBC to APB

D4 Distance from WALA Vertical to CR

LAI Angle measurement of tooth long axis at ROP

Long axis inclination (LAI) of posterior teeth

Relative to the Reference Occlusal Plane, the long axis inclination (LAI) of each of the mandibular posterior teeth
was measured from the long axis of the clinical crown., ( Fig.6 (fig0006) ).

Figure6
Measurement of LAI with reference to ROP.

Measurement of WALA ridge vertical (WV) to center of resistance (CR)

The center of resistance (CR) of each of the posterior teeth was first measured first from the sagittal view. The CR
of molars were measured from the top of the clinical crown to the furcation area ( Fig.7 (fig0007) ). The CR of
premolars were measured from the top of the clinical crown to 1/3 of the distance from the alveolar crest to the
apex. The CR and WALA vertical measurements were then transferred to the coronal view ( Fig.8 (fig0008) ). The
distance between CR and WALA vertical was then measured and designated as D4 .
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Figure7
Measuring center of resistance in the sagittal view.

Figure8
Schematic demonstrating data points and reference lines. See Table 2 (tbl0002) for descriptions of points and lines.

Measurement of center of alveolar bone to center of resistance

Alveolar bone measurements were measured at the center of resistance point (CR) and the apex point alveolar
(APA) for each of the posterior teeth. The buccal lingual distance from the alveolar bone internal cortex was
measured at CR and APA. These values were divided in half to approximate the center of the alveolar bone at
these two locations represented by ABC1 and ABC2, respectively. The distance of CR and APA to the alveolar
center point was designated as D1 and D2 respectively ( Fig.9 (fig0009) ).

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Figure9
Alveolar bone measurements in the coronal view.

Measurement of center of basal bone (BBC) to apex of basal bone (APB)

Basal bone measurements were measured at the basal bone center point (BBC) which was located vertically by
taking half the distance from the tooth apex to the most inferior basal bone border (IBB). Once this vertical
position was identified, the buccal lingual distance from the basal bone internal cortex was measured. This value
was divided in half to approximate the center of the basal bone (BBC). The apex point basal bone (APB) was then
constructed with a line from the tooth apex perpendicular to the ROP to identify the apex location relative to the
basal bone. The distance between BBC to APB was measured and designated as D3 ( Fig.10 (fig0010) ).

Figure10
Basal bone measurements in the coronal view.

Data analysis
Data were analyzed using the JMP version 10 SAS Software. Descriptive statistics were performed to calculate the
mean, standard deviation, minimum, and maximum for the distance between WALA vertical and CR, D2, D3 and
D4 for each of the posterior teeth. Single linear regression analysis was performed to evaluate the relationship

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between both the long axis inclination and WALA Ridge variables compared to D1, D2, and D3, variables.

Results
Descriptive statistics
Descriptive statistics were used to determine the mean, standard deviation, minimum and maximum a p-values
for each of the variables ( Tables 4 (tbl0004) & 5 (tbl0005) ). Table 4 (tbl0004) shows that using a one-sample t-test
there was statistical significance (p-value < .05) for all four variables (P1-D4), (P2-D4), (M1-D4), and (M2-D4).
Table 5 (tbl0005) summarizes the variables assessing the centeredness of the center of resistance to alveolar bone
(D1), the apex point to alveolar bone (D2), and the apex point to basal bone (D3). The results show statistical
significance (p-value < .05) for all points except (P1-D3), (P2-D2), and (M1-D2). Although most variables were
small numbers several were relatively larger either in mean or standard deviation (P1-D3), (P2-D3), M1-D3),
(M2-D3).

Table4
Distance between WALA vertical and center of resistance (D4) for posterior teeth

Variable Mean Std dev Std Err Mean Upper 95% Mean Lower 95% Mean P-value

P1-D4 1.25 0.811 0.139 1.533 0.966 <0.0001

P2-D4 1.68 0.753 0.129 1.948 1.422 <0.0001

M1-D4 0.86 0.646 0.11 1.09 0.639 0.0024

M2-D4 1.56 0.818 0.14 1.846 1.275 <0.0001

Table5
Distance from ABC2 to CR (D1), distance from ABC1 to APA (D2) and distance from BBC to APB (D3) for posterior teeth

Variable Mean Std dev Std Err Mean Upper 95% Mean Lower 95% Mean P-value

P1-D1 0.511 0.545 0.093 0.702 0.321 <0.001 * (tb5fn1)

P1-D2 0.838 1.601 0.274 1.397 0.279 0.0045 * (tb5fn1)

P1-D3 0.305 2.734 0.468 1.259 −0.648 0.5187

P2-D1 0.411 0.664 0.113 0.643 0.18 0.001 * (tb5fn1)

P2-D2 −0.105 1.521 0.26 0.425 −0.636 0.6875

P2-D3 −1.423 1.985 0.3405 −0.73 −2.116 0.0002 * (tb5fn1)

M1-D1 0.2147 0.4936 0.0846 0.3869 0.0424 0.0161 * (tb5fn1)

M1-D2 −0.294 1.94 0.332 0.382 −0.971 0.383

M1-D3 −1.997 2.02 0.347 −1.29 −2.7 <0.0001 * (tb5fn1)

M2-D1 −0.638 0.993 0.17 −0.291 −0.984 0.0007 * (tb5fn1)

M2-D2 −1.626 1.574 0.2699 −1.0771 −2.175 <0.0001 * (tb5fn1)

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Variable Mean Std dev Std Err Mean Upper 95% Mean Lower 95% Mean P-value

M2-D3 −3.35 1.88 0.324 −2.69 −4.01 <0.0001 * (tb5fn1)

= p < .05.

Single linear regression analysis

Tables 6–12 (tbl0006) show the correlation between the long axis inclination and the variables D1, D2, and D3 using
single linear regression analysis. Correlation was also performed between WALA Ridge variables and the
variables D1, D2, and D3. At the level of the center of resistance (D1) there was only correlation at the second
molar (M2) with a p-value of 0.036. The apex points alveolar (D2) showed correlation at the first premolar (P1)
with a p-value of 0.0049, however no other teeth at this level in the bone showed correlation with statistical
significance. At the level of the basal bone (D3) there was again correlation with the first premolar (P1) with a p-
value of 0.0485. The second premolar (P2), first molar (M1), and second molar (M2) showed no correlation with
statistical significance. It should also be noted that although the first premolar (P1) showed statistical significance
it closely approached the cut off for significance.

Table6
Long axis Inclination/center of resistance in alveolar bone

Linear Fit R square p-value for testing slope = 0

P1-LAI/P1-D1 0.0614 0.157

P2-LAI/P2-D1 0.0153 0.485

M1-LAI/M1-D1 0.0007 0.88

M2-LAI/M2-D1 0.129 0.036 * (tb6fn1)

= p < .05.

Table7
Long axis inclination/apex point in alveolar bone

Linear Fit R square p-value for testing slope = 0

P1-LAI/P1-D2 0.222 0.0049 * (tb7fn1)

P2-LAI/P2-D2 0.051 0.1961

M1-LAI/M1-D2 0.0071 0.6334

M2-LAI/M2-D12 0.0083 0.6068

= p < .05.

Table8
Long axis inclination/apex point over basal bone

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Linear Fit R square p-value for testing slope = 0

P1-LAI/P1-D3 0.116 0.0485 * (tb8fn1)

P2-LAI/P2-D3 0.0661 0.1421

M1-LAI/M1-D3 0.0357 0.2842

M2-LAI/M2-D3 0.0086 0.6009

= p < .05.

Table9
DWALA/center of resistance in alveolar bone

Linear Fit R square p-value for testing slope = 0

P1-DWALA/P1-D1 0.0214 0.4091

P2-DWALA/P2-D1 0.0029 0.7609

M1-DWALA/M1-D1 0.0172 0.459

M2-DWALA/M2-D1 0.00229 0.7879

Table10
DWALA/apex point in alveolar bone

Linear Fit R square p-value for testing slope = 0

P1-DWALA/P1-D2 0.0108 0.5585

P2-DWALA/P2-D2 0.0001 0.9516

M1-DWALA/M1-D2 0.0375 0.2719

M2-DWALA/M2-D2 0.1852 0.0111 * (tb10fn1)

= p < .05.

Table11
DWALA/apex point over basal bone

Linear Fit R square p-value for testing slope = 0

P1-DWALA/P1-D3 0.0021 0.793

P2-DWALA/P2-D3 0.003 0.7578

M1-DWALA/M1-D3 0.0126 0.527

M2-DWALA/M2-D3 0.2403 .0032 * (tb11fn1)

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= p < .05.

Table12
Long axis inclination/DWALA

Linear Fit R square p-value for testing slope = 0

P1-LAI/P1-DWALA 0.002 0.7985

P2-LAI/P2-DWALA 0.123 0.0414 * (tb12fn1)

M1-LAI/M1-DWALA 0.461 <0.0001 * (tb12fn1)

M2-LAI/M2-DWALA 0.067 0.1387

= p < .05.

The variable DWALA shows no correlation for any posterior teeth at the center of resistance location (D1). At
apex point alveolar the second molar (M2) has statistical significance with a p-value of 0.0111. P1, P2, and M1
show no correlation. At the level of the basal bone the second molar (M2) has statistical significance with a p-
value of 0.032. P1, P2, and M1 show no correlation.

As for correlation between the long axis inclination and DWALA, significant differences (p-value <0.05) were
found for the second premolar (P2) and first molar (M1). P2 had a p-value of 0.0414. M1 had a p-value of
<0.0001 showing very strong correlation. There was no correlation found for the first premolar (P1) or second
molar (M2). P1 had a p-value of 0.7985 and M2 with a p-value of 0.1387.

Discussion
This study specifically investigated the concept that more ideally inclined mandibular posterior teeth have roots
more centered over basal bone and more centered in alveolar bone. In addition, it examined the proposal by
Andrews regarding use of the WALA Ridge as an anatomic landmark for defining an optimal mandibular arch
form with teeth at ideal inclination and roots centered over basal bone and within alveolar bone.

Previous studies provided strong evidence of a highly significant statistical correlation between the FA Points of
mandibular crowns and the WALA Ridge. 13 The current study did not support statistically Andrews's proposal
that mandibular teeth aligned to the WALA Ridge had roots more centered in alveolar bone or over basal bone.

However, findings did indicate clinical significance that the tooth center of resistance was centered in the alveolar
bone. In addition, the current study likewise found clinical significance that the estimated vertical position of the
center of resistance of the teeth and the vertical position of the WALA Ridge coincided for all teeth, the means
and standard deviations being less than 1.0 mm.

In light of these findings, it is perhaps worth considering a broader perspective on traditionally accepted concepts
of optimal root position over/in bone as well as the possible usefulness of the WALA Ridge as a landmark for
clinically defining the mandibular arch form (size and shape).

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“Basal bone” appears to be a term uniquely used in orthodontics. Anatomists are generally not familiar with the
term and find no structural or histologic difference between alveolar bone and the bone it resides upon. As seen
in Fig.11 (fig0011) , it is tempting to define bone remaining after resorption of alveolar bone in an edentulous
patient as “basal bone” and tempting to make a subjective assumption that optimally positioned teeth are
centered over this bone. Interestingly, note the absence of significant “basal bone” in the edentulous maxilla.

Figure11
Edentulous maxilla and mandible.

The concept of centeredness seems to often work well for incisors ( Fig.12 (fig0012) ). Frequently the symphysis
and alveolar process is a tear-dropped form and our sense of symmetry fits well with the concept of
“centeredness” of the root position. Other images display an alveolar process and incisor root position that make
it difficult to suggest an optimal position of the root over the oblique underlying symphyseal bone ( Fig.13 (fig0013)
). Furthermore, while the tear-dropped incisor/chin form is common, examination of posterior teeth associated
alveolar bone and the underlying bone rarely demonstrate a symmetrical form ( Fig.14 (fig0014) ). In fact, the
alveolar process anatomically appears somewhat cantilevered from the underlying bone ( Fig.15 (fig0015) ).

Figure12
Mandibular incisor “centered” in teardrop-shaped alveolar process/symphysis. (For interpretation of the references to colour in
this figure legend, the reader is referred to the web version of this article.)

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Figure13
Mandibular incisor in oblique-shaped alveolar process/symphysis.

Figure14
Mandibular molar, alveolar process and “basal bone”.

Figure15
Alveolar process cantilevered over “basal bone”. (For interpretation of the references to colour in this figure legend, the reader is
referred to the web version of this article.)

Before additional discussion, it is worth noting that the current study found the centers of resistance of
mandibular posterior teeth were centered in alveolar bone and were also correlated to the WALA Ridge vertically.
With consideration of previous studies showing the highly significant correlation between the WALA Ridge and
the FApoints of crowns, 8 a strong argument can bemade for the usefulness of the WALA Ridge for defining an
optimal mandibular arch form insize and shape (the “centeredness” of the rootover the basal bone and within the
alveolar bone aside). Biomechanically, a single buccally applied force to a tooth crown will result in tipping of the

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tooth near the center of resistance of the tooth ( Fig.16 (fig0016) ). Therefore, arch wires shaped to the WALA Ridge
in concept would tip teeth to an upright position with the center of resistance remaining centered in the alveolar
bone.

Figure16
Buccally applied force which would cause a tipping movement with a moment and a center of rotation near a center of resistance.

Further discussion suggests that the concept of root “centeredness” over basal bone and in alveolar bone may be a
subjective and unsubstantiated objective for orthodontists to treatment plan. Certainly, it may be useful to
eliminate use of the term “basal bone”. The eruption of teeth is what develops alveolar bone; teeth do not erupt
into alveolar bone. In addition, there is wide variation in the thickness of the dentoalveolar process among
patients. Consideration should be given to a perspective that equal amounts of alveolar bone on the buccal and
lingual of roots, or “centeredness”, is perhaps not essential as long as there is adequate bone. Certain
compromised periodontal conditions can be managed with periodontal therapy if necessary. From a stability
perspective, the value of maintaining a root's center of resistance centered in alveolar bone while only tipping the
tooth to an upright position is certainly worth attention.

Additional significance to this notion is apparent from awareness that tipping posterior teeth to an upright
position can define a customized mandibular arch form (size and shape) unique to each individual. An existing
optimal or corrected mandibular arch form derived in this manner can serve as a template for a preferred
maxillary arch form in size and shape. As seen in a Fig.17 (fig0017) schematic, upright mandibular posterior teeth
in crossbite with upright maxillary posterior teeth is a condition indicating a maxillary skeletal transverse
discrepancy and a need for skeletal expansion. Likewise, Fig.18 (fig0018) shows lingually inclined mandibular
posterior teeth not in crossbite with upright maxillary posterior teeth. This also indicates a condition for
maxillary skeletal expansion if the mandibular posterior teeth are tipped buccally to an upright position. Fig.19
(fig0019) depicts a condition with no crossbite, upright mandibular posterior teeth, and buccally inclined maxillary
posterior teeth. Maxillary transverse skeletal expansion is needed if the maxillary teeth are tipped palatally to an
upright position. Fig.20 (fig0020) shows a situation where there is no crossbite but maxillary teeth are inclined
buccally and mandibular posterior teeth are inclined lingually, an indication for maxillary skeletal expansion if

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teeth in both arches are tipped to upright positions. And finally, Fig.21 (fig0021) depicts a condition where
mandibular and maxillary teeth are lingually/palatally inclined and no crossbite. Buccal tipping of posterior teeth
in both arches results in no need for maxillary skeletal expansion.

Figure17
Upright maxillary and mandibular molars; crossbite - maxillary skeletal expansion indicated.

Figure18
Lingually inclined mandibular molars; upright maxillary molars; no crossbite-maxillary skeletal expansion indicated if mandibular
molars are buccally tipped to upright position.

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Figure19
Upright mandibular molars; buccally inclined maxillary molars; no crossbite – maxillary skeletal expansion indicated if maxillary
molars are tipped palatally to upright position.

Figure20
Buccally inclined maxillary molars; lingually inclined mandibular molars; no crossbite – maxillary skeletal expansion indicated if
maxillary molars are tipped palatally to upright position and mandibular molars are tipped buccally to upright position.

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Figure21
Lingually inclined maxillary and mandibular molars; no crossbite – no maxillary skeletal expansion indicated if maxillary and
mandibular molars are tipped buccally to upright positions.

In the absence of a reliable landmark for mandibular arch form, expansion and uprighting of the lower arch
involving bodily movement would move the center of resistance of the teeth buccally, potentially compromising
the periodontium, and arbitrarily dictating the maxillary transverse arch dimension.

Of note, is the relatively small values of all the data and the statistical interpretation whereby there is little clinical
significance of the differences. Additional research should repeat this type of study addressing the “centeredness”
of untreated teeth with and without optimal inclination. Also, long term prospective randomized controlled trials
investigating the “centeredness” of the center of resistance, and the long-term stability and periodontal health of
teeth with and without mandibular arch forms developed per the WALA Ridge and tipping would help clarify the
concepts.

Conclusions
1. More upright posterior teeth based on the long axis inclination are not statistically more centered in alveolar
bone or over basal bone, however, the difference is clinically insignificant.

2. Teeth more closely related to the WALA Ridge landmark are not statistically more centered in alveolar bone
or over basal bone, however, the difference is clinically insignificant.

3. The WALA Ridge landmark is within clinical significance of being located vertically at or near the center of
resistance for all posterior teeth.

4. Considering the clinical significance of the location of the center of resistance of posterior teeth in alveolar
bone and to the WALA ridge, the WALA ridge may be a useful landmark for customizing mandibular arch form
if teeth are tipped to an upright position.

Acknowledgement

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The authors wish to thank Dr. Carl Roy of Virginia Beach, Virginia for providing the CBCT scans of patients
from his office for this study.

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