Changes in the molar relationship between

the deciduous and permanent dentitions:

A longitudinal study
Samir E. Bishara, B.D.S., D.D.S., D. Ortho., MS.,* Brad J. Hoppens, D.D.S., MS.,**
Jane Ft. Jakobsen, B.S., M.A.,*** and Frank J. Kohout, Ph.D.****
Iowa City, Iowa, and Ogallala, Neb.

The purpose of this study was to describe the changes in the molar relationship from the deciduous
dentition to the permanent dentition in 121 subjects from the Iowa Longitudinal Growth Study. In
addition, an attempt was made to determine the association between the various dentofacial variables
and the changes in the molar relationship in 55 persons (33 male and 22 female subjects) with
normal occlusion. All subjects were ev+uated at three stages of dental development: stage I,
completion of the deciduous dentition (X age = 4.94 years); stage II, when permanent first molars
initially erupt into occlusion (x age = 6.91 years); and stage III, at the completion of eruption of
the permanent dentition excluding third molars (X age = 13.01 years). The following sets of variables
were evaluated: molar relationship, mesiodistal crown diameters of single and groups of deciduous
and permanent teeth, dental arch widths, arch lengths, and various cephalometric dentofacial
variables. Correlation coefficients and regression analyses were used to assess the relationships
between these measurements and the changes in the molar relationship from the deciduous to
the permanent dentition. The findings indicate that of the 242 sides evaluated in the deciduous
dentition, 61.6% developed into a Class I molar relationship, 34.3% into Class II, and 4.1% into
Class III. Those sides that started with a distal step in the deciduous dentition proceeded to develop
into a Class II molar relationship in the permanent dentition. Of the sides with a flush terminal
plane relationship in the deciduous dentition, 56% progressed to a Class I molar relationship and
44% to Class II in the permanent dentition. The presence of a mesial step in the deciduous dentition
indicates a greater probability for a Class I molar relationship and a lesser probability for a
Class II molar relationship. In the 55 subjects who achieved normal occlusion, the magnitude of
change in the molar relationship was 1.91 mm in male subjects and 1.64 mm in female subjects. On
the average, these cases had a mesial step in the deciduous dentition of 0.8 mm in male subjects
and 1.0 mm in female subjects. There was a favorable difference between the maxillary and
mandibular leeway spaces of 1.3 mm in male subjects and 1 .l mm in female subjects. There was
also a favorable decrease in the Wits appraisal of 1.2 mm in male subjects and 0.6 mm in female
subjects. There was only a weak correlation between the change in the molar relationship and
the change in the Wits appraisal, and no correlation with the magnitude of the difference in the
leeway space between the maxillary and mandibular arches. The results of the regression analysis
indicated that a number of changes in various dentofacial variables-for example, intercanine widths,
arch lengths, maxillary and mandibular relationships-are associated with changes in the molar
relationship. The clinical implications of the present findings are discussed. (AM J ORTHOD DENTOFAC
ORTHOP 1988;93:19-28.)

The establishment and maintenance of nor-

mal occlusion constitute one of the important objectives
*I’rofessor, Department of Orthodontics, College of Dentistry, University of
Iowa.
**Private practice of cwtlwdontics, Ogallala, Neb.
***Biostatistician, Department of Fkventive and Community Dentistry, Col-
lege of Dentistry. University of Iowa.
****Associate Professor, Department of Preventive and Community Dentistry,
College of Dentistry, University of Iowa.
of orthodontic treatment whether it is preventive, in-
terceptive, or corrective.
The understanding of the anteroposterior changes
that occur in the occlusion between the deciduous and
permanent dentitions is crucial for the clinician involved
in early orthodontic treatment.
Several investigators have described the character-
istics of a Class I dentitionl-” It is agreed that in the
deciduous dentition it is common to have spacing be-
tween the teeth and for the second molars to have a

19
20 Bishara et al.
Table I. Ages of subjects (years) at each of the three stages
- -..-_
StugeI”:
N x
Male subjects 33 5.0
Female subjects 22 4.9
*Stage I = Completion of the deciduous dentition.
kStage II = After eruption of permanent first molars.
kStage III = Aftereruption of permanent second molars.
N = Sample size; X = mean; SD = standard deviation.
flush terminal plane relationship.3T5 Such a molar re-
lationship is observed in almost 50% of a normal pop-
ulation. “~‘2~24
At the time of eruption of the permanent first mo-
lars, their initial occlusion is dependent on the terminal
plane relationship of the deciduous second molars.‘,”
As a result, the first molars frequently erupt into a cusp-
to-cusp relationship-that is, with the mesiobuccal cusp
of the maxillary first permanent molar anterior to the
buccal groove of the mandibular first permanent mo-
lar. “J’ Arya, Savara, and Thomas” found that molars
that erupted into a distal or mesial relationship main-
tained similar relationships in the permanent dentition.
On the other hand, of tbe molars that initially erupted
into a cusp-to-cusp relationship, 70% developed into a
Class I relationship; the other 30% maintained their end-
to-end relationship or developed into a Class II molar
relationship.
It has been suggested that for an initial cusp-to-cusp
relationship to develop into a Class I permanent mo-
lar relationship, two mechanisms come into play:
(1) greater anterior growth of the mandible relative to
the maxilla and (2) a greater leeway space in the man-
dibular arch compared with the maxillary arch resulting
in a greater mesial migration of the mandibular per-
manent molars. 3,5
Various estimates have been made for the amounts
of maxillary and mandibular leeway spaces. Meyers’
calculated them to be 2.6 mm in the maxillary arch and
6.2 mm in the mandibular arch; in other reports they
have been estimated to be 1.8 mm and 3.4 mm in the
maxillary and mandibular arches, respectively. 13-15In
spite of these large variations in the estimates, it is
generally agreed that the leeway spaces are greater in
the mandibular arch,5~‘“~‘5,‘6and that these differences
contribute to the change in the permanent first molar
relationship from the initial cusp-to-cusp relationship
into a Class I occlusion.5.“.‘2.‘4,‘6
This brief review indicates that a number of studies
have reported on the changes in the molar relationship
Srqe Ilf Stage IIt$
---_.
SD x SD x SD
0.5 6.9 0.6 13.0 0 9
0.3 6.9 07 13.0 0.X
and in the dental arches, but very little is known on the
relative importance of these variables for the develop-
ment of a Class I occlusion.
The purposes of this study are to (1) describe the
changes in the molar relationship from the deciduous
to the permanent dentition and (2) determine the as-
sociation between the changes in the molar relationship
and several dentofacial variabIes in a normal dentition.
The material for this investigation was obtained
from the Facial Growth Study at the University of Iowa.
The study was started in 1946 on 167 subjects.‘7,‘RThe
records for the present investigation were selected for
subjects of whom models and cephalograms were
available biennially between the ages of 3.5 and 12
years, and annualIy through age 17. Ninety-seven per-
cent of the subjects were of northwestern European
ancestry.
Of the 167 subjects (81 males and 86 females) who
were initially evaluated, 43 lacked records through the
permanent dentition. As a result, the changes in the
molar relationship were evaluated on 121 subjects (60
males and 61 females). None of these subjects had
congenitally missing teeth; none had exhibited early
loss of deciduous first or second molars nor had un-
dergone orthodontic therapy.
The subjects with normal occlusion included 33
male subjects and 22 female subjeets. Each subject had
a clinically acceptable occlusion in the permanent den-
tition-that is, Class I molar and canine relationship,
anterior crowding of less than 2 mm, and no apparent
facial disharmony. in addition, eaeh subject had a com-
plete set of data at three stages of dental development-
namely, (1) at the completion of the deciduous denti-
tion, (2) at the time the permanent first molars initially
erupted into occlusion, and (3) at the completion of
Volume 93 Changes in molar relationship between deciduous and permanent dentitions 21
Number 1
Fig. 1. Measurements of molar relationship at the three stages
of dental development.
eruption of the permanent dentition excluding third mo-
lars. These selection criteria limited the number of sub-
jects in this investigation to 55. The ages of the subjects
with normal occlusion at the various stages evaluated
are detailed in Table I.
Dental cast measurements
At each of the three stages and for each subject, the
following dental arch measurements were evaluated:
1. Molar relationship. This is defined as the dis-
tance in millimeters between perpendicular pro-
jections, on the occlusal plane, from the distal
surfaces of deciduous second molar crowns at
stage I or the mesial surfaces of permanent first
molar crowns at stages II and III (Fig. 1).
2. Segmental and total lengths of the maxillary and
mandibular dental arches. The segments mea-
sured were (1) anterior segment, defined as the
distance between the distal surface of the lateral
incisor to the midway point between the mesial
surfaces of the central incisors, and (2) posterior
segment, defined as the distance between the
distal surface of the lateral incisor to the distal
surface of the deciduous second molar or the
mesial surface of the permanent first molar. The
arch lengths for each side in each of the two
dental arches were calculated in addition to the
differences between the maxillary and mandib-
ular arch lengths.
3. Maxillary and mandibular arch widths for the
canines, deciduous second molars, and per-
manentjrst molars. Intercanine width was mea-
sured between cusp tips; intermolar width was
measured between the mesiobuccal cusp tips of
Fig. 2. Cephalometric landmarks used.
the deciduous second molars or permanent first
molars. 1930
4. Mesiodistal crown dimension of all the decidu-
ous teeth in both arches and all the permanent
teeth from jirst molar to first molar. These mea-
surements were obtained from casts in which the
dentition was complete and in good condition.
Crown diameters were taken as the distance be-
tween anatomic contact points.2’,22
In addition, the following measurements were
derived;
a. Leeway space for each quadrant, calculated
as the difference between the combined me-
siodistal widths of the deciduous canines, and
first and second molars, and their permanent
successors
b. The difference between the maxillary and
mandibular leeway spaces for each side
c. The difference between the total deciduous
tooth size and the size of their permanent
successors
Cephalometric measurements
The following landmarks were identified on each
cephalogram (Fig. 2): anterior-most point on the oc-
cipital condyle (0), articulare (Ar), porion (PO), sella
turcica (S), sphenoidal wing point (W), nasion (N),
orbitale (Or), anterior nasal spine (Ans), A point (A),
22 Bishara et al.

Table If. Changes in the molar relationship from the deciduous to the permanent dentition in 60 male
subjects (120 sides) and 61 female subjects (122 sides)
----__--
First molar occlusion in the permanenr dentition

Initial occlusion Class II or

in the deciduous dentition N Class 1* Class II tendency? Class Ill-t

Distal step of 1 to 7 mm
Male subjects 6.6% 8 8
Female subjects 12.3% 1s 15
TOTAL 9.5% 23 -~ 23 .-
Flush terminal plane
Male subjects 39.2% 47 28 19
Female subjects 19.7% 24 12 12
TOTAL 29.4% 71 40 31
Mesial step of 1 mm
Male subjects 41.7% 50 38 12 --
Female subjects 41.8% 51 39 II I
TOTAL 41.7% 101 77 23 1
Mesial step of 2 mm or more
Male subjects 12.5% is 12 3
Female subjects 26.2% 32 20 6 6
TOTAL 19.4%> 47 32 6 9

N = Number of sides.
*In Class I occlusion, the distancebetween the mesial surfaces of the maxillary and mandibular first molars was +3 to +4 mm (see text for
definition).
tin Class II/Class II tendency occlusion, the distance between the surfaces ranged between - 4 and + 2 mm.
‘$In Class III occlusion, the distance between the surfaces was greater than + 4 mm.

B point (B), pogonion (Pog), menton (Me), gonion I amd w

(Go), long axes of the most protrusive maxillary and
mandibular incisors (l- and 7). In addition, articulare
prime (Ar’) and anterior nasal spine prime (Ans’) were
identified as projections from Ar and Ans on S-Go and
N-Me, respectively. The definition of all these land-
marks correspond to those given by Bishar~,*~ Knott,”
Frogman and Sassouni,25 Meredith and Chadha, and
Riolo and associates.*’ All bilateral landmarks were
projected to the midsagittal plane.
From these landmarks, the following variables were
measured:263o
A. Maxillary and mandibular anteroposterior relation-
ships: SNA, SNB, SWA, SWB, AWB, SWPog, and
the Wits appraisal. The Wits appraisal is the dis-
tance in millimeters between perpendiculars from
points A and B on the occlusal plane2*
B. Maxillary and mandibular depths: O-A and 0-Pog
C. Anterior and posterior facial heights: N-Ans’,
N-Me, N-Ans’/N-Me%, Ar’-Go, S-Go, Ar’-Got
S-Go%, and S-Go/N-Me%
D. Incisor angulations: l-:x, i:SN, i:FH and i:MP
A total of 3 10 different variables were measured or
calculated from the various measurements.
Sliding calipers, dial calipers, protractors, and a
magnifying hunp were used to obtain the various mea-
s-nts. The reliabiiity of the measurements with
these calipers has been previously demonstrated;22
To minimize measurement error, a11linear and an-
gular measurements were performed by two investi-
gators working indeperuient~y. Each investigator per-
formedeach measurement twice on different occasions.
When their initial measurements were within 0.25 mm
or 0.5” of each other, the average of the two was used.
If the disparity was greater, each made two additional
measurements and the closest three were averaged.
Descriptive statistics including the mean, standard
deviation, and minimum and maximum values were
calculated for each parameter at the thme stages.
Student’s t teats were used to determine whether
significant differences were present between male and
female subjects, and between the right and left sides.
Signilicance was predetermined at the 0.05 ?evel of
confidence.
Correlation coefficients (r) were calculated to de-
Volume 93 Changes in molar relationship between deciduous and permanent dentitions 23
Number 1

Changes in the dentofacial structures between 5 years-

3 months, and 12 years-6 months in a female subject with
an untreated Class II occlusion.

5Y-3M 7Y-6M 12Y-6M

SNA’= 83 63 85
Flg. 3. Dental and facial changes in a patient with Class II SNB” 76 78 82
malocclusion between the deciduous and permanent dentitions. ANB” 7 5 3
A, Facial photographs at 5 years 3 months, 7 years 6 months, Wits mm 3 1 0
and 12 years 6 months of age.
Leeway difference between the maxillary and mandibular
arches = 2.0 mm/side.

termine the association between the change in the molar
relationship, the change in the max+ry-mandibular
relationship, and the difference in the leeway space
between the two arches.
Stepwise regression analysis3’ was used to deter-
mine which of the variables should be included in a
regression model. This procedure is useful in isolating
a subset of predictor variables that best explain the
variation of the dependent variable.
Separate stepwise regressions were first performed
for each of four categories of available variables:
a. Deciduous and permanent mesiodistal tooth di-
mensions in addition to the differences between
these dimensions for both arches in the two den-
titions
b. Maxillary and mandibular arch widths at the
three stages
c. Maxillary and mandibular arch lengths at the
three stages
d. Cephalometric measurements including skel-
etal and dental relationships at the three
stages.
Then, the best subset of predictors from each of the
stepwise regressions was entered in a final regression
analysis and those predictors that no longer contributed
to explained variance were deleted from the model. As
noted later, all regression analyses were done separately
for male and female subjects.
Discriminant analysis3’ was used to supplement the
findings of the regression analysis because it provides
a means of assessing predictive accuracy (percentage
Fig. 3 (Cont’d). B, Superimpositions of cephalometric tracings
of each two consecutive stages.
of cases correctly classified by a prediction equation),
which is not available through conventional regression
analysis.
FINDINGS
Changes in molar relationship from the deciduous
to the permanent dentition in the overall sample
(Tables II and Ill)
As stated earlier, the findings on the 60 male sub-
jects and 61 female subjects are presented separately
as right and left sides for a total 242 sides.
Of the 23 sides with distal steps in the initial oc-
clusion (9.5% of the total), all progressed to a Class II
tendency or a full Class II molar relationship in the
permanent dentition. In general, there was a tendency
for the distal occlusion to slightly improve with age but
not to the extent of becoming a Class I relationship. A
change to a Class I molar relationship occurred in two
cases as a result of the premature loss of the mandibular
second deciduous molars due to caries. These two cases
were not included in the study.
Of the 71 sides with fiush terminal planes (29.4%
of the total) in the initial occlusion, 56.3% became
Class I in the permanent dentition; 43.7% became
Class II in the permanent dentition. These findings in-
dicate that the presence of either a flush terminal plane
in the deciduous dentition or an end-to-end relationship
 Fig. 3 (Cont’d). C, Occlusal relationships at the three stages evaluated.

Table III. Summary of the percent change in molar relationship for the total sample evaluated
_______.-_
First molar occlusion in the permanent dentition
-.---_
Initial occlusion in the Class I1 or
.1’ l-----
!
deciduous dentition c‘luss I* Class II tendency? Class IIIi

Distal step of I to 7 mm 23 I) 23 (100%) 0

Flush terminal plane 71 40 (56.3%) 31 (43.7%) 0
Mesial step of 1 mm 101 17 (76.2%) 23 (22.8%) I i 1%)
Mesial step of 2 mm or more 47 32 (68.1%) 6 (12.8%) 9 (19.1%)
TOTAL SAMPLE 242 149 (61.6%) 83 (34.3%) 10 (4.1%)
- ---
N = Number of sides.
*In Class I occlusion, the distance between the mesial surfaces of the maxillary and mandibular first molars was + 3 to i-4 mm (see text for
definition).
?In Class II/Class II tendency occlusion, the distance between the surfaces ranged between - 4 and t 2 mm.
$In Class III occlusion, the distance between the surfaces was greater than +4 mm.

at the time of eruption of the first molars will lead to
a Class II occlusion in almost 44% of the sides.
Of the 101 sides with a 1.0 mm mesiul step (41.7%
of the total) in the deciduous dentition, 76.2% became
Class I in the permanent dentition; 22.8% became
Class II and one side became Class III.
Of the 47 sides with a mesial step of 2.0 mm or
more (19.4% of the total) in the deciduous dentition,
61.6% became Class I, 12.8% became Class II, and
19.1% became Class III molar relationships in the per-
manent dentition.
In summary, of the 121 subjects (242 sides) eval-
uated in this study, 61.6% ended with a Class I molar
relationship, 34.3% with Class II, and 4.1% with
Class III (Table III).
The present findings indicate that the average an-
teroposterior change in molar relationship from the de-
ciduous or mixed dentition to the permanent dent&on
is 1.91 mm for males and 1.64 mm for females.
The changes in the Wits appraisal-that is, tbe an-
Volume 93
Changes in molar relationship between deciduous and permanent dentitions 25
Number 1

Table IV. Molar relationship in millimeters (see Fig. 1) for 55 subjects with normal occlusion at the three
stages of development evaluated (the right and left sides were averaged)
Boys Girls Combined

x SD x SD x SD

Stage I 0.78 0.67 1.02 0.46 0.87 0.60

Stage II 1.45 0.86 1.19 0.61 1.34 0.78
Stage III 2.69 0.45 2.66 0.63 2.68 0.52
Change from stage I to stage III 1.91 1.64 1.81

x = Mean; SD = standard deviation.

Table V. Descriptive statistics (in millimeters) for the leeway spaces (right and left sides averaged) and the
changes in the Wits appraisal
Male subjects Female subjects Combined

x SD x SD x SD

(1) Maxillary leeway space 1.1 1.1 1.3 0.9 1.2 1.0
(2) Mandibular leeway space 2.4 1.1 2.4 1.0 2.4 I .o
(3) Difference between (1) and (2) 1.3 0.7 1.1 0.9 1.2 0.8
(4) Change in Wits appraisal from -1.2 2.1 -0.6 1.8 -0.9 2.0
stages I to III

% = Mean; SD = standard deviation

*Dependent variable is the change in the molar relationship between stages I and II.

teroposterior relationship between points A and B- analysis. On the other hand, many of the dental arch
indicated an average decrease of 1.2 mm in male sub- and cephalometric measurements showed marked dif-
jects and 0.6 mm in female subjects. ferences between male and female subjects-for ex-
The differences in the leeway spaces (Table V) be- ample, the mesiodistal diameters of the permanent ca-
tween the maxillary and mandibular teeth were calcu- nines and molars, intercanine and intermolar widths,
lated to be 1.29 mm for male subjects and 1.08 mm and facial heights. As a result of this finding, and also
for female subjects. because previous literature indicated that male and fe-
Correlation coefficients were calculated to deter- male subjects should be treated separately,33 regression
mine the degree of association in the changes in the equations were calculated separately for the male and
molar relationship, the Wits appraisal, and the leeway female subjects.
difference. The only significant association present was
between the change in the molar relationship and that Regression analysis (Table VI)
of the Wits appraisal between stages I and III (r = The regression analysis indicated a number of as-
-0.35 for the right side, P = 0.04; r = -0.38 for sociations between the changes in molar relationship
the left side, P = 0.02). from stages I through III and various dentofacial
The next step was to determine whether other den- variables.
tofacial variables are associated with the change in the As explained earlier, four regression analyses were
molar relationship; for this purpose, multiple regression used to identify significant associations between the
analyses were performed. At this point it was necessary changes in the molar relationship and four groups of
to determine whether a separate analysis was needed variables: tooth size, arch widths, arch lengths, and
for the right and left sides as well as for male and female cephalometric dentofacial dimensions and relation-
subjects. ships. From these analyses, it was possible to identify
Comparisons of contralateral tooth size and bilateral 23 variables for male subjects and 19 for female sub-
dental arch measurements indicated virtually no differ- jects that were used in calculating the final regression
ences between the right and left sides; therefore, all analysis.
bilateral measurements were averaged for the regression The results of the final regression analysis are pre-
26 Bishara et al.
Table VI. Results of the regression analysis (beta values)*
Male subjects, F’ = 3.8356
Maxillary canine width, stage II
Maxillary arch length, stage I1
Differences in arch length between stages I and III
Difference in maxillary and mandibular arch
length at stage I
SWPog at stage II
Change in Wits appraisal between stages 1 and III
Change in 1: FHP between stages II and III
*Dependent variable is the change in the molar relationship between stages I and III.
sented in Table VI, which indicates that seven variables
explained more than 83% of the variation in the change
in molar relationship in males while nine variables ex-
plained 94% of the variation in females.
Stepwise regression analysis was used to determine
which variables at stage I can be useful in predicting
changes in molar relationship. For male subjects, 64%
of the variation was explained by the following inde-
pendent variables: maxillary molar width, SWPog, Wits
appraisal, l-:-i, maxillary arch length, and the ratio
N-Ans’/N-Me. For female subjects, 72% of the varia-
tion was explained by mandibular deciduous tooth size,
SWA, Ar’-Go, ratio of S-Go/N-Me, and the difference
between maxillary and mandibular leeway spaces.
Discriminant analysis3* was used to verify the pre-
dictive accuracy of the regression equations. Using the
variables identified through the prediction regression
analysis, the discriminant analysis indicated that the
final equation correctly classified 87% of the male
subjects and 95% of the female subjects as to their
stage III occlusal status.
DlSCUSSK)N
Changea in molar inthetatrd
The findings in this investigation indicated that if
the initial occlusion in the permanent dentition has a
distal step, the molar relationship in the permanent den-
tition develops into a Class II. Therefore, cases with a
distal occlusion in the deciduous dentition will, at least
for all clinical purposes, become Class II in the per-
manent dentition.
These findings indicate that distoocclusion in the
deciduous or mixed dentition will not self-correct with
growth and that orthodontic treatment will need to be
initiated as soon as it is indicated.
In those cases with a flush terminal plane, 56%
became Class I and 44% became Class II in the per-
manent dentition. On the other hand, of the cases with
Am. J. Orthod. Lkntofirc. Orrhq.
.Imuurv I98X
---,--
Female subjects, R2 = 0.9388
0.1141 Difference between the sum of mandibular deciduous teeth and - 0.0684
-0.1518 permanent successors
0.3764 Width of mandibular second deciduous molars 0.6940
0.1981 Mandibular canine width at stage I -0.1380
Maxillaty canine width change in between stages I and 111 0.0931
0.0342 SWA at stage I 0.0920
-0.1178 SWB at stage I 0.0400
-0.0348 SWA at stage II - 0.0659
NAPog at stage II 0.0813
Change in N-Ans’ between stages II and III -- 0.0967
a 1 mm mesial step, 76% became Class I, 23% changed
to Class II, and 1% to Class III. In cases with a mesial
step of 2 mm or more in the deciduous dentition, 68%
became Class I, 13% Class II, and 19% Class III.
These findings indicate that a more favorable molar
relationship in the deciduous dentition will lessen the
chance for a Class II occlusion in the permanent den-
tition. For example, in the present study the incidence
of a Class II developing from a flush terminal plane is
44%; from a 1 mm mesial step the incidence is 23%,
and from a mesial step of 2 mm or more it is only 13%.
Furthermore, the incidence of a Class III molar rela-
tionship in the permanent dentition is increased when
there is a larger mesial step in the deciduous dentition-
for example, the incidence is 1% with a 1 mm mesial
step and increases to 19% with a mesial step of 2 mm
or more.
The present findings have some important clinical
implications regarding treatment and its timing. As an
example, none of the sides that started with a distal
step (Class II) in the deciduous dentition were able to
e self-correct. These findings and observations provide
credence to a frequently repeated axiom: “Once a
Class II, always a Class II.”
The absence of “self-correction” in Class II mal-
occlusions in growing persons is illustrated in the case
presented in Fig. 3. The records were taken at 5 years
3 months, 7 years 6 months, and 12 years 6 months-
that is, over a span of 7 years 3 months. These records
indicate the presence of a favorable mandibular growth
as evidenced by a reduction in the AN3 angle of 4” and
in the Wits appraisal of 3 mm, in addition to a favorable
difference betwreen the maxillary and mandibular lee-
way spaces of 2.0 mm per side. The superimpositions
illustrate the substantial and favorable mandibular
growth as it relates to that of the maxilla at the different
Volume 93 Changes in molar relationship
Number 1
stages. The occurrence of all these favorable dental and
skeletal changes did not contribute significantly in the
correction of the preexisting dental malrelationships.
The findings and clinical observations imply that cases
with distal steps in the deciduous dentition should be
observed on a regular basis and treatment started
as soon as the clinician and the patient are ready to
initiate it.
Patients with a “flush terminal plane relationship”
present a more challenging diagnostic question. The
findings suggest that slightly more than half of these
cases will progress to a normal Class I molar relation-
ship, while 44% of the cases will end with a Class II
or end-to-end occlusion. No attempt was made in this
study to determine if the change can be predicted. The
findings imply that what is considered “normal” occlu-
sion in the deciduous or mixed dentition does not nec-
essarily lead to a “normal” occlusion in the permanent
dentition for a large number of persons. Therefore, it
is important for the clinician to closely observe these
cases and, when needed, to initiate treatment at the
appropriate tnme .
For cases with a mesial step in the deciduous den-
tition, the present findings indicate that the greater the
mesial step, the greater the probability for the molar
relationship to develop into a Class I occlusion. Fur-
thermore, the development of a Class II molar rela-
tionship, although still possible, is less probable. Con-
versely, the incidence of a Class III molar relationship
increases.
Attainment of Class I molar relationship
In the 55 cases with normal occlusion, the change
in the molar relationship between stages I and III was
on the average 1.9 1 mm for male subjects and 1.64
mm in female subjects (Table IV). It has been assumed
that the change in the molar relationship from an end-
to-end relationship toward a Class I occlusion is the
result of the difference in the leeway space between the
maxillary and mandibular arches as well as the result
of differential growth between the maxilla and man-
dible, in favor of the latter.
The differences in the leeway spaces between the
maxillary and mandibular arches were 1.3 mm for male
subjects and 1..1 mm for female subjects (Table V). The
decrease in the Wits appraisal between stages I and III
was 1.2 mm for male subjects and 0.6 mm in female
subjects (Table V). When the difference in the leeway
space and the change in the Wits appraisal are added
(2.5 mm for males and 1.7 mm for females), they are
on the average slightly larger than the change in the
molar relationship, which is 1.9 for males and 1.6 mm
for females.
between deciduous and permanent dentitions 27
Such a proposition is both a simple and attractive
explanation of how the change in the molar relationship
occurs. But for this assumption to be true, a high cor-
relation should exist between the change in the molar
relationship and these two variables. The results of the
correlation coefficients did not substantiate this as-
sumption. The only significant correlation (r = - 0.35
and -0.38) was between the change in the Wits ap-
praisal and the change in the right and left molar re-
lationships from the deciduous to the permanent den-
tition. These correlations are low and explain less than
10% of the variation in the change of molar relationship.
The results of the regression equations further sub-
stantiate these findings and indicate that a number of
dental arch and dentofacial changes are associated with
the change in the molar relationship (Table VI).
Clinical implications
Although these findings seem surprising, they in-
dicate that the change in the molar relationship might
be more complex than was previously assumed and is
associated with changes in a number of variables in the
dental arches and the rest of the dentofacial structures.
This complexity might explain why none of the cases
with a distal step and many of the cases with a flush
terminal plane or a mesial step in the deciduous den-
tition do not change to a Class I permanent molar re-
lationship.
The findings also indicate that the presence of a
favorable difference in the leeway spaces between the
maxillary and mandibular arches is not a good predictor
of whether a Class I molar relationship will be estab-
lished in the permanent dentition, and that the final
molar occlusion is dependent on a number of dental
and facial skeletal changes, both genetic and environ-
mental, that interact to achieve, or not achieve, normal
occlusion.
SUMMARY AND CONCLUSIONS
One hundred twenty-one subjects (242 sides) were
followed from the deciduous dentition to the permanent
dentition for an average period of 8 years.
The findings indicate the following.
1. A total of 61.6% of the sides will end in a
Class I molar relationship, 34.3% in Class II, and 4.1%
in Class III.
2. Those sides that started with a distal step in the
deciduous dentition developed into a Class II molar
relationship in the permanent dentition. Since none of
these cases self-corrected, treatment should be initiated
by the clinician as early as it is indicated.
3. Of the cases with a flush terminal plane rela-
tionship in the deciduous dentition, 56% will develop
28 Bishara et al.
into a Class I molar relationship and 44% into a
Class II molar relationship in the permanent dentition.
Since a flush terminal plane in the deciduous and mixed
dentitions could develop into an unfavorable molar re-
lationship in the permanent dentition, these casesshould
be closely observed in order to initiate orthodontic treat-
ment if necessary.
4. The presence of a mesial step in the deciduous
dentition suggests a greater probability of a Class I
molar relationship and a lesser probability of a
Class II molar relationship in the permanent dentition.
The incidence of a Class III molar relationship increases
as the magnitude of the mesial step increases.
5. In those cases (55 subjects) that ended with a
normal occlusion, the magnitude of change in the molar
relationship from the deciduous to the permanent den-
tition was 1.91 mm in male subjects and 1.64 mm in
female subjects. On the average these cases had a mesial
step in the deciduous dentition of 0.8 mm in males and
1.O mm in females. Only a weak correlation was found
between the change in the molar reiationship and the
change in the Wits appraisal, and virtually no corre-
lation was found between these two variables and the
difference in the leeway space between the maxillary
and mandibular arches.
6. The results of the regression analysis indicate
that a number of dental arch and dentofacial variables-
for example, intercanine widths, arch lengths, maxil-
lary and mandibular relationships-are also associated
with the changes in the molar relationship.
7. The present findings might be helpful to clini-
cians involved in the management and treatment of
young patients in the deciduous and mixed dentitions.
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Reprrnt requests IO:
Dr. Samir Bishara
Department of Orthodontics
University of Iowa
Iowa City, IA 52242