A Systematic Review and Meta-Analysis On Bolton's Ratios: Normal Occlusion and Malocclusion

886322 JOO Journal of OrthodonticsMachado et al.
Scientific Section
Journal of Orthodontics
A systematic review and meta- 2020, Vol. 47(1) 7–29

https://doiDOI:10..1177/1465312519886322org/10.1177/146312519886322
Author(s) 2019
© The
analysis on Bolton’s ratios: Normal Article reuse guidelines:

sagepub.com/journals-permissions
occlusion and malocclusion journals.sagepub.com/home/joo
Vanessa Machado1,2 , João Botelho1, Paulo

Mascarenhas1, José João Mendes1 and Ana Delgado1,2
Abstract
Introduction: The purpose of this study was to seek and summarise the Bolton overall index (OI) and
anterior index (AI) regarding normal occlusion and Angle’s malocclusion according to gender, and to assess
if these indices support Bolton’s standards as general references.
Methods: PubMed, LILACS, Embase, CENTRAL and Google Scholar databases were searched up to June
2019 (CRD42018088438). Non-randomised clinical studies, published in English and assessing Bolton’s OI
and/or AI in normal occlusion and Angle’s malocclusion groups, were included. OI and AI means, sample size
and SDs were collected. The National Heart, Lung, and Blood Institute’s Quality Assessment Tool for
Observational Cohort and Cross-Sectional Studies was used to assess the risk of bias. Pairwise random-
effects and multilevel Bayesian network meta-analyses were used to synthesise available data.
Results: Fifty-three observational studies were included (11,411 participants; 3746 men, 4430 women; 15 studies lacked
gender information). For normal occlusion, pooled estimates for OI and AI means were 91.78% (95% confidence interval
[CI] = 91.42–92.14; I2 = 92.87%) and 78.25% (95% CI = 77.87–78.62; I 2 = 90.67%), respectively. We could identify in
Angle’s Class III patients meaningful OI and AI mean deviations from normal occlusion (0.76, 95% credible interval [CrI]
= 0.55–0.98 and 0.61, 95% CrI = 0.35–0.87, respectively), while in Class II patients we found a meaningful mean deviation from
normal occlusion only for OI (−0.28, 95% CrI = −0.52–−0.05). Concerning gender impact, male patients presented higher OI (0.30, 95% CI =
0.00–0.59) and AI (0.41, 95% CI = 0.00–0.83) mean values than female patients in Class I.
Conclusion: Normal occlusion OI and AI mean values differ from Bolton’s original values. Class II division 2,
for OI mean values, and Class III, for both OI and AI, are proportionally larger than normal occlusion patients.
Gender had almost no impact on teeth mesiodistal proportion.
Keywords
tooth size, tooth size discrepancy, Bolton ratios, meta-analysis, systematic review
Date received: 16 February 2019; revised: 14 September 2019; accepted: 13 October 2019
Introduction 1Clinical Research Unit (CRU), Centro de Investigação

Interdisciplinar Egas Moniz (CiiEM), Egas Moniz - Cooperativa de
An appropriate balance of mesiodistal tooth widths Ensino Superior, C.R.L., Monte de Caparica, Almada, Portugal
2Orthodontics Department, Clinical Research Unit (CRU), Centro de Investigação
between the maxillary and mandibular arches allows
Interdisciplinar Egas Moniz (CiiEM), Egas Moniz - Cooperativa de Ensino
correct inter-digitation, overbite and overjet in normal Superior, C.R.L., Monte de Caparica, Almada, Portugal
occlusion, with proper aesthetic and function (Bolton,
1958). Currently, the extent of mesiodistal movement Corresponding author:
grounds clinical practice from conventional through to Vanessa Machado, Clinical Research Unit (CRU), Centro de
Investigação Interdisciplinar Egas Moniz (CiiEM), Egas Moniz -
orthodontic aligner treat-ments. It has also allured clinical Cooperativa de Ensino Superior, C.R.L., Campus Universitário,
interest, particularly in anteroposterior malocclusions Quinta da Granja, Monte de Caparica, Caparica, 2829-511,
correction (Kravitz et al., 2009; Lombardo et al., 2017). Portugal. Email: vmachado@egasmoniz.edu.pt
8 Journal of Orthodontics 47(1)
The concept of a proportional balance between the mesi- and malocclusions in multiple populations (Endo et al., 2008;
odistal sums of maxillary and mandibular teeth may have Kumar et al., 2013; Manopatanakul and Watanawirun, 2011;
arisen from the beginnings of dental articulation theories. O’Mahony et al., 2011; Ricci et al., 2013; Santoro et al.,
Bonwill (1899) stated that ‘Nature left to herself, always 2000), there is no consensus about its correlation with the
brings proposition. . . the proportions of upper teeth to the different types of malocclusions classified by Angle.
lower teeth are as exact as any’. This nature theory was per-
vasive in early orthodontics and was seen in the strict non- Objectives
extraction period started by Edward Angle. The mesiodistal
widths of teeth were initially investigated by Black (1902). No study has investigated, in an evidence-based manner,
Historically, Young (1923) was the first to study the inter- normative values for mesiodistal proportions of normal
maxillary tooth width ratio in occlusion and, thereafter, occlusion and Angle’s malocclusion, from worldwide
Gilpatric (1923) found that the upper arch was 8–12 mm researched data. For that reason, the primary aim of this sys-
wider than the lower arch. Over the years, to account and be tematic review was to synthesise worldwide estimates for
aware of this proportion, several methods have been sug- normal occlusion OI and AI mean values, and to compare
gested to assess the interarch tooth size relationship (Bolton, such values with those proposed by Bolton, to address the
1968, 1962; Kesling, 1945; Neff, 1949, 1957), but Bolton’s following focused question: Are current standards globally
ratios have become widely applied in orthodontics research. appropriate? Second, we aimed to compare the obtained val-
In this regard, the overall index (OI) is the percentage ues between gender for normal occlusion and each malocclu-
obtained by summing the widths of the 12 mandibular sion type. Finally, we intended to obtain OI and AI pooled
teeth divided by the sum of the widths of the 12 maxillary estimates for each type of Angle’s malocclusion and com-
teeth. The anterior index (AI) is the percentage obtained pare them against the obtained values for normal occlusion
by sum-ming the widths of the six mandibular anterior under a multilevel Bayesian network meta-analysis model.
teeth divided by the sum of the widths of the six maxillary
anterior teeth (Bolton, 1958, 1962). On average, the OI Materials and methods
was 91.3% (± 1.91) and AI was 77.2% (± 1.65); these
promptly became standard values in the diagnosis and Protocol and registration
guidance of orthodon-tic treatments. The protocol for this systematic review was made a priori,
Over time, Bolton’s analyses have proved to be clini- agreed upon by all authors and registered in PROSPERO
cally useful in extreme teeth size discrepancies. However, (ID number: CRD42018088438). This systematic review
without neglecting its value, its methodology and conclu- was conducted according to the Cochrane Handbook
sions should be carefully evaluated. First, these studies (Higgins et al., 2003) and reported according to the
had a potential selection bias since the population was not PRISMA statement (Preferred Reporting Items for
spec-ified, particularly concerning race, ethnicity and Systematic Reviews and Meta-Analyses) (Liberati et al.,
gender. Second, although the author has stated that his 2009) (Supplement S1) and its extension for abstracts
ratios were based on 55 cases ‘where excellent occlusions (Beller et al., 2013).
existed’, 44 models were from patients who underwent
orthodontic treatment and only 11 were untreated (Bolton,
1958). According to the literature, teeth size variation is
Eligibility criteria
ethnic-and gender-related (Bishara et al., 1989; Black, Studies were eligible for inclusion based on the following
1902; Hattab et al., 1996; Lavelle, 1972; Santoro et al., criteria:
2000; Smith et al., 2000), pointing out an anthropological
signifi-cance with genetic underpinnings (Dempsey and 1. Randomised and non-randomised (cohort/longitudi-
Townsend, 2001; Hughes et al., 2000). For this reason, the nal or cross-sectional studies);
application of Bolton analyses and the proposed standard 2. English language studies;
values for a harmonious dentition might not be valid for 3. Human study population;
other popula-tions. Therefore, this population-based 4. Determined Bolton’s analysis with normal
variation has become a subject of interest for many occlusion and/or Angle’s Class I, Class II, Class II
researchers, resulting in several attempts to establish division 1, Class II division 2 and/or Class III, in patients
normative standards for dif-ferent racial groups (Al- with-out previous orthodontic treatment;
Khateeb and Abu Alhaija, 2006; Al-Omari et al., 2008; 5. Dental casts or digital models with all permanent
Bernabé et al., 2004; Lavelle, 1972; Santoro et al., 2000). teeth from the maxillary and mandibular right first molar
Another relevant question is the relationship between the to the left first molar completely erupted, without tooth
tooth size discrepancy for both OI and AI and the various types deformities (Scheid and Weiss, 2012), mesiodistal
of Angle’s malocclusion. Although several investigators have restorations, caries or abrasion that could affect the teeth’s
emphasised the relationship between Bolton ratio discrepancies mesiodistal diameter;
Machado et al. 9
6. The study measured the largest mesiodistal teeth Risk of bias

dimension to the nearest 0.01 mm, through digital calliper
or software. The Quality Assessment Tool for Observational Cohort and
Cross-Sectional Studies statement proposed by National
Heart, Lung, and Blood Institute (NIHLBI) was used to
Narrative reviews, case reports and case series studies
appraise study quality (https://www.nhlbi.nih.gov/health-
were excluded from review.
topics/study-quality-assessment-tools). The checklist was
adapted since criteria 7, 8, 10 and 13 did not apply. The
Search strategy reviewers (VM, JB) determined a total quality score for each
article. Each methodologic quality criterion was assigned 1
A systematic search was conducted and updated in June
point, to a total maximum of 10 achievable points. Studies
2019, covering the following electronic databases:
reaching 9 or 10 points were arbitrarily con-sidered of high
PubMed, LILACS, Embase, CENTRAL (The Cochrane
quality, studies with 7 or 8 points were clas-sified as medium
Central Register of Controlled Trials) and Google Scholar.
quality, and studies with 6 points or less considered of low
The strategy used for the electronic search was the
methodologic quality. To be included, articles could not be of
following: [‘Bolton ratio’ OR ‘tooth size discrepancy’ OR
low quality, as recommended by the Cochrane Handbook
‘Bolton dis-crepancy’ OR ‘tooth-size ratios’ OR ‘tooth-
(Higgins et al., 2003).
size measure-ment’ OR ‘Bolton analysis’].
No limitations were applied regarding publication year.
The reference lists of included articles and relevant
Summary measures and synthesis of results
reviews were manually searched. Grey literature was
searched using the latter strategy in OpenGrey. Authors The objective of synthesis of the initial (priors) normal
were contacted when necessary for additional data or occlusion OI and AI mean values was accomplished by pair-
clarifications. wise random effects meta-analysis using OpenMetaAnalyst
(Wallace et al., 2017) software. Quantities I2 and Tau2 were
measured to account for the heterogeneity associated with the
Assessment of eligibility Bolton ratios mean estimates. Funnel plots were used to
The eligibility of each study was assessed independently visualise and quantify meta-analysis publication bias, respec-
by two investigators (VM and JB) who screened the titles tively, if appropriate (Doi et al., 2015a, 2015b; Egger and
and/or abstracts of retrieved studies. Inclusion was Smith, 1998; Furuya-Kanamori et al., 2018; Higgins and
depend-ent on the following eligibility criteria: Green, 2011; Sterne et al., 2011). All tests were two-tailed
randomised or non-randomised studies with OI and/or AI with alpha set at 0.05 except for the z-test whose significance
data. Final selection of studies was performed by three level cut-off was adjusted to 0.10 when comparing meta-
authors independently (JB, VM, PM) and verified by a analysis outcomes. Unpaired z-test was used to compare our
fourth and fifth author (JJM, AD), by reviewing the full normal occlusion mean results with Bolton original values.
text based on the inclu-sion criteria above. Discussion In a number of articles (Asma, 2013; Bugaighis et al.,
resolved any disagree-ments. Non-full papers, such as 2015; Crosby and Alexander, 1989; Kansal et al., 2012;
conference abstracts and letters to editors, were excluded. Machado et al., 2018; Mahmoud et al., 2017; McSwiney et
al., 2014; O’Mahony et al., 2011; Oktay and Ulukaya,
2010; Uysal et al., 2005), Class II division 1 and division
Data extraction 2 summary statistics were published separately, and it was
Data were extracted to a predefined table. We used the necessary to calculate the combined mean and SD for the
following information: the first author’s name; study overall Class II following the algorithms in Altman et al.
design; publication year; country and continent where the (2000). Similarly, in the studies by McSwiney et al.
study was conducted; number of cases and participants; (2014) and Nie and Lin (1999), there were published data
gender; tooth width measurement method; and OI and AI for surgi-cal and non-surgical in Class III, and we used the
(mean and SD). Type of occlusion was classified into aforemen-tioned procedure to combine the mean and SD.
normal occlusion, Angle’s Class I, Class II (division 1 and To fulfil the second objective, we were required to esti-
division 2) or Class III. Populations were categorised into mate the OI and AI overall mean of Angle’s malocclusion
continental groups: African; American; Asia (includ-ing types and compare each of them against the normal occlu-
Japanese populations based in Hawaii); European; and sion overall mean value. Due to the complexity of the distri-
Oceania. We extracted Bolton OI, AI means and SDs, for bution of the extracted data across the selected reports, we
both genders, in all selected studies population samples. aimed to address such an issue under a multilevel Bayesian
Concerning additional data/clarifications, we tried to network meta-analysis (Bayesian NMA) model, as previ-
contact corresponding authors (until June 2019) ously used (Barbato et al., 2015; Kotsakis et al., 2018;
(Supplement S2). Tedesco et al., 2018). Bayesian NMA has been developed to
cope with limitations in traditional pairwise meta-analysis. Study characteristics

NMA incorporates all available evidence into a general
framework model for comparisons of all available factors. A Setting. Table 1 summarises the characteristics of the
further development in the NMA is to use a multilevel included studies. In total, the analysis included 11,411
Bayesian statistical approach, which provides a more flexi- participants (3746 men, 4430 women). However, 16 stud-
ble modelling framework to take into account heterogeneity ies (Al-Duliamy et al., 2016; Alkofide and Hashim, 2002;
in the evidence and covariance between means due to the Asma, 2013; Bugaighis et al., 2015; Cançado et al., 2015;
complexity in the data structure. Therefore, we went through Chugh et al., 2015; Crosby and Alexander, 1989; Kansal
Rstan, a R package that inter-connects R and STAN lan- et al., 2012; Mahmoud et al., 2017; Manopatanakul and
guages making the design and handling of such a complex Watanawirun, 2011; McSwiney et al., 2014; Mulimani et
model easy. Priors were sourced as the initial mean and vari- al., 2018; Ricci et al., 2013; Shastri et al., 2015; Zer-
ance for AI and OI normal occlusion values from the pair- ouaoui et al., 2014) lacked gender information (3235 par-
wise meta-analysis (Pairwise MA). Furthermore, we ticipants). In addition, two multicentre studies (Al-
modelled all of the classes’ differences (across all of the stud- Duliamy et al., 2016; Lavelle, 1972) included samples
ies) using a single multivariate normal distribution with a
from two and three different countries and from different
vector as mean and with a covariance matrix. After sampling
continents and, consequently, they were counted as three
from the posterior distribution, the function returned fit sta-
samples; however, in Lavelle (1972), the author did not
tistics that included adjusted estimates and associated credi-
specify the African country, preventing it from being ana-
lysed in meta-regression.
bility intervals (CrI; 2.5–97.5 percentiles) for normal
occlusion (adjusted), for all mean values of malocclusion Table 1 and Figure 2 show that only one study with nor-
classes and for malocclusion classes mean differences to normal occlusion participants (Lavelle, 1972) was published in
mal occlusion. We performed both random effects and fixed the 1970s, and thereafter was a lack of published reports for
effects Bayesian approaches. Both models fit well with coin- almost 30 years. In addition, the first author that investigated
cident point estimates and, recently, we selected the fixed- the Bolton ratios in Angle’s malocclusion groups was Crosby
effects variant results because this had the lowest deviance and Alexander (1989), more than 30 years after Bolton’s arti-
information criteria (DIC). Once again, I 2 and Tau2 were cle (Bolton, 1958). After 1999, larger datasets were pub-
measured through random effects meta-analysis to account lished on different continents. Fifty-three cross-sectional
for the heterogeneity at each malocclusion subset. studies from four different continents, namely Africa, Asia,
South America and Europe were included in the qualitative
The GRADE (Grading of Recommendations Assessment,
synthesis (Table 1). The studies by Lavelle (1972) and Al-
Development, and Evaluation) approach rated the quality of
Duliamy et al. (2016) were multicentric studies that com-
evidence (Guyatt et al., 2011). The quality of evidence was
prised European, Asian and African participants, and Asian
based on five factors: (1) limitations of the study design or
and African participants, respectively. Notably, no study was
the potential risk of bias across all studies; (2) inconsistency
performed in Oceania or North America. Due to the inade-
of results (or heterogeneity); (3) indirectness (generalisabil-
quacy of continent representation, continent subgroup analy-
ity); (4) imprecision (sufficient data); and (5) the potential for
sis was not conceivable to perform.
publication bias (Schüneman et al., 2013). As recom-mended
by GRADE approach to systematic reviews, quality score
was not defined (Schüneman et al., 2013). Risk of bias. The Quality Assessment Tool for Observa-
tional Cohort and Cross-Sectional Studies statement pro-
posed by the NIHLBI score in the final sample of articles was
Results in the range of 6–8 out of 10 (as shown in Supplement S4).
Among the included studies, no study was of high quality.
Study selection Moreover, 47 articles presented medium quality, of which 11
The initial electronic database search resulted in a total of articles presented 8 points (Asma, 2013; Bugaighis et al.,
2935 articles, leaving 2926 articles after the removal of 2015; Cançado et al., 2015; Celikoglu et al., 2013; Ismail and
duplicates. No additional relevant articles were identified Abuaffan, 2015; Machado et al., 2018; McSwiney et al.,
after a hand search of reference lists. After title and abstract 2014; Nie and Lin, 1999; Shahid et al., 2016; Saritha et al.,
screening, 190 studies were selected for full-text evalua-tion. 2017; Ta et al., 2001) and 39 articles presented 7 points (Al-
After full-text eligibility assessment, 127 studies were Duliamy et al., 2016; Al Sulaimani and Afify, 2006; Alkofide
excluded (Supplement S3). Five studies were excluded for and Hashim, 2002; Carreiro et al., 2005; Chugh et al., 2015;
presenting with low quality and high risk of bias (see the Cİğer et al., 2006; Crosby and Alexander, 1989; Elsheikhi et
‘Risk of Bias’ in Materials and Methods section). Only six al., 2017; Endo et al., 2007, 2009, 2010; Fernandes et al.,
articles reported data for one Angle’s malocclusion, pre- 2010; Freire et al., 2007; Hashim et al., 2015; Hyder et al.,
venting its inclusion in the Bayesian NMA. Finally, 53 2012; Jindal and Bunger, 2013; Jóias and Scanavini, 2011;
studies were included in this review (Figure 1). Jóias et al.,
Machado et al. 11
Figure 1. Flow chart of the study selection process.
2010; Kansal et al., 2012; Lavelle, 1972; Lee et al., 2011; 2013; Kansal et al., 2012; Lee et al., 2011; Machado et al.,
Lombardo et al., 2016; Machado et al., 2018; Manopa- 2018; Nie and Lin, 1999; Saritha et al., 2017; Ta et al.,
tanakul and Watanawirun, 2011; Maurya et al., 2015; Mol- 2001) and seven determined the sample size (Bugaighis et
labashi et al., 2019; Mulimani et al., 2018; O’Mahony et al., al., 2015; Cançado et al., 2015; Celikoglu et al., 2013;
2011; Oktay and Ulukaya, 2010; Patel et al., 2017; Ricci et Ismail and Abuaffan, 2015; McSwiney et al., 2014; Shahid
al., 2013; Sakoda et al., 2016; Shahid et al., 2016; Shastri et et al., 2016; Ta et al., 2001). Strategies to minimise the
al., 2015; Škrinjarić et al., 2018; Uysal et al., 2005; Vela et potential sources of bias were not clearly described in
al., 2011; Zerouaoui et al., 2014). Five were of low qual-ity most articles. Twelve articles fail to explain how they
(Anil and Monika, 2010; Devi et al., 2017; Kumar and Chitra, evaluated intra- and/or inter-examiner errors or random
2017; Mirzakouchaki et al., 2007; Subbarao et al., 2014) and, error determi-nation (Anil and Monika, 2010; Devi et al.,
consequently, were excluded. 2017; Kachoei et al., 2011; Kansal et al., 2012; Kumar et
Moreover, two articles were excluded (Kachoei et al., al., 2015; Lee et al., 2011; Mirzakouchaki et al., 2007;
2011; Poosti and Jalali, 2007) due to abnormal SD values Mollabashi et al., 2019; Mulimani et al., 2018; Poosti and
(10 and 100 times lower than the mean value of SD pre- Jalali, 2007; Škrinjarić et al., 2018; Subbarao et al., 2014).
sented in the remaining studies, respectively)
(Supplements S7–S10). These unusual SD values frame
narrow confi-dence intervals (CIs) gaining unreasonable
Meta-analysis findings
weight in the meta-analysis. We unsuccessfully tried to Pairwise MA findings for normal occlusion. In normal
contact the authors and, therefore, we decided to exclude occlu-sion group, the assessment of OI and AI was sourced
these, pon-dering the likely negative consequences for the from 25 and 26 studies, respectively (Figures 3 and 4). All
veracity of the results. the 26 studies provided data for AI assessment, while one
More specifically, only seven studies reported the setting, study (Jóias and Scanavini, 2011) had no data regarding OI.
locations and relevant dates of cast models (Asma, Overall pooled results suggest an OI mean of 91.78% (95%
Table 1. Baseline characteristics for studies included in pairwise meta-analysis and Bayesian network meta-analysis.
12
Included in Included in
pairwise Bayesian
Participants Total OI Total AI meta- network meta-
Study (year) (country) (city) Continent (n) F/M Method (SD) (SD) F / M OI (SD) F / M AI (SD) analysis analysis
Normal occlusion
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 92.73 (1.74) 78.43 (2.31) NS NS Yes Yes
(Iran) (Hamadan) (0.01 mm)
Machado et al. (2018) Europe 29 10 / 19 Digital calliper 92.10 (2.20) 78.40 (3.50) 91.70 (2.20) / 92.9 (2.10) 77.90 (3.10) / 79.3 (4.10) Yes Yes
(Portugal) (Almada) (0.01 mm)
Patel et al. (2017) (India) Asia 50 25 / 25 Digital calliper 92.73 (2.69) 80.80 (2.86) 91.92 (3.40) / 93.55 (1.36) 80.34 (3.27) / 80.60 (2.45) Yes No
(Pune) (0.01 mm)
Sakoda et al. (2016) (Brazil) America 90 45 / 45 Digital calliper 91.63 (1.95) 77.57 (2.45) 91.35 (1.87) / 91.91 (2.04) 77.30 (2.28) / 77.85 (2.64) Yes No
(São Paulo) (0.01 mm)
Shahid et al. (2016) Asia 128 64 / 64 Digital calliper 92.80 (2.79) 79.25 (3.81) 93.10 (2.40) / 92.50 (3.10) 79.50 (3.60) / 79.00 (4.40) Yes No
(Pakistan) (different states) (0.01 mm)
Lombardo et al. (2016) Europe 56 22 / 34 Intraoral Scanner 91.56 (2.00) 77.65 (2.46) 91.55 (2.00) / 91.57 (2.00) 77.88 (2.00) / 77.30 (3.00) Yes No
(USA) (New York) (3shape)
Chugh et al. (2015) (India) Asia 50 25 / 25 Digital calliper 91.88 (1.99) 79.64 (2.61) 91.80 (2.34) / 91.96 (1.63) 79.16 (2.23) / 80.12 (1.73) Yes Yes
(Lucknow) (0.01 mm)
Bugaighis et al. (2015) (Libya) Africa 15 NS Digital calliper 90.24 (1.89) 76.88 (2.42) NS NS Yes Yes
(Benghazi) (0.01 mm)
Ismail and Abuaffan (2015) Africa 55 25 / 30 Digital calliper 91.47 (2.83) 77.46 (3.16) 91.25 (2.94) / 91.73 (2.90) 77.22 (3.43) / 77.73 (2.82) Yes Yes
(Sudan) (Khartoum) (0.1 mm)
Hashim et al. (2015) (Sudan) Africa 60 30 / 30 Digital calliper 90.80 (3.50) 76.90 (3.60) 90.60 (3.10) / 91.00 (3.90) 77.00 (3.70) / 76.90 (3.60) Yes No
(Khartoum) (0.01 mm)
Ricci et al. (2013) (Brazil) America 35 NS Digital calliper 90.38 (1.58) 77.49 (2.20) 90.36 (1.70) / 90.44 (1.20) 77.73 (2.39) / 76.68 (1.19) Yes Yes
Celikoglu et al. (2013) Europe 26 14 / 12 CBCT 90.69 (2.21) 77.58 (2.71) NS NS Yes No
(Turkey) (Karadeniz Ereğli)
Jóias and Scanavini (2011) America 35 8 / 27 Digital calliper NS 77.48 (2.22) NS 77.61 (2.45) / 77.05 (1.10) Yes No
(Brazil) (São Paulo) (0.01 mm)
Fernandes et al. (2011) America 140 70 / 70 Digital calliper 91.32 (1.98) 77.00 (2.71) 90.87 (1.94) / 91.77 (1.96) 76.54 (2.79) / 77.46 (2.61) Yes No
(Brazil) (Bauru) (0.01 mm)
Manopatanakul and Asia 37 NS Digital calliper 91.66 (1.74) 77.09 (2.18) NS NS Yes No
Watanawirun (2011) (0.01 mm)
(Thailand) (Bangkok)
Lee et al. (2011) (South Asia 307 188 / Digital calliper 90.42 (1.94) 77.54 (2.54) 90.30 (2.00) / 90.50 (1.90) 77.60 (2.60) / 77.50 (2.50) Yes No
Korea) (Seoul) 119 (0.01 mm)
Oktay and Ulukaya (2010) Europe 100 61 / 39 RMI 550 3D (0.01 92.10 (1.95) 79.28 (2.53) 91.63 (2.04) / 92.39 (1.84) 79.17 (2.65) / 79.35 (2.47) Yes Yes
(Turkey) (Erzurum) mm)
(Continued)
Journal of Orthodontics 47(1)
Table 1. (Continued)
Machado et al.
pairwise Bayesian
Jóias et al. (2010) (Brazil) America 35 8 / 27 Intraoral Scanner 91.58 (2.20) 78.66 (2.72) NS NS Yes No
(São Paulo) (3shape)
Freire et al. (2007) (Brazil) America 30 15 / 15 Digital calliper 91.46 (1.63) 77.83 (2.19) NS NS Yes No
(Rio de Janeiro) (0.01 mm)
Endo et al. (2007) (Japan) Asia 60 30 / 30 Digital calliper 91.60 (2.11) 78.39 (2.18) 91.69 (2.35) / 91.51 (1.88) 78.57 (2.19) / 78.21 (2.18) Yes No
(Niigata) (0.01 mm)
Cİğer et al. (2006) (Turkey) Europe 125 55 / 70 Digital calliper 91.95 (2.20) 77.95 (2.35) 91.82 (1.99) / 91.97 (1.65) 78.43 (2.41) / 78.62 (2.24) Yes Yes
(Hacettepe) (0.01 mm)
Carreiro et al. (2005) America 41 20 / 21 Microscribe 3DX 91.76 (2.51) 78.24 (3.40) NS NS Yes Yes
(Brazil) (Paraná)
Uysal et al. (2005) (Turkey) Europe 150 72 / 78 Digital calliper 91.90 (3.21) 78.56 (3.23) 91.73 (2.26) / 89.83 (2.33) 78.33 (2.42) / 78.18 (2.82) Yes Yes
(Konya) (0.01 mm)
Alkofide and Hashim (2002) Asia 60 NS Digital calliper 93.58 (2.12) 78.86 (2.55) 92.36 (2.37) / 92.12 (1.67) 78.79 (3.19) / 78.75 (2.27) Yes Yes
(Saudi Arabia) (Jeddah) (0.01 mm)
Nie and Lin (1999) (China) Asia 60 30 / 30 Software 93.27 (2.48) 81.52 (2.82) 93.11 (2.64) / 93.44 (2.35) 81.10 (2.27) / 81.95 (2.28) Yes Yes
(Beijing)
Lavelle (1972) Europe 40 20 / 20 Digital calliper 91.25 (2.00) 77.15 (1.60) 90.80 (1.85) / 91.70 (2.04) 77.50 (1.62) / 76.80 (1.49) Yes No
(0.1 mm)
Africa 40 20 / 20 Digital calliper 93.20 (2.11) 79.00 (2.02) 92.90 (1.78) / 93.50 (2.35) 78.60 (1.89) / 79.40 (2.06) Yes No
(0.1 mm)
Asia 40 20 / 20 Digital calliper 92.75 (1.53) 78.45 (1.55) 92.10 (1.55) / 92.60 (2.47) 78.20 (1.38) / 78.70 (1.66) Yes No
(0.1 mm)
Class I
Mollabashi et al. (2019) Asia 60 30 / 30 Digital calliper 92.61 (2.29) 78.79 (2.85) NS NS - Yes
Mulimani et al. (2018) Asia 15 NS Digital calliper 90.80 (2.15) 77.1 (2.3) NS NS - Yes
(Malaysia) (Melaka) (Indian) (0.01 mm)
Asia 27 NS Digital calliper 91.0 (1.72) 77.9 (2.3) NS NS - Yes
(Chinese) (0.01 mm)
(Malay) (0.01 mm)
Škrinjarić et al. (2018) Europe 39 20/19 ATOS II SO 91.57 (1.81) 78.19 (2.70) 91.24 (1.61) / 91.89 (1.99) 77.65 (2.49) / 78.75 (2.86) - Yes
(Croatia) (Zagreb)
Machado et al. (2018) Europe 50 29 / 21 Digital calliper 92.90 (2.70) 79.30 (4.00) 93.4 (2.30) / 92.50 (2.90) 79.60 (2.90) / 79.00 (4.60) - Yes
Saritha et al. (2017) (India) Asia 168 110 / 58 Digital calliper 92.38 (1.86) 79.37 (2.98) 92.39 (1.95) / 92.38 (1.82) 79.49 (2.37) / 79.30 (3.27) - Yes
(Telangana) (0.01 mm)
(Continued)
13
14
pairwise Bayesian
Mahmoud et al. (2017) Asia 52 NS Digital calliper 91.37 (2.98) 78.44 (2.91) NS NS - Yes
Elsheikhi et al. (2017) (Libya) Africa 20 10 / 10 Digital calliper 89.91 (1.79) 74.42 (2.06) NS NS - Yes
Cançado et al. (2016) (Brazil) America 321 NS Digital calliper 91.61 (2.04) 78.37 (2.68) NS NS - Yes
(Dourados) (0.01 mm)
Al-Duliamy et al. (2016) Asia 70 NS Digital calliper 91.23 (2.20) 78.72 (4.53) NS NS - Yes
(Iraq) (Baghdad) (0.01 mm)
Al-Duliamy et al. (2016) Africa 70 NS Digital calliper 91.63 (2.58) 78.85 (2.79) NS NS - Yes
(Egypt) (Cairo) (0.01 mm)
Chugh et al. (2015) (India) Asia 50 25 / 25 Digital calliper 93.06 (2.28) 79.60 (3.02) 93.35 (2.31) / 92.79 (2.28) 80.17 (3.13) / 79.09 (2.92) - Yes
(Lucknow) (0.01 mm)
Shastri et al. (2015) (India Asia 40 NS Digital calliper 91.73 (3.6) 76.89 (4.16) NS NS - Yes
(North)) (Lucknow)
Bughaighis et al. (2015) Africa 220 NS Digital calliper 91.55 (2.40) 78.29 (2.53) NS NS - Yes
(Libya) (Benghazi) (0.01 mm)
Ismail et al. (2015) (Sudan) Africa 49 26 / 23 Digital calliper 91.47 (2.83) 77.46 (3.16) 91.51 (3.27) / 91.39 (2.54) 77.00 (4.65) / 76.55 (3.34) - Yes
(Khartoum) (0.1 mm)
Maurya et al. (2015) (India) Asia 60 30 / 30 Digital calliper 92.38 (2.51) 80.13 (3.48) 93.03 (2.34) / 91.72 (2.58) 80.86 (3.28) / 79.40 (3.64) - Yes
(Madhya Pradesh) (0.01 mm)
Zerouaoui et al. (2014) Africa 30 NS Digital calliper 91.37 (2.05) 77.93 (2.60) NS NS - Yes
(Morocco) (Rabat)
Jindal and Bunger (2013) Asia 300 150 / Digital calliper 92.75 (3.15) 79.82 (3.85) 93.93 (3.34) / 91.58 (2.44) 80.87 (43135) / 78.77 - Yes
(India) (Punjab) 150 (0.01 mm) (3.38)
Asma (2013) (Malaysia) Asia 50 NS Digital calliper NS 78.83 (4.06) NS NS - Yes
(Selangor) (0.01 mm)
Ricci et al. (2013) (Brazil) America 35 NS Digital calliper 91.19 (2.70) 78.16 (2.87) 91.25 (3.24) / 91.17 (2.58) 78.66 (3.64) / 78.01 (2.66) - Yes
Hyder et al. (2012) Asia 40 20 / 20 Digital calliper 90.40 (2.69) 77.70 (2.81) 89.82 (3.06) / 91.06 (2.18) 77.92 (2.80) / 77.49 (2.87) - Yes

(Bangladesh) (Dhaka) (0.01 mm)
Kansal et al. (2012) (India) Asia 231 NS Digital calliper 91.80 (3.30) 79.20 (3.80) NS NS - Yes
(Karnataka) (0.01 mm)
O’Mahony et al. (2011) Europe 60 30 / 30 OrhoAnalyzer 92.30 (2.20) 79.00 92.4 (2.20) / 92.10 (2.20) 78.40 (2.90) / 79.60 (3.20) - Yes
(Ireland) (Cork) (Software) (43376)
Vela et al. (2011) (USA) America 207 110 / 97 Digital calliper NS 78.97 (2.29) NS 79.12 (1.99) / 78.84 (2.49) - No
(Texas) (0.01 mm)
Endo et al. (2010) (Japan) Asia 66 33 / 33 Digital calliper 91.10 (2.20) NS 91.18 (2.27) / 91.01 (2.17) NS - Yes
(Niigata) (0.01 mm)
(Continued)
Machado et al.
pairwise Bayesian
Oktay and Ulukaya (2010) Europe 100 65 / 35 RMI 550 3D (0.01 92.27 (2.16) 78.61 (2.80) 92.33 (1.88) / 92.24 (2.32) 78.66 (2.41) / 78.58 (3.01) - Yes
Strujić et al. (2009) (Croatia) Europe 110 68 / 42 Digital calliper 91.81 (1.99) 78.25 (2.58) NS NS - Yes
(Zagreb) (0.01 mm)
Endo et al. (2009) (Japan) Asia 101 59 / 42 Digital calliper 91.15 (2.14) 77.84 (2.46) 91.14 (2.33) / 91.15 (1.99) 77.97 (2.55) / 77.74 (2.39) - Yes
(Niigata) (0.01 mm)
(Niigata) (0.01 mm)
Al Sulaimani et al. (2006) Asia 98 62 / 36 Ortho-l software 93.90 (4.07) 81.11 (5.07) NS NS - Yes
(Saudi Arabia) (Jeddah)
Cİğer et al. (2006) (Turkey) Europe 125 70 / 55 Digital calliper 91.95 (2.20) 77.95 (2.35) 91.97 (1.65) / 91.82 (1.99) 78.62 (2.24) / 78.43 (2.41) - Yes
Carreiro et al. (2005) America 44 22 / 22 Microscribe 3DX 92.13 (2.08) 77.13 (3.15) NS NS - Yes
(Brazil) (Panamá)
Uysal et al. (2005) (Turkey) Europe 156 150 / 6 Digital calliper 91.90 (3.21) 78.56 (3.23) 91.65 (3.51) / 91.57 (2.98) 78.18 (3.31) / 78.44 (3.18) - Yes
(Konya) (0.01 mm)
Laino et al. (2003) (Italy) Europe 57 31 / 26 Digital calliper 91.72 (2.20) 78.12 (2.41) NS NS - Yes
(Campania) (0.01 mm)
Araújo et al. (2003) (Brazil) America 100 58 / 42 Digital calliper NS 78.18 (2.85) NS NS - Yes
(Belo Horizonte) (0.01 mm)
Alkofide and Hashim (2002) Asia 60 30 / 30 Digital calliper 92.24 (2.04) 78.77 (2.74) 92.12 (1.67) / 92.36 (2.37) 78.75 (2.27) / 78.79 (3.19) - Yes
Ta et al. (2001) (Hong Kong) Asia 50 25 / 25 Digital calliper 90.65 (1.19) 77.55 (1.80) 91.10 (1.00) / 90.20 (1.20) 77.60 (1.80) / 77.50 (1.80) - Yes
(Sheung Wan) (0.01 mm)
Nie and Lin (1999) (China) Asia 60 30 / 30 Software (0,01 93.27 (2.48) 81.52 (2.82) 93.62 (2.42) / 93.41 (2.53) 81.87 (2.51) / 81.25 (2.87) - Yes
(Beijing) mm)
Crosby and Alexander America 30 NS Digital calliper 91.30 (2.40) 77.2 (2.70) NS NS - Yes
(1989) (USA) (Texas) (0.01 mm)
Class II
Škrinjarić et al. (2018) Europe 55 34 / 23 ATOS II SO 91.27 (2.04) 77.46 (2.17) 91.50 (2.23) / 90.94 (1.71) 77.51 (1.93) / 77.39 (2.51) - Yes
(Croatia) (Zagreb)
(Chinese) (0.01 mm)
(Continued)
15
16
pairwise Bayesian

(Malay) (0.01 mm)
Saritha et al. (2017) (India) Asia 103 70 / 33 Digital calliper 92.296 78.642 92.14 (1.9) / 92.37 (2.05) 78.21 (2.56) / 78.84 (2.99) - Yes
(Telangana) (0.01 mm) (1.997) (2.868)
Cançado et al. (2016) (Brazil) America 324 NS Digital calliper 91.46 (2.06) 78.31 (2.39) NS NS - Yes
(Dourados) (0.01 mm)
Al-Duliamy et al. (2016) Asia 40 NS Digital calliper 91.54 (2.66) 79.05 (2.64) NS NS - Yes
(Iraq) (Baghdad) (0.01 mm)
Al-Duliamy et al. (2016) Africa 40 NS Digital calliper 89.14 (5.13) 78.46 (3.97) NS NS - Yes
(Egypt) (Cairo) (0.01 mm)
Shastri et al. (2015) (India Asia 50 NS Digital calliper 90.77 (2.13) 81.10 (5.01) NS NS - Yes
(North)) (Lucknow)
Ismail and Abuaffan (2015) Africa 59 27 / 22 Digital calliper 92.05 (3.11) 77.45 (4.8) 92.22 (3.84) / 91.92 (2.35) 77.17 (6.05) / 77.68 (3.44) - Yes
Maurya et al. (2015) (India) Asia 60 30 / 30 Digital calliper 91.69 (2.4) 79.06 (2.56) 91.67 (1.92) / 91.7 (2.87) 77.98 (1.95) / 80.14 (2.7) - Yes
(Madhya Pradesh) (0.01 mm)
Zerouaoui et al. (2014) Africa 30 NS Digital calliper 92.597 79.5975 NS NS - Yes
(Morocco) (Rabat) (2.41398) (2.94213)
McSwiney et al. (2014) Europe 60 30 / 30 Software (0.01 90.20 (2.27) 76.50 (2.77) 89.90 (2.31) / 90.50 (2.24) 76.50 (2.87) / 76.55 (2.70) - Yes
(Ireland) (Dublin) mm)

O’Mahony et al. (2011) Europe 120 60 / 60 OrhoAnalyzer 92.20 (2.19) 79.40 (3.36) 92.30 (2.31) / 92.05 (2.03) 79.50 (3.56) / 79.35 (3.20) - Yes
(Ireland) (Cork) (Software)
(Niigata) (0.01 mm)
(Continued)
Machado et al.
pairwise Bayesian
(Zagreb) (0.01 mm)
(Niigata) (0.01 mm)
(Niigata) (0.01 mm)
Al Sulaimani et al. (2006) Asia 52 34 / 18 Ortho-l software 93.06 (3.65) 81.88 (4.31) NS NS - Yes
Uysal et al. (2005) (Turkey) Europe 191 105 / 86 Digital calliper 91.27 (3.35) 78.59 (3.48) NS NS - Yes
(Konya) (0.01 mm)
Laino et al. (2004) (Italy) Europe 24 18 / 6 Digital calliper 91.24 (1.85) 78.04 (2.35) NS NS - Yes
Nie and Lin (1999) (China) Asia 120 60 / 60 Software (0.01 92.06 (2.50) 80.79 (3.19) 92.10 (2.66) / 92.02 (2.33) 80.69 (3.72) / 80.89 (2.54) - Yes
(Beijing) mm)
(1989) (USA) (Texas) (0.01 mm)
Class II – Division 1
Elsheikhi et al. (2017) (Libya) Africa 20 10 / 10 Digital calliper 91.38 (3.06) 76.29 (3.02) NS NS - Yes
Chugh et al. (2015) (India) Asia 40 20 / 20 Digital calliper 91.53 (2.49) 78.96 (3.56) 92.24 (2.43) / 90.83 (2.41) 79.95 (2.78) / 77.97 (3.66) - Yes
(Lucknow) (0.01 mm)
(Continued)
17
18
pairwise Bayesian

Ricci et al. (2013) (Brazil) America 35 NS Digital calliper 90.67 (2.4) 77.29 (2.51) 90.37 (2.35) / 90.76 (2.45) 77.27 (2.08) / 77.3 (2.65) - Yes
Cİğer et al. (2006) (Turkey) Europe 71 40 / 31 Digital calliper 90.83 (3.9) 78.04 (2.57) 90.54 (3.4) / 91.05 (4.24) 77.94 (2.46) / 78.11 (2.65) - Yes
Carreiro et al. (2005) America 54 26 / 28 Microscrrib 3DX 92.24 (2.56) 79.79 (4.24) NS NS - Yes
(Brazil) (Panamá)
Uysal et al. (2005) (Turkey) Europe 157 82 / 75 Digital calliper 91.12 (3.34) 78.50 (3.30) 91.19 (2.53) / 91.07 (3.96) 78.68 (3.06) / 78.33 (2.42) - Yes
(Konya) (0.01 mm)
(Beijing) mm)
(1989) (USA) (Texas) (0.01 mm)
Class II – Division 2
Machado et al. (2018) Europe 28 20 / 8 Software (0.01 91.60 (2.60) 78.60 (3.40) 92.3 (2.00) / 91.30 (2.90) 78.50 (3.70) / 78.70 (3.30) - Yes
(Portugal) (Almada) mm)
Mahmoud et al. (2017) Asia 3 NS Software (0.01 92.42 (2.17) 78.57 (1.53) NS NS - Yes
(Sudan) (Khartoum) mm)
Bughaighis et al. (2015) Africa 12 NS Software (0.01 91.56 (1.21) 78.20 (2.29) NS NS - Yes
(Libya) (Benghazi) mm)
Asma (2013) (Malaysia) Asia 50 NS Software (0.01 NS 80.33 (4.71) NS NS - Yes
(Selangor) mm)
Kansal et al. (2012) (India) Asia 17 NS Software (0.01 91.80 (2.90) 79.10 (3.00) NS NS - Yes
(Karnataka) mm)
(Continued)
Machado et al.
pairwise Bayesian
Uysal et al. (2005) (Turkey) Europe 34 23 / 11 Software (0.01 91.94 (3.34) 79 (4.23) 90.81 (2.27) / 89.81 (4.65) 79.63 (3.35) / 78.70 (4.64) - Yes
(Konya) mm)
(Beijing) mm)
Crosby and Alexander America 29 NS Software (0.01 91.50 (3.10) 76.80 (5.30) NS NS - Yes
(1989) (USA) (Texas) mm)
Class III
Škrinjarić (2018) (Croatia) Europe 27 15 /12 ATOS II SO 91.50 (2.88) 78.08 (3.03) 92.23 (2.50) / 90.92 (3.12) 78.62 (3.22) / 77.67 (2.10) - Yes
(Zagreb)
(Chinese) (0.01 mm)
(Malay) (0.01 mm)
Machado et al. (2018) Europe 38 25 / 13 Software (0.01 92.00 (2.00) 78.00 (2.90) 91.80 (1.60) / 92.10 (2.30) 78.00 (2.90) / 78.10 (2.90) - Yes
(Portugal) (Almada) mm)
Saritha et al. (2017) (India) Asia 40 21 / 19 Software (0.01 92.967 79.72 (2.52) 92.99 (1.75) / 92.94 (1.38) 79.92 (3.06) / 79.54 (1.97) - Yes
(Telangana) mm) (1.546)
Mahmoud et al. (2017) Asia 11 NS Software (0.01 91.38 (2.04) 78.37 (3.16) NS NS - Yes
(Sudan) (Khartoum) mm)
Elsheikhi et al. (2017) (Libya) Africa 20 10 / 10 Software (0.01 92.05 (2.96) 76.65 (4.09) NS NS - Yes
(Benghazi) mm)
Cançado et al. (2016) (Brazil) America 66 NS Software (0.01 91.22 (2.07) 77.90 (2.85) NS NS - Yes
(Dourados) mm)
Al-Duliamy et al. (2016) Asia 10 NS Software (0.01 91.82 (2.24) 78.80 (2.15) NS NS - Yes
(Iraq) (Baghdad) mm)
Al-Duliamy et al. (2016) Africa 10 NS Software (0.01 90.65 (3.71) 78.65 (4.20) NS NS - Yes
(Egypt) (Cairo) mm)
Chugh et al. (2015) (India) Asia 30 NS Software (0.01 94.05 (2.01) 81.23 (3.11) 94.48 (1.83) / 93.47 (2.11) 81.96 (3.17) / 80.49 (2.98) - Yes
(Lucknow) mm)
(Continued)
19
20
pairwise Bayesian
Shastri et al. (2015) (India Asia 20 NS Software (0.01 91.33 (2.32) 77.51 (5.64) NS NS - Yes
(North)) (Lucknow) mm)
Bughaighis et al. (2015) Africa 13 NS Software (0.01 90.97 (2.93) 77.48 (3.51) NS NS - Yes
(Libya) (Benghazi) mm)
Ismail et al. (2015) (Sudan) Africa 43 27 / 16 Software (0.01 92.60 (3.01) 77.71 (4.20) 93.58 (2.71) / 92.02 (3.03) 78.01 (4.12) / 77.53 (4.24) - Yes
(Khartoum) mm)
Maurya et al. (2015) (India) Asia 24 12 / 12 Software (0.01 94.72 (1.13) 84.49 (1.33) 95.51 (0.72) / 93.93 (0.88) 85.56 (0.93) / 84.33 (1.57) - Yes
(Madhya Pradesh) mm)
Zerouaoui et al. (2014) Africa 30 NS Software (0.01 92.075 78.2358 NS NS - Yes
(Morocco) (Rabat) mm) (2.2062) (2.85751)
McSwiney et al. (2014) Europe 60 NS Software (0.01 92.25 (2.31) 78.35 (2.42) 92.30 (2.27) / 92.20 (2.41) 78.15 (2.37) / 78.55 (2.58) - Yes
(Ireland) (Dublin) mm)
Asma (2013) (Malaysia) Asia 50 NS Software (0.01 NS 79.09 (2.82) NS NS - Yes
(Selangor) mm)
(Niigata) (0.01 mm)
(Zagreb) (0.01 mm)
(Niigata) (0.01 mm)
(Niigata) (0.01 mm)
Carreiro et al. (2005) America 46 23 / 23 Microscribe 3DX 92.30 (2.69) 79.54 (4.46) NS NS - Yes
(Brazil) (Panamá)
Uysal et al. (2005) (Turkey) Europe 113 55 / 58 Digital calliper 91.69 (3.66) 78.83 (3.46) 92.34 (3.67) / 91.01 (3,56) 79.59 (3.67) / 78.03 (3.06) - Yes
(Konya) (0.01 mm)
(Continued)
Machado et al.
pairwise Bayesian
Al Sulaimani et al. (2006) Asia 10 2/8 Ortho-l software 96.30 (1.45) 80.58 (3.74) NS NS - Yes
Laino et al. (2004) (Italy) Europe 13 6/7 Digital calliper 90.94 (2.26) 78.19 (2.27) NS NS - Yes
(Beijing) mm)
AI, Anterior Index; OI, Overall Index; CBCT, cone-beam computed tomography; NS, not stated; SD, standard deviation.
21
Figure 2. Datasets by year and population group by normal occlusion and Angle’s malocclusion groups. Area of
the circle is proportional to sample size.
Figure 3. Forest plot of studies with OI mean values for normal occlusion patients. Mean effect size estimates have been
calculated with 95% CIs and are shown in the figure. Area of squares represents sample size, continuous horizontal lines and
diamond width represents 95% CI. Blue diamond centre and the vertical red dotted line point to the overall pooled estimate.
Machado et al. 23
Figure 4. Forest plot of studies with AI mean values for normal occlusion patients. Mean effect size estimates have been
calculated with 95% CIs and are shown in the figure. Area of squares represents sample size, continuous horizontal lines and
diamond width represents 95% CI. Blue diamond centre and the vertical red dotted line point to the overall pooled estimate.
CI = 91.42–92.14) and an AI mean of 78.25% (95% CI = possible. Thus, we adopted a Bayesian NMA approach to
77.87–78.62). In both syntheses, heterogeneity was high (I 2 pool all available direct and indirect comparisons between
= 92.87% and I2 = 90.67% in OI and AI, respectively). normal occlusion versus Angle’s Class I, Class II, Class II
Next, we looked for gender differences on OI and AI division 1, Class II division 2 and Class III values. The net-
through gender subgroup meta-analysis. Only Class I pre- work fit statistic outcome included adjusted normal occlu-
sented a gender impact with male patients having a higher sion mean values for each Angle’s malocclusions and the
OI (0.30, 95% CI = 0.00–0.59) and AI (0.41, 95% CI = estimated normal versus malocclusion difference of means,
0.00–0.83) mean values than female patients (Supplement with the degree of certainty of such differences reported as
S5). The GRADE assessment is depicted in Table 5. CrIs and heterogeneity as I2 and Tau2 (Tables 3 and 4).
The mean change from normal occlusion for AI means
Pairwise MA normal occlusion versus Bolton’s original Class I, Class II, Class II division 1 and Class II division 2
val-ues. Direct comparison of the Pairwise MA pooled esti- was −0.01 (95% CrI = −0.26 to 0.24), −0.10 (95% CrI =
mates for AI and OI normal occlusion mean values with −0.35 to 0.15), −0.14 (95% CrI = −0.42 to 0.14) and 0.19
Bolton’s original values, through Z-test, revealed signifi-cant (95% CrI = −0.17 to 0.55), respectively, but in all, the
differences in both AI and OI (P < 0.10) (Table 2). 95% CrI included zero (Table 3). A similar trend was also
observed for OI means when we compared the means of
Bayesian network meta-analysis findings for Angle’s Class I, Class II and Class II division 2 with normal
malocclu-sions groups. The difference in mean change for occlusion (Table 4).
normal occlusion (baseline) compared with different Angle’s In contrast, we found a meaningful difference between
mal-occlusion groups is presented in Tables 3 and 4, and can be Angle’s Class III versus normal occlusion for both OI and
seen as a measure of the average effort required to treat each AI means (0.76, 95% CrI = 0.55–0.98, and 0.61, 95% CrI
represented malocclusion towards a proportional occlusion. In = 0.35–0.87, respectively) and for Class II division 1
studies with no normal occlusion data, the comparison with the (−0.28, 95% CrI = −0.52 to −0.05) against normal occlu-
different types of Angle’s malocclusions was not sion AI means, since the null difference is not within the
Table 2. Comparison of Pairwise MA of normal occlusion with Bolton’s original values.
AI OI
n Mean (%) SD (%) P (Z-test) n Mean (%) SD (%) P (Z-test)
PMA normal occlusion 1954 78.25 8.5 < 0.001 1919 91.78 4.1 0.08
Bolton’s original values 55 77.20 1.65 55 91.3 1.91
Significant correlations identified in bold (P < 0.10).

AI, Anterior Index; MA, meta-analysis; OI, Overall Index; SD, standard deviation.
Table 3. Results of pairwise MA of normal occlusion and Bayesian NMA of Angle’s malocclusion groups and
difference to normal occlusion in the AI.
AI Heterogeneity
Mean difference to
normal occlusion (%) Studies
Model n Mean [95% CI] [95% CrI] (n) Tau2 [SE] I2
Random effects
Normal occlusion 1954 78.25 [77.87–78.62] - 28 0.896 [0.623] 90.67
Bayesian NMA
Normal occlusion 780 78.29 [61.64–95.05] - - - -
(network adjusted)
Class I 3425 78.26 [61.58–95.01] −0.01 [−0.26 to 0.24] 11 0.100 [0.165] 27.36
Class II 2717 78.10 [61.60–94.66] −0.10 [−0.35 to 0.15] 8 0.07 [0.160] 25.73
Class II / division 1 1111 78.07 [61.47–94.69] −0.14 [−0.42 to 0.14] 10 0.265 [0.265] 49.93
Class II / division 2 453 78.41 [61.85–95.08] 0.19 [−0.17 to 0.55] 6 0 [0.231] 0
Class III 1503 78.86 [62.14–95.51] 0.61 [0.35–0.87] 10 0.135 [0.207] 31.41
Bold values indicate significant difference to normal occlusion.

CI/CrI boundaries and I2 in %.
Malocclusion classes heterogeneity estimators were extracted from difference to normal Pairwise MA, while normal occlusion
heterogeneity was related to raw mean pairwise MA.
AI, Anterior Index; CI, confidence interval; CrI, credibility interval; MA, meta-analysis; NMA, network meta-analysis.
credibility region (Tables 3 and 4). The GRADE assess- years have been of increased interest (Figure 2). Our
ment is described in Table 5. results in patients with normal occlusion demonstrated that
the OI mean was 91.78% (95% CI = 91.42–92.14) and AI
mean was 78.25% (95% CI = 77.87–78.62) worldwide,
Additional analyses while the values proposed by Bolton (1958) were
Funnel plots revealed no evidence of publication bias respectively smaller.
(Supplement S6). Clinically, and according to Bolton’s original values, if
the OI are > 91.3% and > 77.2%, respectively, it indicates
mandibular tooth material excess. In this case, maxillary
Discussion teeth are relatively smaller compared to the mandibular
teeth, and mandibular teeth stripping or extraction can be
Summary of main findings pondered as a treatment option. Since Bolton’s original
To the best of our knowledge, this is the first systematic val-ues are not the same as those found in this meta-
review that attempted to estimate overall OI and AI values in analysis for normal occlusion patients, then unnecessary
patients with normal occlusion and Angle’s malocclu-sion. stripping or teeth extraction can be performed, which can
Despite the apparent gap in observational studies about lead to clini-cal complications when trying to reach a
normal occlusion between 1972 and 1998, the last 20 stable occlusion based on Andrew’s six keys.
Machado et al. 25
Table 4. Results of Pairwise MA of normal occlusion and Bayesian NMA of Angle’s malocclusion groups and
difference to normal occlusion in OI.
OI Heterogeneity
Mean difference to normal
Model n Mean [95% CI] occlusion (%) [95% CrI] Studies (n) Tau2 [SE] I2
Random effects
Normal occlusion 1919 91.78 [91.42–92.14] - 27 0.828 [0.712] 92.87
Bayesian NMA
Normal occlusion 780 91.78 [75.46–108.05] - - - -
(network adjusted)
Class I 3134 91.92 [75.72–108.10] 0.16 [−0.04 to 0.37] 11 0.455 [0.294] 72.24
Class II 2641 91.71 [75.37–108-08] −0.06 [−0.27 to 0.15] 8 0.412 [0.317] 73.39
Class II / division 1 1061 91.50 [75.35–107-65] −0.28 [−0.52 to −0.05] 10 0.356 [0.269] 65.09
Class II / division 2 403 91.70 [75.39–107.92] 0.01 [−0.28 to 0.30] 6 0.553 [0.513] 73.41
Class III 1419 92.52 [76.27–108.89] 0.76 [0.55–0.98] 10 0.887 [0.553] 82.63
Bold values indicate significant difference to normal occlusion.

Mean and CrIs boundaries in %.
Baseline normal occlusion is the covariate in the adjusted NMA.
Malocclusion classes heterogeneity estimators were extracted from difference to normal Pairwise MA, while normal occlusion
heterogeneity was related to raw mean pairwise MA.
CrI, credibility interval; MA, meta-analysis; NMA, network meta-analysis; OI, Overall Index.
Table 5. GRADE evidence profile for OI and AI in normal occlusion and malocclusions.
Outcome Study design Risk of bias Inconsistency Indirectness Imprecision Publication bias
Normal OI Observational Not serious Serious* Not serious Not serious Not serious
occlusion studies (serious)
AI Observational Not serious Serious* Not serious Not serious Not serious
studies (serious)
Malocclusions OI Observational Not serious Serious* Not serious Not serious Not serious
studies (serious)
AI Observational Not serious Serious* Not serious Not serious Not serious
studies (serious)
*Downgraded for serious inconsistency: even considering the large sample sizes and the use of digital, some degree of
heterogeneity is still perceptible.
AI, Anterior Index; GRADE, Grading of Recommendations Assessment, Development, and Evaluation; I Explanations: GRADE
Working Group grades of evidence; OI, Overall Index.
In fact, pooled Pairwise MA normal occlusion estimates representative of the continent as a whole. There is a lack of
were not significantly different from Bolton’s values; how- studies in the continents of North America and Oceania.
ever, this direct comparison, though necessary, is quite unfair Similarly, the African continent is portrayed only by Libya,
and disproportionate as shown by the extraordinarily low Egypt, Morocco and Sudan, the European continent is repre-
statistical power. Also, the computed SDs from meta- sented mainly by studies in Turkey and Ireland, the Asian
analytical pooled estimates revealed very discrepant and continent is mostly represented by studies from India, and the
elevated values when compared with Bolton’s, and we American continents only had two studies from North
believe that these direct comparisons are biased since it is not America and the remaining studies are from Brazil. Despite
adequate to compare so unequal samples. this restriction, future research should address race and
It is important to remark that we have not made geographic genetic backgrounds to weigh their influence on the mesio-
subgroups based on continent since the studies are not fully distal proportions since it was not possible to perform this in
this study due to the lack of such data. Still, globalisation and opinion, these results can be obtained from the lack of
inter-racial/inter-ethnic mixing strongly support the concept high methodological homogeneity, but also from a high
of non-static proportions and the necessity for continued varia-bleness of mesiodistal width proportions among the
research. Further, gender and geographic location, in general, populations.
are not factors that influence dental width proportions. Regarding methodology, most studies took teeth meas-
Regarding the relation between normal occlusion and Angle urements from plaster models. Only one investigation used
malocclusions, in general, our results determined that no cone-beam computed tomography (CBCT) (Celikoglu et al.,
significant difference in the tooth size discrepancy existed for 2013), five studies have digitised plaster models and
the OI and AI between normal occlusion and different mal- subsequently performed the measurements (Al Sulaimani and
occlusion groups, except for the Class III malocclusion in both Afify, 2006; Jóias et al., 2010; Lombardo et al., 2016;
AI and OI, and Class I malocclusion in OI only. Under these O’Mahony et al., 2011; Škrinjarić et al., 2018) and three also
circumstances, the results indicate that the discrepancy of used an electronic measuring device (Carreiro et al., 2005;
intermaxillary tooth size may be one of the important factors in Nie and Lin, 1999; Oktay and Ulukaya, 2010). Although in
the cause of malocclusions, especially in Angle’s Class III. the past calliper measurement in plaster mod-els was the gold
The results also suggest that these OI and AI differences standard, nowadays the study of models with virtual three-
for normal occlusion in Angle’s Class I and Class III may be dimensional (3D) technology has higher reliability and
explained by upper and/or lower discrepancy. For both accuracy (Aragón et al., 2016; De Luca Canto et al., 2015;
Angle’s Class I and III difference for normal occlusion, a Fleming et al., 2011; Luu et al., 2012) and should be used as
possible clinical explanation for this discrepancy may be due the first choice for diagnosis and treatment planning in
to smaller mesiodistal maxillary tooth sizes and/or greater orthodontics, specifically to deter-mine the width of teeth.
mesiodistal mandibular widths. Additionally, study models pro-duced by CBCT are far from
perfect for replacing digital models. Hence, in the future, with
proper improvement, CBCT will ensure a multiplicity of
Quality of the evidence and potential
analyses from a single record (Ferreira et al., 2017).
biases in the review process Furthermore, it is imperative that, in addition to the
All studies included in the meta-analysis presented overall mesiodistal width, the labio-lingual and inclination data
medium quality, according to our predefined quality assess- should be evaluated since they may also present great
ment and risk of bias. However, there are important matters variability in populations. Thus, a 3D orthodontic diagnosis
that need to be pointed out. Hypothetical limitations would and treatment plan is more desirable than a two-dimensional
be the fact that this systematic review only contains obser- assessment.
vational studies and language biases, because only studies in The overall results of this study are in line with a previ-
English were included. However, except for restorative or ous comprehensive review (Othman and Harradine, 2006).
traumatic reasons, mesiodistal width of teeth remains pro- Although gender has no clinically significant effect on
spectively unchanged. Therefore, randomised controlled tri- tooth size discrepancy (TSD) in general, this study con-
als, and prospective or retrospective studies on this theme, firmed a significant difference in Class I malocclusion
would be inappropriate unless they were the result of a sec- between men and women. Besides, we proved what was
ondary observation. comprehensively stated that Class III malocclusions have
On the other hand, we must emphasise that most stud- higher average ratios (Othman and Harradine, 2006).
ies lack sample size calculation and are non-representa-
tive of the population, but are rather from an academic
setting. Besides, too many studies show a lack of informa- Conclusions
tion on calibration method or the number of examiners. The results of this systematic review show that overall pooled
These items are extremely important to minimise selec- OI and AI mean values for normal occlusion patients are
tion bias and strengthen the generalisation of results, and slightly above Bolton’s original values. Class I, for OI mean
its absence weakens the results of this systematic review. values, and Class III, for both OI and AI, are propor-tionally
Additionally, no study has reported the existence of blind- larger than normal occlusion patients. Gender had almost no
ing examiners, since presumably the researchers them- impact on teeth mesiodistal proportion.
selves were involved in measurements of teeth and
Angle’s evaluation. This potential bias should be consid-
ered in future research. Implications for clinical
Significantly, the heterogeneity revealed by our meta- practice and research
analysis refers, conceptually, to the variation in study out- Despite being one of several measures used in orthodon-
comes between studies. This variation could flag some tic planning, the results of this systematic review suggest
problems; however, we need to carefully assess this dis- that Bolton’s original values may be slightly underesti-
crepancy, contrary to common meta-analysis. In our mated as the OI and AI global standard. The use of
Machado et al. 27
inadequate standard measures for the dental proportion of Data availability

each population can lead to diagnostic errors and could Data are available at https://doi.org/10.5281/zenodo.3407853
influence the patient’s treatment outcome. Also, despite
these AI and OI mean values being originally developed Supplemental material
only for tooth width reduction (through interproximal
Supplemental material for this article is available online.
stripping or extraction), several patients with mesiodistal
disproportionality, mainly due to microdontia or agenesis
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A Systematic Review and Meta-Analysis On Bolton's Ratios: Normal Occlusion and Malocclusion

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886322 JOO Journal of OrthodonticsMachado et al.

A systematic review and meta- 2020, Vol. 47(1) 7–29

analysis on Bolton’s ratios: Normal Article reuse guidelines:

occlusion and malocclusion journals.sagepub.com/home/joo

Vanessa Machado1,2 , João Botelho1, Paulo

Introduction 1Clinical Research Unit (CRU), Centro de Investigação

6. The study measured the largest mesiodistal teeth Risk of bias

cope with limitations in traditional pairwise meta-analysis. Study characteristics

Figure 1. Flow chart of the study selection process.

Journal of Orthodontics 47(1)

Asia 9 NS Digital calliper 91.2 (2.49) 78.9 (3.43) NS NS - Yes

Journal of Orthodontics 47(1)

Asma (2013) (Malaysia) Asia 50 NS Digital calliper NS 78.75 (3.85) NS NS - Yes

Table 2. Comparison of Pairwise MA of normal occlusion with Bolton’s original values.

n Mean (%) SD (%) P (Z-test) n Mean (%) SD (%) P (Z-test)

Significant correlations identified in bold (P < 0.10).

Bold values indicate significant difference to normal occlusion.

Mean difference to normal

Bold values indicate significant difference to normal occlusion.

inadequate standard measures for the dental proportion of Data availability

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