Professional Documents
Culture Documents
I
t has been shown that naturally
possess distinctive dimensional characteristics;
well-aligned mandibular incisors
these teeth are significantly
smaller mesiodistally and significantly larger faciolingually, when compared
with average population tooth dimensions. 1 It appears, therefore, that tooth
shape (mesiodistal and faciolingual dimensions) is a determining factor in the
presence and absence of lower incisor cr0wding.l These new findings have
stimulated this present effort.
The purpose of this article is to present the scientific basis and the clinical
application of a new method for detecting and evaluating tooth shape deviations
of the mandibular incisors.
Presented in part before the twentieth annual meeting of the Middle Atlantic Society
of Orthodont,ists, Washington, D. C., Oct. 5, 1971, and the forty-second annual meet-
ing of the Great Lakes Society of Orthodontists, Columbus, Ohio, Oct. 26, 1971.
*Assistant Professors of Orthodontics, Boston University School of Graduate
Dentistry.
384
Volume 61
Number 4 Index for assessing tooth shape deviations 385
*The tooth dimension referred to in this article as faciolingud is also known as buccolingwcl
and Zabiolingtd. The term buccolingual is commonly used with reference to the posterior teeth,
while ZabdoEingzlaZ is an anterior tooth designation. However, faciolingual, like mesiodistal, is a
term applicable to all the teeth and is therefore preferred by the authors.
Am. J. Orthod.
386 Peck and Peck April 1972
Fig. 1. A mandibular central incisor showing the mesiodistal (MD) and faciolingual (FL)
crown diameters. The MD/FL index (MD/FL X 100) is a numerical expression of the crown’s
shape as seen from the incisal aspect. For the incisor shown, the MD diameter approx-
imately equals the FL diameter, yielding an MD/FL index OF 100. If the MD diameter of
this tooth were greater than its FL diameter, the index would be greater than 100.
Similarly, if the MD diameter were less thar. the FL diameter, the index would be less
than 100.
Table I. Values of the MD/FL index (F x 100) for the mandibular incisors
Group
/female J
(‘&ml incisors
Perfect alignment 90 xx.4 4.3 ix.?- 97.i
6.0 9.3n*
Control population 130 Ij4.4 4.9 80.0-1’05.3
Lateral incisors
Perfect alignment 90 90.4 4.8 i8.0-101.9
6.4 9.27*
Control population 130 96.8 5.2 x5.7-112.7
N = Number of teeth.
SD = Standard deviation.
d = Difference between the means.
t = test value.
“Very highly significant difference, p < 0.001
tleviat,ion of 5.2. The difference between the means (d = 6.4) was again very
highly significant (p < 0.001).
DISCUSSIOK. These findings indicate that well-aligned mandibular central and
lateral incisors possess remarkably distinctive crown shape, as expressed by the
ND/FL index.
Since the experimental sample was selected on the basis of exceptionally good
lower incisor alignment, a close association between the absence of incisor
crowding and certain tooth shape characteristics becomes evident. Lower incisors
apparently conducive to good alignment hare MD/FL indices significantly
lower t,han the population averages for the same teeth. In fact, we would expect
any lower arch possessing central incisors with an MD/FL index of less than or
equal to 88.4 and lateral incisors with an MD/FL index of less than or equal
t,o 90.4 to have excellent incisor alignment. There are, however, many factors
other than tooth shape which may lead to lower incisor irregularity. Therefore,
one may find occasional cases in which mandibular incisors are crowded and yet
possess favorable MD/FL indices.
It is also expected that a similar relationship between incisor shape and
incisor position exists in the opposite direction: MD/FL indices higher than the
“perfect alignment” mean values (for the respective mandibular incisors) should
be characteristic of crowded incisors. Logically, the higher the index, the greater
the tooth shape deviation and the greater the likelihood and degree of associated
incisor crowding.
The estimated population incidence of “perfectly aligned” mandibular
incisors is quite low for AmericanP and Europeans.34 It is probable, therefore,
that the “average” dentition in the population has a detectable amount of lower
incisor crowding. In this light, the control population means for the MD/N,
index (cmtral incisor = 94.4, lateral incisor = 96.8) are themselves indicative
of some degree of tooth shape deviation.
Volume 61 Index for assessing tooth shape deviations 389
Nvm her 4
Fig. 2. The crown shape typical of naturally well-aligned mandibular incisors. This tooth, a
central incisor, has an MD/FL index of approximately 87. The geometric diagram illustrates
the “kite-shaped” crown form which appears especially characteristic of mandibular in-
cisors with low MD/FL indices (less than 90).
Garn, Lewis, and Kerewsky 26 have reported sex differences in tooth shape
throughout the dentition. Estimates of the mandibular incisor MD/FL indices
for males and females which we constructed from their dataz6 and from
odontometric data of other+ 7, 35s36 generally indicate lower MD/FL indices for
males than for females of the same population.* This difference, however, does
not appear marked, roughly averaging 2 per cent of the MD/FL index value for
both central and lateral incisors. Therefore, on the basis of available information,
we may conclude that male-female differences in the MD/FL index are not
significant clinically. We may assume for clinical purposes that our values for
the MD/FL index of females are representative also of the MD/FL index of
males.
Comment on the possible mechanisms responsible for the relationship between
mandibular incisor shape and the presence and absence of crowding can only be
conjectural at this stage. The lower incisor crown, as viewed incisally, resembles
a diamond-shaped kite (Fig. 2). The kite’s width (side to side) would be
equivalent to the MD crown diameter, and the kite’s length (top to bottom)
would be equivalent to the FL crown diameter. A kite’s width is less than its
length, just as the average lower incisor’s MD width is less than its FL length.’
As this difference between the MD width and the FL length increases, the
MD/FL index decreases, and the mandibular incisor crown form appears more
characteristically “kite shaped.” Perhaps the “kite-shaped” pattern represented
*An interesting corollary derives from this observation. If mandibular incisor shape in-
fluences mandibular incisor position, as our study suggests, then the incisors of males should
actually demonstrate a lower frequency of crowding than the incisors of females, because of
their naturally lower MD/FL index. Only one published study (by Seipelsr) gives the fre-
quency of crowding of the individual teeth separately for males and females. It indeed shows
the frequency of crowding for the mandibular central and lateral incisors to be appreciably
less among males than among females, thus confirming this corollary and supporting a causal
relationship between incisor shape and crowding.
Am. J. Orthod.
390 Peck nrld Pick April 1972
by a low MD/FL index (less than 90) confers upon the incisor crown ant1 root
an anatomic advantage over the phenomena of tooth rotat,ion and overlap.
The relatively narrowed MD diameter characteristic of well-alignrtl man
tlibular incisors’ obviously cont,ributes less tooth substance to manclibular arc11
length. This factor, coupled with the chance that a more “kite-shaped” incisor
would tend to hare “flatter,” less acute mesial and distal surfaces, less susceptible
mechanically to cornact slippage. may account in part for the incisor shapcb--
alignment relationship.
The observed relationship between mandibular incisor shape and the presence
and absence of mandibular incisor crowding has significant clinical relevance.
The MD/FL index as previously described and utilized is a numerical expression
of crown shape. As such, it provides an effective clinical method for diagnosing
tooth shape deviations which influence and contribute to mandibular incisor
crowding.
The remainder of this article introcluccs a method of tooth size analysis based
upon the MD/FL index and used by us in clinical diagnosis and treatment
planning.
Clinical principles. In order to recognize tooth shape deviations, a knowledge
of optimum tooth shape is necessary. For the mandibular incisors, the lower the
MD/FL index, the more favorable the tooth shape relative to good alignment.
0ur studies show that well-aligned mandibular central incisors have an MD/FL
index of 88.4 _+4.3, while well-aligned mandibular lateral incisors have an indes
of 90.4 + 4.8.
From these data we have adapted the clinical standards which we use in
determining whether a lower incisor is favorably or unfavorably shaped relative
to good alignment. The following ranges are employed as clinical guidelines for
the maximum limit of desirable MD/FL index *values for the lower incisors:
Mandibular central incisor 88-92
Mandibular lateral incisor 90-95
The lower limit of each range represents approximately the mean value of
the MD/FL index of well-aligned teeth. The upper limit of each range is derived
from the lower limit plus one standard deviation.
liower incisors wit,hin or below these ranges are considered favorably shapetl.
Any lower incisor with an MD/FI, index above these ranges, howe\-er, is con-
sidered to have a crown shape deviation which may influence or contribute to the
crowding phenomenon (Fig. 3).
Of course, this is not always the case. Since we are dealing with four teeth
when we speak of mandibular incisor crowding, good alignment is often present,
with various combinations of favorably and unfavorably shaped teeth. For
instance, lateral incisors with an index of 97 may be well aligned in a mandibular
arch with central incisors that have an index of 86.
However, an MD/Fli index in excess of 100 for any of the lower incisors
represents a severe shape deviation, characteristic of existing or potential tooth
irregularity. From the previously described cont,rol population sample, we have
VoZume 61 Index for assessing tooth shape deviations 391
Number 4
Fig. 3. Variations of mandibular incisor shape. Pictured are the low er incisors of four
adul Its, untreated orthodontically. The number lingual to each tooth i s its MD/FL i ndex
valu me. from studying the photographs, one may readily gather that ( 1) incisor shat 38 is
high IlY variable, (2) incisor shape and incisor alignment are closely relc rted variables, and
(31 1O\n I MD/FL index values are characteristic of well-aligned incisors, while high M D/FL
inde x\ values are characteristic of crowded incisors.
Am. J. Orthod.
392 Peck and Peck AfwiZ1972
Fig. 4. A, Measuring the maximum mesiodistal (MD) diameter of a lower incisor. A dial
caliper is employed. The caliper beaks are positioned near the incisal edge and are held
perpendicular to the long axis of the tooth. B, Measuring the maximum faciolingual (FL)
diameter of a lower incisor. The dial caliper beaks are slipped slightly beneath the gin-
gival margin and are held parallel to the long axis of the tooth.
deduced that approximately 15 per cent of the population have an MD/FL index
greater than 100 for one or both mandibular central incisors. Similarly, about
25 per cent of the population have mandibular lateral incisors with an MD/FL
index in excess of 300. The aT-erage orthodontic practice contains a high con-
centration of these persons. They usually arc the patients exhibiting bimaxillarJ
crowding.
Patients whose mandibular incisors have MD/FL indices above the desired
ranges may well bc candidates for the removal of some mesial and/or distal tooth
substance in conjunction with orthodontic therapy. This procedure is commonly
called “stripping.” Although part of the orthodontic vernacular, “stripping” is a
somewhat distasteful term. Articles and texts frequently resort to euphemisms,
such as “proximal reduction.” We are convinced that purposeful tooth size
alteration will have an increasingly significant place in the orthodontist’s
therapeutic armamentarium. It is therefore deserving of a more exacting, more
Index for assessing tooth shape deviations 393
MD/FL
Index
88-92 1
88-92
90-95
Fig. 5. Table for clinically recording MD and FL crown dimensions. These measurements are
used in computing the MD/FL index for each lower incisor. Sample measurements [in milli-
meters] are written in.
developed for this purpose (Table II). The reference table provides the computed
value of the MD/FL index, given the MD and FL crown dimensions. It contains
only MD/FL index values from 86 to 119. All values below 86 are exceedingly
favorable and therefore require no further clinical consideration. Values above
119 are exceedingly unfavorable but occur very rarely.
Using the MD and FL data given in Fig. 5, we shall illustrate the use of the
reference table. The measurements for the mandibular right lateral incisor are
MD = 6.0 and FL = 6.3. With this information, we go to the reference table
which displays MD dimensions horizontally and FL dimensions vertically, in
graduations of 0.1 mm, We first look across the MD dimensions until MD = 6.0
is found. Then we search down the FL dimensions to find FL = 6.3. Where the
selected MD column and FL row intersect lies the appropriate MD/FL index,
which in this case is 95. Similarly, the MD/FL index for the right central incisor
(MD = 5.4, FL = 6.0) is 90; for the left central incisor (MD = 5.1, FL = 5.8),
88; and for the left lateral hcisor (MD = 6.1, FL = 5.9), 103. In the absence
of the reference table, longhand computations of the MD/FL index are rounded
off to the nearest whole number.
Index for assessing tooth shape deviations 395
The MD/FL bdex i?L cli~~iccd diagnosis. To illustrate the clinical application
of the MD/FL index as a means of detecting and evaluating tooth shape devia-
tions of the mandibular incisors, three diagnostic cases will be presented.
DIAGNOSTIC CASE 1 (BIG. 6). All four lower incisors of this patient show ex-
treme tooth shape deviations. The right and left lateral incisors have MD/FL
indices of 119 and 112, respectively, The right and left central incisors have
MD/FL indices of 102 and 103, respectively. There is marked crowding, for
which the untoward shape and size of the lower incisors-are at least partly
responsible. As part of this patient’s orthodontic treatment (which in this cake
calls for premolar extractions), reproximation of the four mandibular incisors
is mandatory. Otherwise, recrowding of the lower anterior teeth will surely
follow retention.
The lateral incisors are so severely deviated that reproximation, limited by
the thickness of the mesial and distal enamel, can only lessen the deviations
rather than eliminate them completely. For the central incisors, however, we may
expect that reproximation will yield favorable MD/FL indices.
With tooth shape deviations of the intensity observed in these incisors, we
would expect a total of 2 to 3 mm. of mesiodistal enamel to be removed by
reproximation. A loss of tooth substance of this magnitude may upset the
maxillary to mandibular anterior tooth size ratio. Therefore, selective reproxima-
tion of the maxillary incisors may also be indicated to maintain a harmonious
anterior intermaxillary relationship. (For example, if the pretreatment anterior
Bolton indexz2 appears satisfactory, but reproximation of the mandibular incisors
396 Peck and Peck Am. J. Orthod.
April 1972
MD/FL
MD/FL Index
Tooth MD FL Index Standards
’ -q 6.6 7.0 94 90-95
-4
MD/FL
Index
Standards
90-95
The substantial evidence that lower incisor shape has significant bearing on
lower incisor alignment may well affect many areas of orthodontic practice.
For one thing, the introduction of a tooth shape index for use in .clinical
orthodontics opens up new channels of communication. Now we have a means
of numerically expressing what perhaps many orthodontists have been sub-
consciously perceiving all along-a fundamental anatomic difference between a
stable-looking orthodontic result and a not-so-stable-looking result. When, for
example, a colleague now speaks of “an extraction case with MD/FL indices for
the mandibular incisors all in excess of 100,” a significant message has been
succinctly communicated. Besides its use in orthodontic diagnosis and treat-
ment planning, the MD/FL index may prove useful as a parameter in treatment-
priority assessments and epidemiologic surveys of malocclusion.
The observed relationship between lower incisor shape and alignment may
alter some present concepts of retention. Posttreatment retention in orthodontics
is a valuable ingredient of successful therapy. Most orthodontists would agree
that a provision for retention should be included routinely in orthodontic treat-
ment plans.
Perhaps the most worrisome area for the orthodontist during the retention
phase of treatment is the lower incisor segment of the dentition. Over the years
this has led to wide acceptance of “prolonged retention” or “indefinite retention”
398 Peck and Peck Am. J. Ov-thod.
April 1972
Fig. 9. irregular mandibular incisors with favorable MD/FL indices. Factors other than
tooth shape are responsible for this crowding.
for these teeth. d canine-to-canine fixed retainer is often used for this purpose.
It is frequently left in for some years as “insurance” against the “indeter-
minable” causes of incisor relapse. In light of our findings, however, prolonged
retention seems more a postponement of the problem than a solution. We contend
that most of the cases presently “demanding” prolonged retention for the lower
incisors probably require instead judicious reproximation because of tooth shape
deviations.
In orthodontic cases requiring premolar estractions because of major tooth
size-arch size discrepancies (such as malocclusions of the Class I bimaxillary
crowding type), post-retention lower incisor crowding is often observed, even in
the presence of residual extraction space. This is not idiopathic or indeterminable
but is, rather, a logical consequence. In these cases it is usually clear that there
is a generalized excess in the mesiodistal dimension of all the teeth. Although
premolar extractions nicely eliminate the arch length discrepancy, the crown
shape of the remaining teeth is still exaggerated. The mandibular incisors are
often markedly wide and “fan shaped,” with MD/FL indices approaching or in
excess of 100. Incisors of these proportions are destined to recrowd in time, no
matter how “perfect” the posttreatment occlusion and alignment may appear
to be.
Lest the MD/FL indes be misconst,rue<l as an orthodontic “divining rod,”
we hasten to add some qualifying remarks. Thcrc are many persons with optimum
Volume 61 Index for assessing tooth shape deviations 399
Number 4
lower incisor crown shape (according to their RID/FL index values) but with
noticeable displacement or overlapping of these teeth. (Fig. 9 and see Fig, 7). It
is well known that there are many potential factors surrounding the etiology of
lower incisor crowding. Certainly, other dominant variables, such as occlusion,
habits, supra-alveolar fibers, and early deciduous tooth loss, to name only a few,
are capable of upsetting any alignment stability conferred by tooth morphology
alone. Then, too, dental crowding may be a natural aging phenomenon; even
the best-shaped, best-aligned incisors may inevitably crowd with age.
Within the framework of clinical orthodontics, however, seldom can any
degree of mandibular incisor alignment or stability be achieved without some
consideration of crown dimensions, tooth shape, and the ;MD/FL index.
This article presents the scientific basis and the clinical application of a new
method for detecting and evaluating tooth shape deviations which influence and
contribute to mandibular incisor crowding.
It has been shown that mesiodistal (MD) and faciolingual (FL) crown
dimensions appear to be related to mandibular incisor alignment.* However, a
survey of odontometric procedures used today by orthodontists reveals that the
FL crown dimension is completely neglected in orthodontic diagnosis and treat-
ment planning.
An index incorporating both dimensions is proposed for clinical orthodontics.
It is constructed in the following manner :
The final part of this article introduces a clinical method of lower incisor
toot,11 size analysis based upon the MU/FL index. Clinical principles and pro-
cedures related to the use of the MU/FL index are explained. Cases art:
presented to illustrate the use of the index in orthodontic diagnosis and treat-
ment planning. Reproximation (“stripping”) is described as a clinical procedure
for correcting tooth shape deviations.
A consideration of tooth shape and the MU/FL index appears essential foi
the successful orthodontic management of mandibular incisor irregularities.
Special acknowledgment is expressed to Miss Gail N. Cross, Director of the Dental As-
sistant Programs at. Boston University School of Graduate Dentistry and Beth Israel Hospital,
Boston, and to Miss Barbara Schultz, Assistant Dean at the Forsyth School for Dental Hy-
gienists, Boston, for their cooperation in implementing the odontometric study. The authors
are grateful to Miss Sylvia Fleisch, Assistgnt Director, Boston University Computing Center,
for her valued assistance.
REFERENCES
1. Peck, S., and Peck, H. : Crown dimensions and mandibular incisor alignment, Angle Orthod.
(In press.)
2. Black, G. V.: Descriptive anatomy of the human teeth, ed. 4, Philadelphia, 1902, 8. 9.
White Dental Mfg. Co.
3. Nelson, C. T.: The teeth of the Indians of Pecos pueblo, Am. J. Phys. Anthropol. 23: 261,
1938.
4. Selmer-Olsen, R.: An odontometrical study on the Norwegian Lapps, Oslo, 1949, Norske
Videnskaps-Akademi.
5. Rantanen, A. V. : Suomalaisten hampaiden suurussuhteista, Suom. HammaslZk. ‘l’oim.
60: 250, 1964.
6. Twiesselmann, F., and Brabant, H.: Nouvelles observations SUT les dents et les maxill-
aires d’une population ancienne d’age franc de Coxyde (Belgique), Bull. Group. Int.
Rech. Sci. Stomatol. 10: 5, 1967.
7. Lunt, D. A.: An odontometric study of mediaeval Danes, Acta Odontol. Stand. 27:
Supp. 55, 1969.
8. lvioorrees, C. F. A.: The Aleut dentition, Cambridge, 1957, Harvard University Press,
pp. 80, 90-93.
9. Goose, D. H.: Dental measurement: An assessment of its value in anthropological
studies. 1% Brothwell, D. R. (editor): Dental Anthropology, New York, 1963, Pergamon
Press, p. 130.
10. Moyers, R. E.: Handbook of orthodontics, ed. 2, Chicago, 1963, Year Book Xeliical
Publishers.
Il. Nance, H. N.: The limitations of orthodontic treatment. 1. IMixed dentition diagnosis
and treatment, AM. J. ORTHOD. 33: 177,1947.
12. Ballard, M. L., and Wylie, W. L.: Mixed dentition case analysis-Estimating size of
unerupted permanent teeth, AK J. ORTHOD. 33: 754,1947.
13. Stlhle, H.: The determination of mesiodistal crown width of unerupted permanent
cuspids and bicuspids, Helv. Odontol. Acta 3: 14, 1959.
14. Hixon, E. H., and Oldfather, R. F.: Estimation of the sizes of unerupted cuspid and
bicuspid teeth, Angle Orthod. 28: 113, 1958.
15. Nance, H. N.: The limitations of orthodontic treatment. II. Diagnosis and treatment in
the permanent dentition, AM. J. ORTHOD. 33: 253,1947.
16. Howes, A. E.: Case analysis and treatment planning based upon the relationship of the
tooth material to its supporting bone, AK J. ORTHOD. 33: 499, 1947.
17. Carey, C. W.: Linear arch dimension and tooth size, AM. J. ORTHOD. 35: 762, 1949.
Volume
Number
61
4
Index for assessing tooth shape deviations 401
18. Rees, D. J.: A method for assessing the proportional relation of apical bases and con-
tact diameters of the teeth, AM. J. ORTHOD. 39: 695, 1953.
19. Beazley, W. W.: Assessment of mandibular arch length discrepancy utilizing an in-
dividualized arch form, Angle Orthod. 41: 45, 1971.
20. Lundstrom, A.: Intermaxillary tooth width ratio and tooth alignment and occlusion,
Acta Odontol. &and. 12: 265, 1954.
21. Neff, C. W.: The size relationship between the maxillary and mandibular anterior seg-
ments of the dental arch, Angle Orthod. 27: 138, 1957.
22. Bolton, W. A.: Disharmony in tooth size and its relation to the analysis and treatment
of malocclusion, Angle Orthod. 28: 113, 1958.
23. Ramstrom, M.: Piltdown-Fund, Bull. Geol. Inst. (Upsala) 16: 294, 1918.
24. Pedersen, P. 0.: The East Greenland Eskimo dentition, Med. Grenland 142: l-256, 1949.
25. Thomsen, S.: Dental morphology and occlusion in the people of Tristan da Cunha;
Results of the Norwegian Scientific Expedition to Tristan da Cunha, 1937-1938, No. 25,
Oslo, 1955.
26. Garn, S. M., Lewis, A. B., and Kerewsky, R. S.: Sex difference in tooth shape, J. Dent.
Res. 46: 1470, 1967.
27. Garn, S. M., Lewis, A. B., and Kerewsky, R. S.: Shape similarities throughout the den-
tition, J. Dent. Res. 46: 1481, 1967.
28. Rosenzweig, K. A.: Tooth form as a distinguishing trait between sexes and human
populations, 5. Dent. Res. 49: 1423, 1970.
29. Lysell, L.: Qualitative and quantitative determination of attrition and the ensuing
tooth migration, Acta Odontol. &and. 16: 267, 1958.
30. Wolpoff, M. H.: Interstitial wear, Am. J. Phys. Anthropol. 34: 205, 1971.
31. BjGrk, A., Krebs, A., and Solow, B.: A method for epidemiological registration of mal-
occlusion, Acta Odontol. &and. 22: 27, 1964.
32. Garn, S. M., Lewis, A. B., and Walenga, A. J.: Maximum confidence values for the
human mesiodistal crown dimension, Arch. Oral Biol. 13: 841, 1968.
33. Massler, M., and Frankel, J. M.: Prevalence of malocclusion in children aged 14 to 18
years, AM. J. ORTHOD. 37: 751, 1951.
34. Cryer, B. 8.: Lower arch changes during the early teens, Trans. European Orthod. Sot.
41: 87, 1965.
35. Barrett, M. J., Brown, T., and McDonald, M. R.: Dental observations on Australian
aborigines: Mesiodistal crown diameters of permanent teeth, Aust. Dent. J. 8: 150, 1963.
36. Barrett, M. J., Brown, T., Arato, G., and Ozols, I. V.: Dental observations on Australian
aborigines: Buccolingual crown diameters of deciduous and permanent teeth, Aust. Dent.
J. 9: 280, 1964.
37. Seipel, C. M.: Variation of tooth position, Sven. Tandlak. Tidskr. 29: Supp., p. 70, 1946.