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THE ROLE OF VERTICAL PARAMETERS IN THE

DEVELOPMENT OF LOWER INCISOR CROWDING
AMONGST PATIENTS

Article · August 2012

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 Role of vertical parameters

ORIGINAL ARTICLE

THE ROLE OF VERTICAL PARAMETERS IN THE DEVELOPMENT OF

LOWER INCISOR CROWDING AMONGST PATIENTS
1
GHULAM RASUL, BDS, FCPS
2
ASFAND ALI KHAN, BDS, Resident MCPS
3
FAHAD QIAM, BDS, Resident MCPS

ABSTRACT

Mandibular Incisor crowding is one of the common problem faced by orthodontic patients. Many
factors including skeletal discrepancy are considered responsible in the development of lower incisor
crowding.
The aim of the present study was to assess whether, vertical parameters such as Maxillary to
Mandibular plane angle and Lower facial height play a significant role in the development of lower
incisor crowding.
A total 213 subjects (81 males and 132 females) were selected. Cephalogram tracings were used
to determine vertical parameters such as Maxilla to Mandibular plane angle and Lower Facial height
and study casts were used for Lower incisor crowding. The Pearson Chi square test was used to
determine whether vertical parameters play a significant part in the development of Lower incisor
crowding or not.
Hyper-divergent cases showed the highest percentage of Lower Incisor crowding (92.6%) followed
by Normo and Hypo-divergent profiles. The Pearson Chi-Square test revealed that Vertical parameters
play a significant role in the development of Lower incisor crowding (p value = 0.006) and such
parameters must be kept in mind while formulating treatment strategies for patients with such
complaints.
Key words: Maxillary to Mandibular plane angle, Lower Facial Height, Lower Incisor Crowding

INTRODUCTION Premature loss of deciduous teeth, morphology of the

An Orthodontist comes across a variety of chief
complaints over the course of his/her career, amongst
the most common of which is that of dental crowding.1,2
The crowding may affect the whole arch or be localized
to the anterior segment, though crowding in the ante-
rior segment is reported to be the more common than
in the posterior segment of the lower arch.3
A variety of factors have been theorized and re-
ported to be responsible for lower incisor segment such
as inclination of mandibular incisors during mixed
dentition,4 inclination and size of mandibular perma-
nent 1st molars5, high mandibular plane angles, short
mandibular body lengths, great upper face height, and
small vertical dimensions in upper posterior segments6.
mandibular incisors and size of dental arch are also
deemed to be contributing factors to lower incisor
crowding.7-12 This research was done on Northwest
Europeans and selected American races with little or
no corroboration from data obtained on patients of
Asian ethnicities.
As crowding is one of the most common malocclu-
sion faced by an orthodontist during his/her profes-
sional carrier. The extraction versus non extraction
treatment modalities of crowding patients have been
the most debated issues in the history of orthodontics.
Similarly in the lower anterior region, late lower
incisor crowding has been discussed in the literature.
In international studies it has been proven that skel-

1
Professor & Head Department of Orthodontics, Khyber College of Dentistry, Peshawar University Campus,
Cell: 0333-9126029
2,3
Residents

Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012) 244
 Role of vertical parameters

etal growth pattern correlate with lower incisor crowd- constituted the predominant age group on this study
ing5, a factor to be considered in treatment plans (73.2%). The 28-36 year age group comprised only 3
including retention in orthodontic patients. But there patients and hence was the least represented age group
is no local research available on the subject noted in this study (1.4%). The details of the age distribution
above. The objective of Part I of this paper is to assess of the sample are given in Table 1.
whether, or not, vertical parameters such as Maxillary
The number of normodivergent were the highest ie
to Mandibular plane angle and Lower facial height
108 (50.7%) whereas only 24 Hypo-divergent patients
play a significant role in the development of lower
were noted in the study and comprised the least
incisor crowding amongst the patients, reporting to
represented group in the sample (11.3%). The detailed
Department of Orthodontics, Khyber College of
results of the vertical classification of the sample are
Dentistry, Peshawar. The role of sagittal parameters
given in Table 2.
such as SNA and SNB will be assessed in Part II of this
study. The sample showed Lower Incisor crowding in 174
patients (81.7%) and spacing amongst 30 patients (14.1%).
METHODOLOGY 9 patients showed neither Lower Incisor crowding nor
The study was conducted at the Department of spacing (4.2%). The details of the distribution of Lower
Orthodontics in Khyber College of Dentistry, Peshawar Incisor crowding are shown in Table 3.
Khyber Pakhtunkhwa from January 2010 to June Crowding of 2mm was seen in majority of lower
2011. Patients with a full complement of healthy incisor crowding cases (15.5%) followed by 1mm (14.1%),
dentition were included in the study. The exclusion whereas spacing of 5mm was seen in the majority of the
criteria barred those patients from the study, who patients (5.6%) followed by spacing of 1mm (4.2%). The
had a history of trauma, surgery, previous ortho- details of the crowding observed in this study are given
dontic treatment and those with congenital ano- in Fig I.
malies.
Lower incisor crowding was divided into 3 catego-
Informed consent was taken from the patients and ries, Positive (crowding), Negative (spacing) and Nor-
pertinent information was collected on a custom made
proforma. To ensure uniformity of the radiographs, all TABLE 1: DISTRIBUTION OF AGE GROUPS
Lateral cephalograms were taken on the same ma- OF THE SAMPLE
chine. The cephalogram tracings, calculations and
Age in years n %
lower incisor crowding measurements were taken by
the same operator. The vertical parameters measured 12-20 156 73.2
were Maxilla to Mandibular plane angle (MMA) and
21-28 54 25.4
Lower Facial Height (LFH). On the basis of these
parameters, the sample was divided into normo, hypo 29-36 3 1.4
and hyperdivergent.
TABLE 2: DISTRIBUTION OF VERTICAL
This data was entered and analyzed using SPSS PARAMETERS OF THE SAMPLE
Version 17. The Pearson Chi square test was used to
Vertical classification n %
determine if there was a significant relationship be-
tween Lower incisor crowding and vertical parameters Normo – divergent 108 50.7
such as MMA and LFH, with a critical p-value set at
Hyper – divergent 81 38.0
<0.05.
Hypo – divergent 24 11.3
RESULTS
A total of 213 patients comprised the sample of this TABLE 3: RESULTS OF LOWER INCISOR
study of which 81 patients were male (38%) and 132 SPACE ANALYSIS
patients were female (62%) with a Male to Female ratio Lower Incisor space analysis N %
of 1:1.629.
Crowding 174 81.7
The age of the sample ranged from 12-36 years with
Spacing 30 14.1
a mean age of 16.96±5.79years. Out of 213 patients, 156
patients belonged to the 12-20years age group and Neither 9 4.2

Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012) 245
 Role of vertical parameters

TABLE 4: DISTRIBUTION OF LOWER INCISOR CROWDING AS PER VERTICAL CLASSIFICATION

Vertical Classification
Hypo- Normo- Hyper-
divergent divergent divergent
Lower Incisor crowding Negative 3 21 6
12.5% 19.4% 7.4%
Normal 3 6 0
12.5% 5.6% 0%
Positive 18 81 75
75.0% 75.0% 92.6%
Total 24 108 81
100.0% 100.0% 100.0%

Chi-Square Tests
Value Df P – value
Pearson Chi-Square 14.475 4 .006

Fig 1: Distribution of crowding observed in the study sample

mal (LIC = 0mm) and was cross-tabulated against the
vertical classification of patients. Hyper-divergent pro-
files showed the greatest amount of cases with Lower
incisor crowding (92.6%) followed equally in second by
both Hypo and Normo-divergent profiles (75%). The
details are LIC distribution according to the vertical
classification are given in Table 4.
The Pearson Chi-Square test was applied and it
revealed that a significant relationship existed be-
tween MMA and Lower Facial Height with Lower
incisor crowding (p-value = 0.06) amongst patients
reporting to Department of Orthodontics at Khyber
College of Dentistry, Peshawar.
DISCUSSION
This study found a significant relationship between
vertical parameters such as MMA and lower facial
height with lower incisor crowding (p-value = 0.06)
which is in agreement with current literature.

Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012) 246

This study utilized only two measurements to
assess the vertical configuration of the sample namely
MMA and LFH. Contemporary literature, in contrast,
is replete with studies who have utilized upto 16
parameters to assess the vertical configuration and its
role in the development of lower incisor crowding.
Most of the comparative studies are quite old, dating
back to the late 1980’s which could bring into question
the validity and need for such a study in the 21st
century. Our justification lies in the absence of baseline
data of the Pakistani population which forces us to
utilize Caucasian norms while performing cephalomet-
ric analysis. Hence it is imperative to compare and
contrast the etiologic factors of lower incisor crowding
and test their validity on the Pakistani population. This
in turn will help to deliver more comprehensive care to
patients undergoing orthodontic treatment.
One of the earliest studies conducted on the rela-
tionship between lower arch crowding and vertical
craniofacial dimensions was by Sakuda et al6 in 1976
and they found a positive relationship of lower arch
crowding with high mandibular plane angles, short
mandibular body lengths, great upper face height, and
small vertical dimensions in the upper posterior seg-
ments. This study provided the basis for the study
conducted by Leighton and hunter who in 1982 con-
ducted a study to assess the relationship between lower
arch crowding/spacing, facial height and depth. They
used Frankfurt to mandibular plane angle (FMA),
occlusal angles, facial heights and mandibular body
measurements and found that patients with smaller
FMA and occlusal angles, shorter mandibular body and
facial heights showed a higher proportion of crowding.
They did not use MMA but they did use facial heights
and their study supported our study findings.
Miethke13 in 2000 conducted a study to determine
the relationship between primary mandibular anterior
crowding and vertical craniofacial configuration. That
study utilized 16 parameters of vertical configuration
and compared it with 9 parameters of lower incisor
inclination whereas our study only utilized 2 param-
eters of vertical dimension and 1 parameter for assess-
ing lower incisor crowding. Miethke concluded
that there is no correlation between primary man-
dibular anterior crowding and vertical craniofacial
configuration which does not conform to our study
findings.
Türkkahraman and Sayin14 conducted a study in
2003 and analyzed whether incisor proclination, over-
jet and overbite, cranial base dimensions, maxillary
Pakistan Oral & Dental Journal Vol 32, No. 2 (August 2012)
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Role of vertical parameters
and mandibular relationships, face heights and growth
direction of mandible had a significant etiologic rela-
tionship with lower incisor crowding. While they cor-
roborated the role of overjet, overbite, and FMIA, their
findings could not corroborate the role of MMA and
facial heights in the development of lower incisor
crowding.
CONCLUSION
This study concludes that a positive correlation
exists between MMA and LFH in the development of
lower arch crowding amongst a segment of the popula-
tion of Khyber Pakhtunkhwa. This trait must be
diagnosed in patients so appropriate treatment plan-
ning can be instituted for its management.
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