Diagnosis of transverse problems

Chun-Hsi Chung

Traditionally, maxillary and mandibular skeletal widths and buccolingual

inclination of posterior teeth are evaluated by using posteroanterior (PA)
cephalogram and dental casts. However, it is difficult to identify the land-
marks and make a diagnosis due to the superimposed structures on the PA
cephalogram. As for the dental casts, they can neither reveal skeletal dimen-
sions of maxilla and mandible, nor the root positions in the alveolar bone.
Nowadays, the advent of CBCT enables clinicians to view craniofacial struc-
tures in three planes of space without any obstruction or superimposition of
structures. In this article, a CBCT analysis on the transverse dimension is
introduced. The maxillary and mandibular skeletal widths at different tooth
levels, buccolingual inclination of each tooth, and their root positions in the
alveolar bone can be determined. Thus, a proper transverse diagnosis can be
made. (Semin Orthod 2019; 25:16–23) © 2019 Elsevier Inc. All rights reserved.

Introduction lacrymomaxillary, nasomaxillary, ethmoidomax-

n orthodontics, among the three planes of
I space - sagittal, vertical, and transverse, the
transverse is the least studied. In the orthodontic
literature, there are plenty of articles related to
sagittal and vertical dimensions of the face, but
few related to the transverse dimension. Trans-
verse facial growth and diagnosis and treatment
planning deserve a lot more attention. The trans-
verse facial growth normally completes before the
sagittal and vertical growth. Understanding the
transverse growth is important in making proper
diagnosis and treatment planning of the trans-
verse problems. Thus, a brief review of transverse
growth of maxilla and mandible is presented first,
and then the diagnosis will follow in this article.
Transverse skeletal growth of maxilla and
mandible
Maxillary growth
There are two components of maxillary growth -
sutural and periosteal. The sutures involved in
the maxillary growth are - frontomaxillary,
Department of Orthodontics, School of Dental Medicine, Univer-
sity of Pennsylvania, 240 South 40th Street, Philadelphia, PA 19104-
6303, USA.
Corresponding author. E-mail: chunc@upenn.edu
© 2019 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2019.02.003
illary, zygomaticomaxillary, intermaxillary (mid-
palatal), and vomeromaxillary. Bjork and Skiel-
ler1 conducted a longitudinal study on the maxil-
lary transverse growth of 9 boys. Subjects had
implant pins inserted in left and right zygomatic
crests at age 4. At age 10
11, implant pins were
inserted in the apical areas of incisor on both
sides. Annual posteroanterior (PA) and lateral
cephalograms were taken from age 4 to adult age.
On the PA cephalogram, the increase in distance
between the left and right implants was reported
as sutural growth. They found that in the maxil-
lary molar region, most transverse skeletal growth
is from sutural growth, with a small amount from
periosteal growth (bone remodeling). In addi-
tion, more sutural growth was found in the molar
region than in the incisor region. Thus, there was
a rotation of the two halves of maxilla.
Ricketts et al.2 reported the transverse
growth changes from age 9 to 16, for both gen-
ders, on PA cephalograms. The maxillary skele-
tal width was determined as the distance
between the left J (Jugale) and right J (Jugale),
which increased from 62 mm to 66.2 mm
(0.6 mm per year). The J point was located at
the jugal process, the intersection of the outline
of the tuberosity of the maxilla and the zygo-
matic buttress. In a later study, Ricketts and
Grummons3 reported in males, from age 3 to
21, an increase in J-J distance from 55 mm to
73 mm or1 mm per year.

16 Seminars in Orthodontics, Vol 25, No 1, 2019: pp 16
23

 Diagnosis of transverse problems 17

In a longitudinal study on PA cephalograms of
subjects from age 5 to 18, Cortella et al.4
reported that males had greater maxillary trans-
verse dimensions than females. In addition, the
maxillary transverse growth (J-J) for females com-
pleted at age 14, but for males it continued to
about age18. Wagner and Chung5 found that
there was a relationship between the transverse
growth and vertical facial type. At age 6, the doli-
chofacial (high mandibular plane angle) subjects
had smaller maxillary (J-J) widths than the bra-
chyfacial (low mandibular plane angle) subjects.
This trend continued until age 18.
Mandibular growth
There are two types of growth in the mandible -
cartilaginous and periosteal. The condyles are
the only places in the mandible having cartilagi-
nous growth, the rest of mandibular growth is
periosteal growth and remodeling. The basal
bone under dental arch almost completes its
width development at the end of pubertal
growth. However, the condyles continue to grow
and the rami continue to remodel after the
growth spurt.
Ricketts et al.2 reported from age 9 to 16, on
PA cephalogram the distance between the left
Ag (antegonion) and right Ag (antegonion)
increased from 76 mm to 85.8 mm or 1.4 mm per
year for both sexes. The Ag point was located at
the antegonial notch. Later on Ricketts and
Grummons3 reported for males from age 3 to 21,
the Ag-Ag distance increased from 68 to 94 mm
or 1.5 mm per year. Cortella et al.4 reported
from age 5 to 18, for mandibular growth (Ag-Ag)
on PA cephalograms, females completed growth
at around age 16, and males continued to age 18.
Wagner and Chung5 reported at age 6, the high-
angle group had smaller mandibular (Ag-Ag)
widths than the low-angle group. This trend con-
tinued until age 18. It should be noted that the
Ag is located at the angular area of ramus, which
is far from dentition and should not represent
the mandibular basal bone.
Transverse growth of maxillary and
mandibular dental arches
In their longitudinal study, Moyers et al.6
reported the arch width development of maxilla
and mandible on canines, premolars and molars
from age 6 to 18 for male and female (Table 1).
They found that the mandibular intermolar
width at the first molars was established at age 12
for girls with no more changes after age 12; for
boys, the increase was only 1 mm to age 18. For
maxillary intermolar width, it was established at
age 12 for girls; for boys it increased 1.4 mm
from age 12 to 18. For intercanine width, it was

Table 1. Mean arch width measurements (longitudinal). Data from Moyers RE, et al.6
Mean arch width measurements*
MALE FEMALE
AGE Canine First premolar First molar Canine First premolar First molar
Maxillary Arch
6 27.53y 32.26y 41.85 26.88y 31.67y 41.34
8 29.7y 33.69y 43.12 29.06y 33.04y 42.38
10 30.47y 34.35y 44.46 29.77y 33.62y 43.52
12 32.54 35.66 45.34 31.52 35.11 44.64
14 32.45 35.98 45.86 31.30 34.93 44.32
16 32.25 36.55 46.63 31.43 35.16 45.01
18 32.31 36.66 46.69 31.18 34.64 43.94
Mandibular Arch
6 22.33y 28.68y 40.15 22.19y 28.43y 39.96
8 24.31y 29.73y 40.93 23.95y 29.46y 40.33
10 24.55y 30.18y 41.47 24.06y 29.72y 40.98
12 25.14 32.52 42.08 24.81 31.62 41.80
14 24.73 32.25 41.13 24.39 31.03 41.11
16 24.66 32.34 42.77 23.90 30.98 41.46
18 24.81 32.83 42.96 23.08 30.83 41.68

* Millimeter distance between centers of teeth.

y
Primary predecessor.
18
established for maxillary and mandibular arches
at age 12 for both genders (Table 1).
Another longitudinal growth study on the
transpalatal width was conducted using the meas-
urements from the gingival margin of lingual
groove of the first molar to the contralateral side.
McNamara and Brudon7 reported that, genders
combined, the transpalatal width increased only
2.6 mm from age 7 to 15. The mean value was
32.7 § 1.4 mm at age 7, 33.2 § 1.5 mm at age 8,
33.2 § 1.4 mm at age 9, 33.7 § 1.5 mm at age 10,
34.5 § 1.4 mm at age 11, and 35.2 § 1.4 mm at
age 12. After age 12, there was no change on the
transpalatal width.
Buccolingual inclination changes of
molars with growth
Wilson8 was first to report on the buccolingual
inclination of the grinding teeth, the mandib-
ular molars being inclined lingually and the
maxillary molars being inclined buccally. This
occlusal curve on the coronal plane has been
referred to as curve of Wilson. Dempster et
al.9 studied the arrangement of the roots of
the teeth in skulls with typical dentition and
confirmed the lingual inclination of the man-
dibular posterior teeth.
Interestingly, the buccolingual inclinations of
molars are not stable throughout life. Bjork and
Skiller’s1 implant study showed that from ages
10
11 to 20 the posterior suture opening aver-
aged 3 mm, yet the intermolar width increased
by only 1.8 mm. These results demonstrate that
with growth, maxillary molars become more
upright with buccal root torque. The authors
also reported that from ages 10
11 to 20, the
anterior suture opening was 0.9 mm, but the
intercanine width almost stayed the same. These
results also demonstrate that with growth, maxil-
lary canines become more upright with buccal
root torque.
Measuring clinical crowns of molars on dental
casts, Marshall et al.10 and Sayania et al.11 showed
that buccolingual inclination changes with
growth. Normally, maxillary molars erupt with
buccal inclination and become more upright
with age; mandibular molars erupt with lingual
inclination and become more upright with age.
In adults, the lingual cusps of maxillary molars
are more occlusal than the buccal cusps, and the
buccal cusps of mandibular molars are more
Chung
occlusal than lingual cusps. Thus, the curve of
Wilson is maintained.
Yang and Chung12 evaluated the buccolingual
inclination of the long axis (whole tooth) of first
molars on Caucasian children and adults using
coronal sections on their CBCT images. The
authors reported that for children from ages
6
9, each maxillary first molar exhibited about
11° of buccal inclination, but for adults, the
molars exhibited about 5° buccal inclination. In
the mandible, each first molar revealed about
17° lingual inclination, but for adults, the lingual
inclination was about 13°. Clearly, the molars
become more upright with growth. Alkhatib and
Chung13 in their CBCT study, concluded that in
Caucasian adult normal occlusion, there was a
curvature to the first molars in untreated adults,
where the long axis of maxillary molars had a
slight buccal inclination (about 5° each) and the
long axis of mandibular molars had a slight lin-
gual inclination (about 13°). Tong et al.14
reported, for a group subjects from age 12 to
36 years (mean 21.5 years) combined with a few
different races, the long axis of maxillary molar
showed about 4.5° of buccal inclination and the
long axis of mandibular first molar showed about
8° of lingual inclination on their CBCT images.
The buccal inclination of the maxillary first
molars and lingual inclination of the mandibular
first molars (whole tooth) are demonstrated in
Fig. 1.
Figure 1. A coronal section on first molars of CBCT
image of a subject with normal occlusion. The maxil-
lary molars show buccal inclination and mandibular
molars show lingual inclination.
 Diagnosis of transverse problems
Interestingly, the mandibular basal bone inclina-
tion frequently aligned with the lingual inclina-
tion of the lower molars (Fig. 1). Studying the CT
scans on male Asiatic Indians, Kohakura et al.15
reported a similar relationship between the tooth
axis and the bone axis, where lower first molar
averaged about 10° of lingual inclination and the
bone inclination was averaged about 8°.
A potential link between buccolingual inclina-
tion of molars and vertical facial type has been
studied, but the results are scattered and incon-
sistent in the literature. Janson et al.16 found that
there was no statistical variation between low-
and high-angle subjects in mandibular posterior
tooth inclination, but maxillary molars had
greater buccal inclinations in high-angle sub-
jects. Conversely, Tsunori et al.17 found that
short facial types had more lingual molar inclina-
tion in the mandible.
Diagnosis of transverse problems
Clinically, posterior crossbite is a common and
valid indicator of transverse problems, used by
most clinicians. However, there are many
patients with transverse problems that do not
show a posterior crossbite. The dental compensa-
tion may obscure the skeletal and dental trans-
verse problems.18,19
There have been several reported methods to
diagnose the skeletal and dental transverse prob-
lems:
Maxillomandibular transverse differential
In 1999, Vanarsdall proposed the use of a Maxillo-
mandibular Transverse Differential as a diagnostic
tool for diagnosing transverse skeletal problems.20
The method was based on the Ricketts et al’s2
norms of maxillary and mandibular growth mea-
sured from PA cephalograms. The maxillary skele-
tal width (J-J) and mandibular skeletal width
(Ag-Ag) of patient are measured on a PA cephalo-
gram and compared with the norms of Ricketts’
et al. The maxillomandibular width difference
(Ag-Ag and J-J) of the patient and difference of
Ricketts’ norms of the same age (Ag-Ag and J-J)
were calculated and compared. Normally the dif-
ference should be within 5 mm. If it is more than
5 mm, a transverse skeletal problem exists.
The limitation of this method is that the land-
mark Ag is far back from the dentition and may
19
not be an accurate landmark to be used to deter-
mine the skeletal transverse width of the basal
bone. In addition, there was no consensus on
what the norms of transverse skeletal widths (J-J,
Ag-Ag) are for males and females determined
from PA cephalogram. Several reported studies
show different values.2-5 Nevertheless, the diffi-
culties for landmark identification of J and Ag on
a PA cephalogram posed other problems. Studies
have shown that this analysis was not sensitive
enough to detect the transverse problems.21-24
Transpalatal width
The transpalatal width, determined from the gin-
gival margin of lingual groove of the first molar
to the first molar of the other side. As mentioned
earlier, McNamara and Brudon7 reported the
mean normal values from age 7 to 15. The
patient’s transpalatal width can be compared
with the reported values to determine if the
upper arch is normal. For example, a 12 years-
old patient with a transpalatal width of 32 mm.
Compared to the mean normal value of 35 §
1.4 mm at the same age, the upper arch of this
patient can be diagnosed as narrow.
Cautions should be made when using this
method, since the norms are combined with
both genders and the dental compensations
(buccolingual inclination) are not considered.
Moreover, the transpalatal width may be affected
by vertical facial types. Isaacson et al.25 reported
that the width of palate (distance between the
mesiolingual cusp tips of the first molars)
increased as the mandibular plane angle (MP

SN) decreased. Forster et al.26 reported male
arch widths were significantly larger than those
of females. For both males and females, there
was a trend that as MP
SN angle increased, the
arch width decreased.
Andrews’s WALA ridge
When evaluating the dental casts, Andrews27 sug-
gested that the primary landmark for assessing
mandibular arch width and shape is the WALA
Ridge. The WALA is an acronym for Will
Andrews and Larry Andrews, who defined the
ridge as the most prominent portion of a mandi-
ble’s mucogingival junction.27
Andrews28 suggested that when an optimal
mandibular arch is viewed from the occlusal
20
perspective, the distance of FA point (center of
facial axis of the crown) of the first molar to
WALA Ridge should be 2 mm. In this position,
the mandibular first molars are decompensated,
and the arch width between the central fossae of
the mandibular first molars is the optimal man-
dibular arch width. For the maxilla, the occlusal
plane on the maxillary first molars should be par-
allel to the transverse plane of the head from the
frontal perspective. In this position, the maxillary
first molars are decompensated and the distance
between the mesio-lingual cusp tips of the right
and left maxillary first molars should be equal to
the distance between the mandibular right and
left central fossa.
It should be noted that since the diagnosis is
made on the dental casts, the root positions in
the alveolar bone are not known unless a
3- dimensional image such as a CBCT is taken.
CBCT evaluation
In the literature, most studies on maxillary and
mandibular skeletal (basal bone) widths and buc-
colingual inclination of posterior teeth were eval-
uated with PA cephalograms and dental casts. It
is well known that the limitations of the PA ceph-
alogram includes the overlapping of structures
and difficulty to identify the landmarks. In addi-
tion, there is an inherent error of magnification
on the film. Using dental casts for evaluation,
they cannot reveal the basal bone and the root
positions in the alveolar bone. In addition, the
long axis of the tooth is hard to determine due
to the uneven occlusal wear and irregular crown
morphology. Thus, a new method that can ana-
lyze the skeletal and dental structures in 3 planes
of space without obstructed views is critical. With
the advent of cone beam computed tomography
(CBCT), the transverse dimension of dentofacial
structures can be visualized and measured. As a
result, the widths of maxillary and mandibular
basal bones and their relationship, the buccolin-
gual inclination of each whole tooth, and their
root positions in the alveolar bone can be visual-
ized and analyzed and a proper diagnosis can be
made (Figs. 1, 2).
When examining using CBCT on the trans-
verse dimension, normally there should be
proper skeletal widths of maxilla and mandible
and a harmonious relationship. The roots of
teeth are positioned in the center of alveolar
Chung
Figure 2. A coronal section on first molars of CBCT
image of the same subject. The roots of maxillary and
mandibular molars are positioned in the center of the
medullary bones.
bones, the maxillary molars slightly incline buc-
cally and mandibular molars slightly incline lin-
gually (Fig. 1, 2). Miner et al.19 reported that in
normal occlusion, at the mid-alveolar bone levels
of lingual surfaces of the first maxillary and man-
dibular first molars, the maxillary width is about
1.2 § 2.9 mm less than mandibular width with a
wide range.
For a narrow skeletal maxilla without dental
crossbite, the maxillary posterior teeth tend to
compensate and incline buccally, and mandibu-
lar posterior teeth tend to compensate and
incline lingually. The palatal width at the mid-
root level of maxilla is significantly less than that
of mandible (Fig. 3A). As a result, a significant
curve of Wilson takes place. The normal curve of
Wilson allows for proper occlusal function, how-
ever, excessive curve of Wilson results in balanc-
ing interferences.29 In making diagnosis and
treatment planning of this case, the molars
should be de-compensated first and their roots
must be in the alveolar housing. In addition, a
mild curve of Wilson should be maintained
(Fig. 3B). In this position, the molars become in
crossbite. The treatment objective is to expand
the maxillary basal bone, so the lingual cusps of
maxillary molars occlude on central fossae of
mandibular molars. The needed amount of
expansion would be the difference between the
inter-lingual cusp width of maxillary molars and
 Diagnosis of transverse problems 21

Figure 3. CBCT images of a 12 years 9 months girl. (A) Pre-treatment radiograph showing transverse skeletal defi-
ciency and significant dental compensations. (B) In diagnosis and treatment planning, when maxillary and man-
dibular molars were de-compensated, the molars resulted in posterior crossbite, (C) Post-expansion radiograph
showing corrected molar relationship. Patient was expanded with a TADs supported RPE. (Courtesy of Dr. Nor-
man Boucher).

the inter-central fossa width of the mandibular
molars (Fig. 3B). This case was treated with a
TADs supported RPE. The dental de-compensa-
tion and skeletal expansion can be see on Fig. 3C.
For a wide maxilla without crossbite, the max-
illary posterior teeth tend to compensate and
incline lingually, and mandibular posterior teeth
tend to compensate and incline buccally. The
palatal width at the mid-root level of maxilla is
significantly wider than that of mandible (Fig. 4).
As a result, a reverse curve of Wilson appears.
For this patient, the roots were very prominent
and the root apices of maxillary premolars could
be palpated. The conventional PA cephalogram
cannot detect these problems.
The buccolingual inclination of posterior teeth
and the root positions in the alveolar bone can
only be detected with 3D images. Fig. 5 shows an
adult with missing upper canines and crowding on
mandibular anterior teeth. The roots of mandibu-
lar posterior teeth were prominent on palpation,
and posterior teeth were in edge-to-edge bite. Pan-
oramic film shows normal periodontal bone level.
But the CBCT image shows limited bone coverage
on buccal surfaces of mandibular premolars and
molars. The maxilla is narrow and the mandibular
molars are not in the alveolar housing and show
significant lingual tipping (Fig. 6).
It should be noted that CBCT has limitations
on identifying dehiscence and determining the
thickness of buccal or lingual bony plates when
the most popularly used voxel size of 0.3 or
0.4 mm is used.30,31

Figure 4. Clinical photos and CBCT images of a
patient with no posterior crossbite but with significant
dental compensations due to wide maxilla. (A, B) Buc-
cal views of the dentition, (C) Coronal section on first
molars, (D) Coronal section on first premolars.
Summary
The knowledge of transverse growth of maxilla
and mandible is crucial in the diagnosis and treat-
ment planning of transverse problems. The maxil-
lary transverse growth is mainly from the sutural
growth. The transverse growth of mandibular basal
bone completes at around the end of pubertal
growth. As presented in this article, after 12 years
old, almost no change for females and very little
increase (about 1 mm) should be expected on the
intermolar widths of maxilla and mandible. The
intercanine widths of maxilla and mandible tend
to decrease slightly after age 12 for both males and
females. Thus, caution needs to be taken when the
arches are significantly widened through dental
expansion during treatment to avoid periodontal
complications and instability.
22
Figure 5. Intraoral photographs and panoramic x-ray of an adult patient with edge-to-edge bite on posterior
teeth. No significant periodontal findings were found except root prominence on palpation.
Figure 6. CBCT images of an adult. (A) Coronal section
on the first molars, (B) Buccal view on the left side.
Traditionally, the dental casts and PA cephalo-
grams are used to diagnose transverse problems of
maxilla and madible. However, they have limita-
tions. In contemporary orthodontics, CBCT is an
excellent diagnostic tool, particularly for adults, to
diagnose transverse problems. The maxillary and
mandibular skeletal widths at different tooth level,
buccolingual inclination of each tooth, and root
positions in the alveolar bone can be determined
and evaluated from the CBCT. With all these infor-
mation, the clinicians can make a proper diagnosis
and treatment planning for the patient.
Acknowledgement
The author would like to thank Drs. Norman
Boucher, Boryana Dimitrova, Hyeran Helen
Jeon, and Cassie Truong for their help in prepar-
ing the images.
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