Iowa Prediction Method for Both Arches

Another prediction method using data from the Iowa Facial Growth Study was developed by

Staley et a19 to predict the mesiodistal widths of unerupted canines and premolars in both the

upper and lower arches. With this method, only measurements of the radi- ographic widths of

unerupted canines and premolars are used as predictor variables. The standard errors of

estimate are 0.48 mm in the upper arch and 0.47 mm in the lower arch. Records needed for

the complete analysis are casts of the upper and lower arches and periapical radi- ographs of

the upper canines and premolars and lower premolars taken with a long-cone paralleling or

right angle technique.

Upper Arch Prediction

1. Measure the mesiodistal widths of the upper right canine and second premolar on the radi-

ographs. 2. Transfer the sum of these widths to the prediction graph (Figure 12-6) to obtain

the predicted sum of the upper right canine and premolar widths. 3. For the most accurate

prediction, measurements should be repeated for the left side.

Lower Arch Prediction

1. Measure the mesiodistal widths of the lower right premolars on the radiographs. 2.

Transfer the sum of these widths to the prediction graph (Figure 12-7) to obtain the predicted

sum of the lower right canine and premolar widths. 3. For the most accurate prediction,

measurements should be repeated on the left side. NOTE: For various reasons, good

measurable radiographic views of the unerupted premolars and canine on one side of the

mouth may not be obtainable. Staley et a19 found that a measurement from a satisfactory

radiograph of a tooth on one side of the arch could be substituted for an unmeasur- able

antimere tooth without significantly altering the accuracy of the prediction.

How to Use the Graphs The sum of the radio- graphic tooth widths measurement is located

on the horizontal axis at the bottom of each prediction graph and then projected vertically to

intersect the prediction line. For example, the sum of the upper right canine and second

premolar widths as measured on the peri- apical film is 15 mm, which is located on the

horizon- tal axis of the graph. Follow the vertical line from the 15-mm point on the bottom

line of the prediction graph until it intersects with the solid prediction line (see Figure 12-6).

Next, follow the horizontal line at the point of intersection to the left side of the chart to find

the predicted sum of the canine and premolar widths (21.1 mm). Step-by-step charts to

calculate the TSALD were developed for the upper and lower arches for use by clinicians and

are presented in Figures 12-8 and 12-9.

It is desirable that a prediction method be reason- ably accurate, easily used, and cross-

validated, that is, tested in a group of patients to determine how well it performs. The revised

Hixon-Oldfather and Iowa pre- diction methods6,9 described here have acceptably low

standard errors of estimate, have easy-to-use predic- tion tables, and were successfully cross-

validated on a sample of 53 orthodontic patients.

Proportional Equation Prediction Method

If most of the canines and premolars have erupted and if one or two succedaneous teeth are

still unerupted, an alternative prediction method can be used to esti- mate the mesiodistal

width of the unerupted perma- nent tooth. The widths of the unerupted teeth (e.g., a second

premolar) and an erupted tooth (e.g., a pri- mary second molar) are measured on the same

peri- apical film.

The width of the erupted tooth, a primary second molar, is measured on a plaster cast. These

three meas- urements comprise the elements of a proportion that can be solved to obtain the

widths of the unerupted tooth on the cast:

NONRADIOGRAPHIC PREDICTION METHODS

The main advantage of nonradiographic prediction methods is that they can be performed by

measuring the erupted permanent lower incisors or primary teeth without the need of

additional measurements from radiographs.8,10,11 On the other hand, these methods are less

accurate, as indicated by their larger standard errors of estimate as compared with the

suggested radiographic methods. Moyers8 and Tanaka and Johnston,10 in separate sam- ples,

correlated the sum of the mesiodistal widths of the four permanent lower incisors to the sum

of the widths of the permanent canine, first premolar, and second pre- molar on one side of

the arch in the maxilla and mandible. Moyers' prediction tables have been widely available,

and his method has been used by many clini- cians because the measurements are easily

taken and the results can be obtained in a short time. No information is available concerning

the correlation coefficients and error of his method. Tanaka and Johnston10 developed

prediction tables that were, essentially, similar to those of Moyers.8 Their correlation

coefficients were r = 0.63 for the maxillary teeth and r = 0.65 for the mandibular teeth. The

standard errors of estimate were 0.86 mm for the maxillary teeth and 0.85 mm for the

mandibular teeth. Unlike Moyers, who separated the sexes, Tanaka and Johnson combined

the sexes in their study. The prediction tables of Tanaka and Johnston in Box 12-2 contain the

fiftieth percentile values. They recom- mended using the seventy-fifth percentile (higher)

esti- mates as a hedge against underpredicting tooth size. However, evidence from other

studies indicate that this method at the fiftieth percentile on average overpredicts the true size

of the canine and premolars by 0.6 mm in

the upper arch,3 0.4 mm in the lower arch,4 and in a third study, 1.1 mm in the lower arch."

Therefore the fiftieth percentile prediction most likely provides a desired hedge against

underprediction of tooth size. Other nonradiographic methods using primary teeth are

available but are also less accurate than the previously discussed radiographic methods."
APPLYING PREDICTION METHODS TO DIFFERENT RACIAL GROUPS

The radiographic and nonradiographic methods for predicting the mesiodistal widths of

unerupted perma- nent canines and premolars in patients in the mixed dentition that are

described in this chapter were devel- oped in American white subjects of European ancestry.

Evidence indicates that these methods would be acceptable in Egyptian and northern Mexican

patients .12 Lee-Chan et a113 found that the nonradiographic method of Tanaka and

Johnston10 did not satisfactorily predict tooth size in Americans of Asian ancestry. Therefore

they calculated more accurate prediction tables based on the correlation of lower incisor

widths to canine and premolar widths in a sample of Asian Americans. Ferguson et a114

developed a nonradio- graphic prediction method for a sample of American blacks by

correlating lower incisor widths with the widths of canines and premolars. On average, the

pre- dicted values of canine and premolar width sums for each corresponding sum of incisor

widths was larger in blacks by 0.2 mm in the maxilla and 0.6 mm in the mandible when

compared with the values based on white Americans.10 For these reasons it is recom-

mended that clinicians use prediction methods in Asian-American and black patients that

were devel- oped in samples of these populations.

OTHER FACTORS THAT INFLUENCE THE ESTIMATION OF THE TOOTH

SIZE-ARCH LENGTH ANALYSIS

The primary and most important part of a tooth size- arch length analysis is the comparison of

the size of the teeth to the size of the arch. This is the basic TSALD. Clinicians also need to

consider the impact of other factors on TSALD when developing the complete diagnosis of a

patient. The other factors may not be readily quantified, therefore, clinicians have to make a

qualitative judgment of how a particular factor may either increase or decrease the basic

TSALD.
Incisor Inclination and Position

The inclination and anteroposterior position of the inci- sors affects the arch length analysis.

Orthodontic move- ment of lingually inclined incisors in a labial direction increases arch

length, and lingual movement of incisors decreases arch length. According to Tweed,15

inclining the lower incisors 1 degree labially increases arch length by 0.8 mm. Conversely,

inclining the lower incisors 1 degree lingually decreases arch length by 0.8 mm.

Orthodontists assess the inclination of the lower incisors by measuring the angle formed by

the long axis of the mandibular incisor with both the mandibu- lar and Frankfort horizontal

planes on a cephalogram. Anteroposterior position can be determined by meas- uring the

perpendicular distance from the incisal tip of the mandibular incisor to the nasion-B line.

Further information about the normative values of these meas- urements is given in Chapters

10 and 11.

Curve of Spee

The curve of Spee is an important factor to consider in the overall space analysis because the

curve is usually leveled during orthodontic treatment. During the lev- eling procedure, the

incisors tip labially (Figure 12-10). If the lower incisors are in a satisfactory anteroposte- rior

position or are inclined too far labially before treatment, leveling of the curve of Spee

produces undesirable labial movement of the incisors unless there is excess arch length. In

the latter cases, excess arch length (spacing) minimizes the movement of the incisors during

leveling. Baldridge 16 studied 30 patients who had an exaggerated curve of Spee in the

mandibular arch and with all the permanent teeth erupted, excepting third molars. He found

the mean additional arch length needed for leveling the curve of Spee without labial tipping

of the incisors to be 3.5 mm ± 0.1 mm, with a minimum of 2.3 mm and a maxi- mum of 5.2
mm depending on the degree of curve. As the curve of Spee becomes more exaggerated, the

probability for an arch length deficiency increases.

To estimate the amount of additional arch length needed to level the curve of Spee for an

individual patient, Balridge16 suggested measuring the greatest depth of the curve on both

sides of the arch, dividing the sum of both sides by 2, and adding 0.5 mm.

Position of the Permanent First Molars

If the primary second molars are intact and healthy before their physiologic exfoliation, the

permanent first molars are probably well positioned between the premolars mesial to them

and the second and third molars distal to them. Distal movement of well- positioned

permanent first molars to create additional arch length in the mixed dentition may impact the

per- manent second molars. Distal movement of maxillary permanent molars in a Class II

malocclusion is appro- priate treatment that increases arch length; however, this movement is

usually started in the early perma- nent dentition. After a patient prematurely loses a primary

second molar, the permanent first molar will move too far mesially unless arch length is held

with a space main- tainer. When a patient loses arch length for this reason, the permanent

molar should be moved back with an orthodontic appliance to its original position in young

patients. After the molars have been returned to an appropriate location, a space maintainer

appliance is constructed to retain the regained arch length. Information about mesially tipped

molars should be included in an arch length analysis.

Second and Third Molar Evaluation

The position of the unerupted molars in the alveolus is of importance. When unerupted

second molar and third molar tooth buds are separated by spaces and the developing second

molar is spatially separated from the erupted first molar, adequacy of posterior arch length is

probable. When the unerupted second molar and the third molar buds are packed together
tightly against the distal surface of the first molar, posterior arch length inadequacy is

probable. Impaction of second molars requires treatment. Orthodontists can usually correct

second molar impaction. When the mandibular third molar bud is located closely behind and

above the impacted lower second molar, an oral surgeon can remove the third molar-a

procedure that may free the second molar to erupt. Impacted third molars are usually

extracted, but extraction is commonly delayed until these molars have some root structure.

INTERPRETATION OF AN ARCH LENGTH ANALYSIS IN THE PERMANENT

DENTITION

The factors discussed previously have an important impact on the interpretation of an arch

length analysis. Therefore a precise threshold value for arch length deficiencies, above which

extraction of teeth is required, does not exist. As an arch length deficiency exceeds 6 or 7

mm, careful consideration should be given to the factors that affect an extraction decision.

Arch length deficiencies in excess of 10 mm have a high probability of requiring extraction.

When extractions are contemplated for a patient, their effect on the resulting occlusion must

be consid- ered. If two premolars must be extracted in the mandibular arch in patients with

Class I or Class II malocclusions because of arch length deficiency, two premolars must also

be removed from the maxilla to obtain Class I canine and molar relationships and nor- mal

overbite and overjet. The removal of two lower premolars without removal of two upper

premolars produces a Class III molar relationship in which the upper second molars occlude

with the lower third molars. If the lower third molars are not erupted or if they are not

present, the upper second molars may become unopposed by lower teeth and could over-

erupt and eventually will need to be extracted. Extraction of only two lower premolars is

acceptable in some patients who have a Class III malocclusion and in some adult patients

with Class II malocclu- sions who will undergo a mandibular advancement surgery. The

extraction of only two maxillary premo- lars is acceptable for some patients who have no
arch length deficiency in the mandible but who have either an arch length deficiency in the

maxilla or a Class II malocclusion. This treatment results in Class II molar and Class I canine

relationships, with normal overbite and overjet.

INTERPRETATION OF A MIXED DENTITION ARCH LENGTH ANALYSIS

1. If an analysis predicts that a child will have no crowding problem, continue routine care

and periodic observation of the patient. 2. When an analysis predicts borderline crowding (1

mm to 4 mm), maintain arch length with an

appliance and periodically examine the patient. If a permanent first molar moved mesially

because of premature loss of a primary molar, use an appliance to regain the lost arch length

before making a space maintainer. Prepare patients with borderline crowding for possible

orthodontic treatment. 3. If an analysis predicts crowding in excess of 4 mm, the patient will

likely develop crowding of the permanent teeth that will require orthodontic treatment

following a comprehensive evaluation of the malocclusion. 4. If crowding in excess of 6 mm

is predicted in the lower arch, the patient may benefit from serial extraction treatment (see

Chapter 18). Monitor all mixed dentition patients at regular inter- vals to follow tooth

eruption and facial development.