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Can crown-root ratio predict premolar eruption?

Article in American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American
Board of Orthodontics · April 2006
DOI: 10.1016/j.ajodo.2004.10.013 · Source: PubMed

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ORIGINAL ARTICLE

Can crown-root ratio predict premolar eruption?

Paul Rowlands,a Rebecca Poling,b Dina Slater,c Ross Hobson,c and Nick Steend
Cockermouth, Cumbria, United Kingdom, Anchorage, Alaska, and Newcastle upon Tyne, United Kingdom

Introduction: The purpose of this study was to establish a method to prospectively predict the eruption of
mandibular second premolars with panoramic radiographs. This technique could be used clinically to
optimize the timing of comprehensive treatment, detect abnormalities of development and eruption, or
effectively estimate eruption timing and determine the need for early intervention because of caries or defects
of the deciduous dentition. Methods: Three hundred one white children from an orthodontic practice in
Alaska between the ages of 6 and 16 years were examined and monitored with serial panoramic radiographs
until all premolars had erupted. Eruption of the mandibular second premolar was predicted at the first
examination based on the panoramic radiograph. When the mandibular second premolar erupted, a
researcher measured the crown length to crown-plus-root length ratio on the radiograph using the Simpson
and Kunos scale, and the prospectively predicted timing of eruption was compared with the actual timing.
Results and conclusions: The Simpson and Kunos scale allowed a rapid assessment for predicting the time
of eruption of mandibular second premolars. The mean age of eruption of the mandibular second premolar
in these children was 12.5 years. (Am J Orthod Dentofacial Orthop 2006;129:331-6)

T
he ability to accurately predict when a tooth
will erupt benefits both patient and dentist. In
orthodontics, all premolars often need to be
erupted before efficient treatment can begin. Most
commonly, the last premolar to erupt is the mandibular
second, usually between the ages of 11 and 12 years.1
The patient might make several visits to the orthodon-
tist for evaluation of eruption; if the time between visits
is long, the patient might wait longer than necessary
before starting treatment. More accurate prediction of
eruption could reduce the number of recall appointments
before the start of treatment, saving both time and money.
In pediatric dentistry, the ability to predict premolar
eruption might influence the diagnosis and treatment
planning of a carious deciduous dentition.2 Also, if
tooth transplantation is planned, accurate prediction
of the eruption date would facilitate the timing of
surgery.3
Tooth eruption has been studied to find a reliable
and clinically usable process for prediction. Simpson
and Kunos4 examined tooth development from cross-
a
St Helen’s Dental Practice, Cockermouth, Cumbria, United Kingdom.
b
Private practice, Anchorage, Alaska; adjunct clinical assistant professor,
Department of Orthodontics, Arthur A. Dugoni School of Dentistry, University
of the Pacific, San Francisco, Calif.
c
Department of Child Dental Health, School of Dental Sciences, Newcastle
upon Tyne, United Kingdom.
d
Department of Statistics, University of Newcastle upon Tyne, Newcastle upon
Tyne, United Kingdom.
Reprints requests to: Dr Rebecca Poling, 1000 O’Malley Rd, Suite 105,
Anchorage, AK 99515; e-mail, snowbird@alaska.net.
Submitted, May 2004; revised and accepted, October 2004.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2004.10.013
sectional and longitudinal radiographs of contemporary
urban children aged 3 months to 18 years. They suggested
2 techniques to improve the description of dental growth
and development. By reducing the interval between
periodic radiographs, the accuracy of identifying subtle
morphological changes in the growing dentition in-
creased. They analyzed craniodental radiographs from
36 subjects from the Bolton-Brush Growth Study (www.
cwru.edu/dental/bbgsc/) and 267 subjects from a con-
temporary pediatric dental clinic. Their second ap-
proach was to describe morphological increments of the
changing anatomy. Each tooth was scored on a scale of
0.00 to 2.00 in increments of 0.01; 0.00 indicated no
radiographic evidence of crown formation, 1.00 indi-
cated a complete enamel crown, and 2.00 indicated
apical root closure. This system of scoring can easily be
translated into the stage scores of Demirjian5 and
Moorrees et al.6
Simpson and Kunos4 might have had a bias toward
older subjects for completion of dental development.
Although the Bolton Brush radiographs were well
maintained, extensive use had resulted in scratches, and
certain structures were sometimes difficult to resolve.
In addition, the radiographs taken for that study were
intended to identify cranial landmarks, and the resolu-
tion of the dental tissues was not maximized.
In addition to individual variation, tooth eruption
is affected by local factors. For example, the rate of
eruption might be increased by early loss or abscess
formation of the deciduous predecessor7 or by a devel-
opmental cyst.8 On the other hand, tooth eruption can
be delayed by ankylosis of the deciduous predecessor
331
332 Rowlands et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2006

or by impactions and ectopic eruption of a canine,

premolar, or molar.2
The purpose of this study was to establish a reliable
method, that can be used in the clinical situation, of
prospectively predicting completion of mandibular second

Crown
premolar tooth eruption with panoramic radiographs.

MATERIAL AND METHODS

The sample comprised 301 consecutive white pa-
tients (120 boys, 181 girls) from 1 Alaskan orthodontic
practice, aged 6 to 16 years; they were in the mixed
dentition at the first examination. All had initial records
taken for orthodontic examination, including panoramic
radiographs, between August 1983 and March 1997, and
were monitored with intermittent serial radiographs until
all premolars had erupted. This gave 1190 panoramic

radiographs.
Patients with medical conditions that might affect
the rate of tooth eruption— eg, hypodontia, hyperdon-
tia, epithelial/endothelial dysplasia, amelogenesis im-
perfecta, or dentinogenesis imperfecta—were excluded.
The results of this study should not be applied to patients
with these conditions.
Completion of eruption was defined as when the
tooth was first recorded as visible in the mouth.
Mandibular right and left second premolars were mon-
itored separately for completion of eruption. Prediction
of eruption timing was estimated for both the mandib-
ular right and left second premolars together, unless
there was significant variation in development at the
assessment; then separate predictions were made.
Prior and subsequent tooth development was re-
corded by measuring the crown and root lengths from
the panoramic radiograph in millimeters with an elec-
tronic vernier micrometer with the aid of a magnifying
glass (4⫻ magnification) and recording it as the ratio of
crown to root length. This overcomes the problem of
magnification with these radiographs. Crown length
was defined as the distance between the most coronal
aspect of the tooth to the cementoenamel junction. Root
length was defined as the distance between the cemen-
toenamel junction and the most apical aspect of the
cementum (Fig 1).
In addition, the dental development scale described
by Simpson and Kunos4 was used. Measurements were
taken from panoramic radiographs, from the earliest
until there was a clinical record or a radiograph document-
ing eruption into the oral cavity (Fig 2).
All measurements were made by the same examiner
(P.R.). Examiner reliability was determined by repeat-
ing the measurements for 20 randomly chosen radio-
graphs 3 weeks after the initial assessment. The Student
Root
Fig 1. Drawing of tooth and how crown-root ratio was
measured.
t test found no significant differences between the 2
examinations (P ⬎ .05).
Statistical analysis of the crown-root ratio and the
Simpson and Kunos4 scale and their ability to predict
eruption was undertaken by using multiple regression.
The dependent variable was “months to eruption.”
Because there were observations on up to 2 teeth at
several visits for each child, the analysis was made with
the multilevel modeling package, MLwiN (Multilevel
Models Project, Institute of Education, University of
London, London, United Kingdom). Variation between
children, variation between teeth, and variation be-
tween visits were included as random effects. Age, the
crown to crown-plus-root ratio, and the Simpson and
Kunos score were the fixed effects.
To evaluate whether the final model can be used to
inform the decision about when to recall the child for
further examination, 4 recall strategies, based on data
from the first visit, were considered. Two of these made
no use of the predicted time to eruption; the first
assumed a recall every six months after the first
appointment, and the second assumed a recall every 12
months after the first appointment. The other 2 were
American Journal of Orthodontics and Dentofacial Orthopedics Rowlands et al 333
Volume 129, Number 3

Fig 2. Panoramic radiograph series used to predict time to eruption based on crown length to
crown-plus-root-length ratio. A, November 2, 1992, age 7 years 7 months, crown formed but no root
formation, eruption predicted in 4-5 years (actual time, 5 years 2 months). B, April 26, 1994, age 9
years, crown length to crown-plus-0.25-root length ratio was 4:5, eruption predicted in 3-4 years
(actual time, 3 years 10 months). C, June 5, 1995, age 10 years 2 months, crown length to
crown-plus-0.5-root length ratio was 4:6, eruption predicted in 2-3 years (actual time, 2 years 8
months). D, June 5, 1996, crown length to crown-plus-0.75-root length ratio was 4:7, eruption
predicted in 1-2 years (actual time, 1 year 8 months). At recall, age 12 years 2 months, premolars
had not erupted, crown length to crown-plus-0.75-root length ratio was 4:8, eruption predicted in
6 months-1 year (actual time, 8 months). At March 3, 1998, recall, age 12 years 10 months,
premolars erupted.

based on the predicted number of months to eruption
calculated by substituting data from the first visit into
the regression model. When the predicted time to
eruption was less than 6 months (including negative
estimates), it was rounded up to 6 months. The first
alternative strategy was based on a decision to recall the
child on the predicted date of eruption and then visits
every 6 months; the second was based on recalling the
child 3 months before eruption followed by visits every
6 months if the tooth had not erupted. For each strategy,
the mean number of unnecessary visits (when the tooth
had not erupted) and the mean time the child waited for
an appointment after eruption were calculated.
RESULTS
Three hundred one patients were included in the
study (181 girls and 120 boys); each patient had initial
dental panoramic radiographs available before eruption
of mandibular premolars. The mean age when the
patients were first seen was 9.5 years. The mean age at
eruption of the mandibular second premolar was 12.5
years (SD 1.4). There was no significant difference
between the mean ages of eruption in girls (12.3 years)
and boys (12.8 years).
The ability to predict eruption is illustrated in the
scatterplots of the raw data (Figs 3 and 4), which
support an association between the indexes of tooth
growth and time to eruption by demonstrating a strong
linear association.
Two possible predictors of time to eruption were
studied: Simpson and Kunos descriptors4 and measured
crown-root ratio. It is possible to assess the relative
predictive power of each index by including each in a
regression model and examining the r 2 statistic. When
the Simpson and Kunos index is used as the predictor,
the value of r 2 is 0.66. When the crown to crown-plus-
root index is used as the predictor, the r 2 statistic is
0.71.
The exact relationship between time to eruption and
the various predictors of interest is best examined by
using multilevel modeling. This takes into account the
hierarchical nature of the data set (for each child,
334 Rowlands et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2006

3500 Table I.Multilevel model: parameter estimates (depen-

dent variable ⫽ time to eruption in months)
Parameter Estimate SE
2500

Fixed
Constant term 129.49 1.92
Crown to crown-plus-root index 7.90 1.02
1500
Age in years 10.57 0.11
Time to e rupt ion in da ys

Random
␴2 child 224.01 19.26
500
␴2 tooth 20.89 1.91
␴2 visit 5.86 0.23

-500
.25 .50 .75 1.00 1.25 1.50 1.75 2.00 2.25
Table II. Performance of 4 recall strategies
Simpson and Kunos Index
Number of Number of
unnecessary weeks without
Fig 3. Scatterplot of time to eruption against Kunos and visits treatment
Simpson index.
Recall strategy Mean SD Mean SD

Every 6 mo 5.4 3.1 13.6 7.9

3500
Every 12 mo 2.5 1.6 27.3 16.1
3000
On predicted eruption date,
then every 6 mo 1.1 1.6 31.6 31.1
2500
3 mo before predicted eruption
date, then every 6 mo 1.4 1.7 26.4 26.9
2000

1500 sidered. The relative performance of these strategies

T im e to errup ti on i n days

was studied by applying them to the children in our

1000
500
0
-500
.2 .3 .4 .5
Crown to (crown + root) index
Fig 4. Scatterplot of time to eruption against crown to
crown-plus-root index.
observations were recorded on up to 2 teeth on several
occasions). When both of these indexes were included
in the model, the parameter estimate corresponding to
the Simpson and Kunos index did not differ signifi-
cantly from zero (coefficient ⫽ 0.84 with SE 0.67). The
multilevel model that best represented the data included
a fixed intercept term, the crown to crown-plus-root
index, the child’s age in years, and 3 random error
terms corresponding to the 3 levels in the model
(Table I).
To investigate whether this model can be used to
inform the decision about when to recall a child for
further examination, 4 alternative strategies were con-
sample at their first visit (Table II).
An unnecessary visit was defined as one when a
child attends for examination, but the tooth has still not
erupted. The number of weeks without treatment is the
time between the tooth’s actual eruption and the next
.6 .7 .8 .9 1.0 1.1
visit scheduled according to the strategy adopted.
For example, if all children in our sample had
simply been recalled every 6 months (strategy 1), there
would have been an average of 5.4 further visits when
the tooth had still not erupted. Each child would, on
average, have waited 13.6 weeks between the time the
tooth actually erupted and the next scheduled appoint-
ment.
By increasing the time interval between recalls
(strategy 2), the number of unnecessary visits can be
reduced, but the length of time the child waits for
treatment after eruption of the tooth is increased.
By using the multilevel model to predict time of
eruption (strategies 3 and 4), the number of unneces-
sary visits can be markedly reduced, but the average
time a child waits for treatment after the tooth has
erupted is about 6 months.
Clearly, if a value is placed on an unnecessary visit
and a week without treatment, an optimal strategy for
recalling children can be determined.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 129, Number 3
DISCUSSION
Certain precautions were followed to minimize
error in data collection. Because panoramic radiographs
are known to have problems with distortion and mag-
nification,9 a ratio was used in this study instead of a
linear measurement. Also, the location of the cemen-
toenamel junction on some radiographs with poor
contrast between enamel and dentin was a problem,
and, in these cases, measurements were taken in rela-
tion to the constriction of the follicle in unerupted teeth
and cervical burnout in erupted teeth.
The average eruption age of the mandibular second
premolars in these children was 12.5 years. This age is
similar to that predicted by Berkovitz et al.1
The finding that the Simpson and Kunos scale4 and
the crown to crown-plus-root ratio were accurate pre-
dictors of mandibular second premolar eruption sug-
gests that this scale and ratio can be used to reasonably
predict the time of eruption of this tooth after exami-
nation with panoramic radiographs. Both systems of
assessing tooth development are simple and easy to apply
and do not require measuring tools or calculations.
The use of the Simpson and Kunos scale4 and the
crown to crown-plus-root ratio rather than direct mea-
surements from the radiographs would minimize the
inaccuracies associated with magnification of the image
and allow comparison of serial radiographs, reducing
the problems of reproducibility of patient position in
the radiograph machine.
Current practice in general dental services for recall
strategies involves recalls every 6 months; however,
there is no scientific basis for this interval between
examinations.10 If the traditional 6-month recall strat-
egy is applied while awaiting tooth eruption, our results
suggest that 5 or more unnecessary visits would occur
during this interval.
Our data show that, on average, patients seen on a
6-month recall interval have 5.4 unnecessary visits
without complete tooth eruption with an average wait
of 13.6 weeks beyond the time the tooth actually erupts
before the next recall appointment.
If patients are recalled yearly, this reduces the
average number of unnecessary visits to 2.5. However,
the average wait between tooth eruption and the next
recall appointment increases to 27.3 weeks, essentially
doubling the waiting time between eruption and possi-
ble start of treatment.
Two recall strategies are proposed. For both, the
Simpson and Kunos scale or the crown to crown-plus-
root ratio is initially used to calculate the time to
eruption; then either stratregy can be followed.
Rowlands et al 335
Strategy 1: The patient is recalled on the predicted date
of eruption. If the tooth has not yet erupted, the
patient is recalled every 6 months after that.
Strategy 2: The patient is recalled 3 months before the
predicted date of eruption. If the tooth has not
erupted, the patient is recalled every 6 months after
that.
If strategy 1 is followed, a mean of only 1.1
unnecessary visits is predicted; however, the patient
would wait an average of 31.6 weeks between tooth
eruption and the next recall appointment. With strategy
2, a mean of 1.4 unnecessary visits is predicted with, on
average, 26.4 weeks between actual tooth eruption and
the next recall appointment. In this study, the observed
differences between these strategies were not statisti-
cally significant.
With reference to malocclusion, a literature review
in 198011 showed no information about the frequency
of examinations necessary to detect predisposing fac-
tors to malocclusion. Nor are there any controlled
studies indicating whether a yearly delay, for example,
in detection and treatment of malocclusions would alter
the final outcome.
This study raises interesting points of discussion:
● Should patients be recalled more frequently at the
expense of clinical time?
● Should the number of recalls be reduced to a mini-
mum at the expense of a longer wait between tooth
eruption and further review?
Six-month recalls resulted in 5.4 unnecessary visits
compared with 1.1 to 1.4 unnecessary visits when the
Simpson and Kunos scale4 or the crown to crown-plus-
root ratio was used followed by 1 of the proposed recall
strategies. This significant difference indicates the ac-
curacy benefit of predictive estimation of tooth eruption
of these evaluation systems.
Yearly recalls showed no significant difference
compared with strategies 1 and 2 in the number of
weeks between tooth eruption and the next recall
appointment. However, as expected, regular 6-month
recalls showed a significantly shorter wait between
tooth eruption and the next recall appointment. Despite
this, the many unnecessary visits associated with recalls
every 6 months make this method of reevaluation
inefficient.
While awaiting tooth eruption, predictive estima-
tion of tooth eruption with the Simpson and Kunos
scale4 or the crown to crown-plus-root ratio followed
by recall strategy 1 or 2 will provide greater efficiency
without sacrificing optimal timing of treatment. This
technique offers an accurate estimation of the timing of
 336 Rowlands et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2006

tooth eruption and thereby reduces the number of
unnecessary recall appointments to a minimum.
CONCLUSIONS
The mean age of eruption of the mandibular second
premolar in this cohort of children was 12.5 years. The
Simpson and Kunos scale4 or the crown length to
crown-plus-root length ratio, as viewed on panoramic
radiographs, allows a rapid assessment of time to
eruption of the mandibular second premolars.
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5. Demirjian A. Dental development: a measure of physical matu-
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6. Moorrees CFA, Fanning EA, Hunt EE. Age variation of forma-
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