Original Article

Tooth size discrepancies in Irish orthodontic patients among different

malocclusion groups
Gerard O’Mahonya; Declan T. Millettb; Mark K. Barryc; Grant T. McIntyred; Michael S. Cronine

ABSTRACT
Objective: To determine the prevalence of tooth size discrepancies (TSDs) in an Irish orthodontic
population among different malocclusion groups.
Materials and Methods: From 850 pretreatment sets of orthodontic models at a university clinic,
240 were selected with 30 female and 30 male sets for each malocclusion (Class I, Class II division
1, Class II division 2, and Class III). Digital models were produced, and the mesial and distal
contact points were digitized to calculate overall and anterior tooth size ratios. The differences
between the male and female groups and among the malocclusion groups were analyzed using
two-way analysis of variance (ANOVA) (P , .05).
Results: A clinically significant anterior TSD (more than two standard deviations from the Bolton
means) existed in 37.9% of the subjects. No differences existed in the prevalence of overall TSDs
between the male and female groups (P 5 .5913) or among the malocclusion groups (P 5 .0809).
For the mean anterior tooth size ratios in the male group, the values for Class III and Class II
division 2 were higher than in Class II division 1, and the value for Class II division 2 was higher
than in Class I (P 5 .0184).
Conclusions: The prevalence of anterior tooth size discrepancies in this sample of Irish
orthodontic patients was 37.9%. There were no statistically significant differences in the prevalence
of mean overall TSDs with regard to malocclusion or gender. In the male group, the mean anterior
tooth size ratio was higher in Class III and in Class II division 2 malocclusion than in Class II
division 1 and higher in Class II division 2 malocclusion than in Class I malocclusion. (Angle
Orthod. 2011;81:130–133.)
KEY WORDS: Tooth size discrepancy; Bolton; Malocclusion

INTRODUCTION the absence of a TSD is the seventh ‘‘key’’ for an ideal

occlusion.2 Overall, TSDs relate to all teeth excluding
A tooth size discrepancy (TSD) is a disproportion
second permanent and third molars, whereas anterior
among the sizes of the individual teeth.1 As significant
TSDs involve the six anterior teeth.
tooth size discrepancies prevent an ideal occlusion
Among patients undergoing orthodontic treatment,
being produced at the end of orthodontic treatment, the prevalence of an overall TSD has varied from 4%–
11%3–6 but is about 5% in the nonorthodontic popula-
a
Specialist in Orthodontics, HSE South, Cork University tion.7 Anterior TSDs, however, have a prevalence
Dental School and Hospital, Wilton, Cork, Ireland. between 17% and 31% among orthodontic pa-
b
Professor, Oral Health and Development, Dental School, tients,3,6,8–10 and this is similar to the prevalence of
University College Cork, Ireland.
20.5% in nonorthodontic patients.7
c
Lecturer, School of Manufacturing Engineering, Dublin
Institute of Technology, Dublin 1, Ireland. Trends have been identified in the prevalence of
d
Consultant, Department of Orthodontics, Dundee Dental TSDs among the malocclusion groups. TSDs are more
Hospital and School, Dundee, Tayside, UK. common in Class II division 1 malocclusions8 and in
e
Lecturer, Department of Statistics, Western Gateway, Class III malocclusions.5,10–13 Although Uysal and Sari14
University College Cork, Ireland.
found no differences in tooth size ratios between
Corresponding author: Prof Declan T. Millett, Oral Health and
Development, Dental School, University College Cork, Ireland malocclusion groups, a greater prevalence of larger
(e-mail: [email protected]) tooth size ratios was noted when orthodontic and
Accepted: July 2010. Submitted: May 2010. nonorthodontic groups were compared.
G 2011 by The EH Angle Education and Research Foundation, While in general men have bigger teeth than
Inc. women,15 this does not mean that they have larger

Angle Orthodontist, Vol 81, No 1, 2011 130 DOI: 10.2319/050610-246.1

TOOTH SIZE DISCREPANCY IN IRISH PATIENTS 131

tooth size ratios or an increased prevalence of TSDs. N No previous orthodontic treatment

In particular, Lavelle16 and Smith et al.17 found larger N No factors which prevented accurate measurement
tooth size ratios in men than in women, but the of mesiodistal tooth widths including restorations,
differences at 0.6%–1.0% were not significant. This fractured teeth, or broken teeth on models
was confirmed by Mirzakouchaki et al. 18 in an
The first 60 sets of each malocclusion subgroup
investigation of Iranian-Azari subjects.
(Class I, Class II division 1, Class II division 2, and
Ethnicity/race has also been found to be an
Class III), with 30 male and 30 female sets in each
influence on TSDs. Mean overall and anterior tooth
group, were selected to produce a total sample of 240
size ratios in subjects with excellent occlusions have
model sets. The incisor relationship was classified
been found to be on average greater in Blacks than
according to the British Standards Institute classifica-
in either Mongoloids or Whites.16 Smith et al.17 found
tion.26 The severity of the malocclusion or skeletal
that Black people had the highest overall tooth size
relationship was not assessed. The models were
ratios (93.4%) followed by Hispanics (92.3%) and then
scanned using an R250 orthodontic study model
Whites (91.2%). The anterior tooth size ratio was
scanner (3Shape A/S, Copenhagen, Denmark) to
higher for Hispanics (80.5%) than for Black people
produce digital images and were then evaluated using
(79.3%). Despite these findings, Othman and Harra-
OrthoAnalyzer (3Shape A/S). The mesial and distal
dine19 noted that the trend to larger overall tooth size
aspects of all teeth (excluding the second and third
ratios in Black populations is unlikely to be clinically
permanent molars) were landmarked by one assessor.
relevant. Significant discrepancies in the overall and
The overall and anterior tooth size ratios according to
anterior tooth size ratios have been found in Japanese,
Bolton1 were then automatically calculated. Using SAS
Iranian-Azari, Spanish, and Brazilian subjects.4,18,20,21
(version 9.1.3, SAS Institute Inc, Cary, NC), differenc-
Although the prevalence of tooth size ratios has been
es were calculated between the classes, with compar-
investigated in the British population,6 and tooth size
isons being adjusted using the Sidak method27 to
has been investigated in subjects with bimaxillary
preserve the overall type I error rate at 5%. Residual
dental protrusion in a British subgroup,22 specific data
analyses were performed to confirm the adequacy of
regarding overall and anterior tooth size ratios in the
the analysis of variance (ANOVA) models. Intraobser-
Irish population are not available.
ver reliability for landmark identification was assessed
The most common method of assessing a TSD
by relandmarking a 10% random sample of the digital
involves the measurement of the mesiodistal widths of
images (24 model sets across the entire sample)
teeth using conventional fine-pointed calipers or digital
6 weeks after the initial assessment and evaluating
calipers.1 The development of digital scanning of study
differences in the automatically calculated anterior and
models has facilitated the automated calculation of
overall Bolton ratios using two-way ANOVA.
tooth size ratios once the mesial and distal points of
each tooth have been identified.20,23,24 Measurements
RESULTS
derived using 3D digital study models have been found
to be an appropriate alternative to those derived using Within this study sample 37.9% had a clinically
plaster models and digital calipers20,23,24 with the significant mean anterior TSD, as defined by those
advantages of being faster and providing easier cases having ratios more than two standard deviations
storage of data.25 from the means in Bolton’s study1 of cases with good
The aim of this study is to determine the prevalence occlusions. There were no statistically significant
of tooth size discrepancies (TSDs) in Irish orthodontic errors associated with the measurement of either the
patients among different malocclusion groups using mean overall tooth size ratios (mean difference 5
3D digital study models. .004; SD .011) or the mean anterior tooth size ratios
(mean difference 5 .001; SD .014). For the mean
MATERIALS AND METHODS overall tooth size ratios, no statistically significant
differences were found between the genders (Tables 1
From 850 pretreatment sets of orthodontic study
and 2) (P 5 .5913) or among the malocclusion classes
models at a university clinic, models were identified
(P 5 .0809). For the mean anterior tooth size ratios
that fulfilled the following criteria:
(Tables 3 and 4), there was an interaction between
N Permanent central incisor-first permanent molar gender and the incisal class (P 5 .0184). There were
erupted in each quadrant differences between the incisal classes (P 5 .0143)
N Subjects of Irish ethnic background determined from and, as the interaction was significant, these differ-
case records ences between incisal classes were not the same for
N No retained primary teeth the two genders. For the female group there were no
N No abnormal tooth morphology differences between the incisal classes.

Angle Orthodontist, Vol 81, No 1, 2011

132 O’MAHONY, MILLETT, BARRY, MCINTYRE, CRONIN

Table 1. Mean Overall Tooth Size Ratios Table 3. Mean Anterior Tooth Size Ratios
Gender Gender
Female Male Total Female Male Total
Malocclusion n Mean SD n Mean SD n Mean SD Malocclusion n Mean SD n Mean SD n Mean SD
Class I 30 .921 .022 30 .924 .022 60 .923 .022 Class I 30 .796 .032 30 .784 .029 60 .790 .031
Class II Class II
division 1 30 .918 .018 30 .918 .024 60 .918 .021 division 1 30 .793 .033 30 .779 .036 60 .786 .035
Class II Class II
division 2 30 .923 .022 30 .928 .021 60 .926 .022 division 2 30 .794 .031 30 .811 .027 60 .802 .030
Class III 30 .929 .021 30 .927 .022 60 .928 .022 Class III 30 .796 .032 30 .803 .030 60 .799 .031
Total 120 .923 .021 120 .924 .022 240 .924 .022 Total 120 .794 .032 120 .794 .033 240 .794 .032

DISCUSSION and Souki.10 There was a difference in the mean

anterior tooth size ratios among the malocclusion
The prevalence of clinically significant anterior
groups for men. The highest mean anterior tooth size
TSDs1 in this Irish sample (37.9%) is higher than the
ratios for men were for Class II division 2 (.811) and for
recorded 17.4% in a British orthodontic population.6
Class III (.803) compared to Class I (.784) and Class II
The prevalence, however, falls between that reported
division 1 (.779). This trend towards higher tooth size
in a US population by Freeman et al.9 and a Dominican
ratios in Class III malocclusion was noted previously by
American population by Santoro et al.3 Furthermore,
Ta et al.12 in a Chinese population and Alkofide and
the overall mean tooth size ratio in the Bolton study
Hashim13 in a Saudi population. Strujic et al.5 found
was .91 compared to .92 in the present study, and the
there was a tendency for mandibular tooth excess in
mean anterior tooth size ratio in the Bolton study was
subjects with Class III malocclusions and for maxillary
.77 compared to .79 in the present study.
tooth excess in subjects with Class II malocclusions in
When considering the mean overall tooth size ratios,
an orthodontic population. Othman and Harradine19
there were no statistically significant differences
suggested that this may be another factor that
between men and women corroborating with previous
complicates the treatment of Class III malocclusion.
studies that have identified minor (statistically insignif-
There was also a higher prevalence of mean anterior
icant) differences between men and women.16,17,19
tooth size ratios in the male Class II division 2
Furthermore, we were unable to find any statistically
malocclusion group which may have restorative
significant differences in the mean overall tooth size
implications.
ratios between the different malocclusion groups. This
The high prevalence of anterior TSDs in this Irish
is in accordance with the findings of Uysal and Sari14
orthodontic population suggests that a tooth size
who identified no differences in tooth size ratios
analysis should be conducted at the treatment
between malocclusion groups in a Turkish population,
planning stage. Where significant TSDs are detected,
but contrasts with Nie and Lin28 who identified a higher
this is normally accommodated by the reduction or
prevalence of increased overall tooth size ratios in
augmentation of tooth tissue.29
Class III malocclusions compared to Class I and Class
II malocclusions in a Chinese population.
In this study, the mean anterior tooth size ratios
CONCLUSIONS
exhibited no statistically significant differences be-
tween genders and no statistically significant differ- N The prevalence of anterior tooth size discrepancies
ences among the malocclusion groups. This is similar in this sample of Irish orthodontic patients was
to the findings by Crosby and Alexander8 and Araujo 37.9%.

Table 2. Analysis of Mean Overall Tooth Size Ratios Table 4. Analysis of Mean Anterior Tooth Size Ratios
Type III Tests of Fixed Effects Type III Tests of Fixed Effects
Effect NumDF DenDF F Value Pr . F Effect NumDF DenDF F Value Pr . F
Gender 1 232 .29 .5913 Gender 1 232 0.00 .9868
Class 3 232 .27 .0809 Class 3 232 3.60 .0143
Gender*Class 3 232 .38 .7661 Gender*Class 3 232 3.41 .0184
(Num DF 5 Numerator Degrees of Freedom; Den DF 5 (Num DF 5 Numerator Degrees of Freedom; Den DF 5
Denominator Degrees of Freedom; F Value 5 F-statistics value; Denominator Degrees of Freedom; F Value 5 F-statistics value;
Pr . F: P value). Pr . F: P value).

Angle Orthodontist, Vol 81, No 1, 2011

TOOTH SIZE DISCREPANCY IN IRISH PATIENTS 133

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the prevalence of overall TSDs with regard to mesiodistal crown dimensions for a Turkish population.
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Class I malocclusion. Dentofacial Orthop. 1989;96:416–422.
16. Lavelle CL. Maxillary and mandibular tooth size in different
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