DEPARTMENT OF PEDODONTICS

MIXED DENTITION

ANALYSIS
SUBMITTED BY,
SHIFANA A A
FINAL YEAR PART II
ROLL NO: 30
 CONTENTS
1. INTRODUCTION
2. FUNDAMENTALS OF MODEL ANALYSIS
3. OBJECTIVES OF IDEAL STUDY MODEL
4. ADVANTAGES OF MODEL ANALYSIS
5. DUSADVANTAGES OF MODEL ANALYSIS
6. CLASSIFICATION
7. RADIOGRAPHIC METHODS
8. NON RADIOGRAPHIC METHODS
9. COMBINATION
10. DIGITAL ANALYSIS
11.CONCLUSION
12.REFERENCE
 INTRODUCTION

Model analysis is the study of dental casts, which helps to study the occlusion and
dentition from all three dimensions and analyze the degree and severity of
malocclusion and to derive the diagnosis and plan for treatment.

Model analysis can be defined as the study of maxillary and mandibular arches in
all the three planes of space (sagital, vertical, transverse) and is available tool in
orthodontic diagnosis and treatment planning.
 FUNDAMENTALS OF MODEL ANALYSIS

Study model analysis compares the space available and the space required in a
dentition.
Space
required

Space Model Space

available Analysis Deficiency

Space
excess
 OBJECTIVES OF IDEAL STUDY MODELS

1. Models should accurately reproduce the teeth and their surrounding

soft tissue.

2. Soft tissue should not be altered.

3.Models should be well finished.

 ADVANTAGES OF MODEL ANALYSIS

1.They are three dimensional records of the patient’s dentition.

2. Occlusion can be visualized from the lingual aspect.

3. They provide a permanent record of the intermaxillary relationship.

4. Helps to motivate the patients, as they can visualized the treatment progress.
5. They are needed for comparison purposes at the end of treatment & act
as a reference for post treatment changes.

6. They serve as reminder for the parent & the patient of the condition
present at the start of treatment.

7. In case the patient has to be transferred to another clinician, study

model are an important record.
 DISADVANTAGES OF MODEL ANALYSIS

1. Vertical skeletal jaw discrepancy can't be ascertained from cast.

2. Dental cast simply provide an idea of the relative anteroposterior

relationship of the jaws to each other.

3. Wheather the maxilla is retrusive or protrusive can't be ascertained

from casts i.e.anteroposterior status of jaw to skeletal craniofacial
complex can't be determined from study cast.

4. Degree of labial/lingual inclination of incisors observed on cast can be

misleading because one tends to judge in relation to the artistic portion of
the dental cast base.
 CLASSIFICATION
Model analysis can be classified in the following ways

1. Based on whether the analysis is on the permanent dentition or on the

mixed dentition.

PERMANENT DENTITION ANALYSES

 Ashley howe's
 Carey’s
 Arch perimeter
 Pont's
 Linder Hearth's
 Korkhau’s
 Bolton’s
 Peck and peck index
 Sanin savara tooth size analysis
 Schwarz analysis

PRIMARY DENTITION
 Boston University approach
 Boston University approach using Tanaka- Johnston
analysis
MIXED DENTITION ANALYSIS

NON-RADIOGRAPHIC SPACE ANALYSES

 Moyer’s mixed dentition analysis

 Tanaka Johnston
 Ballard and Wylie

RADIOGRAPHIC ANALYSES›
 Nance Carey’s Analysis
 Hay Nance mixed dentition analysis
 Huckaba’s Analysis
COMBINATION OF RADIOGRAPHS AND PREDICTION CHARTS

 Hixon and Old father

 Staley Kerber
 Total space analysis

2. Based on the arch in which the analysis is carried ou they can be

classified as:-

MAXILLARY ARCH

 Pont’s
 Linder hearth’s
 Korkhau’s
 Arch perimeter
MANDIBULAR ARCH
 Carey’s
 Hixon and Old father
 Peck and peck
 Total space analysis
 Staley Kerber
 ELLIS CLASS V FRACTURE

TOTAL TOOTH LOSS


(AVULSION)
Term used to describe complete displacement of tooth from its alveolus. It
is also called as exarticulation and most often involves the maxillary teeth.
SPACE ANALYSIS

INCIDENCE
0.15% to 16% of all traumatic injuries.
CLINICAL FEATURES
• Bleeding socket with missing tooth.

Associated injuries
• Fracture of alveolar socket wall
• Injury to the lips and cheeks

RADIOGRAPHIC FEATURES
• Empty socket.
• Associated bone fractures.
• If the wound is recent then laminadura is visible other wise
it is obliterated.
TREATMENT
• Reimplantation depends on extraoral time.
• If apical foramen is not closed—endodontic therapy is delayed till first signs of
apical closure are seen.
• If apical foramen is closed—endodontic therapy is done after 1 to 2 weeks
depending on type of reimplantation.

PROGNOSIS
• Tooth survival: 51 to 89 percent.
• PDL healing: 9 to 50 percent.
• Pulp healing: 4 to 15 percent.
REIMPLANTATI
ON
 Case history should include exact information on the time interval
between injury and reimplantation as well as conditions under which
the tooth has been stored.

 The following conditions should be considered before replanting a

permanent tooth:

 The alveolar socket should be reasonably intact in ordertoprovide a

seat for the . avulsed tooth.
 The extra-alveolar period.
Short extra-alveolar
storage:
This is done if the tooth since the time of injury has been placed in a suitable medium
and the extra-alveolar time elapsed is short.

The tooth is placed in saline.

If visibly contaminated, the root surface is cleansed with a stream of saline until visible
contaminants have been washed away. No effort should be made to sterilize the root
surface as such procedure will damage or destroy vital periodontal tissue and cementum
 The socket is then examined for the evidence of fracture. The alveolus is also cleaned
with a flow of saline to remove contaminated coagulum

The tooth is replanted using slight digital pressure. Only light pressure should be used, as
this will permit detection of resistance from displaced alveolar bone fragments that
impede reimplantation. The replanted incisor should fit loosely in the alveolus

Suture gingival lacerations

Apply splint for 1 week only as prolonged splinting of replanted mature teeth increases
the extent of root resorption

Proper repositioning can now be evaluated by the occlusion of tooth

Verify position radiographically

 Tetanus prophylaxis is important, as most teeth have been in contact with soil, or the
would itself is soil-contaminated

The value of antibiotic therapy is questionable

If apical foramen is closed then perform endodontic therapy 1 week reimplantation, prior
to removal of splint
 Long extra-alveolar
storage:
This is done if the extra-alveolar time elapsed is long.

Treat the tooth with 2.4% sodium fluoride (NaF) for 20 minutes prior to reimlantation.

Clean the tooth with saling and remove the PDL also.
Extraoral root canal treatment is performed by extirpating pulp. Doing enlargement of
canals and finally obturating

Bevel la created at the apical end and it is restored.

Remove coagulum from socket.

Reimplant the tooth.

Splint for 2 weeks.

STORAGE MEDIA FOR AVULSED TEETH
To achieve a successful functional outcome, it is recommended to store the avulsed
teeth in an interim storage medium, in cases of delayed reimplantation.

Types of Storage
Media
Saline
solution
The saline solution provides osmolality of 280 mOsm/kg and despite
being compatible to the cells of the periodontal ligament, it lacks
essential nutrients necessary to the normal metabolic needs of the cells
of the periodontal ligament.

Tap water
This is an unacceptable storage media for avulsed tooth. They
attributed the increased cell damage to the cells lysis caused by the
very low osmolarity of tap water.
Saliva
It can be used as a storing medium for a short period of time, for it can
damage the cells of the periodontal ligament if used for longer than an
hour.

Milk
Milk is significantly better than other solutions for its physiological
properties, including pH and osmolality compatible to those of the cells
from the periodontal ligament.

Hank’s balanced salt

solution
It is a standard saline solution that is widely used in biomedical research
to support the growth of many cells types.
This solution is nontoxic, it is biocompatible with periodontal ligament
cells, pH balanced at 7.2.
LIMITATION
S
To achieve a successful functional outcome, it is recommended to store
the avulsed teeth in an interim storage medium, in cases of delayed
reimplantation.
 PERIODONTAL HEALING
REACTIONS
Healing with a Normal
Periodontal ligament
This is characterized by complete
regeneration of PDL, which usually takes
place 2 to 4 weeks to complete.

Healing with surface resorption

This is characterized by localized areas along

the root surface, which show superficial
resorption lacunae repaired by new
cementum.
 Healing with ankylosis
(Replacement resorption)

This is characterized by fusion of bone and

the root surface and can be demonstrated 2
weeks after reimplantation.

Healing with inflammatory

resorption
This is characterized by bowl-shaped
resorption cavities in cementum and dentin
associated with inflammatory changes in the
adjacent PDL space.
 STABILIZATION
SPLINT

A splint has been defined as “a rigid or flexible device that maintains in position a displaced or
movable part; also used to keep in place and to protect injured part.
 ELLIS CLASS VI FRACTURE

Fracture of the root with or without loss of


crown structure
Term used to describe complete displacement of tooth from its alveolus. It
is also called as exarticulation and most often involves the maxillary teeth.
This method uses the width of the lower incisors to predict the widths of
the unerupted cuspids and bicuspids of the upper and lower arch.

They had conducted their study on 506 orthodontics patients in

Cleveland.

They believed that the Moyer’s equations and the size of his confidence
intervals have never been validated on any other samples.

They undertook the study in the Orthodontic Department of Case Western

University school of dentistry
Available arch length = total arch length - sum of incisors + predicted width

+ value: space surplus

- value: space deficit

Tanaka and Johnston prediction values:

 One half of the mesio-distal width of four lower incisors + 10.5 mm = estimated
width of mandibular canine and premolar in one quadrant.

 One half of the mesio-distal width of four lower incisors + 11.0 mm = estimated
width of maxillary canine and premolar in one quadrant.

INFERENCE
✓ If the result is positive, there is more space available in the arch than is needed for
the unerupted teeth.

✓ If the result is negative, the unerupted teeth require more space than is available to
erupt into ideal alignment.
ADVANTAGE
S
• Improving on the Moyer's analysis, it is relatively accurate for children of
European ancestry. The technique involves simple, easily repeated procedures
and minimal material needs. It does not use prediction charts.
• No additional radiographs required.
• Reasonable accuracy.
• Can be applied to both arches.

LIMITATIONS

• There may be error in the predicted size of the unerupted teeth if patients are not
of North-western European descent.
 BALLARD AND WYLIE’S
MODIFICATION (1947)
Ballard and Wylie were so concerned about the distortion of the X-ray film that
they devised a scheme for establishing or estimating the width of mandibular
canine and the premolars on the basis of combined width of 4 lower incisors.
 Using the plaster model of 441 cases, they measured and recorded the
width of all mandibular teeth including 1” molar.
 On the average the sum of the 4 permanent lower incisors were
23.84±0.08 mm.
 The average sum of canine, 1st and 2nd premolars turned out to be
21.97±0.06 mm.
Although not particularly high, the coefficient of correlation of +0.64 seemed
sufficiently high to justify a prediction. They modified the equation as:

Y = 9.41+0.527(x)

Testing these calculations on 60 cases Ballard and Wylie came to a conclusion

that their method had only 2.6% error as compared to the 10.5% error when
using only the X-rays. They do indicate the good X-ray should be used and
suggest that their method was an adjunct to Nance method.
 RADIOGRAPHIC ANALYSIS

NANCE AND CAREY’S

ANALYSIS (1947)
This is same as arch perimeter analysis:-

Tooth material (space required)

Arch perimeter (space available)
• Arch length discrepancy.
PROCEDURE
The arch length is measured anterior to the 1st permanent molar
using a soft brass wire

Wire should be extended mesial aspect of lower 1st permanent

molar to buccal cusps of premolars and incisal edges of the
anterior to continue upto mesial of the 1st molar of the
contralateral side.
If anteriors are proclined, brass wire should be passed along the
cingulum of anterior teeth . If anterior are retroclined, pass along
the labial surface.

The mesiodistal width of cuspid and bicuspid are measured from

IOPA and summed up as total tooth material

The differenc between the arch length and the actual measured
tooth material gives discrepancy.
 TREATMENT
PLAN
✓ If the discrepancy is 0 to 2.5 mm, it indicates minimal tooth material excess where
proximal stripping is carried out to reduce the tooth material.

✓ If the discrepancy is between 2.5 and 5 mm, it indicates the need to extract the 2nd
premolars.

✓ A discrepancy of more than 5 mm indicates the need to extract the 1st premolars.
 HAY NANCE MIXED DENTITION
ANALYSIS
 It is similar to Carey's arch perimeter analysis in permanent

dentition.
 It's a radiographic mixed dentition space analysis. .
. Measure the width of the unerupted tooth (cuspids and bicuspids)
by using the IOPA. This can be called as the space required.

The total mesiodistal width of all the teeth in each quadrant

indicates space required to accommodate permanent teeth.

Measure the arch perimeter from the mesial side of the first
permanent molar to the contralateral side first permanent molar.
This can be called as the space available.

The difference between the space required and available can be

called as the arch length discrepancy.
ADVANTAGE
S
• Results in minimal errors.
• It can be performed with reliability.
• Allows analysis of both arches.

LIMITATIONS

• Requires knowledge of Tweed's analysis and accurate tracing.

• Time-consuming.
• Requires cephalometric radiograph.
 HUCKABA ANALYSIS (1964)

• It is also called as Proportional Equation Prediction Method and was given

by Huckaba G W. He used both study casts and radiographs for
determining the width of unerupted tooth.
• To compensate for enlargement of radiographic images, measure an
object that can be seen both in radiograph and on the cast such as
primary molar tooth. Accuracy of this method of determining the width of
the unerupted tooth is fair to good, depending upon the quality of the
radiographs and their position in the arch.
• This technique can be used both in maxillary and mandibular arches in all
ethnic groups
 Then a simple proportional relationship can be established as follows:

Y1= X1 Y2
X2

Actual width of primary molar (X1)

Apparent width of primary molar (X2)
Actual width of unerupted premolar (Y1)
Apparent width of unerupted premolar (Y2)

ADVANTAGE
S
• Very easy, practical and relatively accurate
method.
• Does not require any prediction table.
• Can be used in both maxillary and mandibular
arches.
 COMBINATION

HIXON AND OLDFATHER METHOD

(1956)
• It was given in the year 1956. It is the prediction method for the mandibular
arch. It is mainly used for estimating the size of newly erupted canine and
premolar.

• It's a combined form of mixed dentition space analysis.

• The original analysis which was given stated the measurement of the
incisors on the left side of the arch. But modified Hixon and Old father
method was given by Staley and Kerber. They revised this in a study they
conducted in lowa in 1980 called the lowa facial growth study in which both
the sides of the arch were used. They said that by using both sides of the
midline the revised equation had a significantly reduced standard error.
PROCEDURE
Mesiodistal width of the mandibular central incisor and lateral
incisor are obtained from the cast

Determine the width of the premolars from the intraoral periapical

radiographs with paralleling technique

Sum up the width of the central and lateral incisor along with the
width of unerupted premolars of that particular side

Estimated sum total width of the cuspids and bicuspids of that

particular side can be obtained from the standard chart

Measured sum width of incisors and bicuspids has a corresponding

sum width of the cuspids and premolars in the chart.
Using the measured value, the estimated value can be interpreted. The following
values help in predicting the estimated tooth size.

MEASURED VALUE ESTIMATED TOOTH SIZE

23 mm 18.4 mm

24 mm 19.0 mm

25 mm 19.7 mm

26 mm 20.3 mm

27 mm 21.0 mm

28 mm 21.6 mm

29 mm 22.3 mm

30 mm 22.9 mm

DISADVANTAGE
S
• Error is caused due to distortion of radiographic image
• Can be used only in mandibular arch
STALEY KERBER ANALYSIS (1980)
 From the casts, on one side, measure the mesiodistal width of the permanent mandibular
central and lateral incisor.

 From periapical radiographs, measure the mesiodistal width of unerupted 1st and 2nd
premolar.

 Total the mesiodistal width of 4 teeth. Compare the measured value to estimated tooth
size from the Hixon old father chart. Repeat step 1-3 for the other side of the arch.

ADVANTAGE:

✓ It is a very accurate technique.

LIMITATION:

✓ Can be used only for lower arch.

• A graph was made for clinical use in the prediction of mandibular canine and
premolar width.
• This prediction graph is accurate to the nearest 0.1 mm
 TOTAL SPACE ANALYSIS

This analysis was developed by Leven Merrifield.

Here the lower arch is divided into three areas- anterior, middle and posterior
to analyse the space required in the lower arch.

Measurements from the study models and cephalograms are used in this
analysis. This discrepancy for each area has to be calculated, and the
resultant value is added together to yield the discrepancy of the arch.

ANTERIOR AREA

SPACE REQUIRED

Measure the width of the mandibular incisors on the cast and the
width of the cuspids from the radiographs.
Cephalometric correction for the incisor positioning is calculated according to
Tweed’s method; TMIA is taken into consideration instead of IMPA of Tweed.
The incisors are repositioned, and the difference in the actual and proposed
TMIA is determined. The difference in angulation is multiplied by 0.8 to get
the difference in mm.

Soft tissue modification: Upper lip thickness is measured from the vermilion
border of the upper lip to the greatest

Z angle of Merrifield
The total chin thickness is measured from the soft tissue chin to the NB line. If
the lip thickness is greater than chin thickness, the difference is determined
and multiplied by 2 and added to the space required.
If it is less than or equal to chin thickness, no soft tissue modification is
necessary.
Measure the "Z" angle of Merrifield and add the cephalometric correction to it.
If the correction "Z" angle is >80°, the mandibular incisor angulation was
modified as necessary (up to IMPA of approximate 92°). If the corrected angle
is <75°, additional uprighting of the mandibular incisor is necessary.

SPACE AVAILABLE: Measure the space available by using a brass wire from
the mesiobuccal line angle of first primary molar of one side to the other.
MIDDLE AREA

SPACE REQUIRED

MD width of the first permanent molars on the cast and measure the width of
the unerupted premolar from the radiographs.

CURVE OF OCCLUSION

A flat object is placed on the occlusal surface of mandibular teeth contacting

the incisors and the first permanent molars. The deepest point between this
flat surface and the occlusal surface of primary molars is measured on both
the sides. This formula is applied to know the space required for leveling the
curve of occlusion

= Depth on right side + depth of left side + 0.5mm

SPACE AVAILABLE 2

It is measured using a brass wire from the mesiobuccal line angle of first
primary molar to the distobuccal line angle of first permanent molar on either
side.
POSTERIOR AREA

SPACE REQUIRED

MD width of second and third molars is obtained from the radiographs as they
might be unerupted. If these molars are not visible on the radiographs,
Wheeler method is used for calculation, i.e. X = Y –X’
Y’

where X is the estimated value of third molar in the individual patient, Y is the
actual size of permanent mandibular first molar, X' is the Wheeler's value of
third molar and Y' is the Wheeler's value of first molar.

SPACE AVAILABLE

: The amount of space available consisted of space presently available on the

casts and the estimated increase.
INFERENCE

 Space presently available: This was obtained by measuring the distance

on the occlusal plane tangent to distal surface of first permanent molars
to the anterior border of ramus on a lateral cephalogram.

 Estimated increase or prediction: The estimated increase is 3 mm/year,

i.e., 1.5 mm on either side until 14 years of age in girls and 16 years of
age in boys. The age of the patient is subtracted from 14 or 16 according
to the sex of the patient and is multiplied by 3 to obtain the estimated
increase.

 Total space deficit/discrepancy: The total space deficit is arrived at by

comparing the space required and space available in anterior, middle and
posterior areas. Thus, this analysis tells us precisely where the
discrepancy is present i.e., in the anterior, middle or the posterior
 PRIMARY DENTITION ANALYSIS

BOSTON UNIVERSITY
APPROACH
Gianelly proposed a prediction method, i.e. based on the mesiodistal widths
(MDW) of primary mandibular canine and first molars with an idea for early
prediction of unerupted permanent mandibular teeth widths. This was
prepared in Boston University (BU) and hence named as the Boston University
approach.

This approach requires the presence of deciduous canines and first molars,
which is as follows:-
MDW OF PRIMARY
MD WIDTH OF PERMANENT
MANDIBULAR CANINE + 2
MANDIBULAR CANINES
(MDW OF PRIMARY
AND PREMOLARS
MANDIBULAR FIRST MOLAR
 BOSTON UNIVERSITY APPROACH USING
TANAKA-JOHNSTON VALUES

In a new approach for primary dentition analysis, accurate prediction of

canine and premolar dimension was made using the Boston University
approach and comparing the obtained values using Tanaka-Johnston (T/J)
method. It was observed that BU approach cannot be suggested in boys
according to this method, although not much difference was found. However,
the comparison of the mean values obtained through BU and T/J approaches
showed an encouraging point.

Results: Statistically significant (p = 0.00) positive correlation (r = 0.52-0.55)

was observed between T/J and BU approaches. A statistically significant (p =
0.00) strong positive correlation (r = 0.72-0.77) was observed among girls,
whereas boys showed a statistically nonsignificant weak positive correlation
(r=0.17-0.42) based on gender.
 DIGITAL MODEL ANALYSIS
Digital models are rapidly replacing tradition plaster models. Their numerous
advantage has lead to many practices adopting their use. Measurement on
the digital casts can be carried on digital model without the cumbersome
use of callipers. This software also performs computerised analysis of the
cast.
CONCLUSION
None of the Mixed Dentition Analyses are as precise as one
might like, and all must be used with judgment and
knowledge of development.

Hixon and Oldfather:- most accurate

Tanaka and johnston:- most practical
Radiographic method: for population other method: for
population other than Caucasians.

Inaccuracy in radiographic tooth size measurements is not

the dentist's fault. It occurs because the developing teeth
are not always placed exactly at right angles to the central
ray; therefore, the radiographic image of the tooth, when
slightly rotated or tipped, is significantly larger than the
actual size of the tooth
 REFERENCE
1.NIKHIL MARWAH TEXTBOOK OF PEDIATRIC DENTISTRY- 5 TH
EDITION

2 SHOBHA TANDON PEDIATRIC DENTISTRY – 3 RD EDITION

3 CONTEMPORARY ORTHODONTICS PROFFIT – 2 ND EDITION

4 S I BHALAJI TEXTBOOK OF ORTHODONTICS – 7 TH EDITION