

ORIGINAL ARTICLE 



Year : 2017  Volume
: 35
 Issue : 1  Page : 6874 

Applicability of different mixed dentition analysis in Lucknow population
Nishi Grover, Sonali Saha, Abhay Mani Tripathi, JN Jaiswal, Madhuchanda Palit
Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh, India
Date of Web Publication  31Jan2017 
Correspondence Address: Nishi Grover Department of Pedodontics and Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow, Uttar Pradesh India
Source of Support: None, Conflict of Interest: None  Check 
DOI: 10.4103/09704388.199220
Abstract   
Aims: The aim of this study was to test the reliability of Moyer's and TanakaJohnston method of mixed dentition analysis among Lucknow population and also derive a linear regression equation that would predict sum of mesiodistal widths of upper and lower canines and premolars for both sexes. Setting and Design: Moyer's and TanakaJohnston mixed dentition space analysis were developed from a sample of North European descent children. Hence, it becomes questionable when applied to individuals with different ethnic origin. Materials and Methods: Actual mesiodistal widths of permanent upper and lower incisors, canines, and premolars were recorded on 100 dental casts for both sexes using digital Vernier caliper nearest of 0.02 mm. Predicted values of mesiodistal widths of permanent upper and lower canines and premolars were obtained using Moyer's probability analysis at the 75^{th} percentile and TanakaJohnston method. Both actual and predicted values for both sexes were put to statistical evaluation using student “t” test and unpaired “t” test. Results: Differences between the actual and predicted values of upper and lower permanent canines and premolars were statistically significant in both sexes (P < 0.05) for both Moyer's and TanakaJohnston mixed dentition analysis. Four linear regression, equations were developed for both sexes to predict mesiodistal widths of erupting upper and lower permanent canines and premolars using the lower incisors. No significant difference was observed when the regression equations were applied. Conclusion: Predictions from linear regression equations matched well with the data obtained from the samples of the present study for both males and females of Lucknow population.
Keywords: Mixed dentition analysis, Moyer's analysis, TanakaJohnston analysis
How to cite this article: Grover N, Saha S, Tripathi AM, Jaiswal J N, Palit M. Applicability of different mixed dentition analysis in Lucknow population. J Indian Soc Pedod Prev Dent 2017;35:6874 
How to cite this URL: Grover N, Saha S, Tripathi AM, Jaiswal J N, Palit M. Applicability of different mixed dentition analysis in Lucknow population. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2017 Aug 23];35:6874. Available from: http://www.jisppd.com/text.asp?2017/35/1/68/199220 
Introduction   
An important aspect of diagnosis in the mixed dentition is a determination of the relationship of tooth size to arch length.^{[1]} Hence, mixed dentition space analyses form an essential part of an early orthodontic evaluation. They help determine the amount of space available, for the accommodation of unerupted permanent teeth, usually the canines and premolars. An accurate analysis is an important criterion in determining whether the treatment plan may involve serial extraction, guidance of eruption, space maintenance, space regaining, or just periodic observation of the patient during mixed dentition period.^{[2]} Because the arch length is generally diminished (particularly in the mandibular arch) during the transition from mixed to permanent dentition, the mixed dentition analysis is commonly performed in the mandible.^{[3]}
The previous references in literature attempts in the forecasting of unerupted teeth sizes made to Black's average mesiodistal tooth sizes. Clinically, these approximations were not reliable because of the great variability in tooth size between different individuals. In an attempt to obtain greater accuracy, several methods were subsequently developed and used for predicting the sizes of unerupted teeth.^{[1]} Three methods commonly used to predict unerupted permanent canine and premolar mesiodistal widths are radiographic methods, nonradiographic methods, combinations of both methods.^{[3],[4]}
Dentists have always believed that there is some harmony in tooth size in one's mouth. That is, if the incisors of a given person are somewhat larger than the average, the canines, premolars, and molars in that person will be correspondingly larger, as well. The mandibular permanent incisor teeth have been found to be the most reliable indices of the size for remaining permanent teeth of both arches. This has permitted investigators to compile a prediction chart for the combined mesiodistal widths of the maxillary and mandibular permanent canine and premolar teeth when the combined widths of the lower permanent incisor teeth are known. This can be found in tables prepared by Moyers and in prediction equations derived by TanakaJohnston.^{[5]} Accuracy with these methods is fairly good. However, the development of these two methods of prediction is based on data derived from a population of Northern European descent.
Therefore, the accuracy of these prediction methods could possibly be in question when applied to a population of different ethnic origin.^{[2]} In addition, there is some evidence of secular trends of changing dimensions of the teeth which may require progressive modifications of mixed dentition analysis for different population.^{[6]} Bailit (1975) stated that minor differences in dental traits among and within a population can be of great interest and importance.^{[7]} It has been shown by Lavelle (1972) that variations in tooth sizes occur based on the ethnicity of a particular population group and within the population, sexual dimorphisms with respect to tooth size prevail.^{[8]} Thus, the accuracy of these predictive methods is questionable when applied to different population groups.^{[9]}
Very few studies in literature have been cited, addressing the applicability of using the standard Moyer's and TanakaJohnston equations for North Indian population. Because of the secular trend and sexual dimorphism of tooth sizes and the need for more research in this area, the present study was designed in an attempt to evaluate and compare the applicability of two mixed dentition space analysis among Lucknow population and find a more accurate and precise formula to predict the sizes of the unerupted premolars and canines.
Materials and Methods   
The present study was conducted in the Department of Pedodontics and Preventive Dentistry after approval of the Institutional Ethical Committee. A pilot study on five casts was done previously before commencing the study.
Source of data
The subjects for the study were derived from existing diagnostic records of patients after taking their informed consent from the Department of Pedodontics and Preventive Dentistry and the Department of Orthodontics and Dentofacial Orthopedics.
Sample size
The sample of the crosssectional study included study models of 200 subjects (100 boys and 100 girls) in the age group of 11–15 years.
Inclusion criteria
 Indigenous subjects of Lucknow origin (one previous generation) with permanent dentition in both jaws (except third molars)
 Patients free from any systemic disease or serious health problem
 Patients with no history of previous orthodontic treatment
 A maximum of 15 years of age to preclude any discrepancy due to significant proximal attrition
 Highquality dental casts free from distortions.
Exclusion criteria
 Study models with proximal restorations or fracture
 Study models with dental anomalies which may alter the size, shape, number, or form of teeth.
Highquality study models were used. All impressions and study casts were obtained from alginate (Septodont, New Delhi, India) and high quality orthodontic dental stone (Type III dental stone; orthokal), respectively.
The mesiodistal width was obtained by measuring the greatest distance between contact points on the proximal surfaces. This was measured by a dental digital caliper (0–300 mm, Masel Ortho, UK) set to read to the nearest 0.01 mm and held parallel to the occlusal surface if the tooth appeared to be in normal alignment.
The sum of the mesiodistal measurements of the four mandibular incisors, combined width of mandibular measured canines and premolars, and combined width of maxillary canines and premolars were measured on both the quadrants, i.e., right and left and for both the sexes.
Moyer's mixed dentition analysis was used for calculating expected widths of maxillary and mandibular canines and premolars, i.e., mandibular calculated canine and premolar width and maxillary calculated canine and premolar width for both the sexes. TanakaJohnston analysis was used for calculating expected widths of maxillary and mandibular canines and premolars for both the sexes.
The regression equations were formulated using the sum of mandibular incisors.
Statistical analysis
The statistical analysis was done using Statistical Package for Social Sciences version 15.0 (Charlotte, North Carolina, USA) statistical analysis software. The mean and standard deviation between the calculated and expected width of maxillary and mandibular canines and premolars were calculated both by Moyer's and TanakaJohnston mixed dentition analysis in either sex. Student's ttest was used to compare and correlate the actual sum and the predicted width of the permanent mandibular canines and premolars obtained from various methods. Regression equations were generated by the method of least square.
Results   
On the comparison between actual and predicted measurements by Moyer's mixed dentition analysis among males, statistically significant differences were observed for the maxillary arch on evaluating the predicted value against actual value. However, for the mandibular arch, although no significant difference was observed for the right side, a significant difference was observed for the left side (P < 0.005) [Table 1].  Table 1: Comparison between actual and predicted measurements among males (n=100) (Moyer's Analysis)
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On comparing actual and predicted measurements by Moyer's mixed dentition analysis among females, statistically no significant difference values for maxillary arch was found; however, for the mandibular arch of both right and left sides, mean values were significantly lower (P < 0.001) [Table 2].  Table 2: Comparison between actual and predicted measurements among females (n=100) (Moyer's Analysis)
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On the comparison between actual and predicted measurements for males according to TanakaJohnston analysis, mean of predicted values for maxillary arch was observed to be significantly lower as compared to actual values (P < 0.04). However, no significant difference was observed on both sides of mandibular arch [Table 3].  Table 3: Comparison between actual and predicted measurements among males (n=100) (Tanaka Johnston's Analysis)
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On the comparison between actual and predicted measurements among females based on TanakaJohnston analysis, mean of predicted values was observed to be significantly higher as compared to actual values of both the arches on both the sides (P < 0.001) [Table 4].  Table 4: Comparison between actual and predicted measurements among females (n=100) (Tanaka Johnston's Analysis)
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Prediction using genderspecific regression analysis
Genderspecific regression analysis was derived for calculation of the sum of canine and premolars based on the sum of mandibular incisors in maxillary arch for males. The proposed equation was:
y = 15.935 + 0.315 × MdI.
The derived equation showed a significant association between the actual and predicted sum of maxillary canine and premolar values (P = 0.001) [Table 5].  Table 5: Gender specific regression analysis for calculation of sum of canine and premolars based on sum of mandibular incisors in maxillary arch among males
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Genderspecific regression analysis was derived for calculation of the sum of canine and premolars based on the sum of mandibular incisors in mandibular arch for males.
The proposed equation was:
y = 8.556 + 0.620 × MdI.
The derived equation showed a significant association between the actual and predicted sum of maxillary canine and premolar values (P = 0.008) [Table 6].  Table 6: Gender specific regression analysis for calculation of sum of canine and premolars based on sum of mandibular incisors mandibular arch among males
Click here to view 
Genderspecific regression analysis was derived for calculation of the sum of canine and premolars based on the sum of mandibular incisors in maxillary arch among females. The proposed equation was:
y = 15.133 + 0.269 × MdI.
The derived equation showed a significant association between two (P < 0.001) [Table 7].  Table 7: Gender specific regression analysis for calculation of sum of canine and premolars based on sum of mandibular incisors in maxillary arch among females
Click here to view 
Genderspecific regression analysis was derived for calculation of the sum of canine and premolars based on the sum of mandibular incisors in mandibular arch among females.
The proposed equation was:
y = 11.350 + 0.403 × MdI.
The derived equation showed a significant association between the actual and predicted sum of maxillary canine and premolar values (P < 0.001) [Table 8].  Table 8: Gender specific regression analysis for calculation of sum of canine and premolars based on sum of mandibular incisors in mandibular arch among females
Click here to view 
On the genderspecific comparison between actual and predicted measurements for males, statistically no significant difference was observed for maxillary arch for both sides. For mandibular arch, the difference between the values derived from the regression equation was not significant [Table 9].  Table 9: Gender specific comparison between actual and predicted measurements among males (n=100) (Regressed values)
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On the genderspecific comparison between actual and predicted measurements for females, statistically no significant difference between actual and predicted values derived from the regression equation was observed for both the arches and sides [Table 10].  Table 10: Gender specific comparison between actual and predicted measurements among females (n=100) (Regressed values)
Click here to view 
Discussion   
The mixed dentition stage is the time of developing occlusion, in which simultaneously permanent and deciduous teeth are present.^{[3]} It is the most dynamic phase in terms of changes in occlusion and final outcome of dentoskeletal relationship. Pediatric dentists must manage and guide the mixed dentition of a child into permanent occlusion, with space available and tooth size intimately being involved in treatment planning.^{[10]} Early intervention of the developing malocclusions can be done by a proper space assessment in mixed dentition phase.^{[11]}
Space analysis in the mixed dentition is an important aspect of orthodontic diagnosis and treatment planning. The mixed dentition analysis is performed when the four permanent mandibular incisors and the first permanent molars are erupted.^{[3]}
Among the different methods available, Moyer's probability tables and prediction equations of TanakaJohnston analysis are the most widely used.^{[12]}
Moyer's tables led TanakaJohnston to do their study by repeating Moyer's observation but on a new sample of the same ethnicity. They presented prediction equations which had relatively similar values to Moyer's tables but were easier to utilize.^{[13]} TanakaJohnston developed prediction tables comparable with that of Moyers from the measurement of teeth from study models and introduced the application of simple regression equations for estimating the summed width of the maxillary and mandibular canine and premolar segments.^{[14]} Since then, their method of prediction has been widely used as it requires no radiographs or tables.^{[15]} The accuracy of these prediction methods could possibly be in question when applied to a population of different ethnic origin.^{[16]} This is because there are genetic and racial differences with respect to tooth sizes that should be taken into consideration.^{[13]}
There have also been questions about applying these methods, which are based on pooled male and female data, rather than considering the sexes separately (Keiser 1990). In addition, there is some evidence of secular trends changing dimensions of the teeth, which may require progressive modifications of mixed dentition space analysis for different populations.^{[6]} The reasons for the tooth size variations in different racial groups have not been clearly elucidated, but, obviously, genetic factors play a major role, and nutrition and environmental exposure during tooth development might have secondary roles.^{[17]} Hence, racial and genderspecific mixed dentition analysis requires revision of validation once every generation.^{[18]}
Considering all these factors, a need for specific regression equations for the local population of Lucknow was felt. The study sample selection could not exclude patients with the crowded arches as the study was conducted on orthodontic patients. Patients with malocclusions had shown to have no differences in tooth size compared with those with no malocclusions.^{[10]}
In an attempt to improve the reliability of the measurements, the following methods were used: Highquality dental casts made of dental stone (Type III), dental calipers with digital display which reduced eye fatigue and the possibility of reading error, as suggested by Bishara et al. (1989) reduction of intraexaminer error by repeated training till the errors were reduced to minimum of 1% and predetermination of interexaminer and intraexaminer reliability at 0.2 mm Ajayi (2014).^{[14]} The use of digital calipers has been shown to be more accurate method of measuring mesiodistal tooth dimension on dental study models, reducing the possibility of introducing systemic and random errors in measurements. This method was reported to be highly reproducible and accurate for measuring mesiodistal crown widths by Kaur et al (2014).^{[11]}
A maximum age of 15 years had to be set as an upper age limit since it has been reported that beyond 15 years individual teeth may be reduced significantly by interproximal attrition and arch space also may be reduced due to pathological migration in anterior as well as posterior teeth and this could bias the results of our study.^{[19]} The mandibular incisors have been chosen for measuring since they erupt first in the mouth early in the mixed dentition, are measured accurately, and are directly in the midst of most space management problems. The maxillary incisors are not used in any of the predictive procedures since they show too much variability in size, and the correlations with other groups of teeth are of lower predictive value.^{[20]} No endeavor was made to test the deciduous teeth as predictors of the breadths of unerupted premolars and permanent canines since it had been shown that the correlation between the breadths of deciduous teeth and permanent teeth was weaker than that between the breadths of permanent teeth. Moreover, one or more of the deciduous teeth was often missing because of premature extraction or exfoliation. Any prediction could, therefore, not be used on all children.^{[21]}
Statistical significant differences were found between male and female tooth widths in the present study. Thus, data analysis was performed separately for each sex. This is in accordance with studies of Hu et al. (1983), Paula et al. (1995), Staley et al. (2003), Legovic et al. (2003), and Bernabe and FloresMir (2005). However, Tanaka and Johnston (1974), Lima and Monneret (1992), AlKhadra (1993), and Martinelli et al. (2005) did not consider sex differences in their studies.^{[22],[23]}
Singh and Singla conducted a study in the population of Himachal state and concluded that the Moyer's tables tended to underestimate the mesiodistal caninepremolar widths, including at the recommended 75^{th} percentile level.^{[24]} Buwembo and Luboga (2004) conducted a metaanalysis on the applicability of Moyers method in different ethnic groups and concluded that it could be universally applied to different populations and it was safer to develop prediction tables for specific populations.^{[25]}
Results of the present study revealed that Tanaka and Johnston's method of prediction overestimated the tooth dimension of both maxillary and mandibular arch for females (P < 0.001). This was supported by the study done by Ramesh et al. in Kodava population, where except for the maxillary unerupted canines and premolars in female subjects, the Tanaka and Johnston prediction equations overestimated the actual size for Kodava teeth.^{[26]} According to Al Khadra (1993), Tanaka and Johnston equations overestimated the size of buccal segments in a Saudi Arab population.^{[11]} Similar results were obtained by Diagne et al. on Senegalese population where the Tanaka and Johnston equations overestimated the actual values.^{[27]} Buwembo et al. conducted a study on Ugandan population and concluded that this technique tends to overestimate the tooth widths.^{[28]} Tanaka and Johnston analysis significantly overestimated the actual mesiodistal widths of maxillary and mandibular canines and premolars in both male and female population of Nalgonda in accordance to study done by Manjula et al. (2013).^{[29]} Similarly, several studies which were carried out in various populations around the world showed that Tanaka and Johnston analysis overestimated the actual mesiodistal widths of canines and premolars in their respective subjects.^{[29]}
For formulating a regression equation, different combinations of teeth have been used in the past. Using a combination of the sum of incisors, statistically significant difference was observed between the actual and the predicted sum of canine and premolar in the studies carried out by Jaroontham and Godfrey (2000), Bherwani and Fida (2011), and Ahluwalia et al. (2014).^{[6],[30]}
To further determine whether the new linear regression equations would improve the accuracy of the prediction of the canines and premolars, four regression equations were validated on the whole males and females samples separately.
When comparing the predicted width obtained from the present study regression equation with the actual sum of canine and premolar of the Lucknow sample, statistically insignificant difference was found for overall population as well as for males and females separately. This finding was also corroborated in various studies (Melgaço et al. {2007}; Jaju et al. {2010}; Mittar et al. {2012}; and Memon and Fida {2012}).^{[3],[31]} The results suggested that regression equation formulated using the sum of mandibular incisors fulfilled the requirement of obtaining an accurate prediction method wherein, statistically insignificant difference existed between actual width and the predicted width.
These linear regression equations formulated for the Lucknow population may be easy to use with no requirements of software or specific equipment for mixed dentition analysis. Based on this regression equation, prediction tables at varying values of the sum of mandibular incisors could be formulated for the Lucknow population making it simpler and easy to use.
Furthermore, the present study regression equation should be tested in a large and representative sample to confirm its predictive accuracy and consistency.
Conclusions   
On the basis of the observations, results, and statistical analysis, the following conclusions could be drawn:
 Statistically significant difference was found when Moyer's probability table and TanakaJohnston method were used considering it to be inapplicable for the Lucknow population
 As both the prediction methods were not applicable to the population, a regression equation was proposed for the same population using sum of mandibular incisors
 The regression equations proposed for males:
 y = 15.935 + 0.315 × MdI (maxillary arch)
 y = 8.556 + 0.620 × MdI (mandibular arch).
 The regression equations proposed for females:
 y = 15.133 + 0.269 × MdI (maxillary arch)
 y = 11.350 + 0.403 × MdI (mandibular arch).
 Statistically significant difference was observed between the actual and predicted sum of canines and premolars using the present study regression equation considering it as one of the most accurate methods when applied to Lucknow population.
However, this method should be tested in a large population and other groups to confirm its applicability and consistency.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]
