MIXED DENTITION ANALYSIS

definition of occlusion
Malocclusion is any deviation from normal occlusion. Dental malocclusion can occur as a
result of genetic factors, environmental factors or combination of both factors. Most of them
are the result of an imbalance between teeth size and arch sizes with which teeth are
associated. Dental malocclusion arise during mixed dentition period and if they are managed
timely they can be reduced in severity or even removed entirely.

Mixed Dentition Period and Its Importance in Interceptive Orthodontics

Mixed dentition period is between six to twelve years of age during which both deciduous
and permanent teeth are present. During this period one can make accurate and specific
prediction of future dental development and also can assess whether there will be spacing or
crowding of teeth in the dental arch. In interceptive orthodontics treatment planning, it is
important to predict space required and available for unerupted canine and premolars in the
arch and this determination of tooth size must be done before eruption of canine and
premolars by a method called Mixed Dentition Space Analysis (MDSA).
Mixed Dentition Space Analysis

In mixed dentition space analysis, mesiodistal width of unerupted canine and premolars is
predicted so that discrepancy between space available and space required for these teeth in
the dental arch can be determined. This also helps to determine whether sufficient space is
available for posterior teeth in the arch so that they can erupt freely with good alignment.
This analysis is very important regarding orthodontic diagnosis and treatment planning. It
helps in determining whether treatment plan is going to involve serial extractions, eruption
guidance, regaining of space, space maintenance, or simple observation of patient for the time
period is required. Accurate prediction of size of unerupted posterior teeth is important in
order to establish a good orthodontic treatment plan.

The use of an inappropriate method may hinder the entire treatment plan because both
overestimation and underestimation of crown diameters of unerupted canines and premolars
can influence treatment planning, especially decisions regarding extractions
Three main approaches have been used to estimate the mesiodistal crown widths of the
permanent canine and premolar in the mixed dentition patients: (a) measurement of the
unerupted teeth on the radiographs (Nance 1947, Bull 1959); (b) a combination of
measurements from erupted teeth and radiographs of unerupted teeth (Hixon and Oldfather
1958, Huckaba 1964); (c) use of regression equation that relates the mesiodistal widths of
erupted teeth to mesiodistal of unerupted teeth (Moyer 1958 and 1973, Tanaka and
Jonston1974)
The lower the standard error more precise is the measurement. The measurement utilising the
mesiodistal measurement of erupted teeth has the highest standard error(MOYERS and
TANAKA JOHNSON) but the advantage is that the measurement can be taken directly from
the mouth and does not need radiographs
combined technique

In combined method, mesiodistal width of permanent canine and premolars is predicted from
sum width of first and second premolars measured from radiograph plus width of erupted
mandibular central and lateral incisor of the same quadrant. It was first recommended by
Hixon and Old Father (1958). He established regression equation to predict size of unerupted
mandibular canine and premolars from radiographic measurement of mandibular
premolars.Hixon and oldfather technique was based on data from americans who participated
in the Iowa facial growth study.The original prediction systematically underpredicted the size
of canines and premolars.(Staley and Kerber 1980)

Oldfather’s method was modified by Stahle (1959) by including the sizes of the mandibular
permanent incisor to predict mesiodistal width of canine and premolars.
Staley, R. N. and P. E. Kerber (1980) revised Hixon and Old Father and developed prediction
equation and made a graph for the estimation of mesiodistal width of unerupted caine and
premolars

Central incisor+Lateral incisor +premolar 1+premolar 2

predicted sum from graph + standard error- posterior tooth width

posterior arch length measured(B)

posterior arch length - posterior tooth width

anterior arch length (distal surface of lateral incisor- midline)- anterior tooth width

IOWA prediction method

upper cast

measurement --- upper canines + PM 2

lower cast

PM 1 + PM 2
SE = 0.46

Radiographic Vs Prediction Equation and / or Table

Accurate radiographic prediction requires good quality radiographic technique and

equipment. Radiograph gives two dimensional image of object so it may give false
measurement when teeth may be rotated in their bony crypt. It also have disadvantage of
exposure to increase radiation dose. So prediction equation and or tables based on mesiodistal
width of already. erupted permanent teeth are the most widely used methods. The most
commonly used are Moyer’s probability tables and Tanaka and Johnston’s regression
equations.

HUCKABA 1964
This analysis compensates for radiographic enlargement of tooth image in intraoral periapical
radiograph
width of primary tooth on IOPA - Y'
width of its underlying successor on IOPA -X'
width of primary tooth on cast - Y
width of its underlying successor on cast -X

Moyers Probability Method

It was developed at the University of Michigan from a sample comprising northern

European white subjects.
Moyers (1958) developed two probability tables to predict mesiodistal width of unerupted
canine & premolars during mixed dentition based on sum of mesiodistal width of four
mandibular permanent incisors.
The probabilities range from 5% to 95% and the author suggests the use of the table at a level
of 75% in order to overestimate the value and avoid potential crowding.
This is the most widely used for mixed dentition because of the following advantages:
1) Minimal known systematic error.
2) Can be used by beginner and expert with equal reliability.
3) Less time consuming.
4) doesn’t require specific equipment or exposure to radiographs.
5) Applicable to both upper and lower dental arches.
5) Best done on dental cast but it can be done in mouth with reasonable accuracy. Moyers
method is applied most frequently by many populations. Profit and Ackerman also found
Moyers method to be satisfactory.
Mixed dentition space analysis: a reviewsidra butt, Pakistan Oral & Dental Journal Vol 32, No. 3 (December 2012)

basis-- high correlation among groups of teeth,thus by measuring one group of teeth it is
possible to make prediction on the size of other groups of teeth.

technique

CI s+ LI s
the sum is used in the probability chart (75% value) --- width of unerupted molars and
premolars

space available-- measured from mesial side of first molar to the first molar on the opposite
side using a brass wire- incisor width after alignment

M.S MUTHU

The biggest clinical problem exists when, at 75%, the predicted values underestimate the real
values, in which case there will not be enough space to properly align the teeth. When the
values overestimate the real values, it means that there will be more space to accommodate
the posterior teeth, which is not considered a real clinical problem.

For the Brazilian population, at 75%, the Moyers analysis overestimated the real values in
one article (Farret et al), underestimated the real values in another article (Cabral and Pessôa
), and was appropriate in two articles (De Paula et al)and for the lower arch, only, in one
article (Pereira Neto et al)

Applicability of Moyers analysis in mixed dentition: A systematic review

Mariana de Aguiar Bulhões Galvão,Gladys Cristina Dominguez,Sérgio Thomaz Tormin,Alex Akamine,André
Tortamano4, Solange Mongelli de Fantini Dental Press J Orthod. 2013 Nov-Dec;18(6):100-5

Tanaka and Johnton Method

Tanaka and Johnson (1974) developed probability equation to predict mesiodistal width of
unerupted canine & premolars by using sum of width of four mandibular incisors.
This is simple, easy, relatively noninvasive and accurate, applicable for both dental arches
and genders. This method has also been used widely with an acceptable accuracy for both
dental arches and in both genders.
technique -- space available is measured from mesial end of first molar to the other first
molar by dividing arch into several segments.
sum of 4 mandibular incisors /2 + 10.5--- space needed for unerupted canines and premolars
in one quadrant
total arch length - sum of incisor width + twice width of unerupted canine and premolars

Racial and Ethnic Difference in Tooth Size

Literature shows that tooth size varies among different racial and ethnic groups. This
variation in tooth size is related to genetic, epigenetic and environmental factors Since Moyer
and Tanaka and Johnston prediction equation and tables were developed for North American
Caucasian children. So its applicability in population of other racial and ethnic origins has
been studied and doubted by many researchers.

Gender Difference in Tooth Size

These methods were not developed for both genders separately while literature shows that
tooth size. varies among both males and females with males having larger teeth than females.
Many authors reported that sex factor should also be included as an additional predictor for
the estimation of MDW sum of unerupted canine and premolars based on sexual dimorphism
on teeth size. So regression equation and or tables must be made separate for both males and
females.

Combination of Group of Teeth Used as Predictor

Different combinations of teeth have been used as predictor for the estimation of size of
unerupted canine and premolars in mixed dentition space analysis.

Sum of Four Mandibular Incisors

Sum of mesiodistal width of four mandibular incisors has been most widely used to develop
regression equation to accurately predict size of unerupted canine & premolars specific to
their own population by many researchers.

Most methods use the mandibular permanent incisors to predict the sum of mesiodistal
dimensions of the canine and premolars, since these incisors are the first to erupt in mixed
dentition, have less variability in shape and size, can be easily and accurately measured and
have a high correlation with other groups of teeth.
Other Combinations of Group of Teeth Used as Predictor
In addition to mandibular incisors, combinations of other erupted permanent teeth (e.g
mandibular first molar, maxillary first molar and maxillary incisors) also have been used by
some researchers to accurately predict size of unerupted canine & premolars.

Fonseca (1961) firstly introduced an additional combination of teeth (sum of maxillary first
molar and maxillary four permanent incisors) to develop a multiple regression equation.
Recent studies have reported that sum of mesiodistal width of permanent mandibular incisors
is not the best predictor for estimating mesiodistal width of unerupted permanent canine &
premolars, so other teeth along with incisors also have been evaluated to predict mesiodistal
width of unerupted canine & premolars.

Sum of mesiodistal width of permanent mandibular incisors and mandibular first molar has
been used as predictor in Brazilian population

Sum of mesiodistal width of maxillary central incisor and mandibular first molar is found to
be the best predictor to estimate mesiodistal width of permanent canine & premolars in
Spanish and Egyptian population

Bernabe E, Flores Mir-C (2005) reported that sum of maxillary and mandibular central
incisor and maxillary 1st molar is more accurate predictor for estimating mesiodistal width of
unerupted canine & premolars in Peru population.

Sum of mesiodistal width of maxillary first molar and mandibular incisors is found to be the
best predictor to estimate mesiodistal width of unerupted canine & premolars by most of the
researchers in Syrian, Croatia and Italian population. Nourallah (2001

Legovic et al (2003) developed regression equation based on mesiodistal and buccolingual

width of permanent incisors and maxillary first molar to estimate size of unerupted canine
and premolars in a population sample of Croatia

Cattaneo C et al (2010) studied combination of group of teeth to predict size of unerupted

canine and premolars with most common groups of teeth including four mandibular incisors;
mandibular incisors and mandibular first molar; mandibular incisors and maxillary first molar
and concluded that sum of four mandibular incisors and maxillary 1st molar is the best
predictor for estimating mesiodistal width of unerupted permanent canine & premolars in
Italian sample.