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Treatment of Adults with Anterior Mandibular Teeth Crowding: Reliability of

Little’s Irregularity Index

Article  in  International Journal of Dentistry · January 2017

DOI: 10.1155/2017/5057941

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Hindawi Publishing Corporation
International Journal of Dentistry
Volume 2017, Article ID 5057941, 6 pages
https://doi.org/10.1155/2017/5057941

Research Article
Treatment of Adults with Anterior Mandibular Teeth Crowding:
Reliability of Little’s Irregularity Index

J. Antoszewska-Smith,1 M. Bohater,1 M. Kawala,2 M. Sarul,1 and M. Rzepecka-SkupieN1

1
Department of Dentofacial Orthopedics and Orthodontics, Wroclaw Medical University, Wroclaw, Poland
2
Department of Prosthodontics, Wroclaw Medical University, Wroclaw, Poland

Correspondence should be addressed to M. Rzepecka-Skupień; gonia.skupien@gmail.com

Received 15 October 2016; Accepted 4 January 2017; Published 6 February 2017

Academic Editor: Gilberto Sammartino

Copyright © 2017 J. Antoszewska-Smith et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

The attempt of this article was to assess reliability of Little’s Irregularity Index (LII) as for stability of the treatment outcomes in
adults with crowded mandibular incisors. LII was measured on a digital cast prior to an orthodontic treatment (T1) of the 302
patients thus allowing us to establish the treatment plan, which called for (a) expansion (group 1), interproximal stripping (group
2), or extraction of one of the mandibular incisors. LII was measured after debonding (T2) and a year after retention (T3). Treatment
resulted in significant reduction of LII values after treatment, in T1-T2 period in all groups. As for T2-T3 period it brought significant
but clinically irrelevant relapse that occurred in groups 1 and 2; group 3 presented with insignificant improvement of occlusion.
Conclusively, 30 years after introducing LII it has been a reliable parameter that allows selection of optimal treatment methods,
provided that the appropriate ranges of values displaying dentoalveolar discrepancy are obeyed, namely, (1) up to 3 mm: expansion,
(2) from 3 to 5 mm: interproximal enamel reduction, and (3) above 5 mm: extraction.

1. Introduction of the craniofacial structures rather than with the teeth size.
On the contrary Bishara et al. [11] and Vaden et al. [12]
Nowadays orthodontics not only is the treatment of children proved that mandibular growth that does not cease after
and adolescents: booming development of the therapeutic puberty but continues, at a slower rate, throughout adulthood
techniques has excluded an age from the list of limiting independently on the patients’ gender might be a cause.
factors. Therefore, the number of adults actively seeking help Increase of the mandibular length reduces an overjet and,
to correct their malocclusion has been constantly increasing, subsequently, space for the lower incisors exposing them to
possibly due to the social reasons [1–3]. The most common crowding. Last but not least mesial movement of third molars
abnormality they present with is crowding of the lower is the most controversial concept: Nanda [13], Southard et
incisors, of which etiology and prevention have been fer- al. [14], and Mockers et al. [15] found no evidence on the
vently discussed for years. contrary to Mockers et al. [16], Šidlaukas and Trakinienê [17],
Studies from the past three decades brought the evidence and Tüfekçi et al. [18] who confirmed the discussed negative
that individuals over twenty mostly exhibit late crowding impact of third molars thus establishing their extraction
[4–6]. Previously, Begg [7] and Müller [8] attempted to as the prophylaxis of late crowding. As etiology of the
elucidate its etiology. Analyzing prehistoric populations Begg mandibular anterior teeth has been an obvious matter of
found that insufficient interproximal and occlusal enamel dispute, the mode of an orthodontic treatment in adults
reduction may be a factor, whereas Müller suggested that who do not accept extraction of two or four premolars is
cheek overpressure developed due to improperly lowered by far more debatable: expansion of the dental arch [19],
tongue posture is likely to tilt the teeth, which reduces space interproximal enamel reduction [20–22], or extraction of one
they normally occupy. In turn Masztalerz [9] as well as lower incisor [23–25]. Certainly any decision proceeds careful
Corruccini [10] associated crowding with gradual reduction diagnosis. The dentoalveolar discrepancy in the mandible is
2 International Journal of Dentistry

usually evaluated by measuring, for example, Bolton’s ratio, B C

intercanine or intermolar width, lower arch perimeter [26, D
27], and last but not least Little’s Irregularity Index [28]. The A E
latter not only allows us to quantify the range of crowding
[29] but also determines the treatment mode, although its
certain drawbacks are obvious. Severe displacement of one
or more incisors in the labiolingual direction leads to bias:
falsely high values of the discussed index; neglecting tooth-
morphology, patients’ age, and their facial aesthetics may also Figure 1: A template applied for measurement Little’s Irregularity
be listed. Regardless of all explicit imperfections Little’s Irreg- Index [16]. The sum of linear displacement of anatomical contact
ularity Index has been continuously applied for orthodontic points of six mandibular anterior teeth, expressed in mm: 0: per-
purposes in adults with mandibular incisors crowding [30– fect alignment, 1–3 mm: minimum irregularity, 4–6 mm: moderate
32]; therefore an assessment of its current clinical validity irregularity, 7–9 mm: severe irregularity, and 10 mm and more: very
seems to be essential in contemporary orthodontics. severe irregularity.

2. The Aim
Controversy around Little’s Irregularity Index and only few teeth. Changes of Little’s Irregularity Index values achieved
studies [33–35] objectively evaluating its power dictated from T1 to T2 were significantly different (𝑝 < 0.05) in all
purpose of this study. The aim was both to assess reliability groups separately; as for intragroup comparison groups 1 and
of Little’s Irregularity Index 30 years after its introduction and 2 as well as groups 2 and 3 varied significantly (𝑝 < 0.05).
to establish an efficient algorithm for treatment of adults with Final improvement of occlusion, namely, changes of
crowding in the mandibular front area. Little’s Irregularity Index values achieved with different treat-
ment modalities from T1 to T3, was similarly efficient, which
was proved by statistic intragroup evaluation (𝑝 > 0.05);
3. Materials and Methods intergroup assessment of changes of Little’s Irregularity Index
values turned out to be statistically significant in all cases
Material comprised digital dental casts of 302 patients: 201
again proving the efficiency and fully justifying selection of
women and 101 men, aged from 21 to 39 years, with late
the treatment method.
crowding of the mandibular anterior teeth prior to treatment
The most severe relapse of crowding was noted in group
(T1). After measuring of Little’s Irregularity Index (Figure 1)
1, where statistically significant (𝑝 = 0.00) increase of Little’s
all patients were allocated into 3 groups (Table 1).
Irregularity Index reached 0.48 mm in the period from T2
Subsequently Little’s Irregularity Index was calculated
to T3. This difference was more than twice smaller in group
after debonding (T2) and one year after treatment (T3) when
2: it equaled 0.18 mm still displaying statistic significance
relapse is the most likely to occur.
(𝑝 = 0.02). Only in group 3 Little’s Irregularity Index the
value decreased by 0.1 mm from T2 to T3 but in statisti-
4. Statistical Analysis cally insignificant manner (𝑝 = 0.11) showing the minor
improvement of occlusion that occurred during retention
The obtained data was analyzed using Statistica software stage. At the same time this stability achieved in group 3
(Statistica 15.0, SPSS, Chicago, IL) utilizing was statistically significant (𝑝 = 0.00) comparing with the
(1) Shapiro-Wilk test to check normality of data distri- changes obtained in patients treated with expansion (group
bution and Levene’s test to check homogeneity of 1) and interproximal enamel reduction (group 2).
variance,
(2) Student’s 𝑡-test for independent and dependent vari- 6. Discussion
ables, Wilcoxon’s nonparametric tests for dependent
variables, or Mann–Whitney’s test for independent Literature reports prove that sticking to specific limits of
ones. Little’s Irregularity Index values while choosing a method
of treatment of the mandibular anterior teeth crowding in
The significance level was set at 𝑝 < 0.05. adults determines obtaining the successful outcomes. The
evidence is brought by case reports where Little’s Irregularity
5. Results Index values were efficiently reduced. Crowding expressed
by the index less than 3 mm or ranging from 3 to 4 mm
The statistic results of Little’s Irregularity Index values and and from 6 to 9 mm was alleviated by dental arch expansion
their changes from T1 to T3 are presented in Figures 2 and [36–38], interproximal enamel reduction [39–41], and last
3. All values of the discussed index reduced after treatment, but not least extraction of the lower incisor [42–44], respec-
in T2 stage. The lowest and the highest values were found tively. That is why following the standards recommended
in groups 1 and 3, respectively, proving that the dental by researchers and in order to obtain the reproducible and
arch expansion in the properly selected cases is the most reliable treatment results we followed the same algorithm
efficient treatment method to align the mandibular front in the current study. We allocated the patients to suitable
International Journal of Dentistry 3

Table 1
Group Dentoalveolar discrepancy Treatment option Number (𝑛)
1 Less than 3 mm Expansion of the dental arch 100
2 From 1 to less than 5 mm Interproximal enamel reduction 101
3 More than 5 mm Extraction of one lower incisor 101

Irregularity index Irregularity index

7 8
6
5 6

4
4
3
2
2
1
0 0
−1
−2 −2
T1 T2 T3 T1 T2 T3

±1.96 ∗ Standard dev. Mean value ±1.96 ∗ Standard dev. Mean value
±1.00 ∗ Standard dev. ±1.00 ∗ Standard dev.
(a) (b)
Irregularity index
14
12
10
8
6
4
2
0
−2
T1 T2 T3

±1.96 ∗ Standard dev. Mean value

±1.00 ∗ Standard dev.
(c)

Figure 2: Results of statistic analysis of Little’s Irregularity Index values in (a) group 1, (b) group 2, and (c) group 3.

Little’s Irregularity Index value (mm)

T1 T2 T3 T1-T2 T1-T3 T2-T3
Group 1 2.90 0.28 0.76 −2.62∗ ∗ −2.14∗ 0.48∗
∗
Group 2 3.86 0.71 0.95 −3.12∗ −2.94∗ 0.18∗ ∗
∗ ∗
Group 3 7.99 0.43 0.35 −7.56∗ −7.66∗ −0.1

Figure 3: Mean values of Little’s Irregularity Index and their changes from beginning (T1) via leveling (T2) until retention stage (T3) of an
orthodontic treatment, ∗ 𝑝 < 0.05.
4 International Journal of Dentistry

groups dependent on the treatment mode carefully assessing emphasize that maintaining the intercanine width during
Little’s Irregularity Index values prior to treatment (T1): orthodontic treatment makes outcomes of the latter stable.
2.90 mm before expansion, 3.86 mm before interproximal Simultaneously only group 3 displayed no relapse: Little’s
enamel reduction, and 7.99 mm before extraction of the lower Irregularity Index values improved with time of retention
incisor. Clinical results obtained in our study could therefore decreasing by 0.1 mm, however, in statistically insignificant
support the evidence that the limits of values of Little’s Irreg- manner. Intergroup comparison proved significant difference
ularity Index, regardless of reports upon its disadvantages, (𝑝 < 0.05) of Little’s Irregularity Index improvement in
are the diagnostic measurement, which allows selection of group 3 when comparing with group 1 or 2. Groups 1 and
appropriate orthodontic biomechanics, namely, treatment 2 also varied significantly (𝑝 < 0.05). Therefore, it may
option. Obeying those limits leads to stable outcomes that are be concluded that extraction of the lower incisor is most
functionally and aesthetically satisfying when treating adults effective in adults with crowding; furthermore, it is stable
presenting with dental crowding in the mandible. for at least a year after alleviation. Hegde et al. [54], Barbosa
Despite Little’s Irregularity Index values posttreatment [55], and Valli de Almeida et al. [48] reported similar results
reduction up to 0.28, 0.71, and 0.43 in groups 1 (dental arch as well as Zhylich and Suri [56] who established individual
expansion), 2 (interproximal stripping), and 3 (extraction of indications for extraction of one of the mandibular incisors.
the lower incisor), respectively, none of the patients from On the contrary, Kahl-Nieke et al. [57] while evaluating
study groups presented with the value that dropped to 0 mm postretention crowding and incisor irregularity found that
in T2 period. Value of the index was closest to an ideal 0 mm stripping is more stable than extraction of one of the lower
in group 1, which indicates susceptibility of the mandibular incisors in a long-term follow-up evaluation, although in
dental arch to expansion, even in adults. It is in accordance insignificant manner.
with the results obtained by Pandis [45], Scott et al. [46], Regretfully further feasible comparison of our results
and Fleming et al. [47] who efficiently alleviated crowding in with those obtained by other clinicians is impossible due
mandibular front area by proclining the lower incisors and to the lack of original studies present in the literature.
increase the intercanine width. The highest value recorded in Nevertheless, one cannot forget that Little’s Irregularity Index
group 2 indicated the least efficient reduction of crowding at values achieved in our study during the retention period did
T2 stage when interproximal enamel reduction was chosen as not exceed 0.5 mm in any of the groups, which is why 30 years
a treatment method. It may be partially justified based on the after the introduction of Little’s Irregularity Index it is still
results published by Valli de Almeida et al. [48]. They proved effective and reliable clinical indicator of stability provided
that stripping is efficient only in conservative treatment of that the treatment methods based on well-defined limits of
teeth with a triangular shape displaying potential for wear, the discussed index are chosen.
provided that pleasant profile requiring minor changes, Class
I, Bolton Index ≤ 3 mm, or mild to moderate mandibular 7. Conclusion
crowding with normal overjet and overbite exist, not to
mention low incidence of caries and proper oral hygiene. Thirty years after its introduction Little’s Irregularity Index
Since they also emphasized that the treatment plan should is a parameter that—provided the appropriate range of val-
be confirmed by set-up model tests, it becomes apparent ues displaying dentoalveolar discrepancy is obeyed—allows
that the list of diagnostic indicators leading to interproximal selection of reliable treatment method even in adults: (1) up to
stripping should not be limited to Little’s Irregularity Index 3 mm: expansion, (2) from 3 to 5 mm: interproximal enamel
itself if the interproximal stripping is a method of choice. reduction, and (3) above 5 mm: extraction; thus relapse may
Our studies showed no statistically significant intergroup be avoided. However, it should be emphasized that since the
difference in Little’s Irregularity Index value changes obtained most stable results are obtained after extraction of one of
from the beginning of therapy up to one year of retention the mandibular incisors, that is to say, in cases where Little’s
(T1–T3) allowing us to conclude that Little’s Irregularity Irregularity Index value exceeds 5 mm, thus cases with the
Index is a reliable diagnostic tool since similar and expected lower values should be approached with caution, especially
improvement of occlusion occurs after extremely different after the growth has been completed.
protocols of therapy have been applied.
As for the T2 to T3 period statistically significant relapse
occurred after expansion (group 1) and after interproximal
Competing Interests
enamel reduction (group 2): Little’s Irregularity Index values The authors declare that they have no competing interests.
were doubled in group 1 comparing with group 2. It is
quite likely that unstable enlargement of intercanine width
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