ORIGINAL ARTICLE

Prediction of the occurrence and

severity of mandibular incisor crowding
in the early mixed dentition using
craniofacial parameters
Ahmadreza Sardariana and Faezeh Ghaderib
Shiraz, Iran

Introduction: With the recent interest in esthetics at an early age, prediction of mandibular incisor crowding is of
significant importance. Since dental arch development is related to craniofacial growth, we conducted a cohort
study to find a regression model for mandibular incisor crowding based on various craniofacial parameters in
children. Methods: A total of 250 children, all in the early mixed dentition, were selected randomly by cluster
sampling from primary schools. Craniofacial parameters were measured by a caliper bow, and intercanine
widths were measured on dental casts. After a 12-month follow-up period, mandibular incisor crowding and
intercanine width were assessed on each subject's dental cast. Discriminant and multiple regression
analyses were performed separately for boys and girls. Results: Of 250 children, 148 returned for the 1-year
follow-up and met the inclusion criteria. Regression analyses of patients with normal occlusion showed a
statistically significant correlation between anterior dental crowding and facial height and bigonial width in
both sexes. A significant inverse correlation was found between initial intercanine width and incisor crowding
in girls. Furthermore, using the aforementioned parameters, the occurrence of mandibular incisor crowding
could be predicted with an accuracy of 92.6%. Conclusions: We found that the occurrence and severity of
mandibular incisor crowding in the early mixed dentition can be predicted accurately based on certain craniofa-
cial parameters. (Am J Orthod Dentofacial Orthop 2018;153:701-7)

C
rowding of the permanent teeth, especially in the especially in the early mixed dentition, has significant
anterior part of the mandible, is one of the most value to clinicians for decisions regarding the
prevalent forms of malocclusion among chil- beginning of preventive therapy in the form of space
dren.1,2 For esthetic reasons, these patients comprise a management and preservation of the leeway space.9,10
significant portion of visits to a dental office.3 Mandib- In line with the reported correlations between facial
ular anterior crowding is the result of a discrepancy be- and cranial parameters with dental arch changes in the
tween the sum of mesiodistal widths of 4 permanent literature,11-14 various authors have evaluated the
incisors widths and the available space in the alveolar relationship between dental crowding and craniofacial
process. Several factors are related to the development measurements.3,6-8,15 However, the results of these
of mandibular incisor crowding in the mixed dentition: studies have yielded dissimilar and conflicting
arch dimensions, increased intercanine width, and results.3,16-18 Since the current literature on this topic
mandibular growth pattern.4-8 The ability to predict consists of cross-sectional studies evaluating a limited
the development of mandibular incisor crowding, number of variants, the need for a well-designed cohort
study to find a predictable regression model based on
From the School of Dentistry, Shiraz University of Medical Sciences, Shiraz, Iran.
a
Orthodontics Research Center, Department of Orthodontics. craniofacial parameters seems apparent. To the best
b
Department of Pediatric Dentistry of our knowledge, this study is the first cohort study
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
investigating the relationship between incisor crowding
tential Conflicts of Interest, and none were reported.
Address correspondence to: Faezeh Ghaderi, Department of Pediatric Dentistry, and anthropometric parameters. Our aim was to deter-
School of Dentistry, Ghasr-e-dasht Street, Shiraz, Iran; e-mail, ghaderi_fa@ mine whether mandibular incisor crowding can be
sums.ac.ir.
predicted in the early mixed dentition stage using
Submitted, December 2016; revised and accepted, August 2017.
0889-5406/$36.00 craniofacial measurements; this could provide a valuable
Ó 2018 by the American Association of Orthodontists. All rights reserved. tool for treatment planning.
https://doi.org/10.1016/j.ajodo.2017.08.025

701
702 Sardarian and Ghaderi

MATERIAL AND METHODS

Table I. Craniofacial measurements and definitions
The individuals enrolled in the study were selected
Measurement Definition
based on a cluster sampling method. To this end, various
Facial height From nasion* to mentony measured on the soft
districts in Shiraz, Iran, were selected as clusters, and the
tissue
primary schools in each cluster were each given a num- Facial width Distance between the most prominent points of
ber. Five schools in each cluster were selected randomly, zygomatic bones in soft tissue from the frontal
yielding a total of 1700 white children aged 7 to 8 years. view
From this population, 250 subjects were selected Cranial height Summit of glabellaz to furthest occipital point
Cranial width Widest measurement of the cranium at right
randomly to take part in the study.
angles to median plane
The inclusion criteria for the study were children with Bigonial width Measurement from gonion§ to gonion on soft
a normal molar relationship defined as a flush terminal tissue
plane (1 mm deviation of the mandibular molars either
mesial or distal from this position was deemed accept- *The deepest point of the concavity between the forehead and the
soft tissue contour of the nose in the midsagittal plane; yThe most
able), an orthognathic growth pattern, erupted mandib-
inferior point of the soft tissue chin in the midsagittal plane; zThe
ular permanent central incisors, exfoliated or mobile most prominent point of the soft tissue drape of the forehead in
mandibular deciduous lateral incisors, bilateral decidu- the midsagittal plane; §The mandibular angle point projected most
ous canines, no evidence of interproximal caries or cus- downward, backward, and outward identified by palpation.
pal wear in the mandibular deciduous canines, and
erupted mandibular permanent first molars. The skeletal 90 seconds. The impressions were rinsed with cold water
growth pattern was analyzed based on the positions of and disinfected using a glutaraldehide solution for
subnasale and pogonion relative to the true vertical 10 minutes. After a final rinse, the impressions were
line from the deepest point on the nasal bridge. Subjects stored in a damp and cool environment for 1 hour and
with a history of previous orthodontic intervention and subsequently poured using type IV dental stone (GC Cor-
detected oral habits were excluded as were those who poration, Tokyo, Japan) where 100 g of powder was
began orthodontic therapy during this study. Of the hand-mixed with 30 mL of water. The impressions
250 children, 148 returned at the 1-year follow-up. were subjected to vibration for 20 seconds and allowed
There were many reasons for this drop in attendance. to set for an hour at room temperature.
Some children changed schools, and others did not Dental casts were used to obtain the mandibular in-
respond to the second visit call. Furthermore, some chil- tercanine width. The intercanine width was measured
dren were excluded due to loss or extraction of decidu- directly on the casts using a digital caliper (Shoka Gulf,
ous teeth or starting orthodontic treatment. After Spain) in millimeters with an accuracy of 0.01 mm
explaining the study procedure, written informed con- from the canine cusp tip of 1 side to the other. A second-
sent was obtained from the parents of all participants. ary alginate impression was obtained at the 12-month
Cranial and facial dimensions (height and width) of follow up and used to acquire dental measurements
the sample population were measured on soft tissue including mandibular intercanine widths, incisor widths,
landmarks by a caliper bow (ICS-Spreading Caliper- and available space. The measurements were performed
SPCG01P, Industrial and Commercial Services, Telan- 3 times by a board-certified orthodontist (A.S.), and
gana, India). The measurements and the landmarks are an average was used. Ten percent of the casts were re-
summarized in Table I. The measurements were per- measured, and the intraexaminer reliability was calcu-
formed 3 times, and an average was reported for each lated as 0.88 using the ICC method. The mean error of
parameter. Some subjects (10% of the total sample pop- the 2 measurements was 0.38 6 0.27 mm.
ulation) were reassessed 2 days later to analyze the intra- Mandibular incisor crowding was measured on
examiner reliability using the intraclass correlation dental casts with a digital caliper. Incisor widths were
coefficient (ICC); this was determined to be 0.87. The measured as described by Hunter and Priest.19 The tips
mean error of the 2 measurements was 0.23 6 0.21 cm. of the digital caliper were introduced from the labial
Mandibular arch impressions of the children side of the teeth and held incisally parallel to the occlusal
were taken at the first visit by mixing 52 g of plane, and the distances between the anatomic contact
alginate powder (Tropicalgin; Zhermack, Badio Polesine, points of the teeth were measured. The available incisor
Italy) and 40 mL of water for 15 seconds. The paste was space was measured between the mesial surfaces of the
immediately placed on a tray while the patient rinsed deciduous canines by allocating the dental arch into 2
with warm water. Once the tray was seated on the dental straight-line segments (from the mesial contact point
arch, it was kept in place under finger pressure for of the mandibular canine to the mesial contact point

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Sardarian and Ghaderi 703

of the central incisor). To calculate the severity of crowd- measurements were significantly greater in boys at the
ing, the sum of incisor widths was subtracted from the initial measurement (Table II). There was also a signifi-
available incisor space. For the prevalence of incisor cant inverse correlation between intercanine width at
crowding. the children were classified into 2 groups the first visit and the amount of increase in this param-
based on the amount of incisor crowding. Crowding eter during the 1-year period. The Pearson coefficients
greater than 2 mm was regarded as the threshold for demonstrating this correlation were –0.73 for girls and
clinical significance because of reports of spontaneous –0.65 for boys. Stronger correlations were present be-
improvement of irregularities less than this amount.3 tween the 2 parameters in subjects with crowding
All measurements were performed 3 times by a board- (Table III).
certified orthodontist, and an average was used. Ten The craniofacial parameters selected for this study
percent of the casts were remeasured, and the intraexa- had significantly greater values in boys (Table II). A step-
miner reliability was calculated as 0.91 using the ICC wise discriminant analysis in girls provided a model in
method. The mean error of the 2 measurements was which bigonial width, facial height, and initial interca-
0.12 6 0.23 mm. nine width could predict those who would develop man-
dibluar incisor crowding (.2 mm). The same model in
Statistical analysis boys included only bigonial width and facial height.
The Student t test was used to compare the values for The results of the discriminant analysis are shown in
the craniofacial parameters and the measurements from Table IV. As is apparent, excluding initial intercanine
the dental casts between boys and girls. Both groups had width, all variables remaining in the models for both
a normal distribution. To compare the prevalence of sexes were significantly different between the crowding
mandibular incisor crowding between boys and girls, and noncrowding groups. Subsequently, a formula was
the chi-square test was applied. The increase in interca- derived for predicting whether a subject would develop
nine width was evaluated using the paired t test. To crowding in the future (Table IV). The letter D stands
analyze the relationship between the initial intercanine for the threshold of the discriminant analysis where
width and the subsequent increase in intercanine width, one can predict whether crowding will occur if the value
the Pearson coefficient was used. A stepwise discrimi- obtained from the formula is more negative than the
nant analysis was performed to render a quick tool for threshold. This threshold number has no units and
the prediction of patients who will have crowding only has a numeric value for a yes or no answer regarding
(.2 mm) later. Stepwise multiple regression to analyze crowding. The threshold values for the prediction of
the potency of the craniofacial parameters in predicting crowding were 0.396 for girls and 0.412 for boys.
the severity of mandibular incisor crowding was per- We then used the model to see whether it could accu-
formed. For all statistical tests, P values less than 0.05 rately predict those in our sample who developed crowd-
were considered significant. The tests were performed ing. The result for girls was sensitivity of 88%, specificity
using the Statistical Package for the Social Sciences of 95.3%, and total accuracy of 92.6%. The same anal-
(version 18; SPSS, Chicago, Ill). ysis in boys resulted in sensitivity of 96.4%, specificity of
90.9%, and total accuracy of 92.8%.
The subsequent stepwise multiple regression also
RESULTS excluded the same parameters as the discriminant anal-
Of the 250 children, 148—83 boys (56%) and 65 girls ysis in both sexes and was based on the parameters
(44%),—with a mean gge of 7.4 6 0.48 years partici- deemed more influential in predicting the severity of
pated in the follow-up. This reduction of the sample crowding (Table V). The discriminant analysis singled
was because some participants changed schools and out subjects who were likely to develop crowding of
were out of reach or refused to comply, and others more than 2 mm, whereas the multiple regression spec-
were excluded because they began orthodontic treat- ified the amount of crowding. The correlation coeffi-
ment or had tooth extractions. Mandibular incisor cients of the models were 0.81 and 0.85 for boys and
crowding (.2 mm) was found in 36% of the girls, respectively, yielding R2 values of 0.65 and 0.73.
sample population (boys, 28; girls, 25). Applying the After use of the derived formulae for the estimation of
chi-square test, we found no significant difference in mandibular incisor crowding in the 2 groups, we calcu-
the prevalence of crowding between boys and lated the standard errors of the estimate. The calculated
girls (P .0.05). The amounts of mean crowding of values for boys and girls were 0.69 6 0.54 mm
the mandibular incisors were 2.1 mm for girls and and 0.62 6 0.57 mm, respectively. The percentage
2.7 mm for boys, with no statistically significant differ- errors of the estimate were 7.39% 6 12.89% and
ence between them (P .0.05). Intercanine width 11.43% 6 18.29%, respectively.

American Journal of Orthodontics and Dentofacial Orthopedics May 2018  Vol 153  Issue 5
704 Sardarian and Ghaderi

Table II. Craniofacial parameters and sum of mandibular incisor widths (means and standard deviations)
Boys Girls P value* Crowding No crowding P value
Facial neight)cm) 10.31 6 0.73 9.92 6 0.58 \0.001 10.55 6 0.64 9.91 6 0.61 \0.001
Facial width (cm) 9.48 6 0.92 8.63 6 0.52 \0.001 8.75 6 0.78 9.3 6 0.87 \0.001
Height of head (cm) 16.25 6 0.63 16.16 6 0.53 0.28 16.3 6 0.54 16.17 6 0.61 0.2
Width of head (cm) 12.37 6 0.67 11.51 6 0.64 \0.001 11.83 6 0.79 12.08 6 0.78 0.07
Bigonial width (cm) 6.65 6 0.65 6.12 6 0.39 \0.001 5.89 6 0.33 6.7 6 0.52 \0.001
Tooth size (mm) 20.60 6 0.92 20.53 6 0.72 0.59 20.69 6 0.74 20.5 6 0.88 0.18
Intercanine width (mm) 28.15 6 1.02 26.42 6 0.97 \0.001 28.03 6 1.52 27.69 6 1.69 0.15

*The P value pertains to the Student t test.

prevalence of crowding observed in this study, consid-

Table III. Pearson correlation between initial interca-
ering the 2-mm threshold, is similar to previous reports
nine width and the increase in width after 1 year
by Keski-Nisula et al23 (38.9%) and Borzabadi-
Boys Girls Farahani et al24 (32.7%) in white populations, whereas
0.65 0.73 studies of Brazilian and German children reported prev-
Crowding No crowding Crowding No crowding alences of 29% and 14.3%, respectively.25,26 The
0.78 0.48 0.76 0.72 differences in the prevalence of crowding can be
attributed to the 2-mm cutoff point selected in this
study and the different ethnic groups in the studies.
DISCUSSION As a whole, the measured craniofacial parameters
We aimed to evaluate the predictive potential of were significantly greater in boys compared with girls;
selected craniofacial parameters in determining mandib- the only exception was height of the head, which did
ular incisor crowding at an early age. These parameters not show a significant difference between the sexes.
were based on the literature in a way that parameters Tooth size was marginally greater in males, and the dif-
linked with mandibular incisor crowding were selected. ference was insignificant. This is contradictory to the
A stepwise discriminant analysis was performed that findings of Moorrees and Reed.27 and Niswander and
excluded parameters having no particular effect in our Chong,28 who reported larger teeth in boys in white
predictive model. The parameters that remained in the and Japanese populations, respectively, and also to the
model were facial height and bigonial width in both reports of Sampson and Richards29 in an American
sexes and initial intercanine width in girls. Multiple aboriginal population with larger incisors in girls, but
regression analysis showed that the correlation coeffi- it closely resembles a study on Dominican Americans
cients of the overall model in boys and girls are 0.81 that also found similar tooth sizes between the sexes.30
and 0.85, respectively, demonstrating the strong predic- Regarding intercanine width, boys demonstrated
tive value of the model in both sexes. significantly greater values. Moreover, the increase in in-
Measurement of crowding at the second visit showed tercanine width was significantly more pronounced in
that 36% of the subects had crowding of the mandibular boys. By correlating the initial intercanine width with
incisors (.2 mm). The 2-mm cutoff point was chosen its subsequent increase, we found a negative relation-
because it is believed that at mandibular incisor eruption ship, meaning that subjets with a smaller intercanine
there is a 1.6-mm discrepancy due to the difference be- width had a greater increase in this parameter during
tween the width of the deciduous and permanent teeth the 1-year period. This finding supports the reports of
termed “incisor liability.”20 This discrepancy is usually Sampson and Richads29 of a greater reduction in crowd-
relieved by mechanisms such as labial positioning of ing in subjects with more crowding initially. The multiple
the permanent incisors, a mild increase in intercanine regression model demonstrated that, in boys, interca-
width, and a slight distal positioning of the canines nine width at the time of early mixed dentition was
into the primate space.21,22 Thus, 2 mm of crowding is not significantly correlated with crowding and therefore
the amount that is expected to self-correct due to events lacks predictive value. However, in girls, this parameter
related to normal development and not as a result of remained in the stepwise multiple regression model
filling the leeway space. Although the leeway space (P \0.01). This could be because girls have significantly
could also help to alleviate any crowding in the less growth in intercanine width compared with boys;
mandible, it is usually reserved for the mesial migration therefore, the initial measurement of intercanine width
of the molars leading to a Class I molar relationship. The was closer to the same measurement a year later.

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Sardarian and Ghaderi 705

Table IV. Results of the stepwise discriminant analysis (means and standard deciations)
Crowding

Sex Parameter Yes No P value Wilk's l DCF

Female* Bigonial width (cm) 5.75 6 0.22 6.34 6 0.3 \0.001 0.702 3.401
Facial height (cm) 10.3 6 0.61 9.7 6 0.44 \0.001 0.474 1.547
Initial intercanine width (mm) 26.6 6 1.43 26.75 6 1.1 0.628 0.346 0.305
Maley Bigonial width (cm) 5.99 6 0.35 6.99 6 0.48 \0.001 0.804 2.065
Facial height (cm) 10.75 6 0.6 10.07 6 0.68 \0.001 0.468 0.722

DCF, Discriminant function coefficient.

*The discriminate formula for girls: D 5 –13.632  1.547 (facial height) 1 0.305 (initial intercanine width) 1 3.40 1 (bigonial width); yThe discrim-
inate formula for boys: D 5 –6.298  0.722 (facial height) 1 2.065 (bigonial width).

prediction and severity of crowding; this was true for

Table V. Results of the stepwise multiple regression
both sexes. We found no studies regarding the relation-
analysis
ship between bigonial width and mandibular incisor
Sex Parameter Beta SE crowding in the literature; however, the link between
Female* Bigonial width (cm) 2.633 0.285 increased facial height and divergence has been previ-
Facial height (cm) 1.386 0.203 ously reported in both treated and untreated sub-
Intercanine width (mm) 0.3 0.095
jects.31,32 Moreover, Sakuda et al16 reported positive
Maley Bigonial width (cm) 1.908 0.189
Facial height (cm) 0.622 0.167 correlations between mandibular incisor crowding and
high mandibular planes, short mandibular body length,
*The formula for prediction of crowding severity in girls: and reduced vertical dimension in the maxillary posterior
X 5 11.559 1 1.386 (facial height)  0.3 (initial intercanine width) segments.16
 2.633 (bigonial width); yThe formula for prediction of crowding
Our results give the clinician an accurate tool to pre-
severity in boys: X 5 7.451 1 0.622 (facial height)  1.908 (bigonial
width). dict whether a patient will develop crowding in the early
mixed dentition based on craniofacial parameters that
can readily be determined. Furthermore, the severity of
The relationship between intercanine width and crowd- the expected crowding can also be calculated based on
ing has been previously demonstrated by Sayin and the same parameters. The correlation coefficients for
Turkkahraman,20 who reported smaller values in pa- the prediction of the severity of mandibular incisor
tients with crowding. crowding using the multiple regression model were
To obtain a quick tool for categorizing patients into 0.81 for boys and 0.85 for girls; these are considerably
those who will develop crowding in the future and those higher than the figures for conventional mixed dentition
who will not, we performed a discriminant analysis on analyses. A systematic review on the validity of mixed
the measured parameters. The resultant formulas were dentition space analysis methods reported correlation
accurate (92.6% for girls; 92.8% for boys) in predicting coefficient values about 0.6 when Tanaka-Johnston
who will have at least 2 mm of crowding in the 1-year and Moyers methods are used.33 Another advantage of
period of this study. By opting for a stepwise discrimi- the present method is that it does not depend on the
nant analysis, we aimed to reduce the number of mea- presence of permanent teeth for accurate prediction of
surements required to predict crowding. For girls, 3 crowding. Conventional techniques use the widths of
parameters remained in the final model: facial height, the mandibular permanent incisors for prediction of
bigonial width, and intercanine width; for boys, only crowding; this means that the clinician must wait until
the first 2 made it to the final model. We compared the permanent incisors have erupted; furthermore, alter-
the mean values of these parameters between subjects ations in the morphology of these teeth would add error
with and without crowding, and except for intercanine to the calculations.
width in girls, all parameters significantly differed be- The prediction of whether a person will develop
tween the groups; facial height was higher, and bigonial crowding in the future together with the severity of
width was narrower in subjects with crowding. Accord- the expected crowding can enable the clinician to better
ing to the stepwise multiple regression, the same param- plan for future treatment and to provide valuable infor-
eters also had a significant value in predicting the mation to parents. Although crowding in the early mixed
severity of crowding. Bigonial width had the most pre- dentition may seem insignificant, a longitudinal study of
dictive value among the selected parameters, both in 150 subjects showed that 89% of those with crowding in

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706 Sardarian and Ghaderi

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American Journal of Orthodontics and Dentofacial Orthopedics May 2018  Vol 153  Issue 5