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Original Article

A Comparison Between Panoramic Radiography and Dental Study Model

for Space Maintainer
Muhammad Chair Effendi, Berty Pramartika1, Dini Rachmawati

Department of Pediatric Background: A space maintainer is an appliance used to maintain the jaw space

Abstract
Dentistry, Faculty of due to the premature loss of deciduous teeth. Moyer’s method is used to determine
Dentistry, 1Department of the need for a space maintainer by measuring the discrepancy. Objective: The aim
Dental Radiology, General
of this article is to determine the difference between measurements using Moyer’s
Hospital, Universitas
Brawijaya, 65145 Malang, method on a dental study model and on panoramic radiographs. Methods:
Indonesia Researchers measured the available space in 60 dental study models using two
methods—the segmental method and contouring of the jaw arch using a 0.6 mm
diameter arch wire. Moyer’s prediction table was used to predict the mesial-distal
width of the permanent canines and premolars. Software ImageJ (SIJ) was used
to measure the available space and required space on panoramic radiographs. We
performed image calibration so that the measurement results could be presented
in millimeters. Results: There was no significant difference (P = 0.935) in the
discrepancy prediction between the panoramic radiographs and the dental study
model. The Bland–Altman test result showed no significant difference, and the
conformity between the panoramic radiographs and the dental study model was
0.02770. The sensitivity and specificity values of the panoramic radiographs and
dental study model were above the 50% line. The area under curve values of the
panoramic radiographs and dental study model were considered to be very good.
Conclusion: Application of Moyer’s method to panoramic radiographs using
SIJ to determine space maintainer requirements can be performed on pediatric
Received: 24-02-21
Revised: 03-08-21
patients to predict special discrepancies.
Accepted: 29-08-21
Published Online: 18-10-21
Keywords: Deciduous, panoramic, space maintainer

Background was 41.2% in primary first molars, 37.3% in primary

canines, and 21.6% in primary second molars.[5]
D ata from World Health Organization (WHO)
showed that the rates of dental caries in school-age
children were 60–90%, and nearly 100% of dental caries
Premature loss of the deciduous teeth causes problems
such as tooth alignment changes and changes to the
in adults caused pain and discomfort.[1] The percentage size of the dental arch. The space created due to the
of people who had dental and oral health problems was premature loss of deciduous teeth causes migration
57.6%, the percentage of people who brush their teeth of the surrounding teeth, so that the space becomes
properly was 2.8%, and the percentage who received
dental treatment from the dentist was 10.2%.[2] Dental
Address for correspondence: Dr. Muhammad Chair Effendi,
caries, dental trauma, abnormal resorption, or systemic Department of Pediatric Dentistry, Faculty of Dentistry, Universitas
disease can cause premature loss of deciduous teeth.[3,4] Brawijaya, Jl. Veteran, 65145 Malang, East Java, Indonesia.
The prevalence of premature deciduous tooth loss E-mail: chaireffendi@gmail.com

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How to cite this article: Effendi MC, Pramartika B, Rachmawati

DOI: 10.4103/SDJ.SDJ_82_21 D. A comparison between panoramic radiography and dental study
model for space maintainer. Sci Dent J 2021;5:115-21.

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Effendi, et al.: Comparison of discrepancy’s measurements

narrower. The effects of dental space loss are tooth All of the panoramic radiographs were taken using
crowding, ectopic eruption, supra-eruption of Instrumentarium OP 200D-1 Digital Panoramic
opposing teeth, impacted permanent teeth, shifting of and Cephalometric System (70 kVp, 8 mA, 12 s;
the permanent first molars, and cross-bite.[6-8] Dentists Instrumentarium Dental, Tuusula, Finland).
usually use a space maintainer for pediatric patients
The inclusion criteria were medical records of patients
with premature loss of deciduous teeth. A space
who had no history of orthodontic treatment,
maintainer is an appliance used to maintain the space
high-quality dental casts, high-quality panoramic
due to the premature loss of deciduous teeth until the
radiographs, class I first molar occlusion, end-to-
eruption of the permanent teeth. Space maintainers
end permanent first molar occlusion, panoramic
are used to prevent malocclusion during mixed tooth
radiographs with complete permanent tooth buds,
periods by detecting tooth size differences.[9,10]
good permanent incisive relation, and permanent
A mixed dentition analysis is the first step to determine tooth buds still covered with alveolar bone. The
a treatment plan for patients with mixed dentition. exclusion criteria were dental casts with restorations or
Mixed dentition analysis allows the identification of proximal fractures, class II or III permanent first molar
tooth size and the discrepancy between the available occlusion, overbites and overjet of more than 4 mm,
space and the required space. Based on the results of dental impressions with tooth abnormalities (number,
mixed dentition analysis, the dentist can plan dental shape, and size), patients with systemic disease, and
treatment, for example, eruption guidance, space patients with craniofacial anomalies.
reclamation, a space maintainer, serial extractions,
The measurement of available space in the dental
or keeping the dental growth under observation.[11] study model
Moyer’s mixed dentition space analysis method is the
There are two methods to measure the available space:
most frequently used method. Moyer’s analysis uses a
(1) the segmental method and (2) contouring the jaw
probability table to predict the mesial-distal diameter
arch using a 0.6 mm diameter arch wire. The authors
of the canines and premolars in both arches.[12] It does
used the segmental method if there was excessive loss
not require specific equipment, and it uses a dental
of tooth contact points due to dental caries and there
cast to measure the available space and required space
was a significant tooth premature loss. The upper and
measurement.[13]
lower model was divided into three segments: segment
The dentist usually uses panoramic photographs to (a), the distance from the distal contact point of the
evaluate maxillofacial deformities and lesions in the second deciduous molar to the distal deciduous canine;
oral and maxillofacial region. In our current research, segment (b), the mesiodistal width of the deciduous
the researchers modified Moyer’s analysis using a canine crown; and segment (c), the distance from the
panoramic radiograph instead of a dental cast. This distal contact point of the lateral incisor to the mesial
was intended to simplify the discrepancy assessment of the central incisor. The measurement was taken on
for space maintainers. The aim of our study was to both sides. The measurement of each contact point was
determine the difference between the predictions of performed with a caliper from the left side to the right
discrepancy using Moyer’s method on a dental cast and side, as shown in Figure 1A.[14]
on panoramic radiographs. The study hypothesis was
The authors performed the second method, using
that there is no difference between the prediction of
an arch wire, when there was excessive loss of tooth
discrepancy using Moyer’s analysis (MDA) on a dental
contact points due to dental caries, rotational teeth,
cast and a panoramic radiograph.
and the number of teeth that were prematurely lost.
Materials and Methods The researcher calculated the available space using
a 0.6 mm diameter arch wire. The authors traced the
The research method was quasi-experimental with a occlusal surface along the incisal edge from the mesial
cross-sectional design. The study samples were derived contact points of the right first permanent molar to the
from the existing medical records (secondary data) mesial of the left first permanent molar or vice versa
of the Department of Pediatric Dentistry, Faculty of [Figure 1B]. Afterward, the arch wire was straightened,
Dentistry, Universitas Brawijaya, Malang, Indonesia. and its length was measured with a millimeter ruler.[15]
The study was approved by the Ethics Commission
of the Faculty of Medicine, Universitas Brawijaya, Specifically for the mandible, the occlusion relation
Indonesia (No. 211/EC/KEPK-S1/12/2020). The of the first permanent molar (i.e., an end-to-end
sample size was 60 with an age range of 8–12 years. occlusion or class I occlusion relation) was necessarily
The samples consisted of 27 females and 33 males. determined to assess the available space. Once the

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Effendi, et al.: Comparison of discrepancy’s measurements

Figure 1: (A) The measurement of the available space using the segmental method. (B) The measurement of the available space using
0.6 mm diameter arch wire

end-to-end occlusion relation was determined, the the result with the predicted mesial-distal width of
molar correction could be performed. In this case, the the mandibular canines and premolars obtained from
available space was the difference between the distance Moyer’s prediction table.
mesial permanent M1 to M1 (the segmental method or Statistical analysis
with the curved wire) and the corrected molar.[14,16]
A paired t-test was used to evaluate the differences
The required space was the predicted width of the between the discrepancy using Moyer’s MDA on the
mandibular canines and premolars on both sides. It was dental study models and panoramic radiographs.
obtained by summing the mesial-distal measurements A Bland–Altman test (mean difference or limits of
of the mandibular incisors. Afterward, Moyer’s agreement) was used to analyze the mean difference
prediction table was used to predict the mesial-distal or agreement between Moyer’s MDA in the dental
width of the canines and premolars. After that, the study models and panoramic radiographs. The area
authors summed the result (the predicted mesial-distal under curve (AUC) was used as a diagnostic test for
width of the canines and premolars) with the sum of the measurement of the discrepancy on the panoramic
the mesial-distal distance of the mandibular/maxilla photo and the dental study model. The AUC also
incisor crowns to get the required space measurement. provided sensitivity and specificity values that
Moyer’s method provides a closer prediction of the represented the overall diagnostic performance of each
mesial-distal dimensions of canines and premolars variable in the discrepancy measurement. The data
than other methods.[12,16] Furthermore, the authors were statistically analyzed using the Statistical Package
calculated the discrepancy, defined as the difference for Social Sciences software (IBM Corp.; Armonk, NY,
between the available space and the required space. USA).
The available space and required space measure- Results
ment on panoramic radiograph
The paired t-test result [Figure 3] shows that the mean
Image processing software ImageJ (FIJI; Eliceiri/LOCI
discrepancy prediction using panoramic radiography
Lab, WI, USA and MPI-CBG, Dresden, Germany)
was −0.3244, whereas that of the dental study model
was utilized to measure the available and required
was −0.2967. The mean difference between the two
space on panoramic radiographs. Image calibration
measurements was −0.02770, which means that it was
was performed so that the measurement results could
not statistically significant (P = 0.935).
be presented in millimeters. This was done by entering
a known standard value on the scale setting menu. The Bland–Altman test was performed to analyze the
Afterward, the authors entered the measurement unit. agreement between the discrepancy predictions on the
ImageJ then displayed the calibration function. The panoramic radiograph and the dental study model. If
available space was found by measuring the distance the difference between the variable is zero, then there
between the right mesial permanent first molar and is no difference [Table 1]. The result showed that the
the left mesial permanent first molar [Figure 2A]. The mean difference was 0.02770 and the P-value was 0.935
required space was obtained by measuring the greatest (P > 0.05). The mean difference between the panoramic
mesial-distal distance of the mandibular/maxilla incisor radiography and dental study model predictions was at
crowns [Figure 2B]. Thereafter, the authors summed the limit of agreement, no more than 5.

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Effendi, et al.: Comparison of discrepancy’s measurements

Figure 2: (A) Available space measurement by measuring the distance between the right mesial permanent first molar and the left mesial
permanent first molar. (B) Required space measurement by measuring the greatest mesial-distal distance of the incisor crowns. After that,
the researcher summed the result with the predicted mesial-distal width of the canines and premolars (Moyer’s prediction)

Figure 3: Mean of the discrepancy prediction using panoramic radiographs and the dental study model. ns = not significant

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Effendi, et al.: Comparison of discrepancy’s measurements

Table 1: Mean difference

t df Sig. (two-tailed) Mean difference 95% confidence interval of
the difference
Lower Upper
Difference 0.082 59 0.935 0.02770 −0.6523 0.7077

Figure 4: AUC of the discrepancy prediction of panoramic radiography and the dental study model. The diagnostic value was above the
50% line. *Receiver operating characteristic curve analysis for medical diagnostic test evaluation

AUC values were used for diagnostic tests of the arch during the growth of deciduous teeth, mixed teeth,
discrepancy prediction of the panoramic radiograph and permanent teeth affect the development of future
and dental study models. The discrepancy prediction occlusion.[18]
was in the range of −3 to 3 mm. The sensitivity value
There are a variety of methods for estimating the size
of the panoramic radiograph was 86.2%, and the
of the unerupted teeth in patients with mixed dentition
specificity value was 100%. The sensitivity value of the
by using dental casts and radiographs.[13] It is deemed
dental study model was 100% and the specificity value
mandatory to predict the discrepancy between available
was 100%. The diagnostic value of the discrepancy
and required space to determine whether there is a lack
prediction of the panoramic radiograph and dental
or an excess of space for permanent tooth eruption
study models was above the 50% line [Figure 4]. In Table
before we make the space maintainer. Prediction
2, the AUC value of the panoramic radiograph was
of the unerupted tooth size at the mixed tooth stage
0.931 or 93.1% (>90–100%), which was considered to
is a key factor in determining a treatment plan and
be very good (P = 0.039). The AUC value of the dental
malocclusion management.[19-21]
study model discrepancy prediction was 100% (>90–
100%), which was considered excellent (P = 0.017). The t-test result [Figure 3] showed that there was no
significant difference between the mean differences
Discussion found using panoramic radiography (−0.3244) and
The best way to maintain the space needed for permanent the dental study model (−0.2967). Based on the
tooth eruptions is by maintaining the health of the Bland–Altman test result, the mean difference of the
deciduous teeth. When there was premature tooth loss, discrepancy prediction was 0.02770, the value of P was
space maintainers were needed to help children both 0.935 (P > 0.05), and the limit of the agreement did
functionally and aesthetically.[17] Nowadays, the lack of not exceed 5. It represented no difference between the
space for permanent dentition becomes an orthodontic prediction of discrepancy using panoramic radiography
problem. The treatment and observation of the jaw and the dental study model [Table 1]. This result is in

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Effendi, et al.: Comparison of discrepancy’s measurements

Table 2: Area under the curve

Test result variable(s) Area Std. error Asymptotic Sig. b Asymptotic 95% confidence interval
Lower bound Upper bound
Panoramic radiography 0.931 0.056 0.039 0.821 1.000
Dental study model 1.000 0.000 0.017 1.000 1.000
*a. Under the non-parametric assumption
b. Null hypothesis: true area = 0.5

line with the previous studies. Previous results showed it difficult for the operator to make a high-quality
that linear measurements on panoramic radiographs dental cast for space maintainer measurement.[27] The
were reliable in the posterior mandibular area and that application of Moyer’s method with SIJ on panoramic
measurement errors were small for all dimensions.[22,23] radiographs can eliminate psychological barriers for
The magnification deviation was ±5%.[23] pediatric patients during the dental molding process.
The sensitivity analysis is a test that determines a tool’s Panoramic radiography has several advantages,
ability to correctly classify individuals affected by a including relatively low radiation, relatively short
disorder. The specificity test demonstrates the ability of exposure time, and relatively cheap cost. However,
the tool to correctly classify an individual as disease- panoramic radiography also has disadvantages, one of
free. Low sensitivity means that the tool missed many which is the distortion caused by incorrect positioning
affected individuals. Low specificity means that the tool of the head during the exposure process.[28] This imaging
puts a large number of people in the affected group, method is sensitive to head position because the focal
even though they do not have the disease. If a tool trough or image layer is thin, especially in the anterior
has low sensitivity and specificity, it means that the region.[29,30] Measurements of the anterior mandibular
tool has low accuracy.[24-26] In this study, the diagnostic are less reliable than those of the posterior. However,
test determined that the leeway predictions are limited this can be minimized by correctly positioning the
within the range of −3 to 3 mm, which means that patient’s head.[22]
when lacking space of more than −3 mm and excessing
in space of more than 3 mm, the patient does not need Conclusion
a space maintainer. There was no significant difference in the discrepancy
The panoramic radiographic sensitivity value was prediction, and there were agreements between
86.2%, and the specificity value was 100%. The the mean result of Moyer’s method on panoramic
sensitivity of the dental study model was 100%, radiographs and the dental study model. The sensitivity
and the specificity value was also 100%. Both of and specificity values of the panoramic radiographs
these values were above the 50% line [Figure 4]. The and the dental study models were above the 50% line.
panoramic radiographic prediction sensitivity value The AUC values of the panoramic radiographs and
was 86.2%, indicating that the ability to classify dental study models were both considered to be very
patients who require room maintenance was 86.2%, good. Therefore, modification of Moyer’s method on
and a probability of false-negative was 13.8%. The panoramic radiographs using SIJ for space maintainers
panoramic radiograph prediction specificity was can be performed in pediatric patients. One of the
100%, which indicates that panoramic radiography potential problems with panoramic radiography is the
has the ability to correctly classify patients who do distortion caused by incorrect head positioning during
not require a space maintainer. The sensitivity and the exposure process. However, we can minimize the
specificity values of the dental study model prediction distortion and improve the measurement accuracy by
were both 100%, indicating that there were no false- positioning the patient’s head correctly. Further research
negatives or false-positives. The diagnostic test of still needs to be performed with a larger sample to get
discrepancy prediction on panoramic radiography more accurate results. Appropriate software is also
was 0.931 or 93.1%, which was considered to be very needed to determine indications for space maintainers
good. The diagnostic test of discrepancy prediction using much more up-to-date modalities, such as 3D
on the dental study model was 1.00 or 100%, which CBCT or a digital dental study model.
was also considered to be very good [Table 2]. Financial support and sponsorship
In some cases, pediatric patients may have psychological No funding was received for conducting this study.
issues such as fear and anxiety that cause them to avoid The sample for our study was derived from the
dental treatment such as dental impressions. This makes existing medical records (secondary data) of the

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Effendi, et al.: Comparison of discrepancy’s measurements

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Comparative evaluation of three mixed dentition analyses and
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