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J Bagh College Dentistry Vol. 23(2), 2011 The dentoalveolar compensation The dentoalveolar compensation in different skeletal patterns of Iraqi adults Dr. Shaymaa Sh. Taha, B.D.S., M.Sc. (1) ABSTRACT Background: For different skeletal discrepancies, the maxillary and mandibular incisors were inclined in normal incisor relationships as a result of dentoalveolar compensatory mechanism. The aims of this study were to compare the dentoalveolar compensation among skeletal class I, skeletal class II, and skeletal class III jaw patterns, and to determine the gender difference in each class. Materials and Methods: The patients’ history, clinical examination and Lateral cephalometric radiographs were taken for 85 adult subjects. According to ANB angle the sample classified into: 30 adult subjects skeletal class I (control samples), 30 adult subjects skeletal class II and 25 adult subjects skeletal class III (study samples), the cephalometric radiographs are analyzed by using AutoCAD 2008 program. Results and Conclusion: Sagittal jaw parameters show classes difference (by using ANOVA and LSD test) among different skeletal classes, vertical and dental parameters show gender and classes differences, while linear measurements show gender difference (by using independent t-test). Dentoalveolar compensation is affected by lower incisors in skeletal class II and by upper and lower incisors in skeletal class III. Key words: Dentoalveolar compensation, different skeletal patterns. (J Bagh Coll Dentistry 2011;23(139-145). INTRODUCTION Facial esthetics is an important motivating factor for many patients seeking orthodontic treatment1-3.Differing methods for evaluating facial profiles have been proposed in the orthodontic literature including traditional cephalometrics and repose soft tissue analysis .Traditional cephalometrics uses internal osseous land marks to define points, lines, and/or planes, which in turn are used to quantify anteroposterior (AP) jaw and incisor positions4. During facial growth and development, normal occlusion can be attained and maintained despite some variation in facial pattern, primarily as a result of dental compensation5-10. For existing sagittal jaw discrepancies, compensatory inclination of the maxillary and mandibular incisors results in normal incisor relationships 57,9-10 . The cant of the occlusal plane adjusts sagittal relationships between the maxillary and mandibular dental arches8. Some authors have suggested that malocclusion results from insufficient dentoalveolar compensation for variations in facial patterns5,7,9. The position of upper and lower incisors relative to each other and to their supporting bones is an important feature in a case analysis, post treatment stability, and harmony and balance of the facial profile. Since the introduction of cephalometrics, incisor position in the sagittal plane has become a valuable tool in assessing a malocclusion11. (1)Assistant lecturer /Department of Orthodontics, College of Dentistry, University of Baghdad Orthodontics, Pedodontics and Preventive Dentistry139 The aims of this study were to compare the dentoalveolar compensation among different skeletal patterns, and to determine the gender difference in each class. MATERIALS AND METHODS Sample Pretreatment lateral cephalograms of 85 untreated Subjects, who were selected from patients attended the Orthodontic Clinic in the Orthodontic Department at the College of Dentistry, University of Baghdad. According to ANB angle, the sample were consisted of 3 groups: 30 adults skeletal class I (15 males and 15 females) in which 2˚ <ANB< 4˚, 30 adults skeletal class II (15 males and 15 females) in which ANB> 4˚ and 25 adults skeletal class III (11 males and 14 females) in which ANB< 2˚, selected from the patients attended to the Orthodontic department at the College of Dentistry, University of Baghdad meeting the following criteria: 1. All the subjects were Iraqi Arab in origin, aged 18-25 years old with no history of facial trauma. 2. No history of previous orthodontic treatment. 3. Full permanent dentition regardless the third molar. 4. The incisors had not been crowned or severely rotated. 5. Clinically (palpation method of Foster) and cephalometrically (according to ANB angle) skeletal class I, II, and III. J Bagh College Dentistry Vol. 23(2), 2011 Method The patients’ history, clinical examination and cephalometric radiographs were taken for 85 adult subjects. The cephalometric radiographs were taken by standard method by using Planmeca machine. The radiographs were taken with Frankfort plane horizontal, the teeth in centric occlusion, and the patients in rest head position. Every lateral cephalometric radiograph was analyzed by AutoCAD program 2008 to calculate the cephalometric measurements. Once the picture is imported to the AutoCAD program, it will appear in the master sheet on which the points and planes were determined, and then the measurements were obtained. The angles were measured directly as they were not affected by magnification while the linear measurement was divided by scale for each picture to overcome the magnification. Cephalometric landmarks (Figure 1) The following points were used in this study and defined according to Rakosi 12: Sella (S), Nasion (N), Anterior nasal spine (ANS), Posterior nasal spine (PNS), Articulare (Ar), Gonion (Go), Menton (Me), Point A, Point B, Incisor superius (Is), Incisor inferius (Ii), Frontal and Distal points of occlusal plane (Fpop, Dpop), Apicale ¯1¯(Ap1), and Apicale 1 (Ap2). Reference lines (Figure 2): 1. Sella nasion (SN)12: Anteroposterior extent of anterior cranial base. 2. Occlusal plane (OP)13: located as the bisected occlusal plane, extend from frontal point of occlusal plane (Fp Op)to the dorsal point of occlusal plane(Dp op) 3. A-B13: Formed by a line joining points A and B. 4. Palatal plane (PP)12: formed by a line joining points ANS and PNS. 5. Mandibular plane (MP) 12: formed by a line joining points Go and menton Me. 6. N-A plane14: formed by a line joining points A and N. 7. N-B plane14: formed by a line joining points B and N. Angular measurements (Figure2): I. Sagittal jaw parameters 1. SN-AB Angle: Angle between SN line and AB line13. 2. ANB Angle: Difference between SNA and SNB12. II. Vertical jaw parameters The dentoalveolar compensation 3. SN-MP: This angle gives the inclination of the mandible to the anterior cranial base12. 4. SN-PP: Angle between SN line and palatal plane12. 5. PP-MP: Angle between palatal plane and mandibular plane12. III. Dental parameters 6. SN-U1: Angle between SN line and upper incisor axis12,13 7. SN-L1: Angle between SN line and lower incisor axis12,13. 8. SN-OP: Angle between SN line and occlusal plane13. 9. U1-PP: Angle between upper incisor axis and palatal plane, anteriorly12. 10. L1-MP: Angle between lower incisor axis and mandibular plane, posteriorly12. 11. U1-NA: Angle between upper incisor axis and NA plane14. 12. L1-NB: Angle between lower incisor axis and NB plane14. 13. Inter-incisal Angle (U1-L1): Angle between upper incisor axis and lower incisor axis posteriorly12. Linear measurements (Figure 2): 1. Maxillary length12: The horizontal distance of palatal plane (Pal) between ANS point and PNS point. 2. Upper anterior facial height (UAFH) 12 : The vertical distance between N point and ANS point. Statistical analysis Data were statistically analyzed by a software computer program SPSS, version 15 to obtain descriptive statistics (means, standard deviation, and standard error), and inferential statistics: independent t-test, one way analysis of variance (ANOVA), and LSD test between the three skeletal classes. RESULTS AND DISCUSSION Tables (1) and (2)show the descriptive statistics, gender difference by using independent t-test, and classes difference by using one way analysis of variance(ANOVA) for skeletal jaw and dental parameters respectively. Tables (3) and (4) show LSD post hoc test for males and females respectively, are used to determine any significant difference between three skeletal classes. 1. Angular measurements: A. Sagittal jaw parameters: As shown in Table (1) the SN-AB˚ and ANB˚ angles have no Orthodontics, Pedodontics and Preventive Dentistry140 J Bagh College Dentistry Vol. 23(2), 2011 significant gender difference in all three skeletal classes. As shown in table (1) the SN-AB ˚and ANB˚ angles are very high significant difference among all three skeletal classes. As shown in table (3) LSD test for males shows that SN-AB˚ is very high significant difference between skeletal class I and II, and between skeletal class II and III. Table (4) LSD for females shows that the SN-AB˚ has a very high significant difference among all three skeletal classes. Also LSD for males and females show that ANB˚ has a very high significant difference among all three skeletal classes. The mean values of SN-AB˚ for males and females in skeletal class II are less than that of skeletal class I and III. These results show the differences in the sagittal jaw relationships which might be due to mandibular rotation, so backward rotation is carrying point B away from point A, while forward rotation is bringing point B forward15.These results show no mechanism acting to reduce the sagittal jaw discrepancy in this sample and this agrees with Bibby 10. B. Vertical jaw parameters: As shown in table (1), the mean values of each of SN-MP˚ and PP-MP˚ angles in skeletal class I and II are higher in females than males.SN-MP˚ has a significant gender difference in skeletal class II and very highly significant gender difference in skeletal class I. While PP-MP˚ has a significant gender difference in skeletal class I, this disagrees with Hassan16, this is may be due to difference in sample size or selection while PP-MP˚ shows no significant classes difference. The SN-MP˚ gives the inclination of the mandible to the anterior cranial base. Schudy had introduced the concept of posterior and anterior inclination, if the angle is greater than 32˚the inclination is posterior, but if it’s less than32˚the inclination is anterior12.So females in skeletal class I and II have posterior inclination of the mandible to the anterior cranial base. SN-MP˚ for males shows significant classes difference, table (3) LSD for males shows that there is significant classes difference between skeletal class I and III, these results may be due to dentoalveolar compensation for skeletal class III jaw discrepancies which can be expressed as counter clockwise rotational change in the entire dentoalveolar structure17.SN-PP shows nonsignificant gender and classes differences. C. Dental parameters: Table (2) U1-PP˚, U1NA˚, and L1-MP˚ angles show no gender difference, while SN-U1˚ (skeletal class I), SNOP˚ (skeletal class II), and U1-L1˚ (skeletal class III) angles show significant gender difference. SN-L1˚, U1-L1˚, and L1-NB˚ (skeletal class II) Orthodontics, Pedodontics and Preventive Dentistry141 The dentoalveolar compensation and SN-OP ˚ (skeletal class I) angles show very highly significant gender difference. The mean values of SN-U1˚,U1-PP˚,L1-MP˚, andU1-NA˚ angles in skeletal class I are statistically higher in males for each angle, while in skeletal class II and class III these angles are statistically higher in females for each angle. The mean values of SNL1˚ (all skeletal classes) and U1-L1˚ (skeletal class II and class III) angles are statistically higher in males for each angle. U1-L1˚ (skeletal class I) and L1-NB˚ (all skeletal classes) angles are statistically higher in females for each angle. As shown in table (2) SN-U1˚,U1-PP˚,U1-L1˚, and L1-NB˚ angles for females show very high significant classes difference for each angle, while SN-L1˚,L1-MP˚,and U1-NA˚angles for males show significant classes difference for each angle, while the same angles for females show very high significant classes differences. The mean values of each of SN-OP˚ and SN-MP˚ angles (in skeletal class I and class II) are statistically higher in females, As mentioned previously, females in skeletal class I and II have posterior inclination of the mandible to the anterior cranial base, so their SN-OP˚ become steeper in skeletal class I and class II, due to that the mandibular and occlusal planes may rotate in conjunction with each other or rotate separately8 .SN-OP˚ shows nosignificant classes difference. The interincisal angle is an important indicator for stable orthodontic treatment, and is greatly influenced by dentoalveolar compensation18, as shown in table 1 and 3, the mean value of U1-L1˚ in skeletal class II (due to proclination of U1) is smaller than that in skeletal class I and class III, while skeletal class III (due to U1proclination and L1retroclination) U1-L1˚is more than class I and class II. Tables (1,2,3 and 4) show that dentoalveolar compensation can be seen in lower incisor only (by proclination tendency) for skeletal class II and this disagrees with Bibby10,and in upper incisor(by proclination tendency) and lower incisor (by retroclination tendency) for skeletal class III and this agrees with Bibby10and Ishikawa13.Proclination of upper incisors in skeletal class II cases is an unexpected finding , which can be explained by insufficient maxillary dentoalveolar compensation or due to soft tissue factor (lower lip acting behind upper incisors),this finding shows that the skeletal class II samples are dentally class II division 1. The present results show that there are dentoalveolar changes in the axial inclination of the maxillary and mandibular incisors in different skeletal patterns. Some investigators have suggested that malocclusions J Bagh College Dentistry Vol. 23(2), 2011 result from insufficient dentoalveolar compensation for variation in facial patterns7,13. 2-Linear measurements: As shown in table (1) the mean values of each of maxillary length and UAFH linear measurements are statistically larger in males than that of females, this gender difference may be due to19,20: • The smaller and smoother boney and alveolar process in females. • The average weakness of musculature in females that plays an important role in facial breadth measurements, width, and height of the dental arch. REFERENCES 1. Dorsey J, Korabik K. Social and psychological motivations for orthodontic treatment. Am J Ortho 1977; 72:460-7. 2. Kilpelanien P, Phillips C, Tulloch JFC. Anterior tooth position and motivation for early treatment. Angle Ortho 1993; 63:171-4. 3. McKiernan EXF, McKiernan F, Jones ML. Psychological profile and motives of adults seeking orthodontic treatment. Int J Adult Orthod Orthognath Surg 1992; 7:1887-98. 4. Will A.A. AP relationship of the maxillary central incisor to the forehead in adult white females. Angle Orthod 2008; 78: 662-9. 5. Proffit WR. Contemporary orthodontics.3rd edition. St. Louis: Mosby, 2000. 6. Björk, A. Sutural growth of the upper face studied by the implant method. Acta Odontol Scand 1966; 24:109-27 7. Solow B. The pattern of craniofacial associations: A morphological correlation and factor analysis study on young male adults. Acta Odontol Scand 1966; 24: Supp 46. 8. Enlow DH, Kuroda T, Lewis AB. Intrinsic craniofacial compensations. Angle Orthod 1971; 41:27185. The dentoalveolar compensation 9. Björk A. Facial development and tooth eruption: An implant study at the age of puberty. Am J Orthod 1972; 62:339-82. 10. Bibby RE. Incisor relationships in different skeletofacial patterns. Angle Orthod 1980; 50: 41-4. 11. Ellis EE, McNamara J. A Cephalometric evaluation of incisor position. Angle Orthod 1986; 56: 324-44. 12. Rakosi T. An atlas and manual of cephalometric radiography. 2nd ed. London: Wolfe medical publications Ltd.; 1982. 13. Ishikawa H, Nakamura S, Iwasaki H, Kitazawa S, Tsukada H, Chu S. Dentoalveolar compensation in negative overjet cases. Angle Orthod 2000; 70(2):145-8. 14. Ceylan I, Baydas B, Bölukabasi B. Longitudinal cephalometric changes in incisor position, overjet, and overbite between 10 and 14 years of age. Angle Orthod 2002; 72(3): 246-50. 15. Al-Chalabi H. Skeletodental measurements in Iraqi patients sample with class II division 1 malocclusion and different vertical discrepancies. Master thesis, Department of Orthodontics, University of Baghdad, 2009. 16. Hassan MN. Dentoalveolar compensation in relation to mild skeletal discrepancies. Master thesis, Department of Orthodontics, University of Baghdad, 2007. 17. Ishikawa H, Nakamura S, Iwasaki H, Kitazawa S, Tsukada H, Sato Y. Dentoalveolar compensation related to variations in sagittal jaw relationships. Angle Orthod 1999; 69(6): 534-8. 18. Al-Hashimi H, Al-Bustani A, Abdulla N. Dentoalveolar compensation in skeletal class III malocclusion and the treatment requirements. Iraqi Orthod 2007; 3(1): 40-2. 19. Younes SA. Maxillary arch dimensions in Saudi and Egyptian population sample Am J Orthod Dentofac Orthop 1984; 85:83-7. 20. Al-Hadithy SF. Dental arch dimensions and forms in Sulaimania Kurdish population sample aged 1624 years with Class I normal occlusion. Master thesis, Department of Orthodontics, University of Baghdad, 2005. Figure 1: Cephalometric landmarks Figure 2: Cephalometric analysis: identification (cephalometric points) cephalometric planes, angular and Orthodontics, Pedodontics and Preventive Dentistry142 J Bagh College Dentistry Vol. 23(2), 2011 The dentoalveolar compensation Table 1: Descriptive statistics, gender difference and classes’ difference for skeletal jaw parameters (sagittal and vertical) Descriptive statistics Classes difference Variables Gender Class I Class II Class III Mean S.D S.E Mean S.D S.E Mean S.D S.E F-test p-value Male 76.47 3.48 0.90 70.73 4.01 1.03 79.30 3.47 1.10 18.04 0.000 *** Female 74.67 2.02 0.52 68.80 3.34 0.86 79.71 3.83 1.02 43.89 0.000 *** SN-ABº t-test 1.73 1.43 -0.27 p-value 0.09 (NS) 0.16(NS) 0.79(NS) Male 2.73 1.10 0.28 5.53 1.13 0.29 -0.10 1.29 0.41 72.11 0.000 *** Female 2.87 1.06 0.27 6.33 1.45 0.37 -0.14 1.46 0.39 85.87 0.000 *** ANBº t-test -0.34 -1.69 0.07 p-value 0.74(NS) 0.10(NS) 0.94(NS) Male 28.87 5.57 1.44 31.73 4.74 1.22 34.50 6.11 1.93 3.31 0.05 * Female 34.20 3.76 0.97 35.20 4.26 1.10 34.43 5.77 1.54 0.19 0.83(NS) SN-MPº t-test -3.07 -2.11 0.03 p-value 0.000 *** 0.04 * 0.98(NS) Male 7.47 3.68 0.95 8.40 2.16 0.56 8.80 2.70 0.85 0.70 0.50(NS) Female 9.33 3.54 0.91 8.27 3.01 0.78 10.14 3.03 0.81 1.25 0.30(NS) SN-PPº t-test -1.42 0.14 -1.12 p-value 0.17(NS) 0.89(NS) 0.28(NS) Male 21.27 4.74 1.22 23.27 4.96 1.28 25.60 4.77 1.51 2.43 0.10(NS) Female 24.87 4.49 1.16 26.93 5.28 1.36 24.14 5.83 1.56 1.13 0.33(NS) PP-MPº ANS-PNS (mm) UAFH (mm) t-test -2.14 -1.96 0.65 p-value 0.04 * 0.06(NS) 0.52(NS) Male 53.61 4.09 1.06 53.91 2.91 0.75 53.07 3.92 1.24 0.16 0.85(NS) Female 48.93 4.10 1.06 50.94 3.07 0.79 49.47 3.16 0.84 1.34 0.27(NS) t-test 3.13 2.72 2.49 p-value 0.000 *** 0.01 ** 0.02 * Male 52.22 2.72 0.70 52.78 2.77 0.72 53.53 2.55 0.81 0.71 0.50(NS) Female 50.78 2.45 0.63 50.55 2.85 0.74 50.22 2.58 0.69 0.16 0.85(NS) t-test 1.53 2.17 3.11 p-value 0.14 (NS) 0.04 * 0.01 ** Orthodontics, Pedodontics and Preventive Dentistry143 J Bagh College Dentistry Vol. 23(2), 2011 The dentoalveolar compensation Table 2: Descriptive statistics, gender difference and classes’ difference for dental parameters Descriptive statistics Classes difference Variables Gender Class I Class II Class III Mean S.D S.E Mean S.D S.E Mean S.D S.E F-test p-value Male 105.60 5.19 1.34 104.60 5.34 1.38 106.30 5.12 1.62 0.33 0.72 (NS) Female 101. 27 5.47 1.41 107. 27 4.08 1.05 108.86 5.26 1.41 9.55 0.000 *** SN-U1º t-test 2.22 -1.54 -1.19 p-value 0.03 * 0.14(NS) 0.25(NS) Male 53.60 5.03 1.30 48.93 3.24 0.84 53.00 6.73 2.13 3.78 0.03 * Female 50.27 4.40 1.14 41.87 4.69 1.21 50.07 4.14 1.11 17.45 0.000 *** SN-L1º t-test 1.93 4.80 1.32 p-value 0.06(NS) 0.000 *** 0.20(NS) Male 11.33 3.89 1.00 13.20 3.43 0.88 14.80 3.99 1.26 2.65 0.08(NS) Female 16.40 3.00 0.77 15.93 2.79 0.72 14.64 3.75 1.00 1.17 0.32(NS) SN-OPº t-test - 4.00 -2.40 0.10 p-value 0.000 *** 0.02 * 0.92(NS) Male 113.27 5.75 1.48 113.00 5.84 1.51 115.10 5.55 1.75 0.45 0.64(NS) Female 110.53 4.07 1.05 115.47 4.03 1.04 118. 93 5.12 1.37 13.27 0.000 *** U1-PPº t-test 1.50 -1.35 -1.74 p-value 0.14(NS) 0.19(NS) 0.09(NS) Male 97.53 5.14 1.33 99.20 5.58 1.44 92.70 7.36 2.33 3.74 0.03 * Female 95.80 6.03 1.56 102.93 4.91 1.27 95.71 5.68 1.52 8.25 0.000 *** L1-MPº t-test 0.85 -1.95 -1.13 p-value 0.40(NS) 0.06(NS) 0.27(NS) Male 127.80 8.25 2.13 124.33 7.37 1.90 126.80 8.74 2.76 0.73 0.49(NS) Female 128.87 7.93 2.05 114.67 6.10 1.58 121.14 3.55 0.95 19.86 0.000 *** U1-L1º t-test -0.36 3.91 2.20 p-value 0.72(NS) 0.000 *** 0.04 * Male 22.40 4.97 1.28 20.27 5.74 1.48 26.90 5.38 1.70 4.62 0.02 * Female 19.60 5.37 1.39 22.80 3.71 0.96 29.43 4.50 1.20 17.25 0.000 *** U1-NAº t-test 1.48 -1.44 -1.25 p-value 0.15(NS) 0.16(NS) 0.22(NS) Male 27.07 5.32 1.37 29.73 4.17 1.08 26.30 5.56 1.76 1.74 0.19(NS) Female 28.47 4.10 1.06 36.20 4.65 1.20 29.57 3.11 0.83 16.11 0.000 *** L1-NBº t-test -0.81 -4.01 -1.84 p-value 0.43(NS) 0.000 *** 0.08(NS) Orthodontics, Pedodontics and Preventive Dentistry144 J Bagh College Dentistry Vol. 23(2), 2011 Table 3: LSD test for males Variables Classes 5.73 0.000 *** III -2.83 0.07 (NS) II III -8.57 0.000 *** II 4.67 0.01 ** III 0.60 0.77(NS) II III -4.07 0.05 * II -1.67 0.45(NS) SN-ABº I SN-L1º I Variables Classes SN-ABº SN-U1º SN-L1º Mean p-value Difference II 5.87 0.000 *** III -5.05 0.000 *** II III -10.91 0.000 *** II -6.00 0.000 *** III -7.59 0.000 *** II III -1.59 0.39(NS) I I II 8.40 0.000 *** III 0.20 0.91(NS) II III -8.20 0.000 *** II -4.93 0.000 *** III -8.40 0.000 *** II III -3.46 0.04 * II -7.13 0.000 *** III 0.09 0.97(NS) I III 4.83 0.05 * II III 6.50 0.01 ** II -2.80 0.000 *** III 2.83 0.000 *** II III 5.63 0.000 *** II -2.87 0.16(NS) III -5.63 0.02 * II III -2.77 0.22(NS) II III 7.22 0.000 *** II -3.47 0.000 *** III 3.01 0.000 *** II III 6.48 0.000 *** I II 14.20 0.000 *** III 7.72 0.000 *** II III -6.48 0.01 ** II -3.20 0.06(NS) L1-MPº I ANBº I SN-MPº II 2.13 0.28(NS) III -4.50 0.05 * II III -6.63 0.000 *** I U1-NAº Table 4: LSD test for females Mean p-value Difference II I The dentoalveolar compensation N.B. The following levels of significance are used: • Non significant (NS): P>0.05 • Significant (*):0.05>P>0.01 • Highly significant (**):0.01>P>0.001 • Very highly significant (***): P<0.001 U1-PPº L1-MPº ANBº I I I U1-L1º M U1-NAº L1-NBº Orthodontics, Pedodontics and Preventive Dentistry145 I III -9.83 0.000 *** II III -6.63 0.000 *** II -7.73 0.000 *** III -1.10 0.46(NS) II III 6.63 0.000 *** I