University of Iowa

Iowa Research Online

Theses and Dissertations

Spring 2014

Maxillary central incisor crown-root relationships

in Class I normal occlusions and Class II division 2
malocclusions
Thomas J. Bauer
University of Iowa

Copyright 2014 Thomas John Bauer

This dissertation is available at Iowa Research Online: http://ir.uiowa.edu/etd/4572

Recommended Citation
Bauer, Thomas J.. "Maxillary central incisor crown-root relationships in Class I normal occlusions and Class II division 2
malocclusions." MS (Master of Science) thesis, University of Iowa, 2014.
http://ir.uiowa.edu/etd/4572.

Follow this and additional works at: http://ir.uiowa.edu/etd

Part of the Orthodontics and Orthodontology Commons

MAXILLARY CENTRAL INCISOR CROWN-ROOT RELATIONSHIPS IN CLASS I
NORMAL OCCLUSIONS AND CLASS II DIVISION 2 MALOCCLUSIONS.

by
Thomas J. Bauer

A thesis submitted in partial fulfillment

of the requirements for the Master of
Science degree in Orthodontics
in the Graduate College of
The University of Iowa

May 2014

Thesis Supervisor: Professor Robert N. Staley

 Graduate College
The University of Iowa
Iowa City, Iowa

CERTIFICATE OF APPROVAL

_______________________

MASTER'S THESIS
_______________

This is to certify that the Master's thesis of

Thomas J. Bauer

has been approved by the Examining Committee

for the thesis requirement for the Master of Science
degree in Orthodontics at the May 2014 graduation.

Thesis Committee:
Robert N. Staley, Thesis Supervisor

David Jones

Lina Moreno Uribe

Fang Qian
 ACKNOWLEDGMENTS

I wish to thank the members of my thesis committee Drs. Robert Staley, Lina

Moreno Uribe, David Jones, and Fang Qian for their assistance with this project.

I also wish to express my gratitude to the faculty I have had here at the University

of Iowa. They have made this residency my favorite years of all my education.

A special thanks to my wife Eden, my daughter Maddy, and son Hayden for

bringing me love and happiness beyond what I ever thought possible.

ii
 TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................. iv

LIST OF FIGURES .............................................................................................................v

INTRODUCTION ...............................................................................................................1

LITERATURE REVIEW ....................................................................................................4

The collum angle ..............................................................................................4

The occlusal plane ............................................................................................7

MATERIALS AND METHODS .........................................................................................9

Sample selection ...............................................................................................9
Cephalometric data .........................................................................................11
Description of measurements .........................................................................12
Measurement reliability ..................................................................................17
Intra-observer agreement ................................................................................18
Inter-observer agreement ................................................................................20
Statistical analysis ...........................................................................................22

RESULTS ........................................................................................................................23

Mean CA for Class I normal occlusions .........................................................23

Correlation between CA and LCRA ...............................................................23
Analysis of torque measurements ...................................................................29
Analysis of CA and LCRA measurements .....................................................31
Comparisons of CA and LCRA between two groups ...............................31
Comparisons of CA and LCRA among three groups ...............................31

DISCUSSION ....................................................................................................................36

Case report ......................................................................................................37

Mean CA for Class I normal occlusions .........................................................42
Correlation between CA and LCRA ...............................................................42
Torque .............................................................................................................43
CA, LCRA differences between Class I normal occlusions and .......................
Class II division 2 malocclusions ...................................................................44
Limitations of the study ..................................................................................45
Future research................................................................................................47

CONCLUSIONS................................................................................................................48

REFERENCES ..................................................................................................................49

iii
 LIST OF TABLES

Table

1. Interpretation of the intraclass correlation coefficient. .............................................17

2. Intra-observer measurement agreement for CA, LCRA, and torque ........................19

3. Inter-observer measurement agreement for CA, LCRA, and torque ........................21

4. Interpretation of the Pearsons correlation coefficient .............................................23

5. Mean torque values among the three sample groups ................................................29

6. Mean CA values among the three sample groups.....................................................32

7. Mean LCRA values among the three sample groups ...............................................34

8. Comparisons of CA, LCRA and Torque between D.W. and expected means
for a Class II division 2 malocclusion. .....................................................................39

iv
 LIST OF FIGURES

Figure

1. The collum angle ......................................................................................................14

2. The labial crown-root angle ......................................................................................15

3. The torque angle .......................................................................................................16

4. Correlation between CA and LCRA for all samples. ...............................................25

5. Correlation between CA and LCRA for Class I ideal samples. ...............................26

6. Correlation between CA and LCRA for Class I expanded samples. ........................27

7. Correlation between CA and LCRA for Class II division 2 samples. ......................28

8. Box and whisker plot of torque among groups. ........................................................30

9. Box and whisker plot of CA among groups. ............................................................33

10. Box and whisker plot of LCRA among groups. .......................................................35

11. Pre-treatment radiographs of Class II division 2 patient D.W. .................................40

12. Post-treatment radiographs of patient D.W. .............................................................41

v
 1

INTRODUCTION

The practice of modern orthodontics is largely based on the use of the straight-

wire edgewise appliance originally described by Andrews in 1968. The advent of this

technique has allowed the orthodontist to practice more efficiently by placing fewer

bends in wires, particularly at the finishing stages of treatment, with more predictable

results. The limitations of the straight-wire appliance become apparent, however, when

one considers the variability inherent in natural crown forms, as well as the variability of

root position in relation to the clinical crown. While the former may be readily visualized

and compensated for by alterations in wire or bracket position, the latter is typically not

addressed routinely in clinical practice. Typically, the root angulation in relation to the

crown is assumed to be zero, and in fact this assumption is built in to standardized

cephalometric incisor tracing templates. This is in spite of the fact that variations in the

crown-root angle, or "collum angle" (CA), have been described by several authors as

occurring in various types of malocclusions, particularly Class II division 2 patients, as

discussed below (Bryant 1984, Delivanis 1980). Kaley and Phillips (1991) have shown

that root translation or torqueing into the palatal cortex significantly increases the odds of

root resorption. Thus to achieve greater predictability in root position, and to anticipate

difficulties with intrusion, extrusion, or torqueing mechanics, it seems that a more

thorough understanding of crown-root relationships in the bucco-lingual plane, and their

application to clinical practice, is warranted.

Cephalometric landmarks and measurements gain clinical acceptance not only

because they yield diagnostic information, but also because they are reliable, stable, and

reproducible. Nevertheless Baumrind and Frantz (1971) have shown that errors in

landmark identification are too great to be ignored, and that the amount of error depends

on the landmark identified. Additionally, they noted the amount of error increases when
a landmark is constructed (a bisection or tangent line), interpreted (a point on a curve), or
 2

confounded by noise of adjacent structures (superimposition). For example, the

maxillary central incisor collum angle is defined by three points: U1 (central incisor)

incisal edge (incision superius), the bisection point of labial and lingual cementoenamel

junctions, and U1 root apex. This measurement suffers from poor reliability and limited

clinical utility because it is by nature constructed, and defined in part by a point (lingual

CEJ) that is often superimposed by other structures. U1 torque is another measurement

that has suffered a similar fate. Intended to define the desired third order position of the

clinical crown, torque has been defined by various authors as a tangent point at various

levels on the clinical crown. The rigor of this definition is weakened because it requires

interpretation, and as a result, incisor bracket prescriptions vary widely in their torque

values, and are still debated.

This investigation proposes new angular measurements of crown-root angulation

and torque that are constructed of visible anatomic points, in the hope of increasing their

reliability and usefulness. An analysis using these measurements will be conducted on a

control sample and an experimental sample of Class II division 2 subjects to assess their

merit.

The purposes of the present study are several. First, this investigation proposes to

establish a mean value for maxillary incisor CAs from a given sample of Class I normal
occlusions. To our knowledge, mean CA values have thus far been obtained only for

subjects with malocclusion. The null hypothesis states that the mean CA for Class I

normal occlusions is not statistically different from zero. Second, we wish to identify a

new crown-to-root angle, defined by three anatomic points: U1 incisal edge, U1 labial

cementoenamel junction, and U1 root apex. We will define this angle as the "labial

crown root angle" (LCRA) and attempt to correlate it with the CAs of the same sample.

We believe the utility of this new angle lies in the ease with which these three points can

typically be identified anatomically on lateral cephalometric radiographs, the fact that

they are already used in standard cephalometric tracings, and the closer approximation
 3

they should have with the actual position of the straight wire bracket on the labial surface

of an incisor. Previous efforts to identify the surface angle on which the bracket will be

placed have involved rather complex algorithms for determining the constructed tangent

line or curve of the given surface. These processes may be too cumbersome for everyday

practice. If the LCRA can be correlated with the CA of a given tooth, then difficulties

with abnormal root positioning could be anticipated directly from this simple

measurement. The null hypothesis specifies that the CA and the LCRA will not have a

statistically significant correlation. Third, this investigation will measure torque using

anatomic points, and use descriptive statistics to identify a mean torque angle in the Class

I normal occlusion sample group in order to identity an ideal bracket prescription for

incisors in normal occlusion. Fourth and finally, we will analyze the CA and LCRA for a

sample of known Class II division 2 subjects to detect any differences with Class I

normal occlusions, and correlate the CA and the LCRA for the Class II division 2 sample.

The null hypothesis states that these measurements will be no different from those

observed in Class I normal occlusions.

 4

LITERATURE REVIEW

The collum angle

Although Andrews introduced the concept of the straight wire appliance as early

as 1968, his description of it and the philosophy behind its use in treatment is best

outlined in his 1989 book, Straight Wire: The Concept and Appliance. In it, he reiterates

the well-known six keys to normal occlusion, of which crown inclination is the third. He

describes the method by which crown inclination is determined, using a constructed

tangent line on the facial surface of the clinical crown as it intersects with a line drawn

perpendicular to the occlusal plane. Using this method, he determined average crown

inclination for every tooth in the arches, and specified the maxillary incisor crown to be,

on average, inclined plus seven degrees. The sample used by Andrews (1989) was

comprised of 120 sets of records from patients with naturally occurring normal occlusion,

collected from various sources over a period of four years. Although the modern straight

wire appliance is based on these findings, Andrews never addressed the possibility that

the crown and root of a given tooth may be inclined relative to each other. Indeed, in

Chapter 9, entitled Fully Programmed Standard Brackets, drawings pertaining to crown

inclination assume that the collum angle (CA) is zero for each tooth. One is left to

wonder if Andrews originated the assumption of the zero degree CA.

Carlsson and Ronnerman (1973) investigated CAs on 88 extracted teeth. They

categorized their sample according to the amount of abrasion found, and it was presumed

by the authors that incision superius tends to move facially as abrasion progresses. The

type of malocclusion for each sample was not reported. Thirty-four teeth comprised

Group I, which was characterized by enamel abrasion only and a mean CA of -0.4

degrees. Group II, consisting of 29 teeth, exhibited moderate abrasion into dentin and a

mean CA of 0 degrees. Group III, 25 teeth, exhibited severe abrasion into dentin and a
mean CA of 2.6 degrees. Unfortunately, the mean values ascertained in this study are not
 5

particularly informative. First, it seems problematic to make measurements of damaged

teeth on which one of the points to be measured is missing or distorted. This can hardly

be expected to capture the natural prevalence of CAs in the general population.

Secondly, the authors noted the large ranges in their measurements: 11 degrees, 13

degrees, and 11.5 degrees, respectively, for Groups I, II, and III. These ranges show that

CAs are highly variable and warrant examination for identifiable patterns. Finally, as

mentioned previously, samples were not categorized according to Angle classification

and so any ability to find mean values in normal occlusion is lost.

Delivanis and Kuftinec (1980) conducted a retrospective study consisting of fifty-

three patients who were diagnosed clinically with Class II division 2 malocclusion, and

fifty-three matched control patients who exhibited a variety of other malocclusions,

excluding Class I normal occlusion and Class II division II malocclusion. No control

group with normal occlusion was studied. The authors found that the mean CA for Class

II division 2 patients was 6.14 5.14 degrees, compared to control values of 1.52 4.36

degrees. The authors concluded that the statistically significant bent character of

incisors in Class II division 2 malocclusions may account for anecdotal evidence of

unpredictability when intruding or torqueing these teeth.

Bryant et al (1984) conducted an investigation in two phases, using two different

samples. In the first phase, 98 extracted central incisors were placed into one of four

categories according to the type of malocclusion from which each sample originated.

Again, no sample from Class I normal occlusions was identified. Each sample was

radiographed, magnified, and measured. In the second phase of the study, the authors

obtained 100 cephalometric radiographs and categorized them in the same way as in the

first phase. Only patients with malocclusion were sampled, and in fact the sample was

chosen with preference given to patients with the most severe and readily identifiable

malocclusions. Based on the combined measurements from both phases of the study, the
authors concluded that crowns of incisors from patients with Class II division 2
 6

malocclusion are "bent" lingually to a degree that is statistically greater than the other

categories. No other significant differences in incisor anatomy between the four groups

were noted.

The problematic nature of inconsistencies in straight wire appliance theory has

been addressed by some authors. Vardimon and Lambertz (1986) recorded normal

torque values on models of fifty-four ideal occlusions, thirty-four treated and twenty

untreated. The molar classification of the subjects was not noted, and discussion was

limited only to crown position. The authors studied torque values for all teeth in each

case, and noted wide variability in all cases. Of particular interest to this study, the

authors noted an average torque value of 1 5 degrees for the maxillary central incisor,

which contrasts with Andrews (7 degrees) and Ricketts (22 degrees) data. They also

acknowledged-- but did not include within the scope of their study-- the wide variability

in CA, the impossibility of consistent tangent line placement on facial surfaces of crowns,

and the unpredictability of treatment mechanics that may result if the first two problems

are not satisfactorily addressed.

Germane et al (1989) studied a sample of 600 extracted teeth, from incisors to

molars, in order to determine mean facial contour values for homologous teeth from

different individuals, mean faciolingual contours when viewed from the incisal/occlusal,
and mean CAs. The facial contour means were calculated using multiple constructed

tangent lines that intersected various points surrounding the facial midpoint of the inciso-

gingival dimension of the clinical crown, or LA point. Importantly, the authors found

that variability in facial contour increases as one proceeds posteriorly in the dentition.

The authors also found no evidence that the CAs for the maxillary central incisor,

maxillary second premolar, and first molar were statistically different from zero. The

standard deviation for maxillary central incisors was found to be approximately 3

degrees. No effort was made to categorize extracted teeth according to the type of
 7

occlusion in which they were found, and the variability of CAs in different malocclusions

discussed previously was not addressed.

Harris et al (1993) studied cephalometric samples of central incisors from treated

cases of Class I, II, and III malocclusions. The three goals of this study were to establish

mean values for crown-root angulations in these three types of malocclusions, to

determine if crown-root angulation predisposed to root resorption, and to discover

cephalometric predictors of crown-root angulation. No attempt was made to establish a

mean value for CAs found in Class I normal occlusions. He determined that Class I and

II malocclusions exhibited mean CAs of 6.1 and 5.6 degrees, respectively, with no

statistically significant difference between them. However, class III malocclusions were

shown to have a different, statistically significant mean CA of about 12 degrees. With

regard to root resorption, the study found no statistically significant relationship between

molar classification and resorption, nor between CA and resorption. The relevance of

this finding will be addressed in the discussion of the present study. Cephalometric

prediction of CAs was related to cases of extreme Class III malocclusion, in which

cephalometric prognathism was combined with a smaller U1-FH angle, indicating that

the maxillary incisors were contained within the lower arch due to negative overjet. The

possibility that a higher CA may cause a predisposition for anterior crossbite is not
discussed. Instead, it is presumed that alterations in CA occur in situations where a tooth

is deflected lingually as it erupts and its root is mineralized.

The occlusal plane

Downs originally defined the occlusal plane as a line drawn from the bisection of

mesiobuccal cusp tips of the first molars to the bisection of the incisal edges of the most

anterior central incisors. He revised this definition for cases in which incisors were

severely malpositioned, limiting the occlusal plane in such cases to the bisection of
overlapping cusps on the first molars and first premolars (1948, 1952, 1956). This
 8

functional definition of the occlusal plane was later endorsed by Steiner and Ricketts

(Jacobson 1985). For a malocclusion in which the incisors are stepped up or down, the

occlusal plane derived from Downs original definition may be distorted, and so

modifying the definition to limit the plane posteriorly is a logical step. Nevertheless, it

was the original definition that was chosen for this study, since incisal edges of the most

anterior central incisors are typically more readily visible on cephalometric radiographs,

and indeed are already landmarked on a typical cephalometric analysis.

.
 9

MATERIALS AND METHODS

Sample selection

This investigation was designed as a retrospective, cross-sectional study to

measure the CA, LCRA, and torque angle of maxillary central incisors on patients with

Class I normal occlusions and Class II division 2 malocclusions. Samples with normal

occlusion, taken from the Iowa Growth Study conducted by Meredith and Knott (1973),

were so designated as having Class I molars with mild crowding/spacing. The normal

sample was further subdivided into two groups, an ideal sample with 1mm of

crowding/spacing, and an expanded sample with 2-4mm of crowding/spacing. Both

groups were utilized for this study.

The Iowa Growth Study, conducted by Howard V. Meredith and L.B. Higley,

began in 1946 (Meredith and Knott, 1973). It consisted of 130 subjects. Ninety-seven

percent of the subjects were of northwestern European ancestry and the remaining three

percent were of central or southeastern European lineage. Dental casts were made twice

every year until age 12, annually until age 17 and periodically through adulthood on

patients that remained in the study. The sample was described as follows,

All members of the sample resided in or near Iowa City, Iowa, and were

voluntary participants in a long-term research program begun in 1946 at the State

University of Iowa. Enrollment for study was based on willingness to participate and

likelihood of continuing residence in the community. The subjects were physically

normal children unselected in respect to cephalic or faciodental characteristics (Meredith

and Knott, 1973).

The normal sample of subjects in the Iowa Growth Study was originally defined

in a previous thesis conducted by Kuntz, in which the subjects were separated into groups

based on Angle molar classification and amount of crowding/spacing (Kuntz, 1993). The
subjects selected by Kuntz for the normal sample had good occlusion with a Class I
 10

molar relationship, mild crowding/spacing, and no other skeletal or dental abnormalities

of note. For the purposes of our study, the normal sample was further divided based on

magnitude of crowding/spacing, with one group exhibiting 1 mm of crowding/spacing,

and the other 2-4mm of crowding/spacing. Subjects that had orthodontic treatment

previously were excluded, since this would confound our ability to observe ideal,

naturally occurring torque values. Subjects whose cephalometric radiographs were of

generally poor quality, or those for whom measurements were not easily readable, were

also excluded. These limitations reduced the Class I normal occlusion sample size from

74 to 57. The sample included radiographs from 31 males and 26 females. Of those there

were 33 patients (17 male and 16 female) with 1 mm of crowding/spacing and 24

patients (14 male and 10 female) with 2-4mm of crowding/spacing.

The sample of Class II division 2 malocclusion subjects used for this study was

obtained from two sources. Lists of previously treated patients with certain

malocclusions are maintained in the University of Iowa orthodontics department for

study by future residents. Thirty-seven of the Class II division 2 subjects were identified

in this way. After the exclusion criteria were applied to this group, thirty-one records of

high quality, for which relevant landmarks could be easily identified, remained. The

second method used to populate the Class II division 2 sample was to utilize a sample
previously identified in a University of Iowa masters thesis written by Huth (1988).

This source yielded a further seventeen subjects, which was reduced to eleven after

exclusion criteria were applied. Thus the entire sample of Class II division 2

malocclusion subjects for this study was comprised of forty-two cephalometric

radiographs.

Class II division 2 malocclusion subjects exhibited, at a minimum, 3mm of

antero-posterior Class II discrepancy bilaterally, or 6 mm of Class II discrepancy

unilaterally. This is consistent with American Board of Orthodontics standards for Class
II case submission. These subjects were also previously characterized by various
 11

providers as division 2 because of a retroclined position of maxillary central incisors.

No attempt was made in this study to dispute this characterization or standardize the

minimum amount of upper incisor retrusion necessary to qualify for division 2 status.

Although it is relatively easy to find records of patients with Class II division 2

malocclusion in the long history of the University of Iowa orthodontics clinic, it must be

reiterated that multiple methods for obtaining these records were employed to ensure that

those utilized for our study were of the highest quality possible. In short, subjects were

chosen that exhibited obvious landmarks.

All samples were scanned, uploaded, and measured in Dolphin Imaging software

(version 11.5). Paixao et al observed that measurements using Dolphin Imaging version

11 are reliable and reproducible. Measurements were recorded in Excel spreadsheets

Cephalometric data

Original lateral cephalometric radiographs from the Iowa Growth Study were

scanned, digitized, and loaded into Dolphin for landmark identification and measurement.

Scanning and basic image formatting was accomplished by the University of Iowa

College of Dentistry Educational Media Department. Since all of the measurements for

this study were angular, no image calibration was necessary. A customized analysis was

then created to serve the needs of this investigation. Since Dolphin lacks the capability to
measure the collum angle or labial crown root angle per se, landmark labels typically

used for other purposes were simply re-utilized for these measurements.

Prior to landmark identification, samples were subjected to our exclusion criteria

for image quality and clarity. The most common reasons for exclusion were large

restorations on the first molars that made identification of the occlusal plane difficult,

poor visualization of the root apex due to superimposition of other structures or teeth, and

generalized poor image quality due to darkness or contrast. Great emphasis was placed
 12

on sample quality in this study in order to maximize observer agreement: landmarks on

the radiographs chosen were intended to be as obvious as possible.

Measurements were accomplished according to a predetermined protocol intended

to ensure measurement reliability. The primary observer (T.B.) placed landmarks for all

subjects and recorded all measurements in Excel spreadsheets. The statistician (F.Q.)

then selected fifteen samples at random for reliability analysis. The digital records of

these fifteen samples were duplicated twice, once for intra-observer reliability testing and

once for inter-observer reliability testing. T.B.s original landmarks were erased from all

duplicate records. The second observer (E.K.), a dental student, was trained on how to

identify relevant landmarks, as well as how to utilize the custom analysis tools in

Dolphin. Several weeks later, T.B. and E.K. re-accomplished landmark placement and

measurement on the selected samples, and recorded their new measurements in separate

spreadsheets. This procedure blinded T.B.s second measurements and E.K.s second

observer measurements from T.B.s original measurements.

All recorded measurements were reviewed and vetted for obvious measurement

errors, typographical errors, and omissions. They were formatted to facilitate analysis

and were submitted to statistician F.Q.

Description of measurements
The CA is traditionally measured according to three points on the most anterior

maxillary central incisor: the undamaged incisal edge [incisor superius, or IS] (Rakosi

1982), the constructed bisection of the facial and lingual cementoenamel junctions (fCEJ

and lCEJ, respectively), and the anatomic root apex [upper incisor apicale, or UIA]

(Rakosi 1982). The CA is the supplement (180 degrees x) of this angle. A straight

tooth will have a CA of zero, a lingually inclined root will have a positive angle, and a

labially inclined root will have a negative angle. The traditional CA measurement, used
in this study, is illustrated in Figure 1.
 13

The labial crown root angle (LCRA), as we propose it in this writing, is

constructed on a cephalometric radiograph with three points on the most anterior

maxillary central incisor: IS, fCEJ, and UIA. The LCRA is the supplement (180 degrees

x) of this angle. It may be more clinically useful than the CA, not only because the

plane defined by IS and fCEJ more closely approximates the labial surface of the upper

central incisor crown, but also because the anatomic points of the angle are already

typically identified on a cephalometric analysis. The ultimate utility of this measurement,

however, depends on how it correlates with the CA, since the ultimate goal of the LCRA

is to describe crown-to-root angulation. The labial crown-root angle is illustrated in

Figure 2.

Torque is defined in this study as an angle formed by two lines. The first line is

formed by fCEJ and IS. This differs from previous definitions of torque that have

utilized a tangent line on the labial surface of the crown. The second line is drawn

perpendicular to the occlusal plane through IS, where the occlusal plane is identical to

that originally defined by Downs: a line from the bisection of U6 occlusal and L6

occlusal surfaces to the bisection of U1 incisal edge and L1 incisal edge (Downs 1948).

A positive torque angle indicates buccal crown inclination, and a negative torque angle

indicates lingual crown inclination (as was observed in some pre-treatment records of
Class II division 2 subjects). The torque angle used in this investigation is illustrated in

Figure 3.
 14

UI

fCEJ
X X
lCEJ

IS

Figure 1. The collum angle (CA).

 15

Figure 2. The labial crown-root angle (LCRA).

 16

Figure 3. The torque angle.

 17

Measurement reliability

Fifteen samples (n=5 per group) were randomly selected and used for evaluation

of intra- and inter-observer agreement. Intraclass correlation coefficients were computed

as a measure of agreement between two duplicate measurements of CA, LCRA, and

torque, made on the same subject either by a single observer (T.B.) or by two separate

observers (T.B. and E.K.). Table 1 shows an approximate guide for interpreting

agreement between two measurements based on the intraclass correlation coefficient.

In addition, a paired-sample t-test was used to determine whether a significant

difference existed between two duplicated measurements made on the same subject by a

single observer or by the two observers. All tests employed a 0.05 level of statistical

significance. SAS for Windows (v9.3, SAS Institute Inc., Cary, NC, USA) was used for

the data analysis.

Table 1. Interpretation of the intraclass correlation coefficient.

0 No agreement

0.0-0.20 Weak agreement

0.20-0.40 Fair agreement

0.40-0.60 Moderate agreement

0.60-0.80 Good agreement

0.80-1.00 Strong agreement

1.00 Perfect agreement

 18

Intra-observer agreement

Intra-observer agreement for CA measurements was evaluated to assess

agreement on duplicate measurements made on the same subject by the primary observer

(T.B.). Overall, there was very strong evidence that the intraclass correlation differed

from zero (p<0.0001), and the correlation coefficient of 0.98 indicated strong agreement

between the two measurements made by the primary observer. Moreover, no significant

difference was found between first and second measurements of CA made by observer

T.B. (p=0.8770, a paired-sample t-test). The overall mean difference between the two

measurements was 0.051.15 (Table 2).

Intra-observer agreement for LCRA measurements was evaluated similarly.

Overall, there was very strong evidence that the intraclass correlation differed from zero

(p<0.0001), and the correlation coefficient of 0.98 indicated strong agreement between

the two measurements made by the primary observer. In addition, no significant

differences were found between first and second measurements of LCRA made by the

primary observer (p=0.3428, a paired-sample t-test). An overall mean difference between

the two measurements was -0.301.18 (Table 2).

Intra-observer agreement for torque measurements, evaluated in the same way,

showed very strong evidence that the intraclass correlation differed from zero
(p<0.0001), and the correlation coefficient of 0.99 indicated strong agreement between

the two measurements made by observer T.B. Furthermore, there was no statistically

significant difference between first and second measurements of torque made by the

primary observer (p=0.3601, a paired sample t-test). The overall mean (or median)

difference between these two measurements was -0.230.96 (Table 2).

 19

Table 2. Intra-observer measurement agreement for CA, LCRA, and torque.

Variable N Mean Std Minimum Maximum Median p-Value

Dev
1st CA 15 3.62 4.93 -6.40 12.10 2.70

2nd CA 15 3.57 5.13 -6.10 11.20 1.90

CA Difference between 15
0.05 1.15 -1.90 1.60 -0.10
1st and 2nd 0.8770*
Measurements
1st LCRA 15 34.29 5.23 24.60 42.10 33.60

2nd LCRA 15 34.59 5.50 24.20 43.50 34.10

LCRA Difference 15
-0.30 1.18 -2.30 1.90 -0.40
between 1st and 2nd 0.3428*
Measurements
1st Torque 15 8.57 8.17 -2.70 22.00 9.10

2nd Torque 15 8.80 8.20 -1.90 22.70 7.60

Torque Difference 15
-0.23 0.96 -1.90 1.70 -0.40
between 1st and 2nd 0.3601*
Measurements

*Not statistically significant (p>.05) using a paired sample t-test.

 20

Inter-observer agreement

An average of the two measurements made by the primary observer (T.B.),

compared with the singular measurements of the second observer (E.K.), was used to

evaluate the inter-observer reliability of measurements in the study (Table 3).

Inter-observer agreement for CA measurements was evaluated to assess

agreement of duplicate measurements made on the same subject by the two observers.

Overall, there was very strong evidence that the intraclass correlation differed from zero

(p<0.0001), and the correlation coefficient of 0.99 indicated strong agreement between

the measurements made by the two observers. Moreover, no significant difference was

found between measurements of CA made by the two observers (p=0.5829, a paired

sample t-test), with an overall mean (or median) difference of -0.140.99 (Table 3).

Inter-observer agreement for LCRA measurements was evaluated to assess

agreement on duplicate measurements made on the same subject by the two observers.

Overall, there was very strong evidence that the intraclass correlation differed from zero

(p<0.0001), and the correlation coefficient of 0.99 indicated strong agreement between

the two measurements made by the two observers. No significant difference was found

between measurements of LCRA made by the two observers (p=0.0681, a paired sample

t-test), with an overall mean (or median) difference of 0.430.84 (Table 3).
Inter-observer agreement for torque measurements was evaluated to assess

agreement on duplicate measurements made on the same subject by the two observers.

Overall, there was very strong evidence that the intraclass correlation differed from zero

(p<0.0001), and the correlation coefficient of 0.99 indicated strong agreement between

measurements made by the two observers. Additionally, there was no statistically

significant difference between measurements of torque made by the two observers

(p=0.8862, a paired-sample t-test), with a mean difference of -0.040.97 (Table 3).

 21

Table 3. Inter-observer measurement agreement for CA, LCRA, and torque.

Variable N Mean Std Minimum Maximum Median p-Value

Dev
1st Observer CA 15 3.60 5.00 -6.25 11.50 2.00

2nd Observer CA 15 3.74 4.74 -4.40 12.00 2.50

CA Difference between 15 -0.14 0.99 -1.85 2.05 -0.25 0.5829*

Two Observers
st
1 Observer LCRA 15 34.44 5.34 24.40 42.80 33.80

2nd Observer LCRA 15 34.01 5.28 22.90 41.80 33.60

LCRA Difference 15
0.43 0.84 -1.40 1.85 0.55
between Two 0.0681*
Observers
st
1 Observer Torque 15 8.68 8.17 -2.15 22.35 8.35

2nd Observer Torque 15 8.72 8.40 -2.20 23.40 8.60

Torque Difference 15
-0.04 0.97 -1.35 1.95 0.00
between Two 0.8862*
Observers

*Not statistically significant (p>0.05) using a paired-sample t-test.

 22

Statistical analysis

Comparisons of CA, LCRA and torque measurements between the two groups

were performed using the two-sample t-test. When the study samples were divided into

three groups (i.e. Class I Ideal, Class I Expanded and Class II division 2), a one-way

ANOVA with the post-hoc Tukey-Kramer test was performed to test for a difference

among the three groups. Correlations between CA, LCRA and torque were assessed with

the Pearsons correlation coefficient. Additionally, one-sample t-test was used to

determine whether the mean collum angle was different from zero for a normal maxillary

central incisor.

Throughout the statistical analyses, a p-value of less than 0.05 was used as a

criterion for statistical significance. SAS for Windows (v9.3, SAS Institute Inc, Cary,

NC, USA) was used for the data analysis.

 23

RESULTS

Mean CA for Class I normal occlusions

The first aim of this investigation was to evaluate whether the mean collum angle

is different from zero for a normal maxillary central incisor. The mean CA for the Class I

normal group as a whole was 1.78 degrees, which was NOT statistically different from

zero at a .05 level of significance, (p=0.0657, one-sample t-test), although a p-value of

.0657 is suggestive. Considered separately, the mean CA values (standard deviations) for

the Class I Ideal and Expanded groups were 1.09 (3.29) and 2.73 (4.69), respectively.

Correlation between CA and LCRA

The second aim of this study was to determine whether the LCRA was correlated

with the CA. The null hypothesis in this case specifies that there is no correlation

between these two independent measurements. Pearsons correlation was used to test for

a linear relationship between CA and LCRA. Table 4 illustrates an approximate guide

for interpreting the strength of the relationship between two variables, based on the

absolute value of the Pearsons correlation coefficient.

Table 4. Interpretation of the Pearsons correlation coefficient.

0.0 No correlation

0.2 Weak correlation

0.5 Moderate correlation

0.8 Strong correlation

1.0 Perfect correlation

 24

When all subjects, from all groups, were combined and treated as a single sample

(n=99), a significant correlation between CA and LCRA was found using Pearsons

correlation (p<0.0001). A Pearsons correlation coefficient of 0.88 for the entire study

indicated that there was a strong increasing relationship between the two variables

(Figure 7). The sample groups were also analyzed separately.

For ideal Class I normal occlusion subjects (n=33), a significant correlation

between CA and LCRA was found using Pearsons correlation (p<0.0001). A Pearsons

correlation coefficient of 0.76 indicated that there was a moderate increasing relationship

between the two variables (Figure 8).

For the expanded Class I normal occlusion subjects, (n=24), a significant

correlation between CA and LCRA was found using Pearsons correlation (p<0.0001). A

Pearsons correlation coefficient of 0.83 indicated that there was a strong increasing

relationship between the two variables (Figure 9).

For the Class I normal subjects as a whole (n=57), a significant correlation

between CA and LCRA was found using Pearsons correlation (p<0.0001). A Pearsons

correlation coefficient of 0.80 indicated that there was a strong increasing relationship

between the two variables.

For the Class II division 2 malocclusion samples (n=42), a significant correlation

between CA and LCRA was found using Pearsons correlation (p<0.0001). A Pearsons

correlation coefficient of 0.91 indicated that there was a strong increasing relationship

between the two variables (Figure 10).

 25

CA and LCRA Correlation, All Samples (n=99)

60

50

40
CA and LCRA Correlation, All
Samples (n=99)
30
Linear (CA and LCRA
Correlation, All Samples
20 (n=99))

10

0
-10.0 0.0 10.0 20.0 30.0

Figure 4. Correlation between CA and LCRA for all samples.*

*Pearsons coefficient of 0.88.

 26

Figure 5. Correlation between CA and LCRA for Class I ideal samples.*

*Pearsons coefficient of 0.76.

 27

Figure 6. Correlation between CA and LCRA for Class I expanded samples.*

*Pearsons coefficient of 0.83.

 28

Class II division 2 (n=42)

60

50

40
Class II division 2 (n=42)
30
Linear (Class II division 2
20 (n=42))

10

0
-5 0 5 10 15 20 25 30

Figure 7. Correlation between CA and LCRA for Class II division 2 samples.*

*Pearsons coefficient of 0.91.

 29

Analysis of torque measurements

The third aim of this investigation was to establish and evaluate mean torque

values for each of the sample groups studied. Results of a one-way ANOVA test

revealed that sample category had a significant effect on torque (F (2,96) = 13.56; p =

0.0037). The post-hoc Tukey-Kramer test indicated that the mean torque for Class II-2

group was significantly lower than those observed for Class I ideal and expanded groups.

However, no significant differences were found between the Class I ideal and expanded

groups themselves. Table 5 provides detailed results from the post-hoc Tukey-Kramer

test.

The data were also divided into two groups (Class I normal and Class II division

2) and analyzed. Based on the two-sample t-test, there was a significant difference in

torque between the Class I and Class II-2 groups (p<0.0001). The data showed that mean

torque observed in Class I group (12.545.82) was significantly greater than that

observed in Class II-2 group (3.9510.85).

Table 5. Mean torque values among the three sample groups.

Group
Group N Mean Torque (SD)
Comparisons

Class I Ideal 33 13.60 (5.45) A*

Class I Expanded 24 11.09 (6.11) A*

Class II div 2 42 3.95 (10.85) B*

*Group comparisons with the same letter are not significantly different using the post-hoc
Tukey-Kramer test (P > 0.05).
 30

30

20
Torque angle (degrees)

10

-10
Class I Ideal Class I Expanded Class II div 2

-20

-30

Figure 8. Box and whisker plot of torque among groups.

 31

Analysis of CA and LCRA measurements

In order to compare the CA and LCRA measurements among sample groups,

descriptive statistics were calculated, and the data were analyzed in two ways. When

divided into two groups (Class I normal and Class II division 2), a two-sample t-test was

used to detect differences in measurements of CA and LCRA between them. When the

study samples were divided into three groups (Class I ideal, Class I expanded and Class II

division 2), a one-way ANOVA with the post-hoc Tukey-Kramer test was performed to

detect differences among the three groups.

A total of 99 subjects (51 females and 48 males), including 57 Class I normal (33

ideal and 24 expanded) and 42 Class II division 2, were included in the analysis. A mean

of two duplicate measurements by the primary observer of each variable was used for the

statistical analysis. Descriptive statistics are summarized below.

Comparisons of CA and LCRA between two groups

Based on the two-sample t-test, there was a significant difference in CA between

the Class I normal and Class II division 2 groups (p = 0.0178). The data showed that

mean CA observed in Class II division 2 group was significantly greater than that

observed in the Class I normal group (4.29 vs. 1.78 ). Based on the two-
sample t-test, there was also a significant difference in LCRA between the Class I normal

and Class II division 2 groups (p = 0.0037). The data showed that the mean LCRA

observed in the Class II division 2 group was significantly greater than that observed in

the Class I normal group (34.84 vs. 31.60 ).

Comparisons of CA and LCRA among three groups

Results of a one-way ANOVA revealed that sample grouping had a significant

effect on the CA (F (2,96) = 4.14; p = 0.0189). The post-hoc Tukey-Kramer test

indicated that the mean CA for the Class II division 2 group was significantly greater
 32

than that observed for the Class I ideal group. However, no significant differences were

found between the Class II division 2 group and the Class I expanded group, nor between

the Class I ideal and expanded groups. Table 6 provides detailed results from the post-

hoc Tukey-Kramer test. Descriptive statistics for the CA among groups are illustrated in

Figure 12.

Results of a one-way ANOVA revealed that sample grouping had a significant

effect on the LCRA (F (2,96) = 5.94; p = 0.0037). The post-hoc Tukey-Kramer test

indicated that the mean LCRA for the Class II division 2 group was significantly greater

than that observed for the Class I ideal group. However, no significant differences were

found between the Class II division 2 group and the Class I expanded group, nor between

the Class I ideal and expanded groups. Table 7 provides detailed results from the post-

hoc Tukey-Kramer test. Descriptive statistics for the LCRA among groups are illustrated

in Figure 13.

Table 6. Mean CA values among the three sample groups.

Types of Groups N Mean CA (SD) Group Comparisons

Class II 42 4.29 (5.77) A*

Class I Expanded 24 2.73 (4.60) A, B*

Class I Ideal 33 1.09 (3.29) B*

*Group comparisons with the same letter are not significantly different using the post-hoc
Tukey-Kramer test (P > 0.05).
 33

30

25

20
Collum angle (degrees)

15

10

-5
Class I Ideal Class I Expanded Class II div 2
-10

Figure 9. Box and whisker plot of CA among groups.

 34

Table 7. Mean LCRA values among the three sample groups.

Types of Groups N Mean LCRA (SD) Group Comparisons

Class II 42 34.84 (5.95) A*

Class I Expanded 24 32.65 (4.46) A, B*

Class I Ideal 33 30.84 (3.96) B*

*Group comparisons with the same letter are not significantly different using the post-hoc
Tukey-Kramer test (P > 0.05).
 35

60

50

40
LCRA (degrees)

30

20

10

0
Class I Ideal Class I Expanded Class II div 2

Figure 10. Box and whisker plot of LCRA among groups.

 36

DISCUSSION

The specialty of orthodontics has historically assumed that the long axes of the

crown and root of a maxillary central incisor are identical, that the collum angle is zero.

As has been mentioned previously, this assumption may have originated with Andrews

(1968), and, as Bryant et al. have noted, has been perpetuated in cephalometric tracing

templates since that time. The results of the present study show, among other things, the

wide variability of this basic morphological parameter and the difficulty inherent in

assigning universally ideal values to it. In spite of the fact that the straight wire appliance

has been used for nearly half a century, we have found no attempt in the literature during

that time to establish a mean value for the collum angle of maxillary central incisors in

Class I normal occlusions. This is perhaps due not only to assumptions about the

quantitative angle of the CA, but also to the fact that it is sometimes difficult to read and

measure in lateral cephalograms and is not typically included in cephalometric analysis.

The basic concern surrounding the CA, and by proxy, the LCRA, is that it may

offer predictive value for the susceptibility of an incisor root to be torqued into the palatal

cortical plate during treatment, causing root resorption or dehiscence. Root dehiscence,

depending on its severity, could compromise the periodontium around the affected tooth,

or even the vitality of that tooth if its apex is moved into or through the palatal cortical
plate. Root resorption, a topic reviewed comprehensively by Kaley and Phillips (1991),

remains an incompletely understood phenomenon. Although it is noted to occur to some

degree in most patients undergoing orthodontic treatment (DeShields 1969), it has been

reported to occur more frequently and more severely in maxillary incisors whose roots

are translated into the palatal cortex(Ten Hoeve and Mulie 1976, Goldson 1975, and

Hickham 1986). This seems intuitive, since the maxillary central incisor roots project

into the most concave portion of the maxillary skeletal arch. In fact, root torqueing has
been noted to be the single most predisposing factor for root resorption, with an odds
 37

ratio of 4.5 for root torqueing in general that increases to 20 if the torqueing approximates

roots against the palatal cortex (Kaley and Phillips 1991). Although root resorption has

not been shown to decrease the prognosis of a tooth, preventing its occurrence, if

possible, must certainly be considered a primary goal of orthodontic treatment.

Several manufacturers offer a high torque version of maxillary incisor brackets

that are designed to complement commonly accepted prescriptions. Anecdotally, it

seems that some clinicians choose these brackets when it is anticipated that retroclined

maxillary incisors will need powerful torqueing mechanics to create an ideal

overbite/overjet relationship. In cases such as Class II division 2 malocclusion, for

example, where retroclined incisors are a common finding, it may be argued based on the

data procured in this study that it is precisely on these patients for whom torqueing

mechanics may need to be moderated to avoid excessive palatal displacement of the root.

In Class III patients, for whom Harris et al (1993) found higher U1 collum angle values,

the decision to place large amounts of torque in an effort to create Class III dental

compensation may be similarly affected.

Harris et al (1993) postulated the deflection theory of the CA, whereby the crown

of the incisor is deflected during the development of the root, leading to a bent tooth.

In the case of Class II division 2 patients, the deflection would be caused by forces
emanating from the lower lip, and in Class III cases, from the lower incisors (1993). And

while it is true that not every patient in these high-risk malocclusions exhibits higher

collum angles, it is our hope to offer the LCRA as a simple tool for anticipating cases

such as these for which excessive torque should be avoided.

Case report

Analysis of the CA, LCRA, and torque angle is easily applied to both treatment

planning and post-treatment case analysis. Patient D.W., illustrated in the figures below,
was a 12 year 5 month old Class II division 2 patient who presented to the University of
 38

Iowa Department of Orthodontics, for whom full treatment records of good quality exist.

The initial cephalometric radiograph clearly shows a full Class II molar relationship and

retroclined maxillary central incisors. The anatomic points of U1 are reasonably clear.

Pre-treatment measurements of CA, LCRA, and torque, along with comparisons to

expected means for Class II division 2 patients, are listed in Table 8. All measurements

for patient D.W. easily fall within one standard deviation of expected means for Class II

division 2 patients.

Before treatment was initiated, a full mouth series of radiographs was taken to

document the condition of the dentition. A periapical view of the maxillary central

incisors shows normal anatomy, with fully formed apices and undamaged incisal edges.

The patient was congenitally missing maxillary lateral incisors and mandibular second

premolars. She was treated with canine substitution to replace lateral incisors, and

prosthetic replacement of her mandibular second premolars. She had a 4 degree ANB

angle.

The patient was treated with standard edgewise techniques, with the exception

that Unitek Victory SeriesTM high torque MBT brackets were used on the maxillary

incisors (22 degrees on the maxillary central incisor). The post-treatment cephalogram

(Figure 16) shows that the central incisors were torqued to 18.7 degrees, compared to the
mean (standard deviation) torque of 13.6 (5.45) degrees for Class I Ideal subjects found

in this investigation and a 17-degree torque built into a standard MBT prescription

bracket. With an initial torque of -6.1 degrees, then, a total of 24.8 degrees of U1 torque

was added. A closer view of the maxillary incisors (Figure 17) shows root resorption and

probable dehiscence through the anterior palatal cortex. Given that the root apices are

mutilated in this image, CA and LCRA are no longer measurable. The post-treatment

periapical view of the maxillary central incisors (Figure 18) captures the full extent of

root resorption. Note that the canines were protracted into the lateral incisor positions,
not without resorption also, and restored for esthetics.
 39

Table 8. Comparisons of CA, LCRA and Torque between D.W. (pre-treatment) and

expected means for a Class II division 2 malocclusion.

Patient D.W. Mean(Standard Deviation)

CA (degrees) 7.2 4.29 (5.77)

LCRA (degrees) 35.6 34.84 (5.95)

Torque (degrees) -6.1 3.95 (10.85)

 40

Figure 11. Pre-treatment cephalometric radiograph of Class II division 2 patient D.W.*

*Central incisor CA and LCRA in this case are 7.2 and 35.6 degrees, respectively (inset).
Note the steepness of the anterior palatal cortex, which brings it into close approximation
to the incisor roots. Pre-treatment torque of U1 crown was -6.1 degrees. Pre-treatment
periapical radiograph of patient D.W.s maxillary central incisors (inset).
 41

Figure 12. Post-treatment cephalometric radiograph of patient D.W.*

*Central incisors were torqued to 18.7 degrees using high torque brackets (Unitek,
Victory SeriesTM MBT high torque: 22 degrees). Note marked resorption of central
incisor roots and probable dehiscence through palatal cortex (inset). The post-treatment
periapical radiograph of patient D.W.s maxillary central incisors (inset) shows marked
resorption of central incisor roots. Canines were protracted into lateral incisor positions
(with some root resorption also) and esthetically restored.
 42

The extreme variability of CA and LCRA, considered within the context of

previous reports by Delivanis (1980) and Bryant (1984) of greater CA measurements for

Class II division 2 malocclusions, necessitated postulation of the final hypotheses in this

study. It seemed only natural to follow our preliminary efforts to define the CA, LCRA

and torque with applied comparisons of these same measurements between a sample of

Class I normal occlusions and Class II division 2 malocclusions, repeating and

confirming the work of previous investigators using a control sample and our own

methods for measurement. Our discussion of torque is treated separately, as its value is

not necessarily related to the CA or LCRA, and is primarily descriptive in nature.

Mean CA for Class I normal occlusions

The null hypothesis for this portion of the study states that the mean CA for Class

I normal occlusions is not statistically different from zero at a .05 level of significance.

The findings of this study support the null hypothesis, and agree with the assumption

made in previous investigations. Caution is in order, however, as large standard

deviations were found in both the Class Ideal and Expanded samples, with 18.2 percent

and 20.8 percent of samples, respectively, being greater than one standard deviation away

from the mean. Although the mean CA for the Class I expanded sample was greater than
that for the Class I ideal sample, the difference was not statistically significant.

Correlation between CA and LCRA

In an effort to make the collum angle a more accessible and readily useful

measurement, this investigation has proposed a new way of measuring crown-root

angulation. The LCRA, as it has been described previously, is comprised of anatomic

points that are already landmarked in standard cephalometric analyses and used to

position the templated tracing of U1. It would seem to be only a small matter to
incorporate the LCRA into cephalometric tracing software, and modify the incisor
 43

template to more accurately depict the angular relation between the crown and root of the

incisor.

The high correlation between the CA and LCRA (r=0.88) derived in this

investigation and the anatomically based landmarks of the LCRA merit further study and

consideration for its use in clinical practice as a measure of facial-lingual crown-root

angulation. It seems intuitive that these measurements should correlate, since the facial

axes of the crown and root roughly follow their respective central axes. Using the

LCRA, any cephalometric software could easily be programmed to detect extreme

variations from mean values found in this study and offer a note of caution about the use

of high-torque brackets.

Torque

The author recognizes that the plane defined by the two points, labial

cementoenamel junction (CEJ) and incision superius (IS), does not perfectly capture the

plane on which the bracket is placed. The bracket plane depends on its incisogingival

position as well as the facial curvature of the clinical crown. The torque angle, as we

have defined it using the labial CEJ and IS, is intended merely to be a useful, reliable and

reproducible approximation of the bracket torque for the maxillary central incisor. The
focus of this investigation, again, is on anatomic points that are readily identified on

standard analyses of cephalometric radiographs.

Mean torque values (standard deviations) of 13.60 (5.45) and 11.09 (6.11) found

in the Class I ideal and expanded samples, respectively, suggest a number of interesting

conclusions. First, it is important to remember that these samples were taken from the

University of Iowa Meredith Growth study, for which Class I normal subjects were

selected on the basis of patients willingness to participate and likelihood of continuing

residence in Iowa City. The subjects were physically normal children unselected in
respect to cephalic and faciodental characteristics (Meredith and Chadha, 1962). It is
 44

interesting that even though torque was not a consideration in the selection of these

subjects, the mean torque values found in this study are close to two of the most widely

used bracket prescriptions used today (MBT, +17 degrees, and Roth, +12 degrees).

Furthermore, the variability of torque values found in the Class I normal sample suggest

that acceptable, and ostensibly attractive, maxillary central incisor torque values vary

over a wide range. This is in keeping with the wide variety of bracket prescriptions

currently available. The clinician should therefore not be led to rigidly adhere to a given

incisor torque, and when anatomic considerations such as crown-root angulation suggest

caution in full torque expression, some flexibility in this regard may still yield an

acceptable esthetic and occlusal result.

CA, LCRA differences between Class I normal occlusions

and Class II division 2 malocclusions

To confirm the work of previous authors and to more rigorously test the

correlation between CA and LCRA, comparative analyses were conducted between a

Class I normal occlusion sample and a Class II division 2 malocclusion sample. When

comparing these two groups, the Class II sample showed a statistically significant greater

CA than the Class I normal (4.29 vs. 1.78). The Class I normal sample was also
subdivided into an ideal group and an expanded group. The mean CA (standard

deviation), evaluated among three groups, showed a greater CA and variability in the

Class II sample than in the Class I ideal subgroup. The Class I expanded subgroup was

not statistically different from either the Class I ideal subgroup or the Class II sample.

When comparing LCRA between two groups, the Class II sample showed a statistically

significant greater LCRA than the Class I normal group (34.84 vs. 31.60). We therefore

reject the null hypothesis and conclude that the mean CA and LCRA values observed in

Class II div 2 malocclusions are statistically different from those observed in Class I
normal occlusions.
 45

Limitations of the study

The sample was obtained from the Iowa Growth Study that originated in the

1940s. After more than seventy years, the records continue to be in very good shape, but

there are several radiographs that have been scratched or blemished by general use or

previous measurement. Fortunately, the sample is large enough that unreadable samples

could be excluded without weakening the power of the study significantly.

Additionally, no cephalometric study would be complete without some mention

of measurement error and the limitations of cephalometric analysis in general. Although

Dolphin Imaging software (version 11.5) reports angular measurements to the nearest

tenth of a degree, one is compelled to question the reliability of measurements that rely so

heavily on observer judgment. Baumrind and Frantz published an excellent article series

in 1971 on cephalometric measurement reliability that lends itself well to the current

discussion (1971, 1.). They identified numerous sources of measurement error, to include

inconsistent magnification, inconsistent head orientation, and landmark identification

error. The first two may be due to inconsistent records created by multiple operators

using multiple machines. The latter may be caused by confounding noise of adjacent

structures, or a lack of rigor in defining the landmark of interest. With regard to dental

landmarks specifically, they observed high reliability in measurements of U1 incisal edge

(.37.11 mm), and slightly lower reliability for U1 root apex (.98.50 mm), due to their

clear definitions and low incidence of confounding noise. They also noted low reliability

of L1 root apex (1.74.59) due to commonly occurring superimposition of the

mandibular symphysis.

This investigation arbitrarily designated 1.5 degrees as a tolerance above which

discrepancies required re-measurement. The collum angle is a sparsely studied topic and

to our knowledge no attempt has been made to establish acceptable limits on reliability.

The closest approximation can be found in the work of Baumrind and Frantz (1971, 2.),
who used five judges to conduct iterative measurements on twenty cephalograms, and
 46

noted a standard deviation of the interincisal angle measurement to be 3.54 degrees. One

might conclude that the poor reliability of L1 apex might be the reason for the large

variability in these measurements, but the authors do not discuss that conclusion. In our

study, the possibility of observer error must be taken into account: differences between

Class I ideal and Class II division 2 samples for mean CA and LCRA were, respectively,

only 3.2 and 4.0 degrees.

Furthermore, the ability to extrapolate the results of the study to the population at

large may be somewhat limited due to the homogeneity of the sample group, which

consisted entirely of Caucasians, with 97% of them having northwestern European

descent.

Finally, one could criticize the definition for the occlusal plane used in this study.

Downs original definition may not be recommended for incisors that are grossly

malpositioned, such as in Class II division 2 malocclusions with deep overbite, but the

author felt that the ease with which incisal edges on the most anterior central incisors

could be identified made Downs original definition most attractive. If one were to

accept a functional definition for the occlusal plane, defined strictly by molars and

premolars, one would be forced to use landmarks that are not as readily visible.
 47

Future research

This study is a first effort to establish mean values of crown-root relationships for

subjects with Class I normal occlusion. In order to use the Iowa Growth Study Class I

normal sample, this investigation was necessarily limited to the maxillary central incisor,

which is likely the only tooth that is typically measurable on a standard lateral

cephalometric radiograph. With the advent of cone beam computed tomography

(CBCT), however, similar studies could be conducted for every tooth, using analogous

measurements. And while it would be impractical to describe these landmarks and angles

for every clinical case, establishing these mean values for normal occlusion samples and

malocclusion samples would allow the creation of a more accurately torqued straight-

wire appliance, customizable even to the patients occlusal phenotype if needed.

For the time being, the simple cephalometric techniques proposed in this study

could be applied to a Class III sample. Harris observed a greater mean collum angle for

Class III subjects, particularly those for whom the maxillary incisors are in anterior

crossbite (1993). He postulated that deflection of the crown by the lower dental arch

during tooth development caused bending of the crown-root angle. Although Harris

found no correlation between incidence of root resorption and either collum angle or

molar classification, this seems counterintuitive and warrants further study. Perhaps the
amount of torque applied during treatment to achieve dental compensation should be

taken into account. In addition, it would be instructive to describe the plane of the

anterior palatal cortex and correlate it with the initial incisor torque and the incidence of

root resorption.
 48

CONCLUSIONS

Based on the results of this investigation, the following conclusions may be

drawn:

1. The mean CA in Class I normal occlusions is not statistically different from

zero degrees.

2. The LCRA is strongly correlated with the CA in both Class I normal

occlusions and Class II division 2 malocclusions.

3. The mean maxillary central incisor torque values for Class I normal

occlusions is similar to that found in bracket prescriptions currently offered.

4. Patients with Class II division 2 malocclusion exhibit statistically higher mean

CA and LCRA values than patients with Class I ideal occlusion.

 49

REFERENCES

Andrews LF. Straight wire: the concept and appliance. L.A. Wells Co. 1989.

Andrews LF. The six keys to normal occlusion. AM J Orthod 1972; 296-309.

Andrews LF. The straight-wire appliance, origin, controversy, commentary. J Clin

Orthod 1976; 10: 99-114.

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