An index for assessing tooth shape

deviations as applied to the

mandibular incisors
Harvey
Boston,

Peck,

D.D.S.,

M.Sc.D.,*

and

Sheldon

Peck,

D.D.S.,

M.Sc.D.*

Mass.

t has been shown that naturally

well-aligned
mandibular
incisors
possess distinctive
dimensional characteristics;
these teeth are significantly
smaller mesiodistally and significantly
larger faciolingually,
when compared
with average population
tooth dimensions. 1 It appears, therefore, that tooth
shape (mesiodistal and faciolingual dimensions) is a determining factor in the
presence and absence of lower incisor cr0wding.l
These new findings have
stimulated this present effort.
The purpose of this article is to present the scientific basis and the clinical
application of a new method for detecting and evaluating tooth shape deviations
of the mandibular incisors.
The

scientific

basis

Any

consideration
of tooth dimensions must to some degree involve
odontometry,
the science of measuring the size and proportion of teeth. Many
orthodontists
today practice some form of odontometry, perhaps unknowingly,
as part of their routine case diagnosis. Since this article largely concerns
odontometric procedures, it is important that we become totally familiar with
the nature and scope of odontometry as it relates to orthodontics.
Orthodontic
odontometry.
The crown dimension most frequently reported in
dental literature is the mesiodistal (hereafter abbreviated MD) diameter. For
the incisors, it is a measurement easily obtainable from plaster casts with a
reliability comparable to that of measurements taken directly from the mouth
or from skeletal materials.
Presented
in part before
the twentieth
annual
meeting
of the Middle
Atlantic
Society
of Orthodont,ists,
Washington,
D. C., Oct. 5, 1971, and the forty-second
annual
meeting of the Great
Lakes
Society
of Orthodontists,
Columbus,
Ohio,
Oct. 26, 1971.
*Assistant
Professors
of Orthodontics,
Boston
University
School
of Graduate
Dentistry.

384

Volume

Number

61
4

Index

for

assessing

tooth shape deviations

385

The faciolingual
(hereafter abbreviated FL) crown diameter is reported in
the literature far less often than the MD dimension. The primary sources of FL
tooth size data for the incisors have been skeletal material and extracted teeth,2-7
not plaster casts. In odontometric studies utilizing plaster casts, the FL diameters
of the incisors are usually not reported. Moorreess has justified this omission by
stating : It cannot be ascertained whether these teeth have erupted sufficiently
to make the greatest labiolingual
dimension measurable [on plaster casts].
To this deliberate oversight by odontologists,
orthodontists
add another,
perhaps greater, reason for the general neglect of FL measurements. One paper
summed it well : [The orthodontist]
is mainly interested in mesiodistal widths
of teeth in relation to the available space in the jaws, and would not normally
measure buccolingual diameters.
Tooth size measurements, obtained either from the mouth or from plaster
casts, play an important role in orthodontic diagnosis. Orthodontists use them
primarily in the spatial analysis of existing or potential malocclusions.
Each diagnostic analysis utilizing tooth size data is designed to serve at least
one of three functions:
1. Prediction of unerupt,ed tooth size.
2. Assessment of tooth size-arch size compatibility
within the same
arch.
3. Assessment of tooth size compatibility
between the two arches.
The first category includes mixed-dentition
analyses, such as those described
by Moyers,lO Nance,ll and others.10-14 Examples of the second group are found
in various arch length discrepancy determinations
of the permanent
dentition.15-19 The last category includes analyses of maxillomandibular
tooth size
relationships, such as those relating the tooth widths of the maxillary anterior
segment with the tooth widths of the mandibular
anterior segment in the
permanent dentition.20-22
It is worth noting that all of these orthodontic diagnostic procedures require
only MD tooth measurements in their construction. No currently used clinical
alzalysis employs or even takes into consideration the BL tooth dimension.
In contrast, tooth size indices incorporating both FL and MD dimensions have
been quite useful in physical anthropology.
In 1918 RamstrijmZ3 employed a
breadth-length
index in reporting the dimensions of fossil lower molars. Since
then, FL-MD crown indices have been advantageously employed to facilitate
anthropologic
communication. 3, 4a?, sl 24-28 In addition, these indices have been
well applied in studies of approximal and occlusal tooth wear.29, 3o
The index. At best, assessments of tooth size deviation presently used in
orthodontic practice are rather empirical. Decisions are often based on experience
and expediency. When a Boley gauge is employed, it is directed only to the MD
crown dimension.
T;Ve now know that both MD and FL dimensions appear to be related to
*The
tooth
dimension
referred
to in this article
as faciolingud
is also
and Zabiolingtd.
The term buccolingual
is commonly
used with reference
while ZabdoEingzlaZ
is an anterior
tooth designation.
However,
faciolingual,
term applicable
to all the teeth and is therefore
preferred
by the authors.

known
as buccolingwcl
to the posterior
teeth,
like mesiodistal,
is a

386

Am. J. Orthod.

Peck and Peck

April

1972

Fig. 1. A mandibular
central
incisor
showing
the mesiodistal
(MD)
and faciolingual
(FL)
crown
diameters.
The MD/FL
index
(MD/FL
X 100) is a numerical
expression
of the crowns
shape
as seen from
the incisal
aspect.
For the incisor
shown,
the MD diameter
approximately
equals
the FL diameter,
yielding
an MD/FL
index
OF 100. If the MD diameter
of
this tooth
were
greater
than
its FL diameter,
the index
would
be greater
than
100.
Similarly,
if the MD diameter
were
less thar.
the FL diameter,
the index
would
be less
than
100.

incisor a1ignment.l Therefore, an index incorporating

both dimensions would
seem ideally suited for orthodontic
tooth size analysis, at least of the lower
incisors.
The index proposed in this article for clinical orthodontics utilizes an MD/FL
ratio. It is constructed in the following manner :
Index

Mesiodistal
Faciolingual

(MD)
(FL)

crown

diameter

in mm.

crown

diameter

in mm.

x 1Oo

In this article the use of the MD/FL

index; as a numerical expression of
shape as viewed incisally is confined to the mandibular incisors (Fig. 1).
Crown shape and snandibular incisor alignment. Employing
the MD/FL
index, a study was undertaken to determine the relationship between mandibular
incisor shape and the absence of crowding. The question investigated was: Do
naturally well-aligned mandibular
incisors possess distinctive crown shape as
expressed by the MD/FL index 1
MATERIALS
AND
METHODS.
The mandibular
incisors of two groups of young
female Caucasian adults from the Northeastern
region of this country were
studied. One group was designated as the group with perfect mandibular
incisor alignment,
while the other was designated as the control population
group. The members of both samples were all within the same age range
(17 to 27 years) and were of European ancestry.
The group with perfect mandibular incisor alignment consisted of forty-five
subjects selected from a clental survey of several hundred. Selections were based
on the following criteria :
1. Complete mandibular
dentition
(excluding third molars),
2. No orthodontic treatment received.
3. Approximal
contact present among the mandibular
incisors.
crown

Index

for assessing tooth shape deviations

387

4. The absence of overlapping in the mandibular incisors.

5. Minimal rotational
deviation from the ideal arch form in the
mandibular incisors.
An evaluation of rotational deviations according to the method described by
Bjiirk, Krebs, and So10w~~ was originally attempted as part of the selection
procedure. However, this method proved unworkable since the tooth rotations in
question were always very small (less than 10 degrees divergence from the chord
of the ideal incisal arc) and therefore were difficult to measure. Instead, a
subjective evaluation by both investigators independently
was utilized, This
procedure proved effective in setting the limit of acceptable tooth rotation for
the perfectly aligned sample.
The control population
group consisted of seventy subjects of comparable
age and of European stock but was otherwise unselected.
For each subject in both groups, the maximum mesiodistal (MD) crown
diameter and the maximum faciolingual
(FL) crown diameter for each mandibular incisor tooth were measured directly in the mouth. A Helios dial
caliper with 0.05 mm. readout was used for all measurements. The caliper tips
were specially pointed to facilitate accurate measurement, The maximum MD
diameter was usually found at or near the incisal edge. To record the maximum
FL diameter, however, the caliper tips had to be placed subgingivally in most
cases.
In order to quantify the reliability of the measuring technique, the first
twenty-five measurements of each tooth dimension were taken a second time.
The error of the method was then determined statistieal1y.l The measurement
error in this study proved to be under 1 per cent for all dimensions measured.
The MD/FL
index for each tooth measured was then calculated ant1 recorded.
For the statistical analysis of the data, the right and left teeth of the same
category (central incisors, lateral incisors) were pooled within each of the two
groups of subjects. This procedure is in accordance with accepted odontometric
methods.32 For the perfect alignment group, the number of teeth (N) equaled
90 (45 right + 45 left) for the central and lateral incisors each. For the control
population group, this number equaled 130 (70 right + 60 left), rather than 140,
because of lack of data for ten left incisors in each tooth category.
The means and standard deviations for the MD/FL
index were computed.
The differences between the means were evaluated statistically.
FINDINGS.
The mean values of the MD/FL index for two groups of femalesa group with perfect mandibular
incisor alignment and a control population
group-are
presented in Table I with supplementary statistical data.
The mandibular
central incisors of the group with perfect alignment had a
mean MD/FL
index of 88.4 with a standard deviation of 4.3. The same teeth in
the control population
group showed a mean index of 94.4 with a standard
deviation of 4.9. The difference between the means (d = 6.0) was very highly
significant (p < 0.001).
The mandibular lateral incisors of the group with perfect alignment had a
mean MD/FL
index of 90.4 with a standard deviation of 4.8. The mean index
for the lateral incisors of the control population group was 96.8 with a standard

388

Peck and Peck

Table

I. Values
Group
/female

of the

MD/FL

Lateral

(F

x 100)

for

the

mandibular

population

90

xx.4

4.3

ix.?-

97.i

130

Ij4.4

4.9

80.0-105.3

alignment

90

90.4

4.8

i8.0-101.9

Control

population

130

96.8

5.2

x5.7-112.7

N =

Number
=

Standard

d =

Difference

t =

test

Very

6.0

9.3n*

6.4

9.27*

incisors

Perfect

SD

incisors

(&ml
incisors
Perfect
alignment
Control

index

of teeth.
deviation.
between

the

means.

value.
highly

significant

difference,

p < 0.001

tleviat,ion of 5.2. The difference between the means (d = 6.4) was again very
highly significant (p < 0.001).
DISCUSSIOK.
These findings indicate that well-aligned mandibular central and
lateral incisors possess remarkably distinctive crown shape, as expressed by the
ND/FL
index.
Since the experimental sample was selected on the basis of exceptionally good
lower incisor alignment,
a close association between the absence of incisor
crowding and certain tooth shape characteristics becomes evident. Lower incisors
apparently
conducive to good alignment hare MD/FL
indices significantly
lower t,han the population averages for the same teeth. In fact, we would expect
any lower arch possessing central incisors with an MD/FL index of less than or
equal to 88.4 and lateral incisors with an MD/FL
index of less than or equal
t,o 90.4 to have excellent incisor alignment. There are, however, many factors
other than tooth shape which may lead to lower incisor irregularity.
Therefore,
one may find occasional cases in which mandibular incisors are crowded and yet
possess favorable MD/FL
indices.
It is also expected that a similar relationship between incisor shape and
incisor position exists in the opposite direction: MD/FL indices higher than the
perfect alignment mean values (for the respective mandibular incisors) should
be characteristic of crowded incisors. Logically, the higher the index, the greater
the tooth shape deviation and the greater the likelihood and degree of associated
incisor crowding.
The estimated population
incidence of perfectly
aligned
mandibular
incisors is quite low for AmericanP
and Europeans.34 It is probable, therefore,
that the average dentition in the population has a detectable amount of lower
incisor crowding. In this light, the control population means for the MD/N,
index (cmtral incisor = 94.4, lateral incisor = 96.8) are themselves indicative
of some degree of tooth shape deviation.

Volume
61
Nvm her 4

Fig.
central
the
cisors

2. The

Index

crown

incisor,

shape
has

an

kite-shaped
with

low

typical
MD/FL

crown
MD/FL

form

indices

of

naturally

index

of

which
(less

than

assessing tooth shape deviations

for

well-aligned

approximately
appears

mandibular
87.

especially

The

geometric

characteristic

incisors.

This

diagram
of

389

tooth,

illustrates

mandibular

in-

90).

Garn, Lewis, and Kerewsky 26 have reported sex differences in tooth shape
throughout
the dentition. Estimates of the mandibular incisor MD/FL
indices
for males and females which we constructed from their dataz6 and from
odontometric data of other+ 7, 35s36 generally indicate lower MD/FL
indices for
males than for females of the same population.*
This difference, however, does
not appear marked, roughly averaging 2 per cent of the MD/FL index value for
both central and lateral incisors. Therefore, on the basis of available information,
we may conclude that male-female differences in the MD/FL
index are not
significant clinically. We may assume for clinical purposes that our values for
the MD/FL
index of females are representative also of the MD/FL
index of
males.
Comment on the possible mechanisms responsible for the relationship between
mandibular incisor shape and the presence and absence of crowding can only be
conjectural at this stage. The lower incisor crown, as viewed incisally, resembles
a diamond-shaped
kite (Fig. 2). The kites width (side to side) would be
equivalent to the MD crown diameter, and the kites length (top to bottom)
would be equivalent to the FL crown diameter. A kites width is less than its
length, just as the average lower incisors MD width is less than its FL length.
As this difference between the MD width and the FL length increases, the
MD/FL
index decreases, and the mandibular incisor crown form appears more
characteristically
kite shaped. Perhaps the kite-shaped pattern represented
If mandibular
incisor
shape
in*An interesting corollary derives
from
this
observation.
fluences
mandibular
incisor
position,
as our study
suggests,
then the incisors
of males should
actually
demonstrate
a lower
frequency
of crowding
than the incisors
of females,
because
of
their
naturally
lower
MD/FL
index.
Only
one published
study
(by Seipelsr)
gives the frequency
of crowding
of the individual
teeth separately
for males and females.
It indeed
shows
the frequency
of crowding
for the mandibular
central
and lateral
incisors
to be appreciably
less among
males than among
females,
thus confirming
this corollary
and supporting
a causal
relationship
between
incisor
shape and crowding.

390

Peck nrld Pick

Am.

J. Orthod.
April
1972

by a low MD/FL
index (less than 90) confers upon the incisor crown ant1 root
an anatomic advantage over the phenomena of tooth rotat,ion and overlap.
The relatively narrowed MD diameter characteristic of well-alignrtl
man
tlibular incisors obviously cont,ributes less tooth substance to manclibular arc11
length. This factor, coupled with the chance that a more kite-shaped
incisor
would tend to hare flatter, less acute mesial and distal surfaces, less susceptible
mechanically to cornact slippage. may account in part for the incisor shapcb-alignment relationship.
The

clinical

application

The observed relationship between mandibular incisor shape and the presence
and absence of mandibular
incisor crowding has significant clinical relevance.
The MD/FL index as previously described and utilized is a numerical expression
of crown shape. As such, it provides an effective clinical method for diagnosing
tooth shape deviations which influence and contribute to mandibular
incisor
crowding.
The remainder of this article introcluccs a method of tooth size analysis based
upon the MD/FL
index and used by us in clinical diagnosis and treatment
planning.
Clinical principles. In order to recognize tooth shape deviations, a knowledge
of optimum tooth shape is necessary. For the mandibular incisors, the lower the
MD/FL
index, the more favorable the tooth shape relative to good alignment.
0ur studies show that well-aligned mandibular central incisors have an MD/FL
index of 88.4 _+4.3, while well-aligned mandibular lateral incisors have an indes
of 90.4 + 4.8.
From these data we have adapted the clinical standards which we use in
determining whether a lower incisor is favorably or unfavorably shaped relative
to good alignment. The following ranges are employed as clinical guidelines for
the maximum limit of desirable MD/FL
index *values for the lower incisors:
Mandibular central incisor
88-92
90-95
Mandibular
lateral incisor
The lower limit of each range represents approximately
the mean value of
the MD/FL index of well-aligned teeth. The upper limit of each range is derived
from the lower limit plus one standard deviation.
liower incisors wit,hin or below these ranges are considered favorably shapetl.
Any lower incisor with an MD/FI,
index above these ranges, howe\-er, is considered to have a crown shape deviation which may influence or contribute to the
crowding phenomenon (Fig. 3).
Of course, this is not always the case. Since we are dealing with four teeth
when we speak of mandibular incisor crowding, good alignment is often present,
with various combinations
of favorably and unfavorably
shaped teeth. For
instance, lateral incisors with an index of 97 may be well aligned in a mandibular
arch with central incisors that have an index of 86.
However, an MD/Fli
index in excess of 100 for any of the lower incisors
represents a severe shape deviation, characteristic of existing or potential tooth
irregularity.
From the previously described cont,rol population sample, we have

VoZume
Number

61
4

Index

for assessing tooth shape deviations

Fig. 3. Variations
of mandibular
incisor
shape.
Pictured
are the low
orthodontically.
The number
lingual
to each
tooth
adul Its, untreated
valu me. from
studying
the photographs,
one may
readily
gather
that
high IlY variable,
(2) incisor
shape
and incisor
alignment
are closely
relc
index
values
are characteristic
of well-aligned
incisors,
(31 1O\n I MD/FL
inde x\ values are characteristic
of crowded
incisors.

391

er incisors
of four
i s its MD/FL
i ndex
( 1) incisor
shat 38 is
rted variables,
and
while
high M D/FL

Fig.

4.

caliper

A,

Measuring

the

is employed.

perpendicular
diameter
gival

Am.

Peck and Peck

392

to
of

margin

The
the

lower

and

are

maximum
caliper

long
incisor.
held

mesiodistal
beaks

axis

of
The

parallel

the
dial

are
tooth.
caliper

to the

(MD)

diameter

positioned

long

near

B, Measuring
beaks
axis

are
of the

of

a lower

the

incisal

the

maximum

slipped

slightly

J. Orthod.

AfwiZ1972

incisor.

edge

and

A dial
are

faciolingual
beneath

held
(FL)

the

gin-

tooth.

deduced that approximately

15 per cent of the population have an MD/FL index
greater than 100 for one or both mandibular central incisors. Similarly, about
25 per cent of the population have mandibular lateral incisors with an MD/FL
index in excess of 300. The aT-erage orthodontic practice contains a high concentration of these persons. They usually arc the patients exhibiting bimaxillarJ
crowding.
Patients whose mandibular incisors have MD/FL
indices above the desired
ranges may well bc candidates for the removal of some mesial and/or distal tooth
substance in conjunction with orthodontic therapy. This procedure is commonly
called stripping.
Although part of the orthodontic vernacular, stripping
is a
somewhat distasteful term. Articles and texts frequently resort to euphemisms,
such as proximal
reduction.
We are convinced that purposeful
tooth size
alteration
will have an increasingly
significant place in the orthodontists
therapeutic armamentarium.
It is therefore deserving of a more exacting, more

Index

for assessing tooth shape deviations

393

MD/FL

Index
88-92

88-92
90-95
Fig.

5. Table

for

used in computing
meters]
are written

clinically

recording

the MD/FL
in.

index

MD

and

FL crown

for

each

lower

dimensions.
incisor.

Sample

These

measurements

measurements

are
[in milli-

appropriate name. In place of stripping

we propose reproximation,
a word
whose derivation implies (the act of redoing the approximal surfaces. As used
in this article and by definition, tooth reproxinzation is a clinical procedure
involving the reduction, anatomic recontowing,
and protection of the mesial
and/or distal enamel surfaces of a permanent tooth. Protection in this instance
refers to the topical application
of cariostatic agents, such as acidulated
phosphate-fluoride.
Clinical methods. The mesiodistal (MD) and faciolingual
(FL) crown diameters of the mandibular incisor teeth are measured directly in the mouth, not on
plaster casts. The maximum MD diameter is usually located at or near the
incisa.1 edge, while the maximum FL diameter is found almost always beneath the
gingival margin, thus precluding the use of plaster casts (Fig, 4).
Measurements are taken with a millimeter caliper calibrated at least to tenths
of a millimeter.
Some calipers have a vernier scale (the Boley gauge, for
example) for reading out the measurements, while others have a dial scale. For
tooth measurements, where tenths of a millimeter are important,
we prefer a
dial caliper because of its superior readability and precision (Fig. 4). The caliper
tips must be specially sharpened to a knife-edged point to make accurate measuring possible.
,
We take the lower incisor measurements in a sequence, beginning with the
four MD measurements, right lateral incisor to left 1atera.l incisor, followed by
the four FL measurements, right lateral incisor to left lateral incisor. The
accuracy of each measurement is quickly checked by comparing the values
recorded for the right lateral incisor with those of the left lateral incisor and
making the same comparisons for the central incisors. Any gross discrepancy
observed between right and left measurements is often a sign that a measurement
error was made, since right and left tooth dimensions usually correspond closely.
In these cases the measurements in question are routinely repeated, even though
gross asymmetries in crown dimension are not uncommon.
The MD and FL crown measurements are recorded in an appropriate table or
grid (Fig. 5). The next step is to compute the MD/FL
indices of the four teeth
measured.
This procedure is simplified with the use of a mathematical reference table

394

Peck and Peck

Table

II.

Reference

table

Am.

of values

for

the MD/FL

q,g 89 Pd Q 94 96 98 100 ma 04 106 ma /IO L? KS /I

*Dimensions

are

J. Orthod.
April 1972

index*

it9

in millimeters.

developed for this purpose (Table II). The reference table provides the computed
value of the MD/FL
index, given the MD and FL crown dimensions. It contains
only MD/FL
index values from 86 to 119. All values below 86 are exceedingly
favorable and therefore require no further clinical consideration. Values above
119 are exceedingly unfavorable but occur very rarely.
Using the MD and FL data given in Fig. 5, we shall illustrate the use of the
reference table. The measurements for the mandibular right lateral incisor are
MD = 6.0 and FL = 6.3. With this information,
we go to the reference table
which displays MD dimensions horizontally
and FL dimensions vertically, in
graduations of 0.1 mm, We first look across the MD dimensions until MD = 6.0
is found. Then we search down the FL dimensions to find FL = 6.3. Where the
selected MD column and FL row intersect lies the appropriate MD/FL
index,
which in this case is 95. Similarly, the MD/FL index for the right central incisor
(MD = 5.4, FL = 6.0) is 90; for the left central incisor (MD = 5.1, FL = 5.8),
88; and for the left lateral hcisor
(MD = 6.1, FL = 5.9), 103. In the absence
of the reference table, longhand computations of the MD/FL index are rounded
off to the nearest whole number.

Index

Fig.

for assessing tooth shape deviations

6. Diagnostic

Case

395

1.

The MD/FL
bdex i?L cli~~iccd
diagnosis. To illustrate the clinical application
of the MD/FL
index as a means of detecting and evaluating tooth shape deviations of the mandibular incisors, three diagnostic cases will be presented.
DIAGNOSTIC
CASE 1 (BIG. 6). All four lower incisors of this patient show extreme tooth shape deviations. The right and left lateral incisors have MD/FL
indices of 119 and 112, respectively, The right and left central incisors have
MD/FL
indices of 102 and 103, respectively. There is marked crowding, for
which the untoward shape and size of the lower incisors-are at least partly
responsible. As part of this patients orthodontic treatment
(which in this cake
calls for premolar extractions), reproximation
of the four mandibular incisors
is mandatory.
Otherwise, recrowding of the lower anterior teeth will surely
follow retention.
The lateral incisors are so severely deviated that reproximation,
limited by
the thickness of the mesial and distal enamel, can only lessen the deviations
rather than eliminate them completely. For the central incisors, however, we may
expect that reproximation will yield favorable MD/FL indices.
With tooth shape deviations of the intensity observed in these incisors, we
would expect a total of 2 to 3 mm. of mesiodistal enamel to be removed by
reproximation.
A loss of tooth substance of this magnitude
may upset the
maxillary to mandibular anterior tooth size ratio. Therefore, selective reproximation of the maxillary incisors may also be indicated to maintain a harmonious
anterior intermaxillary
relationship. (For example, if the pretreatment
anterior
Bolton indexz2 appears satisfactory, but reproximation of the mandibular incisors

396

Am.

Peck and Peck

MD/FL
Index
Standards

Tooth

MD

FL

MD/FL
Index

-q

6.6

7.0

94

90-95

5.7

6.6

86

88-92

5.7

6.5

88

88-92

6.6

6.9

96

90-95

Fig.

7. Diagnostic

Case

J. Orthod.
April 1972

is indicated for posttreatment

stahilky, then an equal amount of maxiZZary
anterior reproximation
should be planned.)
In summary, this case represents extreme tooth shape deviation requiring
reproximation
of the lower incisors as an integral part of orthodontic therapy.
DIAGNOSTIC
CASE 2 (FIG.
7). This is a case of bimaxillary crowding requiring
orthodontic therapy with premolar extractions. The lower incisors appear grossly
irregular.
However, the MD/FL
indices of all four incisors are essentially
favorable. The central incisors, with indices of 88 and 86, are exceptionally well
shaped, while the lateral incisors, with indices of 96 and 94, average out at
the high end of our acceptable range. Lower incisor reproximation
is not
indicated. In the posttreatment
period for this patient we would not expect any
lower incisor alignment complications or instability because of tooth shape.
It is instructive to compare the photograph of this case (Fig. 7) with that of
Case 1 (Fig. 6). In the two photographs, we notice a distinct difference in the
nature of the lower incisor crowding. While Case 1 is essentially a kotation and
overlap irregularity,
Case 2 is primarily a displacement
irregularity
with the
lateral incisors characteristically
displaced lingually and the central incisors
squeezed labially. It is the shape-MD
ad FL dimensions-of
these incisors,
not their MD widths alone, that explains this observed difference in irregularity.
DIAGNOSTIC
CASE 3 (FIG.
8 ) . In this case we observe mild irregularity
of the
central incisors only. Inspection of the MD/FL
indices reveals that the lower
lateral incisors are quite favorably shaped, while the shape of both lower central
incisors is slightly deviant. This is a circumstance in which slight reproximation

Volume
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61
4

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assessing tooth shape deviations

-4

397

MD/FL
Index
Standards
90-95

I
F

5.3

5.6

5.4

5.5

88-92

5.6

1 6.1

90-95

Fig.

8. Diagnostic

of only the central incisors is indicated

planned for the lower arch.
Concluding

88-92

Case

3.

as part of any orthodontic

treatment

remarks

The substantial evidence that lower incisor shape has significant bearing on
lower incisor alignment may well affect many areas of orthodontic practice.
For one thing, the introduction
of a tooth shape index for use in .clinical
orthodontics opens up new channels of communication.
Now we have a means
of numerically
expressing what perhaps many orthodontists
have been subconsciously perceiving all along-a
fundamental
anatomic difference between a
stable-looking orthodontic
result and a not-so-stable-looking
result. When, for
example, a colleague now speaks of an extraction case with MD/FL
indices for
the mandibular
incisors all in excess of 100, a significant message has been
succinctly communicated.
Besides its use in orthodontic
diagnosis and treatment planning, the MD/FL index may prove useful as a parameter in treatmentpriority assessments and epidemiologic surveys of malocclusion.
The observed relationship between lower incisor shape and alignment may
alter some present concepts of retention. Posttreatment retention in orthodontics
is a valuable ingredient of successful therapy. Most orthodontists would agree
that a provision for retention should be included routinely in orthodontic treatment plans.
Perhaps the most worrisome area for the orthodontist
during the retention
phase of treatment is the lower incisor segment of the dentition. Over the years
this has led to wide acceptance of prolonged retention or indefinite retention

398

Fig.
tooth

Peck and Peck

9.

irregular
shape

are

Am.

5.4

6.0

90

88-92

12

5.9

6.3

94

90-95

mandibular
responsible

incisors
for

this

with

favorable

MD/FL

indices.

Factors

J. Ov-thod.
April
1972

other

than

crowding.

for these teeth. d canine-to-canine fixed retainer is often used for this purpose.
It is frequently
left in for some years as insurance
against the indeterminable causes of incisor relapse. In light of our findings, however, prolonged
retention seems more a postponement of the problem than a solution. We contend
that most of the cases presently demanding
prolonged retention for the lower
incisors probably require instead judicious reproximation
because of tooth shape
deviations.
In orthodontic cases requiring premolar estractions because of major tooth
size-arch size discrepancies (such as malocclusions of the Class I bimaxillary
crowding type), post-retention lower incisor crowding is often observed, even in
the presence of residual extraction space. This is not idiopathic or indeterminable
but is, rather, a logical consequence. In these cases it is usually clear that there
is a generalized excess in the mesiodistal dimension of all the teeth. Although
premolar extractions nicely eliminate the arch length discrepancy, the crown
shape of the remaining teeth is still exaggerated. The mandibular incisors are
often markedly wide and fan shaped, with MD/FL indices approaching or in
excess of 100. Incisors of these proportions are destined to recrowd in time, no
matter how perfect
the posttreatment
occlusion and alignment may appear
to be.
Lest the MD/FL
indes be misconst,rue<l as an orthodontic divining
rod,
we hasten to add some qualifying remarks. Thcrc are many persons with optimum

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399

lower incisor crown shape (according to their RID/FL index values) but with
noticeable displacement or overlapping of these teeth. (Fig. 9 and see Fig, 7). It
is well known that there are many potential factors surrounding the etiology of
lower incisor crowding. Certainly, other dominant variables, such as occlusion,
habits, supra-alveolar fibers, and early deciduous tooth loss, to name only a few,
are capable of upsetting any alignment stability conferred by tooth morphology
alone. Then, too, dental crowding may be a natural aging phenomenon; even
the best-shaped, best-aligned incisors may inevitably crowd with age.
Within the framework
of clinical orthodontics,
however, seldom can any
degree of mandibular
incisor alignment or stability be achieved without some
consideration of crown dimensions, tooth shape, and the ;MD/FL index.
Summary

and

conclusions

This article presents the scientific basis and the clinical application of a new
method for detecting and evaluating tooth shape deviations which influence and
contribute to mandibular incisor crowding.
It has been shown that mesiodistal (MD) and faciolingual
(FL) crown
dimensions appear to be related to mandibular incisor alignment.* However, a
survey of odontometric procedures used today by orthodontists reveals that the
FL crown dimension is completely neglected in orthodontic diagnosis and treatment planning.
An index incorporating
both dimensions is proposed for clinical orthodontics.
It is constructed in the following manner :
Index

Mesiodistal
Faciolingual

(MD)

crown

diameter

in mm.

(FL)

crown

diameter

in mm.

x 100.

In this article the MD/FL index is used as a numerical expression of mandibular

incisor crown shape as viewed incisally.
An odontometric
study was undertaken
to investigate the question Do
naturally
well-aligned mandibular
incisors possess distinctive crown shape as
expressed by the MD/FL index?
Two samples of young American white women of European ancestry were
utilized. The first group consisted of forty-five subjects carefully selected for
their perfect lower incisor alignment. The second sample was a control population group of seventy subjects. MD and FL crown diameters of the mandibular
incisors were recorded for each subject in both groups by direct intraoral
measurement. The MD/FL index for each tooth was then calculated, and the data
were processed statistically.
The main conclusions drawn from this study are as follows :
1. A substantial relationship exists between mandibular incisor shape
and the presence and absence of mandibular incisor crowding.
2. Well-aligned
mandibular
central and lateral incisors have a remarkably distinctive crown shape, as expressed by the MD/FL
index.
3. Well-aligned mandibular incisors have MD/FL indices significantly
lower than those of crowded incisors.
4. Male-female differences in the MD/FL
indices for the mandibular
incisors appear to be below clinical significance.

Am.

J. O&hod.
April
1972

The final part of this article introduces a clinical method of lower incisor
toot,11 size analysis based upon the MU/FL
index. Clinical principles and procedures related to the use of the MU/FL
index are explained. Cases art:
presented to illustrate the use of the index in orthodontic diagnosis and treatment planning. Reproximation
(stripping)
is described as a clinical procedure
for correcting tooth shape deviations.
A consideration of tooth shape and the MU/FL
index appears essential foi
the successful orthodontic
management
of mandibular
incisor irregularities.
Special
acknowledgment
is expressed
to Miss Gail N. Cross,
Director
of the Dental
Assistant
Programs
at. Boston
University
School of Graduate
Dentistry
and Beth Israel
Hospital,
Boston,
and to Miss
Barbara
Schultz,
Assistant
Dean at the Forsyth
School for Dental
Hygienists,
Boston,
for their
cooperation
in implementing
the odontometric
study.
The authors
are grateful
to Miss
Sylvia
Fleisch,
Assistgnt
Director,
Boston
University
Computing
Center,
for her valued
assistance.

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