An Analysis of Three Mixed Dentition Analysis

The accuracy of prediction of three mixed dentition analyses was compared. Hixon and Oldfather’s
method was found to be the most accurate. A simplified version of the analysis obviates referral to
a table, allowing assessment of the size of the unerupted teeth prior to eruption of the lateral
incisor.

J Dent Res 56 (11): 1337-1343 November 1977

Numerous methods have been proposed for the estimation of mesiodistal dimensional differences
between the primary canine and molars and their successors in the mandibular arch. The most
accurate mixed dentition analysis currently available appears to be that developed by Hixon and
Oldfather1 who found that they could predict the space required by the permanent canine and
premolars from the sum of the mesiodistal widths of the central and lateral incisor and the images
of the first and second premolar from long cone radiographs (r=0.88). However, this method has
been criticized for having a consistently optimistic in its prediction.

The mixed dentition analysis developed by Moyers utilized the sum of the mandibular permanent
incisors as the independent variable. At the 50% level this analysis tended to be optimistic. But at
the 80% level, the number of over-estimations were balanced by the number of under-estimations.
Moyers considered this level to be superior to that of other mixed dentition analyses tested.

Recently a simplified analysis has been proposed by Tanaka and Johnston. 3 They found by linear
regression that the mesiodistal width of the permanent mandibular canine and premolars could be
predicted at the 75%confidence interval by adding 10.5 mm to half the width of the mandibular
incisors. Their results closely matched Moyers’ 75% level.

Correlations between the mandibular permanent incisors and the permanent canine and
premolars have been found to be relatively low. Ballard and Wylie 4 found r=0.64, Hixon and
Oldfather r=0.69, Bolton5 r0.65 and Tanaka and Johnston r=0.625.

The purpose of this paper is to examine and compare the accuracy of the Hixon-Oldfather, Moyers
and Tanaka-Johnston mixed dentition analyses and investigate whether an improved prediction
could be arrived at by regression analysis.

Materials and Methods

The data were collected form dental study casts and intraoral periapical radiographs of 104
children (51 females and 53 males) selected from the longitudinal growth study conducted by the
Child Study Clinic at the School of Dentistry, University of Oregon Health Sciences Center. Subjects
were American-born, of Northwestern European ancestry, and average (or above) socioeconomic
status. All resided in or near Portland, Oregon.

Measurements were made with a finely pointed vernier caliper and read to the nearest 0.05 mm.
Images of mandibular first and second premolars were measured from the periapical radiographs
which were taken in the mixed dentition with a long-cone dental x-ray unit having a skin-target
distance of 19 inches. The unerupted mandibular first and second premolars were measured only
from clear x-ray images; teeth with obvious rotations were excluded. Individuals with inadequate
radiographs on one side were included but had incomplete data. The mixed dentition records were
taken at ages ranging from 5 years 10 months to 10 years 11 months (mean, 7 years 6 months).
Actual tooth dimensions were obtained from mandibular study casts with permanent incisors,
canines and premolars erupted and free of dental caries and proximal restorations. These records
were obtained at ages ranging from 10 years 2 months to 18 years 6 months with an average of 13
years 1 month.

Measurement error was determined by replicate measurements made two weeks following data
collection on 21 randomly selected cases, The standard errors of the measure ranged from 0.09 to
0.13 mm for the cast and x-ray variables.

Predicted values for the sum of the mesiodistal widths of the permanent canine, first and second
premolars were calculated for the Hixon-Oldfather analysis, the Moyers analysis at the 95%, 85%
75% and 65% probability levels and for Tanaka-Johnston’s method.

Statistical Analysis

Preliminary analysis indicated that predictive differences between sexes and sides were not
statistically significant, so the samples were combined. Of the 104 individuals ,30 had incomplete
data on one side; and of the 74 cases with complete data, one side was randomly selected. The
104 sides were made up of 49 right and 55 left sides.

The following statistical techniques were used:

Pearson’s product-moment correlation coefficients of the sum of the mesiodistal width of the
permanent canine first and second premolars as measured on the mandibular casts with their
predicted values obtained by the Hixon-Oldfather, Moyers, and Tanaka-Johnston methods.

For each method of prediction, paired t tests were used to test the significance of the difference
between the predicted and actual values for each method as well as to test for differences
between the different methods.

Regression analysis of the dependent variable (the sum of the mesiodistal widths of the
permanent canine first and second premolars) was performed with various combinations of
independent variables to determine the bets predictive combination for these data.

Findings

Correlation coefficients for the sum of the actual mesiodistal width of the canine and premolars
with their predicted values obtained by each of the tree analyses revealed r=0.884 for Hixon-
Oldfather, r=0.621 for Moyers an r=0.645 for Tanaka-Johnston (all statistically significant).

Table 1 presents the results of the paired t test of the mean difference between the actual and
predicted values of the canine and premolars obtained by each of three methods. The mean
difference was least for the Hixon-Oldfather method: 0.154 mm. This value was positive indicating
that the Hixon-Oldfather analysis had a very minimal tendency to underpredict. All the other
methods on average overpredicted with Moyers 95% having the greatest mean difference (-2.057
mm) and Moyers 65% having the least (-0.757 mm). Tanaka-Johnston’s fell somewhere between
Moyers 65% and 75% levels.

Figures 1 through 6 are histograms of the frequency distribution of the millimeter differences
between actual and predicted values by the three methods. Hixon and Oldfather’s method
approximates a normal distribution while Moyers’ and Tanaka-Johnston’s methods tend to over-
estimate the size of the unerupted teeth. Moyers 95% level over-estimated 95.2%; 75% level over-
estimated 85.6%; 65% level over-estimated 76.9%, and Tanaka-Johnston over-estimated 81.7% of
cases.

The results of the regression analysis are presented in Table 2. Abbreviations of the independent
variables are:

XFP = x-ray measurement of first premolar

XSP = x-ray measurement of second premolar

CI = central incisor

LI = lateral incisor

RCI = right central incisor

LCI = left central incisor

RLI = right lateral incisor

LLI = left lateral incisor

A simple linear regression using the summed x-ray variables (equation [2] Table 2) resulted in a
correlation (r) of 0.878 and mean square residual (MSR) of 0.339. The amount of variation
explained did not differ significantly from the equation generated by entering these two variables
in a stepwise manner, The inclusion of a central incisor in the multiple regression [3] improved the
r to 0.899 and reduced MSR to 0.290. However, the addition of the lateral incisor did not
contribute to the regression. When the incisors and x-ray variables were summed [4], r=0.885 and
MSR = 0.322 which was significantly different from the multiple regression [3].

When the variables are summed excluding the lateral incisor [5] r increased to 0.897 and MSR
dropped to 0.290. This regression was not significantly better than the multiple regression [3] but
was a significant improvement over regression [4]. Regression analysis utilizing the central and
lateral incisors unilaterally or bilaterally, in simple or multiple regression, produced correlation
coefficients ranging from 0.645 to 0.620 (equations [6-9] Table 2).

Discussion

The results of this study indicate that the Hixon-Oldfather analysis was the most accurate of the
three methods for predicting the size of the unerupted permanent canine, first and second
premolars. This analysis produced a correlation coefficient that was higher and a mean difference
between actual and predicated values that was significantly less than those obtained by Moyers’
and Tanaka-Johnston’s methods (see Table 1).
The correlation coefficient utilizing the Hixon-Oldfather formula was 0.884 which was almost
identical with Hixon and Oldfather’s r=0.88. Regression analysis entering the same independent
variable as Hixon and Oldfather produced r=0.884 ([4] Table 2). The correlation coefficient from
Moyers’ method was 0.621 an from Tanaka-Johnston’s method 0.645; both compared favorably
with correlations found by others.1, 3-5

Regression analysis confirmed the inadequacy of Moyers’ and Tanaka-Johnston’s methods which
are based on the relationship of the lower incisors and the canine and premolars. The best
prediction obtained with the central and lateral incisor unilaterally was r=0.645 while the sum of
the four incisors only produced r=0.620.

While the Hixon-Oldfather analysis produced a slight positive mean difference between the actual
and predicted values of the unerupted canine and premolars, the distribution of the difference was
relatively unbiased. On the other hand, Tanaka-Johnston and Moyers’ 65% through 95% levels
over-predicated in at least 95% of cases.

Regression analysis revealed the best predictor variables to be the x-ray image of the second
premolar, x-ray image if the first premolar and the central incisor entered in stepwise manner, but
this did not differ significantly when their sum was entered as a single independent variable. The
multiple regression formula

Y = -0.4725 + 1.2147 XSP + 0.9807 XFP + 0.8267 CI

Was generated in a stepwise fashion. The x-ray variables were the first to enter, indicating that they
were relatively more important than the incisor variables. This is further confirmed by the fact
greater weight is given to the x-ray measurements, than to the incisor. The fact that the lateral
incisor variable is redundant was pointed out previously by Stahle. 6 The contribution of the
radiographic variables explains why the Hixon-Oldfather method is superior to the other methods.

As expected, regressions generated from the present data gave slightly improved results than by
applying Hixon and Oldfather’s formula: Y=3.493 + 0.6474 X compared to the best simple linear
regression equation from the present dara: Y = -0.6931 + 1.0386 (Sum XSP, XFP, CI).

The main criticism of Hixon and Oldfather’s analysis has been that it underpredicts. While this
occurred in 53% of the cases in this study it is considered to be more desirable than overprediction
which was found to occur with Moyers’ and Tanaka-Johnston’s methods. Underprediction would
result in a more conservative clinical approach, while overprediction tends to exaggerate space
requirements and to result in unnecessary extraction.

Underprediction can for practical purposes be eliminated by computing confidence intervals for
each predicted value to include cases at the high end of the distribution. Table 3 gives the
predicted values obtained from the best simple regression equation for these data. By adding
computed values (tXSy) to the predicted values the upper limit of the confidence interval (at 70%,
95% and 99% probability levels) can be obtained for different level of the independent variable.
The predicted values obtained in the present study are almost exactly the same as the measured
values, although a slight increase occurs above 20 mm.
It is suggested that this method obviates referral to a table by merely measuring the sum of a
lower central incisor and mesidistal width of a first and second premolar from a periapical
radiograph taken with a long-cone. The probability of underprediction can be reduced by adding
0.3 mm to values below 20 mm, and 0.4 mm to values 20 to 22 mm and 0.5 mm to values 23 mm
and above. In this way, 70% of cases are included in the upper limit of the confidence interval. If it
is desired to include 95% or 99% of cases, Table 3 displays the relevant values that need to be
added to the predicted value. Another benefit utilizing this method is that some estimate of the
size of the successional buccal teeth can be made prior to eruption of the mandibular permanent
lateral incisor. This might be advantageous if early premature loss of a mandibular second primary
molar occurs prior to eruption of the lateral incisor.