Arch

COMPARISON OF DENTAL ARCH DIMENSIONS OF UNTREATED
MIXED DENTITION PATIENTS WITH CLASS II DIVISION 1,
CLASS II DIVISION 2, AND CLASS III MALOCCLUSION
Somkamol Vanichvatana, D.D.S., M.Sc.
A Thesis Presented to the Graduate Faculty of

Saint Louis University in Partial Fulfillment
Of the Requirements for the Degree of
Master of Science in Dentistry
2015
COMMITTEE IN CHARGE OF CANDIDACY:
Professor Eustaquio A. Araujo,

Chairperson and advisor
Professor Rolf G. Behrents

Assistant Professor Hiroshi Ueno
i
DEDICATION
To my father. Although he is no longer here to see my
achievement, I always believe that he would be proud of me.
Without his love, support and patience, I would not be the
person I am today.
To my wife, Dr.Kochanipa, who left her career and
everything behind to come and begin a whole new journey
with me. Thank you for your unwavering support and for
making this place a home away from home. I could not have
made it this far without you by my side.
Lastly, to the faculty of Saint Louis University,
whose guidance and instruction have built a strong
foundation for my orthodontic career.
ii
ACKNOWLEDGEMENTS
The author wishes to express his sincerest gratitude
to the following individuals:
Dr. Eustaquio Araujo, for serving as chairman of my
thesis committee and for his guidance, encouragement, input
on the project design, and also in providing the knowledge
in orthodontics.
Dr. Rolf Behrents, for his wise guidance throughout
this project and for allowing me to obtain an orthodontic
education at Saint Louis University.
Dr. Hiroshi Ueno, for his attention to detail during
my thesis preparation and helping me think about the
projects.
Dr. William Mastorakos, for providing the samples that
made this thesis possible.
Dr. Heidi Israel, for her patience and assistance with
the statistics for this study.
iii
TABLE OF CONTENTS
LIST OF TABLES............................................vi
LIST OF FIGURES..........................................vii
CHAPTER 1: INTRODUCTION....................................1
CHAPTER 2: REVIEW OF THE LITERATURE........................3

The mixed dentition period..................... 3
Development of intercanine width............... 5
Development of intermolar width................ 6
Development of interpremolar width............. 7
Development of arch length..................... 8
Development of arch depth...................... 9
Class II division 1 malocclusion.............. 10
Class II division 2 malocclusion.............. 13
Class III malocclusion........................ 15
Gender dimorphism............................. 16
Digital models................................ 17
Summary and statement of thesis............... 18
References.................................... 20
CHAPTER 3: JOURNAL ARTICLE................................27

Abstract...................................... 27
Introduction.................................. 29
Materials and methods......................... 33
Sample.................................... 33
Measurements.............................. 36
Error study............................... 43
Statistical analysis...................... 43
Results ...................................... 44
Comparison between the different
malocclusion groups....................... 44
Arch widths.......................... 44
Arch depths.......................... 46
Gender dimorphism......................... 46
Maxillary minus mandibular arch width
differences............................... 48
Discussion.................................... 50
Comparison of the present study to the
literature................................ 50
Gender dimorphism......................... 56
Correlation to the permanent dentition
studies................................... 57
Conclusion.................................... 58
References.................................... 60
iv
VITA AUCTORIS.............................................65
v
LIST OF TABLES
Table 3.1: Characteristics of each study group........... 34
Table 3.2: Comparison of arch dimensions in Class II

division 1, Class II division 2, and
Class III (gender pooled) ...................... 45
Table 3.3: Gender dimorphism of arch dimensions in

Class II division 1, Class II division 2,
and Class III ................................ 47
Table 3.4: Comparison of maxillary minus mandibular arch

width differences in Class II division 1,
Class II division 2, and Class III (gender
pooled) ...................................... 48
Table 3.5: Gender dimorphism of maxillary minus

mandibular arch width differences in Class II
division 2, Class II division 2, and
Class III .................................... 49
Table 3.6: Comparison of the overall mean arch widths

and depths in the present study and the
literature ................................... 53
Table 3.7: Comparison of mean arch widths and arch

depths in the Michigan Growth Study and the
present study ................................ 54
Table 3.8: Comparison of arch widths studies............. 55
vi
LIST OF FIGURES
Figure 3.1: Example of digital cast in Class II

division 1 group ............................. 35
Figure 3.2: Example of digital cast in Class II

division 2 group ............................. 35
Figure 3.3: Example of digital cast in Class III group... 36
Figure 3.4: Points used for measurements in molar (A),

canine (B), and incisors (C) ................. 38
Figure 3.5: Measurements of arch width: Maxillary

primary canines (A), Mandibular primary
canines (B), Maxillary primary second molars
(C), Mandibular primary second molars (D),
Maxillary permanent first molar (E), and
Mandibular permanent first molars (F) ........ 40
Figure 3.6: Dash lines represent measurements of arch

depth: Maxillary primary canines (A),
Mandibular primary canines (B), Maxillary
primary second molars (C), Mandibular primary
second molars (D), Maxillary permanent first
molar (E), and Mandibular permanent first
molar (E), and Mandibular permanent first
molars (F) .................................. 42
Figure 3.7: Maxillary arch shapes of three groups

created from mean arch widths and arch depths 51
Figure 3.8: Mandibular arch shapes of three groups

created from mean arch widths and arch depths 52
vii
CHAPTER 1: INTRODUCTION
Malocclusion has been associated with bullying,1 poorer
oral health-related quality of life,2 and self-
dissatisfaction with appearance.3 Therefore, early
diagnosis and treatment of malocclusion may be useful for
many patients. Early treatment in orthodontics is the
intervention in the primary, early mixed (permanent first
molars and incisors present), or mid mixed dentition period
(before emergence of first premolars and permanent
mandibular canines) with removable or fixed appliance.4
Several studies have shown that early orthodontic treatment
can significantly reduce the complexity of some cases.5-7
Therefore, it is essential to know the characteristics of
different types of malocclusions in order to create an
appropriate treatment plan.
There are studies that have investigated arch
dimension of each malocclusion type.8-11 However, many of
these studies were done in permanent dentition, with a
limited number of subjects, or without clear inclusion
criteria; this had led to conflicting results of the
literature. Accordingly, this review of the literature
will attempt to demonstrate the controversies that exist in
the current literature regarding the arch dimensions of
each malocclusion type.
1
This review will begin with a brief review of normal
development in mixed-dentition, normal development of arch
width and arch depth, followed by literature reporting arch
dimensions of Class II division 1, Class II division 2, and
Class III malocclusions, as well as gender dimorphism.
2
CHAPTER 2: REVIEW OF THE LITERATURE
The mixed dentition period
The mixed dentition period starts when the first
permanent tooth appears in the mouth, typically the first
permanent molar, and lasts until the last primary tooth is
lost. It is a transitional stage from the primary to the
permanent dentition.
Angle was the first to develop a simple terminology
based on the sagittal relationship between the mesiobuccal
cusp of the maxillary first molar and the mesial buccal
groove of the mandibular first molar.12 Malocclusion can be
divided into Class I, Class II division 1, Class II
division 2, and Class III. Occlusal relationships in the
mixed dentition parallel those in the permanent dentition,
but the descriptive terms are different. A method of
classifying the sagittal relation between the maxillary and
mandibular dentition by using the antero-posterior
relationship between the distal surface of the maxillary
and mandibular second primary molars is called “terminal
plane relationship”.13
A normal relationship of the primary molar teeth is
the flush terminal plane relationship. A distal step is
equivalent to Angle’s Class II. However, an equivalent of
Class III is rarely seen in the primary dentition because
3
of the normal craniofacial growth pattern in which the
mandible lags behind maxilla.
At the time the primary second molars are lost, both
maxillary and mandibular molars tend to shift mesially into
the leeway space, but the mandibular molars normally
mesially move than maxillary molars. This contributes to
the normal transition from a flush terminal plane to a
Class I relationship in the permanent dentition. Arya et
al.14 found that 70 percent of flush terminal plane
relationship adjust to a Class I molar occlusion; whereas,
30 percent remain in an end-to-end relationship.
The transition to the permanent dentition usually
occurs by via a 3 to 4 mm forward movement of the lower
molar and a combination of differential growth and tooth
movements. A child’s initial distal step relationship may
change during the transition to end-to-end (one half cusp
Class II) relationship in the permanent dentition but is
not likely to be corrected all the way to Class I. It also
is possible that the molar relationship in the permanent
dentition will probably remain a full cusp Class II.
Early mandibular growth may produce a mesial step
relationship in the primary molars and which consequently
lead to a Class I molar relationship at an early age. It
is possible for this mesial step relationship to progress
4
to a half-cusp Class III during the molar relationship with
continued mandibular growth. On the contrary, if
differential mandibular growth no longer occurs, the mesial
step relationship at an early age may become a Class I
relationship later.
Development of intercanine width
Intercanine widths were investigated by Barrow and
White,15 Moorrees et al.,16 and Sillman.17 They all observed
that there was a rapid increase from 6 to 9 years of age
associated with the eruption of the permanent incisors and
canines. The mean increase in the intercanine width is
completed after full eruption of the crown of the permanent
lateral incisors.18 Thereafter, there was a decrease in
intercanine width from 10 to 12 years of age, which then
remained stable.16 Sinclair and Little19 found that there
were small decreases in intercanine width, with the most
significant change occurring in females from 13 to 20.
Similar observations were made by DeKock20 who quantified
the average reduction to be 10%. In the untreated
University of Michigan growth series, the maxillary and
mandibular intercanine widths decreased significantly.21
In the study by Arslan et al.,22 there were insignificant
decreases in mandibular intercanine widths in both sexes
5
between the ages of 9 and 14. Ross-Powell and Harris23
found that the anterior arch segment broadens significantly
in proportion to its depth from about 3 to 5 years of age
and again from 12 to 18 years of age. They also found that
intercanine widths increase significantly during the
deciduous phase but exhibit no systematic change after
emergence of the permanent canines.23 Bishara et al.24 found
that mandibular intercanine width was established by 8
years of age or after the eruption of the four incisors.
They concluded that after the eruption of the permanent
dentition, the clinician should either expect no changes or
a minimal decrease in arch widths. In a longitudinal study
by Knott,25 he concluded that the maximum intercanine width
of both arches showed little change after the stage of
permanent dentition was attained. In the mandibular arch,
increase in this width occurred largely before the eruption
of the permanent canine teeth.
Development of intermolar width
Intermolar width has commonly been used as a measure
of posterior arch dimension. In general, this dimension
remains very stable with some degrees of sexual dimorphism
present. In a longitudinal study of dental development
between the ages of 3 and 18, Moorrees et al.26 found that
6
the mandibular intermolar distance increased between the
ages of 9 and 14 in both sexes but that thereafter it
remained constant. Arslan et al.22 found that from mixed
dentition to permanent dentition in girls, there were
increases of 1.36 mm in maxillary intermolar width and 1.64
mm in mandibular intermolar width. In boys, the respective
values were 1.58 and 0.91 mm. However, Sinclair and Little
found that males showed insignificant increases while the
females showed a small but significant decrease from 13 to
20 years.19
Development of interpremolar width
Interpremolar width was investigated by several
authors.21,22,27 Arslan et al.22 demonstrated that there were
statistically significant increases in maxillary and
mandibular interpremolar widths in the girls. There was a
significant increase only in mandibular interpremolar width
in the boys. The increases in interpremolar widths were
1.49 mm in the maxilla and 1.88 mm in the mandible for
girls, and 1.37 mm in the mandible for boys. In the study
of Lundström27 on twins between the ages of 9 and 19, there
were minimal increases in permanent interpremolar widths.
In addition, the Michigan Growth Study showed premolar
7
width increases in both jaws, with a greater increase in
the maxilla than in the mandible.21
Development of arch length
Arch length or arch circumference is also an important
parameter for the study of growth changes. Moorrees et
al.26 reported that arch length does not actually change in
the primary dentition from ages of 4 to 6 years. However,
arch length increases about 3 mm during eruption of the
permanent maxillary and mandibular incisors.
During the mid- to late-mixed dentition, additional
space becomes available because primary molars have a
larger mesiodistal width than their succedaneous teeth, the
premolars. This difference is the so-called leeway space.
It serves for alignment of the permanent canine, which is
larger than the primary canine in crown size. Proffit et
al.13 reported that the leeway space is 2.5 mm in the
mandibular arch and about 1.5 mm in the maxillary arch.
Moorrees and Chandha16 reported similar numbers, 1.20 mm for
the maxillary arch and 2.16 mm for the mandibular arch.
Arch length of both sexes decreasesF between the ages
of 9 and 14 because of changes in the dentition. This
decrease was more significant in girls. The decreases in
arch length exceed the increase associated with the incisor
8
emergence in the average child, therefore, arch length is
shorter at 18 years than at 4 years, especially in the
mandible.26 Arch length then remains constant after the age
of 14. Similar observations were made by DeKock20 and
Sinclair and Little.19 In addition, Bishara et al.28 found
that the decrease in segmental and total mandibular arch
lengths was significantly greater in male than in female.
Development of arch depth
Arch depth was investigated by Moorrees and Reed.26
They found a slight decrease of arch depth from age 4 to 6
due to the closure of interdental spaces between the
primary posterior teeth. However, arch depth increases
after the eruption of incisors in the maxilla because of
the greater labial inclination of the maxillary incisors.
Moorrees and Reed26 reported that the changes in arch
depth in average are: a slight decrease initiated before
emergence of the permanent first molars as a consequence of
closure of the spaces between primary molars; a small
increase during the eruption of permanent incisors in the
maxilla but a reduction in the mandible; a decrease
following the shedding of primary molars, especially the
second molar.
9
Arch depth was also investigated by Knott,25 in a
longitudinal study of sixteen boys and thirteen girls.
Knott found that in the 3-year period from the ages of 12
to 15 years all twenty-nine subjects registered a decrease
in arch depth. The amount of decrease varied from near
zero to over 3.0 mm averaging approximately 1.5 mm for each
arch of each sex. A longitudinal study by DeKock20 showed
that means for both maxillary and mandibular arch depth
decreased with age throughout the period studied in each
sex, with the rate of change being less after the age of 15
years. The mean decrease in mandibular arch depth from 12
to 26 years of age was 3.2 mm for male subjects. For female
subjects, the mean decrease in arch depth was 2.6 mm and
revealed no significant change during the 14-year span
from 12 to 26 years of age. Every person in the study
showed a decrease in arch depth after the age of 15
years. The range of decrease in the mandibular arch for
the period from 15 to 26 years of age was 0.1 mm to 2.3 mm.
Class II division 1 malocclusion
Class II malocclusion is the most frequently seen
skeletal disharmony in white population and has been
analyzed in many cephalometric and dental model studies.

8,18,29-33
Class II division 1 malocclusion patients often
10
reveal a transverse discrepancy between the dental arches.
Several cross-sectional models studies have shown that the
maxillary arch was narrower in patients with Class II
division 1 malocclusion.18,29-31 Moorrees et al.18 compared
Class II division 1 subjects to a control subjects. They
found that the intercanine and intermolar distances were
smaller than average for the Class II division 1 group.
Staley et al.29 also reported similar results in that
patients with Class II division 1 malocclusion had narrower
maxillary intercanine, intermolar, and alveolar widths.
Similarly, Tollaro et al.30 found that patients with Class
II malocclusion had significantly narrower maxillary area
during the mixed dentition phase. A study from Buschang et
al.31, which was one of the few that measured arch length,
stated that Class II division 1 females had the longest and
narrowest arches.
In addition to studies in Caucasian subjects, a study
involving a Jordanian sample also showed the similar
results. Al-Khateeb and Abu Alhaija34 compared arch widths
in the different malocclusions in a Jordanian sample. They
reported that the maxillary interpremolar and intermolar
widths in Class II division 1 malocclusion were
significantly smaller than those in the other malocclusion
groups. In the mandibular arch, the intercanine,
11
interpremolar, and intermolar widths were all significantly
smaller in Class II division 1 group than that in Class
III.
In a longitudinal study by Bishara et al.,35 they
compared the dental casts of normal subjects with untreated
Class II division 1 subjects from the Iowa Growth Study.
The dental arches were analyzed longitudinally at five,
eight, and thirteen years, and arch width was measured at
the second primary molars and the premolars. They found a
relative constriction of the maxillary intermolar width in
the Class II division 1 group, which was statistically
significant only in boys. In another longtitudinal study
by Lux et al.,8 which used a different group of untreated
subjects from the Belfast Growth Study, they found similar
results. They compared Class II division 1 subjects with
Class II division 2, Class I group, and a control group
with good occlusion. They concluded that maxillary
intermolar widths were smaller in Class II division 1 group
than in Class I and the good-occlusion groups. This
difference was found during the total period of
observation, from seven to fifteen years, and was
statistically significant at most ages. In mandibular
intermolar widths, the Class II division 1 cases were also
slightly smaller than the control group, but group
12
differences were statistically insignificant. The Class II
division 1 groups also exhibited the largest molar
differences, which were about -2.5 mm in boys and -1.5 to
-2 mm in girls.
Using posteroanterior cephalograms and morphometric
analysis, Alarashi et al.36 found that subjects with Class
II malocclusion exhibited significant shape differences in
frontal plane when compared with subjects with normal
occlusion. These differences mainly consisted of
constriction of the maxilla at both the skeletal and
dentoalveolar levels.
In contrast to the Class II division 1 studies above,
Fröhlich32 found no difference in transverse dimensions
between Class I and Class II subjects. Moreover, Sayin and
Turkkahraman33 and Uysal et al.37 reported that mandibular
intercanine widths were significantly larger in a Class II
division 1 group compared to a Class I group.
Class II division 2 malocclusion
Class II division 2 malocclusion is not a common form
of malocclusion. Even though this type of malocclusion
appears to be more common among Caucasians than other
ethnic groups, its prevalence has been estimated to range
only between 2.3% and 5% among Caucasians.38,39 Different
13
ethnic groups have also been studied. In African American
individuals, the prevalence of Class II division 2
malocclusion was reported to be 1.6%, while 1.7% was found
for the Arab population.40,41 Due to limited numbers of
Class II division 2 patients, there were only few studies
that have evaluated Class II division 2
malocclusion.8,9,18,31,42 Moorrees et al.26 found that in Class
II division 2 subjects, the maxillary and mandibular
intercanine width were greater than a control normal
occlusion group. Lux et al.8 also found that there were no
differences between maxillary and mandibular intermolar
widths between the Class II division 2 group and the normal
occlusion group. In addition, Uysal et al.43 found that the
maxillary intermolar widths were wider in the Class II
division 2 group than in Class II division 1 group.
On the contrary, several studies demonstrated that
Class II division 2 subjects appear to have smaller arch
width than normal. Isik et al.9 found that the mandibular
intercanine width in Class II division 2 subjects were
statistically significant less than the Class II division 1
group. Buschang et al.31 reported that the Class II
division 2 patients had mandibular intercanine and
intermolar widths less than Class I and Class II division 1
patients. Furthermore, Walkow and Peck42 found that
14
mandibular intercanine width in the Class II division 2
deep bite group was significantly less than control.
Class III malocclusion
Class III malocclusion has the least prevalence in any
ethnic background. It is most frequent in Asians, followed
by Hispanics, African- American and Caucasians. The
prevalence of Class III malocclusion in white population is
relatively low with estimates ranging from 0.2% to 12%.44
Studies of Class III malocclusion were mainly investigated
in sagittal plane.45,46 In spite of that, there are several
studies that have investigated transverse discrepancies
between maxillary and mandibular arches.10,43,46,47 Kuntz et
al.48 reported significantly smaller maxillary intermolar
and alveolar widths in the Class III group compared to the
Class I normal group. Krneta et al.47 used scanned study
casts to evaluate interarch discrepancy in 7-8 years old
patients. They found a statistically significant
difference between the Class III and the control normal
occlusion groups with respect to the gingival surface area
of the maxilla. However, they found no significant
difference of palatal volume and gingival surface area of
mandible. Franchi and Baccetti46 used posteroanterior
cephalograms to study transverse maxillary deficiency in
15
Class II and Class III malocclusions. They reported that
the maxillary width, both at the skeletal and dentoalveolar
levels was significantly smaller in both the Class II and
Class III groups when compared with the control normal
occlusion group.
In contrast to Uysal et al.,43 who compared arch widths
in a large sample of Class III Turkish subjects with an
average age of 15 years with subjects with normal
occlusions who averaged 21 years of age, reported that the
maxillary intercanine widths were similar in Class III
malocclusions and Class I normal occlusion subjects.
However, in the mandible, they found that the mandibular
intercanine and intermolar alveolar widths were
significantly larger in the Class III group than in normal
occlusion group.43 Al-Khateeb and Abu Alhaija34 compared
arch widths in 13- to 15-year-old Jordanian students with
Class I and Class III malocclusions. They found that
maxillary and mandibular intercanine and intermolar widths
were similar in both groups.
Gender dimorphism
Gender dimorphism regarding arch dimensions has been
investigated in a few studies.8,29,47-49 Staley et al.29 found
that only male subjects with normal occlusion had
16
significantly larger mandibular intermolar widths when
compared with the Class II group. Lux et al.8 also found
greater differece of intermolar widths in boys than in
girls. In addition, Huth et al.49 found that narrow Class
II arches is more pronounced in male than in female
subjects. However, Buschang et al.31 reported that in an
adult female sample, maxillary intermolar width of Class II
subjects were smaller than the Class I group.
The study of gender dimorphism of Class III subjects
by Kuntz et al.48 showed that male subjects had
significantly larger intermolar arch widths than females in
both the Class III and Class I groups. In contrast Krneta
et al.47 found that there were no gender differences between
Class III and control Class I groups.
Digital models
Digital models are increasingly available and provide
qualified diagnostic images at a reasonable cost. With new
advances in 3-dimensional dental and orthodontic software,
orthodontists can examine intra-arch and interarch
relationships digitally. Transverse relationships between
maxillary and mandibular arches can be better evaluated
when 3-dimensional models are viewed in occlusion from
different perspectives as viewed on a screen.50 Several
17
studies in the literature have verified the accuracy of
angular and linear measurements accomplished on 3-
dimensional digital models.50-53 Sousa et al.50 concluded
that the reproducibility of digital measurements of arch
width and length on digital models was similar to direct
measurements on the dental casts with calipers.
Measurements of arch width and length on digitized models
showed high accuracy. Moreover, digital models can be used
for storing cast information and for research with
satisfactory degrees of accuracy and reproducibility of
linear measurements of arch width and length.
Summary and statement of thesis
From the existing literature, there is still a certain
degree of controversy when comparing the arch dimensions of
differing malocclusion types. Most of studies have focused
almost exclusively on the permanent dentition and very few
studies have focused on the early- to mid-mixed dentition.
Unfortunately, none of these studies have a clear cut
inclusion criteria regarding canine. For example, they
have included subjects with both primary and permanent
canines. Moreover, there are limited Class II division 2
subjects for available study, especially in early- to mid-
mixed dentition. In addition, there are relatively little
18
data on maxillary and mandibular arch depths in each
malocclusion type. No previous study has described nor
compared gender dimorphism in malocclusion in mixed
dentition subjects. Furthermore, most of studies were done
with measurements taken directly by sliding calipers on
plaster casts, which often are not repeatable due to
material defects.
Hence, the purpose of this study is to investigate
arch dimensions defined on digitized models of untreated
American Caucasian children in the early- to mid-mixed
dentition with Class II division 1, Class II division 2,
and Class III malocclusions. The following four null
hypotheses will be tested: (1) that there are no
differences in arch widths and arch depths between the
three malocclusion groups; (2) that there are no
differences in gender dimorphism in arch widths and arch
depths across the three malocclusion groups; (3) that there
are no differences in the maxillary minus mandibular arch
width differences between three malocclusion groups; and
(4) that there are no gender dimorphism in the interarch
differences within the three malocclusion groups.
19
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21
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28. Bishara SE, Jakobsen JR, Treder J, Nowak A. Arch
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29. Staley RN, Stuntz WR, Peterson LC. A comparison of

arch widths in adults with normal occlusion and adults
with class II, Division 1 malocclusion. Am J Orthod.
1985;88:163-9.
30. Tollaro I, Baccetti T, Franchi L, Tanasescu CD. Role

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31. Buschang PH, Stroud J, Alexander RG. Differences in

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division 1 malocclusion and subjects with Class I
ideal occlusion. Angle Orthod. 2004;74:356-60.
34. Al-Khateeb SN, Abu Alhaija ES. Tooth size

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23
36. Alarashi M, Franchi L, Marinelli A, Defraia E.
Morphometric analysis of the transverse dentoskeletal
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dentition. Angle Orthod. 2003;73:21-5.
37. Uysal T, Memili B, Usumez S, Sari Z. Dental and

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division 1 and class II division 2. Angle Orthod.
2005;75:941-7.
38. Massler M, Frankel JM. Prevalence of malocclusion in

children aged 14 to 18 years. Am J Orthod.
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1983;84:337-43.
42. Walkow TM, Peck S. Dental arch width in Class II

Division 2 deep-bite malocclusion. Am J Orthod
43. Uysal T, Usumez S, Memili B, Sari Z. Dental and

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44. Proffit WR, Fields HW, Jr., Moray LJ. Prevalence of

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24
45. Alexander AE, McNamara JA, Jr., Franchi L, Baccetti T.
Semilongitudinal cephalometric study of craniofacial
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Orthod Dentofacial Orthop. 2009;135:700 e1-14;
discussion -1.
46. Franchi L, Baccetti T. Transverse maxillary deficiency

in Class II and Class III malocclusions: a
cephalometric and morphometric study on postero-
anterior films. Orthod Craniofac Res. 2005;8:21-8.
47. Krneta B, Zhurov A, Richmond S, Ovsenik M. Diagnosis

of Class III malocclusion in 7- to 8-year-old
children-a 3D evaluation. Eur J Orthod. 2014.
48. Kuntz TR, Staley RN, Bigelow HF, Kremenak CR, Kohout
FJ, Jakobsen JR. Arch widths in adults with Class I
crowded and Class III malocclusions compared with
normal occlusions. Angle Orthod. 2008;78:597-603.
49. Huth J, Staley RN, Jacobs R, Bigelow H, Jakobsen J.

Arch widths in class II-2 adults compared to adults
with class II-1 and normal occlusion. Angle Orthod.
2007;77:837-44.
50. Sousa MV, Vasconcelos EC, Janson G, Garib D, Pinzan A.

Accuracy and reproducibility of 3-dimensional digital
model measurements. Am J Orthod Dentofacial Orthop.
2012;142:269-73.
51. Quimby ML, Vig KW, Rashid RG, Firestone AR. The
accuracy and reliability of measurements made on
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2004;74:298-303.
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25
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Major PW. Validity, reliability, and reproducibility
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Orthop. 2006;129:794-803.
26
CHAPTER 3: JOURNAL ARTICLE
Abstract
Objective: To test the hypothesis that there is no
difference between mixed dentition subjects with Class II
division 1, Class II division 2, and Class III
malocclusions with respect to (1) arch widths and arch
depths, (2) gender dimorphism, and (3) maxillary/mandibular
widths differences. Material and Methods: This study was
conducted on dental models of 150 untreated American
Caucasian early- to mid-mixed dentition patients, which
were divided into three groups: (1) Class II division 1 (25
males and 25 female), (2) Class II division 2 (25 males and
25 females), and (3) Class III (25 males and 25 females).
The dental models were digitized by 3-D scanner and arch
dimensions were measured by Ortho Insight 3DTM software
(Motionview Software LLC, Hixson, Tenn). Six linear
and three proportional measurements were calculated
for the maxillary and mandibular arches. Results:
Significant differences between malocclusion types were
found in all arch measurements (p<.05) except for
mandibular permanent first molars width and depth. The
Class II division 1 group had the largest maxillary and
mandibular primary canines widths, whereas the Class III
group had the largest widths for other arch width
27
measurements. The Class II division 1 had the largest arch
depth in all arch depth measurements. Gender differences
were found in all malocclusions. Females showed a tendency
to having smaller arch dimensions than males in all
malocclusion groups. The only significance for
maxillary/mandibular widths differences was found in
primary second molars width between the Class II division 1
and Class III groups. Conclusions: Arch widths and depths
differences were found among the malocclusion groups and
between males and females.
28
Introduction
Malocclusion has been associated with bullying,1 poorer
oral health-related quality of life,2 and self-
dissatisfaction with appearance.3 Therefore, early
diagnosis and treatment of malocclusion may be useful for
many patients. Early treatment in orthodontics is the
intervention in the primary, early mixed (permanent first
molars and incisors present), or mid mixed dentition period
(before emergence of first premolars and permanent
mandibular canines) with removable or fixed appliance.4
Several studies have shown that early orthodontic treatment
can significantly reduce the complexity of some cases.5-7
Therefore, it is essential to know the characteristics of
different types of malocclusions in order to create an
appropriate treatment plan.
There are several studies that investigated arch
dimensions of each malocclusion type.8-11 As one of the most
frequently seen orthodontic problems, Class II division 1
malocclusions have been analyzed in many studies.8,12-17
Cross-sectional studies by Moorrees et al.,12 Staley et
al.,13 and Tollaro et al.14 reported similar results that the
intercanine and intermolar distances in Class II division 1
subjects were found to be smaller than Class I normal
occlusion group. In longitudinal studies by Bishara et
29
al.15 and Lux et al.,8 they reported a relative constriction
of the maxillary intermolar width in the Class II division
1 group. In contrast to the Class II division 1 studies
above, Fröhlich16 found no difference in transverse
dimensions between Class I and Class II subjects.
Moreover, Sayin and Turkkahraman17 reported that mandibular
intercanine widths were significantly larger in a Class II
division 1 group compared to a Class I group.
Due to limited numbers of Class II division 2
patients, there were only few studies that have evaluated
Class II division 2 malocclusions.8,9,18-20 Moorrees et al.12
found that the maxillary and mandibular intercanine width
in Class II division 2 subjects were greater than a control
normal occlusion group. Lux et al.8 also found that there
were no differences between maxillary and mandibular
intermolar widths between the Class II division 2 group and
the normal occlusion group. In addition, Uysal et al.21
found that the maxillary intermolar widths were wider in
the Class II division 2 group than in Class II division 1
group. On the contrary, several studies presented that
Class II division 2 subjects appear to have smaller arch
width than normal. Isik et al.,9 Buschang et al.,19 and
Walkow and Peck20 found that the mandibular arch widths in
30
Class II division 2 subjects were statistically significant
less than the Class II division 1 group.
Class III malocclusion has the least prevalence in any
ethnic background. In spite of that, there were some
studies that have investigated transverse discrepancies
between maxillary and mandibular arches.10,21-23 Kuntz et
al.,24 Krneta et al.,23 and Franchi and Baccetti22 reported
significantly smaller maxillary intermolar and alveolar
widths in Class III group compared to a Class I normal
group. In contrast to Uysal et al.,21 they reported that
the maxillary intercanine widths were similar in Class III
malocclusions and Class I normal occlusion. However, in
the mandible, they found that the mandibular intercanine
and intermolar alveolar widths were significantly larger in
the Class III group than in the normal occlusion group.21
The traditional arch dimension measurement tools have
been sliding calipers, but recently three-dimensional
scanners and specialized software have been developed to
provide accurate digital models of dental structures that
allow us to do more precise measurements.25-29
From the existing literature, there is still a certain
degree of controversy when comparing arch dimensions of
differing malocclusion types. Most of studies have focused
almost exclusively on the permanent dentition and very few
31
studies have focused on the early to mid-mixed dentition.
Unfortunately, none of these studies have a clear cut
inclusion criteria regarding canines. For example, they
have included subjects with both primary and permanent
canines. Moreover, there are limited Class II division 2
subjects available for study, especially in early to mid-
mixed dentition. In addition, there are relatively little
data on maxillary and mandibular arch depth in each
malocclusion type. No previous study has described nor
compared gender dimorphism in mixed dentition subjects.
Furthermore, most of studies have been done with
measurements taken directly by sliding calipers on plaster
casts, which often are not repeatable.
Hence, the purpose of this study is to investigate
arch dimensions defined on digitized models in American
Caucasian children in the early to mid-mixed dentition with
Class II division 1, Class II division 2, and Class III
malocclusions. The following four null hypotheses will be
tested: (1) that there are no differences in arch widths
and arch depths between the three malocclusion groups; (2)
that there are no differences in gender dimorphism in arch
widths and arch depths across the three malocclusion
groups; (3) that there are no differences in the maxillary
minus mandibular arch width differences between three
32
malocclusion groups; and (4) that there are no gender
dimorphism in the interarch differences within the three
malocclusion groups.
Materials and methods
Sample
Maxillary and mandibular dental models of 150
untreated subjects were collected from patient records at
the orthodontic clinic at the Center for Advanced Dental
Education, Saint Louis University, and a private
orthodontic practice in Saint Louis.
Subjects were initially selected based on the
following inclusion criteria:
1. No history of previous orthodontic treatment.
2. Presence of all maxillary and mandibular permanent
central incisors.
3. Presence of all maxillary and mandibular primary
canines.
4. Presence of all maxillary and mandibular permanent
first molars.
5. Presence of all maxillary and mandibular primary
second molars.
6. No syndrome or developmental disorder.
33
Each of 150 subjects was broken down into three groups
(See table 3.1)
Table 3.1: Characteristics of each study group

Mean Standard
Group Gender* Range
Age Deviation
M 9y7m 1y0m 8y0m-11y10m
Class II
division 1 F 9y1m 1y2m 7y9m-11y8m
M + F 9y3m 1y1m 7y9m-11y10m
M 9y9m 1y2m 7y1m-11y7m
Class II
division 2
F 8y11m 10m 7y7m-11y0m
M + F 9y3m 1y1m 7y7m-11y7m
M 9y2m 10m 7y2m-10y5m
Class III F 8y5m 11m 7y0m-10y3m
M + F 8y8m 11m 7y7m-10y5m
*M = Male, F = Female
The inclusion criteria for each group were:
Group 1 Class II division 1 (50 subjects: 25 males and 25
females)(Figure 3.1):
1. End-to-end to distal-step terminal plane
relationships of distal surfaces of upper and lower
second primary molars on both sides.
2. Proclination of maxillary incisors.
3. Overjet ≥ 5 mm.
34
Figure 3.1: Example of digital cast in Class II division 1
group
Group 2 Class II division 2 (50 subjects: 25 males and 25
females)(Figure 3.2):
1. End-to-end to distal-step terminal plane
relationships of distal surfaces of upper and lower
second primary molars on both sides.
2. Retroclination of two maxillary central incisors.
Figure 3.2: Example of digital cast in Class II division 2

group
35
Group 3 Class III (50 subjects: 25 males and 25 females)
(Figure 3.3):
1. Mesial-step terminal plane relationships of distal
surfaces of upper and lower second primary molars on
both sides.
2. Anterior crossbite or edge to edge bite of at least
two central incisors.
Figure 3.3: Example of digital cast in Class III group
Measurements
All the casts were digitized by using the Ortho
Insight 3D laser scanner (Motionview Software LLC, Hixson,
Tenn). All measurements of scanned models were done by
Ortho Insight 3DTM program with a scanning resolution set on
high. The Ortho Insight 3D software (version 6.0.7044,
Motionview Software LLC, Hixson, Tenn) was used for the
measurements.
36
The following points were used for measurements
(Figure 3.4):
1. Distal Midpoint (DM): the point on distal side of
the tooth, midway between the buccal and lingual
surfaces.
2. Most Buccal Point (BP): the point at buccal fissure
location for the permanent molars and second primary
molars. For the canines, the point was the most
buccal point on buccal surface.
3. Most Lingual Point (LP): the point at lingual
fissure location for the permanent molars and second
deciduous molars. For the canines, the point was the
most ligual point on the lingual surface.
4. Mesial Midpoint (MM): the point on mesial side of
tooth, midway between the buccal and lingual
surfaces.
5. Midpoint between the approximal midpoints (A):
halfway between DM and MM.
6. Midpoint between buccal and lingual points (B)
7. Centroid (C): halfway between point A and point B
8. Most Labial point (La): the midpoint of the most
labial points of the central incisors.
37
Figure 3.4: Points used for measurements in molar (A),
canine (B), and incisors (C)
The following measurements were then taken:
1) Maxillary primary canines width (UC width): The
distance between the centroids of maxillary primary
canines (Figure 3.5A).
2) Mandibular primary canines width (LC width): The
distance between the centroids of mandibular primary
canines (Figure 3.5B).
38
3) Maxillary primary second molars width (UE width):
The distance between the centroids of maxillary
primary second molars (Figure 3.5C).
4) Mandibular primary seconds molars width (LE width):
The distance between the centroids of mandibular
primary second molars (Figure 3.5D).
5) Maxillary permanent first molars width (U6 width):
The distance between the centroids of maxillary
permanent first molars (Figure 3.5E).
6) Mandibular permanent first molars width (L6 width):
The distance between the centroids of mandibular
permanent first molars (Figure 3.5F).
7) Maxillary primary canines arch depth (UC depth): The
depth from the midpoint of the most labial points of
the maxillary central incisors (La) to the maxillary
canines at the distal midpoint (DM)(Figure 3.6A).
8) Mandibular primary canines arch depth (LC depth):
The depth from the midpoint of the most labial
points of the mandibular central incisors (La) to
the mandibular canines at the distal midpoint
(DM)(Figure 3.6B).
39
Figure 3.5: Measurements of arch width: Maxillary primary
canines (A), Mandibular primary canines (B), Maxillary
primary second molars (C), Mandibular primary second molars
(D), Maxillary permanent first molar (E), and Mandibular
permanent first molars (F)
40
9) Maxillary primary second molar arch depth (UE
depth): The depth from the midpoint of the most
labial points of the maxillary central incisors (La)
to the maxillary primary second molars at the distal
midpoint (DM)(Figure 3.6C).
10) Mandibular primary second molar arch depth (LE
labial points of the mandibular central incisors
(La) to the mandibular primary second molars at the
distal midpoint (DM)(Figure 3.6D).
11) Maxillary permanent first molar arch depth (U6
labial points of the maxillary central incisors (La)
to the maxillary permanent first molars at the
distal midpoint (DM)(Figure 3.6E).
12) Mandibular permanent first molar arch depth (L6
labial points of the mandibular central incisors
(La) to the mandibular permanent first molars at the
distal midpoint (DM)(Figure 3.6F).
41
Figure 3.6: Dash lines represent measurements of arch
depth: Maxillary primary canines (A), Mandibular primary
canines (B), Maxillary primary second molars (C),
Mandibular primary second molars (D), Maxillary permanent
first molar (E), and Mandibular permanent first molar (E),
and Mandibular permanent first molars (F)
42
Error study
The precision of landmarks identification was tested
by double determination by the same examiner, separated by
at least a 10-day interval. A random number generator was
utilized to select 10% of all models (30 models) for
evaluating measurement error. Intraclass correlation was
estimated using Cronbach’s alpha. For all variables,
Cronbach’s alpha was within a range of 0.90-0.99.
Statistical analysis
Data were analyzed using the statistical package
program (SPSS® Version 23.0, IBM®, Armonk, New York).
Descriptive statistics including the means and standard
deviations were calculated for each group. Each
measurement data from Group 1, 2, and 3 were compared by
using ANOVA test followed by Tukey’s post hoc evaluation.
Male and female data differences in each group were
analyzed using independent samples’ t-test.
Mandibular arch widths were subtracted from
corresponding maxillary arch widths to compare
maxillary/mandibular arch differences. ANOVA test was used
to compare maxillary/mandibular arch differences between
groups followed by Tukey’s post hoc evaluation.
43
For all analysis, P values less than 0.05 were
considered statistically significant.
Results
Comparison between the different malocclusion groups
Arch widths
With genders pooled, the three occlusion groups fell
into five significantly different for UC, UE, U6, LC, and
LE widths. No differences were observed between the
occlusion groups for L6 width (Table 3.2). The Class III
group had the largest UE, LE, and L6 width, whereas the
Class II division 1 group has the largest UC and LC width.
In contrast, the Class II division 2 group had the smallest
widths for all arch width measurements.
UE and U6 widths in the Class III malocclusions were
significantly larger than those in the other malocclusion
groups. The Class III group had significantly larger LC
and LE width than the Class II division 2 group. The Class
II division 1 group had significantly larger UC, UE, and LE
widths than the Class II division 2 group.
44
Table 3.2: Comparison of arch dimensions in Class II
division 1, Class II division 2, and Class III (gender pooled)
Variable Group Mean SD P Groups with
significant
(mm) (mm) differences
Maxillary widths
Primary canines II-1 31.89 2.31 .009* II-1 vs II-2
II-2 30.39 2.26
III 31.44 2.78
Primary second II-1 39.52 2.85 .001* II-1 vs III
molars II-2 38.89 2.67 II-2 vs III
III 40.87 2.69
Permanent first II-1 44.82 2.85 .005* II-1 vs III
III 46.33 2.78
Mandibular widths
II-2 24.71 2.32 II-2 vs III
III 26.05 2.12
molars II-2 35.37 2.22
III 36.50 1.90
Permanent first II-1 41.46 2.33 .066
molars II-2 41.19 2.62
III 42.26 2.09
Maxillary depths
Primary canines II-1 14.54 1.71 <.001* II-1 vs II-2
II-2 10.87 1.64 II-1 vs III
III 9.89 2.13 II-2 vs III
Primary second II-1 30.02 2.21 <.001* II-1 vs II-2
III 25.31 1.85 II-2 vs III
Permanent first II-1 40.68 2.34 <.001* II-1 vs II-2
III 35.60 1.87 II-2 vs III
Mandibular depths
II-2 6.62 1.32 II-1 vs III
III 6.61 1.58
Primary second II-1 24.56 2.38 .025* II-1 vs II-2
molars II-2 23.44 1.74
III 24.00 1.94
molars II-2 34.08 2.11
III 34.59 2.24
II-1 = Class II division 1, II-2 = Class II division 2,
III = Class III
*Statistically significant difference
45
Arch depths
With gender pooled, the three occlusion groups fell
into five significantly different for UC, UE, U6, LC, and
LE depths. No differences were observed between the
occlusion groups for L6 depth (Table 3.2). The Class II
division 1 group had largest arch depth for all
measurements. On the other hand, the Class III group has
the smallest UC, UE, U6, and LC arch depths and the Class
II division2 group had the smallest LE and L6 depths.
Gender dimorphism
For arch widths, gender dimorphism occurred in the
Class II division 1 group in all arch width measurements,
which were all males larger than females (Table 3.3). In
contrast, the Class III group had gender dimorphism only in
maxillary and mandibular permanent first molars width, with
males larger than females. In the Class II division 2
group, the measurements that were significantly larger in
males than females were UE, U6, LE, and L6 widths.
For arch depths, gender dimorphism occurred in the
Class II division 1 group for LE, and L6 depths. For the
Class II division 2 group, males had significantly
46
Table 3.3: Gender dimorphism of arch dimensions in Class II
division 1, Class II division 2, and Class III
Gender
Group Variable P
dimorphism
II-1 Maxillary widths
Primary canines M>F .003*
Primary second molars M>F .006*
Permanent first molars M>F .022*
Mandibular widths
Primary canines M>F .001*
Maxillary depths
Primary canines No .973
Primary second molars No .845
Permanent first molars No .203
Mandibular depths
II-2 Maxillary widths
Primary second molars M>F <.001*
Mandibular widths
Maxillary depths
Mandibular depths
III Maxillary widths
Primary second molars No .056*
Mandibular widths
Maxillary depths
Mandibular depths
III = Class III
47
Table 3.4: Comparison of maxillary minus mandibular arch
width differences in Class II division 1, Class II division
2, and Class III (gender pooled)
Variable
Mean SD Groups with
(Maxillary minus
Group P significant
mandibular arch (mm) (mm) differences
width)
Primary canines II-1 5.80 2.05 .697
difference II-2 5.68 3.03
III 5.39 2.35
molars difference II-2 3.52 2.08
III 4.37 2.23
molars II-2 3.39 2.66
difference III 4.07 2.65
III = Class III
larger U6, LE, and L6 depths. For the Class III
group, males had significantly larger U6 and L6 depths
(Table 3.3).
Maxillary minus mandibular arch width differences
With gender pooled, significant difference was
observed only in the differences between UE and LE width
(Table 3.4). The Class II division 1 group had a
significantly larger primary second molars difference than
the Class III group. However, no gender dimorphism was
found in any group (Table 3.5).
48
Table 3.5: Gender dimorphism of maxillary minus mandibular
arch width differences in Class II division 2, Class II
division 2, and Class III
Variable
Gender
Group (Maxillary minus P
dimorphism
mandibular arch width)
II-1 Primary canines No .770
II-2 Primary canines No .548
III Primary canines No .654
III = Class III
49
Discussion
The present study provides information regarding arch
dimensions for each malocclusion type of untreated mixed
dentition subjects. In maxillary arch, one can see that
the Class II division 1 arch is longer and wider in the
anterior segment than the Class II division 2 and Class III
arches (Figure 3.7). The Class II division 2 arch was
slightly longer than the Class III arch, but narrower in
both frontal and posterior segments. In figure 3.8, which
represents the measurement points of the mandibular arch,
the difference among the three groups are smaller than in
the maxillary arch. In spite of the small difference, the
Class II division 2 arch was the smallest and the narrowest
when compared to the others. The Class II division 1 arch
was slightly longer, but slightly narrower in the posterior
segment than the Class III arch.
Comparison of the present study to the literature
Ideally, the results of subjects with different
malocclusions should be compared to control Class I normal
occlusion subjects. However, it is difficult to find data
of normal untreated Class I occlusion. The alternative was
to seek comparisons with other studies that included
samples with normal Class I occlusion and other
50
Figure 3.7: Maxillary arch shapes of three groups created
from mean arch widths and arch depths
malocclusions. However, few studies investigated it.30-33
Table 3.6 shows the mean arch widths and arch depths
in Knott,31 Bishara et al.,32 and Defraia et al.33 compared
to the overall mean in the present study. The reasons for
the difference might be related to the different
measurement landmarks utilized or the different age of the
samples.
51
Figure 3.8: Mandibular arch shapes of three groups created
from mean arch widths and arch depths
One of the largest dental arch studies commonly
utilized as reference that includes all types of
malocclusion and normal occlusion subjects, is “The
Standards of Human Occlusal Development”,30 also known as
“The Michigan Growth Study”. Comparing the results of the
present study with the Michigan Growth Study becomes then
more relevant. In the Michigan Growth Study, the
anatomical landmarks used are the same as the one utilized
in the present study as previously demonstrated.
52
The data of the subjects with chronological age of nine
years were the closest comparable with the present study
(overall mean = 9 years old).
Table 3.6: Comparison of the overall mean arch widths and

depths in the present study and the literature
Present Michigan Bishara Defraia
Gender Study30
Knott31
Study et al.32 et al.33
Mean age 9y0m 9y0m 9y4m 8y0m 8y6m
UC width M 31.79 30.36 38.4 32.5 26.61

(mm) F 30.69 29.56 36.3 30.7 25.95
UE width M 40.71 39.11 51.7 N/A N/A

(mm) F 38.82 38.06 48.3 N/A N/A
U6 width M 46.13 44.02 N/A 51.0 44.38

(mm) F 44.36 42.87 N/A 48.1 43.42
LC width M 26.06 24.93 31.3 25.5 25.79

(mm) F 25.17 24.24 29.9 24.4 25.38
LE width M 36.57 35.74 47.5 N/A N/A

(mm) F 35.49 35.14 44.6 N/A N/A
L6 width M 42.44 41.28 N/A 44.6 46.20

(mm) F 40.83 40.44 N/A 42.1 45.62
M = Male, F = Female
Table 3.7 shows that the overall mean maxillary and
mandibular arch widths in the present study are larger than
in the Michigan Growth Study. If we examine each group in
the present study separately, the Class II division 1 and
the Class III groups show larger maxillary and mandibular
arch widths than the Michigan Growth Study. On the other
53
hand, the Class II division 2 group only shows larger U6
width, whereas other arch widths are slightly smaller than
the Michigan Study.
Table 3.7: Comparison of mean arch widths and arch depths

in the Michigan Growth Study and the present study
Present Study
Michigan Class II Class II
Class
Study30 Overall division division
III
1 2
UC width (mm) 30.00 31.24 ↑ 31.89 ↑ 30.39 ↔ 31.44 ↑
UE width (mm) 38.62 39.76 ↑ 39.52 ↑ 38.89 ↔ 40.87 ↑
U6 width (mm) 43.48 45.25 ↑ 44.82 ↑ 44.59 ↑ 46.33 ↑
LC width (mm) 24.63 25.62 ↑ 26.09 ↑ 24.71 ↔ 26.05 ↑
LE width (mm) 35.46 36.03 ↑ 36.22 ↑ 35.37 ↔ 36.50 ↑
L6 width (mm) 40.88 41.34 ↑ 41.46 ↑ 41.19 ↔ 42.26 ↑
UC depth (mm) 14.47 11.77 ↓ 14.54 ↔ 10.87 ↓ 9.89 ↓
UE depth (mm) 30.01 27.22 ↓ 30.02 ↔ 26.34 ↓ 25.31 ↓
U6 depth (mm) 38.74 37.73 ↓ 40.68 ↑ 36.91 ↓ 35.60 ↓
LC depth (mm) 9.34 6.92 ↓ 7.52 ↓ 6.62 ↓ 6.61 ↓
LE depth (mm) 26.12 24.00 ↓ 24.56 ↓ 23.44 ↓ 24.00 ↓
L6 depth (mm) 36.01 34.58 ↓ 35.06 ↓ 34.08 ↓ 34.59 ↓

↑ = Larger than in the Michigan Growth Study, ↓ = Smaller
than in the Michigan Study, ↔ = Less than 0.5 mm of
difference from the Michigan Study
For arch depths, the overall means in maxilla and
mandible are smaller than in the Michigan Study. The Class
II division 1 group shows slightly larger maxillary arch
54
depths, but smaller mandibular arch depths than the
Michigan Study. Both the Class II division 2 and the Class
III groups show smaller maxillary and mandibular arch
depths. The larger maxillary arch depths in Class II
division 1 group are most likely due to the proclination of
upper incisors. On the contrary, smaller arch depths in
Class II division 2 group has probably been caused by the
retroclination of the upper incisors. In addition,
anterior crossbite could be a factor of smaller maxillary
arch depth in the Class III group.
Table 3.8: Comparison of arch widths studies

Present study vs
Widths Literature
Michigan Study30
Maxillary Baccetti et al.34 II-1 < I II-1 > P
intermolar II-2 > P
8
Lux et al. II-1 = I III > P
Kilic et al.35 III < I
Mandibular Baccetti et al.34 II-1 = I II-1 > P

intermolar II-2 = P
Lux et al.8 II-1 = I III > P
Kilic et al.35 III = I
I = Class I, II-1 = Class II division 1, II-2 = Class II

division 2, III = Class III, P = Pool of Class I, Class II, and
Class III from the Michigan Growth Study
Maxillary intermolar width comparison between the the
present study and the means from the Michigan Growth Study
differ from previous studies (Table 3.8).8,34,35
A longitudinal study by Baccetti et al.34 demonstrates that
55
the maxillary intermolar width in the Class II division 1
group is larger than the Class I group. However, Lux et
al.8 show that there is no difference between the Class II
division 1 and Class I groups. A study by Kilic et al.35
reveals that the Class III mixed-dentition subjects have
smaller maxillary intermolar width than the Class I group.
Mandibular intermolar width comparison between the
results from the present study and the means from the
Michigan Growth Study also differ from previous
studies.8,34,35 Baccetti et al.34 and Lux et al.8 indicates no
difference between the Class II division 1 and the Class I
group. No significant difference between the Class III and
the Class I groups is reported in the study by Kilic et
al.35
Gender dimorphism
Although there are limited number of studies regarding
gender dimorphism, longitudinal studies by Bishara et al.32
and Moorrees and Reed12 report gender difference. Males
have larger arch dimensions than females in the mixed
dentition (mean age = 8 yo). This finding is similar to
the present study. However, gender dimorphism is not
present for all arch dimensions. A few arch widths and
56
depths present no difference between males and females as
previously demonstrated.
Correlation to the permanent dentition studies
The findings of mixed dentition subjects in the
present study suggest the different trend from the previous
permanent dentition studies. Several permanent dentition
studies have compared arch widths of Class II division 1
and normal occlusion groups.8,13,16,17,36-38 Many of them show
significant larger arch widths in normal occlusion than in
Class II division 1 group.8,13,17,36,37 Some of them show no
significant difference for the maxillary intercanine
width.16,17,38 Only one study reports no significant
difference of maxillary intermolar width.16
Similar to Class II division 1, the findings for Class
III differ from previous permanent dentition studies. Kuntz
et al.24 show no significant difference in maxillary and
mandibular intercanine width. They also report
significantly larger maxillary intermolar width in the
normal occlusion group compared to the Class III group.
Uysal et al.21 present similar result for maxillary
intercanine width, however, Kuntz et al.24 point out no
significant difference for mandibular intermolar width,
57
whereas Uysal et al.21 show larger mandibular intermolar
width in the Class III group.
The Class II division 2 group shows similar findings
to the studies of Frolich16 and Lux et al.8 They report no
difference between Class I normal occlusion and Class II
division 2 groups. However, Huth at el.36 demonstrate
larger intermolar and maxillary intercanine widths in Class
I normal occlusion than in Class II division 2. In
addition, Walkow and Peck20 indicate significantly larger
mandibular intercanine width in control mixed-dentition
subjects.
Conclusion
The conclusions from the present study are:
1. The Class II division 2 group had the smallest arch
width in all arch width measurements.
2. The Class III group had the largest UE, U6, LE, and
L6 widths, whereas the Class II division 1 group had the
largest UC and LC widths.
3. The Class II division 1 group had the largest arch
depth in all arch depth measurements.
4. No significant difference between malocclusion
types was found in L6 width and depth measurements.
58
5. Females showed a tendency to having smaller arch
dimensions than males in all malocclusion groups.
6. The Class II division 1 group had a
maxillary/mandibular primary second molar difference
smaller than the Class III group.
59
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33. Defraia E, Baroni G, Marinelli A. Dental arch

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34. Baccetti T, Franchi L, McNamara JA, Jr., Tollaro I.
Early dentofacial features of Class II malocclusion: a
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35. Kilic N, Celikoglu M, Oktay H. Effects of the

functional regulator III on transversal changes: a
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Orthod. 2011;33:727-31.
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64
VITA AUCTORIS
Somkamol Vanichvatana was born on May 25, 1985 in
Bangkok, Thailand. He received his D.D.S. (Honors) degree
from Faculty of Dentistry, Chulalongkorn University,
Bangkok, Thailand, in 2008. He pursued his graduate
studies in pediatric dentistry and received a M.Sc.
(Pediatric Dentistry) degree from Faculty of Dentistry,
Chulalongkorn University in 2012. He began his graduate
studies in orthodontics at Saint Louis University in 2013.
He is currently a candidate for the degree of Master of
Science in Dentistry in December 2015.
65

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COMPARISON OF DENTAL ARCH DIMENSIONS OF UNTREATED

MIXED DENTITION PATIENTS WITH CLASS II DIVISION 1,

CLASS II DIVISION 2, AND CLASS III MALOCCLUSION

Somkamol Vanichvatana, D.D.S., M.Sc.

A Thesis Presented to the Graduate Faculty of

Professor Eustaquio A. Araujo,

Professor Rolf G. Behrents

To my father. Although he is no longer here to see my

achievement, I always believe that he would be proud of me.

Without his love, support and patience, I would not be the

To my wife, Dr.Kochanipa, who left her career and

everything behind to come and begin a whole new journey

made it this far without you by my side.

Lastly, to the faculty of Saint Louis University,

whose guidance and instruction have built a strong

foundation for my orthodontic career.

The author wishes to express his sincerest gratitude

to the following individuals:

Dr. Eustaquio Araujo, for serving as chairman of my

thesis committee and for his guidance, encouragement, input

on the project design, and also in providing the knowledge

Dr. Rolf Behrents, for his wise guidance throughout

this project and for allowing me to obtain an orthodontic

education at Saint Louis University.

Dr. Hiroshi Ueno, for his attention to detail during

my thesis preparation and helping me think about the

Dr. William Mastorakos, for providing the samples that

made this thesis possible.

Dr. Heidi Israel, for her patience and assistance with

the statistics for this study.

CHAPTER 2: REVIEW OF THE LITERATURE........................3

CHAPTER 3: JOURNAL ARTICLE................................27

Table 3.1: Characteristics of each study group........... 34

Table 3.2: Comparison of arch dimensions in Class II

Table 3.3: Gender dimorphism of arch dimensions in

Table 3.4: Comparison of maxillary minus mandibular arch

Table 3.5: Gender dimorphism of maxillary minus

Table 3.6: Comparison of the overall mean arch widths

Table 3.7: Comparison of mean arch widths and arch

Table 3.8: Comparison of arch widths studies............. 55

Figure 3.1: Example of digital cast in Class II

Figure 3.2: Example of digital cast in Class II

Figure 3.3: Example of digital cast in Class III group... 36

Figure 3.4: Points used for measurements in molar (A),

Figure 3.5: Measurements of arch width: Maxillary

Figure 3.6: Dash lines represent measurements of arch

Figure 3.7: Maxillary arch shapes of three groups

Figure 3.8: Mandibular arch shapes of three groups

Malocclusion has been associated with bullying,1 poorer

oral health-related quality of life,2 and self-

dissatisfaction with appearance.3 Therefore, early

diagnosis and treatment of malocclusion may be useful for

many patients. Early treatment in orthodontics is the

intervention in the primary, early mixed (permanent first

molars and incisors present), or mid mixed dentition period

(before emergence of first premolars and permanent

mandibular canines) with removable or fixed appliance.4

Several studies have shown that early orthodontic treatment

can significantly reduce the complexity of some cases.5-7

Therefore, it is essential to know the characteristics of

different types of malocclusions in order to create an

appropriate treatment plan.

There are studies that have investigated arch