A CBCT Evaluation of Root Position in Bone Long Axis Inc - 2019 - Seminars in O PDF
A CBCT Evaluation of Root Position in Bone Long Axis Inc - 2019 - Seminars in O PDF
A CBCT Evaluation of Root Position in Bone Long Axis Inc - 2019 - Seminars in O PDF
Correct tooth position in all planes of space while respecting the boundaries
of the underlying bone is important for stability of teeth after orthodontic
treatment as well as the health of the supporting periodontium.1,2 The aim of
this study was to determine: 1) if mandibular posterior teeth are more cen-
tered over basal bone when they are more upright or close to WALA Ridge
norms proposed by Andrews3; 2) if mandibular posterior teeth are more cen-
tered in alveolar bone when they are more upright or close to the WALA
Ridge norms; 3) if the estimated center of resistance mandibular posterior
teeth is most often centered in alveolar bone; and 4) if the WALA Ridge is
located at or near the estimated center of resistance of mandibular posterior
teeth. A sample of 34 pre-treatment CBCT scans and mandibular casts of
patients ages 12 18 were included in the study. CBCT scans were digitized
and analyzed using the Carestream 3D Imaging Software Version 3.5.7.
Casts were digitally scanned using the Ortho Insight 3D scanner. The WALA
Ridge horizontal measurements were made using the Six ElementsTM soft-
ware (MotionView, Chattanooga, TN). The WALA Ridge vertical measure-
ments were obtained from the casts using a digital caliper. Coronal CBCT
images were used to measure tooth positions of pre-treatment mandibular
posterior teeth relative to surrounding bone. Centeredness of teeth within
the bone was quantified and compared to their inclination and to the WALA
Ridge location: D1, D2, D3 and D4. Data were analyzed using the JMP version
10 SAS Software. Descriptive statistics were used to calculate the mean,
standard deviation, minimum, and maximum values for the distance
between WALA Ridge vertical and CR, D2, D3 and D4 for each of the poste-
rior teeth. Single linear regression analysis was performed to evaluate the
relationship between both the long axis inclination and WALA Ridge varia-
bles compared to the D1, D2, D3, variables. No statistical significance was
found for centeredness of mandibular posterior teeth over basal bone when
they were more upright or approached WALA Ridge norms. No statistical
significance was found for centeredness of mandibular posterior teeth in
alveolar bone when they were more upright or approached the WALA Ridge
norms. Significant differences were found for the mandibular posterior teeth
center of resistance being centered in the alveolar bone regardless of the
long axis inclination or WALA Ridge norms (p-value <0.05). Significant differ-
ences were also found for the Wala Ridge being located at or near the center
of resistance of mandibular posterior teeth (p-value <0.05). 1) More upright
mandibular posterior teeth based on long axis inclination or mandibular
Private practice, 200 Carmichael Way, Chesapeake, Virginia, USA; Department of Orthodontics, Medical University of South Carolina, 173
Ashley Avenue, Charleston, South Carolina, USA; Department of Orthodontics, West Virginia University, 1 Medical Center Drive, Morgantown,
West Virginia, USA.
Corresponding author. E-mail: [email protected]
© 2019 Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2019.02.004
posterior teeth more closely related to the WALA Ridge landmark are not
more centered over basal bone. 2) More upright mandibular posterior teeth
based on long axis inclination or teeth more closely related to the WALA
Ridge landmark are not more centered in alveolar bone. 3) The center of
resistance of all mandibular posterior teeth can most often be found in the
center of the alveolar bone regardless of inclination. 4) The WALA Ridge is
located at or near the center of resistance for all mandibular posterior teeth.
5) The WALA Ridge may be a useful landmark for customizing mandibular
arch form if teeth are tipped to an upright position. (Semin Orthod 2019;
25:24–35) © 2019 Published by Elsevier Inc.
Results
Descriptive statistics
Figure 7. Measuring center of resistance in the sagit-
tal view. Descriptive statistics were used to determine
the mean, standard deviation, minimum and
maximum a p-values for each of the variables
Measurement of center of alveolar bone to center (Tables 4 & 5). Table 4 shows that using a
of resistance one-sample t-test there was statistical signifi-
cance (p-value < .05) for all four variables
Alveolar bone measurements were measured at the (P1-D4), (P2-D4), (M1-D4), and (M2-D4).
center of resistance point (CR) and the apex point Table 5 summarizes the variables assessing the
alveolar (APA) for each of the posterior teeth. The centeredness of the center of resistance to
buccal lingual distance from the alveolar bone inter- alveolar bone (D1), the apex point to alveolar
nal cortex was measured at CR and APA. These val- bone (D2), and the apex point to basal bone
ues were divided in half to approximate the center (D3). The results show statistical significance
of the alveolar bone at these two locations repre- (p-value < .05) for all points except (P1-D3),
sented by ABC1 and ABC2, respectively. The dis- (P2-D2), and (M1-D2). Although most varia-
tance of CR and APA to the alveolar center point bles were small numbers several were relatively
was designated as D1 and D2 respectively (Fig. 9). larger either in mean or standard deviation
(P1-D3), (P2-D3), M1-D3), (M2-D3).
Measurement of center of basal bone (BBC) to
apex of basal bone (APB) Single linear regression analysis
Basal bone measurements were measured at the Tables 6 12 show the correlation between the
basal bone center point (BBC) which was located long axis inclination and the variables D1, D2,
A CBCT evaluation of root position in bone 29
Figure 8. Schematic demonstrating data points and reference lines. See Table 2 for descriptions of points and lines.
and D3 using single linear regression analysis. with a p-value of 0.036. The apex points alveolar
Correlation was also performed between WALA (D2) showed correlation at the first premolar
Ridge variables and the variables D1, D2, and D3. (P1) with a p-value of 0.0049, however no other
At the level of the center of resistance (D1) there teeth at this level in the bone showed correlation
was only correlation at the second molar (M2) with statistical significance. At the level of the
basal bone (D3) there was again correlation with
the first premolar (P1) with a p-value of 0.0485.
The second premolar (P2), first molar (M1), and
second molar (M2) showed no correlation with
statistical significance. It should also be noted that
Figure 9. Alveolar bone measurements in the coronal Figure 10. Basal bone measurements in the coronal
view. view.
30 Glass et al
Table 4. Distance between WALA vertical and center of resistance (D4) for posterior teeth
Variable Mean Std dev Std Err Mean Upper 95% Mean Lower 95% Mean P-value
P1-D4 1.25 0.811 0.139 1.533 0.966 <0.0001
P2-D4 1.68 0.753 0.129 1.948 1.422 <0.0001
M1-D4 0.86 0.646 0.11 1.09 0.639 0.0024
M2-D4 1.56 0.818 0.14 1.846 1.275 <0.0001
Table 5. Distance from ABC2 to CR (D1), distance from ABC1 to APA (D2) and distance from BBC to APB (D3)
for posterior teeth
Variable Mean Std dev Std Err Mean Upper 95% Mean Lower 95% Mean P-value
P1-D1 0.511 0.545 0.093 0.702 0.321 <0.001*
P1-D2 0.838 1.601 0.274 1.397 0.279 0.0045*
P1-D3 0.305 2.734 0.468 1.259 ¡0.648 0.5187
P2-D1 0.411 0.664 0.113 0.643 0.18 0.001*
P2-D2 ¡0.105 1.521 0.26 0.425 ¡0.636 0.6875
P2-D3 ¡1.423 1.985 0.3405 ¡0.73 ¡2.116 0.0002*
M1-D1 0.2147 0.4936 0.0846 0.3869 0.0424 0.0161*
M1-D2 ¡0.294 1.94 0.332 0.382 ¡0.971 0.383
M1-D3 ¡1.997 2.02 0.347 ¡1.29 ¡2.7 <0.0001*
M2-D1 ¡0.638 0.993 0.17 ¡0.291 ¡0.984 0.0007*
M2-D2 ¡1.626 1.574 0.2699 ¡1.0771 ¡2.175 <0.0001*
M2-D3 ¡3.35 1.88 0.324 ¡2.69 ¡4.01 <0.0001*
* = p < .05.
although the first premolar (P1) showed statistical regarding use of the WALA Ridge as an ana-
significance it closely approached the cut off for tomic landmark for defining an optimal man-
significance. dibular arch form with teeth at ideal
The variable DWALA shows no correlation for inclination and roots centered over basal bone
any posterior teeth at the center of resistance loca- and within alveolar bone.
tion (D1). At apex point alveolar the second molar Previous studies provided strong evidence of a
(M2) has statistical significance with a p-value of highly significant statistical correlation between
0.0111. P1, P2, and M1 show no correlation. At the the FA Points of mandibular crowns and the
level of the basal bone the second molar (M2) has WALA Ridge.13 The current study did not sup-
statistical significance with a p-value of 0.032. P1, P2, port statistically Andrews’s proposal that mandib-
and M1 show no correlation. ular teeth aligned to the WALA Ridge had roots
As for correlation between the long axis incli- more centered in alveolar bone or over basal
nation and DWALA, significant differences bone.
(p-value <0.05) were found for the second pre- However, findings did indicate clinical signifi-
molar (P2) and first molar (M1). P2 had a cance that the tooth center of resistance was cen-
p-value of 0.0414. M1 had a p-value of <0.0001 tered in the alveolar bone. In addition, the current
showing very strong correlation. There was no study likewise found clinical significance that the
correlation found for the first premolar (P1) or estimated vertical position of the center of resis-
second molar (M2). P1 had a p-value of 0.7985 tance of the teeth and the vertical position of the
and M2 with a p-value of 0.1387. WALA Ridge coincided for all teeth, the means
and standard deviations being less than 1.0 mm.
In light of these findings, it is perhaps worth
Discussion
considering a broader perspective on tradition-
This study specifically investigated the concept ally accepted concepts of optimal root position
that more ideally inclined mandibular poste- over/in bone as well as the possible usefulness of
rior teeth have roots more centered over basal the WALA Ridge as a landmark for clinically
bone and more centered in alveolar bone. In defining the mandibular arch form (size and
addition, it examined the proposal by Andrews shape).
A CBCT evaluation of root position in bone 31
Table 6. Long axis Inclination/center of resistance in Table 10. DWALA/apex point in alveolar bone
alveolar bone
Linear Fit R square p-value for testing slope = 0
Linear Fit R square p-value for testing slope = 0 P1-DWALA/P1-D2 0.0108 0.5585
P1-LAI/P1-D1 0.0614 0.157 P2-DWALA/P2-D2 0.0001 0.9516
P2-LAI/P2-D1 0.0153 0.485 M1-DWALA/M1-D2 0.0375 0.2719
M1-LAI/M1-D1 0.0007 0.88 M2-DWALA/M2-D2 0.1852 0.0111*
M2-LAI/M2-D1 0.129 0.036*
* = p < .05.
* = p < .05.
Table 7. Long axis inclination/apex point in alveolar Table 11. DWALA/apex point over basal bone
bone
Linear Fit R square p-value for testing slope = 0
Linear Fit R square p-value for testing slope = 0 P1-DWALA/P1-D3 0.0021 0.793
P1-LAI/P1-D2 0.222 0.0049* P2-DWALA/P2-D3 0.003 0.7578
P2-LAI/P2-D2 0.051 0.1961 M1-DWALA/M1-D3 0.0126 0.527
M1-LAI/M1-D2 0.0071 0.6334 M2-DWALA/M2-D3 0.2403 .0032*
M2-LAI/M2-D12 0.0083 0.6068
* = p < .05.
* = p < .05.
Figure 12. Mandibular incisor “centered” in tear- Figure 15. Alveolar process cantilevered over “basal
drop-shaped alveolar process/symphysis. (For inter- bone”. (For interpretation of the references to colour
pretation of the references to colour in this figure in this figure legend, the reader is referred to the web
legend, the reader is referred to the web version of version of this article.)
this article.)