Relationship of buccolingual inclination between the alveolar bone and first molar in different vertical facial types: a CBCT study

doi:10.21203/rs.3.rs-3787340/v1

Background

This study aimed to investigate the differences in the buccolingual inclination and transverse width of maxillary and mandibular first molars among different vertical facial types.

Methods

In all, 78 samples were divided into three groups based on the GoGn-SN angle: the low-angle group (n = 26, mean age = 24.21 ± 5.11), average-angle group (n = 26, mean age = 22.66 ± 3.72), and high-angle group (n = 26, mean age = 22.23 ± 2.43). Cone beam computed tomography (CBCT) measurements were used to assess the buccolingual inclination of the axis of the maxillary and mandibular first molars, as well as the buccolingual inclination of the basal bone, the dental arch width, and the basal bone width. One-way ANOVA, the LSD test, and Pearson correlation analysis were performed.

Results

The high-angle group showed significantly greater lingual inclination of the maxillary basal bone than the other two groups. The difference in buccolingual inclination of the axis of the maxillary first molar and the basal bone was significantly greater in the high-angle group than in the low-angle group. Both the maxillary and mandibular dental arch were significantly narrower in the high-angle group than in the other two groups. The mandibular basal bone was also significantly narrower in the high-angle group than in the other two groups.

Conclusions

The upper basal bone in the high-angle group showed significantly greater lingual inclination than that in the other two groups. Transverse matching of the maxillary and mandibular dental arch and basal bone in the high-angle group may be achieved through lingual inclination of the maxillary basal bone.

vertical

transverse

buccolingual inclination

basal bone

compensatory

CBCT

The development of the craniofacial complex is crucial for establishing balanced relationships among the teeth, jaws, and other facial tissues^[1]. The growth potential of the craniofacial complex is driven by genetics and influenced by environmental factors^[2]. The craniofacial structure is typically studied in three dimensions: sagittal, vertical, and transverse. In clinical practice, patients often present with simultaneous malocclusion in the sagittal, vertical, and transverse dimensions that are mutually influential, thereby increasing the complexity of orthodontic treatment. In facial growth and development, width is the first dimension to be completely developed, followed by length and height^[3]. Transverse development occurs earliest in three dimensions and has profound effects on subsequent jaw growth. Therefore, addressing transverse problems is a focus in orthodontic treatment, as achieving harmony in transverse relationships plays an important role in establishing ideal occlusal outcomes with aesthetic results that are stable posttreatment. Recent research has focused primarily on sagittal-transverse relationships ^[4–6], but there have been few studies on how vertical facial types affect transverse characteristics.

Fenestrations and dehiscences are manifestations of alveolar bone defects, which essentially result from a mismatch in thickness, width, and angle between the teeth and alveolar bone. In previous studies on vertical and transverse facial types, the width of dental arches has been extensively researched ^[7–9]. Lee et al. ^[10] reported a significant correlation between transverse differences in maxillary and mandibular molar inclination. Jason et al. ^[11] reported that while maxillary molars exhibited greater buccal inclination in the vertical facial type than in the horizontal facial type, there was no statistically significant difference in the inclination of mandibular molars between the two groups. Tsunori et al. ^[12] found that mandibular first molars showed greater lingual inclination in the short facial type. There is still controversy regarding the buccolingual inclination of posterior teeth in different vertical facial types. Ricketts suggested that the long facial type is associated with longer and narrower dental arches, often accompanied by crowded dentition and weaker bite force. On the other hand, the short facial type is associated with shorter and wider dental arches along with a strong, square-shaped mandible ^[13]. The body possesses its own compensatory mechanisms to harmonize vertical differences through changes in dental arch width, basal bone width, and buccolingual tooth inclination. However, it remains unclear whether compensation for transverse differences relies solely on tooth inclination or whether basal bone inclination also plays a role, and there have been few studies on the angle of basal bone inclination ^{[14, 15]}. The relationships between transverse differences in teeth and basal bone inclination in different vertical facial types also remain to be investigated.

The purpose of this study was to investigate the relationship between the transverse width and buccolingual inclination of the first molars and alveolar bone among different vertical facial types, which will help clinicians understand preexisting compensatory mechanisms in natural populations. The results will be beneficial for clinicians to develop appropriate treatment strategies, select suitable torque prescriptions, and prevent movement of teeth beyond physiological limits during the treatment process, thereby avoiding fenestration and dehiscence.

This was a cross-sectional retrospective study in which CBCT data were collected from orthodontic patients treated at the Department of Orthodontics, Affiliated Stomatological Hospital of Zhejiang Chinese Medical University between 2021 and 2023. The inclusion criteria were as follows: (1) age 18-30 years, with permanent dentition; (2) no missing teeth or posterior defects; (3) no full crowns, bridges, or implant restorations on posterior teeth; (4) anterior overbite less than grade II and an overjet less than grade II; (5) posterior crowding less than 4 mm and no crossbite; (6) no history of orthodontic or orthognathic treatment; and (7) no evident craniofacial or spinal deformity or significant facial asymmetry. Samples exhibiting periodontal disease were excluded. A total of 87 samples were collected in this study and divided into three groups based on the GoGn-SN angle: the low-angle group (GoGn-SN <27.7°), average-angle group (27.7°≤GoGn-SN≤37.3°), and high-angle group (GoGn-SN >37.3°). Each group consisted of 26 samples, as shown in Table 1.

Table 1 Descriptive statistics for different vertical facial types
Variable	Low angle	Average angle	High angle	P value
Number	26	26	26
Age	24.21 ± 5.11	22.66 ± 3.72	22.23 ± 2.43	0.165
Sex
Female	11	17	22
Male	15	9	4
GoGn-SN	24.17 ± 2.57	31.19 ± 2.53	41.00 ± 2.57	<0.001***

* P<.05; ** P<.01; *** P<.001

The CBCT data collected in this study were captured using a KAVO OP 3D Vision system (Imaging Sciences International LLC, USA) with a slice thickness of 0.25 mm. The exposure parameters were set at a voltage of 120 kV, current of 5 mA, and duration of 7 s. During the imaging process, the patient sat upright facing straight ahead, keeping the intercuspal position and the Frankfurt horizontal plane parallel to the ground plane. Mimics Research software (Materialise NV, version 21.0.0.406) was utilized to measure the required angles and distances by importing DICOM data for the reconstruction of three-dimensional models of the jawbones and dentition. This approach allowed for precise calibration of the desired points for automated measurements using the "Measurement & Analysis" function under "Analysis".

For measurement and calculations, reference planes were established: the transverse plane (Frankfurt horizontal plane) passed through the bilateral orbital points and midpoint between bilateral porion points; the sagittal plane was a vertical plane passing through the anterior nasal spine point (ANS) and posterior nasal spine point (PNS), perpendicular to the transverse plane; and the coronal plane was a vertical plane passing through the ANS, perpendicular to both the transverse and sagittal planes.

The following measurements were obtained from the maxilla:

1. Buccolingual inclination of the upper first molar (UTA): The angle between the axis of the upper first molar (Fig. 1) and the cut of the sagittal reference plane.

2. Buccolingual inclination of the upper basal bone (UBA): The angle between the axis of the upper basal bone (Fig. 2) and the cut of the sagittal reference plane.

3. Difference in inclination between the upper first molar axis and basal bone axis (UD, UBA minus UTA).

4. Upper first molar dental arch width (UOW; UFAW): The distance between the central O points of the occlusal surface of bilateral maxillary first molars (UOW) and the distance between FA points (UFAW) (Fig. 3).

5. Width of the upper basal bone (UMXW): The distance between bilateral upper Mx points, measured according to the Pennsylvania University's transverse analysis method^[16] (Fig. 4).

The following measurements were obtained from the mandible:

1. Buccolingual inclination of the lower first molar (LTA): This method is consistent with that for the UTA (Fig. 1).

2. Buccolingual inclination of the lower basal bone (LBA): This method is consistent with that for the UBA (Fig. 2).

3. Difference in inclination between the lower first molar axis and basal bone axis (LD, LBA minus LTA).

4. Width of the lower first molar dental arch (LOW; LFAW): This method is consistent with that for the UOW and UFAW (Fig. 3).

5. Width of the lower basal bone (LWLW): The distance between bilateral lower WL points, measured according to the Pennsylvania University's transverse analysis method ^[16] (Fig. 5).

In addition, the difference in width between the upper and lower arch (OD, UOW minus LOW) and the difference in width between the upper and lower basal bone (BD, UMXW minus LWLW) were calculated.

Figure 1 Buccolingual inclination of the upper and lower first molars.

A is the furcation of the upper first molar, and B is the central point of the occlusal surface of the upper first molar. The line AB represents the axis of the upper first molar. N is the furcation of the lower first molar, and M is the central point of the occlusal surface of the lower first molar. The line MN represents the axis of the lower first molar. The inclination of the teeth was positive for buccal inclination and negative for lingual inclination.

Figure 2 Buccolingual inclination of the upper and lower basal bone.

The image shows a cross-section of a tooth passing through the furcation point. C and D indicate the crest on the buccal and palatal side of the upper first molar's alveolar ridge, respectively. H is the midpoint of C and D. A transverse section parallel to the Frankfurt horizontal plane was made at a distance of 9 mm apical from H, and the intersection points between this plane and the buccal and palatal cortical bone are E and F. G is the midpoint of E and F. The line GH represents the buccolingual axis of the upper basal bone. O and P indicate the crest on the buccal and lingual side of the lower first molar's alveolar ridge, respectively. S is the midpoint between O and P. A transverse section parallel to the Frankfurt horizontal plane was made at a distance of 9 mm apical from S, and the intersection points between this plane and the buccal and lingual cortical bone are Q and R. T is the midpoint of Q and R. The line ST represents the buccolingual axis of the lower basal bone. The inclination of the basal bone was positive for buccal inclination and negative for lingual inclination.

Figure 3 Width of the upper and lower dental arch.

I and J represent the central points of the occlusal surface of the upper first molars, and K and L represent the FA points for these teeth. The distance between I and J is UOW, and the distance between K and L is UFAW. U and V are the central points of the occlusal surface of the bilateral mandibular first molars, and W and X are the FA points for these teeth. The distance between U and V is LOW, and the distance between W and X is LFAW.

Figure 4 Width of the upper basal bone.

The coronal section through the bilateral furcation point of the upper first molar is shown. Mx points are located on the right and left sides of the maxillary skeletal base at the depth of the concavity of the lateral maxillary contours, at the junction of the maxilla and the zygomatic buttress. The distance between the bilateral Mx points is UMXW.

Figure 5 Width of the lower basal bone.

The skeletal representation of the WALA ridge, the WL point, is located at the intersection of the transverse section parallel to the Frankfurt horizontal plane and the outer cortical bone on the buccal side, passing through the furcation point of bilateral lower first molars. The distance between bilateral WL points is LWLW.

Statistical analysis

The average values of the angles measured bilaterally were included in the statistical analysis. Statistical analyses were performed using SPSS 25.0 software; all measurement data were normally distributed and had homogeneous variance. Descriptive statistics, including the mean and standard deviation, were calculated for each group. One-way ANOVA and the LSD post hoc test were used to examine differences between groups. Pearson correlation analysis was also conducted to explore the factors influencing the intergroup differences and mandibular plane angle. A P value less than 0.05 was considered to indicate statistical significance.

As shown in Table 2, the UBA in the high-angle group significantly differed from that in the low-angle and average-angle groups, with greater lingual inclination in the high-angle group than in the other two groups. No significant difference was found in the UTA among the three groups. The UD was significantly greater in the high-angle group than in the low-angle group. There were no significant differences in the LBA, LTA or LD among the three groups.

Table 2 Buccolingual inclination of teeth and basal bone in different vertical facial types and their differences
Variable	L	A	H	P value	Post hoc
Number	26	26	26		L vs. A	L vs. H	A vs. H
UBA	-1.19 ± 4.77	-3.47 ± 5.13	-6.18 ± 4.09	0.001		***	*
UTA	3.47 ± 5.55	2.08 ± 7.37	2.18 ± 4.03	0.631
UD	-4.65 ± 5.65	-5.55 ± 5.75	-8.36 ± 4.80	0.042		*
LBA	-2.18 ± 4.99	-3.94 ± 5.55	-3.27 ± 7.28	0.570
LTA	-16.51 ± 4.91	-17.37 ± 6.18	-18.05 ± 4.76	0.580
LD	14.33 ± 4.66	13.43 ± 5.34	6.76

L, low angle; A, average angle; H, high angle

UD and LD represent differences, with the magnitude of their absolute values reflecting the size of the discrepancy.

* P<.05; ** P<.01; *** P<.001

As shown in Table 3, the LOW, LFAW, LWLW, UOW and UFAW were all significantly lower in the high-angle group than in the average-angle and low-angle groups, while there were no significant differences in the UMXW, OD, or BD among the three groups.

Table 3 Width of dental arches and basal bone in different vertical facial types and their differences
Variable	L	A	H	P value	Post hoc
Number	26	26	26		L vs. A	L vs. H	A vs. H
LFAW	55.15 ± 2.25	54.88 ± 2.45	52.93 ± 1.91	0.001		**	**
LOW	44.29 ± 2.35	43.79 ± 2.59	41.80 ± 2.08	0.001		***	**
LWLW	57.72 ± 2.32	57.63 ± 2.24	55.49 ± 2.04	<0.001		***	**
UFAW	59.01 ± 2.80	58.94 ± 2.43	56.70 ± 2.13	0.001		**	**
UOW	49.55 ± 3.30	48.99 ± 2.64	46.69 ± 2.11	0.001		***	**
UMXW	64.75 ± 3.47	64.87 ± 2.99	63.15 ± 3.21	0.106
OD	5.27 ± 1.88	5.20 ± 1.02	4.90 ± 1.38	0.628
BD	7.04 ± 3.31	7.24 ± 2.97	7.66 ± 3.36	0.779

L, low angle; A, average angle; H, high angle

* P<.05; ** P<.01; *** P<.001

As shown in Table 4, Pearson correlation analysis was performed between the measurement items showing statistical significance in the above analysis (UBA, UD, UFAW, UOW, LFAW, LOW, and LWLW) and the GoGn-SN angle. The results showed that the UBA, UD, UFAW, UOW, LFAW, LOW, and LWLW were negatively correlated with the GoGn-SN angle.

Table 4 Correlation analysis
Variable	r	P value
UBA	-0.386	<0.001
UD	-0.235	0.038
UFAW	-0.329	0.003
UOW	-0.372	0.001
LFAW	-0.382	0.001
LOW	-0.391	<0.001
LWLW	-0.371	0.001

* P<.05; ** P<.01; *** P<.001

This study revealed a compensatory lingual inclination of the maxillary basal bone in the high-angle group by analyzing the width and angle of the basal bone and teeth. In the maxilla, there was no significant difference in the basal bone width between the high-angle group and the other two groups, while the dental arch width was significantly reduced. The buccolingual inclination of the maxillary first molar in the high-angle group was not significantly different from that in the other two groups, but there was greater lingual inclination of the basal bone in the high-angle group than in the other two groups. We believe that lingual inclination of the maxillary alveolar bone may occur in the high angle type to compensate for the reduced dental arch width.

In terms of dental arch width, the findings of this study are consistent with those of previous research^{[7, 17]}, indicating a decrease in the dental arch width with an increase in the mandibular plane angle. In the mandible, we found that the basal bone width in the high-angle group was narrower than that in the low-angle group, which is consistent with the findings of previous research^[18]. However, there were no significant differences in the maxillary basal bone width among the three groups, which differs from the findings of previous studies ^[19]. This may be attributed to sex differences within the sample population of this study. We found no statistically significant differences in the OD or BD among the three groups, suggesting a weak relationship between different vertical facial types and transverse dental or skeletal differences in the maxilla and mandible. In terms of the numerical values for the OD and BD, the high-angle group showed larger skeletal differences but smaller dental differences, which was consistent with the findings reported by Chen et al. ^[18], indicating that different vertical facial types may have a greater impact on skeletal width growth than dental arch width growth. Wagner et al. ^[20] revealed that the maxillary basal bone width in patients with different vertical facial types exhibited minimal growth after approximately 14 years of age. Additionally, those in the high-angle group did not exhibit a significant transverse increase in the mandible after 14 years of age, while the mandible of those in both the low-angle and average-angle groups continued to grow until 18 years of age. Iseri et al. ^[21] suggested that the width development of the mandible occurs later than that of the maxilla, continuing until approximately 18 years of age. Due to the earlier completion of maxillary than mandibular width development, insufficient maxillary width can affect mandibular growth and position in early stages, leading to differences in the width of the upper and lower jaws, which may increase over time. Cortella et al. ^[22] not only observed a sequential growth pattern in the transverse dimension of the maxilla and mandible, as previously found by Wagner et al. ^[20] and Iseri et al. ^[21], but also noted more growth in the mandible than the maxilla. They suggested that there is a compensatory mechanism that allows for normal occlusal relationships (no crossbite) among posterior teeth by utilizing transverse differences in both skeletal and dental aspects ^[18].

We simultaneously measured the buccolingual inclination of the upper and lower first molars and found no statistically significant differences among the three groups. This finding is consistent with those of previous studies ^{[23, 24]}. Tsunori et al. ^[12] reported that, in terms of the buccolingual inclination of the basal bone at the lower first molar, the low-angle group exhibited greater lingual inclination than both the average-angle and high-angle groups. Han et al. ^[25] compared the buccolingual inclination of the basal bone at the lower first molar between a horizontal and vertical growth pattern group but observed no significant difference between the two groups. Ravikumar ^[26] proposed a new method for separately measuring the inclination of the maxillary cortical bone on the buccal-palatal side and found greater buccal inclination in both the average-angle and low-angle groups than in the high-angle group. These findings align with our measurements of basal bone axial inclination. In this study, no significant differences were found in terms of basal bone inclination in the mandible among the three groups; however, in the maxilla, the high-angle group exhibited greater lingual inclination than the low-angle and average-angle groups. Based on the results for the width of the maxillary and mandibular dental arch, the width of the basal bone, and the inclination of the basal bone and teeth, it is speculated that the transverse width match in the high-angle group may be achieved through lingual inclination of the maxillary basal bone. Functionally, according to the Moss functional matrix hypothesis, the growth and development of the jawbones are mediated by soft tissues in response to functional demands ^[27]. The morphology of the jawbones is closely related to that of the masticatory muscles and is initially determined by genes; subsequently, the jawbones interact with masticatory muscle groups to form a functional system ^[28]. During the growth period, individuals with a high-angle vertical facial type will have smaller masseter muscle dimensions ^{[29, 30]} and thinner cortical bone on the buccal side ^[31], while those with a low-angle vertical facial type will have thicker bone structures for stronger support. This may contribute to the transmission of chewing pressure from the molar area through the teeth, alveolar bone, basal bone, and zygomatic process pillar to the frontal bone and cranial base and might also partially explain why the basal bone exhibited greater palatal inclination in the high-angle group than in the low-angle group.

In addition, the axis of the basal bone was determined by selecting the tangent line of the buccal or lingual cortical bone in the maxilla ^[26], while in the mandible, a line connecting the lowest point of its inferior border with the midpoint of the buccolingual crest was used as a reference ^{[12, 14, 25]}. However, due to its irregular shape, it is difficult to divide the jawbone into two parts using a straight line. Therefore, in this study, we attempted to select the basal bone at the tooth location as much as possible when determining the axis. This method provides additional direct information for studying the root-bone relationship and can partially avoid variations caused by highly variable lowest points on the mandible's inferior border and irregularities in jawbone structure.

Currently, arch expansion is commonly used to create space in clinical practice. Different types of expansion appliances, such as tooth-borne, bone-borne, and tissue– bone-borne types, are utilized due to variations in buccal inclination ^{[32, 33]}. Based on the results of this study, it is important for orthodontists to carefully consider the difference in inclination between the maxillary teeth and basal bone in patients with a high-angle vertical facial type who need expansion treatment. Before treatment, CBCT should be used to assess the inclination and the amount of buccopalatal bone mass. This approach will help prevent complications such as fenestration and dehiscence during the expansion process. We will continue to investigate the distance between tooth roots and alveolar bone in different vertical bone facial types, such as whether the midsection of palatal roots in high-angle individuals is closer to the palatal cortical bone and whether the buccal cortical bone is farther from the midsection of the buccal roots. Enhos et al.^[34] reported a lower incidence of maxillary first molar fenestration in high-angle individuals than low-angle individuals. Currently, there is limited research on alveolar bone fenestration and dehiscence in patients with different vertical facial skeletal patterns. However, the occurrence of fenestration and dehiscence is related not only to the difference in inclination between the teeth and basal bone but also to the thickness of the buccal and palatal cortical bone, as well as the alveolar bone^[6]. Fenestration and dehiscence may even be associated with root curvature and deformation. Therefore, further research is needed.

The upper basal bone showed significantly greater lingual inclination in the high-angle group than the other two groups. The difference in inclination between the upper first molar axis and basal bone axis in the high-angle group was significantly greater than that in the low-angle group.

The coordination between the dental arch and the basal bone for the maxilla and the mandible in the high-angle group may be achieved through palatal inclination of the maxillary basal bone.

It is necessary for orthodontists to carefully evaluate patients' CBCT results before expansion treatment, especially in those with a high-angle vertical facial pattern, to prevent bone fenestration and dehiscence.

Ethics approval and consent to participate

The study protocol received approval from the institutional Ethics Committee of the Hospital of Stomatology, Zhejiang Chinese Medical University

Consent for publication

Not applicable

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests

The authors declare that they have no competing interests

Funding

Not applicable

Authors' contributions

X.C.: Conceptualization, Methodology, Writing-Original draft preparation.

H.T.: Editing, Data collection

Y.Z.: Methodology, Data collection, Statistical analysis.

X.L.: Supervision, Conceptualization, Project administration, Review & Editing.

All authors read and approved the final manuscript.

Acknowledgements

This manuscript was edited for proper English language, grammar, punctuation, spelling by one or more of the highly qualified native English speaking editors at American Journal Experts (AJE).

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No competing interests reported.

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Relationship of buccolingual inclination between the alveolar bone and first molar in different vertical facial types: a CBCT study

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Introduction

Materials and Methods

Results

Discussion

Conclusions

Declarations

References

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1