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Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 3  |  Page : 115-121

A comparison between panoramic radiography and dental study model for space maintainer


1 Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Brawijaya, 65145 Malang, Indonesia
2 Department of Dental Radiology, General Hospital, Universitas Brawijaya, 65145 Malang, Indonesia

Date of Submission24-Feb-2021
Date of Decision03-Aug-2021
Date of Acceptance29-Aug-2021
Date of Web Publication18-Oct-2021

Correspondence Address:
Muhammad Chair Effendi
Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Brawijaya, Jl. Veteran, 65145 Malang, East Java.
Indonesia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/SDJ.SDJ_82_21

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  Abstract 

Background: A space maintainer is an appliance used to maintain the jaw space due to the premature loss of deciduous teeth. Moyer’s method is used to determine the need for a space maintainer by measuring the discrepancy. Objective: The aim of this article is to determine the difference between measurements using Moyer’s method on a dental study model and on panoramic radiographs. Methods: Researchers measured the available space in 60 dental study models using two methods—the segmental method and contouring of the jaw arch using a 0.6 mm diameter arch wire. Moyer’s prediction table was used to predict the mesial-distal width of the permanent canines and premolars. Software ImageJ (SIJ) was used to measure the available space and required space on panoramic radiographs. We performed image calibration so that the measurement results could be presented in millimeters. Results: There was no significant difference (P = 0.935) in the discrepancy prediction between the panoramic radiographs and the dental study model. The Bland—Altman test result showed no significant difference, and the conformity between the panoramic radiographs and the dental study model was 0.02770. The sensitivity and specificity values of the panoramic radiographs and dental study model were above the 50% line. The area under curve values of the panoramic radiographs and dental study model were considered to be very good. Conclusion: Application of Moyer’s method to panoramic radiographs using SIJ to determine space maintainer requirements can be performed on pediatric patients to predict special discrepancies.

Keywords: Deciduous, panoramic, space maintainer


How to cite this article:
Effendi MC, Pramartika B, Rachmawati D. A comparison between panoramic radiography and dental study model for space maintainer. Sci Dent J 2021;5:115-21

How to cite this URL:
Effendi MC, Pramartika B, Rachmawati D. A comparison between panoramic radiography and dental study model for space maintainer. Sci Dent J [serial online] 2021 [cited 2021 Nov 27];5:115-21. Available from: https://www.scidentj.com/text.asp?2021/5/3/115/328426




  Background Top


Data from World Health Organization (WHO) showed that the rates of dental caries in school-age children were 60—90%, and nearly 100% of dental caries in adults caused pain and discomfort.[1] The percentage of people who had dental and oral health problems was 57.6%, the percentage of people who brush their teeth properly was 2.8%, and the percentage who received dental treatment from the dentist was 10.2%.[2] Dental caries, dental trauma, abnormal resorption, or systemic disease can cause premature loss of deciduous teeth.[3],[4] The prevalence of premature deciduous tooth loss was 41.2% in primary first molars, 37.3% in primary canines, and 21.6% in primary second molars.[5]

Premature loss of the deciduous teeth causes problems such as tooth alignment changes and changes to the size of the dental arch. The space created due to the premature loss of deciduous teeth causes migration of the surrounding teeth, so that the space becomes narrower. The effects of dental space loss are tooth crowding, ectopic eruption, supra-eruption of opposing teeth, impacted permanent teeth, shifting of the permanent first molars, and cross-bite.[6],[7],[8] Dentists usually use a space maintainer for pediatric patients with premature loss of deciduous teeth. A space maintainer is an appliance used to maintain the space due to the premature loss of deciduous teeth until the eruption of the permanent teeth. Space maintainers are used to prevent malocclusion during mixed tooth periods by detecting tooth size differences.[9],[10]

A mixed dentition analysis is the first step to determine a treatment plan for patients with mixed dentition. Mixed dentition analysis allows the identification of tooth size and the discrepancy between the available space and the required space. Based on the results of mixed dentition analysis, the dentist can plan dental treatment, for example, eruption guidance, space reclamation, a space maintainer, serial extractions, or keeping the dental growth under observation.[11] Moyer’s mixed dentition space analysis method is the most frequently used method. Moyer’s analysis uses a probability table to predict the mesial-distal diameter of the canines and premolars in both arches.[12] It does not require specific equipment, and it uses a dental cast to measure the available space and required space measurement.[13]

The dentist usually uses panoramic photographs to evaluate maxillofacial deformities and lesions in the oral and maxillofacial region. In our current research, the researchers modified Moyer’s analysis using a panoramic radiograph instead of a dental cast. This was intended to simplify the discrepancy assessment for space maintainers. The aim of our study was to determine the difference between the predictions of discrepancy using Moyer’s method on a dental cast and on panoramic radiographs. The study hypothesis was that there is no difference between the prediction of discrepancy using Moyer’s analysis (MDA) on a dental cast and a panoramic radiograph.


  Materials and Methods Top


The research method was quasi-experimental with a cross-sectional design. The study samples were derived from the existing medical records (secondary data) of the Department of Pediatric Dentistry, Faculty of Dentistry, Universitas Brawijaya, Malang, Indonesia. The study was approved by the Ethics Commission of the Faculty of Medicine, Universitas Brawijaya, Indonesia (No. 211/EC/KEPK-S1/12/2020). The sample size was 60 with an age range of 8—12 years. The samples consisted of 27 females and 33 males. All of the panoramic radiographs were taken using Instrumentarium OP 200D-1 Digital Panoramic and Cephalometric System (70 kVp, 8 mA, 12 s; Instrumentarium Dental, Tuusula, Finland).

The inclusion criteria were medical records of patients who had no history of orthodontic treatment, high-quality dental casts, high-quality panoramic radiographs, class I first molar occlusion, end-to-end permanent first molar occlusion, panoramic radiographs with complete permanent tooth buds, good permanent incisive relation, and permanent tooth buds still covered with alveolar bone. The exclusion criteria were dental casts with restorations or proximal fractures, class II or III permanent first molar occlusion, overbites and overjet of more than 4 mm, dental impressions with tooth abnormalities (number, shape, and size), patients with systemic disease, and patients with craniofacial anomalies.

The measurement of available space in the dental study model

There are two methods to measure the available space: (1) the segmental method and (2) contouring the jaw arch using a 0.6 mm diameter arch wire. The authors used the segmental method if there was excessive loss of tooth contact points due to dental caries and there was a significant tooth premature loss. The upper and lower model was divided into three segments: segment (a), the distance from the distal contact point of the second deciduous molar to the distal deciduous canine; segment (b), the mesiodistal width of the deciduous canine crown; and segment (c), the distance from the distal contact point of the lateral incisor to the mesial of the central incisor. The measurement was taken on both sides. The measurement of each contact point was performed with a caliper from the left side to the right side, as shown in [Figure 1]A.[14]
Figure 1: (A) The measurement of the available space using the segmental method. (B) The measurement of the available space using 0.6 mm diameter arch wire

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The authors performed the second method, using an arch wire, when there was excessive loss of tooth contact points due to dental caries, rotational teeth, and the number of teeth that were prematurely lost. The researcher calculated the available space using a 0.6 mm diameter arch wire. The authors traced the occlusal surface along the incisal edge from the mesial contact points of the right first permanent molar to the mesial of the left first permanent molar or vice versa [Figure 1]B. Afterward, the arch wire was straightened, and its length was measured with a millimeter ruler.[15]

Specifically for the mandible, the occlusion relation of the first permanent molar (i.e., an end-to-end occlusion or class I occlusion relation) was necessarily determined to assess the available space. Once the end-to-end occlusion relation was determined, the molar correction could be performed. In this case, the available space was the difference between the distance mesial permanent M1 to M1 (the segmental method or with the curved wire) and the corrected molar.[14],[16]

The required space was the predicted width of the mandibular canines and premolars on both sides. It was obtained by summing the mesial-distal measurements of the mandibular incisors. Afterward, Moyer’s prediction table was used to predict the mesial-distal width of the canines and premolars. After that, the authors summed the result (the predicted mesial-distal width of the canines and premolars) with the sum of the mesial-distal distance of the mandibular/maxilla incisor crowns to get the required space measurement. Moyer’s method provides a closer prediction of the mesial-distal dimensions of canines and premolars than other methods.[12],[16] Furthermore, the authors calculated the discrepancy, defined as the difference between the available space and the required space.

The available space and required space measurement on panoramic radiograph

Image processing software ImageJ (FIJI; Eliceiri/LOCI Lab, WI, USA and MPI-CBG, Dresden, Germany) was utilized to measure the available and required space on panoramic radiographs. Image calibration was performed so that the measurement results could be presented in millimeters. This was done by entering a known standard value on the scale setting menu. Afterward, the authors entered the measurement unit. ImageJ then displayed the calibration function. The available space was found by measuring the distance between the right mesial permanent first molar and the left mesial permanent first molar [Figure 2]A. The required space was obtained by measuring the greatest mesial-distal distance of the mandibular/maxilla incisor crowns [Figure 2]B. Thereafter, the authors summed the result with the predicted mesial-distal width of the mandibular canines and premolars obtained from Moyer’s prediction table.
Figure 2: (A) Available space measurement by measuring the distance between the right mesial permanent first molar and the left mesial permanent first molar. (B) Required space measurement by measuring the greatest mesial-distal distance of the incisor crowns. After that, the researcher summed the result with the predicted mesial-distal width of the canines and premolars (Moyer’s prediction)

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Statistical analysis

A paired t-test was used to evaluate the differences between the discrepancy using Moyer’s MDA on the dental study models and panoramic radiographs. A Bland—Altman test (mean difference or limits of agreement) was used to analyze the mean difference or agreement between Moyer’s MDA in the dental study models and panoramic radiographs. The area under curve (AUC) was used as a diagnostic test for the measurement of the discrepancy on the panoramic photo and the dental study model. The AUC also provided sensitivity and specificity values that represented the overall diagnostic performance of each variable in the discrepancy measurement. The data were statistically analyzed using the Statistical Package for Social Sciences software (IBM Corp.; Armonk, NY, USA).


  Results Top


The paired t-test result [Figure 3] shows that the mean discrepancy prediction using panoramic radiography was −0.3244, whereas that of the dental study model was −0.2967. The mean difference between the two measurements was −0.02770, which means that it was not statistically significant (P = 0.935).
Figure 3: Mean of the discrepancy prediction using panoramic radiographs and the dental study model. ns = not significant

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The Bland—Altman test was performed to analyze the agreement between the discrepancy predictions on the panoramic radiograph and the dental study model. If the difference between the variable is zero, then there is no difference [Table 1]. The result showed that the mean difference was 0.02770 and the P-value was 0.935 (P > 0.05). The mean difference between the panoramic radiography and dental study model predictions was at the limit of agreement, no more than 5.
Table 1: Mean difference

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AUC values were used for diagnostic tests of the discrepancy prediction of the panoramic radiograph and dental study models. The discrepancy prediction was in the range of −3 to 3 mm. The sensitivity value of the panoramic radiograph was 86.2%, and the specificity value was 100%. The sensitivity value of the dental study model was 100% and the specificity value was 100%. The diagnostic value of the discrepancy prediction of the panoramic radiograph and dental study models was above the 50% line [Figure 4]. In [Table 2], the AUC value of the panoramic radiograph was 0.931 or 93.1% (>90—100%), which was considered to be very good (P = 0.039). The AUC value of the dental study model discrepancy prediction was 100% (>90—100%), which was considered excellent (P = 0.017).
Figure 4: AUC of the discrepancy prediction of panoramic radiography and the dental study model. The diagnostic value was above the 50% line. *Receiver operating characteristic curve analysis for medical diagnostic test evaluation

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Table 2: Area under the curve

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  Discussion Top


The best way to maintain the space needed for permanent tooth eruptions is by maintaining the health of the deciduous teeth. When there was premature tooth loss, space maintainers were needed to help children both functionally and aesthetically.[17] Nowadays, the lack of space for permanent dentition becomes an orthodontic problem. The treatment and observation of the jaw arch during the growth of deciduous teeth, mixed teeth, and permanent teeth affect the development of future occlusion.[18]

There are a variety of methods for estimating the size of the unerupted teeth in patients with mixed dentition by using dental casts and radiographs.[13] It is deemed mandatory to predict the discrepancy between available and required space to determine whether there is a lack or an excess of space for permanent tooth eruption before we make the space maintainer. Prediction of the unerupted tooth size at the mixed tooth stage is a key factor in determining a treatment plan and malocclusion management.[19],[20],[21]

The t-test result [Figure 3] showed that there was no significant difference between the mean differences found using panoramic radiography (−0.3244) and the dental study model (−0.2967). Based on the Bland—Altman test result, the mean difference of the discrepancy prediction was 0.02770, the value of P was 0.935 (P > 0.05), and the limit of the agreement did not exceed 5. It represented no difference between the prediction of discrepancy using panoramic radiography and the dental study model [Table 1]. This result is in line with the previous studies. Previous results showed that linear measurements on panoramic radiographs were reliable in the posterior mandibular area and that measurement errors were small for all dimensions.[22],[23] The magnification deviation was ±5%.[23]

The sensitivity analysis is a test that determines a tool’s ability to correctly classify individuals affected by a disorder. The specificity test demonstrates the ability of the tool to correctly classify an individual as disease-free. Low sensitivity means that the tool missed many affected individuals. Low specificity means that the tool puts a large number of people in the affected group, even though they do not have the disease. If a tool has low sensitivity and specificity, it means that the tool has low accuracy.[24],[25],[26] In this study, the diagnostic test determined that the leeway predictions are limited within the range of −3 to 3 mm, which means that when lacking space of more than −3 mm and excessing in space of more than 3 mm, the patient does not need a space maintainer.

The panoramic radiographic sensitivity value was 86.2%, and the specificity value was 100%. The sensitivity of the dental study model was 100%, and the specificity value was also 100%. Both of these values were above the 50% line [Figure 4]. The panoramic radiographic prediction sensitivity value was 86.2%, indicating that the ability to classify patients who require room maintenance was 86.2%, and a probability of false-negative was 13.8%. The panoramic radiograph prediction specificity was 100%, which indicates that panoramic radiography has the ability to correctly classify patients who do not require a space maintainer. The sensitivity and specificity values of the dental study model prediction were both 100%, indicating that there were no false-negatives or false-positives. The diagnostic test of discrepancy prediction on panoramic radiography was 0.931 or 93.1%, which was considered to be very good. The diagnostic test of discrepancy prediction on the dental study model was 1.00 or 100%, which was also considered to be very good [Table 2].

In some cases, pediatric patients may have psychological issues such as fear and anxiety that cause them to avoid dental treatment such as dental impressions. This makes it difficult for the operator to make a high-quality dental cast for space maintainer measurement.[27] The application of Moyer’s method with SIJ on panoramic radiographs can eliminate psychological barriers for pediatric patients during the dental molding process. Panoramic radiography has several advantages, including relatively low radiation, relatively short exposure time, and relatively cheap cost. However, panoramic radiography also has disadvantages, one of which is the distortion caused by incorrect positioning of the head during the exposure process.[28] This imaging method is sensitive to head position because the focal trough or image layer is thin, especially in the anterior region.[29],[30] Measurements of the anterior mandibular are less reliable than those of the posterior. However, this can be minimized by correctly positioning the patient’s head.[22]


  Conclusion Top


There was no significant difference in the discrepancy prediction, and there were agreements between the mean result of Moyer’s method on panoramic radiographs and the dental study model. The sensitivity and specificity values of the panoramic radiographs and the dental study models were above the 50% line. The AUC values of the panoramic radiographs and dental study models were both considered to be very good. Therefore, modification of Moyer’s method on panoramic radiographs using SIJ for space maintainers can be performed in pediatric patients. One of the potential problems with panoramic radiography is the distortion caused by incorrect head positioning during the exposure process. However, we can minimize the distortion and improve the measurement accuracy by positioning the patient’s head correctly. Further research still needs to be performed with a larger sample to get more accurate results. Appropriate software is also needed to determine indications for space maintainers using much more up-to-date modalities, such as 3D CBCT or a digital dental study model.

Financial support and sponsorship

No funding was received for conducting this study. The sample for our study was derived from the existing medical records (secondary data) of the Department of Pedodontics Dentistry of Brawijaya Dental Hospital.

Conflicts of interest

The authors declare that they have no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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