Original Research Article

Comparison of Incisor, Molar & Lower Anterior Facial Divergence in

Hypodivergent, Hyperdivergent and Normodivergent Patient:
A Study Model and Cephalometric Study
Jignesh Keshubhai Kakadiya1,*, Prabhuraj Kambalyal2, Mukesh single3, Jyoti Jingar4, Pradeep Vishnoi5
1,3,4,5Post graduate student, 2Professor and Head, Dept. of orthodontics and Dentofacial Orthopedics,
Darshan Dental College and Hospital, Udaipur.

*Corresponding Author
E-mail: [email protected]

Abstract
Background: There is a strong genetic influence in determination of tooth dimensions bearing an influence on the facial
dimension.
Aims and Objective:-To determine a correlation between clinical crown height of upper and lower permanent incisor (11 and
41), molar (16 and 46) and lower facial height clinically and cephalometrically in males and females.
Materials & Methods:-A sample of 180 patients were (90 males and 90 females) included in our study, (60-hypodivergent, 60-
normodivrgent and 60-hyperdivergent) with an age range of 17-25 years. Three anthropometric measurements were considered.
The lower facial height from subnasale(Sn) to menton, and cephalometric lower facial height distance from anterior nasal
spine(ANS) to menton and the clinical crown height of maxillary and mandibular incisors and molars were measured.
Observations:-Significant difference was observed in relation to 16 in normodivergent patient and lower facial height clinically
and cephalometrically in hyperdivergent growth patient. No significant difference between clinical & cephalometric lower facial
height in normodivergent, hypodivergent and hyperdivergent male and female patient. Significant difference was observed
between 41 to lower facial height in hypodivergent & 11, 41 & 46 to lower facial height in hyper divergent patient.
Conclusion:-A strong significant correlation was observed with clinical crown height of lower central incisor and lower facial
height in hyper divergent and hypodivergent patient.

Keywords: Clinical crown height of incisor & molar, Lower facial height, Lateral cephalogram.

Introduction jaws with the rest of the face have obvious clinical
Dental size and shape has been commonly used to importance in cases of severe open bite and cases of
learn biological relationships among human deep bite.6
populations.1 A well balanced attractive face generally In the cephalometric literature it has become
indicate a straight profile with equal proportion of increasingly clear that the cephalometric characteristics
upper, middle and lower facial thirds. Profile as well as of a long or short face structure are predominantly
height of face, helps in diagnosing gross deviation in located below the palatal plane.7 Vertical growth of the
maxilla-mandibular relationship both Antero-Posteri- maxilla has much relevant importance and is closely
orly and vertically.2 associated with overall facial proportions and together
The facial height of young adult subject is regarded with the growth of the maxillary posterior alveolar
a potential determinant in developing the facial process is the primary cause of increase in anterior
harmony and the esthetic. Moreover, they are essential facial height.8
factors in designing the facial type.3 The alveolar structure is a flexible area located
The lower facial height is an important component between the facial skeleton and occlusal dynamics.
of face. Patient with different malocclusions present Maintaining its growth for many years, this structure
with varying lower anterior facial heights.4 The facial tries to establish and maintain occlusal relationships on
height distance is potentially affected by the more the basis of changing mandibular and maxillary
increment or reduction through the compensatory relationship.9
growth pattern of the basoalveolar bone, and the dental The growth of condyle and alveolar process act as
eruption. The divergent growth pattern of the facial final equalizing factors; and the upper and lower dental
bones permits the vertical growth of the dentoalveolar and alveolar arches can be considered as a kind of
components.5 flexible ribbon, adapted to varying jaw relationships
Vertical measurements in cephalometric analysis and flexible ribbon, adapted to varying jaw relation-
have received little attention because of large number of ships and thereby maintaining the normal relationship
horizontal measurements, and few studies have been between dental arches for aesthetics and function.
devoted directly to facial esthetics that would enable a The proper diagnosis and classification of
person to distinguish which dimensions of face and individual patients is of paramount importance for
teeth are responsible primarily for a pleasant or an successful treatment planning in orthodontics. Such a
unpleasant face. However the vertical relationships of diagnosis includes careful evaluation of the dento-facial
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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

complex in the anteroposterior, transverse, and vertical Table 1: Sample division into vertical and horizontal
dimensions. Skeletal dysplasia in any dimension facial types using jarabak’s ratio
typically complicates treatment, and may implicitly Group Sex Jarabak’s Total
warrant or preclude certain treatments. Malocclusions ratio (%) sample
of a skeletal nature can be especially difficult to treat, Normodivergent Male 62-65 30
and therefore are particularly important to diagnose Female 62-65 30
correctly.10 Evaluation of facial proportions and Hyperdivergent Male <62 30
aesthetics should be conducted during clinical Female <62 30
examination and the findings should be compared with Hypodivergent Male <65 30
cephalometric radiographs.11 Female <65 30
Clinical crown height is a type of dental height
which is usually measured to determine the dimension Study Design
of a tooth. Both clinical crown height and facial height A cross sectional study was conducted which
are affected by both genetic and environmental factors. included a total of 180 patients, out of which 90 were
The greater molar height can be influenced by different males and 90 were females (60 hypodivergent, 60
facial growth types and directions. normodivrgent and 60 hyper divergent). A purposive
The aim of our study was to determine whether a convenience type sampling technique was carried out to
correlation existed between clinical crown height of select the patients included in the study. Patients
maxillary and mandibular right permanent incisor, included in the study were under the age group ranging
molar and lower facial height clinically and cephalome- from 17 to 25 years. Patients who had undergone any
trically. orthodontic treatment and who did not wish to give
informed consent were excluded from the study.
Material and Methods Informed consent was obtained from all the patients
Source of data: Study sample consisted of 180 patients included in the study. The landmarks utilized in the
reporting to the Department of Orthodontics & study are enlisted in Table 2. The length of clinical
Dentofacial Orthopedics, Darshan Dental College & crown was measured by means of a slide gauge with
Hospital, Udaipur, Rajasthan. sharpened points for the maxillary central incisor and
Inclusion Criteria: 1st molar and mandibular central incisor and 1 st molar.
1. Patient between 17 to 25 years of age These records were taken on the facial surface of each
2. No missing teeth crown from cusp tip or incisal edge to the deepest
3. Full complement of teeth till permanent second curvature of the gingival margin for 11, 41. The
molar measurements on the molar for 16 & 26 teeth were
4. Normal overjet & overbite & proportionate made at the mesiobuccal cusp (fig. 1). All the
upper and lower facial height parameters were measured twice at different interval
5. No history of previous orthodontic therapy and the average readings were calculated and recorded
6. No history of trauma or surgery in the by two investigators one for clinical crown height and
dentofacial region one for lower facial height & Lateral Cephalogram
7. No facial asymmetry respectively. The investigators were blinded for their
8. Angle’s class I molar relationship individual measurements respectively. Three anthropo-
Exclusion Criteria: metric measurements were measured; one was of soft
1. Pre-pubertal patient tissue and two of hard tissues. In soft tissue the lower
2. Patients associated with some syndrome facial height was measured from soft tissue subnasale to
3. Patients having any tooth agenesis or soft tissue menton (Fig. 2). In hard tissue the clinical
supernumeraries, developmental anomalies, crown height of right central incisors and first
traumatic injuries or fractured upper and lower permanent molars of upper and lower teeth were
incisors and molars, complex craniofacial measured clinically (Fig. 3 A-D) & in cephalometric
deformities or syndromes lower facial height was measured from hard tissue
anterior nasal spine to hard tissue menton (Fig. 4).
Mean and standard deviation was calculated for all
individual parameters, T test was carried out to
determine significance among the samples included for
the study with respect to 11, 16, 41, 46 and lower facial
height clinical & cephalometric. Correlation coefficient
was also determined with 11, 16, 41, and 46 to lower
facial height.

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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

Table 2: List of Landmarks utilized in the study

Landmarks Definition
Soft tissue subnasale The point at which the columella merges with the upper lip in
the midsagittal plane.
Soft tissue menton Lowest point on the contour of the soft tissue chin. Found by
dropping perpendicular from the horizontal plane through
skeletal menton.
01Lower facial height Millimetric measurement from soft tissue subnasale to soft
clinical tissue menton.
Lower facial height The linear distance from anterior nasal spine (ANS) to
cephalometric menton.
Clinical crown height Measurement of crown that can be seen intraorally.

Fig. 1: Measurement of Incisor and Molar by Slide gauge

Fig. 2: Measurement of Lower Facial Height

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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

Fig. 3: Measurement of clinical crown height (A-11; B-16; C-41; D-46)

Fig. 4: Measurement of Cephalometric Lower Facial Height

Results
A mean age of 20.67±1.34 and 20.64±1.34 years was observed with males and females in hypodivergent,
hyperdivergent and normodivergent. A statistically non-significant difference was observed for age in between
males and females in hypodivergent, hyperdivergent and normodivergent.
On an overall a mean value of 10.08±0.89 mm and 9.92±1.00 mm for normodivergent, 10.37±1.28 mm and
9.85±1.01 mm for hypodivergent & 10.68±1.16 mm and 10.27±0.90 mm for hyperdivergent of clinical crown height
of maxillary right central incisor was observed for males and females (Graph 1).
A mean value of 6.53±0.54 mm and 6.02±0.77 mm for normodivergent, 6.47±0.90 mm and 6.12±0.67 mm for
hypodivergent & 6.63±0.82 mm and 6.47±0.88 mm for hyperdivergent of clinical crown height of maxillary right
permanent molar was observed for males and females (Graph 2).
Clinical crown height of right lower incisor revealed a mean value of 8.14±1.18 mm and 8.45±1.09 mm for
normodivergent, 8.40±0.98 mm and 8.11±1.22 mm for hypodivergent & 8.63±1.29 mm and 8.80±1.13 mm for
hyperdivergent for males and females (Graph 3).
A mean value of 6.35±0.77 mm and 6.37±0.57 mm for normodivergent, 6.53±0.61 mm and 6.45±0.76 mm for
hypodivergent & 6.68±0.90 mm and 6.58±0.62 mm for hyperdivergent of clinical crown height of right lower
permanent molar was observed for males and females (Graph 4).
Lower facial height had a mean value of 68.18±4.83 mm and 66.63±5.29 mm for normodivergent, 66.93±5.07
mm and 66.40±3.21 mm for hypodivergent & 76.73±5.47 mm and 71.30±5.75 mm for hyperdivergent for males and
females respectively (Graph 5).
Cephalometric Lower facial height had a mean value of 69.73±4.81 mm and 67.53±5.93 mm for
normodivergent, 67.67±5.47 mm and 67.13±3.22 mm for hypodivergent & 77.93±5.67 mm and 72.97±6.31 mm for
hyperdivergent for males and females respectively (Graph 6).

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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

Graph 1: Mean and standard deviation of clinical crown height of 11

Graph 2: Mean and standard deviation of clinical crown height of 16

Graph 3: Mean and standard deviation of clinical crown height of 41

Graph 4: Mean and standard deviation of clinical crown height of 46

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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

Graph 5: Mean and standard deviation of Soft tissue Lower facial height(mm)

Graph 6: Mean and standard deviation of cephalometrically Lower facial height(mm)

On Statistical analysis, high significance was observed for 16 in normodivergent and lower facial height
clinically and cephalometrically in Hyperdivergent (Table 3).

Table 3: T test 11, 16, 41, 46, clinical lower facial height and cephalometric lower facial height
Normodivergent Hypodivergentl Hyperdivergent
t- value P value t- value P value t- value P value
11 0.68 0.498 1.74 0.088 1.56 0.124
41 -1.06 0.295 1.00 0.320 -0.53 0.596
16 3.01 0.004** 1.71 0.092 0.76 0.451
46 -0.10 0.924 0.47 0.642 0.50 0.619
Clinical lower facial height 1.03 0.306 0.49 0.628 3.75 0.000**
Cephalometric lower facial height 1.58 0.120 0.46 0.647 3.21 0.002**
P>0.05 (NS); P<0.05 (S); P<0.01 (HS)

Not statistically significant was observed on comparison between clinical lower facial and cephalometric lower
facial height in male and female (Table 4).

Table 4: Comparison between clinical lower facial height and cephalometric lower facial height in male and
female
Clinically and cephalometrically lower Female Male
facial height t- value p-value t- value p-value
Normodivergent 0.48 0.631 1.25 0.218
Hypodivergent 0.88 0.381 0.54 0.592
Hyperdivergent 1.07 0.289 0.83 0.408
Total 1.23 0.219 1.14 0.254
P>0.05 (NS); P<0.05 (S); P<0.01 (HS)
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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

In males correlation coefficient was determined of 11, 16, 41, and 46 to soft tissue lower facial height. In
hypodivergent patient 41 is highly statistically significant with respect to lower facial height. In hyperdivergent
patient 11 & 41 is statistically significant and 46 highly statistically significant with respect to lower facial height
(Table 5).

Table 5: Correlation coefficient (p-value) soft tissue lower facial height for male
Normodivergent Hypodivergent Hyperdivergent
Tooth no. Lower facial height Lower facial height Lower facial height
11 -0.004 (0.985) 0.283 (0.130) 0.373(0.042)*
16 0.193 (0.308) 0.283 (0.130) 0.220(0.243)
41 0.080 (0.672) 0.534 (0.002)** 0.380(0.038)*
46 0.136 (0.475) 0.150 (0.429) 0.480(0.007)**
P>0.05 (NS); P<0.05 (S); P<0.01 (HS)

In females correlation coefficient was determined of 11, 16, 41, and 46 to soft tissue lower facial height. In
hypodivergent & hyperdivergent patient 41 is statistically significant with respect to lower facial height (Table 6).

Table 6: Correlation coefficient (p-value) soft tissue lower facial height for female
Normodivergent Hypodivergent Hyperdivergent
Tooth no. Lower facial height Lower facial height Lower facial height
11 0.092 (0.629) 0.115 (0.546) 0.098(0.608)
16 0.090 (0.638) 0.018 (0.926) 0.057(0.767)
41 -0.231 (0.219) 0.433 (0.017)* 0.393(0.032)*
46 0.044 (0.818) -0.048 (0.801) 0.202(0.285)
P>0.05 (NS); P<0.05 (S); P<0.01 (HS)

When comparison of correlation coefficient between lower facial height of 11,16,41 and 46 to males and
females was done, in hypodivergent patient 41 was seen to be statistically highly significant & in hyperdivergent
patient 11 & 41 were statistically significant & 46 statistical highly significant (Table 7).

Table 7: Comparison of correlation coefficient (p-value) soft tissue lower facial height for male and female
Normodivergent Hypodivergent Hyperdivergent
Tooth Lower facial height Lower facial height Lower facial height
no. male Female P value male female P value Male Female P vale
11 -0.004 0.092 0.647 0.283 0.115 0.072 0.373 0.098 0.018*
16 0.193 0.090 0.200 0.283 0.018 0.113 0.220 0.057 0.214
41 0.080 -0.231 0.478 0.534 0.433 0.000** 0.380 0.393 0.015*
46 0.136 0.044 0.493 0.150 -0.048 0.630 0.480 0.202 0.007**
P>0.05 (NS); P<0.05 (S); P<0.01 (HS)

Discussion significant role in determining an orthodontic treatment

A perfect smile is an important component of planning and the smile makeover of a patient.1
esthetics and this goes beyond having white and straight Literature also suggests that clinical crown height
teeth. Vertical proportions of both face and dentition and lower facial height gets affected in patients who
play a significant role to determine the facial attractive- have undergone orthodontic treatment. When age of
ness and identity of an individual.1 The proportion of samples included in the study was compared for males
facial structures and the relationship between facial and females a statistical non significance was observed.
measurements and natural teeth is used as a guide to Probable cause for such an observation could be
achieve facial harmony and esthetics for an individual.2 attributed to the study design, in which the samples
Orthodontically when a patient is visualized for the included in the study had an age range of 17-25 years.
treatment; macro-esthetics, mini- esthetics and micro- On an overall the clinical crown height of 11, 16,
esthetic measurements are taken into consideration.14,15 clinically lower facial height and cephalometric lower
All the parameters i.e. macro, mini and micro- facial height were both clinically and statistically larger
esthetics are considered while planning an orthodontic in males in comparison to females in Normodivergent,
treatment and smile designing. Hence the lower facial hyperdivergent and hypodivergent patient. The clinical
height and the clinical crown height of incisor play a crown height 41, 46 in hypodivergent patient & clinical
crown height 46 in hyperdivergent patient were both
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Jignesh Keshubhai Kakadiya et al. Comparison of Incisor, Molar & Lower Anterior Facial Divergence in…..

clinically and statistically larger in male in comparison measurements was accomplished in the hyperdivergent
to female. (Table 2). By Zarana Purohit the clinical patterns, all the teeth appeared supra-erupted. The
crown height of 16, 41, 46 and lower facial height were anterior dental height in hyperdivergent patients
both clinically and statistically larger in males in increased approximately twice as much as the posterior
comparison to females.1 Our observations correlated dental height. In hypodivergent and hyperdivergent
with observations made by Morley J, Eubank J.1 skeletal dysplasias, the anterior teeth were infra-erupted
However, the clinical crown height of 11 was found to and supraerupted, respectively, more than the posterior
be smaller in males in comparison to females. teeth. The showed significant increases as the vertical
T test was carried out to determine significance height increased.
among the samples included for the study with respect The overbite was shown to increase significantly
to 11, 16, 41, 46 and clinically & cephalometrically over normal patterns in hypodivergent patterns and to
lower facial height. Statistical significance was decrease significantly in hyperdivergent patterns. There
observed in 16 in normodivergent and clinically & were no correlations between proportional dental
cephalometric lower facial height in hyperdivergent as heights and overbite in any of the vertical classifica-
observed in table 3. By Zarana Purohit Statistical tions. Relatively few correlations between proportional
significance was observed among all the parameters dental heights were recorded for the skeletal dysplasias
except for 16 and 41 and lower facial height. other than the teeth proportioned with each other. The
The lower facial height is influenced by both hyperdivergent vertical patterns showed correlations
maxillary and mandibular jaws. Movable mandibular between all proportional dental heights except 16. No
jaw could be attributed for such an observation. The correlations existed between dental height and amount
lower third of face is further divided into upper 1/3rd of discrepancy present.
and lower 2/3rd a further study has to be conducted to When comparison of correlation coefficient
find out a correlation of the clinical crown height and between lower facial height of 11, 16, 41, and 46 to
lower facial thirds. No Statistical significance was males and females was done in hypodivergent patient
observed in clinically and cephalometric lower facial lower central incisor & in hyperdivergent patient
height in normodivergent, hypodivergent & clinical central upper incisor, central lower incisor and
hyperdivergent. (Table 4) molar revealed statistical significance. 11, 41 and 46
When correlation coefficient was determined in revealed significance at 99% confidence interval in
males with 11, 16, 41, and 46 to lower facial height a hyperdivergent (Table 7).
strong statistical significant correlation was observed
with 41 to lower facial height in hypodivergent & 11, Conclusion
41 & 46 to lower facial height in hyperdivergent (Table On an overall statistically and clinically, male had
5). In females a strong correlation coefficient was a larger height of both clinical crown height and lower
observed with 41 to lower facial height. This facial height clinically and cephalometric in
observation revealed that 41 had significant correlation hypodivergent, normodivergent and hyperdivergent
both clinically and statistically in hypodivergent and patient except 41 in hyperdivergent and normodiver-
hyperdivergent patient (Table 4). gent. Clinical crown height of 11, 41, 46 had significant
We found that 41 contributed more proportionally positive correlation with lower facial height in
to lower facial height than the maxillary dental height. hyperdivergent patient. And 41 had significant positive
The proportionally dental heights in hypodivergent correlation with lower facial height in hypodivergent
types showed no significant except 41 differences from patient. A further study has to be conducted to find out
the proportional dental heights in normodivergent a correlation of the clinical crown height and lower
patients. The hyperdivergent patient, however, recorded facial thirds.
significant differences of except 16 of all of their
proportional dental heights when compared to Conflict of Interest: None
normodivergent patient (Table 7). by R.J. Parlow The
proportionally dental heights in hypodivergent types Source of Support: Nil
showed no significant differences from the proportional
dental heights in normal patients. References
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