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A CBCT evaluation of root position in

bone, long axis inclination and


relationship to the WALA Ridge
Timothy R. Glass, Timothy Tremont, Chris A. Martin, and Peter W. Ngan

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: pngan@hsc.wvu.edu
© 2019 Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0
https://doi.org/10.1053/j.sodo.2019.02.004

24 Seminars in Orthodontics, Vol 25, No 1, 2019: pp 24 35


A CBCT evaluation of root position in bone 25

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.

Introduction Damon8 (2005) suggested that the use of light


continuous orthodontic force could be used in
orrect tooth position in all planes of space
C while respecting the boundaries of the
underlying bone is important for stability of teeth
crowded cases to expand the alveolar bone and
maintain its integrity. Previous studies including
Howes9 (1947) and Downs10 (1948) have
after orthodontic treatment as well as the health
attempted to locate basal bone with little consen-
of the supporting periodontium.1,2 Despite all
sus. Not surprisingly, confusion still exists among
the research over many decades, clinicians are
clinicians and researchers as to the location of
still divided, leading to debate on extraction ver-
basal bone and its true relevance to stable clinical
sus non-extraction.3 It is generally believed that
orthodontic treatment.
when tooth mass is too small relative to basal
The Six Elements of Orofacial HarmonyTM
bone, interdental spacing or diastemas will likely
developed by Andrews presents a set of parame-
occur. Conversely, if the basal bone in the body
ters and guidelines to aid in obtaining optimal
of the mandible is too small relative to tooth
goals for the teeth, arches, and jaws.11 Element I
mass, teeth will be crowded. To this point, suc-
states that an optimal arch exists when teeth are
cessful alignment of the teeth, among other fac-
centered over basal bone and the clinical crowns
tors, is dependent on the size of the basal bone
are optimally inclined so that the occlusal surfa-
in relation to the tooth mass.4 Does this mean
ces can interface and function ideally with the
that teeth should be centered over basal bone?
teeth in the opposing arch.12 Andrews proposed
The term “basal bone” has been used loosely
using the WALA Ridge to serve as a landmark for
for decades to describe the bone over which
assessing mandibular arch form (size and shape)
teeth should be positioned to obtain stability for
which in turn can provide a template for the
both function and health. According to several
maxillary arch form. The WALA Ridge is a band
authors, basal bone is the bone that underlies,
of soft tissue immediately coronal to the muco-
supports, and is continuous with the alveolar pro-
gingival junction of the mandible and suggested
cess.5 The term “apical base” was first introduced
to be at or near the level of the center of resis-
by Lundstrom in 1923 but failed to stimulate a
tance of the teeth (Fig. 1).12 This landmark aids
sufficient response until Tweed presented the
the clinician in establishing the correct arch
concept again in 1944 as “basal bone”.6 Tweed
form leading to the most ideal tooth position in
defined basal bone as the bony ridge over which
the mandible relative to the basal bone.12
the mandibular central incisors must be situated
The objectives of this study were to investigate
to produce permanence of orthodontic results.
1) if mandibular posterior teeth are more cen-
The focus of Tweed’s research was to find the
tered over basal bone when they are more
most stable lower incisor position relative to the
upright or close to the WALA Ridge norms; 2) if
underlying basal bone to prevent post orthodon-
mandibular posterior teeth are more centered in
tic relapse.
alveolar bone when they are more upright or
Lundstrom (1925) theorized that the apical
close to the WALA Ridge norms; 3) if the esti-
base did not change to fit the normal occlusion
mated center of resistance of mandibular poste-
but rather the establishment of normal occlusion
rior teeth is most often centered in alveolar
was controlled by the apical base.7 In contrast
26 Glass et al

bone; and 4) if the WALA Ridge is located at or


near the estimated center of resistance of man-
dibular molar and premolar teeth.

Methods and materials


IRB exemption was obtained from the West Vir-
ginia University Institutional Review Board prior
to the start of this study (#1506708605). Pre-treat-
ment orthodontic records including CBCT scans
and mandibular casts were obtained from the Figure 2. WALA Ridge was identified on a cast with a
orthodontic practice of Dr. CR. The inclusion cri- red pencil. (For interpretation of the references to col-
teria include patients 12 18 years of age in the our in this figure legend, the reader is referred to the
web version of this article.)
permanent dentition with no previous orthodon-
tic treatment, who had a pretreatment cone beam
computed tomography scan, and a mandibular with red pencil (Fig. 2). A stainless steel end-
study cast taken prior to orthodontic treatment. odontic ruler (Miltex by Integra, Patterson Com-
The exclusion criteria included presence of any pany, Saint Paul, MN) was then laid across the
craniofacial anomalies; absence of mandibular occlusal surface of each second molar (M2), first
first and second molars; absence of mandibular molar (M1), second premolar (P2), and first pre-
first and second premolars; abnormal root mor- molar (P1) and its contralateral counterpart
phology; and any previous orthodontic treatment. (Fig. 3). A digital caliper was used to measure
The CBCT scans were digitized and analyzed the distance in millimeters from the top surface
using the Carestream 3D Imaging Software Ver- of the ruler to the WALA Ridge on each tooth
sion 3.5.7. Mandibular casts were digitally scanned (Fig. 4). To account for the ruler thickness,
using the Ortho Insight 3D scanner (MotionView 0.5 mm was subtracted from each measurement.
Software, Chattanooga, TN). The WALA Ridge
horizontal was measured using the Six Elements
WALA ridge horizontal measurements
of Orofacial HarmonyTM software (MotionView
Software, Chattanooga, TN). Coronal CBCT The WALA Ridge horizontal was measured using
images were used to measure tooth positions of the Six ElementsTM software (Fig. 5). The digital
pre-treatment molars and premolars. models were calibrated, and landmarks were
identified according to the software specifica-
tions. WALA Ridge horizontal measurements
WALA ridge vertical measurements
(WH) of the second molars (M2), first molars
The WALA Ridge landmark according to (M1), second premolars (P2), and first premo-
Andrews was identified on each cast and marked lars (P1) were obtained. Once the measurements

Figure 3. A stainless steel endodontic ruler was laid


across the occlusal surface of each posterior tooth for
Figure 1. Schematic depicting WALA Ridge, FA Point, vertical measurements from the ruler to the WALA
Center of Resistance, and Basal Bone. Ridge.
A CBCT evaluation of root position in bone 27

Table 2. Data points & reference lines


Points Description
ROP Reference Occlusal Plane
CR Center of Resistance
ABC2 Alveolar Bone Center at level of Center of Resistance
Location
ABC1 Alveolar Bone Center at level of Apex Location
APA Apex Point Alveolar Bone
APB Apex Point Basal Bone
BBC Basal Bone Center
IBB Most Inferior Basal Bone Border
LAI Tooth Long Axis Inclination (degrees)
WV WALA Vertical
WH WALA Horizontal

Figure 4. Digital caliper was used to measure the dis-


tance from the ruler to the WALA Ridge or WALA
Ridge vertical (WV).
descriptions. Table 3 shows the CBCT variables
included in the study. The following measure-
ments were made for each of the posterior
teeth including the second molar (M2), first
molar (M1), second premolar (P2) and first pre-
molars (P1).

Long axis inclination (LAI) of posterior teeth


Relative to the Reference Occlusal Plane, the
long axis inclination (LAI) of each of the man-
dibular posterior teeth was measured from the
long axis of the clinical crown., (Fig. 6).

Figure 5. WALA Ridge using the 6 Elements software.


Measurement of WALA ridge vertical (WV) to
center of resistance (CR)
were made, each of the values were subtracted
from the norms proposed by Andrews (Table 1).3 The center of resistance (CR) of each of the pos-
This new value, DWALA, represents the differ- terior teeth was first measured first from the sag-
ence between the actual values and the norm ittal view. The CR of molars were measured from
(DWALA = WALA Ridge horizontal measure- the top of the clinical crown to the furcation
ment norm value). area (Fig. 7). The CR of premolars were mea-
sured from the top of the clinical crown to 1/3
of the distance from the alveolar crest to the
Measurements from CBCT scans
apex. The CR and WALA vertical measurements
All CBCT DICOM files were de-identified and were then transferred to the coronal view
downloaded onto the Carestream 3D Imaging (Fig. 8). The distance between CR and WALA
Software Version 3.5.7 for data collection. Table 2 vertical was then measured and designated as
shows the data points and reference line D4.

Table 3. CBCT variables


Table 1. WALA ridge horizontal norms per Andrews3
Variable Definition
Tooth Type WALA Horizontal Norms (mm)
D1 Distance from ABC2 to CR
First Premolar 0.8 D2 Distance from ABC1 to APA
Second Premolar 1.3 D3 Distance from BBC to APB
First Molar 2.0 D4 Distance from WALA Vertical to CR
Second Molar 2.2 LAI Angle measurement of tooth long axis at ROP
28 Glass et al

vertically by taking half the distance from the tooth


apex to the most inferior basal bone border (IBB).
Once this vertical position was identified, the buc-
cal lingual distance from the basal bone internal
cortex was measured. This value was divided in
half to approximate the center of the basal bone
(BBC). The apex point basal bone (APB) was
then constructed with a line from the tooth apex
perpendicular to the ROP to identify the apex
location relative to the basal bone. The distance
between BBC to APB was measured and desig-
nated as D3 (Fig. 10).

Figure 6. Measurement of LAI with reference to ROP. Data analysis


Data were analyzed using the JMP version 10 SAS
Software. Descriptive statistics were performed to
calculate the mean, standard deviation, mini-
mum, and maximum for the distance between
WALA vertical and CR, D2, D3 and D4 for each
of the posterior teeth. Single linear regression
analysis was performed to evaluate the relation-
ship between both the long axis inclination and
WALA Ridge variables compared to D1, D2, and
D3, variables.

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.

Table 12. Long axis inclination/DWALA


Table 8. Long axis inclination/apex point over basal Linear Fit R square p-value for testing slope = 0
bone P1-LAI/P1-DWALA 0.002 0.7985
Linear Fit R square p-value for testing slope = 0 P2-LAI/P2-DWALA 0.123 0.0414*
M1-LAI/M1-DWALA 0.461 <0.0001*
P1-LAI/P1-D3 0.116 0.0485* M2-LAI/M2-DWALA 0.067 0.1387
P2-LAI/P2-D3 0.0661 0.1421
M1-LAI/M1-D3 0.0357 0.2842 * = p < .05.
M2-LAI/M2-D3 0.0086 0.6009

* = p < .05. note the absence of significant “basal bone” in


the edentulous maxilla.
Table 9. DWALA/center of resistance in alveolar
The concept of centeredness seems to often
bone work well for incisors (Fig. 12). Frequently the
symphysis and alveolar process is a tear-dropped
Linear Fit R square p-value for testing slope = 0
form and our sense of symmetry fits well with the
P1-DWALA/P1-D1 0.0214 0.4091 concept of “centeredness” of the root position.
P2-DWALA/P2-D1 0.0029 0.7609
M1-DWALA/M1-D1 0.0172 0.459
Other images display an alveolar process and
M2-DWALA/M2-D1 0.00229 0.7879 incisor root position that make it difficult to sug-
gest an optimal position of the root over the obli-
que underlying symphyseal bone (Fig. 13).
Furthermore, while the tear-dropped incisor/
“Basal bone” appears to be a term uniquely chin form is common, examination of posterior
used in orthodontics. Anatomists are generally teeth associated alveolar bone and the underly-
not familiar with the term and find no structural ing bone rarely demonstrate a symmetrical form
or histologic difference between alveolar bone (Fig. 14). In fact, the alveolar process anatomi-
and the bone it resides upon. As seen in Fig. 11, cally appears somewhat cantilevered from the
it is tempting to define bone remaining after underlying bone (Fig. 15).
resorption of alveolar bone in an edentulous Before additional discussion, it is worth noting
patient as “basal bone” and tempting to make a that the current study found the centers of resis-
subjective assumption that optimally positioned tance of mandibular posterior teeth were cen-
teeth are centered over this bone. Interestingly, tered in alveolar bone and were also correlated
32 Glass et al

Figure 14. Mandibular molar, alveolar process and


“basal bone”.

Figure 11. Edentulous maxilla and mandible.

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.)

be made for the usefulness of the WALA Ridge


for defining an optimal mandibular arch form
in size and shape (the “centeredness” of the
root over the basal bone and within the alveolar
bone aside). Biomechanically, a single buccally
applied force to a tooth crown will result in tip-
ping of the tooth near the center of resistance of
the tooth (Fig. 16). Therefore, arch wires shaped
to the WALA Ridge in concept would tip teeth to
an upright position with the center of resistance
remaining centered in the alveolar bone.
Further discussion suggests that the concept
of root “centeredness” over basal bone and in
Figure 13. Mandibular incisor in oblique-shaped alve- alveolar bone may be a subjective and unsubstan-
olar process/symphysis.
tiated objective for orthodontists to treatment
plan. Certainly, it may be useful to eliminate use
to the WALA Ridge vertically. With consideration of the term “basal bone”. The eruption of teeth
of previous studies showing the highly significant is what develops alveolar bone; teeth do not
correlation between the WALA Ridge and the erupt into alveolar bone. In addition, there is
FA points of crowns,8 a strong argument can wide variation in the thickness of the
A CBCT evaluation of root position in bone 33

Figure 17. Upright maxillary and mandibular molars;


crossbite - maxillary skeletal expansion indicated.
Figure 16. Buccally applied force which would cause a
tipping movement with a moment and a center of
rotation near a center of resistance. depicts a condition with no crossbite, upright man-
dibular posterior teeth, and buccally inclined maxil-
dentoalveolar process among patients. Consider- lary posterior teeth. Maxillary transverse skeletal
ation should be given to a perspective that equal expansion is needed if the maxillary teeth are
amounts of alveolar bone on the buccal and lin- tipped palatally to an upright position. Fig. 20 shows
gual of roots, or “centeredness”, is perhaps not a situation where there is no crossbite but maxillary
essential as long as there is adequate bone. Cer- teeth are inclined buccally and mandibular poste-
tain compromised periodontal conditions can be rior teeth are inclined lingually, an indication for
managed with periodontal therapy if necessary.
From a stability perspective, the value of main-
taining a root’s center of resistance centered in
alveolar bone while only tipping the tooth to an
upright position is certainly worth attention.
Additional significance to this notion is apparent
from awareness that tipping posterior teeth to an
upright position can define a customized mandibu-
lar arch form (size and shape) unique to each indi-
vidual. An existing optimal or corrected mandibular
arch form derived in this manner can serve as a tem-
plate for a preferred maxillary arch form in size and
shape. As seen in a Fig. 17 schematic, upright man-
dibular posterior teeth in crossbite with upright
maxillary posterior teeth is a condition indicating a
maxillary skeletal transverse discrepancy and a need
for skeletal expansion. Likewise, Fig. 18 shows lin-
gually inclined mandibular posterior teeth not in
crossbite with upright maxillary posterior teeth. This
Figure 18. Lingually inclined mandibular molars;
also indicates a condition for maxillary skeletal upright maxillary molars; no crossbite-maxillary skele-
expansion if the mandibular posterior teeth are tal expansion indicated if mandibular molars are buc-
tipped buccally to an upright position. Fig. 19 cally tipped to upright position.
34 Glass et al

Figure 21. Lingually inclined maxillary and mandibu-


lar molars; no crossbite no maxillary skeletal expan-
Figure 19. Upright mandibular molars; buccally sion indicated if maxillary and mandibular molars are
inclined maxillary molars; no crossbite maxillary tipped buccally to upright positions.
skeletal expansion indicated if maxillary molars are
tipped palatally to upright position.

maxillary skeletal expansion if teeth in both arches


are tipped to upright positions. And finally, Fig. 21
depicts a condition where mandibular and maxillary
teeth are lingually/palatally inclined and no cross-
bite. Buccal tipping of posterior teeth in both arches
results in no need for maxillary skeletal expansion.
In the absence of a reliable landmark for
mandibular arch form, expansion and upright-
ing of the lower arch involving bodily move-
ment would move the center of resistance of
the teeth buccally, potentially compromising
the periodontium, and arbitrarily dictating the
maxillary transverse arch dimension.
Of note, is the relatively small values of all the
data and the statistical interpretation whereby
there is little clinical significance of the differences.
Additional research should repeat this type of study
addressing the “centeredness” of untreated teeth
with and without optimal inclination. Also, long
term prospective randomized controlled trials
investigating the “centeredness” of the center of
Figure 20. Buccally inclined maxillary molars; lingually
inclined mandibular molars; no crossbite maxillary resistance, and the long-term stability and peri-
skeletal expansion indicated if maxillary molars are odontal health of teeth with and without mandibu-
tipped palatally to upright position and mandibular lar arch forms developed per the WALA Ridge and
molars are tipped buccally to upright position. tipping would help clarify the concepts.
A CBCT evaluation of root position in bone 35

Conclusions 2. Vaden JL, Klontz H, Dale J. Standard edgewise: tweed


Merrifield philosophy, diagnosis, treatment planning
1. More upright posterior teeth based on the long and force systems. In: Current Principles and Techni-
axis inclination are not statistically more centered ques, 6th edition, ed. Graber LW, Vanarsdall RL, Vig
KWL, Hwang GJ, Elsevier, St. Louis, Missouri, Chapter
in alveolar bone or over basal bone, however, the
19, pp. 485.
difference is clinically insignificant. 3. Baumrind S, Korn EL, Boyd RL, Maxwell R. The deci-
2. Teeth more closely related to the WALA Ridge sion to extract II. Analysis of clinicians’ stated reasons
landmark are not statistically more centered in for extraction. Am J Orthod Dentofacial Orthop. 1996;109
alveolar bone or over basal bone, however, the (4):393–402.
4. Bell GD. Three-dimensional cone beam computerized
difference is clinically insignificant.
tomography assessment of basal bone parameters and
3. The WALA Ridge landmark is within clinical sig- crowding 2008.
nificance of being located vertically at or near 5. Daskalogiannakis J. Glossary of orthodontic terms. Am J
the center of resistance for all posterior teeth. Orthod Dentofacial Orthop. 2002;122(3):335.
4. Considering the clinical significance of the 6. Tweed CW. A philosophy of orthodontic treatment. Am J
Orthod Oral Surg. 1945;31:74–103.
location of the center of resistance of poste-
7. Lundstrom AF. Malocclusion of the teeth regarded as a
rior teeth in alveolar bone and to the WALA problem in connection with the apical base. International
ridge, the WALA ridge may be a useful land- Journal of Orthodontia, Oral Surgery and Radiography.
mark for customizing mandibular arch form if 1925;11(9):793–812.
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9. Howes A. Expansion as a treatment procedure Where
Acknowledgement does it stand today? Am J Orthod. 1960;46(7):515–534.
10. Downs WB. Variations in facial relationships: Their sig-
The authors wish to thank Dr. Carl Roy of Vir- nificance in treatment and prognosis. Am J Orthod.
ginia Beach, Virginia for providing the CBCT 2008;134(3):430–438.
scans of patients from his office for this study. 11. Andrews LF. The 6-elements orthodontic philosophy:
treatment goals, classification, and rules for treating.
Am J Orthod Dentofacial Orthop. 2015;148:883–887.
12. Andrews LF. The six keys to normal occlusion. Am J
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1. Singh G. Retention and relapse in orthodontics. In: Text- 13. Ronay V, Miner RM, Will LA, Arai K. Mandibular arch
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