Original Article

Evidence favoring a secular reduction in mandibular leeway space

Tyler R. Allena; Terry M. Trojanb; Edward F. Harrisc

ABSTRACT
Objective: Researchers have documented secular trends in tooth size among recent generations.
This study was a test for a change in mandibular leeway space.
Materials and Methods: Dental casts from participants in the Denver Growth Study (23 boys, 22

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girls; born in the 1930s) were compared with casts from a contemporary series of orthodontic
patients (23 boys, 22 girls; born in the 1990s). All were phenotypically normal, healthy American
whites.
Results: Analysis of variance (accounting for sex) showed that the cumulative mandibular primary
canine plus first and second primary molar size (c þ m1 þ m2) was slightly larger in the recent
cohort (23.53 mm earlier vs 23.83 mm recent cohort; mean difference: 0.30 mm; P ¼ .009),
principally due to larger second primary molars (m2) in the recent cohort. In turn, the sum of the
permanent canine and two premolars (C þ P1 þ P2) was significantly larger in the recent cohort
(21.08 mm earlier vs 21.80 mm recent cohort; mean difference: 0.72 mm; P ¼ .002). Larger teeth in
the contemporary series produced a mean leeway space per quadrant of 2.03 mm versus 2.45 mm
in the earlier cohort—a clinically and statistically significant reduction (P ¼ .030). Some tooth types
(primary second molar and permanent canine) were significantly larger in boys than in girls, but the
sex difference in leeway space was not statistically significant.
Conclusion: Results suggest that mandibular leeway space is decreasing in 21st century
American whites and may present a challenge to orthodontists in managing tooth size–arch length
discrepancies. (Angle Orthod. 2017;87:576–582)
KEY WORDS: Leeway; Tooth size; Arch size; Environment; Secular trend

INTRODUCTION cause of the primary second molar’s larger mesiodistal

crown dimension compared with the second premolar.5
Leeway space is the difference in size of the Orthodontists often rely on leeway space, an anticipated
mesiodistal crown widths of the primary canines and gain of 1–2 mm per quadrant, in their treatment
molars compared with that of their permanent succes- protocols to help resolve anterior crowding.6–8
sors (canine, first and second premolars; Figure 1).1–4 It is unknown who first observed the space resulting
The primary teeth typically possess a larger mesiodistal from these crown-size differences, but Nance9,10
sum than the permanent teeth that replace them— commonly is cited as initially describing its clinical
especially in the mandibular arch, predominantly be- application. He coined the term ‘‘leeway’’ and labeled it
a ‘‘fundamental fact concerning the human dentition.’’
a
Resident, Department of Orthodontics, College of Dentistry, Nance9 cited descriptive tooth sizes reported as early
University of Tennessee Health Science Center, Memphis, Tenn. as 1890 by G.V. Black in the latter’s first edition of
b
Associate Professor and Chair, Department of Orthodontics, Descriptive Anatomy.11 Black’s sample consisted of
College of Dentistry, University of Tennessee Health Science
Center, Memphis, Tenn. extracted teeth (sexes pooled) from an unreported
c
Professor, Department of Orthodontics, College of Dentistry, number of cases. Although the source and method of
University of Tennessee Health Science Center, Memphis, Tenn. measurement is poorly defined,12 it is arguably the
Corresponding author: Dr Edward F. Harris, Department of most commonly cited set of tooth dimensions, certainly
Orthodontics, College of Dentistry, University of Tennessee
so in the clinical literature. Using Black’s figures,
Health Science Center, 875 Union Avenue, Memphis, TN 38163
(e-mail: eharris@uthsc.edu) Nance reported leeway space averages of 0.9 mm
per quadrant in the maxilla and 1.7 mm per quadrant in
Accepted: January 2017. Submitted: September 2016.
Published Online: March 20, 2017 the mandible.
Ó 2017 by The EH Angle Education and Research Foundation, Leeway is not a constant, but differs among people.
Inc. Nance9 described cases varying from 0.0 to 4.0 mm of

Angle Orthodontist, Vol 87, No 4, 2017 576 DOI: 10.2319/091416-688.1

EVIDENCE FAVORING REDUCING MANDIBULAR LEEWAY SPACE 577

observations suggest that environmental improvement

might also affect leeway space, which is derived from
differences among crown sizes.
For the face and teeth, much of our knowledge is
derived from several human growth studies conducted
in the 20th century. These are largely now com-
plete.32,33 Although they reflect children’s growth of
several generations ago, these studies are a principal
source of information for many of today’s clinical
decisions. The purpose of the present study was to
test for a secular trend, focusing on mandibular leeway
space. The null hypothesis was that average leeway

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space has remained unchanged. We examined leeway
space in the mandibular arch since it is larger and
clinically more challenging than in the maxilla.
Figure 1. Illustration of the three primary and three successor teeth
constituting leeway space in the mandibular right quadrant (labial MATERIALS AND METHODS
aspect). Mesiodistal widths were scaled to the mean sizes reported
by G.V. Black.
An a priori power analysis was conducted assuming
a factorial two-way analysis of variance (ANOVA),
partitioning on cohort while controlling for sex in crown
mandibular leeway space. Numerous authors report
size.34,35 Statistical power is the probability of rejecting
different averages of leeway space, apparently de-
the null hypothesis when it truly is false. Assuming a
pending on regional or population tooth crown differ-
ences plus sampling variation.13 In addition, Hille14 0.5-mm difference in mandibular leeway space be-
found that mandibular leeway space averaged 2.4 tween cohorts (ie, minimum nontrivial effect size), with
mm in girls, but was significantly smaller in boys (mean alpha settings of 0.05 and sample sizes of 45 per
¼ 1.9 mm). cohort (equal arms), expected power was 85%. To be
Northway et al.15 found that when maxillary primary conservative, we assumed that the interaction effect
first molars were lost prematurely, (1) maxillary primary accounted for no variation.34
second molars and permanent first molars drift Tests36 indicated that variables were normally
mesially, (2) canines drift distally, (3) first premolars distributed, so inferential tests used two-way ANOVA,37
emerge more mesially, and (4) permanent maxillary with cohort and sex as fixed effects. Subject’s sex was
canines emerge labially with risk of being blocked out. included to account for the tendency for boys to have
An effective solution, if treated in time, is to preserve larger crowns than do girls.38 Statistical significance
the leeway space with, for example, a distal shoe was set at the conventional level of 0.05, and tests
space maintainer, lingual holding arch, or Nance were two-tailed.
appliance.16,17 Leeway space in the mandibular arch A contemporary series (23 boys, 22 girls)—born
is often more critical; there are fewer therapeutic between 1990 and 2000—was obtained by inspecting
options in this arch because of its limited potential for all early treatment cases in the University of Tennes-
expansion, unstable labialization of incisors, and see Health Science Center Graduate Orthodontic
difficulty of molar distalization.18 Clinic (IRB approval 14-03570-XM). Casts with bilater-
Children in first-world countries have been experi- al fully erupted mandibular primary teeth were identi-
encing secular trends over recent generations. Among fied. Those individuals who received a second phase
the best-known examples are increase in stature,19 of treatment (when the premolars and permanent
reduction in age at menarche,20 and gain in body canines had emerged into functional occlusion) were
weight.21 The conventional explanations for these selected for inclusion. This created a series of pairs of
generational changes are centered on improved casts of the same subjects, one with primary teeth and
environment; diminished morbidity; and (principally) the other with successors.
better, more dependable nutrition. Positive secular The earlier cohort used for comparison also consist-
trends have been described for tooth crown sizes,22–24 ed of 45 cases (23 boys, 22 girls), participants
and larger teeth have been implicated as a contributor randomly selected from the Denver Growth Study39
to dental crowding.25–28 Tooth size–arch length discrep- and born in the 1930s. Casts from successive ages
ancies appear to have increased.29 Additionally, the were used to measure the primary and permanent
tempo of tooth emergence has quickened.30,31 These teeth on the same persons.

Angle Orthodontist, Vol 87, No 4, 2017

578 ALLEN, TROJAN, HARRIS

Table 1. Results of Two-factor Analysis of Variance for Mandibular Teetha

Cohort Sex Interaction
df b
F P df F P df F P
Primary Teeth
Canine (c) 1 0.54 .4638 1 0.74 .3907 1 0.07 .7919
First molar (m1) 1 0.05 .8325 1 0.48 .4890 1 0.03 .8563
Second molar (m2) 1 7.58 .0072 1 6.05 .0159 1 0.55 .4624
Sum c þ m1 þ m2 1 2.43 .1226 1 1.40 .2407 1 0.11 .7436
Permanent Teeth
Canine (C) 1 2.10 .1505 1 14.05 .0003 1 3.50 .0648
First premolar (P1) 1 8.80 .0039 1 0.70 .4048 1 0.50 .4816
Second premolar (P2) 1 13.71 .0004 1 0.63 .4289 1 1.42 .2364
Sum C þ P1 þ P2 1 11.09 .0013 1 4.69 .0330 1 2.19 .1426

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Leeway space 1 5.08 .0267 1 1.69 .1970 1 1.90 .1719
a
Each row is a separate analysis, with ‘‘cohort’’ and ‘‘sex’’ as fixed effects. F indicates the F-ratio; P, the associated probability value. Leeway
space is (c þ m1 þ m2) minus (C þ P1 þ P2).
b
df indicates degrees of freedom.

All individuals in both cohorts were phenotypically difference, so the arithmetic means of the left and right
normal American whites (based on photographs and homologues were used for subsequent analysis. A
patient records) with no congenitally missing teeth and subset of the casts (n ¼ 20 casts, 240 paired
no known syndrome or systemic condition that might measurements), both primary and permanent, were
affect growth. Cases with exfoliated or extracted teeth remeasured after a washout period to estimate intra-
in the midarch, either primary or permanent, were observer reliability.41,42
eliminated. Teeth with marginal restorations or carious
defects were excluded, as well as any distortions or RESULTS
irregularities in the model. Intraobserver repeatability was high. No variable
Maximum mesiodistal crown diameters of the man- showed a systematic difference between measure-
dibular teeth were measured in both the left and right ment sessions, and Dahlberg’s di was less than 0.1
quadrants on plaster dental casts using a digital- mm (mean ¼ 0.07 mm), making measurement error
readout sliding caliper (Mitutoyo, Aurora, Ill ). The appreciably less than the observed cohort differences.
beaks of the caliper had been machined to fit well into Cronbach’s alpha was 0.998, and the intraclass
the dental embrasures. Measurements were made in a correlation between measurements (mixed model,
standardized manner40 and recorded to the nearest fixed observer) was also 0.998 (95% CI: 0.998–
0.01 mm even though the caliper’s readout was 0.999), which was highly significant (P , .001).
precise to 0.005 mm. All data were acquired by the Neither the primary canine nor primary first molar
senior author. Initial testing showed no significant side differed in size between cohorts (Table 1). Despite

Figure 2. Comparison of average tooth sizes defining mandibular leeway space (sexes pooled). Mandibular tooth codes: primary canine (c),
primary first molar (m1), primary second molar (m2), permanent canine (C), first premolar (P1), and second premolar (P2). Leeway space: (c þ m1
þ m2) minus (C þ P1 þ P2).

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EVIDENCE FAVORING REDUCING MANDIBULAR LEEWAY SPACE 579

Table 2. Descriptive Statistics of Tooth Crown Sizes by Cohort and Sex (mm)
Earlier Cohort (1930s) Recent Cohort (1990s)
Sexes Sexes
Boys Girls Pooled Boys Girls Pooled
LS Meana SEM LS Mean SEM Mean SEM LS Mean SEM LS Mean SEM Mean SEM
Primary canine 5.89 0.061 5.85 0.059 5.87 0.045 5.95 0.061 5.89 0.061 5.91 0.039
Primary first molar 7.84 0.090 7.89 0.088 7.87 0.070 7.85 0.090 7.93 0.088 7.89 0.055
Primary second molar 9.66 0.087 9.94 0.085 9.80 0.065 9.96 0.087 10.11 0.085 10.04 0.060
Sum c þ m1 þ m2 23.39 0.191 23.67 0.187 23.53 0.148 23.75 0.191 23.91 0.187 23.83 0.117
Permanent canine 6.63 0.082 7.08 0.080 6.86 0.066 6.89 0.082 7.05 0.080 6.97 0.057
First premolar 7.02 0.096 7.16 0.094 7.09 0.067 7.37 0.096 7.38 0.094 7.37 0.066
Second premolar 7.04 0.096 7.23 0.094 7.14 0.061 7.49 0.072 7.47 0.094 7.49 0.072

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Sum C þ P1 þ P2 20.68 0.219 21.47 0.214 21.08 0.174 21.72 0.219 21.87 0.214 21.80 0.174
Leeway spaceb 2.71 0.190 2.20 0.186 2.45 0.140 2.03 0.190 2.04 0.186 2.03 0.139
a
LS means indicates least squares means; SEM, standard error of the mean; sample sizes were 23 earlier boys, 22 earlier girls, 23 recent
boys, and 22 recent girls.
b
Leeway space indicates mandibular leeway space per quadrant.

these findings, the cumulative mandibular primary statistically. Figure 3A shows that the leeway space
canine plus first and second primary molar size (c þ regressed on primary tooth size (ie, sum of c þ m1 þ
m1 þ m2) was slightly larger in the recent cohort (23.53 m2). The association was positive and statistically
mm earlier vs 23.83 mm recent cohort, a mean significant (P ¼ .0166), so the larger the primary teeth,
difference of 0.30 mm; P ¼ .009), principally due to the larger the predicted leeway space. This is intuitive
larger second primary molars (m2) in the recent cohort in that larger primary teeth preserve more arch space
(Figure 2). that contributes to leeway space. The earlier cohort
When we compared the permanent dentitions, we had a higher y-intercept (a ¼3.58), but the regression
found that the first and second premolars were each coefficient—the change in leeway space per unit of
significantly larger in the recent cohort, resulting in a primary-tooth size (c þ m1 þ m2)—was less. In the
significant difference of leeway space. Leeway space recent cohort, the y-intercept was lower (a ¼7.41), but
averaged 2.45 mm per quadrant in the earlier cohort the regression slope was steeper. In clinical practice,
and 2.03 mm in the recent group (sexes pooled), though, the difference in slopes (0.26 vs 0.40; Figure
though sample variability remained the same (Table 2). 3A) is unlikely to be noticeable. Regression coefficients
The increases in tooth size were at the expense of are listed in Table 4.
leeway space. Tests of this are the association Figure 3B shows that permanent tooth size (C þ P1 þ
between tooth size and leeway space (Figure 3). Table P2) was negatively associated with leeway space; an
3 lists the results of three ANOVA tests, considering increase of 1 mm in C þ P1 þ P2 predicted that the
the effects of cohort and sex on the association leeway space was reduced by 0.51 mm. Cohort and
between crown size and mandibular leeway space. sex are combined since they differed insignificantly
Of note, none of the interaction effects was significant (Table 3B).

Figure 3. (A) Primary tooth size (c þ m1þ m2) was significantly predictive of leeway space, and the recent cohort had a lower intercept and a
steeper slope. (B) Permanent tooth size (C þ P1 þP2) likewise was significantly (negatively) predictive of leeway space. (C) There was a highly
significant positive association between primary (c þ m1 þ m2) and permanent (canine plus the premolars) tooth size. Error bands are the 95th
confidence limits of the regression lines. The relationships were unaffected by the subject’s sex. Statistical tests are shown in Table 3.

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580 ALLEN, TROJAN, HARRIS

Table 3. Results of Three-way Analyses of Variance Primary and permanent tooth sizes were positively
correlated (Figure 3C); children with large primary teeth
A. Leeway Space Predicted by Primary Tooth Sizes
were likely to have large permanent teeth. The
correlation coefficient between c þ m1 þ m2 and C þ
Source df F Ratio P Value
P1 þ P2 was 0.599 (95% CL ¼ 0.447 and 0.717,
Cohort 1 7.30 .0084 respectively; r 2 ¼ 0.395). While this sample is small (n
Subject’s sex 1 2.14 .1473
¼ 45), the association shows the weak predictive power
Primary (c þ m1 þ m2) 1 11.21 .0012
Cohort-x-sex 1 2.40 .1255 in mixed dentition analyses. Statistical significance is
Cohort-x-primary 1 0.52 .4729 attainable with adequate sample sizes, but clinical
Sex-x-primary 1 0.36 .5498 precision cannot be improved because of the biologic
Cohort-x-primary-x-sex 1 2.87 .0943 limit of the association.
B. Leeway Space Predicted by Permanent Tooth Sizes

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Source df F Ratio P Value DISCUSSION
Cohort 1 0.03 .8708 Tooth size is regulated by the size of the pulp cavity,
Subject’s sex 1 0.05 .8295 which is established before deposition of mineralized
Permanent (CþP1þP2) 1 40.70 ,.0001
tissue.43,44 Statistically significant differences (Tables 1
Cohort-x-sex 1 0.16 .6945
Cohort-x-permanent 1 1.12 .2940 and 2) were found between cohorts for the two
Sex-x-permanent 1 1.28 .2604 premolars. These crowns mineralize perinatally,45 after
Cohort-x-permanent-x-sex 1 0.02 .8817 the in utero formation of most primary crowns.46,47 One
C. Primary Sizes Tested Against Permanent Sizes explanatory scenario is that the prenatal environ-
ment—depending principally on maternal physiolo-
Source df F Ratio P Value
gy48—has remained generally static across the two
Cohort 1 3.39 .0693
cohorts, but childhood nutrition has improved (and
Subject’s sex 1 0.48 .4925
Primary (cþm1þm2) 1 1667309.00 ,.0001 morbidity has lessened),49 thus promoting larger
Permanent (CþP1þP2) 1 2270952.00 ,.0001 postnatal permanent tooth development,50,51 while
Cohort-x-sex 1 0.33 .5655 primary tooth sizes remain unchanged.
Cohort-x-primary 1 0.78 .3808 As leeway space seems to be less dependable now
Cohort-x-permanent 1 0.01 .9144
Sex-x-primary 1 0.46 .4980
than in the past, orthodontists should consider relying
Sex-x-permanent 1 0.14 .7108 more on alternate solutions to resolve anterior crowd-
ing. Solutions can involve extraction therapy or greater
a
Interaction terms, such as cohort-by-sex are coded as ‘‘Cohort-x-
sex’’. These are first-order interaction terms; the one second-order use of interproximal reduction. Not all tooth types were
term is ‘‘Cohort-x-primary-x-sex’’. measured, but the positive associations among tooth

Table 4. Linear Regression Equations

A. Mandibular Primary Tooth Size (c þ m1 þ m2) Predicting Leeway Space (per Cohort)
Earlier Cohort Alone
Term Estimate St Error L1 L2 t-test P value
Y-intercept 3.579 3.270 10.172 3.015 1.09 .2798
Coefficient (c þ m1 þ m2) 0.256 0.139 -0.024 0.536 1.85 .0719
Recent Cohort Alone
Term Estimate St Error L1 L2 t-test P value
Y-intercept 7.408 3.692 14.853 0.038 2.01 .0511
Coefficient (c þ m1 þ m2) 0.396 0.155 0.084 0.708 2.56 .0141
B. Permanent Tooth Size (C þ P1 þ P2) Predicting Leeway Space (Cohorts Pooled)
Term Estimate St Error L1 L2 t-test P value
Y-intercept 13.220 1.490 10.259 16.182 8.87 ,.0001
Coefficient (C þ P1 þ P2) 0.512 0.069 0.650 0.374 7.38 ,.0001
C. Primary Tooth Size (c þ m1 þ m2) Predicting Permanent Tooth Size (C þ P1 þ P2) (Cohorts Pooled)
Term Estimate St Error L1 L2 t-test P value
Y-intercept 4.025 2.485 0.914 8.963 1.62 .1089
Coefficient (c þ m1 þ m2) 0.735 0.105 0.527 0.944 7.01 ,.0001

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EVIDENCE FAVORING REDUCING MANDIBULAR LEEWAY SPACE 581

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Angle Orthodontist, Vol 87, No 4, 2017