RESEARCH

Correlation of the Anteroposterior Relationships of the Dental Arch and Jaw-Base in subjects with Class I, Class II and Class III Malocclusions.
Shendre Shrikant,1 Karan Ganapathy K.,2 Ravinarayana Reddy P. R.,3 Mamtha Thomas4
been introduced to evaluate the sagittal plane relationships of the maxilla and mandible. Today there still remains a debate over whether the anteroposterior dental arch relationship coincides with that of the jaw-base. Few studies however put to test these assumptions. In the present study, an attempt has been made to evaluate the skeletal anteroposterior relationships between Angles malocclusion classes and cephalometric measurements of sagittal apical base difference such as ANB angle and Wits appraisal.

ABSTRACT
Aims and Objectives: A Study was done to determine the correlation between the anteroposterior relationships of the dental arch and the anteroposterior relationship of the jaw-base as well as to compare the angular vs. linear measurements of the association between anteroposterior dental arch and jaw-base relationships Methods: Lateral cephalograms and study models of 276 untreated adult orthodontic patients representing Angles Class I, Angles Class II and Angles Class III malocclusions were taken. The patients were classified into Angles classes on the basis of the sagittal occlusal relationship between the maxillary and mandibular first permanent molars. ANB angle and Wits appraisal were measured on the radiographs which were indicative of the skeletal relationship. The two were then compared. Results: The Angles class I malocclusion group showed mildly class II skeletal bases, the Angles class II malocclusion group showed evident class II skeletal bases and Angles class III malocclusion group showed class III skeletal bases. The ANB angle and Wits appraisal showed a significant positive correlation when applied to the above three groups. Key Words: Cephalometrics; Orthodontics; Malocclusion

Objectives
To determine the correlation between the anteroposterior relationships of the dental arch and in addition, the study aimed to compare the angular vs. linear measurements of the association between anteroposterior dental arch and jaw-base relationships.

Method used for the study

Study models of the patients were taken and assessed for the existing molar relationship. Patients were classified into Angles malocclusion classes such as Angles Class I, Class II, Class III [Fig.1] based on the Introduction sagittal occlusal relationship of maxillary and Orthodontic diagnosis is an important criterion mandibular first permanent molar as seen on the study for the success of any orthodontic treatment and models. therefore it is pertinent that the orthodontist have The lateral cephalogram taken in natural head adequate knowledge of dental occlusion and the position for each individual was traced accurately on to underlying skeletal occlusion as the dentoalveolar the acetate tracing paper using 0.3mm pencil. The compensations take place in order to reduce the overall tracings were carefully checked for any errors. severity of the malocclusion. The lateral cephalogram of each subject was then taken Angles classification1 is the most widely used and assessed for both linear (WITS) and angular (ANB classification in orthodontic diagnosis and treatment angle) anteroposterior relationship.[Fig.2] planning. The basis of Angles classification was the Statistical assessment was made to obtain a anteroposterior relationship of the maxillary and correlation between Angles dental arch relationship mandibular first molars and the alignment of all the and anteroposterior jaw base relationship. teeth to the line of occlusion. However this popular Descriptive statistical analysis has been carried system of classification has the drawback of out in the present study. Results on continuous representing only the dental relationship in the sagittal measurements are presented on Mean SD (Min-Max) plane and not the skeletal relationship. and results on categorical measurements are presented In orthodontic diagnosis and treatment in Number (%). Significance is assessed at 5 % level of planning great importance has been attached to significance. evaluating the sagittal apical base relationship. The Kruskal Wallis has been used to find the Cephalometric parameters such as ANB angle by Reidel2 significance of the ANB angle and Wits between the and Steiners3 and Wits appraisal by Jacobson4 have three molar groups, McNemmar Test of significance of been introduced to evaluate the sagittal plane correlation between two Molar and Skeletal IJCD MARCH, 2011 2(2) 5 68 relationships of the maxilla and mandible. classification. 2011 Int. Journal of Contemporary Dentistry Inclusion criteria includes lateral cephalograms of 276

correlation between two Molar and Skeletal classification.5 Inclusion criteria includes lateral cephalograms of 276 untreated male and female patients with clearly distinguishable landmarks. Presence of first molars in

all four quadrants was mandatory to assess the molar relationship. No obvious jaw pathology, gross asymmetry or TMJ ankylosis should be present which could alter the measured skeletal relationship in any way.

FIG. 1: ANGLES CLASSIFICATION OF MALOCCLUSION

Fig.2: ANGLES AND MEASUREMENTS USED IN THE STUDY

69

IJCD MARCH, 2011 2(2)

2011 Int. Journal of Contemporary Dentistry

RESEARCH
ANB angle Mean 4.04 SD 2.30 WITS Mean 2.01 SD 3.01

Molar classification Group 1 - Angle's Class I Malocclusion Group 2 - Angle's Class II Malocclusion Group 3 - Angles Class III Malocclusion Total

Number

100

100

5.48

2.83

4.72

2.73

76 276

-2.26

3.29

-5.65

5.06

<0.001**

<0.001**

Table 1: Mean ANB angle and Wits according Group

Results
ANB ANGLE IN EACH GROUP [Table 1] When the ANB angle was evaluated in each of the malocclusion groups, a highly significant difference existed in the three groups. The measured values in group I and group II indicated a Class II skeletal base. In group III the mean value showed a Class III skeletal base. However, the increase of ANB angle in group II was more than in group I, thereby suggesting an increased severity of skeletal base Class II relationship in group II. WITS APPRAISAL IN EACH GROUP [Table 1] When the Wits appraisal was evaluated in each malocclusion group, a highly significant difference existed in the three groups. In group I, mean value of Wits appraisal showed a mild Class II skeletal base. Group II showed a moderate to severe Class II skeletal base. In group III the mean value of Wits appraisal showed a Class III skeletal base. CORRELATION OF ANB ANGLE AND WITS APPRAISAL [Table 2] The correlation coefficient between the ANB angle and Wits appraisal was highly significant in each group. Group I and II showed a positive correlation. As ANB angle increased so did the Wits appraisal. Group III also showed a positive correlation with Wits appraisal decreasing as ANB angle decreased.
8 6 4 2 0 -2 -4 -6 -8 Group 1 Group 2

Molar classification Group 1 - Angle's Class I Malocclusion Group 2 - Angle's Class II Malocclusion Group 3 - Angles Class III Malocclusion

Angle vs. WITS Pearson correlation P value

0.573

<0.001**

0.683

<0.001**

0.773

<0.001**

Table 2: CORRELATION OF ANB ANGLE AND WITS APPRAISAL

Discussion

Molar classification

Angles classification of malocclusion is based on the mesiodistal relationship between the upper and lower dental arches. Subsequent studies revealed that the dental arch relationship is largely affected by the facial skeleton upon which the teeth are invested. An area of extensive debate within ANB angle orthodontics is whether the anteroposterior dental arch WITS correlates with the jaw-base relationship, and thus whether both need to be assessed in orthodontic diagnosis and treatment planning. Ashish Dhopatkar et al6 stated that the cranial base flexure does not play a pivotal role in determining malocclusion. Jaw size however, was significantly different between the main classes of malocclusion. According to Arndt Klocke et al7 subjects with a Group 3 large cranial base angle in the primary dentition demonstrated a skeletal class II tendency at the initial IJCD MARCH,observation 2011 2(2) and at the longitudinal follow-up. The 70 2011 Int. Journal of Contemporary Dentistrybetween cranial base flexure and skeletal relationship

RESEARCH
Molar cl. I II III Kappa coefficient McNemar test Skeletal classification No. I 100 100 76 59(56.0%) 36(36.0%) 24(31.6%) ANB angle II 38(38.0%) 62(62.0%) 2(2.6%) K=0.419; P<0.001** III 3(3.0%) 2(2.0%) 50(65.8%) I 47(47.0%) 15(15.0%) 17(22.4%) Wits II 49(49.0%) 84(84.0%) 3(3.9%) K=0.509; P<0.001** III 4(4.0%) 1(1.0%) 56(73.7%)

2MN=16.387; P=0.001**

2MN=27.110; P<0.001**

Table 3: Correlation of Molar classification with skeletal classification of ANB angle

100 90 80 70 60 50 40 30 20 10 0
I II III

100 90 80 70

Percentages

Percentages

60 50 40 30 20 I
I II III

ANB
I II III

WITS
II III

10 0

Molar classification

Molar classification

demonstrated a skeletal class II tendency at the initial observation and at the longitudinal follow-up. The relationship between cranial base flexure and skeletal pattern of the jaws seems to be established before the age of 5 years. Lei Zhou et al8 found that the anteroposterior relationship of the dental arch and jaw-base fail to match in at least one out of every three individuals and that linear measurement of anteroposterior jawbase relationships is a more valid reflection of the dental arch relationship than angular measurements. Both angular and linear measurements have been proposed in the assessment of anteroposterior jaw-base relationship. However, each of the methods described exhibits its own inherent weakness, based on the variability of factors other than the jaw relationship itself. The ANB angle, which is one of the angles used in this study, has also been recognized as a skeletal sagittal discrepancy indicator and has become the most commonly used measurement till date. More recently it has been claimed that the ANB angle is affected by various factors and thus diagnosis based on this angle may give false results. In

order to overcome this, Jacobson4 introduced the Wits appraisal. In a study done by Saul Rothbergit9 it was concluded that when a positive ANB angle of 4 degrees or less existed, the Wits value could be either positive or negative; and that there was no correlation between the ANB angle and Wits measurements, if the Wits was negative. In the present study, it showed that when the ANB angle value was 4 degrees or more, it had a positive Wits appraisal and there was a highly significant positive correlation found when ANB angle and Wits were positive. The ANB angle is affected by a number of factors10; i.e. Patients age, change of spatial position of the nasion either in the vertical or anteroposterior direction or both, the upward or downward rotation of the SN plane, the upward or downward rotation of the jaws, the change in the angle SN to the occlusal plane. Because of the inaccuracy of ANB angle measurements, a number of different, new measurements have been developed to determine the actual relationships of the denture bases. To eliminate the influence of the anatomic variations in nasion on the sagittal relationship of the

71

IJCD MARCH, 2011 2(2)

2011 Int. Journal of Contemporary Dentistry

RESEARCH
jaws, Jacobson4 presented the Wits appraisal. The Wits appraisal avoids the use of nasion and reduces the rotational effects of jaw growth but it uses the occlusal plane, which is dental parameter, to describe the skeletal discrepancies. Wits appraisal relates points A and B to the occlusal plane. Palleck S et al11 tested the reproducibility and validity of 3 sagittal reference planes with the use of the Wits analysis - the functional occlusal plane, the bisected occlusal plane, and the maxillomandibular bisectors. The maxillomandibular bisector was determined to be an easily identifiable and reproducible reference plane that exhibited greater stability over time. Iwasaki H et al12 found that the jaw discrepancy is assessed more severely using the ANB angle than by the Wits appraisal in these Angle Class III subjects and the ANB angle is a more critical cephalometric parameter than Wits appraisal. Even though the ANB angle and Wits appraisal have been in use as cephalometric parameters to estimate the anteroposterior relation of the skeletal bases, they have their own drawbacks; therefore the orthodontist should be cautious when applying these parameters. In more recent years, alternative parameters for establishing the anteroposterior relation have been introduced. These include the Wits appraisal using the maxilla mandibular bisector13, Anteroposterior dysplasia indicator14 and Beta angle15. However the validity and reliability of these parameters in accurately forecasting the anteroposterior relationships are yet to be established. 5. Bernard Rosner (2000), Fundamentals of Biostatistics, 5th Edition, Duxbury, page 80-240 6. Ashish Dhopatkar, Bhatias, Rock P: An investigation into the relationship between the cranial base angle and malocclusion. Angle Orthod 2002 oct, 72 (5) 456 63. 7. Arndt Klocke, Dr Med Dent, Ram S Nanda: Role of cranial base flexure in developing sagittal Jaw discrepancies. Am J Orthod Dentofacial Orthop 2002 0ct, 122 (4): 386 9. 8. Lei Zhou, Chung-Wai Mok, Urban Hagg, Colman McGrath, Margareta Bendeus, John Wu. Anteroposterior Dental Arch and Jaw-Base Relationships in a Population Sample. Angle Orthod. 2008; 78:1023 1029. 9. Rotbergs, Fried N, Kane J, Shapiro E. Predicting the Wits appraisal from the ANB angle. Am J Orthod Dentofacial Orthop 1980 jun; 77 (6): 636 42. 10. Ferrario VF, Sforza C, Miami A J, Tertaglia GM: The use of linear and angular measurements of maxillo mandibular anteroposterior discrepancies. Clin Orthod Res. 1999 Feb; 2 (1): 34 41. 11. Palleck S, Foley TF, Hall Scott J. The reliability of 3 sagittal reference planes in the assessment of ClassI and ClassIII treatment. Am J Orthod Dentofacial Orthop. 2001 Apr; 119 (4); 426 35. 12. Iwasaki H, Ishikawa H, Chowdhury L, Nakamura, Lida J: Properties of ANB angle and Wits appraisal in the skeletal estimation of Angles Class III Patients. Eur J Orthod 2002 oct; 24 (5): 477-83. 13. Jennifer Hall Scott: The maxillary mandibular planes angle (MM) bisector. A new reference plane for anteroposterior measurement of the dental bases. Am J Orthod dentofacial Orthop 1994, 105, 583 91. 14. Dinte AF, Brezniak N, Wasserstein A: Anteroposterior dysplasia indicator. Angle Orthod. 1995; 65 (6): 384 5. 15. Chong Yol Baik et al: A new approach of assessing sagittal discrepancies: The Beta angle. Am J Orthod Dentofacial Orthop 2004; 126:100-5.

Conclusion
The results from this study showed that there was a significant correlation that existed between Angles malocclusion groups and skeletal base variables. The Angles class I malocclusion group showed mildly class II skeletal bases.The Angles class II malocclusion group showed evident class II skeletal bases.The Angles class III malocclusion group showed class III skeletal bases. The ANB angle and Wits appraisal showed a significant positive correlation when applied to the above three groups.

References
1. Angle EH. Classification of malocclusion. Dental Cosmos. 1899;41:248264. 2. Riedel RA. An analysis of dentofacial relationships, Am J Orthod. 43: 103 119, 1957. 3. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment. Am J Orthod 1960;46;721 35. 4. Jacobson A: The Wits appraisal of jaw disharmony. Am J Orthod 1975 Feb; 67 (2) 125 38.
IJCD MARCH, 2011 2(2)
2011 Int. Journal of Contemporary Dentistry

72

RESEARCH
About the Authors

1. Dr. Shendre Shrikant, MDS, IM ORTH RCPS (London), M ORTH RCS (Edinburgh) Professor, Dept. of Orthodontics, The Oxford Dental College, Hosur Main Road, Bommanahalli, Bangalore- 560068. 2.Dr. Karan Ganapathy K., PG Student, Dept. of Orthodontics, The Oxford Dental College, Hosur Main Road, Bommanahalli, Bangalore- 560068. 3.Dr. Ravinarayana Reddy P. R., MDS, Professor and Head Dept. of Orthodontics, The Oxford Dental College, Hosur Main Road, Bommanahalli, Bangalore- 560068. 4.Dr. Mamtha Thomas, MDS, Practitioner, HSR Layout, Bangalore. Address for Correspondence

Dr. Shendre Shrikant, MDS

Professor, Dept. of Orthodontics, The Oxford Dental College, Hosur Main Road, Bommanahalli, Bangalore- 560068. Mobile: 9880312115
Email: ortho_rshri@hotmail.com

73

IJCD MARCH, 2011 2(2)

2011 Int. Journal of Contemporary Dentistry