ORIGINAL ARTICLE

Evaluation of skeletal and dental asymmetries in Angle Class II subdivision malocclusions with cone-beam computed tomography
quio A. Arau  jo,b Rolf G. Behrents,b Peter H. Buschang,c Orlando M. Tanaka,d Craig M. Minich,a Eusta e and Ki Beom Kim Chagrin Falls, Ohio, St Louis, Mo, Dallas, Tex, and Curitiba, Paran a, Brazil Introduction: The purpose of this study was to determine whether Angle Class II subdivision malocclusions have skeletal or dental asymmetries between the Class II and Class I sides. Methods: A sample of 54 untreated Angle Class II subdivision patients with pretreatment photos and cone-beam computed tomography (CBCT) scans was used. The photos were used to identify the Class II subdivision malocclusion and to record the amount of crowding per quadrant. Landmarks were plotted on each CBCT volume so that direct 3dimensional measurements could be made to compare the positions and dimensions of the skeletal and dental structures on the Class II side vs the Class I side. Results: Signicant differences were found for 2 skeletal measurements: the position of the maxilla relative to the cranial base, and the mandibular dimension from the mandibular foramen to the mental foramen. Statistically signicant dental differences were found for the position of the mandibular rst molars and canines in relation to the maxilla and the mandible. Statistically significant differences were found for the maxillary rst molars and canines in relation to the mandible. Conclusions: There were signicant skeletal and dental differences between the Class I and Class II sides. The dental asymmetries accounted for about two thirds of the total asymmetry. (Am J Orthod Dentofacial Orthop 2013;144:57-66)

lass II subdivision malocclusions can be extremely challenging for diagnosis and treatment planning because many clinicians have difculty in identifying the cause of the malocclusion.1 Since Angle Class II subdivision malocclusions possess characteristics of both Class I and Class II malocclusions, there is asymmetry between the right and left sides of the dentition. This asymmetry often requires asymmetric extractions or mechanics during treatment, which can be very complicated.1-4 The etiology of the asymmetry can be quite

C
a b

Private practice, Chagrin Falls, Ohio. Professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. c Professor, Department of Orthodontics, Baylor College of Dentistry, Texas A&M Health Science Center, Dallas, Tex. d Professor, Graduate Dentistry Program in Orthodontics, School of Health and Biosciences, Pontif cia Universidade Cat olica do Paran a, Curitiba, Paran a, Brazil. e Associate professor, Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St Louis, Mo. All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conicts of Interest and none were reported. Reprint requests to: Ki Beom Kim, 3320 Rutger St, St Louis, MO 63104; e-mail, kkim8@slu.edu. Submitted, December 2012; revised and accepted, February 2013. 0889-5406/$36.00 Copyright 2013 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2013.02.026

complex. It could be dental related, skeletal related, or a combination of both. Any time a dental midline deviation or an asymmetric occlusion is observed, the clinician must check for skeletal asymmetries, dental asymmetries, and functional shifts.5-8 Manipulating the patient into centric relation or using an occlusal splint to verify the position of the mandible is an important rst step in correctly diagnosing any type of asymmetry.5 Previous studies used 2-dimensional radiographs (posteroanterior cephalograms, submentovertex view, and corrected oblique cephalograms) to evaluate Class II subdivisions for dental and skeletal asymmetries between the Class II and Class I sides of the skull and the dentition.1,4,9,10 These studies showed that the differences between the 2 sides were primarily dentoalveolar. The main factor is the distal positioning of the mandibular rst molar on the Class II side with a mandibular dental midline deviation toward the Class II side (type 1). A secondary factor is the mesial positioning of the maxillary rst molar on the Class II side with a maxillary dental midline deviation away from the Class II side (type 2).1,4,11-13 These authors found no statistically signicant skeletal differences between the 2 sides, but they mentioned a tendency
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for mild skeletal asymmetries in Class II subdivisions and recommended further research to investigate these minor asymmetries.13,14 The purpose of this study was to analyze Class II subdivision malocclusions for skeletal and dental asymmetries by using cone-beam computed tomography (CBCT).
MATERIAL AND METHODS

In this retrospective study, we evaluated 54 pretreatment records (photos and CBCT volumes) of patients from the Department of Orthodontics of Case Western Reserve University in Cleveland, Ohio. Initial pretreatment photographs of 300 Angle Class II malocclusion patients were examined to search for Class II subdivision malocclusions that met the following criteria: (1) erupted permanent dentition from rst molar to rst molar in both arches; (2) no missing teeth, excluding third molars; (3) no craniofacial syndromes that would cause severe skeletal asymmetries; (4) one side of the arch with an Angle Class I molar relationship and the other side with at least a halfstep Angle Class II molar relationship or greater; and (5) clear pretreatment photographs and CBCT volumes. Once the patients were identied, the amounts of crowding per quadrant were estimated by the principal investigator (C.M.M.) and recorded so that the role of dental crowding could also be evaluated in the Class II subdivision malocclusions. Two groups were created: a noncrowded group (no crowding or #2 mm of crowding in any quadrant), and a crowded group ($3 mm of crowding in any quadrant). Patients with excess spacing were not included in either group. The scans were made by using the CBCT unit (Hitachi, Tokyo, Japan) at Case Western Reserve University's Craniofacial Imaging Center. All images were taken at settings of 2 mA, 120 kV, and 12-in eld of view. The CBCT volumes were analyzed and measured by using Dolphin 3D software (version 11.0 premium software; Dolphin Imaging & Management Solutions, Chatsworth, Calif). Establishing a consistent method of orientation ensured that the coordinate systems would be the same for each image so that the measurements for each subject could be reliably compared. This was done in the Dolphin 3D software by setting the x-, y-, and z-axes on reproducible anatomic landmarks that could be easily identied. From the right lateral view, the z-axis was set to the Frankfort horizontal, a line passing through the right porion and right orbitale. Then the y-axis was set perpendicular to the z-axis through the middle of the sella turcica by clipping the image from the sagittal view to obtain a clear view of the sella.

Fig. Skeletal landmarks.

From the frontal view, the x-axis was dened by a line passing through the right and left orbitales. From the superior view, the z-axis was constructed by drawing a line from the crista galli through the middle of the sella and perpendicular to the x-axis through the middle of the sella. By establishing the x-, y-, and z-axes, 3 planes in space were created that intersected at the origin. The origin (0, 0, 0) was located along the midsagittal plane, just below the sella, and at the level of Frankfort horizontal. After the reconstructed model was oriented and the axes and planes were dened, landmarks could be plotted in precise anatomic locations by using sagittal, coronal, and axial slices of the CBCT volume. Twenty-one digital landmarks, skeletal and dental, were selected based on ease of identication and reproducibility (Fig, Table I). Three midline landmarksorigin, incisive foramen, and genial tubercleswere chosen to represent the middle of the cranial base, the maxilla, and the mandible, respectively. The other 18 landmarks were located on the right and left halves of the skull and dental arches. Each landmark was assigned unique coordinates (x, y, z) when it was plotted in the Dolphin 3D software. These coordinates could then be copied and pasted into Excel (Microsoft, Redmond, Wash), with a spreadsheet designed so that the direct measurements in millimeters could be calculated between any 2 landmarks by using the distance formula. In 3-dimensional space, the

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Table I. Landmark abbreviations*

Landmark 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Specic name Origin (0, 0, 0) Class II side foramen rotundum Class I side foramen rotundum Class II side mandibular foramen Class I side mandibular foramen Class II side superior, posterior, lateral condyle Class I side superior, posterior, lateral condyle Class II side foramen ovale Class I side foramen ovale Class II side mental foramen Class I side mental foramen Incisive foramen Midpoint between genial tubercles Class II side mesial buccal cusp tip of upper 6 Class I side mesial buccal cusp tip of upper 6 Class II side mesial buccal cusp tip of lower 6 Class I side mesial buccal cusp tip of lower 6 Class II side cusp tip of upper 3 Class I side cusp tip of upper 3 Class II side cusp tip of lower 3 Class I side cusp tip of lower 3 Generic name Cranial base Maxilla II Maxilla I Mandible II Mandible I Condyle II Condyle I Foramen ovale II Foramen ovale I Mental foramen II Mental foramen I Incisive foramen Genial tubercles Upper 6 II Upper 6 I Lower 6 II Lower 6 I Upper 3 II Upper 3 I Lower 3 II Lower 3 I Abbreviation CB MxII MxI MdII MdI CoII CoI FOII FOI MeFII MeFI IF GT U6II U6I L6II L6I U3II U3I L3II L3I

6, First molar; 3, canine. *The subdivision side is the Class II side, and the other side is the Class I side; the right side is always the Class II side in this study, and the left side is always the Class I side; therefore, Class II side and right side are used interchangeably in the study, as well as Class I side and left side.

distance between points (x1, y1, z1 and x2, y2, z2) is determined with this equation: q 2 2 2 d5 x2 x1 1y2 y1 1z2 z1 Measurements were also made in the Class II side of the maxilla and the mandible that were compared with the measurements in the Class I side of the maxilla and the mandible (Table II). These measurements were evaluated to determine whether there were any Class II side vs Class I side differences in the following. 1. The positions of the maxilla or the mandible in relation to the cranial base (rotation of the maxilla or the mandible, when one side is ahead of or behind the other side). The positions of the maxilla and the mandible in relation to each other (intermaxillary measurement). Intramaxillary dimensions (one side larger or smaller than the other). Intramandibular dimensions. The intra-arch positions of the molars and canines relative to the maxilla (mesial or distal position of the teeth in the arch on 1 side). The intra-arch positions of the molars and canines relative to the mandible.

Fifteen of the 54 subjects were randomly selected, and the CBCT orientations, landmark identications, and measurements were repeated by the same examiner (C.M.M.) to test for reliability. The method error (ME), or casual error, Pwas calculated by using Dahlberg's formula15: ME5O d2=2n; with d as the difference between the original and repeated measurements and n as 15 for the sample size that was repeated. The method error tests for the reproducibility of each measurement and provides an estimate of the standard deviation around the mean of each measurement.
Statistical analysis

2. 3. 4. 5.

6.

Each measurement was a straight-line distance between the 2 points.

The null hypothesis was that no signicant difference would exist between the Class II and Class I sides for the skeletal and dental measurements of Class II subdivision malocclusions. A second hypothesis was that there would be no signicant difference in skeletal or dental measurements between the 2 sides when Class II subdivision malocclusions were separated into a noncrowded group with minimal or no dental crowding and a crowded group with moderate to severe dental crowding. To test these hypotheses, descriptive statistics (means and standard deviations) were calculated for all 32 variables. Paired-samples correlations were used to determine whether there were relationships between

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Table II. Paired-samples descriptive statistics and

method errors*
Measurement pair 1 CB to MxII CB to MxI 2 CB to MdII CB to MdI 3 MxII to MdII MxI to MdI 4 MxII to IF MxI to IF 5 MdII to MeFII MdI to MeFI 6 MdII to GT MdI to GT 7 FOII to MdII FOI to MdI 8 CoII to MdII CoI to MdI 9 MxII to U6II MxII to L6II 10 MxII to U3II MxII to L3II 11 MxI to U6I MxI to L6I 12 MxI to U3I MxI to L3I 13 MdII to U6II MdII to L6II 14 MdII to U3II MdII to L3II 15 MdI to U6I MdI to L6I 16 MdI to U3I MdI to L3I Mean 24.601 24.219 52.531 52.185 46.004 45.855 61.726 61.867 58.947 59.569 72.259 72.701 33.238 33.024 35.252 35.380 55.265 55.585 69.199 67.099 54.767 56.616 68.858 68.428 45.083 44.435 66.632 65.347 43.141 45.714 64.861 66.729 SD 1.683 1.965 3.038 3.206 3.857 3.668 4.625 4.680 4.183 3.925 4.321 3.996 3.726 3.413 3.469 3.329 5.066 5.252 5.487 5.859 5.052 5.330 5.367 5.864 3.640 3.689 4.521 4.348 3.233 3.409 3.746 3.969 Method error 0.418 0.723 0.741 0.439 0.694 0.427 0.852 0.927 0.751 1.097 0.737 0.886 0.687 0.613 0.747 0.845 0.366 0.352 0.409 0.379 0.542 0.434 0.533 0.548 0.776 0.794 0.783 0.829 0.713 0.647 0.587 0.688

*Each measurement for the Class II side is paired with its counterpart from the Class I side to give 16 measurement pairs and 32 measurements and variables; all measurements are in millimeters.

the variables on the Class II side and the Class I side. Paired-samples t tests were run to evaluate any signicant differences between the corresponding variables of the Class II and Class I sides. The alpha value was set at 0.05 for this study. Statistical analyses were run by using SPSS software (version 15.0; SPSS, Chicago, Ill).
RESULTS

Only 2 of the 32 variables had signicant systematic errors: right foramen ovale to right mandibular foramen, and left mandibular foramen to mandibular left rst molar. Method errors ranged from .35 to 1.10 (Table II), with only 1 variable having an error over 1 mm (MdI to MeFI). The orientations, landmark identications, and measurement methods used in this study were found to be repeatable and reliable.

The mean and standard deviation of each variable are shown in Table II. The pairs of measurements were compared with each other in Tables III through IX via pairedsamples correlations and t tests. The average amount of subdivision discrepancy for the entire sample was estimated on the CBCT images by measuring from the mesiobuccal cusp tip of the maxillary rst molar to the buccal groove of the mandibular rst molar on the Class II side in the sagittal plane (3.92 6 .96 mm). This was done to have a rough frame of reference for the total amount of subdivision to be accounted for with skeletal and dental 3-dimensional measurements. All 16 pairs of measurements showed statistically signicant correlations with one another when the entire sample was evaluated and when it was separated into the noncrowded and crowded groups (Tables III-IX). The mean values (Table II) of each measurement in each pair were extremely close together; this also suggested a relationship between the Class II and Class I sides. The r values ranged from .73 to .99, and all were signicant at the P \0.05 level. The position of the maxilla was signicantly different on the Class II side vs the Class I side when the entire sample was compared (P 5 0.045) and when the crowded group was compared with the noncrowded group (P 5 0.018) (Table III). However, the position of the maxilla was not signicantly different when the noncrowded group was compared with crowded group. There were no signicant positional differences between the 2 sides of the mandible relative to the cranial base. Intermaxillary comparisons relating the position of the maxilla to the mandible on both the Class II and Class I sides showed no signicant differences (Table IV). Of the intramaxillary and intramandibular comparisons in Table V, the only signicant difference that was found was for mandibular foramen to mental foramen (MdII to MeFII MdI to MeFI, P 5 0.020) when the entire sample was compared. This difference was not statistically signicant for the 2 groups. No other skeletal measurements in the maxilla and the mandible were statistically signicant between the Class II and Class I sides. In Table IV, signicant differences are shown for maxillary molar positions (P 5 0.019), mandibular molar positions (P \0.001), and mandibular canine positions (P \0.001) relative to the maxilla. The noncrowded group showed signicant differences in mandibular molar positions (P 5 0.001) and mandibular canine positions (P \0.001) relative to the maxilla. The crowded group also had signicant differences in mandibular molar positions (P 5 0.018) and mandibular canine positions (P 5 0.034) relative to the maxilla. Statistically signicant differences were found between the Class II and Class I sides for maxillary molar

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Table III. Class II side minus Class I side (positions of the maxilla and the mandible relative to the cranial base, pairedsamples correlations, and t tests)
Class II subdivision (n 5 54) Correlation t test Paired differences Noncrowded (n 5 25) Correlation t test Paired differences Crowded (n 5 22) Correlation t test Paired differences

r P Mean SD P r P Mean SD P r P Mean SD P 0.002* 0.730 1.335 0.018* CB to MxII 0.731 \0.001* 0.382 1.364 0.045* 0.744 \0.001* 0.234 1.416 0.417 0.625 CB to MxI CB to MdII 0.810 \0.001* 0.345 1.933 0.195 0.881 \0.001* 0.399 1.322 0.144 0.782 \0.001* 0.409 2.472 0.447 CB to MdI *Statistically signicant at P \0.05.

Table IV. Class II side minus Class I side (position of the maxilla related to the mandible, paired-samples correlations, and t tests)
Class II subdivision (n 5 54) Correlation t test Paired differences Noncrowded (n 5 25) Correlation t test Paired differences Crowded (n 5 22) Correlation t test Paired differences

r P Mean SD P r P Mean SD P r P Mean SD P MxII to MdII 0.863 \0.001* 0.149 1.976 0.581 0.845 \0.001* 0.565 2.347 0.240 0.879 \0.001* 0.131 1.535 0.692 MxI to MdI *Statistically signicant at P \0.05.

Table V. Class II side minus Class I side (intramaxillary skeletal measurements and intramandibular skeletal measure-

ments, paired-samples correlations, and t tests)

Class II subdivision (n 5 54) Correlation MxII to IF MxI to IF MdII to MeFII MdI to MeFI MdII to GT MdI to GT FOII to MdII FOI to MdI CoII to MdII CoI to MdI t test Paired differences Noncrowded (n 5 25) Correlation t test Paired differences Crowded (n 5 22) Correlation t test Paired differences

r P Mean SD P 0.949 \0.001* 0.141 1.490 0.489

r P Mean SD P r P Mean SD P 0.927 \0.001* 0.078 1.692 0.819 0.968 \0.001* 0.022 1.362 0.941

0.891 \0.001* 0.623 1.910 0.020* 0.878 \0.001* 0.607 2.216 0.184 0.899 \0.001* 0.704 1.713 0.067 0.908 \0.001* 0.442 1.810 0.078 0.890 \0.001* 0.213 1.701 0.360 0.925 \0.001* 0.484 2.039 0.247 0.911 \0.001* 0.556 1.795 0.161 0.901 \0.001* 0.052 1.296 0.841 0.858 \0.001* 0.321 2.220 0.505 0.124 2.209 0.795

0.867 \0.001* 0.128 1.758 0.595

0.919 \0.001* 0.171 1.257 0.503 0.852 \0.001*

*Statistically signicant at P \0.05.

positions, mandibular molar positions, maxillary canine positions, and mandibular canine positions relative to the mandible for the entire Class II subdivision sample, the noncrowded group, and the crowded group (Table VII). Tables VIII and IX show the results for the interarch measurements that were done to verify the subdivision between the 2 sides. Tables X through XIII quantify the amounts of signicant skeletal and dental asymmetries for each group.

DISCUSSION

Previous studies used 2-dimensional radiographs and found signicant dental asymmetries; the primary factor was the distal position of the mandibular rst molar on the Class II side.1,4,9-13,16,17 Other studies found a secondary factor involved in creating the subdivision: the mesial position of the maxillary rst molar on the Class II side.1,4,9,11-13 No study found major signicant skeletal asymmetries to go along

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Table VI. Class II side minus Class I side (intra-arch molar and canine positions relative to the maxilla, paired-samples correlations, and t tests)
Class II subdivision (n 5 54) Correlation MxII to U6II MxI to U6I MxII to L6II MxI to L6I MxII to U3II MxI to U3I MxII to L3II MxI to L3I r P 0.956 \0.001* t test Paired differences Mean SD 0.498 1.507 Noncrowded (n 5 25) Correlation t test Paired differences Mean SD 0.475 1.578 Crowded (n 5 2) Correlation t test Paired differences Mean SD P 0.596 1.615 0.098

P r P 0.019* 0.955 \0.001*

P r P 0.146 0.956 \0.001*

0.962 \0.001* 1.031 1.454 \0.001* 0.963 \0.001* 1.023 1.426 0.960 \0.001* 0.341 1.537 0.109 0.976 \0.001* 0.270 1.252

0.001* 0.960 \0.001* 0.881 1.606 0.018* 0.292 0.945 \0.001* 0.481 1.978 0.266

0.961 \0.001* 1.329 1.644 \0.001* 0.964 \0.001* 1.460 1.611 \0.001* 0.966 \0.001* 0.798 1.655 0.034*

*Statistically signicant at P \0.05.

Table VII. Class II side minus Class I side (intra-arch molar and canine positions relative to the mandible, pairedsamples correlations, and t tests)
Class II subdivision (n 5 54) Correlation MdII to U6II MdI to U6I MdII to L6II MdI to L6I MdII to U3II MdI to U3I MdII to L3II MdI to L3I t test Paired differences Noncrowded (n 5 25) Correlation t test Paired differences Crowded (n 5 22) Correlation t test Paired differences

r P Mean SD P r P Mean SD P r P Mean SD P 0.889 \0.001* 1.942 1.669 \0.001* 0.933 \0.001* 2.177 1.695 \0.001* 0.843 \0.001* 1.622 1.781 \0.001* 0.914 \0.001* 1.278 1.494 \0.001* 0.922 \0.001* 1.387 1.798 0.923 \0.001* 1.771 1.796 \0.001* 0.960 \0.001* 0.001* 0.935 \0.001* 1.165 1.194 \0.001* 1.680 1.956 0.001* 0.003*

1.657 1.762 \0.001* 0.869 \0.001*

0.922 \0.001* 1.382 1.684 \0.001* 0.938 \0.001* 1.473 1.909

0.001* 0.907 \0.001* 1.142 1.562

*Statistically signicant at P \0.05.

with the dental asymmetries; however, a few discovered tendencies for skeletal asymmetries and suggested further research to explore this area.13,14,18 Sanders et al19 found that the etiology of Class II subdivision malocclusions is primarily due to an asymmetric mandible that is shorter and positioned posteriorly on the Class II side. We conrmed the previous ndings for dental asymmetries and contributed some new ndings for skeletal asymmetries. The results showed a signicant difference in the position of the maxilla relative to the cranial base on the Class II side vs the Class I side (0.382 mm, Table III). The Class II side of the maxilla was actually positioned wider (.426 mm), farther forward (0.161 mm), and more inferior (0.170 mm) than the Class I side of the maxilla. This asymmetry is most likely a positional or rotational difference rather than a dimensional discrepancy because no signicant difference was found in the

intramaxillary measurements from the foramen rotundum to the incisive foramen for the 2 halves of the maxilla. The positions of the maxilla were asymmetric in the entire sample and in the crowded group, but not asymmetric in the noncrowded group. This result could be because the sample size was not large enough to detect a difference in the noncrowded group, or that the maxilla was positioned symmetrically in the noncrowded group, and other factors were responsible for the subdivision. This is the rst time that the maxilla has been shown to have an asymmetric position in Class II subdivision malocclusions. Janson et al13 mentioned that skeletal asymmetries are more likely in the mandible, since most Class II subdivisions are type 1, with distal positioning of the mandibular rst molar on the Class II side and a dental midline deviation also toward the Class II side. Azevedo et al14 found no skeletal differences in the maxilla but

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Table VIII. Subdivision verication (interarch dental measurements in relation to maxilla, paired-samples correla-

tions, and t tests)

Class II subdivision (n 5 54) Correlation MxII to U6II MxII to L6II MxII to U3II MxII to L3II MxI to U6I MxI to L6I MxI to U3I MxI to L3I t test Paired differences Noncrowded (n 5 25) Correlation t test Paired differences Crowded (n 5 22) Correlation t test Paired differences P 0.257 0.002*

r P Mean SD 0.983 \0.001* 0.321 0.971 0.955 \0.001*

P r P Mean SD 0.019* 0.986 \0.001* 0.310 0.855

P r P Mean SD 0.082 0.983 \0.001* 0.262 1.055 1.421 1.933

2.099 1.742 \0.001* 0.972 \0.001*

2.416 1.361 \0.001* 0.952 \0.001*

0.985 \0.001* 1.849 0.929 \0.001* 0.991 \0.001* 1.808 0.713 \0.001* 0.992 \0.001* 1.739 0.868 \0.001* 0.965 \0.001* 0.430 1.565 0.049* 0.984 \0.001* 0.687 1.124 0.005* 0.946 \0.001* 0.142 2.051 0.748

*Statistically signicant at P \0.05.

Table IX. Subdivision verication (interarch dental measurements in relation to mandible, paired-samples correla-

tions, and t tests)

Class II subdivision (n 5 54) Correlation MdII to U6II MdII to L6II MdII to U3II MdII to L3II MdI to U6I MdI to L6I MdI to U3I MdI to L3I t test Paired differences Noncrowded (n 5 25) Correlation t test Paired differences Crowded (n 5 22) Correlation t test Paired differences P 0.169 0.002*

r P Mean SD P r P Mean SD P r P Mean SD 0.948 \0.001* 0.647 1.178 \0.001* 0.969 \0.001* 0.919 1.118 \0.001* 0.924 \0.001* 0.376 1.236 0.943 \0.001* 1.285 1.511 \0.001* 0.970 \0.001* 1.096 1.338 \0.001* 0.898 \0.001* 1.353 1.743

0.979 \0.001* 2.573 0.706 \0.001* 0.984 \0.001* 2.645 0.657 \0.001* 0.975 \0.001* 2.411 0.746 \0.001* 0.964 \0.001* 1.868 1.058 \0.001* 0.982 \0.001* 2.034 0.920 \0.001* 0.950 \0.001* 1.469 1.097 \0.001*

*Statistically signicant at P \0.05.

Table X. Amount of signicant skeletal and dental asymmetry in relation to the maxilla (dental asymmetry measured

at the molars, measurements in millimeters)

Maxillary asymmetry Mandibular asymmetry Maxillary molar asymmetry relative to maxilla Mandibular molar asymmetry relative to maxilla Total signicant asymmetry NS, Not signicant. Class II subdivision (n 5 54) 0.382 0.623 0.498 1.031 2.534 Noncrowded (n 5 25) NS NS NS 1.023 1.023 Crowded (n 5 22) 0.730 NS NS 0.881 1.611

did nd minor skeletal differences in the mandible. They showed a small, but statistically signicant difference from the midcondylar point to the mandibular skeletal midline (the most anterior point of the mandibular body on a submentovertex radiograph). We found a signicant difference in an intramandibular skeletal measurement, mandibular foramen to mental foramen (MdII to MeFII

MdI to MeFI, a measurement within the measurement of the midcondylar point to the mandibular midline); this supports the ndings of Azevedo et al.14 The distance from the mandibular foramen to the mental foramen was shorter on the Class II side by .623 mm and was statistically signicant for the entire sample (P 5 0.020). It was not statistically signicant for the noncrowded (P 5 0.184)

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Table XI. Amount of signicant skeletal and dental asymmetry in relation to the maxilla (dental asymmetry measured at the canines)
Maxillary asymmetry Mandibular asymmetry Maxillary canine asymmetry relative to maxilla Mandibular canine asymmetry relative to maxilla Total signicant asymmetry NS, Not signicant. Class II subdivision (n 5 54) 0.382 0.623 NS 1.329 2.334 Noncrowded (n 5 25) NS NS NS 1.460 1.460 Crowded (n 5 22) 0.730 NS NS 0.798 1.528

Table XII. Amount of signicant skeletal and dental asymmetry in relation to the mandible (dental asymmetry mea-

sured at the molars)

Maxillary asymmetry Mandibular asymmetry Maxillary molar asymmetry relative to mandible Mandibular molar asymmetry relative to mandible Total signicant asymmetry NS, Not signicant. Class II subdivision (n 5 54) 0.382 0.623 1.942 1.278 4.225 Noncrowded (n 5 25) NS NS 2.177 1.387 3.564 Crowded (n 5 22) 0.730 NS 1.622 1.165 3.517

Table XIII. Amount of signicant skeletal and dental asymmetry in relation to the mandible (dental asymmetry mea-

sured at the canines)

Maxillary asymmetry Mandibular asymmetry Maxillary canine asymmetry relative to mandible Mandibular canine asymmetry relative to mandible Total signicant asymmetry NS, Not signicant. Class II subdivision (n 5 54) 0.382 0.623 1.771 1.382 4.158 Noncrowded (n 5 25) NS NS 1.657 1.473 3.130 Crowded (n 5 22) 0.730 NS 1.680 1.142 3.552

and crowded (P 5 0.067) groups, but this might be due to the reduced power from the smaller sample sizes of the 2 crowding groups. Our results agree with the ndings of previous studies that the mandibular teeth are positioned asymmetrically between the Class II and Class I sides. The positions of the mandibular molars and canines were statistically different in all 3 groups when measured in relation to the maxilla and the mandible (Tables VI and VII). Since the Class I side measurement was always subtracted from the Class II side measurement, the mean was negative for all mandibular dentition comparisons in relation to the maxilla and the mandible; this signies that the Class I side measurement is greater than the Class II side measurement. This nding was consistent, and it supports that the distal positioning of the mandibular molar on the Class II side is a major factor in Class II subdivision malocclusions.13,14,18 Sanders et al19 concluded that a mesially positioned maxillary molar and a distally positioned mandibular molar on the Class II side are also minor contributing factors.

The positions of the maxillary teeth also had significant differences, but the differences were not seen in every circumstance. The position of the maxillary molars in relation to the maxilla was statistically signicant for the entire sample but not for the noncrowded and crowded groups. This could be due to the smaller sample sizes of the 2 crowding groups or could be because of the mesial positioning of the maxillary molars on the Class II side. The positions of the maxillary canines in relation to the maxilla were not statistically different in any of the 3 groups. However, the positions of the maxillary molars and canines in relation to the mandible were statistically signicant for all 3 groups (Tables VI and VII). This is an interesting nding because it provides indirect evidence for an asymmetrically positioned maxilla. If the maxillary molar and canine positions are symmetric in relation to the maxilla but asymmetric in relation to the mandible, it suggests that the maxilla could be rotated, or asymmetrically positioned, relative to the cranial base.

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Class II subdivisions can be caused by various factors, and this study shows that there are signicant skeletal and dental differences between the Class II and Class I sides. The amount of skeletal asymmetry is smaller than the amount of dental asymmetry, but it still accounts for a signicant portion of the subdivision. The asymmetry in the position of the maxilla (for the entire sample) accounts for about .4 mm of the discrepancy, whereas the asymmetry in the mandible contributes .6 mm (Tables X-XIII). Therefore, the total skeletal asymmetry is 1 mm. The amount of dental asymmetry can be calculated in several ways: it can be measured at the level of the molars or at the level of the canines, and in relation to the maxilla or the mandible. At the level of the molars and in relation to the maxilla, the dental discrepancy was about 1.5 mm (Table X). The discrepancy was 1.3 mm for the canines in relation to the maxilla (Table XI). At the level of the molars and in relation to the mandible, the dental discrepancy was 3.2 mm (Table XII). The discrepancy was 3.2 mm for the canines in relation to the mandible (Table XIII). Therefore, the amount of subdivision was essentially the same whether it was measured at the level of the molars or at the level of the canines. However, there was a large difference in the amount of subdivision depending on whether it was measured in relation to the maxilla or the mandible (1.5 vs 3.2 mm). It is not clear why the dental asymmetry is much greater when measured in relation to the mandible, but most of this difference comes from the measurement of the mandible to the maxillary rst molar (MdII to U6II minus MdI to U6I 5 1.9 mm) vs the maxilla to the maxillary rst molar (MxII to U6II minus MxI to U6I 5 0.5 mm). When the skeletal asymmetry was added to the dental asymmetry, there was a total of 2.5 mm of discrepancy in relation to the maxilla, or 4.2 mm of discrepancy in relation to the mandible. The discrepancy in relation to the mandible was similar to the average amount of total subdivision (3.92 6 0.96 mm) that was calculated as a reference in the sagittal plane for the entire sample. Since dental asymmetry accounts for more than half of the total discrepancy, this shows that it is a greater component of the subdivision.
CONCLUSIONS

2.

3.

4.

5.

A signicant mandibular asymmetry was identied. The distance was shorter on the Class II side between the mandibular foramen and the mental foramen. The distance was shorter in the positions of the molars and the canines on the Class II side in relation to the maxilla and the mandible. The differences in the positions of the maxillary molars and canines were signicant in relation to the mandible, but not in relation to the maxilla. Dental asymmetries were a greater part of the total asymmetry than were skeletal asymmetries.

REFERENCES 1. Turpin DL. Correcting the Class II subdivision malocclusion. Am J Orthod Dentofacial Orthop 2005;128:555-6. 2. Janson G, Carvalho PE, Canc ado RH, de Freitas MR, Henriques JF. Cephalometric evaluation of symmetric and asymmetric extraction treatment for patients with Class II subdivision malocclusions. Am J Orthod Dentofacial Orthop 2007;132:28-35. 3. Janson G, Dainesi EA, Henriques JF, de Freitas MR, de Lima KJ. Class II subdivision treatment success rate with symmetric and asymmetric extraction protocols. Am J Orthod Dentofacial Orthop 2003;124:257-64. 4. Janson GR, Metaxas A, Woodside DG, de Freitas MR, Pinzan A. Three-dimensional evaluation of skeletal and dental asymmetries in Class II subdivision malocclusions. Am J Orthod Dentofacial Orthop 2001;119:406-18. 5. Bishara SE, Burkey PS, Kharouf JG. Dental and facial asymmetries: a review. Angle Orthod 1994;64:89-98. 6. Burstone CJ. Diagnosis and treatment planning of patients with asymmetries. Semin Orthod 1998;4:153-64. 7. Lewis PD. The deviated midline. Am J Orthod 1976;70: 601-16. 8. Warren DW. Subdivision malocclusions: cracking the riddle. J Clin Orthod 2001;35:93-9. 9. de Araujo TM, Wilhelm RS, Almeida MA. Skeletal and dental arch asymmetries in Class II division 1 subdivision malocclusions. J Clin Pediatr Dent 1994;18:181-5. 10. Sabah ME. Submentovertex cephalometric analysis of Class II subdivision malocclusions. J Oral Sci 2002;44:125-7. 11. Alavi DG, BeGole EA, Schneider BJ. Facial and dental arch asymmetries in Class II subdivision malocclusion. Am J Orthod Dentofacial Orthop 1988;93:38-46. 12. Janson G, Cruz KS, Barros SE, Woodside DG, Metaxas A, de Freitas MR, et al. Third molar availability in Class II subdivision malocclusion. Am J Orthod Dentofacial Orthop 2007;132: 279.e215-21. 13. Janson G, de Lima KJ, Woodside DG, Metaxas A, de Freitas MR, Henriques JF. Class II subdivision malocclusion types and evaluation of their asymmetries. Am J Orthod Dentofacial Orthop 2007; 131:57-66. 14. Azevedo AR, Janson G, Henriques JF, Freitas MR. Evaluation of asymmetries between subjects with Class II subdivision and apparent facial asymmetry and those with normal occlusion. Am J Orthod Dentofacial Orthop 2006;129:376-83. 15. Dahlberg G. Statistical methods for medical and biological students. New York: Interscience Publications; 1940. 16. Alkode EA. Class II division 1 malocclusions: the subdivision problem. J Clin Pediatr Dent 2001;26:37-40.

The following differences were found between the Class II and Class I sides of Class II subdivision malocclusions. 1. A signicant skeletal difference was found for the position of the maxilla relative to the cranial base. The maxilla was positioned farther forward, wider than, and more inferior on the Class II vs the Class I malocclusion side.

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17. Rose JM, Sadowsky C, BeGole EA, Moles R. Mandibular skeletal and dental asymmetry in Class II subdivision malocclusions. Am J Orthod Dentofacial Orthop 1994;105:489-95. 18. Janson G, Cruz KS, Woodside DG, Metaxas A, de Freitas MR, Henriques JF. Dentoskeletal treatment changes in Class II subdivision malocclusions in submentovertex and posteroanterior

radiographs. Am J Orthod Dentofacial Orthop 2004;126: 451-63. 19. Sanders DA, Rigali PH, Neace WP, Uribe F, Nanda R. Skeletal and dental asymmetries in Class II subdivision malocclusions using cone-beam computed tomography. Am J Orthod Dentofacial Orthop 2010;138:542.e1-20; discussion 542-3.

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