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CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

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 ORTHODONTICS
CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED
Adil Osman Mageet1a*
1
Department of Orthodontics, MBR University, Hamdan Bin Mohamed College of Dental Medicine, Dubai, UAE

PhD, BDS, CES, MSc (Orthodontics), M.Orth.RCSEd, FDS.RCSEd, Associate Professor

a

Received: July 2, 2016

Accepted: July 4, 2016
Available online: August 12, 2016

Cite this article:

Mageet AO. Classification of Skeletal and Dental Malocclusion: Revisited. StomaEduJ. 2016;3(2):

ABSTRACT

Orthodontic dental classification used is dated more than 100 years ago. Skeletal and dental classifica-
tion of malocclusion has an important role in diagnosis and treatment planning. The aim of this study is
to facilitate the grouping of skeletal and dental malrelationships and to build an accurate diagnosis and
to suggest treatment planning.
Material and method
The main orthodontic classification systems for skeletal and dental relationship were reviewed.
Results
The proposed skeletal and dental classification proved detailed accuracy and focus on relating the cat-
egories with the suggested treatment planning. The new modification of the skeletal and dental classifi-
cation explained clearly the occlusal relationship and helped in setting treatment strategies.
Conclusions
This present skeletal and dental classification is faster, accurate and easily applicable clinically and dealt
with the shortcoming of the previous classification systems. It also helped in the suggestion of Orthodon-
tic treatment protocols.
Keywords: orthodontic malocclusion, skeletal classification, dental classification

Introduction II: Distal mandibular development in relation to

the maxilla. The profile is prognathic (Convex).
In 1930 Simon was the first to relate the dental He subclassified skeletal II into: Class II/1: Narrow
arches to the face and cranium in the three planes maxillary arch with crowding in the canine region;
of space: Frankfurt horizontal plane (F-H plane), Class II/2: Lingually Inclined maxillary incisors, the
also called (E-EP). Or-Po plane. Vertical: Attrac- laterals may be normal or proclined. Skeletal Class
tion or Abstraction; Orbital plane (Perpendicular III: Over growth of the mandible with obtuse man-
to F-H plane at the margin of the bony orbit), an- dibular angle. The profile is retrognathic profile
tero-posterior: Protraction or Retraction; Median (Concave).2
sagittal plane (The MSP is determined by points The scholar Edward Hingley Angle (1899) classi-
approximate1.5cm apart on the median raphe fied Orthodontic malocclusion in the mesio-distal
of the palate. The raphe median plane passes relationship of teeth. His classification is based on
through these two points at right angles to the F-H the maxillary permanent 1st molar where he con-
plane), transverse: Contraction or Distraction.1 sidered it as the key ridge and accordingly he clas-
Salzmann in 1950 was the first to classify to the un- sified the molar relationship into class I, II and III
derlying skeletal structure, he stated that Skeletal using Roman numbers and subdivided class II into
Class I: Purely dental with the bones of face and division 1 and 2 using Arabic numbers.3
jaws being in harmony with one another and with Because of the drawback of Angle’s classifica-
the rest of the head. The profile is orthognathic tion, listed as; the Maxillary permanent 1st molar
(Straight). Then he added divisions to the skeletal is not a fixed anatomic point (key ridge); cannot
I, Division 1: Local mal-relationship of incisors, ca- classify for mesially drifted, impacted, missing or
nines and premolars; Division 2: Maxillary incisor extracted Maxillary permanent 1st molars; did not
protrusion; Division 3: Maxillary incisors retrusion; consider single tooth malposition; cannot classify
Division 4: Bimaxillary protrusion. Skeletal Class the primary teeth, in addition did not classify the

*Corresponding author:
Associate Prof. Dr. Adil Osman Mageet
PhD, BDS, CES (France), MSc (Orthodontic, UK), M.Orth.RCSEd, FDS.RCSEd
Department of Orthodontics, Hamdan Bin Mohamed College of Dental Medicine, MBR University, Dubai, UAE , P.O.Box 505097 Dubai UAE
Tel: +971 4 424 8631 ; Fax: +971 4 424 8687
e-mail: [email protected]

38 STOMA.EDUJ (2016) 3 (2)

 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

models in the Broadbent-Bolton study.8 Another

study conducted by Baumrind et al., (1996) on
whether to extract in orthodontic treatment, found
that 28-33% disagreement among the 5 participat-
ing orthodontist.9
Katz (1992a) showed inter-examiner disagree-
ment of 49% among 270 orthodontists using An-
gle’s classification.10 The percentage agreement
of Katz’s technique proved superior to that of the
classical Angle’s classification.11,12 Rinchuse found
Angle’s classification to be limited because it is a
system of discrete classes as compared to continu-
ous transition of maxillo-mandibular dental arches
in sagittal plane.13
The British Standard Institute (BSI) in 1983 classi-
fied dental malocclusion according to the maxil-
lary and mandibular incisors relationship. Class I:
When the mandibular incisor edges lie or below
the cingulum plateau of the maxillary incisors.
Class II: When the mandibular incisor edges lie
posterior to the cingulum plateau of the maxillary
incisors, the maxillary incisors could be proclined
where it is classified as Class II / 1, or retroclined
maxillary centrals and proclined laterals, or both
central and lateral incisors are retroclined where it
Figure 1. Skeletal classification is grouped under Class II / 2. Class III: where the
mandibular incisor edges lie anterior to the cingu-
skeletal relationship and did not predict the etio- lum plateau of the maxillary central incisors.14
logical factors, so revisiting was always needed. The BSI classification was more accurate in group-
Deway’s in 1915 modified Angle’s Class I and III ing the malocclusion.15 The British method of over-
malocclusion by segregating malposition of ante- jet and overbite assessment15 and the quantitative
rior and posterior segments, CL I: type 1 (Crowd- technique proposed by Katz (1992b)16 developed
ing of Max anterior teeth); type 2 (Proclined Max over the years, proved to be more amenable to re-
incisors); type 3 (Max incisors are in cross-bite); production than Angle’s classification.11,15
type 4 (Posterior cross-bite); type 5 (Mesial drift Du et al., (1998) in their study where four orth-
of molars). CL II (no modifications). CL III: type 1: odontic faculty at one dental school classified 25
(Edge to edge bite), type 2: (Crowded Mandibular dental casts according to the classification sys-
incisors and lingual to Max incisors); type 3: (Un- tems of Angle, Katz, and the British Incisor Clas-
derdeveloped crowded Maxillary arch and a well sification.11 The dental casts were selected from
developed Mandibular arch).4 a pool of 350 pretreatment graduate orthodontic
Lischer in 1933 further modified Angle classifica- cases and were those deemed the most atypical.
tion by giving substitute names; CL I (Neutrocclu- The results demonstrated that Katz’s classification
sion); CL II (Distocclusion); CL III (Mesiocclusion). was more reliable than both Angle and the British.
He also proposed terms to designate individual Angle’s classification was the least reliable of the
tooth malposition, Mesio-version (Mesial to nor- three methods.
mal position); Disto-version (Distal to normal po-
sition); Linguo-version (Crossbite); Labio-version Skeletal classification: revisited
(Increased OJ); Infra-version (Submerged tooth); In the author view Orthodontic skeletal classifica-
Supra-version (Super-erupted); Axio-version tion could be grouped into class I (straight), class
(Tipped tooth); Torsi-version (Rotated tooth); II (convex) and class III (concave). Salzmann clas-
Trans-version (Transposed tooth).5 sification did not specify that the problem is due
Ackerman and Proffit (1969) introduced a very to maxillary protrusion, mandibular retrusion or a
comprehensive system of classification using the combination of both. The same for the concave
Venn diagram. The classification considered five profile, his method did not specify that the prob-
characteristics and their inter-relationships were lem is due to maxillary retrusion, mandibular pro-
assessed, namely; alignment, profile, transverse, trusion or a combination of both.
class and overbite.6 The author agrees with all scholars that skeletal
Angle’s classification still seems the method of the class I has straight profile (Fig. 1), which explains
most popular tool for classification of malocclu- homogeneous relationship between the maxilla
sion, despite its well-known disadvantages.7 Hans and mandible, or in another terms they grow in
et al., (1994), noted the inadequacy of Angle’s unison. In cases of Skeletal I the problem is den-
classification when they were unable to classify tal malrelationships. It is present in two planes,
approximately 7% of a large sample (n=4309) of the vertical and the transverse planes where the

39
 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Figure 2. Incisor’s Classification

Table 1. Suggested Treatment Protocol for Skeletal bases

Suggested Treatment Protocol

There is a harmonious relationship antero-posteriorly; the problem is either in the vertical or trans-
Skeletal I verse plane. Advice surgical correction if needed.

Functional appliance (growing children) or mandibular surgery (adult or syndromic patients e.g.
Type 1
Pierre Robin).

Type 2 Headgear (children and adolescents) or maxillary surgery for adults.

Here the treatment could of combination, functional [removable e.g. twin block or fixed e.g. Forsus],
Skeletal II Type 3 Headgear, camouflage with the extraction of upper 1st premolars alone or in combination with lower
2nd premolars or Bi-maxillary orthognathic surgery.

Functional appliances e.g. Yanagisawa Class III shield (YC3)19.

Type 1 Palatal expansion ± facemask (Delaire, reverse pull headgear by Nakamura) advised before the age
of 10 years.20

Type 2 Mandibular excess is treated with surgery e.g. Bilateral sagittal split osteotomy (BSSO).

Skeletal III Here the treatment could of combination:

functional (Yanagisawa,YC3), palatal expansion ± facemask, camouflage with the extraction of lower
Type 3
1st premolar and upper 2nd premolars, or extraction of a single lower central incisor, Bi-maxillary
orthognathic surgery (Le Fort I ± BSSO) or genioplasty in some cases.

antero-posterior plane is normal or within average. and type 3 (combination of both). (Fig. 1)
There is always a question arises in cases where it The same applies for Class III (concave profile),
is straight to mild convexity or mild concavity. The again Salzmann did not specify either it is due to
author view is to enlarge the description of skeletal maxillary retrusion or mandibular protrusion. Ac-
I so as to include the mild convexity and mild con- cording to my explanation it could be due to max-
cavity as far as it is confirmed by the ANB angle. illary retrusion (Skeletal III type 1), or mandibular
The range of skeletal I would be straight to mild protrusion (Skeletal II type 2), or a combination of
convexity or mild concavity. both (skeletal III type 3), which gives detailed ex-
Salzmann Skeletal II (convex profile) did not indi- planation aiding in diagnosis and treatment plan-
cate either it is due to protruded maxilla or retrud- ning. (Fig.1)
ed mandible or a combination of both. In this pres-
ent study, Skeletal II could be of three types; type Occlusal Classification: revisited
1 (retruded mandible), type 2 (protruded maxilla) The BSI and Katz’s classification deal with partial

40 STOMA.EDUJ (2016) 3 (2)

 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Figure 3. Canine’s Classification

description of the malocclusion. The British system velop the older classification. The reconsideration
of classification related to the anterior teeth where is done in the antero-posterior and on both sides,
it needs further elaboration while Katz system fo- where molar classification is more elaborated. In
cuses on the premolar occlusion and ignore the this revision class IV, V and VI are generated which
canines and molar classification. helped in treatment planning and suggesting
Snyder and Jerrold (2007), have concluded that treatment protocol.
a modification of Angle’s system that is more de- Accurate and detailed classification is always
scriptive is needed, after they have sent e-mail needed to drive an accurate diagnosis and treat-
survey to the department chair or the program ment plan.
director of every orthodontic program in the Unit- The author followed the BSI incisor classification
ed States, Canada, and Puerto Rico (n = 80). The with modifications for class II and III, accepts ca-
survey included photos of models placed into ¼ nine classification and modifies molar classifica-
cusp, ½ cusp, and ¾ cusp distal occlusions, and tion, which are further elaborated for the ease of
the participants were asked to classify them by se- diagnosis and accuracy of treatment planning in
lecting from a list of terms or writing one of their orthodontics.
own. They were also asked whether they thought
that the Angle molar classification was adequate Incisor’s Classification (Fig. 2)
for communication and diagnosis.  A fourty surveys Class I: When the mandibular incisor edge lie or
were completed and returned. The results showed below the cingulum plateau of the maxillary inci-
a variety of terminology being taught, and most sor (BSI, 1983), the overjet is 2-4 mm.
educators do not use Angle’s classification as he Class II: When the mandibular incisors edges lie
defined it. About half of the respondents were dis- posterior to the cingulum plateau of the maxillary
satisfied with the Angle molar classification sys- incisors (BSI, 1983). It could be:-
tem.17 Class II/1: Proclined maxillary incisors with overjet
Siegel in 2002 conducted 57 surveys which were more than 4 mm.
mailed to department chairs in the United States, Class II/2a: Retroclined maxillary centrals and pro-
asking them to identify the definition to which their clined laterals, or both central and lateral incisors
orthodontic residency program subscribes; 34 sur- are retroclined with normal or reduced overjet.
veys were returned. Class II/2b: Retroclined maxillary centrals and pro-
Twenty-two responses supported the notion that clined laterals, or both central and lateral incisors
subdivision refers to the Class II side, 8 responses are retroclined but with increased overjet.
said that it refers to the Class I side, 3 responses Class III: When the mandibular incisors edges lie
supported neither view, and 1 response indicated anterior to the cingulum plateau of the maxillary
that not everyone in the program could agree on incisors (BSI, 1983).
the meaning of subdivision. Class III type 1: Positive overjet but less than 2 mm.
Although the prevailing belief appears to be that Class III type 2: Edge to edge incisors relationship.
subdivision indicates the side with a molar mal- Class III type 3a: Negative overjet.
occlusion, the orthodontic community does not Class III type 3b: Negative overjet but patient can
have a consistent standard, and it is time to resolve make edge to edge (pseudo Class III).
this controversy.18 Due to the low reliability of the The author believes that incisor classification could
Angle’ method, a reconsideration is needed to de- also be used for esthetic considerations.

41
 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Table 2. Suggested Treatment Protocol for dental malocclusion

Suggested Treatment Protocol

Non extraction:
stripping, expansion, derotation, uprighting or distalisation
Extraction:
Class I malocclusion U/L 4s, U/L 5s, U/L 6s, U/L 7s or a symmetric extraction e.g. right U/L 4s + left U/L 5s, U/L 6s
+ U/L 4s or 5s, single tooth extraction.
Non extraction:
Distalisation with headgear
Type 1 Extraction:
4s, (U 4s + L 5s), (U/L 6s), (U/L 7s) or a symmetric extraction e.g. (right U/L 4s + left U/L
5s), (U/L 6s + U/L 4s or 5s). or a single U4.
Always advise non extraction treatment using a headgear + Nudger or an intra-oral distal-
izer.
Type 2a If crowding is to be relieved by extraction, then it is advisable to extract the 2nd premolar
than the 1st premolar because of difficulty of space closure.
Class II malocclusion
Transfer the case to CL II/1 and treat accordingly.
Headgear + Nudger
Type 2b Orthognathic surgery treatment (proclined upper anteriors and retroclined lower anteriors-
decompensation: plan for surgery)
Camouflage with stripping lower arch and proclining upper teeth.
Type 1
Expansion of upper arch ± fixed appliance therapy.
Expansion of upper arch ± fixed appliance therapy with CL III elastics.
Extraction of lower 1st premolars and upper 2nd premolars + U/L fixed orthodontic therapy
Type 2 with CL III elastics.
Expansion of upper arch + extraction of a single lower central incisor + U/L fixed orthodon-
tic therapy with CL III elastics.
Expansion of upper arch ± fixed appliance therapy with CL III elastics.
Extraction of lower 1st premolars and upper 2nd premolars + U/L fixed Orthodontic therapy
Type 3a with CL III elastics.
Class III malocclu- Expansion of upper arch + extraction of a single lower central incisor + U/L fixed orthodon-
sion tic therapy with CL III elastics.
Expansion of upper arch ± fixed Orthodontic therapy.
Extraction of lower 1st premolars and upper 2nd premolars + U/L fixed Orthodontic therapy.
Type 3b
Expansion of upper arch + extraction of a single lower central incisor + U/L fixed Orth-
odontic therapy with CL III elastics.

lar 1st permanent molar lie posterior to the mesio-

Canine’s Classification (Fig. 3) buccal cusp of the Maxillary 1st permanent molar.
Class I: mesial incline of the upper canine overlaps Class II ½ unit: When the maxillary 1st permanent
the distal slope of the lower canine (The maxillary molar cusps occlude with the
canine occludes between the mandibular canine mandibular 1st permanent molar cusps in an edge
and 1st premolar). to edge.
Class II: Distal slope of the maxillary canine oc- Class II full unit: When the maxillary 1st permanent
cludes or contact the mesial slope of the lower molar cusps occlude anterior to the mandibular 1st
canine. permanent molar.
Class III: The mandibular canine is displaced ante- Class III. The mesio-buccal groove of the mandibu-
rior to the maxillary canine with no overlapping. lar 1st permanent molar lie anterior to the mesio-
buccal cusp of the Maxillary 1st permanent molar.
Molar’s Classification (Fig. 4) Relationship between right and left buccal occlu-
The author modified Angle’s classification to in- sion is further grouped to resolve the notion of
clude different molar relationship on both sides subdivisions:
and renamed the subdivision. Class IV. Class I on one side and Class II (either ½
Class I: The mesio-buccal groove of the mandibu- unit or full unit) on the other side.
lar 1st permanent molar occludes with the mesio- Class V: Class I on one side and Class III on the
buccal cusp of the Maxillary 1st permanent molar. other side.
Class II: The mesio-buccal groove of the mandibu- Class VI: Class III on one side and Class II (either ½

42 STOMA.EDUJ (2016) 3 (2)

 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Figure 4. Molar’s Classification

unit or full unit) on the other side. Conclusion

A suggested treatment protocols are easily de- The author concluded that an incisor, canine and
rived from the present classification skeletal (Table molar classification should always be used accu-
1) dental (Table 2). rately to diagnose and to plan the final occlusion.
This is varying from mechanics to mechanics, but The present study pressing on a class I incisor
the idea is to help the undergraduate to under- and canine relationship at the end of treatment to
stand orthodontic diagnosis and treatment plan- assure long term stability while molar relationship
ning and for the postgraduate residents and the could be class I, II (full unit) or III relationship.
The author recommends further study on methods
orthodontists to formulate an accurate stable orth- of classification and establishing orthodontic treat-
odontic treatment results. ments’ protocols.

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43
 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Adil Osman MAGEET

PhD, BDS, CES (France), MSc (Orthodontic, UK), M.Orth.RCSEd, FDS,
RCSEd, Associate Professor, Consultant Orthodontist
Department of Orthodontics
Hamdan Bin Mohamed College of Dental Medicine
MBR University, Dubai, UAE , P.O.Box 505097 Dubai, UAE

CV
Licensed by CPQ (UAE), the Saudi Commission for Higher Specialties and the Sudanese Medical Council as
a consultant orthodontist. I treat orthodontic problems from mild to complex cases with variety of treatment
options, removable, functional, fixed, clear orthodontics, orthodontic part of orthognathic surgery and cleft
lip / palate cases. I also manage snorers and mild to moderate obstructive sleep apnoea hypopnoea patients
using intra-oral appliances. I have been working as an orthodontist for the past 20 years. Examiner of the
RCSEd for the 2nd part MFDS and the M.Orth. Reviewer of the Oral Hygiene and Dental Management
Journal. Published many articles in reputable journals.

44
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