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CEPHALOMETRIC FEATURES OF CLASS II

MALOCCLUSION
ARTICLE SEPTEMBER 2014

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Orthodontics

CEPHALOMETRIC FEATURES OF CLASS II MALOCCLUSION

Georgeta ZEGAN1, Cristina Gena DASCLU2, Loredana GOLOVCENCU3,
Daniela ANISTOROAEI3
Assoc. Prof., PhD, Surgery Dept., Faculty of Medical Dentistry, Gr. T. Popa U.M.Ph. Iai
Lecturer, PhD, Preventive Medicine and Interdisciplinarity Dept., Faculty of Medicine, Gr. T. Popa U.M.Ph. Iai
3
Lecturer, PhD, Surgery Dept., Faculty of Medical Dentistry, Gr. T. Popa U.M.Ph. Iai
Corresponding author: cdascalu_info@yahoo.com
1
2

Abstract
The study aimed at identifying the quantitative and
relational features of the bone, dental and soft tissue
structures, for class II malocclusion, with its divisions on
sexes and intervals of age, by means of 53 digital
cephalometric measurements. 84 conventional lateral
cephalometric radiographies were divided into two
groups, according to ANB angle (60=class II and 24=class
I), while the divisions of class II were clinically diagnosed
according to the overjet (24=division 1 and 36=division 2).
Application of Kolmogorov-Smirnov, t-Student and
Levene tests of program SPSS, version 16.0, evidenced
statistically significant differences between the two skeletal
classes (28 characteristics), between the divisions of class
II (10 characteristics), between sexes (6 measurements) and
between the age intervals (28 measurements). The
multitude of cephalometric characteristics of this
malocclusion requires a special orthodontic therapy.
Keywords: conventional lateral cephalometric radiography,
class II malocclusion, digital cephalometric measurements

1. INTRODUCTION
Class II malocclusion is characterized by a
skeletal difference of the maxillary bases vs the
basis of the skull, produced through maxillary
protrusion and/or mandibular retrusion. The
molar and canine sagital relation is distalized,
evidencing according to the classification of
Angle - two clinical entities: division 1, with
proclination of the upper incisors and increased
overjet; division 2, with retroclination of the
upper incisors and minimum overjet [1].
Introduction of cephalometric radiography, in
1934, by Hofrath in Germany and by Broadbent,
respectively, in the USA, permitted study of
malocclusions by evidencing skeletal
discrepancies. Several authors made known the
cephalometric analyses they had performed for
the diagnosis of skeletal malocclusions, including
222

various angular, linear and percentual

measurements. The literature of the field provides
numerous cephalometric studies, developed
comparatively on skeletal classes I and II, on
sexes, age, clinical divisions, dentitions and
different populations [28]. The results are
debatable, if considering the size and selection
criteria of the experimental groups, ethnic
heterogeneity, races and diversity of the
investigation methods applied [911].
The present investigation aimed at establishing
the cephalometric features of class II skeletal
malocclusion, on an sample of non-orthodontically
treated patients of north-east Romania. The
study intended to compare the cephalometric
measurements of skeletal class I with those of
class II, and to identify the quantitative and
relational differences of the bone, dental and soft
tissues structures between the two classes, the
two divisions of class II, sexes and intervals of
age.

2. MATERIALS AND METHOD

The retrospective study was conducted on 84
conventional lateral cephalometric radiographies
taken in the Orthodontics Clinic at St. Spiridon
Emergency Universitary Hospital of Iassy,
Romania, between January 2005 - Decembrer
2013. The criterion of cephalograms selection
was their good technical quality. All radiographies
were made on a STRATO-X orthopantomograph
(11.8% magnification).
The sample of patients was formed of 33 boys
and 51 girls, with ages between 7-26 years (mean
age 14.335.758 years), having had no orthodontic
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CEPHALOMETRIC FEATURES OF CLASS II MALOCCLUSION

treatment. The sample was divided into two

groups, according to the skeletal class (ANB
angle): cases=60 patients (22 boys and 38 girls)
with class II skeletal malocclusions (ANB>4);
control=24 patients (11 boys and 13 girls) with
class I skeletal malocclusions (ANB4). The
divisions of class II have been clinically
diagnosed, on considering the incisive sagital
relation: division 1 (n=24: boys=9 and girls=15)
with increased overjet (>2mm), and division 2
(n=36: boys=13 and girls=23) with minimum
overjet (<2mm). The patients affected with
genetic and endocrine syndroms have not been
accepted. The study was conducted according to
the regulations of the Helsinki Declaration of
1975, revised in 2000, and patients informed
consent was obtained.
The anatomic contours of the conventional
lateral cephalometric radiographies were drawn
on tracing paper, with a 0.5 mm in diameter
pencil. The tracing paper was scanned (MFD
Canon Pixma MP280) in digital format (JPG File)
and introduced in the computer (Asus Eee PC
1015BX) [12]. Digital cephalometric analysis was
made on an Onyx CephTM (Onyx CEPH 2.7.18
(174) Image Instruments GmbH, Chemnitz,
Germany). The radiological cephalometric
landmarks were localized directly with the
mouse pointer on the image of the digitalized
paper of the screen, on using the zoom, for
avoiding identification errors (fig. 1). For each
image, 53 cephalometric measurements (28
angles, 21 distances and 4 percent values) were
made, according to Steiner, Tweed and Jarabak

analyses [1315] (fig. 2). Measurements were

performed under identical calibration conditions
of the size of the cephalometric images. All data
provided by analyses were extracted and stored
in electronic format (Microsoft Office Excel
97-2003 Worksheet). The protocol included a
quantitative evaluation of the basis of the skull,
maxillary, mandible, and of the relations between
them, as well as with the dental and soft tissues.

Fig. 1 - Cephalometric landmarks: sella (S), nasion

(N), E-point (E), L-point (L), porion (Po), condylion
posterior (ppCond), articular (Ar), orbital (Or),
gonion (Go), menton (Me), gnathion (Gn), pogonion
(Pog), D-point (D), anterior nasal spine (ANS),
A-point (A), A-point acc. to Jarabak (AJ), prosthion
(Pr), infradental (Id), B-point (B), upper incisor apex
(Ap1u), upper incisor crown tip (1u), upper incision
(I1u), lower incision (I1l), lower incisor crown tip
(1l), lower incisor apex (Ap1l), anterior point of the
occlusal plane (AOcP), posterior point of the occlusal
plane (POcP), pronasal (Pn), upper labral (Ls), lower
labral (Li) and pogonion soft tissue (Pog).

Fig. 2 - Cephalometric parameters (a) acc. Steiner: SNA, SNB, ANB, SND, II, SN-OcP, SN-GoGn, Max1-NA,
Max1-SN, Mand1-NB, 1u-NA, 1l-NB, Pog-NB, Holdaway ratio, S-L and S-E. (b) acc. Tweed: FMIA, FMA,
IMPA, Wits, PoOr-OcP, Z, PFH, AFH and AFH:PFH. (c) acc. Jarabak: MeGo-OcP, Mand1-MeGo, 1u-NPog,
1l-NPog, Ls-PnPog, Li-PnPog, NSAr, SArGo, ArGoMe, Sum, N-S, S-Ar, NGoAr, NGoMe, Ar-Go,
S-Ar:Ar-Go, Go-Me, SN-GoMe, GoMe:NS, N-Go, S-Me, NSGn, S-Go, N-Me, SGo:NMe, SNPog and NAPog.
International Journal of Medical Dentistry

223

Georgeta ZEGAN, Cristina Gena DASCLU, Loredana GOLOVCENCU, Daniela ANISTOROAEI

Statistical analysis was made with program

SPSS, version 16.0 (SPSS Inc., Chicago, IL), for
Windows. The numerical values were calculated
according to the parameters of descriptive
statistics (mean value, standard deviation (SD),
error of standard deviation (SEM), minimum
and maximum value). To compare the measured
values of the two skeletal classes, divisions, sexes
and age intervales, the Kolmogorov-Smirnov,
t-Student and Levene tests for the equality of
variances were applied, value p0.05,
Variables

SNA
SN-GoGn
FMA
MeGo-OcP
NSAr
ArGoMe
NGoMe
SN-GoMe
Sum
NSGn
NAPog
Max1-NA
Mand1-NB
FMIA
Z
S-L
Go-Me
Wits
1u-NA
1l-NB
Holdaway
1u-NPog
1l-NPog
Ls-PnPog
Li-PnPog

224

Cases with skeletal class II

(n=60)
Mean
SD
SEM
83.1065
32.6233
27.8272
17.2708
122.4365
128.8025
75.7782
35.0682
395.0682
68.7418
168.5328
19.7573
27.3725
56.5245
68.5663
48.5842
62.1487
3.3862
4.3577
5.7268
3.8662
9.7533
3.5032
-1.8217
-0.6248

corresponding to the 95% confidence interval,

being considered statistically significant.

3. RESULTS
Table 1 evidences statistically significant
differences between the two skeletal classes for
the mean values of angular and linear
measurements, and of the bone, dental and soft
tissues structures ratios.
Control with skeletal class I
(n=24)
Mean
SD
SEM

p value

4.23026
7.65389
6.82642
5.20074
5.62944
8.09690
5.86638
7.61173
7.61173
4.35942
4.48051
9.66171
6.00689
7.10917
10.82260

Angular ()
0.54612
80.7038
0.98811
28.7871
0.88129
22.4987
0.67141
13.8633
0.72676
125.6046
1.04531
122.7921
0.75735
70.7229
0.98267
30.1100
0.98267
390.1100
0.56280
66.7404
0.57843
176.7813
1.24732
24.6783
0.77549
20.4154
0.91779
64.9429
1.39719
75.6438

3.09720
5.25848
5.35326
3.85878
4.79078
5.41522
4.60316
5.17420
5.17420
3.09286
1.97550
7.37017
6.85486
6.79298
7.68934

0.63221
1.07338
1.09273
0.78767
0.97791
1.10538
0.93962
1.05618
1.05618
0.63133
0.40325
1.50443
1.39924
1.38661
1.56958

0.014**
0.027*
0.001***
0.005**
0.017**
0.001***
0.000***
0.004**
0.004**
0.044*
0.000***
0.027**
0.000***
0.000***
0.005**

9.43642
6.52827
3.23626
2.28440
2.18188
2.60529
4.47429
3.23229
3.37497
3.47953

Linear (mm)
1.21824
53.1608
0.84280
66.8333
0.41780
-0.3163
0.29491
5.5350
0.28168
3.6167
0.33634
2.0646
0.57763
6.0708
0.41729
0.4429
0.43571
-4.2250
0.44920
-2.6613

5.57675
7.90436
3.73168
2.13288
1.37529
1.48163
2.51376
2.72691
2.93086
2.94068

1.13835
1.61347
0.76173
0.43537
0.28073
0.30244
0.51312
0.55663
0.59826
0.60026

0.008**
0.026**
0.000***
0.033*
0.000***
0.002***
0.000***
0.000***
0.003**
0.013**

Volume 4 Issue 3 July / September 2014

CEPHALOMETRIC FEATURES OF CLASS II MALOCCLUSION

Ratio (%)
AFH:PFH
GoMe:NS
SGo:Nme

75.8658
88.6752
66.9525

10.18556
9.12110
6.22924

1.31495
1.17753
0.80419

80.9875
93.9050
69.7362

8.93843
10.62951
4.44223

1.82455
2.16974
0.90677

0.034*
0.026*
0.050*

Table 1 Descriptive statistics and significant differences between groups for cephalometric measurements
(*p<0.05; **p<0.01; ***p<0.001)

As a function of the two divisions of class II,

statistical differences were observed for the mean

Variables
Angular ()
II
Max1-NA
Max1-SN
IMPA
Mand1-MeGo
Linear (mm)
N-S
Wits
1u-NA
1u-Npog
Ratio (%)
GoMe:NS

Division 1 (n=24)
Mean
SD

values of angular and linear measurements and

of the bone and dental structures ratios (table 2).
Division 2 (n=36)
Mean
SD

p value

120.7717
23.4033
106.3567
97.9517
98.1308

13.65901
11.21191
9.78103
6.75621
6.69558

130.0667
17.3267
100.5344
94.1136
94.1136

11.21347
7.71748
7.98892
6.16053
6.16053

0.006**
0.016**
0.014**
0.027*
0.020*

72.1029
4.8717
5.2590
12.1196

3.59887
2.98930
2.08728
3.98931

69.0172
2.3958
3.7569
8.1758

5.72875
3.04318
2.23733
4.10970

0.022*
0.003**
0.011**
0.001***

85.3583

9.93585

90.8864

7.92434

0.020**

Table 2 Descriptive statistics and significant differences between division of skeletal class II for
cephalometric measurements (*p<0.05; **p<0.01; ***p<0.001)

Highly statistically significant differences

were observed between the two sexes of class II
divisions for the mean values of the angular

International Journal of Medical Dentistry

dental and linear measurements of some bone

structures (table 3).

225

Georgeta ZEGAN, Cristina Gena DASCLU, Loredana GOLOVCENCU, Daniela ANISTOROAEI

Division 1 (n=24)

Variables

Male
(n=9)
MeanSD

Female
(n=15)
MeanSD

Angular ()
IMPA
Mand1-MeGo

102.037.39
102.037.39

Linear (mm)
S-Ar
Go-Me
N-Go
S-Go

35.872.19
64.057.06
117.238.23
79.337.08

Division 2 (n=36)
p value

Male
(n=13)
MeanSD

Female
(n=23)
MeanSD

p value

95.505.15
95.795.17

0.018*
0.023*

94.354.94
94.354.94

93.976.85
93.976.85

0.865
0.865

34.232.37
59.936.84
112.137.19
78.156.30

0.106
0.173
0.125
0.675

36.054.40
31.974.26
65.436.47
60.995.55
114.9013.10 107.787.57
80.4013.15 73.037.28

0.010*
0.037*
0.046*
0.037*

Table 3 Descriptive statistics and significant differences between gender division of skeletal class II for
cephalometric measurements (*p<0.05)

Table 4 indicates statistical differences of the

age intervals for the mean values of angular
and linear measurements, and of the ratios of
Variables

Division 1 (n=24)
Division 2 (n=36)
Age14 years Age>14 years p value Age14 years Age>14 years
(n=15)
(n=9)
(n=23)
(n=13)
MeanSD
MeanSD
MeanSD
MeanSD

Angular ()
SN-GoGn
FMA
MeGo-OcP
ArGoMe
NGoAr
NGoMe
SN-GoMe
Sum
NAPog
II
Max1-NA
Max1-SN
Max1-SN
Mand1-NB

32.986.32
28.265.44
17.834.84
129.079.01
53.575.25
75.506.38
34.866.46
394.866.46
168.255.33
118.687.40
23.888.22
106.828.81
106.828.81
30.685.11

31.669.88
26.017.80
17.275.93
128.868.51
53.744.23
75.116.97
34.539.30
394.539.30
166.273.64
124.2420.46
22.5915.54
105.5811.74
105.5811.74
25.616.89

Linear (mm)
Ar-Go
PFH
AFH

47.035.90
47.035.90
63.687.56

51.557.10
51.557.10
63.847.61

226

bone, dental and soft tissues structures for class

II divisions.

0.691
0.414
0.804
0.956
0.933
0.891
0.918
0.918
0.339
0.346
0.791
0.771
0.771
0.051*
0.107
0.107
0.959

p value

35.457.00
30.126.72
18.494.66
131.846.97
54.044.92
77.794.86
37.986.97
397.986.97
168.024.02
126.0110.32
19.378.05
102.827.94
102.827.94
28.225.17

27.856.73
24.516.81
14.455.50
123.066.041
50.073.74
72.985.41
30.507.07
390.507.07
171.313.75
137.249.15
13.705.68
96.486.52
96.486.52
23.265.50

0.003*
0.022*
0.025*
0.001*
0.017*
0.010*
0.004*
0.004*
0.022*
0.003*
0.032*
0.020*
0.020*
0.011*

43.535.72
43.535.72
60.314.19

52.018.83
52.018.83
64.766.63

0.001*
0.001*
0.043*

Volume 4 Issue 3 July / September 2014

CEPHALOMETRIC FEATURES OF CLASS II MALOCCLUSION

N-Go
S-Go
N-Me
Wits
Pog-NB
1l-NPog
Ls-NsPog
Li-NsPog

113.158.30
77.737.01
116.159.99
4.282.65
2.570.96
4.132.91
-0.832.96
0.682.93

115.537.21
80.045.54
118.3010.13
5.853.40
2.431.08
2.954.25
-1.714.19
-0.703.43

0.483
0.410
0.618
0.220
0.745
0.427
0.555
0.302

106.336.66
71.627.05
111.387.04
1.563.31
1.761.43
4.282.76
-1.432.84
-0.123.08

117.4712.03
82.8911.35
117.198.83
3.871.77
3.502.22
1.763.19
-3.723.70
-2.963.92

0.001*
0.001*
0.037*
0.010*
0.007*
0.018*
0.045*
0.022*

Ratio (%)
AFH:PFH
SAr:ArGo
SGo:NMe

74.066.34
75.739.32
66.973.46

81.6914.73
64.0513.93
68.087.23

0.172
0.022*
0.617

72.258.65
75.1911.96
64.446.49

80.2910.27
68.768.91
70.576.10

0.017*
0.101
0.009*

Table 4 Descriptive statistics and significant differences between age interval division of skeletal class II
for cephalometric measurements (*p<0.05)

4. DISCUSSION
The present research was focused on
comparing class I and II cephalometric
measurements, for identifying the quantitative
features and relations of the bone, dental and soft
tissues structures of class II malocclusion with
its divisions on sexes and age intervals. The
skeletal class was identified by angle ANB,
accepted in literature as an index of skeletal
discrepancies [16, 17]. Class II divisions were
clinically identified, according to the overjet, in
agreement with some other studies [6,18] yet no
additional variables have been introduced, as in
the case of other works [2], for not complicating
too much the statistical analyses.
The results obtained on the basis of a large
diversity of digital cephalometric measurements
permitted to establish the characteristics of class
II malocclusion in an original manner. Thus,
starting from the highly statistically significant
differences observed between the two skeletal
classes, class II was characterized by 28
measurements (15 angular, 10 linear and 3
percentual): (a) sagital angular skeletal of the
maxillary and temporo-mandibular joint vs the
basis of the skull, of the growth pattern and of
the convexity angle; (b) vertical angular skeletal
of the pattern of mandibular growth and of the
occlusal plane vs the mandibular one; (c) sagital
angular dental-skeletal of the maxillary and
International Journal of Medical Dentistry

mandibular incisors; (d) angular of the soft tissue

profile; (e) linear skeletal of skull anterior basis,
of the mandible and of the A-O distance vs the
occlusal plane; (f) linear dental-skeletal of the
maxillary and mandibular incisors; (g) linear of
the lips; (h) percentual of the anterior facial
height and posterior facial height and of the
sizes of the mandible and of skull anterior basis.
Previous studies on class II malocclusion
evidenced only sagital dental-skeletal features of
the skull basis length, position of the maxillary,
mandible and upper and lower incisors, and of
the growth patterns [3-5, 19-21].
The present study established 10 cephalometric
measurements (5 angular, 4 linear and 1
percentual), which differentiated between the
two divisions of class II: (a) sagital angular
dental-skeletal of the maxillary and mandibular
incisors; (b) linear skeletal of the anterior basis
of the skull and of distance A-O vs the occlusal
plane; (c) linear dental-skeletal of the maxillary
incisor; (d) percentual of the size of the mandible
and of the anterior basis of the skull. Previous
studies on class II divisions were mainly oriented
on the vertical facial dental-skeletal characteristics
[6, 7, 10, 11, 22]. The results obtained showed sex
differences for class II divisions (6 measurements:
2 angular dental and 4 linear manibular), as well
differences between the age intervals (28
measurements: 14 angular, 11 linear and 3
percentual). To this end, the contradictions
227

Georgeta ZEGAN, Cristina Gena DASCLU, Loredana GOLOVCENCU, Daniela ANISTOROAEI

observed comparatively with the conclusions of

previous studies may be due to the ethnic
characteristics and age of the subjects under
analysis [2, 8, 23, 24].

5. CONCLUSIONS
The present study evidences the large variety
of cephalometric features of class II malocclusion
and of its divisions on sexes and age intervals in
the sample studied, which calls for a specific and
individualized orthodontic therapy of each
patients suffering from it.
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Volume 4 Issue 3 July / September 2014