ORIGINAL ARTICLE

Determining the limits of orthodontic treatment

of overbite, overjet, and transverse
discrepancy: A pilot study
Douglas Squire,a Al M. Best,b Steven J. Lindauer,c and Daniel M. Laskind
Longmont, Colo, and Richmond, Va

Introduction: Because of the severity of some malocclusions, it is not always possible to treat them without
a combination of orthodontics and orthognathic surgery. However, many insurance carriers have difficulty in
deciding whether such treatment should be covered. The purpose of this study was to develop a simple
method that can be used by insurance carriers to determine when a malocclusion is not correctable by
orthodontics alone. Methods: Twenty-eight orthodontists independently evaluated 30 sets of pretreatment
dental models (10 with overjet from ⫺6 to 12 mm, 10 with overbite from 60% to 100%, and 10 with transverse
discrepancies from single tooth to total arch crossbite) to determine whether the conditions were
orthodontically treatable. They were instructed to assume that growth was complete and that the treatment
would not seriously compromise facial esthetics. Results: It was the opinion of the orthodontists that a
positive overjet greater than 8 mm, a negative overjet of ⫺4 mm or greater, and a transverse discrepancy
greater than 3 mm were not orthodontically treatable. However, most orthodontists believed that they could
treat all overbite patients without surgery. Conclusions: These data can serve as a simple guideline for
helping insurance carriers determine the need for orthognathic surgery. (Am J Orthod Dentofacial Orthop
2006;129:804-8)

O
ral and maxillofacial surgeons have performed
orthognathic surgery to correct skeletally re-
lated malocclusions for many years. During
this time, the specialty has advanced this field of
surgery to a high degree of both predictability and
stability. The problem, however, is that some insurance
companies don’t cover the costs of this surgery, even
though these procedures have functional benefits for the
patient.1-5 The reasons for this are often related to the
surgery not meeting the insurance companies’ specific
criteria for medical necessity. However, some criteria
have not been altered for many years and are often
unrealistic by today’s standards— eg, malnutrition or
documented speech pathology.
Because skeletal discrepancies and the associated
a
Private practice, Longmont, Colo.
b
Associate professor, Department of Biostatistics, Virginia Commonwealth
University School of Medicine, Richmond, Va.
c
Professor and chairman, Department of Orthodontics, Virginia Common-
wealth University School of Dentistry, Richmond, Va.
d
Professor and chairman emeritus, Department of Oral and Maxillofacial
Surgery, Virginia Commonwealth University School of Dentistry, Richmond,
Va.
Reprint requests to: Dr Daniel M. Laskin, Department of Oral and Maxillofa-
cial Surgery, Virginia Commonwealth University School of Dentistry, PO Box
980566, Richmond, VA 23298-0565; e-mail, dmlaskin@vcu.edu.
Submittted, July 2004; revised and accepted, February 2006.
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.02.003
804
malocclusions can cause functional problems, correc-
tion of these malocclusions is important.1-8 Thus, the
appropriate criterion for determining coverage for or-
thognathic surgery should be whether or not the con-
dition is orthodontically correctable.
There have been previous attempts to quantify the
need for orthodontic treatment, and several indexes are
used for determining access to publicly funded orth-
odontic services.9-12 However, these studies intended
only to determine whether a patient would benefit from
orthodontic therapy without considering surgical cor-
rection as a treatment option. Proffit and White12
developed an “envelope of discrepancy” for the jaws,
describing the limits of orthodontic tooth movement
alone and the limits of change possible with a treatment
plan including both orthodontics and orthognathic sur-
gery. In this model, they suggested 2 and 5 mm as the
maximum amounts of forward orthodontic tooth ad-
vancement possible for maxillary and mandibular an-
terior teeth, respectively. They also suggested that the
maximum amounts of anterior tooth retrusion possible
were 7 and 3 mm for the maxilla and mandible, respec-
tively. However, they noted that these values are only
guidelines and might overestimate or underestimate the
possibilities for any given patient.
The purpose of this pilot study was to determine
whether there is general agreement among orthodon-
American Journal of Orthodontics and Dentofacial Orthopedics Squire et al 805
Volume 129, Number 6

tists about the limits of orthodontic therapy for correct- Table I. “Yes” answers (orthodontically treatable) for
ing skeletally related malocclusions. If so, these data overjet
could then be the basis for an algorithm to be used by Count Percentage “yes”
insurance companies in determining coverage for or- Overjet
thognathic surgery. (mm) Yes No Observed Predicted 95% CI

⫺6 0 28 0 0 (0, 1)
MATERIAL AND METHODS
⫺4 0 28 0 2 (0, 11)
We examined 3 important measures of occlusion: 3 26 2 93 92 (85, 96)
overjet, overbite, and transverse discrepancy. Ten sets 4 28 0 100 95 (89, 97)
5 28 0 100 96 (91, 98)
of pretreatment dental models were selected for each
7 27 1 96 96 (92, 98)
parameter to be evaluated from patients treated either 8 25 3 89 95 (91, 98)
orthodontically or with combined orthodontics and 10 22 6 79 90 (82, 95)
orthognathic surgery in the Department of Orthodontics 11 22 6 79 84 (70, 92)
at Virginia Commonwealth University. The 10 sets 12 24 4 86 72 (49, 87)
representing the overjet category ranged from ⫺6 to 12
mm, the 10 sets representing overbite ranged from
⫺60% (open bite) to 100%, and the 10 transverse sets 100
ranged from a single-tooth crossbite to a total-arch
crossbite. Percent Yes 80

The 30 sets of models were given to the orthodon-

tists with the following instructions: “independently
assess each set of models only for the indicated
parameter and, based on the amount of that discrep-
ancy, indicate whether the condition is orthodontically
treatable or if orthognathic surgery would also be
necessary.” For all cases, the orthodontists were in-
structed to “assume that growth was complete and that
the treatment would not seriously compromise the
facial esthetics.” The orthodontists were given no other
sources of diagnostic information such as radiographs
or clinical photographs, and no measuring devices such
as rulers or calipers were provided. The respondents
indicated their “yes” (orthodontically treatable) or “no”
(orthognathic surgery) replies on answer sheets.
Twenty-eight orthodontists completed this study,
and their answers were totaled for each set of 10
models. The data were then statistically analyzed by
using logistic regression to relate the amount of each
discrepancy to the probability that the patient could be
treated orthodontically.
RESULTS
In the overjet category, the relationship between the
percentages of “yes” and “no” answers and the amount
of overjet is shown in Table I and Figure 1. The
relationship with the amount of overjet showed a
significant increase and then a decrease (P ⫽ .0088).
With negative overjets of 4 mm or greater (mandibular
prognathism), all answers were “no.” Because there
were no models to evaluate an overjet between ⫺4 and
⫹3, it was not possible to determine the exact point at
which the transition from “no” to “yes” answers oc-
curred. However, at ⫹3 mm, the percentage of “yes”
60
40
20
0
-8 -6 -4 -2 0 2 4 6 8 10 12
(mm)
Observed 95% CI Predicted
Fig 1. Relationship between amount of overjet and
percentage of respondents who indicated that, “yes,” it
was orthodontically treatable. Observed percentage
values are shown as dots, and predicted percentage of
“yes” answers is shown by solid line; 95% confidence
interval on predicted value is also shown.
answers was 93%, and it reached 100% at ⫹4 and ⫹5
mm of overjet, remaining high until ⫹8 mm, when it
began to decrease.
In the overbite category, the relationship between
the percentages of “yes” and “no” answers and the
amount of overbite is shown in Table II and Figure 2.
There was no evidence for a relationship (P ⫽ .3280).
With the exception of the set of models with an anterior
open bite (⫺60%), the set with 0% overbite, and the set
with 100% overbite, there was almost unanimous
agreement that these patients were orthodontically
treatable.
In the transverse discrepancy category, the relation-
ship between the percentages of “yes” and “no” an-
swers and the amount of transverse discrepancy is
806 Squire et al American Journal of Orthodontics and Dentofacial Orthopedics
June 2006

Table II. “Yes” answers (orthodontically treatable) for Table III. “Yes” answers (orthodontically treatable) for
overbite transverse discrepancy
Count Percentage “yes” Transverse Count Percentage “yes”
Overbite amount
(%) Yes No Observed Predicted 95% CI (mm) Yes No Observed Predicted 95% CI

⫺60 8 20 29 24 (14, 37) 1.5 20 8 71 77 (49, 92)

0 18 10 64 90 (69, 97) 2.0 7 21 25 70 (45, 87)
5 28 0 100 92 (72, 98) 2.0 25 3 89 70 (45, 87)
10 26 2 93 92 (74, 98) 3.0 16 12 57 52 (34, 69)
20 28 0 100 94 (78, 98) 3.0 21 7 75 52 (34, 69)
50 28 0 100 94 (85, 98) 3.0 26 2 93 52 (34, 69)
60 27 1 96 94 (85, 98) 3.5 4 24 14 42 (27, 60)
60 26 2 93 94 (85, 98) 4.0 3 25 11 33 (19, 52)
90 28 0 100 86 (66, 95) 5.0 2 26 7 19 (7, 43)
100 18 10 64 80 (46, 95) 5.0 10 18 36 19 (7, 43)

100 100

80 80
Percent Yes
Percent Yes

60 60

40 40

20 20

0 0
1 2 3 4 5
-60 -40 -20 0 20 40 60 80 100
amount (mm)
(%)
Observed Predicted 95% CI
Observed 95% CI Predicted

Fig 2. Relationship between amount of overbite and
percentage of respondents who indicated that, “yes,” it
was orthodontically treatable. Observed percentage
values are shown as dots, and predicted percentage of
“yes” answers is shown by solid line; 95% confidence
interval on predicted value is also shown.
Fig 3. Relationship between amount of transverse dis-
crepancy and percentage of respondents who indicated
that, “yes,” it was orthodontically treatable. Observed
percentage values are shown as dots, and predicted
percentage of “yes” answers is shown by solid line; 95%
confidence interval on predicted value is also shown.

shown in Table III. As can be seen in Figure 3, there
was a linear relationship (P ⫽ .0491), with the percent-
age of “yes” answers generally decreasing as the
amount of transverse discrepancy increased beyond
3 mm, although the percentage agreement varied
widely.
DISCUSSION
The results of this study showed 100% agreement
among the orthodontists that an overjet of ⫺4 mm or
more is not correctable by orthodontic treatment alone.
Because no negative overjet examples less than ⫺4 mm
were included in the study, it was not possible to
determine whether these patients could be treated
without surgery. However, based on the “envelope of
discrepancy” of Proffit and White,12 it appears that
these patients can be treated orthodontically. Future
studies should include more examples of mild negative
overjet to determine specifically at which point orth-
odontists believe surgery is not necessary.
With overjets between 3 and 10 mm, there was
greater than 90% agreement about the effectiveness of
orthodontic treatment alone. However, with overjet
values greater than 10 mm, the agreement among the
orthodontists fell below 90%. The lower 95% confi-
dence interval on the predicted value for the 10-mm
overjet example was only 82% (Table I). This means
that if the study was repeated with 28 different orth-
odontists, the 90% agreement found for the 10-mm
example in this study could be as low as 82%. There-
fore, if 90% agreement is the chosen confidence level,
8 mm is the limit at which the orthodontists believe that
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 129, Number 6
surgery was not a necessary adjunct to orthodontic
therapy.
In the overbite group, the results showed no statis-
tical relationship between the probability of a “yes”
response and the amount of overbite. In patients with
overbites between 5% and 90%, there was almost
universal agreement that they could be treated orth-
odontically. The 2 sets of models that led to the
equivocal results were the 0% and 100% overbite
examples. In these extreme cases, most orthodontists
(64%) still thought that they could treat the malocclu-
sion with orthodontic therapy alone.
Only 1 case of anterior open bite (⫺60%) was
included in the overbite category. Although there is no
explanation as to why 8 orthodontists believed that they
could treat such a severe case without surgery, 71% of the
respondents thought that surgery would be required; this
agrees with the generally held opinion that such skeletally
related malocclusions need to be treated by LeFort I
osteotomies with posterior impaction.13 Future studies on
this topic should include more examples of negative
overbite (ie, anterior open bite) to more fully investigate
orthodontists’ opinions on this skeletal malocclusion.
The transverse discrepancy group showed a statis-
tically significant linear trend. As the amount of trans-
verse discrepancy decreased, the proportionate number
of “yes” responses increased. However, both the pre-
dicted and lower 95% confidence interval values were
low. The reason for this seemed to arise from the
difficulty in quantifying the transverse discrepancy
uniformly. Some transverse issues are related to dental
tipping of at least 1 tooth, but others are a skeletal
growth problem. Clearly, the chosen treatment for a
transverse discrepancy depends on the underlying prob-
lem. In our sets of models, there were examples ranging
from a single tooth in crossbite due to dental tipping to
a full-arch crossbite due to maxillary skeletal constric-
tion. Future studies should perhaps divide the trans-
verse discrepancies into 2 separate categories: dental
tipping and skeletal growth constriction, because the
former category is generally orthodontically treatable,
but the latter often requires orthognathic surgery.
Although the number of “yes” responses in the
transverse discrepancy group showed a significant in-
crease as the amount of discrepancy decreased, there
was inconsistency in the orthodontists’ evaluation of a
set of models in the 2.0 and 5.0 mm categories
(Table III). A possible explanation for the orthodon-
tists’ selection of orthognathic surgery in the 2-mm
case might have been related to the minimal overbite,
so that any tipping of the teeth orthodontically would
most likely cause occlusal interference and develop-
ment of an anterior open bite. In the 5-mm case, the
Squire et al 807
patient had an irregular omega-shaped arch form so that
some orthodontists might have thought that the trans-
verse discrepancy would improve by aligning the teeth
orthodontically.
This pilot study was designed to determine orthodon-
tists’ opinions about the limits of orthodontic treatment
alone for correcting overjets, overbites, and transverse
discrepancies. Although some limits appear to be well
defined in this study, others remain unclear because of the
lack of uniformity in the sequential differences of the
models in each series. Because of the difficulty in obtain-
ing models to show consecutively graded differences,
future efforts designed to build on this pilot study should
probably use simulated computer models that incremen-
tally increase the degree of malocclusion.
CONCLUSIONS
Based on the results of this study, it appears that
mature patients with positive overjets greater than 8
mm or negative overjets of ⫺4 mm or greater are not
treatable with orthodontic therapy alone. Likewise,
treatment of a transverse discrepancy greater than 3 mm
or an anterior open bite also requires orthognathic
surgery. However, in patients with overbites between
0% and 100%, most orthodontists believed that they
could treat these patients orthodontically.
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Editors of the International Journal of Orthodontia (1915-1918),

International Journal of Orthodontia & Oral Surgery (1919-1921),
International Journal of Orthodontia, Oral Surgery and Radiography (1922-1932),
International Journal of Orthodontia and Dentistry of Children (1933-1935),
International Journal of Orthodontics and Oral Surgery (1936-1937), American
Journal of Orthodontics and Oral Surgery (1938-1947), American Journal of
Orthodontics (1948-1986), and American Journal of Orthodontics and Dentofacial
Orthopedics (1986-present)

1915 to 1932 Martin Dewey

1931 to 1968 H. C. Pollock
1968 to 1978 B. F. Dewel
1978 to 1985 Wayne G. Watson
1985 to 2000 Thomas M. Graber
2000 to present David L. Turpin