A cephalometric description.

of Class II,
Division 1 malocclusion
H. Perry Hitchcock, D.M.D., M.S.D.*
l3irmingham, Ala.

T his is part. of a continuing effort to determine where some of our

problems lie in dealiilg with various classes of malocclusion.’ One hundred and
nine Class I I, Division 1 malocclusions were documented from crphalometric
head films, according to the Alabama Analysis, and compared with a standard
sample of forty normal occlusion cases.“, 3
The vlassificatioil was made from the models ant1 photographic: evaluations,
according to Strang‘s first six steps.’ It JVWSriot made from some prejudged dif-
fcrenccs-from-llornlal of any particular c~cphalometric mcasuremcnt. There were
fifty-seven female anal fifty-two 1rm1c sub,jects in the study. The age range was
from 7 years to 28 years. The mean age was 13 years. Means, standard deviations,
anti co&cicnts of correlation were obtained. Means wcrc compared st,atistically
with the means of the normal occlusion sample, which formed the basis of the
Alabama Analysis.
Means of Class II boys were compared with those of Class II girls. Means
below 12 years of age were compared to means abo\-c 12 years of age.

Findings

Comparisons to nornlal occlusions are shown in Fig. 1. Items 1 to 16 are

based on the values of all 100 Class II, Dirision 1 patients. For fifty-seven
subjects, data were available for the upper incisor to Na, the overbite, and over-
.jet, according to “A Cephalometric Supplement.“”
The SNA measurement of Class I1 patients (80 degrees ? 3.8 degrees) is not
significantI?- different from that of the normal occlusion sample (81.0 tlegrces
L 3.2 degrees). Wet many- Class II, Division 1 malocclusions have the maxilla
too far forward; 0111)~nine cases out of fiftv-seven show an XKL4 greater than
ant’ stantlaiul de\-iation aborc 81 degrees.
This ~voulcl seem to be in contradistin~tioll to Philatlelphia c*hildren, who
have large maxillas and greater cranial Icngth, according to Rothsteins
This research was supported by the Southern Society of Orthodontists.
“Clmirmnn, Department of Orthodontics, University of Ahbamn.

414
Volume 63
Nuna be?- 4
Cephnlometric description of C’lms II, Dilisio>t 1 415

Normal Occlusions (N-40) Class II div. I IN-1091 Diff Signif.

Measurment Mean S. D. Mean s. a of Means of diff.
I. WA bl. 0 3. 2 bO.0 3.8 I. 0 N. S.

2. SNB lb. 2 2. 9 14.4 3. 7 3.b +*

3. St&I-SNB 2.8 2.0 5.6 2.2 2.h ‘*
4. Facial fNP to SN 79.0 2.8 75.9 4.0 3.1 **
5. Yaxis to SN M. I 2.8 69.6 4.3 3.5 **
b. 33. 9 5.9 I. 9 N. S.
6. Mand. to SN 32.0 4. 5
9. 36.8 7. 5 4.8 **
7. Occlusal to SN 16.4 3.3 16.I 4.5 0.3 N. S.

b. AB to Occlusal 90. I 3.5 61.6 4.3 8.5 **

9.lto Ccclusal 59. 7 4.7 55.3 6. I 4.4 -*

‘alto NA 23.2 5.0 28.6 1.4 5.4 **

Il.lto SN 103.8 6.6 Ic8. I 8.2 4.3 **

12.&o AP (MM) 5.9 2.0 lo.3 2.4 4.4 **

13Tto Mand. 91.3 6.3 95.9 1. 2 1.4 N. 5.

14.Tto Occlusal 61.2 5.5 64.1 5.8 2.5 *

l5.Tio SN 5Cl8 6.2 48.6 7.1 2.2 N. S.

ld.Tto NB IMM) 5.4 I.6 5.8 2. 2 0.4 N. 5.

17&o NA (MM) 5.6 I. 7 1.2 2.4 1.6 ‘*
13.Overbite 3.2 1.3 N-57 3.6 2.1 a4 N. S.
19.Overjet 3.5 I. I i 8.1 3.0 5.2 *’
NS-Nof Significant
a-. a5
*a-. 01

Fig. 1. Comparison of Class It, Division 1 measurements with normal standards, according
to the Alabama Analysis.
 Majority Limits of Natural Variation
(N = 40) Normalocclusions
WA

SNB

ANB

SNP

Y--SN

M--SN

OCC-SN

AB--0CC

LOCC

&IA

LSN

LAP

TM

TXC

I-SN

TNB

yA 2

Overbite I o
d&

Overjet a, I

Fig. 2. A ladder arrangement of the majority limits of natural variation among normal
occlusions. Plus and minus one standard deviations are represented by circles at the ends of
the rungs.

Items 8 through 12 are the arbitrary upper dental measurements. All of

these cshibit highly significant tlift’erenccs, when Class II, IXvixion 1 malocclu-
sions are conlparecl to the normal occlusion sample.
In the lower dental area, items 13 to 16 show no highly significant differences
betvwn Class II subjects and the normal controls. One item only (the lower
incisor to the occlnsal plane measurement) shows a diffcrencc at the 0.05 level
but not at the highly significant 0.01 level.
No statistically significant differences were found below the age of 12 years
as compared to above 12 years. This is in agreement with the findings of
(:ianrlly.”
Concerning the supplemental measurements (N = 57)) there seems to be
no significant tlifYcxnce between ovcrhitcs in normal occlusions and Class II,
Dirision I malocclusions. The 1 to Na measurement and the overjet we sig-
nificantly clift’erent in C’lass Il,%ivision 1 subjects.

Interpretation

T\‘c call the mean, plus and minus one standard deviation, “the majokty
limits of natural \-ariation.” This is justified on the basis that the mean, plus and
 class II di”.lw=109)

0 80.0 3.8

I- 74.4 3.1

5.6 2.2

% 75.9 4.4
a------- 0

69.6 4.3 o
u2, Ol

48.6 7.1
0

Fig. 3. Majority limits of natural variation among Class II, Division 1 malocclusions. The
means and plus and minus one standard deviations are represented by small squares. The
same units are used as for the normal occlusion ladder, the means of which are shown
along the center line.
 Am. J. Orthod.
April 1973

Majonry LlmiIs or Nawral varlaIlon

(N = 40) Normal occlusions (N = 109) class II div. 1
. . . . . .._........................*
SNA

SNB

ANB

SNP

Y--SN

M--SN

OCC--SN

AB--0CC

LOCC
0 55.3

LNA
. .......... ......... 42
I-94
LAP

TM
0.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .
Tocc

-i%N

TNB

Overbite

Overjet

Fig. 4. Superposition of Class II, Division 1 malocclusion over the normal majority limits
of natural variation. Note the nearly identical means for the ~~~lu~al plane to SN. Note
entire separation of majority limits for AB-occlusal plane, 1 to AP, and the overjet.

occlusal plane to SX relation shows nearly perfect agreement for means and
very little differewe in the standard deviations. This is carried over from a
comparison with Class I malocclusions also. 1 Not only are the means nearly
identical among normal occlusions, Class I malocclusions and Class II, Division
1 malocclusions; the standard deviations are quite small for angular measure-
ments and are similar for all three groups of owlnsions: normal, Class I, and
Class 11, I>ivision 1 malocclusions. As (1 stclxdard, the unique?ress of the OCClUsd
plane to SN mcc~sw-uuest is crbsolufel~y estublislaed.

The lower incisor to NB linear measurement also falls in this category of

similarity, with nearly identical means and (as expected) somewhat larger
standard deviations among the group of malocclusions as compared to normal
occlusions.
Name CLASSII div. 1 &e .13.07 + 4. 16 ALABAMA ANALYSIS (revised 1971) N-40
l-4 c~~~‘~‘[Y-*-~~N s I,-,9

28-30
31-33
34-36
37.40[

. .. .. . . . . . .
a * --.. 1. . .
56-59D.!- -
60-62, lrntii]~
63-65 1~6tg.~ SN PI. 1 . . . .
66-69mtii 16.1 k _ ,
70-721 riW%.! NA mm j) . .,.‘

73-76rlmrq 1F over Rite KN : 57 012 -..‘.... +“--<

Fig. 5. Class II, Division 1 malocclusions plotted against the Alabama Analysis. Within the
zigzag limits of plus and minus one standard deviation will be found most of the measure-
ments of the majority of Class II, Division 1 malocclusions among white patients in the
southeastern United States. The mean for Class II, Division 1, malocclusions is represented
by the heavy dotted line, and the standard deviations are represented by lighter dotted
lines.

I. AB to occ~lusal plant lllC3Sul’elll~‘llt.

Tlw

‘1. The linear measurement 1 to AI’.

3. The owrjet.
For the 1 to LZf’ mcasnrement, the mean minus one staiitlarcl deviation of
(‘1ilSS 1 I ma7owlnsions pkks up where tliv mean plus one stantlartl deviation
 Am. J. O?Thod.
April 1973

Fig. 6. A comparison of the female composite [solid line) with the male composite (dotted
line).

of normal occlusion lea\-es off. There is no o\xrlap, statistically, for this linear
lnfuSllrCn1Cllt.
A larger o\x:rjot is implicit in the tlefinition of Class II, Division 1 maloc-
clusion, and this falls completely above the normal occlusion mean plus 1 s.d.
Bet\\-eel1 thcsc csaml)lcs of’ each estrcme of coincidence and scparat3ion lie
the other mcasurcments with statistically siqnificalit differences. Not all of
them have yuitc the clinically important implications which have sometimes
been asc*ribcd to tlicm.
The most conspicuous csamplc of such misplaced trust is the ANB mcasure-
mcnt or SNB-SNB difference. As can be seen in Fig. 4, there is all overlap
from 3.4 tlcgrccs to 4.8 tlc~grccs, within which can occur tither normal occlusions
or Class II, Division 1 nialo~~lusions, both satisfying their credentials within the
majority limits of natural variation.
In F’ig. 5 the Class II, Division 1 means, plus and minus one standard dcvia-
tion, arc plotted against the Alabama Analysis chart. Within this zigzag pattern
will be found most of the measurements of the majority of the Class II, Division
1 malocclusions among white patients in the southeastern United States. The
last three items arc based on fifty-seven casts only.
Fig. ci shows a comparison of the composite Class II, Division 1 female
(solid line) with the composite of t,he Class II, Division 1 male (dotted line).
Among normal occlusions, Class I, and Class II, Division 1 malocclusions,
the most nearly constant tr,lguZnr mcasurcment is the occlusal plant to SN angle.
I’&, in an)- one I)erson this can show a considerable tlifference from the average.
How can this be interpreted? This is where the coefficient of correlation can
give us a partial explanation. The largest coefficient of correlation involving
Fig. 7. Using the same planes-SN, occlusal, and mandibular-the angles show widely
different coefficients of correlation. (See text.)

the occlusal p1a11r to SK mcasurcment is with the facial plane (NP) to SN.
Tt is -0.79682 for Claw II, Division 1 malocclusions. Squaring this, 62 per cent
of the variability in the owlusal plane to RN measurement is associated with
variahilit,v in the facial plane to ,SN rncasnrernent. As one gets larger, there is
3 tt~nclt~ncy for the otliw to get smaller. It is important to note that the largest
cwffi~icnt of corwlatiolr oi’ tlw owlusal plane to SN measurement is ~of with the
mantliln~lar l)lancJ to SK.
Fig. 7 shows \\hy this is so. Tllis illustration is hascd on the normal occlusion
saml)lc, so thr vsact numlwrs arc tlifferent, hut the prillc+iplr is the same.
 Ant. J. Orthod.
April 1973

SOME INTRINSIC COEFFICIENTS OF CORRELATION

normals (highest 2) N=40 Class II (highest 2) N = IDJ
SNA SNB 0.802 FAC-SN 0.699 SNB 0.830 FAC-SN a 750

SNB Fat-SN a950 SNA am FAC-SN a964 SNA a830

ANB AB-Occl -0.68 _LNA lin -0.669 AB-Occl.-0.588 Ito NAa -o.5@

FAC-SN SNB 0.950 Yaxis -a846 SNB 0.965 Yaxis -a 8&l

‘Y’ Axis SN Fat-SN d.846 SNB a 781 Fat-SN -0.881 Man-SN 0.851

Man-SN ‘Y’ax SN 0.780 Fat-SN -0.711 ‘Y’ a* aa51 Fat-SN 4.762

Occl-SN Fat-SN a716 Man.SN 0.672 Fat-SN -0.7% ‘Y’axis-SN 0. 755

AB-Occl ANB -a678 INA lin 0.528 ANB -a589 SNB a 301

ltooP Lto SN -0. 760 Ito NAa -0.720 !-tow -a804 ItoSN -0.724

-ito NA Ito NAlin a 790 Ito 0. P. a 790 Lto0. P.-a8@l Ito SN a779

Lto SN no 0. P. -a 760 Ito NAa a 670 ito NA 0.779 Lt0 0. P. -a 725

_ItoAP Tto NB a802 ItoO. P. 0.653 Lto 0. P. -0.547 _Lto NA 0.376

Tto Man. i-to 0. P. -0.856 Tto SN -O. 740 ito 0. P. O. 727 Tto SN 0.548

7to occl. -itoMan. -a856 Tto SN 0.84 l-to SN Cl762 TtoMP -0.727

-it0 SN Tto 0. P. a 841 TNBlin. 0.716 l-to 0. P. 0.762 Tto NB lin -0.763

?io NBI ItoAPlin am2 TtoOP -a726 rto SN -0.763 Tto 0. P. -O.678

PtoNB ito NB -a724 JtoAP -a684

N-57
-Ito NA lin. Lto NAa a790 AN0 -0.669 j.toNAa 0.800 It0o.p. -a7M
Overbite 0vJt a42 TtoNB lin -a413 M to SN (1472 _ItOO. P. a434
Overjet AB-OP -a515 OvBt a42 LtOAP 0.642 ItoOc -a633

Fig. 8. The highest coefficients of correlation for Class II, Division 1 malocclusions are not
always the same items for normal occlusions.

The lower incisor to NB linear measurement and the overbite are similar in
normal occlusions and Class II, Division 1 malocclusions.
Those C~lass II, Tjirision 1 measurements in which we expect the greatest
\,ariation from normal are the upper incisor to AP linear measurement, the Al3
plane to owlusal plane measuremellt, and the overjet. Some interesting differ-
cnws show up in a comparison of the two highest cocffieients of correlation
in Class II, Division 1 malocclusion, with the highest cocfficicnts of correlation
in normal occlusion (Fig. 8).
The highest coefficient of correlation for the upper incisor to AI’ linear
measurement is with the upper incisor to occlusal plant angular measurement,
but it is only -0.54718. In normal occlusions its highest correlation is with t’he
lower incisor to KB linear nw;tsurement.
The AB to o~clu~al plane mcasaremcwt is most closely assoeiatcd with the
WA-SKB diffcrcnce. However, the minus coeffkicnt of correlation is only
-0.58582 in Class II malocclusions and only -0.678 in normal occlusions.
Conclusion

The ccplialonictri~ differences which show up in Class II, l>ivision 1 maloc-

c*lusions are found in the unner tooth positions and the lower jaw position.
 ‘1%~ Alabama Analysis (revid ) stems to provitltb most of the measure-
ments for making distinctions for vlinival l)urposes. Some orthodontic colleagues
hare expressed thcmsel\-cs to the effcc+t that they think the Alabama Analysis
is great, but they (10 not USCit because of the name. For such scientists, I would
suggest a shortening, to the “AJ” analysis. The first and last letter of “America”
is also d. I would not want insiu~mountable scmantivs to prevent the wide-
spread use of this worthwhile tool.
REFERENCES
1. Hitchcock, H, P.: A cephalometric description of Class I malocclusion, ,4&f. J. ORTHOD.
55: 124-134, 1969.
2. Taylor, w., and Hitchcock, H.: The Alabama Analysis, Ax ,T. ORTXIOD. 52: 245-265, 1966.
3. Hitchcock, H. P.: A cephalomctric supplement, AX. J. ORTHOD. 57: 47-54, 1970.
4. Strang, R., and Thompson, W.: A textbook of orthodontia, Philadelphia, 1958, Lea &
Febiger, p. 89.
5. Rothstein, T.: Facial morphology and growth (Abstr.), AM. J. ORTHOD. 60: 619, 1971.
6. Gianelly, A.: Age and sex wphalometric norms, AM. J. ORTHOD. 57: 497-501, 1970.

Graduate courses in orthodontia of an academic grude equivalent in quality to graduate

work in other departments oY the university should be available wherever the facilities of
the dental school make this possible, for it is in this way that teachers and clinical special-
ists may be trained and where research will carry forward the torch of new knowledge.
Research usually paves the way for advances in the teaching of a subject. So great is
the need for fundamental research in the science of orthodontia that every encourage-
ment should be given this part of its development. (Miner, Leroy: The Place of Orthodontia
in Dental Education, Transactions of the Second [ 1931 1 International Orthodontic Con-
gress, St. Louis, 1933, The C. V. Mosby Company, p. 106.)