ORIGINAL ARTICLE

Craniofacial morphology in women with

Class I occlusion and severe maxillary
anterior crowding
Misa Ikoma and Kazuhito Arai
Tokyo, Japan

Introduction: Our objective was to investigate craniofacial morphology in women with Class I occlusion and
maxillary anterior crowding (MxAC) with bilateral palatal displacement of the lateral incisors and facial displace-
ment of the canines. Methods: Thirty-three women with normal occlusion (mean age, 20.7 6 2.3 years) were
selected as the control group, and 33 women with severe MxAC (mean age, 23.3 6 3.8 years) with bilateral palatal
and facial displacement of the lateral incisors and canines, respectively, were selected as the MxAC group. Mesio-
distal tooth crown diameter, arch length discrepancy, facial-palatal displacement of lateral incisors and canines,
and dental arch dimensions were measured. Fourteen skeletal and 10 dental cephalometric measurements
were made. Medians, interquartile ranges, means, and standard deviations were calculated for each parameter,
and the nonparametric Mann-Whitney U test (P \0.05) was used to compare the 2 groups. Results: Compared
with the control group, the MxAC group showed a significantly wider angle (P \0.05) and shorter length
(P \0.01) in the cranial base, a smaller sagittal maxillary base (P \0.01), and a hyperdivergent skeletal pattern
(P \0.01 and P \0.05). Conclusions: Women with Class I occlusion and severe MxAC exhibited a significantly
wider angle and shorter length in the cranial base, a smaller sagittal maxillary base, and a hyperdivergent skeletal
pattern. These skeletal and dental characteristics and cranial base dysmorphology may be helpful as potential in-
dicators for orthodontic treatment with extractions. (Am J Orthod Dentofacial Orthop 2018;153:36-45)

P
ostadolescent female patients often seek ortho-
dontic treatment, complaining of maxillary ante-
rior crowding (MxAC) as a main concern in smile
esthetics. MxAC is typically characterized as combined
facial (often described as labial, buccal, or labiobuccal)
displacement of the maxillary canines and palatal
displacement of the maxillary lateral incisors.1 This
malocclusion is usually considered the result of a
discrepancy between a relatively larger tooth size and a
shorter dental arch perimeter.2-4
The etiology of displaced maxillary canines has been
investigated in relation to craniofacial morphology.
Larsen et al5 analyzed sagittal, vertical, and transversal
dimensions of the maxillary complex in patients with
From the Department of Orthodontics, School of Life Dentistry at Tokyo, Nippon
Dental University, Tokyo, Japan.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Kazuhito Arai, School of Life Dentistry at Tokyo, Nip-
pon Dental University, 1-9-20 Fujimi, Chiyoda-ku, Tokyo 102-8159, Japan;
e-mail, drarai@tky.ndu.ac.jp.
Submitted, December 2016; revised, March 2017; accepted, May 2017.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2017.05.026
36
ectopic maxillary canines using cephalometric and
dental cast analyses. They found that in patients with
ectopic canines the size of the maxillary complex was
excessive transversally and deficient sagittally and verti-
cally. However, no distinction was considered in buccal
or palatal displacement of the canines. Sacerdoti and
Baccetti6 evaluated vertical craniofacial morphology in
patients with palatally displaced canines and found a
significantly higher prevalence of hypodivergent skeletal
patterns compared with control subjects. In addition,
Mucedero et al4 evaluated 49 patients with unilateral
or bilateral buccally displaced canines and found a
higher prevalence of hyperdivergent skeletal patterns
and narrower maxillary intercanine widths in them
than in the control subjects. They concluded that the
etiology of buccal displacement of the maxillary canines
is a result of local environmental factors, as opposed to a
predominant genetic control observed in palatally
displaced canines.4,7
The cranial base is generally analyzed using 4
measurements: cranial base angle (often called the
saddle angle), anterior cranial base length, posterior
cranial base length, and total cranial base length.
Although differences in cranial base morphology among
Ikoma and Arai
Angle classifications have been widely studied, their
influence on dental crowding has been investigated
only for the mandibular dental arch.8 Melo et al9 found
a relatively short anterior cranial base length in 11
patients with mandibular crowding compared with 12
participants with no mandibular crowding in the decid-
uous dentition. Conversely, T€ urkkahraman and Sayin10
compared groups with and without mandibular anterior
crowding in the early mixed dentition and observed no
significant differences in the cranial base angle, anterior
cranial base length, or posterior cranial base length.
To date, there are no specific measurements to evaluate
the severity of MxAC. Previous studies have used arch
length discrepancy,2,10,11 which was originally proposed
for the mandibular arch, or Little's irregularity index9,12
for mandibular incisors, which has been uncommonly
applied to the maxillary arch. Therefore, it has been rather
difficult to evaluate quantitatively the severity of facial
displacement of the canines and palatal displacement of
the lateral incisors in patients with MxAC.13
The purpose of this study was to investigate craniofacial
morphology in Angle women with Class I occlusion and se-
vere MxAC selected by an objective evaluation of facially
displaced maxillary canines and palatally displaced lateral
incisors using the fourth-order polynomial equation.
MATERIAL AND METHODS
The protocol of the study was approved by the
ethics committee of Nippon DentalUniversity (number
T2014-34).
This was designed as a retrospective cross-sectional
study. The sample size was estimated to have an effect
size of 0.973, which was determined based on a previous
study using the G-power statistical program (version 3.1;
Heinrich Heine Universitat Dusseldorf Experimentelle
Psycologie, Dusseldorf, Germany).14 Power analysis indi-
cated that the required minimum sample size for each
group was 18 subjects to detect this effect size with
80% power and a significance level of 5%.
Approximately 100 male and female subjects with
normal occlusion who were initially selected from a total
population of about 4000 students at Nippon Dental
University and other related schools were evaluated by
2 orthodontists.15,16 The following inclusion criteria
were used in the initial selection process.
1. Age 18 years or older without previous orthodontic
treatment or congenital craniofacial anomalies such
as cleft lip or palate.
2. Straight profile without strain on the lips or mentalis
muscle.
3. Normally erupted permanent teeth from
second molar to second molar in the maxillary and
American Journal of Orthodontics and Dentofacial Orthopedics
37
mandibular arches with an Angle Class I relationship
without anterior or posterior crossbites, and no
obvious asymmetric continuous dental arch.
4. No teeth with abnormal crowns (including fused
teeth, macrodont or microdont teeth, severe tooth
wear, fractured teeth, minimum restorations that
cover incisal edges or cusp tips that obstruct the
measurements for this study), no rotated, displaced,
impacted, transposed teeth or prolonged retained
deciduous teeth.
5. Healthy periodontal tissues without gingivitis or
gingival recession.
Based on these inclusion criteria, 69 women were
selected. The purpose of this study, the protocol, and
the potential risk due to radiation exposure during ceph-
alographic imaging were explained in writing, and 58
subjects agreed to participate and provided informed
consent. Dental casts and cephalograms of these
subjects were taken. The dental casts were measured
using a digital caliper (NTD12-15C; Digimatic, Mitu-
toyo, Kawasaki, Japan), and subjects with the following
criteria were further selected: overbite and
overjet, 11.0-3.0 mm; curve of Spee, \1.5 mm in the
mandibular dental arch; and arch length discrepancy,
6 2.0 mm in the maxillary and mandibular arches.
Furthermore, lateral cephalograms were analyzed by a
software program (version 11.5; Dolphin Imaging,
Chatsworth, Calif), and subjects with the following
were selected: ANB angle, 2.5
6 2.0
. Accordingly, 33
women (mean age, 20.7 6 2.3 years; range, 18-29 years)
were selected as the control group.
For the MxAC group, dental casts, facial and intraoral
photographs, lateral cephalograms, and treatment
records of approximately 4200 patients diagnosed at
Nippon Dental University Hospital between July 1998
and December 2015 were reviewed by 2 evaluators in
the Department of Orthodontics to select female
patients aged 18 years or older with the following inclu-
sion criteria.
1. No previous orthodontic treatments or congenital
anomalies including cleft lip or palate.
2. Straight facial profile without signs of lip incompe-
tence.
3. Completely erupted permanent teeth from
second molar to second molar in the maxillary and
mandibular arches except for third molars (subjects
with incomplete eruption of a maxillary canine were
excluded).
4. Crowding (arch length discrepancy, \4.0 mm) in
the maxillary dental arch and at least 1 maxillary
canine displaced in the facial direction from the
January 2018  Vol 153  Issue 1
38 Ikoma and Arai

Fig 1. A, Reference point locations and B, dental arch measurements of 3D cast images.

Fig 2. Cephalometric measurements.

dental arch (ie, the tip of the canine must be
displaced on the facial side from the line between
the center of the lateral incisor edge and the buccal
cusp tip of the first premolar observed in the
occlusal plane).11
5. No abnormal crowns (eg, fused teeth or macrodont
or microdont teeth), supernumerary teeth, trans-
posed teeth, prolonged retained deciduous teeth,
severe dental wear, occlusal attrition, fractures,
minimum restorations that cover incisal edges, or
cusp tips that obstruct the measurements for this
study (except for the third molars).
6. Healthy periodontal tissues without gingivitis or
gingival recession.
Accordingly, dental casts and lateral cephalograms of
174 patients were evaluated. Those with Angle Class I
first molar relationships without posterior crossbite
were selected. Additionally, patients with tooth rotation
greater than 45
were excluded based on observation of
the maxillary dental cast in the occlusal plane. The
dental casts of the selected patients were measured
using the digital caliper, and then subjects with overbite
and overjet within 11.0 to 4.0 mm were selected.
Maxillary dental casts of subjects in the control
group were scanned using a 3-dimensional (3D) laser
scanner (Surflacer model VMS-100F; UNISN, Osaka,
Japan),17 and reference points were identified at the
center of incisor edges, cusp tips of canines, and buccal

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Ikoma and Arai
Table I. Cephalometric landmarks
Point
Sella S Center of the hypophyseal fossa in the midsagittal plane
Nasion N Most anterior point of the frontonasal suture in the
Articulare Ar
Point A A Deepest point on the midsagittal plane between the
Point B B Deepest midline point on the mandible between
Anterior nasal spine ANS
Posterior nasal spine PNS
Pterygomaxillary fissure Ptm
Menton Me
Gonion Go
U6D U6D
U6M U6M
cusps of premolars using 3D point cloud evaluation
software (Inspect version 7.5; GOM, Braunschweig,
Germany). Three-dimensional coordinates were then
converted to a file for Microsoft Office Excel 2013
(Microsoft, Redmond, Wash). Next, the fourth-order
polynomial equation was fit using the least squares
method to create a curve through the reference points
at each tooth excluding both lateral incisors and
canines in the occlusal plane.17 The horizontal
distances between the curve and the reference points
at the lateral incisor and canine were calculated as
facial-palatal displacement of the lateral incisor and
canine, respectively (Fig 1). The distance toward the
facial direction was defined as a positive value, and
palatal displacement was defined as a negative value.
At this point, the subjects in the control group were
considered unilaterally, and palatal displacement of
lateral incisors was subtracted from facial displacement
of the canines for 66 sides of the 33 subjects. These
data were pooled, and the means and standard devia-
tions (0.86 6 0.72 mm) was calculated. To evaluate
facial-palatal displacement of the lateral incisors and
canines of the 174 patients initially selected for the
MxAC group, 2 SD was added to the mean value
obtained in the control group and determined as the
standard value (2.31 mm) for the facial-palatal posi-
tional relationship between the lateral incisors and
canines. Thus, patients having values that exceeded
this standard value were selected as the most severe
MxAC subjects.
American Journal of Orthodontics and Dentofacial Orthopedics
39
Location
(sella turcica)
midsagittal plane
Intersection point of the posterior border of the mandible
and the inferior border of the basilar part of the
occipital bone
supradentale and the anterior nasal spine
pogonion and the crest of the mandibular alveolar
process
Most anterior point on the bony hard palate
Most posterior point on the bony hard palate
The contour of the pterygomaxillary fissure formed
anteriorly by the retromolar tuberosity of the maxilla
and posteriorly by the anterior curve of the pterygoid
process of the sphenoid bone
Most inferior midline point on the mandibular symphysis
Most posterior inferior point at the angle of the mandible
Distal contact of the maxillary first molar
Mesial contact of the maxillary first molar
Consequently, patients with an ANB angle within
2.5
6 2.0
were selected by the cephalometric anal-
ysis, and 33 women (mean age, 23.3 6 3.8 years; range,
18-31 years) were selected as the MxAC group.
All subjects in both groups were selected from the
same ethnic population in Japan. We set the minimum
age as 18 years because we considered patients aged
18 years or older to have completed growth. Patients
in the MxAC group were selected to match the age range
of the control group as much as possible.
Mesiodistal tooth crown diameters for the maxillary
central incisors, lateral incisors, canines, first and second
premolars, and first molars were measured using the
digital caliper, and the bilateral measurements were
pooled. The median and interquartile range (IQR) with
means and standard deviations were then calculated
for both groups.
For the central incisor relationship, overjet and over-
bite were measured on dental casts using the digital
caliper, and medians and IQRs with means and standard
deviations were calculated for both groups.
Tooth size-arch size relationship was measured using
the segment arch method with the digital caliper.11
Facial-palatal displacements of the lateral incisors and
canines were measured (Fig 1). Medians and IQRs with
means and standard deviations for these measurements
were then calculated for both groups.
Dental arch dimensions were measured by the 3D
cloud evaluation software. Dental arch widths were
measured as the distances between reference points on
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40 Ikoma and Arai

Table II. Cephalometric analysis

Measurement Unit Description
Cranial base


1 Cranial base angle Angle formed between the S-N plane and S-Ar line. The
S-N plane was formed by points S and N. This angle is
also known as the saddle angle
2 Anterior cranial base length mm Liner distance between points S and N
3 Posterior cranial base length mm Liner distance between points S and Ar
4 Total cranial base length mm Liner distance between points N and Ar
Skeletal sagittal


5 SNA angle Angle formed between the S-N plane and N-A line


6 SNB angle Angle formed between the S-N plane and N-B line


7 ANB angle Angle formed between the lines N-A and N-B
8 A-Ptm distance mm Linear distance between point A and point Ptm
Skeletal vertical


9 SN-mandibular plane angle (SN-MP) Angle formed between the S-N plane and mandibular
plane. The mandibular plane was formed by
connecting gonion and menton


10 SN-palatal plane angle (SN-PP) Angle formed between the S-N plane and palatal plane.
The palatal plane was formed by connecting ANS and
PNS


11 Palatal plane-mandibular Angle formed between the palatal plane and mandibular
plane angle (PP-MP) plane
12 Upper anterior facial height mm Vertical distance between point N and point ANS
13 Lower anterior facial height mm Vertical distance between point ANS and point Me
14 Anterior facial height mm Vertical distance between point N and point Me
Dental


15 U1-SN angle Angle formed by the intersection of the long axis of the
maxillary central incisor (U1) and the S-N plane


16 U1-palatal plane angle Angle formed by the intersection of the long axis of U1
(U1-PP) and the palatal plane. The palatal plane was formed by
points ANS and PNS
17 U1-NA distance mm Horizontal distance from the edge of U1 to the N-A line


18 U1-NA angle Angle formed by the intersection of the long axis of U1
and the N-A line
19 L1-NB distance mm Horizontal distance from the edge of the mandibular
central incisor (L1) to the N-B line


20 L1-NB angle Angle formed by the intersection of the long axis of L1
and the N-B line


21 L1-MP angle Angle formed by the intersection of the long axis of L1
and the mandibular plane


22 Interincisal angle Angle formed by the intersection of the long axes of U1
and L1
23 U6D-Ptm distance mm Linear distance between distal contact of the maxillary
first molar (U6D) and point Ptm
24 U6M-A distance mm Linear distance between mesial contact of the maxillary
first molar (U6M) and point A

bilateral canines, first and second premolars, and first
molars (midpoint of mesiodistal buccal cusps of the first
molars). Dental arch depths were measured as the
distances between the midpoint of the center of the
edges of bilateral central incisors and the midpoints of
bilateral reference points at the canines, first and second
premolars, and first molars (Fig 1). Medians and IQRs
with means and standard deviations for these measure-
ments were then calculated for both groups.
All cephalograms were taken with the same machine
(CX-150SK; Asahi-Roentgen, Kyoto, Japan), and
magnification was automatically adjusted to 1:1 by the
cephalometric analyzing software program. Based on pre-
vious studies, 14 skeletal and 10 dental cephalometric
measurements were conducted using the analyzing
software program, and medians and IQRs with means
and standard deviations were calculated for both groups
(Fig 2; Tables I and II).18-20 All reference points were
identified by 1 evaluator (M.I.). Articulare was used as
the reference at the most posterior point of the cranial
base, which is considered to be a more biometrically
reliable point than basion.8,21,22

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Ikoma and Arai
Fig 3. Comparison of the results of cephalometric mea-
surements in the MxAC and control groups. Medians of
reference point locations in the x-y coordinates for each
group were superimposed at sella and the S-N line.
In addition, all x-y coordinates for each patient were
exported as text data and imported into the Microsoft
Office Excel program. The coordinates were superim-
posed at sella as the origin and on the sella-nasion line
at 7
above the horizontal line for each group.23
Medians for each reference point were calculated for
each group, and a graph was drawn (Fig 3).
To calculate and examine intraexaminer errors with
Dahlberg's formula,24 10 subjects were randomly
selected from both groups (total, 20 subjects). The
same cephalometric measurements were taken twice
with a minimum of a 2-week interval by 1 evaluator
(M.I.) and once by another evaluator (a member of the
orthodontic department) using the same general clinical
procedure without a calibration session. The maximum
intraexaminer and interexaminer error values for the
cephalometric analysis were 0.55 and 0.63 mm for linear
measurements and 0.61
and 0.79
for angular
measurements, respectively. For mesiodistal tooth crown
diameter measurements on dental casts, the same 20
subjects were evaluated. The maximum intraexaminer
and interexaminer error values were 0.17 and
0.36 mm, respectively.
In addition, to analyze intraexaminer and interexa-
miner errors for dental cast measurements obtained by
the 3D laser scanner, 5 dental casts from both groups
American Journal of Orthodontics and Dentofacial Orthopedics
41
(total, 10 casts) were also randomly selected. All
measurement landmarks were identified twice with a
minimum of a 2-week interval by 1 evaluator (M.I.)
and once by another evaluator with a careful calibration
session, since we do not use this system clinically. The
maximum intraexaminer and interexaminer error values
for the 3D dental cast measurements were 0.10 and
0.12 mm, respectively.
Statistical analysis
All statistical analyses were performed using SPSS
software for Windows (version 24.0; IBM, Armonk,
NY). Because some parameters did not show normal
distributions according to the Kolmogorov-Smirnov
test, medians and IQRs were calculated for each param-
eter, and the nonparametric Mann-Whitney U test was
used to compare the 2 groups. Parameters that did not
show a normal distribution were displacement of lateral
incisor for the control group, overbite, and sum of the
displacements for 1 side for the MxAC group, and lower
anterior facial height, anterior facial height, and L1-NB
distance. For all statistical analyses, P values less than
0.05 were considered significant.
RESULTS
Mesiodistal diameters of tooth crowns of the MxAC
group were significantly larger than those of the control
group for all teeth except for the first molar (P \0.01).
Overbite was significantly smaller in the MxAC group
compared with the control group (P \0.01) (Table III).
Arch length discrepancy and facial-palatal displace-
ment of the lateral incisors and canines from the dental
arch were significantly smaller and greater, respectively,
in the MxAC group compared with the control group
(P \0.01).
Dental arch widths at the first and second premolars
(P \0.01) and the first molars (P \0.01) and dental arch
depths at the canine (P \0.01), the first premolar
(P \0.01), and the second premolar (P \0.05) in the
MxAC group were significantly smaller than in the con-
trol group.
The cranial base angle was significantly greater in the
MxAC group compared with the control group
(P \0.05). Median cranial base length measurements
for anterior cranial base length, posterior cranial base
length, and total cranial base length (P \0.01) were
4.10 mm (5.89%), 3.95 mm (10.12%), and 5.16 mm
(5.38%) shorter in the MxAC group compared with the
control group, respectively (Fig 3; Table IV).
SNA and SNB angles and the A-Ptm distance were
significantly smaller in the MxAC group compared with
the control group (P \0.01).
January 2018  Vol 153  Issue 1
42 Ikoma and Arai

Table III. Comparison of the dental cast analysis in the maxillary arches between the groups
Statistical
Control group (n 5 33) MxAC group (n 5 33) analysis

Measurement (mm) Median IQR Mean SD Median IQR Mean SD P value

Mesiodistal tooth dimensionz
y
Central incisor 8.42 0.56 8.47 0.41 8.63 0.70 8.73 0.50 0.000
y
Lateral incisor 7.05 0.51 7.13 0.43 7.48 0.94 7.59 0.56 0.000
y
Canine 7.80 0.28 7.80 0.19 8.14 0.70 8.17 0.40 0.000
y
First premolar 7.30 0.52 7.30 0.39 7.67 0.58 7.74 0.40 0.000
y
Second premolar 6.89 0.45 6.84 0.34 7.08 0.47 7.09 0.33 0.000
First molar 10.47 0.62 10.41 0.50 10.60 0.91 10.53 0.55 0.110 NS
Central incisor relationship
Overjet 2.52 1.18 2.53 0.82 2.76 0.95 2.65 1.01 0.387 NS
Overbite 2.05 0.78 2.16 0.57 1.69 1.27 1.72k 0.98 0.005 y

Tooth size-arch size relationship

y
Arch length discrepancy 0.01 1.00 0.05 0.77 9.71 7.51 10.00 3.94 0.000
(1) Displacement of lateral 0.30 1.71 0.19k 1.55 2.72 2.69 2.86 1.94 0.000 y

incisorz
(2) Displacement of caninez 0.44 1.13 0.48 0.95 3.03 2.45 2.99 1.64 0.000 y

Sum of the displacements 0.76 0.79 0.86 0.72 5.61 2.74 5.76k 1.72 0.000 y

for 1 sidez§
Dental arch width
(3) Canine 35.37 2.54 35.62 1.43 35.52 4.04 35.61 2.33 0.954 NS
y
(4) First premolar 43.60 2.21 43.67 1.91 40.55 4.06 40.18 2.78 0.000
y
(5) Second premolar 49.80 2.89 49.86 2.43 45.34 5.38 45.61 3.55 0.000
y
(6) First molar 55.20 3.17 55.38 2.44 52.66 4.08 52.42 2.83 0.000
Dental arch depth
y
(7) Canine 8.33 1.23 8.34 1.03 5.67 3.82 6.04 2.12 0.000
y
(8) First premolar 15.44 1.98 15.61 1.40 14.11 4.42 14.01 2.44 0.006
(9) Second premolar 22.23 2.04 22.11 1.59 20.80 3.82 20.87 2.57 0.038 *
(10) First molar 30.66 2.67 30.52 2.03 30.00 4.33 29.79 2.76 0.267 NS

IQR, Interquartile range; MxAC, maxillary anterior crowding; NS, not significant.
(1) and (2), A positive number indicates displacement toward the facial direction.
(1)-(10), Correspond to the numbers shown in Figure 1.
*P\0.05; yP\0.01; zThe right and left side data were pooled; §The sum of the displacement was calculated as (2) – (1) for each side (ie, subtraction
of lateral incisor displacement from canine displacement); kNonnormal distribution.

Significantly greater SN-mandibular plane (MP), SN-
palatal plane (PP) (P \0.01), and PP-MP angles
(P \0.01) were observed in the MxAC group compared
with the control group, indicating a hyperdivergent skel-
etal pattern of this malocclusion.
Regarding dental components, the MxAC group
showed a significantly greater U1-PP (P \0.01) and
U1-NA (P \0.05) angles, smaller interincisal angle
(P \0.01), and smaller U6D-Ptm distance (P \0.05)
than did the control group.
DISCUSSION
In this study, the maxillary dental arch in the MxAC
group exhibited narrower interpremolar and interfirst
molar widths and shorter dental arch depths at the
canines and premolars when compared with the con-
trol group. However, no significant difference in
maxillary intercanine width was observed between
the 2 groups. Therefore, the direction of canine
displacement can be evaluated in the anterior direc-
tion, rather than the transverse, because of the short
dental arch depths observed at the canines and first
premolars. In the Japanese language, “yaeba” refers
to the condition of multiple anterior overlapping teeth
in the frontal smile. In contrast to our subjects, who
were selected from the same Japanese population, Ital-
ian patients with similar malocclusion status and
buccally displaced maxillary canines demonstrated
significantly wider intercanine widths and no intermo-
lar width differences.4 Therefore, heritability of cranial
base morphology may explain differences in the direc-
tion of maxillary canine displacement between ethnic-
ities.14,25,26 However, further studies in other
populations are necessary to determine the effect of
ethnic variation on cranial base morphology and
position of ectopic maxillary canines.
In orthodontics, the cranial base angle has often been
investigated to identify differences among Angle

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Ikoma and Arai 43

Table IV. Comparison of the results of cephalometric and dental cast analyses between the groups
Statistical
Control group (n 5 33) MxAC group (n 5 33) analysis

Measurement Unit Median IQR Mean SD Median IQR Mean SD P value

Cranial base


1 Cranial base angle 122.50 5.85 122.09 3.71 124.90 7.60 124.90 5.30 0.028 *
y
2 Anterior cranial base length mm 69.60 3.65 69.73 3.01 65.50 4.20 66.11 3.43 0.000
y
3 Posterior cranial base length mm 39.00 3.85 38.70 3.02 35.05 4.40 34.97 3.42 0.000
y
4 Total cranial base length mm 96.00 6.99 96.39 4.19 90.84 8.21 90.39 5.35 0.000
Skeletal sagittal

y
5 SNA angle 82.90 4.50 82.43 2.94 79.05 4.27 79.77 3.80 0.001

y
6 SNB angle 79.60 3.45 80.24 2.74 77.70 5.95 76.70 3.43 0.000


7 ANB angle 2.30 3.05 2.18 1.93 2.75 3.63 3.09 2.47 0.228 NS
y
8 A-Ptm distance mm 48.40 2.45 48.89 2.21 45.35 4.38 45.58 3.01 0.000
Skeletal vertical

y
9 SN-mandibular plane angle 35.00 7.15 34.64 5.00 41.40 8.50 42.02 6.05 0.000
(SN-MP)

y
10 SN-palatal plane angle 7.00 4.95 6.21 3.87 10.80 4.20 10.98 2.51 0.000
(SN-PP)

y
11 Palatal plane-mandibular 26.30 5.75 26.31 4.27 30.00 6.80 31.07 4.61 0.000
plane angle (PP-MP)
12 Upper anterior facial height mm 57.90 3.70 58.06 2.87 56.45 5.30 56.20 3.36 0.024 *
13 Lower anterior facial height mm 73.40 3.95 74.08z 4.10 72.55 5.72 72.11 4.16 0.116 NS
14 Anterior facial height mm 128.10 5.95 129.24z 5.30 125.05 7.40 124.83 5.04 0.004 y

Dental


15 U1-SN angle 106.10 6.68 106.47 4.75 108.25 7.18 107.74 4.69 0.248 NS

y
16 U1-palatal plane angle 115.60 5.15 114.50 4.12 119.50 7.43 118.62 4.92 0.001
(U1-PP)
17 U1-NA distance mm 6.90 3.50 7.14 2.16 7.40 4.78 7.45 3.04 0.551 NS


18 U1-NA angle 24.70 6.10 24.39 4.18 26.90 8.08 27.88 5.11 0.014 *
19 L1-NB distance mm 8.00 3.05 7.33z 2.27 8.30 4.35 8.44 3.09 0.156 NS


20 L1-NB angle 30.10 7.25 28.83 4.85 31.40 12.18 31.17 6.43 0.139 NS


21 L1-MP angle 93.70 4.25 93.97 5.13 92.45 10.53 92.65 6.97 0.308 NS

y
22 Interincisal angle 123.80 7.20 124.62 5.46 116.65 15.85 117.86 9.39 0.002
23 U6D-Ptm distance mm 15.01 2.90 15.35 2.38 13.38 4.27 13.90 3.14 0.021 *
24 U6M-A distance mm 22.62 2.93 22.87 2.54 22.30 3.55 21.83 3.27 0.105 NS
IQR, Interquartile range; MxAC, maxillary anterior crowding; NS, not significant.
*P \0.05; yP \0.01; zNonnormal distribution.

classifications.8,27-29 Previous studies have suggested
that larger and smaller cranial base angles determine
the posterior and anterior positions of the condyle in
the cranial base, resulting in skeletal Class II and Class
III relationships, respectively.25,30,31 However, only a
few studies have used the cranial base angle to
compare differences between patients with and
without crowding in the mandibular arch, with no
significant differences in the cranial base angle
observed.9,10 We found a significantly larger cranial
base angle in the MxAC group with Class I dental and
skeletal patterns. This finding supports the results of a
previous study in Class I patients.29 These findings may
be attributed to a topographic correlation between the
cephalometric measurements and the reference
points.32-34 The cranial base, maxilla, dental arch, and
teeth are adjacent anatomic components, and thus
may be associated with one another during the growth
period from the embryonic phase. Therefore, the
cranial base angle may influence the establishment of
MxAC. However, the precise biologic mechanisms are
still not well understood and require further
longitudinal studies of growing subjects.29
Larsen et al5 observed that children with either
facially or palatally impacted maxillary canines that
required fenestration surgery had a significantly shorter
anterior cranial base length (approximately 1 mm),
which was not necessarily the result of anterior crowding
when compared with a reference group. Although we
studied adults, we observed a larger difference for ante-
rior cranial base length between groups than the previ-
ous study in growing patients.5 In addition, we found
significantly smaller posterior cranial base length and
total cranial base length in the MxAC group than in
the control group. These findings suggest the possibility
of early prediction of MxAC even before establishment of

American Journal of Orthodontics and Dentofacial Orthopedics January 2018  Vol 153  Issue 1
44
the permanent dentition according to a smaller cranial
base on cephalometric analysis.25
The MxAC group demonstrated a significantly
smaller anterior cranial base length and anteroposterior
dimension of the maxilla (A-Ptm distance) compared
with the control group. These findings support the
conclusion of a recent review article, which suggested
that anterior cranial base length has a stronger influence
on facial growth than posterior cranial base length.35
Although the correlation between cranial base size and
cleft palate remains unclear,36 it is plausible that a
history of cleft palate repair greatly affects maxillary
development, but this altered maxillary development
has no significant influence on morphology or size of
the cranial base.37 In addition, use of rapid maxillary
expansion appliances in 8- to 11-year-olds resulted in
limited expansion effects in spheno-occipital synchond-
rosis.38 Therefore, orthodontic intervention with
maxillary development to resolve arch length discrep-
ancy in patients with severe MxAC may be limited,
even in growing patients.
In Italy, Mucedero et al4 found a significantly higher
possibility of hyperdivergent skeletal patterns using the
SN-GoGn angle in cephalometric analysis in patients
with buccally displaced maxillary canines. We observed
similar significant hyperdivergent skeletal patterns with
greater SN-MP, SN-PP, and PP-MP angles in the
MxAC group than in the control group. A shorter poste-
rior cranial base length and obtuse cranial base angle
cause the glenoid fossa and condyle to have relatively
higher positions, which may increase the SN-MP and
PP-MP angles (Fig 3).39
In previous studies, subjects with a long face usually
have narrower transverse dimensions, and those with a
short face have wider transverse dimensions.25,40,41 In
contrast, the MxAC group in this study showed
significantly smaller maxillae as measured by upper
anterior facial height, anterior facial height, and A-Ptm
distance, despite exhibiting a hyperdivergent skeletal
pattern. Therefore, smaller vertical and sagittal
dimensions of the maxilla could be 1 characteristic of
MxAC and may cause smaller dental arch dimensions.
Traditionally, a hyperdivergent skeletal pattern is
often attributed to functional problems including oral
breathing and lower tongue posture, which is also
considered to correlate with a narrower maxillary dental
arch.11 Forster et al42 observed that patients with hyper-
divergent patterns tend to exhibit a narrower dental arch
width and suggested that lower masseter muscle func-
tion causes undergrowth of the mandible in a transverse
direction. However, family and twin studies showed a
strong genetic influence in the development of the
cranial base.43,44 The influence of cranial base
January 2018  Vol 153  Issue 1 American Journal of Orthodontics and Dentofacial Orthopedics
Ikoma and Arai
morphology on maxillary and mandibular growth is
often observed in heritable developmental anomalies
such as cleft lip and palate, Down syndrome, Turner
syndrome, and craniosynostosis.36,45 Therefore, in
addition to environmental factors, genetic factors may
cause cranial base dysmorphology and potentially
impact maxillary undergrowth, consequently
establishing MxAC indirectly.
Few treatment options for MxAC are currently avail-
able. Clinically, maxillary arch expansion in the mixed
dentition and premolar extraction in the permanent
dentition are commonly performed. As Enlow and
Hans25 hypothesized and Klocke et al46 demonstrated,
morphology and size of the cranial base are determined
in the early stage of development (as early as 5 years of
age). Clinically, a greater cranial base angle, shorter
anterior cranial base length and posterior cranial base
length, and larger mesiodistal width of the maxillary
central incisors detected in the early mixed dentition
may predict MxAC. In addition, the effect of maxillary
expansion may be limited, and serial extraction may be
recommended for such Class I MxAC patients.
Greater arch length discrepancy and displacement of
the maxillary lateral incisors and canines, smaller dental
arch dimensions, and slightly labially tipped maxillary
central incisors were observed in the MxAC group
compared with the control group. Although these results
were expected based on the selection criteria of subjects
in this study, these findings suggest the necessity of
premolar extractions with consideration of maximum
anchorage for patients with MxAC.
Although the selection criterion for overbite in the
MxAC group was 1 mm larger, overbite values with a
significantly smaller median, which reflects individual
variation, were observed in the MxAC group compared
with the control group. Moreover, overbite values for
the MxAC group did not show a normal distribution
(Table III). These findings suggest that subjects in the
MxAC group had a skewed overbite distribution, and
the peak in smaller overbite values might be caused by
the hyperdivergent skeletal pattern observed when
compared with the control group.
CONCLUSIONS
Women with Class I occlusion and severe MxAC ex-
hibited significantly wider angles and shorter lengths
in the cranial base, smaller sagittal maxillary bases,
and hyperdivergent skeletal patterns.
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