Special Report

The 100-year dilemma: what is a normal occlusion,

and how is malocelusion classified?
Morton I. Katz* / Jeanne C. Sinkford** / Charles F Sanders, Jr***

Orthodontic treatment cannot properly begin until the malocclusion is de.\rribed.

Angle's classification of malocclusion, developed a century ago, is still the subject
of debate and controversy. A review of the literature is presented and the differing
viewpoints are di.Kussed. (Quintessence Int 1990:21:407-414.)

Introduction
Classification is a vital element in the diagnosis of a
maloeclusion and in treatment planning for ortho-
dontic care. After countless numbers of individual
malocclusions have been segregated into groups con-
taining common factors, conclusions pertaining to
etiology, prevention, proper mechanics, prognosis,
and retention that aid the practitioner in resolving the
problems can be made. Classification also facilitates
communication between professionals since it pro-
vides dentists with a common descriptive language.
When two dentists discuss a patient's orthodontic
prohlem, it is axiomatic thai Angle's classification of
malocelusion probably will be mentioned within the
first sentence, or surely within the second. So pervasive
is acceptance of Angle's classification, that, nearly a
century after its introduction, it is virtually the only
universally accepted classification of malocelusion.
His concept, whieh has stood the test of time in the
rapidly evolving profession of dentistry for 100 years,
has been eminently useful — but is it precise?
The authors, as academicians and chnicians, have
found it difficult to apply Angle's classification to the
* Assistant Professor, DeparlraenE of Orthodontics, Howard
University, College of Dentistry, WashmgLQii DC 20059.
*' Dean. Howard University, College of Dentistry.
*** Assistant Professor and Acling Chairman. Department of Or-
thodontics. Howard University.
Address all correspondence to Dr Morton I. Katz, 3435 Philips
Drive, Baltimore. Maryland 21208.
diversity of malocclusions seen in the population. We
question the concept of Class I as a treatment goal.
Are these concerns merely anecdotal, and based on
personal biases, or have others also observed weak-
nesses in classification methods?
Etiology versus morphology
Basically, there are only two approaches to classifying
a maloeclusion. The first method considers etiology.
Kingsley. in 1880. focused on causitive factors in his
pioneering work.' However, since the etiology of a
malocelusion is frequently multifaclorial and often not
discernible, his classification was not widely accepted.
By far. the preponderance of orthodontic classifi-
cations utilize morphology. Morphologic classifica-
tions are comphcated by the wide variations found in
human occlusions and anatomic forms, the variations
in severity of malocclusions, and the frequent over-
lapping of numerous problems in a patient. Angle, in
the 1890s, utilized the presumed constancy of the po-
sition of the maxillary first molar to develop a mor-
phologic standard.
Angle's classification
In 19ÜÜ Angle--^ stated, "The key to occlusion is the
relative positions of the first molars. In normal occiu-
sion the mesio-buccal cusp of the upper first molar is
received in the buccal groove of the lower first mo-
l a r . . . . The mesial inchne of the upper cuspid oc-
cludes with the distal incline ofthe lower cuspid, the
[cuspid's] distal incline occluding with the mesial in-
cline of the buccal cusp of the lower first bicuspid . . .
and the distal incline of the distal eusp of the upper

Quintessence International Volume 21, Number 5/1990 407

Special Report
Fig 1 A drawing by Angle of ¡deal occlusion. (Reprinted
from Angle.')
first molar occluding with the mesial inchne of the
mesial cusp of the lower second molar It will thus
be seen that each of the teeth in both jaws has two
antagonists or supports in the opposite jaw, except the
lower central and the upper third molar" (Fig 1).
In his 1900, sixth edition text, Angle defmed Class
11 malocclusion as an abnormal mesiodistal relation
of jaws and dental arches in which all mandibular
teeth occlude distally to normal by the width of one
bicuspid. Class III malocclusion was defined as an
abnormal relation in which the mandibular teeth are
positioned mesial to normal by the width of one bi-
cuspid.
However, in 1907, when Angle'' published his seventh
edition work, he made a significant modification in
the definition of Class II and Class III malocclusions.
Angle altered the amount of deviation from ideal
Class I to either Class II or Class III malocclusion
from "the width of a bicuspid'" to "a deviation from
ideal of more than one-half the width of one cusp."
408
Controversy
For a concept of occlusion that was destined to van-
quish all others. Angle's principles met with immedi-
ate criticism. Crycr,^ in 1904, took Angle to task for
idealizing the straight white profile of an Apollo Bel-
vedere (Fig 2}, while selecting as his example of an
ideal dentition Broomell's "'Old Glory'" skull of a
prognathic black male (Fig 3), These two ideals could
never have coexisted in one individual. Cryer^ believed
that, in contrast to Angle's teachings, the outline of
the face in all of its individual variations, the appear-
ance of the teeth when the lips arc open, and the
importance of occlusion in regard to vocalization and
mastication should all be considered. For these rea-
sons, Cryer' considered extraction of teeth as an ac-
ceptable solution to malocclusion, in direct contra-
diction to Angle's strict prohibition against extraction
for orthodontic purposes.
Case*^* also criticized Angle's belief that, when the
dentures are placed in normal occlusion and the max-
illary first molars are related properly to the cranium,
the facial outhne will take care of itself Case' said,
"Failure to extract teeth where demanded [by facial
profile considerations] is quite as much malpractice as
the extraction of teeth where not demanded.'" Case
made plaster masks of faces to illustrate facial types
and esthetic concerns. He considered Angle's classi-
fication imprecise. Case's classification divides Class
I into a division 1 with seven subtypes of dental ir-
regularities and a division 2 for facial considerations.
His Class II has a division 1 for cases in which the
mandible is retrusive (with two subtypes) and a divi-
sion 2 for cases in which the maxilla is protrusive (with
four subtypes). His Class III has four divisions that
describe combinations of maxillary retrusions and
mandibular protrtisions. That Angle's classification
remains the standard, while Case's superior effort nev-
er became popular, was an unfortunate result of the
personality cult that surrounded early orthodontic
giants.
In 1915 Van Loon' publisbed criticism of Angle's
classification and proposed an improved technique for
trimming plaster casts. He also oriented casts of teeth
into plaster facial masks so that the true relationship
of the teeth to the soft tissue of the face could be
evaluated.
Dewey,'" an early student of Angle and then fellow
teacher who philosophically parted company with his
mentor, wrote in 1915, "I have great respect for the
first molar as an organ of mastication, and they are
Quintessence International Volume 21, Number 5/1990

Fig 2 Apollo Belvedere, drawn by Angie. (Reprinted from
Angle.')
very necessary in producing normal occlusion, but as
a basis of classification, when taken alone, I have not
mueh respect for them, as they are as liable as any
other teeth to assume an abnormal position under
certain conditions." Dewey'" recommended that clas-
sification be based on the anteroposterior relation of
the arches as a whole rather than only the first molars.
Dewey'" snbclassified Class I into three types, and
Anderson" later added two more.
In 1920 Hellman'-" stated, "In all its simplicity, the
Angle classification does not convey exactly the same
idea to everyone. This is, perhaps, due to the fact that
its definition is not sufficiently accurate," Hellman
illustrated his contention with photographs of casts
about which considerable difference of opinion could
occur regarding their classification. Hellman'^'' stud-
ied comparative anatomy and the evolution of pri-
mitive landmarks of occlusion. He recommended
elimination of the buccal cusp relationship as the focus
of classification. The mesiolingual cusp of the max-
illary first molar occludes in the central fossa of the
mandibular molar. Hellman'^" considered this lingual
eusp to be the only reliable distinguishing feature, be-
cause it was the most primitive landmark of occlusion
still retained by modern man. He observed in a high
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Special Report
Fig 3 Broomeli's skull, known in the dentai literature as
"Old Glory." (Reprinted Irom Angle.')
percentage of malocclusions that the maxillary first
molar had rotated on the longitudinal axis of the lin-
gual cusp, and the buccal cusps had rotated mesially.
The mesially rotated maxillary buccal cusps falsely
indicated a Class II occlusion, while the more "pri-
mitive" maxillary hngual cusp sat in its ideai Class I
position.
What is normal and what is ideal?
Orthodontic practitioners wrestled with the practical
and philosophical tniplications of the concept of ideal
occlusion as a goal in treatment. Johnson,'"' m a series
of lectures delivered at the University of Pennsylvania
and then pubhshed in 1923, pondered this conundrum.
He asked, '-What is nonnal occlusion? Does it [nor-
mal] mean an ideal, a goal to be sought after but never
found?" If normal is synonymous with typical or av-
erage, can normal be taken as a standard because of
a high frequency of occurrence? Or does normal mean
natural? Some believed that teeth moved to normal
occlusion will be stable. If normal is defined as ae-
eording to, or not deviating from, an established
norm, then norm is a rule or authoritative standard.
Normal cannot be synonymous with ideal or natural.
409
Special Report
Stages of occlusion trom threp yeEirs of age to old age, [A]. At ttirce
years of age the triangular ndge of tfie medio-buccal cus]) ol upper
second deciduous molar occlndes in the buccat groove ot tiie lfAVOr
second deciduous molai ¡B) At five and a half years of age ttie tower
arch fias moved forwards, so that the buccal groove of the lower
second deddiious molai is media! to the triangutar ridge of the upper
second deciduous molar. (C), At eight years of^age the lower arch has
moved slightly more forwards in retation to the upper arch. The per-
manent incisors and first permanent molars havt? erupted The point
of tbe aisp of the upper first permanent motar is slightly medial to
the buccal groove of the tower first permanent molar, p). Young adult.
All the permanent teeth are in occtusion. The point of She cusp of the
upper first permanentmolaris opposite the buccat groove of the lower
first permanent molai. (E). Old age. Teeth worn. Lower teeth in more
forward relation to upper teeth. Buccal groove of tower first molar is
madiaf to medio-buccal cusp point of upper fiist motar. Disto-buccal
cusp of upper first molar is in contact with medio-buccal cusp of lower
second molar. Incisors meet edge to edge.
Fig 4 Stages of occlusion trorr 3 years to old age, (Re-
printed from Friel,^'}
since perfection is not the rule in animal organization.
Johnson''' discussed Hellrnan's concept of variation
from normal. He agreed with Helhnan that normal
occlusion, as conceived by dentists to represent 100%
perfection, was a myth.
410
felt that norms cannot be used as treat-
rnent goals, beeause the anatomic variation in size atid
shape of teeth among individuals is so large that
iiorrns cannot distinguish excellent occlusion from
tiialocciusion,
Horowitz and Hixon' considered normal, meaning
typical or usual, not atrccptable as a goal in treatment,
hccause malocclusion is the most typically seen situ-
ation. Ideal occlusion, being very rare in a population
is, in trnth. abnormal. Ideal occlusion is a theoretical
model, a manufactured convenience, not a biologic
reality or necessity.
Further occlusion research
Bennett'" was a precursor of Simon when, in 1912, he
recommended classifying malocclusions in sagittal,
transverse, and vertical planes of space, Bennett,"' an
Englishtnan, developed a classification that also uses
Class I, il, and III, but he divides malocclusions by
etiology rather than morphology.
In the 1920s Simon""'^ of Berlin developed a gna-
thostatic system using an elaborate facehow and
impression-orienting apparatus to create study casts
that were ccphalometrically oriented to the patient's
orbital plane (a line drawn from orbitale perpendic-
uiar to Frankfort horizontal). According to Simon's
law of the canine, the orbital plane is coincident with
the distal third of the maxillary canines, Simon'^""
related the dentition to the craniutn in three dimen-
sions of space: the median sagittal plane (using the
midpalatal raphe) at right angles to the Frankfort hor-
izontal plane, and at right angles to the orbital plane.
While advanced for his time, the complexity of the
equipment and the preeision required to produce ac-
curately oriefited sttidy casts obviated ready accept-
ance of his gnathostatic models. Further research has
proved Simon's law of the canine to be in error, but
his concept of three-dirnensionai orientation of the
dentition to the cranium was a forerunner of modem
day gnathology,
in 1927 Friei""'-' published his stages of occlusion
frorn 3 years of age to old age. He demonstrated not
only numerous changes in the primary dentition,
which Angle did not address, but also the variability
of first molar position in a normal occlusion as it
undergoes its metamorphosis from the transitional
mixed dentition to the worn teeth of old age (Fig 4),
Friel-" -' thus illustrated the difficulty of trying to force
Angle's static ideal on a changing mechanism.
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 Special Report

Aogle answers critics

In 1928 Atigle-- reiterated his befiefthat the rnaxillary

first molar was the most rehable point of reference
from which to compare other teeth, becanse of its
constancy in taking correct position on eruption.
However, Angle acknowledged that the tirst molars
may erupt in modified positions when inflnenced by
the malposition of other teeth, either pnmary or per-
manent, or by the loss or nondevelopment of teeth
anterior to the first molars. Therefore, Angle recom-
mended visuahzing the first molars into their proper
positions relative to the jugal buttress (key ridge) be-
fore classifying the maloccluston {Fig 5). Angle- said,
"Notwithstanding the efforts of the prejudiced and the
superficially informed to disprove them, lhe first per-
manetit molars are now and must continue to be rec-
ognised by all who know the growth, physiology and
mechanics of the denture, as the chief reliance, not
only as a basis for diagnosis, but also as a basis from Fig 5 Turners si<uli. An iliustration ot ideal occlusion. (Re-
which to note changes both favorable and unfavorable printed Irom Angle.')
in the positions of the other teeth throughout the
whole process of treatment and retention." Angle was
not a man given to equivocation or timidity in pre-
senting an inflexible position, even in the face of con-
trary evidence. a relationship between the maxillary first molar and
the cranium. However, by showing that these relation-
ships change with age and among different racial
types, he neutralized Angle's absolutist dogma.
The debate continues
In 1951 Massier-^ remarked that, even when dentists
In 1938 Strang-' felt strongly that the process of clas- are carefully trained, applying Angle's classification
sification should include inclined plane relationships, meets with considerable subjective judgment and dif-
the axial inclination of each tooth, a frontal analysis ferent results with different examiners.
of midline deviations and possible asymmetric con- In ¡954 Stoller" integrated concepts from Angle,
dylar positions, rotations of posterior teeth, and facial Strang, and others. He observed that the mesiobuccal
and skeletal considerations using photographs and ce- cusp of the maxillary first molar should ideally be
phalometric radiographs. In effect, Strang-' advocated slightly distal to the mandibular molar buccal groove,
making a complete diagnosis, using all available rec- contrary to usual practice. Cases in whieh the max-
crds, before deciding on the true classification of a illary mesiobuccal cusp fit exactly in the mandibular
case, rather than basing classification on the dental buccal groove did not exhibit proper interdigitation
occlusion alone. He believed that Angle's reliance on of the premolars and canines. Also, Stoiier-' reiterated
the constancy ofthe maxillary first molars to the cran- Strang's observation that the maxillary first molar
ium led to unreliable classification results. Strang's crown should be tipped mesially (or, expressed another
textbook-'' gave elaborate examples of ten cases and way, that the roots tip distally) in ideal occlusion (Fig
his method for obtaining Angle's classificafion. His 6). This places the distobuccal cusp lower (more oc-
directions required mentally repositioning the first clusally) than the mesiobuccal cusp. Therefore, the
molars to their "proper" locafion using determina- distobuccal cusp of the maxillary first molar should
tions such as ideal axial positions of other teeth, es- rest well down into the embrasure between the man-
pecially canines. The fallacy in this technique, how- dibular first and second molars. StoUer-^ noted that,
ever, lies in the inconsistent application of subjective when the maxillary first molar is not tipped the max-
measures by different clinicians. illary premolars and canines mesh shghtly mesial to
In 1939 Atkinson" defended Angle's hypothesis of the embrasures of the mandibular teeth- The maxillary

Quintessence International Voiume 21, Number 5/1990 411

Special Report
Fig 6a The molars may appear to be in ideal Class 1 oc-
clusion (mesiobuccal cusp ot the maxillary first molar fitting
in the buccal groove ol the mandibular first molar), but the
premolars and canines do not interdigitate properly be-
cause the maxillary first molar is too upright.
canine is, therefore, riding up on the mandibular can-
ine, a situation that causes mandibular anterior col-
lapse in postretention. In addition, Stoller'' thought
that if the maxillary first molar, instead of proper
buccal outset from the second premolar, is rotated
mesiolingually so that its buccal cusps line up with
the premolar, the maxillary molar occupies more space
(because of its trapezoidal shape), and thereby causes
an anterior positioning of all teeth mesial to the max-
illary first molar.
Ricketts and others,-* working with Rocky Moun-
tain Data Systems in the late 1960s, designed a com-
puterized cephalometric analysis that classified mal-
occlusions from a cephalometric radiograph rather
than from casts. Measuring the distance along occlu-
sal plane between the distal surfaces of the mandibular
and maxillary molars, it was determined that in Class
I the mandibular molar is 3 mm forward, in Class 11
the maxillary molar is forward of even, and in Class
i n the mandibular moiar is more than 6 mm forward.
Using the canines as an additional anteroposterior
classification aid, they determined that in Class I the
maxillary canine cusp tip is 2 mm distal to the man-
dibular canine cusp tip, in Class II the maxillary cusp
tip is 1 mm or more forward, and in Class Hi the
maxillary cusp tip is more than 5 mm distal to the
mandibular cusp.
In 1969 Ackerman and Proffit^' acknowledging the
¡imitations of Angle's classification, proposed a new
412
Fig 6b An ideal premolar and canine interdigitation can
be achieved by tipping the crown of the maxiliary first molar
mesially and by placing the mesiobuccal cusp of the max-
iilary first molar slightly distai to the groove of the mandib-
ular first moiar.
classification scheme that combines five descriptive
characteristics for malocclusions: alignment in occlu-
sal view, profile and soft tissue, transverse plane de-
viations (crossbites). sagittal plane deviations (antero-
posterior) using Angle's classification, and vertical
problems of bite depth. The five characteristics can
each be found alone or in overlapping combination
for a total of nine classification groups. This classi-
fication lends itself to computerization.
In 1972 Andrews^" published six keys to normal oc-
clusion. Molar relation was discussed in key 1. First,
the distal surface of the distobuccal cusp of the max-
illary first permanent molar should occlude with the
mesial surface of the mesiobuccal cusp of the man-
dibular second molar. Second, the mesiobuccal cusp
of the maxillary first molar should fall in the groove
between the mesial and middle cusps of the mandib-
ular first molar, as per Angle. Andrews'" thought that
this relationship alone could be insufficient, because
it is possible to have Angle's Class I and to have the
maxillary second premolar not fit properly in the em-
brasure between the mandibular premolar and molar.
Third, the mesiolingual cusp of the maxillary first mo-
lar must be seated in the central fossa of the mandib-
ular first molar. Keys 2 through 6 also contain objec-
tives that must be met for the occlusion to be consid-
ered correct.
In 1973 Arya et al" published a paper that studied
the relationship between the terminal piano of the sec-
Quintessence International Volume 21, Number

ond primary molars and the subsequent occlusion of
llie permanent first molar. In cases in which the per-
manent first molars erupted initially into cusp to cusp
occlusion, 70% became Class I and the remainder
eventually became Class II. Because of the inconsis-
tency of molar occlusion over lime in an individual,
a classification technique that helps bridge the tran-
sition from primary through permanent dentition is
needed.
Graber and Swain'- noted that Angle's classification
fails to separate maiocclusions with analogous antero-
posterior relationships but with other characteristics
that are dissimilar and thus require different treatment
plans. They warned that the tendency to treat mal-
occlusions of the same classification in a similar man-
ner is detrimental to patients who do not have ho-
mologous malocclusions.
Integrating occlusioD to physiology
Graber''-'"' stressed that modern concepts of normal
occlusion require three main areas of health: the oc-
dusal position of teeth in contact, in harmony with
the postural resting position as determined by the
musculature, and the temporomandibular joint mor-
phology. A fourth element could be added: the antero-
posterior development of the maxilla and mandible.
Each of these elements must be healthy, individually
and in combination, for optimal function and com-
fort-
Roth"" stated that form and function are not al-
ways coincidental. Excellent occlusion and morpho-
logic form may not always be in harmony with the
temporomandibular joints. The patient's neuromus-
cuiar protective meehanism could cause him or her to
avoid occluding when interferences are present in the
patient's terminal hinge centric relation path of clo-
sure as dictated by the temporomandibular joint. To
avoid contacting interferences, the mandible slides in-
to a maximal intercuspation, which looks beautiful in
a hand-held set of plaster casts. Unfortunately, the
condyles have translated away from the healthy centric
relation position (condyle most centered and superior)
into an unhealthy position, with the condyles m their
fossae. When the discrepancy between the dictates of
the joint and the dictates of occlusion becomes too
great, muscles go into spasm and it becomes virtually
impossible to find the ideal path of closure and the
offending occlusal interferences. Roth's'' criteria for a
good functional occlusion include proper condylar
and disk position upon closure and movement, even
Quintessence International Volume 21, Number 5/1990
Special Report
occlusal contad bilaterally, holding centric contacts,
harmonious anterior guidance, and posterior clear-
ance on excursions.
Elsasser'* published a numeric classification in 1978.
Using millimeter measurements of incisai overbitc,
overjet, maxillary midline, mandibular midline, right
canine, left canine, right first molar (mesiodistal),
right first molar (buccolingual), left first molar
(mesiodistal), and left first molar (buccolingual),
he developed a ten-number classification. A patient's
malocclusion is compared to the ideal goal of
2200-00-0202.
The enormous challenge involved in developing a
classification method that is "all inclusive" has, so far,
defeated dentistry's greatest minds.
The present and Ihe future
Roth" recommends centric relation recording tech-
niques in conjunction with fully adjustable articula-
tors and detailed facebow transfer methods to obtain
mounted casts that are properly related to the joints.
Clinicians of the 1990s find no fault with the veracity
of his recommendations. However, for many practi-
tioners, economics and the demands of the market-
place make adherence lo Roth's complex methodology
difficult to follow for routine orthodontic treatment.
The challenge of developing more simplified systems
for estabhshing accurate recording of occlusion-
temporomandibular joint interrelationships may rest
with the next generation of dentists.
Koski'^ wrote concerning the difficulty of estabhsh-
ing a diagnostic norm for the dentition, as well as a
therapeutic norm to serve as a basis for treatment. Bui
Koski'^ optimistically noted, "However, the general or-
derliness of nature (naturally allowing for common
variations) and the rather close structural-functional
synchronization of the different parts of an organism
seem to suggest that there may esist certain basic reg-
ularities or norms also within the dento-facial com-
plex, which might be discovered through more system-
atic and diversified effort than heretofore."
We witness at the end of the twentieth century the
recent return of the personality cult and the dogma
of absolutist extraction theory that plagued the early
twentieth century, with Angle against his peers. His-
tory has a way of coming full circle.
One hundred years of occlusion research has ended.
What advances can we expect in the next century? The
search continues.
413
Special Report
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Quintessence International Voiume 21, Number 5/1990