Application of the “Wits” appraisal

A. Jacobson, M.D.S., M.S., Ph.D.

Johannesburg, South Africa

T
he “Wits” appraisal2 is a diagnostic aid which enables the severity of
degree of anteroposterior jaw disharmony to be measured from a lateral cepha-
lometric head film. Briefly, the method entails drawing perpendiculars from
points A and B on the maxilla and mandible, respectively, onto the occlusal
plane. The points of contact of the perpendiculars onto the occlusal plane arc
labeled A0 and BO, respectively (Fig. 1). On average, it was found that in
female normal occlusions points A0 and BO coincided, whereas in males point
BO was located approximately 1 mm. ahead of point AO. The “Wits” reading in
females having a normal occlusion would thus be 0, whereas in males it would
be -1.0 mm.
The ANB angle (the difference between the SNA and SNB angles) is the
most commonly used measurement in appraising horizontal jaw disharmony. The
ANB reading, however, does not take into consideration the relative relationship
of the denture bases to cranial reference planes. The singular advantage of
the “Wits” appraisal is that it overcomes this shortcoming and concomitantly
emphasizes an awareness of this relationship in the over-all interpretation
of a cephalometric analysis.
Various lateral cephalometric head film tracings have been selected to
illustrate this point and to outline a method of application of the “Wits” ap-
praisal.

Application of “Wits” appraisal

Relating jaws to cranial reference planes introduces inherent inconsisten-

cies because of variations in craniofacial physiognomy. Included among these
craniofacial skeletal variations are (1) the anteroposterior spatial relation-
ship of nasion relative to jaws and (2) the rotational effect of the jaws relative
to cranial reference planes.
A high.ANB angle frequently observed in persons with excellent occlusions2
may be attributed to anterior positioning of jaws relative to nasion and/or
clockwise rotational effect (downward tipping of ANS) of the jaws relative
From the Department of Orthodontics, University of the Witwatersrand, Dental
School.

179
180 Jacobson. A?% J. Orthod.
August 1976

Fig. 1. Points A0 and BO are the points of contact of perpendiculars dropped from points
A and B, respectively, onto occlusal plane.

to anterior cranial base (Figs. 2 and 3). Fig. 4 shows an example of a Lengua
Indian with an excellent occlusion but in whom, because of retropositioning
of nasion (short anterior cranial base) and clockwise rotation of the jaws
(high palatal, occlusal, and mandibular plane angles), the ANB reading is
9 degrees. The “Wits” appraisal of -1.0 mm. indicates very mild mandibular
prognathism (probably due to attrition, thereby permitting rotation of the
mandible), which for this population group is norma1.3
In many instances, however, the ANB angle is suspect. The manifest ques-
tion therefore is how to determine whether the ANB angle is reliable or suspect.
In an endeavor to answer the question, it is necessary to ascertain (1) the
relative anteroposterior position of the jaws to nasion and (2) the rotational rela-
tionship of the jaws relative to the anterior cranial base.
Anteroposterior relationship of jaws to nasio,n. At the outset, it should be
pointed out that all cranial reference planes are relative to each other and that
no single plane may be used reliably as a baseline from which to measure all
craniofacial relationships for diagnostic purposes. This was adequately demon-
strated by Nanda and Sassouni,4 who reviewed various cranial reference planes
and revealed the shortcomings of each in five different analyses.
 Applica~tion of “Wits” nppraisd 181

AV. NORMAL CL. III ROTATION CL. 11 ROTATION

ANB 2” AND --5” ANB 8”
‘WITS’ Omm ‘WITS’ Omm ‘WITS’ Omm
Fig. 2. “Average” cranial base (A). The effect of long and short anterior cranial bases on
ANB angle is illustrated in B and C.

AV. NORMAL LONG ANT. CRANIAL SHORT ANT. CRANIAL

BASE (SN) BASE (SN)
Fig. 3. Average “normal” occlusion (A). The effect of anticlockwise and clockwise rota-
tions of jaws relative to anterior cranial base on ANB angle is shown in B and C.
182 Ja#cobson Am. J. Orthod.
August 1976

Fig. 4. Tracing of lateral cephalometric head film of Lengua Indian male with excellent
occlusion. ANB angle is 9 degrees, “Wits” appraisal is -1 mm.

The SNA angle, however, offers a simple method of ascertaining whether

the maxilla is forward or backward relative to nasion. An angle of higher than
82 degrees indicates forward positioning of the upper jaw relative to nasion,
whereas an angle of less that 82 degrees indicates retropositioning of the
maxi11a.5-7
This reading, however, tends to be reliable only when and if the mandibular
plane angle to SN reading approximates 32 degrees. Mandibular plane angles
considerably higher or lower than 32 degrees immediately cause the SNA angle
to be suspect. (In a series of twenty-five male and twenty-three female Caucasians
with excellent occlusions, the mean mandibular plane angles for the sexes were
30.3 degrees [S.D. 5.01 and 29.4 degrees [S.D. 6.41, respectively.3 For conve-
nience, and since the Steiner analysis is so extensively used, a mean mandibular
plane angle of 32 degrees is used.) A high mandibular-plane-angle reading
generally suggests a divergent type of profile. In most of these eases the
anterior cranial base is tipped superiorly in front. This, in effect, reduces the
SNA angle reading, thereby providing specious information, The converse is
true, a particularly low mandibular-plane-angle reading suggests a con-
vergent type of profi1e.l The SNA angle in these cases would be larger than
the average 82 degrees. Therefore, high or low mandibular-plane-angle readings,
 f&&cation of “Wits" appraisal 183

q.&++c$

u
.. ............ ...’ .,... .,..,,,,......... .. .

-=+t *

..... ,,..,,.......
” . . ............
7
Q......
..... “...., ...
-==-+t
...... ........
.......
‘....
-
.. .. 3
. ........... ..
Fig. 5. Palatal
of the palate.
plane
T
Stippled
drawn
line
as a solid
joins anterior nasal
7
line passing
AX
spine
through
to
the most
posterior
radiopaque
nasal spine.
portion
Angular
differences are evident.

usually in execess of 1 standard deviation (6 degrees), causes the SNA reading

to be suspect.
Rotational e#ect of jaws. To determine the extent of clockwise rotation
(downward tipping of ANS) of the jaws relative to anterior cranial base, the
mandibular plane angle is again noted.
A high mandibular plane angle (above 37 degrees) would, in effect, be an
indication of clockwise rotation of the jaws, thereby increasing the ANB
angle (divergent facial type). Reduction of the mandibular plane angle (con-
vergent facial type) will have the opposite effect, namely, reducing the ANB
angle.
In the sample of “normal” occlusions, the degrees of variability of palatal, oc-
clusal, and mandibular planes relative to anterior cranial base (SN) were calcu-
lated (Table I).
The plane exhibiting the greatest coefficient of variability was the palatal
104 Ja.cobson Am. J. Orthod.
Awust 1976

Fig. 6. Tracings illustrating methods of drawing occlusal plane. Solid (concave upward)
line is drawn through points of maximum contact of teeth. Stippled line is plane drawn
joining mesiobuccal cusp of upper first molar to point midway between overlap of upper
and lower incisors. (See text.)

Table I. Relationship of palatal, occlusal, and mandibular planes to SN

Males (N=25) Females (N=23)

Parameter Mean S.D. 1 C.V. Mean S.D. c. v.

SN - Palatal plane 7.4 3.9 0.530 8.4 3.5 0.422

SN - Occlusal plane 13.3 3.9 0.296 14.1 4.5 0.317
SN - Mandibular plane 30.3 5.0 0.166 29.4 6.4 0.219

plane (C. V. males 0.530, females, 0.422), followed by the occlusal plane (C.
V. males 0.296, females 0.317), the least variable being the mandibular plane (C.
V. males 0.166, females 0.219).
The greater degree of variability of palatal and occlusal planes may be
attributed in part to difficulty or inaccuracy in identifying the respective planes.
A line joining anterior nasal spine to posterior nasal spine is not necessarily
representative of the palatal plane. A line passing through the most radiopaque
portion of the palate in a lateral head film would probably more accurately
reflect the plane of the palate. Fig. 5 shows a series of tracings in which a solid
line is drawn through the most radiopaque section of the palate, whereas the
stippled line joins ANS to PNS. The angular differences between these planes
are immediately evident.
 The occlusal plane is likewise difficult to measure accurately, particularly
in adult dentitions in which third molars are present. The occlusal plane is not
flat; rather, it is concave. In more mature dentitions, therefore, the plane oi
maximum intercuspation cannot always be used in that this plane follows a turns
(solid line in Fig. 6). A line joining the mesiobuccal cusp of the upp~ first
molar to a point midway between the overlap of the upper and lower incisors is D
satisfactory method of standardizing occlusal plane measurement in most normal
occlusions (stippled line in Fig. 6, 8). In occlusions with a deep curve of Specl
and in malocclusions with supra- or infra-erupted upper or lower incisors, the
latter method is likewise unsuitable. Probably the most suitable and convenient
method of standardizing the plane of occlusion is to join midpoints of overlalj
of the mesiobuccal cusps of the first molars and the buccal cusps of the first
premolars.

SNA, ANB, reliable or suspect?

In many instances the SNA, SNB, and ANB angles accurately reflect thr
degree of anteroposterior positioning of the jaws in the relationship of the
jaws to each other. There are other instances however in which these angles
are in no way representative of jaw relationship or disharmony. It is here that
the “Wits” appraisal could be conveniently applied and prove clinicall>
useful .
Should the mandibular plane be in excess of or less than 1 standard deviation
of the mean of 32 degrees (+ 5 degrees), the interpretation of an SNA angle of
82 degrees becomes suspect. An angular reading of less than 82 degrees does not,
necessa.rily mean a relatively (to anterior cranial base) recessive maxilla or ric*c
versa.
When the mandibular plane angle reading is in excess of or less than 1
standard deviation of the mean, the ANB angle is likewise suspect. A high
mandibular plane angle reading generally suggests a divergent type of profile,
whereas a low reading usually obtains in the convergent type of profile. The
jaws in a divergent type of profile tend to rotate clockwise (lowering of anterior
part of hard palate), thus increasing the ANB reading. The opposite condition
prevails in the convergent. type of profile; that is, the ANB reading is lowered.
Should the mandibular plane angular reading be within the range of nor-
mality-82 degrees (rt 5)-the SNA angle interpretation is usually reliable.
However, this is not necessarily the case in the interpretation of the ANB angle.
The “Wits” appraisal is a more reliable measure of anteroposterior jaw relation-
ship.
In sum, therefore, a high mandibular-plane reading causes SNA and ANB
readings to be suspect. Mandibular-plane-angle readings within the range of
normality are usually reliable reflections of maxillary position (anteropostrri-
orly) ; that is, SNA is reliable, but ANB is not necessarily so.
Mandibular plane angle high or low - SNA suspect
- ANB suspect
Mandibular plane “normal” - SNA reliable
- ANB not necessarily reliahlr
 186 Jacobson Am. J. Orthod.
August 1976

‘WITS’ lmm

fig. 7. Patient D. M.
“WITS” APPRAISAL

Parameter 1 Ref. Norm 1 Mearure- Interpretation

/ ment 1 SNA Eable SNA qsuspect
Mandibular 32” (-+ 5) 46” High mandibular plane angle; therefore, 79”
plane SNA angle is suspect; ANB of 10.5” like-
SNA 82” (-+ 3.5) 79” wise suspect
ANB 2” p 2) 10.5” “Wits” appraisal of 1 mm. indicates very
“Wits” mild Class II jaw dysplasia in spite of
Male -1 mm. (? 2) 1 mm. high ANB angle (10.5”)
Female 0 mm. (+ 2)

Fig. 8. Patient J. Y.
“WITS” APPRAISAL

Parameter 1 Ref. Norm Measure- Interpretation

ment SNA reliable SNA suspect

El cl
Mandibular 32” (+ 5) 34” Average mandibular plane angle, SNA prob-
plane ably reliable indicating relative forward
SNA 82” (k 3.5) 85.5” positioning of iaws causing ANB reading
ANB 2” (+ 2) 8.5” (8.5”) to be high
“Wits” “Wits” appraisal of 2.5 mm. indicates mild
Male -1 mm. (2 2) jaw disharmony, but not as severe as
Female 0 mm. (* 2) 2.5 mm. ANB of 8.5” would indicate
 Application of ‘Tits” appraisal 187

fig. 9. Patient K. P.
“WITS” APPRAISAL
--
Parameter 1 Ref. Norm Measure- Interpretation
ment SNA reliable SNA suspect

q EJ
Mandibular 32” (+ 5) 37” Mandibular plane fairly high; therefore,
plane SNA of 90” and ANB 10” are suspect;
SNA 82” (It 3.5) 90” maxilla probably forward and relatively
ANB 2” (? 2) 10” rotated
“Wits” Wits” measurement of 2 mm. indicates
Male -1 mm. (+ 2) 2 mm. mild Class II, but not nearly as much as
Female 0 mm. (* 2) ANB of 10” would indicate
-

Fig. 10. Patient A. K.

“WITS” APPRAISAL

Parameter Ref. Norm Measure- Interpretation

ment , SNA reliable SNA suspect

cl lzl
Mandibular 32” (+ 5) 42” High mandibular plane angle; 80” SNA
plane angle therefore suspect; ANB of 1.0” like-
SNA 82” (+ 3.5) 80” wise suspect
ANB 2” (5 2) 1” “Wits” appraisal of -6.5 mm. reflects severe
“Wits” Class III jaw dysplasia in spite of AN8
Male -1 mm. (? 2) measurement of only 1’
Female 0 mm. (t 2) -6.5 mm.
__-
188 Jacobson Am J. Orthod.
Aumst 1976

Fig. 11. Patient I. K.

“WITS” APPRAISAL

Parameter Ref. Norm Measure- Interpretation

merit SNA reliable SNA suspect

lxl Cl
Mandibular 32” (+ 5) 35” Maxilla possibly mildly retropositioned rela-
plane tive to nasion, viz. 79” instead of 82”;
SNA 82” (-c 3.5) 79” AN6 of 2” indicates “normal” jaw rela-
ANB 2” (2 21 2” tionship
“Wits” “Wits” appraisal of -4.5 mm., however,
Male 0 mm. (+ 2) suggests Class III tendency (more reli-
Female -1 mm. (+ 2) -4.5 mm. able-clinically observed)

Application of the “Wits” cppraisal

The following cases show the usefulness of the “Wits” appraisal in assessing
the reliability of the SNA and ANB angles.

Summary

The “Wits” appraisal is intended as a diagnostic aid to be used in conjunction

with other analyses.
Whereas the popularly used ANB angular reading is a simple method of
measuring degree of jaw disharmony, there are many instances in which this
reading is suspect. The “Wits” appraisal permits easy identification of these
Volume 70
Number2

shortcomings and substitutes a reasonably reliable means of measuring extent

of anteroposterior jaw disharmony.
My sincere thanks and appreciation to Mr. Paul Fatti of the Department of Applies1
Mathematics for his invaluable aid and suggestions in computing the statistical data.

REFERENCES
1. Jacobson A., Evans, W. G., Preston, C. R., and Sadowsky, P. L.: Mandibular prognxthisrn,
AM. J. ORTHOD. 66: 140-171, 1974.
2. Jacobson, A.: The “Wits” appraisal of jaw disharmony, AM. J. ORTHOD. 67: 125-138, I97L
3. Jacobson, A., Preston, C. R., Roettner, V., and Perreira, C.: The crania-facial skeletal
pattern of the Lengua Indians of Paraguay. (Submitted for publication in Am. J. Phys.
Anthropol.)
4. Nanda, 8. K., and Sassouni, V.: Planes of reference in rocntgenographia cephalometry,
Angle Orthod. 35: 311-319, 1965.
5. Steiner, Cecil C.: Cephalometrics for you and me, AM. J. ORTHOD. 39: 729-755, 1!)5:L
6. Steiner, Cecil C.: Cephalometrics in clinical practice, Angle Orthod. 29: 8-29, .1959.
7. Steiner, Cecil C.: The use of cephalometrics as an aid to planning and assessing ottho-
dontic treatment, AM. J. ORTHOD. 46: 721.735, 1960.

Probably the community will be best served when every dentist has a working knowledge
of orthodontics whereby he will be able to recognize in their early stages and so to prevent
deformities before they arise, and to treat at any rate the simpler cases when circum-
stances make it desirable and when in every district there is available a specialist to
whom the general practitioner may refer such patients as he may be unwilling or unable
to deal with himself. It will be for the specialist to remain the pioneer and the expert,
and he will be none the worse if his rank be recruited from those of the general practi-
tioner. (Badcock, J .H.: Discussion of President’s Address, Transactions of the First [ 19261
International Orthodontic Congress, St. Louis, 1927, The C. V. Mosby Company, p. 11.)