Journal of the World Federation of Orthodontists xxx (2020) 1e5

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Journal of the World Federation of Orthodontists

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Quantifying changes in incisor inclination before and after

orthodontic treatment in class I, II, and III malocclusions
Chung H. Kau a, *, Konstantinos Bakos b, Ejvis Lamani c
a
Professor and Chairman, Department of Orthodontics, School of Dentistry, University of Alabama at Birmingham, Birmingham, AL
b
Former Resident, Department of Orthodontics, School of Dentistry, University of Alabama at Birmingham, Birmingham, AL
c
Assistant Professor and Director of Research, Department of Orthodontics, School of Dentistry, University of Alabama at Birmingham, Birmingham,
AL

a r t i c l e i n f o a b s t r a c t

Article history: Background: This study was designed to determine if orthodontic treatment significantly changes the
Received 24 June 2020 upper incisor position in Class I, II, and III dental and skeletal malocclusions.
Received in revised form Methods: Ninety nonextraction-treated patients were included in this retrospective cohort study and
2 August 2020
divided into three groups: Class I, Class II, and Class III. All cephalometric measurements (ANB, Wits, U1-
Accepted 4 August 2020
Available online xxx
PP, U1-SN, U1-NA, U1 perpendicular to FH and U1-L1) were taken using the Dolphin Management and
Imaging Software, Version 05.05.5070.221436 (United States and Canada).
Results: The posttreatment values of ANB, Wits appraisal, U1-NA mm, U1-FH mm, IMPA and U1-L1
are
Keywords:
Changes in incisor position
statistically significant (P < 0.05) among the Class I, II, and III when compared with the normal values.
Incisor inclination Also ANB
changes after orthodontic treatment in Class I, II, and III were statistically significant with the
Orthodontic malocclusions greater changes in Class III malocclusion.
Conclusions: There is a significant amount of dento-alveolar compensation for the maxillary incisors not
only in patients with Class II and III but also in Class I malocclusions that underwent nonextraction
treatments.
Ó 2020 World Federation of Orthodontists.

1. Introduction
In orthodontics, the final arrangement of the upper central
incisor is often used as a reference landmark to support the
dentition. This tooth position is not only significant in supporting
the upper lip, but it also is important to the dentition as it relates to
the dynamic smiling [1]. Often, orthodontists use normative values
(mainly cephalometric readings) in trying to position these teeth.
However, once the plan is established, the biomechanical principles
of tooth movement during treatment may or may not bring an ideal
final position of the teeth [2,3].
Incisor angulation plays an important role both in obtaining a
normal occlusion and presenting a facial balance of surrounding
Funding: The authors have not declared a specific grant for this research from
any funding agency in the public, commercial or not-for-profit sectors.
Competing interest: Authors have completed and submitted the ICMJE Form for
Disclosure of potential conflicts of interest.
Provenance and peer review: Not commissioned, Externally peer reviewed.
* Corresponding author: Professor and Chairman, Department of Orthodontics,
School of Dentistry, University of Alabama at Birmingham, 305, 1919 7th Avenue
South, Birmingham, AL 35294.
soft tissues [4]. Changes in arch length can be influenced not only by
inadequate angulation of incisors but also by extractions of teeth for
orthodontic purposes. There has been a continuous debate between
extraction and nonextraction orthodontic treatment, mainly due to
the emphasis placed on esthetics. Most laypersons prefer full facial
profiles, and many orthodontists have been treating according to
the soft tissue paradigm. Konstantonis [5], in a sample of 215
borderline cases based on lower crowding, had four first premolars
extracted in 66 patients (30.6%). By comparing the extraction and
nonextraction groups, this study found that the extraction group
showed a significantly greater lip retraction and a more obtuse
nasiolabial angle (þ5.34 degrees), whereas the incisor display
changes between the two groups was insignificant. In cases with
Class II camouflage treatment, Seben et al. [6] showed that the
greater the overjet to begin with, the greater the upper incisor
retraction and greater the reduction of ANB. However, this study
did not show any significant nasolabial angle changes [6]. Other
studies also have found that patients with extractions are charac-
terized by straight profiles and upright upper incisors with no
detrimental effects on the facial profile [7].
The debate on extraction and nonextraction treatment has existed
for a long time [8,9]; however, no studies to date have described the

2212-4438/$ e see front matter Ó 2020 World Federation of Orthodontists.

https://doi.org/10.1016/j.ejwf.2020.08.002

Please cite this article in press as: Kau CH, et al., Quantifying changes in incisor inclination before and after orthodontic treatment in class I, II,
and III malocclusions, Journal of the World Federation of Orthodontists (2020), https://doi.org/10.1016/j.ejwf.2020.08.002
2 C.H. Kau et al. / Journal of the World Federation of Orthodontists xxx (2020) 1e5

inclination of the anterior teeth during nonextraction treatment on
different skeletal bases. The aim of the current study was to determine
if the upper incisor position changed significantly after orthodontic
treatment in Class I, II, and III dental and skeletal malocclusions.
2. Subjects and methods
Approval for this study was given by University of Alabama
Institutional Review Board and the committee assigned the ethics
protocol number E140214011. Subjects who finished nonextraction
orthodontic treatment to an American Board of Orthodontics
standard were automatically included into the study. Each of these
subjects had to meet the following criteria:
1. All nonextraction cases should be finished in a Class I molar and
cuspid relationship.
2. Normal cusp to fossa/cusp to embrasure position of teeth at
completion of treatment.
3. Normal overjet (1e2 mm) and overbite (1e2 mm), where the
mandibular canines and incisors contact the lingual surfaces of
the maxillary canines and incisors with a normal interincisal
angle.
4. Good quality of cephalometric radiographs before and after
orthodontic treatment.
5. Orthodontic cases that had crowding less than 6 mm and could
be treated nonextraction only.
Furthermore, no patients with significant dento-facial deformity
(3  ANB  þ5) were included in the study. Because ANB is
influenced by the mandibular plane, we excluded all patients with a
mandibular plane angle less than 27
or greater than 37
. To reduce
bias, only consecutive cases were included into the sample. The
average age of the patients was 16 years  5 months for boys and
15 years  8 months for girls.
Our sample consisted of 90 patients with 30 patients in each
Class I, Class II, and Class III malocclusion group. All the orthodontic
cases were treated with upper and lower pre-adjusted edgewise
appliances (0.022  0.028-inch slot) with McLaughlin, Bennet and
Trevisi prescription. A 0.019  0.025 inch stainless steel were used
as final archwire for all the cases. All patients had mild to moderate
dental crowding (not more than 6 mm) with the greatest amount of
crowding presented in Class I malocclusions. All the patients in
Class II and III groups were treated with Class II and III intermax-
illary elastics, respectively. In some Class II cases, Forsus (3M Unitek
Corporation, Monrovia, CA) were used due to poor patient
compliance with elastics.
Based on the initial treatment malocclusions and the pretreat-
ment cephalometric measurements, such as the ANB angles, Wits
appraisals, and the mandibular plane angles, the patients who met
the inclusion/exclusion criteria were organized into three groups:
1. Class I malocclusion with ANB from 0e2
, Wits from 1 to 0
2. Class II malocclusion with ANB >2
and Wits > 1
3. Class III malocclusion with ANB <0
and a Wits <1
An initial search of orthodontic patients who had completed
their treatment was performed using the Dolphin Management and
Imaging Software system database. Almost 1500 patients were
registered to be in the system having Class I, II and III malocclusions
at that time. All the lateral cephalograms were taken using the
Orthopantomograph OP100, Instrumentarium Corp. Imaging Divi-
sion machine (Tuusula, Finland) and traced digitally using the
Dolphin Management and Imaging Software, Version
05.05.5070.221436 (United States and Canada). After applying the
inclusion and exclusion criteria, 90 consecutive completed ortho-
dontic cases were included in the study.
A summary of the cephalometric landmarks and planes used in
the study can be found in Tables 1 and 2. The parameters analyzed
in this study were categorized into skeletal and dental. To evaluate
the skeletal relationships of the jaws with the cranial base, the SNA
and SNB angles were recorded, whereas both the ANB angle and
Wits analysis were used to evaluate the relationship of jaws to each
other. The angle of the mandible in relation to the cranial base and
Frankfort Horizontal Plane, MP, and FMA, respectively, was also
measured. On the other hand, the maxillary and mandibular incisor
positions were evaluated using cephalometric measurements such
as U1-PP (
), U1-SNo, U1-NAo, U1-NA (mm), U1 perpendicular to FH
mm, and U1-L1 (
).
2.1. Statistical analysis
The sample size calculation was performed using the non-
inferiority test based on the standard deviation for U1-SN (
) and
U1-NA (mm), as these showed the highest variability. Based on the
ability to have a noninferiority value of 2, both millimetric and
degrees for U1-NA and 4 degrees for U1-NA and 4 degrees for SN
,
it was deemed that at least 30 individuals were needed in each
group.

Table 1
Comparison of mean difference between pre- and posttreatment cephalometric measurements by occlusion class

Parameters measured Normal Class I Class II Class III P value*

Mean difference from Mean difference from Mean difference from

pretreatment value pretreatment value pretreatment value
ANB(
) 1.6 0.221.05 1.341.30 0.251.96 0.0057
Wits Appraisal (mm) 1 0.552.04 2.032.47 0.302.19 <0.0001
SN-GOGN (
) 33 1.054.05 0.416.98 0.703.52 0.4077
FMA (MP-FH) (
) 25 0.455.19 0.293.44 0.175.52 0.9748
U1-SN(
) 102.3 7.556.65 5.619.78 6.508.62 0.1652
U1-NA (
) 22.8 6.746.90 6.508.62 4.176.86 0.3457
U1-NA (mm) 4.3 1.031.52 1.152.41 1.243.55 0.9527
U1-(per to FH)mm 3.2 0.202.19 0.152.12 3.550.77 0.5424
U1-PP(
) 110 5.947.75 6.557.72 0.9221.87 0.2441
U1-Oc.Pl (
) 57.6 5.565.80 7.526.60 3.487.79 0.0750
L1-APO(mm) 2.7 0.891.78 2.151.33 0.822.53 <0.0001
IMPA (L1-MP) 95 2.498.58 2.955.21 3.437.27 0.0011
U1-L1 (
) 130 5.9714.45 9.1910.03 1.0011.29 0.0344

ANB, A point, nasion, B point; Go, gonial; IMPA, incisor to mandibular plane angle; L1, lower central incisor; MP, mandibular plane; N, nasion; SN, sella nasion; U1, upper central
incisor.
* P value based on analysis of variance.

Please cite this article in press as: Kau CH, et al., Quantifying changes in incisor inclination before and after orthodontic treatment in class I, II,
and III malocclusions, Journal of the World Federation of Orthodontists (2020), https://doi.org/10.1016/j.ejwf.2020.08.002
 C.H. Kau et al. / Journal of the World Federation of Orthodontists xxx (2020) 1e5 3

Table 2
Comparison of mean difference between posttreatment cephalometric measurements with respective normal value by occlusion class

Parameters measured Normal Class I Class II Class III P value*

Mean difference Mean difference Mean difference

from normal from normal from normal
ANB(
) 1.6 0.35  1.10 2.04  1.67 3.00  1.73 <0.0001
Wits Appraisal (mm) 1 0.47  1.91 1.10  2.21 2.86  2.86 <0.0001
SN-GOGN (
) 33 1.09  6.73 0.90  7.36 1.54  6.13 0.3341
FMA (MP-FH) (
) 25 1.24  4.66 0.69  4.57 3.28  6.07 0.1271
U1-SN(
) 102.3 8.45  8.55 3.68  3.68 10.73  7.84 0.0021
U1-NA (
) 22.8 6.87  7.03 1.97  5.64 8.98  5.73 0.0001
U1-NA (mm) 4.3 1.49  1.77 0.84  1.60 2.80  2.73 <0.0001
U1-(per to FH)mm 3.2 2.85  1.92 1.54  1.68 4.27  2.48 <0.0001
U1-PP(
) 110 6.45  5.89 4.66  5.51 6.42  20.72 0.8368
U1-Oc.Pl (
) 57.6 0.92  5.54 1.70  3.72 2.08  5.17 0.6444
(L1-APO) (mm) 2.7 0.05  2.02 0.40  2.08 0.29  2.71 0.5018
IMPA (L1-MP) 95 1.85  7.43 2.65  7.65 11.06  8.60 <0.0001
U1-L1 (
) 130 5.83  9.12 8.58  7.73 1.57  8.82 <0.0001

ANB, A point, nasion, B point; Go, gonial; IMPA, incisor to mandibular plane angle; L1, lower central incisor; MP, mandibular plane; N, nasion; SN, sella nasion; U1, upper central
incisor.
* P value based on analysis of variance.

All the pretreatment and posttreatment lateral cephalograms This study also used a range of 2 mm/degrees of the normal
included in this study were traced by an orthodontic resident (K.B). value to evaluate the incisor arrangements, and determine any
The same lateral cephalograms were traced by one senior ortho- significant differences in their posttreatment positions among
dontist (C.H.K). The interobserver reliability was performed to Classes I, II, and III (Table 3). The Wits values remained within the
determine any random and systematic error in tracing. The intra- range in Class I and II malocclusions, whereas the U1-NA mm fell
observer reliability was determined using the intraclass correlation within this range only in the Class II group. The results also
coefficient statistical analysis. The Shrout-Fleiss reliability score showed that Class III cases had a tendency to show more positive
was used in this study to evaluate intra- and interrater reliability for U1-SN
, U1-NA
, U1-NA mm, and U1-FH mm, followed by Class I
measurements stratified by initial and final values. and Class II, respectively. Although the U1-PP
was not within the
To determine if there is a statistically significant difference for range, it had almost the same mean difference between Class I
the posttreatment position of maxillary incisors among the Class I, and III, but with a high variability in the range of movement of
II, and III, the range of 2 degrees or millimetric of difference was the maxillary incisors positions. The only cephalometric mea-
used and an analysis of variance test was performed. A difference surement that fell within the range of 2 for all three maloc-
beyond that range were considered as a significant difference for clusions is the L1-Apo mm.
the posttreatment position of maxillary incisors position among the The inter- and intraobserver analysis showed reliable mea-
Class I, II, and III malocclusions. surements. The reliability ranged from 0.623 to 1, with most mea-
surements close to 1 (denoting excellent reliability).
3. Results
4. Discussion
A comparison of mean difference between pretreatment (T1)
and posttreatment (T2) measurements was performed to observe To date, few studies of significant sample size have been pub-
the difference in the movement during treatment by malocclusion lished on the use of maxillary incisor position as a reference point in
classification. Negative values indicated a backward movement and diagnosis and treatment of orthodontic patients. Therefore, the goal
positive values indicated forward movement of the maxillary in-
cisors, respectively. As shown in Table 1, significant changes (P <
0.05) were observed in Wits appraisal and lower incisor position
(IMPA and L1-APO).
To show if there is a difference in how far the measurements
were from the normal value by occlusion class, the mean differ-
ences between the posttreatment measurements and normal
values were evaluated (Table 2 and Fig. 1). The posttreatment values
of ANB, Wits appraisal, U1-NA mm, U1-FH mm, IMPA, and U1-L1

show a statistical significance (P < 0.05) among Classes I, II, and III
when compared with the normal values. However, the U1-SN
and
U1-PP
do not show significant differences from the normal values,
with the Class III presenting with the most positive values for the
maxillary incisors, followed by Class I and Class II malocclusions.
These data suggest that there is a significant amount of dento-
alveolar compensation for the maxillary incisors not only in pa-
tients with Class II and III but also in Class I malocclusions that have
been treated with nonextraction. On the other hand, the ANB

changes that happened with orthodontic treatment in Classes I, II,
and III were statistically significant with the greater changes in Fig. 1. Mean difference between posttreatments and normal cephalometric measure-
Class III malocclusion. ments by occlusion class.

Please cite this article in press as: Kau CH, et al., Quantifying changes in incisor inclination before and after orthodontic treatment in class I, II,
and III malocclusions, Journal of the World Federation of Orthodontists (2020), https://doi.org/10.1016/j.ejwf.2020.08.002
4 C.H. Kau et al. / Journal of the World Federation of Orthodontists xxx (2020) 1e5

Table 3
Equivalence tests for posttreatment cephalometric measurement compared with the respective normal value

Parameters Class I Equivalence Class II Equivalence Class III Equivalence

measured Mean difference P value Mean difference P value Mean difference P value
from normal (90% CI) from normal (90% CI) from normal (90% CI)
ANB(
) 0.35 (0.69 to [0.01]) <0.0001 2.04 (1.52 to 2.56) 0.5473 3.00 (3.53 to [2.46]) 0.9982
Wits Appraisal 0.47 (0.24 to 1.19) <0.0001 1.10 (0.42 to 1.79) 0.0171 2.86 (3.50 to [2.23]) 0.9862
(mm)
SN-GOGN (
) 1.09 (3.18 to 0.99) 0.2331 0.90 (1.39 to 3.18) 0.2100 1.54 (3.45 to 0.46) 0.3432
FMA (MP-FH) (
) 1.24 (2.98 to 0.50) 0.1886 0.69 (2.11 to 0.72) 0.0641 3.28 (5.17 to [1.40]) 0.8718
U1-SN(
) 8.45 (5.80 to 11.10) 0.9999 3.68 (1.69 to 5.66) 0.9189 10.73 (8.30 to 13.17) 1.0000
U1-NA (
) 6.87 (4.69 to 9.05) 0.9997 1.97 (0.22 to 3.72) 0.4872 8.98 (7.20 to 10.75) 1.0000
U1-NA (mm) 1.49 (0.94 to 2.04) 0.0641 0.84 (1.33 to [0.34]) 0.0002 2.80 (1.96 to 3.65) 0.9408
U1-(per to FH)mm 2.85 (2.26 to 3.45) 0.9894 1.54 (1.01 to 2.06) 0.0712 4.27 (3.50 to 5.04) 1.0000
U1-PP(
) 6.45 (3.24 to 9.66) 0.9959 4.66 (2.95 to 6.37) 0.9934 6.42 (0.003 to 12.85) 0.8741
U1-Oc.Pl (
) 0.92 (2.64 to 0.80) 0.1464 1.70 (2.86 to [0.54]) 0.3292 2.08 (3.68 to [0.48]) 0.5321
L1 Protrusion 0.05 (0.80 to 0.70) <0.0001 0.40 (0.25 to 1.04) 0.0001 0.29 (1.13 to 0.55) 0.0008
(L1-APO) (mm)
IMPA (L1-MP) 1.85 (4.16 to 0.45) 0.4573 2.65 (0.28 to 5.02) 0.6775 11.06 (13.73 to [8.40]) 1.0000
Interincisal Angle 5.83 (8.66 to [3.00]) 0.9856 8.58 (10.98 to [6.18]) 1.0000 1.57 (1.16 to 4.31) 0.3964
U1-L1 (
)

ANB, A point, nasion, B point; CI, confidence interval; Go, gonial; IMPA, incisor to mandibular plane angle; L1, lower central incisor; MP, mandibular plane; N, nasion; SN, sella
nasion; U1, upper central incisor.

of this retrospective cohort study was to evaluate the posttreatment
values of maxillary incisors and determine the significant difference
in their final position among Class I, II, and III malocclusions.
According to the inclusion/exclusion criteria of this study, 90
subjects were collected from the orthodontic clinic at the University
of Alabama Birmingham. All cases were treated with fixed appli-
ances and according to the standards of American Boards. By using
a range of Sn-Go between 27
and 37
and an ANB
between 3

and 5
, the study had a sample to represent an average range of
orthodontic treatment complexity. In this study the average post-
treatment values of U1-PP
was 116
in both Class I and III, whereas
this angle was 114
for Class II. In comparison with the study of
McLaughlin and Bennett [10] regarding the U1-PP normal value
after orthodontic treatment, the current study showed that there
was an additional difference of 14
in the Class II (114
instead of
100
) and 4
less in the Class III (116
instead of 120
). Furthermore,
this study also displayed an average posttreatment value of 116
for
the U1-PP in the Class I group (similar to that of the Class III). This is
in agreement with other studies in which the average posttreat-
ment value of U1-PP
is between 108
and 117
[11].
In this study, both millimetric and angular cephalometric mea-
surements were used to determine the maxillary incisor position
changes relative to the anteroposterior position of this tooth in
facial complex. It was found that changes in the incisor position
tended to follow the skeletal malocclusion. When the cases were
skeletal Class II, the incisors were upright and when the cases were
Class III, the incisors were flared. This is consistent with clinical
observations.
In the literature, the maxillary incisor position is important
because of its effect on space within the dental arches; there is no
reference measurement available for nonextraction treatment. In
extreme cases, incisor protrusion can produce an ideal alignment of
the teeth instead of severe crowding of teeth, at the expense of lip
competence. This paper represents the first time the incisor posi-
tions have been evaluated based on skeletal and dental malocclu-
sion. However, no perception of smile aesthetics was performed at
this time.
Future studies could attempt to have a more uniform sample
with regard to the amount of crowding presented among Class I, II,
and III malocclusions. It seems that the final position of maxillary
incisors was not only influenced by both their pretreatment posi-
tion and the jaw discrepancy but also by their variability of
crowding among the malocclusions. From the preceding, we could
compare more precisely the final position of maxillary teeth among
the three malocclusions. By relating the data presented in this
study, it may be possible to meet this goal.
5. Conclusions
The following conclusions may be inferred from the study:
1. There is a significant difference in the position of the maxillary
incisors in different malocclusions.
2. The posttreatment measurements such as U1-FH mm, U1-NA
mm, and U1-SN
and U1-NA
present a significance difference
among Class I, II, and III malocclusions. In the Class II, the
maxillary teeth were more upright than Class I and III maloc-
clusions after orthodontic treatment.
3. The U1-PP
showed no significant difference among the mal-
occlusions. In this study, the U1-PP
was the same for Class I
and III.
4. The U1-L1
presented a significant difference among the three
malocclusions, with the greatest amount of reduction in Class II,
followed by Class I malocclusion. On the other hand, this angle
was increased in Class III malocclusions.
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and III malocclusions, Journal of the World Federation of Orthodontists (2020), https://doi.org/10.1016/j.ejwf.2020.08.002
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Please cite this article in press as: Kau CH, et al., Quantifying changes in incisor inclination before and after orthodontic treatment in class I, II,
and III malocclusions, Journal of the World Federation of Orthodontists (2020), https://doi.org/10.1016/j.ejwf.2020.08.002