dentistry journal

Article
Distribution of the Condylion-Gonion-Menton
(CoGoMeˆ) Angle in a Population of Patients from
Southern Italy
Vincenzo D’Antò 1 , Ada Carolina Pango Madariaga 1 , Roberto Rongo 1, *, Rosaria Bucci 1 ,
Vittorio Simeon 2 , Lorenzo Franchi 3,4 and Rosa Valletta 1
1 Department of Neurosciences, Reproductive Sciences and Oral Sciences, Section of Orthodontics, University
of Naples “Federico II”, 80131 Naples, Italy; vincenzo.danto@unina.it (V.D.);
apangom@gmail.com (A.C.P.M.); rosaria.bucci@unina.it (R.B.); valletta@unina.it (R.V.)
2 Department of Mental Health and Preventive Medicine, Medical Statistics Unit, University of Campania
“Luigi Vanvitelli”, 80138 Naples, Italy; vittoriosimeon@gmail.com
3 Department of Experimental and Clinical Medicine, Section of Dentistry, Orthodontics, University of
Florence, 50134 Florence, Italy; lorenzo.franchi@unifi.it
4 Department of Orthodontics and Pediatric Dentistry, School of Dentistry, The University of Michigan, Ann
Arbor, MI 48109, USA
* Correspondence: roberto.rongo@gmail.com; Tel.: +39-390817462192




Received: 13 August 2019; Accepted: 28 October 2019; Published: 3 November 2019


Abstract: The condylion-gonion-menton angle (CoGoMeˆ) is commonly used as a pre-treatment

indicator of responsiveness in Class II patients treated with functional appliances. The distribution
of this angle in the Caucasian population is still unknown. This study aimed to determine the
distribution of the CoGoMeˆ and its relationship with age, sagittal jaw relationship (ANPgˆ), and
mandibular inclination (SNˆGoGn) in patients from Southern Italy. The sample included 290 subjects
(median14 years of age; Interquartile range, IQR, 12–17) with lateral cephalograms taken before the
orthodontic treatment. The distribution of the CoGoMeˆ was assessed with the Shapiro–Wilk test, and
the differences according to the ANPgˆ and the SNˆGoGn were estimated using one-way ANOVA.
Linear regression analysis was performed to evaluate how the CoGoMeˆ varied according to age.
The statistical significance was set at P < 0.05. The results showed that the CoGoMeˆ was normally
distributed (P = 0.290) with a mean value of 127.2◦ ± 7.7◦ . The distribution of the CoGoMeˆ in groups
with different SNˆGoGn angles was significantly different (P < 0.001). These angles showed a positive
association (Beta coefficient B = 0.6; 95% CI: 0.51, 0.67; P < 0.001). In growing patients, the CoGoMeˆ
decreased every year by 0.6◦ (B = −0.6; 95% CI: −1.05, −0.12; P = 0.014). In conclusion, the CoGoMeˆ
was associated with mandibular inclination and could be considered to be a predictor of vertical
growth patterns.

Keywords: craniofacial growth; cephalometric analysis; digital orthodontics; sagittal jaw relationship;
mandibular divergence; orthodontic treatment planning

1. Introduction
The purpose of orthodontic treatment is to achieve an aesthetic improvement and provide
functional occlusion and balanced facial features [1]. A precise diagnosis is essential for choosing the
correct therapy and determining the prognosis adequately. Therefore, orthodontic treatment planning
requires an accurate prediction of the amount and direction of craniofacial development [2–4]. Since
Broadbent [5] introduced lateral cephalometric radiography in 1931, studies on craniofacial growth and
development have increased in number and many researchers have suggested definitions and norms

Dent. J. 2019, 7, 104; doi:10.3390/dj7040104 www.mdpi.com/journal/dentistry

Dent. J. 2019, 7, 104 2 of 10

for the normal occlusion. Hence, radiographic cephalometry has become one of the most important
instruments of clinical and research orthodontics [6].
The appropriate interpretation of any cephalometric analysis requires norms that are calculated
from populations and adjusted according to age, gender, and ethnic group [5,6]. The cephalometric
value norms represent a valuable aid for clinicians to determine the measure of deviations from the
population average, or what is considered “healthy”. Currently, orthodontic patients in clinical practice
range from children to adults and they belong to a variety of ethnic groups; therefore, a wide range of
representative standards would ideally be needed to perform an individualised orthodontic treatment
plan [7,8].
Mandibular growth prediction is a factor of utmost importance in orthodontic/orthopaedic
treatment planning [9]. Indeed, it seems crucially important to identify the mandibular growth pattern
before treatment, as patients with signs of posterior mandibular growth rotation (hyperdivergent
growth pattern) are assumed to be more difficult to treat than those with an anterior mandibular
rotation (hypodivergent growth pattern) [10–12]. The most widely used method for establishing the
jaw growth rotation is cephalometric analysis. Several different analyses have been introduced to
evaluate a patient’s divergency, such as the Ricketts analysis or the Jarabak analysis [13,14].
The SNˆGoGn is a very useful diagnostic parameter to consider before starting an orthodontic
treatment because it evaluates the facial pattern of a subject and it reflects the variability of the
mandibular plane in relation to the anterior cranial base [15].
Another important morphological characteristic of the lower jaw related to the anterior/posterior
rotational growth pattern is the angle formed by the condylar axis (CoGo) and the mandibular base
(GoMe), i.e., the Condylion-Gonion-Menton angle (CoGoMeˆ) [10,11]. Although this angle has been
proposed as a possible predictor of responsiveness during orthopaedic therapies [16], there are no
studies on the distribution of the CoGoMeˆ and its relationship with classical cephalometric vertical
(SNˆGoGn) and sagittal measurements (ANPgˆ).
Finally, ANPgˆ is an angle useful for the sagittal classification of the malocclusion, Class I, Class II,
or Class III skeletal relationship, and it is formed by the NA (Nasion-point A line) line through N and
A and the NPg (Nasion-Pogonion line) line through N and Pg.
Therefore, the aim of this study was to determine the distribution of the CoGoMeˆ and its
relationship with age, sagittal jaw relationship (ANPgˆ), and mandibular inclination (SNˆGoGn) in
a population of patients from Southern Italy. The null hypothesis was that there is no relationship
between the CoGoMeˆ and the SNˆGoGn.

2. Materials and Methods

This research protocol was approved by the Ethics Committee of the University of Naples Federico
II (121/19; 18 March 2019).
For this retrospective study, the lateral cephalograms of patients, treated at the Section of
Orthodontics at the University of Naples Federico II, were screened. Due to the retrospective design
of the study, it was not possible to obtain the informed consent from all the participants, however,
before orthodontic treatment, all patients provided authorization to use their clinical records for
research purposes.
The lateral cephalograms were selected based on the following inclusion criteria:

• age ≥8
• a good quality lateral x-ray

The following conditions were considered as exclusion criteria:

• patients with systemic diseases

• patients with genetic syndromes
• previous orthodontic treatment
Dent. J. 2019, 7, 104 3 of 10

All the lateral radiographs were taken before the orthodontic treatment in natural head
position [17,18]. One operator traced all lateral cephalograms with a cephalometric software program
(Dolphin, Chatsworth, CA, USA).
For this study, the cephalometric analysis was performed as shown in Figure 1a,b. Briefly, three
cephalometric variables were assessed: the CoGoMeˆ measured the mandibular structure, which is
the angle between the condylar axis (Condylion-Gonion) and the mandibular base (Gonion-Menton);
the SNˆGoGn determined jaw divergence, which is the angle between the anterior cranial base
(Sella-Nasion)
Dent. J. 2019, 7, 104and the mandibular plane (Gonion-Gnathion); and the ANPgˆ assessed sagittal jaw
3 of 10
discrepancy, which is the angle between the Nasion-point A line and the Nasion-Pogonion line [19].
The sagittal
All the malocclusion
lateral radiographswaswere classified into three
taken before groups according
the orthodontic to the
treatment inANPgˆ: Class position
natural head III with
an ANPgˆ equal to or less than −1 ◦ ◦ ◦
−1 and 5 , and
[17,18]. One operator traced all ,lateral
Class I cephalograms
with an ANPgˆwithbetween
a cephalometric Class IIprogram
software with an
ANPgˆ equal to or greater than 5◦ . Similarly, the sample was divided into three groups according to
(Dolphin, Chatsworth, CA, USA).
their vertical
For thismalocclusion: hypodivergent
study, the cephalometric with an
analysis wasSNˆGoGn equal
performed to or less
as shown in than
Figure27◦1a,b.
, normodivergent
Briefly, three
with an SNˆGoGn between ◦
27 assessed: ◦
and 37 , and
cephalometric variables were the hyperdivergent
CoGoMe^ measuredwith athe
SNˆGoGn
mandibularequalstructure,
to or greater
whichthan
is
37 ◦ , as seen Figure 2a–c.
the angle between the condylar axis (Condylion-Gonion) and the mandibular base (Gonion-Menton);
the SN^GoGn determined jaw divergence, which is the angle between the anterior cranial base (Sella-
Statistical Analysis
Nasion) and the mandibular plane (Gonion-Gnathion); and the ANPg^ assessed sagittal jaw
discrepancy, which is
The Dahlberg’s the angle
formula [20]between
and thethe Nasion-point
paired Student’s A linewith
t-test and the Nasion-Pogonion (P <
line [19].
type I error set at 0.05
The sagittal
0.05) were used tomalocclusion was classified
assess the method into three
of error. Hence, 101groups
randomlyaccording
selectedtolateral
the ANPg^: Class IIIwere
cephalograms with
an ANPg^ by
reassessed equal
the to
sameor less than −1°,
examiner Class
after I with an
a memory ANPg^period
washout between
of at−1° and8 5°,
least and Class II with an
weeks.
ANPg^ equal to variables
Categorical or greaterwere
than reported
5°. Similarly, the sampleand
as frequencies waspercentages,
divided into andthreecontinuous
groups according
variablesto
their reported
were verticalasmalocclusion: hypodivergent
means and standard with
deviations if an distribution
the data SN^GoGn was equal to or
normal less
or as than and
medians 27°,
normodivergent
interquartile rangewith andata
if the SN^GoGn
showed between
a skewed27°distribution.
and 37°, andThehyperdivergent
Shapiro–Wilkwith (SW)a SN^GoGn equal
test was used to
to or greater
evaluate than 37°,
normality as seen Figure 2a–c.
assumption.

(a)

Figure 1. Cont.
 Dent. J. 2019, 7, 104 4 of 10
nt. J. J.
Dent.
Dent. 2019,
J.
2019,7, 7,
2019,1047,
104104 Dent. J. 2019,
Dent. 7, 104
J. 2019, 7, 104 4 4of4of10
of1010 4 of4 10
of 10

(b)(b)
(b) (b)(b)

Figure
Figure 1.1.(a)
Figure Cephalometric
1.(a)(a)
CephalometricFigure
Cephalometric Figure
Figure 1. (a)
analysis
analysis
1. (a) Cephalometric
1. (a)
analysis Cephalometric
andand landmarks.
and
Cephalometric analysis
landmarks.
landmarks. analysis and
Landmarks:
analysis and
Landmarks:
Landmarks:
and landmarks.
Alandmarks.
A(Point
landmarks.A(Point
(Point Landmarks:
A),A),Landmarks:
most
A), most
Landmarks: AA
posterior
most (Point
A(Point
posterior
posterior (Point
pointA),A),
point
point ofmost
A), most
of
ofmost posterior
posteriorpoint
posterior of of
point
point
the
thefrontal
thefrontal concavity
frontal concavity
concavity ofthe
ofofthefrontal
the
ofthe
the frontalconcavity
maxillary
the concavity
maxillary
maxillary
frontal between of
between
between
concavity the
of
ofthemaxillary
the
the maxillary
anterior
the anterior
anterior
maxillary between
nasal between
nasal
nasal spine
between the
spine
spine andanterior
the
and
the anterior
the
and the
anterior nasal
nasal
alveolar
the spine
spine
nasalprocesses;
alveolar
alveolar and
processes;
spine the
and
andNthe
processes; alveolar
the processes;
alveolar
NNalveolar processes; NN
processes;
(Nasion),
(Nasion),
(Nasion), most
most anterior
most anterior(Nasion),
anterior (Nasion),
point point
point
N (Nasion), mostmost
ofofthe
ofthe
most anterior
anterior
junction
the junction
junction
anterior point
point
ofofthe
ofthe
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the nasal
of the junction
the
and junction
andandfrontal
junction of
frontal
frontal the
ofofbone nasal
the
bone
bone
the nasal and and
(frontonasal
nasal frontal
(frontonasal
(frontonasal
and frontal bone
suture);
frontal bone
suture);
suture);
bone (frontonasal
S (frontonasal
S(frontonasal
S suture);
suture); S S
suture);
S
(Sella),
(Sella),centre
(Sella), centre
centre ofofthe
ofthe (Sella),
(Sella),
hypophyseal
the hypophyseal
(Sella), centre
hypophyseal centre
centre of
fossa;
of the
ofGo
fossa;
fossa;
the hypophyseal
the
Go hypophyseal
(Gonion),
Go (Gonion),
(Gonion),
hypophyseal fossa;
fossa;
midpoint
midpoint
midpoint
fossa; Goof
Go Go(Gonion),
of(Gonion),
ofthe the
(Gonion), curvature
the midpoint
curvature
curvature midpoint
midpoint atatthe of
atthe
of the
of
angle
the curvature
the
angle
angle
the ofcurvature
ofthe
ofthe
curvature the at the
at the angle
at the
angle of the
angle
of the
of the
mandible;
mandible;
mandible; Co Co (Condylion)
Co mandible;
(Condylion)
(Condylion) mandible;
the the
the Co Co
highest (Condylion)
highest
highest (Condylion)
andand most
and the
most
most highest
the
posterior highest
posterior
posterior and
point and
point
point most
on onmost
the
on posterior
the posterior
contour
the
mandible; Co (Condylion) the highest and most posterior point on the contour of the mandibular contour
contour point
of point
ofthe
oftheon the
on
mandibular
the contour
the
mandibular
mandibular contour of the
of mandibular
the mandibular
condyle;
condyle;
condyle; PgPgPg(pogonion),
(pogonion),
(pogonion), condyle;
condyle;
the
condyle; the most
the Pg
most
most
Pg (pogonion),
Pg (pogonion),
anterior
anterior
anterior
(pogonion), point theof
the
point
point
the most
ofthe
most most
ofthe anterior
anterior
symphysis;
the symphysis;
symphysis;
anterior point
point point
Gn Gn of the
of
(Anatomical
ofGn symphysis;
the symphysis;
(Anatomical
(Anatomical
the symphysis; GnGn
gnathion), Gn(Anatomical
gnathion),
gnathion), (Anatomical
point gnathion),
point gnathion),
point
(Anatomical gnathion),point
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of
ofofof
the
the mandibular
the mandibular
mandibular of the
symphysis
symphysis
symphysis
the mandibular
ofmandibular
the mandibular
onononthethe symphysis
facial
the facial
symphysis symphysis
facialaxis;
axis;
axis;
on and
the on
and
and the
on
MeMe
facial the
Me facial
facial
(Menton), axis;
(Menton),
(Menton),
axis; and Me axis;and
most and
most
most Me Me(Menton),
inferior
(Menton), (Menton),
inferior
inferiormostpointpoint
point most
ofofof
inferior most
thethe
pointinferior
theinferior point of
of the mandibularthe
point of the
mandibular
mandibular
mandibular symphysis.
symphysis.
symphysis. mandibular
mandibular
(b)(b)
symphysis. Reference:
(b) symphysis.
Reference:
Reference:
(b) symphysis.
NA NA NA
Reference: (b)(b)
Reference:
(Nasion-point Reference:
(Nasion-point
(Nasion-point
NA NA
AAline)
A NA
line)
(Nasion-point (Nasion-point
line
line) (Nasion-point
lineAthrough
line through
through
line) NN
line Aand
Nline)
Aand
and A;A;
through line
line) NPg through
line
A;NPg
N NPg through
(Nasion-
and N and
(Nasion-
(Nasion-
A; NPg A; A;
NPg (Nasion-
N(Nasion-Pogonion
and NPg (Nasion-
Pogonion
Pogonion
Pogonion line)
line) line
line) line Pogonion
Pogonion
through
line through
line) line N
through line)
N
throughline)
and
N and line
andPg; line
NPg; through
Pg;
andSN through
SNSN N(Sella-Nasion
(Sella-Nasion
Pg; Nandand
(Sella-Nasion
(Sella-Nasion
SN Pg; Pg;
line) SN
line)
line) SN (Sella-Nasion
line
line
line) (Sella-Nasion
through
line through
through
line through S Sline)
and line)
SSand
andline
N;N;line
N; through
GoGn
N; through
GoGn
GoGn S and
S and
(MandibularN; N;GoGn
GoGn
plane)
(Mandibular
(Mandibular
(Mandibular plane)
plane)
plane) line(Mandibular
line
line (Mandibular
through
line through
through
through Go Goplane)
Goand
Go plane)
and
and Gn;
and line
Gn;Gn;
Gn; through
line
CoGo through
CoGo
CoGo
CoGo Go
(condylar and
Go
(condylar
(condylar
(condylar andGn;
axis)
axis)Gn;
axis) CoGo
line
axis) CoGo
line (condylar
through
line
line (condylar
through
through
through CoCo axis)
and
Co
Co and
andGo;
and line
axis)
Go; and
Go; through
line
and
andthrough
GoMe Co and
Co Go;
and and
Go;
GoMe (Mandibular base)
GoMe GoMe
and GoMe
(Mandibular
(Mandibular
(Mandibular base)
base) line
base) (Mandibular
line
line (Mandibular
through
through
through Go Go base)
and
Go base)
and line
Me.
and Me.Me. through
line through Go
SN^GoGn, andand
Go
SN^GoGn,
SN^GoGn,
SNˆGoGn, Me.Me. SN^GoGn,
SN^GoGn,
CoGoMe^,
CoGoMe^,
CoGoMe^,
CoGoMeˆ, CoGoMe^,
ANPg^. CoGoMe^,
ANPg^.
ANPg^.
ANPgˆ. ANPg^.
ANPg^.

(a) (a)
(a) (a)(a) (b)(b)
(b) (b)(b)

Figure 2. Cont.
Dent. J. 2019, 7, 104 5 of 10
Dent. J. 2019, 7, 104 5 of 10

(c)
Figure
Figure 2. 2.(a,b)
(a,b)Hypodivergent
Hypodivergentand andhyperdivergent
hyperdivergentpatients
patientsaccording
accordingtotoSNˆGoGn;
SN^GoGn;and
and(c)(c)
Normodivergent
Normodivergent patient
patient according
according to SN^GoGn.
to SNˆGoGn.

2.1.The
Statistical
PearsonAnalysis
correlation analysis was used to assess the relationship between continuous variables,
when requested.
The Dahlberg’s formula [20] and the paired Student’s t-test with the type I error set at 0.05 (P <
Differences in the CoGoMeˆ among individuals with different ANPgˆ and SNˆGoGn were estimated,
0.05) were used to assess the method of error. Hence, 101 randomly selected lateral cephalograms
as appropriate, by using one-way Analysis of Variance (ANOVA).
were reassessed by the same examiner after a memory washout period of at least 8 weeks.
Linear regression analysis was performed to evaluate (1) how the CoGoMeˆ (used as a dependent
Categorical variables were reported as frequencies and percentages, and continuous variables
variable) changed according to age and (2) how the CoGoMeˆ (used as an independent variable and
were reported as means and standard deviations if the data distribution was normal or as medians
adjusted for age) was able to predict the SNˆGoGn. For the first issue, two models for linear regression
and interquartile range if the data showed a skewed distribution. The Shapiro–Wilk (SW) test was
analysis were performed. One model included growing patients younger than 17 years of age and the
used to evaluate normality assumption.
other included patients aged 17 years of age and older. Beta coefficients and 95% confidence intervals
The Pearson correlation analysis was used to assess the relationship between continuous
were calculated.
variables, when requested.
The level of statistical significance was set at P < 0.05. Statistical analysis was performed using
Differences in the CoGoMe^ among individuals with different ANPg^ and SN^GoGn were
STATA version 14.0 (StataCorp LP, Stata Statistical Software, College Station, TX, USA).
estimated, as appropriate, by using one-way Analysis of Variance (ANOVA).
Linear regression analysis was performed to evaluate (1) how the CoGoMe^ (used as a
3. Results
dependent variable) changed according to age and (2) how the CoGoMe^ (used as an independent
The sample
variable includedfor
and adjusted 290 subjects:
age) 122to
was able males (42.1%)
predict and 168 females
the SN^GoGn. For the(57.9%), agedtwo
first issue, 8 to models
53 yearsfor
(median 14; Interquartile range IQR 12–17).
linear regression analysis were performed. One model included growing patients younger than 17
older.=Beta
0.4◦coefficients = 0.995%
Theofmethod ◦,
years age anderror for the
the other three angles
included assessed
patients aged 17in years
the study was
of age andANPgˆ , SNˆGoGn and
and = 1.3 , and
CoGoMeˆintervals
confidence
◦ there
were were no systematic errors for any measurements (P > 0.05).
calculated.
In The
the total sample of 290 patients,
level of statistical significance thewas
CoGoMeˆ
set at Pwas normally
< 0.05. distributed
Statistical analysis (SW
was test, P = 0.290),
performed using
with a mean value of 127.2 ◦ ± 7.7◦ , as seen in Table 1 and Figure 3. The ANPgˆ and the SNGoGnˆ
STATA version 14.0 (StataCorp LP, Stata Statistical Software, College Station, TX, USA).
presented a mean value of 2.6◦ ± 3.2◦ and 31.9◦ ± 6.8◦ , respectively (Table 1).
3. Results
Table 1. Cephalometric values in the study sample.
The sample included 290 subjects: 122 males (42.1%) and 168 females (57.9%), aged 8 to 53 years
Variablesrange IQR
(median 14; Interquartile Mean
12–17). Median Standard Deviation
◦ 2.9◦in the study was3.2 ◦
The method error
ANPgˆfor the three2.6
angles assessed ANPg^ = 0.4°, SN^GoGn = 0.9°,
SNˆGoGn 31.9 ◦ 32 ◦ 6.8 ◦
and CoGoMe^ = 1.3°, and there were no systematic errors for any measurements (P > 0.05).
CoGoMeˆ 127.2◦ 127.5◦ ◦
In the total sample of 290 patients, the CoGoMe^ was normally7.7distributed (SW test, P = 0.290),
with a mean value of 127.2° ± 7.7°, as seen in Table 1 and Figure 3. The ANPg^ and the SNGoGn^
presented a mean value of 2.6° ± 3.2° and 31.9° ± 6.8°, respectively (Table 1).

Table 1. Cephalometric values in the study sample.

Variables Mean Median Standard Deviation

Dent. J. 2019, 7, 104 6 of 10

ANPg^ 2.6° 2.9° 3.2°

SN^GoGn 31.9° 32° 6.8°
Dent. J. 2019, 7, 104 CoGoMe^ 127.2° 127.5° 7.7° 6 of 10

Figure 3.
Figure 3. Graph
Graph describing
describing the
thedistribution
distributionofofthe
theCoGoMeˆ
CoGoMe^inin the
the study
study population
population = 290;
(N(N = 290; ±
mean
mean
SD = =127.2
± SD ◦ ± 7.7◦ [CI 95% 112.1◦ –142.3◦ ]).
127.2° ± 7.7° [CI 95% 112.1°–142.3°]).

After
After dividing
dividing the
the sample into three
sample into three groups
groups according
according to to the
the ANPg^,
ANPgˆ, the
the CoGoMeˆ
CoGoMe^ showed
showed no
no
statistically significant difference (P = 0.560). In particular, Class III (ANPgˆ ≤−1 ◦ ) included 32 patients
statistically significant difference (P = 0.560). In particular, Class III (ANPg^ ≤−1°) included 32 patients
◦ ◦ ◦ < ANPgˆ <5◦ ) included 196 patients and
and
and showed
showed aa mean
mean CoGoMeˆ 128.59°±±7.8
CoGoMe^ofof128.59 7.8°;; Class
ClassII(−1
(−1°< ANPg^ <5°) included 196 patients and
◦ ◦ ◦
presented
presented aa mean
mean CoGoMeˆ
CoGoMe^ of 127.09° ±± 7.8
of 127.09 7.8°;; and
and Class
Class II (ANPg^ ≥5
II (ANPgˆ ≥5°)) included
included 62 62 patients
patients and
and
showed a mean CoGoMeˆ of 126.9 ◦ ± 7.2 ◦ , as seen in Table 2.
showed a mean CoGoMe^ of 126.9° ± 7.2°, as seen in Table 2.
When the sample was divided into three groups according to the SN^GoGn, a statistically
Table 2. Distribution of the CoGoMeˆ according to the ANPgˆ and the SNˆGoGn. Differences in
significant difference in the CoGoMe^ was observed (P < 0.001). In particular, 60 patients were
CoGoMeˆ among individuals with different ANPgˆ and SNˆGoGn were estimated as appropriate using
hypodivergent (SN^GoGn <27) and presented a mean CoGoMe^ of 120.1° ± 6.63°; 166 patients were
one-way ANOVA. Bold text indicates statistically significant differences.
normodivergent (27≤ SN^GoGn ≤37) and presented a mean CoGoMe^ of 127.1° ± 6.11°; and 64
patients were hyperdivergent
Variables (SN^GoGn >37)NandMean
Groups presented
Sd a mean
P50 CoGoMe^
P25 of 134.02°
P75 ± 6.18°, as
ANOVA
shownANPgˆ
in Table 2 and Figure 4.
Class III (≤−1◦ ) 32 128.59◦ 7.8◦ 129.2◦ 123.65◦ 133.5◦
Class I (−1◦ < x <5◦ ) 196 127.09◦ 7.8◦ 127.4◦ 122.45◦ 132.85◦ F(2, 287) = 0.58,
Table 2. Distribution Class
of theII CoGoMe^
(≥5◦ ) according
62 to the
126.9 ◦ ANPg^
7.2◦ and◦ the121.8
125.9 SN^GoGn.
◦ 130.8◦ Differences
P = 0.56
in
CoGoMe^
SNˆGoGn among individuals with different ANPg^ and SN^GoGn were estimated as appropriate
Hypodivergent (≤27 ◦) 60 120.1◦ significant
6.63◦ 120.4 ◦ 102.5◦ 134◦
using one-way ANOVA. Bold text indicates statistically differences. F (2, 287) =
Normodivergent (27 < x <37 )
◦ ◦ 166 127.1 ◦ 6.11◦ 127.1 ◦ 110.2◦ 143.8◦
◦ ◦ ◦ ◦ ◦ ◦ 77.04, P < 0.001
Variables Hyperdivergent (≥37N)
Groups Mean64 134.02
Sd 6.18
P50 133.7
P25 121.7 P75 156.5 ANOVA
ANPg^
Class III (≤−1°) 32 128.59° 7.8° 129.2° 123.65° 133.5°
When the Class
sample was
I (−1°< divided196
x <5°) into 127.09°
three groups
7.8° according
127.4° to the
122.45° SNˆGoGn, a statistically
132.85°
F(2, 287) = 0.58, P = 0.56
significant difference
Classin the CoGoMeˆ
II (≥5°) 62 was observed
126.9° < 0.001).
7.2° (P125.9° 121.8°In particular,
130.8° 60 patients were
SN^GoGn
hypodivergent (SNˆGoGn <27) and presented a mean CoGoMeˆ of 120.1◦ ± 6.63◦ ; 166 patients were
Hypodivergent (≤27°) 60 120.1° 6.63° 120.4° 102.5° 134°◦
normodivergent (27≤ SNˆGoGn ≤37) and presented a mean CoGoMeˆ of 127.1 ± 6.11◦ ; and 64 patients
Normodivergent (27°< x F(2, 287) = 77.04, P <
were hyperdivergent (SNˆGoGn
<37°) >37) 166 127.1°
and presented 6.11° 127.1°
a mean CoGoMeˆ 143.8° ◦ ± 6.18◦ , as shown in
110.2° of 134.02
0.001
Table 2 and Figure 4.
Hyperdivergent (≥37°) 64 134.02° 6.18° 133.7° 121.7° 156.5°
Dent.
Dent. J.J. 2019,
2019, 7,
7, 104
104 77 of
of 10
10

ANPg^ SN^GoGn

Figure 4. Box-and-whiskers plots (upper panel) of the CoGoMe angle by ANPgˆ and SNˆGoGn. Line in
Figure 4. Box-and-whiskers plots (upper panel) of the CoGoMe angle by ANPg^ and SN^GoGn. Line
the box: median value. Box hinges: 25th–75th percentiles; ends of the segments: 5th–95th percentiles;
in the box: median value. Box hinges: 25th–75th percentiles; ends of the segments: 5th–95th
and dots: outliers. Histograms with kernel distribution (lower panel) were presented to describe
percentiles; and dots: outliers. Histograms with kernel distribution (lower panel) were presented to
ANPgˆ and SNˆGoGn variables. Cut-off values were highlighted with dashed line (−1 and 5).
describe ANPg^ and SN^GoGn variables. Cut-off values were highlighted with dashed line (−1 and
5). correlation between the CoGoMeˆ and the SNˆGoGn was moderate (Pearson’s r, r = 0.6,
The
P < 0.0001). On the other hand, the correlation between the CoGoMeˆ and the ANPgˆ was absent
The correlation between the CoGoMe^ and the SN^GoGn was moderate (Pearson’s r, r = 0.6, P <
(r = −0.02, P = 0.74), while a weak correlation was observed between the SNˆGoGn and the ANPgˆ (r =
0.0001). On the other hand, the correlation between the CoGoMe^ and the ANPg^ was absent (r =
0.21, P = 0.0003).
−0.02, P = 0.74), while a weak correlation was observed between the SN^GoGn and the ANPg^ (r =
In the linear regression analysis performed on patients under 17 years of age (N = 210), a clear
0.21, P = 0.0003).
decrease of the CoGoMeˆ during growth was observed (beta coefficient, B = −0.6; 95% CI: −1.05, −0.12;
In the linear regression analysis performed on patients under 17 years of age (N = 210), a clear
P = 0.014), as shown in Table 3. However, in the liner regression performed on subjects older than 17
decrease of the CoGoMe^ during growth was observed (beta coefficient, B = −0.6; 95% CI: −1.05, −0.12;
years of age (N = 80), this association disappeared and the angle remained stable over time (B = 0.004;
P = 0.014), as shown in Table 3. However, in the liner regression performed on subjects older than 17
95% CI: −0.31, 0.32; P = 0.98), as seen in Table 3.
years of age (N = 80), this association disappeared and the angle remained stable over time (B = 0.004;
95% Table
CI: −0.31, 0.32; P = 0.98),
3. Distribution asCoGoMeˆ
of the seen in Table 3. to the ANPgˆ and the SNˆGoGn. Differences in
according
Finally, the results of the regression model
CoGoMeˆ among individuals with different ANPgˆ and with the SN^GoGn
SNˆGoGn as the
were estimated dependentusing
as appropriate variable
reported thatANOVA.
one-way each degree
Bold of increase
text indicatesinstatistically
the CoGoMe^ resulted
significant in an increase in the SN^GoGn by 0.6°
associations.
(B = 0.6; 95% CI: 0.51, 0.67; P < 0.001, Table 3).
Models B CI 95% P
Table
1 3. Distribution
CoGoMeˆ/Agedof the CoGoMe^
younger than 17 years (Nto= the
according 210)ANPg^
−0.6and the SN^GoGn.
−1.05, −0.12 Differences
0.014 in
2 CoGoMeˆ/Aged 17 years and older (N = 80) 0.004 −0.31, −0.32
CoGoMe^ among individuals with different ANPg^ and SN^GoGn were estimated as appropriate 0.98
3 SNˆGoGn/CoGoMeˆ*Age (N = 290) 0.6 0.51,
using one-way ANOVA. Bold text indicates statistically significant associations.0.67 <0.001

Models B CI 95% P
Finally, the 1results of the regression
CoGoMe^/Aged younger model with(N
than 17 years the= 210)
SNˆGoGn−0.6 as −1.05,
the dependent
−0.12 variable reported
0.014
that each degree2 of increase
CoGoMe^/Aged 17 years andresulted
in the CoGoMeˆ older (N =in
80)an increase
0.004 in −0.31,
the−0.32 0.98 by 0.6◦ (B = 0.6;
SNˆGoGn
3 SN^GoGn/ CoGoMe^*Age (N = 290) 0.6 0.51, 0.67 <0.001
95% CI: 0.51, 0.67; P < 0.001, Table 3).

4. Discussion
4.
Theaim
The aimofofthis
this study
study waswas to determine
to determine the distribution
the distribution of theof the CoGoMe^
CoGoMeˆ in a population
in a population of
of patients
patients from Southern Italy and to assess the association of this mandibular angle with vertical
from Southern Italy and to assess the association of this mandibular angle with vertical and sagittal and
sagittal cephalometric parameters. The results showed that the CoGoMe^ was normally distributed
Dent. J. 2019, 7, 104 8 of 10

cephalometric parameters. The results showed that the CoGoMeˆ was normally distributed in the
studied population, and it was correlated to the vertical facial type (SNˆGoGn). However, it was not
influenced by the anteroposterior jaw relationship (ANPgˆ).
Our study is the first to report a strong association between the CoGoMeˆ and the SNˆGoGn,
with these two angles positively correlated. Indeed, each degree of increase of the CoGoMeˆ resulted
in an increase of the SNˆGoGn by 0.6◦ . Moreover, the mean value of the CoGoMeˆ was statistically
significantly different according to the identified subgroups of the SNˆGoGn. Hence, the CoGoMeˆ
could help to identify mandibular growth patterns, and therefore clinicians are suggested to consider
this variable carefully at the beginning of the orthodontic therapy. Indeed, CoGoMeˆ might be useful
to understand the mandibular rotational pattern, giving more accurate information than the SNˆGoGn,
that is influenced also by the inclination of the anterior cranial base [15]. The CoGoMeˆ is a variable
related only to mandibular structure (condylar axis and mandibular base), hence its evaluation is not
affected by any other external structures. This strong correlation between CoGoMeˆ and SNˆGoGn
is related both to an anatomical consideration—both angles evaluate the mandibular base—and to
functional consideration—usually hyperdivergent patients have a lower muscles thickness and a lower
bite force—that might have less control on the vertical growth pattern [21,22].
In the current study, the CoGoMeˆ decreased with growth up to 17 years of age. Björk and
co-workers [23,24] studied mandibular rotation and distinguished 2 types of rotation, internal and
external, by superficial remodelling. From the age of 4 years to adulthood, the internal rotation is about
15◦ forward, while the external rotation is about 11◦ /12◦ backward, producing a 3◦ /4◦ total decrease of
the mandibular angle during growth [23,24]. Hence, the natural backward rotation of the mandible
during growth might be responsible for the reduction of the CoGoMeˆ observed in the current study.
This study included patients equal to or older than 8 years old because it is the minimum age when a
lateral cephalogram is usually indicated. The age of 17 years old was considered as an average age of
growth end [19,25].
The clinical significance of this study is related to the importance of growth predictors for the
orthodontic diagnosis and treatment planning, with possible implications on the success rate and
the duration of the orthodontic treatment for each specific malocclusion [26]. During orthodontic
diagnosis and treatment planning, the possibility to correctly identify the mandibular rotational pattern
during growth is a fundamental factor [16]. It is well recognised that patients with a hyperdivergent
mandibular growth pattern are more difficult cases [9,10,17]. Not only the cephalometric analysis but
also anatomical characteristics were used to identify the mandibular rotational patter. Already in the
early 1970s, Björk and Skieller underlined the possibility of predicting the mandibular growth pattern
by looking at some specific anatomic mandibular structures in longitudinal lateral cephalograms with
the purpose of identifying facial morphology and the progression of mandibular rotation [23–25]. They
introduced seven mandibular morphological signs that identified hyperdivergent and hypodivergent
mandibular patterns [23]. Although, the CoGoMeˆ is a cephalometric angle, it is strongly related to the
mandibular anatomy and, due to its correlation with the SNˆGoGn, it might improve the accuracy of
the cephalometric diagnosis.
Class II malocclusion is one of the most prevalent orthodontic problems in the Caucasian
population [27–29]. It might cause detrimental aesthetic effects and social impairment in children’s
daily lives as it affects their oral-health-related quality of life, and it is a risk factor for dental
traumas [30]. In growing subjects, one treatment option to correct skeletal Class II malocclusions
uses functional/orthopaedic appliances, [31] but, still, great variability in the achievable mandibular
advancement has been observed across the literature due to numerous factors. One factor that might
be responsible for different growth potentials is mandibular morphology. Petrovic pointed out that the
individual mandibular growth potential and the responsiveness to the functional orthopaedic treatment
were strongly influenced by the mandibular growth pattern [10,11]. The CoGoMeˆ was proposed
as a pre-treatment indicator of lower jaw responsiveness in Class II patients treated with functional
appliances at the mandibular growth spurt [16]. The cut-off degree of the CoGoMeˆ greater or less
Dent. J. 2019, 7, 104 9 of 10

than 125.5◦ was found by Franchi and Baccetti in their work of 2006 [16]. These authors suggested
that the CoGoMeˆ could be used for an efficient discrimination between good (CoGoMeˆ <125.5◦ ) and
bad (CoGoMeˆ >125.5◦ ) responders to functional treatment of skeletal Class II malocclusion due to
mandibular retrusion. This is the first study that evaluated the distribution and the associations of
the CoGoMeˆ with the SNˆGoGn and the ANPgˆ in a large population from Southern Italy, providing
cephalometric norms for Caucasian patients.
The limitation of this study was that, due to ethical issues, it was not possible to collect an
untreated longitudinal sample.

5. Conclusions
In conclusion, this study showed the following:
• In the studied sample, the CoGoMeˆ presented a mean value of 127.2◦ ± 7.7◦ .
• Skeletal sagittal jaw discrepancies did not influence the CoGoMeˆ.
• From 8 to 17 years of age, the CoGoMeˆ decreased 0.6◦ per year.
• For each degree of increase of the CoGoMeˆ, the SNˆGoGn increased by 0.6◦ .
• The CoGoMeˆ can be considered a useful cephalometric parameter for the diagnosis of the vertical
facial growth pattern.

Author Contributions: Conceptualization, V.D., R.R., and R.V.; Methodology, A.C.P.M., R.R., V.S., L.F., and V.D.;
Validation, A.C.P.M., R.B., V.D., and R.V.; Formal analysis, A.C.P.M., R.R., V.S., and V.D.; Investigation, A.C.P.M.,
and R.R.; Resources, V.D. and R.V.; Data Curation, A.C.P.M., R.B., and V.S.; Writing—Original draft preparation,
A.C.P.M., R.R., and V.D.; Writing—Review & Editing, R.B., V.S., L.F., and R.V.; Visualization, A.C.P.M., R.B., and
R.R.; Supervision, L.F., V.D., and R.V.; Project Administration, A.C.P.M., V.D., and R.R.
Funding: This research received no external funding.
Acknowledgments: The authors thank Giovanni Monti for his contribution in this research.
Conflicts of Interest: The authors declare no conflict of interest.

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