The International Journal of

Orthodontia and Oral Surgery

(All rights strictly reserved)

VOL. VI ST. LOUIS, MARCH, 1920 NO.3

ORIGINAL ARTICLES

DENTAL-OCCLUSAL CLASSIFICATION OF MALOCCLUSION

By CALVIN S. CASE, M.D., D.D.S., CHICAGO, ILL.

T HE principal object of a classification in any of the sciences is to enable one

to obtain quickly a general mental grasp of the thing referred to, and to
recognize it or to define it as distinguished from other things of a similar nature,
thus producing a clear mental flashlight-word picture of the thing itself. This is
accomplished through a systematic arrangement of the objects or material into
distinct groups, classes, divisions, types, etc., each one of which is characterized
by some stable peculiarity in form, structure, or property of recurring constancy,
not found elseuihcre in the classification. Therefore, in naming a class in any
classification, with the division of that class, and the type of the division of the
class, we have presented a mental picture of the thing and its peculiar distin-
guishing characteristics.
In an attempt to follow this commonly accepted system of nomenclature with
a view to intelligently classify malocclusions of the teeth, we are confronted with
somewhat the same difficulties that confronts the science of medicine in classify-
ing diseases.
In orthodontia, the present most popular accepted basis for the classification
of malocclusions is the disto-mesial occlusal relations of the buccal teeth. This
naturally divides malocclusions into three classes as follows: In Class I, the
disto-mesial occlusal relations of the buccal teeth are normal or nearly so. In
Class II, the disto-mesial occlusal relations of the lower buccal teeth are about
the width of a cusp distal to normal; and in Class III, the disto-mesial occlusal
relations of the lower buccal teeth are about the width of a cusp mesial to normal.
The consistent reason for this natural division into the three classes is as
follows: In a normal occlusion of the teeth, the cusps of the buccal teeth of
one denture fit evenly and anatomically into the sulci of the other. During the
eruptive stage, if from some cause they do not quite take this exact anatomic
relation, the forces of mastication soon drive them fully into it along the in-
135
136 Th e International ] ournal of Orthodon tia and Or al S urgery

clined planes of the sliding fac et s ; except in those cases where certa in causes,
local or inherent, have forced the teeth to er upt so that the crests o f th e cusps of
one denture are mor e or less outside the grasp of th eir nor mal spheres of influence.
In thi s instance the y at once commence to dri ft along the inclined planes toward
the wrong, or abn ormal sulci , until they ha ve fitted th emselves as closely as
possible into th eir interlocking grasps, with the result that the buccal teeth of
one dentu re in rela tion to th e othe r, on th e rig ht or the left, or both sides, are
comm only found to occlude in nor mal, or about the width of a cu sp mesial or
distal to normal occlusio n.
A s the teeth erupt a nd come int o cont act with their mast icating fell ows, th ey
are o ften for ced to move disto-mesially and bucco -Iingua lly, fro m thei r er upted
positions through the fitting processes of their cusps, in exa ctly th e same way
that they a re moved by orthodonti c for ces. There is no doubt that whol e den-
tures a re frequentl y cau sed to move antero-posteriorly to a considerable extent
by the mesial or distal movement of their ma sti cating teeth in Nature's processes
of fitting the cu sps into their normal or abn or mal interdigit at ing sulci, which
con stitutes the basis of our pr esent three class es o f mal occlusion .
W hile thi s dento-occlusal classification here p resented is qui te diff er ent fr om
the A ngle class ification, it will be found by teac he rs and students, of th e grea tes t
practi cal value, enabling a systematic presenta tion of th e most ad vanced princi-
ples of dent o-facial orthop edia, at prese nt unequaled by any othe r classificati on.
F or the very gr eat advantage of perfect ha rmony and unanimity in our litera-
ture and teaching, I would have gladly ad opt ed the Angle classification were it
not for the fact that as it now stands it can not be made to ex press a large num-
ber of very important characters of malocclusion which shou ld be full y recog-
nized and systematically scheduled as independent Di visions, or Types of Divi -
sions of one or the other of the three Classes. Furthermore, the Angle classi-
ficat ion does not recognize those wide diff erences in th e cha racter of cer tain
malocclusions which ha ve the same disto- mesial occlusion of the buccal teeth .
It will be found by a careful study of malocclu sions that these differences in
dent o-Facial character s a nd deman ds of trea tment 'i.t'ith in eacli class are fully
as grea t and quit e as impo rta nt in orthodontia as the differen ces whic h a rise be-
t ween the characters of one class and another.
N ote the wide distinctively different charact er s within each one of the th ree
cla sses shown by th e chart on page 139, and then let me ask: tha t if we tak e the
disto-m esial occlusal re lations of the buccal tee th as the distinguishing standard
or basis of our classificati on, mu st we not necessa rily place in each one of th e
cla sses-in the divisions or ty pes-all th e dist inctiv e recurring charac ters w hose
buc cal occlusi on corresponds to th e basic occlusion of the class !
W hen we name a class to which a 'certa in malocclu sion belongs, we convey
a ment al pictur e of only th e disto-mesial occl usal relations of its bu ccal teeth
and nothing more, exce pt the fancied conception of its real cha racter an d dento-
faci al relations. And when we go further, and name the Division of its Class,
we still have placed it only as one of a fam ily of malocclus ions whose individual
members may differ quite decidedly from each other, though all are alike in
one d istinguishing character istic. Neither can we place in the mind 's eye the
ind ividu ally complete d cha rac ter of the case in hand until we have nain ed its
 Dento-occlusal Classification of Malocclusion 137

Type, its Division, and its Class. There are, however, certain Divisions whose
different types are so similar they require no mention in a classified chart,
though in practical treatment they may differ considerably, all of which with a
variety of variations should be fully outlined in the textbook teaching. In this
classification, the family or divisional characteristic is based upon dento-Iacial
relations, except in Division 1 of Class I, which it has seemed best, for teaching
purposes, to distinguish as having arisen from a local cause, though differing
quite decidedly in their dento-facial relations.
As a large majority of orthodontists have already become accustomed to
divide malocclusions according to the three distinct occlusions of the buccal
teeth-normal, mesial, and distal-the placing of all the commonly recurring
dento-facial types which have a similar occlusion, in one class, will doubtless give
a greater opportunity to define their wide differences in character and demands
of treatment, and thus prevent as far as possible the too common error of treat-
ing cases alike on the basis of their occlusal similarity. It is hoped also, that
it will tend toward preventing the insistence of placing certain dentures in a
normal occlusion whose deforming facial protrusions demand extraction. And
on the other hand, it is most earnestly hoped that it will prevent the extraction
of teeth by those who unfortunately have made a wrong interpretation of my
teaching. It certainly should appeal to those orthodontists who favor the occlusal
classification, and whose highest aim iri practice is a truthful and scientific
diagnosis of their cases.
To those who believe that no teeth should ever be extracted for the dento-
facial correction of the decided unimaxillary and bimaxillary protrusions, .Dr.
Angle's classification will be found quite consistent with that system of practice.
It was because of the marked differences in the character, facial outlines,
and required treatment of malocclusions in Class II-in which the upper denture
is about the width of a cusp in front of a normal occlusion-s-that led me to di-
vide this class in a former classification, into Classes II and III, as I believed this
would more strongly emphasize the importance of a differential diagnosis of
demo-facial characters having the same occlusion of the teeth, certain types of
which demand the extraction of teeth in their proper correction, while with
others, such a procedure would be decided malpractice. In other words, it was my
desire to free it from the mechanical and mathematical trend toward which the
science seemed to be drifting, and to induce a deeper consideration and study of
facial art and beauty as important factors of diagnosis and treatment. With
the present advancement in the practical principles of orthodontia, it is hoped
that a systematized arrangement of all the distinctive types of malocclusion
under three heads, upon the basis of their occlusal peculiarity, will enable a full
appreciation of the wide differences in dento-Iacial outlines with patients hav-
ing, practically, the same occlusal relations of the teeth.
By carefully scanning my present classification, it will be seen that while
the distinct characters of malocclusion are now divided among the three classes
upon the basis of their disto-mesial occlusion, their true basis of diagnosis and
treatment is dependent very largely upon the facial outlines in relation to the
standard of esthetic perfection for the individual, because it is not otherwise
138 The I nternational Journal of Orth odon tia and Oral S urgery

possible as a guide to treat ment to determine whet her the de ntures-c-one or both
-are really pr otruded or retrud ed.
'While the dento-occlusal classification pos sesses the adv antag e of enab ling
us to divide an d segrega te a gre at variety of malocclu sions into a sma ller num ber
of cla sses, it w ill be found as one becomes more and mor e ad vanced in th e
science of orthodontia, th at the re will arise a full er ap pre ciation of th e fa ct tha t
the disto-mes iai occlusion of th e bucc al teeth is a very un certain and of ten mis-
lea ding guide as a basis of diagnosis in dete rmin ing rea l condi tion s and the
kind of treatmen t demanded, because in everyone of th e three cla sses- if all
their dist inct charac ters of mal occlu sion are ta bulat ed-th ere will be found re -
markably diverse characters of dento-facial deformities and malposit ion s.
One of th e most da ngerous fea tures of the Angle classification, as formerly
set fo rth, a nd one wh ich, strange to say, has te nd ed to popu larize it in th e
minds of orthodo ntists, is the univer sally ap plied teachin g that wh en den tures
are placed in normal occlusion, the facial outline s will tak e care o f th em selves;
and therefore, the highest possible orthodontic attainment for that individual
is ac complished. I f this were as tru e as it is believed by many, it would simplify
the whole practice of orthodontia, becau se in th eory it er adica tes th e necessity of
a deep comprehension of dento-f acial ar t, and many other imp ortant pr inciples
which are so difficul t for ortho dont ist s to understand.
A careful study of th e great ques t ion of extraction which is so largely
dep endent upon Cal)SCS, and which lies ' at th e very fou ndation of adv ance d dento-
faci al orth opedi a, mu st con vince every receptive tru th-seek ing min d, stri ving for
th e highest atta inments of hi s ar t, of the delu siveness of a te aching whic h asserts
the universal applica b£lity of the " norma l occlu sion theo ry," which mean s that
eve ry tooth or its artificial substitute is necessar y for the perfect correcti on of
dental or dent o-f acial mal occlu sions.
In a dopting the occlusal clas sificat ion, th eref or e, it should be remembered
that th e disto-mesial cha ra cter of a buccal malocclu sion is no mor e or less th an one
of the incident s o f th e ca se in hand, r equiring correction if demanded, along with
other mal positi ons wh ich may be pre sent, and whic h are equally important to cor -
rect. It is one, mor eover , that demands to the full est extent th at the masti cating
cu sps shall be in pe rfect int erd igitating occlusion ; an d fur thermore-it goes with-
out saying- they sh ould always be placed in normal occlusion, ex cept in those
co mpa ra tive ly fe w in stan ces where this rul e is incon sistent with imperat ive fac ial
demands.
T here are , however, certain special an d qui te common malpositi on s which
are found in everyon e of the th ree clas ses, because they arise from local cau ses,
wh ich may atta ck an y inh er ited disto -rnesial occlusion of th e tee th, and therefore,
th ey can 110t be classified as special division s or types of any a ile particular class,
not wi th stand ing th e fac t th at they frequentl y domin at e and character ize the
wh ole malocclu sion of the case in ha nd. This refers to Mal eruptio n of Cuspids,
Thumb- Slickin g Protru sion s, L at eral Mal occlu sion, O pen-B ite Malocclusion , In -
fra- and Supra-Occlusions, Malalignm ent s, Malturned T eeth , Contr acted and
E x panded Arches, Ab no rmal Interproximat e Spaces, a nd Impacted Teeth. It
is qu ite as imp ortant that the pr inciples and treatment of the se mal occlu sions
be taught, as th ose of the distinctly classifiable cha ra cters .
 Dento-occlusal Classi fication of M aloccl usion 139

Inasmuch as th e first four of th is group produce at times quite ma rked

facial imperfecti ons, and as a ll locally caused ma locclusions a rise most fr e-
quen tly in connection with normal occlusio ns, these specia l characters of maloc-
clusion are placed in the Practical Treatment of Class I , Division 1. The " P rac-
tical T echnic Treatment" of th e re st of th is group of ir regul ariti es is full y ou t-
lined separately', with the view o f showing th e different metho ds which I emp loy
for th eir correction in connectio n with th e classifi ed malocclu sion in which they
arise.

CLASSIFIED TABLE OF DENTO·FACIAL MALOCCLUSION

CLASS I. NORMAL DISTO-MESIAL OCCLUSION OF THE BUCCAL TEETH.
Division 1: Locally Caused Dento-Facial Malocclusions.
TY PE A : UNI LATERAL MALERUPTION 0 1' C USPIDS .
TYPB B: BI LA'f ERAL MALERl'PTIO"I 0 1' CUSPIDS .
T YPE C : B II. ATERAL MALERUPTION 01' CUS PIDS REQ UI RI NG EXTRACTION.
(FROM C LASS II.)
T YPE D: PRO'fRUSION 0 1' U P PER FRONT T EETH .
T YPE: E : R ETRUSION 01' U PPE R FRONT T EET H . (TRE:ATED IN D IVISION 2,
CLASS III. )
T\'P E F : L ATERAL M ALOCCLU SI ON.
T YP E G : OP EN -B lTE "MALOCCLUSIO N.
Di vision 2: Bimaxillary Protrusion and Retrusion.

CLASS II. DISTAL MALOCCLUSION OF LOWER BUCCAL TEETH.

Division 1: Retrusion of Lower Denture.
T YPE A: PROKOU NCED R ETRU SION OF L OW ER D E: NT URE, WI'fH UPPER NOR-
:\IAL.
T YPE B: l f OllERATE RETR USIO N 01' TH E L OW ER DEN'I' URE, wrra MOD -
ERATE PROTRUSION 01' TH E U PPER D ENT URE.

Division 2 : Protrusion of the Upper, with Lower Nonnal.

T YPB A : "UPP ER CORONAL P ROTRUSION .
T YP E B : U P PER BODI LY PROTRU SION.
T YPE C : "UPPER CORO NA L PROTRU SION W IT H APICAL R ETRUSJOX.
T YPE D: U PPER A PICAL PROTRl' SION WITH L I KGU AL I NCLINATIO N.

Concomitant Characters of Class II.

R ETRUS ION 0 1' TH E MA N DIBLE AND L OWER D ENTURE .
CLo SE-B n E M ALOCCLU SIO NS.
M ALERUPTI ON OF C USPIDS . (TREATED IN Cr..\SS 1.)

CLASS III. MESIAL MALOCCLUSION OF LOWER BUCCAL TEETH.

Division 1: Bod ily Ret rusion of the Upper D enture an d Maxilla.
(Wi th lo wer no r mal, though apparently pr otruded)
Division 2 : Contracted Retrusion of the Upper Denture.
(Due t o inh ibited devel opment of ma xi llas)
Di vision 3 : Retrusion of the Upper with Protrusion of Lower Denture.
(Wi th no pr otr u sive position of th e mand ible)
Division 4: Retrusion of the Upper with Prognathic Mandible.
(C om mon ly ac companied with Op en-Bite Mal occl us ion)
140 The International Journal of Orthodontia and Oral Surgery

In regard to the Classified Table of Dento-Facial Malocclusions here pre-

sented, it should be understood that only the dist ingui shing types of th e different
Divisions of the Classes are stated in the accompanying table.
It was my hope to present this subject, illu strated with lantern slides before
the American Society of Orthodontists, where it would be subj ected to a free
discussion of the propositions; though I may be pardoned for beli eving that
a competent discussion of so much importance as one which proposes a radical
change in an accepted- classification of malocclu sions should not be engaged in
without a deep unbiased study of the changing demands in our advancement, and
the broad principles in volved in th is new classification.
For my benefit and instruction as a teacher, and for the benefit of many
others who are more or less guided by my teaching, I should like to have pub-
lished in subsequent number s of this or other dental journals, a free friendl y
discussion of the merits and demerits of this classification from the pens of dis-
tinguished orthodontists, with specific statements in regard to its faults and
reasons why it should not be adopted as an improvement, at lea st, over the
present den to-occlusal classification,
This would give me an opportunity to more clearly define certain parts
which may not be fully explained or understood, and to accept with thanks irref-
ragable sugge stions for its improvement in character or phraseology, with the
hope that we may finally arrive at a classification that can be acceptably adopted
as the standard nomenclature of malocclusions and of teaching and practice.
There is nothing in my opinion that could advance orthodontia so mu ch, or do
more to carry it out of the quagmi res of prejudice, distrust and un certainty,
and place it on a sure foundation as a science.