European Journal of Orthodontics, 2016, 251–258

doi:10.1093/ejo/cjv067
Advance Access publication 18 September 2015

Original article

Influence of maxillary posterior discrepancy on

upper molar vertical position and facial vertical
dimensions in subjects with or without skeletal
open bite

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Luis Ernesto Arriola-Guillén*, Aron Aliaga-Del Castillo**,
Luis Fernando Pérez-Vargas*** and Carlos Flores-Mir****
*Division of Orthodontics, Faculty of Dentistry, Universidad Científica del Sur—UCSUR, Lima, Perú, **Department of
Orthodontics, Bauru Dental School, University of São Paulo, Brazil, ***Division of Orthodontics, Faculty of Dentistry,
Universidad Nacional Mayor de San Marcos—UNMSM, Lima, Perú, ****Division of Orthodontics, Faculty of
Medicine and Dentistry, University of Alberta, Edmonton, Canada

Correspondence to: Luis Ernesto Arriola-Guillén, Calle Los Girasoles # 194, Dpto. # 302, Urb. Residencial Los Ingenieros de
Valle Hermoso, Santiago de Surco, Lima, Perú. E-mail: luchoarriola@gmail.com

Summary
Objectives: To determine the influence of maxillary posterior discrepancy on upper molar vertical
position and dentofacial vertical dimensions in individuals with or without skeletal open bite (SOB).
Materials and methods: Pre-treatment lateral cephalograms of 139 young adults were examined.
The sample was divided into eight groups categorized according to their sagittal and vertical skeletal
facial growth pattern and maxillary posterior discrepancy (present or absent). Upper molar vertical
position, overbite, lower anterior facial height and facial height ratio were measured. Independent
t-test was performed to determine differences between the groups considering maxillary posterior
discrepancy. Principal component analysis and MANCOVA test were also used.
Results: No statistically significant differences were found comparing the molar vertical position
according to maxillary posterior discrepancy for the SOB Class I group or the group with adequate
overbite. Significant differences were found in SOB Class II and Class III groups. In addition, an
increased molar vertical position was found in the group without posterior discrepancy.
Limitations: Some variables closely related with the individual’s intrinsic craniofacial development
that could influence the evaluated vertical measurements were not considered.
Conclusions and implications: Overall maxillary posterior discrepancy does not appear to have a
clear impact on upper molar vertical position or facial vertical dimensions. Only the SOB Class III
group without posterior discrepancy had a significant increased upper molar vertical position.

Introduction (molar area) (5). It has been suggested that the posterior discrepancy
may be related to crowding relapse and third molar impaction (5).
In orthodontics, space discrepancies are usually considered by meas-
This may occur based on three basic effects on dental occlusion:
uring tooth mesiodistal size mesial to the first molars (required
First, it generates a mesial inclination of the posterior teeth associ-
space) and then contrast it to the alveolar base mesial to the first
ated with occlusal interferences. Second, it limits the available space
molars (available space) (1–4). Nevertheless, there is controversy if
for the eruption of the third molar. Finally, it may produce second
the space discrepancy must also consider the posterior discrepancy
and first molar supraeruption (5–10).

© The Author 2015. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
251
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252 European Journal of Orthodontics, 2016, Vol. 38, No. 3

First or second molar supraeruption may be due to lack of space
in the dental arch for the erupting third molar. This eruption could
produce an anterior pressure on the second molars leading to poten-
tial second molar crowding and/or supraeruption (6, 7, 9, 10). An
occlusal interference can be produced simultaneously that could lead
to a functional alteration of the occlusal plane and, maybe, to abnor-
mal growth. In clockwise growing individuals the mandibular plane
is usually hyperdivergent. In response to this, the occlusal plane
would likely be steeper to be able to establish a functional occlu-
sion. In cases where the occlusal plane is not steep enough, posterior
occlusal interferences are likely to occur that could further affect the
vertical relationship of the dentition (6, 9, 10).
Although there are no studies that have directly assessed the
influence of the posterior discrepancy on dentofacial vertical
dimensions, it has been shown that in skeletal open bites (SOBs)
an increased molar vertical position was reported in comparison to
at 16 mA, 72 kV, and 9.9 seconds. All the cephalometric measure-
ments were performed digitally by two calibrated examiners with
the MicroDicom viewer 0.8.1 software (Simeon Antonov Stoykov),
without magnification, at a scale of 1:1.
Measurements (mm)
Maxillary posterior discrepancy
The primary diagnosis of maxillary posterior discrepancy was made
through radiographic evaluation by two calibrated examiners. When
the eruption of the maxillary third molar was potentially blocked
by the presence of the erupted second molar at visual evaluation, a
maxillary posterior discrepancy was deemed present. (Figures 1 and
2) This was the diagnostic criteria used for the statistical analysis.
An additional analysis of maxillary posterior discrepancy based
on radiographic measurements was considered. If the ratio of the
anterior maxillary base length A′6′ to the maxillary base length A′P′

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controls (11–14). (A′6/ A′P′) was greater than 0.46 (5) then a maxillary posterior dis-
Although posterior discrepancy can be measured in the maxilla crepancy was determined (Figure 3).
and mandible, in this study only maxillary posterior discrepancy was
evaluated. If indeed a strong association existed, then this would
Maxillary molar vertical position
be a factor to be considered during orthodontic treatment planning
Maxillary molar vertical position was measured as the length of
as it would be suggestive of the potential importance of the third
a line perpendicular to the palatal plane extending from the pala-
molar eruption path in conditions of unfavourable angulation or
tal plane to the mesial cusp tip at the occlusal plane (OP) for each
lack of available space. Therefore, the purpose of this study was to
respective upper molar (Figure 4).
determine the association of maxillary posterior discrepancy on the
upper first and second molar vertical position and any consequently
Overbite
increase in dentofacial vertical dimensions in subjects with or with-
Overbite was measured in mm as the distance between incisal edges
out a SOB.
of maxillary and mandibular central incisors, perpendicular to
occlusal plane (20) (Figure 5).
Materials and methods
Lower anterior and ratio facial height
The study protocol was approved by the ethical committee of the
Lower anterior facial height was measured as the distance from ante-
School of Dentistry, Científica del Sur University—Lima, Perú. The
rior nasal spine point to mental point (21). The ratio facial height was
sample included 139 pre-treatment lateral cephalograms (66 men,
measured as the ratio of posterior facial height (S–Go) and anterior
73 women) taken with the occlusion at maximum intercuspation.
facial height (N–Me). (S–Go/N–Me × 100) (22) (Figure 4; Table 2).
All the cephalograms were taken with the lips at rest. Subjects
with previous or under orthodontic treatment at the time of image
acquisition, and without third molars (extracted or missing) were Statistical analysis
not considered. The age range of these patients varied from 15 to All statistical analyses were performed using SPSS Ver.21 for Windows
30 years. (IBM SPSS, Chicago, Illinois, USA). The normality was satisfied using
Sample size was calculated considering a mean difference of Shapiro Wilk tests. An independent t-test was performed to determine
2 mm in the upper second molar vertical position as a clinically rel- differences between two groups classified by the maxillary posterior
evant difference between groups with and without maxillary poste-
rior discrepancy. A standard deviation of 1.75 mm was considered
(obtained from a previously conducted pilot study) with a two-sided Table 1. Sample distribution by group, gender, and age.
significance level of 0.05 and a power of 80%. Therefore a minimum
Group Male Female Total Age* Mean (SD)
of 12 subjects per group was required.
The study sample comprised of eight groups categorized OBCIG–PD 10 10 20 20.40 (4.67)
according to their sagittal skeletal facial growth patterns (Class I, OBCIG–WPD 7 8 15 20.87 (4.79)
II, or III) (3, 15), overbite condition (SOB or adequate overbite) OBCIIG–PD 9 13 22 22.64 (5.39)
(16), and maxillary posterior discrepancy (present or absent) (5, OBCIIG–WPD 11 12 23 21.74 (4.46)
17) (Table 1). The definitions of the cephalometric points, distances OBCIIIG–PD 8 7 15 20.67 (3.83)
OBCIIIG–WPD 7 7 14 22.69 (3.79)
and angles between them are shown in Table 2, when both meth-
AOBG–PD 7 8 15 21.33 (3.59)
ods to diagnose the sagittal skeletal facial growth pattern (ANB
AOBG–WPD 7 8 15 20.13 (3.96)
and APDI) did not coincide, then a decision was made based on
Total 66 73 139
a radiographic evaluation and clinical judgment that included the
analysis of bone profile (sagittal relationship of the points N, A,
OBCIG, open bite Class I group; OBCIIG, open bite Class II group; OBCI-
and Pg), soft profile convexity [via the facial angle G′ –Sn–Pog′ IIG, open bite Class III group; AOBG, adequate overbite group; PD, posterior
(18)] and overjet. discrepancy; WPD, without posterior discrepancy.
Imaging was performed with digital cephalometric panoramic *Not significant based on independent t-test according to posterior dis-
equipment (ProMax®, Planmeca, Finland). Device settings were set crepancy by groups.
L. E. Arriola-Guillén et al. 253

Table 2. Definitions of cephalometrics points and angles used in

this study.

Definition

Angular measurements
SNA The angle between points Sella (S), Nasion
(N), and Sub nasal (A) in degrees (19)
SNB The angle between points Sella (S), Nasion
(N), and Supra Mental (B) in degrees (19)
ANB The angle to assess the skeletal relationship
between points A and B in degrees (19)
APDI The anterior-posterior dysplasia indicator
to assess the skeletal relationship and is ob-
tained from the algebraic sum of the angles Figure 1. Example of maxillary posterior discrepancy. Third molar was
N–Pg–FH (facial plane) plus/minus the angle potentially blocked by the presence of the erupted second molar.
AB-facial plane (is positive when the point B
is ahead of point A and is negative when the

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point A is ahead of point B) and plus/minus
the angle FH–PP (palatal plane) (is negative
when PP is tilted upward and positive when
tilted down) (15)
FMP The angle between the Porion–Orbital line
and mandibular line in degrees (11)
ODI The overbite depth indicator to assess the
tendency toward open bite is obtained from
the algebraic sum of the angles AB–MP plus/
minus the angle FH–PP (palatal plane), is
negative when PP is tilted upward and posi-
tive when tilted down (16)
Linear measurements
A′P′ The distance between the perpendicular Figure 2. Example of maxillary posterior discrepancy. Third molar was
extensions of points A and P on the palatal potentially blocked by the presence of the erupted second molar.
plane (A′P′) in mm: Point A′ is the perpen-
dicular projection of point A to the palatal
plane and point P′ is the perpendicular pro-
jection of the posterior—most point of the
maxillary tuberosity to the palatal plane (5)
A′6′ The distance between A′ and 6′ in mm, the
anterior maxillary base length is defined by
the measurement between A′ and 6′. Point
6′ is the perpendicular projection of the
anterior-most point on the proximal surface
of the maxillary first molar to the palatal
plane (5, 17)
Ratio (A′6′/A′P′) The ratio of the anterior maxillary base
length A′6′ to the maxillary base length A′P′
(A′6′/A′P′) (5, 17)
 Upper first molar The length of a line perpendicular to the
vertical position palatal plane extending from the palatal
plane to the mesial cusp tip of upper first
molar (11)
 Upper second molar The length of a line perpendicular to the Figure 3. Maxillary posterior discrepancy evaluated by the ratio of the anterior
vertical position palatal plane extending from the palatal maxillary base length A′6′ to the maxillary base length A′P′ (A′6′/A′P′).
plane to the mesial cusp tip of upper second
molar (11) discrepancy condition (present or absent). A principal component
Overbite The overbite in mm is the distance between analysis (PCA) was used to reduce the number of variables to con-
incisal edge of maxillary and mandibular sider for the multivariate analysis. Finally MANCOVA test was used.
central incisor, perpendicular to occlusal Statistical significance was set at P < 0.05 for all the tests.
plane (20)
 Lower anterior facial The length in mm of a line between points
height anterior nasal spine (ANS) and mental (Me) Results
(21)
 Ratio facial height The ratio of posterior facial height and
Reliability
(S–Go/N–Me × 100) anterior facial height (22) Inter and intra-examiner reliability was assessed with an intra-
class correlation coefficient (ICC). All values were greater than 0.90
254 European Journal of Orthodontics, 2016, Vol. 38, No. 3

Table 3. Sample characteristics by facial growth pattern, overbite,

and upper posterior discrepancy.

Measure-
ment Group Mean SD Group Mean SD

SNA OBCIG–PD 81.17* 2.89 OBCIG–WPD 84.54* 4.82

SNB 78.65 3.35 81.03 4.45
ANB 2.54* 1.20 3.47* 1.41
APDI 83.45 2.93 81.95 2.26
FMP 30.48 2.70 31.15 3.11
A′P′ 42.45* 2.89 47.07* 3.10
A′6′ 21.48 2.16 20.66 2.71
Ratio 0.50* 0.04 0.43* 0.03
(A′6′/A′P′)
ODI 64.23* 5.14 68.48* 4.94
SNA OBCIIG–PD 80.97 3.09 OBCIIG–WPD 82.51 2.79
SNB 74.54 2.90 75.83 2.99

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ANB 6.42 1.44 6.68 1.24
APDI 74.06 3.37 75.41 4.20
FMP 34.93 4.84 34.02 4.28
A′P′ 43.62* 3.63 45.96* 2.72
A′6′ 23.02* 2.68 21.23* 2.77
Ratio 0.52* 0.04 0.46* 0.05
(A′6′/A′P′)
ODI 71.55 4.84 71.18 6.08
SNA OBCIIIG– 81.84* 3.27 OBCIIIG– 78.22* 2.31
SNB PD 83.45* 4.16 WPD 80.14* 1.90
ANB -1.61 1.36 -1.92 0.93
Figure 4. Linear measurements (all in mm): PNS, posterior nasal spine; ANS, APDI 91.51* 4.48 87.67* 0.68
anterior nasal spine; MX7, second molar maxillary height; MX6, first molar FMP 31.91* 3.60 29.21* 3.36
maxillary height; ANS–Me, lower anterior facial height; N–Me, anterior facial A′P′ 43.88 5.00 44.06 4.32
height; S–Go, posterior facial height. A′6′ 20.68 2.18 19.71 2.12
Ratio 0.47 0.06 0.44 0.04
ODI 58.88 9.44 62.93 1.08
SNA AOBG–PD 81.53 2.92 AOBG–WPD 82.93 3.31
SNB 79.11 2.24 80.02 2.78
ANB 2.42 1.38 2.91 1.11
APDI 82.75 2.62 82.35 3.30
FMP 26.63* 2.47 23.24* 3.87
A′P′ 45.49 4.53 47.62 3.60
A′6′ 23.78 2.43 21.59 3.48
Ratio 0.52* 0.04 0.45* 0.05
(A′6′/A′P′)
ODI 69.29 4.20 70.46 4.15

*Significant based on independent t-test.

Age and gender distribution based on the classification grouping

Figure 5. Overbite measurement relative to the occlusal plane.
[95% confidence interval (CI) 0.85–0.98]. In addition, the Dahlberg
error was less than 1 mm for linear measurements and 0.9 degree
(95% CI 0.80–0.99) for angular measurements. All the cephalomet-
ric tracings were drawn with a 1-month interval between them.
Outcome variables
Supplementary Table 1 shows the concordance found between the
two maxillary posterior discrepancy methods. Approximately 70%
concordance was found (Tables 3–7 and Supplementary Table 1).
can be found in Table 1. Descriptive statistics for the outcome vari-
ables can be found in Tables 3 and 4.
The outcome variables first and second maxillary molar vertical
position, overbite, and lower anterior facial height were contrasted
according to the considered groups. For both the first and second
maxillary molar vertical position differences were found in the
Class II and III groups with and without maxillary posterior discrep-
ancy. The Class II group without maxillary posterior discrepancy had
more erupted first and second upper molars (1.27 mm—P = 0.025
and 1.14 mm—P = 0.035, respectively). The Class III group with-
out maxillary posterior discrepancy had more erupted first and sec-
ond upper molars (2.46 mm—P < 0.001 and 3.49 mm—P < 0.001,
respectively). The overbite was significantly decreased in Class I and
II with less overbite in the groups without maxillary posterior dis-
crepancy (P = 0.043 and P = 0.039, respectively). The lower anterior
facial height was significantly increased in Class III with more height
in the group without maxillary posterior discrepancy (P = 0.005),
L. E. Arriola-Guillén et al. 255

Table 4. Molar vertical position, overbite, lower anterior facial was modified by FMP, the lower anterior and ratio facial height
height, and facial height ratio according to upper posterior discrep- were modified by the SNA angle, FMP, and A′P′ (Table 7). Finally,
ancy and sagittal and vertical facial growth pattern. the correlations between the maxillary posterior discrepancy
Measurement Group Mean SD Min Max
(A′6′/A′P′) and the dependent variables were evaluated, finding
a low strength of association in all observations (Supplementary
Maxillary first OBCIG–PD 23.70 1.85 21.12 28.64 Table 2).
molar vertical OBCIG–WPD 23.41 1.52 20.16 26.79
position OBCIIG–PD 23.20 1.72 20.23 26.66
OBCIIG–WPD 24.70 1.83 20.83 28.12 Discussion
OBCIIIG–PD 24.12 1.30 22.38 26.25
OBCIIIG–WPD 26.58 0.89 25.18 28.00 The purpose of this study was to determine the influence of maxil-
AOBG–PD 22.26 2.11 19.25 26.00 lary posterior discrepancy on upper molar’s vertical position and, if
AOBG–WPD 23.29 1.95 19.00 26.30 applicable, a consequent increase in the dentofacial vertical dimen-
Maxillary OBCIG–PD 20.99 2.15 18.05 25.50 sions in subjects with or without SOB. It’s has been proposed that
second molar OBCIG–WPD 20.82 1.56 17.50 23.79 one of the effects of a maxillary posterior discrepancy is second
vertical OBCIIG–PD 19.97 1.57 17.20 24.00 and first molar’s extrusion. This could lead to a decreased over-
position OBCIIG–WPD 21.29 1.88 17.00 25.09 bite and increased lower anterior facial height (5, 6, 8–10, 13), but

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OBCIIIG–PD 21.10 1.52 18.00 23.52
his hypothesis has yet to be scientifically demonstrated. Our study
OBCIIIG–WPD 24.60 1.40 22.75 26.59
intended to make this direct comparison.
AOBG–PD 18.67 3.06 14.46 25.00
The expected results, based on existing hypothesis (5, 6, 8–10,
AOBG–WPD 20.34 2.44 14.16 22.73
Overbite OBCIG–PD -1.58 1.07 -4.73 -0.25 13), are that there should be an increase in the vertical posi-
OBCIG–WPD -2.50 1.52 -5.58 -0.78 tion of the maxillary first and second molars with a consequent
OBCIIG–PD -2.25 1.56 -6.14 -0.30 increase in the facial vertical dimension. However, our results did
OBCIIG–WPD -2.99 1.29 -6.04 -1.00 not support this hypothesis. In general terms, a slightly increase
OBCIIIG–PD -1.97 1.67 -5.51 -0.35 between 0.5 and 3 mm was found for the maxillary molar verti-
OBCIIIG–WPD -1.78 1.54 -5.00 -0.30 cal position in the group without compared to the group with
AOBG–PD 1.87 0.93 0.45 3.50 maxillary posterior discrepancy. The overbite was smaller, and
AOBG–WPD 1.90 1.10 0.20 4.96
anterior lower facial height was increased in the group without
Lower anterior OBCIG–PD 67.99 4.88 60.55 78.64
maxillary posterior discrepancy, but when the facial height ratio
facial height OBCIG–WPD 69.31 3.85 59.25 75.58
was used instead of lineal measurements no differences were
OBCIIG–PD 70.54 5.69 62.90 82.90
OBCIIG–WPD 73.44 5.12 60.56 84.67 found in all groups. Therefore it was considered that maxillary
OBCIIIG–PD 70.37 4.18 62.87 76.80 posterior discrepancy is not associated with facial height ratio.
OBCIIIG–WPD 74.27 2.55 71.58 78.70 Rather it seems to be more influenced by mandibular plane incli-
AOBG–PD 67.56 6.18 57.00 80.00 nation, SNA angle, and A′P′.
AOBG–WPD 67.28 2.30 62.70 70.16 The open bite groups presented a SOB (23), including some
Facial height OBCIG–PD 60.73 3.04 55.27 65.93 features like a negative overbite, mandibular plane hyperdiver-
ratio OBCIG–WPD 62.50 3.22 57.11 67.25 gency, and counterclockwise inclination of the palatal plane.
OBCIIG–PD 58.50 3.41 51.12 63.18
The differences between the groups were clearly significant with
OBCIIG–WPD 59.70 3.23 50.66 63.72
respect to the skeletal facial growth pattern and maxillary poste-
OBCIIIG–PD 59.84 2.36 56.79 64.40
rior discrepancy. Some important variables were not considered
OBCIIIG–WPD 60.52 1.65 56.97 62.87
AOBG–PD 64.81 2.80 59.63 69.90 including features related with the individual’s intrinsic craniofa-
AOBG–WPD 65.22 4.32 57.01 72.84 cial development and facial size that could influence the evalu-
ated vertical measurements. However, the vertical facial pattern
OBCIG, open bite Class I group; OBCIIG, open bite Class II group; OBCI- was based on skeletal (FMA, ODI, and facial height ratio) and
IIG, open bite Class III group; AOBG, adequate overbite group; PD, posterior one dental (OB) variables. It could be argued that this may be an
discrepancy; WPD, without posterior discrepancy. oversimplification of the complexity of craniofacial growth, but
there is not a universally accepted classification method for verti-
cal facial patterns. FMA is among the most used by the clinicians.
but when considering the facial height ratio not differences were The impact of using other vertical facial pattern classification tool
found in all groups (Table 5). was not addressed in this study.
Through a PCA it was determined that ANB and ODI, as well In order to obtain comparable groups in subjects with open bite,
as SNA, A′P′ and A′6′, equally A′6′ and ratio, were significantly the authors sought controls with the same vertical and sagittal skel-
associated in this sample (Table 6). Therefore from the following etal characteristics, varying only in the condition of maxillary poste-
variables SNA, SNB, ANB, APDI, ODI, FMP A′P′, A′6′, and ratio rior discrepancy, so that the effect of maxillary posterior discrepancy
only SNA, ANB, FMP A′P′, and ratio were used in the multivariate could be isolated as much as possible from other variables. In addi-
analysis. tion, two other control groups with a skeletal Class I, without open
A MANCOVA test simultaneously assessed first and second bite, and with different maxillary posterior discrepancy conditions
maxillary molar vertical position, overbite, lower anterior facial were also used. It was considered that these groups represent ideal
height, and facial height according to several cephalometric vari- parameters to be contrasted.
ables was completed. The SNA angle, maxillary posterior discrep- Maxillary posterior discrepancy was identified as present or
ancy as a continuous variable (A′6′/A′P′) and gender significantly absent based on two radiographic criteria, the first method was
modified the height of the first and second molar. The overbite only associated with the third molar’s eruption pattern, while the
256 European Journal of Orthodontics, 2016, Vol. 38, No. 3

Table 5. Differences for maxillary molar vertical position, overbite, lower anterior facial height, and facial height ratio according to the grouping.

95% confidence interval

Measurement Group P Mean difference, WPD − DP Lower Upper

Maxillary first molar vertical position OBCIG–PD 0.631 −0.28 −1.48 0.91
OBCIG–WPD
OBCIIG–PD 0.025* 1.27 0.16 2.37
OBCIIG–WPD
OBCIIIG–PD <0.001* 2.46 1.60 3.32
OBCIIIG–WPD
AOBG–PD 0.176 1.03 −0.49 2.55
AOBG–WPD
Maxillary second molar vertical position OBCIG–PD 0.797 −0.17 −1.51 1.17
OBCIG–WPD
OBCIIG–PD 0.035* 1.14 0.08 2.21
OBCIIG–WPD

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OBCIIIG–PD <0.001* 3.49 2.37 4.61
OBCIIIG–WPD
AOBG–PD 0.109 1.67 −0.40 3.74
AOBG–WPD
Overbite OBCIG–PD 0.043* −0.92 −1.81 −0.02
OBCIG–WPD
OBCIIG–PD 0.039* −0.89 −1.74 −0.04
OBCIIG–WPD
OBCIIIG–PD 0.748 0.19 −1.03 1.42
OBCIIIG–WPD
AOBG–PD 0.940 0.02 −0.73 0.79
AOBG–WPD
Lower anterior facial height OBCIG–PD 0.396 1.31 −1.79 4.42
OBCIG–WPD
OBCIIG–PD 0.095 2.74 −0.50 5.99
OBCIIG–WPD
OBCIIIG–PD 0.005* 3.93 1.27 6.59
OBCIIIG–WPD
AOBG–PD 0.870 −0.28 −3.77 3.20
AOBG–WPD
Facial height ratio OBCIG–PD 0.108 1.76 −0.40 3.93
OBCIG–WPD
OBCIIG–PD 0.232 1.20 −0.79 3.20
OBCIIG–WPD
OBCIIIG–PD 0.377 0.68 −0.88 2.24
OBCIIIG–WPD
AOBG–PD 0.760 0.40 −2.31 3.13
AOBG–WPD

OBCIG, open bite Class I group; OBCIIG, Open bite Class II group; OBCIIIG, open bite Class III group; AOBG, adequate overbite group; PD, posterior dis-
crepancy; WPD, without posterior discrepancy.
*Significant independent t-test.

second method refers to the quantity of available space for their
eruption. The method utilized to diagnose maxillary posterior dis-
crepancy has been previously reported in the literature (5) and
uses a ratio between the space from point A′ to mesial of the first
superior molar, in relation to the space from point A´ to the pos-
terior most point of the maxillary tuberosity; when this ratio is
increased, the chances of the molars find space in the upper arch
is diminished. In general terms, all groups with PD had smaller
A′P′ space which reduced the possibility that all the molars could
erupt normally. Simultaneously, the amount of space available for
posterior teeth eruption was decreased in the group with PD. This
is corroborated by ratios A′6′/A′P′ increased in cases of maxillary
posterior discrepancy compared to their controls. One potential
problem with this ratio based method is that it does not consider
the eruption direction from the maxillary third molar. This can
generate false positives or negatives (Table 3). In some cases, there
could be available space for eruption (and the ratio indicated no
presence of maxillary posterior discrepancy), but the mesioan-
gualted eruption pattern could create the impaction (false nega-
tive). In other cases there could be enough available space for the
third molar eruption (even if the ratio indicated maxillary pos-
terior discrepancy), but with a good maxillary third molar erup-
tion pattern (false positive). Based on this, it was decided to only
consider the primary maxillary discrepancy as visually determined
by the two calibrated examiners, and not the proposed by Sato
(6) as diagnostic criteria for the grouping of the individuals in the
different categories.
No significant differences were found in Class I open bite and
control group. This may imply that the maxillary posterior dis-
crepancy in this malocclusion group may not have much influence.
L. E. Arriola-Guillén et al. 257

Table 6. Principal component analysis to reduce the number of Table 7. MANCOVA assessing maxillary molar vertical position,
variables under study. overbite, lower anterior facial height, and facial height ratio based
in fixed factors and co-variables.
Component
Dependent variable Fixed factors and co-variables P
Variables 1 2 3 4
Maxillary first molar vertical Corrected model <0.001*
SNA −0.034 0.820* −0.109 0.397* position Intercept <0.001*
SNB −0.742 0.590* 0.071 0.193 SNA 0.002*
ANB 0.913* 0.130 −0.207 0.182 ANB 0.313
APDI −0.930 0.092 0.105 −0.090 FMP 0.099
FMP 0.406 −0.275 0.159 0.783* A′P′ 0.092
A´P´ 0.098 0.766* −0.324 −0.007 Ratio (A′6′/A′P′) 0.013*
A´6´ 0.407 0.631* 0.590* −0.148 Gender 0.004*
Ratio 0.348 0.101 0.903* −0.156 Maxillary second molar Corrected model <0.001*
ODI 0.644* 0.274 −0.391 −0.458 vertical position Intercept <0.001*
SNA 0.010*
Component 1: bone sagittal and vertical component; Component 2: maxil- ANB 0.051

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lary component; Component 3: posterior discrepancy component; Compo- FMP 0.309
nent 4: mandibular inclination component. A′P′ 0.098
*Related. Ratio (A′6′/A′P′) 0.001*
Gender 0.001*
Overbite Corrected model <0.001*
Conversely significant findings were found in other malocclusion Intercept 0.133
groups. A statistically, but not clinically (1 mm), significant increase SNA 0.286
in the molar vertical position was found in the Class II open bite ANB 0.950
group without maxillary posterior discrepancy. However, this dif- FMP <0.001*
ference was larger and clinically significant (3 mm) in the Class III A′P′ 0.610
open bite group also without maxillary posterior discrepancy. Ratio (A′6′/A′P′) 0.129
Gender 0.358
These findings nevertheless contradict the previously proposed
Lower anterior facial height Corrected model <0.001*
hypothesis. Another possible hypothesis is that in the group with
Intercept <0.001*
maxillary posterior discrepancy, the pressure from the erupting SNA 0.007*
upper third molar may generate a major mesial displacement of ANB 0.717
the second molar roots with a concurrent simultaneous distal rota- FMP <0.001*
tion of the associated crowns, that in cases of severe inclination by A′P′ 0.002*
maxillary posterior discrepancy would decrease the molar height. Ratio (A′6′/A′P′) 0.929
However, the quantification of this effect was not evaluated in Gender <0.001*
this study. Facial height ratio Corrected model <0.001*
Furthermore, previous studies (11, 12) that evaluated the molar Intercept <0.001*
SNA 0.010*
vertical position did not differentiate if the subjects presented poste-
ANB 0.949
rior discrepancies or not. In general terms it is not enough to point
FMP <0.001*
out that the third molar was present or not, since this may or may A′P′ 0.023*
not generate a posterior discrepancy depending on available space Ratio (A′6′/A′P′) 0.262
and the eruption pattern. Gender 0.092
Finally, it can be suggested that knowledge of a maxillary
posterior discrepancy has significant importance when treatment *Significant MANCOVA test.
planning. In cases with an inadequate space for maxillary third
molar eruption or an unfavourable angulation, the extraction
Conclusions
of this tooth is a viable alternative to allow compensate of the
molar’s angulation. Nevertheless, maxillary posterior discrepancy
1. The vertical position of upper molars is not associated with
seems not to be of any influence over the extrusion of maxillary
maxillary posterior discrepancy in open bite or adequate over-
second or first molars, as well as alterations of the facial vertical
bite Class I groups. Differences were observed in the open bite
dimensions.
Class II group, but with little clinical impact.
Some limitations were identified for this study. First, the sample
2. The SOB Class III group without maxillary posterior discrepancy
size evaluated by group, despite using a sample size calculation,
had an increased upper molar vertical position. This difference can
was relatively small in the subgroups (7–8 individuals in some sub-
be considered clinically significant.
groups). A significantly different individual case could have biased
3. The maxillary posterior discrepancy is not associated with over-
any group measurements in a significant form. Second, skeletal
bite, lower anterior facial height or facial height ratio in subjects
anterior open bite in adult patients can have three main causes:
with or without SOB and different sagittal skeletal relationships.
Posterior maxillary growth excess; mandibular ramus growth defi-
ciency or anterior maxillary growth deficiency. These causes were
not individually assessed in the current sample. In general popula- Supplementary material
tion the most common cause of an open bite is posterior maxillary Supplementary material is available at European Journal of
growth excess. Orthodontics online.
258 European Journal of Orthodontics, 2016, Vol. 38, No. 3

References 12. Kucera, J., Marek, I., Tycova, H. and Baccetti, T. (2011) Molar height and
dentoalveolar compensation in adult subjects with skeletal open bite. The
1. Tweed, C. (1963) Treatment planning and therapy in the mixed dentition.
Angle Orthodontist, 81, 564–569.
American Journal of Orthodontics, 49, 881–906.
13. Ribeiro, G.L., Regis, S. Jr., da Cunha, T.M., Sabatoski, M.A., Guariza-
2. Moyers, R.E. (1973) Handbook of Orthodontics. Mosby Year Book, Chi-
Filho, O. and Tanaka OM. (2010) Multiloop edgewise archwire in the
cago, IL, 3rd edn.
treatment of a patient with an anterior open bite and a long face. Ameri-
3. Steiner, C.C. (1960) The use of cephalometrics as an aid to planning and
can Journal of Orthodontics and Dentofacial Orthopedics, 138, 89–95.
assessing orthodontic treatment. American Journal of Orthodontics,
14. Schendel, S.A., Eisenfeld, J., Bell, W.H., Epker, B.N. and Mishelevich, D.J.
46,721–735.
(1976) The long face syndrome: vertical maxillary excess. American Jour-
4. Tanaka, M.M. and Johnston, L.E. (1974) The prediction of the size of
nal of Orthodontics, 70, 398–408.
unerupted canines and premolars in a contemporary orthodontic popu-
15. Kim, Y.H. and Vietas, J.J. (1978) Anteroposterior dysplasia indicator:
lation. Journal of the American Dental Association (1939), 88, 798–
an adjunct to cephalometric differential diagnosis. American Journal of
801.
Orthodontics, 73, 619–633.
5. Sato, S. (1991) An Approach to the Treatment of Malocclusion in Consid-
16. Kim, Y.H. (1974) Overbite depth indicator with particular reference to
eration of Dentofacial Dynamics (In Japanese). Torin Books, Tokyo.
anterior open-bite. American Journal of Orthodontics, 65, 586–611.
6. Sato, S. (1987) Alteration of occlusal plane due to posterior discrepancy
17. Celar, A.G., Freudenthaler, J.W., Celar, R.M., Jonke, E. and Schneider, B.
related to development of malocclusion—introduction to Denture Frame
(1998) The Denture Frame Analysis: an additional diagnostic tool. Euro-
Analysis. Bulletin of Kanagawa Dental College, 15, 115–123.
pean Journal of Orthodontics, 20, 579–587.

Downloaded from https://academic.oup.com/ejo/article/38/3/251/2599926 by guest on 16 June 2023

7. Sato, S. and Suzuki, Y. (1988) Relationship between the development of
18. Arnett, G.W., Jelic. J.S., Kim, J., Cummings, D.R., Beress, A., Worley, C.M.
skeletal mesio-occlusion and posterior tooth-to-denture base discrepancy.
Jr., Chung, B. and Bergman, R. (1999) Soft tissue cephalometric analysis:
Journal of Japanese Orthodontic Society, 47, 796–810.
diagnosis and treatment planning of dentofacial deformity. American Jour-
8. Sato, S., Motoyanagi, K., Suzuki, T., Imasaka, S. and Suzuki, Y. (1998)
nal of Orthodontics and Dentofacial Orthopedics, 116, 239–253.
Longitudinal study of the denture frame and its relationship with the
19. Steiner, C.C. (1953) Cephalometrics for you and me. American Journal of
development of skeletal malocclusions. Journal of Japanese Orthodontic
Orthodontics, 39, 729–755.
Society, 47, 186–196.
20. Janson, G., Crepaldi, M.V., de Freitas, K.M., de Freitas, M.R. and Janson, W.
9. Sato, S., Takamoto, K. and Suzuki, Y. (1988) Posterior discrepancy and devel-
(2008) Evaluation of anterior open-bite treatment with occlusal adjustment
opment of skeletal Class III malocclusion: its importance in orthodontic cor-
American Journal of Orthodontics and Dentofacial Orthopedics, 134,10–11.
rection of skeletal Class III malocclusion. Orthodontic Review, 2, 16–29.
21. McNamara, J.A. Jr. (1984) A method of cephalometric evaluation. Ameri-
10. Tanaka, E.M. and Sato, S. (2008) Longitudinal alteration of the occlusal
can Journal of Orthodontics, 86, 449–469.
plane and development of different dentoskeletal frames during growth.
22. Jarabak, J.R. and Fizzel, J.A. (1972) Technique and Treatment with Light
American Journal of Orthodontics and Dentofacial Orthopedics, 134,
Wire Appliances. CV Mosby, St Louis, MO, 2nd edn.
602.e1–611.e1; discussion 602–603.
23. Kuitert, R., Beckmann, S., Van Loenen, M., Tuinzing, B. and Zentnere, A.
11. Arriola-Guillén, L.E. and Flores-Mir, C. (2014) Molar height and inci-
(2006) Dentoalveolar compensation in subjects with vertical skeletal dys-
sor inclinations on adult subjects with skeletal open bite Class II and
plasia. American Journal of Orthodontics and Dentofacial Orthopedics,
III. American Journal of Orthodontics and Dentofacial Orthopedics, 145,
129, 649–657.
325–332.