ORTHODONTICS

CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Adil Osman Mageet1a*
1
Department of Orthodontics, MBR University, Hamdan Bin Mohamed College of Dental Medicine, Dubai, UAE

PhD, BDS, CES, MSc (Orthodontics), M.Orth.RCSEd, FDS.RCSEd, Associate Professor

a

Received: July 2, 2016

Accepted: July 4, 2016
Available online: August 12, 2016

Cite this article:

Mageet AO. Classification of Skeletal and Dental Malocclusion: Revisited. Stoma Edu J. 2016;3(2):205-211.

ABSTRACT

Introduction: The orthodontic dental classification used datedes for more than 100 years. The skeletal
and dental classification of malocclusion has an important role in diagnosis and treatment planning. The
aim of this study is to facilitate the grouping of skeletal and dental malrelationships and to build an ac-
curate diagnosis and to suggest treatment planning.
Material and method: The main orthodontic classification systems for skeletal and dental relationship
were reviewed.
Results: The proposed skeletal and dental classification proved detailed accuracy and focus on relating
the categories with the suggested treatment planning. The new modification of the skeletal and dental
classification explained clearly the occlusal relationship and helped in setting treatment strategies.
Conclusions: The present skeletal and dental classification is faster, accurate and easily applicable clini-
cally and dealt with the shortcoming of the previous classification systems. It also helped in the sugges-
tion of orthodontic treatment protocols.
Keywords: orthodontic malocclusion, skeletal classification, dental classification.

1. Introduction Maxillary incisors retrusion; Division 4: Bimaxillary

In 1930 Simon was the first to relate the dental protrusion. Skeletal Class II: Distal mandibular
arches to the face and cranium in the three planes development in relation to the maxilla. The profile
of space: Frankfurt horizontal plane (F-H plane), is prognathic (Convex). He subclassified skeletal II
also called (E-EP). Or-Po plane. Vertical: Attraction into: Class II/1: Narrow maxillary arch with crowding
or Abstraction; Orbital plane (Perpendicular to in the canine region; Class II/2: Lingually Inclined
F-H plane at the margin of the bony orbit), antero- maxillary incisors, the laterals may be normal or
posterior: Protraction or Retraction; Median proclined. Skeletal Class III: Over growth of the
sagittal plane (The MSP is determined by points mandible with obtuse mandibular angle. The
approximate1.5cm apart on the median raphe profile is retrognathic profile (Concave)2.
of the palate. The raphe median plane passes Scholar Edward Hingley Angle (1899) classified
through these two points at right angles to the F-H Orthodontic malocclusion in the mesio-distal
plane), transverse: Contraction or Distraction1. relationship of teeth. His classification is based
on the maxillary permanent 1st molar where he
2. Material and Method considered it as the key ridge and accordingly he
Salzmann in 1950 was the first to classify the classified the molar relationship into class I, II and
underlying skeletal structure, and he stated that III using Roman numbers and subdivided class II
Skeletal Class I: Purely dental with the bones into division 1 and 2 using Arabic numbers3.
of the face and jaws being in harmony with Angle’s classification has a number of drawbacks,
one another and with the rest of the head. The such us: the Maxillary permanent 1st molar is
profile is orthognathic (Straight). Then he added not a fixed anatomic point (key ridge); cannot
divisions to the skeletal I, Division 1: Local mal- classify for mesially drifted, impacted, missing or
relationship of incisors, canines and premolars; extracted Maxillary permanent 1st molars; did not
Division 2: Maxillary incisor protrusion; Division 3: consider single tooth malposition; cannot classify

*Corresponding author:
Associate Prof. Dr. Adil Osman Mageet, PhD, BDS, CES (France), MSc (Orthodontic, UK), M.Orth.RCSEd, FDS.RCSEd
Department of Orthodontics, Hamdan Bin Mohamed College of Dental Medicine, MBR University, Dubai, UAE , P.O.Box 505097 Dubai UAE
Tel: +971 4 424 8631 ; Fax: +971 4 424 8687, e-mail: Adil.mageet@hbmcdm.ac.ae

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 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

the primary teeth, in addition did not classify maxillary centrals and proclined laterals, or both
the skeletal relationship and did not predict the central and lateral incisors are retroclined where it
etiological factors, so revisiting was always needed. is grouped under Class II / 2.
In 1915 Deway’s modified Angle’s Class I and Class III: where the mandibular incisor edges lie
III malocclusion by segregating malposition of anterior to the cingulum plateau of the maxillary
anterior and posterior segments, CL I: type 1 central incisors14.
(Crowding of Max anterior teeth); type 2 (Proclined The BSI classification was more accurate in grouping
Max incisors); type 3 (Max incisors are in cross- the malocclusion15. The British method of overjet
bite); type 4 (Posterior cross-bite); type 5 (Mesial and overbite assessment15 and the quantitative
drift of molars). CL II (no modifications). CL III: technique proposed by Katz (1992b)16 developed
type 1: (Edge to edge bite), type 2: (Crowded over the years, proved to be more amenable to
Mandibular incisors and lingual to Max incisors); reproduction than Angle’s classification11,15.
type 3: (Underdeveloped crowded Maxillary arch In the Du et al. study (1998) in their study where
and a well developed Mandibular arch)4. four orthodontic faculty members at one dental
Lischer in 1933 further modified Angle’s classification school classified 25 dental casts according to the
by giving substitute names; CL I (Neutrocclusion); classification systems of Angle, Katz, and the British
CL II (Distocclusion); CL III (Mesiocclusion). He Incisor Classification11. The dental casts were
also proposed terms to designate individual tooth selected from a pool of 350 pretreatment graduate
malposition, Mesio-version (Mesial to normal orthodontic cases and were those deemed the
position); Disto-version (Distal to normal position); most atypical. The results demonstrated that Katz’s
Linguo-version (Crossbite); Labio-version (Increased classification was more reliable than both the
OJ); Infra-version (Submerged tooth); Supra-version Angle and the British one. Angle’s classification
(Super-erupted); Axio-version (Tipped tooth); Torsi- was the least reliable of the three methods.
version (Rotated tooth); Trans-version (Transposed
tooth)5. 4. Discusion
4.1. Skeletal classification: revisited
3. Results In the author’s view orthodontic skeletal classification
Ackerman and Proffit (1969) introduced a very could be grouped into class I (straight), class II
comprehensive system of classification using the (convex) and class III (concave).
Venn diagram. The classification considered five Salzmann’s classification did not specify that the
characteristics and their inter-relationships were problem is due to maxillary protrusion, mandibular
assessed, namely: alignment, profile, transverse, retrusion or a combination of both.
class and overbite6. The same is true for the concave profile, his method
Angle’s classification still seems to be the most did not specify that the problem is due to maxillary
popular tool for classification of malocclusion, retrusion, mandibular protrusion or a combination of
despite its well-known disadvantages7. Hans both.
et al., (1994), noted the inadequacy of Angle’s The author agrees with all scholars that skeletal
classification when they were unable to classify class I has a straight profile (Fig. 1), which explains
approximately 7% of a large sample (n=4309) of homogeneous relationship between the maxilla
models in the Broadbent-Bolton study8. Another and mandible, or in another terms they grow in
study conducted by Baumrind et al., (1996) on unison. In cases of Skeletal I the problem is dental
whether to extract in orthodontic treatment, malrelationships. It is present in two planes, the
found that 28-33% disagreement among the 5 vertical and the transverse planes where the antero-
participating orthodontist9. posterior plane is normal or within average.
Katz (1992a) showed an inter-examiner There is always a question which arises in cases where
disagreement of 49% among 270 orthodontists it is straight to mild convexity or mild concavity.
using Angle’s classification10. The percentage The author’s view is to enlarge the description of
agreement of Katz’s technique proved superior skeletal I so as to include the mild convexity and mild
to that of the classical Angle’s classification11,12. concavity as far as it is confirmed by the ANB angle.
Rinchuse found Angle’s classification to be The range of skeletal I would be straight to mild
limited because it is a system of discrete classes convexity or mild concavity.
as compared to continuous transition of maxillo- Salzmann’s Skeletal II (convex profile) did not
mandibular dental arches in the sagittal plane13. indicate either whether it is due to protruded maxilla
The British Standard Institute (BSI) classified dental or retruded mandible or a combination of both.
malocclusion in 1983 according to the maxillary In the present study, Skeletal II could be of three
and mandibular incisors relationship. types; type 1 (retruded mandible), type 2 (protruded
Class I: When the mandibular incisor edges lie or maxilla) and type 3 (combination of both). (Fig. 1)
are below the cingulum plateau of the maxillary The same applies for Class III (concave profile),
incisors. again Salzmann did not specify either whether it is
Class II: When the mandibular incisor edges lie due to maxillary retrusion or mandibular protrusion.
posterior to the cingulum plateau of the maxillary According to my explanation it could be due to
incisors, the maxillary incisors could be proclined maxillary retrusion (Skeletal III type 1), or mandibular
where it is classified as Class II / 1, or retroclined protrusion (Skeletal II type 2), or a combination of both

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 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Twenty-two responses supported the notion that

subdivision refers to the Class II side, 8 responses
said that it refers to the Class I side, 3 responses
supported neither view, and 1 response indicated
that in the program not everyone could agree on
the meaning of subdivision.
Although the prevailing belief appears to be
that subdivision indicates the side with a molar
malocclusion, the orthodontic community does
not have a consistent standard, and it is time to
resolve this controversy18.
Due to the low reliability of the Angle method, a
reconsideration is needed to develop the older
classification.
The reconsideration is done in the antero-posterior
and on both sides, where molar classification is
more elaborated.
In this revision class IV, V and VI are generated which
helped in treatment planning and suggesting
treatment protocol.
Skeletal Class III malocclusion was strongly
differentiated from the other sagittal classes,
specifically in the mandible, as calculated through
Björk and Jarabak analysis19.
A review article emphasizes the need to identify
Figure 1. Skeletal classification genetic and environmental factors that cause or
contribute risk to skeletal malocclusion and the
(skeletal III type 3), which gives detailed explanation possible association with other medical conditions
aiding in diagnosis and treatment planning. (Fig.1) to improve assessment, prognosis and therapeutic
approaches20.
4.2. Occlusal Classification: revisited Accurate and detailed classification is always
The BSI and Katz’s classification deal with the needed to drive an accurate diagnosis and
partial description of the malocclusion. treatment plan.
The British system of classification related to the The author followed the BSI incisor classification
anterior teeth where it needs further elaboration with modifications for class II and III, accepts canine
while Katz’s system focuses on the premolar classification and modifies molar classification,
occlusion and ignore the canines and molar which are further elaborated for the ease of
classification. diagnosis and accuracy of treatment planning in
Snyder and Jerrold (2007), have concluded that orthodontics.
a modification of Angle’s system that is more 4.3. Incisor’s Classification (Fig. 2)
descriptive is needed, after they have sent an Class I: When the mandibular incisor edges lie or
e-mail survey to the department chair or the are below the cingulum plateau of the maxillary
program director of every orthodontic program in incisor (BSI, 1983), the overjet is 2-4 mm.
the United States, Canada, and Puerto Rico (n = 80). Class II: When the mandibular incisors edges lie
The survey included photos of models placed into posterior to the cingulum plateau of the maxillary
¼ cusp, ½ cusp, and ¾ cusp distal occlusions, and incisors (BSI, 1983). It could be:
the participants were asked to classify them by • Class II/1: Proclined maxillary incisors with
selecting from a list of terms or writing one of their overjet more than 4 mm.
own. • Class II/2a: Retroclined maxillary centrals and
They were also asked whether they thought that proclined laterals, or both central and lateral
the Angle molar classification was adequate for incisors are retroclined with normal or reduced
communication and diagnosis. overjet.
Fourty surveys were completed and returned. The • Class II/2b: Retroclined maxillary centrals and
results showed a variety of terminology being proclined laterals, or both central and lateral
taught, and most educators do not use Angle’s incisors are retroclined but with increased overjet.
classification as he defined it. Class III: When the mandibular incisors edges lie
About half of the respondents were dissatisfied anterior to the cingulum plateau of the maxillary
with the Angle molar classification system17. incisors (BSI, 1983).
In 2002 Siegel conducted 57 surveys which were • Class III type 1: Positive overjet but less than 2
mailed to department chairs in the United States, mm.
asking them to identify the definition to which their • Class III type 2: Edge to edge incisors relation-
orthodontic residency program subscribes; 34 ship.
questionnaires were returned. • Class III type 3a: Negative overjet.

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 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

• Class III type 3b: Negative overjet but patient and 1st premolar).
can make edge to edge (pseudo Class III). Class II: Distal slope of the maxillary canine
The author believes that incisor classification could occludes or contacts the mesial slope of the lower
also be used for esthetic considerations. canine.
4.4. Canine’s Classification (Fig. 3) Class III: The mandibular canine is displaced
Class I: mesial incline of the upper canine overlaps anterior to the maxillary canine with no
the distal slope of the lower canine (The maxillary overlapping.
canine occludes between the mandibular canine

Figure 2. Incisor’s classification

Figure 3. Canine’s classification

4.5. Molar’s Classification (Fig. 4) 1st permanent molar lie posterior to the mesio-
The author modified Angle’s classification to buccal cusp of the Maxillary 1st permanent molar.
include different molar relationship on both sides • Class II ½ unit: When the maxillary 1st permanent
and renamed the subdivision. molar cusps occlude with the mandibular 1st
Class I: The mesio-buccal groove of the mandibular permanent molar cusps in an edge to edge.
1st permanent molar occludes with the mesio- • Class II full unit: When the maxillary 1st permanent
buccal cusp of the Maxillary 1st permanent molar. molar cusps occlude anterior to the mandibular 1st
Class II: The mesio-buccal groove of the mandibular permanent molar.

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 CLASSIFICATION OF SKELETAL AND DENTAL MALOCCLUSION: REVISITED

Class III. The mesio-buccal groove of the jaw relationships is a practical tool in determining
mandibular 1st permanent molar lies anterior to the soft tissue harmony. Soft tissue measurements
mesio-buccal cusp of the Maxillary 1st permanent provide a sagittal differential diagnosis in relation
molar. to Angle’s classification of malocclusion21.
Relationship between right and left buccal A suggested treatment protocol is easily derived
occlusion is further grouped to resolve the notion from the present classification skeletal (Table 1)
of subdivisions: and dental (Table 2).
Class IV. Class I on one side and Class II (either ½
unit or full unit) on the other side. This varies from mechanics to mechanics, but the
Class V: Class I on one side and Class III on the idea is to help the undergraduate to understand
other side. orthodontic diagnosis and treatment planning and
Class VI: Class III on one side and Class II (either ½ for postgraduate residents and orthodontists to
unit or full unit) on the other side. formulate accurate stable orthodontic treatment
Analyzing profile photographs to evaluate sagittal results.

Figure 4. Molar’s classification

Table 1. Suggested treatment protocol for skeletal bases

Suggested Treatment Protocol

There is a harmonious relationship antero-posteriorly; the problem is either in the vertical or trans-
Skeletal I verse plane. Advice surgical correction if needed.

Functional appliance (growing children) or mandibular surgery (adult or syndromic patients e.g.
Type 1
Pierre Robin).

Type 2 Headgear (children and adolescents) or maxillary surgery for adults.

Here the treatment could of combination, functional [removable e.g. twin block or fixed e.g. Forsus],
Skeletal II Type 3 Headgear, camouflage with the extraction of upper 1st premolars alone or in combination with lower
2nd premolars or Bi-maxillary orthognathic surgery.

Functional appliances e.g. Yanagisawa Class III shield (YC3)19.

Type 1 Palatal expansion ± facemask (Delaire, reverse pull headgear by Nakamura) advised before the age
of 10 years.20

Type 2 Mandibular excess is treated with surgery e.g. Bilateral sagittal split osteotomy (BSSO).

Skeletal III Here the treatment could of combination:

functional (Yanagisawa,YC3), palatal expansion ± facemask, camouflage with the extraction of lower
Type 3
1st premolar and upper 2nd premolars, or extraction of a single lower central incisor, Bi-maxillary
orthognathic surgery (Le Fort I ± BSSO) or genioplasty in some cases.

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 Table 2. Suggested treatment protocol for dental malocclusion
Suggested Treatment Protocol

Non extraction:
stripping, expansion, derotation, uprighting or distalisation
Extraction:
CLASSIFICATION OF SKELETAL
Class I malocclusion AND
U/L 4s, U/L 5s, U/LDENTAL
6s, U/L 7s or aMALOCCLUSION: REVISITED
symmetric extraction e.g. right U/L 4s + left U/L 5s, U/L 6s
+ U/L 4s or 5s, single tooth extraction.
Non extraction:
Distalisation with headgear
Type 1 Extraction:
4s, (U 4s + L 5s), (U/L 6s), (U/L 7s) or a symmetric extraction e.g. (right U/L 4s + left U/L
5s), (U/L 6s + U/L 4s or 5s). or a single U4.
Always advise non extraction treatment using a headgear + Nudger or an intra-oral distal-
izer.
Type 2a If crowding is to be relieved by extraction, then it is advisable to extract the 2nd premolar
than the 1st premolar because of difficulty of space closure.
Class II malocclusion
Transfer the case to CL II/1 and treat accordingly.
Headgear + Nudger
Type 2b Orthognathic surgery treatment (proclined upper anteriors and retroclined lower anteriors-
decompensation: plan for surgery)
Camouflage with stripping lower arch and proclining upper teeth.
Type 1
Expansion of upper arch ± fixed appliance therapy.
Expansion of upper arch ± fixed appliance therapy with CL III elastics.
Extraction of lower 1st premolars and upper 2nd premolars + U/L fixed orthodontic therapy
Type 2 with CL III elastics.
Expansion of upper arch + extraction of a single lower central incisor + U/L fixed orthodon-
tic therapy with CL III elastics.
Expansion of upper arch ± fixed appliance therapy with CL III elastics.
Extraction of lower 1st premolars and upper 2nd premolars + U/L fixed Orthodontic therapy
Type 3a with CL III elastics.
Class III malocclu- Expansion of upper arch + extraction of a single lower central incisor + U/L fixed orthodon-
sion tic therapy with CL III elastics.
Expansion of upper arch ± fixed Orthodontic therapy.
Extraction of lower 1st premolars and upper 2nd premolars + U/L fixed Orthodontic therapy.
Type 3b
Expansion of upper arch + extraction of a single lower central incisor + U/L fixed Orth-
odontic therapy with CL III elastics.

5. Conclusion The author recommends further study on

Incisor, canine and molar classification should methods of classification and establishing
always be used accurately to diagnose and to plan orthodontic treatments’ protocols.
the final occlusion.
A final class I incisor and canine relationship at the Acknowledgments
end of treatment is always the aim so to provide The author declare no conflict of interest related to
long term stability while molar relationship could this study. There are no conflicts of interest and no
be class I, II (full unit) or III relationship. financial interests to be disclosed.

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19. Rodriguez-Cardenas YA, Arriola-Guillen LE, Flores-Mir C. Björk- 2015; 76(4): 294-304.
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Adil Osman MAGEET

PhD, BDS, CES (France), MSc (Orthodontic, UK), M.Orth.RCSEd, FDS,
RCSEd, Associate Professor, Consultant Orthodontist
Department of Orthodontics
Hamdan Bin Mohamed College of Dental Medicine
MBR University, Dubai, UAE , P.O.Box 505097 Dubai, UAE

CV
Licensed by CPQ (UAE), the Saudi Commission for Higher Specialties and the Sudanese Medical Council as
a consultant orthodontist. I treat orthodontic problems from mild to complex cases with a variety of treatment
options, removable, functional, fixed, clear orthodontics, orthodontic part of orthognathic surgery and cleft
lip / palate cases. I also manage snorers and mild to moderate obstructive sleep apnoea hypopnoea patients
using intra-oral appliances. I have been working as an orthodontist for the past 20 years. Examiner of the
RCSEd for the 2nd part MFDS and the M.Orth. Reviewer of the Oral Hygiene and Dental Management Journal.
Published many articles in reputable journals.

Questions
An 11 year-old female patient with a chief complaint “my upper teeth are crowd-
ed”. She presented a Class II/2 incisor relation, class II ½ unit canines and molars,
on Skeletal II base deep bite and centre line shift. Lateral cephalometry shows
SNA of 84°, SNB 78° ANB of 6° and decreased maxillary mandibular plane angle.
The treatment would be:
qa. Extraction of 14 and 24 with upper and lower fixed Orthodontics treatment;
qb. Distalisation of upper 16 and 26 by HG and a Nudger appliance with upper and lower fixed
qc. Extraction of 14, 24, 35 and 45 with upper and lower fixed Orthodontics;
qd. Transfer the case to CL II/1 and treat with functional appliance and treat accordingly.

What is the treatment of choice in case of skeletal Class III cases is with reduced anterior
cranial base and retruded maxilla in a 9 year-old boy.
qa. Rapid palatal expansion alone;
qb. Functional appliance and fixed Orthodontics;
qc. Rapid palatal expansion and Face mask;
qd. Orthognathic surgery by Le Fort I osteotomy.

How do you define Class II/2b incisor relation from the article:
qa. Upper incisors retroclined laterals are procline;
qb. All upper anteriors are retroclined with increased overjet;
qc. All upper anteriors are retroclined with a deep bite;
qd. Upper incisors retroclined laterals are procline.

Define skeletal Class III type 3 from the paper:

qa. Retruded maxilla;
qb. Retruded maxilla with protruded mandible;
qc. Straight profile;
qd. Protruded maxilla.

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