Braz J Oral Sci. January/March 2005 - Vol.

4 - Number 12

Cephalometric evaluation of Class III

malocclusion by a modified Tweed-
Merrifield analysis
Mayury Kuramae1
Maria Beatriz Borges de Araújo Magnani2 Abstract
João Sarmento Pereira Neto2 A sample of cephalograms of 20 White Brazilian subjects (9 males,
Darcy Flávio Nouer3 11 females) of 17-36 years old, who presented Class III dental
Paulo Roberto Aranha Nouer4 malocclusion was selected and traced. Results showed statistically
1
MDS, DDS Student, FOP/UNICAMP significant differences among genders for FMIA, SNA, SNB, 1.NB,
2
DDS, Professor of the Pediatric Clinic, FOP/ PFH, AFH, 1-NB and mandibular length. Anteroposterior jaw relation,
UNICAMP as shown by SNA and SNB, presented a maxilla correctly positioned,
3
Chairman, Department of the Pediatric Clinic, as well as mandibular protrusion, which was related to a normal
FOP/UNICAMP upper jaw length and an augmented lower jaw length. A vertical
4
Coordinator of the Postgraduation Course, CPO
growth pattern prevailed, as evidenced by FMA, AFH, PHF and
- São Leopoldo Mandic.
OCC.PL. Angle. The Z Angle, total chin and upper lip failed to
clearly show any disturbance of facial esthetics and IMPA, 1.NA, 1-
NA, 1.NB and 1-NB revealed dental compensation.

Received for publication: March 08, 2004 Key Words:

Accepted: November 29, 2004 cephalometrics, class III malocclusion, mandibular prognatism.

Correspondence to:
Mayury Kuramae
Rua Major Moura Campos, 792 – Bairro Alto
CEP 18601-040 – Botucatu – SP
Tel: (14) 38823315
E-mail: mayury@bol.com.br

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Braz J Oral Sci. 4(12): 680-684 Cephalometric evaluation of Class III malocclusion by a modified Tweed-Merrifield analysis

Introduction an Ethics in Human Research Committee - FOP/UNICAMP.

The Class III malocclusion is characterized by a lower jaw The cephalometric tracings were performed by the researcher
mesially positioned in relation to upper jaw, mainly skeletal who was responsible for each subject. Anatomical reference
origin, and its etiology is basically hereditary1. It presents structures were marked, and lines and planes were drawn in
a low prevalence, though this varies among studied order to generate Tweed-Merrifield Analysis 10 and other
regions. In White subjects, it comprehends only 1-2%, measures11-12 (Figure 1, Table 1).
but it is more frequent in Asian countries, such as Japan,
where it affects about 4-13% of the population2. In Brazil,
a prevalence of about 2.93% is estimated3.
Class III malocclusion does not imply on a typical facial
pattern, and several skeletal profiles can be associated to
it and be grouped according to various extents of upper
and lower jaw retrognatism4-6. Lower jaw size and position
may vary, thus generating a variety of Class III types.
Compensation of cephalometric measures such as a low
gonial angle while in presence of a large cranial base would
neutralize a large lower jaw7.
The most significant difference between Class III
malocclusion and normal occlusion lies: in the ANB angle,
specially due to the protruded lower jaw; in a shorter
cranial base which, when rotated, may result in a relative
maxillary deficiency, and in an obtuse gonial angle where
the temporal fossa is located relatively farther in an
anteroposterior direction 1.
Class III malocclusion presents some striking
characteristics, such as dental compensation rate,
labialization of upper incisors and lingualization of inferior
incisors, especially in permanent dentition. In most of the
subjects who show a Class III facial pattern, a facial
Fig. 1 - Cephalometric measures of modified Tweed-Merrifield analysis
deficiency is shown in the zygomatic region, especially in
the infraorbital area, indicating some degree of midface
Table 1 – Cephalometric measures of modified Tweed-
deficiency; the excessive lenght of the chin-neck line
Merrifield analysis
shows the mandibular prognatism5-6,8-9.
The purpose of this study was to perform a research based Cephalometric measures
on the Tweed-Merrifield Analysis10 and other measures11-
12
related to Class III malocclusion, in order to determine 1. FMA 8. Z Angle 15. AFH
mean values for these measures, and verify the occurrence 2. FMIA 9. 1.NA 16. Maxillary length
of sexual dimorphism, as well as to interrelate all acquired 3. IMPA 10. 1.NB 17. Mandibular length
measures. 4. SNA 11. AO-BO 18. 1-NA
5. SNB 12. Upper lip 19. 1-NB
Material and Methods 6. ANB 13. Total chin 20. FHI=PFH/AFH
About 400 orthodontic outpatient files were examined from 7. OCC.PL 14. PFH
the archives of the service of scientific documentation,
Postgraduation Course in Orthdodontics of the College
of Dentistry, FOP/UNICAMP, all belonging to White In order to determine the cephalometric tracing error, 20
Brazilian subjects of 17-36 years and 4 months old. Twenty of the radiographs were twice traced after 10 days, and
of all examined files met the following criteria: Class III the arithmetic mean was calculated13.
molar and canine relationship, confirmed by dental casts The mean values underwent to a variance analysis and
and cephalometric measures such as FMA (< 30°) and Van der Warden test for non-parametric data at
SN.Gn (<68°), showing a vertical growth pattern. The significance level of 5%.
management of the outpatient files followed the standards
of the Health Ministry and the resolution number 196/96 Results
of the National Health Council and was also approved by Gender-related statistic data which were evaluated during

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 Braz J Oral Sci. 4(12): 680-684 Cephalometric evaluation of Class III malocclusion by a modified Tweed-Merrifield analysis

Table 2 – General mean values of cephalometric measures.

Cephalometric Error Limits of reliable interval

measures mean SD standard 95%

inferior superior

FMA (º) 35.13 4.479 0.708 33.69 36.56

FMIA (º) 66.85 7.665 1.212 64.40 69.30
IMPA (º) 77.98 5.279 0.835 76.29 79.66
SNA (º) 81.11 1.041 0.165 80.78 81.45
SNB (º) 83.95 1.142 0.181 83.58 84.32
ANB (º) -2.838 1.211 0.191 -3.225 -2.450
OCC.PL. (º) 12.13 4.421 0.699 10.71 13.54
Z Angle (º) 77.10 8.360 1.322 74.43 79.77
1.NA (º) 30.40 1.171 1.134 28.11 32.69
1.NB (º) 20.70 6.422 1.015 18.65 22.75
AO-BO (mm) -9.675 3.668 0.580 -10.85 -8.502
Upper lip (mm) 13.08 1.913 0.303 12.46 13.69
Total chin (mm) 14.43 1.999 0.316 13.79 15.06
PFH (mm) 49.23 4.865 0.769 47.67 50.78
AFH (mm) 76.83 5.583 0.883 75.04 78.61
FHI (%) 0.637 0.0544 0.0086 0.620 0.655
Mx. length (mm) 54.70 1.224 0.193 54.31 55.09
Md. length (mm) 126.4 7.755 1.226 123.9 128.9
1-NA (mm) 7.138 2.239 0.354 6.421 7.854
1-NB (mm) 5.688 1.584 0.250 5.181 6.194

Table 3 - Mean values of cephalometric measures for both this study are displayed at Table 2 and 3, Graph 1, 2, 3 and
genders 4. According to the variance analysis, there were
statistically significant differences between genders
FEMALE MALE related to the following variables: FMIA, SNA, SNB, 1.NB,
CEPHALO-
METRIC PFH, AFH, 1-NB and mandibular lengths (Table 3).
MEASURES mean SD mean SD

FMA 34.36 0.977 36.06 1.011

FMIA 68.64 8.594 64.67 5.861
SNA 80.59 0.996 81.75 0.691
1.NB 18.36 6.169 23.56 5.649
Total chin 14.45 1.845 14.39 2.227
PFH 46.95 3.645 52.00 4.802
AFH 73.82 4.148 80.50 4.926
Mand. length 123.7 8.102 129.7 6.029
1-NA 7.409 2.239 6.806 2.257
1-NB 5.023 1.607 6.500 1.138
FHI 0.633 0.0562 0.643 0.0532
Graph 1 - Mean values and standard deviation of angle
cephalometric measures for both genders.

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Braz J Oral Sci. 4(12): 680-684 Cephalometric evaluation of Class III malocclusion by a modified Tweed-Merrifield analysis
Graph 2 - Mean values and standard deviation of ANB for both
genders.
Graph 3 - Mean values and standard deviation of linear cephalometric
measures for both genders.
Graph 4 - Mean values and standard deviation of AO-BO for both
genders
Discussion
The mean FMA for males was 36.06º, and 34.36º for
females, which showed no sexual dimorphism. As this
angle indicates the growth direction of the lower face,
such results indicate a non-favorable growth vector and
a bad prognosis14. The FMIA angle showed a mean value
of 64.67º for males and 68.64º for females; such gender
differences were statistically significant. IMPA presented
a mean value of 79.28º and 76.91º for males and females,
respectively, and no statistically significant difference
between genders. Proper facial esthetics and balance are
only achieved when lower incisors are upright on basal
bone with an IMPA variation14 of 90º ± 5º. The mean value
observed for IMPA was quite elucidative on lingual
inclination of the lower incisors, in relation to the
mandibular plane, as a means of compensating the Class
III malocclusion1,4,6,8,15-16.
For males, the mean value of SNA of 81.75º was observed
to be statistically different from the mean value of 80.9º
for females. These results showed that the position of
upper jaw, as related to the cranial base, was close to the
standards. Mean values of SNB were 84.11º for males and
83.82º for females, presenting statistical difference between
genders. Vertical growth displaced the pogonion into a
lower position, while anteroposterior growth leaded it
anteriorly. These growth directions can result either in
prognatism or retrognatism, depending on each facial
pattern. ANB mean value was -2.36º for males, and -3.23º
for females, and presented no significant differences. This
means a mandibular protrusion relating to the cranial base,
since the upper jaw was in a normal position. Results then
demonstrated an evident mandibular protrusion 1,4 , and
also showed that, for this sample, while the upper jaw was
correctly positioned relating to the cranial base, the lower
jaw was the responsible for the Class III malocclusion.
Maxillary lengths were observed to be larger for males
(54.89mm) than for females (54.55mm), and mandibular
lengths were also statistically different for males
(129.70mm) and females (123.70mm). Thus, though the
upper jaw was correctly positioned, its length, as well as
the mandibular length, was not on normal standards.
The mean values for the Z Angle17, for males (73.44º) and
females (80.09º) were not significantly different. These
values showed angular values almost similar to normal
standards; this might be explained by the vertical facial
type of these subjects, which displaced pogonion
downward and backwards. Mean values for upper lip of
this sample were 13.89mm for males and 12.41mm for
females, and also did not show gender dimorphism. The
soft tissues represent upper lip and total chin and reflect
the subjacent skeletal structures.
AO-BO measured -9.55mm for males and -9.77mm for
females, showing no gender-related differences. The Wit’s
appraisal, according to the resulting values, queries the
ANB angle 18 , though our results evidence the great
anteroposterior divergence of both jaws, which excluded
possible measuring errors resulting from cephalometric
point variations and rotational effect of the jaws.
The mean values for PFH (posterior facial height)19 were
52.00mm for males and 46.95mm for females, showing
statistically significant difference between genders. Mean
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Braz J Oral Sci. 4(12): 680-684 Cephalometric evaluation of Class III malocclusion by a modified Tweed-Merrifield analysis

values of AFH (anterior facial height)19 were 80.50mm for
males and 73.82mm for females, showing statistically
significant difference between genders. The higher value
of AFH in the Class III malocclusion showed mandibular growth
and a clockwise rotation, what would result in a vertical growth
pattern with steep horizontal planes5,6. In the case of FHI (facial
height index)20, mean values for males (0.64) and females
(0.63) did not show significant difference between genders.
There were no significant differences between genders
for 1-NA, which has shown values of 6.81mm for males
and 7.41mm for females. The resulting mean values for
1.NA were 28.89º for males and 31.84º for females. Both of
these measures reflected a dental compensation to
protrusion and inclination of the upper incisors that occur
in Class III malocclusion 1,5-6,8-9 . 1-NB presented mean
values of 6.50mm for males and 5.02mm for females,
showing sexual dimorphism. 1.NB presented mean values
of 25.36º for males and 18.36º for females, indicating higher
values for males and, thus, the lingual inclination in
females was greater.
In this study the occlusal plane (OCC.PL.) angle was 12.5º
for males and 11.82º for females, showing no significant
difference. The steeper of all occlusal planes showed a greater
divergence, caused by the clockwise rotation of the jaws, thus
presenting a greater challenge to orthodontic therapeutics.
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Acknowledgments
To FAPESP, for providing a master degree scholarship
(process nº 00/04351-2).

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