10.

5005/jp-journals-10021-1170
ORIGINAL ARTICLE
Preeti Bhardwaj et al

Assessment of Sagittal Skeletal Discrepancy:

A Cephalometric Study
1
Preeti Bhardwaj, 2DN Kapoor, 3MS Rani

ABSTRACT

Introduction: Sagittal discrepancies are more commonly encountered in day to day practice. Angular and linear measurements have been
incorporated into various cephalometric analyses to help the clinician for diagnosing this anteroposterior discrepancy.
The purpose of the study was to assess sagittal skeletal discrepancy with Beta angle and to compare and correlate the Beta angle with
angular measurements—ANB angle, AFB angle and with linear measurements –AO-BO, AF-BF and App-Bpp.
Materials and methods: Pretreatment lateral cephalograms of 100 young adults (50 men and 50 women) were divided into skeletal Class I, II
and III. The data was subjected to statistical analysis using the statistical software namely SPSS 11.0 and Systat 8.0.
Results: The results of the present study showed that the mean Beta angle is 32.54 ± 0.86. Significant negative correlation exists between Beta
angle with other angular measurements (ANB angle, AFB angle) and with linear measurements (AO-BO, AF-BF and App-Bpp). Sex difference
was statistically insignificant.
Conclusion: Increase and decrease of Beta angle from normal demonstrate skeletal Class III and Class II discrepancy respectively. There was
negative correlation between Beta angle and other linear and angular measurements for assessing sagittal skeletal discrepancy.
Keywords: Sagittal discrepancies, Beta angle, ANB angle, AFB angle, AO-BO, AF-BF, App-Bpp.

How to cite this article: Bhardwaj P, Kapoor DN, Rani MS. Assessment of Sagittal Skeletal Discrepancy: A Cephalometric Study. J Ind Orthod
Soc 2013;47(4):262-265.

INTRODUCTION plane 11,12,14 and change in the angulation of the functional

occlusal plane.15 Freeman16 described a method to evaluate
Angular and linear measurements have been incorporated into
the anteroposterior denture base relationship that aimed at
various cephalometric analyses for diagnosing these
eliminating point N for a more accurate evaluation. Although
anteroposterior discrepancies. Downs1 introduced the A-B
the AFB angle may not be affected by the vertical displacement
plane angle. A few years later, Riedel2 recommended use of
of point A, it may be affected by the vertical positioning of
SNA, SNB, and ANB angles. The ANB angle has become the
point B. Therefore, the AFB angle does not describe
most commonly used measurement since that time.3 Steiner4
exclusively the anteroposterior jaw relationship. Chang5
opined with Reidel2 that SN plane could be used as reference
introduced AF-BF distance which eliminates N point and
line because both points are osseous structures that are easily
vertical displacement of points A and B. Nanda and Merrill15
located in lateral cephalograms. He suggested the angle ANB—
introduced App-Bpp and selected as the best indicator of
was an important indicator of skeletal sagittal discrepancy. It
sagittal maxillomandibular relationship and is predictive of
has been claimed that the ANB angle is influenced by several
the true sagittal jaw relation. But its inclination is highly
other factors. 5-12 The Wits appraisal was introduced by
variable, making it difficult to establish mean values for the
Jacobson9 to overcome problems related to the ANB angle2,13
norm.15 Each one of the reference planes had their own
but it had problem in accurate identification of the occlusal
limitations. Chong Yol Baik17 introduced Beta angle would
be especially valuable whenever, previously established
1
Reader, 2Professor, 3Professor and Head cephalometric measurements, such as ANB angle and the Wits
1
Department of Orthodontics, KD Dental College, Mathura, Uttar appraisal, cannot be accurately used because of their
Pradesh, India dependence on varying factors. Hence, the present study is
2
Department of Orthodontics and Dentofacial Orthopedics, Kothiwal undertaken to assess Beta angle and to compare and correlate
Dental College and Research Centre, Moradabad, Uttar Pradesh, India
3
Department of Orthodontics and Dentofacial Orthopedics, VS Dental
it with other angular and linear measurements for assessing
College and Hospital, Bengaluru, Karnataka, India sagittal skeletal discrepancy.
Corresponding Author: Preeti Bhardwaj, Reader, Department of
Orthodontics, KD Dental College, Mathura, Uttar Pradesh, India MATERIALS AND METHODS
e-mail: prety.dr@gmail.com Lateral cephalograms of 100 young adults (50 men and 50
women) were chosen randomly for the study from the
Received on: 17/1/12 Department of Orthodontics VS Dental College and Hospital.
Accepted after Revision: 22/11/12 The cephalometric tracing was done onto acetate tracing paper

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Assessment of Sagittal Skeletal Discrepancy: A Cephalometric Study

Beta angle, ANB, AFB, A0-B0, AF-BF, App-Bpp (Fig. 1). The
data was subjected to statistical analysis using the software
namely SPSS 11.0 and Systat 8.0. Microsoft Word and Excel
were used to generate graphs and tables.

Assessment of Error
Total of 20 lateral cephalograms were selected at random and
were retraced to evaluate the intra- and interoperator reliability.
Statistically insignificant difference was found between the
first and second measurements.

Fig. 1: Cephalometric measurements showing: (1) Beta angle, (2) ANB
angle, (3) AFB angle, (4) AO-BO linear measurement, (5) AF-BF linear
measurement, (6) App-Bpp linear measurement
using 4H pencil. Based on ANB angle and profile patients were
divided into Class I skeletal pattern group (normal), skeletal
Class II and III. All patients selected were Indian, 18 years and
above in age, had never undergone orthodontic treatment. The
landmarks, planes and angles were included in the study were
RESULTS
Table 1 shows the mean value for Beta angle, AFB angle, AO-
BO, AF-BF, App-Bpp in the skeletal Class I, II and III.
Statistically insignificant sex difference in the mean value of
the Beta angle was observed within the groups. Comparison
of Beta angle in the Class I and II shows that Beta angle in
Class II is less (29.50 ± 0.74) when compared to Class I (32.54
± 0.86) with p = 0.019 (Table 2), however difference is
significant, when the effective size is computed by using
Cohen ‘d’ and the value is 3.8 which is a very large effect.
Comparison of Beta angle in Class I and III sample (Table 2)

Table 1: Mean of Beta angle, AFB, AO-BO, AF-BF and App-Bpp in skeletal Class I, II and III

Parameters Classification Male Female Total

(n = 50) (n = 50) (n = 100)
Mean SE Mean SE Mean SE

Beta angle Class I 32.38 1.62 32.63 1.03 32.54 0.86

(degrees) n = 23
Class II 28.81 1.39 30.05 0.74 29.50 0.74
n = 54
Class III 40.11 1.32 40.40 0.51 40.17 1.04
n = 23
AFB angle Class I 5.81 1.58 4.73 0.77 5.11 0.73
(degrees) n = 23
Class II 7.85 0.75 8.57 0.54 8.25 0.45
n = 54
Class III 0.89 0.99 –0.50 0.32 0.59 0.78
n = 23
AO-BO (mm) Class I 0.94 0.93 0.70 0.59 0.78 0.49
n = 23
Class II 3.23 0.75 2.38 0.46 2.76 0.42
n = 54
Class III –4.81 1.24 –3.80 1.75 –4.59 1.03
n = 23
AF-BF (mm) Class I 8.06 2.29 5.57 0.75 6.43 0.94
n = 23
Class II 10.54 1.07 10.88 0.82 10.73 0.65
n = 54
Class III 1.25 1.30 –0.50 0.32 0.87 1.03
n = 23
App-Bpp (mm) Class I 6.06 1.92 4.93 0.76 5.33 0.81
n = 23
Class II 8.77 0.88 10.40 0.78 9.68 0.59
n = 54
Class III –1.03 1.13 –1.50 0.50 –1.13 0.88
n = 23

The Journal of Indian Orthodontic Society, October-December 2013;47(4):262-265 263

Preeti Bhardwaj et al
Table 2: Comparison of Beta angle in Class I, II and III
Pair Student ‘t’ ‘p’ value
Class I vs Class II 2.403 0.019
Class I vs Class III 5.675 <0.001
Table 3: Pearson correlation of Beta angle with ANB angle
AFB angle, AO-BO (mm), AF-BF (mm) and App-Bpp (mm)
Pair Pearson correlation
Beta angle vs ANB angle –0.648**
Beta angle vs AFB angle –0.650**
Beta angle vs AO-BO –0.621**
Beta angle vs AF-BF –0.588**
Beta angle vs App-Bpp –0.674**
Beta angle vs AO-BO –0.621**
Beta angle vs AF-BF –0.588**
Beta angle vs App-Bpp –0.674**
**Strongly significant; Up to 0.1: trivial correlation; 0.1-0.3: small
correlation; 0.3-0.5: moderate correlation; 0.5-0.7: large correlation;
0.7-0.9: very large correlation; 0.9-1.0: nearly perfect correlation;
1: perfect correlation
shows statistically significant difference between Class I
and III sample with p < 0.001 and it is a very large effect (8.03)
according to Cohen ‘d’. Effective size computed by using
Cohen ‘d’ (Table 2). The r-value (Table 3) of Pearson
correlation between Beta angle and ANB angle was –0.648
and Beta angle, AFB angle was –0.650. In the linear
measurements Pearson correlation between Beta angle and
AO-BO (mm) was –0.621, AF-BF (mm) was –0.588, App-
Bpp (mm) was –0.674. It is observed from above that
significant negative correlation between Beta angle and ANB
angle, AFB angle and with linear measurements –AO-BO, AF-
BF and App-Bpp (Table 3). With the increase of Beta angle,
AFB angle, ANB angle AO-BO, AF-BF and App-Bpp decreases.
DISCUSSION
An accurate AP measurement of jaw relationships is critically
important in orthodontic treatment planning. A new
measurement Beta angle was given by Chong Yol Baik and
Maria Ververidou.17 Beta angle17 uses three skeletal landmarks
–points A, B, and the apparent axis of the condyle (point C)
precisely tracing the condyle and locating its center is not
always easy. For that reason, some clinicians might hesitate
to use the Beta angle. To accurately use that angle, the
cephalometric X-rays must be high quality. It is then much
easier for the clinician to follow the posterior surface of the
ramus and locate the head of the condyle. The apparent axis of
the condyle (point C) described by Baik and Ververidou17 has
an advantage over condylion point that very precise tracing of
the condyle is not really necessary. The clinician can visualize
and approximate the center with a minimum error in Beta angle
as long as that point is within 2 mm of its actual location. If
center of condyle is located within 2 mm radius, then Beta
angle is affected less than 1°, making it still acceptable. A
Beta angle indicating a Class II or III skeletal pattern does not
264
determine which jaw is prognathic or retrognathic. If the
clinician needs to diagnose which jaw has abnormal growth or
whether the deformity is due to the growth of both jaws, further
cephalometric data are needed. The results of the present study
are in accordance of Baik and Ververidou,17 who also reported
that there was statistically insignificant difference between
sexes. The results of the present study are in accordance with
Baik and Ververidou17 for Class I and III Beta angle, whereas
the Beta angle for Class II skeletal pattern shows a variation.
According to Chang5 the mean AFB angle for male sample
was 2.72 ± 2.27, the mean for female sample was 3.35 ± 2.28
which is different from the present study. The variability may
be due to the racial variation. The mean AO-BO (mm) –Wits
appraisal is shown in Table 1 Jacobson9 gave the Wits reading
in females having normal occlusion as 0, whereas in males as
–1. Chang5 suggested the mean of AO-BO (mm) for male
sample as –1.03 ± 2.14, the mean of AO-BO (mm) for female
sample as –1.14 ± 2.32 is contrary to the present study. The
difference may be attributed to racial variation. Del Santo18
concluded from his study that Wits appraisal was influenced
by occlusal plane angle. There was a tendency for lack of
consistency between ANB and Wits assessments in high
occlusal plane angle patients and lack of certainty in at least
one measurement. In the low occlusal plane angle patients,
both assessments were consistent. Lisa et al19 suggested that
the Wits appraisal in Chinese population was –4.9 and
–4.5 mm being the normal values for male and female children
respectively which is different from this study. Rotberg
et al20 studied the correlation between the Wits appraisal and
angle ANB and came to the conclusion that there were no
strong or predictable correlations between the Wits appraisal
and the ANB angle. This is easily understood because they did
not fully analyze all the variables affecting angle ANB.
Jarvinen10 found that correlation of the ANB angle with
the other measurements for determining the apical base
relationship was relatively low, with coefficients of
correlation ranging from 0.61 to 0.64. The correlation of the
‘Wits’ measurement with other indicators was also low (0.41-
0.62) the highest correlation being between ‘Wits’
measurement and the ANB angle. The correlation between the
AXD angle and A-D’ distance, however, was high (0.93) which
might indicate that the effect of inter-individual variation in
anterior face height on the AXD angle is not very significant.
Nanda and Merrill 15 suggested mean App-Bpp (mm) as
5.2 ± 2.9 mm in white women and 4.8 ± 3.6 mm for white
men. The App-Bpp measurement was close to their study.6
They compared App-Bpp with the ANB angle, the AO-BO and
nasion perpendicular in 50 randomly selected persons to
determine how these measures compared in diagnosing the
sagittal maxilla mandibular relation. In those persons
determined to be Class I and II by the A to B measurement on
palatal plane, the Wits appraisal was found to be biased in favor
of Class III relationships, while the measures to nasion
perpendicular and ANB angle were seen to be variable. All
these measures were able to accurately describe Class III

Assessment of Sagittal Skeletal Discrepancy: A Cephalometric Study
skeletal relations between the jaws. In this study there was a
large negative correlation between Beta angle with ANB angle,
AFB angle (Table 3), AO-BO (mm), AF-BF (mm) and App-
Bpp (mm) in the present study. With the increase of Beta angle
the other linear and angular measurements decreases and vice
versa.
Oktay3 found statistically significant positive relationships
among ANB, Wits, AF-BF and APDI. On the basis of his result
he concluded that the AF-BF measurement was affected by
the inclinations of the Frankfort horizontal plane and the
occlusal plane more than the Wits appraisal. Otkay3 further
suggested that the mean AF-BF for male sample as 8.62 ±
4.72 mm, where as the mean for female sample was 7.30 ±
4.37 mm. In the present study the mean AF-BF for male sample
was 8.06 ± 2.29 and for female sample it was 5.57 ± 0.75
which are close to Judy et al21 and Oktay.3 Judy et al21 suggested
the mean AF-BF for male sample as 6.5 ± 4.2 mm, the mean
for female sample was 5.2 ± 2.9 mm. Kapoor22 and others
reported that JYD angle showed very high level of significance
when correlated with AXB and ANB angle. Kapoor23 and others
further stated that A-D distance was more reliable as compared
to Wits appraisal. Beta angle enriches the current
Cephalometric tools available and enables better diagnosis and
treatment planning for patients having skeletal dysplasia. But
a clinician should not totally rely on one measurement
therefore an orthodontist should assess cases with other
cephalometric analyses as possible for reevaluation and
diagnosis for effective treatment planning.
CONCLUSION
1. Irrespective of sex average Beta angle was 32 ± 1.6 in
skeletal Class I where increase and decrease of Beta angle
was directly related to skeletal Class III and II dysplasia.
2. Increase and decrease of Beta angle from normal
demonstrate skeletal Class III and II respectively.
3. Correlation between Beta angle and ANB, AFB and AO-
BO, AF-BF and App-Bpp demonstrate that with the increase
of Beta angle anteroposteriorly skeletal dysplasia
decreases significantly.
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