YIJOM-3564; No of Pages 6

Int. J. Oral Maxillofac. Surg. 2016; xxx: xxx–xxx

http://dx.doi.org/10.1016/j.ijom.2016.12.001, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Orthodontic camouflage versus P. Martinez1, C. Bellot-Arcı́s1,

J. M. Llamas2, R. Cibrian1,
J. L. Gandia1, V. Paredes-Gallardo1

orthognathic surgery for class

1
Stomatology Department, Faculty of
Medicine and Dentistry, University of
Valencia, Valencia, Spain; 2Stomatology
Department, Orthodontics, University of

III deformity: comparative Seville, Seville, Spain

cephalometric analysis
P. Martinez, C. Bellot-Arcı́s, J. M. Llamas, R. Cibrian, J. L. Gandia, V. Paredes-
Gallardo: Orthodontic camouflage versus orthognathic surgery for class III
deformity: comparative cephalometric analysis. Int. J. Oral Maxillofac. Surg. 2016;
xxx: xxx–xxx. # 2016 International Association of Oral and Maxillofacial Surgeons.
Published by Elsevier Ltd. All rights reserved.

Abstract. The objective of this study was to compare different cephalometric

variables in adult patients with class III malocclusions before and after treatment, in
order to determine which variables are indicative of orthodontic camouflage or
orthognathic surgery. The cases of 156 adult patients were assessed: 77 treated with
orthodontic camouflage and 79 treated with orthodontics and orthognathic surgery.
The following cephalometric variables were measured on pre-treatment (T1) and
post-treatment (T2) lateral cephalograms: sella–nasion–A-point (SNA), sella–
nasion–B-point (SNB), and A-point–nasion–B-point (ANB) angles, Wits appraisal,
facial axis angle, mandibular plane angle, upper and lower incisor inclination, and
inter-incisal angle. There were statistically significant differences in cephalometric
variables before and after treatment between the two groups. The percentage of
normal pre-treatment measurements in the camouflage orthodontics group was
30.7%, which worsened slightly to 28.4% post-treatment. However in the group
receiving surgery, this was 24.5% pre-treatment, improving to 33.5% after surgery.
SNA, SNB, Wits appraisal, lower incisor inclination, and inter-incisal angle showed
differences between the two groups before and after treatment. Wits appraisal, Key words: class III; orthodontic camouflage;
lower incisor inclination, and inter-incisal angle were indicative of one or other orthognathic surgery; dental decompensation.
treatment. Upper and lower incisor decompensation in both groups did not reach
ideal values, which impeded complete skeletal correction in 52% of surgical cases. Accepted for publication 6 December 2016

The prevalence of class III malocclusion
varies considerably between Asians
(12%), Europeans (1.5–5.3%), and Cau-
casians (1–4%).1,2 The A-point–nasion–
B-point (ANB) angle is one of the most
widely used variables for determining
skeletal class,3 although some authors
consider that Wits appraisal is the most
useful parameter for identifying patients
who can then be treated by orthodontic
treatment alone or in combination with
orthognathic surgery.4–6 Wits is the dis-
tance in millimetres from A point to B
point projected and measured on the
occlusal plane.7

0901-5027/000001+06 # 2016 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Martinez P, et al. Orthodontic camouflage versus orthognathic surgery for class III deformity:
comparative cephalometric analysis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.12.001
YIJOM-3564; No of Pages 6

2 Martinez et al.

Dentoalveolar compensation before

treatment varies depending on the skeletal
discrepancies. Correct positioning of the
lower incisors has been considered an
important treatment objective before
orthognathic surgery.8 Some authors have
stated that certain skeletal class III patients
treated with orthognathic surgery showed
more severe skeletal discrepancies and
greater compensation in incisor inclina-
tion before surgery than others.9–11
Non-growing patients with moderate
class III skeletal malocclusion and accept-
able facial aesthetics can benefit from
camouflage orthodontic treatment, while
patients with severe class III skeletal mal-
occlusion can benefit from orthognathic
surgery.10,12,13 When surgical treatment is
planned, an optimal result will depend on
incisor decompensation.9,14 Some of these
patients fail to achieve an ideal ANB angle
or an optimal result due to incomplete
decompensation of the upper14,15 and
lower incisors resulting from a lack of
vestibular bone support or excessive
retroclination of the lower incisors before
treatment.9,14,16
Studies comparing class III patients
treated by orthodontics alone or by orthog-
nathic surgery are scarce. The aims of this
study were (1) to compare different ceph-
alometric variables in adult patients with
class III malocclusion between a group
treated with camouflage orthodontics
and another treated with orthodontics
and orthognathic surgery, in order to de-
termine which variables are indicative of
one or other treatment, and (2) to evaluate
the repercussions of incisor decompensa- Fig. 1. Cephalometric measurements.
tion on the skeletal correction of surgical
cases.
Department of the Faculty of Medicine and formed the surgery group (group S; 30
and Dentistry, University of Valencia, female, 49 male). Of these latter patients,
Materials and methods
Spain, between January 2005 and April 30 underwent maxillary advancement,
The protocol for this cross-sectional ob- 2015 were selected to take part in the 16 underwent mandibular setback, and
servational human study was approved by study. A number of additional patients 33 underwent bimaxillary surgery.
the Ethics Committee on Human Research were recruited to compensate for possible Initial (T1) and final (T2) lateral cepha-
of the University of Valencia, Spain. dropouts. lograms were selected for the cephalomet-
Rights were protected by the Institutional Inclusion criteria established prior to ric study. Fourteen cephalometric hard
Review Board. This study followed crite- commencement were the following: age tissue landmarks per radiograph were dig-
ria established in the Declaration of over 20 years at the beginning of treat- itized and nine measurements were
Helsinki for research involving human ment, Wits appraisal 3 mm, good quality obtained. These measurements were based
subjects, and also conformed to STROBE initial and final lateral radiographs, on the cephalometric analyses of Steiner17
guidelines. patients who had not undergone any and Tweed18 (Fig. 1 and Table 1). The
Power analysis showed that a sample extractions, and patients without any cephalometric analysis software used was
size of at least 60 patients would provide congenital deformity, syndrome, or cleft NemoCeph 11.3.1 (Nemotec, Madrid,
an 80% probability of detecting a medium palate. Spain).
effect (f = 0.2) associated with an interac- Following the application of the inclu- To characterize the reproducibility of
tion term, using an analysis of variance sion criteria, a sample of 156 patients was measurements, intra-observer and inter-
(ANOVA) model at a confidence level of selected (mean age 23.2  2.6 years, observer coefficients of variation (CV)
95% and assuming a correlation of 0.45 range 20.5–31.1 years). Seventy-seven were calculated. To quantify the intra-
among repeated measurements. had received camouflage orthodontic observer CV, all lateral cephalometric
Three hundred and forty patients who treatment (group C; 36 female, 41 male), radiographs were traced and measured 1
underwent treatment in the Orthodontic while 79 patients had undergone surgery week after the main data collection. All

Please cite this article in press as: Martinez P, et al. Orthodontic camouflage versus orthognathic surgery for class III deformity:
comparative cephalometric analysis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.12.001
YIJOM-3564; No of Pages 6

Camouflage vs. surgery for class III 3

Table 1. Cephalometric measurements, definitions, and mean values.

Measurement Definition Mean value  SD
SNA (8) Angle between S–N and N–A planes 82  2
SNB (8) Angle between S–N and N–B planes 80  2
ANB (8) Angle between N–A and N–B planes 22
Wits (mm) Distance in millimetres from AO to BO on the occlusal plane 1  2 male
0  2 female
Facial axis, FA (8) Angle between S–N and S–Gn planes 66  2
Mandibular plane angle, MPA (8) Angle between S–N and the mandibular plane (Ag–Me) 32  2
Upper incisor inclination, UII (8) Angle between the axis of the upper incisor (UIA–UIT) 110  2
and palatal plane (PNS–ANS)
Lower incisor inclination, LII (8) Angle between the mandibular plane (Ag–Me) and the 90  2
axis of the lower incisor (LIA–LIT)
Inter-incisal angle, IA (8) Angle between the upper incisal axis and the lower incisal axis 132  6
SD, standard deviation; S, sella; N, nasion; A, A-point; B, B-point; O, occlusal plane; Gn, gnathion; Ag, antigonion; Me, menton; UIA, upper
incisor apex; UIT, upper incisor tip; PNS, posterior nasal spine; ANS, anterior nasal spine; LIA, lower incisor apex; LIT, lower incisor tip.

lateral cephalometric radiographs were
traced and measured again by a second
observer. An intra-class correlation coef-
ficient (ICC) was calculated to assess the
reliability of intra- and inter-observer
measurements.
A parametric model was chosen when
checking the normality of the distribution
of variables using the Kolmogorov–Smir-
nov test. Comparisons between groups
were performed with the Student t-test
and ANOVA. Factor comparison was
performed using the x2 test and linear
correlations with Pearson’s r correlation
coefficient and R2 estimation. All mea-
surements were analyzed using the statis-
tics program SPSS v. 15.0 for Windows
(SPSS Inc., Chicago, IL, USA). The stat-
istician was blinded to group assignment.
Results
Measurement reproducibility results
showed an intra-observer CV lower than
the inter-observer CV (1.5% and 2.3%,
respectively). The ICC was 0.981 for
intra-observer measurements and 0.92
for inter-observer measurements.
Table 2 shows the mean and standard
deviation (SD) values for the cephalomet-
ric variables before (T1) and after treat-
ment (T2) and the changes produced as
a result of treatment (difference between
T1 and T2) for the two study groups:
orthodontic camouflage and orthognathic
surgery. Statistically significant differ-
ences were found between the two groups
for Wits appraisal, lower incisor inclina-
tion, and inter-incisal angle (P < 0.05),
due to greater skeletal discrepancy in
the surgery group. Wits appraisal was
identified as being an ideal parameter
for determining surgical treatment. The
sella–nasion–B-point (SNB) angle was
higher in the surgery group than in the
camouflage group, with a clinically signif-
icant difference, but not a statistically
significant difference (P = 0.054). There
was no statistically significant difference
in facial axis or mandibular plane
angle between the groups (P > 0.05).

Table 2. Measurement values (mean  SD) obtained before treatment (T1) and after treatment (T2), and the change during treatment (T2 T1).
T1 T2 T2 T1
Measurement Groupa Ideal value
Sig.
Sig.b Sig.b Sig.b Pearson’s rc (bilateral)
SNA (8) C 82  2 80  4.2 0.438 80.3  4.4 0.002* 0.29  2.1 0.003* 0.883 0.000
S 80.9  4 84.1  4.2 3.20  4.3 0.446 0.015
SNB (8) C 80  2 82  4 0.054 81.2  4.2 0.036* 0.77  1.7 0.984 0.910 0.000
S 84.1  4.2 83.3  3.3 0.79  3.7 0.555 0.002
ANB (8) C 22 1.9  2.3 0.083 1  2.8 0.015* 0.92  1.9 0.000* 0.736* 0.000
S 3.2  3.1 0.8  2.5 4.03  3.3 0.350 0.062
Wits (mm) C 1  2 (M) 7  1.9 <0.0001* 4.7  2.7 0.859 2.28  2.9 0.000* 0.663* 0.000
S 0  2 (F) 11.2  3.2 4.6  2 6.62  4.2 0.225 0.241
FA (8) C 66  2 66.7  3.9 0.749 67.4  4.5 0.132 0.66  1.7 0.226 0.926* 0.000
S 66.4  4.4 65.4  5.3 1  6.9 0.802* 0.000
MPA (8) C 32  2 33.4  5.9 0.426 34.4  6.2 0.384 0.96  1.6 0.616 0.966* 0.000
S 34.8  6.6 37  13.9 2.17  12.3 0.749* 0.000
UII (8) C 110  2 114  5.5 0.388 116.7  9.3 0.933 2.74  9.8 0.514 0.133 0.509
S 112.7  5.5 116.9  7.6 4.20  6.7 0.491 0.007
LII (8) C 90  2 86.2  6 <0.0001* 79.6  8.1 0.035* 6.55  7.4 0.000* 0.490 0.010
S 77.5  8.7 85.4  11.6 7.93  12.3 0.470 0.010
IA (8) C 132  6 133.3  7.7 0.008* 136.1  12 0.042* 2.85  13.4 0.003* 0.137 0.496
S 140  10.4 124.9  25.4 15.07  26.9 0.185 0.338
SD, standard deviation; SNA, sella–nasion–A-point angle; SNB, sella–nasion–B-point angle; ANB, A-point–nasion–B-point angle; M, male; F,
female; FA, facial axis angle; MPA, mandibular plane angle; UII, upper incisor inclination; LII, lower incisor inclination; IA, inter-incisal angle.
a
S, surgery group (n = 79); C, camouflage group (n = 77).
b
Asterisk (*) denotes a statistically significant difference, P < 0.05.
c
Asterisk (*) denotes a statistically significant difference, r > 0.6.

Please cite this article in press as: Martinez P, et al. Orthodontic camouflage versus orthognathic surgery for class III deformity:
comparative cephalometric analysis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.12.001
YIJOM-3564; No of Pages 6

4 Martinez et al.

SNA, sella–nasion–A-point angle; SNB, sella–nasion–B-point angle; ANB, A-point–nasion–B-point angle; FA, facial axis angle; MPA, mandibular plane angle; UII, upper incisor inclination; LII,
48.1 (38)
65.8 (52)

17.7 (14)
41.8 (33)
79.7 (63)
17.7 (14)
13.9 (11)
These measurements were not found to be

11.4 (9)
Above

0 (0)
relevant in the decision to perform sur-
gery, as they were identified as normal and

Surgery group (n = 79)

remained unchanged in the post-treatment
group. Table 2 also shows that there was a

(30)
(16)
(29)

(43)
(43)
(10)
(19)
(39)
(9)
strong correlation between the values in

Norm
both groups before and after treatment.

38.0
20.3
36.7
11.4
54.4
54.4
12.7
24.1
49.4
Positive and statistically significant Pear-
son’s correlation was obtained between
ANB and the inclination of the lower

T2 (after treatment), % (n)

(11)
(11)
(41)
(70)
(22)

(46)
(29)
(3)
(6)
incisor in the surgical group at T1 and

Below
in both groups at T2.

3.8
7.6
13.9
13.9
51.9
88.6
27.9

58.2
36.7
Table 3 shows an overall assessment of
the numbers of individual patients whose
cephalometric variables could be classi-

18.2 (14)
37.7 (29)

41.5 (32)
37.7 (29)
67.5 (52)

37.7 (29)
3.9 (3)

7.8 (6)
Above
fied as below the norm, at the norm, and

0 (0)
above the norm before and after treatment,

Camouflage group (n = 77)

thus evaluating the extent of norm fulfil-
ment. For patients treated by camouflage
orthodontics, 30.7% of the measurements

(26)
(31)
(17)
(15)
(20)
(37)
(11)

(34)
(6)
showed normal values at T1, while at T2

Norm
this value dropped to 28.4%. For patients

33.7
40.2
22.1
19.5
26.0
48.0
14.3

44.1
7.8
treated by orthognathic surgery, 24.5% of
the measurements showed normal values
at T1, while at T2 normal values rose to

(37)
(17)
(57)
(62)
(25)
(11)
(14)
(65)
(14)
Below
33.5%.

48.1
22.1
74.0
80.5
32.5
14.3
18.2
84.4
18.2
Discussion
Table 3. Patient distribution in the below norm (below), norm, and above norm (above) value categories. .

12.7 (10)
65.8 (52)

24.0 (19)
41.8 (33)
49.4 (39)

50.6 (40)
Differences between cephalometric

11.4 (9)
Above

0 (0)
measurements 0 (0)
Comparing cephalometric measurements
Surgery group (n = 79)

between the groups before treatment (T1),

surgery patients showed a more negative
36.7 (29)
30.4 (24)

38.0 (30)
41.8 (33)
30.4 (24)

35.5 (28)
7.6 (6)
Norm

Wits appraisal, greater lower incisor lin-

0 (0)

0 (0)
gual inclination, and a greater inter-incisal
angle, due to greater skeletal discrepancy.
These results are in agreement with those
of various studies by other authors.9–11
T1 (before treatment), % (n)

50.6 (40)

92.4 (73)

38.0 (30)
16.4 (13)
20.2 (16)
88.6 (70)
13.9 (11)
3.8 (3)

100 (79)

The results also confirm the claims of

Below

many researchers that Wits appraisal is

an ideal parameter for differentiating be-
tween class III patients suited to treatment
by orthognathic surgery and those suited
51.9 (40)

37.7 (29)
28.6 (22)
63.6 (49)

27.3 (21)

to treatment by orthodontics alone.4,5

11.7 (9)

1.3 (1)

11.7 (9)
Above

0 (0)

Analyzing differences in values before

Camouflage group (n = 77)

and after treatment, statistically significant

lower incisor inclination; IA, inter-incisal angle.

differences were identified for sella–

nasion–A-point (SNA), ANB, lower inci-
40.2 (31)
29.9 (23)

29.9 (23)
55.8 (43)
22.1 (17)
33.8 (26)
54.5 (42)

sor inclination, inter-incisal angle, and Wits

10.4 (8)
Norm

0 (0)

appraisal. ANB increased in the surgery

group as a result of an increase in SNA, a
finding that contradicts the results of Troy
et al.9 Pre-treatment values for facial axis
48.1 (37)
18.2 (14)
88.3 (68)

32.4 (25)
15.6 (12)
14.3 (11)
54.5 (42)
18.2 (14)

angle and mandibular plane angle were

100 (77)
Below

classified as normal in the surgery group,

and so correction was not a surgical objec-
tive and these values remained unchanged.9
For patients who underwent orthog-
nathic surgery, incomplete decompensa-
Wits (mm)

MPA (8)
ANB (8)
SNA (8)
SNB (8)

tion impeded complete surgical correction

UII (8)
LII (8)
FA (8)

IA (8)

of the jaws, a result similar to those

reported in several other studies.9,14–16

Please cite this article in press as: Martinez P, et al. Orthodontic camouflage versus orthognathic surgery for class III deformity:
comparative cephalometric analysis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.12.001
YIJOM-3564; No of Pages 6
A strong correlation was found between
initial and final values, indicating that the
effect of treatment behaved in a very
similar way for all patients. For variables
corresponding to anteroposterior skeletal
analysis, the correlation was much greater
in cases treated by camouflage orthodon-
tics. Surgery produced changes in values
that were more dependent on treatment
than on the pre-treatment value.9
Correlation between ANB angle and
incisor inclination
The relationship between incisor decom-
pensation and surgical success in class II
surgical-orthodontic cases has been docu-
mented in the literature,19 while there have
been only two studies describing the rela-
tionship between ANB angle and incisor
inclination before treatment in class
III.8,11 The present results indicated no
significant correlation between ANB an-
gle and upper incisor inclination in both
groups. This finding differs from that of
Kim et al.8 However, the present study did
identify a correlation between ANB angle
and lower incisor inclination before treat-
ment, but only in orthognathic surgery
cases, a finding that is in agreement with
those of Kim et al.8 and Ishikawa et al.11
Patient distribution as below the norm, at
the norm, or above the norm before
treatment (T1)
The SNA angle was below the norm in
48.1% of patients treated by orthodontic
camouflage before treatment, indicating
that the SNA value might have little
relevance when it comes to deciding
the treatment plan. This is in agreement
with Guyer et al.20 However, the SNB
angle showed values above the norm in
both groups. SNB did have some rele-
vance for deciding whether to treat with
or without surgery. This finding is in
agreement with Guyer et al.20 and Bettina
and Kiliaridis.21 Wits appraisal was be-
low the norm in all patients. This con-
firms the findings of other authors who
have stated that Wits appraisal is the
most decisive parameter.4,5
Most patients presented increased upper
incisor inclinations, which were more
frequent in the orthodontic camouflage
group. This differed from lower incisor
inclination, which was more frequent in
the surgery group. This confirms the find-
ings of the present study detailed above
and those of Ishikawa et al.11 and Kim
et al.,8 who also reported that the more
negative the ANB angle, the more nega-
tive the lower incisor angle.
Please cite this article in press as: Martinez P, et al. Orthodontic camouflage versus orthognathic surgery for class III deformity:
comparative cephalometric analysis, Int J Oral Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.ijom.2016.12.001
Camouflage vs. surgery for class III
Patient distribution as below the norm, at
the norm, or above the norm after
treatment (T2)
SNA showed similar values in the two
groups and only a third of the sample
presented ideal values. Those with SNB
angles at the norm who underwent orthog-
nathic surgery showed little change as a
result of treatment; this is similar to the
finding of Johnston et al.16 In the present
study, only 36.7% of patients treated with
orthognathic surgery presented ideal ANB
angle values, a percentage similar to that
reported by Johnston et al.,16 but lower
than the percentage (65%) obtained by
Troy et al.9
Upper incisor inclination was the same
and increased in both groups. These results
are similar to those of Troy et al.9 and
Pereira-Stabile et al.14 The incomplete pre-
surgical decompensation of the upper inci-
sors places limitations on maxillary correc-
tion by surgery.9,14,15 This in turn
influences both Wits appraisal values and
SNA, SNB, and ANB angles, which failed
to undergo complete correction.
Lower incisor inclination presented the
opposite situation, as treatment by orthog-
nathic surgery produced vestibular incli-
nation, although the decompensation
remained incomplete in 24.1% of cases,
with 58.2% remaining lingually inclined;
these results are very similar to those of
Pereira-Stabile et al.,14 but are slightly
higher than those of Johnston et al.16 Up-
per and lower incisor decompensation in
both groups did not reach ideal values,
which impeded complete skeletal correc-
tion in 51.9% of surgical cases.
In conclusion, SNA and SNB angles,
Wits appraisal, lower incisor inclination,
and inter-incisal angle showed differences
between the two groups before or after
treatment. Wits appraisal, lower incisor
inclination, and inter-incisal angle were
indicative of orthodontic camouflage or
orthognathic surgery. A correlation be-
tween the ANB angle and lower incisor
inclination before treatment was found,
but only in the cases treated by orthog-
nathic surgery. Upper and lower incisor
decompensation in both groups did not
reach ideal values, which impeded com-
plete skeletal correction in half of the
surgical cases.
Funding
No sources of funding were needed.
Competing interests
The authors declare no conflict of interest.
5
Ethical approval
The protocol of this cross-sectional obser-
vational human study was approved by the
Ethics Committee on Human Research of
the University of Valencia, Spain
(#H1373014083626).
Patient consent
Not required.
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