ORIGINAL ARTICLE

Comparison of dental arch and

mandibular-maxillary base widths
between true and pseudo-Class III
malocclusions
Burcin Akan and Ilknur Veli
Izmir, Turkey

Introduction: The aim of the study was to analyze the morphology of dental arches and skeletal mandibular-
maxillary bases in untreated pseudo-Class III and true Class III malocclusions, by using posteroanterior
radiographs and 3-dimensional digital models. Methods: The records of 50 untreated patients (24 boys and 26
girls between 14 and 16 years of age) with Class III malocclusions were included in this study. They were divided
into 2 groups according to their Class III malocclusion type: true or pseudo-Class III malocclusion. Maxillary skeletal
base, and bigonial and biantegonial widths were measured on posteroanterior cephalograms. Also, maxillary and
mandibular intermolar widths were calculated on 3-dimensional digital models. For the statistical evaluation, the
independent-samples t test was used, and the Pearson correlation coefficient was calculated to determine the
relationship between the dental and skeletal widths. Results: Maxillary intermolar, and bigonial and biantegonial
widths in true Class III malocclusions were significantly larger than those in pseudo-Class III malocclusions
(P \0.05). On the other hand, maxillary skeletal base width in pseudo-Class III malocclusions was significantly
larger than in true Class III malocclusions (P \0.05). Also, mandibular intermolar widths in true Class III
malocclusions were larger than in pseudo-Class III malocclusions, but the difference was not significant
(P .0.05). Significant positive correlations were determined not only between the maxillary and mandibular
molar widths but also between the bigonial and biantegonial widths (P \0.01). Conclusions: The morphologies
of the dental arches and the skeletal mandibular-maxillary bases differ in a significant manner between untreated
pseudo-Class III and true Class III malocclusions. (Am J Orthod Dentofacial Orthop 2017;151:317-23)

A
Class III malocclusion is one of the most difficult
malocclusions to treat, and its prevalences were
reported as 16.8% in the Kenyan population1
and 1.4% in the Danish population.2 Data from the third
National Health and Nutrition Examination Survey
showed that only a fraction of a percentage of all adults
have Class III malocclusions in the United States.3
Among 965 Turkish children, a 3.5% incidence of Class
III malocclusion was found in the region of Konya.4 Gel-
gor et al5 reported that the prevalence of Class III maloc-
clusion is 10.3% in the Turkish population.
From the Department of Orthodontics, Faculty of Dentistry, Izmir Katip Celebi
University, Izmir, Turkey.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Burcin Akan, Department of Orthodontics, Faculty of
Dentistry, Izmir Katip Celebi University, Cemil Meriç Blvd, 6780 St. No: 48, Cigli,
Izmir 35640, Turkey; e-mail, burcin.yksel@gmail.com.
Submitted, February 2016; revised and accepted, June 2016.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.06.039
Class III malocclusions may have an underlying skel-
etal or dental components.6 Skeletal Class III malocclu-
sions are often seen with maxillary retrognathia,
mandibular prognathia, or a combination of these con-
ditions.7 Bell et al8 reported that there is some degree of
maxillary deficiency in addition to the more obvious
mandibular excess for most patients with skeletal Class
III malocclusions. Tweed9 divided Class III malocclusions
into 2 categories: category A for a pseudo-Class III
malocclusion with a normal mandible and an underde-
veloped maxilla, and category B for a skeletal (true) Class
III malocclusion with a large mandible. True Class III
malocclusions may develop as a result of an inherent
growth abnormality, usually accompanied by a Class III
dental malocclusion. Pseudo-Class III malocclusions
are caused by premature occlusal contacts that lead to
functional forward positioning or shifting of the
mandible at centric occlusion. In patients with pseudo-
Class III malocclusion, when the mandible is guided
into a normal centric relationship, a normal overjet or
an edge-to-edge position of the incisors can be
317
318 Akan and Veli

obtained.10 Pseudo-Class III malocclusion is character-

ized by certain morphologic, dental, and skeletal charac-
teristics: retrusive upper lip, decreased midface length,
retroclined maxillary incisors, increased maxillomandib-
ular difference, normal SNA, and slightly increased SNB
because of the forward positioning of the mandible. Na-
kasima et al11 studied craniofacial morphology in
different types of malocclusions and reported the
following etiologic factors in pseudo-Class III malocclu-
sion.
1. Dental factors: ectopic eruption of the maxillary
central incisors and premature loss of the deciduous
molars.
2. Functional factors: anomalies in tongue position,
neuromuscular features, and nasorespiratory or
airway problems.
3. Skeletal factors: minor transverse maxillary discrep-
ancy.11
Diagnosis and treatment of Class III dentofacial
disharmony poses a significant challenge to clinicians.
Detailed and exhaustive dentofacial analysis should be
performed to evaluate the anteroposterior disharmony
and the transverse structure of the mandibular- Fig 1. PA cephalometric landmarks used: Ma, Maxillare-
maxillary base. The growth potential of a Class III patient maxillary skeletal base width; Go, gonion-bigonial width;
may directly affect the treatment outcome; thus, it is Ag, antegonion-biantegonial width.
important to determine, if possible, the patient's growth
potential to enhance success.12
Plaster orthodontic models are important tools for with posteroanterior (PA) cephalometric radiographs and
diagnosis and treatment planning and for evaluating digital models. The null hypothesis tested in this study
progress and outcomes of treatment.13 However, they was that dental arch widths and mandibular-maxillary
have been criticized for the demand on storage space, base widths are not different between true and pseudo-
the high risk of breakage, the loss of information, the Class III malocclusions.
labor-intensive work, and the difficulty of sending
them to other clinicians in multidisciplinary cases.13,14 MATERIAL AND METHODS
To overcome these problems, some alternatives to A power analysis established by G*Power software
plaster models have been suggested.15,16 (version 3.1.3; Franz Faul University, Kiel, Germany),
Three-dimensional (3D) digital models now offer based on an equal ratio among groups and a group
some advantages and have increased in popularity.17 size of 24 subjects, would give 85% power to detect sig-
Garino and Garino,18 Caspersen et al,19 and Zilberman nificant differences with an 0.8 effect size and at the
et al20 compared linear dental anatomic measurements a 5 0.05 significance level (critical t, 1.678660; noncen-
obtained from plaster and digital models. They found trality parameter, l 2.771281). So, for the 2 groups, a to-
statistically significant differences between plaster and tal of 50 patients (24 boys, 26 girls) were included.
digital model linear measurements but concluded that Fifty PA radiographs, lateral cephalograms, and 3D
the average difference was clinically insignificant. digital models were used, and sample selection was
In the literature, most studies have compared dental based on the initial dentoalveolar and skeletal character-
arch widths of Class II patients with those of normal oc- istics. The selection criteria were the following: (1)
clusion samples.21-23 Only a few studies are available normal SNA (82
6 2
), increased SNB (.82
), and
with respect to Class III malocclusions, represented negative ANB (\0
) values24; (2) negative Wits value25;
10.3% of patients in Turkey, and especially pseudo- (3) family history of mandibular prognathism for true
Class III malocclusions.5 Therefore, the purpose of this Class III malocclusions; (4) at least 2 incisors with nega-
study was to evaluate the skeletal and dental components tive overjet and overbite at habitual occlusion; (5)
in untreated Class III and pseudo-Class III malocclusions centric relation-centric occlusion discrepancy (forward

February 2017  Vol 151  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Akan and Veli
Fig 2. Maxillary intermolar width: distance between the central fossae of the maxillary right and left first
molars.
displacement of the mandible to permit closure into a
position in which the posterior teeth can comfortably
occlude); (6) minimal or no crowding26; (7) all perma-
nent teeth up to the first molars; (8) no supernumerary
or congenitally missing teeth, excluding third molars,
or teeth with extensive restorations or gross decay; (9)
no ectopic teeth or anomalies in tooth shape; and (10)
no previous orthodontic treatment.
Also, patients with nasal obstruction, tongue
thrusting, or abnormal swallowing and sucking behav-
iors indicating narrow maxillary dental arch widths
were excluded from this study.
All subjects had white ancestry. The assessments of
the stages of cervical vertebral maturation on the lateral
cephalograms for each subject were performed by 1
investigator (B.A.); the baseline assessments corre-
sponded to stages V and VI.27 The mean age of the pa-
tients was 15.5 years. The mean values were 81.18
6
1.28
for SNA angles and 84.39
6 1.99
for SNB angles
for the true Class III group.
The skeletal landmarks used in this study were as fol-
lows (Fig 1).
1. Maxillary skeletal base width. This is the distance
between the right and left maxillares. Maxillare is
the intersection of the lateral contour of the maxil-
lary alveolar process and the lower contour of the
maxillozygomatic process of the maxilla.28,29
2. Bigonial width. This is the distance between both
gonia. Gonion is the most inferior, posterior, and
lateral point on the external angle of the
mandible.30
American Journal of Orthodontics and Dentofacial Orthopedics
319
3. Biantegonial width. This is the distance between
both antegonia. Antegonion is the deepest point
on the curvature at the antegonial notch.28,31
Digital models were generated from plaster models
scanned with a 3D model laser scanner (D250 3D Dental
Scanner; 3Shape A/S, Copenhagen, Denmark). The dig-
ital models were analyzed by 1 investigator (B.A.) using
the 3Shape Orthoanalyzer software (version 1.0; 3Shape
A/S). The dental landmarks used in this study were as
follows (Figs 2 and 3).
1. Maxillary intermolar width. This is the distance be-
tween the central fossae of the maxillary right and
left first molars.
2. Mandibular intermolar width. This is the distance
between the tips of the distobuccal cusps of the
mandibular right and left first molars.12
Ten randomly selected PA radiographs and 10 models
were redigitized and remeasured by the same investi-
gator (B.A.) 2 weeks after the first measurements to
calculate the method error by means of
Dahlberg's formula.32 Intraexaminer reliability was
quantified by using the intraclass correlation coefficient.
Statistical analysis
All data analyses were carried out using SigmaStat
(version 3.5; Systat Software, San Jose, Calif) with a pre-
specified level of statistical significance of P \0.05.
Normal distribution of the data was verified with the
Kolmogorov-Smirnov test. The data were normally
distributed, and there was homogeneity of variance
February 2017  Vol 151  Issue 2
320
Fig 3. Mandibular intermolar width: distance between the tips of the distobuccal cusps of the mandib-
ular right and left first molars.
among the groups. Thus, statistical evaluation was per-
formed using parametric tests.
Unpaired and paired-sample t tests were used for sex
and data comparisons, respectively. Because no sex dif-
ferences were found in all measured parameters, the pa-
tients were pooled in each group. Pearson correlation
coefficients were calculated to determine the associa-
tions among measurements between true and pseudo-
Class III malocclusions.
RESULTS
The method errors for the measurements on the
dental casts were 0.17 mm for maxillary intermolar
width, 0.25 mm for mandibular intermolar width, and
0.31 mm for molar difference. Measurement errors
made on the radiographs were 0.40 mm for biantegonial
width, 0.46 mm for maxillary skeletal base width, and
0.31 mm for bigonial width. A high degree of intraexa-
miner reliability was noticed for all variables. (intraclass
correlation coefficient values, 0.936-0.982).
The sex distribution in the groups is shown in Table I.
Table II summarizes the descriptive statistics and intra-
group comparisons of sex differences in transverse skel-
etal and dental measurements, and no statistically
significant differences were found in either group.
According to the findings shown in Table III, statisti-
cally significant differences were detected in maxillary
intermolar, and bigonial and biantegonial widths be-
tween true and pseudo-Class III malocclusions. Maxillary
intermolar width was significantly lower in pseudo-Class
III malocclusions than in true Class III malocclusions. On
February 2017  Vol 151  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Akan and Veli
Table I. Distribution of subjects with pseudo-Class III
and true Class III malocclusions
Subjects True Class III Pseudo-Class III
Boys 11 13
Girls 14 12
Total 25 25
the other hand, no significant changes were found in
mandibular intermolar widths between pseudo-Class III
and true Class III malocclusions. Moreover, although sig-
nificant differences were found in bigonial and biante-
gonial widths, the mean maxillary skeletal base widths
were not significant.
The correlations between skeletal measurements ob-
tained from PA radiographs and the dental arch mea-
surements obtained from digital models are
summarized in Table IV. The results indicated statisti-
cally significant positive correlations between maxillary
and mandibular intermolar widths (r 5 0.53), bigonial
and biantegonial widths (r 5 0.90), bigonial and maxil-
lary skeletal base widths (r 5 0.47), and biantegonial
and maxillary skeletal base widths (r 5 0.47) in true Class
III malocclusions. In pseudo-Class III malocclusions, sta-
tistically significant positive correlations were found be-
tween bigonial and biantegonial widths (r 5 0.92),
bigonial and maxillary skeletal base widths (r 5 0.44),
and biantegonial and maxillary skeletal base widths
(r 5 0.47)
Based on these findings, the null hypothesis was re-
jected.
Akan and Veli 321

Table II. Descriptive statistics and intragroup comparisons of sex differences in transverse skeletal and dental mea-
surements
True Class III Pseudo-Class III

Male Female Male Female

Mean SD Mean SD P Mean SD Mean SD P

RU6-LU6 48.29 3.23 45.62 3.23 0.05 44.37 3.08 45.25 3.14 0.49
RL6-LL6 50.43 3.35 46.86 2.65 0.07 46.89 2.07 46.86 3.22 0.98
RGo-LGo 93.64 8.38 89.07 5.67 0.12 86.22 5.67 83.85 7.23 0.37
RAg-LAg 82.05 6.88 78.94 4.79 0.19 77.69 4.35 75.252 5.61 0.23
RMa-LMa 52.78 4.88 52.8 4.59 0.99 53.13 4.53 54.52 4.06 0.44

RU6-LU6, Maxillary intermolar width; RL6-LL6, mandibular intermolar width; RGo-LGo, bigonial width; RAg-LAg, biantegonial width; RMa-
LMa, maxillary skeletal base width.

Table III. Comparison of dental and skeletal measure- Table IV. Pearson correlation coefficients for the vari-
ments between true and pseudo-Class III malocclu- ables in true and pseudo-Class III malocclusions
sions
RU6-LU6 RL6-LL6 RGo-LGo RAg-LAg RMa-LMa
True Class III Pseudo-Class III True Class III
RU6-LU6 1.00 0.53y 0.27 0.36 0.16
Measurement Mean SD Mean SD P RL6-LL6 0.53y 1.00 0.20 0.15 0.09
RU6-LU6 46.79 3.44 44.76 3.07 0.032* RGo-LGo 0.27 0.20 1.00 0.90y 0.47*
RL6-LL6 48.43 3.43 46.88 2.57 0.08 RAg-LAg 0.36 0.15 0.90y 1.00 0.47*
RGo-LGo 91.08 7.21 85.18 6.39 0.004y RMa-LMa 0.16 0.09 0.47* 0.47* 1.00
RAg-LAg 80.31 5.88 76.62 4.99 0.021* Pseudo-Class III
RMa-LMa 52.79 4.62 53.74 4.30 0.46 RU6-LU6 1.00 0.21 0.30 0.20 0.10
RL6-LL6 0.21 1.00 0.15 0.14 0.04
RU6-LU6, Maxillary intermolar width; RL6-LL6, mandibular inter- RGo-LGo 0.30 0.15 1.00 0.92y 0.45*
molar width; RGo-LGo, bigonial width; RAg-LAg, biantegonial RAg-LAg 0.20 0.14 0.92y 1.00 0.48*
width; RMa-LMa, maxillary skeletal base width. RMa-LMa 0.10 0.04 0.45* 0.48* 1.00
*P \0.05; yP \0.01.
RU6-LU6, maxillary intermolar width; RL6-LL6, mandibular inter-
molar width; RGo-LGo, bigonial width; RAg-LAg, biantegonial
width; RMa-LMa, maxillary skeletal base width.
DISCUSSION
*Correlation is significant at the 0.05 level; yCorrelation is significant
The ability to distinguish pseudo-Class III malocclu- at the 0.01 level.
sions from true Class III malocclusions is necessary to
formulate the proper treatment plan for these patients.
It is also essential to identify diagnostic criteria for PA radiographs give basic information about skeletal
pseudo-Class III malocclusions. Our current study and dentoalveolar relationships in the transverse plane.
showed the relationship between dental arch For radiographic identification and evaluation of trans-
morphology and skeletal mandibular-maxillary bases verse skeletal discrepancies, it is the most readily avail-
in Class III malocclusions associated with the Class III able and reliable diagnostic tool. Also, orthodontists
malocclusion types. Moreover, width measurements can evaluate the angular relationships between the
described in this article will help clinicians to diagnose dental arch and the bony base in the transverse plane,
and plan the treatment of patients with true Class III detect maxillary and mandibular widths and their trans-
and pseudo-Class III malocclusions. verse positions, define the width of the nasal cavity,
Patients included in this study represented the local analyze the vertical and transverse facial asymmetries,
population from west Anatolia in Turkey. Because ge- and assess dental asymmetries.33
netic and environmental interacting factors could affect In orthodontics, the most important thing for diag-
the etiology of malocclusions, all patients were selected nosis and treatment planning, and at the same time
from the same territory and ethnicity. Also, patients were for the evaluation of treatment outcomes, is a plaster or-
chosen according to their skeletal vertebral maturation thodontic model.13 However, there are some challenges
instead of their chronologic age to reduce the effect of such as storage necessity, high risk of breakage,
growth in the dental and skeletal changes. labor-intensive work, and transfer difficulty

American Journal of Orthodontics and Dentofacial Orthopedics February 2017  Vol 151  Issue 2
322
in multidisciplinary cases.13,14 To eliminate these
challenges, some alternatives to plaster models have
been suggested,15,16 and 3D digital models have
gained popularity in recent years.17 Sousa et al34 evalu-
ated the reliability of measurements made on 3D digital
models obtained with the 3Shape D250 surface laser
scanner and concluded that linear measurements on
digital models are accurate and reproducible.
Braun et al35 investigated the form of dental arches
by using 40 sets of pretreatment orthodontic models
and found that maxillary dental arch widths in Class III
malocclusions are greater than those of Class I malocclu-
sions. Opposite to that study's findings, Uysal et al36 re-
ported that the maxillary interpremolar and intermolar
widths, and all maxillary alveolar width measurements
were significantly narrower in the Class III group than
in the normal occlusion sample. The difference between
these 2 studies could be attributed to the different types
of Class III malocclusion. No specific identification was
reported about the type of Class III malocclusion. The
findings of our study indicated that maxillary molar
width measurements were narrower in patients with
pseudo-Class III malocclusion. This may verify the accu-
racy of transverse maxillary discrepancy as an etiologic
factor in pseudo-Class III malocclusion. This finding
may help clinicians to diagnose and plan the treatment
of patients for maxillary expansion, because the impor-
tance of the transverse dimension in Class III malocclu-
sion is indicated indirectly by the clinical protocols of
therapy, which includes a preliminary phase of maxillary
expansion before maxillary protraction.37,38 In our
study, although a high correlation was detected
between the maxillary and mandibular molar widths in
true Class III malocclusions, there was no correlation in
pseudo-Class III malocclusions.
Chen et al39 analyzed the development of dental
arch widths and skeletal mandibular-maxillary bases
in untreated Class III malocclusions in subjects aged
10 to 14 years. They found statistically significant dif-
ferences in biantegonial width. In our study, biantego-
nial width showed statistically significant differences
between pseudo-Class III and true Class III malocclu-
sions as well.
Allen et al40 assumed the linear measurement be-
tween the antegonion points as effective mandibular
width in their study which were defined by Ricketts
et al.41 We used this reference line as the biantegonial
width in our study. According to our findings, there
was a high correlation between biantegonial and
bigonial widths, so not only biantegonial but also
bigonial widths may inform about effective mandib-
ular width.
February 2017  Vol 151  Issue 2 American Journal of Orthodontics and Dentofacial Orthopedics
Akan and Veli
Tollaro et al42 investigated the relationship between
posterior transverse interarch discrepancy and mandib-
ular size and position in Class II patients by using plaster
models and lateral cephalograms. They calculated poste-
rior transverse interarch discrepancy as the difference
between maxillary and mandibular intermolar widths
and concluded that this interarch discrepancy is a simple
and effective parameter for assessing the transverse
congruence of dental arches.
According to Allen et al,40 effective maxillary and
mandibular widths are 58.5 6 5.7 and
80.5 6 5.3 mm, respectively, in patients with posterior
crossbite. In our study, effective maxillary and mandib-
ular widths were 52.79 6 4.62 and 80.31 6 5.88 mm,
respectively, in true Class III malocclusions and
53.74 6 4.30 and 76.62 6 4.99 mm, respectively, in
pseudo-Class III malocclusions. When these findings
were evaluated, biantegonial widths predicted maxil-
lary skeletal base widths moderately in both groups.
Similarly, there was a medium correlation between
bigonial and maxillary skeletal base widths.
A longitudinal study with records that fulfill the
comprehensive inclusion criteria in our study would be
an ideal endeavor to confirm these outcomes. However,
irrespective of the small sample size (a limitation of this
study), the results provide clinically useful information,
but it should be interpreted cautiously until further serial
information can be obtained.
CONCLUSIONS
Within the limitations of this study, the following
conclusions can be drawn.
1. Dental arch widths and mandibular-maxillary base
widths are different between true and pseudo-
Class III malocclusions.
2. Significant differences were found in maxillary
molar and biantegonial widths between true and
pseudo-Class III malocclusions.
3. Maxillary molar widths were positively correlated
with mandibular molar widths.
4. There are medium correlations between bigonial
and maxillary skeletal base widths and between
biantegonial and maxillary skeletal base widths in
both groups.
5. In both groups, there was a high correlation be-
tween biantegonial and bigonial widths.
ACKNOWLEDGMENT
We thank to Bulent Ozkan for his support and guid-
ance in the statistical assessment.
Akan and Veli
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February 2017  Vol 151  Issue 2