British Journal of Orthodontics

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The Assessment of Antero-posterior Dental Base

Relationships

D. Millett B.D.Sc., F.D.S., M.Orth. & J. F. Gravely L.D.S., M.Ch.D., D.Orth.

To cite this article: D. Millett B.D.Sc., F.D.S., M.Orth. & J. F. Gravely L.D.S., M.Ch.D., D.Orth. (1991)
The Assessment of Antero-posterior Dental Base Relationships, British Journal of Orthodontics,
18:4, 285-297, DOI: 10.1179/bjo.18.4.285

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 British Journal t~{ Ortlwdontics/Vnl. 18/1991/285-297

The Assessment of Antero-posterior

Dental Base Relationships
D. MILLETT,* B.D.Sc., F.D.S., M.ORTH.
J. F. GRAVELY, L.D.S., M.CH.D., D.ORTH.
Department of Child Dental Health, Leeds University Dental School, Clarendon Way, Leeds LS2 9LU
Received for publication July 1990

Abstract. The reliability and validity offour methods ofassessing skeletal pattern ( Reidel's method, Eastman
correction, Bollard's method, and 'Wits' analysis) from cephalometric tracings have been examined, and the
levels of agreement between them investigated. The possibility of the Y-axis length and SN- Y-axis angle
having a bearing on the skeletal pattern was also examined. Strong correlation was found between the four
methods considered. Ballard's method correlated very closely with Reidel's method, and like 'Wits' method, is
not as unreliable as previously reported. Measurement of the SN- Y-axis angle was not found to be ofbenefit to
the assessment of the anteroposterior dental base relationship. Reidel's method, which is the easiest to apply, is
recommended as the method of choice, and routine application of the Eastman correction is not recommended.
Index words: Skeletal Pattern, Cephalometric Analysis, Reliability, Validity.

Introduction Literature review

The anteroposterior relationship between the
maxillary and mandibular dental bases is defined as
the dental base relationship. It is sometimes called
the skeletal pattern, the jaw relationship, or the
sagittal apical base relationship (Houston, 1975;
Chang, 1987; Jarvinen, 1981).
Not only does the skeletal pattern play a great
part in occlusal development, but it also imposes
limits to the amount of anteroposterior movement
of the incisor teeth during treatment. Variations in
the size of the jaws and their position relative to the
cranial base, may alter the skeletal relationship
(Reidel, 1952; Steiner, 1953; Hussels and Nanda,
1984).
Great importance has been attached to the
evaluation of the sagittal apical base relationship in
orthodontic diagnosis and treatment planning (Bal-
lard, 1951; Moorrees, 1953; Mills, 1970). This may
be affected clinically by an overall profile view of the
patient (Barnett, 1975), but a more accurate impres-
sion may be given by palpation of the anterior
surfaces of the basal part of the jaws with teeth in
occlusion (Mills, 1987). A better assessment may be
made by the use of lateral skull radiographs.
Angle ( 1907) provided one of the first assessments
of jaw relationship. Although his method is not now
used to assess skeletal relationships, it is a conve-
nient method of recording the anteroposterior
relationship of the teeth. He believed that first
permanent molars, bearing a constant relationship
to their dental bases, could be used to assess a
sagittal jaw relationship. Angle classified three main
groups, 'based on the mesio-distal relations of the
teeth, dental arches and jaws, which primarily
depend upon the positions mesio-distally assumed
by the first permanent molars on their eruption and
locking'. By assuming that the position of the upper
first permanent molar was stable, he reasoned that
the relationship between the upper first permanent
molar and the lower first permanent molar reflected
the relative degree ofprognathism or retrognathism
of the mandible to the maxilla. Angle's classifica-
tion is widely used today as a classification of
malocclusion, perhaps primarily due to its conve-
nience, but it is well known that the first permanent
molar relationship is very rarely an accurate reflec-
tion of skeletal pattern.
Simon (1926) developed a system of gnathosta-

• Present address: Department of Orthodontics, Newcastle upon Tyne Dental Hospital, Richardson Road, Newcastle upon Tyne
NE2 4AZ.
030 1·228X/91/008000 + 00$02.00 ,1~: 1991 British Society for the Study of Onhodontics
286 D. Millett and J. F. Gravely
tics, which related the dental arches to the skull
using a three-dimentional co-ordinate system based
on the median sagittal plane, the Frankfort plane
and the Orbital plane. Simon did not claim that the
teeth bore a constant relationship to these planes,
but implied that in a well balanced face, the orbital
planes should pass through the cusps of the upper
canine teeth.
The validity of Simon's classification was ques-
tioned by Sved ( 1931 ), who demonstrated that
minor errors in locating the Frankfort plane could
have a major effect on the orientation of the orbital
plane and on its relationship to the teeth. Further-
more, the orbital plane did not bear a constant
relationship to the upper canine teeth, even in
individuals with excellent occlusions and well
balanced faces. Simon's classification was notable
in that it focused attention on the importance of an
independent assessment of the skeletal and occlusal
relationships, which are not always concordant.
Hell man ( 1921 ), Si mon ( 1926), and more recently
Hixon (1956) recognized the need to differentiate
between dental alveolar and skeletal discrepancies,
and to evaluate the respective contributions to-
wards the creation of the malocclusion.
The introduction of cephalometry provided a
method of recording, measuring and quantifying
skeletal morphology, and of relating skeletal factors
to occlusion. The method was developed indepen-
dently in 1931 by both Broadbent and Hofrath, and
has since remained fundamentally unaltered.
Cephalometric methods were adopted by several
workers in the U.S.A., notably Brodie (1941),
Downs ( 1948; 1952), Rei del ( 1952), Wylie and
Johnson ( 1952), Margolis ( 1953), Moorrees (1953),
Steiner (1953), Coben (1955), and Graber (1958),
and in Europe by Bjork (1947).
There are, for example, approximately 50 meth-
ods of assessing dental base relationships presently
available. Some of these focus attention on dental
structures, some embrace a comprehensive dental
and skeletal assessment, and others even incorpor-
ate prediction of growth changes. One of the earliest
comprehensive analyses was that devised by Downs
( 1948, 1952) who, with the aid of lateral skull
radiographs, related the maxillary and mandibular
dentitions to the cranial base. In this method, the
relationship of the deepest points on the concavity
of the profile labial to the apices of the upper and
lower incisor teeth (which he labelled Points A and
B, respectively) is assessed using the Facial Plane
(N-Pog) as a reference. Downs provided a measure
of the anteroposterior relationship of the jaws using
the angle subtended by a line through Points A and
B from the Facial Plane (Fig. l ).
BJO Vol. 18 No. 4
Orientation of
A· B line to
Facial Plane
FIG. I Down's analysis.
Reide/'s analysis ( 1952)
Rei del ( 1952) suggested that the difference between
the angles SNA and SNB (Angle ANB), might be
used to classify the anteroposterior dental base
relationship, Points A and B being taken to be the
most anterior points on the surfaces of the apical
bases of the maxilla and mandible, respectively, and
SN as a representation of the anterior cranial base
(Fig. 7). The anterior cranial base is included,
because the general slope of the face in relation to
the cranium is critical in the interpretation of the
assessment, and the sella-nasion line enables the
facial slope to be determined. Classification of cases
is based on the following:
Skeletal class
Angle ANB
2-4'' I
greater than 4 o II
III
less than 2°
This method of assessment, although widely used,
has been criticized in as much as points A and Bare
points on the alveolar processes, rather than on the
dental bases. Growth and orthodontic treatment
may produce variation in these points due to
alveolar rather than skeletal changes (Steiner, 1953;
Bjork, 1954).
Furthermore, angle ANB is affected by the size of
angle SNA and is thus dependent on the length and
cant of the sella-nasion line: despite these objec-
tions, angles SNA and SNB are generally assumed
to give a reasonable estimate of prognathism or
retrognathism for each jaw.
Freeman (1950) demonstrated the variation
BJO Nor•ember /99/
introduced by different positions of nasion, and
because nasion moves forward with growth of the
frontal sinus, apparent changes in the skeletal
pattern can be recorded, where none in fact has
taken place.
Rei del ( 1952), and Steiner (1953, 1959, 1960)
chose the sella-nasion line as a reference line
because sella and nasion are both located in hard
unyielding tissue, are directly visible in a profile
radiograph and are located in the mid-sagittal
plane, where errors due to displacement through
variation of head position are minimal. The Steiner
analysis (1953, 1959, 1960) involves an assessment
of the position of the jaws in relation to the cranial
base, together with a comparison of these para-
meters with a population of averages. Reidel ( 1952)
found angle ANB to have a mean value of 3·4
degrees with a range of0·5-7 degrees. He based his
study on a small sample of cases with good profiles
rather than on a sample of people with 'normal'
occlusion. Stein er ( 1953) found mean values for
angles SNA and SNB of 82 and 80 degrees,
respectively, his analysis being based on 'normal'
occlusions. Kowalski and Walker (1971) in a study
of 1110 'normal' children, found the mean angle
ANB value to be 4·5 degrees at the age of 12-14
years. This angle reduced to 3·5 degrees in adult
males, but remained stable in females.
Eastman analysis ( ajier Mills, 1970)
Variation in the anteroposterior and vertical pos-
ition of nasion will affect angle ANB, the signifi-
cance of which varies according to the size of angle
SNA (Fig. 2a,b). The severity of the anteroposterior
dental base discrepancy, when judged by the value
of angle ANB alone may, therefore, be masked. A
FrG. 2 (a) Variation in the antero-posterior position of nasion.
Antero-posterior dental base relationships 287
(b) Variation in the vertical position of nasion.
method of adjustment is incorporated into the
Eastman analysis to compensate for variations in
angle SNA; for every degree SNA is greater/less
than 81 degrees, half of a degree is subtracted/added
from/to the original ANB angle.
The position of sella in the cranium can also
affect the angles SNA and SNB without affecting
angle ANB. This may be verified by relating the
maxillary plane to the sella-nasion plane. For
example, if angle SNA is reduced because of a low
position of sella rather than a forward position of
nasion, the angle between the sella-nasion plane
and the maxillary plane will be increased, but angle
ANB will be unaffected.
Ballard's method ofassessing skeletal pattern ( 1948)
In contrast to Reidel's ( 1952) method of assessing
skeletal pattern, Ballard's (1948) method relates the
lower incisor-mandibular planes angle to the
Frankfort-mandibular planes angle. In 1951, Bat-
lard modified the method by using the maxillary-
mandibular planes angle in preference to the Frank-
fort-mandibular planes angle, the Frankfort plane
being more poorly defined radiographically than
the maxillary plane. In this method, the maxillary
and mandibular incisors are repositioned at stan-
dardized angles to the maxillary and mandibular
plane, respectively. Measurement of the overjet
then gives a measure of the anteroposterior dental
base relationship.
The procedure is as follows:
I. The maxillary, mandibular, and functional
occlusal planes are traced (Fig. 3a).
288 D. MilieU and J. F. Gravely
FIG. 3 (a) Angular measurements recorded for Ballard's
method. (b) Rotation of the upper incisor about point U2. (c)
Measurement of the overjet to classify the skeletal pattern.
2. The outline of upper and lower incisors are
traced, and points U 2 and L2 located (Fig. 5a,b).
3. The MMA and UIA are measured and recorded,
for example: MMA = 24 degrees; UIA = 120
degrees (Fig. 3b).
4. •On a separate sheet of cellulose acetate paper,
maxillary, mandibular, functional planes, and
points U2 and L2 are traced.
5. This second tracing is then overlaid on to the first
tracing, and the upper incisor is rotated about
points u2 until it forms an angle of 109 degrees to
the maxillary plane. The outline of the upper
incisor is then traced on the second tracing.
6. The lower incisor is then rotated about point L2
until it assumes its 'corrected' angle to the
mandibular plane. For example, if MMA is 24
degrees, which is 4 degrees less than the mean of
28 degrees then 4 degrees would be added to the
BJO Vol. /8 No. 4
mean LIA of 92·5 degrees, making 96·5 degrees
(the 'corrected' lower incisor-mandibular planes
angle).
7. In those instances where the outline of the lower
incisor overlaps that of the upper incisor, the
lower incisor is moved inferiorly along the lower
incisor axis.
8. The 'overjet' is then measured in a direction
parallel to the functional occlusal plane, the
value recorded, and the skeletal pattern assessed
using the following criteria:
Overjet Skeletal class
2-4 mm I
greater than 4 mm II
less than 2 mm Ill
The main drawback of this method is the diffi-
culty in accurately identifying the incisor apices,
especially those of the lower incisors. Several
observers, including Hixon (1956), Backlund
( 1963), Mills ( 1964, 1966), Ben nett and Smales
(1969), K vam and Krogstad (1969), Baumrind and
Frantz (1971a,b), Gravely and Benzies (1974), and
Stabrun and Danielsen (1982) have referred to the
particularly low level of reliability of tracings of
incisor teeth and, consequently, of large errors in
assessment of their axial inclinations. Furthermore,
Ballard's assumption that teeth tilting to the final
positions as they erupt, having a fixed pivotal point
situated one-third of the root length from the apex is
rather speculative. The validity of assessing the
anteroposterior dental base relationship by this
method was questioned by Houston (1975).
'Wits' analysis (Jacobson, 1975)
It has been suggested that the vanatwn in the
anteroposterior position of nasion, the degree of
facial prognathism, the rotation of the jaws, and
variation in the anterior facial height make the use
of the angle ANB as a measure of skeletal pattern
misleading (Taylor, 1969; Beatty, 1975; Jacobson,
1975). Moorrees (1953) and Moore (1959) have
shown that measurements involving reference to the
cranial base do not necessarily provide a reliable
expression of anteroposterior jaw relationship in
the dento-facial complex. 'Wits' appraisal of jaw
disharmony employs the functional occlusal plane
as a reference plane because it is common to both
maxillary and mandibular dental bases. By using
this method, rotation of the jaws relative to cranial
or extracranial reference planes in no way affects the
overall assessment of the severity of jaw dishar-
mony. It is intended not as a single diagnostic
criterion, but as an additional measurement which
BJO Nm·emh<•r /991
Functional
Occlusal Plane
'Wits' Measurement
B
FIG. 4 'Wits' measurement.
may be incorporated in cephalometric analysis to
assist in the assessment of the degree of antero-
posterior jaw disharmony. Perpendicular lines are
drawn to points A and B from the functional
occlusal plane (which is drawn through the region
of maximal cuspal interdigitation), labelled AO and
BO, respectively (Fig. 4), and the assessment of
anteroposterior dental base relationship made by
determining the position of point BO relative to
point AO.
A skeletal I dental base relationship is defined as
point BO lying within 2 mm of point AO (thus
having a range of 4 mm, from -2 to + 2 mm). From
this, it follows that a skeletal II relationship is
defined as occurring when point AO is greater than
2 mm anterior to point 80, and a skeletal Ill
relationship where point BO is greater than 2 mm
anterior to point AO.
Aim of the study
The aim of the present investigation is to assess the
reliability of four methods of assessing skeletal
Pattern from cephalometric tracings and to deter-
mine the level of agreement between them. The
cephalometric analyses investigated are:
(I) measurement of the angle ANB, after Reidel
(1952);
(2) the Eastman adjustment analysis, after Mills
(1970);
(3) the 'conversion' method described by Ballard
(1948);
(4) the 'Wits' appraisal of jaw disharmony de-
scribed by Jacobson (1975).
In addition, the possibility of the y-axis length
Antero-posterior dental base relationships 289
and SN-y-axis angle having a bearing on the
anteroposterior dental base relationship is investi-
gated.
Methods and materials
A sample of 60 cephalographs was selected at
random from the record files of orthodontic
patients currently under treatment in the Orthodon-
tic Department at the Leeds Dental Hospital. All
films were traced with the right side of the patient's
face orientated towards the X-ray tube and the left
side nearer the film, with the central ray passing
through the porion-porion axis. Each radiograph
was traced on to a cellulose acetate sheet by the
same operator (D.M.) using fluorescent tracing
screens to provide illumination. Fifteen cephalo-
metric landmarks were located, marked, and identi-
fied with a pencil. The relevant lines and angles were
drawn and measured using standard equipment. No
further reference was made to the tracings or
cephalographs for at least 2 weeks, when the
procedure was repeated. Thus, two tracings of each
film were obtained, each performed on a separate
occasion with an interval of at least 2 weeks between
tracings. This procedure was adopted to eliminate
memory bias.
Anatomical landmarks recorded
The following anatomical landmarks were recorded
on the tracings (Fig. 5a,b).
N-nasion: the anterior point of the suture at the
junction of the frontal and nasal bones in the mid-
sagittal plane.
S-sella turcica: the centre of the pituitary fossa
of the sphenoid bones located by taking the mid-
point of the greatest diameter.
A-point A: the deepest point on the maxillary
profile between ANS and the alveolar crest.
B-point B: the deepest point on the mandibular
profile between the pogonion and the alveolar crest.
U!-upper incisor tip: the incisal tip of the most
prominent maxillary central incisor.
U2-upper incisor ph•ot: the point, one-third of
the root length from the apex of the tooth, about
which the tooth is assumed to tilt.
U3-upper incisor apex: the tip of the root of the
maxillary central incisor with the most prominent
crown.
Ll-/ower incisor tip: the incisal tip of the most
prominent mandibular central incisor.
L2-/ower incisor pivot: the point, one-third of
290 D. Millet! and J. F. Gravely BJO Vol. 18 No. 4

PNS-posterior nasal spine: the most posterior

point in the median plane on the bony hard palate.
Go-gonion: the junction between the posterior
border of the mandibular ramus and the lower
border of the mandibular body located at the point
where the bisector of tangents to these borders
meets the angle of the mandible. Where two man-
dibular borders were projected, an 'average' border
was drawn and the constructions related to this.
Ar-articulare: the projection on a lateral skull
radiograph of the posterior outline of the condylar
process onto the inferior outline of the cranial base.
Me-menton: the most inferior point on the
mandibular symphseal outline.
Gn-gnathion: the junction between the anterior
border of the mandibular symphysis and the lower
border of the mandibular body located at the point
when the bisector of tangents to these borders meets
the mandibular symphysis.

FIG. 5 (a) Cephalometric landmarks recorded (1).

Cephalometric lines and planes recorded
The landmarks recorded were used to construct
ANS
lines representing the following (Fig. 6):
I. Se/la-nasion line: anterior cranial base-the line
joining sella and nasion (S-N).
2. Maxillary plane: the line between the anterior
and posterior nasal spines (ANS-PNS).
3. Functional occlusal plane: the line joining the
mid-point of the overlap of the mesio-buccal
cusps of the first permanent molars and the
buccal cusps of the premolars or deciduous
molars.

(b) Cephalometric landmarks recorded (2).

3
the root length from the apex of the tooth, about
which the tooth·is assumed to tilt.
L3-lower incisor apex: the tip of the root of the
mandibular central incisor with the most prominent
crown.
ANS-anterior nasal spine:· the tip of the bony
anterior nasal spine in the median plane .. FIG. 6 Cephalometric planes and lines recorded.
BJO Nor•emher /99/
4. Mandibular plane: the line through menton and
gonion (Me-Go).
5. Y-axis: the line joining sella and gnathion.
Other cephalometric constructions
6. U,-U3: the line joining the upper incisor tip and
upper incisor apex.
7. LrL3 : the line joining the lower incisor tip and
lower incisor apex.
Angular measurements recorded
The following angles were measured (Fig. 7):
I. SNA: the included angle determined by sella,
nasion, and point A.
2. SN B: the included angle determined by sella,
nasion, and point B.
3. ANB: the difference between angles SNA and
SNB.
4. SN-y-axis: the angle formed by the S-N plane
and the y-axis.
5. M M A-maxillary mandibular planes angle: the
acute angle formed by the intersection of the
maxillary plane and the mandibular plane
(ANS-PNS/Go-Me).
6. Gonia/ angle: the obtuse angle formed by the
intersection of the lineAr-Go and the mandibu-
lar plane (Ar-GojGo-Me).
7. U.I.A.-upper incisor angle: the included angle
determined by the intersection of the upper
incisor line and the maxillary plane (U 1-U 3/
ANS-PNS).
8. LIA-/ower incisor angle: the included angle
FIG. 7 Angular measurements recorded.
Antero-posterior dental base relationships 291
determined by the intersection of the lower
incisor line and the mandibular plane (L 1-L 3/
Go-Me).
Angular measurements were recorded to the nearest
0·5 degree.
Linear measurements recorded
The following linear measurements were made (Figs
3, 4, and 6):
I. 'Overjet': after Ballard's 'conversion method'.
2. 'Wits' Measurement
3. Length ofy-axis
Linear measurements were recorded to the nearest
0·5mm.
The mean of the two recordings made for each
method was used to classify the skeletal pattern. For
the purpose of this investigation, the. ranges pre-
viously quoted for Reidel's method were adopted
for initial classification of the case and applied
subsequently following the Eastman correction.
The overjet measurements previously given were
used to classify the cases following Ballard's conver-
sion, and the distance between points AO and 80
used to classify the cases following the 'Wits'
analysis.
The 60 cases were then ranked, using the range
previously given for each method of analysis on a
scale of increasing order through Class Ill to Class I
to Class 11.
Statistical analysis
Coefficients of correlation were calculated for each
of the four methods of assessing anteroposterior
dental base relationship and SN-y-axis angle andy-
axis length (Table 2).
The 60 cases were ranked, according to the result
of the four analyses on a scale of increasing value.
Spearman's rank correlation coefficient was then
calculated for each of the four methods of analysis,
Sn-y-axis angle and y-axis length (Table 5).
Findings
Confidence limits for methods of assessment of
dental base relationships. y-axis length,
and SN-y-axis angle
It was established that the confidence limits within•
which the four analyses of dental base relationship
could be measured from a single measurement
ranged from approximately I degree for angular
measurements and 2 mm for ·linear measurements.
292 D. Millet! and J. F. Gravely BJO Vol. 18 No. 4

TABLE I Confidence limits for four methods of assessment of Correlation coefficients for the analyses of skeletal
dental base relationship; y-axis length and SN-y-axis angle at pattern
P= I per cent
The results obtained from the four methods of
Difference between assessing skeletal pattern were compared. The
Single measurements from
Method of analysis measurement two tracings
coefficients of correlation were calculated and
appear in Table 2. It is evident that all four analyses
Reidels Angle ANB ±1·42" ± 1·75' correlate at a probability level of 0·1 per cent, but
method that y-axis length and SN-y-axis angle both corre-
Eastman 'adjustment' ±1·30' ±1·50" late very poorly with the four methods investigated.
analysis
Ballard's method ±2·4 mm ±3·25 mm
'Wits' analysis ±1·51 mm ±2·33 mm
y-axis length ±2·44mm
Reliability of assessment of dental base relationship
± 1·55 mm
SN-y-axis angle ± 1·36' ± 1·55' from pairs of tracings
Finding that all methods of analysis inter-corre-
lated at a highly significant level, each tracing was
classified into a skeletal category according to each
The confidence limits for the methods of analysis of method. The results are given in Table 3. The high
dental base relationship appear in Table I from level of consistency in classification into the differ-
which it can be seen that the Eastman ANB ent skeletal categories is clearly seen. For example,
correction method is the most reliable one of those in the Eastman analysis, 35 cases were assessed as
using angular measurements, and the 'Wits' method skeletal 11 from the first tracing and 30 from the
of those using linear measurements. second tracing. Similarly, reasonably high levels of

TABLE 2 Coefficients o_fcorrelation between the four methods ofassessing antero-posterior dental base relalionships, y-axis length, and
SN-y-axis angle

Reidels angle East man Ballard's 'Wits' r-Axis SN-y-axis

Method of analysis ANB method analysis method method ·length angle

Reidels angle 0·760 0·789 0·750 -0·305 0·076

ANB method
Eastman analysis 0·760 0·679 0·62 -0·325 0·410
Ballard's method 0·789 0·679 0·719 -0·260 0·067
'Wits' analysis 0·750 0·622 0·719 -0·290 0·033
y-Axis length -0·305 -0·325 -0·260 -0·290 0·086
SN-y-axis angle 0·076 0·410 0·067 0·037 0·086

TABLE 3 Reliability of assessments of dental base relationship

Number in each skeletal

category Number of
Methods of Skeletal agreement between Reliability Percentage
arfalysis classification I st tracing 2nd tracing two tracings ratio agreement

Reidel's ANB method 2 31 38 31 31 :38 82%

I 18 15 11 11:18 60'Y.,
3 10 9 7 7:10 70"!.,
Eastman analysis 2 35 30 27 27:35 74%
I 14 17 9 9:17 53%
3 11 13 9 9:13 70%
Ballard's method 2 31 36 31 31:36 86'Yt,
I 16 12 10 10:16 62%
3 13 11 8 8:13 61%
'Wits' method 2 26 25 21 21:26 80%
I 20 25 13 13:25 52%
3 13 7 8 8:13 61%
BJO Nm·t•mht•r /YYJ Antero-posterior dental base relationships 293

TABLE 4 Comparison rJf' assessments of antero-posterior dental
base relationship by four methods of analysis
Number of cases in each skeletal
category classified from the mean
of two tracings
Method of analysis Skeletal 2 Skeletal I Skeletal 3
Reidel's Angle ANB 34 15 11
method
Eastman analysis 34 16 10
Ballard's method 32 17 11
'Wits' analysis 23 24 13
Total number of cases, n = 60.
repeatability were obtained for skeletal Ill assess-
ments, but less so for skeletal I assessments, i.e. 70
per cent for Class Ill cases and 53 per cent for Class
I cases. Because the standard error of the method
for Eastman ANB is 0·48 degree, it follows that a
case classified as skeletal 11 at the first tracing is
unlikely to be classified as skeletal Ill from the
second tracing, and this was borne out by observa-
tion. The levels ofrepeatability between the first and
second tracings are shown for Reidel's method and
the Ballard and 'Wits' analyses. All are of a high
order, apart from those cases classified as Class I by
the 'Wits' method.
In none of the methods of dental base relation-
ship was the level of discordancy greater than I
category; no case was classified as skeletal 11 at the
first tracing and as skeletal Ill at the second tracing
or vice-versa (as reference to the values of the
standard errors of each method attests). The per-
centage agreement between the first and second
tracings for all methods of analysis of dental base
relationship was high, indicating a high level of
repeatability expect from those classified as Skeletal
I by Eastman and 'Wits' analyses. A considerable
number of these were, however, 'borderline' cases.
Comparability of assessment of dental base
relationships
Having examined the level of repeatability from
pairs of tracings, the comparability between the
analyses was investigated. The mean measurements
n between the first and second tracings were taken,
and the individual cases re-classified into each
60 category of skeletal pattern for each of the four
methods of analysis. The results are shown in Table
60
60
4. Classification by the Eastman, Ballard, and
60 'Wits' analyses were compared. It can be seen from
Table 4 that all tend to classify an almost equal
number of cases as skeletal 11.
In this investigation, it was found that by apply-
ing the Eastman 'correction', some cases which were
classified as skeletal Ill by angle ANB (less than 2
degrees) were classified as skeletal I when the
Eastman 'correction' was applied, reflecting the fact
that a low value of angle SNA creates a low value
for angle ANB unless 'corrected' in this way. Four
cases with a high SNA angle were classified as
skeletal 11 by angle ANB, but following the East-
man 'correction', were classified as skeletal I.
Correlation coefficients for the ranking of cases
using the four methods of analysis and y-axis
length and SN-y-axis angle
Each of the 60 cases was ranked on an increasing
order using the scale appropriate to each analysis.
Table 5 shows that Ballard's method correlates
closer than any of the other methods with Reidel's
ANB angle, the Eastman analysis appearing to have
the lowest correlation. Neither they-axis length nor
the SN-y-axis angle bore any correlation with the
ranking of cases in this order.
Discussion
From the foregoing, one may conclude that for
clinical purposes, where one is mainly concerned

TABLE 5 Spearman rank correlation between thefour methods()( assessing antero-posterior dental base re/mionship, andy-axis length
and SN-y-axis angle

Reidcls angle Eastman Ballard's 'Wits' y-axis S- NIy-axis

Method of analysis ANB method analysis method method length angle

Reidel's Angle ANB 0·712 0·784 0·739 -0·355 0·072

method
Eastman analysis 0·712 0·645 0·615 -0·377 0·394
Ballard's method 0·784 0·645 0·693 -0·263 0·070
'Wits' method 0·739 0·615 0·693 -0·253 0·003
Y-Axis length -0·355 -0·377 -0·263 -0·253 -0·064
S-N/y-axis angle 0·072 0·394 0·070 0·003 -0·064
294 D. Millett and J. F. Gravely
with establishing a gross skeletal discrepancy, the
four analyses give very similar results in most cases.
Where differences exist, it is pertinent to ask the
question, 'Which method provides the more valid
assessment?'.
All methods have their shortcomings (Moyers
and Bookstein, 1979). Objection to the methods of
assessment dependent on points A and B are that
these points are located on the alveolar processes,
and are consequently more affected by treatment
procedures than are 'true' skeletal reference points
(Holdaway, 1956; Baumrind and Frantz, 197la).
Reidel's method is, however, very reliable because
the error pattern of points A, N, and B is mainly in
the vertical plane (Baumrind and Frantz, 1971 b).
Moreover, provided there is an awareness that A
and B are strictly speaking alveolar points, this fact
does not invalidate assessments made by this meth-
od. Methods involving nasion are also open to
criticism as this area is subject to growth changes,
especially during the period of growth of the frontal
sinus. Thus, skeletal classification based purely on
the value of angle ANB may be misleading because
of variation in the anteroposterior position of
nasion, the degree of facial prognathism, the
rotation of the jaws and the variation in anterior
facial height (Taylor, 1969; Beatty, 1975; Jacobson,
1976; Freeman, 1981; Hussels and Nanda, 1984,
1986). The present study, however, failed to show
any significant correlation between the ANB differ-
ence and the S-N/y-axis angle or y-axis length. The
sample was, however, fairly small, and was not
selected to include a high proportion of very
marked discrepancies in dental base relationship.
Many investigators, including Taylor ( 1969) and
Beatty (1975) have attempted to eliminate the effect
of these variables by creating more complex angular
and linear measurements (Jarvinen, 1981, 1986a,b).
Angle ANB, the most widely used method of
evaluating anteroposterior dental base discrepan-
cies, depends not only on the anteroposterior
relationship of the dental bases, but also on varia-
tion in the length of the sella-nasion line and angle
S'NA. Too much importance should, therefore, not
be given to angle ANB when considered in isolation
in clinical practice (Jacobson, 1975; Jarvinen, 1985;
Chang, 1987). It should not, therefore, be consi-
dered an absolute measure of anteroposterior den-
tal base relationship, but merely a starting point by
providing data which should be checked by other
methods.
The 'Wits' appraisal, by relating points A and B
to the occlusal plane eliminates cranial landmarks
and the geometric inconsistencies associated with
the anteroposterior and vertical position of nasion.
However, the difficulty associated with the identifi-
BJO Vol. 18 No. 4
cation of the occlusal plane and the additional error
involved in drawing perpendiculars to it from
points A and B casts doubt on the validity of the
'Wits' measurement (Roth, 1982; Jacobson, 1988).
It is also evident that the results of the method are
closely related to the inclination of the occlusal
plane, and for this reason alone, validity of this
method must be questioned (Bishara et al., 1983).
The findings of the present study support Jacob-
son's (1975) view that there is good agreement
between the 'Wits' appraisal and angle ANB in
some, but not all, situations. The 'correction' of
Angle ANB by the Eastman analysis has been
thought to increase agreement with the other analy-
ses. However, if the Eastman correction improved
validity of Reidel's angle ANB, one would expect
the modified 'resultant' ANB difference to correlate
more closely with the result of the other analyses.
However, this does not appear to be the case (see
Table 2), and in this study, both Ballard's method
and 'Wits' analysis correlate more closely with
Reidel's ANB method. Perhaps this is due to the
correction being applied even in cases where it is less
appropriate. The relation of the cranial base (S-N)
to the maxillary plane must be assessed before any
correction is considered.
Jacobson ( 1976) mentioned the difficulties in
location of the occlusal plane. Richardson ( 1966)
demonstrated that both sella and nasion were
highly reproducible points. The line sella-nasion is,
therefore, located with greater consistency than the
occlusal plane, and thus, the angle ANB has been
and will continue to be widely employed. The 'Wits'
appraisal may be used as a diagnostic aid in
conjunction with other analyses. Results of this
analysis correlate well with the other analyses
examined. The nature and severity of a malocclu-
sion, and the extent to which the positions of the
teeth can be altered within the limits delineated by
the relationship of the maxillary and mandibular
dental bases by a simple 'tipping' movement, or a
more complex bodily movement, can be assessed
from a cephalograph. In this respect, Ballard's
method may be clinically useful.
The high error involved in tracings of incisor
teeth and the number of mechanical steps involved
in the Ballard 'conversion' method makes one
sceptical of its usefulness, but surprisingly the
standard error of the method for Ballard's analysis
when carried out by the present investigator was
only slightly greater than that of the 'Wits' analysis,
both methods involving linear measurements. This
was also borne out by Kenneth (1983) who, in a
similar study, examined the usefuless of various
methods of assessing skeletal pattern. Furthermore,
Ballard's method correlated closer to Reidel's than
BJO November /99/
any of the other analyses in the ranking of cases in
an order of increasing ANB difference.
The conclusion that has been drawn from this
investigation is that the simplest and most reliable
method of assessing skeletal pattern is Reidel's
method, which involves the least number of con-
~tructions and calculations and employs readily
Identifiable landmarks. Where angle SNA deviates
appreciably from 81 degrees, the Eastman method
of adjustment of angle ANB is of limited value.
Naturally, some cases will fall on different sides of
the arbitrary divisions between skeletal categories,
?ut if the results of the cephalometric analysis are
Interpreted intelligently, treatment is unlikely to be
affected.
Conclusions
1. There is a strong correlation between the four
methods of assessing skeletal pattern considered;
the correlation being significant at the 0·1 per
cent level of probability, suggesting that the four
analyses are intimately related.
2. The simplest method of assessing the antero-
posterior dental base relationship is Reidel's
method.
3. Routine application of the Eastman correction is
not to be recommended, as it did not appear to
provide more valid data than Reidel's method.
4. Ballard's method, although very time consum-
ing, provides results which correlate more closely
With Reidel's method than any of the other
analyses.
5. The two linear analyses (Ballard's method and
'Wits' analysis) correlate very closely with each
other, but both correlate poorly with the East-
man analysis.
6. The 'Wits' analysis is reputedly unreliable due to
the unreliability of identifying the occlusal plane.
This was not borne out by this study. Moreover,
it correlates very well with the other methods
used here.
7. The use of the SN-y-axis angle would appear to
be of no benefit in assessment of anteroposterior
dental base relationship.
Acknowledgements
We would like to thank Or P. H. Gordon for his
telpful advice with the statistical analysis, and Miss
· Brown for typing the manuscript.
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