PLOS ONE
RESEARCH ARTICLE
a1111111111
a1111111111
a1111111111
a1111111111
a1111111111
OPEN ACCESS
Citation: Liu F, Huang H, Shi X, Liu Y, Liu D (2023)
A study of transverse maxillomandibular
discrepancy and dental compensation in early
mixed dentition with skeletal Class III malocclusion
without posterior crossbite. PLoS ONE 18(6):
e0287343. https://doi.org/10.1371/journal.
pone.0287343
Editor: Claudia Trindade Mattos, Universidade
Federal Fluminense, BRAZIL
Received: January 24, 2023
Accepted: June 4, 2023
Published: June 15, 2023
Copyright: © 2023 Liu et al. This is an open access
article distributed under the terms of the Creative
Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in
any medium, provided the original author and
source are credited.
Data Availability Statement: The data of digital
radiography cannot be shared publicly because the
scanned CBCT data contains patients’ private
information and the national policy restricted the
information seriously. Data are available from the
Ethics Committee of the hospital of Stomatology,
Shandong University(If necessary, please contact
via shaohuage@sdu.edu.cn) for researchers who
meet the criteria for access to confidential data.
PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023
A study of transverse maxillomandibular
discrepancy and dental compensation in early
mixed dentition with skeletal Class III
malocclusion without posterior crossbite
Fangming Liu ID1, Haiyun Huang2, Xiaoyang Shi1, Yi Liu1*, Dongxu Liu ID1*
1 Department of Orthodontics, School and Hospital of Stomatology, Cheeloo College of Medicine, Shandong
University & Shandong Key Laboratory of Oral Tissue Regeneration & Shandong Engineering Laboratory for
Dental Materials and Oral Tissue Regeneration & Shandong Provincial Clinical Research Center for Oral
Diseases, Shandong, China, 2 Department of Implantology, School and Hospital of Stomatology, Cheeloo
College of Medicine, Shandong University & Shandong Key Laboratory of Oral Tissue Regeneration &
Shandong Engineering Laboratory for Dental Materials and Oral Tissue Regeneration & Shandong Provincial
Clinical Research Center for Oral Diseases, Shandong, China
* liudongxu@sdu.edu.cn (DL); yiliu@sdu.edu.cn (YL)
Abstract
Objective
To evaluate transverse maxillomandibular discrepancy and dental compensation in first
molar areas in 7- to 9-year-old children with skeletal Class III malocclusion without posterior
crossbite using cone-beam computed tomography (CBCT).
Methods
The sample of this retrospective study consisted of 60 children (7 to 9 years old), who were
divided into the skeletal Class III malocclusion group (study group, skeletal Class III maloc-
clusion without posterior crossbite, N = 31) and the Class I occlusion group (control group,
Class I occlusion with one or two impacted teeth, N = 30). CBCT data were obtained from
the database of the Department of Radiology of Hospital of Stomatology, Shandong Univer-
sity. For three-dimensional reconstruction of the head, the dental arch width, basal bone
width, and buccolingual inclination angle were measured using MIMICS 21.0 software. Inde-
pendent-sample t tests were used to compare the two groups.
Results
The mean age of the children was 8.18±0.83years. The width of the maxillary basal bone
was significantly smaller in the skeletal Class III malocclusion group (59.75 ± 3.14 mm) than
in the Class I occlusion group (62.39 ± 3.01 mm) (P < 0.01). The mandibular basal bone
width was significantly larger in the skeletal Class III malocclusion group (60.00 ± 2.56 mm)
than in the Class I occlusion group (58.19 ± 2.42 mm) (P < 0.01). The difference in the width
of the maxillary and mandibular bases in the skeletal Class III malocclusion group (–0.25 ±
1.73 mm) was significantly different from that in the Class I occlusion group (4.20 ± 1.25
1 / 13
PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

Funding: This study was funded by the National mm) (P < 0.01). However, there was no significant difference in the upper or lower dental
Natural Science Foundation of China (No. arch width between the two groups (P > 0.05). The buccal inclination of the maxillary molars
81571010), the Key Clinical Research of Shandong
University (No. 2020SDUCRCA 005), the
in the skeletal Class III malocclusion group (31.4˚ ± 8.9˚) was significantly higher than that in
Shandong University Graduate Education and the Class I occlusion group (17.64˚ ± 7.3˚) (P < 0.01), as was the lingual inclination angle of
Teaching excellent achievement training program mandibular molars (45.24˚ ± 8.3˚ vs. 37.96˚ ± 10.18˚; P < 0.01).
(No. ZY2019004), the National Natural Science
Foundation of China (No. 81701008), the Key
Research and Development Program of Shandong Conclusion
Province, China (No. 2019GSF108187), and the
Transverse maxillary and mandibular discrepancies in the posterior area and transverse
Undergraduate Teaching Reform and Research
Project of Shandong University Cheeloo Medical dental compensation were found in the early mixed dentition of patients with skeletal Class
College (No. qlyxjy-202027). The funders had no III malocclusion without posterior crossbite. This suggests that even in the absence of poste-
role in study design, data collection and analysis,
rior crossbite, maxillary expansion can be attempted to correct the maxillomandibular trans-
decision to publish, or preparation of the
manuscript. verse discrepancy.

Competing interests: The authors have declared

that no competing interests exist.

Introduction
Skeletal Class III malocclusion is a growth-related clinical craniofacial abnormality that mani-
fests primarily as the lower arch protruding in front of the upper arch [1, 2]. This abnormality
establishes itself early in life and is not a self-correcting discrepancy [3–5]. Sagittal dental and
skeletal abnormalities can be diagnosed easily via clinical performance or imaging. However,
for patients with early mixed dentition without posterior crossbite, transverse maxillomandib-
ular discrepancy can be masked by changes in the inclination of the upper and lower molars.
Krishnaswamy [6] noted that although transverse maxillomandibular discrepancies are major
components of several forms of malocclusion, crossbite and transverse discrepancies do not
form a homologous group; the transverse dimension grows the least and stops growing the
soonest by the time the patients are seen. Intervention in the early mixed dentition phase (pre-
pubertal growth phase) is recommended [7–9]. Hence, it is vital to assess the craniofacial skele-
ton in the transverse dimension as early as possible to identify the need for transverse
maxillary expansion and reduce the extent of the burden of severe Class III malocclusion in
late adolescence [1, 10].
In clinical practice, the diagnosis of transverse maxillomandibular discrepancies can be dif-
ficult and often includes one or more of the following methods: clinical evaluation, dental cast
assessment, and radiograph analysis. The advent of cone-beam computed tomography
(CBCT) and medical image reconstruction software [11] allows the visualization and analysis
of the width of the maxillary and mandibular basal bones and their relationship, the buccolin-
gual inclination of each whole tooth, and their root positions in the alveolar bone [10, 12, 13].
Miner et al. [14] found skeletal discrepancies in the crossbite group by developing a transverse
analysis based on CBCT data. Yang et al. [15] found that maxillary first molars exhibited buc-
cal inclination and that adults displayed less inclination than did children in CBCT images.
Additionally, Ahn et al. [16] found that transverse dental compensation is closely related to
sagittal and transverse skeletal discrepancy in skeletal Class III patients in adults through
CBCT. Until now, there have been few studies on transverse maxillomandibular discrepancy
and dental compensation with permanent dentition and skeletal Class III malocclusion with-
out posterior crossbite [14, 17], but no research data on transverse maxillomandibular discrep-
ancy and dental compensation in children with early mixed dentition
The objective of this study was to evaluate the transverse maxillomandibular discrepancy
and dental compensation in early mixed dentition with skeletal Class III malocclusion without

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 2 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

posterior crossbite, in order to provide a theoretical foundation in transverse discrepancy diag-

nosis and treatment planning.

Materials and methods

Subjects
This retrospective study included 7- to 9-year-old children who visited the Hospital of Stoma-
tology, Shandong University from January 2018 to June 2021. Instead of recruiting partici-
pants for research, we retrospectively searched CBCT images and identified individual medical
records that were archived in the Hospital of Stomatology, Shandong University during the
time mentioned above for diagnosis or treatment planning, including planning for orthodon-
tic treatment and surgical removal of impacted supplementary teeth.
All procedures performed in the study were approved by the Ethics Committee of the Hos-
pital of Stomatology, Shandong University (No. 20201209) and were in accordance with the
Declaration of Helsinki for research involving human participants. All patients’ parents pro-
vided written informed consent.

Inclusion and exclusion criteria

Sample size estimation was performed using PASS software (Number Cruncher Statistical Sys-
tems, version 2000, Kaysville, UT, USA), following the “Two-Sample T-Tests Assuming Equal
Variance” calculation method. The used variable was Mx-Mx width. To detect a mean differ-
ence of 3.8 mm in the maxillary wide between both groups with a standard deviation of 4.0
mm [18], a test power of 80%, and a significance level of 5%, 19 patients would be needed in
each group. To increase test power, even more, all the patients fit the selection criteria were
included. At last, the study group (with skeletal Class III malocclusion, N = 31) and the control
group (with skeletal Class I occlusion, N = 30) were included, and the final test power reached
95%.
The distribution of sex and age among all samples is shown in Table 1.
Patients in the study group who met the following criteria were included: (1) ANB angle
[formed by the subspinale (A), nasion (N), and supramental (B)] less than 0˚; anterior teeth
couldn’t reach to edge-to-edge relationship when the mandible was retruded; skeletal Class III,
symmetry, with Me deviation less than 2 mm;(2) Maxilla to cranial base- Nasion perpendicular
to point A (A-Np) less than 0mm [19]; (3) Mandible to cranial base- Pogonion to nasion per-
pendicular(Pog-Np) more than -6mm [19]; (4) Tweed, who declared that the mandibular inci-
sors should upright in the mandibular anterior alveolus in ideal occlusion, presented the
theory that the measurement of mandibular plane angle (FMA) was also essential in demon-
strating different growth patterns [20]. Therefore, the FMA—measured between the Frankfort
horizontal plane (FH) and the mandibular plane on a lateral cephalogram were used in the cri-
teria. The angle between 22˚ and 32˚ (according to Chinese standards) [21] were considered as
an average face angle, and the patients meet with this criteria were included.; (5) full eruption

Table 1. Distribution of sex and age.

Variable Class III Class I Total
Sex, n (%)
Male 15 (48.4) 17 (56.7) 32 (52.5)
Female 16 (51.6) 13 (43.3) 29 (47.5)
Age (y)
Average (SD) 8.10 (0.83) 8.27 (0.83) 8.18 (0.83)
https://doi.org/10.1371/journal.pone.0287343.t001

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 3 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

of all maxillary and mandibular first permanent molars to the occlusal plane; (6) bilateral first
permanent molars with Class III malocclusion; (7) absence of crossbite on permanent molars.
Patients in the control group were selected using the following criteria: (1) 1˚ <
ANB < 4.5˚ [3]; (2) A-Np about 0mm [19]; (3) Pog-Np between -8mm and -6mm [19]; (4)
FMA between 22˚ and 32˚; (5) bilateral first permanent molars with Class I relationship; (6)
bilateral maxillary and mandibular first permanent molars fully erupted to the occlusal plane,;
(7) no previous orthodontic treatment and approximate symmetry in frontal view and fair pro-
file; (8) anterior crowding, less than 4 mm.
The exclusion criteria were as follows: (1) patients with functional Class III relationship
(the mandible could retruded to anterior teeth edge-to-edge position) or a mandibular func-
tional shift; (2) severe dental or maxillofacial deformities, such as cleft lip or palate; (3) any of
the first molar has caries, restoration, pulp or periapical disease; (4) abnormal teeth position
(one or more permanent teeth missing, premature loss of deciduous teeth).

Data collection and processing

Data collection. All data in this study were obtained using a NewTom 5G CBCT scanner
(Verona, Italy). Taking into account radiation doses, safety, and patient protection, the opera-
tors followed the As Low As Reasonably Achievable principle before scanning [22, 23] by
reducing the standard dose for the echo scan (110 kV, 17.76 mAs), shortening the time of irra-
diation, and minimizing exposure of the surface of the body. We highlighted the features
through which CBCT provided advantages over conventional two-dimensional imaging in
paediatric dentistry before orthodontic treatment [24]. Clinical data and records were
obtained from the Department of Orthodontics, Hospital of Stomatology, Shandong
University.
Head position reorientation. The CBCT output was obtained in digital imaging and
communications in medicine (DICOM) format. Then, the original patient CBCT data were
imported into Materialism’s Interactive Medical Image Control System (MIMICS) software
(21.0, Leuven, Belgium) to reconstruct a three-dimensional model of the patient’s head, as
shown in Fig 1. The landmarks were used as follows:
① Right porion points (P): the most superior point of the right external acoustic meatus.
② Bilateral orbital point (O1 and O2): the most inferior point of the right (O1) and the left
(O2) infraorbital rim.
③ Skull base point (Ba): the most anterior point of the great foramen (foramen magnum)
④ Nasal root point (N): the most anterior point of the sutura nasofrontalis.

Fig 1. Head position correction. A: Corrected head position on the coronal plane; B: side view of corrected head
position. C: Sagittal view of corrected head position.
https://doi.org/10.1371/journal.pone.0287343.g001

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 4 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

⑤ Upper molar point (U6): mesiobuccal root tip point of the right upper molar.

The following three reference planes were established using the specified points and planes
for head position correction [25]:
① Horizontal reference plane: established through P, O1 and O2.
② Sagittal reference plane: established through Ba and N perpendicular to the horizontal ref-
erence plane.
③ Coronal reference plane: established as a plane perpendicular to the horizontal reference
plane and the sagittal reference plane, crossing the mesiobuccal root tip point at U6.
The fluoroscopy function on the view menu was used to redefine new coordinates, or the
established plane was used as a reference plane to correct the three-dimensional position of the
CBCT scan so that the horizontal plane was parallel to the ground plane. Therefore, the head
position was reoriented.
Points: P: right porion point; O1: right infraorbital point; O2:left infraorbital point N: nasal
root point; Ba: skull base point; U6: mesiobuccal root tip point of right upper molar
Planes:①Horizontal reference plane(FH): established through P, O1 and O2.②Sagittal ref-
erence plane(MSP): established through Ba and N perpendicular to the horizontal reference
plane.③Coronal reference plane(VRP): established as a plane perpendicular to the horizontal
reference plane and the sagittal reference plane, crossing the mesiobuccal root tip point at U6.

Measurements
Width. We established another analysis system using the “Measure and Analyze—Analy-
sis Overview” menu; the system was built to specify eight positioning points, and the type of
measurement was set as distance (2 points). The eight points and four distances were defined
as follows:
(1) On the coronal view, the location of the maxillary measurement points (MxR and MxL)
were on the right and left intersection points of the maxillary tuberosity outline and the
zygomatic buttress; on the sagittal view, they were in accordance with the position of maxil-
lary first molar. The distance between them corresponded to the width of the maxillary
basal bone width (MxBW) [24] (Fig 2).
(2) On the axial view, the most prominent points of the buccal alveolar process were allocated,
the vertical positions were in accordance with the center of resistance points of the mandib-
ular first molars. They were defined as the right and left mandibular width measurement
points (MnR and MnL). The distance between them was in correspondance with the widths
of the mandibular basal bone widths (MnBW). (Fig 3).
(3) Points U6R and U6L were the central fossa of the right and left maxillary first molars, and
the dental arch widths (MxAW) was the distance between them; the central fossa of the
right and left mandibular first molars were allocated at Points L6R and L6L, the distance
between them was defined as mandibular dental arch width (MnAW) [26] (Fig 4).

After the positioning was completed, the “Measure and Analyze” function of MIMICS soft-
ware automatically obtained the measurements of each width in three-dimensional space. The
difference between the basal bone width was defined as the MxBW minus MnBW, and the dif-
ference between the dental arch width was MxAW minus MnAW. The value was considered

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 5 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

Fig 2. Locations of points and measurements in maxillary basal bone width. A. On the coronal view, the location of
the maxillary measurement points (MxR and MxL) were on the right and left intersection points of the maxillary
tuberosity outline and the zygomatic buttress; on the sagittal view, they were in accordance with the position of
maxillary first molar. B The distance between MxR and MxL corresponded to the width of the maxillary basal bone
width (MxBW).
https://doi.org/10.1371/journal.pone.0287343.g002

positive when width of the maxilla is larger than that of the mandible, and negative when the
former is smaller than the latter.
Angle. The central point of the clinical crown (CC) and the root centre (RC) point were
defined by the method proposed by Alkhatib [27]. At first, the root centre (RC) point was
defined as the center of root furcation, which were located and calibrated in three dimensions.
Then the coronal cut where the RC located was chosen; the midpoint of the buccal-lingual
width of the crown was located and defiend as the central point of the clinical crown (CC).
The long axis of the tooth (LAT) was defined as the line connecting CC and RC points. The
coronal plane passing through the CC point and the RC point was selected as the measuring
plane, and the angle between the LAT and the vertical line perpendicular to the FH was mea-
sured. The maxillary LAT was considered positive on the buccal side of the vertical line and
negative on the lingual side; while the mandibular LAT was considered positive on the lingual
side of the vertical line and negative on the buccal side (Fig 5).

Fig 3. Locations of points and measurements in mandibular basal bone width. A. On the axial view, the most
prominent points of the buccal alveolar process were allocated, the vertical positions were in accordance with the
center of resistance points of the mandibular first molars. They were defined as the right and left mandibular width
measurement points (MnR and MnL). B. The distance between MxR and MxL was in correspondence with the widths
of the mandibular basal bone widths (MnBW).
https://doi.org/10.1371/journal.pone.0287343.g003

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 6 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

The central point of the clinical crown (CC) and the root centre (RC) point were defined by
the method proposed by Alkhatib [27]. At first, the root centre (RC) point was defined as the
center of root furcation, which were located and calibrated in three dimensions. Then the cor-
onal cut where the RC located was chosen; the midpoint of and buccal-lingual width of the
crown was located and defiend as the central point of the clinical crown (CC). The long axis of
the tooth (LAT) was defined as the line connecting CC and RC points. The coronal plane pass-
ing through the CC point and the RC point was selected as the measuring plane, and the angle
between the LAT and the vertical line perpendicular to the FH was measured. The maxillary
LAT was considered positive on the buccal side of the vertical line and negative on the lingual
side; while the mandibular LAT was considered positive on the lingual side of the vertical line
and negative on the buccal side.
Repeated data measurement. Using MIMICS software, the experimenter used the same
method to repeat the measurements again after a two-week interval. The intragroup correla-
tion coefficient (ICC) of the data obtained from the two measurements was calculated to evalu-
ate the reliability The random errors (RE) were evaluated using Dahlberg formula [28]:
pffiP
ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
D¼ ðd2 =2nÞ (where d indicates deviations between the 2 measurements, and n indicates
number of paired objects). The final values of the aforementioned measurements were
averaged.

Statistical analysis
Standard descriptive statistics, including means and standard deviations, were calculated for
each measurement. The normality of the outcome data of widths and angles was examined
using the Kolmogorov–Smirnov test with SPSS 25.0 (IBM SPSS Statistics 25.0) software. As all
data conformed to a normal distribution, independent-sample t tests were performed to com-
pare the two groups. A P value <0.05 indicated statistical significance.

Results
By analysing, the intraclass correlation coefficients of repeated measurements were all greater
than 0.85, indicating good reliability. The random error of each of the measurements were
shown as follows: the error of angle measurements ranged from 0.47˚ to 0.57˚, whereas the
error of the width measurements ranged from 0.38 mm to 0.46 mm.
A comparison of the maxillary base width (MxBW) and mandibular base width (MnBW)
between the two groups showed a significantly narrower maxillary molar area and a signifi-
cantly wider mandibular molar area in skeletal Class III malocclusion without posterior cross-
bite than in Class I occlusion (P < 0.01). The difference in the width of the maxillary and
mandibular bases was 4.20 ±1.25 mm in Class I occlusion and –0.25 ± 1.73 mm in skeletal
Class III malocclusion without posterior crossbite, and the difference was significant
(P < 0.01) (Table 2).
There was no significant difference in the maxillary dental arch width (MxAW), the man-
dibular dental arch width (MnAW), or the difference between the two (MxAW–MnAW)
between the two groups (P > 0.05) (Table 3).
The analysis also revealed no significant difference in the indexes between the sexes in the
two groups (P > 0.05) (Table 4).
The upper molar inclination angle (UMIA) and lower molar inclination angle (LMIA) of
the buccolingual orientation of the left and right molars were not significantly different
(P > 0.05). Therefore, data from the left and right sides were combined for subsequent com-
parisons between the groups.

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 7 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

Fig 4. Location of marked points in the maxillary and mandibular arches. A~C: Central fossa of the right maxillary
first molar on the coronal, sagittal and axial planes; D: Maxillary arch width (MxAW): distance between the two central
fossa of the maxillary first molars (U6R-U6L); Mandibular arch width (MnAW): distance between the two central fossa
of the mandibular first molars (L6R-L6L).
https://doi.org/10.1371/journal.pone.0287343.g004

The UMIA in the skeletal Class III malocclusion and Class I occlusion groups was
31.4 ± 8.9˚ and 17.64 ± 7.3˚, respectively; the difference between the two groups was significant
(P < 0.01). The LMIA was higher in skeletal Class III malocclusion without posterior crossbite
(45.24 ± 8.3˚) than in Class I occlusion (37.96 ± 10.18˚, P< 0.01) (Table 5). There were no sig-
nificant differences in the two aforementioned indexes between the sexes in the two groups
(P > 0.05) (Table 4).

Discussion
The results of our study show that in the skeletal Class III malocclusion group, the maxillary
basal bone width was significantly narrower (P < 0.01) and the mandibular basal bone width
was significantly wider (P < 0.01) than that in the Class I occlusion group, which is similar to
results reported for a population with permanent dentition by our previous studies [25, 29].
This indicates that patients with skeletal Class III malocclusion without posterior crossbite in
the early stage of mixed dentition also suffer from insufficient maxillary width and/or excessive
mandibular width; in other words, uncoordinated maxillary and mandibular widths emerge

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 8 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

Fig 5. Inclination measurements for the maxillary and mandibular first molars. A: Angles of maxillary first molars
on coronal view. B: Angles of mandibular first molars on coronal view.
https://doi.org/10.1371/journal.pone.0287343.g005

during this period. However, no significant difference in the upper or lower arch width
between the two groups were found in our study. The compensation of the maxillary and max-
illary permanent molars before orthodontic treatment is present in the period of mixed denti-
tion in patients with skeletal Class III malocclusion. Therefore, during clinical diagnosis, the
dental arch widths cannot fully reflect the coordination of the transverse widths of the upper
and lower jaws; indeed, measurement of the width of the maxillary and mandibular basal bone
might be more clinically significant.
Wilson [30] was the first to report the lateral inclination of the grinding teeth, with the
lower teeth inclined lingually and the upper teeth inclined buccally. It is important to deter-
mine the appropriate amount of buccolingual tooth inclination for adequate function and to
quantify it so that treatment goals are well supported by evidence. Yang et al. [15] reported
that the normal buccal inclination of the maxillary and mandibular first molars in children
with untreated Class I occlusion was 21.1˚ ± 9.5˚ and 34.9˚ ± 11˚, respectively, similar to that
in the Class I occlusion patients in our study. Alkhatib and Chung [27] showed that the maxil-
lary buccal and mandibular lingual inclination in normal adults was 4.9˚ and 12.6˚, respec-
tively. Marshall et al. [31] found that the buccolingual inclination of the molars gradually
decreased with age, explaining the difference between their research and our measurement
results.
The result of our study showed that the first permanent maxillary molars of children with
skeletal Class III malocclusion without posterior crossbite compensated more for the buccal
inclination than those with Class I occlusion (P < 0.01), and the mandibular first molars were

Table 2. Comparison of the widths of the maxillary and mandibular bases in the two groups.
Groups Class III Class I t P
MxBW 59.75 ± 3.14 62.39 ± 3.01 3.356 0.001**
MnBW 60.00 ± 2.56 58.19 ± 2.42 –2.833 0.006**
MxBW–MnBW –0.25 ± 1.73 4.20 ± 1.25 11.488 0.000**

*P < 0.05; **P < 0.01.

MxBW, maxillary base width; MnBW, mandibular base width

https://doi.org/10.1371/journal.pone.0287343.t002

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 9 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

Table 3. Comparison of the widths of the maxillary and mandibular arches in the two groups.
Groups Class III Class I t P
MxAW 47.74 ± 2.81 48.20 ± 3.53 0.560 0.578
MnAW 47.49 ± 3.00 48.42 ± 2.25 1.373 0.175
MxAW–MnAW 0.26 ± 1.75 –0.22 ± 2.32 –0.911 0.366

*P < 0.05; **P < 0.01.

MxAW, maxillary dental arch width; MnAW, mandibular base width.

https://doi.org/10.1371/journal.pone.0287343.t003

more lingual (P < 0.01). McNamara [17] reported that the buccal inclination of the maxillary
molars and the depth of the Wilson curve of the mandibular molars tended to increase when
the posterior teeth had no crossbite but the width of the maxilla was insufficient. Miner et al.
[14] used CBCT in the analysis of the transverse dimension in mixed or permanent dentition.
They found that within the clinical non-crossbite group, a significant number of patients were
revealed to have skeletal transverse jaw discrepancy that had been masked by dental compen-
sation; these results are in accordance with the results of our study.
In this study, the maxillary and mandibular basal bone widths were measured, and the mea-
surement points were located with reference to the first molars. Based on former studies, it is
common to use teeth position to locate bone reference, but there is no doubt that teeth posi-
tion could affect the result of basal bone width measurement. When the molars moving mesi-
ally, the corresponding basal bone width would be narrower. On the other hand, when the
molars moving distally, the basal bone width would be wider. One or more permanent teeth
missing, premature loss of deciduous teeth would affect the position of the first molars. In this
study, patients with abnormal teeth position were excluded, thus the influence would be
minimized.
The information obtained from CBCT imaging provides several substantial advantages. For
example, CBCT imaging provides accurate measurements, improves localization of impacted
teeth, provides visualization of airway abnormalities comparison to conventional radiograph.
Moreover, CBCT imaging involves only a minimal increase in radiation dose relative to com-
bined diagnostic modern digital panoramic and cephalometric imaging. But CBCT is not a
standard method of diagnosis in Orthodontics. most frequent indication of CBCT in Ortho-
dontics, includes retained/impacted permanent teeth; severe craniofacial anomalies; and so
on. In this study, the indications in study group (skeletal Class III malocclusion) were severe
craniofacial anomalies; in control group were at least one impacted tooth and the As Low As
Reasonably Achievable principle [22, 23] was conducted in our study.

Table 4. Comparison of the widths and inclination angles by sex.

Class I P 0.982 0.388 0.422 0.182 0.266 0.297 0.279 0.436
t 0.023 0.878 -0.815 1.369 1.134 1.062 1.104 0.790
Female 48.18±2.66 48.01±2.42 0.17±2.36 61.55±3.02 57.62±2.41 3.93±1.43 15.97±6.84 36.27±11.24
Male 48.21±4.15 48.74±2.13 -0.53±232 63.04±2.92 58.63±2.40 4.42±1.10 18.93±7.58 39.25±9.42
Class III P 0.682 0.835 0.763 0.418 0.882 0.208 0.605 0.462
t 0.414 0.210 0.304 -0.821 -0.149 -1.288 0.523 0.745
Female 47.54±3.04 47.38±3.33 0.16±1.97 60.20±3.82 60.06±2.96 0.13±1.74 30.58±7.51 44.16±7.90
Male 47.96±2.63 47.61±2.71 0.36±1.56 59.27±2.25 59.93±2.16 -0.66±1.68 32.28±10.38 46.40±8.83
Group MxAW MnAW MxAW–MnAW MxBW MnBW MxBW–MnBW UMIA LMIA
https://doi.org/10.1371/journal.pone.0287343.t004

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 10 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

Table 5. Comparison of inclination angles in the two groups.

Group Class III Class I t P
UMIA 31.40 ± 8.90 17.64 ± 7.30 –6.589 0.000**
LMIA 45.24 ± 8.30 37.96 ± 10.18 –3.068 0.003**

*P < 0.05; **P < 0.01.

LMIA, lower molar inclination angle; UMIA, upper molar inclination angle.

https://doi.org/10.1371/journal.pone.0287343.t005

There are some limitations of this study. First of all, considering the large variations in
growth and different types of dentition replacement among 7- and 9-year-old children, the
sample size of the study is limited. Furthermore, the population is limited to Chinese, therefore
the results couldn’t be generalized to other populations. Larger sample size and different popu-
lations are needed in further study. Second, longitudinal study is preferred to give more clini-
cal evidence. But leaving a skeletal Class III patients untreated is against ethics. Data acquired
from previous studies could be used, and future study should be carefully designed. In addi-
tion, the classification of skeletal Class III malocclusion is complex. This study was not speci-
fied whether class III was due to mandibular prognathism, maxillary retrognathism or a
combination of both. Skeletal Class III patients with different pathogenesis should be explored
for better results.

Conclusions
The main findings were as follows:
(1) Abnormal transverse development of the maxillary and mandibular basal bones in patients
with skeletal Class III malocclusion without posterior crossbite is present in the early stage
of mixed dentition. RME might be the most efficient and effective treatment for transverse
problems in Class III patients in early mixed dentition stage.
(2) In patients with mixed dentition, the inclination of the upper and lower molars is higher
among those with skeletal Class III malocclusion without posterior crossbite than among
those with Class I occlusion due to compensation for maintaining occlusal contact.

Supporting information
S1 Checklist. STROBE statement—checklist of items that should be included in reports of
observational studies.
(DOCX)

Author Contributions
Conceptualization: Dongxu Liu.
Data curation: Xiaoyang Shi.
Methodology: Xiaoyang Shi, Yi Liu.
Supervision: Haiyun Huang.
Writing – original draft: Fangming Liu.
Writing – review & editing: Haiyun Huang, Yi Liu, Dongxu Liu.

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 11 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

References
1. Zere E, Chaudhari PK, Sharan J, Dhingra K, Tiwari N. Developing Class III malocclusions: challenges
and solutions. Clin Cosmet Investig Dent. 2018; 10:99–116. Epub 2018-1-20. https://doi.org/10.2147/
CCIDE.S134303 PMID: 29950903.
2. Williams S, Andersen CE. The morphology of the potential Class III skeletal pattern in the growing child.
Am J Orthod. 1986; 89(4):302–11. Epub 1986-4-1. https://doi.org/10.1016/0002-9416(86)90052-7
PubMed 3457529. PMID: 3457529
3. Guyer EC, Ellis ER, McNamara JJ, Behrents RG. Components of class III malocclusion in juveniles and
adolescents. Angle Orthod. 1986; 56(1):7–30. Epub 1986-1-1. https://doi.org/10.1043/0003-3219
(1986)056<0007:COCIMI>2.0.CO;2<0007:COCIMI>2.0.CO;2. PubMed 3485393. PMID: 3485393
4. Baccetti T, Reyes BC, McNamara JJ. Craniofacial changes in Class III malocclusion as related to skele-
tal and dental maturation. Am J Orthod Dentofacial Orthop. 2007; 132(2):171.e1–171.e12. Epub 2007-
8-1. https://doi.org/10.1016/j.ajodo.2005.07.031 PMID: 17693366.
5. Rutili V, Nieri M, Giuntini V, McNamara JJ, Franchi L. A multilevel analysis of craniofacial growth in sub-
jects with untreated Class III malocclusion. Orthod Craniofac Res. 2020; 23(2):181–191. Epub 2020-5-
1. https://doi.org/10.1111/ocr.12356 PMID: 31677327.
6. Krishnaswamy NR. Expansion in the absence of crossbite–rationale and protocol. APO Trends Orthod.
2019; 9:126–137. PubMed.
7. Westwood PV, McNamara JJ, Baccetti T, Franchi L, Sarver DM. Long-term effects of Class III treatment
with rapid maxillary expansion and facemask therapy followed by fixed appliances. Am J Orthod Dento-
facial Orthop. 2003; 123(3):306–20. Epub 2003-3-1. https://doi.org/10.1067/mod.2003.44 PMID:
12637903.
8. Cha KS. Skeletal changes of maxillary protraction in patients exhibiting skeletal class III malocclusion: a
comparison of three skeletal maturation groups. Angle Orthod. 2003; 73(1):26–35. Epub 2003-2-1.
https://doi.org/10.1043/0003-3219(2003)073<0026:SCOMPI>2.0.CO;2 PMID: 12607852.
9. Baratieri CL, Alves MJ, Mattos CT, Lau GW, Nojima LI, de Souza MM. Transverse effects on the naso-
maxillary complex one year after rapid maxillary expansion as the only intervention: a controlled study.
Dental Press J Orthod. 2014; 19(5):79–87. Epub 2014-9-1. https://doi.org/10.1590/2176-9451.19.5.
079-087.oar PMID: 25715720.
10. Harrell WJ, Hatcher DC, Bolt RL. In search of anatomic truth: 3-dimensional digital modeling and the
future of orthodontics. Am J Orthod Dentofacial Orthop. 2002; 122(3):325–30. Epub 2002-9-1. https://
doi.org/10.1067/mod.2002.126147 PMID: 12226616.
11. Hajem S, Brogardh-Roth S, Nilsson M, Hellen-Halme K. CBCT of Swedish children and adolescents at
an oral and maxillofacial radiology department. A survey of requests and indications. Acta Odontol
Scand. 2020; 78(1):38–44. Epub 2020-1-1. https://doi.org/10.1080/00016357.2019.1645879 PMID:
31385739.
12. Adams GL, Gansky SA, Miller AJ, Harrell WJ, Hatcher DC. Comparison between traditional 2-dimen-
sional cephalometry and a 3-dimensional approach on human dry skulls. Am J Orthod Dentofacial
Orthop. 2004; 126(4):397–409. Epub 2004-10-1. https://doi.org/10.1016/j.ajodo.2004.03.023 PMID:
15470343.
13. Harrell WJ. 3D Diagnosis and treatment planning in orthodontics. Semin in Orthod. 2009; 15:35–41.
PubMed.
14. Miner RM, Al QS, Rigali PH, Will LA. Cone-beam computed tomography transverse analysis. Part I:
Normative data. Am J Orthod Dentofacial Orthop. 2012; 142(3):300–7. Epub 2012-9-1. https://doi.org/
10.1016/j.ajodo.2012.04.014 PMID: 22920695.
15. Yang B, Chung CH. Buccolingual inclination of molars in untreated children and adults: A cone beam
computed tomography study. Angle Orthod. 2019; 89(1):87–92. Epub 2019-1-1. https://doi.org/10.
2319/010418-6.1 PMID: 30080127.
16. Ahn J, Kim SJ, Lee JY, Chung CJ, Kim KH. Transverse dental compensation in relation to sagittal and
transverse skeletal discrepancies in skeletal Class III patients. Am J Orthod Dentofacial Orthop. 2017;
151(1):148–156. Epub 2017-1-1. https://doi.org/10.1016/j.ajodo.2016.06.031 PMID: 28024769.
17. McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop. 2000; 117(5):567–70.
Epub 2000-5-1. https://doi.org/10.1016/s0889-5406(00)70202-2 PMID: 10799117.
18. Franchi L, Baccetti T. Transverse maxillary deficiency in Class II and Class III malocclusions: a cephalo-
metric and morphometric study on postero-anterior films. Orthod Craniofac Res. 2005; 8(1):21–8. Epub
2005-2-1. https://doi.org/10.1111/j.1601-6343.2004.00312.x PMID: 15667642.
19. McNamara JJ. A method of cephalometric evaluation. Am J Orthod. 1984; 86(6):449–69. Epub 1984-
12-1. https://doi.org/10.1016/s0002-9416(84)90352-x PubMed 6594933. PMID: 6594933

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 12 / 13

PLOS ONE A study of transverse maxillomandibular discrepancy and dental compensation in early mixed dentition

20. TWEED CH. The Frankfort-mandibular plane angle in orthodontic diagnosis, classification, treatment
planning, and prognosis. Am J Orthod Oral Surg. 1946; 32:175–230. Epub 1946-4-1. https://doi.org/10.
1016/0096-6347(46)90001-4 PMID: 21022281.
21. Minkui F, Mao X. Cephalometic study of 144 normal occlusion Chinese people. J Peking Univ Health
Sci. 1965; 04:251–256. PubMed.
22. Daniela GG, Louise RC, Claudia RL, Guilherme J. Is there a consensus for CBCT use in Orthodontics?
Dental Press J Orthod. 2014; 19(5):136–149. PubMed. https://doi.org/10.1590/2176-9451.19.5.136-
149.sar PMID: 25715727
23. De Grauwe A, Ayaz I, Shujaat S, Dimitrov S, Gbadegbegnon L, Vande VB, et al. CBCT in orthodontics:
a systematic review on justification of CBCT in a paediatric population prior to orthodontic treatment.
Eur J Orthod. 2019; 41(4):381–389. Epub 2019-8-8. https://doi.org/10.1093/ejo/cjy066 PMID:
30351398.
24. Andrews LF, Andrews WA. The six elements of orofacial harmony. Andrews Journal. 2000; 1:13–22.
PubMed.
25. Tan XM, Liu DX, Zhang KL, Zhang CX. A comparative study of basal and dental arch width in skeletal
class III malocclusion and Class I normal occlusion. Stomatology. 2021; 41(4):315–318. PubMed.
26. Paredes N, Colak O, Sfogliano L, Elkenawy I, Fijany L, Fraser A, et al. Differential assessment of skele-
tal, alveolar, and dental components induced by microimplant-supported midfacial skeletal expander
(MSE), utilizing novel angular measurements from the fulcrum. Prog Orthod. 2020; 21(1):18. Epub
2020-7-13. https://doi.org/10.1186/s40510-020-00320-w PMID: 32656601.
27. Alkhatib R, Chung CH. Buccolingual inclination of first molars in untreated adults: A CBCT study. Angle
Orthod. 2017; 87(4):598–602. Epub 2017-7-1. https://doi.org/10.2319/110116-786.1 PMID: 28375034.
28. G D. Statistical methods for medical and biological students. London, United Kingdom: G. Allen &
Unwin Ltd. 1940.
29. Zhang CX, Tan XM, Wu W, Liu H, Liu Y, Qu XR, et al. Reliability of 2 methods in maxillary transverse
deficiency diagnosis. Am J Orthod Dentofacial Orthop. 2021; 159(6):758–765. Epub 2021-6-1. https://
doi.org/10.1016/j.ajodo.2020.02.019 PMID: 33722409.
30. Wilson G. A Manual of Dental Prosthetics.: Philadelphia,Pa: Lea & Febiger; 1911.
31. Marshall S, Dawson D, Southard KA, Lee AN, Casko JS, Southard TE. Transverse molar movements
during growth. Am J Orthod Dentofacial Orthop. 2003; 124(6):615–24. Epub 2003-12-1. https://doi.org/
10.1016/s0889-5406(03)00630-9 PMID: 14666073.

PLOS ONE | https://doi.org/10.1371/journal.pone.0287343 June 15, 2023 13 / 13