Malocclusion- classification

NEED TO CLASSIFY THE MALOCCLUSION

• “The classification is the morphological description of the dental
skeletal and soft tissue deviations from the norms.”
• Morphological deviation from the norms can be compiled into a
problem list which is essential for treatment planning.
• For the purpose of comparison and communication.
• To recall the past difficulties with similar cases.
VARIOUS CLASSIFICATION OF MALOCCLUSION
• ANGLE’S CLASSIFICATION, ITS MERIT ,ITS DRAWBACK AND
MODIFICATION.
• SIMON’S CLASSIFICATION.
• BENNET’S CLASSIFICATION.
• SKELETAL CLASSIFICATION.
• ACKERMAN-PROFFIT SYSTEM OF CLASSIFICATION
• BRITISH STANDARD INSTITUTE CLASSIFICATION
Angle’s classification
• Normal occlusion - Normal (Class I) molar relationship,
teeth on line of occlusion
• Class I malocclusion - Normal (Class I) molar relationship
teeth crowded, rotated, etc.
• Class II malocclusion -Lower molar distal to upper molar,
relationship
Class III malocclusion-Lower molar mesial to upper molar,
relationship
Molar relation
CLASS I CLASS II Molar CLASS III Molar
Molar and and Jaw and Jaw
Jaw Relationship Relationship
Relationship
Angle’s Class I Malocclusion –
• The mesiobuccal cusp of the
permanent maxillary first molar
occludes in the m-b
developmental groove of the
permanent mandibular first
molar

• The distal marginal ridge of the

maxillary first molar occludes
with the mesial marginal ridge of
the mandibular second molar.
ANGLE STATED THAT NORMAL OCCLUSION IS
MAINTAINED BY-
• The occlusion inclined planes of the cusp.
• Support given by the harmony in size of the Mx and Md arches.
• The influence of the muscles labially, buccally and lingually.
• He concluded that these factors are also powerful in maintaining
malocclusion.
• According to Begg’s normal occlusion of the tribal people is the true
normal occlusion of the humans.
 Class II MO
Skeletal Dental

•Mandibular deficiency •Maxillary dental protrusion

•Maxillary excess •Mesial drift of upper 1st molars
•Both

Skeletal Cl II
Usually associated with dental Cl II MO
Dental compensations seen - Protrusive Mandibular Insicors
- Retrusive Maxillary incisors
Angle’s Class II Malocclusion-
The mesiobuccal cusp of maxillary
permanent first molar occludes in the
embrasure formed between the
mandibular permanent first molar
and second premolar

The mandibular dental arch and the

body of the mandible are in distal
relation to the maxillary arch by
full/half cusp width of a
permanent first molar

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Class II Div 1
• Half cusp width/end-on
Angle’s Class II Division 1
The maxillary incisor teeth are in
labioversion
increased overjet

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ANGLE’S CLASSIFICATION OF MALOCCLUSION
• In 1899Edward H. Angle published his classification (Angle EH
:classification of malocclusion, Dental Cosmos41:248-264;350-
357,1899)
• His classification is based on the irregularity of the teeth in sagittal
direction
• The classification are based on the relationship of the mesiobuccal
cusp of the Mx first molar and the buccal groove of the Md first
molar.
• He considered Mx first permanent molar to be key to occlusion as it
seldom varies from its position.
KEY RIDGE
• Angle basis of classification was fixed maxillary molar position in
relation with key ridge
CLASS I
 Angle’s class I malocclusion is characterized by the presence of normal inter-arch
molar relationship.
OTHER FEATURES
Straight profile
Competent or incompetent lips
Crowding
Proclination
Retroclination
Crossbite
Bimaxillary protrusion
ANGLE’S CLASS II MALOCCLUSION
• The distobuccal cusp of Mx first permanent molar occludes in the
mesiobuccal groove of the lower first permanent molar.
IT MAY BE –
➢CLASS-II ,DIVISION 1
➢CLASS -II,DIVISION2
CLASS II DIVISION 1(25-30)
CLASS II DIVISION 2(5-10)
• CLASS-II,SUBDIVISION –When a class II molar relation exists on one
side and a class I relation on the other hand.
 COMPARISION B/W CLASS II
MALOCCLUSION
CLASS II, DIVISION 1 CLASS , II DIVISION 2
 Proclined Mx incisors with increased  Mx centrals are retroclined and
overjet laterals are proclined
 Convex profile
 Straight or mildly convex
 Short and incompetent lips
 Lips are normal
 Increased mentalis and buccinator
activity  Normal muscles activity
 Normal or increasd lower facial hight  Decreased lower facial hight
 Normal path of closure  Backward path of closure
 Not prominent malar process
 Prominent malar process
 Deep overbite
 ‘V’ shaped narrow arch
• Closed bite
 Deep palate  ‘U’ shaped and square arch
 Normal palatal depth
ANGLE’S CLASS III MALOCCLUSION
• The mesiobuccal cusp of the Mx first permanent molar occluding in
the interdental space b/w the Md first and second molars.
IT MAY BE-
➢TRUE CLASS III- Skeletal class III malocclusion of genetic origin.
➢PSEUDO CLASS III- Postural or habitual class III.
➢CLASS III SUBDISION- Characterized by class III molar relationship on
one side and class I relation on other side.
CLASS III(5-10)
• CLASS II, DIVISION1 SUBDIVISION
• CLASS II, DIVISION2 SUBDIVISION
• CLASS III SUBDIVISION
 COMPARISION B/W ANGLE’S CLASS III
MALOCCLUSION
TRUE CLASS III PSEUDO CLASS III
 Concave profile.  Straight to concave profile.
 Hereditary origin.  Habitual or developmental
 Premature contacts are in origin.
absent.  Premature contacts are
 Forward path of closure. present.
 Increased or decreased  Deviated path of closure.
gonial angle.  Normal gonial angle.
 Further retrusion of Md is  Further retrusion of Md is
not possible. possible.
 Treated by orthopedic or  Treated by elimination of
surgical correction. prematurities.
 DRAWBACKS OF ANGLE’S CLASSIFICATION
 Angle’s considered malocclusion only in sagittal plane.
 He considered the first permanent molars as fixed point in skull . But
this is not found to be so.
 The classification can not be applied if the first permanent molars are
extracted or missing and in deciduous dentition.
 The classification does not differentiate b/w skeletal and dental
malocclusion.
 The classification does not highlight the etiology of malocclusion.
 Individual tooth malpositions have not been considered by Angle.
 LISCHER’S MODIFICATION OF ANGLE’S
CLASSIFICATION
• NEUTRO-OCCLUSION: It is synonymous with Angle’s class I.

• DISTO-OCCLUSION: It is synonymous with Angle’s class II.

• MESIO-OCCLUSION: It is synonymous with Angle’s class III.

 DEWEY’S MODIFICATION
CLASS I MALOCCLUSION CLASS III MALOCCLUSION
• TYPE 1: Crowded anteriors.  TYPE1: The Mx & md dental
arches when viewed
• TYPE2: Proclined Mx separately are in normal
incisors. alignment. But when the
arches are made to occlud
• TYPE3: Anterior crossbite. patient shows on edge to
edge incisor alignment.
• TYPE4: Posterior crossbite.
 TYPE2:Md incisors are
• TYPE 5:Mesially drifted crowded &are lingual to Mx
permanent molar due to incisor.
early extraction of second  TYPE3:Mx incisors are
deciduous molar or crowded & are in crossbite
second premolar. in relation to Md incisors.
(i) Class 1 modifications of Dewey
Type 1:Class I malocclusion with bunched or crowded
anterior teeth.
Type 2:Class I with protrusive maxillary
incisors
Type 3:Class I malocclusion with anterior cross-bite
Type 4:Class I molar relation with
posterior cross-bite
Type 5:The permanent molar has drifted
mesially due to early extraction of
second deciduous molar or
second premolar.
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(ii) Class III modification of Dewey

Type 1:upper & lower dental arches when viewed

separately are in normal alignment.But when arches
are made to occlude, patient shows an edge to
edge incisor alignment, suggestive of a forwardly
moved mandibular dental arch.

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Type 2: The mandibular incisors are crowded &
are in lingual relation to maxillary incisors.

Type 3:maxillary incisors are crowded & are in

cross-bite in relation to mandibular anterior.

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BENNET CLASSIFICATION – based on etiology

Sir Normal Bennet introduced a classification of

abnormalities of occlusion which was based on
their etiology. Briefly the classification is as
follows:

1. Class I :Abnormal position of one or more teeth

due to local causes.

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2. Class II :Abnormal formation of a part or whole
of either arch due to developmental defects of
bone.

3. Class III:Abnormal relationships between upper

and lower arches and between either arch and
facial contour and correlated abnormal
formation of either arch.

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BALLARDS CLASSIFICATION
• Based on long axis of the lower
incisors
• Skeletal classification
BALLARD’ SKELETAL CLASSIFICATION
• CLASS-I:The inclination of the teeth & dental base relationship are
normal. The upward projections of the axis of Md incisors would pass
through the crown of Mx incisors.
BALLARD’ SKELETAL CLASSIFICATION
• CLASS-II: The Md apical base is relatively too far back. The Md incisor
axis would pass palatal to Mx incisor crown.
BALLARD’ SKELETAL CLASSIFICATION
• CLASS-III: The Md apical base is placed relatively too for forward, the
projection of Md incisor axis would pass labial to Mx incisors crowns.
BRITISH STANDARD INSTITUTE INCISOR
CLASSIFICATION
 CLASS-I: The Mandibular incisor edges occlude with, or lie
immediately below, the cingulum plateau of Mx incisors.
BRITISH STANDARD INSTITUTE INCISOR
CLASSIFICATION
 CLASS-II: The Md incisor edges lie posterior to the cingulum plateau
of Mx incisors.
BRITISH STANDARD INSTITUTE INCISOR
CLASSIFICATION Class- II
➢Division1:There is an increase in overjet & Mx incisors are proclined.
➢Division2: The Mx central incisors are retroclined & overjet is usually
minimal.
BRITISH STANDARD INSTITUTE INCISOR
CLASSIFICATION
• CLASS-III: The Md incisors edges lie anterior to the cingulum plateau
of the Mx incisors. The overjet is reduced or reversed
BRITISH STANDARD INSTITUTE INCISOR
CLASSIFICATION
 INCISOR CLASSIFICATION

Class-I Class-II Div I Class-II Div II Class-III

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 SIMON’S CLASSIFICATION
• Simon’s system of
classification made use
of three anthropometric
plane namely-

• F-H PLANE
• ORBITAL PLANE
• MID-SAGITTAL PLANE
 SIMON’S CLASSIFICATION – FH Plane
• IN F-H PLANE- transverse plane, Dividing the head into upper and
lower halves.
• It describes the position of the teeth in vertical direction, superior
and inferior relationship
Attraction-Teeth are placed closure to this plane.
Abstraction-Teeth are away from this plane.
SIMON’S CLASSIFICATION – Orbital plane
• Frontal plane vertical plane-
Dividing the head into front and
back. Passes through pupil of the
eye
• Also known as orbital plane
describe anteroposteriopr
relationship
Protraction- If teeth are
placed forward.
Retraction- If teeth are
placed behind this plane.
SIMON’S CLASSIFICATION
Mid Sagittal plane – anteroposterior plane
• –An imaginary plane that passes longitudinally through the midline of
head and divide it into right and left halves.
SIMON’S CLASSIFICATION -Mid Sagittal plane
– anteroposterior plane
Used to describe the right and left relationship.
Contraction-If teeth are closure to this plane.
Distraction-If teeth are away from this plane.
One upper premolar (B) opposing two lower
premolars (B) in modified Class I. Note traditional
Angle only classifies molars and would call this
excellent occlusion a Class II!

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Two upper premolars (B) opposing one lower
premolar (B) in modified Class I. Note traditional
Angle only classifies molars and would call this
excellent occlusion a Class III!
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One premolar (B) in each quadrant.

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ACKERMANN-PROFFIT SYSTEM OF
CLASSIFICATION
Ackerman and Profitt in 1960
diagrammatic classification of malocclusion
In this system five characteristics & their interrelations are assessed &
BASED ON Venn symbolic logic diagram as an organizing framework.
 The salient features of the classification includes-
 Addresses the limitations of Angle’s classification of malocclusion
FIVE MAJOR CHARACTERISTICS OF
CAKERMANN-PROFFIT CLASSIFICATION
 INTRA-ARCH ALIGNMENT-SYMMETRY – shown by
square
➢ Ideal/crowding/spacing.
• PROFILE - shown by a big circle
➢ Convex/straight/Concave & Facial divergent.
• TRANSVERSE DEVIATION - shown by small circle
➢ Skeletal or Dental crossbite.
• SAGITTAL DEVIATION(A-P) - shown by small circle
➢ Angle’s classification.
➢ Skeletal/Dental.
• VERTICAL DEVIATION - shown by small circle
➢ Open bite / Deep bite/Posterior collapsed
bite/Skeletal/Dental
Step 1 (Alignment):
• Since the degree of alignment and symmetry are
common to all dentitions,this is represented as
outer envelope or universe (Group 1)
• It is classified as ideal/ crowded/ spaced.
• Individual tooth irregularities are described.

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Step 2 (Profile):
• The profile is affected by many malocclusions, so it
becomes a major set within the universe (Group 2)
• The profile is considered as convex/ straight /
concave.
• The facial divergence is also considered i.e. anterior
or posterior divergence.

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Step 3 (Type) (Group 3):

• It assesses lateral or transverse dental arch

characteristics.
• The term type is used to describe various kinds of
cross-bite which may further be unilateral or bilateral.
• In addition,differentiation is made between skeletal &
dental cross-bite.

90
Step 4 (Class or group 4):

• This involves the assessment of the sagittal

relationship.
• It is classified as Angle’s class I, class II or class III
malocclusion.
• In addition, differentiation is made between skeletal
and dental malocclusions.

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Step 5 (Bite depth or group 5):

• Malocclusions in the vertical plane are noted.

• They are described as anterior or posterior open
bite, anterior deep bite or posterior collapsed bite.
• mention is made whether malocclusion is skeletal
or dental.

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• overlapping of groups is seen in the centre of Venn
diagram (Group 6 to 9).
• These are more severe problems, with characteristics
from contiguous and overlapping groups.
• Group 9 would be the most severe, with
involvement of criteria from all group (alignment,
profile, transverse, antero-posterior and vertical
problems)

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VENN SYMBOLIC DIAGRAM 94
Scoring
• 0 – ideal
• 1 - slight
• 2 – slight to moderate
• 3 - moderate
• 4 – moderate to severe
• 5 - severe
Indices
Indices
• Recording of malocclusion and its severity in different population
groups. For the following purposes
• Prevalence
• Type and severity
• Scientific studies
• Prioritize treatment
Occlusal index
• Given by Summer
• Based on scoring 9 characteristics
1-dental age
2-molar relation
3-overbite
4-overjet
5-posterior cross bite
6-posterior open bite
OI - Occlusal index
7-tooth displacement
8-midline relation
9-missing permanent incisor
OI - Occlusal index
• It define 2 divisions – div I (normal) and div II (distal molar relation)
• and 7 malocclusion syndromes
• Syndrome A- overjet + anterior overbite
• B- distal molar relation,+ve overjet,overbite ,post cross bite,midline
diastemma/deviation
• C- congenitally missing incisors
OI - Occlusal index
• D- potential tooth displacement
• E- posterior open bite
• F-mesial molar relation,-ve overjet,,overbiteposterior cross bite,
midline diastemma/deviation
• G- mixed dentition analysis and tooth displacement
OI - Occlusal index
• Different scoring scheme for different ages
• Dental development from dental age 0-VI

• DISADVANTAGE – COMPLICATED SCORING SYSTEM

TPI - Treatment priority index-
• Treatment priority index- by Grainger- 1967
• Weighted and defined measurements
1-upper anterior segment overjet
2-lower anterior segment overjet
3-overbite
4-Anterior open bite
5-congenital missing incisors
TPI - Treatment priority index-
6-distal molar relation
7-mesial molar relation
8-posteriotr cross bite (maxillary teeth buccal to normal)
9-posteriotr cross bite (maxillary teeth lingual to normal)
10-Tooth displacement
11-Gross anomalies
TPI - Treatment priority index-
• Seven malocclusion syndromes
1-Maxillary expansion syndrome
2- overbite
3-retrognathism
4-open bite
5-prognathism
6-maxillary collapse syndrome
7-congenitally missing incisors
TPI - Treatment priority index-
• Disadvantage- does not consider potential tooth displacement
• Omitted mixed dentition analysis
IOTN – Index of orthodontic treatment need
• Index of orthodontic treatment need
• Given by Evans, shaw
• Brook shaw
• Shaw and richmond
IOTN – Index of orthodontic treatment need
• Rank malocclusion in terms of significance of various occlusal traits
for persos dental health and percieved esthetic impairment
• It has 2 parts
• Dental health component
• Aesthetic compoent
IOTN – Index of orthodontic treatment need
• Dental health component-grouped in 5 categories
• Grade-1- no treatment required
• Grade-2- little treatment required
• Grade-3- moderate/borderline tt required
• Grade-4- great need of tt required
• Grade-5- very great need of tt required
IOTN – Index of orthodontic treatment need
• Aesthetic component-
• Ranking (1-10) is done by colour photographs
• Rank-1 most attractive
• Rank-10 least attractive
IOTN – Index of orthodontic treatment need
• Limitations of IOTN
• emphasis is given on alignment alone
• all patients of cleft lip and palate are in grade 5, irrespective of type
and severity of cleft
PAR - peer assessment rating index
• Peer assesment rating index-given by a group of british orthodontist S
Richmond, WC Shaw
• Purpose- to quantify the changes that occurred after ortho treatment
therefore measure the treatment success based on initial severity of
malocclusion
• Applied on study models
• no consideration of profile
PAR - peer assessment rating index
• Scoring 0-50
• 0- perfect occlusion
• 50- worst occlusion
PAR - peer assessment rating index
• 7 parameters
• Ant-post
• Transverse
• Vertical
• Midline
• Overbite
• Contact point
• overjet
PAR – peer assessment rating index
• Improvement measured in 3 categories
• 1- unchanged/worse
• 2-improved
• 3-greatly improved