American Journal of ORTHODONTICS

Volume 56, Number 5, November, 1969

ORIGINAL .ARTICLES

The characteristics of malocclusion: A

modern approach to classification
and diagnosis
James 1. Ackerman, D.D.S.,* and William R. Proffit, D.D.S., Ph.D.**
Phkdelphia, Pa., and Lexington, Icy.

W hat me today call normal occlusion was described as early as the

eighteenth century by John Hunter. Carabelli, in the mid-nineteenth century,
was probably the first to describe in any systematic way abnormal relationships
of the upper and lower dental arches. The terms edge-to-edge bite and overbite
are actually derived from Carabelli’s system of classification. The term
orthodontics (orthodontosie) was coined by Lefoulon of France at approximately
the same time as interest in these problems became widespread.l
Even though several treatises on orthodontics had already been written by
the beginning of the twentieth century, most notably the one by Norman Kings-
ley, these authors had no acceptable method for describing irregularities and
abnormal relationships of the teeth and jaws. Edward II. Angle contributed
the concept that if the mesiobuccal cusp of the maxillary first molar resbs in
the buccal groove of the mandibular first molar, and if the rest of the teeth
in the arch are aligned, ideal occlusion will result. Angle described three basic
types of what he termed malocclusion, all of which represented deriations in
an anteroposterior dimension.”
The Angle classification was readily accepted by the dental profession, since
it brought order out of what previously had been confusion regarding dental
relationships. It was recognized almost immediately, however, that there were
deficiencies in the Angle system. One of the most severe critics was Calvin Case,
who pointed out that Angle’s method disregarded (in treatment planning as

*Associate Professor and Chairman, Department of Orthodontic.s, School of Dental

Medicine, University of Pennsylvania.
**Associate Professor and Chairman, Depart,ment of Orthodontics, College of Den-
tistry, University of Kentucky.

443
 well as classification) the relationship of the teeth to the face (t,hat is, thc~
profile). Another criticism by Case and others was that, although malocclusion
was a three-dimensional problem, in thr Angle system only anteroposterior &vi-
<Itions (sagittal plane) were taken into consideration. To quote Case”: “For
i he very a,dvantage of perfect, harmony and unanimity in our literatllrc altti
tcaaching, the author would gladly have adopted the Angle classification. wt~t+~.
iI- not for the fact that as it now stands it cannot be ma& to express a lar~c.
rlumber of very important characters of malocclusion which should be I’ull~-
I*ccognized and systematically included. . ~ . Furthermore, the Angle classificii
1ion does not recognize those wide differences in the> character of certain m:i /.
occlusions which have the same distomesial occlusion of the buecal t&h.”
In 1912, in a report to the British Society for the Study of 0rthodon&s.
Norman Bennet? suggested that malocclusions bc classified with regard to dcvi-
;Itions in the transverse dimension, the sagittal climc~nsion. and thr: vfkrticill
dimension. This recommendation, rcjectod at the t,ime, was later realized in I irra
\vork of Simon5 and the development of his system of gnathostatics. SinI
relat,ed the teeth to the rest off the fact and cranium in all three dimensions 16
space. His approach, although somewhat complcs, clearly represented an ;1(1-
!.;ince. If it had not. been for the introduction cJf roentgmographic cephalo-
tllet,rics in the 1930’s and 1940’s, bonathostat,ics probably would hart mad(. :I
crcat,er impact on present-day orthodontics. With the advent of the latcra 1
c*(tphalogram, many of the relationships that could bc dct,ermined from gnatho-
static casts could more easily be observed on the cephalomctric head film.
Another early criticism of the Angle system was that it. merely described
il~e relationship of the teeth and did not include a diagnosis. Simon.” l,nu&
strom.F Hellma,n.7 and most, recently Horowitz and I-tixon” recognized the Ned
10 differentiate dentoalveolar and skeletal discrepancies and to evaluate tlicil’
relative contributions toward the creation of a malocclusion. These authors SUF-
xested that classification should include this t,ypcLof diagnosis atld point logicall;
I 1)a treatment plan.
Analogous and homologous malocclusions

This difficulty becomes apparent when it is recognized that malocclusions

having the same Angle classification may, indeed, be only ccnalogous malocclu-
sions (having only the same occlusal relationships) and not necessarily homo-
7ogozcs (having all characteristics in common). Despite the informal additions
to Angle’s system which most orthodontists use! there is a tendency to treat
malocclusions of the same classification in a similar manner. Homologous mal-
occlusions require similar treatment plans, whereas analogous malocclusions
may require different treatment approaches. Some poor responses to treatment
are undoubtedly related to this fault in diagnosis. Fig. 1 illustrates two nearly
identical Angle Class II, Division 1 malocclusions in children of the same age.
There are differences in skeletal proportions and in the relationships of the teeth
to their respective jams, both of which affect the profile. Individual orthodontists
may differ concerning treatment plans, but the two cases should not be treated
c-xactly the same. These are analogous malocclusions.
Volume 56 Characteristics of malocclusion 445
Number 5

Fig. 1. Clinical records of apparently similar Angle Class II, Division 1 malocclusions. The
malocclusions are analagous but not homologous. Different treatment procedures are
required.
Fig. 2. A complex Angle Class I malocclusion. The casts are trimmed to represent the
cant of the occlusal plane relative to the Frankfort plane.
Volume 56 C%ara.cteristics of malocclusion 447
Yumber 5

referred to o’rthodontists include an anteroposterior problem. (In surveys of

large population groups, this is less common) .g For many years, orthodontists
have extended the Angle classification, in a nonstandard and nonsystematic way.
To quote Simon5 : “If one asks an experienced orthodontist : ‘How do you treat
Class I (Angle) ?’ he usually replies with the question: ‘Which kind of mal-
occlusion do you really mean?’ ” Fig. 2 illustrates an Angle Class I malocclusion
which obviously would require further description. We believe that the criti-
cisms leveled at the Angle system are valid and must be overcome.
In this article, we propose a classification scheme for malocclusions in
which five characteristics and their interrelationships are assessed. We are sug-
gesting not that the Angle system be discarded but, rather, that it be enhanced
systematically. It is interesting that ours is a synthesis of two schemes, the
Angle classification and the Venn diagram, both of which were proposed late
in the nineteenth century by Angle and Vcnn.
A complex of interrelated variables, as encountered in malocclusion, may
be represented most conveniently through the use of sets. Venn proposed this
representation in 1880, and it has become prominent in symbolic logic for com-
puter use. The set theory deals with collections or groups of entities, rather than
with single entities, and it represents the relationships between these groups by
graphic patterns.lO
A Venn diagram offers a visual demonstration of interaction or overlap
among parts of a complex structure. A collection or group in this system is
defined as a set, and all elements contained in a set have some common prop-
erty. The interrelationships of two sets, X and Y, are illustrated in Fig. 3.
Our representation of malocclusion, using a modified Venn diagram, is

Fig. 3. The interrelationships of two sets (X and Y). X and Y in A represent sets which
have no overlapping qualities. Both sets are contained in a universe or frame of refer-
ence represented by the box which encloses them. In B the sets X and Y share common
qualities in the area of overlap. In C all Y’s have qualities of X. Y in this case is called a
subset. D shows that elements of the universe are contained in sets X and Y.
 Ant. J. Orthodontics
November1969

shown in Fig. 4. In our scheme a set is defined on the basis of morphologic devi
ations from the idea.1. With regard to the dentition itself, the standard is ideal
alignment into arch form and ideal interdigitation. If the teeth are perfectI).
aligned in both arches, by definition ideal occlusion will occur when the mesicr-
lingual CUSpS Of tllcl maxillary first, I~lola7X red in the ct~tltld fOSSil(‘ Of tilt,
~nandibular first molars, 1)rovidetl the curves of Spec are harmonious ant1 thcgr.cL
is no tooth-size discrctl)~lll(.\-.ll This, 01’ course, is the original Angle cotlcdel)l
l’rofile ideals may vary, depending upon ethnic and racial differences.

Classification by groups

Common to all dentitions is the degree of alignment and symmetry of tlie

teeth within t,hc dental arches. We represent this as the universe (Group 1)

/ ‘_ ._
,/ .’
‘_’ ‘j
/’ ‘1\

Fig. 4. Representation of malocclusion using a modified Venn diagram in which sets are
defined on the basis of morphologic deviations. (See text.)
Volume 56 Characteristics of malocclusion 449
.l’umber 5

Many malocclusions affect the profile. For this reason, profile is represented as,
a major set (Group 2) within the universe. Lateral (transverse), anteropos-
terior (sagittal) , and vertical deviations and their interrelationships (Groups 3
to 9) are represented by three interlocking subsets within the profile set. This
scheme allows any malocclusion to be sufficiently described by five or fewer
characteristics.
This classification system can most easily be described by outlining the
method of application. For the sake of simplicity in describing the system, we
will assume that complete diagnostic records (casts, facial photographs, and
radiographs, including a cephalometric head film) are available. Classification
may be made, however, by careful observation of the patient’s occlusion and
facial appearance. It is generally agreed that in ideal occlusion the maximum
intercuspal contact (centric occlusion) and the unstrained retruded position
of the mandible (centric relation) should approximately coincide. In this classi-
fication, if there is a shift of more than 1 to 2 mm. between the point of initial
tooth contact in terminal hinge closure and maximum intercuspation, the point
of initial contact should be used.
Step 1 in the classification procedure is an analysis of the alignment and
symmetry of the teeth in the dental arches (interproxima.1 contact relation-
ships). Alignment is the key word of Group 1; among the possibilities are ideal,
crowding (arch-length deficiency), spacing, and mutilated. Irregularities of
individual teeth are described, if desired, by the method of Lischer,5 namely,
the use of the suffix -ver.sioll to describe the direction of individual tooth mal-
alignments. Ideal occlusion, plus many (but by no means all) Angle Class I
malocclusions, would fall into our Group 1.
In Step 2 one views the patient’s profile. This can be done most accurately
from a good profile or silhouette photograph. In the profile view, it should be
noted whether the face is anteriorly divergent (mandible prominent) or pos-
teriorly divergent (mandible recessive) I2 and whether the lips are convex
(prominent), straight, or concave relative to the nose and chin. The “diver-
gence” is most often related to the facial skeleton ; lip position is strongly in-
fluenced by the teeth. Lip and mouth posture should also be considered in the
evaluation.
In Step 3 the dental arches are viewed with regard to lateral dimensions
(transverse plane), and the buccolingual relationships of the posterior teeth
are noted. The term type is used to describe the various kin.ds of cross-bite. A
judgment is also made as to whether the problem is basically dentoalveolar or
skeletal or due to a combination of the two. There is, of course, a continuous
range from problems which are entirely skeletal to those which are entirely
dental. Most cases have components of both, with one or the other predom-
inating. Thus, a bilateral pal&al cross-bite would be a type of malocclusion.
If this were due entirely to constriction of maxillary development, it would be
a skeletal problem. A similar constriction of the maxillary dental arch alone
would be dentoalveolar in nature. As a general rule, maxillary or mandibular
is used to indicate where the problem is.
In Step 4 the patient and dental arches are viewed in the anteroposterior
Fig. 5. This complex Group 9 malocclusion can be sufficiently described by reference to
five characteristics.
Volume 56 Charncte~risfics of malocclusion 451
Number 5

dimension (sagittal plane). In this dimension, the Angle classification system

is utilized and is merely supplemented by stating whether a deviation is skele-
tal, dentoalveolar, or a combination. This information can be derived from ob-
serving the patient or more accurately from a cephalometric head film.
In Step 5 the patient and the dentition are viewed with regard to the
vertical dimension. Rite depth is used to describe the vertical relationships. The
possibilities are anterior open-bite, anterior deep-bite, posterior open-bite, or
posterior collapsed bite. To determine whether this is on a skeletal, dentoalveo-
lar, or combined basis, a ccphalometric analysis may be particularly helpfu1.13-15

Examples of group classification

As one can see from Fig. 4, this approach defines nine groups of malocclu-
sions. The complexity of the orthodontic problem increases with the group num-
ber. Thus, a G-roup 9 malocclusion is the most complex in that there is an align-
ment problem, a problem in profile, and problems in the lateral, vertical, and
anteroposterior dimensions as well. Such a malocclusion (Fig. 5) would be
classified and sufficiently described (which constitutes diagnosis) as follows :
GROUP 9
Alignment: Both arches crowded
Profile: Posteriorly divergent, convex
Type: Maxillary palatal cross-bite, bilateral, skeletal and dental
Class: Class I, excessive overjet, dental; Class II, skeletal
Bite depth: Open-bite, skeletal
Jt can be seen that Case A in Fig. 1 is a :
GROUP -I
Aligwaent: Ideal
Profile: Posterior divergent, convex
Class: Class II, Division 1, skeletal
Since all other characteristics are normal, no further description is needed.
The logic of the system specifies this case well enough that its records could be
approximated from this description alone.
Similarly, another a.ctnal case (Fig. 6) would be classified and described as
follows :
GROUP 2
Alignment: Ideal
Profile: Convex
This case (the classic Class I bimaxillary protrusion) is sufficiently described
without further qualification. Again, the logic of the system uniquely specifies
this case.
The case presented in Fig. 2 can be seen to have problems of alignment and
symmetry and deviations laterally and anteroposteriorly but not vertically. It,
therefore, should be classified as follows:
GROUP 6
Alignnze?l.t: Both arches crowded, midline deviation
profile: Posteriorly divergent, convex
Type: Maxillary palatal cross-bite of the premolars, bilateral,
dental
 Aln. J. Orthodontzcs
RTovember 1969

Fig. 6. This malocclusion can be sufficiently described by two characteristics.

Class: Class I, anterior cross-bite of ma.xillary right lateral incisor.

dental
One can see from these examples that the type, class, or bite depth is not
indicated if it is found to be normal. As stated earlier, ideal occlusion with good
facial esthetics is classified as follows :
GROUP 1
Alignment: Ideal

Summary and conclusions

This method of classification based on five descriptive characteristics and
defining nine groups of malocclusions overcomes the major weaknesses of the
Angle system. Specifically, arch-length problems, w&h or without an influence
Volume 56
Number 5 Chamcteristics of malocclusion 453

on the profile, are recognized ; the influence of the dentition on the profile is
taken into account; all three planes of space, not just the sagittal plane, are taken
into consideration; the differentiation between dental and skeletal problems is
made at the appropriate level ; and diagnosis is inherent in the classification.
An additional advantage is that the logical approach used in constructing
the classification is similar to that employed for preparing computer programs.
This means that this new system should lend itself well to surveys and to other
uses where data processing by computers is desired. Quantification and assess-
ment of severity of malocclusion (as in determination of the presence of handi-
capping malocclusion) still requires a numerical scale which can be easily
d&d to our system.
We would like to avoid the implication made so often in the past that ac-
curate classification, diagnosis, and treatment planning are the only important
aspects of orthodontic evaluation. In the long run, etiology is a key factor, for
if the cause of a malocclusion cannot be altered or eliminated during treatment,
the treatment result may not be stable. Ideally, etiology should be included in a
classification scheme, but the present state of our knowledge still does not permit
this. Similarly, the view of occlusion taken in this classification in part remains
the “static” view traditional in orthodontics. A dynamic analysis of tooth con-
tacts in functional mandibular movements should already be part of ortho-
dontic evaluation, particularly after the completion of orthodontic tooth move-
ment. Occlusal contact of the teeth, in the final analysis, is the major criterion
for assessment of occlusion.
We believe that this particular scheme can enhance communication between
orthodontists. It can also serve as an aid in logical treatment planning and
should be particularly helpful as a teaching tool. Finally, the computer com-
patibility of this classification will make it u,seful for automated data retrieval
and processing.
REFERENCES
1. Weinberger, B. W.: Historical resume of the evolution and growth of orthodontics. In
Anderson, G. M.: Practical orthodontics, ed. 8, St. Louis, 1955, The C. V. Mosbp Company.
2. Angle, E. H.: Classification of malocclusion, Dental Cosmos 41: 245-264, 350-357, 1899.
3. Case, C. 8.: Techniques and principles of dental orthopedia, (reprint of 1921 edition),
New York, 1963, Leo Bruder, pp. 16-18.
4. Bennett, N. G.: Report of the Committtee on Orthodontic Classification, Oral Health 2:
321-327, 1912.
5. Simon, P. W.: Fundamental principles of a systematic diagnosis of dental anomalies
(translated by B. E. Lischer), Boston, 1926, Stratford Co., p. 320.
6. Lundstrom, A. F.: Malocclusion of the teeth regarded as a problem in connection with
the apical base, Svensk tandl. tdskr. 16: 147-296, 1923.
7. Hellman, M. : Diagnosis in orthodontia and the method I use in practice, Angle Orthodontist
13: 3-14, 1944.
8. Horowitz, S., and Hixon, E. H.: The nature of orthodontic diagnosis, St. Louis, 1966,
The C. V. Mosby Company.
9. Zwemer, J. D., and Young, W. D.: Summary of studies on the prevalence of malocclusion.
In Proffit, W. R., and Norton, L. A. (editors) : Education for Orthodontics in General
Practice, Lexington, 1966, University of Kentucky.
10. Feinstein, A. R.: Boolean algebra and clinical taxonomy, New England J. Med. 269:
929-938, 1963.
Orthodontists are not in accord with the idea that the dentition may be permitted to
pursue a vicarious course of development until the teeth have reached an uncertain
position of latitude and longitude, then expect, by the institution of some form of me-
chanical violence, to eradicate all the evidences of perverted growth, and obtain a result
comparable with the perfect correlation of parts in unrestricted development. (Singleton,
L. G.: The value of teeth in the design of the face, American Orthodontist 3: 204-211,
1912.)