Article published online: 2020-06-26

THIEME
Original Article 429

The Importance of the Occlusal Plane in Predicting

Better Facial Soft Tissue in Class II Malocclusion in
Ethnic Javanese
I. Gusti Aju Wahju Ardani1 Floretta Charlene Dinata1 Ari Triwardhani1

1 Department of Orthodontic, Faculty of Dental Medicine, Address for correspondence I. Gusti Aju Wahju Ardani, DDS, MSc, PhD
Universitas Airlangga, Surabaya, Indonesia Department of Orthodontic, Faculty of Dental Medicine, Universitas
Airlangga, Campus A, Jl Prof Dr Moestopo, No. 47, Surabaya 60132,
East Java, Indonesia (e-mail: wahju_ardani@fkg.unair.ac.id).

Eur J Dent:2020;14:429–434

Abstract Objectives Class II malocclusion is largely due to a retrognathic mandible. Mandibular

rotation is closely related to changes in the occlusal plane during growth. The prob-
lems in the occlusal plane could cause disadvantages in the soft tissue profile in Class
II malocclusion, presenting treatment challenges for an orthodontist. This study aimed
to investigate the importance of the occlusal plane for a better soft tissue profile in
Class II malocclusion for Javanese patients.
Materials and Methods The total number of cephalogram softcopies of patients
with skeletal Class II malocclusion were selected based on ANB values (> 4 degrees),
no agenesis teeth except the third molar, and all permanent teeth. The cephalograms
were calculated using digital tracing by Morpheus 3D imaging. The points and areas
to be analyzed on the cephalogram were predetermined. The examination was per-
formed in a span of 1 month and performed via a statistical test using Pearson’s test
and multiple regression analysis (p < 0.05).
Keywords Results There were significant correlation values between the angles produced
►►skeletal Class II by the occlusal plane to sella national, Frankfurt horizontal, mandibular plane, and
malocclusion Z-angle (p < 0.05).
►►occlusal plane Conclusion Patients with skeletal Class II malocclusion have a significant correlation
►►soft tissue between the occlusal plane and the vertical plane, thereby affecting the shape of the
►►facial profile soft tissue profile, which causes a facial imbalance. By improving mandibular move-
►►cephalometric ment, the soft tissue profile can also be corrected.

Introduction Generally, in cephalometrics, a Class II malocclusion with

anteroposterior skeletal discrepancy has a characteristic of
A Class II skeletal malocclusion has a 15% presentation in the large ANB calculation, indicating an unfavorable relation-
world’s population, and most of the cases encountered are ship between the upper and lower jaws. An anteroposterior
the angle Class II division 1. This malocclusion is accompa- skeletal discrepancy is usually accompanied by vertical dis-
nied by skeletal discrepancies between the mandible and crepancies, such as a shorter anterior face.3,4 The occlusal
the maxilla, the protrusion of maxilla, the retrusion of the plane refers to an imaginary surface that is anatomically
mandible, or a combination of both.1 The characteristics of related to the cranium. Theoretically, it touches the incisal
Class II division 2 are often accompanied by severe deep bite, edges of the incisors and the tips of the occluding surfaces
maxillary and mandible central incisive inclination toward of the posterior teeth (first molar). The occlusal plane is the
the lingual, as well as a lateral incisive of maxilla inclination plane established if a line was drawn through all the buccal
toward the labial.2 cusp tips and incisal edges of the mandibular teeth and then

DOI https://doi.org/ ©2020 Dental Investigation

10.1055/s-0040-1713331 Society
ISSN 1305-7456.
430 Occlusal Plane in Predicting Better Facial Soft Tissue in Malocclusion Ardani et al.

broadened into a plane to include the lingual cusp tips, con-

tinuing across the arch to include the buccal and lingual cusp
tips of the opposite side.5
Soft tissue becomes one of the factors causing Class II mal-
occlusions, such as in the case of Class II division 1, causing
a hypotonic upper lip or retrusion of lower jaw incisors due
to a hyperactive lower lip.6 Mandibular rotation is closely
related to occlusal plane changes during growth. Previous
research has observed continuous horizontal changes of the
occlusal plane accompanied by a reduction of the mandible
during growth and development. This suggests that changes
in the occlusal plane may affect the growth pattern of Class II
skeletal malocclusion.7 The aim of this study is to investigate
the importance of the occlusal plane to predict a better soft
tissue profile in Class II malocclusion for Javanese patients.

Materials and Methods

Sample
The number of malocclusion samples obtained from the
Faculty of Dental Medicine, Airlangga University Dental
Hospital in 2017 to 2018 was 233 patients. No patient
included had previous orthodontic treatment, with Class I
malocclusions (ANB = 1–3 degrees) of 124 people (53.22%),
Class II (ANB ≥4 degrees) with 63 people (27.04%), and Class
III (ANB ≤0 degrees) with 46 people (19.74%).
Fig. 1 Digital cephalometric analysis performed using Morpheus 3D.
In this study, Class II malocclusions were adjusted accord-
ing to predetermined criteria. Inclusion criteria of sample
selection include Javanese individuals, aged between 15 and
35 years old, and complete permanent dentition, as well as 7. OCC-SN: Angle formed by occlusal plane to sella–nasion
ANB ≥4 degrees. Beside the ANB, we added the Y-axis ≥ 65.5 plane.
degrees and facial axis ≥ 90 degrees. Exclusion criteria of 8. OCC-FH: Angle formed by occlusal plane to the FH plane.
samples selection include a history of orthodontic treat- 9. OCC-MP: Angle formed by occlusal plane to the mandib-
ment, dentofacial trauma or temporomandibular joint disor- ular plane.
ders, genetic syndrome, missing teeth, and supernumerary 10. Z-angle: Angle formed by the FH plane and profile line
teeth. After selection, we had a total of 51 samples wherein (line formed by touching chin and lower lip).
10 samples were male and 41 samples were female. The con- 11. Go angle: Angle formed from the points articulare
fidentiality of the patient’s identity remained protected, and, (Ar), Go, and menton (Me).
for patients younger than 17 years, informed consent was 12. Y-axis: Angle formed from the FH plane with the
represented by their parents. S–gnathion line, used to determine the direction of
Lateral cephalometric was then taken for each patient mandibular growth.
in the natural head position while the patient closed their 13. Facial axis: Angle between basion to nasion and
teeth in centric occlusion and lips were in a relaxed position. posterosuperior aspect of pterygomaxillary fissure to
Cephalometric analysis was performed using Morpheus 3D constructed gnathion.
Imaging (digital tracing cephalogram; Morpheus Co., Ltd.,
Gyeonggi-do, Korea) digital cephalometric by a single exam- Statistical Analysis
iner (►Fig. 1). Reference lines and landmarks to be analyzed The mean and standard deviation (SD) of the measurements
included: were determined using Statistical Package for Social Science
1. SNA: Angle formed from the points sella (S), nasion (N), 17.0 (SPSS Inc.; Chicago, Illinois, United States). The data nor-
and A. mality was calculated using Kolmogorov–Smirnov’ test and
2. SNB: Angle formed from the points S, N, and B. Shapiro–Wilk’s test (p > 0.05), while the correlation between
3. ANB: Angle between SNA and SNB. each variable was analyzed using the Pearson’s correlation
4. FMA: Angle formed by extending mandibular plane to test and multiple regression analysis (p < 0.05).
the Frankfort horizontal (FH) plane.
5. FMIA: Angle formed by extending mandibular incisor
Results
long axis to the FH plane.
6. IMPA: Angle formed by extending lower incisor long axis A normality test is a test conducted with the aim to assess the
to the mandibular plane. distribution of data in a group of data or variables (►Table 1).

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 Occlusal Plane in Predicting Better Facial Soft Tissue in Malocclusion Ardani et al. 431

After the normality test was done, we calculated the mean There was a positive correlation of OCC-SN to OCC-MP, Go
and SD for the data (►Table 2). In this statistical table, there angle, and Y-axis, while negative correlations were found for
was no correlation between SNA and Z-angle, OCC-MP, Go the Z-angle and facial axis, while OCC-FH did not have a cor-
angle, Y-axis, and facial axis, but we detected a negative relation with OCC-SN, OCC-MP, and Go angle; however, it has
correlation with OCC-SN and OCC-FH. There was a positive a negative correlation with the Z-angle and facial axis, and a
correlation of SNB with the Z-angle and a negative correla- positive correlation with the Y-axis. In OCC-MP, a significant
tion for OCC-SN and OCC-FH. There was no ANB correlation correlation was obtained in the parameters of OCC-FH, Go
with OCC-FH, OCC-MP, Go angle, Y-axis, and facial axis, but angle, Y-axis, and facial axis.
there was a positive correlation of OCC-SN and a negative There was a negative correlation between the Z-angle
correlation with the Z-angle. There was a positive correlation and OCC-SN, OCC-FH, OCC-MP, Go, and Y-axis, and a posi-
of FMA with OCC-SN and OCC-FH and a negative correlation tive correlation with the Z-angle (up) and facial axis. In the
with the Z-angle, whereas FMIA has a negative correlation Z-angle, there was no correlation with OCC-MP, but there
with OCC-SN and OCC-FH and positive correlation with the was a negative correlation with OCC-SN, OCC-FH, Go angle,
Z-angle. No correlation was found from IMPA with the prede- and Y-axis, and a positive correlation with the Z-angle (low)
termined parameters (►Table 3). and facial axis.

Table 1 Normality test result

Tests of normality
Kolmogorov–Smirnov Shapiro–Wilk
Statistic df Significance Statistic df Significance
SNA 0.093 51 0.200 a
0.965 51 0.137
SNB 0.106 51 0.200a 0.978 51 0.471
ANB 0.058 51 0.200 a
0.993 51 0.99
FMA 0.099 51 0.200a 0.965 51 0.133
FMIA 0.076 51 0.200 a
0.985 51 0.744
IMPA 0.078 51 0.200a 0.983 51 0.685
OCC-FH 0.133 51 0.026 0.959 51 0.076
OCC-SN 0.085 51 0.200a 0.98 51 0.547
OCC-MP 0.15 51 0.006 0.904 51 0.001
Z angle 0.1 51 0.200a 0.957 51 0.064
Go angle 0.083 51 0.200 a
0.976 51 0.375
Y-axis 0.109 51 0.187 0.978 51 0.444
Facial axis 0.088 51 0.200 a
0.981 51 0.567
This is a lower bound of the true significance.
a

Note: Lilliefors significance correction.

Table 2 Mean, SD, and normal values of each variable

Variable Minimum Maximum Mean ± SD Normal
SNA (deg) 75.72 88.26 82.1 ± 3.53 84.3
SNB (deg) 66.63 85.71 75.4 ± 4.07 81.4
ANB (deg) 0.98 11.81 6.7 ± 2.09 ±2.9
FMA (deg) 11.03 67.86 39.8 ± 9.35 25
FMIA (deg) 17.91 58.5 39.8 ± 9.15 65
IMPA (deg) 86.55 118.21 100.4 ± 7.59 90
OCC-SN (deg) 9.97 45.19 25.8 ± 6.4 14
OCC-FH (deg) 2.69 27.91 16.6 ± 5.7 9.3
OCC-MP (deg) 14.06 29.14 14.8 ± 4.6 15
Z-angle 20.63 74.69 54.7 ± 11.7 ±75
Go angle (deg) 95.32 137.89 120.5 ± 6.93 119
Y-axis (deg) 59.61 90.47 76 ± 7.1 65.5
Facial axis (deg) 66.3 91.76 78.78 ± 5.86 90.0
Abbreviation: SD, standard deviation.

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432 Occlusal Plane in Predicting Better Facial Soft Tissue in Malocclusion Ardani et al.

Table 3 Statistical calculation result of Pearson and multiple regression analysis

Pearson SNA SNB ANB FMA FMIA IMPA OCC-SN OCC-FH OCC-MP Z-angle Go Y-axis Facial
(deg) (deg) (deg) (deg) (deg) (deg) (deg) (deg) (deg) angle (deg) axis
(deg)
SNA – 0.859a 0.017 -0.401a 0.332b 0.093 -0.444a -0.413a 0.244 0.130 0.248 0.245 0.250
(deg)
0.000 0.908 0.004 0.017 0.516 0.001 0.003 0.085 0.362 0.079 0.083 0.076
SNB 0.859a – -0.498a -0.493a 0.510a -007 -0.586a -0.374a 0.220 0.361a 0.229 -0.225 0.232
(deg)
0.000 0.000 0.000 0.000 0.961 0.000 0.007 0.120 0.009 0.107 0.112 0.101
ANB 0.017 -0.498a – 0.284b -0.433a 0.171 0.393a 0.134 -0.018 -0.483a -0.026 0.025 -0.029
(deg)
0.908 0.000 0.043 0.002 0.229 0.004 0.348 0.903 0.000 0.854 0.863 0.838
FMA -0.401a -0.493a 0.284 – -0.664a -432a 0.630a 0.654a -0.219 -0.608a -0.240 -0.238 -0.248
(deg)
0.004 0.000 0.043 0.000 0.002 0.000 0.000 0.122 0.000 0.090 0.092 0.080
FMIA 0.332b 0.510a -0.433a -0.664a – -0.387a -0.637a -0.579a 0.191 0.674a 0.197 0.194 0.201
(deg)
0.017 0.000 0.002 0.000 0.005 0.000 0.000 0.180 0.000 0.167 0.172 0.156
IMPA 0.093 -0.007 0.171 0.432a -0.387a – -0.007 -0.107 0.040 -0.064 0.059 0.059 0.062
(deg)
0.516 0.961 0.229 0.002 0.005 0.959 0.453 0.779 0.657 0.680 0.679 0.663
OCC-SN -0.444a -0.586 0.393a 0.630a -0.637a -0.007 – 0.233 0.438a -0.497a 0.472a 0.510a -0.643a
(deg)
0.001 0.000 0.002 0.000 0.000 0.479 0.100 0.001 0.000 0.000 0.000 0.000
OCC-FH -0.339 -0.408a 0.224 0.654a -0.579a -0.107 0.263 – -0.234 -0.398a 0.256 0.741a -0.496a
(deg)
0.008 0.001 0.057 0.000 0.000 0.227 0.063 0.099 0.004 0.069 0.000 0.000
OCC-MP -0.126 -0.208 193 534 a
-183 -439 a
-0.033 -0.288 b
– 0.068 0.999 a
0.999 a
0.999a
(deg)
0.189 0.071 087 0.000 0.100 0.001 0.818 0.041 0.638 0.000 0.000 0.000
Z-angle 0.130 0.361 -0.483 0.608 0.674 -0.064 -0.497 a
-0.398 a
-0.284 b
– -0.419 a
-0.569 a
0.598a
0.181 0.005 0.000 0.000 0.000 0.329 0.000 0.004 0.044 0.002 0.000 0.000
Go -0.124 -0.184 0.141 0.744 -0.397 a
-0.438 a
0.472 a
0.256 0.696 a
-0.419 a
– 0.411 a
-0.491a
angle
0.387 0.197 0.323 0.395 0.004 0.001 0.000 0.069 0.000 0.002 0.003 0.000
(deg)
Y-axis -0.537 -0.609 0.235 0.874 0.641 -0.304 0.510a 0.741a 0.303b -0.569a 0.411a – -0.689a
(deg)
0.477 0.208 0.096 0.558 0.402 0.030 0.000 0.000 0.031 0.000 0.003 0.000
Facial 0.466a 0.683 -0.513a 0.770 0.618 0.205 -0.643a -0.496a -0.451a 0.598a -0.491a -0.689a –
axis
0.001 0.830 0.000 0.391 0.138 0.150 0.000 0.000 0.001 0.000 0.000 0.000

A positive correlation was found between Go angle and protrusion, lip formation, facial convexity, and occlusion sta-
OCC-SN, OCC-MP, and Y-axis, while negative correlations bility.8,9 Characteristics of Class II malocclusion include the
were discovered between the Z-angle and facial axis. The protrusion of the upper jaw and upper lip, incompetent lip
Y-axis has a correlation with OCC-SN, OCC-FH, OCC-MP, and growth, poor chin morphology, and small nasolabial angles,
Go, while there was a negative correlation with the Z-angle which are often the main complaint of patients.10-12
and facial axis. In addition, the facial axis has a positive cor- Measurements in this study were divided into three
relation with Z-angle and negative correlation with OCC-SN, parts: occlusal plane (OCC-SN, OCC-FH, and OCC-MP),
OCC-FH, OCC-MP, Go angle, and Y-axis. facial balance and soft tissue profile (FMA, FMIA, IMPA, and
Z-angle), and vertical plane of the face (Y-axis and facial
axis) as support. First, this study will discuss the relation-
Discussion
ship between SNA, SNB, and ANB with the occlusal plane
At the beginning of the 20th century, the primary goal of (functional occlusal plane [FOP]). This field is used because
orthodontic treatment was to achieve normal occlusion. FOP shows stability in orthodontic patients in a skeletal
However, soft tissue is the primary determinant of a patient’s Class II or Class III malocclusions.13
facial appearance. After a paradigm shift, orthodontists now It is known that SNA and SNB have a negative correla-
place more emphasis on the soft tissue outcomes of their tion with the occlusal plane of OCC-SN and OCC-FH. The
treatments. Changes in the facial profile in a skeletal Class II mean value of SNA (82.1) is normal, while the SNB (75.4) is
malocclusion are very challenging for an orthodontist. Many smaller than normal. According to Li et al, individuals with
factors need to be considered when treating adult patients, grade II skeletal malocclusions have mandibular retrusion,
such as aesthetics, skeletal vertical dimensions, dentoalveolar a finding consistent with McNamara (1984).13,14 SNB has a

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 Occlusal Plane in Predicting Better Facial Soft Tissue in Malocclusion Ardani et al. 433

positive correlation with the Z-angle, while ANB has a neg- vertical facial development is indicated by positive values
ative correlation with the Z-angle. This is consistent with (>90 degrees), which are obtained by measuring the basion
statements made by Oh et al and Amer et al in that a SNB angle–PTM–gnathion and are expected to have an upright
that is small in value will affect the size of the Z-angle which position on the face when balanced. In this study, the ver-
becomes smaller than the normal size (normal 78, mean tical plane of the face is represented by the Y-axis and facial
56.7) and the larger ANB size (> 40, mean 6.7). This greatly axis. The Y-axis has a positive correlation with OCC-SN,
affects the balance of the face.15,16 OCC-FH, OCC-MP, and Go angle, but a negative correlation
Tweed (1964) noted that the relationship of the three with the Z-angle and facial axis. However, the facial axis has
measurement angles, namely, FMA, FMIA, and IMPA, pro- a positive correlation only with the Z-angle and a negative
vides information about the vertical shape of one’s skel- correlation with OCC-SN, OCC-FH, OCC-MP, Go angle, and
etal, mandibular incisor relation to basal bone, and the Y-axis.14,22
relative amount of protusion on the face. In an interview According to previous studies, such as those conducted by
in December 1967, Tweed said that of these three mea- Sharma and Xin, gender variations do not have a significant
surement angles, FMIA is the most stable measurement effect on the skeletal and dental components of Class II mal-
because according to the research, FMIA calculations did occlusions. Likewise, in this study, gender variations did not
not change during growth. In this study, a positive correla- affect the calculations performed.23
tion was obtained from FMA with OCC-SN and OCC-FH,
and FMIA with the Z-angle. This could be interpreted as Conclusion
the greater the value of the FMA, the greater the value
Based on this study, we can conclude that there is a cor-
of OCC-SN and OCC-FH, as well as FMIA, the greater the
relation between the occlusal plane to the soft tissue pro-
value, the greater the value of the Z-angle. Negative cor-
file and facial balance in ethnic Javanese malocclusion
relations were obtained for FMA against the Z-angle and
patient. Patients with Class II skeletal malocclusions in
FMIA against OCC-SN and OCC-FH, with the understanding
ethnic Javanese reveal a significant correlation between
that the greater the FMA value, the smaller the value of the
the occlusal plane and Z-angle, thereby affecting the shape
Z-angle drift, and the greater the FMIA value, the greater
of the soft tissue profile, causing a disturbed facial balance.
the OCC-SN and OCC-FH values.17,18
The occlusal plane is considered important in determining
For practitioners, changing the problematic occlusal
orthodontic diagnosis and treatment plans. Effective con-
plane in patients is the ultimate goal in an orthodontic
trol and more attention to the occlusal plane in therapy
treatment, whereas for patients, the change of facial pro-
can avoid unfavorable mandibular rotation and achieve a
file becomes more important.8 A positive correlation of
good facial profile. However, further research is needed to
OCC-SN to OCC-MP and a negative correlation of OCC-MP
confirm the importance of the occlusal plane after ortho-
to OCC-FH were obtained. There is also a negative correla-
dontic treatment for better prognosis.
tion of OCC-SN and OCC-FH on the Z-angle and facial axis,
while there was a positive correlation for the OCC-SN and
Conflict of Interest
OCC-FH on the Y-axis. According to Kim et al, skeletal
None declared.
Class II malocclusion reveals a close relationship between
the occlusal and vertical fields, as in this study. In addi-
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