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A.new approach of assessing sagittal dysplasia: The W.angle

Article  in  The European Journal of Orthodontics · February 2011

DOI: 10.1093/ejo/cjr001 · Source: PubMed

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European Journal of Orthodontics 35 5 66–70 © The Author 2011.
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Advance Access publication 8 February 2011

A new approach of assessing sagittal dysplasia: the W angle

Wasundhara A. Bhad*, Subash Nayak* and Umal H. Doshi**
*Department of Orthodontics and Dentofacial Orthopedics, Government Dental College and Hospital, Nagpur and
**Department of Orthodontics and Dentofacial Orthopedics, Government Dental College and Hospital, Aurangabad,
India

Correspondence to: Dr Umal H. Doshi, Department of Orthodontics and Dentofacial Orthopedics, Government
Dental College and Hospital, Government Medical Campus, Nagpur, Maharashtra, India. E-mail: umal_16@
rediffmail.com

SUMMARY In orthodontic diagnosis and treatment planning, an accurate antero-posterior measurement

of jaw relationships is critically important. Previously described angular and linear measurements
can be inaccurate because of their dependency on various factors. The purpose of this study was to
introduce a new cephalometric measurement, named the W angle, to assess the sagittal relationship
between maxilla and mandible with accuracy and reproducibility. This angle uses three skeletal
landmarks—point S, point M, and point G—to measure an angle that indicates the severity and
the type of skeletal dysplasia in the sagittal dimension. One hundred and forty-two pre-treatment
cephalometric radiographs of patients between the age of 15 and 25 years were selected. They were
again subdivided into Classes I, II, and III groups on the basis of Beta angle, Wits appraisal, and ANB
angle. The W angle was measured between the perpendicular from point M on S–G line and the
M–G line. The mean and the standard deviation for the W angle were calculated. After using the

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one-way analysis of variance and the Newman–Keuls test, receiver operating characteristics curves were
obtained. Results showed that a patient with a W angle between 51 and 56 degrees can be considered
to have a Class I skeletal pattern. With an angle less than 51 degrees, patients are considered to have a
skeletal Class II relationship and with an angle greater than 56 degrees, patients have a skeletal Class III
relationship.

Introduction
can also differ because of variance in the length of the
In diagnosis and treatment planning of skeletal malocclusions, cranial base (Jacobson, 1975).
the evaluation of the antero-posterior (AP) jaw relationship Wits appraisal was projected to overcome the existing
is an indispensable step, and this relationship is generally limitations of angle ANB (Jacobson, 1975). The Wits
determined by cephalometric analysis. Since Wylie’s (1947) appraisal avoids the use of nasion and reduces the rotational
rst attempt to describe AP jaw relationship, various other effects of jaw growth, but it uses the occlusal plane, which is
cephalometric parameters have been proposed. Of these a dental parameter, to describe the skeletal discrepancies. The
parameters, the ANB angle (Riedel, 1952), the Wits appraisal occlusal plane can be easily affected by tooth eruption and
(Jacobson, 1975), and recently Beta angle (Baik and dental development as well as by orthodontic treatment
Ververidou, 2004) are the commonly used parameters. Still, (Richardson, 1982; Frank, 1983; Sherman et al., 1988). This
sagittal jaw relationships are difcult to evaluate because of can profoundly inuence the Wits appraisal. Furthermore,
rotations of the jaws during growth, vertical relationships accurate identication of the occlusal plane is not always easy
between the jaws and the reference planes, and a lack of or accurately reproducible (Rushton et al., 1991; Haynes and
validity of the various methods proposed for their evaluation Chau, 1995), especially in mixed dentition patients or patients
(Jacobson, 1975; Moyers et al., 1979; Baik and Ververidou, with open bite, canted occlusal plane, multiple impactions,
2004; Nanda, 2005). missing teeth, skeletal asymmetries, or steep curve of Spee.
With regard to the validity of the ANB angle and Wits Because of these geometric effects, a conjunctive use of
appraisal, various studies have pointed out a number of the ANB angle and the Wits appraisal has been recommended
distorting factors. Number of studies have questioned (Moyers et al., 1979; Nanda, 2005). However, when there is
stability of nasion (N; Nanda, 1955; Moore, 1959; Enlow, a difference in the jaw relationship assessment between the
1966; Binder, 1979). two parameters, it is difcult to know on which parameter
During shooting of cephalogram, rotation of head side to base a selection.
wards or upwards can affect the ANB reading. Furthermore, Some authors have suggested angles or linear
rotation of the jaws by either growth or orthodontic measurements based on the palatal plane (Nanda and
treatment can also change the ANB reading. The ANB angle Merrill, 1994). Although palatal plane is stable with age,
2 NEW
A of 5 APPROACH OF ASSESSING SAGITTAL DYSPLASIA W. A. BHAD ET AL.
67

its inclination is highly variable, requiring additional

cephalometric data to ensure a more accurate diagnosis
(Nanda and Merrill, 1994).
To determine true apical base relationship independent of
the cranial reference planes or dental occlusion, Beta angle
was developed (Baik and Ververidou, 2004). Although it
gives fair idea of true apical elation, it still uses point A as a
reference point for the AP position of the maxilla. The
position of point A is believed to be affected by alveolar bone
remodelling associated with orthodontic tooth movement of
the upper incisors (Arvysts, 1990; Erverdi, 1991; Nanda,
2005). The other problem is locating point condylion. The
reproducibility of the location of condylion on mouth-closed
lateral head lms is limited (Adenwalla et al., 1988; Moore
et al., 1989; Ghafari et al., 1998).
Most recently introduced sagittal dysplasia indicator is
YEN angle (Neela et al., 2009). But since it measures an
angle between line SM and MG, rotation of jaw because of
growth or orthodontic treatment can mask true basal
dysplasia, similar to ANB angle.
To overcome these existing problems, a measurement
was developed and named the W angle. This angle does not

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depend on any unstable landmarks or dental occlusion and
would be especially valuable to assess true sagittal changes
because of growth and orthodontic treatment.

Figure 1 The construction and mode of measuring the W angle.

The W angle
The W angle is a new measurement for assessing the skeletal
discrepancy between the maxilla and the mandible in the were screened in the Orthodontic Department of
sagittal plane (Figure 1). It uses three skeletal landmarks— Government Dental College, Nagpur.
point S, point M, and point G—to measure an angle that After the initial selection, all x-rays were retraced; the
indicates the severity and the type of skeletal dysplasia in ANB and Beta angles and the Wits appraisal were measured
the sagittal dimension (Figure 1). The W angle can be found by each investigator separately. The mean values of
by, rst, locating three points: those measurements were calculated. All tracings and
Point S—midpoint of the sella turcica; measurements were repeated by the same operators at a
Point M—midpoint of the premaxilla; 2 week interval. The combined error was calculated with
Point G—centre of the largest circle that is tangent to the the Dahlberg’s formula. The mean difference was within
internal inferior, anterior, and posterior surfaces of the 0.7 degrees for angular measurements and was insignicant.
mandibular symphysis. For a patient to be included in the Classes I, II, or III
Next, dening four lines: skeletal pattern group, criteria for Beta angle along with one
Line connecting S and M points. of two (ANB angle and Wits appraisal) had to be met. A
Line connecting M and G points skeletal Class I relationship was indicated by an ANB of
Line connecting S and G points. 2–4 degrees, a Wits coincidence of AO and BO in females
Line from point M perpendicular to the S–G line. or BO 1 mm ahead of AO in males, and a Beta angle of
Finally, measuring the W angle, which is the angle 27–35 degrees. Sixty lateral cephalograms (35 female and
between the perpendicular line from point M to S–G line and 25 male) that met the above criteria comprised the skeletal
the M–G line (Figure 1). The purposes of this study were to Class I group.
dene the mean value and the standard deviation for this A skeletal Class II relationship was indicated by an ANB
angle in people with the Classes I, II, and III skeletal pattern. of greater than 4 degrees, a Wits appraisal with AO ahead of
BO in females or AO coinciding with or ahead of BO in
males, and a Beta angle less than 27 degrees. Forty-six
Materials and methods
lateral cephalograms (26 female and 20 male) were collected
To assign samples to the Classes I, II, and III skeletal pattern from the screened les that met the above criteria to form
groups, many les of individuals between 15 and 25 years the skeletal Class II group.
A NEW
68 APPROACH OF ASSESSING SAGITTAL DYSPLASIA W. A. BHAD3ETof 5
AL.

The skeletal Class III individuals were characterized by Table 1 Mean (SD) values of W angle in Class I, Class II, and
an ANB less than 2 degrees, a Wits BO ahead of AO in Class III groups. SD, standard deviation.
females or BO ahead of AO by more than 1 mm in males,
and a Beta angle greater than 35 degrees. Thirty-six lateral Class
cephalograms (20 female and 16 male) met the required
criteria. I II III
To construct the W angle, points S, M, and G were
located. To locate points M and G, as suggested by Nanda Female 53.8 48.7 57.4
Male 53.6 49.2 60.4
and Merrill (1994) and Braun et al. (2004), a template with Mean (SD) 53.7 (2) 48.9 (2.1) 58.7 (3.2)
concentric circles whose diameters increased in 1 mm
increments was used.
After classifying the patients, W angle was measured by
two operators and mean value was taken. To measure the Table 2 Student-Newman-Keuls testing for pairwise
comparisons of group means.
method error using Dahlberg’s formula, same procedure
was repeated after 2 weeks and it was found to be 0.5
degrees. Class N Subset

Statistical analysis 1 2 3

Data collected by the investigators were rst entered to II 46 48.910

Excel (Microsoft, Redmond, Washington, USA). Collected I 60 53.756
III 35 59.441
data were screened for any missing values or outliers and Signicance 1.000 1.000 1.000
for validity of distribution assumptions. To summarize the

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data, means and standard deviations of W angle in three
groups were calculated. The one-way analysis of variance
show that the cut-off point between the Class I and Class II
(ANOVA) was used followed by Newman–Keuls post hoc
groups could be considered a W angle of approximately
testing to determine whether there was a statistically
51 degrees, and the cut-off point between the Class I and
signicant difference between the mean values W angle of
Class III groups could be considered a W angle of
the three groups. A P value ≤0.05 was considered to be
approximately 56 degrees. The results also indicate that a
statistically signicant. Receiver operating characteristics
patient with a W angle less than 51 degrees has a Class II
curves were run to examine the sensitivity and specicity of
skeletal pattern and one with a W angle greater than
W angle as a test to discriminate between the three different
56 degrees has a Class III skeletal pattern.
skeletal pattern groups. All statistics were performed in
SPSS (SPSS 13, Chicago, Illinois, USA).
Discussion
In orthodontic diagnosis and treatment planning, the
Results
evaluation of the AP jaw relationship is an indispensable
The mean value for the W angle in the Class I skeletal step and this relationship is generally determined by
pattern group was 53.7 degrees with SD of 2.0, whereas the cephalometric analysis. To evaluate this relationship,
mean values in the Classes II and III skeletal pattern groups various angular and linear measurements have been
were 48.9 and 58.7 degrees with a SD of 2.1 and 3.2, suggested. But these can be erroneous as angular
respectively (Table 1). measurements are affected by changes in face height, jaw
The one-way ANOVA followed by Newman–Keuls post inclination, and total jaw prognathism; linear variables can
hoc testing showed (Table 2) that there was a statistically be affected by the inclination of the reference line (Williams
signicant difference between the mean values of W angle et al., 1985; Jacobson, 1988).
of the three groups. Between genders, according to unpaired The most popular parameter for assessing the sagittal jaw
t-test, there was no statistically signicant difference except relationship remains the ANB angle, but it is affected by
in skeletal Class III group (Table 2). various factors and can often be misleading. When using the
Receiver operating characteristics curves showed that a ANB angle, factors such as the patient’s age, growth rotation
W angle less than 51 degrees has 96 per cent sensitivity and of the jaws, vertical growth, and the length of the anterior
90 per cent specicity for discriminating the Class II group cranial base (AP position of N) should be considered, which
from the Class I group. A W angle greater than 56 degrees makes the interpretation of this angle much more complex
has 95 per cent sensitivity and 98 per cent specicity for (Jacobson, 1975).
discriminating the Class III group from the Class I group. To overcome these problems, the Wits appraisal was
Therefore, the receiver operating characteristics curves introduced (Jacobson, 1975). Although not affected by
4 NEW
A of 5 APPROACH OF ASSESSING SAGITTAL DYSPLASIA W. A. BHAD ET AL.
69

landmarks or jaw rotations, it still has the problem of

correctly identifying the functional occlusal plane, which
can sometimes be impossible, especially in mixed dentition.
Furthermore, changes of the Wits measurement throughout
orthodontic treatment might also reect changes in the
functional occlusal plane rather than pure sagittal changes
of the jaws (Moore et al., 1989; Ishikawa et al., 2000).
A popular recent alternative Beta angle avoids use of
functional plane and is not affected by jaw rotations (Baik
and Ververidou, 2004). But it uses point A and point B,
which can be remodelled by orthodontic treatment and
growth (Richardson, 1982; Frank, 1983; Rushton et al.,
1991). Furthermore, as shown by various studies, the
reproducibility of the location of condylion on mouth-closed
lateral head lms is limited (Adenwalla et al., 1988; Moore
et al., 1989; Ghafari et al., 1998). Instead of condylion,
centre of condyle could be used, but approximation of centre
of condyle is difcult (Baik and Ververidou, 2004). This
could give a non-signicant error of approximately 1 degree.
All other AP parameters introduced over the years are
affected by at least one of the factors, namely patient’s age,
jaw rotations, poor reproducibility of landmarks, growth Figure 2 W angle remains relatively stable even when jaws are rotated.

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changes in reference planes, and changes due to orthodontic
treatment (Ishikawa et al., 2000).
angle is that it can be used for evaluation of treatment
To overcome some of the limitations of the previously
progress because it reects true changes of the sagittal
discussed parameters, the W angle was developed. This
relationship of the jaws, which might be due to growth or
measurement does not depend on unstable landmarks or the
orthodontic or orthognathic intervention.
functional occlusal plane. It uses three stable points—point
However, precisely tracing the premaxilla and locating
S, point M, and point G. W angle is measured between a
its centre is not always easy. To accurately use this angle,
perpendicular line from point M to the S–G line and M–G
the cephalometric x-rays must be high quality. It is then
line. Based on statistical analysis, a patient with a W angle
much easier for the clinician to follow the contour of
between 51 and 56 degrees has a Class I skeletal pattern.
premaxilla and locate its centre.
Patient with a W angle less than 51 degrees has a skeletal
In Class II and Class III skeletal cases, similar to Beta
Class II pattern and one with a W angle greater than 56
angle, W angle cannot determine which jaw is prognathic or
degrees has a skeletal Class III pattern. In females with
retrognathic. To clarify this, clinician should be aware of
class III skeletal pattern, W angle has a mean value of 57.4
importance of other cephalometric measurements.
degrees, while in males, it is 60.4 degrees.
Cephalometrics is not an exact science. Cephalometric
ANB angle has been shown to be affected by vertical
analyses based on angular and linear measurements have
facial growth as well as by jaw rotations (Ishikawa et al.,
obvious limitations and hence dependency on any one
2000). The geometry of the W angle gives it the advantage
parameter for skeletal assessment is discouraged. W angle
to remain relatively stable even when the jaws are rotated or
adds a valuable tool for assessment of AP jaw relationship.
growing vertically (Figure 2). This is a result of rotation of
Along with other parameters, it should enable better
the S–G line along with jaw rotation, which carries the
diagnosis and treatment planning for patients.
perpendicular from point M with it. Because the M–G line
is also rotating in the same direction, the W angle remains
relatively stable. Therefore, measurement of W angle is Conclusions
useful sagittal parameter in skeletal patterns with clockwise
or counterclockwise rotation of the jaws as well as during 1. Previously established measurements for assessing the
transitional period when vertical facial growth is taking sagittal jaw relationship can often be misleading.
place. 2. A new angle, the W angle, was developed as a diagnostic
Cranial base length (position of point N) can sometimes tool to evaluate the AP jaw relationship more consistently.
camouage true skeletal classes I, II, and III patterns. In this 3. Subjects with a W angle between 51 and 56 degrees
regard, W angle can be a valuable tool for planning have a Class I skeletal pattern; a W angle less than 51
orthopaedic or orthognathic procedures as this angle is degrees indicates a Class II skeletal pattern and a W
independent of cranial base length. Another advantage of W
 A NEW
70 APPROACH OF ASSESSING SAGITTAL DYSPLASIA W. A. BHAD5ETof 5
AL.

angle greater than 56 degrees indicates a Class III Haynes S, Chau M 1995 The reproducibility and repeatability of the Wits
analysis. American Journal of Orthodontics and Dentofacial Orthopedics
skeletal pattern. 107: 640–647
4. There is no statistically signicant difference between Ishikawa H, Nakamura S, Hiroshi I, Kitazawa S 2000 Seven parameters
mean W angle values of males and females except for describing anteroposterior jaw relationships: postpubertal prediction
class III malocclusion. In females with Class III skeletal accuracy and interchangeability. American Journal of Orthodontics and
Dentofacial Orthopedics 117: 714–720
pattern, W angle has a mean value of 57.4 degrees, while
Jacobson A 1975 The “Wits” appraisal of jaw disharmony. American
in males, it is 60.4 degrees. Journal of Orthodontics 67: 125–138
Jacobson A 1988 Update on the Wits appraisal. Angle Orthodontist 57:
205–219
Acknowledgement Moore A W 1959 Observations on facial growth and its clinical signicance.
American Journal of Orthodontics 45: 399–423
The authors gratefully acknowledge the support of Dr Vinay
Moore R N, DuBois L M, Boice P A, Igel K A 1989 The accuracy of
Hazare, Dean, Government Dental College, Nagpur, for his measuring condylion location. American Journal of Orthodontics and
valuable support during this study. Dentofacial Orthopedics 95: 344–347
Moyers R E, Bookstein F L, Guire K E 1979 The concept of pattern in
craniofacial growth. American Journal of Orthodontics 76: 136–148
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