CHAPTER # 1

INTRODUCTION

Malocclusion is a developmental deformity which may be of dental or skeletal

origin. Malocclusions with skeletal discrepancies in the craniofacial region are

caused by abnormal forms, sizes and positions of the cranial base, maxilla and

mandible. The variation in the expression of different facial patterns is a result of

interplay between various factors such as heredity, environment and function. Such

variable factors have an effect on the growth and development of the maxillofacial

complex. (Kuroe K, 2004)

The brain is supported by cranial base which extend anteriorly from foramen

caecum to occipital bone posteriorly. It is a midline structure comprising of the

orbital, ethmoid, nasal ,sphenoid, and occipital bones. Cranial base may affect the

development of both cranium and the face as it is located on the junction between

cranium, midface and glenoid fossa (Scott, 1958).Sella turcica lies near the Centre

of the cranial base and divides it into anterior (Sella to Nasion) and posterior (Sella

to Basion) limbs. The two limbs of the cranial base form a flexon of 130-145 degree

at sella. The maxilla appears attached to the anterior segment and the mandible to

the posterior segment. (Dhopatkar A, 2002)

The cranial base plays an important role in growth of craniofacial region,It

helps to integrate different patterns of growth in various regions of the skull such as

the nasal cavity, the oral cavity, and the pharynx. As the maxilla is connected with

the anterior part of the cranial base and the rotation of mandible is influenced by the

maxilla, so a relationship can be found between cranial base morphology and the

sagittal malposition of the jaws.

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 Cranial base configuration and its relationship to facial prognathism has

been of interest to anthropologists. Cranial base morphology using basicranial axis

on sagittal sections of dried skull to show racial variation has been studied by a

researcher (Huxley, 1863).One researcher suggested that an association may exist

between cranial base morphology and the malocclusion (Young, 1916).

One researcher demonstrated the existence of relationship between cranial base

morphology and jaw relationship using cephalometric radiographs (Bjork,

1955).Another researcher using articulare to represent the posterior limit of the

cranial base, described a linear relationship between the cranial base angle and

prognathism with angle systematically reducing from Class I, via Class II, to Class

III individuals (Hopkin GB, 1968).One researcher found that the cranial base angle

(Ba-S-N) was reduced and the legs(S-N) and (S-Ba) were shortened systematically

from Class II, via Class I, to Class III malocclusions, although mandible exhibited

no systemic difference between these three classes. (Renfroe, 1948)

The saddle angle or cranial base is measured using radiographs as the angle

between Basion-Sella-Nasion points, although the Articulare and Bolton points

have also been used to describe the posterior limit making it difficult to compare

the results of different studies (Kerr, 1978).

Skeletal malocclusion is thought to be influenced by various factors like basicranial

morphology, head and neck posture and soft tissue stretching. This study aims to

find out the importance of cranial base morphology and its role in establishing the

malocclusion by performing cephalometric study.

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 CHAPTER#2

LITERATURE REVIEW

( Kerr and Hirst,1987) in a longitudinal cephalometric study using a sample of 85

children from the Belfast Growth Study, found the cranial base angle to be the best

discriminator between Angle’s class I and class II cases. They also stated that the

cranial base angle at age five years was an accurate predictor of the eventual

occlusal type of the patient at age 15 in approximately 73% of patients

( Kerr and Adams,1988) subdivided a sample of 124 men (mean age range

10.15–10.37 years) on the basis of incisor occlusion and showed a trend of reducing

cranial base angles from class II toward class III malocclusion. However, (Bacon et

al,1992) using a mixed sex sample of eighty-six 10– 12 year olds selected on the

basis of molar occlusion and ANB angle, concluded that although there was a

relationship between cranial base morphology and class II malocclusion, the

contribution of the cranial base was limited

More recently, (Baccetti et al,1997) concluded that the glenoid fossa was

more posteriorly positioned in class II than in class III subjects, whereas (Singh et

al,1997) found a closing of the cranial base angle in class III cases.

Other workers have presented contradictory evidence. (Renfroe,1948) with

a total sample size of 95 subjects, could find no correlation between the cranial base

angle and Angle’s class I or class II malocclusion

(Menezes,1974) and (Wilhelm et al,2001) ,in a longitudinal study with a

mixed-sex sample of 43 individuals, were also unable to confirm a link between

cranial base angle and a class II pattern.

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(Anderson and Popovich,1983) using material from the Burlington Growth Center,

found that large cranial base angles were associated with class II malocclusion, but

small angles were related to Angle’s class I, rather than class III subjects.

(Gilmore,1950) using a sample of adults ranging from 16 to 42 years of age,

suggested that class II subjects had smaller mandibles than class I subjects.

(Guyer et al,1986) used a cross sectional sample selected on the basis of a class III

molar relationship on cephalometric radiographs to compare with a longitudinal

class I sample from the Bolton-Brush study. They also found no association

between cranial base angle and type of malocclusion.

Similarly (Battagel,1993) using tensor analysis on a sample of 64 children classified

using the (British Standards Institution,1983) incisor method, was unable to show

significant differences between the cranial base morphology of class I and class III

cases, which led her to conclude that the relationship between cranial base

morphology and class III malocclusion was tentative. The class III cases in this

study were all classified as suitable for treatment by orthodontics alone.

(Scott,1967) suggested that a number of factors determine or influence static

jaw position and, consequently, the degree of prognathism in individual cases.

These factors included the cranial base angle, the extent to which the mandible and

maxilla moved forward in relation to the cranium, and the amount of surface bone

deposition along the facial profile from Nasion to Menton.

(Ricketts,1960) reported that the skull base area has an important influence

on total facial prognathism and development of anteroposterior relationship

between maxilla and mandible

(Hildwein et al,1986) found no significant difference in the BaSN angle in

individuals with Class II and Class I malocclusion

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 (Kasai et al,1995) investigated the relationship between skull base and

maxillofacial morphology in Japanese subjects and found no difference between

Class I and Class II malocclusions.

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 RATIONALE

This study will help in diagnosis and treatment planning of class I, class II and class III

malocclusions

DEFINITIONS

1) Class I control group : ANB angle 0-4º,bilateral class I molar and canine

relationship, normal overjet and overbite (2-4mm),well aligned upper and lower

arches with less than 3mm of spacing or crowding in either of them.

2) Class II group : ANB >4º,bilateral class II molar and canine relationship, overjet

>4mm.

3) Class III group :ANB < 0º,bilateral class III molar and canine relationship,overjet <

2mm

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 CHAPTER # 3

MATERIALS AND METHODS

1.1 Objective

The objective of our study is to evaluate and compare cranial base morphology in

skeletal Class I, II and III malocclusions.

1.2 Hypothesis

There is positive Relationship between cranial base morphology and skeletal class I,

class II and class III malocclusions.

1.3 Study Design

Case control study.

1.4 Sample

1.4.1Sampling Technique

Consecutive sampling technique.

1.4.2 Sample Size

N=Z2P(1-P)/d2 = (1.96)20.1(1-0.1)/ (0.05)2 =138 .

1.4.3 Inclusion Criteria

• No history of parafunctional habit.

• No oral habit according to the subject history and clinical examination.

• No history of previous orthodontic treatment.

• No gross facial asymmetry .

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 • No history of facial trauma or craniofacial anomalies e.g cleft lip and cleft

palate.

• Patient with full complement of teeth upto 2nd molars.

• Patient with no caries or periodontal problem.

1.4.4 Exclusion Criteria

• History of previous orthodontic treatment.

• Patient having craniofacial deformity e.g cleft lip and cleft palate.

• Patient with facial asymmetry evident on clinical examination.

• Patient with TMJ abnormality.

• Patient who have undergone any surgery.

• Patient with carious or missing tooth.

1.5 Setting and Duration of the study

Orthodontics department of The Children’s Hospital Lahore and Institute of Child

Health Lahore. The study duration will be 6 months from July– December 2018.

1.6 Instrument

In order to gather the data for this study, a performa is designed. A performa is a list of

variables observed from the cephalometric radiographs of the patients, and considered

to extract definite information. A performa is considered after discussion with the

supervisor. This performa is designed to discover the variables concerning the cranial

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base morphology in skeletal class I,II and III malocclusion. The performa consists of

17 variables, involved in the study to meet the requirement of the study.

1.7 Procedure

Radiographs will be taken from the patient after filling of consent form at hospital. First,

the Performa containing variables will be given to Research experts in the School of

Allied health sciences to ensure that the variables are consistent with the objectives of

the study and that no confusing, leading or inappropriate variables are included, that

would need to be modified or removed. Secondly, a pilot study will be done on 10

participants (the parents/guardians) picked randomly from Orthodontics Department at

Children’s Hospital & the Institute of Child Health Lahore. The performas will be again

scrutinized and assessed for their validity based on these pilot study responses before

initiating the actual survey.

138 patients will be selected , according to the inclusion criteria , coming to the outdoor

department of orthodontics CH & ICH Lahore. All the patients will be divided into

three major categories depending upon ANB angle and dental occlusion into class I

control group ,class II and class III. Pretreatment lateral cephalometric radiographs will

be taken and traced upon an A4 size acetate paper with 2B or 3HB hard lead pencil over

well-illuminated viewing screen.The linear measurement will be recorded with a

measuring scale upto precision of 0.5mm.The angular measurements will be analysed

with a protractor upto a precision of 0.5mm.

Following skeletal base measurements will be recorded

Angular measurements:

• SNA.

• SNB.

• ANB.
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Linear measurements:

• Ar-Go.

• S-Go.

• N-Me.

• Jarabak ratio (posterior facial height S-Go ×100 / Anterior

facial height N-Me.

Following cranial base measurements will be taken,

Angular measurements:

• N-S-Ar.

• N-S-Ba.

• SN-FH.

• SBa-FH.

Linear measurements:

• S-N.

• S-Ba.

• N-Ba.

• S-Ar.

Area measurements:

• The area N-S-I.

• The area S-I-J-Ar.

• The area S-Ar-J-Ba.

• The area Ba-N-S.

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1.7.1 Pre-Testing:

Pre-Testing is a technique to estimate the validity of the performa to see whether it

works correctly in the field. After pretesting it will be decide to comprise all variables.

1.7.2 Reliability of Performa:

Reliability of a performa is the consistency of a set of measurements or determining

instrument frequently used to describe a test. This tells that whether the measurement

of the performa give the same measurement when repeated over time. In this study the

reliability of performa will be verified by using the usually used instrument the

Cronbach’s Alpha.

1.8 Statistical Analysis

All the data will be entered in SPSS version 25 software and then analyzed for

statistically significant outcomes by using descriptive statistics including

mean,standard deviation.standard error,minimum ana maximum and by using

inferential statistics including student t-test.

1.8.1 Student’s t-test

Student’s t Test is one of the most commonly used techniques for testing a hypothesis

on the basis of a difference between sample means. Explained in layman’s terms, the t

test determines a probability that two populations are the same with respect to the

variable tested.

The independent Samples t Test compares the means of two independent groups in

order to determine whether there is statistical evidence that the associated population

means are significantly different.The Independent Samples t Test is a parametric test.

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1.9 Scope, Implication and Expected Results of the study

The result of this study will improve the diagnostic and treatment planning steps of

orthodontic treatment in CLASS I ,II and III malocclusion. This study will provide

better insight in understanding the etiology of Class I ,II and III malocclusion and new

treatment modalities for these malocclusion can be obtained in light of this study. We

are expecting positive correlation between cranial base morphology and skeletal Class

I , II and III malocclusion.

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 References

1. Anderson D, Popovich F. Relation of cranial base flexure to cranial form and

mandibular position. Am J Phys Anthropol. 1983; 61:181–187.
2. Bacon W, Eiller V, Hildwein M, Dubois G. The cranial base in subjects with dental
and skeletal class II. Eur J Orthod. 1992;14: 224–228.
3. Baccetti T, Antonini A. Glenoid fossa position in different facial types: a
cephalometric study. Br J Orthod. 1997;24:55–59.
4. Bjork A. Cranial base development. Am J Orthod. 1955;41:198– 225.
5. Battagel JM. The aetiology of class III malocclusion examined by tensor analysis.
Br J Orthod. 1993;20:283–296.
6. Dhopatkar A, Bhatia S, Rock P. An investigation into the relationship between
cranial base angle and malocclusion. Angle Orthod 2002; 72(5): 456-63. (IVSL).
7. Gilmore WA. Morphology of the adult mandible in class II division 1 malocclusion
and in excellent occlusion. Angle Orthod. 1950;20:137–146
8. Guyer EC, Ellis EE, McNamara JA, Behrents RG. Components of class III
malocclusion in juveniles and adolescents. Angle Orthod. 1986;56:7–30
9. Hildwein M, Bacon W, Turlot JC, Kuntz M. Spécificités et discriminants majeurs
dans une population de Classe II division 1. Revue d’Orthopédie Dento-Faciale.
1986 June;20(2):197-208.
10. Huxley TH. Evidence As to Man’s Place in Nature. London: Williams and Norgate;
1863
11. Hopkin GB, Houston WJB, James GA. The cranial base as an etiological factor in
malocclusion. Angle Orthod. 1968;38:250– 255.
12. Kasai K, Moro T, Kanazawa E, Iwasawa T. Relationship between cranial base and
maxillofacial morphology. Eur J Orthod. 1995 Oct;17(5):403-10.
13. Kerr WJS.A method of superimposing lateral cephalometric films for the purpose
of comparison :a preliminary report.Br J Orthod 1978;59(1):51-3
14. Kerr WJS, Hirst D. Craniofacial characteristics of subjects with normal and post
normal occlusions—a longitudinal study. Am J Orthod Dentofac Orthop.
1987;92:207–212
15. Kerr WJS, Adams CP. Cranial base and jaw relationship. Am J Phys Anthropol.
1988;77:213–220.

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16. Kuroe K, Rosas A, Molleson T. Variation in the cranial base orientation and facial
skeleton in dry skulls sampled from three major populations. Eur J Orthod
2004;26(2):201-7.
17. Menezes DM. Comparison of craniofacial features of English children with Angle
class II division 1 and Angle class I occlusions. J Dent. 1974;2:250–254.
18. Renfroe EW.A study of the facial patterns associated with class I,class II division
1,class II division 2 malocclusions.Angle Orthod 1948;18:12-15.
19. Ricketts RM. A foundation for cephalometric communication. Am J Orthod. 1960
May;46(5):330-57.
20. Scott JH. The cranial base. Am J Phys Anthropol 1958; 16(3): 319-348
21. Scott JH. Dento-facial Development and Growth. Oxford: Pergamon Press; 1967.
22. Singh GD, McNamara JA, Lozanoff S. Finite element analysis of the cranial base
in subjects with class III malocclusion. Br J Orthod. 1997;24:103–112
23. Wilhelm BM, Beck FM, Lidral AC, Vig KW. A comparison of cranial base growth
in class I and class II skeletal patterns. Am J Orthod Dentofac Orthop.
2001;119:401–405.
24. Young M. A contribution to the study of the Scottish skull. Trans R Soc Edinb.
1916;51:347–453.

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 PERFORMA

Name :___________________________ Age:___________

Address:_______________________________________________

Type of malocclusion:__________________________

SR# VARIABLES NORMAL PT’s VALUE

1 SNA,SNB,ANB

2 Ar-Go

3 S-Go

4 N-Me

5 Jarabak ratio

6 N-S-Ar

7 N-S-Ba

8 SN-FH

9 SBa-Fh

10 S-N

11 S-Ba

12 N-Ba

13 S-Ar

14 The area N-S-I

15 The area S-I-J-Ar

16 The area S-Ar-J-Ba

17 The area S-Ar-J-Ba

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 Informed Consent Letter
The aim of the present study is to evaluate the ‘Cranial base morphology in skeletal
class I,II and III malocclusions’. We need participants to provide required potential
information for the research. You as a participant will be requested to provide lateral
cephalogram. As a participant you will have access to overall results at the end of the
study. There are no costs in participating in the study. Your participation is voluntary.

Researcher and supervisor (Researcher Name: Hadiqa Afzal, contact number

(03004562218), email address(hadiqaafzal855@gmail.com)on this study will keep all
of your responses confidential. If we will publish a research paper about the results of
this study, it will not contain any identifying material about you or other participants. I
will be pleased to answer any question you may have about the research at this time or
you may call or email me (Name:Hadiqa Afzal, contact number (03004562218), email
address ( hadiqaafzal855@gmail.com).
I have read the above information about the study and by signing below; I give my
voluntary consent to participate in the study.

Signature Date
__________________________ _____________________

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 CONSENT FORM

Department of dentistry
The Children’s Hospital and the Institute of Child Health, Lahore
Title of Research Project: Evaluation of cranial base morphology in
skeletal class I, II and III malocclusions.

I__________________________________ father/mother of
_______________________ hereby fully agrees to contribute to the above
mentioned study. My ID number is ___________________________________. I
understand that the study is designed to add to the medical knowledge. I have been
informed about the nature of procedure and possible risks / discomforts involved. I
had the opportunity to ask any question about the study and I agree to give my data
as requested by Ms. Hadiqa Afzal, the researcher. I have no objection in case the data
obtained from me is published in research profile maintaining confidentiality.

Signature/ Thumb Impression: _______________

NIC number: _____________________________

Date: ___________________________________

Contact no._______________________________

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