VIEWPOINT

Angle classification revisited 1: Is current

use reliable?
Morton I. Katz, DDS"
Washington,D.C.

The Angle method for the classification of malocclusion has been the standard in orthodontics for
100 years, but many academics and private practitioners find difficulty applying the Angle system to
malocclusions in between fully Class II and fully Class II1. To evaluate whether orthodontists are
consistent in classifying malocclusions accordings to Angle's method, study models were selected of
three patients with ideal buccal occlusions, two patients with mutilated occlusions, and five patients
with varying degrees of Class II tendency. One buccal view was photographed of each study model,
and a questionnaire was printed and sent to 347 orthodontists.The 77.8% response demonstrated
significant interest in the subject of dental classification and significant disagreement among
orthodontists in their classification response with all patients except the two obvious ideal occlusions.
Respondents were given the opportunity to comment on Angle classification and their
recommendations for improved classification techniques. Many of their comments are quoted. (AMJ
ORTHODDENTOFACORTHOP1992;102:173-9.)

I n the specialty of orthodontics, the classi-
fication of malocclusion plays several very important
roles. First, classification aids in the diagnosis and treat-
ment planning of malocclusions by orienting the cli-
nician to the type and the magnitude of the problems
and possible mechanical solutions to the problems. For
example, a malocclusion classified "Class II" would
call for Class II mechanics. However, what ifa clinician
incorrectly classified this patient "Class I"? The result
of an improper classification might be that the ortho-
dontist would embark on patient care oriented toward
solving the wrong problem. Second, classification fa-
cilitates communication between specialists, and in this
regard it is imperative that orthodontists all speak the
same language. Consistency is especially vital in dental
education, where the orthodontic student needs a uni-
formly applied congruent occlusion model, and clearly
defined parameters that can be applied toward classi-
fying a malocclusion.
Many orthodontists have developed classification
methods, and among them are Kingsley, ~ Angle, 24
Case, 5-7 Dewey, s Anderson, 9 Hellman, t~ Bennett, Iz
Simon, t3-t5 Ackerman and Proffit) 6 and Elsasser. 17
However, by far the most universally accepted classi-
fication in use today is Edward Angle's method, which
was developed a century ago.
In my private practice and postgraduate orthodontic
teaching, I have observed an inconsistency in the cur-
rent application of the Angle classification to maloc-
clusions that were not fully Class II or fully Class III.
These patients in the gray area of Class I, but possessing
some tendency toward Class II or Class III, seem to
elicit controversy. Are these observations of incon-
sistency merely anecdotal, or does a problem really
exist with contemporary application of the Angle
method? Other clinicians, such as Cryer, t8 Case, 57
Van Loon, t9 Hellman, ~~176 Johnson, 2t Simon, 13-t5
Friel, 22,23 Strang, 2~.25 Atkinson, 26 Massler, 27 Stoller, 28
Koski, :9 Ricketts, 3~Ackerman and Proffit, t6 Andrews, 3t
Arya, 32 Graber, 3335 and Roth, 3~3s have published cri-
tiques or have recommended revisions of the Angle
classification. There appears to be a strong lack of una-
nimity among orthodontists regarding the usefulness of
the Angle method. 39
Are orthodontic practitioners today able to consis-
tently classify malocclusions according to the Angle
method? Do orthodontists feel that a more precise clas-
sification system is needed? What should a new clas-
sification include? By answering these questions, I hope
to examine the concerns expressed about the Angle
classification over the 100 years in which it has been
the standard malocclusion classification, by testing cur-
rent practitioners and academics for the consistency of
their application of the Angle method.
METHODS AND MATERIALS

'Associate Professor, Postgraduate Clinical Director, Department of Ortho-

A questionnaire was developed, according to the tech-
dontics, Ho',vard University College of Dentistry. Washington, D.C. niques of Dillman '~ to provide a means of testing the consis-
8/1/29391 tency of orthodontists who classify malocclusions according
17;3
174 Katz
it
i"
Fig. 1. Model no. 1.
Fig. 2. Model no. 2.
to the Angle method. A variety of plaster models were se-
lected: three had ideal intermeshing (to act as controls), and
the remainder were Class II tendency, to varying degrees.
Among these, several mutilated occlusions were selected to
reflect the increasing number of adult patients being treated
in practice today and to determine if the frequently missing
first molars created a classification problem. Photographs
were taken of one buccal segment of the models selected
(Figs. 1 to 10). The photographs were included in a ques-
tionnaire, with a line under each photograph for the respon-
dents to write their classification preferences. It was believed
that allowing the freedom of response, more honest and per-
sonal classifications would be provided, even though check-
off boxes would have made collating the responses easier.
Several optional questions placed at the end of the question-
naire that allowed orthodontists additional comments in-
cluded: Did you find that these cases fit neatly into the Angle
classification? Do you feel that a more precise classification
system is needed in orthodontics? Why? Do you have any
recommendations regarding dental classification?
A sample of 347 orthodontists (representing approxi-
mately 5% of the active American Association of Orthodon-
tists (AAO) members residing in the United States) was se-
lected from the 1987 AAO directory of members by the fol-
lowing method. All retired members were eliminated, as were
Am. J. Orthod. Dent~ac. Orthop.
August 1992
Fig. 3. Model no. 3.
Fig. 4. Model no. 4.
all satellite offices. In this manner, only active members were
queried, and practitioners with one office had the same chance
of being selected as practitioners with several offices. Ortho-
dontists were selected from every state in the United States
in proportion to the number of orthodontists in that state. The
number of orthodontists per state was then "corrected" by
slightly reducing the most populous states' representation
while slightly increasing the percentage from the less popu-
lous states, so that the probability of all states responding
would be enhanced. By seeking responses throughout the
nation it was thought that the entire spectrum of orthodontic
educations would be represented and regional biases would
be reflected. The sample was also selected and grouped by
date of completion of orthodontic training to see if experience
altered the response. To that end, practitioners were selected
as follows: 88 graduated before 1969, 120 graduated 1970
through 1979, and 88 who graduated since 1980. An addi-
tional subgroup consisted of the chairpersons of orthodontic
departments of the 51 American dental schools, as they should
exemplify the classification concepts taught by dental edu-
cators.
The questionnaires were coded for the decade of ortho-
dontic education or chairperson designation. Only one mailing
was used, with no follow-up reminder letters, cards, or tele-
phone calls.
Volume 102 l',V;ew~o;nt
--" 175
Number 2

.e,..

J
Fig. 5. Model no. 5. Fig. 8. Model no. 8.

Fig. 6. Model no. 6. Fig. 9. M o d e l no. 9.

Fig. 7. Model no. 7. Fig. 10. Model no. 10.

RESULTS 1970 and 1979 (74%); 9and 74 of 88 orthodontists grad-

Of the 347 questionnaires sent, responses were r.e- uated since 1980 (84%).
ceived from 41 of the 51 American orthodontic chair- In the tabulation of the raw data (Table I), five
persons (80%); 66 of 88 orthodontists graduated before categories were used: Class I, Class II, Class III, Mis-
1969 (75%); 89 of 120 orthodontists graduated between cellaneous, and skipped. The first three categories are
176 Katz Am. J. Orthod.Dentofac.Orthop.
August 1992

Table I. Raw data

Respondent subgroups
Orthodontic chairpersons Graduate before 1969
Class Class

Modelno. 1 I!11111 Miscellaneous Skip Miscellaneous Skip

1 28 l0 3 41 12 13
2 17 19 2 3 17 35 1 13
3 30 10 I 40 17 9
4 9 27 5 8 40 18
5 16 21 4 22 32 II 1
6 22 16 2 1 32 23 10
7 40 1 61 2 3
8 41 63 2 1
9 7 29 4 I 6 52 8
l0 15 16 2 8 12 27 12 15
Total mailed 5I 88
Respondents 41 66
Response rate 80% 75%

Table II. Percent of incorrect classification responses

Responses
Class Class Class I disagreeing
Model no. ! 11 111 Total responses with consensus Percent incorrect

! [146] 87 4 237 91 38.4%

2 78 [1481 7 233 85 36.5
3 [186] I 59 246 60 24.4
4 31 [1881 219 31 14.1
5 74 [163] 1 238 75 31.5
6 !18 [1221 240 118 49.2
7 I253l i 7 261 8 3.1
8 [2591 7 266 7 2.6
9 15 [2281 243 15 6.2
I0 54 [140] 194 54 27.8

Highest response as "correct" in brackets.

self-explanatory, but 10% of the classifica.tion responses
did not fit these Angle classes. They were personal,
descriptive classifications, because many respondents
believed pure Angle classification could not be applied.
These efforts were grouped as miscellaneous. I.n some
instances, the respondent inadvertently skipped clas-
sifying one of the models, and this situation was tab-
ulated as skipped.
Only models no. 7 and no. 8, two of the three
examples of ideal occlusion, elicited over 90% classi-
fication agreement within all respondent subgroups.
Model no. 3, the other ideal buccal occlusion control,
showed less unanimity (in only the 75% range of agree-
ment) because 59 orthodontists labeled model no.-3 as
Class III! Unfortunately, high levels of disagreement
existed with the remaining Class II tendency models.
Models no. 1 and no. 6 elicited differing classification
consensus results among different respondent
subgroups, whereas the other five Class II tendency
models showed agreement among all respondent
subgroups as to which classification choice predomi-
nated. However, the degree of consensus varied widely
between the different orthodontist categories.
Among practitioners educated in the 1970s, 37 clas-
sified model no. 1 as a Class I, whereas 38 classified
the same model as a Class II. Within the chairperson
subgroup, 17 chairpersons called model no. 2 a Class
I, whereas 19 chairpersons designated the same model
Class II. Also, 15 chairpersons classified model no. 10
as a Class I, whereas 16 classified the same model as
Class II. In these three illustrations, the accuracy of
classification according to the Angle method by modem
orthodontists was roughly equivalent to a coin toss.
When all respondent subgroups were combined
Volume 102 V;ew,,o;nt 177
Number 2

Respondent subgroups

Graduated between 1970-1979 'after 1980

Miscellaneous Skip Miscellaneous Skip

37 38 3 10 40 27 ! 6
22 59 I 7 22 35 3 14
66 I 18 4 50 14 10
It 63 15 3 58 13
21 62 6 15 48 I 9
37 45 7 26 38 I0
82 I 3 3 70 2 2
88 I 67 4 3
2 83 4 64 9
15 50 6 18 12 47 I0
120 88
89 74
74% 84%

(Table II), the tendencies of the entire sample became
evident. However, before comparisons could be made,
it was necessary to determine the most frequent clas-
sification answer. The consensus winner, the class evok-
ing the largest response for each model, was designated
the "correct" classification. The percent incorrect (Table
II) demonstrated the degree of inconsistency of this
sample of orthodontists when applying the Angle clas-
sification to photographs of models of selected patients.
Models no. 6, no. 1, and no. 2 showed the most sig-
nificant disagreement between orthodontists as to the
proper Angle classification, with incorrect responses of
49.2%, 38.4%, and 36.5%, respectively.
Of the 224 orthodontists who responded to the op-
tional question, "Did you find that these cases fit neatly
into Angle's Classification?" only 34 practitioners
(15%) answered yes. The second optional question "Do
you feel that a more precise classification system is
needed in orthodontics?" received 141 yes answers of
the 205 responses, 68% of the orthodontists polled con-
sidered an improved classification system to be needed.
The last two optional questions could not be eval-
uated statistically because they were free discussion
questions. These responses will be summarized in the
DISCUSSION section.
DISCUSSION
There were 270 responses of the 347 questionnaires
sent, a 77.8% response rate. This response was high
for a single mailing survey with no follow-up mailings
to generate additional respondents, 4~ and illustrated a
strong interest in the subject of classification by the
orthodontists selected for the sample.
Model no. 10 was the most commonly skipped re-
sponse, and because of its solitary location on the back
of the questionnaire, represented a probable question-
naire design error. Respondents demonstrated a ten-
dency to skip no. 10 in their eagerness to answer the
optional questions printed below the model. No other
problems were encountered.
Respondents were prov!ded space to freely answer
"Why do you feel that a more precise classification
system is needed in orthodontics?" Many perceptive
comments were elicited.
Orthodontists mentioned the importance of: "Stan-
dardization for better communication." "We need quan-
tification." "Angle is too broad." "Angle is too limited,
just not specific and detailed enough." "Angle is a
wastebasket classification." "Very few cases fit neaily
into Angle's Classification." "We need more accuracy
for the in-between malocclusions." "Angle is too sub-
ject to individual interpretation, and is commonly con-
fused or misused." "Angle's definitions have changed
with usage, as do many words." "We are precise people
and the current system is not precise! .... This study is
an excellent illustration of the inadequacies of Angle's
Classification."
Angle's reliance on first molars for classification
evoked these responses: "Only a naive individual would
classify anteroposterior relationship by a single factor
such as the mesiobuccal cusp of one tooth on the buccal
groove of another." "What if molars are missing?" "Mo-
lars alone do not represent occlusion." "The molar is
misleading as the key to occlusion." "Molar and cuspid
position doesn't always c o i n c i d e . . , as when tooth
size discrepancies (Bolton), missing, crowded, or r o -
178 Katz
tated teeth are p r e s e n t . . , so one must extrapolate."
"Rotations of the first molars affect c l a s s i f i c a t i o n . . .
and so we need a lingual view to see if the molar is
rotated."
The last question, asking "Do you have any rec-
ommendations regarding dental classification?" resulted
in a wide range of answers. Quite a few orthodontists
considered the canine relation, or canine and premolar
occlusion as being more important than molar relation
for classification purposes. Many respondents wanted
skeletal evaluations, as well as vertical and transverse
considerations added to Angle's basically anteropos-
terior focus. But, others warned, "Keep it simple!"
Some merely wanted to supplement Angle. Since the
Angle method failed to indicate the severity of the mal-
occlusion, many practitioners suggested qualifying
words such as "tendency," "end-to-end" or "end on,"
"weak," "mild," or "super." Several orthodontists
warned about the task of revising classification meth-
ods. While improved classification is, "Much
n e e d e d . . , that, old, habits die slowly."
Is Angle classification truly at fault in this observed
inconsistency? Yes and no! Yes, because Angle made
Class I a range, rather than an ideal point. In 1900
Angle, 3 in the sixth edition of his book, made Class II
a full premolar width disto-occlusion and Class III a
full premolar width mesio-occlusion (resulting in a
Class I range of 14 mm). In the 1907, seventh edition
of his book, Angle 4 revised the definition of Class I
from a full premolar width in either direction to one
half of a cusp in either direction (reducing the range of
Class I to 7 mm). This refinement brought more mal-
occlusions into the Class II and III categories, but still
allowed too large a range for Class I to be considered
an "ideal" or treatment goal in a discipline aspiring to
precision. No, because it is quite probable that Angle
never intended Class I to be construed as a goal of
treatment. Many modern orthodontists have established
the achievement of Class I (rather than normal occlu-
sion) as the major criterion of a successful result, which
may be an inappropriate use of the Angle classification,
as he designed it.
Unfortunately, modern orthodontists rarely appear
to have read the original writings of Angle. Today
orthodontists are well acquainted with the mesiobuccal
cusp of the upper first molar fitting into the buccal
groove of the lower first molar concept, but may be
unaware of Angle's total classification and occlusion
commentary. Angle wrote at great length regarding the
requirements of an ideal, or normal occlusion, describ-
ing the detailed inclined plane and cusp~ contacts
of all teeth, not merely the first molars. Angle stipulated
that all teeth, except the lower central incisors and the
Am. J. Orthod. Dentofac. Orthop.
August 1992
upper third molars, must contact two antagonists in the
normal occlusion. 3"4 Over time, and through common
usage, the rich detail of Angle's descriptive occlusion
has been discarded, and current dentists and orthodon-
tists have been merely using Angle's bones while de-
crying his lack of meat. However, Angle's depiction of
an ideal occlusion is as appropriate today as it was a
century ago.
This survey was done with models in maximum
intercuspation, in conformance with routine orthodontic
practice and tradition. Orthodontists today, however,
consider maximum intercuspation to be valid as a ref-
erence only when the occlusion is coincident with an
unstrained musculature and with mandibular condyles
which are properly seated.
It is also important to note that Edward Angle did
not have the benefit of roentgenography and the plethora
of sophisticated cephalometric x-ray analyses modern
orthodontists have at their disposal. This sampling of
orthodontic opinion about classification would have
been greatly enhanced by including, with each photo-
graph of a study cast, a reproduction of each patient's
cephalometric x-ray film, to give the respondents ad-
ditional clues to help formulate a dental and skeletal
classification. Since x-ray films have a wide tonal
range, reproduction of these films often loses detail in
critical landmark areas. Possibly, tracings of the x-ray
films, rather than the films themselves, could be used
in future classification efforts.
CONCLUSION
The results of this study illustrated the concerns
many practitioners have that the current application of
Angle's system to specific malocclusions was incon-
sistent. This study indicated that further thought should
be given to improving classification methods. While it
is axiomatic that, "If it ain't broke, don't fix it," tra-
dition notwithstanding, it may be time, after a century
of yeoman's service, to modify the Angle classification
of malocclusion to make it appropriate for current
usage.
REFERENCES
1. HorowitzSL, Hixon EH. The nature of orthodontic diagnosis.
St. Louis: CV Mosby, 1966:325-43.
2. Angle EH. Classification of malocclusion. Dent Cosmos
1899;4h248-64, 350-7.
3. Angle EH. Treatmentof malocclusionof the teeth and fractures
of the maxillae. Angle system. 6th ed. Philadelphia: S.S. White
Manufacturing, 1900:6-8.37-44.
4. Angle EH. Treatmentof malocclusionof the teeth and fractures
of the maxillae. Angle system. 7th ed. Philadelphia: S.S. White
Manufacturing, 1907:44-59.
5. Case CS. The teaching of orthopedic dentistry. Dent Items In-
terest 1904;26:481-500.
Volume 102
Number 2
6. Case CS. Principles of occlusion and dentofacial relations. Dent
Items Interest 1905;27:489-527.
7. Case CS. Technics and principles of dental orthopedia. Chicago:
CS Case 1921:15-20.
8. Dewey M. Classification of malocclusion. I,',rr J OR'rHOD
1915;i:133-47.
9. Anderson GM. Practical orthodontics. 9th ed. St. Louis: CV
Mosby, 1960:144-50.
10. Hellman M. An interpretation of Angle's classification of mal-
occlusion of the teeth supported by evidence from comparative
anatomy and evolution. Dent Cosmos 1920;62:476-95.
! I. llellman M. Variation in occlusion. Dent Cosmos 1921;63:608-
19.
12. Bennett NG. Report of the committee on orthodontic classifi-
cation. Oral Health 1912;2:321-7.
13. Simon PW. On gnathostatic diagnosis in orthodontics. It,n" J
Ogntoo 1924;10:755-8.
14. Simon PW. The simplified gnathostatic method. I,'r J OR'roOD
1932;I 8:1081-7.
15. Gresham H. A manual of orthodontics. Christchurch, New Zea-
land: N.M. Peryer, 1957:83-6.
16. Ackerman JL, Proffit WR. The characteristics of malocclusion:
a modem approach to classification and diagnosis. AM J ORrrtOO
1969;56:443-54.
17. Elsasser WA. Orthodontic assessment by the numbers. J Clin
Orthod 1978;12:116-22.
18. Cryer MH. Typical and atypical occlusion of the teeth in relation
to the correction of irregularities. Dent Cosmos 1904;46:713-33.
19. Van Loon JAW. A new method for indicating normal and ab-
normal relations of the teeth to the facial lines. Dent Cosmos
1915;57:973-83, 1093-101, 1229-35.
20. Hellman M. Some facial features and their orthodontic impli-
cations. AM J ORT/IOD 1939;25:927-51.
21. JohnsonAL. Basic principles oforthodontia. DentCosmos 1923;
65:379-89, 503-18, 596-605,719-32, 845-61,957-68.
22. Friel S. Occlusion. Observations on its development from in-
fancy to old age. I,'r J OR'mOP 1927;13:322-34.
23. Friel S. Changes in occlusion of the teeth of diagnostic impor-
tance in orthodontics. Dent Record 1938;58(5):233-49.
24. Strang RHW. A discussion of the Angle classification and its
important bearing on treatment. Angle Orthod 1938;8:182-208.
--o /" * ,
"lZ;ewno;tl 179
25. Strang RttW. A text-book of orthodontia. 3rd ed., Philadelphia:
Lea & Febiger, 1950:107-34.
26. Atkinson SR. Orthodontics as a life factor. AM J ORTttOD ORAL
SURG 1939;25:1133-42.
27. Massler M, Frankel J. Prevalence of malocclusion in children
aged 14 to 18 years. A.~t J ORTHOO ORAL Sting 1951;37:751-
68.
28. Stoller AE. The normal position of the maxillary first permanent
molar. A.',i J OR'ntOD 1954;40:259-71.
29. Koski K. The norm concept in dental orthopedics. Angle Orthod
1955;25:113-7.
30. Ricketts RM, Roth RH, Chaconas SJ, Schulhof RJ, Engel GA.
Orthodontic diagnosis and planning. Vol. 1. Denver: Rocky
Mountain/Orthodontics, 1982:127.
31. Andrews LF. Six keys to normal occlusion. AM J ORTHOD
1972;62:296-309.
32. Arya BS, Sarava BS, Thomas DR. Prediction of the first molar
occlusion. AM J OR'ntOD 1973;63:610-21.
33. Graber TM, Swain BF. Current orthodontic concepts and tech-
niques. 2nd ed. Philadelphia: WB Saunders, 1975:38.
34. Graber TM. Orthodontics principles and practice. 3rd ed. Phil-
adelphia: WB Saunders, 1972:180-202.
35. Graber TM. The fundamentals of occlusion. J Am Dent Assoo
1954;48:177-87.
36. Roth RH. The maintenance system and occlusal dynamics. Dent
Clin North Am 1976;20:761-88.
37. Roth RH. Functional occlusion for the orthodontist. J Clin
Orthod 1981;15:32-51.
38. Roth Rtl. A functional occlusion approach to orthodontics.
Georgetown Orthodontic Alumni Association, Washington,
D.C., June 26, 1987.
39. Katz MI, Sinkford JC, Sanders CF. The hundred year dilemma:
what is a normal occlusion, and how is malocclusion classified?
Quintessence lnt 1990;21:407-14.
40. Dillman D. Mail and telephone surveys. The total design
method. New York: John Wiley, 1978:1-285.
R e p r i n t r e q u e s t s to:
Dr. Morton I. Katz
3435 Philips Dr.
Baltimore, M D 21208