British Journal of Orthodontics

ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19

A Modification to the Incisor Classification of

Malocclusion

A. C. Williams B.D.S., F.D.S., M.C.D.H., D.D.P.H. & C. D. Stephens M.D.S., B.D.S.,

F.D.S., M.Orth.

To cite this article: A. C. Williams B.D.S., F.D.S., M.C.D.H., D.D.P.H. & C. D. Stephens M.D.S.,
B.D.S., F.D.S., M.Orth. (1992) A Modification to the Incisor Classification of Malocclusion, British
Journal of Orthodontics, 19:2, 127-130, DOI: 10.1179/bjo.19.2.127

To link to this article: http://dx.doi.org/10.1179/bjo.19.2.127

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 British Journal of0rthodonticsfVo//9f/991/117-IJO

A Modification to the Incisor

Classification of Malocclusion
A. C. WILLIAMS, B.D.S., F.D.S., M.C.D.H., D.D.P.H.
Department of Dental Public Health, United Bristol Healthcare NHS Trust, 10 Marlborough Street, Bristol BSI 3NP
C. D. STEPHENS, M.D.S., B.D.S., F.D.S., M.ORTH.
Department of Child Dental Health, University of Bristol Dental School, Lower Maudlin Street, Bristol BSI 2LY
Received for publication April 1991

Abstract. During the study of two-hundred orthodontic cases under treatment in the General Dental Service,
four clinicians showed only moderate agreement using the British Standard Classification of Incisor
Ma/occlusion. Cohen's Kappa statistic was used to measure the inter-examiner agreement. The 35 cases in
which there was high disagreement between the examiners were scrutinized to determine the source of this
disagreement. Following discussion, revised definitions were produced which included the introduction of a
Class [[-intermediate group. After an interval of 2 months these 35 cases were reclassified using the new
definitions. Increased inter-examiner agreement was found. Four examiners (three of whom were common to
the original study) then used the modified classification to describe the incisal relationship of lOO cases referred
for treatment at Bristol Dental Hospital. The inter-examiner and the intra-examiner agreement were both
found to be good. It is recommended that the Incisor Classification of M a/occlusion be extended to include a
Class !!-intermediate group.
Index words: Classification of Malocclusion, Reproducibility, Reliability.

Introduction cingulum plateau of the upper incisors.

The incisor classification of malocclusion has
enjoyed wide acceptance since its introduction by
Ballard and Wayman in 1964 and has now super-
ceded Angle's classification in the United Kingdom.
Based on the work ofBacklund (1963) it now forms
the basis of the British Standard Classification of
Malocclusion (BS4492 1982). This states that for an
incisor relationship to be classified as:
Class I: the lower incisor edges preclude with or
lie immediately below the cingulum pla-
teau (middle part of the palatal surface)
of the upper central incisors.
Class II: the lower edges lie posterior to the
cingulum plateau of the upper incisors.
There are two divisions:
division )-there is an increase in over-
jet and the upper central incisors are
usually proclined;
division 2-the upper central incisors
are retroclined. The overjet is usually
minimal, but may be increased.
Class Ill: the lower incisor edges lie anterior to the
030I-228X/92i002000 + 102.00
The overjet is reduced or reversed.
The classification is mainly used to describe the
incisal relationship of cases in verbal and written
communications between clinicians. In 1977 the
WHO recommended that 'there is a need for
consistent standardized diagnosis of dental condi-
tions in surveys of the oral health of populations'.
In 1974 Jago questioned the validity and reliabi-
lity of Angle's classification for epidemiological
studies but emphasized that the classification was
devised as a 'prescription for treatment and not as
an epidemiological tool'. Gravely and Johnson
(1974) tested the reliability of Angle's classification
of malocclusion and found it to be low.
Brown (1967) compared the classification of 20
sets of study models made by five clinicians using
the Angle classification applied to the incisors alone
without regard to the molar occlusion. In only one-
third of cases could the examiners agree on the
classification of Class I cases and none of the
examiners agreed on the classification of Class 11
division 2 relationships.
The aim of the present study was to measure
© 1992 British Society for the Study ofOnhodontics
128 A. C. Williams and C. D. Stephens BJO Vol. 19 No. 2

the reproducibility of the British Standard Incisor TABLE 2 Kappa values for four observers
Classification of Malocc/usion and to introduce using the B.S.I. classification of incisor maloc-
clusion for 200 models
modifications to improve its reliability.
Observer
Materials and Methods B c D
Four experienced clinicians were asked to classify
Observer
independently the incisor relationship of 200 sets of 0·61 0·57 0·64
A
study models chosen at random from those pro- B 0·68 0·61
vided by the Dental Practice Board as part of c 0·53
another study (Shaw et al., 1991). Cohen's Kappa
statistic (Cohen, 1960) was used to measure the Mcan=0·61.
inter-examiner agreement which was classified
according to Land is and Koch ( 1977) (Table 1). The TABLE 3 Incisor cla.!sification of the 35 cases in which fewer than
thirty-five cases in which less than three examiners three examiners agreed
agreed were scrutinized to find the source of the
Number of cases
disagreement. After an interval of several months, Alternatives classified as Class I
these 35 cases were re-examined by the same
examiners using a modified classification. Class Ill 20
As an overall measure of the reliability of the Class 11 I 6
modified classification, the classification was Class 11 2 4
Clss Ill or 11 2 (by different examiners) 5
applied to lOO sets of good quality study models of
patients under treatment at Bristol Dental Hospital Total 35
representing the full range of malocclusion. The
models were examined by four experienced clini-
cians, three of whom were common to the original Confusion also existed as to whether cases in which
study. The same clinicians reclassified the models two incisors were in Class I occlusion and two were
after an interval of 2 weeks to give a measure of the in Class Ill occlusion should be classified as Class I
intra-examiner reliability of the modified classifica- or Class Ill.
tion of incisor relationship. There was disagreement as to whether upright
incisors with an increased overjet should be classi-
fied as Class 11 division 1 or Class 11 division 2 and
Results this was resolved by the introduction of a 'Class 11-
Table 2 shows that agreement between the exa- intermediate category'. This was defined as a maloc-
miners using the British Standard Classification of clusion in which 'The lower incisor edges lie pos-
Incisor Ma/occ/usion to classify 200 sets of study terior to the cingulum plateau of the upper central
models varied from moderate to substantial. incisors. The upper incisors are upright or slightly
Less than three examiners agreed on the classifi- retroclined and the overjet lies between 5 and 7 mm.'
cation of 35 sets of study models in the group. Most When the same examiners used the modified
of the disagreement related to border-line Class I classification to classify the 35 models in which
and Class 11 cases (Table 3) and appeared to arise agreement had previously been slight (Table 4) an
fcom a failure to appreciate that it was the cingulum improved agreement was found (Table 4).
plateau rather than the middle third of the visible The intra-examiner agreement was substantial
palatal surface of the maxillary central incisor when reclassifying the whole sample of lOO models
which is the crucial aspect of the classification. (Table 4).

Discussion
TABLE I Interpretation of kappa values
Classifications are made of biological variation in
Agreement Kappa value order to facilitate communication between clini-
Poor <0·00 cians and as a basis for diagnosis. For a classifica-
Slight 0·00-0·20 tion to be of value it should be simple, objective,
Fair 0·21-0·40 appropriate, reproducible, and reliable. The reliabi-
Moderate 0·41-0·60 lity and reproducibility of the British Standard
Substantial 0·61·0·80
Almost perfect >0·80
Classification has not been tested before despite its
widespread use in clinical practice.
BJO May 1992
TABLE 4 (a) Kappa mlues for four observers
using the British Standard classification ofincisor
malocclusion for 35 models showing poorest
agreement
Observer
B c D (division I and division 2) which are made on the
Observer
A 0·12 0·19 0·34
B 0·32 0·001
c 0·0015
Mean=0·16.
(b) Kappa 1•alues for jimr observer~· using the
modified classification o.fincisor malocclusionfor
35 models
Observer
B c D 'fit' into the existing classification. The Class II-
Observer
A 0·58 0·60 0·28
B 0·74 0-41
c 0·35
Mean=0-49.
(c) Kapptl mlues for ill/er-examiner agreement
betwt•enfour examiners using the modified classi-
fication o.f incisor malocclusion for lOO models
Observer
B c D unclassifiablc', 'normal occlusion', and 'Class II-
Observer
A 0·74 0·75 0·64
B 0·82 0·68
c 0·69
Mean=0·72
The low inter-examiner agreement between exa-
miners using the classification was found by chance
during part of another study. Most of the cases in
which there was disagreement between examiners
were due to a failure to follow the literal interpreta-
tion of the classification accurately. This is partly
due to complacency by experienced clinicians, but
also due to the subjective descriptions used in the
BSI classification. For example, Class II division l
cases are described as those in which the incisors are
'usually' proclined. Once the problem of inaccurate
interpretation of the classification had been
addressed there remained a small but significant
group of cases over which the examiners could not
agree on a classification.
The classifications used in orthodontic cases are
based on the morphology of occlusal relationships
Modification of Incisor Classification of Malocclusion 129
and have no pathological basis to them. Because
malocclusion is an expression of biological varia-
tion, any classification is subject to the problems
associated with the morphological variation of the
teeth and the relationship of the dental bases. This is
particularly true of the Class II sub-classifications
basis of overjet and upper incisor angulation. There
is a tendency to classify any case with an increased
overjet as Class II division I when it is quite possible
to have a Class II division 2 malocclusion where,
although the upper incisors are retroclined, the
overjet is still increased.
The modified classification of incisor malocclu-
sion used in this study introduces a 'Class II-
intermediate' group to overcome this problem
which has specific criteria with specific treatment
implications and is not merely a group that does not
intermediate classification embraces some of those
cases identified as having upright incisors, but an
increased overjet where fixed appliances are
required in order to bodily retract the upper labial
segment. The classification of such cases as Class IJ
division I could lead to inappropriate treatment
being used particularly by the inexperienced opera-
tor.
Gravely and Johnson ( 1974), measured the relia-
bility of Angle's classification of malocclusion
which also included groups for 'malocclusion
unccrtain'. Even with the introduction of such
groups, which must add doubt to the value of the
classification, the inter-examiner agreement was
low. The Class 11-uncertain group was defined as
'one in which doubt existed as to whether the case
was Class 11 division I or Class 11 division 2'. The
proposed Class II-intermediate group is similar to
the 'Class 11-uncertain' classification, but unlike the
latter there are specific criteria for the former.
Gravely and Johnson repeated the reproducibi-
lity measurement but examiners were asked to place
cases that would previously have been classified as
Class'II-uncertain in the Class 11 division I group.
An improved inter-examiner agreement was found,
but it was still sufficiently low for them to conclude
that the 'classification of malocclusions according
to Angle's system cannot be carried out with a high
level of reliability'. The high degree of inter- and
intra-examiner agreement found in the present
study suggests that the introduction of a specific
Class II intermediate group can improve the reliabi-
lity and the reproducibility of the incisor classifica-
tion ofmalocclusion in a way which also highlights
treatment possibilities.
Modification of the incisor classification of
130 A. C. Williams and C. D. Stephens
malocclusion resulted in an increase in inter-exa-
miner reliability in the classification of study models
in the present study. The kappa values obtained in
this study compare well with those found in other
studies (Brook and Shaw, 1989), and show that the
inter- and the intra-examiner agreement using the
modified incisor classification is high enough to
justify its consideration for epidemiological studies.
Conclusions
The British Standard Classification of Incisor
Ma/occ/usion in its present form has a wide margin
of disagreement between examiners and is no
indication of treatment needs. It is recommended
that the classification be extended to include a Class
11 intermediate group.
Acknowledgements
The authors wish to express their gratitude to all the
clinicians who gave of their valuable time to classify
the sets of study models.
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