ORIGINAL ARTICLE

Curve of Spee and its relationship to vertical

eruption of teeth among different malocclusion
groups
Ilknur Veli,a Mehmet Ali Ozturk,b and Tancan Uysalc
Izmir, Turkey

Introduction: Our objectives were to assess the depth of the curve of Spee (COS) in different malocclusion
groups, to relate this to the eruption of anterior or posterior teeth quantitatively, and to determine whether the
depth of the COS is affected by the vertical eruption of anterior or posterior teeth. Methods: Two hundred conventional lateral cephalograms and 3-dimensional models of untreated patients (70 boys, mean age:
16.4 6 1.4 years; 130 young women, mean age: 18.1 6 1.8 years) were included and assigned to 4
malocclusion groups as Class I, Class II Division 1, Class II Division 2, and Class III. The depth of the COS,
overjet, and overbite were measured on 3-dimensional models. The perpendicular distance between the
incisal tip of the mandibular central incisor (L1-MP), the deepest point of the COS (S-MP), and the
distobuccal cusp tip of the mandibular second molar (L7-MP) to the mandibular plane were calculated and
proportioned with each other. The Pearson correlation coefcient was calculated, and multiple linear
regression analysis was carried out. Also, multivariate analysis of variance was performed at the P \0.05
level. Results: The mesiobuccal cusp of the rst molar was the deepest part of the COS in all groups, with a
maximum depth of 2.44 6 0.73 mm in the Class II Division 1 subjects and a minimum depth of 1.76 6 0.94 in
the Class III subjects. The depth of the COS changed as follows: Class II Division 1 . Class II Division
2 . Class I . Class III malocclusion groups. Statistically signicant positive correlations were found between
the depth of the COS and L1-MP/S-MP (r 5 0.541) and L7-MP/S-MP (r 5 0.269) in the Class I and Class III subjects, and between the depth of the COS and overjet (r 5 0.483) and L7-MP/S-MP (r 5 0.289) in the Class II
Division 1 subjects. All variables except overjet had positive correlations with the depth of the COS in Class II
Division 2 subjects. The multivariate analysis of variance showed statistically signicant differences in overjet,
overbite, L1-MP/S-MP, L7-MP/S-MP, and the depth of the COS (P \0.001) among the groups.
Conclusions: Although the overjet differed, vertical eruption of the anterior teeth did not differ among the
different malocclusion groups and had a signicant contribution to the depth of the COS in subjects with Class
I and Class III malocclusions. (Am J Orthod Dentofacial Orthop 2015;147:305-12)

he curve of Spee (COS) is a naturally occurring

phenomenon in the human dentition; this curve
of occlusion was rst described as the line on a cylinder tangent to the anterior border of the condyle, the

From the Department of Orthodontics, Faculty of Dentistry, Izmir Katip Celebi

University, Izmir, Turkey.
a
Assistant professor.
b
Research assistant.
c
Professor and chair.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Tancan Uysal, Izmir Katip Celebi Universitesi Dis
Hekimligi Fakultesi, Ortodonti A.D. Cigli, Izmir 35640, Turkey; e-mail, tancan.
uysal@ikc.edu.tr.
Submitted, May 2014; revised and accepted, October 2014.
0889-5406/$36.00
Copyright 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.10.031

occlusal surface of the second molar, and the incisal

edges of the mandibular incisors.1
The developmental and functional signicances of
the COS have been investigated by several researchers.1
A combination of factors, including growth of orofacial
structures, development of the neuromuscular system,
and eruption of teeth, was suggested for development
of the COS.2
On average, eruption of the mandibular permanent
rst molars precedes that of the maxillary permanent
rst molars by 1 to 2 months, and eruption of the
mandibular permanent central incisors precedes that of
the maxillary permanent central incisors by 12 months.2
Moreover, the mean age for the eruption of the mandibular second molars is 6 months before the maxillary second molars.3,4 This differential timing could permit
unopposed mandibular permanent rst molar and
305

Veli, Ozturk, and Uysal

306

incisor eruptions beyond the established mandibular

occlusal plane. On the other hand, Andrews5 mentioned
a natural tendency for deepening of the COS with aging.
With the growth of the mandible beyond that of the
maxilla, the mandibular incisors are restricted by the
maxillary incisors and forced to move backward and upward, and this causes deepening of the bite and the COS
at the same time. Hemley6 described the COS as mesial
tipping of the mandibular molar and distal tipping of
the mandibular canine with the 2 premolars locked
below the line of occlusion. He indicated that these conditions create an exaggerated COS; by distally uprighting
the molar and mesially uprighting the canine, the 2 premolars will be free to erupt into the line of occlusion.
Strang and Thompson7 described a deep COS as a result
of elevated anterior teeth, depressed premolars, and
mesially inclined molars.
Spee et al1 recommended that the COS should be
taken into account for the construction of dentures to
provide better mastication and prevent a lever effect during function. However, orthodontics differs from reconstructive dentistry regarding the clinical signicance of
the COS.8 Andrews5 described the 6 keys of occlusion
and found that the COS ranged from at to mild in subjects with proper occlusion, remarking that the best static
intercuspation occurred when the occlusal plane was relatively at. He also stated that leveling and attening of
the COS should be the goal of treatment. In a previous
study, increases in the crush-shear ratio of the posterior
teeth and the efciency of the occlusal forces during
mastication were determined to be resulting factors of
the biomechanical function of the COS.9
It has been reported that an excessive COS is associated with deepbite malocclusions.10 Burstone10 stated
that the treatment of deepbite might involve intrusion
of maxillary anterior teeth, intrusion of mandibular
anterior teeth, extrusion of maxillary and mandibular
posterior teeth, or any such combination. However,
Schudy11 advocated that a deepbite and a deep COS
should be corrected by extrusion of the molars because
intrusion of anterior teeth has a high potential for
relapse. Since there is no consensus on this issue, developmental characteristics of the COS need to be evaluated
in terms of differential vertical eruption on anterior or
posterior teeth. Therefore, the purposes of this study
were to determine the depth of the COS in different
malocclusion types and to investigate the relationship
of the depth of the COS with the vertical eruption of
anterior and posterior teeth, aiming to contribute to
the knowledge about the development of the COS. The
null hypotheses tested were the following: (1) there is
no difference in the depth of the COS among different
malocclusions, (2) vertical eruption of anterior or

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Table I. Age and sex distribution of the groups

Male

Class I
Class II, Division 1
Class II, Division 2
Class III
Total

n
15
17
18
17
67

Age (y)
16.4 6 1.2
16.6 6 1.6
16.0 6 1.6
16.6 6 1.2
16.4 6 1.4

Female
n
35
33
32
33
133

Age (y)
18.2 6 2.4
18.9 6 1
17.8 6 1.3
17.7 6 2.7
18.1 6 1.8

posterior teeth has no effect on the depth of the COS,

and (3) the effects of vertical eruption of anterior or posterior teeth on the depth of the COS do not differ among
Class I, Class II Division 1, Class II Division 2, and Class III
malocclusions.
MATERIAL AND METHODS

This study was designed as a retrospective archive

study and was carried out after institutional approval
for the inclusion of human material obtained from Izmir
Katip Celebi University in Turkey. No ethical approval
was sought because of the retrospective characteristics
of the study design. As routine procedures, digital
models and radiographs including lateral cephalograms
are obtained from all patients seeking orthodontic treatment, and the patients or their parents sign an informed
consent form before the orthodontic treatment or x-ray
exposure. Therefore, the patients were not unnecessarily
subjected to additional radiation or any other procedures.
The records of 1378 patients who had orthodontic
treatment in the Department of Orthodontics at our
university between May 2012 and March 2014 were reviewed. Pretreatment conventional lateral cephalograms
and digital models of 200 patients (67 male, mean age:
16.4 6 1.4 years; 133 female, mean age:
18.1 6 1.8 years) were selected and divided into 4 equal
groups according to dental malocclusion type: Class I
(15 male, mean age: 16.4 6 1.2 years; 35 female,
mean age: 18.2 6 2.4 years), Class II Division 1 (17
male, mean age: 16.6 6 1.6 years; 33 female, mean
age: 18.9 6 1 years), Class II Division 2 (18 male,
mean age: 16.0 6 1.6 years; 32 female, mean age:
17.8 6 1.3 years), and Class III (17 male, mean age:
16.6 6 1.2 years; 33 female, mean age:
17.7 6 2.7 years) (Table I). Subjects with a Class I malocclusion had Class I canine and molar relationships. Subjects in the Class II Division 1 and Class II Division 2
malocclusion groups had bilateral Class II molar relationships in centric occlusion with the distobuccal cusp
tip of the maxillary rst molar within 1 mm (anterior
or posterior) from the buccal groove of the mandibular

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Veli, Ozturk, and Uysal

rst molar and Class II permanent canine relationships

with 2 or more proclined or retroclined maxillary incisors, respectively. Subjects in the Class III malocclusion
group had bilateral Class III molar relationships in centric
occlusion with the cusp tip of the maxillary second premolar within the range of 1 mm (anterior or posterior)
from the buccal groove of the mandibular rst molar
and Class III permanent canine relationships with excessive negative overjet. All patients fullled the following
inclusion criteria: (1) dental crowding or spacing less
than 2 mm with well-aligned maxillary and mandibular
dental arches, (2) all teeth present except the third molars, (3) no signicant medical history, (4) no history of
trauma or facial asymmetry, and (5) no previous orthodontic or prosthodontic treatment, or maxillofacial or
plastic surgery.
All plaster models were transformed into digital
format by a 3-dimensional (3D) model laser scanner
(D250 3D dental scanner; 3Shape A/S, Copenhagen,
Denmark), and the digital models were analyzed by 1
investigator (M.A.O.) using 3Shape Orthoanalyzer software (version 1.0; 3Shape A/S). The depth of the COS
was measured as follows.
A horizontal reference plane comprising a line between the central incisors and the distobuccal cusp
tips of the mandibular second molars was constructed
using the grids available on the software. The perpendicular distances from the buccal cusp tips of the involved
teeth to the constructed line through the horizontal
reference plane were evaluated, and the deepest points
of the COS were calculated for the right and left sides
(Figs 1 and 2). The depth was dened as the average
of both sides.
Overjet was measured as the distance (in millimeters)
along a horizontal plane between the incisal edge of the
labial surface of the mandibular central incisor and the
incisal edge of the labial surface of the most labially
positioned maxillary central incisor, and overbite was
measured as the vertical distance (in millimeters) between the incisal edge of the maxillary central incisor
and the incisal edge of the mandibular central incisor using the software.
All conventional lateral cephalograms were taken
from the right side with the orthopantomography
x-ray device (OP100; Instrumentarium, Tuusula,
Finland) in maximal intercuspal position. The measurements were made on Dolphin Imaging software (Dolphin
Imaging & Management Solutions, Chatsworth, Calif) by
1 examiner (M.A.O.). In case of double images, the 2 relevant points were joined by an intersecting line, and the
midpoint was considered as the reference point. The
following reference points and planes were used
(Fig 3): L1, the incisal tip of the mandibular central

307

Fig 1. Perpendicular distances from each buccal cusp tip

on the left side.

Fig 2. Perpendicular distances from each buccal cusp tip

on the right side.

Fig 3. Measurements used in this study.

incisor; L7, the distobuccal cusp tip of the mandibular

permanent second molar; mandibular plane (MP), the
line between gonion and gnathion; L1-MP, the perpendicular distance from the tip of L1 to the mandibular

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308

plane; L7-MP, the perpendicular distance from the distobuccal cusp tip of L7 to the mandibular plane; and
S-MP, the perpendicular distance from the deepest point
of the COS to the mandibular plane. Overjet, overbite,
L1-MP/S-MP, and L7-MP/S-MP were evaluated for
each patient.
The errors of the method were calculated from 20
randomly selected lateral cephalogram and digital
models by means of Dahlberg's formula,12 and intraexaminer reliability was quantied using the intraclass correlation coefcient.
Statistical analysis

The Kolmogorov-Smirnov test of normality showed

that all 5 response variables satised the normal distribution assumption for at least 3 of the 4 groups. However, the multivarate analysis of variance (MANOVA)
analysis yielded a Box's test statistic, implying that the
observed variance-covariance matrices of the outcome
variables were not equal across the groups; this was
also veried by the Levene univariate test for homogeneity of group variances, which indicated signicant results
for the response variables.
The paired sample t test was used for side comparisons, and Pearson correlation coefcients were calculated
to determine the linear associations among overjet, overbite, L1-MP/S-MP and L7-MP/S-MP ratios, and depth of
the COS. To asses the contribution of individual variables
to the depth of COS, linear multiple regression analysis
with the enter method was carried out.
A MANOVA test was performed to compare the 4
groups on 5 response variables: overjet, overbite, L1MP/S-MP ratio, L7-MP/S-MP ratio, and depth of the
COS. After obtaining a signicant multivariate test,
follow-up tests were done: eg, univariate tests and Bonferroni corrected pair-wise comparisons. All statistical
analyses were performed using the Statistical Package
for the Social Sciences software package (SPSS for Windows, version 20.0; IBM, Armonk, NY), and the nominal
alpha level was set at 0.05 for signicance.
RESULTS

The errors for the linear measurements varied

between 0.4 and 0.6 mm, and a high degree of intraexaminer reliability was noted for all variables (intraclass
correlation coefcient, 0.936-0.989).
The means, standard deviations, and minimum and
maximum values of the average perpendicular distances
for all groups are presented in Table II. The mesiobuccal
cusp of the rst molar was the deepest part of the COS in
all groups, with a maximum depth of 2.44 6 0.73 mm in
Class II Division 1 subjects and a minimum depth of

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Table II. Average perpendicular distances (mm)

measured on 3D digital models
Tooth
Group
L2
Class I
Class II
Division 1
Class II
Division 2
Class III
L3
Class I
Class II
Division 1
Class II
Division 2
Class III
L4
Class I
Class II
Division 1
Class II
Division 2
Class III
L5
Class I
Class II
Division 1
Class II
Division 2
Class III
L6
Class I
Class II
Division 1
Class II
Division 2
Class III

n
50
50

Mean
SD Minimum Maximum
0.086 0.338 0.715
0.910
0.223 0.396 0.695
1.785

50 0.023 0.281

0.985

0.635

50
50
50

0.049 0.237
0.248 0.695
0.577 0.986

0.835
1.230
1.550

0.820
2.005
3.760

50

0.253 0.655

1.820

1.555

50
50
50

0.162 0.708
0.955 0.678
1.846 0.862

1.735
0.960
0.530

1.820
2.705
4.610

50

1.637 0.787

0.000

4.110

50
50
50

1.050 1.021
1.561 0.667
2.311 0.766

1.715
0.565
1.125

3.065
3.130
4.710

50

2.312 0.855

0.525

4.660

50
50
50

1.507 1.044
1.942 0.679
2.459 0.738

0.450
0.940
0.870

3.645
4.065
4.705

50

2.394 0.834

0.315

4.585

50

1.767 0.949

0.070

3.945

L, Mandibular; 2, lateral incisor; 3, canine; 4, rst premolar; 5, second premolar; 6, rst molar; SD, standard deviation.

1.76 6 0.94 in Class III subjects. The depth of the COS

changed as follows: Class II Division 1 . Class II Division
2 . Class I . Class III malocclusion groups.
The results of the paired sample t test showed no signicant differences in the depth of the COS between the
right and left sides for all groups (Table III).
The Pearson correlation coefcient was calculated
between overjet, overbite, L1-MP/S-MP, L7-MP/S-MP,
and depth of the COS (Table IV). The results indicated
statistically signicant positive correlations between
depth of the COS and L1-MP/S-MP (r 5 0.541) and
L7-MP/S-MP (r 5 0.269) in Class I and Class III malocclusion groups. Also, a signicant positive statistical
relationship was found between depth of the COS and
overjet (r 5 0.483) and L7-MP/S-MP (r 5 0.289) in
the Class II Division 1 malocclusion group. In the Class
II Division 2 group, all variables except overjet had positive correlations with depth of the COS.
The multiple linear regression analysis with the enter
method showed that L1-MP/S-MP had a signicant

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Table IV. Pearson correlation coefcients for the variables measured on the lateral cephalometric radiographs
Group
Class I

Class II, Division 1

Class II, Division 2

Class III

Measurement
Overjet (mm)
Overbite (mm)
L1-MP/S-MP
L7-MP/S-MP
Overjet (mm)
Overbite (mm)
L1-MP/S-MP
L7-MP/S-MP
Overjet (mm)
Overbite (mm)
L1-MP/S-MP
L7-MP/S-MP
Overjet (mm)
Overbite (mm)
L1-MP/S-MP
L7-MP/S-MP

Mean
3.358
1.952
1.306
0.926
7.226
2.626
1.337
0.909
4.546
5.738
1.344
0.959
0.564
0.402
1.312
0.861

SD
0.982
1.380
0.123
0.043
2.271
1.832
0.095
0.053
1.262
1.553
0.086
0.056
2.592
2.017
0.121
0.083

r
0.234
0.103
0.541z
0.269*
0.483z
0.085
0.219
0.289*
0.175
0.439y
0.268*
0.467z
0.102
0.148
0.438y
0.175

r, Correlation coefcient; SD, standard deviation.

*P \0.05; yP \0.01; zP \0.001.

Table V. Multiple regression analysis of variables

measured on lateral cephalometric radiographs

Measurement
B
SE B
b
Overjet (mm)
0.082 0.095 0.119
Overbite (mm) 0.008 0.065 0.017
L1-MP/S-MP
2.918 0.652 0.530y
L7-MP/S-MP
3.355 1.974 0.214
Class II, Division 1 Overjet (mm)
0.152 0.040 0.468y
Overbite (mm) 0.044 0.051 0.108
L1-MP/S-MP
1.439 1.106 0.184
L7-MP/S-MP
2.109 1.953 0.151
Class II, Division 2 Overjet (mm) 0.005 0.078 0.007
Overbite (mm) 0.233 0.061 0.434y
L1-MP/S-MP
1.210 1.129 0.126
L7-MP/S-MP
6.553 1.796 0.439*
Class III
Overjet (mm) 0.002 0.051 0.006
Overbite (mm) 0.020 0.068 0.042
L1-MP/S-MP
3.394 1.172 0.434*
L7-MP/S-MP 0.227 1.738 0.020
Group
Class I

SD, Standard deviation; SE, standard error.

Mean
Mean
Mean
Mean
t
Side
Mean SD difference SE t value P Mean SD difference SE t value P Mean SD difference SE t value P Mean SD difference SE value P
Right 1.930 0.759 0.024 0.081 0.299 0.767 2.447 0.829 0.025 0.073 0.343 0.733 2.353 0.839 0.082 0.093 0.879 0.383 1.795 0.943 0.056 0.074 0.754 0.455
(mm)
Left
1.954 0.717
2.472 0.732
2.435 0.951
1.738 1.027
(mm)

Class II Division 1 (n 5 50)

Class I (n 5 50)

Table III. Side comparisons of depth of the COS measured on 3D digital models

Class II Division 2 (n 5 50)

Class III (n 5 50)

Veli, Ozturk, and Uysal

r2
0.374

0.319

0.430

0.193

B, Unstandardized regression coefcient; SE B, standard error of B; b,

standardized regression coefcient; r2, coefcient of determination.
*P \0.01; yP \0.001.

contribution to the depth of the COS in the Class I and

Class III malocclusion groups (Table V). Although overjet
had the greatest contribution to the depth of the COS in
the Class II Division 1 malocclusion group, overbite had
the greatest contribution in the Class II Division 2 malocclusion group. The measured variables explained 37.4%,
31.9%, 43.0%, and 19.3% of the total variances of the
depth of the COS in the Class I, Class II Division 1, Class
II Division 2, and Class III groups, respectively.

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Table VI. Bonferroni corrected pair-wise comparisons among groups across the response variables
Univariate tests
Measurement
Depth of COS (mm)
Overjet (mm)
Overbite (mm)
L1-MP/S-MP
L7-MP/S-MP

df
3
3
3
3
3

F
8.844
145.20
85.583
1.502
22.699

P
0.000*
0.000*
0.000*
0.215
0.000*

Class I
h
0.119
0.690
0.567
0.022
0.258
2

Mean
1.9422a
3.358a
1.952a
1.30586a
0.9258a

SD
0.679
0.982
1.380
0.123
0.043

Class II Division 1

Class II Division 2

Mean
2.4594b
7.226b
2.626a
1.33678a
0.90894a

Mean
2.3943b,c
4.546c
5.738b
1.3443a
0.9588b

SD
0.738
2.271
1.832
0.095
0.053

SD
0.834
1.262
1.553
0.086
0.056

Class III
Mean
1.7666a
0.564d
0.402c
1.31206a
0.86062c

SD
0.949
2.592
2.017
0.121
0.083

Multivariate F ratios were generated from the Pillai statistic; multivariate df,15, 582; F, 27.95; h2 5 0.419.
Means in a row with the same subscript letter are not signicantly different from each other.
SD, Standard deviation.
*P \0.001.

MANOVA showed statistically signicant differences

in overjet, overbite, L1-MP/S-MP, L7-MP/S-MP, and
depth of the COS (P \0.001) among the groups, and
further assessment with univariate tests (Table VI) indicated statistically signicant differences among the
groups except for L1-MP/S-MP. The Bonferroni adjustment corrected the pair-wise comparisons and showed
statistically signicant differences in depth of the COS
among the Class I, Class II Division 1, and Class II Division 2 malocclusion groups. On the other hand, the
depth of the COS did not differ signicantly between
the Class II Division 1 and Class II Division 2 malocclusion groups. Similarly, the depth of the COS had no signicant differences between the Class I and Class III
malocclusion groups. Whereas overjet differed in all
pair-wise comparisons, overbite and L7-MP/S-MP
showed no signicant differences between the Class I
and Class II Division 1 groups.
Based on these results, the null hypotheses of the
study were partially rejected.
DISCUSSION

An increased COS is a common feature of patients

undergoing orthodontic treatment; hence, evaluation
of the depth of the COS is a critical point for orthodontic
diagnosis and treatment planning.13 However, understanding why and how the COS develops is limited. In
this study, we aimed to evaluate the depth of the COS
in terms of vertical eruption of the anterior and posterior
teeth quantitatively and to determine whether depth of
the COS is affected by vertical eruption of the anterior
or posterior teeth.
Lack of sex dimorphism in the depth of the COS has
been reported in the literature.14,15 Carter and
McNamara16 reported no difference in depth of the
COS between male and female subjects when it was
measured from dental casts taken before treatment. Xu
et al17 reported no signicant difference in the depth
of the COS between Japanese male and female subjects.

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Therefore, no attempt was made to separate the sample

according to sex in this study.
It has been suggested that the depth of the COS is
stable throughout adolescence and into adulthood.16,18
Because of this, adolescents and young adults with all
teeth present except third molars were included in the
study.
The inuence of craniofacial morphology on the COS
has been systematically investigated in the literature
with conicting ndings. Kumar and Tamizharasi19 conducted a review of the signicance of the COS from
the orthodontic aspect and reported that the COS was
inuenced only to a minor extent by craniofacial
morphology. Therefore, patient selection was based primarily on dental malocclusion. However, patients with
any facial asymmetry were excluded from the study.
Clinically, the COS is determined by the distal marginal ridges of the most posterior teeth in the arch and
the incisal edges of the central incisors.20 However,
some authors do not include the incisors in the depth
measurements because supererupted incisors result in
a greater depth of the curve obtained than when
excluding the incisors.21 Hence, to determine the anterior vertical eruption on depth of the COS, rational measurements were performed among the different
malocclusion groups in this study.
There is little consensus in the literature concerning
measurement of the depth of the COS. Baldridge22
used the perpendicular distances on both sides, and
Bishara et al18 used the average of the sum of the
perpendicular distances to each cusp tip. Braun et al23
and Braun and Schmidt24 used the sum of the maximum
depth on both sides. However, these measurements were
made on plaster models or standardized photographs25
with a caliper.26 Recent advances in 3D technology allowed us to create computerized study models of plaster
casts and to make precise measurements using designated software.27,28 Sousa et al29 evaluated the reliability of measurements made on 3D digital models

American Journal of Orthodontics and Dentofacial Orthopedics

Veli, Ozturk, and Uysal

obtained with the 3Shape D-250 surface laser scanner

and concluded that linear measurements on digital
models are accurate and reproducible. Gracco et al30
concluded that measurements on 3D models are a valid
and reliable alternative to those currently made on plaster models in orthodontic practice, with the advantage of
signicantly reducing measurement times. Considering
the ease of use and reduced time, we used digital models
in this study.
Marshall et al2 found no signicant differences in
depth of the COS between the right and left sides of
the mandibular arch. Similarly, the data obtained in
this study indicated no signicant differences in depth
of the COS between the right and left sides for all groups.
The deepest point of the COS was found at the mesiobuccal cusp of the rst molar for all malocclusion
groups in this study. There are several reports in the literature concerning the deepest point of the COS.
Koyoma31 reported the deepest point at the second premolar area. On the other hand, in accordance with our
ndings, Garcia32 reported that the deepest point in
most patients was at the mesiobuccal cusp of the permanent rst molar.
In our study, depth of the COS was greatest in the
Class II Division 1 malocclusion group, followed by Class
II Division 2, Class I, and Class III, with the least amount
of depth. However, the depth did not differ signicantly
between Class II Division 1 and Class II Division 2 malocclusions. Similarly, depth of the COS had no signicant
differences between Class I and Class III malocclusions.
A previous study examined 100 untreated patients and
reported that the COS was the most severe in the Class
II Division 2 patients, followed by Class II Division 1,
Class I, and Class III patients.33 Shannon and Nanda34
showed that patients with a Class II malocclusion had
a signicantly deeper COS than did those with a Class I
malocclusion. On the other hand, Braun and Schmidt24
reported similar depths of the COS for those with Class
I and Class II malocclusions.
A differential eruption sequence of the maxillary and
mandibular teeth alone or accompanied by the deciduous second molars in a ush terminal plane or the maxillary deciduous second molars with small distolingual
cusps could result in an unopposed mandibular permanent rst molar and incisor eruption beyond the
mandibular occlusal plane.2 It was proposed that this
unopposed eruption would be expected to be even
more exaggerated in a Class II dental or skeletal relationship, leading to excessive deepening of the COS.13
Consistent with literature, the COS is deeper in those
with Class II malocclusions. On the other hand, it may
also be assumed that Class III patients with a negative
increased overjet had greater eruption of the anterior

311

teeth because of uncovering. Our results show that an

increase in vertical eruption of the anterior and posterior
teeth is associated with a tendency for a deeper COS in
Class I and Class III malocclusion patients. Although vertical eruption of the anterior teeth did not differ among
groups, the multiple linear regression analysis indicated
that vertical eruption of the anterior teeth had a significant contribution to the depth of the COS in the Class I
and Class III malocclusion groups. We attributed a
similar amount of anterior eruption to the positive
decreased overjet (0.564 mm) in Class III malocclusions
and the signicant contribution of the anterior teeth
to retroclination and the corresponding extrusion resulting from compensation.
Interestingly, L1-MP/S-MP was estimated as almost
1.3 for all malocclusion groups. This may be a simple
quantitative indicator for the clinician during the
leveling of the COS, and larger ratios may be used for
the indication of anterior intrusion.
Overjet had the greatest contribution to depth of the
COS in the Class II Division 1 malocclusion group. On the
other hand, overbite had the greatest contribution in the
Class II Division 2 malocclusion group. Also, vertical
eruption of the posterior teeth was related to a deeper
COS in the Class II Division 1 malocclusion group. The
results further suggest that any change in overjet in
those with a Class II Division 2 malocclusion has no effect on depth of the COS. These results might suggest
that when the anterior teeth have no vertical stop, their
continued eruption will contribute to deepening of the
anterior aspect of the COS. However, interestingly,
although overjet differed among the groups, the vertical
eruption of the anterior teeth did not differ in this study.
Under many conditions, violating the underlying assumptions, especially when group sizes are equal, does
not necessarily invalidate the results. Departures from
multivariate normality generally have only slight effects
on type I error rates of the 4 MANOVA statistics, but
Roy's greatest characteristic root may sometimes be an
exception.35 Also, as with some other signicance tests,
Box's test might be signicant in case of large samples
even when covariance matrices are relatively similar. As
a general rule, Box's test may be disregarded when group
sample sizes are equal because it is unstable, and we can
assume that Hotelling and Pillai statistics are robust. Tabachnick and Fidell36 suggested that if the larger samples yield greater variances and covariances, then the
probability values will be conservative and can be
trusted.
The cross-sectional design of our study caused a limitation. Further studies with a longitudinal follow-up
would be benecial to better understand the development of the COS. Moreover, the relationships between

American Journal of Orthodontics and Dentofacial Orthopedics

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Veli, Ozturk, and Uysal

312

the COS and the vertical eruption of teeth were detemined on conventional lateral cephalograms. The errors
in using intersection of points in case of double images
and the 2-dimensional characteristics of conventional
lateral cephalograms were other limitations. Therefore,
future studies should evaluate the relationship with 3D
computerized tomography.
CONCLUSIONS

1.

2.

3.

4.

There are no signicant differences in the maximum

depth of the COS between the right and left sides of
the mandibular arch.
The depth of the COS was greatest in the Class II
Division 1 malocclusion group, followed by Class
II Division 2, Class I, and Class III, with the least
amount of depth.
The depth of the COS did not differ signicantly
between those with Class II Division 1 and Class II
Division 2 malocclusions.
Whereas the vertical eruption of the anterior teeth
made a signicant contribution to the depth of
the COS in the Class I and Class III malocclusion
groups, vertical eruption of the posterior teeth had
a signicant effect on the depth of the COS in the
Class II Division 2 group.

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