Original Article

Glenoid Fossa Position in Class II Malocclusion Associated with

Mandibular Retrusion
Veronica Giuntinia; Laura De Toffolb; Lorenzo Franchic; Tiziano Baccettid

ABSTRACT
Objective: To assess the position of the glenoid fossa in subjects with Class II malocclusion
associated with mandibular retrusion and normal mandibular size in the mixed dentition.
Materials and Methods: A sample of 30 subjects (16 male, 14 female), age 9 years ⫾ 6 months,
with skeletal and dental Class II malocclusion associated with mandibular retrusion, normal skel-
etal vertical relationships, and normal mandibular dimensions, was compared with a matched
group of 37 subjects (18 male, 19 female) with skeletal and dental Class I relationships. The
comparisons between the Class II group and the control group on the cephalometric measures
for the assessment of glenoid fossa position were performed by means of a nonparametric test
for independent samples (Mann-Whitney U-test, P ⬍ .05).
Results: Subjects with Class II malocclusion presented with a significantly more distal position of
the glenoid fossa, when compared with the control group as measured by means of three param-
eters (GF-S on FH, GF-Ptm on FH, and GF-FMN).
Conclusions: A posteriorly displaced glenoid fossa is a possible diagnostic feature of Class II
malocclusion associated with mandibular retrusion. An effective cephalometric measurement to
evaluate glenoid fossa position is the distance from the glenoid fossa to the frontomaxillonasal
suture (GF-FMN).
KEY WORDS: Class II malocclusion; Glenoid fossa; Cephalometrics; Mandibular retrusion

INTRODUCTION regard have indicated that the relative position of the

Malocclusions are the result of various combinations glenoid fossa, ie, of the attachment of the mandible to
of underlying dental and skeletal disharmonies that in- the cranium, can affect the dentoskeletal features of
volve several different components of the craniofacial malocclusions, for instance, a more distal position of
region.1 Since the relationship of the mandible to the the fossa can facilitate mandibular retrusion.2–4
cranial base influences both sagittal and vertical facial The evaluation of the direction of growth of the man-
disharmonies, the position of the glenoid fossa in re- dibular condyle and/or its displacement within the
lation to surrounding skeletal structures deserves to be glenoid fossa during masticatory function has empha-
included in the analysis of the skeletal features of the sized the role of the relationship between the lower jaw
individual patient.2,3 The scientific contributions in this and the cranial base in the establishment of occlusal
relationships.5 Experimental and clinical studies have
a
Research Fellow, Department of Orthodontics, University of also shown changes in the region of the glenoid fossa
Florence, Florence, Italy. concurrent with the improvement or correction of den-
b
Research Fellow, Department of Orthodontics, University of toskeletal disharmonies.6–9
Rome, Rome, Italy.
Despite the recognized role of the glenoid fossa in
c
Assistant Professor, Department of Orthodontics, Università
degli Studi di Firenze, Firenze, Italy. the etiology of malocclusions, as well as during ortho-
d
Assistant Professor, Department of Orthodontics, University dontic treatment, the literature provides only limited
of Florence, Florence, Italy. data about the significance or the quantification of the
Corresponding author: Dr Tiziano Baccetti, Department of Or- position of the temporomandibular joint within the hu-
thodontics, University of Florence, Via del Ponte di Mezzo, 46-
48, Florence, Italy 50127 man skull in orthodontic diagnosis.2–4 It should be not-
(e-mail: [email protected]) ed also that most of the research that evaluated the
Accepted: September 2007. Submitted: July 2007.
relationships between the temporomandibular joint po-
 2008 by The EH Angle Education and Research Foundation, sition and malocclusions focused on the degree of cra-
Inc. nial flexure in different sagittal discrepancies,10–14 al-

Angle Orthodontist, Vol 78, No 5, 2008 808 DOI: 10.2319/073007-353.1

CLASS II AND GLENOID FOSSA 809

though this type of cephalometric measurement only

allows for an indirect appraisal of glenoid fossa posi-
tion. Moreover, although the position of the glenoid
fossa affects primarily the relation of the mandible with
the other craniofacial components,15 investigations
that analyzed glenoid fossa position by means of di-
rect measurements3,4 did not differentiate among the
various diagnostic components of the dentoskeletal
discrepancies investigated (eg, maxillary protrusion,
mandibular retrusion, mandibular size deficiency).
The aim here was to assess the position of the glen-
oid fossa in a group of subjects with Class II maloc-
clusion associated with mandibular retrusion in the
mixed dentition in order to better clarify the role of this
craniofacial component in Class II skeletal disharmo-
ny.

MATERIALS AND METHODS

A sample of 30 subjects (16 male, 14 female), age

9 years ⫾ 6 months, with skeletal and dental Class II
malocclusion associated with mandibular retrusion,
normal skeletal vertical relationships, and normal man-
Figure 1. Cephalometric landmarks and planes.
dibular dimensions, was selected from a parent sam-
ple of 2500 patients from the files of the Departments
of Orthodontics at the Universities of Florence and responds to the period in which a Class II malocclu-
Rome ‘‘Tor Vergata.’’ The following selection criteria sion is frequently evaluated for treatment planning.17
were applied: The sample group was compared with a control
group of 37 subjects (18 male, 19 female; average age
• Skeletal Class II malocclusion due to mandibular re- 9 years ⫾ 6 months) selected from the Department of
trusion (SNB ⬍ 73.0⬚ for male subjects and SNB ⬍ Orthodontics of the University of Florence. These sub-
73.3⬚ for female subjects) with normal sagittal posi- jects were characterized by dental and skeletal Class
tion of the maxilla (76.0⬚ ⬍ SNA ⬍ 83.5⬚ for male I occlusion, normal skeletal vertical relationships, ie,
subjects and 75.5⬚ ⬍ SNA ⬍ 82.7⬚ for female sub- they presented with features that matched those of the
jects); Class II sample group with the exception of the molar
• Normal skeletal vertical relationships (31.0⬚ ⬍ SN- relation, overjet (2.5 mm ⬍ OVJ ⬍ 5.5 mm), and man-
mandibular plane ⬍ 40.8⬚ for male subjects and dibular position (73.0⬚ ⬍ SNB ⬍ 79.7⬚ for male sub-
31.8⬚⬍ SN-mandibular plane ⬍ 41.6⬚ for female sub- jects, and 73.3⬚ ⬍ SNB ⬍ 79.7⬚ for female subjects).
jects);
• Normal mandibular dimensions (94.8 mm ⬍ Co-Gn Cephalometric Analysis
⬍ 103.0 mm for male subjects and 93.7 mm ⬍ Co-
For each subject lateral cephalograms were traced
Gn ⬍ 100.5 mm for female subjects);
by the same operator (Dr Giuntini) and checked by
• Full Class II molar relationship and excessive overjet
another operator for landmark location (Dr Franchi).
(OVJ ⬎ 5.5 mm);
Computer-assisted cephalometric analysis was carried
• Absence of tooth agenesis or supernumeraries;
out by means of a digitizer (Numonics 2210, Numon-
• Absence of traumatic injuries;
ics, Lansdale, Pa) and of a software (Viewbox 3.1,
• Absence of complex craniofacial deformities or syn-
copyright D. Halazonetis, Athens, Greece). Post digi-
dromes. tization, all linear measures were standardized to life
The reference values for the cephalometric mea- size (0% enlargement) in order to match reference
sures at the age of 9 years ⫾ 6 months were derived data.16
from the atlas by Bathia and Leighton,16 that reports By means of the computerized cephalometric anal-
ysis the following angular and linear measurements
data for large communities of European subjects with
were calculated (Figure 1):
a strong prevalence rate of subjects with Italian an-
cestry. The selected age of 9 years ⫾ 6 months cor- SNA—angular measurement.

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810 GIUNTINI, DE TOFFOL, FRANCHI, BACCETTI

SNB—angular measurement. The relatively small size of the Class II and Class I
ANB—angular measurement. samples (n ⫽ 30 and n ⫽ 37, respectively) was a con-
Co-Gn—linear distance between point Co (condylion) sequence of the strict inclusion criteria that were
and point Gn (gnathion). adopted. The power of the samples, however, ex-
Co-Go—linear distance between point Co and point ceeded 0.90 as calculated based on the sample size
Go (gonion). and the standard deviation of a linear distance from
Go-Gn—linear distance between point Go and point the glenoid fossa to a vertical line dropped from sella
Gn. in a previous study by Droel and Isaacson.3 The de-
Wits—‘‘Wits’’ index.18 termination of the power assumes the sample to be
GF-S on FH—distance between the projections of distributed normally. In that this is not the case in the
point GF (glenoid fossa, most superior and pos- present study, and the power of a non-parametric test
terior point on the bony contour of the glenoid fos- is approximately 95% that of a parametric test, the
sa, facing point Co) and point S (sella) onto Frank- power of the present study was 0.85.
fort horizontal plane (FH).
S-Ptm on FH—distance between the projections of RESULTS
point S and point Ptm (pterygomaxillary fissure)
Table 1 shows the descriptive statistics and the re-
onto FH.
sults of comparisons with statistical significance.
GF-Ptm on FH—distance between the projections of
The value for SNB angle was significantly smaller in
point GF and Ptm onto FH.
the Class II group, whereas the values for both the
GF-FMN—linear distance between GF and FMN (fron-
Wits index and the ANB angle were significantly great-
tomaxillonasal suture) point.
er in the Class II group compared with normal controls.
Mandibular ramus width—distance between the pro-
Subjects with Class II malocclusion presented with a
jections of anterior ramus point (ARM, point of in-
significantly more distal position of the glenoid fossa,
tersection between the occlusal plane and the an-
when compared with the control group as measured
terior contour of the mandibular ramus),16 and pos-
by means of three parameters (GF-S on FH, GF-Ptm
terior ramus point (PRM, point of intersection be-
on FH, and GF-FMN). No other significant difference
tween the occlusal plane and the posterior contour
between groups was found.
of the mandibular ramus)16 onto the mandibular
plane (Go-Me).
DISCUSSION
Mandibular body length—distance between the projec-
tions of point B and ARM onto Go-Me. In the cephalometric appraisal of the glenoid fossa
Co-Go-Me—mandibular angle. position, subjects with Class II malocclusion associ-
FH-palatal plane—angular measurement between FH ated with mandibular retrusion can present with a pos-
and the palatal plane (PNS-ANS). teriorly displaced glenoid fossa as part of their cranio-
SN-palatal plane—angular measurement between sel- facial characteristics. In the present study, the position
la-nasion plane (SN) and PNS-ANS. of the glenoid fossa was evaluated according to its
SN-mandibular plane—angular measurement be- distance from sella (on Frankfort horizontal line, mm),
tween SN and Go-Me. from pterygomaxillary fissure (GF-Ptm on Frankfort
Palatal plane-mandibular plane—angular measure- horizontal line, mm) and from frontomaxillonasal su-
ment between PNS-ANS and Go-Me. ture (GF-FMN, mm), and it was compared in subjects
with Class II malocclusion and normal occlusion. Sub-
Statistical Analysis jects with Class II malocclusion presented with a sig-
nificantly more distal position of the glenoid fossa,
Descriptive statistics were calculated for each ceph- when compared with the control group as measured
alometric parameter in both Class II and Class I by means of three parameters (GF-S on FH, GF-Ptm
groups. The comparisons between the Class II group on FH, and GF-FMN).
and the control group were performed by means of a The distance between the glenoid fossa and point
nonparametric test for independent samples (Mann- FMN is much more indicative of the differences be-
Whitney U-test, P ⬍ .05). All statistical tests were car- tween Class II and Class I subjects for this skeletal
ried out with statistical software (SPSS for Windows, characteristic than the distance between the glenoid
Version 12.0, SPSS Inc, Chicago, Ill). fossa and sella. GF-FMN length appeared to be a
Method error was calculated by means of the Dahl- more sensitive parameter to evaluate the position of
berg formula on 40 repeated cephalograms, and the the glenoid fossa with respect to GF-S on FH, a pa-
error ranged from 0.2 mm to 1.1 mm for linear mea- rameter that Wylie19 suggested in 1947. This is prob-
surements and from 0.2⬚ to 1.2⬚ for the angular ones. ably because GF-FMN has a geometrical and anatom-

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CLASS II AND GLENOID FOSSA 811

Table 1. Descriptive Statistics and Statistical Comparisons (Mann-Whitney U-Test) Between Class II and Class I Groups
Mann-Whitney
Class II Group (n ⫽ 30) Class I Group (n ⫽ 37) U-Test
Cephalometric
Measurements Mean SD Mean SD Diff. P value
SNA, degrees 80.4 2.2 80.4 2.5 0.0 .870
SNB, degrees 73.5 1.6 76.5 2.1 ⫺3.0 .000
ANB, degrees 6.8 1.7 3.9 1.6 ⫹2.9 .000
Co-Gn, mm 94.5 3.1 95.4 3.2 ⫺0.9 .084
Co-Go, mm 43.8 2.9 44.7 2.7 ⫺0.9 .094
Go-Gn, mm 62.2 2.7 63.2 2.9 ⫺1.0 .130
Wits, mm 1.7 3.1 ⫺1.7 3.4 ⫹3.4 .000
GF-S on FH, mm 12.5 3.4 10.9 2.2 ⫹1.6 .008
S-Ptm on FH, mm 18.9 2.7 18.8 2.3 ⫹0.1 .980
GF-Ptm on FH, mm 31.4 3.0 29.7 2.6 ⫹1.7 .010
GF-FMN, mm 71.0 4.1 67.6 3.5 ⫹3.4 .000
Mandibular ramus width, mm 30.2 1.5 29.8 2.6 ⫹0.4 .734
Mandibular body length, mm 40.2 2.2 40.8 2.7 ⫺0.6 .284
CoGoMe, degrees 126.6 4.6 126.7 3.8 ⫺0.1 .970
SN-palatal plane, degrees 8.7 2.5 8.4 2.6 ⫹0.3 .734
SN-mandibular plane, degrees 37.5 3.3 37.5 2.6 0.0 .930
Palatal plane-mandibular plane, degrees 28.8 4.1 29.1 3.3 ⫺0.3 .623

ical correspondence with the angulation between the The selection criteria of this study explain directly
anterior and posterior portions of the cranial base. Var- some of the other significant differences that were
ious studies in the past have reported a tendency to a found between the Class II malocclusion and control
skeletal Class II pattern in subjects presenting with a group. The values for SNA and SNB angles, and the
large cranial base angle10–13 in association with a distal Wits index showed both the absence of maxillary pro-
position of the temporomandibular joint within the trusion in the Class II sample as well as the presence
skull.3,4 of mandibular retrusion, also confirmed by the ANB
The average distance from the glenoid fossa to fron- angle. The value for this angle was greater than 4⬚ in
tomaxillonasal suture, as measured in the Class II all Class II subjects. Mandibular parameters like Co-
group, was 3.5 mm longer than the same average dis- Gn, Co-Go, Go-Gn, mandibular ramus width, and
tance in the control group. This result is significant not mandibular body length did not reveal statistically sig-
only from a statistical point of view, but also from a nificant differences between the two groups. Once
clinical one, as it shows clearly that in certain clinical again, these data reflected the selection criteria for the
cases and in the absence of other dentofacial discrep- Class II group (normal mandibular dimensions). Like-
ancies (eg, mandibular size deficiency, vertical dishar- wise, SN-mandibular plane angle, and palatal plane-
monies) Class II malocclusion in the individual patient mandibular plane angle, that are related to skeletal
can be related to a distal position of the glenoid fossa vertical relationships, were normal in both groups and,
with the consequence of a significant mandibular re- therefore, not significantly different between the two
trusion. These findings corroborate a previous report groups.
by Droel and Isaacson3 who found approximately 2.5 The findings of the current study also recommend
mm of posterior displacement of the glenoid fossa in assessing glenoid fossa position in those Class II cas-
skeletal Class II subjects when compared with skeletal es that can be recognized otherwise as subjects with
Class I subjects. It should be noted, however, that, in ‘‘functional Class II malocclusion.’’ This type of Class
the study by Droel and Isaacson3 Class II subjects in- II malocclusion is characterized by a posterior shift of
cluded both cases with maxillary protrusion and cases the mandible from postural rest to occlusion.20 In these
with mandibular retrusion/deficiency. By focusing on cases the distal position of the glenoid fossa may en-
Class II malocclusion associated exclusively with man- tail a diagnostic importance for two aspects, ie, a
dibular retrusion, the present study was able to find a ‘‘structural’’ aspect due to the influence of the glenoid
significant difference in glenoid fossa position between fossa position on sagittal skeletal relationships, and a
Class II and Class I samples. Further research is ‘‘functional’’ aspect that has been indicated in the lit-
needed to establish reference values for measure- erature in the past.5,20 The distal position of the glenoid
ments involving glenoid fossa position in subjects at fossa allows for movements of the mandibular condyle
different ages and with different dentoskeletal relation- in a superior and posterior direction during the switch
ships. from rest position to maximal intercuspation.5

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812 GIUNTINI, DE TOFFOL, FRANCHI, BACCETTI

It deserves to be highlighted that the distal position tional appliance therapy on glenoid fossa remodelling. Am
of the glenoid fossa, as an anatomical condition pre- J Orthod. 1987;92:181–198.
7. Ruf S, Pancherz H. Long-term TMJ effects of Herbst treat-
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oid fossa following mandibular advancement and me- Orthod. 2003;73:647–653.
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chanical stimulation of condylar growth. These chang- of 100 patients treated with the Herbst appliance in the pe-
es can contribute significantly to the correction of riod of puberty to adulthood: a long-term radiographic study.
Class II malocclusion associated with mandibular re- Eur J Orthod. 1997;19:657–668.
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198–225.
11. Anderson D, Popovich F. Correlations among craniofacial
CONCLUSIONS angles and dimensions in Class I and Class II malocclu-
sions. Angle Orthod. 1989;59:37–42.
• A posterior position of the glenoid fossa is a possible
12. Kerr WJ, Adams CP. Cranial base and jaw relationship. Am
diagnostic anatomic feature of Class II malocclusion J Phys Anthropol. 1988;77:213–220.
associated with mandibular retrusion. 13. Bacon W, Eiller V, Hildwein M, Dubois G. The cranial base
• An effective measurement to evaluate glenoid fossa in subjects with dental and skeletal Class II. Eur J Orthod.
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14. Reyes BC, Baccetti T, McNamara JA Jr. An estimate of
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craniofacial growth in Class III malocclusion. Angle Orthod.
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