European Journal of Orthodontics, 2015, 412417

doi:10.1093/ejo/cju062
Advance Access publication 11 November 2014

Original article

Development of the curve of Spee in ClassII

subdivision malocclusion: a longitudinalstudy
IlknurVeli, MehmetAli Ozturk and TancanUysal
Department of Orthodontics, Faculty of Dentistry, Izmir Katip Celebi University, Izmir, Turkey
Correspondence to: Tancan Uysal, Izmir Katip Celebi Universitesi, Dis Hekimligi Fakultesi, Ortodonti Anabilim Dal, Cemil
Meric Bulvar, Cigli, Izmir 35630, Turkey. E-mail: tancan.uysal@ikc.edu.tr

Abstract

Introduction
Unilateral Class II malocclusions were classified as Class II subdivision by Angle (1). This type of malocclusion with asymmetric
occlusal relationships; Class II on one side of the dental arch and
Class I on the other side, often pose present difficulties in orthodontic treatment planning (2). Although some studies have already
described many characteristics of ClassII subdivision malocclusions
(3, 4), some questions are still available about the origin and aetiologic factors of unilateral malocclusions.
Alavi etal. (3) were the first to determine that ClassII subdivisions result mainly from asymmetry in the mandibular first molars.
Rose et al. (4) concluded that Class II subdivisions occur from
distal positioning of the mandibular first molars on Class II side.
Janson etal. (5) reported that the components that contributed to

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Objective: To compare the depth of curve of Spee (COS) in Class Iand II sides of ClassII subdivision
malocclusion longitudinally and to describe the changes in the COS in relation to dental arch
overtime.
Materials and Method:The study group comprised 17 subjects exhibiting Class II subdivision
malocclusion. The depth of COS, intermolar width, distances from mesial anatomic contact points
of the first permanent molars to the contact point of the central incisors in Class Iand II sides and
arch length in mandible were analysed on digital models in three different time points based on
cervical vertebral maturation (T1; mean age: 12.4years, T2; mean age: 15.1years, and T3: mean
age: 19.1years). Pearsons correlation coefficients were calculated and linear multiple regression
analysis with enter method was carried out.
Results: No significant differences were found in the depth of COS between Class Iand II sides
in all time periods. The mesiobuccal cusp of the first molar was the deepest part of COS in both
sides and in all time periods, with a maximum depth of 2.370.83mm in T1 and a minimum depth
of 1.910.66mm in T3. Between baseline and final follow-up; the depth of COS, ach length, and
distance in ClassIside decreased significantly. Arch length had a significant correlation with the
depth of COS (r=0.471) in T3.
Conclusions: As the depth of COS did not differ between either the Class II or Isides, the same
mechanics can be used to level the COS in either sides of the mandibular arch.

the asymmetric sagittal relationship in Class II subdivision malocclusions were mainly dentoalveolar, and the primary contributor to
the differences between Class II subdivision malocclusion and the
normal occlusion was the distal positioning of the mandibular first
molars on Class II side. A secondary contributor was the mesial
positioning of the maxillary first molars on ClassII side. Similarly,
Azevedo etal. (2) evaluated ClassII subdivision patients with apparent facial asymmetry and concluded that the subdivision was primarily dentoalveolar with minimal skeletal involvement.
The curve of Spee (COS) is a naturally occurring phenomenon in the human dentition and this curve of occlusion was first
described as the line on a cylinder tangent to the anterior border of
the condyle, the occlusal surface of the second molar, and the incisal
edges of the mandibular incisors (6).

The Author 2014. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved.
For permissions, please email: journals.permissions@oup.com

412

I. Veli etal.
Increased COS in the mandibular dentition is a common feature
of patients undergoing orthodontic treatment; hence evaluation of
the depth of COS is important for the orthodontic diagnosis and
treatment planning. Andrews (7) described the six keys of occlusion
and found that the COS ranged from flat to mild in subjects with
proper occlusion. He also stated that the levelling and flattening of
the COS should be the goal of treatment. Flattening of the COS is
accomplished by anterior intrusion, posterior extrusion, or a combination to achieve an ideal occlusion (8).
Class II subdivision malocclusions present characteristics of
both Class Iand II malocclusions. Therefore, an occlusal asymmetry between Class Iand II sides of the dentition would be expected.
As no study has been published on the longitudinal assessment of
the COS in ClassII subdivision malocclusions, the purpose of this
study was to evaluate the depth of COS and relate the COS with
the arch measurements in ClassII subdivision malocclusion, aiming to contribute to the increase in knowledge about the development of the COS over time. The null hypotheses tested were that:
1.The amount of the depth of COS and the deepest point of the
COS did not differ between Class Iand II sides in ClassII subdivision subjects; 2.There were no significant changes in the depth of
COS over time.

Materials and methods

Figure1. The perpendicular distances from each buccal cusp tip.

6.No crowding or, at most, symmetrical crowding of up to 3mm,

7.No anterior or posterior crossbites, 8.Clear lateral cephalograms
at three time points available for all selected subjects. Additionally,
casts with fractured cusps or severe attrition, molars or premolars on
which more than two-thirds of the occlusal surface had been reconstructed were excluded.
A final sample size of 17 pairs of dental casts (8 boys, 9 girls)
and a total of 34 sides (Class Iand II) were included for analysis.
Cervical vertebral maturation was assessed for each subject on the
lateral cephalograms (11) and T1 corresponded to CS3, T2 corresponded to CS4, and T3 corresponded to CS5. The mean ages
at T1, T2, and T3 were 12.40.1, 15.10.6, and 19.10.6years,
respectively.
All patients included in this study had Type 1 ClassII Subdivision
malocclusion characterized by distal positioning of the mandibular
first molar on ClassII side and coincidence of the maxillary dental
midline with the facial midline and deviation of the mandibular midline (12). Dental midlines were determined on PA radiographs, passing through the root of crista galli perpendicular to a line connecting
the most superior points on the orbital contours (3).
All plaster models were transformed into digital format by a threedimensional (3D) model laser scanner (D250 3D Dental Scanner;
3Shape A/S, Copenhagen, Denmark). The digital models were analysed by one investigator (MAO) using 3Shape Orthoanalyzer, version 1.0 software (3Shape A/S). The depth of COS was measured as
following:
Horizontal reference plane comprised a line between central incisors and distobuccal cusp tips of mandibular second molars was
constructed using the grids available on the dedicated software. The
perpendicular distances from the buccal cusp tips of the involved
teeth to constructed line through the horizontal reference plane were
evaluated, and deepest point calculated as the value for the depth of
COS for ClassII and l sides (Figure1). The depth was defined as the
average of bothsides.
Also, intermolar width (the distance between mesiobuccal cusp
tips or estimated cusp tips in cases of wear facets), distances from
mesial anatomic contact points of the first permanent molars to the
contact point of the central incisors in Class Iand II sides and arch
length (the sum of distances in Class Iand II sides) (13) were measured (Figure2).

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The sample was selected retrospectively from the files of the

University of Michigan Growth Study and longitudinal records of
orthodontically untreated subjects with ClassII subdivision malocclusions were included in thisstudy.
Sample selection was based exclusively on the initial antero-posterior dental relationship, regardless of any other dentoalveolar or
skeletal characteristic. The selection criteria were 1.ClassII molar
relationship 1/2 of a premolar width on one side and ClassImolar
relationship on the other side from buccal aspect and the mesiopalatal cusp of the upper first molar occludes with the mesial triangular fossa of the lower first molar from lingual aspect (9, 10),
2.All permanent teeth present up to the second molars, 3.No supernumerary or congenitally missing teeth excluding third molars or
teeth with extensive restorations or gross decay, 4.No ectopic teeth
or anomalies in tooth shape, 5.No previous orthodontic treatment,

413

414
Ten randomly selected sets of digital models were redigitized
and remeasured 2 weeks after the first set of recordings to calculate
the method error by means of Dahlbergs formula (14) and intraexaminer reliability was quantified by using the intraclasscorrelation
coefficient(ICC).

Statistical analysis

Figure2. Measurements used in this study.

Results
The errors for the measurements varied between 0.2 and 0.5mm and
high degree of intraexaminer reliability was noticed for all variables.
(ICC = 0.9480.993).
The mean, standard deviation (SD), minimum, and maximum
values of average perpendicular distances from the buccal cusp tips
of the involved teeth to constructed line in all time periods were
presented in Table1. The results of paired sample t-test revealed no
significant differences in the depth of COS between Class I and II
sides in all time periods (P > 0.05) (Table2). The mesiobuccal cusp
of the first molar was the deepest part of the COS in all time periods,
with a maximum depth of 2.370.83mm in T1 and a minimum
depth of 1.910.66 in T3 (Table 1). The depth of COS decreased
between baseline and final follow-up.
The mean and SD of arch length, distance in ClassII side, distance
in ClassIside and intermolar width were measured in all time periods
(Table 3). Pearsons correlation coefficient was calculated between
arch length, distance in ClassII side, distance in ClassIside, and intermolar width and the depth of COS (Table3). All variables decreased
over time. The results indicated statistically significant positive correlation between the depth of COS and the distance in ClassIside
(r=0.471) in T3. The COS at each of three time points were weakly
and insignificantly correlated with arch length, distance in Class II
side and intermolar width. Those insignificant correlations did lead
not to examine relationships using multiple linear regressions.
The multiple linear regression analysis with enter method
revealed (Table 4) that arch length had a significant contribution

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All statistical analyses were performed using the Statistical Package

for Social Scientists software package (SPSS for Windows, version
20.0, SPSS Inc, Chicago, IL, USA). The normality properties of the
15 variables (5 distinct variables at 3 time points) were checked
using ShapiroWilk test yielding satisfaction of normality assumption on 13 out of 15 variables.
Paired sample t-test was used for side comparisons and Pearsons
correlation coefficients were calculated to determine the linear associations among arch length, intermolar width, R, L, and the depth of
COS. To assess the contribution of individual variables to the depth
of COS, linear multiple regression analysis with enter method was
carriedout.
Parametric repeated measures analysis of variance (ANOVA),
considered as an appropriate statistic since it would give more
statistical power compared to nonparametric test when normality
is generally achieved, was performed to compare the time points
on five response variables; i.e. arch length, intermolar width, R, L,
and the depth of COS. All values were considered significant when
P<0.05.

European Journal of Orthodontics, 2015, Vol. 37, No. 4

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I. Veli etal.
to the depth of COS in T3. The measured variables explained 16.7,
16.7, and 38.4% of the total variance of the depth of COS in T1, T2,
and T3, respectively.
Repeated measures ANOVA revealed statistically significant
differences in the depth of COS, arch length, and the distance in
ClassIside among time periods (Table5). On the other hand, the
distance in Class II side showed statistically significant differences
only between T1 and T3 and no significant differences were found
in intermolar width among time periods. Between baseline and follow-up periods; the depth of COS, ach length, and the distance in
ClassIside showed statistically significant decreases.
On the basis of current results, the null hypotheses of the study
were failed to be rejected.

Discussion

Table3. Pearson correlation coefficient for the listed variables. SD,

standard deviation; r, correlation coefficient.
Groups

Measurements

Mean

SD

T1

Arch length
Distance in ClassIside
Distance in ClassII side
Intermolar width
Arch length
Distance in ClassIside
Distance in ClassII side
Intermolar width
Arch length
Distance in ClassIside
Distance in ClassII side
Intermolar width

60.846
30.400
30.446
44.486
59.546
29.822
29.724
44.251
58.931
29.560
29.371
44.095

2.504
1.364
1.509
2.041
2.347
1.329
1.212
2.210
2.372
1.286
1.208
2.119

0.382
0.077
0.431
0.193
0.195
0.180
0.477
0.314
0.236
0.028*
0.280
0.096

0.224
0.362
0.045
-0.079
-0.223
0.237
-0.015
0.127
-0.188
0.471
0.152
0.333

T2

T3

*P<0.05, **P<0.01, ***P<0.001.

Table 1.Average perpendicular distances. n, sample size; Min,

minimum; Max, maximum; SD, standard deviation.
Teeth

Time Period

Mean

SD

Min

Max

Lateral incisor

T1
T2
T3
T1
T2
T3
T1
T2
T3
T1
T2
T3
T1
T2
T3

0.181
0.030
0.065
0.191
0.060
0.123
1.359
1.030
0.739
2.156
1.684
1.323
2.370
2.025
1.911

0.299
0.252
0.283
0.531
0.510
0.495
0.740
0.713
0.712
0.917
0.722
0.785
0.837
0.648
0.669

0.390
0.440
0.830
0.935
0.935
1.030
0.185
0.000
0.185
0.800
0.685
0.095
1620
1230
0.970

0.760
0.555
0.390
1.085
0.885
0.495
3.500
2.695
2.350
4.385
3.055
2.750
4.610
3.445
3.305

Canine

First premolar

Second premolar

First molar

Table4. Results of multiple regression analysis. SD, standard deviation; Sp, is the curve of Spee; B, is the unstandardized regression
coefficient; SE B, standard error of B; , standardized regression
coefficient.
Time
Period
T1

T2

T3

Measurements

SE B

Arch length
Distance in ClassII side
Intermolar width
Arch length
Distance in ClassII side
Intermolar width
Arch length
Distance in ClassII side
Intermolar width

0.099
0.383
0.037
0.233
0.386
0.065
0.500
0.828
0.036

0.166
0.302
0.105
0.174
0.342
0.078
0.198
0.399
0.074

0.297 0.167
0.625
0.091
0.843 0.167
0.722
0.221
1.774* 0.384
1.496
0.113

*P<0.05, **P<0.01, ***P<0.001.

Table2. Side comparison of the depth of curve of Spee (mm). n: sample size; SD, standard deviation.
T1 (n=17)

ClassII side
ClassIside
*P<0.05.

T2 (n=17)

T3 (n=17)

Mean

SD

Mean

SD

Mean

SD

2.361
2.379

0.865
0.875

0.881

2.033
2.018

0.664
0.706

0.889

1.853
1.968

0.687
0.724

0.307

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An understanding of the adaptive longitudinal changes in occlusion

is useful in the treatment and retention planning. ClassII subdivision
malocclusions with their asymmetric occlusal relationships often
present treatment difficulties (3). Therefore, our primary concern
was to evaluate the longitudinal changes in the COS in ClassII subdivision malocclusion. By this way, the differential mechanics to be
used to level the COS in either Class II or Isides were evaluated.
Lack of gender dimorphism in the depth of COS has been
reported in literature (15, 16). Carter and McNamara (17) examined the changes in the dental arches between late adolescence and
the fifth or sixth decade of life in untreated subjects and reported
no difference in the depth of COS between males and females when
measured from the dental casts taken before treatment. Similarly,
Xu etal. (18) reported that there is no significant difference in the
COS between Japanese males and females. Therefore no attempt

was made to separate the sample according to gender in this study.

Also, sample selection was performed according to the initial anteroposterior dental relationship, regardless of any other dentoalveolar
or skeletal characteristics. It has already been reported that the main
components contributing to the asymmetric antero-posterior relationship in a patient with a Class II subdivision malocclusion are
dentoalveolar characterized by the distal positioning of the mandibular first molar on ClassII side and less often by mesial positioning
of the maxillary molar on ClassII side (5). Moreover, the influence of
craniofacial morphology on the COS has been systematically investigated in very few studies and with conflicting results (19, 20). Farella
etal. (21) investigated the relationship between the COS and craniofacial morphology, and concluded that the COS was influenced only
to a minor extent by craniofacial morphology.

European Journal of Orthodontics, 2015, Vol. 37, No. 4

416

Table5. Statistical comparison of the curve of Spee (COS), distances in both sides, arch length and intermolar width measurements using
repeated measures analysis of variance (ANOVA). SD, standard deviation.
Measurements

COS
Arch length
Distance in ClassII side
Distance in ClassIside
Intermolar width

Multivariate test

Within- subjects
effects

T1

T2

T3

F(2,15)

F(2,32)

Mean

SD

Mean

SD

Mean

SD

7.570**
14.826***
7.023*
11.672*
1.056

0.502
0.664
0.484
0.609
0.123

13.025***
20.427***
9.043**
18.189***
1.602

0.449
0.561
0.361
0.532
0.091

2.37a
60.84a
30.40a
30.44a
44.48a

0.836
2.500
1.360
1.509
2.040

2.025b
59.546b
29.82a,b
29.724b
44.25a

0.648
2.346
1.320
1.212
2.200

1.91c
58.930c
29.560b
29.370c
44.094a

0.668
2.372
1.286
1.208
2.118

Multivariate F ratios were generated from Pilllai's statistic. Means in a row sharing the same subscript are not significantly different from each other.
*P <0.05; **P <0.01; ***P <0.001.

The depth of COS decreased between baseline and final followup in the present study. Marshall et al. (34) measured the depth
of COS at seven time points from ages 4 (deciduous dentition) to
26 (adult dentition) years and concluded that the depth was minimal in the deciduous dentition and its greatest increase occurred
in the early mixed dentition as a result of differential eruption of
the mandibular permanent first molars and incisors relative to
the deciduous second molars. They further concluded that COS
maintained its depth until it increased to maximum depth with
the eruption of permanent second molars and then remained relatively stable into late adolescence and early adulthood. Although
Marshall etal. (34) examined the development of the COS in subjects with normal occlusion; our finding is consistent with the study
of Marshall etal. (34). On average, eruption of the mandibular permanent first molars precedes the maxillary permanent first molars
by 12 months, and the mandibular permanent central incisors
precede the maxillary permanent central incisors by 12 months.
Also eruption of the mandibular second molars precedes their
maxillary antagonists by 6 months (35, 36). Marshall et al. (34)
reported that unopposed mandibular permanent first molar and
incisor eruption beyond the established mandibular occlusal plane,
followed by relatively unopposed mandibular second molar led to
deepening in theCOS.
The authors have already reported a statistically significant
decrease in mandibular intermolar width in the same untreated subjects over a long period of time (37). Ward etal. (38) compared the
fundamental arch width changes with and without treatment over
20 years and reported a small but insignificant decrease in lower
intermolar arch width for the untreated group between baseline and
final follow-up. It should be noted that the intermolar width and
distance in Class Ior II side might change during the long time observation period because of the changes in arch form. Many factors
influence arch form and therefore, arch width changes must not be
considered in isolation (39).
Consistent with our finding, several studies have indicated a reduction in arch length through time (17, 23). Statistical analysis revealed
that arch length had a significant contribution to the depth of COS in
T3. Arch length together with the distance in ClassII side and intermolar width explained 38.4% of the total variance of the depth of COS in
final follow-up period. Baldridge (22) and Garcia (33) found a linear
relationship between arch circumference and the levelling ofCOS.
The presence of longitudinal records that fulfill the comprehensive inclusion criteria represents the specificity of this study.
However, due to the small sample size which was the limitation of
this study, the results should be interpreted cautiously, requiring further confirmation with larger samples of subjects.

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There is little consensus in the literature concerning the measurement of the depth of COS. Baldridge (22) used the perpendicular
distances on both sides and Bishara etal. (23) used the average of
the sum of perpendicular distances to each cusp tip. Braun etal. (24)
and Braun and Schmidt (25) used the sum of the maximum depth on
both sides. However, these measurements made on the plaster models or using standardized photographs (26) by means of caliper (27).
Recent advances in 3D technology allow creating computerized
study model of plaster cast and enable to perform precise measurements using designated software (28, 29). Sousa etal. (30) evaluated the reliability of measurements made on 3D digital models
obtained with 3Shape D-250 surface laser scanner and concluded
that linear measurements on digital models were accurate and
reproducible. Gracco et al. (31) concluded that measurements
carried out on 3D models are a valid and reliable alternative to
those currently used on plaster models in orthodontic practice,
with the advantage of significantly reducing measurement times.
Considering the ease of use and reduced time, digitals models were
used in the presentstudy.
The deepest point of the COS was found at the mesiobuccal cusp
of the first molar for all investigated time points in the current study.
All patients included in this study had Type 1 ClassII Subdivision
malocclusion characterized by distal positioning of the mandibular
first molar on Class II side. Due to distal positioning of the mandibular first molar on Class II side, a change in placement of the
deepest point of the COS would be expected over time. There are
several reports in the literature concerning the deepest point of the
COS. Koyama (32) reported the deepest point as the second premolar area. On the other hand, in accordance with the present findings,
Garcia (33) reported that the deepest point in most patients was at
the mesiobuccal cusp of the permanent firstmolar.
Indeed, due to asymmetric occlusal relationships in Class II
subdivision malocclusion, any difference would be expected in the
depth of COS due to distal positioning of the first molar. However,
the data obtained in this study indicated no significant differences
in the depth of COS between ClassIand lI sides in all time points.
Marshall etal. (34) examined the development of the COS longitudinally in a sample of untreated subjects with normal occlusion
from the deciduous dentition to adulthood and found no significant differences in the depth of COS between either the right or
left sides of the mandibular arch. The authors think that as the
depth of COS did not differ in either sides of the mandibular arch,
the same mechanics can to be used to level the COS. However;
in case of unilateral mechanics to be used for the correction of
ClassII side, such as ClassII elastics, the clinician should consider
the changes ofCOS.

I. Veli etal.

Conclusion
1. There are no significant differences in maximum depth of COS
between either Class II or Isides of the mandibulararch.
2. Arch length, distance in Class II side and intermolar width
explained 38.4% of the total variance of the depth of COS in
final follow-up period.
3. Arch length had a significant contribution to the depth of COS in
ClassII subdivision malocclusion in final follow-up period.
4. The depth of COS decreased between baseline and final followup period.
5. As the depth of COS did not differ between either Class II or
Isides, the same mechanics can to be used to level the COS in
either sides of the mandibular arch.

Acknowledgments
We thank James A. McNamara, Jr, for sharing the Ann Arbor Growth Study
archive of the University of Michigan.

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