ORIGINAL ARTICLE

A new approach of assessing sagittal

discrepancies: The Beta angle
Chong Yol Baik, DDS, MS,a and Maria Ververidou, DDS, MSb
Oakland, NJ, and Athens, Greece

An accurate anteroposterior measurement of jaw relationships is critically important in orthodontic diagnosis

and treatment planning. The angular and linear measurements that have been proposed can be inaccurate
because they depend on various factors. The purpose of this study was to establish a new cephalometric
measurement, named the Beta angle, to assess the sagittal jaw relationship with accuracy and reproduc-
ibility. This angle uses 3 skeletal landmarks—point A, point B, and the apparent axis of the condyle—to
measure an angle that indicates the severity and the type of skeletal dysplasia in the sagittal dimension.
Seventy-six pretreatment cephalometric radiographs of white patients were selected on the basis of 4 criteria
that indicate a normal Class I skeletal pattern; the mean and the SD for the Beta angle were calculated. This
group was compared with Class II and Class III skeletal pattern groups. After using the 1-way analysis of
variance and the Newman-Keuls test and running receiver-operating-characteristics curves, we obtained
results that showed that a patient with a Beta angle between 27° and 35° can be considered to have a Class
I skeletal pattern. A more acute Beta angle indicates a Class II skeletal pattern, and a more obtuse Beta angle
indicates a Class III skeletal pattern. (Am J Orthod Dentofacial Orthop 2004;126:100-5)

I
n orthodontic diagnosis and treatment planning,
great importance has been attached to evaluating
the sagittal apical base relationship. Both angular
and linear measurements have been incorporated into
various cephalometric analyses to help the clinician
diagnose anteroposterior (AP) discrepancies and estab-
lish the most appropriate treatment plan. Any cephalo-
metric analysis based on either angular or linear mea-
surements has obvious shortcomings, which have been
discussed in detail by Moyers et al.1
Although the ANB angle is still very popular and
useful, it has been demonstrated in the literature2-8 that
there is often a difference between the interpretation of
this angle and the actual discrepancy between the apical
bases. Several authors2,9-11 have shown that the posi-
tion of nasion is not fixed during growth, and any
displacement of nasion will directly affect the ANB
angle.12 Furthermore, rotation of the jaws by either
growth or orthodontic treatment can also change the
ANB reading.3
A second widely used measurement, the Wits ap-
a
Former resident, Tufts University, School of Medicine, Department of
Orthodontics, Medford, Mass; private practice, Oakland, NJ.
b
Former resident, Tufts University, School of Medicine, Department of
Orthodontics, Medford, Mass; private practice, Athens, Greece.
In partial fulfillment of the requirements for the Certificate in Orthodontics at
Tufts University, School of Dental Medicine.
Reprint requests to: Dr Chong Yol Baik, 43 Yawpo Ave, Suite 5, Oakland, NJ
07436, e-mail, doctorbaik@yahoo.com.
Submitted, June 2003; revised and accepted, July 2003.
0889-5406/$30.00
Copyright © 2004 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2003.08.026
100
praisal, was introduced by Jacobson to overcome prob-
lems related to the ANB angle.3,13 However, the Wits
appraisal relates points A and B to the functional
occlusal plane; this generates 2 major problems. First,
accurate identification of the occlusal plane is not
always easy or accurately reproducible,14-16 especially
in mixed dentition patients or patients with openbite,
severe cant of the occlusal plane, multiple impactions,
missing teeth, skeletal asymmetries, or steep curve of
Spee. Second, any change in the angulation of the
functional occlusal plane, caused by either normal
development of the dentition17,18 or orthodontic inter-
vention, can profoundly influence the Wits appraisal.19
Therefore, consecutive comparisons of the Wits ap-
praisal throughout orthodontic treatment might be of
limited value because they also reflect changes in the
occlusal plane instead of pure AP changes of the jaws.
Other authors have suggested angles or linear mea-
surements based on the palatal plane.20 Although a
strong argument for this approach would be the high
stability of the palatal plane with age, its inclination is
highly variable, making it difficult to establish mean
values for the norm. In a patient with a severely tipped
palatal plane, additional cephalometric data should be
considered to ensure a more accurate diagnosis.20
A specific measurement for the apical base differ-
ence should measure this difference and nothing else. A
measurement independent of cranial reference planes or
dental occlusion would be a desirable adjunct in deter-
mining the apical base relationship. Comparison of
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 126, Number 1
pretreatment and postreatment sagittal relationships of
the jaws would then be reliable, because it would reflect
true AP changes as a result of growth and orthodontic
intervention, without being influenced by changes in
occlusion.
Such a measurement was recently developed and
named the Beta angle. This angle does not depend on
any cranial landmarks or dental occlusion and would be
especially valuable whenever previously established
cephalometric measurements, such as the ANB angle
and the Wits appraisal, cannot be accurately used
because of their dependence on varying factors.
The Beta angle
The Beta angle is a new measurement for assessing
the skeletal discrepancy between the maxilla and the
mandible in the sagittal plane. It uses 3 skeletal land-
marks—point A, point B, and the apparent axis of the
condyle (C)—to measure an angle that indicates the
severity and the type of skeletal dysplasia in the sagittal
dimension (Fig 1).
The Beta angle can be found by, first, locating 3
points:
A point (subspinale)—the deepest midline point on the
premaxillae between the ANS and prosthion (de-
scribed by Downs21).
B point (supramentale)—the most posterior point in the
concavity between infradentale and pogonion (de-
scribed by Downs).
The center of the condyle, found by tracing the head of
the condyle and approximating its center (C).
Next, defining 3 lines:
Line connecting the center of the condyle C with B
point (C-B line).
Line connecting A and B points.
Line from point A perpendicular to the C-B line.
Finally, measuring the Beta angle, which is the angle
between the last perpendicular line and the A-B line.
The purposes of this study were to define the mean
value and the standard deviation for this angle in people
with the Class I skeletal pattern, to determine whether
there is a statistically significant difference between the
mean value of Beta angle between the Class I skeletal
pattern population and the Class II and Class III
population groups, and to learn how that angle changes
in those 3 groups.
MATERIAL AND METHODS
To assign samples to the Classes I, II, and III
skeletal pattern groups, many files were screened in the
Tufts orthodontic clinic and 2 private offices in Mas-
Baik and Ververidou 101
sachusetts. For the Class I skeletal pattern group, 130
pretreatment cephalometric x-rays were initially se-
lected from the records and the cephalometric measure-
ments taken by the treating orthodontist.
After the initial selection, all x-rays were retraced,
the ANB and MOCC angles and the Wits appraisal
were measured by each investigator separately, and the
mean values of those measurements were calculated. It
was considered appropriate to include a criterion, such
as the mandibular-occipital (MOCC) angle (as intro-
duced by Margolis22 and previously used in the litera-
ture23,24), which gives an indication of the skeletal
pattern in the vertical dimension, because a normal
skeletal pattern in a cephalometric x-ray should be
defined by normal sagittal and vertical components.
For a patient to be included in the Class I skeletal
pattern group (normal), 4 criteria had to be met: (1)
ANB angle of 1° to 3°, (2) Wits appraisal between 0
and ⫺3 mm, (3) MOCC between ⫺4° and ⫹4°
degrees, and (4) a pleasant profile.
Of the 130 patients initially selected, only 76 met
the criteria to be included after retracing and remeasur-
ing their pretreatment caphalometric x-rays. Therefore,
Group I consisted of 76 patients (35 male, 41 female).
A patient was classified in the Class II group when
the ANB angle was above 4°, the Wits appraisal greater
than or equal to ⫺1 mm, and the profile had a Class II
appearance. Of the 58 patients initially chosen as Class
II, 42 (23 female, 19 male) met the criteria and were
included in Group II.
A patient was classified in the Class III group when
the ANB angle was less than or equal to 1°, the Wits
appraisal less than or equal to ⫺4 mm, and the profile
had a Class III appearance. Of the 53 patients initially
chosen as Class III, 46 (28 female, 18 male) met the
criteria and were included in Group III.
All patients selected were white, between the ages
of 9 and 15 years, and had never undergone orthodontic
treatment. The Beta angle was measured for each
patient in all 3 groups by the 2 investigators separately,
and the mean values were calculated.
Statistical analysis
Data collected by the investigators were first en-
tered to Excel (Microsoft, Redmond, Wash). All data
were visually screened for any missing data or outliers
and for validity of distribution assumptions. Data were
then summarized by finding means and standard devi-
ations. The 1-way analysis of variance (ANOVA) was
used followed by Newman-Keuls post hoc testing to
determine whether there was a statistically significant
difference between the mean values of the 3 groups. A
P value ⱕ 0.05 was considered to be statistically
102 Baik and Ververidou American Journal of Orthodontics and Dentofacial Orthopedics
July 2004

Fig 1. Beta angle. Fig 2. Distribution of Beta angle values in 3 groups. Box
represents 25th, 50th (black bar), and 75th percentiles;
lines connected to boxes by vertical bars show ex-
Table I. Student-Newman-Keuls testing tremes.
Subset
Table II.Beta angle values in Class I, Class II, and
Class N 1 2 3
Class III groups
II 42 24.190
I II III
I 76 31.020
Mean Mean Mean
III 46 40.196
Significance 1.000 1.000 1.000 Female 31.1 24.6 40.8
Male 30.9 23.7 39.2

significant. Receiver operating characteristics curves

were run to examine the sensitivity and specificity of
Beta angle as a test to discriminate between the 3
different skeletal pattern groups. All statistics were
performed in SPSS (SPSS, Chicago, Ill).
RESULTS
The mean value for Beta angle in the Class I
skeletal pattern group was 31.1°, with a standard
deviation of 2.0. The mean value for Beta angle in the
Class II skeletal pattern group was 24.5°, with a
standard deviation of 3.0. The mean value for Beta
angle in the Class III skeletal pattern group was 40.0°,
with a standard deviation of 4.2.
The ANOVA showed that the 3 groups were not the
same; the Newman-Keuls post hoc test found the
groups to be significantly different (Table I, Fig 2).
There was no statistically significant difference in the
mean value of the Beta angle of the sexes within the
groups (Table II).
Receiver operating characteristics curves showed
that a Beta angle less than 27.5° has 95% sensitivity
and 88% specificity for discriminating the Class II
group from the Class I group. A Beta angle greater than
35.5° has 95% sensitivity and 99% specificity for
discriminating the Class III group from the Class I
group. Therefore, the receiver operating characteristics
curves show that the cutoff point between the Class I
and Class II groups could be considered a Beta angle of
approximately 27°, and the cutoff point between the
Class I and Class III groups could be considered a Beta
angle of approximately 35°. Those 2 numbers coincide
with the mean value from group 1 (31°) ⫾ 2 SD.
Therefore, it can be predicted with a high degree of
certainty that a patient with a Beta angle between 27°
and 35° truly has a Class I skeletal pattern. The results
also indicate that a patient with a Beta angle less than
27° has a Class II skeletal pattern, and one with a Beta
angle greater than 35° has a Class III skeletal pattern.
DISCUSSION
An accurate AP measurement of jaw relationships
is critically important in orthodontic treatment plan-
ning. In cephalometrics, both angular and linear vari-
ables have been proposed to analyze sagittal jaw
relationship and jaw position. Angular measurements
can be erroneous as a result of changes in facial height,
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 126, Number 1
Fig 3. Beta angle remains relatively stable even when
jaws are rotated.
jaw inclination, and total jaw prognathism; linear vari-
ables can be affected by the inclination of the reference
line.25
The most popular parameter for assessing the sag-
ittal jaw relationship remains the ANB angle, but it is
affected by various factors and can often be misleading.
When using the ANB angle, all those factors should be
considered; this makes the interpretation of this angle
much more complex than previously thought.
A popular alternative, the Wits appraisal, does not
depend on cranial landmarks or rotation of the jaws but
still has the problem of correctly identifying the func-
tional occlusal plane, which can sometimes be impos-
sible. Furthermore, changes of the Wits measurement
throughout orthodontic treatment might also reflect
changes in the functional occlusal plane, rather than
pure sagittal changes of the relationship of the jaws.
To overcome these problems, a new measurement
was developed. This measurement, the Beta angle, does
not depend on cranial landmarks or the functional
occlusal plane. It uses 3 points located on the jaws—
point A, point B, and the apparent axis of the condyle
(point C)—so changes in this angle reflect only changes
within the jaws. In contrast to the ANB angle, the
configuration of the Beta angle gives it the advantage to
remain relatively stable even when the jaws are rotated,
as shown in Figure 3. For example, when B point is
rotated backward and downward, then the C-B line is
also rotated in the same direction, carrying the perpen-
dicular from point A with it. Because the A-B line is
also rotating in the same direction, the Beta angle
remains relatively stable. Therefore, the Beta angle can
assess the sagittal jaw relationship in skeletal patterns,
Baik and Ververidou 103
Fig 4. If clinician can locate point that falls in circle
between lines 1 and 3, Beta angle is affected less than
1°.
when clockwise or counterclockwise rotation of the
jaws would tend to camouflage it.
Another advantage of the Beta angle is that it can be
used in consecutive comparisons throughout orthodon-
tic treatment because it reflects true changes of the
sagittal relationship of the jaws, which might be due to
growth or orthodontic or orthognathic intervention.
However, precisely tracing the condyle and locating
its center is not always easy. For that reason, some
clinicians might hesitate to use the Beta angle. To
accurately use that angle, the cephalometric x-rays
must be high quality. It is then much easier for the
clinician to follow the posterior surface of the ramus
and locate the head of the condyle. The advantage of
locating the center of the head of the condyle versus the
condylion point, as used by Mc Namara,26 is that very
precise tracing of the contour of the condyle is not
really necessary. The clinician can visualize and ap-
proximate the center with a minimum error in the Beta
angle as long as that point is within 2 mm of its actual
location. As shown in Figure 4, if the true center of the
condyle is at point C, but the clinician locates it within
a circle of 2 mm radius, then the Beta angle is affected
less than 1°; this makes its use still acceptable.
The Beta angle can be a valuable tool when
planning orthognathic surgery for patients with sagittal
and vertical skeletal deformities, because it can help to
distinguish between true skeletal Class I, Class II, and
Class III patterns, regardless of factors that would tend
to camouflage those patterns. This would help the
clinician to decide whether orthodontic camouflage
would be acceptable or whether surgery would be more
appropriate (Fig 5).
A Beta angle indicating a Class II or Class III
104 Baik and Ververidou
Fig 5. Rotation of mandible causes conflicting mea-
surements for ANB angle and Wits, and tends to cam-
ouflage severity of Class III pattern. Beta angle of 37.5°
indicates true Class III skeletal problem that would be
better addressed with orthognathic surgery.
skeletal pattern does not determine which jaw is prog-
nathic or retrognathic. If the clinician needs to diagnose
which jaw has abnormal growth or whether the defor-
mity is due to the growth of both jaws, further cepha-
lometric data are needed.
We do not suggest that clinicians should totally
disregard any previously established cephalometric
measurements. Rather, the Beta angle enriches the
current cephalometric tools available to the clinician
and enables better diagnosis and treatment planning
for patients. Any clinician should be aware of as
many cephalometric analyses as possible but should
use them cautiously and appropriately. By relying on
a single cephalometric analysis that was developed
years ago, without periodically reevaluating it, diag-
nosis might be misleading, and treatment planning
American Journal of Orthodontics and Dentofacial Orthopedics
July 2004
based on such a diagnosis can be insufficient or even
harmful.
CONCLUSIONS
1. Previously established measurements for assessing
the sagittal jaw relationship can often be inaccurate.
2. A new angle, the Beta angle, was developed as a
diagnostic aid to evaluate the sagittal jaw relation-
ship more consistently.
3. White subjects with a Beta angle between 27° and
35° have a Class I skeletal pattern; a Beta angle less
than 27° indicates a Class II skeletal pattern, and a
Beta angle greater than 34° indicates a Class III
skeletal pattern.
4. There is no statistically significant difference
between mean Beta angle values of males and
females.
We thank Drs William Rand, professor of Bio-
statistics, for his significant contributions, and Gui
Hua Zhang, assistant professor, for her guidance, and
all the faculty of the orthodontic department at Tufts
University for their advice and support during the
study.
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