ORIGINALARTICLE

Year:2015|Volume:49|Issue:2|Page:7984

TheHBNAngle
HarshBhagvatiprasadDave1,VikasGill2,DivyaroopRai3,YNNReddy4,
1 PostGraduate, Department of Orthodontics and Dentofacial Orthopedics, Rajasthan Dental College and Hospital, Jaipur,
Rajasthan,India
2 Reader, Department of Orthodontics and Dentofacial Orthopedics, Rajasthan Dental College and Hospital, Jaipur, Rajasthan,
India
3 Senior lecturer, Department of Orthodontics and Dentofacial Orthopedics, Rajasthan Dental College and Hospital, Jaipur,
Rajasthan,India
4ProfessorandHead,DepartmentofOrthodonticsandDentofacialOrthopedics,RajasthanDentalCollegeandHospital,Jaipur,
Rajasthan,India
CorrespondenceAddress:
HarshBhagvatiprasadDave
SIMMSEngineeringPvt.Ltd.,Opp.OceanicHotel,ChowpatyVillaRoad,Porbandar360575,Gujarat
India

Abstract
Aim:Thepurposeofthisstudywastoestablishanewcephalometricmeasurement,namedtheHarshBhagvatiprasad
Nita angle (HBN), to assess the sagittal jaw relationship with accuracy and reproducibility. Materialsand Methods:
Threehundredpretreatmentlateralcephalograms(100eachofClassI,II,andIII)weretakenfromtheDepartmentof
Orthodontics and Dentofacial Orthopedics of Rajasthan Dental College and Hospital, Jaipur (Rajasthan) and were
subdivided into skeletal Class I, II, and III based on ANB, Wits appraisal, and Beta angle. This angle uses 3 skeletal
landmarks the DQCDQ (apparent axis of the condyle), DQMDQ (midpoint of the premaxilla), and
DQGDQ(centerofthelargestcirclethatistangenttotheinternalinferior,anterior,andposteriorsurfacesofthe
mandibularsymphysis).Results:TheresultofthemeanandstandarddeviationfortheHBNanglewerecalculatedinall
three skeletal groups. After using oneway analysis of variance and posthoc multiple comparisons by using
TukeySQshonestlysignificantdifference,homogeneoussubsets,receiveroperatingcharacteristics(ROC)curveto
differentiateClassIIwithClassI,ROCcurvetodifferentiateClassIIIwithClassI,Reliabilityanalysiswithinterclass
correlationofHBNanglewithotherangles,weobtainedresultsthatshowedthatapatientwithaHBNangle40and46
canbeconsideredtohaveaClassIskeletalpattern.Conclusions:Anewangle,theHBNangle,wasdevelopedasa
diagnosticaidtoevaluatethesagittaljawrelationshipmoreconsistently.HBNangle40and46canbeconsideredto
haveaClassIskeletalpattern,amoreacuteHBNangleindicatesaClassIIskeletalpattern,andamoreobtuseHBN
angleindicatesaClassIIIskeletalpattern.

Howtocitethisarticle:
DaveHB,GillV,RaiD,ReddyY.TheHBNAngle.JIndianOrthodSoc201549:7984

HowtocitethisURL:
DaveHB,GillV,RaiD,ReddyY.TheHBNAngle.JIndianOrthodSoc[serialonline]2015[cited2015Sep6]49:79
84
Availablefrom:http://www.jios.in/text.asp?2015/49/2/79/162239

FullText

Introduction

Alotofcephalometricanalyseswithvariousangularandlinearmeasurementshavebeenproposedtoassistorthodontic
cliniciansandresearchworkerstoassessthesagittaljawrelationordiscrepancybetweenmaxillaandmandible,since
theintroductionofradiographiccephalometryin1934byHofrathinGermanyandBroadbent[1]intheUnitedStates.
Theanteroposteriorapicalbaserelationshipwasfirstevaluatedcephalometricallyin1948byDowns,[2]bymeasuring
theangleformedbyABandNPog.Therelativeprotrusionandretrusionofthemandiblewasdenotedbypositiveand
negative signs. "ANB angle" and "Wits appraisal" have been the most popular and currently used cephalometric
diagnosticmethodstoassesssagittaljawrelationship.Severalauthors[3],[4],[5]haveshownthatthepositionofnasion
isnotfixedduringgrowth,andanydisplacementofnasionwilldirectlyaffecttheANBangle.[6]Furthermore,rotationof
thejawsbyeithergrowthororthodontictreatmentcanalsochangetheANBreading.[7]
ToovercomeproblemsrelatedtotheANBangle,Jacobsonintroduced"TheWitsappraisal"[7],[8]relatingpointsAand
B to the functional occlusal plane. However, Wits appraisal also has limited value when its consecutive comparisons
throughout orthodontic treatment were done because it also reflects changes in the occlusal plane instead of pure
anteroposterior changes of the jaws. Earlier studies have shown that occlusal plane is not always easily identified or
accurately reproduced, [9],[10] especially in mixed dentition patients or patients with open bite, steep curve of spee,
severecantoftheocclusalplane,multipleimpactions,missingteethorskeletalasymmetrieschangesintheangulations
of the functional occlusal plane, caused by either normal development of the dentition [11],[12] or orthodontic
intervention,caninfluencetheWitsappraisal.[13]
Therefore,accuracyandreliabilityofboththesefactorshavebeenquestionedbecauseboth"SN"and"occlusal"planes
getinfluencedbyvariousfactors.
Palatal plane has also been used as reference plane for various angular and linear measurements, [14] but again its
stabilityisquestionablewithage,anditsinclinationishighlyvariable,therefore,additionalcephalometricdatashouldbe
consideredtoensureamoreaccuratediagnosis.[14]
To determine the apical base relationship and to compare sagittal relationship of the jaws during the course of
orthodontic treatment a measurement independent of cranial reference planes or occlusal plane would be desirable
whichwouldreflecttrueanteroposteriorchangeswithoutbeinginfluencedbychangesinocclusionduringeithergrowth
ororthodonticintervention.
The angle introduced in the present article is named the HBN angle (Harsh Bhagvatiprasad Nita angle on author's
parent's name), which does not depend on any cranial reference planes or occlusal plane and would be especially
valuablewheneverpreviouslyestablishedcephalometricmeasurements,suchastheANBangleandtheWitsappraisal,
cannotbeaccuratelyusedbecauseoftheirdependenceonvaryingfactors.

HBNAngle

The HBN angle is a new measurement for assessing the sagittal relationship between the maxilla and the mandible.
Threeskeletallandmarkswereused:"C"(theapparentaxisofthecondyle),"M"(midpointofthepremaxilla),and"G"
(center of the largest circle that is tangent to the internal inferior, anterior, and posterior surfaces of the mandibular
symphysis).
"C"thecenterofthecondyle,foundbytracingtheheadofthecondyle,andapproximatingitscenter"M"midpointof
thepremaxillaobtainedbyformingthebestfitcirclethatwastangenttothesuperior,anterior,andpalatalsurfacesof
the maxilla and then approximating its center"G" center of the largest circle that is tangent to the internal inferior,
anterior,andposteriorsurfacesofthemandibularsymphysis.HowtoconstructHBNangle[Figure1]{Figure1}
First step: A line connecting from the condyle to point GSecond step: A line connecting from M to GThird step: A
perpendicularlinedrawnfrompointMtoCGline.Thegoalofthisstudyistodescribesagittaldiscrepanciesinaskeletal
patternofClassI,ClassII,andClassIII.

This study was done to define the mean value and the standard deviation (SD) for the HBN angle in people with the
Class I skeletal base pattern. Moreover, also to corroborate any statistically significant difference between the mean
valuesofHBNanglebetweentheClassIskeletalpatternpopulationandtheClassIIandClassIIIpopulationgroups.

MaterialsandMethods

Six hundred and sixtyseven pretreatment lateral cephalograms were obtained from Department of Orthodontic and
DentofacialOrthopedicofRajasthanDentalCollegeandHospital,Jaipur(Rajasthan)institution.
ThesecephalogramsweretracedbyfourdifferentoperatorstoreducetheoperatorerrorandANB,Witsappraisal,Beta
angle,andmandibularoccipital(MOCC)anglesweremeasured,andthenameanofthevalueswereselected.Itwas
consideredappropriatetoincludeacriterion,liketheMOCCangle(asintroducedbyMargolis[15]andpreviouslyused
intheliterature),[16],[17]whichgivesanindicationoftheskeletalpatternintheverticaldimension,becauseanormal
skeletalpatterninacephalometricXrayshouldbedefinedbynormalsagittalandverticalcomponents.
Exclusioncriteria
QualityofradiographwasnotgoodenoughtolocatethelandmarksSubject(s)headnotcorrectlyorientedtoFrankfurt
horizontal planeAny occlusion disturbances, viz., missing teeth (except through normal exfoliation), teeth not in full
occlusion,etcOrthodonticinterventiondoneCraniomandibularangle(MOCCangles)>393.
Inclusioncriteria
Class I: ANB angle 13 Wits appraisal 0 and 3 mm pleasant profileClass II: ANB >4 Wits appraisal: 4 mm convex
profileClass III: ANB <1 Wits: 2 to 3 mm concave profile.Apart from 667 Xrays, 300 met the criteria. 300
pretreatmentlateralcephalograms(100eachofClassI,II,andIII)weretaken.Apartfrom154male,ClassI47,ClassII
50,ClassIII57selected.
Apartfrom146female,ClassI53,ClassII50,ClassIII43selected.
After the initial selection, 300 pretreatment lateral cephalograms (154 males, 146 females) were selected and were
retraced.TheANBandMOCCanglesandtheWitsappraisalweremeasuredbyeachinvestigatorseparately,toreduce
theoperatorerror.
Statisticalanalysis
Data were summarized as mean and SDs. Oneway analysis of variance (ANOVA) [Table 1] followed by posthoc
evaluationforpeerwisecomparisonbetweendifferentmalocclusiongradeshasbeendonebyusingposthocTukey's
honestlysignificantdifferencetest[Table2].Correlationanalysiswithexistinggrouphasbeendoneandtheinterclass
correlationcoefficientisdepictedin[Table6].ReliabilityanalysiswithaninterclasscorrelationofHBNanglewithother
angles has been done with Cronbach's alpha and depicted in [Table 6]. Cutoff values were ascertained by receiver
operatingcharacteristics(ROC)curves,madetodifferentiateClassIIMalocclusionfromClassIMalocclusion[Table4]
and Class III Malocclusion from Class I Malocclusion [Table 5]. P < 0.05 was taken as significant. Online SPSS
Statistics is a software package used for statistical analysis. Long produced by SPSS Inc., it was acquired by IBM in
2009. The current versions (2015) are officially named IBM SPSS Statistics. The oldest is the statistical software
package MedCalc designed for the biomedical sciences. It has an integrated spreadsheet for data input and can
import files in several formats (Excel, CSV, ...). It includes ROC curve analysis, KaplanMeier survival plots, Bland
Altmanplot,aswellasDemingandPassing&Bablokregressionformethodcomparison.{Table1}{Table2}

Results

ThemeanvalueforHBNangleintheClassIskeletalpatterngroupwas42.88withaSDof2.23.Themeanvaluefor
HBNangleintheClassIIskeletalpatterngroupwas35.19withaSDof3.42.ThemeanvalueforHBNangleinthe
ClassIIIskeletalpatterngroupwas51.89withaSDof4.17.TheANOVAshowedthatthethreegroupswerenotthe
same the posthoc test found the groups to be significantly different [Table 1] [Table 2] [Table 3].{Table 3}{Table 4}
{Table5}{Table6}

Receiver operating characteristics curves showed that a HBN angle <39 has 94% sensitivity and 98% specificity for
discriminating the Class II group from the Class I group [Table 4] and [Figure 2]. The HBN angle >46 has 96%
sensitivity and 97% specificity for discriminating the Class III group from Class I group [Table 5] and [Figure 3].
Therefore,theROCcurvesshowthatthecutoffpointbetweentheClassIandClassIIgroupscouldbeconsidereda
HBNangleofapproximately39,Therefore,theROCcurvesshowthatthecutoffpointbetweentheClassIandClass
IIIgroupscouldbeconsideredaHBNangleofapproximately46.Those2numberscoincidewiththemeanvaluefrom
group 1 (42.88 2.23) SD. Therefore, it can be predicted with a high degree of certainty that a patient with a HBN
anglebetween39and46trulyhasaClassIskeletalpattern.TheresultsalsoindicatethatapatientwithaHBNangle
<39hasaClassIIskeletalpattern,andonewithaHBNangle>46hasaClassIIIskeletalpattern.{Figure2}{Figure3}

Discussion

An accurate AP measurement of jaw relationships is critically important in orthodontic treatment planning. ANB is still
widelyused,butitisaffectedbyvariousfactorsandcanoftenbemisleading.AsJacobsonnoted,itisaffectedbythe
patient's age, growth rotation of the jaws, vertical growth, and the length of the anterior cranial base (anteroposterior
positionofN).Moreover,pointAcannotbeidentifiedinallcephalometricradiographs.
Apopularalternative,theWitsappraisal,doesnotdependoncraniallandmarksorrotationofthejawsbutstillhasthe
problemofcorrectlyidentifyingthefunctionalocclusalplaneinconditionssuchasinmixeddentitionpatientsorpatients
with open bite, severe cant of the occlusal plane, multiple impactions, missing teeth, skeletal asymmetries or steep
curve of Spee. Second, any change in the angulations of the functional occlusal plane, caused by either normal
developmentofthedentition[11],[12]ororthodonticintervention,canprofoundlyinfluencetheWitsappraisal[13]Points
AandB,which,accordingtoHoldaway[18]changetheirsitesubstantiallyduetobothtreatmentandgrowth.
To overcome these problems, new measurement was developed by the name HBN angle. The HBN angle does not
dependoncraniallandmarksorthefunctionalocclusionplaneandpointAandpointB.Ithasthreelandmarkssuchas
theapparentaxisofthecondyle,Mmidpointofthepremaxilla,andGcenterofthelargestcirclethatistangenttothe
internalinferior,anterior,andposteriorsurfacesofthemandibularsymphysis.
Itismucheasierforthecliniciantofollowtheposteriorsurfaceoftheramusandlocatetheheadofthecondyle.The
advantageoflocating"C"thecenteroftheheadofthecondyleversusthecondylionpoint,asusedbyMcNamara[19]
is that very precise tracing of the contour of the condyle is not really necessary. The clinician can visualize and
approximatethecenterwithaminimumerrorintheHBNangleaslongasthatpointiswithin2mmofitsactuallocation.
Asshownin[Figure4],ifthetruecenterofthecondyleisatpointC,buttheclinicianlocatesitwithinacircleof2mm
radius,thentheHBNangleisaffected<1thismakesitsusestillacceptable.{Figure4}
Growth increments according to C axis up to age 14 in males and females display average yearly growth increments
1.14mmand1.31mm/year,respectively.Thisdifferenceisnotstatisticallysignificant.Growthincrementsaccordingto
G axis at 6 years female and male 97.8 mm and 97.6 mm, respectively. This difference is not statistically significant.
Thisclearlyindicatesthattheamountofchangesoccurringat"M"pointand"G"pointarepredictableandmoreovernot
statisticallydifferentinmalesandfemales.[20],[21]Hence,changesinthisanglereflectonlychangeswithinthejaws.
IncontrasttotheANBangle,theconfigurationoftheHBNanglegivesittheadvantagetoremainrelativelystableeven
whenthejawsarerotated[Figure5].Forexample,whenGpointisrotatedbackwardanddownward,thentheCGline
is also rotated in the same direction, carrying the perpendicular from point M with it. Because the MG line is also
rotatinginthesamedirection,theHBNangleremainsrelativelystable.{Figure5}
ThoughHBNangledoesnotindicatewhichjaw(maxilla/mandible)isatfaultbut,however,HBNanglecanbeusedfor
consecutivecomparisonthroughouttheorthodontictreatmentbecauseitreflectstruechangesofthesagittalrelationship
ofthejaws,whichmightbeduetogrowthororthodonticororthognathicintervention.

Conclusions

PreviouslyestablishedmeasurementsofassessingthesagittaljawrelationshipcanoftenbeinaccurateAnewangle,the
HBN angle was developed as a diagnostic aid to evaluate the sagittal jaw relationship more consistentlyHBN angle

between39and46indicatesaClassIskeletalpatternanHBNangle<39indicatesaClassIIskeletalpatternand
HBNangle>46indicatesaClassIIIskeletalpattern.ThereisnostatisticallysignificantdifferencebetweenmeanHBN
anglevaluesofmalesandfemales[Table7].{Table7}

References
1

MoyersRE,BooksteinFL,GuireKE.Theconceptofpatternincraniofacialgrowth.AmJOrthod197976:13648.

Downs WB. Variations in facial relationships their significance in treatment and prognosis. Am J Orthod
194834:81240.

FreemanRS.AdjustingANBanglestoreflecttheeffectofmaxillaryposition.AngleOrthod198151:16271.

MooreAW.Observationsonfacialgrowthanditsclinicalsignificance.AmJOrthod195945:399423.

Nanda RS. The rates of growth of several facial components measured from serial cephalometric
roentgenograms.AmJOrthod195541:65873.

BinderRE.Thegeometryofcephalometrics.JClinOrthod197913:25863.

7
8

JacobsonA.The"Wits"appraisalofjawdisharmony.AmJOrthod197567:12538.
JacobsonA.Applicationofthe"Wits"appraisal.AmJOrthod197670:17989.

HaynesS,ChauMN.ThereproducibilityandrepeatabilityoftheWitsanalysis.AmJOrthodDentofacialOrthop
1995107:6407.
RushtonR,CohenAM,LinneyAD.TherelationshipandreproducibilityofangleANBandtheWitsappraisal.BrJ
Orthod199118:22531.

10
11

Frank S. The Occlusal Plane: Reliability of Its Cephalometric Location and Its Changes with Growth [Thesis].
OklahomaCity:UniversityofOklahoma1983.

12

RichardsonM.Measurementofdentalbaserelationship.EurJOrthod19824:2516.

13

Sherman SL, Woods M, Nanda RS, Currier GF. The longitudinal effects of growth on the Wits appraisal. Am J
OrthodDentofacialOrthop198893:42936.

14

Nanda RS, Merrill RM. Cephalometric assessment of sagittal relationship between maxilla and mandible. Am J
OrthodDentofacialOrthop1994105:32844.
Margolis HI. A basic facial pattern and its application in clinical orthodontics. I: The maxillofacial triangle. Am J
OrthodOralSurg194733:631.

15
16

AdenwallaST,KronmanJH.ClassII,division1treatmentwithFrnkelandEdgewiseappliancesAcomparative
studyofmandibulargrowthandfacialesthetics.AngleOrthod198555:28198.

17

GianellyAA.BidimensionalTechnique:TheoryandPractice.Islandia,NewYork:GACInternational2000.

18

HoldawayRA.ChangesinrelationshipofpointsAandBduringorthodontictreatment.AmJOrthod195642:176
93.

19

McNamaraJAJr.Amethodofcephalometricevaluation.AmJOrthod198486:44969.

20

BraunS,RudmanRT,MurdochHJ,HickenS,KittlesonR,FergusonDJ.Caxis:Agrowthvectorforthemaxilla.
AngleOrthod199969:53942.

21

BraunS,KittlesonR,KimK.TheGAxis:Agrowthvectorforthemandible.AngleOrthod200474:32831.

Sunday,September06,2015
SiteMap|Home|ContactUs|Feedback|CopyrightandDisclaimer