Original Article

Overbite depth indicator and anteroposterior dysplasia indicator

cephalometric norms for African Americans
Samuel Obamiyia; Zhihui Wanga; Edward Sommersb; P. Emile Rossouwc; Dimitrios
Michelogiannakisd

ABSTRACT
Objectives: To examine normal Overbite Depth Indicator (ODI) and Anteroposterior Dysplasia
Indicator (APDI) values in African Americans and to compare them with mean values from white
patients. Secondary aims were to compare mean ODI and APDI values among different age,
gender, and combined age-gender groups in African American patients.

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Materials and Methods: Lateral cephalometric radiographs of 160 African American patients (97
boys and 63 girls; age, 7 to 14 years) with normal occlusion and no history of orthodontic treatment
were collected from the Bolton-Brush Growth Center. Cephalometric images were hand traced, and
ODI and APDI values were assessed. Two-sample t tests were used to compare mean ODI and
APDI values between African American and white patients; and between male and female African
American patients. One-way analysis of variance, followed by the Tukey test, was used to compare
mean ODI and APDI values among different African American age and combined age-gender
groups.
Results: Mean ODI and APDI values were significantly lower (P , .0001) in African American than
white patients with normal occlusion and no history of orthodontic treatment. Mean ODI and APDI
values increased with age in African American patients, and there were no significant gender
differences.
Conclusions: The mean ODI and APDI values in 7- to 14-year-old African Americans with normal
occlusion and no history of orthodontic treatment were 70.98 and 78.18, respectively, and were
significantly lower than the mean values for white patients in the same age range. (Angle Orthod.
2019;89:897–902.)
KEY WORDS: Anteroposterior dysplasia indicator; Cephalometric norms; Overbite depth indicator;
Races

INTRODUCTION
a
Resident, Department of Orthodontics and Dentofacial
Orthopedics, Eastman Institute for Oral Health, University of The advent of cone beam computed tomography
Rochester, Rochester, New York. has facilitated the three-dimensional evaluation of the
b
Clinical Professor, Department of Orthodontics and Dento-
craniofacial region. Nonetheless, conventional, two-
facial Orthopedics, Eastman Institute for Oral Health, University
of Rochester, Rochester, New York. dimensional radiographic techniques, such as pano-
c
Professor and Chairman, Department of Orthodontics and ramic and lateral cephalometric radiographs, are still
Dentofacial Orthopedics, Eastman Institute for Oral Health, widely used in orthodontic practice.1 Cephalometric
University of Rochester, Rochester, New York. radiography has played, and still plays, an important
d
Assistant Professor of Clinical Dentistry, Department of
Orthodontics and Dentofacial Orthopedics; and Community
role in orthodontic diagnosis and planning since it was
Dentistry and Oral Disease Prevention, Eastman Institute for introduced by Broadbent2 in 1931. Different cephalo-
Oral Health, University of Rochester, Rochester, New York. metric analyses have been developed, including
Corresponding author: Dr P. Emile Rossouw, Department of Downs, Tweed, Steiner, and Ricketts analyses; and
Orthodontics and Dentofacial Orthopedics, Eastman Institute for cephalometric norms have been established for differ-
Oral Health, University of Rochester, Rochester, NY 14620
(e-mail: emile_rossouw@urmc.rochester.edu) ent racial and ethnic groups.3–6
The Overbite Depth Indicator (ODI), as described by
Accepted: May 2019. Submitted: February 2019.
Published Online: July 15, 2019 Kim7 in 1974 has been used to assess the vertical
Ó 2019 by The EH Angle Education and Research Foundation, component of malocclusion. Kim evaluated the lateral
Inc. cephalometric radiographs of 119 patients (56 boys

DOI: 10.2319/021619-116.1 897 Angle Orthodontist, Vol 89, No 6, 2019

898 OBAMIYI, WANG, SOMMERS, ROSSOUW, MICHELOGIANNAKIS

and 63 girls) with normal occlusion from the Forsyth ODI and APDI values in African American patients and
Dental Center to determine predictors of incisal to compare them with previously published mean
overbite depth. The patients were all white children values from whites.7,8 Secondary aims were to com-
between the ages of 7 and 14 years (mean age 10 pare mean ODI and APDI values among different age,
years and 8 months). Additionally, lateral cephalomet- gender, and combined age-gender groups in African
ric radiographs of 500 white patients with untreated American patients.
malocclusions from the private dental office of Kim in
Weston, Massachusetts, were assessed in a similar MATERIALS AND METHODS
fashion. Findings from this study showed that the
This retrospective, cross-sectional study was ex-
incisal overbite depth was most strongly correlated with
empt from review by an Institutional Review Board (no.
the angle formed by the AB plane to the mandibular
plane combined with the angle formed by the palatal RSRB00071427) at Eastman Institute for Oral Health,
plane and the Frankfort horizontal plane; and this University of Rochester, Rochester, New York, under
combined measurement was termed ‘‘ODI.’’7 The mean category 45 CFR 46.101.
ODI value for the clinically normal occlusion sample The study sample consisted of 160 African American
was 74.58 (standard deviation ¼ 6.078); mean ODI patients (97 boys and 63 girls) ranging in age from 7 to

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values were significantly different in patients with, than 14 years. The sample was collected from records
those without, malocclusion. Furthermore, it was derived from the Bolton-Brush Growth Center at Case
reported that as ODI increased, there was a tendency Western Reserve University (publicly available at www.
for the overbite to increase, and as the ODI decreased, AAOFlegacycollection.org). The inclusion criteria) were
there was a tendency toward an anterior open bite. (a) radiographs of adequate diagnostic quality; (b)
The Anteroposterior Dysplasia Indicator (APDI) as Angle17 Class I molar relationship; (c) normal occlusion
described by Kim et al.8 has been used to assess the (no crossbite, no openbite, no spacing, no crowding,
skeletal relationship in the anteroposterior plane. The overbite and overjet within normal limits); (d) 7 to 14
APDI is obtained from three measurements: the facial years old; (e) African American; and (f) no history of
angle, the A-B plane, and the palatal plane in relation orthodontic treatment. Participants with malocclusion
to the Frankfort horizontal plane. Geometrically, the (such as crossbite, openbite, spacing, crowding, Angle
APDI is equal to the angle formed by the A-B plane and Class II or Class III malocclusion), history of orthodon-
the palatal plane.9 The mean APDI value for patients tic treatment, age younger than 7 years or older than
with normal (Class I) occlusion was found to be 81.48 14 years, radiographs of poor diagnostic quality, and
(standard deviation ¼ 3.798). Smaller APDI values races other than African American were excluded.
relative to the mean indicate a Class II malocclusion, Participants were categorized into different age (7,
while larger APDI values suggest a Class III maloc- 8–9, 10–11, 12, 13, 14 years), gender (male and
clusion. female) and combined-age gender groups. Female
Several cephalometric analyses have been devel- patients (n ¼ 63) were divided in 4 chronological age
oped to diagnose dental malocclusion and the corre- groups; ages 7 (n ¼ 16), 8-9 (n ¼ 16), 10-11 (n ¼ 15),
sponding skeletal discrepancy with varying and 12-14 (n ¼ 16) years. Male patients (n ¼ 97) were
predictability.10 Previous researchers have shown that divided into 6 chronological age groups: ages 7 (n ¼
he ODI and APDI variables demonstrate a high 17), 8–9 (n ¼ 16), 10–11 (n ¼ 16), 12 (n ¼ 16), 13 (n ¼
diagnostic value in making a link between dental 16), and 14 (n ¼ 16) years.
malocclusion and the corresponding skeletal discrep- Lateral cephalometric radiographs were obtained for
ancy using the receiver operating characteristic anal- each patient, and cephalometric images were hand
ysis.11,12 The ODI and APDI cephalometric variables traced and measured by one standardized and
have assisted orthodontists in proper diagnosis and calibrated investigator (S.O.). The mandibular plane
treatment planning; however, mean ODI and APDI (from menton to gonion), A-B plane (A point to B point
values have been assessed only in whites7,8 and plane), palatal plane (Posterior Nasal Spine [PNS] to
Asians.13,14 To date, there are no published data Anterior Nasal Spine [ANS]), and Frankfort horizontal
regarding the mean ODI and APDI values in African (FH) plane were traced to determine the ODI and APDI
Americans. variables. The ODI variable was defined as the angle
Because differences exist in dentoskeletal and formed by the A-B plane to the mandibular plane
cephalometric characteristics among different racial combined with the angle formed by the palatal plane
groups,15,16 we hypothesized that mean ODI and APDI and the FH plane. When the palatal plane (PNS-ANS)
values would be significantly different between African slopes upward anteriorly (ANS) in relation to the FH
American and white patients. With this background, the plane, the value of the angle between the palatal plane
aim of this retrospective study was to evaluate mean and FH plane (PP-FH angle) is subtracted from the

Angle Orthodontist, Vol 89, No 6, 2019

OPI AND APDI NORMS IN AFRICAN AMERICANS 899

Table 1. Descriptive Statistics of ODI and APDI Values for the Total
Study Sample and Age Groupsa
Age, y Variable N Mean SD Median
7 ODI 33 68.1 4.4 68.0
APDI 33 76.4 4.4 76.0
8–9 ODI 32 72.0 5.5 70.5
APDI 32 77.1 3.9 77.0
10–11 ODI 31 71.1 5.8 71.0
APDI 31 79.2 3.6 79.0
12 ODI 17 70.9 5.9 73.0
APDI 17 77.6 3.8 76.0
13 ODI 17 69.4 6.2 69.5
APDI 17 79.9 4.9 80.5
14 ODI 30 73.2 6.4 71.5
APDI 30 79.2 4.1 79.0
Total ODI 160 70.9 5.8 70.0
APDI 160 78.1 4.2 77.5
a
APDI indicates Anteroposterior Dysplasia Indicator; F, female;

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M, male; N, number of patients; ODI, Overbite Depth Indicator; SD,
standard deviation.

followed by the Tukey test, was used to compare the

mean ODI and APDI values among different African
American age, and combined age-gender groups.
Differences were considered significant when P ,
Figure 1. Digital lateral cephalometric radiograph illustrating the .05. All data were implemented with SAS 9.2 software
planes used to determine the ODI and APDI variables. Abbreviations: (SAS Institute Inc, Cary, NC).
A-B plane indicates A-point to B-point plane; APDI, Anteroposterior
Dysplasia Indicator; FH, Frankfort horizontal plane; MP, mandibular
plane; ODI, Overbite Depth Indicator; PP, palatal plane.
RESULTS
The intra- and interobserver reliabilities were high
ODI value, whereas if the palatal plane slopes (concordance correlation coefficient .0.95).
downward anteriorly (ANS), the value of the PP-FH
angle is added to the ODI value.7 The APDI variable ODI
was defined as the angle formed by the A-B plane and
the palatal plane (Figure 1).7,8 Tables 1 through 3 present the ODI values of the
The same investigator (S.O.) retraced 16 randomly total study sample and age groups, gender groups,
selected radiographs 1 week later to evaluate the and combined age-gender groups, respectively. The
intrainvestigator reliability. A second investigator (E.S.) total study sample had a mean age of 10.28 (standard
retraced 16 randomly selected radiographs to assess deviation ¼ 2.67 years). The ODI values of the total
the interinvestigator reliability. study sample (n ¼ 160) ranged between 568 and 908.
The overall mean and median ODI values for the total
Statistical Analysis study sample were 70.98 and 708, respectively (Table
1). The mean ODI values were significantly different
The sample-size estimation was based on power
between African American (70.9) and white (74.5)7
analysis. A sample size of 144 patients achieved 80%
patients (P , .0001). There were significant differenc-
power, with significance level set at .05, assuming that
the length of the 95% confidence interval was 2. The es (P ¼ .0048) in the mean ODI values among the
concordance correlation coefficient was used to
Table 2. Descriptive Statistics of ODI and APDI Values for Gender
measure the intra- and interobserver reliabilities.18 Groupsa
Descriptive statistics, including mean, median, stan-
Gender N Variable N Mean SD Median Min Max
dard deviation, and range values were calculated for
the ODI and APDI measurements. A two-sample t-test F 63 ODI 63 70.3 5.2 70 59 83
APDI 63 78.6 4.7 79 68 90
was used to compare the mean ODI and APDI values
M 97 ODI 97 71.2 6.2 70 56 90
between African American and white7,8 patients. A two- APDI 97 77.8 3.9 77 70 90
sample t-test was performed to compare the mean ODI a
APDI indicates Anteroposterior Dysplasia Indicator; F, female;
and APDI values between male and female African M, male; Min, minimum; Max, maximum; N, number of patients; ODI,
American patients. One-way analysis of variance , Overbite Depth Indicator; SD, standard deviation.

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900 OBAMIYI, WANG, SOMMERS, ROSSOUW, MICHELOGIANNAKIS

Table 3. Descriptive Statistics of ODI and APDI Values for between 7 and 14 years old with normal occlusion
Combined Age-Gender Groupsa and no history of orthodontic treatment.7,8 To date,
Group N Variable Mean SD Median mean ODI and APDI values have not been assessed in
F7 16 ODI 67.4 4.5 68.5 an African American sample. In the present retrospec-
APDI 76.1 5.2 75.5 tive study, it was hypothesized that mean ODI and
F8–9 16 ODI 71.3 5.6 69.5 APDI values were significantly different between
APDI 77.4 3.8 77
African American and white patients. To test this
F10–11 15 ODI 71 5.7 71
APDI 80.5 3.9 80 hypothesis, and to examine normal ODI and APDI
F12–14 16 ODI 71.7 4.3 71 values in African Americans, lateral cephalometric
APDI 80.7 4.4 80 radiographs from African American patients with
M7 17 ODI 68.6 4.2 67 normal occlusion and no history of orthodontic treat-
APDI 76.6 3.6 76
ment, between 7 and 14 years old, were assessed.
M8–9 16 ODI 72.7 5.5 72
APDI 76.8 4.2 76.5 Results from the present study supported the research
M10–11 16 ODI 71.3 6 71 hypothesis and showed significant racial differences in
APDI 78.1 3.1 78 the mean ODI and APDI values between white and
M12 16 ODI 70.9 5.9 73 African American patients.

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APDI 77.6 3.8 76
It has been reported that differences exist in the
M13 16 ODI 69.4 6.2 69.5
APDI 79.9 4.9 80.5 craniofacial form and dentoskeletal characteristics
M14 16 ODI 74.8 7.9 71.5 among various races.15,16 In the present study, it was
APDI 77.6 3.1 77 shown that the mean ODI value was significantly lower
a
APDI indicates Anteroposterior Dysplasia Indicator; F, female; in African American patients than white patients with
M, male; N, number of patients; ODI, Overbite Depth Indicator; SD, normal occlusion and no history of orthodontic treat-
standard deviation.
ment. This finding indicates that African American
patients had a more vertical growth pattern compared
African American age groups. Specifically, the Tukey with white patients and a tendency toward decreased
test showed that mean ODI values were significantly overbite.7 Similarly, Dibbets and Nolte19 found that,
different (P ¼ .0043) between patients aged 7 years while both European American and African American
and 14 years, and there were no significant differences patients exhibited identical upper face height, the
among the other age groups. There were no significant African Americans had a longer total face height
differences in the mean ODI values among male (n ¼ resulting from a significantly longer lower face height
97) and female (n ¼ 63) African American patients. No than European Americans. Other studies3,19 have also
significant differences in the mean ODI values were reported that the mandibular plane angle was steeper20
reported among combined age-gender groups. and the palatal plane was tipped up anteriorly3 in
African American patients compared with white pa-
APDI tients. Results from the present study indicated that the
The APDI values of the total study sample (n ¼ 160) mean APDI values were significantly lower in African
ranged between 688 and 908. The overall APDI mean American patients compared with white patients. Since
and median values of the total study sample were 78.18 lower APDI values have been associated with a more
and 77.58, respectively (Table 1). The mean APDI values convex skeletal profile,8 the results also indicated that
were significantly different (P , .0001) between the skeletal convexity was increased in African American
African American (78.1) and white (81.4)8 samples. patients compared with white patients with normal
Significant differences (P ¼ .004) were identified in the occlusion and no history of orthodontic treatment. This
mean APDI values among African American age groups; is in accordance with previous studies3,21 that found
in addition, the mean APDI values were significantly greater mean SNA, SNB, and ANB angles3 and more
increased (P ¼ .05) in 13-year-old patients compared convex, bimaxillary protrusive profiles in African
Americans compared with whites.22 Future research
with 7-year-old patients. There were no significant
is warranted to assess and compare mean ODI and
differences in the mean APDI values among male (n ¼
APDI values among other racial groups, such as
97) and female (n¼ 63) African American patients. There
Asians, Hispanics, Native Americans, and Native
were no significant differences in the mean APDI values
Hawaiians.
among combined age-gender groups.
It is important to note that, based on the inclusion
criteria, more male patients (n ¼ 97) than female
DISCUSSION
patients (n ¼ 63) were included in the present African
The normal ODI and APDI values used in cephalo- American sample. Since no significant differences
metric analysis were derived from white patients were found in the mean ODI and APDI values between

Angle Orthodontist, Vol 89, No 6, 2019

OPI AND APDI NORMS IN AFRICAN AMERICANS 901

male and female African American patients, male and introduce bias in the measurements. Nonetheless,
female African American patients were pooled together radiographs of adequate diagnostic quality were
to test the primary hypothesis. Faustini and cowork- included in the present study, a standardized and
ers22 reported an increased vertical skeletal divergence calibrated examiner conducted all measurements, and
in African American males than females. While an the intra- and interobserver reliabilities were high, thus
increased hyperdivergence would suggest lower ODI minimizing the risk of measurement errors.
values in males, this was not observed in the present It is pertinent to mention that in the present study and
study. Nonetheless, the findings of the present study the study by Kim,7 mean ODI and APDI values were
were congruent with the results of Huang et al.,3 who assessed in patients between 7 and 14 years old with
found no significant differences in various angular and mean ages of 10.28 6 2.67 and 10.67 years,
linear cephalometric measurements between male and respectively. It has been reported that craniofacial
female white and African American patients. Addition- growth changes occur between the ages of 13 and 17
ally, a trend was shown in the present study for both years that affect the mandible and, to a lesser degree,
the ODI and APDI values to increase with age in the maxilla.28 Studies have also shown that subtle
African American patients between 7 and 14 years. anteroposterior and vertical changes in craniofacial
This may be explained by normal growth of the morphology may continue throughout adulthood.29,30 It

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mandible during the prepubertal growth period,23 which is therefore hypothesized that mean ODI and APDI
increases both the vertical and anteroposterior dimen- values are significantly different between patients
sions of the mandible, resulting in larger ODI and APDI younger than 7 years, between 7 and 14 years old,
values. Although the present study found no significant and older than 14 years (late adolescents and adults).
differences in the mean ODI and APDI values among Further research is needed to test this hypothesis.
the combined age-gender groups in African American It has been reported that significant differences exist
patients, this could be attributed to sample-size in the mean ODI and APDI values between white
limitations, leading to limited power when performing
patients with and without malocclusion.7,8 It is worth
combined age-gender group comparisons. Further-
noting that, in the present study, mean ODI and APDI
more, due to a limited number of patients representing
values were assessed in African American patients
specific ages (such as 9 and 11 years), patients were
with normal occlusion and no history of orthodontic
grouped based on age ranges to perform meaningful
treatment. It is suggested that mean ODI and APDI
statistical comparisons. In this respect, further research
values are significantly different among African Amer-
is needed to assess the impact of age and gender on
ican patients with and without malocclusion. Further
the mean ODI and APDI values in African American
research is needed in this regard.
patients.
A limitation of the present study was that a white
CONCLUSIONS
sample was not selected from the Bolton Brush sample
as were the African American patients; instead, normal  The mean ODI and APDI values in 7- to 14-year-
ODI and APDI values in white patients were derived oldAfrican American patients with normal occlusion
from previous publications.7,8 It has been reported that and no history of orthodontic treatment were 70.98
results from historical controls should be interpreted and 78.18, respectively.
with caution due to an increased risk of selection  The null hypothesis of the present study was
bias.24,25 Studies have shown that the severity of rejected; the mean ODI (70.98) and APDI (78.18)
selection bias when using historical data as controls values are significantly lower in African American
has not yet been fully appreciated in the field of human patients compared with white patients between 7 and
evolutionary demography. 26,27 The decision to use the 14 years old.
white norms by Kim7 and Kim et al.8 was based on their  Mean ODI and APDI values increased with age in
wide use and acceptability when utilizing ODI and African American patients between 7 and 14 years
APDI variables in orthodontic diagnosis and treatment old.
planning. In this respect, African American patients  No significant differences exist in the mean ODI and
with normal occlusion between the ages of 7 and 14 APDI values between African American male and
years (mean age ¼ 10.28 6 2.67 years) were included female patients between 7 and 14 years old.
in this study in an effort to match the Kim7 and Kim et
al.8 sample (age 7 to 14 years; mean age 10.67 years)
and minimize selection bias. Another limitation of the ACKNOWLEDGMENT
present study was that the tracing measurements for The authors wish to thank Dr C. Feng, Eastman Institute for
the African American and white patients were conduct- Oral Health, University of Rochester, for his statistical
ed by different examiners, which may potentially assistance.

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902 OBAMIYI, WANG, SOMMERS, ROSSOUW, MICHELOGIANNAKIS

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