Versions
- 2026-06-23 (3)
- 2026-06-02 (2)
- 2026-05-19 (1)
Keywords
Diagnostic imaging
Malocclusion
Orthodontics
Statistical analyses
How to Cite
Abstract
Objectives: 1) to determine the diagnostic agreement between five skeletal class cephalometric indicators and four facial biotype cephalometric indicators through Cohen's weighted kappa test, and 2) to compare these results against those obtained after applying Cohen's weighted Chi-square test.
Material and methods: In a sample of 439 lateral teleradiographies, skeletal class indicators (ANB angle, APDI, FABA angle, Wits indicator and beta angle) and facial biotype indicators (FMA, skull base angle, Bjork Jarabak polygon and VERT index) were determined. Diagnostic concordance between them was assessed with Fleiss' kappa, Cohen's weighted kappa and Cohen's weighted Chi-square tests.
Results: Statistically significant differences were observed both in the diagnosis of skeletal class and facial biotype. While in Cohen's weighted kappa test, most of the concordances between skeletal class and facial biotype indicators were “Mild” or “Moderate”, Cohen's weighted Chi-square test showed highly significant discordance in most comparisons, with negative values of the Fleiss' kappa test, indicating the systematic absence of concordance when considering all indicators simultaneously (Fleiss' kappaskeletal class= -0.0714, z = -1.46, p-value = 0.143; Fleiss' kappafacial byotipe= -0.0909, z = -1.28, p-value = 0.201).
Conclusion: 1) When studying the diagnostic agreement between the five skeletal class indicators and the four facial biotype indicators, significant differences were found between them, a result consistently supported by the use of Cohen's weighted Chi2 statistical test, and 2) In relation to the tests to be used to know the level of statistical significance of the diagnostic concordance, it is recommended to take into account: (i) if the evaluators are only two, and they don’t show an extreme discordance in their respective evaluations, use the “classical” Cohen's kappa, (ii) if the evaluators are only two, and they do show an extreme discordance in their respective evaluations, then use Cohen's weighted kappa, and, (iii) for more than two evaluators apply the Cohen's weighted Chi-square test.
References
Sassouni V. A classification of skeletal facial types. Am J Orthod. febrero de 1969;55(2):109-23.
Cerda-Peralta B, Schulz-Rosales R, López-Garrido J, Romo-Ormazabal F. Parámetros cefalométricos para determinar biotipo facial en adultos chilenos. Rev Clínica Periodoncia Implantol Rehabil Oral. 2019;12(1):8-11.
Chite-Quispe L, Sánchez-Tito M. Analysis of the association between facial biotype, overbite and overjet in the permanent dentition. J Clin Exp Dent. 1 de mayo de 2023;15(5):e376-81.
Costea MC, Bondor CI, Muntean A, Badea ME, Mesaroş AŞ, Kuijpers-Jagtman AM. Proximity of the roots of posterior teeth to the maxillary sinus in different facial biotypes. Am J Orthod Dentofac Orthop Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod. septiembre de 2018;154(3):346-55.
Mizoguchi I, Toriya N, Nakao Y. Growth of the mandible and biological characteristics of the mandibular condylar cartilage. Jpn Dent Sci Rev. noviembre de 2013;49(4):139-50.
Riddle PC, Nickel JC, Liu Y, Gonzalez YM, Gallo LM, Conley RS, et al. Mechanobehavior and mandibular ramus length in different facial phenotypes. Angle Orthod. noviembre de 2020;90(6):866-72.
Saadeh M, Fayyad-Kazan H, Haddad R, Ayoub F. Facial soft tissue thickness differences among different vertical facial patterns. Forensic Sci Int. 1 de diciembre de 2020;317:110468.
Baik CY, Ververidou M. A new approach of assessing sagittal discrepancies: The Beta angle. Am J Orthod Dentofacial Orthop. 2004;126(1):100-5.
Jacobson A. The “Wits” appraisal of jaw disharmony. Am J Orthod. 1 de febrero de 1975;67(2):125-38.
Kim Y. WebCeph: Artificial Intelligence Orthodontics and Cloud-Based Orthognatics Platform. [Internet]. [citado 26 de septiembre de 2024]. Disponible en: https://www.webceph.com
Steiner CC, Hills B. Cephalometrics for you and me. Am Journa Orthod. 1953;39(10):729-55.
Rodriguez-Cardenas YA, Arriola-Guillen LE, Flores-Mir C. Björk-Jarabak cephalometric analysis on CBCT synthesized cephalograms with different dentofacial sagittal skeletal patterns. Dent Press J Orthod. diciembre de 2014;19(6):46-53.
Tweed CH. The Frankfort-mandibular plane angle in orthodontic diagnosis, classification, treatment planning, and prognosis. Am J Orthod Oral Surg. abril de 1946;32:175-230.
Riedel R. The relation of maxillary structures to cranium in malocclusion and in normal occlusion. Angle Orthod. 1952;22:142-5.
Paddenberg E, Proff P, Kirschneck C. Floating norms for individualising the ANB angle and the WITS appraisal in orthodontic cephalometric analysis based on guiding variables. J Orofac Orthop. 2021;
Nagar S, Nagar R, Raghav P. Why WITS? Why not a way beyond? Contemp Clin Dent. 2014;5(4):518.
Yang SD, Suhr CH. F-H to AB plane angle (FABA) for assessment of anteroposterior jaw relationships. Angle Orthod. 1 de junio de 1995;65(3):223-31.
Gregoret J. Instrumentación de la cefalometría estática lateral. En: Ortodoncia y cirugía ortognatica : diagnóstico y planificación [Internet]. Barcelona: Espaxs; 1998. p. 227-32. Disponible en: https://books.google.com/books/about/Ortodoncia_y_cirugia_ortognática.html
Cohen J. A Coefficient of Agreement for Nominal Scales. Educ Psychol Meas. abril de 1960;20(1):37-46.
Vach W, Gerke O. Gwet’s AC1 is not a substitute for Cohen’s kappa – A comparison of basic properties. MethodsX. 2023;10:102212.
Cohen J. Weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit. Psychol Bull. octubre de 1968;70(4):213-20.
Cohen J. Weighted Chi Square: an Extension of the Kappa Method. Educ Psychol Meas. abril de 1972;32(1):61-74.
Ahmed M, Shaikh A, Fida M. Diagnostic performance of various cephalometric parameters for the assessment of vertical growth pattern. Dent Press J Orthod. agosto de 2016;21(4):41-9.
Ahmed M, Shaikh A, Fida M. Diagnostic validity of different cephalometric analyses for assessment of the sagittal skeletal pattern. Dent Press J Orthod. 2018;23(5):75-81.
Benedicto EDN, Kairalla SA, Oliveira GMS, Junior LRM, Rosário HD, Paranhos LR. Determination of vertical characteristics with different cephalometric measurements. Eur J Dent. enero de 2016;10(01):116-20.
Zaffiri VZ, Idrovo JDI, Manríquez G, Diaz A. Determinación de la clase esqueletal mediante el indicador de Wits: ¿es correcto diferenciar la norma entre sexos? Odontoestomatología [Internet]. 18 de diciembre de 2024 [citado 8 de abril de 2025];26(44). Disponible en: https://odon.edu.uy/ojs/index.php/ode/article/view/702
Ricketts R. Orthodontic Diagnosis and Planning:Their Roles in Preventive and Rehabilitative Dentistry. En: Orthodontic Diagnosis and Planning:Their Roles in Preventive and Rehabilitative Dentistry. Rocky Mountain/Orthodontics; 1982.
Fleiss JL. Measuring nominal scale agreement among many raters. Psychol Bull. noviembre de 1971;76(5):378-82.
RStudio Team. RStudio: Integrated Development Enviroment for R [Internet]. Disponible en: https://www.rstudio.com/
Matthias Gamer, Jim Lemon, Ian Fellows, Puspendra Singh. Irr: Various Coefficients of Interrater Reliability and Agreement [Internet]. 2005 [citado 15 de agosto de 2025]. p. 0.84.1. Disponible en: https://CRAN.R-project.org/package=irr
Meyer D, Zeileis A, Hornik K, Friendly M. VCD: Visualizing Categorical Data [Internet]. 2002 [citado 26 de septiembre de 2024]. p. 1.4-13. Disponible en: https://CRAN.R-project.org/package=vcd
Landis JR, Koch GG. The Measurement of Observer Agreement for Categorical Data. Biometrics. 1977;33(1):159.
Halazonetis DJ. Morphometrics for cephalometric diagnosis. Am J Orthod Dentofacial Orthop. 2004;125(5):571-81.
Chang HP, Liu PH, Chang CH. Midfacial and mandibular morphometry of children with Class II and Class III malocclusions. Journal of Oral Rehabilitation; 2005 p. 642-7.
Díaz A, Manríquez G. Skeletodental Diagnosis Using a Geometric Morphometric Approach. Int J Odontostomatol. 2014;8(1):05-11.
Moyers RE, Bookstein FL. The inappropriateness of conventional cephalometrics. Am J Orthod. 1979;75(6):599-617.
McIntyre GT, Mossey PA. Size and shape measurement in contemporary cephalometrics. Eur J Orthod. 2003;25(3):231-42.
Castro Arenas MV, Hurtado Peralta M, Oyonarte Weldt R. Performance of cephalometric asessment for sagital intermaxillary diagnosis. A narrative review. Rev Clínica Periodoncia Implantol Rehabil Oral. agosto de 2013;6(2):96-101.
James Rohlf F, Marcus LF. A revolution morphometrics. Trends Ecol Evol. 1993;8(4):129-32.
Freudenthaler J, Čelar A, Ritt C, Mitteröcker P. Geometric morphometrics of different malocclusions in lateral skull radiographs. J Orofac Orthop. 1 de enero de 2017;78(1):11-20.
Wilhelm BM, Beck FM, Lidral AC, Vig KW. A comparison of cranial base growth in Class I and Class II skeletal patterns. Am J Orthod Dentofac Orthop Off Publ Am Assoc Orthod Its Const Soc Am Board Orthod. abril de 2001;119(4):401-5.
Jacob HB, Buschang PH. Mandibular growth comparisons of Class I and Class II division 1 skeletofacial patterns. Angle Orthod. septiembre de 2014;84(5):755-61.
Polat OO, Kaya B. Changes in cranial base morphology in different malocclusions. Orthod Craniofac Res. noviembre de 2007;10(4):216-21.
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Copyright (c) 2026 Germán Manríquez, Juan Diego Idrovo, Valentina Zaffiri Estévez, Alejandro Diaz