Component analysis of Class II, Division

1 discloses limitations for transfer to

Class I phenotype
Joseph G. Ghafari, DMD, and Anthony T. Macari, DDS, MS

Any malocclusion, most particularly Class II, must be diagnosed and treated
on the basis of its many components and not simplified to one or only several
spatial relationships. Research points out the inability of common approaches
of treatment to transform a Class II, Division 1 phenotype to a facial pattern
with normal skeletal relationships that would be expected with a Class I
phenotype. These observations underscore the structural differences
between the various classes of malocclusion in addition to the definition of
treatment outcome as the cumulative effect of small-to-moderate changes in
the various skeletal and dentoalveolar components of the malocclusion,
rather than a major change in simply one of its components. Available data on
component growth in untreated Class II further support these observations.
(Semin Orthod 2014; 20:253–271.) & 2014 Elsevier Inc. All rights reserved.

he study of Class II, Division 1 should be The core cause of this reality is the fact that a
T approached in evaluating the potential of its
correction to neutroclusion, not only at the level
“Class II face” is simply a different phenotype
than a “Class I” appearance, which is often
of the occlusion, but necessarily in consideration characterized with an “orthognathic profile.”
of the surrounding soft tissue envelope. The This statement is not an admission that genetic
latter relates to achieving periodontal health in constraints, translated into constitutional limi-
the oral cavity, and facially to the possibility of tations, force therapeutic concessions. Actually,
attaining an orthognathic profile that is com- environmental factors may be behind the phe-
mensurate with a well-interdigitated Class 1 notypical “landscape.” Accordingly, the study of
occlusion (and corresponding normal cephalo- the malocclusion must consider the components
metric measurements). Any result short of this of the phenotype before addressing the possi-
definition must be considered a compromise, bilities of treatment.
whether mild or maximal. In this context, the Our aim in this paper is to explore the various
expert orthodontist knows that the majority of skeletal and soft tissue constituents of Class II,
the corrections of the Division 1 distoclusion are Division 1, its etiological derivations, diagnostic
indeed compromises. The achievement of features, and finally therapeutic modalities and
“normal skeletal” relations between the jaws is outcome. Each of these panels will be appro-
difficult and neutroclusion is often obtained at ached with the corresponding scientific evi-
the expense of compensatory inclinations of dence, where available.
maxillary and mandibular incisors. The discussion of Class II, Division 1 maloc-
clusion necessarily brings up the original defi-
nition by EH Angle1a: “Lower arch distal to
Division of Orthodontics and Dentofacial Orthopedics, Depart-
normal in its relation to the upper arch—
ment of Otolaryngology-Head and Neck Surgery, Faculty of Medicine, bilaterally distal, protruding upper incisors.”
American University of Beirut, Beirut, Lebanon. Often missing in the communication and
Address correspondence to Anthony T. Macari, DDS, MS, teaching of Angle's definition are 2 tenets that
Division of Orthodontics and Dentofacial Orthopedics, American
the author associated with his classification and
University of Beirut Medical Center, PO Box 11-0236, Riad el Solh,
Beirut 1107 2020, Lebanon. E-mail: am43@aub.edu.lb
its treatment: (1) it is “primarily, at least,
& 2014 Elsevier Inc. All rights reserved.
associated with mouth breathing,”1a inducing
1073-8746/12/1801-$30.00/0 the discussion of etiology; (2) “begin treatment as
http://dx.doi.org/10.1053/j.sodo.2014.09.003 near the beginning of the variation from the

Seminars in Orthodontics, Vol 20, No 4 (December), 2014: pp 253–271 253

254 Ghafari and Macari

normal in the process of development of the diagnosis and, at least theoretically, call for a dif-
dental apparatus as possible,”1b requiring the ferently focused treatment plan.7 In a basic frag-
proper scrutiny of treatment timing. The remain- mentation, no less than 4 units are recognized: the
ing variable that must be addressed relates to the maxillary and mandibular skeletal bases and the
modality of treatment. Appliances may target the corresponding dentoalveolar units. Accordingly, 16
maxilla (e.g., headgear), the mandible (e.g., combinations are possible that do not translate into
functional appliances), or both. In this context, an equal number of therapeutic approaches.
maxilla and mandible refer to both skeletal and Indeed, Class II, Division 1 has been historically
dental structures within the jaw, prompting evaluated as a generic entity distinguished by
segregation of the different components of the mandibular retrognathism, maxillary prognathism
malocclusion within and between the jaws. (albeit refuted as non-occurring by Angle him-
self),1d or a combination thereof. In this scheme,
the dentition often is viewed as compensating for
The Class II, Division 1 phenotype the underlying skeletal discrepancies, of which the
severe ones may represent therapeutic challenges.
Description of Class II, Division 1
At least in this zone of severity, perhaps
Angle1a referred to Class II as the distal “lock” of corresponding to the “pure” definition by Angle,
the lower first molars with the upper first molars can a Class II, Division 1 phenotype be described?
“to the extent of more than one-half the width of Only a few of the many variations are listed to
one cusp on each side.” This description allows illustrate deviations of some key components of
for less than full interdigitation of the molars in the Class II dentofacial complex8: the maxilla
Class II and underscores the principle of bilat- and teeth are anteriorly positioned relative to the
erality, singling out the asymmetry of neu- cranium; the maxillary teeth are anteriorly
troclusion as a “Subdivision.” This classification placed in a normally positioned maxilla; post-
simplified a rather complex relationship among eriorly positioned mandible of normal size;
various skeletal and dentoalveolar units at the underdeveloped mandible; posteriorly posi-
level of their occlusal “meeting plane.” Angle's tioned mandibular teeth on normally posi-
categorization provides a practical guide that also tioned mandible; and various combinations of
facilitates clinical and scientific communication. the above relationships. Further combinations
Mislabeling often is perpetrated when a maloc- must be considered (and many times multiplied)
clusion falls between strict categories of Class I when we distinguish side differences and lip
and Class II. Consequently, authors have advo- variations. Even more arrangements emerge
cated to section the “molar occlusion” into when various parts of a jaw (e.g., mandibular
quarter or half cusps, particularly in research that ramus and chin) and relations among
requires quantification of malocclusion and subcomponents are implicated in the diagnosis
treatment outcome,2,3 and to distinguish gra- and treatment planning (see section Components
dients of overjet severity; whereby, arose the of Class II, Division 1); notwithstanding the vertical
misnomers of Class I, Division 1 or Class I, parameters of malocclusion themselves subject to
Division 2.4,5 Other authors have advocated compartmentalization.7
replacing the Angle classification.2,6 In additional
scrutiny of Angle's1c description, it seems that he
Etiology
had defined a specific “phenotype”: “distal
occlusion of the teeth of both halves of the Different inherited and developmental factors
lower dental arches; a narrowed upper arch, contribute to the formation and eventual treat-
lengthened and protruded upper incisors, short ment of Class II, Division 1. Angle's attribution of
and partially functionless upper lip, lengthened a specific etiology to this malocclusion,1a also
lower incisors, and thickened lower lip.” asserting that Class II, Division 2 does not have a
Enumeration of the various deviations from similar cause, opens up a panel of considerations
the original description invite the realization that of environmental effects in the former
any malocclusion must be dissected into its (supported by mounting evidence), while the
components, because a different arrangement of latter has subsequently been linked with more
these components would yield a nuanced genetic components. Indeed, as Angle suggested,
 Component analysis of Class II, Division 1 occlusion 255

the “Division 1” is at least partially related to development than at the later stages,
mouth breathing. Without much scientific rigor, suggesting the possibility of a “catch-up”
Angle further differentiated mouth breathing period in mandibular growth in Class II,
caused by adenoid blockage as causing Class II, Division 1 subjects at the later stages of
Division 1, while that caused by enlarged tonsils development.
generated Class III malocclusion.1e (5) Soft tissue and nose: Antero-posterior growth
Later evidence, amassed over 100 years after of the nose and soft tissue profile (lips and
Angle's statements, has not reached finalized chin) and subsequent increased anterior
conclusions. Oral breathing has been associated projection of the nose continued in
with increased overjet (along with posterior untreated Class I and Class II, for both
crossbite and anterior open bite, jointly or sep- genders, after skeletal growth had subsided.
arately), but not always with distoclusion. This Females conclude a large proportion of their
finding should not be surprising in light of soft tissue development by age 12 years while
Harvold's experiments of blocking nasal breath- that of males continued until age 17 years,
ing in monkeys, which yielded different maloc- resulting in greater soft tissue dimensions.16
clusions, including Class III.9 Similar findings The angular shapes and positional relation-
have been reported in growing children.10 ships of the nose, lips, and chin remained
Nevertheless, in this context, the environ- constant in both sexes and were independent
mental injury of disturbed breathing occupies of the underlying hard tissues. Particularly,
a paramount place in the etiology of Division 1, nose development was autonomous of the
even though genetics must be at play. One skeletal relationship or unrelated to gender.
hypothesis worth exploring is the potential for (6) Facial profiles of untreated Class II subjects
genetic factors to be prominent in the most maintain their original configuration com-
severe malocclusions. pared to the profiles of treated patients that
show a tendency for improvement.13
Growth in Class II patients
State of evidence on treatment outcome of
The following statements summarize major
Class II, Division 1
findings on growth in Class II malocclusions:
The emphasis in this article is on the nonsurgical
(1) Craniofacial growth of subjects with untreated treatment of Class II, Division 1, especially early
Class II and Class I are essentially similar, treatment expanding on growth modification
except for smaller increases for Class II in and focusing on timing as well as modalities of
mandibular length during adolescent growth treatment. The plethora of publications on Class
spurt.11 Antero-posterior discrepancies between II craniofacial features and treatment abound
the jaws in Class II malocclusions are often because the malocclusion represents a significant
present early and are maintained unless cor- percentage of orthodontic patients.17 Studies
rected orthodontically.12 span the entire spectrum of the evidence tree
(2) The original pattern persists: a severely including key randomized clinical trials and
“retrognathic face” in childhood invariably systematic reviews, probably more than for any
develops into a retrognathic type of adult other malocclusion, albeit much is needed to
face.13 provide definitive answers to still outstanding
(3) Untreated Class II malocclusions with a retro- questions.
gnathic face will maintain the Class II dental The nonsurgical correction of a skeletal dys-
relationship even when growth has improved plasia underlying a Class II, Division 1 presum-
the skeletal mandibular retrusion.14 ably is best achieved during active periods of
(4) Few consistent differences are noted growth.8 Various methods of treatment aim to
between the Class II, Division 1 and normal normalize skeletal relationships between the jaws
subjects from the deciduous to the mixed because a Class II malocclusion does not self-
and permanent dentitions.15The differences correct with growth.11 Treatment includes
in mandibular length and position were enhancement of differential growth between
more evident in the early stages of the jaws. Given the primacy of mandibular
256 Ghafari and Macari

retrognathism, successful outcome is associated mostly through the use of headgear and at
to a great extent with the amount of mandibular times the extraction of teeth (usually
forward growth. In this context, the basic premise premolars). If the malocclusion is mostly
is that the amount of growth depends on the age related to mandibular retrognathism, the
of the patient and amount of residual growth at treatment rationale is the constraint of
the time of treatment. For comparative purposes, maxillary growth, while mandibular
we consider growth without and with treatment. growth is favored or “stimulated” mostly
through the use of functional appliances.
However, there is an empirical tendency to
Treatment outcome of Class II, Division 1
maximize the response of each jaw,
Generalizable evidence from higher-level regardless of the origin of the problem.
research has yielded a number of central ten- This tendency is probably due to our inability
dencies, most of which are summarized in the to accurately predict and influence growth,
following statements. Yet, individual variation particularly in the mandible.
remains important and minimizes the accuracy (4) Most corrections of Class II, Division 1
of outcome prediction. Thus, slicing the maloc- resulted from a combination of favorable
clusion in its various components in future mandibular growth accompanied by
research, particularly longitudinal, might facili- changes in the maxillary and mandibular
tate forecasting. dentitions. The amount of skeletal and
dentoalveolar contributions to the correc-
(1) When the Class II, Division 1 is associated with tion differs with individual patient
oral habits, they must be eliminated, pref- responses that cannot be accurately antici-
erably prior to the correction of the maloc- pated21; whereby, the chin point became
clusion but, sometimes simultaneously.18 more retrognathic or unchanged in nearly
(2) The major consideration in early treatment half of Class II patients with mandibular
of a Class II, Division 1 malocclusion is the retrognathism.13
existence of an underlying skeletal prob- (5) Early treatment focuses on growth modifi-
lem. In this instance, early treatment is cation. The methods utilized are primarily
almost invariably the initial phase in a series headgear (to redirect the growth of the
of 2 or more therapeutic phases, ending maxillary complex or drive the maxillary
with the use of full or partial fixed ortho- teeth distally with extraoral anchorage
dontic appliances in the permanent denti- traction, while the mandible continues its
tion. However, whether the malocclusion is forward growth within its “growth poten-
of a skeletal, dentoalveolar, or combined tial”) and functional appliances (reposition-
origin, treatment approaches have relied ing the mandible in a forward direction
on similar rationales. Perhaps, underlying with guide planes or some other method to
these methods is the practical inability to hold that positioning, in an attempt to
treat a distoclusion with complete control of “stimulate” condylar growth).22–24 The prin-
its skeletal and neuromuscular compo- cipal mechanism of correction is related to
nents. In contrast, the dental system is enhancing the differential growth that
comparatively easier to manage. In this normally occurs between the jaws over time.
perspective, while dentoskeletal changes (6) With specific regard to functional applian-
achieved at the end of treatment favor ces, the following possibilities were
pre-pubertal versus post-pubertal interven- advanced22:
tions, no differences between these time (a) The mandible surpasses its growth
periods were observed (on average) when potential.
growth was completed, highlighting the (b) Mandibular growth is accelerated.
efficiency of treatment as it relates to There is no clear evidence from
duration.19 published reports that either possibility
(3) If maxillary prognathism is diagnosed, the occurs systematically or predictably in
treatment rationale is usually to distalize or studied populations. Furthermore,
at least stabilize the maxillary complex,20 these hypotheses assume that the
 Component analysis of Class II, Division 1 occlusion 257

individual growth potential can be between cranial and maxillary superimpo-

predicted with reasonable accuracy. sitions regarding mandibular displacement:
(c) The mandible is merely positioned the headgear displayed a more horizontal
forward and subsequent growth, if vector (B-point, pogonion, gnathion, and
sufficient, adapts (“catches up”) to this menton) upon maxillary superposition. Infer-
position. This hypothesis assumes that ences on mandibular displacement are more
(i) occlusal interdigitation plays an reliable upon maxillary superposition than
important role in maintaining the cranial superposition when evaluating
mandible in the forward position, and occlusal changes during treatment.24
(ii) a most important effect of a func- (11) Comparisons of fixed and removable func-
tional appliance is the distal force on tional appliances followed by fixed ortho-
the maxillary complex. This effect is dontic appliances indicated similar
achieved through the forces trans- treatment outcomes for Class II, Division
ferred to the maxillary teeth and bone 1 malocclusions.20 The results included a
by the appliance. restrictive effect on the maxilla, but most of
(7) Means other than the headgear to distalize the correction to Class I occlusion was
the maxillary teeth include fixed applian- achieved by dentoalveolar changes with
ces, the pendulum appliance, palatal arches retrusion of the maxillary incisors, dis-
(Cetlin mechanics), and more recently talization of the maxillary molars, protrusion
mini-implant-supported mechanisms. How- of the mandibular incisors,25,26 and extrusion
ever, it is not clear if differential growth of the mandibular molars. Changes in the
occurs with these appliances in a way mandible were concomitant to those found
similar to the use of headgear or functional within the untreated Class II group.20
therapy. (12) In non-growing individuals, retraction of
(8) When comparing different treatment the maxillary dentition has been more
modalities (namely headgear versus func- common, whether with extraction of teeth
tional appliance), the basic premise that (mostly premolars) or distalization of
headgear targets the maxilla and function molars then of the premolars and anterior
regulator targets the mandible has been teeth. The more severe the discrepancies,
supported.22–24 However, each appliance the more accepting are orthodontists of
has an effect on the other jaw that contrib- various degrees of mandibular incisor pro-
utes to the outcome. The effect of func- clination, unless the more ideal orthog-
tional appliances on mandibular length nathic surgery is performed. Paramount in
differed among studies, and conclusions orthodontic treatment of Class II, Division 1
on stimulation of mandibular growth with with deficient growth is the consideration of
functional therapy are not universally sup- maxillary incisor torque, the effect of man-
ported. Suffice it to mention that continued dibular proclination on the gingiva (to avoid
use of these appliances has also not been recession or contemplate grafting), and the
shown to achieve mandibular growth stim- overall effect on facial esthetics.
ulation to a Class III mandibular phenotype. (13) Extraction of maxillary 2 premolars is a
(9) On average, treatment outcome is the result common approach in treating Class II,
of the cumulative effects of small-to- Division 1, often combined with the extrac-
moderate changes within the skeletal and tion of 2 mandibular premolars if warranted
dentoalveolar components, rather than a because of severe mandibular crowding or
major change in either or both of these proclination of mandibular incisors. Much
components. Thus, the difference between controversy remains regarding extraction
appliances is defined by the sum of the versus non-extraction in the treatment of
subtle or moderate changes.24 this malocclusion. When the latter is
(10) The position of the maxillary incisors seems coupled with hyperdivergent mandible,
to influence the anterior displacement of the results of treatment with extraction
the mandible during treatment. Statistically include mesial movement of the molars;
significant differences were observed yet their vertical positions and that of the
258 Ghafari and Macari

incisors along with skeletal measurements distalization of the dentition if achievable) to

did not differ between extraction and non- correct molar and incisor relationships despite
extraction subjects.27 The findings demon- the underlying jaw discrepancy. Orthodontic
strate the limitations of conventional camouflage implies a favorable or at least not a
orthodontics (in addition to existing detrimental effect on facial esthetics.43
constitutional limitations) to alter vertical Adjunctive orthognathic surgery would be the
skeletal pattern by “opening” or “closing” only, not just the ideal, alternative to camouflage
the mandibular plane.28–31 if facial esthetics were to be improved and not
worsened.
Issues of time of treatment The Class I normal occlusion is the working
goal of orthodontists. Because of the variable
Early treatment (in the primary or mixed denti-
nature of human biology, deviations from this
tion) has been advocated to bring natural forces to
norm are deemed “acceptable” when they fall
normal function.32 While many dismiss this tenet
within an optimal biological, functional, and
and would delay treatment to the permanent
esthetic frame. Short of the ideal surgical treat-
dentition, the benefits of early intervention,
ment of a Class I occlusion, “limited compensa-
particularly to avoid the extraction of permanent
tion” may be the appropriate camouflage as the
teeth, find ample support in the literature. The
severity of skeletal discrepancy increases.32 This
controversy actually shifted to the investigation of
compromised option refers to treatment toward,
how early treatment should be implemented.
but not necessarily achieving, Class I occlusion,
Clinical trials on the early treatment of Class II,
commensurate with favorable facial appearance
Division 1 malocclusion concur about starting
(e.g., maintaining an overjet instead of
treatment in late childhood as the first part of a
“flattening” the profile by dentoalveolar
one-phase treatment.33–35 The optimal timing would
compensation). On the other hand, if teeth
correspond to the time just prior to the loss of the
are extracted to maximize compensation, and
primary second molars in the late mixed dentition.
should the patient decide to undergo surgery
Nevertheless, a number of conditions would still
later in life, decompensating the compensatory
warrant a two-stage treatment, the first stage
inclinations of the teeth becomes a task that is
implemented in the mixed dentition, the last in the
both more demanding and prone to more
permanent dentition, probably following an
therapeutic side effects such as root resorption.
interim period of retention.36 These conditions
Other illustrations of compromised outcome
include individual variations such as a premature
due to constitutional limitations include the
dental development relative to a normal or delayed
differential thickness between upper and lower
skeletal maturation, susceptibility to trauma of the
lips. When the upper lip is thinner than the
maxillary incisors because of a severe overjet,37 a
lower, significant retroclination of the maxillary
functional posterior crossbite,38,39 and devel-
incisors and/or proclination of the mandibular
opmental problems that endanger the integrity of
incisors would lead to a reverse step between
the dental arch35,40 (the premature loss of primary
the lips; a more buccal position of the lower
teeth, particularly second molars, or the ectopic
lip relative to the upper undermines the har-
eruption of permanent teeth).
monious rapport between them (Fig. 1).
The long-term advantage of early treatment
Maintaining an increased overjet supports a
remains on average questionable in light of a
more forward position of the upper lip.
number of randomized clinical trials22,37,41,42;
Otherwise, an adjunct plastic procedure to
however, further studies of its effectiveness
thicken the thin upper lip might camouflage
should be focused on individual variation.
the problem.
Considerations of compromised outcome
Components of Class II, Division 1
The treatment of Class II, Division 1 maloc-
clusions (underlined by skeletal discrepancy) Before the age of cephalometrics, Angle1a
ranges from dentoalveolar compensation or proposed that the position of the maxillary first
camouflage to adjunctive orthognathic surgery. permanent molar was constant and the molar
Camouflage involves extraction of teeth (or occlusion referred to the location of the
 Component analysis of Class II, Division 1 occlusion 259

Figure 1. Pre (A)- and post (B)-treatment lateral cephalographs and profile and intraoral photographs of an adult
female with Class II division 1 malocclusion and increased overjet of 6 mm. At the end of treatment (C-E), a
residual overjet is maintained to support the upper lip as if the mandibular incisor was extracted by shifting the
right teeth in extracted molar space. The maxillary incisors are in proper inclination, while the mandibular ones
are in compensatory inclination. Even uprighting of these teeth in decompensation for orthognathic surgery
would not have yielded appropriate results because of the differential thickness of the lips.

mandibular molar relative to its upper This general description may have pre-
counterpart, thus the term distoclusion for cluded treatment reports, despite their profu-
Class II. Other theories related the position of sion, from reflecting the vast craniofacial
the maxillary molar to the key ridge and sella descriptions. Authors are often content with a
turica, but individual variations (including mesial satisfying summary of change in skeletal rela-
drift of the dentition under different conditions) tions and dentoalveolar inclinations. The
precluded such determination. Angle stated obvious reason was the concentration on the
(p.448): “It is a common mistake to suppose occlusal outcome. Yet, the flurry of interest in
that this form of malocclusion is the result of facial esthetics has not translated in routine
overdevelopment of the upper jaw. The author evaluation of esthetic assessments beyond
has never seen a case where this condition descriptions of convexity of facial contour and
existed, neither are the teeth of the upper jaw subnasal profile. Soft tissue thicknesses, par-
‘inherited too far forward.’” This statement may ticularly the differential between upper and
not be generalizable regarding maxillary lower lip thicknesses or within chin compo-
position; however, it underscores what cephalo- nents, are not required measurements. Nev-
metric studies eventually established: the ertheless, variations in soft tissue thicknesses
predominant feature of the malocclusion is may exacerbate or compensate for a skeletal/
mandibular retrognathism.44 dentoalveolar deviation.
260 Ghafari and Macari

The significance of the component analysis is in facial units within encompassing growth
facilitating complete diagnosis and consequently theories such as the functional matrix.45
influencing proper treatment decisions.7 In this
context, it is important to note 2 basic tenets: Components contributing to Class II skeletal
relationship
(1) One is essentially geometric: The coexis-
Structures or relations that emerge as potential
tence of vertical and transverse problems
components of Class II, Division 1 obviously
with the sagittal characteristics multiplies
include both jaws and the cranial base. Specifi-
“sub-phenotypes” beyond the generic phe-
cally, selected features are noted, related to the
notype. The sagittal and vertical components
cranial base and the jaws, most revolve around
are intimately integrated.
the mandible or its relationship with the maxilla
(2) Growth and development studies have dis-
(Fig. 2). Definitions and available evidence
closed the interaction between the jaws and
associated with these features are presented in
among adjacent units within each jaw in
Table 1.14,24,46,49–55 Research exposed in the
response to developmental stimuli.7 The
latter section of this article includes analysis of
units recognized within the mandible
these components.
include the condyle, coronoid process,
angle, corpus and symphysis, and teeth.
Phenotypical differences of components
Those within the maxilla encompass the
palate, the teeth, the sutures, and by In the traditional evaluation of the malocclusion,
extension, the units contiguous to the mandibular retrognathism is reported as a pre-
sutures. Authors have tried to connect the dominant feature.44 However, mandibular

Figure 2. Cephalogram of an adult individual indicating the landmarks, planes, angles, and distances evaluated in
this study. Corresponding listing of components and their means of measurements are displayed in the adjoining
table. The components are defined in Table 1. Landmarks: N (nasion), S (sella), Ba (basion—most inferior point
on the anterior margin of the foramen magnum in the midsagittal plane), Ar (articulare—the intersection of the
bilateral rami with the posterior cranial base), ANS (anterior nasal spine), PNS (posterior nasal spine), A (deepest
point on the premaxilla between anterior nasal spine and dental alveolus), B (deepest midline point on the
mandible between infradentale and pogonion), Me (menton—most inferior point on mandibular symphysis), Pog
(most convex point on the symphysis), Gn (gnathion—geometric midpoint between Pog and Me), Go (gonion—
external angle of the mandible), Co (condylion—most supero-posterior point of the mandibular condyle), St N
(soft tissue Nasion), St Pog (soft tissue pogonion); Planes: V1 (true vertical through N), V2 (true vertical through St
N), PP (palatal plane through ANS and PNS), MP (mandibular plane through Go and Me), I (mandibular incisors
long axis); Angles: N–S–AR, N–S–Ba, SNB, ANB, PP–MP, I/MP; Distances: Pog–V1, St Pog–V2.
 Component analysis of Class II, Division 1 occlusion 261

Table 1. Selected Craniofacial Components of Class II, Division 1 Malocclusion

Component Definition

Cranial base The flexure of the cranial base (saddle angle) or cant of the posterior cranial base has
been shown to vary with different malocclusions.
Increased flexure44,45 and shorter lower cranial heights were observed in Class II subjects compared
with subjects with class I.44 These findings become significant if they affect the antero-posterior
position of the mandible, whereby an otherwise normal size mandible may be retrognathic if set
more caudally within the skull.
Maxillomandibular relations In the sagittal plane (ANB, WITS appraisal) (m1)
In the vertical plane (angle of divergence PP/MP) (m1)
These relations are critical for the initial diagnosis of the intermaxillary discrepancies of all
malocclusions, notably the Class II, division 1.
Maxilla Amount of maxillary prognathism
Most studies reported no statistically significant differences in the skeletal44,46 and
dentoalveolar positions46 of the maxilla in the Class II compared with Class I samples.
However, Baccetti et al.47 reported statistically significant maxillary protrusion during
the transition from the primary to the early mixed dentitions. In the related studies of
components (see section Phenotypical differences of components), maxillary position
was discarded as it is associated with 2 other included variables: maxillary–mandibular
relations and the mandibular position.
Mandible Mandibular retrognathism (m)
While this feature is characteristic of Class II, Division 1 in growing and adult
patients,44–47 the amount of retrognathism is thought to influence treatment outcome.
Mandibular size (m)
While shorter mandibles have been reported in patients with Class II malocclusion in
infancy through adolescence,47–49 some reports indicate no difference in mandibular
growth from the primary to the permanent dentition.14,47 Mandibular size is best
measured between condylion and either gnathion or pogonion. Substituting
condylion with articulare (Ar) reflects more position rather than size of mandible
because of the geometric definition of Ar as the intersection of the bilateral rami with a
midline structure, the posterior cranial base.24
Mandibular incisor inclination (to mandibular plane or NB) (m)
Proclination of the mandibular incisors in patients with Class II malocclusion reflects
dentolaveolar compensation within the intimate association between dentoalveolar
and skeletal parts. Often retroclination of maxillary incisors is also observed, but given
the more prevalent mandibular proclination, only mandibular inclination is
considered as both upper and lower teeth angulations are not entirely independent
variables when viewed in the perspective of the discrepancy between the jaws.
Profile outline (through facial Nose projection in the profile, relative to the rest of the outline.
convexity that is a characteristic The nose is the most prominent feature of the profile, but depending on its relative
of Class II, Division 1) size and position, particularly to the chin, the convexity may not be significantly
affected through orthodontic treatment. Accordingly, the position of pronasale is a
contributing factor to the reality or perception of facial convexity.
N–Pog–P (Projection) (m)
Soft tissue (ST) pogonion (projected on the true vertical) (m)
Soft tissue thickness of the upper and lower lips is also critical, particularly when it
masks or compensates for the underlying hard tissue discrepancy. ST pogonion, as
representative of the chin landmarks, is more accurately measured than ST of the lips
on cephalometric records, as it is less prone to distortion from positional variations.
Shape of chin button (symphyseal The shape of the chin makes a significant difference in the perception of convexity.
angle) (m) Similar malocclusions treated alike may disclose more or less favorable esthetics
depending on the shape of the chin “button” (Fig. 9). In general, the variability of chin
form may be related to growth compensative to the developing jaw, the contiguous soft
and hard tissue contours, as well as the genotype of the mandible.50 Chin size increases
as the mandible flattens toward a “horizontal” inclination, a slight chin button being
associated with leptoprosopically developing faces.51 This disparity may be related to
the function of the chin's immediate environment through the muscular attachment
of the tongue–hyoid–symphyseal complex, albeit the basic shape of the chin has been
related to evolution as a consequence of the tooth size/alveolar bone reduction within
the mandibular complex.50,52 Ghafari et al.55 qualified chin form by considering the
tilt of its anterior and posterior contours to the vertical.
262 Ghafari and Macari

retrognathism may be ascribed to various factors, (IMPA angle; reflecting dentoalveolar compen-
occurring separately or in combination: sation).
mandibular position, mandibular size, and The findings clearly supported the authors'
shape of chin. Studies comparing untreated conclusion that craniofacial growth in untreated
Class II malocclusions with the normal Class I Class II and Class I subjects was essentially similar,
occlusion are not readily available. We found 2 based on the demonstration that temporal growth
publications by the same investigators comparing is nearly comparable. However, by computing the
the cephalometric tracings of untreated continuous data across the ages 10.2, 15.4, and 19.1
distoclusions with control normoclusions.11,56 years, we observed that the starting points on all 4
While one paper dealt with the age bracket parameters were different in Class II subjects: the
10.2–15.4 years11 and the other from 15.7 to 19.1 mandible was smaller, more retrognathic, with less
years,47 we combined and plotted both sets of chin projection and more proclined incisors
data in a continuous display after ascertaining (Fig. 3). This evidence demonstrates that at least
that the same database was used with matching from the age of 10 years, the Class II phenotype is
age groups. The following parameters pertinent on average different from Class I. Data on
to the mandible were evaluated: the distance untreated Class II at ages younger than 10 years
condylion–gnathion (a measure of mandibular are not available to find out whether the various
size); the angle SNB (depicting mandibular features of Class II pattern are set from the very
position); the distance between pogonion and early years of life. Consequently, the following
the vertical through nasion (N–Pog; denoting question is yet to be answered: if treatment of Class
chin projection); and the inclination of II is started in the primary dentition can the
mandibular incisors to mandibular plane pattern be rectified or avoided? The answer

Figure 3. Differences between Class I and Class II untreated subjects between ages 10.1 and 19.2 years. (A)
Mandibular length CO–GN: larger mandibular length in Class I and at equal increments with Class II at all time-
points. (B) Distance between bony pogonion and the vertical through Nasion (N–POG): while individuals with
Class I malocclusion grow to a more forward position of the bony chin almost tangent to the vertical through
Nasion, subjects with Class II malocclusion exhibit a more backward symphyseal position up to
6 mm at
adulthood. (C) SNB: mandibular sagittal position remains in a deficient projection during growth even though
SNB angle increases at a similar rate to that of Class I subjects. (D) IMPA: mandibular incisors inclination is more
increased in Class II than in Class I individuals as compensation to the skeletal discrepancy. Note the decrease in
the inclination at the end of growth as a response to a more forward positioning of the mandible (SNB angle
increases around 2). (Graphs generated from data published by Stahl et al.11 and Baccetti et al.56 - see text for
details)
 Component analysis of Class II, Division 1 occlusion 263

Figure 4. (A) A 10 years and 5 months old female with a Class II, Division 1 malocclusion associated with convex
profile and retrognathic mandible. Headgear treatment along with Class III inter-arch elastics to mandibular
segmental orthodontic fixed appliances aimed to retrocline mandibular incisors anticipating mandibular growth.
Failure of further mandibular growth would not allow a full repositioning of the mandibular incisors despite space
development in the mandibular arch. Class II phenotype features are still dominant irrespective of correction to
Class I dental occlusion. (B) Lateral cephalographs of the same patient at T1 (pre-treatment)—10 years 5 months,
T2—12 years 10 months, and T3 (post-treatment)—13 years 11 months. (C) Superimpositions indicated the need to
maintain dental compensation (i.e., mandibular incisor proclination) with the insufficient growth of the mandible.
264 Ghafari and Macari

Figure 5. Profile and intraoral pictures at start (A,D), 1 year (B,E), and completion of treatment (C,F) on a 11 years and 7
months old female with Class II, Division 1 malocclusion treated with headgear and fixed appliances over 4 years to a Class
I occlusion. Nevertheless, her profile expresses Class II phenotype with a deficient chin projection reflecting more of a
dental rather than skeletal correction as indicated in the post-treatment lateral cephalometric radiograph (G).

necessarily touches upon the etiology of the craniofacial measures early in life, but similar
malocclusion, presumably combining genetic growth patterns in Class II and Class I subjects
factors, but also definite environmental insults to appeared to be similar later.14,46,52,57 More focused
normal development (e.g., removal of obstacles to research is still needed to formulate more defin-
breathing). Some studies refer to differences in itive conclusions.

Figure 6. An 11 years and 6 months old male presenting with a severe Class II, Division 1 malocclusion (ANB¼101;
overjet ¼ 9 mm) with proclined mandibular incisors (IMPA ¼ 1201) aggravated by a Brodie bite and impinging deep
overbite (A,D,E,F,G). Treatment (B,D,H,I,J) included initially the initial successful use of a bionator, followed by
retroclination of the mandibular incisors with fixed appliances to increase the overjet prior to enhancement of
differential growth via a functional appliance. The Brodie bite was corrected by bonding segmental maxillary posterior
teeth and use of crossbite elastics.
 Component analysis of Class II, Division 1 occlusion 265

Figure 7. Pretreatment T1 (A,B,C) and post-treatment T2 (D,E,F) records of a 12-year-old male with a Class II,
Division 1 malocclusion at T1 with ANB angle of 4.91. Headgear and fixed appliances were used during 3 years of
treatment to correct to Class I (T2). Post-treatment records indicate the favorable facial appearance of Class I
phenotype supported by an orthognathic relationship between the maxilla and the mandible (ANB ¼ 21).

Application of component analysis in the (2) Mandibular size was smaller than the age
evaluation and treatment of Class II, average in 2 patients, but normal in one.
Division 1 (3) In most patients, the Class II phenotype
persists, despite the following: (a) the reduc-
Illustration of component analysis through
tion in skeletal discrepancy, (b) the use of
treatment reports
maximized mechanics over longer treatment
The importance of evaluating diagnosis and periods, and (c) even beyond the growth spurt.
treatment through components is best illustrated (4) Mandibular incisor proclination persists,
through 5 treatment reports (Figs. 4–8). Each although reduced, in compensation for the
indicates the prevalence of different components residual Class II skeletal difference.
in determining the outcome, spanning a spectrum (5) In patients whose profile outline approaches
of results from deficient growth with maintenance orthognathism at the end of treatment, the chin
of the Class II phenotype to the approach of the anatomy and/or soft tissue thickness compen-
Class I morphology. The varied results prompt the sated for deficient hard tissue extension.
following conclusions: (6) A sub-phenotype may exist with thicker
upper lip and diminutive chin, accentuating
(1) Mandibular retrognathism is a common the convexity of the profile (Figs. 6 and 8),
denominator. which warrants extended research.
266 Ghafari and Macari

Figure 8. (A,C) Pre-treatment profile picture and lateral cephalometric radiograph of a 12-year-old boy with a
Class II, Division 1 malocclusion (ANB ¼ 61) and mandibular incisor proclination (IMPA ¼ 115.61). This patient
was treated with headgear to enhance differential growth and fixed appliances to retrocline the mandibular
incisors into the leeway space. (B,D) Post-treatment orthognathic relationship between the jaws was achieved (ANB
¼ 1.81) with reduction of the mandibular incisor proclination (IMPA ¼ 1001). However, the increased thickness of
the upper lip favored a convex profile and a tendency to Class II phenotype.

These inferences are similar to the results of included patients with deficient and non-
studies listed below. deficient projection of the chin relative to the
face (Fig. 9A–H), despite the achievement of
neutroclusion.
Studies on components of malocclusion
Based on these observations, we reasoned that
In a study of favorable esthetics following early the difference in the position of the chin through
treatment of Class II, Division 1 malocclusion, we soft tissue pogonion might be related to the
observed that the shape of the chin and/or soft inherent shape of the chin and the thickness of
tissue thickness were associated with a more the soft tissue (constitutional factors). We
pleasing appearance. The material consisted of investigated these 2 factors in the following way:
lateral cephalometric tracings of 63 children the cant (to the vertical) of the posterior and
(ages: 7 years, 2 months–13 years, 4 months) anterior slopes of the symphysis was evaluated in
whose distoclusion was treated with either a relation to the spatial position of the chin
headgear or a function regulator for a period of 2 (pogonion, gnathion, and menton), and the
years.55 The cephalographs and corresponding thickness of the soft tissue was measured at the
profile photographs revealed that both groups levels corresponding to bony landmarks (Fig. 9I
 Component analysis of Class II, Division 1 occlusion 267

Figure 9. (A–D) Patient with Class II, Division 1 malocclusion treated with a headgear, corrected to a Class 1
occlusion. The profile extension of the chin was deficient and not favorable to the esthetics of the face. (E–H)
Occlusion in another boy with a similar malocclusion treated with headgear to a Class I occlusion with a more
harmonious profile because the chin shape was well defined at the onset. (I) Drawing of the component analysis of
the symphysis: anterior slope plane through pogonion and B points; posterior slope though Pogonion 1 (most
convex point on the posterior sympheseal cortical and point B1 (intersection of the parallel to Po–Po1 through B
and the posterior cortical of the symphysis); MP—mandibular plane and V is the true vertical through Nasion. (J)
Drawing of angles and distances measured on the symphysis. Green plane constitutes the true vertical through the
intersection of the anterior (larger red dotted line) and posterior slopes (small red dotted line). Angles a (ANT)
and b (PNT) are the cant of the anterior and posterior slopes to the true vertical, respectively. Distance a0 is
measured from B-point perpendicular to the true vertical. Distance b0 is the distance from B1 to the true vertical.

and J). The Pearson correlation coefficients seemed to be associated with, among other
disclosed a tendency for a more anterior factors, the anatomy and cant of the symphysis
position of pogonion to be associated with the and soft tissue thickness. The findings suggested
backward tilt of the anterior symphyseal slope that the nature of the dysmorphology is
(r ¼
0.60), and a more posterior position of self-limiting from therapeutic and esthetic
pogonion with a forward tilt of the posterior perspectives.
slope (r ¼
0.45). Higher correlations were The importance of chin projection was better
observed between the thicknesses of the upper illustrated in a study of outcome predictors of the
and lower lips (r ¼ 0.89) and the thicknesses of early treatment of Class II, Division 1 maloc-
the soft tissues at pogonion and gnathion clusion. Given the observations that occlusal
(r ¼ 0.89). correction of Class II, Division 1 malocclusion
We concluded that (1) profile differences with mandibular retrognathism was related to
between the appliances were marginally stat- different structural components rather than a
istically significant and apparently of less clinical prevalent change in one of them, we aimed to
significance and (2) the clinically significant determine the dominant predictors of favorable
projection of the chin relative to the face forward chin extension in Class II treatment. The
268 Ghafari and Macari

Table 2. Pre- and Post-Treatment Means and Standard Deviations of Angle ANB in Low- and High-Severity Groups
of Class II, Division 1 Malocclusion
Group (Initial ANB) Low Severity (4.5–6.5) High Severity (Z6.6) p
n 10 23
Age ANB Age ANB Age ANB

Pre-treatment 9.23 (1.34) 5.34 (0.71) 9.66 (1.31) 8.69 (1.01) NS o0.0001
Post-treatment 11.44 (1.43) 4.60 (2.31) 11.79 (1.33) 5.44 (1.39) NS NS
Follow-up (F) 15.33 (1.47) 3.44 (2.25) 14.41 (1.99) 5.93 (1.49) NS 0.006
ANOVA o0.0001 NS o0.0001 o0.0001
Post-hoc (p value)
Pre/post 0.002 NS o0.0001 o0.0001
Pre/F o0.0001 0.02 o0.0001 o0.0001
Post/F o0.0001 NS o0.0001 NS
Difference pre-F
1.90 (2.02)
2.76 (1.34) NS
Difference post-F
1.15 (3.26) 0.08 (2.15) NS
Age in years, ANB angle in degrees

same material used in the above-described study a probability of 68.9%. We concluded that the
was examined. Angular and linear cephalometric cant of the symphysis emerged as a critical
measurements gauged relations among cranial predictor of the anterior projection of the chin
base, maxilla and mandible: chin extension following early Class II treatment that enhanced
(pogonion projection to V through nasion), differential growth between the jaws. More
mandibular length condylion–gnathion (Co– research, particularly longitudinal, should be
Gn), dentoalveolar compensation, shape of chin conducted before definitive formulation of
button, soft-tissue thickness, mandibular retro- these conclusions.
gnathism, cant of posterior cranial base (asso- However, further evaluation of the same
ciated with glenoid fossa position), cant of the population clearly indicated the apparently
symphysis [angle between anterior (ANT) and constitutional limitations imposed on the
posterior (POST) symphyseal slopes to V], nose treatment of Class II, Division 1. If only gauged
projection (PRON-D, pronasale distance to ver- by one measure of intermaxillary relationship,
tical through glabella), palato-mandibular angle namely, the ANB angle that averaged 7.36 (⫾
(PP/MP).58 1.89) before treatment; this angle was on
According to the amount of pogonion pro- average within the Class II domain (5.47 ⫾ 1.79)
jection between pretreatment (T1) and post- at the end of the first phase of treatment (2
reatment records 2 years later (T2), the sample years). Of the 64 subjects who completed the
was divided into 2 groups of good (n ¼ 28) and study, 46 had follow-up records at 1–5 years
bad (n ¼ 33) responders, stratified on achieving post-phase 1 (excluding those who had fixed
at least 3 mm change in the molar relationship appliances at the follow-up evaluation). Patients
toward neutroclusion. Discriminant analysis was who were stratified in the severe Class II, Divi-
applied to select pretreatment predictive varia- sion 1 group (ANB Z 6.6) were likely to
bles of a favorable Class II orthopedic treatment. maintain a greater Class II ANB value (5.93 ⫾
Simultaneous variables selection revealed that 1.49) than those in the less severe group (ANB
patients presenting with large ANT symphyseal ¼ 4.5–6.5) whose ANB correction was closer to
angle and Co–Gn distance, low PP/MP angle, normal values (3.44 ⫾ 2.25) (Table 2). A larger
and short PRON-D responded better to treat- number of observations are needed in a
ment. In addition, a stepwise variable selection future study.
identified a single predictive variable: the ANT
symphyseal angle (Fig. 9J). On the basis of the
equation generated by the multivariate statistical Conclusions
method (dicriminate score DS ¼
2.261 þ
0.147nANT_T1), the treatment outcome for a (1) Among various malocclusions, information
new Class II patient can be predicted with on treatment and stability of correction of
 Component analysis of Class II, Division 1 occlusion 269

Class II, Division 1 is the most based on The evaluation of facial esthetics must be part
“higher-level” evidence; including, random- of treatment reports that are in the greatest
ized clinical trials, systematic reviews, and majority reports of hard tissue (bone and teeth)
meta-analyses. Results indicate the post- changes. Within this evaluation, the contribution
treatment maintenance of the Class II of soft tissue thickness, particularly at the level of
phenotype, at least in the most severe the lips and chin, should gauge their con-
malocclusions (ANB 4 6.5), suggesting the tribution to more favorable or more unfavorable
limitation of growth modification to affect profile outlines.
growth potential and thus inherent con-
straints to transform this condition into a
Class I phenotype. Untreated samples cor-
roborate these findings. References
(2) Differential growth between the jaws and 1. Angle EH, Treatment-preliminary considerations. In:
dental compensations, particularly potential Angle EH, ed. Malocclusion of the Teeth. 7th ed. Phila-
delphia: The S.S. White Dental Manufacturing Co; 1907a:
mandibular growth and associated inclina- 57, b: 309, c: 46, d: 448, e: 309-313.
tion of mandibular incisors, reflect the most 2. Richmond S, Shaw WC, O'Brien KD, et al. The develop-
common findings reported in the orthodon- ment of the PAR Index (Peer Assessment Rating):
tic treatment of Class II, Division 1. reliability and validity. Eur J Orthod. 1992;14(2):125–139.
(3) The skeletal discrepancies accompanying 3. Snyder R, Jerrold L. Black white, or gray: finding
commonality on how orthodontists describe the areas
Class II, Division 1 malocclusion must be between Angle's molar classifications. Am J Orthod
evaluated in their components rather than Dentofacial Orthop. 2007;132(3):302–306.
reflecting a generic mal-relationship. 4. Jarabak JR. Technique and treatment with light wire edgewise
(4) Factors contributing to treatment success appliances. 2nd ed., Saint Louis: CV Mosby Co.; 1972.
5. Ghafari J, Street KW, Dental development in children
include phenotypical variations, besides the
with Class II, Division 2 malocclusion—four types of the
well-documented growth potential, treat- malocclusion defined. In: Davidovitch Z, Mah J, eds.
ment mechanics, and patient cooperation. Biological Mechanisms of Tooth Eruption, Resorption, and
(5) The components of Class II, Division 1 are Replacement by Implants. Boston: The Harvard Society for
defined in hard and soft tissues, including the Advancement of Orthodontics; 1998:589–596.
the shape of cranial base, size and position of 6. Katz MI. Angle classification revisited. 2: a modified Angle
classification. Am J Orthod Dentofacial Orthop. 1992;102(3):
the jaws, and dentoalveolar inclinations. 277–284.
(6) Despite the tendency to use appliances 7. Ghafari JG, Macari AT. Component analysis of predom-
targeting principally the maxilla (headgear inantly vertical occlusal problems. Semin Orthod. 2013;
and other distalization methods) and the 19(4):227–238.
mandible (principally functional applian- 8. Fisk GV, Culbert MR, Grainger RM, Hemrend B, Moyers
R. The morphology and physiology of distocclusion: A
ces), the study of components at pretreat- summary of our present knowledge. Am J Orthod. 1953;
ment may help forecast treatment outcome 39(1):3–12.
or more precisely the intrinsic (other than 9. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate
patient compliance) factors limiting treat- experiments on oral respiration. Am J Orthod. 1981;79(4):
359–372.
ment response.
10. Macari AT, Bitar MA, Ghafari JG. New insights on age-
(7) Research weighing various components of related association between nasopharyngeal airway clear-
this malocclusion point to the dominance of ance and facial morphology. Orthod Craniofac Res. 2012;
chin components: the cant of the anterior 15(3):188–197.
contour of the symphysis (a gauge of chin 11. Stahl F, Baccetti T, Franchi L, McNamara JA Jr.
prominence or insufficiency of chin exten- Longitudinal growth changes in untreated subjects with
Class II Division 1 malocclusion. Am J Orthod Dentofacial
sion) as a predictor of outcome in our Orthop. 2008;134(1):125–137.
preliminary studies. 12. Lande MJ. Growth behavior of the human bony facial
(8) Future analysis of Class II, Division 1 warrants profile as revealed by serial cephalometric roentgenology.
the consideration of the suggested compo- Angle Orthod. 1952;22(2):79–90.
nents to sort out predictive models of out- 13. Moore AW. Orthodontic treatment factors in Class II
malocclusion. Am J Orthod. 1959;45(5):323–352.
come. Differences between individuals may 14. Bishara SE. Mandibular changes in persons with
stem from the dominance of one or more untreated and treated Class II Division 1 malocclusion.
different components between subjects. Am J Orthod Dentofacial Orthop. 1998;113(6):661–673.
270 Ghafari and Macari

15. Bishara SE, Hoppens BJ, Jakobsen JR, Kohout FJ. Changes Angle Class II division 1 patients. Angle Orthod. 2007;
in the molar relationship between the deciduous and 77(2):244–253.
permanent dentitions: a longitudinal study. Am J Orthod. 32. Ghafari J. Emerging paradigms in orthodontics—an
1988;93(1):19–28. essay. Am J Orthod Dentofacial Orthop. 1997;111(5):573–580.
16. Genecow J, Sinclair P, Dechow P. Development of the 33. Ghafari J, Shofer FS, Laster LL, Markowitz DL, Silverton
nose and soft tissue profile. Angle Orthod. 1989;60: S, Katz SH. Monitoring growth during orthodontic
191–198. treatment. Semin Orthod. 1995;1(3):165–175.
17. McNamara JA Jr, Brudon WL. Orthodontics and Dentofacial 34. Gianelly AA. Crowding: timing of treatment. Angle Orthod.
Orthopedics. Ann Arbor: Needham Press; 2001. 1994;64(6):415–418.
18. Salzmann JA. Principles of Orthodontics. Philadelphia: 35. Gianelly AA. Leeway space and the resolution of crowding
Lippincott; 1950. in the mixed dentition. Semin Orthod. 1995;1(3):188–194.
19. Chhibber A, Upadhyay M, Uribe F, Nanda R. Mechanism 36. Ghafari J. Timing the early treatment of Class II, Division
of Class II correction in prepubertal and postpubertal 1 Malocclusion: clinical and research considerations. Clin
patients with Twin Force Bite Corrector. Angle Orthod. Orthod Res. 1998;1(2):118–129.
2013;83(4):718–727. 37. Tulloch JFC, Phillips C, Proffit WR, Early vs. late treat-
20. Lima KJ, Henriques JF, Janson G, Pereira SC, Neves LS, ment of Class II malocclusion: preliminary results from
Cançado RH. Dentoskeletal changes induced by the the UNC clinical trial. In: McNamara JA Jr, ed. Orthodontic
Jasper jumper and the activator-headgear combination Treatment: Outcome and Effectiveness. Ann Arbor: Cranio-
appliances followed by fixed orthodontic treatment. Am J facial Growth Series, Center for Growth and Develop-
Orthod Dentofacial Orthop. 2013;143(5):684–694. ment; 1995:113–138.
21. West EE. Analyses of early Class II, Division 1 treatment. 38. Myers DR, Barenie JT, Bell RA, Williamson EH. Condylar
Am J Orthod. 1957;43(10):769–777. position in children with functional posterior cross-bites:
22. Ghafari J, King GJ, Tulloch JFC. Early treatment of before and after cross-bite correction. Pediatr Dent. 1980;
Class II, Division 1 malocclusion: comparison of alter- 2(3):190–194.
native treatment modalities. Clin Orthod Res. 1998;1(2): 39. Hesse KL, Artun J, Joondeph DR, Kennedy DB. Changes
107–117. in condylar position and occlusion associated with
23. Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, maxillary expansion for correction of functional unilat-
Laster LL. Headgear versus function regulator in the eral posterior crossbite. Am J Orthod Dentofacial Orthop.
early treatment of Class II, Division 1 malocclusion. Am J 1997;111:(4)410-408.
Orthod Dentofacial Orthop. 1998;113(1):51–61. 40. Ghafari J. Early treatment of dental arch problems. I.
24. Efstratiadis S, Baumrind S, Shofer F, Jacobsson-Hunt U, Space maintenance, space gaining. Quintessence Int.
Laster L, Ghafari J. Evaluation of class II treatment by 1986;17(12):423–432.
cephalometric regional superimpositions versus conven- 41. Dolce C, McGorray SP, Brazeau L, King GJ, Wheeler TT.
tional measurements. Am J Orthod Dentofacial Orthop. Timing of Class II treatment: skeletal changes comparing
2005;128(5):607–618. 1-phase and 2-phase treatment. Am J Orthod Dentofacial
25. Franchi L, Alvetro L, Giuntini V, Masucci C, Defraia E, Orthop. 2007;132(4):481–489.
Baccetti T. Effectiveness of comprehensive fixed appli- 42. O'Brien K, Wright J, Conboy F, et al. Early treatment for
ance treatment used with the Forsus Fatigue Resistant Class II Division 1 malocclusion with the Twin-block
Device in Class II patients. Angle Orthod. 2011;81 appliance: a multi-center, randomized, controlled trial.
(4):678–683. Am J Orthod Dentofacial Orthop. 2009;135(5):573–579.
26. Herrera FS, Henriques JF, Janson G, Francisconi MF, de 43. Proffit WR, Fields HW, Sarver DM, Orthodontic treat-
Freitas KM. Cephalometric evaluation in different phases ment planning: from problem list to specific plans. In:
of Jasper jumper therapy. Am J Orthod Dentofacial Orthop. Proffit WR, Fields HW, Sarver DM, eds. Contemporary
2011;140(2):e77–e84. Orthodontics. 5th ed. St. Louis: Mosby; 2013:220–277.
27. Gkantidis N, Halazonetis DJ, Alexandropoulos E, Har- 44. McNamara JA Jr. Components of Class II Malocclusion in
alabakis NB. Treatment strategies for patients with Children 8–10 years of age. Angle Orthod. 1981;51(3):
hyperdivergent Class II Division 1 malocclusion: is vertical 77–202.
dimension affected?Am J Orthod Dentofacial Orthop 45. Moss ML, Rankow RM. The role of the functional matrix
2011;140(3):346–355. in mandibular growth. Angle Orthod. 1968;38(2):95–103.
28. Haralabakis NB, Sifakakis IB. The effect of cervical 46. Ngan PW, Byczek E, Scheick J. Longitudinal evaluation of
headgear on patients with high or low mandibular plane growth changes in Class II division 1 subjects. Semin
angles and the “myth” of posterior mandibular rotation. Orthod. 1997;3(4):222–231.
Am J Orthod Dentofacial Orthop. 2004;126(3):310–317. 47. Baccetti T, Franchi L, McNamara JA Jr, Tollaro I. Early
29. Kim TK, Kim JT, Mah J, Yang WS, Baek SH. First or dentofacial features of Class II malocclusion: a longitu-
second premolar extraction effects on facial vertical dinal study from the deciduous through the mixed
dimension. Angle Orthod. 2005;75(2):177–182. dentition. Am J Orthod Dentofacial Orthop. 1997;111(5):
30. Sivakumar A, Valiathan A. Cephalometric assessment of 502–509.
dentofacial vertical changes in Class I subjects treated 48. Anderson DL, Popovich F. Lower cranial height vs
with and without extraction. Am J Orthod Dentofacial craniofacial dimensions in Angle Class II malocclusion.
Orthop. 2008;133(6):869–875. Angle Orthod. 1983;53(3):253–260.
31. Ozaki T, Ozaki S, Kuroda K. Premolar and additional first 49. Buschang PH, Tanguay R, Turkewicz J, Demirjian A, La
molar extraction effects on soft tissue. Effects on high Palme L. A polynomial approach to craniofacial growth:
 Component analysis of Class II, Division 1 occlusion 271

description and comparison of adolescent males with 54. Keith A. The Antiquity of Man. London: Williams and
normal occlusion and those with untreated Class II Norgate, Ltd; 1915.
malocclusion. Am J Orthod Dentofacial Orthop. 1986;90 55. Ghafari J, Baumrind S, Macari A, et al. Profile character-
(5):437–442. istics related to the anatomy of the chin in a
50. Kerr WJ, Hirst D. Craniofacial characteristics of subjects Class II treatment population. J Dent Res. 2003;82:3020
with normal and postnormal occlusions—a longitudinal [abstract].
study. Am J Orthod Dentofacial Orthop. 1987;92(3):207–212. 56. Baccetti T, Stahl F, McNamara JA Jr. Dentofacial growth
51. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in changes in subjects with untreated Class II malocclusion
dentofacial structures in untreated Class II division 1 and from late puberty through young adulthood. Am J Orthod
normal subjects: a longitudinal study. Angle Orthod. Dentofacial Orthop. 2009;135(2):148–154.
1997;67(1):55–66. 57. Buschang PH, Tanguay R, Demirjian A, et al. Mathemat-
52. Haskell B. The human chin and its relationship to ical models of longitudinal mandibular growth for
mandibular morphology. Angle Orthod. 1979;49 children with normal and untreated Class II, division 1
(3):154–166. malocclusion. Eur J Orthod. 1988;10(3):227–234.
53. Ricketts RM. Planning treatment on the basis of the facial 58. Ghafari JG, Efstratiadis S, Kassab A, et al. Dominance of
pattern and estimate of its growth. Angle Orthod. 1957;27 specific facial components in predicting Class II outcome.
(1):14–37. J Dent Res. 2012;91:2962 [abstract].