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Normal occlusion
Angle’s view (Dental cosmos 1899)
Each dental arch describes a graceful curve, and that the teeth in these arches are so
arranged as to be in the greatest harmony with their fellows in the same arch, as well as with
those in the opposite
Division 1
a. Narrow upper arch, with lengthened and prominent upper incisors; lack of nasal and lip
function, Mouth breathers
b. Same as a, but with only one lateral half of the arch involved, the other being normal, Mouth-
breathers
Division 2
a. Slight narrowing of the upper arch; bunching of the upper incisors, with
overlapping and lingual inclination; normal lip and nasal function
b. Same as (a), but with only one lateral half of the arch involved, the other being
normal; normal lip and mouth function
In spite of Angle's important contribution, it became clear during the early part of the twentieth
century that this classification system was inadequate to characterize the variety of
manifestations of malocclusion presented by skeletal and dental discrepancies in all three planes
of space
Differential diagnosis of Class II malocclusions - Robert E. Moyers et al
With the help of 697 subjects Use of computer statistics Combined analysis of skeletal and
dental features Six subgroups based on horizontal variables
Type A
Result – a class II molar relationship and a greater-than-normal incisal overjet and overbite
Type B
A class II skeletal profile due to midface prominence associated with a mandible of normal size
There is a markedly class II profile, even though both the maxilla and the mandible are farther
back beneath the anterior cranial base than the normal
Upper incisors - either upright or tipped off the base labially according to the vertical category
It is a severe skeletal class ii with a short mandible, a short maxilla, a squarish gonial angle, and
a flat anterior cranial base
Type D
A retrognathic skeletal profile -- small mandible combined with a normal or slightly diminished
midface
Type E
A severe “class II” profile – prominent midface and normal or even prominent mandible
Bimaxillary protrusion class ii malocclusions are more likely to be horizontal type e than any
other
Both dentitions, in Type E, have a tendency to be forward on their bases and the incisors are
often in strong labioversion
Type F
Not well-defined, rigid syndromal class II type but, rather, a loose collection of cases displaying
some skeletal class II characteristics
The skeletal profile tends to be less severe than syndromal Types B, C, D, and E
The tooth positions reflect the vertical subsets associated with Type F
HORIZONTAL TYPES
Type A
Type B
Type C
Type D
Type E
Type F
Vertical types
Type 1 a mandibular plane steeper than normal, steeper functional occlusal plane, palate which
is tipped somewhat downward The anterior cranial base tends to be upward
The result -- an anterior face height - significantly greater than the posterior face height
Type 2
The mandibular plane, functional occlusal plane, and palatal plane are all flatter than normal and
are nearly parallel
The gonial angle approaches orthogonality & anterior cranial base more horizontal than normal
Type 3
During growth, the upper face height does not keep pace with the total face height, resulting in a
strong tendency to open-bite
When the mandibular plane is steeper than normal in vertical type 3, a skeletal anterior open-bite
is inevitable
Type 4
Mandibular plane, the functional occlusal plane, and the palatal plane are all tipped markedly
downward, leaving the lip line unusually high on the alveolar process in the maxilla
Vertical type 4 is among the most rare, severe, and anomalous of the vertical types
Type 5
Closely related to type 2 “the square face syndrome, ” and is found only in horizontal subgroups
B and E
The lower incisors are found in extreme labioversion, whereas the upper incisors are nearly
vertical
Vertical Type 2 -- found in all horizontal types, although it is the dominant feature of horizontal
Types B and E
Vertical Type 4, as noted earlier, is a severe rare group limited to horizontal Type B
Etiology
Considered to be ‘multifactorial’
So even with an identical genotype class II malocclusion does not always develop
Several investigators suggested additional etiological factors that particularly pertain to cl II div
2
a. Genetic predisposition :- Leech published a case report on identical twin, one having Div 1 &
other Div 2
Environmental factors
Important role
Persistent finger habit displacing max dentition forward, tip the occlusal balance more towards
cl II
May lead to lower lip trap, hyper active mentalis – intern tips U1 more labially
Persistent finger, tongue or lip habits can either result in a cl II malocclusion or accentuate an
existing one
The prevalence of malocclusion in north India (Delhi children) age 10-13 years is 45% (44.97%)
The prevalence of malocclusion in rural children in Haryana (age group 12-16) is (55%)
class II (10%)
Definite ethnic trend in prevalence of type of malocclusion from north to south India
For class II
Generalized maxillary spacing associated with the protruded maxillary incisors may be noticed
Cephalometric Presentation
Normal anteroposterior
AO-BO difference
The mandibular incisors -- normal anteroposterior position relative to the NB line, mandibular
plane, and frankfort horizontal
Abnormal values -
If no incisor protrusion results in crowding of the maxillary arch caused by the loss of space in
the arch perimeter
In some cases, both the central and the lateral incisors are lingually inclined and the canines
overlap the lateral incisors on the labial
a The central incisors are tipped lingually, the laterals are in labio-version or normally inclined
b All four incisors are tipped lingually and the canines are in mesiolabioversion
d Mixed type of frontal malposition, with lingually inclined incisors on one side
Deep overbite and minimal overjet
In cases with extreme overbite, the incisal edges of the lower incisors may contact the soft
tissues of the palate
In a few class ii division 2 cases, the mandibular labial gingival tissues may be also traumatized
An exaggerated curve of Spee may be present in the mandibular arch with extrusion of the
mandibular incisors (Strang 1958)
Frolich evaluated the dental arch form during the transitional dentition of children with Class II
malocclusions who did not undergo orthodontic treatment
Class II Division 2
No appreciable differences were present between normal and Class II individuals in absolute
arch length and width
Anterior arch length was found to increase markedly during the transition period for all Class II
types, except the Division 2 group
Overbite and overjet increased in the untreated Class II Division 1 cases and only excessive
overbite increased in the Division 2 cases
Frolich found the shape of the mandibular dental arch to be very similar in all four categories of
Class II malocclusion, but the maxillary dental arch was wider in the Division 2 cases
Clinical significance
As a result, it is very difficult to distinguish and predict the ultimate shape of the dental arch
before the eruption of the permanent incisors
It has also been established that the anteroposterior relationship of the dental arches in untreated
Class II cases, whether in the deciduous, mixed, or permanent dentitions, did not improve with
age (Bishara 1988)
Bishara and coworkers (1996) evaluated the changes in the dental arch width and length from the
deciduous to the mixed and permanent dentitions
The differences between the measurements of maxillary and mandibular intermolar arch widths
were greater in the normal subjects than in subjects with Class II Division 1 malocclusions.
The presence of this relative constriction of the maxillary arch, when related to the mandibular
arch in Class II malocclusions, is expressed from the earlier stages of dental arch development
Clinical significance
These trends continue in the mixed and early permanent dentitions and do not self-correct
without treatment
In general, Class II cases with anteroposterior skeletal discrepancies are characterized by a large
ANB angle and Wits Appraisal, reflecting the malrelationship between the maxilla and mandible
Skeletal discrepancies associated with Class II malocclusions have been termed skeletal Class II
relationships
This term indicates that the Class II malocclusion is one resulting from an anteroposterior
disproportion in size or discrepancy in position of the jaws rather than malposition of the teeth
relative to the jaws
Skeletal class II relationships often are associated with class II dental malocclusions
Natural dental compensation can be observed in the presence of the skeletal discrepancy – dental
discrepancy less severe than the skeletal discrepancy
Mandibular Deficiency
A skeletal class II relationship resulting from a mandible that is small or retruded relative to the
maxilla is termed a mandibular deficiency
Characterized by
Relative deficiency of the chin caused by the small size or retruded position of the mandible
Inadequate vertical support for the maxillary Incisors - overeruption of these incisors
Cephalometric analysis – downward and backward rotation of the mandible caused by the small
size of the ramus and body of the mandible
Normal position of point A but a posterior position of point B relative to nasion perpendicular
The cranial base angle, defined by points nasion, sella,and basion, often is more obtuse ---
glenoid fossa in a relatively posterior position
Normal lower face height in spite of the anteroposterior discrepancy between the maxilla and
mandible
Maxillary Excess
vertical maxillary excess:-more localized to the posterior area, associated with the maxillary
posterior teeth being in an inferior position with a normal vertical position of the incisors
Presentation usually as :- anterior open bite with a normal vertical display of the maxillary
incisors relative to the upper lip both in repose and upon smiling
No anterior open bite, but an excessive vertical display of the maxillary incisors relative to the
upper lip in repose as well as a gummy smile
In either of these two presentations, the mandible is rotated downward and posteriorly (clockwise
rotation), resulting in the class ii skeletal relationship
Both conditions exhibit facial skeletal convexity with a normal anteroposterior position of the
mandible
It is likely that most patients with skeletal class II problems have a combination of mandibular
deficiency and maxillary excess.
Maj and coworkers concluded that the skeletal differences were not due to an abnormal
development in the size of any specific part, but rather were the result of an abnormal
relationship between the parts, that is, the result of variations in the position of the skeletal
structures, in the direction of the discrepancy
Wallis compared Class II Division 2 , Class I and Class II Division 1 individuals and found that
the posterior cranial base was larger in Division 2 cases
He also noted that the mandibular found in a "typical" Division 2 case has relatively more acute
gonial and mandibular plane angles, shorter lower anterior face height, and excessive overbite
Hedges concluded that the only consistent cephalometric finding was the lingual axial inclination
of the maxillary central incisors
Abnormal muscular patterns may be associated with either type of Class II malocclusions
As in Class II Division I, the increased overjet may allow the lower lip to rest between the
maxillary and mandibular incisors maintaining or accentuating the overjet.
During swallowing
In Class II Division 2 individuals, the orbicularis oris and mentalis muscles are often well
developed and active
The lingual inclination of the maxillary incisors may accentuate the appearance of the lower "lip
curl" associated wit the vertical over closure
In addition, the combined effects of the hyperactive mentalis muscle and the reduced vertical
height accentuates the chin prominence
Clinical significance
This is because the mandible can either be in a normal or retruded relationship to the maxilla,
and in turn the maxilla may be either normal or in a protruded relationship to the mandible
As a result, the clinician should evaluate and diagnose, in each individual patient, the occlusal
relationships, the anteroposterior and vertical skeletal discrepancies, the soft tissue facial
relationships, as well as the presence of any abnormal function for appropriate treatment
planning
CONCLUSION
• The clinician should evaluate and diagnose, in each individual patient, the occlusal
relationships, the anteroposterior and vertical skeletal discrepancies, the soft tissue facial
relationships, as well as the presence of any abnormal function for appropriate
management of class II malocclusion
BIBLIOGRAPHY