ORIGINAL ARTICLE

Dental arch width in Class II Division 2 deep-

bite malocclusion
Todd M. Walkow, DMD, MS,a and Sheldon Peck, DDS, MScDb
Newport Beach, Calif, and Boston, Mass

A severe phenotype of Angle’s Class II Division 2 (II/2) malocclusion with extremely deep overbite has been
called cover-bite, or “Deckbiss” in its early German descriptions. This distinctive occlusal variation is
characterized by skeletofacial hypodivergence, mandibular dentoalveolar retrusion, excessive bony chin
projection, reduced mesiodistal tooth size, maxillary incisor retroclination, and at least 100% overbite,
covering at least 1 mandibular incisor in occlusion. In this study, maxillary and mandibular dental arch widths
measured at the first molars and the canines were recorded from dental casts of 23 subjects with II/2
cover-bite malocclusions. The data were compared with a control-reference sample of 46 orthodontic
patients matched for age and gender. In the cover-bite group, the intermolar widths in both arches and the
intercanine width in the maxilla were comparable with those in the control sample. However, mandibular
intercanine width in the II/2 cover-bite group was significantly less than that of the controls (P ⫽ .01). These
findings suggest that II/2 deep overbite malocclusion is characterized by normalized and relatively
compatible transverse dimensions in the maxilla and in the mandibular posterior segments. The transverse
underdevelopment that this study identified in the mandible from canine to canine is probably responsible for
mandibular incisor compression and crowding—natural sequelae of the deep overbite in II/2 cover-bite.
Thus, a reasonable orthodontic treatment plan for the mandibular dentoalveolar compensation often seen in
II/2 deep-bite patients would be anterior expansion of the mandibular arch width, usually reducing the need
for orthodontic tooth extractions and increasing the desirability of fixed retention. (Am J Orthod Dentofacial
Orthop 2002;122:608-13)

A
t the beginning of the 20th century, Edward H.
Angle1-3 differentiated between the first and
second divisions of his Class II type of maloc-
clusion. In contrast to Class II Division 1 (II/1) patients
with characteristically “narrowed upper arches,” Class
II Division 2 (II/2) patients were observed by Angle to
have more nearly normal maxillary arch widths. Other
features of II/2 he described were retrusion of the
maxillary incisors, deep impinging vertical overbites,
and relatively normal nasal and lip functions.
Although Angle astutely noted these distinguishing
features 100 years ago, current scientific notation often
blurs or ignores the distinction between these 2 ana-
tomically different Class II subtypes. For instance,
Enlow and Hans4 discuss generic Class II skeletodental
features and facial growth without differentiating II/2
from II/1. According to them, Class II patients have
long, narrow anterior cranial bases that affect the
a
Private practice, Newport Beach, Calif.
b
Associate clinical professor of Oral and Developmental Biology (Orthodon-
tics), Harvard School of Dental Medicine, Boston, Mass.
Reprint requests to: Dr Todd M. Walkow, 360 San Miguel #706, Newport
Beach, CA 92660; e-mail, twalkow@yahoo.com.
Submitted, February 2002; revised and accepted, April 2002.
Copyright © 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 ⫹ 0 8/1/129189
doi:10.1067/mod.2002.129189
608
nasomaxillary complex and result in long, narrow
palates and maxillary arches. Their conceptual Class II
subject appears to be modeled around the features of
the II/1 dentofacial type, but this was never established.
In an effort to identify some anatomical features
that make the II/2 deep-overbite discrepancy unique,
Peck et al5 investigated characteristics of a severe
expression of II/2 overbite: the cover-bite malocclu-
sion. The II/2 cover-bite condition was first recorded in
1912 in the German literature (as “Deckbiss”).6 This
occlusal phenotype is characterized today by “conceal-
ment or complete covering of the mandibular incisor
crowns due to excessive overbite and retroclination of
the maxillary incisors”5 (Fig 1, A-D). The cephalomet-
ric and odontometric study of Peck et al5 identified the
following additional morphological attributes of a II/2
cover-bite malocclusion: (1) craniomandibular skeletal
hypodivergence, (2) excessive bony chin projection due
to an anteriorly well-developed basal bone region of the
mandibular body, and (3) reduced mesiodistal size of
the maxillary and mandibular incisors.
Angle’s3 clinical observation of the “nearly nor-
mal” width of both arches in II/2 malocclusion rarely
has been examined in controlled studies. Peck et al5
also commented anecdotally on the apparently adequate
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 122, Number 6
Fig 1. Typical Class II Division 2 deep overbite (cover-bite) malocclusions at diagnosis: A, B,
9.2-year-old boy; C, D, 11.3-year-old boy.
transverse jaw dimensions observed in patients with
II/2 deep-bite malocclusions. Moorrees et al7 used
serial dental casts of untreated Class II malocclusions to
compare arch dimensions of II/1 and II/2 subgroups.
Compared with dental-cast measurements from a con-
trol-reference population, II/2 dental casts had maxil-
lary and mandibular intercanine distances greater than
average, and intermolar distances with a normal distri-
bution. In contrast, intercanine and intermolar distances
in II/1 patients measured less than average. Buschang et
al,8 in a cross-sectional study of 386 white women,
found that II/2 patients had greater maxillary interca-
nine and intermolar distances than did II/1 patients.
However, the II/2 patients showed mandibular interca-
nine and intermolar widths less than the Class I and II/1
patients. Neither of the previously mentioned arch-
width studies7,8 of II/2 patients considered the amount
of overbite in the sample group.
Knowledge of arch-width characteristics associated
with severe II/2 deep bite (cover-bite) malocclusion
would be helpful in determining orthodontic treatment
goals and likely posttreatment sequelae for this partic-
ular skeletodental dysmorphology. The purpose of this
study was to assess dental arch width in II/2 cover-bite
subjects. The null hypotheses to be tested states that
there is no mean difference in maxillary and mandibu-
Walkow and Peck 609
lar intercanine and intermolar distances between II/2
cover-bite subjects and a control-reference sample.
MATERIAL AND METHODS
Pretreatment dental casts of 23 orthodontic patients
having II/2 cover-bite malocclusions were collected
from patient records at the Harvard School of Dental
Medicine in Boston and at a private orthodontic prac-
tice in the northeastern United States. The subjects’
ages ranged from 8.4 to 33.9 years (median, 12.4
years). Males predominated over females in the II/2
cover-bite sample with 20 subjects (87%). A control
sample of 46 subjects matched according to age and sex
was selected from orthodontic patient records at the
Harvard School of Dental Medicine: for each II/2
subject, the pretreatment dental casts of 2 matched
control patients were used (Table I). All private prac-
tice patients said they had European ethnicities. Ethnic-
ity and race data were not obtainable for the dental
school clinic patients.
The following diagnostic criteria were used for
inclusion in the experimental sample of II/2 cover-bite
subjects: (1) Class II molar relationship on at least 1
side in centric occlusion, (2) Class II deciduous or
permanent canine relationship, (3) retroclination of 2 or
more maxillary incisors, and (4) a vertical relationship
610 Walkow and Peck American Journal of Orthodontics and Dentofacial Orthopedics
December 2002

● Maxillary and mandibular intercanine width: the

Fig 2. Maxillary and mandibular intercanine width and
intermolar width measurements.
distance between the cusp tips of the right and left
canines, or the center of the wear facets in cases of
attrition.
● Maxillary intermolar width: the distance between the
apices of the mesial triangular fossae of the right and
left first molars. This point is relatively easy to find,
because it is the mesial termination of the central
groove. From clinical experience, we have found this
point to be located without difficulty in restored
teeth.
● Mandibular intermolar width: the distance between
the central pits of the right and left first molars. This
reference point was most accessible because all
developmental grooves converge at this point on the
occlusal surface.
A double-determination method13 applied to the
arch-width measurements gave results that had small
variability relative to the mean, producing a minimal
measurement error (Table II). The low error-of-the-
method results confirms the strong reliability of the
measurement technique and the selected arch-width
measurement reference points.
A 2-sample t test was used to determine whether
there was a statistically significant difference in mean
intercanine and intermolar widths between the II/2
sample and the controls. The ␣ level was set at 0.05.

Distribution and relative frequency of Angle

Table I. RESULTS
malocclusion classes in control sample An exploratory analysis confirmed that the data
Relative were normally distributed, and that the variances be-
Malocclusion Number of frequency tween the groups were equal. With a 2-sample t test, a
Class subjects (%) statistically significant difference in the mean mandib-
Class I 16 34.8 ular intercanine width for the II/2 sample compared
Class II Division 1 22 47.8 with the control sample was found (Table III). Thus, the
Class II Division 2 4 8.7 null hypothesis for the mandibular intercanine width
Class III 4 8.7 variable can be rejected. The mean mandibular interca-
Total 46 100.0
nine width for the II/2 cover-bite sample is signed with
negative value, indicating that it measures significantly
smaller than that of the controls.
in which at least 1 mandibular incisor crown is covered
completely by the corresponding maxillary incisor DISCUSSION
(overbite ⱖ 100%). Of the 4 main categories in Edward H. Angle’s
The arch-width measurements were recorded from ubiquitous classification of malocclusions, the II/2 type
each subject’s pretreatment dental casts by 1 examiner of discrepancy occurs the least often. Obtaining data on
(T.M.W.), using an odontometric dial caliper and re- II/2 patients has always been challenging because of the
cording the data to the nearest 0.1 mm. To reduce low prevalence rates. In a study of 2758 white North
examiner bias, the examiner measured the 138 casts in American adolescents between 14 and 18 years of age,
random order. Four arch-width measurements (Fig 2), Massler and Frankel14 found the prevalence rate of II/2
using methods similar to those of earlier studies,8-12 to be 2.7%. Using that same method of examination,
were taken from the casts of all 69 subjects in this Altemus15 found a prevalence rate of 1.6% for II/2
study: among 3289 black students in the District of Columbia.
American Journal of Orthodontics and Dentofacial Orthopedics Walkow and Peck 611
Volume 122, Number 6

Table II. Error analysis with 10 double determinations

Mean Mean SD of the Error of

absolute signed signed the
Measurement (mm) difference difference difference method

Maxillary intermolar 0.12 0.02 0.14 0.04

Maxillary intercanine 0.20 0.14 0.26 0.08
Mandibular intermolar 0.10 ⫺0.04 0.12 0.04
Mandibular intercanine 0.15 ⫺0.07 0.19 0.06

Table III. Arch width measurements and t test for equality of means
II/2 sample Controls

Measurement (mm) Mean SD Mean SD t P value

Maxillary intermolar 45.2 2.7 44.2 3.1 1.30 .20

Maxillary intercanine 33.0 2.4 33.9 3.3 ⫺1.09 .28
Mandibular intermolar 41.1 2.4 40.4 3.1 0.94 .35
Mandibular intercanine 25.6 1.5 26.8 1.8 ⫺2.65 .01*

*P ⬍ .05.

Prevalence data for II/2 cover-bite malocclusion have
been reported only by Peck et al,5 who found a
prevalence rate of 1.7% in a North American orthodon-
tic patient population.
The case-control method is the most suitable and
efficient investigative approach to study conditions of
infrequent occurrence, such as the cover-bite phenotype
of the II/2 malocclusion. In this study, we collected a
sufficient number of cases by combining pretreatment
subjects from 2 different sample sources. The experi-
mental sample of 23 II/2 deep-overbite patients favored
males over females by a ratio greater than 6 to 1. A
natural bias for male expression in deep-bite malocclu-
sion has been reported earlier.5
Our measurements of arch width in II/2 cover-bite
patients found mandibular intercanine width signifi-
cantly less than that in the control-reference sample. A
possible explanation of this phenomenon might be that
the extreme deep bite in cover-bite patients inhibits
anterior development of the mandibular dentoalveolar
segment. The mandibular incisors could be compressed
by the lack of available space resulting from a forward
growth rotation of the mandible. Thus, mandibular
anterior crowding and dentoalveolar extrusion are pos-
sible sequelae to the mandibular intercanine width
constriction. Another view could be based on the nature
of holding cusps in stabilizing arch form and tooth
position over time: the molars and the premolars meet
their antagonists naturally in a solid, interlocking oc-
clusion, but the canines and the incisors do not have
this advantage and thus would be more likely to shift
position in time.
Bjork16 found the forward (bite-closing) rotation of
the mandible, associated with the II/2 deep bite maloc-
clusion, to be characterized by decreased maxillary
arch length, anterior dental crowding, and deepening of
the anterior dental and skeletal vertical relationships.
The reduced mesiodistal diameters of the mandibular
incisors in II/2 cover-bite patients require a smaller
anterior arch perimeter, actually helping to accommo-
date the reduced mandibular intercanine width to min-
imize the crowding potential of the incisors.5
The small sample size in this study might have
decreased its power. Increasing the sample size would
most likely lead to a greater probability of establishing
statistical significance for the observed trends in the
maxillary intercanine, maxillary intermolar, and man-
dibular intermolar arch-width measurements.
CLINICAL IMPLICATIONS
The skeletodental peculiarities of the II/2 deep-bite
patient often present unique clinical challenges. These
patients have a distinct dentofacial dysmorphology and
thus should not be treated simply as a variation of the
more common II/1 malocclusion. Nonetheless, some
clinicians have reported similar treatment modalities
for all patients in the Class II category.17,18
Treatment planning to address the sagittal and
vertical discrepancies observed in II/2 cover-bite pa-
tients has featured varied approaches. Successful re-
sults have used Class II elastics with extraoral traction
and bite planes,19 or with a functional appliance,20 or
combinations of functional and fixed orthodontic appli-
ances.21,22 Litt and Nielsen23 orthodontically treated
612 Walkow and Peck
identical twin boys with II/2 malocclusions: 1 under-
went extraction treatment, and the other had nonextrac-
tion expansion treatment. Both approaches produced
acceptable outcomes.
Results of this study demonstrate collapsed man-
dibular intercanine width in II/2 cover-bite patients,
probably because of mandibular anterior confinement
from severe overbite. During II/2 orthodontic treat-
ment, the maxillary incisors are usually proclined to
permit a posteriorly displaced mandible to reposition
anteriorly.24 The mandible is thus allowed to develop
more favorable sagittal and vertical postures, and man-
dibular anterior teeth often have fresh space for de-
crowding. In this way, nonextraction arch development
is usually the most reasonable treatment approach for
the overcompensated dentition in severe II/2 discrep-
ancies.
Consideration of mandibular dentoalveolar arch-
width expansion for the treatment of II/2 problems
might generate concern about the increased potential
for unstable orthodontic results. Little et al25 found the
mandibular intercanine width to decrease postorthodon-
tically, regardless of whether this dimension was ex-
panded. During the retention period, no significant
differences in the amount of mandibular anterior
crowding among the different malocclusion classes
were noted. However, II/2 patients demonstrated the
least relapse. Canut and Arias26 retrospectively studied
30 II/2 treated patients for outcome stability. They
found that almost all showed some crowding of man-
dibular incisors at 3 years postretention. Maintenance
of the original mandibular intercanine width and arch
length during treatment proved to be no guarantee for
stability of the anterior teeth in their II/2 sample.
Thus, some overbite rebound seems to be inevitable
in the II/2 deep-bite orthodontic patient.26,27 A post-
treatment increase in overbite could provoke a reduc-
tion of the mandibular intercanine distance and subse-
quent mandibular incisor crowding. Therefore, it might
be prudent to place fixed lingual retention on the
mandibular anterior teeth of cover-bite patients. The
bonded retainer might also help to maintain the overbite
correction by not allowing mandibular anterior arch-
width collapse.
In the current study, the II/2 cover-bite patients had
arch-width measurements comparable with those re-
corded for the control-reference sample, except for
mandibular intercanine width. Based on these findings,
it is unlikely that an interarch transverse discrepancy
would develop during treatment of the typical II/2
cover-bite patient.
American Journal of Orthodontics and Dentofacial Orthopedics
December 2002
CONCLUSIONS
Based on the results of this study, dental arch form
in the II/2 deep-overbite patient might be characterized
as normal, except in the mandibular intercanine width
dimension, which is reduced. The decrease in the
mandibular anterior arch width is probably a result of
the severe overbite that inhibits forward mandibular
dentoalveolar growth but cannot inhibit the strong basal
and symphyseal growth in the II/2 mandible.5 Decom-
pensating the dentition by expanding the mandibular
intercanine width after bite-opening procedures would
appear to be an acceptable treatment approach, espe-
cially for II/2 deep-bite patients with mandibular ante-
rior crowding.
According to our findings, the posterior arch widths
in the maxilla and the mandible of II/2 cover-bite
patients are the same as those of other orthodontic
patients. The postcanine dental arches also appear to be
well related to one another occlusally. Therefore, trans-
verse maxillomandibular discrepancies would not be
suspected as a cause of II/2 deep-bite malocclusions.
We thank Dr Blaine Langberg for his kind help with
the graphics.
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