C L A S S 2 D I V I S I O N I I M A L O C C L U S I O N S 3 1 9

E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6

18
Chapter

Class 2 division ii malocclusions

Nigel Harradine
3 2 0 C L A S S 2 D I V I S I O N I I M A L O C C L U S I O N S
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6

Introduction
These malocclusions have well documented features of which the two most noteworthy are:

• retroclination of the upper incisors

• the tendency to deep overbite

Two features that add to the potential difficulties or dilemmas in some cases are:

• a very low face height

• retroclination of the lower incisors

Deep overbite
The mechanics available to treat this are covered in the chapter on Managing Overbites, but there are
several factors that need particular focus in class 2 division ii malocclusions.

Extruded upper incisors

Almost by definition, the upper incisors, being retroclined by forces from the lip morphology are likely to be
also extruded. A study by Lapatki et al (2002) found that the upper incisor tips are indeed at a more inferior
position in class 2 division ii malocclusions than in class 1. In this study, pressure transducers also
showed more labial pressure at the upper incisal edge than at the cervical margin in class 2 division ii and
the reverse in class 1. The long-supposed role of a high lower lip line and associated lip pressure seems
well supported by this good study and the authors conclude that intrusion of the upper incisors in class 2
division ii will reduce lip pressure and enhance stability. Intrusion of the incisors is therefore likely to be a
sensible biomechanical aim. Burstone-type mechanics may be more frequently suitable in this
malocclusion.

Low face height

Clinical experience suggests that a low face height not only increases the probability of a deep overbite,
but also adds to the difficulty of overbite reduction. The increased forces from the muscles of mastication
may inhibit extrusion of posterior teeth. It is not possible to significantly increase face height beyond the
normal growth expectation. In adults, the slight hinging open of the mandible, associated with molar
extrusion, seems to be stable. This may be due to the tendency to slight continued vertical growth found in
adults by investigators such as Behrents (1986)

Traumatic overbite
Trauma labial to the lower incisors is thankfully rare, but when it does occur, it is almost always found in
this type of malocclusion. This does, of course, increase the imperative for overbite reduction.

Incisor proclination
Proclination of either upper or lower incisors is one method of overbite reduction in any malocclusion. In
class 2 division ii, the upper incisors are by definition retroclined and proclination is an easy tooth
movement. This does, of course, create a class 2 division i malocclusion and this is considered below. If
the lower incisors are also retroclined, proclination of lower incisors is usually necessary if a normal
interincisal angle is to be established. This raises the question of stability of the lower incisor position,
which is also discussed below.
 C L A S S 2 D I V I S I O N I I M A L O C C L U S I O N S 3 2 1
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6

Facial aesthetics
Three aspects are relevant:

• the reduced lower face height

• the frequently prominent labiomental fold
• the lip prominence

The reduced face height is not usually corrected. A small increase may accompany molar extrusion and
this may be permanent in an adult. However, this is not sufficient to alter facial aesthetics. Orthognathic
surgery to increase the face height is rarely advocated. Inferior movement of the maxilla requires bone
grafting and is less stable than almost all other orthognathic procedures.

The prominent labiomental fold is similarly resistant to change. Proclination of the lower incisors does not
significantly alter this feature in class 2 division ii, but may well be necessary in any case for occlusal
reasons, if the lower incisors are retroclined. Genioplasties are sometimes performed to reduce horizontal
prominence and increase the vertical height of the chin in this malocclusion.

The lip prominence is also less influenced by change in incisor position than in a class 2 division i case.
This is the result of the reduction of an increased overbite, which means that significant lower incisor
proclination can occur and the lower incisors still only occupy a position previously occupied by the upper
incisors. The anteroposterior position of the lips is therefore less related to change in the lower incisor
position than in other malocclusions.

Extraction decisions
The same factors influence this as in all malocclusions – as discussed in the chapter on Treatment
Planning. However, for a given amount of crowding or other anchorage demand (e.g. upper incisor
retroclination) several factors drive the decision towards an extraction pattern which provides less
anchorage or a non-extraction plan.

• overbite reduction
Other factors being equal, incisor proclination is preferred because it facilitates overbite
reduction.
• relative nasal and chin prominence
Frequently, these features mean that facial profile balance is more likely to approach normal
values if the incisors are proclined, even if the lips respond by a smaller percentage of the
change than in other malocclusions.
• space closure
There is a definite anecdotal clinical impression that extraction spaces can sometimes be
more difficult to close in a patient with a significantly reduced face height. Presumably this
would be due to the increased masticatory muscle forces inhibiting eruption and mesial drift.
Studies to prove this impression are elusive.

If all other factors considered in the chapter on Treatment Planning leave a choice of extractions, a less
radical or non-extraction plan will tend to emerge because of these three causes.

Stability of lower incisor proclination

This topic has already been discussed in the chapter on Treatment Planning. One factor that would
intuitively seem relevant is the proposition that if the upper incisors are intruded away from the lower lip,
the lower incisors can be moved labially until they occupy the position previously occupied by the upper
3 2 2 C L A S S 2 D I V I S I O N I I M A L O C C L U S I O N S
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6

incisors Selwyn-Barnett (1996). The relationship of hard to soft tissue will not be altered and the proclined
incisors should therefore stay stable in their new, more labial position. This seems a very reasonable
hypothesis. However, the paper by Canut and Arias (1999), showed that class 2 division ii cases treated
with incisor proclination had much more tendency to subsequent increase in arch irregularity than those
where arch length had not been increased. A reasonable hypothesis therefore seems unfortunately to lack
support from investigations.

Some cases leave no choice but to procline the lower incisors, because their retroclined initial position is
not compatible with a low inter-incisal angle and a class 1 incisor relationship. The work by Canut and
Arias supports the view that it is wise to retain the proclined lower incisors with more care and for a much
longer period than is required in other situations. This long-term aspect needs informed consent.

Treatment options
The treatment problems usually include

• retroclination of upper incisors

• a degree of class 2 molar relationship

The lower arch may be crowded, in which case the considerations about extractions outlined above apply.
Frequently, however, the lower arch has little crowding and is treated non-extraction. Palatal root torque of
upper incisors requires anchorage.

The sources of anchorage for correction of upper incisor retroclination are:

• functional appliances to move the upper molars to a class 1 relationship – or other forms of
class 2 traction.
• headgear to achieve the same occlusal change
• upper arch extractions

If the lower arch is non-extraction, this last option will leave a class 2 molar relationship.

Functional appliance treatment

This is a very effective way to correct a class 2 molar relationship and for many it is the treatment of choice
in the growing patient. One consideration is the need to initially procline the upper incisors to permit a
postured bite registration. This is frequently done with a removable appliance, which can usefully
incorporate an anterior bite plane. This pre-functional phase of upper incisor proclination can also be done
very efficiently via an upper sectional appliance, but the advantage of a bite plane is then not available
unless both removable and sectional fixed appliances are used at the same time.

Some clinicians prefer to combine the incisor proclination and functional correction in one appliance (e.g.
Dyer et al 2001). This can work well and has the attraction of starting everything at once, but it can also
create difficulty in obtaining a good postured bite at the start of treatment when there is no overjet and a
deep overbite. These awkwardnesses can lead to lengthy treatment as the cases reported in this paper
showed.

A post-functional phase of fixed appliances is usually required. In suitable cases a functional appliance is
probably the easiest way to treat the patient, providing the appliances are worn.

Headgear
Although entirely appropriate as an alternative method of correcting a class 2 molar relationship, we do not
favour this approach in these cases. Our experience and the compliance studies which we have carried
out (see chapters on Anchorage and Functional Appliances), suggest that compliance with headgear to a
 C L A S S 2 D I V I S I O N I I M A L O C C L U S I O N S 3 2 3
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6

degree sufficient to correct a class 2 molar relationship is much less common than with a twin-block
functional, let alone a fixed functional. The situations where headgear is preferred to a functional are also
outlined in the chapters on Anchorage and on Functional Appliances.

Fixed appliances from the start with extraction of upper premolars

This approach is particularly to be considered

• in adults where headgear and removable functionals are much less likely to succeed
• where substantial upper incisor irregularity would mean a prolonged initial proclination and
alignment pre-functional phase. A lengthy three-phase treatment is then a risk.
• where upper premolar extractions alone would be an appropriate extraction pattern.

One factor in such a treatment plan in adults is the frequent slowness with which the upper premolar
spaces close.

Conclusions
Moderate class 2 division ii cases present no particular challenge. More marked cases with the additional
features described above are most easily treated with a pre-functional, then functional and then fixed
phases. Patients more suitable for initial fixed appliances (see above) can be hard work however they are
treated. Significant lower incisor proclination should be regarded as an indication for effective long-term
retention.

References
Behrents R (1986)
JCO/interviews Dr. Rolf Behrents on adult craniofacial growth.
Journal of Clinical Orthodontics 20: 842-847
Canut JA and Arias S (1999)
A long-term evaluation of treated Class II division 2 malocclusions: a retrospective study model analysis.
European Journal of Orthodontics 21: 377-386
Dyer FM, McKeown HF and Sandler PJ (2001)
The Modified Twin Block Appliance in the Treatment of Class II Division 2 Malocclusions.
Journal of Orthodontics 28: 271-280
Lapatki BG, Mager AS, Schulte-Moenting J and Jonas IE (2002)
The importance of the level of the lip line and resting lip pressure in Class II Division 2 malocclusion.
Journal of dental research 81: 323-328
Selwyn-Barnett BJ (1996)
Class II/division 2 malocclusion: A method of planning and treatment
British Journal of Orthodontics 23: 29-36
3 2 4 C L A S S 2 D I V I S I O N I I M A L O C C L U S I O N S
E X C E L L E N C E I N O R T H O D O N T I C S 2 0 0 6