Class II malocclusion: The aftermath of a

“perfect storm”
Alexandros K. Tsourakis, DDS, MS, and Lysle E. Johnston Jr, DDS, MS, PhD,
FDS RCS(E)

To characterize the relative contribution of skeletal growth and tooth

movement to occlusal development. Longitudinal cephalograms were
obtained for 39 untreated subjects between 5 and 16 years of age. The
sample was divided into three terminal-plane groups: mesial step, flush
terminal plane, and distal step. Based on their final occlusion, the flush group
(24 of the 39 patients) was sub-divided into three sub-groups: Class I, end-to-
end, and Class II. Regional superimposition was used to measure yearly
increments of skeletal and dental change. The mesial- and distal-step groups
tended to maintain their initial Class I or Class II molar relationships. In the
three flush-terminal-plane sub-groups, occlusal progression could be
explained by neither an early nor a late mesial shift, both of which featured
more upper molar movement than lower. Instead, the groups differed in
terms of the timing of the mandibular excess and mesial movement of the
upper molars. Mandibular excess and mesial movement of the maxillary
molars seems to be the most significant determinants of occlusal develop-
ment in flush-terminal-plane subjects. The present data argue that the
strategy of holding lower leeway space and “distalizing” the upper molars is
a rational early-treatment strategy. (Semin Orthod 2014; 20:59–73.) & 2014
Elsevier Inc. All rights reserved.

I n orthodontics, controversies tend to be

nearly immortal, none more so than the
contumely surrounding the treatment of Class II
malocclusion. Is it to be early or late? Fixed or
functional? Extraction or nonextraction?
Unfortunately, at least for the Class II patient, if
not for the clinician, rational decision-making is
distorted by popular, clinically seductive myths
that are largely innocent of reason or proof of
efficacy. Magic is for entertainment in night
clubs; belief in magic is for children, not those
who would treat them.
The etiology of malocclusion is said to be
“multifactorial.” That truism having been said, we
would suggest that the persistence of cusps
divides a continuous, ratio-scale mixture of jaw
Saint Louis University, St. Louis, MO; The University of
Michigan, Ann Arbor, MI.
Address correspondence to Lysle E. Johnston Jr, DDS, MS, PhD,
FDS RCS(E), Box 595, Eastport, MI 49627. E-mail: lejjr@umich.
edu
& 2014 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0
http://dx.doi.org/10.1053/j.sodo.2013.12.006
growth and tooth movement into an artificial
trichotomy—Normal/Class I, Class II, and Class
III. An important determinant of the final
outcome of this interaction is the so-called “ter-
minal-plane relationship,” the antero-posterior
relationship between the distal surfaces of the
maxillary and mandibular second deciduous
molars. In the case of “distal” or “mesial” steps,
the first permanent molars are guided immedi-
ately into Class II or Normal/Class I occlusions,
respectively.1 (In the present communication,
the term “Class I” will be used to denote the
molar relationship common to Normal occlu-
sions and Class I malocclusions.) Further, the
phenomenon of “dentoalveolar compensation”
(a “scientific” term for the fact that inter-
cuspated teeth apparently move in response to
differential jaw growth) is said to ensure that,
once formed, a molar relationship tends to be
stable.2,3 Accordingly, in orthodontics, the study
of occlusal development tends to emphasize the
so-called molar “flush” terminal plane, a com-
mon relationship (Table 1) that guides the first
molars into a presumably unstable end-to-end
occlusion. The ultimate resolution of this

Seminars in Orthodontics, Vol 20, No 1 (March), 2014: pp 59–73 59

60 Tsourakis and Johnston Jr

Table 1. Molar Relationship: Distribution by Stage of Occlusal Development According to Previous Studies
Reference(s) N Deciduous Dentition Mixed Dentition Permanent Dentition

Cross-sectional data

Baume4–6 30 86% Flush terminal plane – –

14% Mesial step
Clinch7 61 43% Flush terminal plane – –
26% Mesial step
31% Distal step
Bonnar8 8 63% Mesial step – –

Longitudinal data

Carlson and Meredith9 109 55% Mesial step 59% Class I –

32% Flush terminal plane 24% Cusp-to-Cusp
13% Distal step 15% Class II
1% Class III
Arya et al.10 118 38% Flush terminal plane 49% Cusp-to-Cusp 59% Class I
48% Mesial step 27% Class I 38% Class II
14% Distal step 23% Class II 2% Class III
1% Class III
Bishara et al.11 121 62% Mesial step – 62% Class I
29% Flush terminal plane 34% Class II
9% Distal step 4% Class III

relationship—the formation of a Class I, II, or III
occlusion—is a key clinical consideration and, as
such, has been the subject of extensive research.
In general, three phenomena are invoked: an
“early mesial shift,” a “late mesial shift,” and
excess mandibular growth.
According to Baume,4–6 if there is spacing in
the deciduous dentition, when the permanent
first molars erupt, there is a mesial “shift” of the
lower deciduous molars into the primate spaces
of the deciduous dentition. Specifically, Baume
found that the antero-posterior distance between
the distal surface of the maxillary and man-
dibular deciduous canines does not change,
whereas the mandibular deciduous molars move
mesially relative to the maxillary with the closure
of the primate spaces. He concluded, therefore,
that the lower deciduous molars drift forward
with the eruption of the permanent first molars
so that there can be a transition from a flush
terminal plane during the deciduous dentition to
a mesial step during the mixed dentition. Many,
however, disagree.
Clinch,7 for example, argued, again from the
study of serial dental casts, that the replacement
of the mandibular deciduous incisors by their
permanent successors could result in a distal
drifting of the mandibular deciduous canines into
the lower primate space, and excess mandibular
growth could explain the mesial shift of the lower
deciduous and first permanent molars. Clearly,
the two interpretations cannot be resolved from
a study of dental casts. Today, it is more common
to emphasize the role of “leeway space,” the
difference in the mesio-distal size of the primary
buccal segments and their permanent successors
(perhaps a bit less than “E-space”), in the tran-
sition to a Class I molar relationship in flush-
terminal-plane subjects.
According to Maher12 and Moyers,1 after incisor
alignment, the leeway space on each side is
1.20 mm in the maxilla and 2.16 mm in the
mandible. This excess space is thought to allow
the mandibular permanent first molars to drift
forward more than the maxillary first molars when
the deciduous second molars exfoliate. Augmented
by the normal pattern of growth (mandible
4 maxilla), this differential movement, the so-
called “late mesial shift,” is thought by many (e.g.,
Baume,4–6 Clinch,7 and Moorrees et al.13) to be the
mechanism by which an end-to-end molar rela-
tionship in the mixed dentition can change to a
Class I in the permanent dentition.
Cephalometric studies by Murray,14 Paulsen,15
White,16 and Kim et al.,17 however, seem to
contradict the general concept of a late mesial
shift. According to these workers, there is a
mesial movement of the permanent first molars
into the leeway space, but there seems to be no
relationship to the difference between the leeway
spaces in the maxilla and the mandible and
final molar relationship. Further, cephalometric
 Class II malocclusion 61

radiographs permitted them to differentiate
between skeletal growth and tooth movement.
Their studies seem to show that the actual mesial
movement of the maxillary first molar during the
period between the mixed and the permanent
dentitions often exceeds that of the mandibular
first permanent molar relative to mandibular
basal bone.
Inferences from the various types of research
are much like the blind men0 s description of an
elephant. In general, studies of dental casts
permit an assessment of tooth movement; how-
ever, they say little about the role of skeletal
growth and tooth movement relative to basal
bone. By way of contrast, cephalometric studies
can provide additional information on the effect
of differential growth and the details of tooth
movement. The findings from a variety of stud-
ies/methodologies are summarized in Table 2.
In order to detect an influence of jaw growth
and tooth movement on occlusal development, a
number of studies (Table 2) have used dental
casts, cephalometric radiographs, or a combina-
tion of the two. Dental casts are perhaps the best
way to depict changes in occlusal relationship
over time; however, when it comes to explaining
the etiology of occlusal change, casts cannot
differentiate between skeletal and dental
components of the change. Skeletal change
can be mis-perceived as tooth movement and
vice versa. Cephalometric studies, on the other
hand, offers, at least in potential, the opportunity
to examine and quantify skeletal and dental
components with the aid of structural regional
superimposition3,21,22—superimposition based
on structures that Björk has shown to be stable.
This approach would seem to provide the nec-
essary information to differentiate between tooth
movement and skeletal growth as determinants
of occlusal changes. Based on this sort of ceph-
alometric data, skeletal growth seems to be the
most important factor in the occlusal adjustment
at the transitional phases of occlusal develop-
ment.
Just as with blind men describing an elephant,
each study no doubt depicts a portion of the
truth. Integration and interpretation, however, is
difficult. A major problem is the increasingly
common observation that the details and sig-
nificance of the late mesial shift are subject to

Table 2. Details of Occlusal Development as a Function of Methodology

Reference(s) N Findings

Casts
Baume4–6 60 In spaced deciduous dentitions, Class I molar adjustment takes place with an early mesial
shift. In closed deciduous dentitions, adjustment occurs by way of a late(er) mesial shift
Clinch7 61 Mandibular growth plays a role in Class I adjustment from deciduous to mixed dentition.
No closing of primate spaces was observed
12
Maher 43 Leeway space is not a critical factor for occlusal adjustment in the transition between the
mixed and permanent dentition
Bonnar8 58 Forward movement of the mandibular dentition can occur during the deciduous
dentition and at the transition between the deciduous and mixed dentition
18
Lamont 96 Leeway space might be a main contributor for molar adjustment toward Class I when the
Wits A–B differential does not change
Micklow19 10 The predominant factor in molar adjustment is excess mandibular growth
Moorrees et al.13 94 Class I molar relationship is achieved from an initial cusp-to-cusp relation by greater
mesial shifting of the mandibular molars
Cephalometric radiographs
Murray14 20 The principal factor in the occlusal adjustment of the buccal segments during the mixed
dentition is the relative growth/displacement of maxillary and mandibular basal bone
White16 34 The normal pattern of facial growth (mandible more than maxilla) is the decisive factor
in molar adjustment from the mixed to the permanent dentition
Kim et al.17 40 Skeletal growth difference between the jaws influenced the change in molar relationship
Casts and cephalometric radiographs
Brin et al.20 60 Differential growth of the maxilla and the mandible plays a significant role in occlusal
relation if dentoalveolar compensation cannot compensate for the differential
15
Paulsen 52 More mandibular growth could contribute to a Class I relation. Change in molar
occlusion during the process of growth and development is a multifactorial
phenomenon
Bishara et al.11 121 No correlation was found between molar relationship and the difference in the leeway
space between the maxillary and mandibular arches
62 Tsourakis and Johnston Jr
question. Firstly, a leeway space differential of a
millimeter or so cannot account for a half-cusp
change in the molar occlusion. More sig-
nificantly, it is probable that the mesial drift of
the upper molars commonly exceeds that of the
lower. For example, Kim et al.17 conducted a
serial cephalometric study of occlusal develop-
ment in which they divided their sample into
three groups based on the long-term pattern of
growth. In the group that featured an excess of
mandibular growth relative to maxilla (Group
A), the mesial drift of the upper molars was much
greater than that of the lowers. Given that the
growth in this group is consistent with the normal
pattern, one is forced to the preliminary con-
clusion that the leeway space may not be a key to
molar occlusal development.
To characterize the key events in the transition
from a flush terminal plane, White16 examined a
sample of 34 Bolton Study subjects whose
selection criterion was an end-to-end molar
occlusion in the early mixed dentition (upper
and lower first molar mesial contact points within
1 mm, parallel to the occlusal plane). He fol-
lowed them up into the permanent dentition and
used regional superimposition to study jaw
growth and tooth movement parallel to an
averaged functional occlusal plane. He found
that the subjects who developed a Class I
occlusion had a significantly greater mandibular
excess than those who did not. Further, in all
groups, the upper molars came forward on basal
bone about twice as far as did the lowers. A
mandibular growth deficit might seem to support
McNamara0 s23 contention that Class II is at
bottom a mandibular problem whose rational
correction would be to grow more mandible;
however, the problem is considerably more
complex.
Donaghey24 used regional cephalometric
superimposition to the compare growth seen in
Class II and Class I subjects. In young Class II
subjects, his findings extend those of White: Class
II subjects from ages 9 to 11 years continue to grow
less well; however, when he followed up the same
subjects for an additional 2 years, the growth
deficit was no longer present. A tentative
interpretation of these findings might be that
Class II patients were unlucky in that they did not
get the right growth at the right time. Although
Class I and Class II subjects show about the same
overall pattern of growth, the gain is not smooth
and continuous (Lande25 and Harvold26). If an
occlusion goes to Class II, the probably favorable
pattern of subsequent growth (mandible 4
maxilla) would have no impact, given that
dentoalveolar compensation tends to maintain
an intercuspated occlusion in the face of a wide
range of maxilla–mandibular growth differentials.
The idea that many Class II patients are merely
unlucky victims of bad timing and the stability of
an intercuspated, dentition, although interest-
ing, seems to require a more detailed explora-
tion. To date, much of the disagreement in the
literature is methods-related. Accordingly, it
would seem that a study of occlusal development
must be capable of measuring and integrating
both jaw growth (i.e., bodily displacement) and
tooth movement (relative to basal bone). Serial
cephalograms, therefore, would seem to be an
appropriate vehicle for such an investigation.
The key to the present communication, however,
is the assumption that increments of change—
both skeletal and dental—must be measured in
an integrated fashion. To this end, we argue that
the occlusal plane is, both literally and figu-
ratively, the “bottom line” at which all compo-
nents of occlusal change are summed. As such,
an analysis based on this frame of reference
should permit a relatively un-confounded
assessment of the relative contributions from
growth and tooth movement to molar occlusal
development.
Materials and methods
The sample consisted of 39 healthy (as certified
by their family physician), untreated subjects (17
males and 22 females) from the Bolton-Brush
Growth Study Center, Case Western Reserve
University, Cleveland, OH. Our goal was to
document their terminal-plane relationship in
the deciduous dentition and then to follow-up
the course of their first-molar adjustment on into
the permanent dentition. Essentially, the only
inclusion criteria were that a series be available at
the time of our visits to the Center and that it has
annual cephalometric radiographs from ages 5
or 6 years to 15 or 16 years. Because of this
variation in the ages at start and finish, statistics
for ages 5 and 16 years are based on fewer than
39 subjects. Although it was largely a sample of
convenience, it should be noted that some attempt
was made to over-sample flush-terminal-plane
 Class II malocclusion
subjects. As a result, the mixture of occlusions
must be expected to differ somewhat from the
historical summary of Table 1. Subjects were
excluded based on premature loss or absence of
teeth, evidence of primary second molar
ankylosis, extensive restorations (subjects with
Class II restorations would be included, but not
subjects with full-crown restorations in deciduous
or permanent teeth), evidence of orthodontic
treatment/appliances, and inadequate film
quality (in the opinion of the junior author, who
executed the tracings). Whenever a marked,
apparently temporary anterior displacement of
the mandible was seen in one film of a series, it
was assumed to have been the result of a man-
dibular functional shift; the affected film was
excluded from the series, and the resulting 2-year
increments of change were divided between the
intervals adjacent to the missing film.
The final sample was divided into three groups
according to the initial terminal-plane relation-
ship at age 5 or 6 years: mesial step, flush terminal
plane, and distal step. The initial terminal-plane
relationship was defined by the distance between
perpendiculars erected through the distal surfa-
ces of the second primary molars from the so-
called “functional occlusal plane,” a best-fit line
drawn by inspection through the buccal-segment
occlusion (Jenkins27). A subject was assigned,
somewhat arbitrarily, to the mesial-step terminal-
plane group if the lower primary second molar
was Z0.5 mm mesial to the upper primary sec-
ond molar (N ¼ 6) and to the distal-step terminal-
plane group if it was Z0.5 mm distal to the upper
(N ¼ 9). The remaining subjects between these
two boundaries were assigned to the flush-
terminal-plane group (N ¼ 24).
The flush-terminal-plane group was divided
further into three sub-groups according to their
occlusion at the end of the series (age 15 or 16
years): Class I, end-to-end, and Class II. The
molar relationship was measured cephalometri-
cally as the distance parallel to the functional
occlusal plane of perpendiculars erected through
the mesial of the upper and lower first perma-
nent molars. Based on a pilot study of post-
treatment cephalograms, subjects from the flush-
terminal-plane group were assigned to the Class I
sub-group if their molar relation at age 15 years
was 4 þ1 mm. Molar relations between 1 and
þ1 were assigned to the end-to-end subgroup and
o 1 mm to the Class II subgroup.
63
All radiographs in a given series were traced at
a single sitting. Bilateral structures were aver-
aged. To maximize consistency in the inter-
pretation of the structural details on which
regional superimposition would be based, the
tracings were executed in adjacent pairs, starting
in the center of the series and working forward
and backward pair wise to the beginning and
end. Although there is considerable change over
a decade, adjacent films are usually similar enough
to permit coordinated tracing and regional
superimposition based on Björk0 s putatively stable
structural details in cranial base, midface, and
mandible. To measure maxillary and mandibular
bodily translation relative to cranial base and
maxillary and mandibular tooth movement rela-
tive to basal bone, the tracing pairs (ages 5 and 6
years, 6 and 7 years, 7 and 8 years, etc.) were
superimposed regionally according to the so-
called “Pitchfork Analysis” (Fig. 1; Johnston21;
also see Duterloo and Planché22). Each super-
imposition was preserved by way of cranial base,
maxillary, and mandibular fiducial lines trans-
ferred throughout the series. The upper and lower
molar movement relative to basal bone up to 2
years after the eruption of the first permanent
molars served as an estimate of the “early” mesial
shift, and the movement after the loss of the
second deciduous molars (on average, 2 years,
Figure 1. Cephalometric regional superimposition
(“Pitchfork Analysis 21”)—maxillary displacement
relative to cranial base and mandibular excess. This
superimposition also is used to measure upper tooth
movement. Lower tooth movement is measured from a
separate mandibular superimposition: mean functional
occlusal plane orientation and D-point registration (by
perpendiculars dropped from the occlusal plane).
64 Tsourakis and Johnston Jr

7 months), an estimate of the “late” mesial shift. In Table 3. Error Estimates for Increments of Change
addition to the increments of change measured Increment Error SD R
from one year to the next, maxillary and
mandibular arch depth (central incisor tip to Maxillary displacement (mm) 1.12 0.80
first-molar mesial contact) and molar relationship Mandibular displacement (mm) 1.21 0.80
Mandibular excess (mm) 0.56 0.85
(upper molar mesial contact to lower molar mesial Upper 6 movement(U6) (mm) 0.25 0.90
contact) were measured on each tracing. Lower 6 movement(L6) (mm) 0.34 0.90
All measurements of yearly change were Maxillary basal rotation (1) 0.42 0.95
Mandibular basal rotation (1) 0.34 0.95
executed parallel to a common mean functional
occlusal plane constructed from two films in the
center of the series and passed forward and again by way of parametric and nonparametric
backward by way of maxillary regional super- analyses.
imposition. For the “pitchfork” data, the incre- Approximately 2 months after the first tracing,
ments of change (measured to the nearest two series were chosen at random and completely
0.1 mm with digital calipers) were given signs re-done—tracing, superimposition, and meas-
according to the nature of their contribution to urement of change. Error standard deviations29
the achievement of a Class I occlusion: positive if and indices of reliability30 (the correlation bet-
the increment helped and negative if it hurt. ween replicate measurements) were calculated
Because the measurements were executed along for the 20 double-determinations of each of the
a common occlusal plane, their algebraic sum seven increments of change. The results are
was equal to the change in molar relationship summarized in Table 3.
and the various components of the sum, the
source/cause of the change.
Among- and between-groups differences were Results
analyzed for the three terminal-plane groups and
separately in the three flush-terminal-plane sub- The distribution of molar relationships by initial
groups. Analysis was performed with PASW Sta- terminal-plane classification during the stages of
tistics 18.00 (IBM SPSS, Armonk, NY). Normality occlusal development studied here—early
was tested with Q–Q plots. Given normal dis- mixed, late mixed, and early permanent—are
tributions, analysis of variance (ANOVA) and summarized in Table 4. The progression of the
Tukey0 s “honestly significant difference” were three terminal-plane groups over time is depicted
used to test for among- and between-groups in the averages of Fig. 2. Arranged by final molar
differences in the various cumulative increments. relationship, the cumulative skeletal and dental
In the case of non-normal distributions, the changes seen in entire sample and in the flush-
Kruskal–Wallace and Mann–Whitney tests were terminal-plane sub-group are presented in
used instead. Additionally, multiple linear cor-
relation was used to examine the relationship Table 4. Molar Relationship by Initial Terminal-Plane
Classification and Stage of Occlusal Development
between the various increments of change and
the total change in molar relationship between 5 Stage of Occlusal Molar Relationship
and 16 years. An additional line of analysis was Development (N ¼ 39)
developed during data collection and thus must Class I End-to-End Class II
be segregated from procedures planned in
Initial mesial step (N ¼ 6)
advance. Early mixed dentition 4 2 –
When mandibular excess was graphed against Before E lost 5 1 –
time, it was low from 5 to 11 years in the subjects Final occlusion 5 1 –
who went to Class II; however, from 11 to 16 years, Initial flush terminal plane (N ¼ 24)
it was high. Overall differences among- and Early mixed dentition 5 15 4
Before E lost 9 11 4
between- the sub-groups were tested separately in Final occlusion 13 6 5
these two intervals. Further, among-groups dif-
Initial distal step (N ¼ 9)
ferences in the rate of change were tested by Early mixed dentition – 1 8
Rao’s28 method of comparing regression slopes Before E lost – 1 8
for mandibular excess plotted against time, Final occlusion – 2 7
 Class II malocclusion 65

Figure 2. Occlusal progression over time: yearly averages for all groups and sub-groups from ages 5 to 16 years.
Note the stability of the mesial- and distal-step groups.

Tables 5 and 6. Based on fiducial lines linked to
Björk0 s stable structures, relative to cranial base,
there was a mean forward maxillary rotation of
2.51 and a mandibular rotation of 10.11. There
were no statistically significant differences among
terminal-plane groups with respect to the
cumulative change in the dental and skeletal
variables measured here. Note that the mesial-
step subjects tended to develop stable Class I
occlusions and distal-step subjects, stable Class II
malocclusions. The cumulative skeletal and
dental changes seen in these two groups are
charted in Figs. 3 and 4. Flush terminal planes, in
contrast, were “balanced on a knife-edge” and
thus were analyzed in greater detail.
The flush-terminal-plane subjects developed
one of three “final” (at age 15 or 16 years) molar
relationships; cumulative change in these sub-
jects is summarized in Figs. 5–7. Again, there
were no statistically significant among-groups
differences in overall skeletal and dental
change. For mandibular excess, however, there
was a significant interaction between growth and
time. Specifically, although at the end of the
study, there was no cumulative among-groups
difference in mandibular excess, it may be seen
in Figs. 7 and 8 that there was a marked delay in
the Class II group.
The among-groups comparison of regression
slopes for mandibular excess within the flush-
terminal-plane category showed that, from 5 to
11 years, those with a Class II outcome had
a lower rate than the Class I sub-group (ANOVA
and Tukey post hoc), whereas, from 11 to 16 years,
the Class II slopes were significantly higher
(Kruskal–Wallis ANOVA by ranks and Mann–
Whitney U.). The effect of this difference
between early and late growth rates can be seen
in the cumulative curves for mandibular excess
depicted in Fig. 8. It also seems to be reflected in
the pattern of upper molar movement. Yearly
one-way analyses of variance showed that, for
ages 7–8 years and 11–15 years, the mesial
movement of the upper molars was consistently
greater in the “flush” subjects whose occlusions
went to Class II. As depicted in Fig. 9, this effect
coincides roughly with timing of the mandibular
“catch-up” growth. Further, multiple regression
showed that variation in the fate of the flush-
terminal-plane subjects could be “explained”
(R ¼ 0.859) by mandibular excess and upper
molar mesial drift. Lower molar movement was

Table 5. All Subjects: Cumulative Skeletal and Dental Change From 5 to 16 Years (mm)
Measure
Final Occlusion N Maxilla Mandible Mandibular Excess U6 L6 U Depth L Depth

Class I 18 5.41 13.25 7.84 7.36 0.26 0.56 1.91

End-to-end 8 7.39 13.17 5.78 5.80 1.14 1.58 1.16
Class II 13 7.92 14.41 6.49 6.00 0.10 0.91 0.72
66 Tsourakis and Johnston Jr

Table 6. Initial Flush-Terminal-Plane Subjects: Cumulative Skeletal and Dental Change From 5 to 16 Years (mm)
Measure
Final Occlusion N Maxilla Mandible Mand. Excess U6 L6 U Depth L Depth

Class I 10 7.68 14.70 7.02 5.64 0.64 0.38 1.62

End-to-end 9 7.02 12.38 5.36 5.46 1.44 2.82 1.48
Class II 5 7.08 11.75 4.67 6.98 1.59 1.27 0.96

not a significant factor. Estimates of “early” and
“late” upper and lower molar “shifts” are pre-
sented in Table 6. Note that in all instances, the
average mesial drift of the upper molars was
greater than that of the lowers.
Discussion
Firstly, it is important to emphasize that,
although more than 400 films were traced and
superimposed, the present study details the
mechanics of occlusal development in 39 subjects
divided into five sub-groups ranging in size from
5 to 13. Of these, perhaps the most interesting—
the flush-terminal-plane subjects who progressed
to Class II—is the smallest. Accordingly, it goes
without saying that the findings may or may not
mirror the expected pattern of occlusal devel-
opment in other subjects. At the very least, the
present describes events in subjects who were
healthy, untreated, and who, on average, showed
a “normal” pattern of “counter-clockwise” growth
rotation and mandibular excess. An analysis of
the way these occlusions developed thus should
constitute a useful heuristic in a consideration of
the prevention and treatment of Class II mal-
occlusions. It is a discussion that reduces to an
examination of the relationship between upper
molar movement and mandibular growth.
In the present study, the mesial- and distal-step
terminal planes produced stable, intercuspated
Class I and II occlusions in which cumulative
upper molar mesial movement relative to basal
bone seemed an exact mirror image of the
mandibular excess relative to maxillary basal
bone. To a first approximation, this mesial
movement of the upper molars can be interpreted
as a dentoalveolar compensation for the excess
growth of the mandible.2,3 It must be noted,
however, that a single maxillary superimposition
was used to measure both upper molar movement
and mandibular excess. As a result, inevitable
superimposition errors would be shared and thus
would elevate, but probably not be completely
responsible for, the significant correlation
between the two processes. As shown in Table 3,
the error standard deviations for mandibular
excess and upper molar movement were 0.56
and 0.25 mm, respectively. These errors are small,
but so too are the increments of change with

Figure 3. Cumulative mandibular excess and U6 and L6 mesial movement in mesial-step subjects, ages 5–16 years.
Note the lack of a L6 mesial shift (actually some distal uprighting) and the apparent balance between mandibular
excess and U6 mesial drift.
 Class II malocclusion 67

Figure 4. Cumulative mandibular excess and U6 and L6 mesial movement in distal-step subjects from ages 5 to
16 years. On average, there may be a slight, temporary mesial shift of about 1 mm at age 10 years.

which they are associated. In any event, the
present data are consistent with that of other
reports (e.g., Björk and Skieller3 and Lundström
and McWilliam31) on naturally occurring
compensations in Class I subjects. Together,
they support the concept of some sort of
physical relationship between differential growth
and molar movement and seem to provide an
adequate explanation for the stability of the
mesial- and distal-step occlusions. In passing, it
is perhaps useful to recall Moyers0 1 view of the
effect of retained cusps on the occlusion (p. 173):
Among people whose diet includes coarse,
rough food…the occlusal surfaces of the
primary teeth wear to a great extent. This
removal of cuspal interferences permits the
mandible, which is growing more at this time

Figure 5. Cumulative mandibular excess and U6 and L6 mesial movement in flush-terminal-plane subjects who
progressed to a Class I molar relationship. On average, there was no obvious late mesial shift until about age 12
years, and then only about 1 mm.
68 Tsourakis and Johnston Jr

Figure 6. Cumulative mandibular excess and U6 and L6 mesial movement in flush-terminal-plane subjects who
went on to an end-to-end molar relationship. In this group, there was on average a 1–2 mm late mesial shift spread
throughout the span of the study, but most pronounced for ages 11–13 years.

than the maxilla, to assume a forward position
more easily. Under these circumstances, the
result for Greek mountain children at age 5 or
6 often is more an edge-to-edge incisal
relationship and a distinct mesial step
terminally.
Moyers0 observations can be seen as a version
of the “trapped mandible” hypothesis: the lower
jaw often yearns to be free (e.g., Class II, Div. 2
malocclusions) and will jump forward if given
a chance. Given a lack of evidence that this
phenomenon actually occurs, the mesial-step
occlusion of the Greek mountain children is
perhaps more easily seen as the result of a lack of
maxillary dentoalveolar compensation—the
normal pattern of growth would change the
terminal-plane relationship by advancing the
mandible while the absence of intercuspation
would allow the upper buccal segments to be left

Figure 7. Cumulative mandibular excess and U6 and L6 mesial movement in flush-terminal-plane subjects who
settled into a molar Class II relationship. Note the mandibular growth deficit relative to maxilla up to age 12 years,
while the upper molars continue to drift forward into a Class II relationship.
 Class II malocclusion 69

Figure 8. Cumulative increments of mandibular excess from age 5 to 16 years in the three sub-groups of the flush-
terminal-plane group. Note the early (8–12 years) deficit in the mandibular excess for the Class II subgroup. This
deficit is followed by what appears to be “catch-up” growth from ages 12 to 16 years.

behind. Flush-terminal-plane subjects—an over-
sampled 62% of the present sample (about twice
the weighted average of the prevalence in the
longitudinal data presented in Table 1)—lack a
molar intercuspation and thus may, in effect, be
similar to the flat-plane occlusions of Moyers0
Greek wartime sample and thus may shed light
on Moyers0 conjecture.
Starting from a presumably unstable end-to-
end relationship, a differential mesial shift of the
lower molars—“early” or “late”—is a commonly
invoked mechanism of occlusal adjustment.
Unfortunately, the lack of study models made it
impossible to distinguish the spaced occlusions in
which an early shift might occur from the un-
spaced occlusions in which it would not. Be that
as it may, the present averages argue against a
lower shift being a major factor in occlusal
development: the average upper mesial shift was
greater than the lower, independent of initial
terminal-plane relationship or timing (Table 7).
Further, it should be noted that, on average, only
about half of the overall reduction in lower arch
depth (1.4 mm) can be attributed to a late
mesial shift of the lower first molars. Indeed, in
our sample, the lower molars often became
more upright, a maneuver that moved their
crowns distally and was perhaps a dentoalveolar

Figure 9. Cumulative maxillary permanent first-molar mesial movement in the three sub-groups of the flush-
terminal-plane group. Note the continuous mesial drift of the upper molars, with the greatest mesial drift seen in
the Class II group from ages 13 to 16 years, roughly coinciding with the mandibular “catch-up” growth depicted in
Fig. 7.
70 Tsourakis and Johnston Jr
Table 7. First-Molar “Mesial Shift” By Initial Terminal-Plane Relationship
Initial Terminal Plane N U6
Mesial step 6 1.76
Flush 24 0.91
Distal step 9 0.96
compensation for a favorable pattern of
mandibular growth. Consistent with this
interpretation, it should be noted that this
distal shift was seen most often in those
subjects who transitioned successfully to a Class
I occlusion (Figs. 3 and 5). Conversely, the most
pronounced approximation of a late mesial shift
was seen in the subjects whose occlusion either
stayed end-on or went on to a Class II maloc-
clusion (Figs. 6 and 7). Their occlusal pro-
gression features a number of interesting,
potentially significant events.
Firstly, for the flush-to-Class II subjects, it is
clear that there was an early lag in the extent to
which the mandible advanced relative to the
midface. This deficit, however, was not mirrored
in the upper arch: the upper molars came for-
ward about the same amount as was seen in the
other flush sub-groups. This independence
implies that mesial upper molar movement is not
always/entirely a compensation for excess man-
dibular growth. Even without a mandibular
excess, the molars came forward. There must,
therefore, be additional mechanisms in play. For
example, Southard et al.32,33 have measured a
mesial component of occlusal force that could
explain the forward drift of the upper molars
(not to mention lower incisor irregularity). Per-
haps excess mandibular growth can add to—but
not subtract from—the effects of this mesial
component. Given a mandibular excess, maxil-
lary dentoalveolar compensation will cancel the
effect; absence of an excess, the upper molars will
come by an amount determined by other factors.
The finding that a mandibular growth deficit
contributes to the formation of a Class II mal-
occlusion might seem to support the concept
that Class II is a “disease” of small mandibles
whose only rational treatment is “growth mod-
ification.” The invidious corollary is that the
maxilla is “the wrong jaw.” The present results
actually contradict both concepts.
Mesial Shift
Early Late
L6 U6 L6
0.28 2.69 1.14
0.27 2.18 0.68
0.59 2.96 0.14
It has long been known (e.g., Lande25) that,
on average, Class II and Class I patients show
about the same pattern of growth. Were it not so,
successful individual growth prediction—the
ability to predict different outcomes for two
children of the same age and sex—could be
based solely on molar classification. Instead,
growth “prediction,” such as it is, has come to
be based solely on averages and is independent of
molar classification. In the present study, the five
flush-terminal-plane subjects who went to Class II
underwent very little excess mandibular growth
(Figs. 7 and 8; flat regression slopes, age 5–11
years) during the transition to the permanent
dentition. This early growth deficit was perhaps
the proximate cause of the development of a
Class II molar relationship. Later, however, the
growth rate of mandible relative to maxilla
increased to the point that, by the end of the
study, the mandibular excess was not significantly
different from that seen in the other flush sub-
groups (Fig. 8). Unfortunately, given that an
intercuspated Class II already had been
established, this “catch-up” growth could have
no impact on the occlusion. Instead, it seems to
have been “absorbed” by maxillary dentoalveolar
compensation (Fig. 9, ages 11–16 years). As
noted earlier, this analysis was suggested by the
data and thus must be considered with care. An
early, temporary growth deficit, however, is
supported by earlier studies. Other investi-
gations, however, have mirrored these findings.
White16 noted a reduced mandibular excess in
flush-terminal-plane subjects who transitioned to
Class II. Similarly, Donaghey24 noted a similar
deficit in Class II subjects age 9–11 years, but
none in the same subjects from 11 to 13 years. For
these subjects, the development of occlusion
appears to have been based on bad luck, rather
than some overall deficit: those who had a
favorable mandibular excess at the right time
went to Class I (or stayed end-to-end) and those
 Class II malocclusion
Figure 10. Terminal-plane management. In this dia-
grammatic summary of the present findings, note that
mandibular excess and upper molar movement tend
to balance (⫾ 6–8 mm) and that lower molar “mesial
drift” is, on average, negligible in comparison (1 to
þ2 mm). A. Given any terminal plane, a major
concern might be the preservation of lower leeway
space. Flush and distal-step terminal planes, however,
require additional steps to achieve a Class I molar
relationship. B. Flush terminal plane—the effect of a
maxillary holding device (Nance button, pendulum,
NiTi coils, Distal Jet, Headgear, etc.) to produce a 1/2
cusp change by preventing maxillary dentoalveolar
compensation. C. Distal step—U6 “distalization” (1/2
cusp), plus a period in which the upper molars are
prevented from compensating for an additional 1/2
cusp of normal mandibular excess. The total of B and
C would produce a Class I molar relationship.
who were unlucky in terms of timing went to
Class II. This “perfect storm” scenario implies
that there are times and events that can be
exploited in the management of occlusal
development and the treatment of Class II
malocclusion. The present study suggests that a
late mesial shift may not be a common, important
phenomenon in occlusal development. In
contrast, leeway space–about 5–6 mm in the
lower arch—is real and, if preserved, as
suggested independently by Dugoni34,35 and
Gianelly,36–39 can assist in achieving incisor align-
ment. Indeed, given the approximation that,
after the anchorage loss attendant to space clo-
sure, bicuspid extraction can free up 8 mm, the
use of a lower lingual archwire is about 60%
efficient relative to extraction. The correction/
prevention of Class II molar relationship is
somewhat more complicated.
For flush-terminal-plane subjects, molar
occlusal adjustment is the algebraic sum of three
components: upper molar movement, lower
molar movement, and excess mandibular
growth. Which of these constitute realistic ther-
apeutic opportunities? The literature and the
magnitude of the effects seen here seem to favor
71
the Dugoni–Gianelly approaches to early treat-
ment: preserve lower leeway space and hold/
“distalize” the upper molars as needed. It is
perhaps appropriate to examine this approach in
light of the present findings.
Growth modification (mandibular growth
modification) is, for a variety of reasons, a pop-
ular strategy. A basic problem with this approach
is that it probably cannot make the mandible
longer. Indeed, even if it could, one would have
to deal with dentoalveolar compensations that
probably would prevent the extra growth from
changing the occlusion. Lager40 apparently saw
all of this when he argued that functional
appliances do what they do by disarticulating
the teeth so that excess mandibular growth (of
the kind generated by the normal pattern of
growth) can change the occlusion. What about
the lower molars?
Many think that a major purpose of premolar
extraction is to achieve a Class I occlusion. The
differential anchorage loss from this treatment,
however, is only about a millimeter; far short of the
width of a cusp.41 Other approaches are
considerably more purposeful in their attack on
the lower arch. Compared with classic “Tweed”
orthodontics, many of our newer treatment op-
Figure 11. Early treatment with functional appliances.
A. Mandible advanced by the functional appliance
(which advancement is assumed to have no impact on
the normal, favorable pattern of growth). B. For a time,
the mandibular excess would produce no maxillary
dentoalveolar compensation, thereby allowing displa-
cement A. to be converted into a change in the
occlusion by the normal pattern of mandibular excess.
C. Variable lower anchorage loss caused by the
functional appliance. The sum, B þ C, more or less
equals the distal-step changes illustrated in Fig. 10.
Both approaches make use of the usual pattern of
growth (mandible 4 maxilla) by controlling maxillary
dentoalveolar compensation. The choice between the
two is a practice management decision, although the
functional appliance probably would produce a slightly
more protrusive dentition.
72 Tsourakis and Johnston Jr
tions—e.g., non-compliance and nonextraction
straight wire—tend to “mesialize” the lower denti-
tion.41 It is an unavoidable side effect that is justified
by convenience, popularity, imaginative concepts of
facial esthetics, “slenderizing,” and lifetime
retention. There must, however, be a limit on the
extent to which anchorage loss can be relied on as a
routine means of preventing or correcting Class II
malocclusion. For many patients and orthodontists
alike, 3.5–7 mm of mesial movement is just too
much. That leaves the maxilla…the “wrong jaw.”
Given the magnitude of the effects docu-
mented here, we would argue that the upper
dentition presents several obvious, uncompli-
cated options for guiding occlusal development
and correcting malocclusion. Mandibular growth
is usually favorable; however, our data suggest
that its timing is both important and unpre-
dictable. Accordingly, for the flush-terminal-
plane subject, a useful strategy would seem to
be some sort of “holding” appliance to prevent
maxillary dentoalveolar compensations until, in
the fullness of time, the mandible outgrows the
maxilla enough to adjust the occlusion to Class I
(Fig. 10A). In the case of a distal step, it probably
would be necessary to go beyond “holding”
(Fig. 10B) to actual “distalization” (Fig. 10C).
Although it is common to dismiss extra-oral
traction with the sweeping argument that
“patients would not wear a facebow,” it is an
obvious option. For those who think Isaac New-
ton got it all wrong, there are many intra-oral,
“non-compliance” treatments that can at least
deal with the molar occlusion. The end result of
this approach can be seen to be the essentially
same as would be achieved with a functional
appliance (Fig. 11)—both manipulate the
position/drift of the upper molars. The only
obvious difference is the probability that
functional appliances would achieve part of
their effect by way of lower anchorage loss.42–45
The “take-home” message of this article is simple:
from the standpoint of prevention and correction
of Class II malocclusion, the maxilla is the right jaw.
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