Occlusal considerations for partially
edentulous skeletal class II patients.
Background information
Thomas A. Curtis, D.D.S.,* Yair Langer, D.M.D.,**
Raymond Carpenter, D.D.S.*‘**
University of California, San Francisco, School of Dentistry, San Francisco, Calif.
P artially or completely edentulous patients with class II
jaw relationships present unique and challenging prob-
lems not evident with other classes of malocclusion.
Many dentists have little understanding of the incidence,
growth and development, and variations among skeletal
class II individuals. This information is important if
these patients require prostheses. Although esthetics,
stability of the prostheses, comfort, and efficiency of
mastication are the major concerns of the dentist and
patient alike, these concerns will be discussed only as
they relate to prosthetic occlusion. Background informa-
tion will be provided as to the incidence, development,
and scope of the problem.
CLASSIFICATION
The incidence of malocclusions is debatable among
orthodontists because of the lack of government on what
constitutes a malocclusion and precise definitions of each
classification.’ For example, Angle’ classified 26% of all
malocclusions as class II. Recently there seems to be
more unanimity regarding the incidence of class II
malocclusions. Hill et a1.3 examined more than 4000
school children 12 to 14 years of age and reported an
overall incidence of 15% class II patients among the
general population. Emrich et a1.4 found the same
percentage of class II patients in a larger sample of the
same age group. In his study, 30% were class I, 15% class
II, and 1% class III.
Because of the early influence of Angle’s classification
system, dentists are likely to consider skeletal class II
patients as a rather homogeneous group with similar
treatment objectives within the two subdivisions. The
assumption is not correct for this complex, heterogeneous
group (Fig. 1).5,6
Angle’s classification is based on the horizontal rela-
tionships of the first molar teeth, which may or may not
*Professor of Restorative Dentistry and Director, Graduate
Prosthodontics.
**Former Resident in Prosthodontics; presently Tel Aviv, Israel.
***Assistant Professor, Department of Restorative Dentistry.
****Former Resident in Prosthodontics; presently San Diego, Calif.
202
or completely
Part I:
Donald A. Curtis, D.M.D.,*** and
be a true indicator of skeletal relationships. Cephalomet-
ric analysis is necessary to determine which compo-
nent(s) of the skeletal system are creating the malocclu-
sion. The maxillae or the mandible may have both
horizontal and vertical growth discrepancies that trans-
late into size and positional discrepancies of the teeth, the
jaws, or both.
Hirschfeld et al.’ applied cluster analyses to 308
North American children to ascertain general categories
of skeletal facial types and to compare these categories
with Angle’s classification. They found that the Angle
class III types of patients could be clustered, but the
general relationship between class I and class II maloc-
clusions was indistinct. Moyers et a1.5 pointed out that
skeletal class II patients have both a horizontal and a
vertical relationship. They studied 697 class II orthodon-
tic patients and found six horizontal and five vertical
subdivisions, each with distinguishing features (Table I).
Moyers et a1.5tabulated these patients into five vertical
cluster groups and indicated the various horizontal
relationships found within each vertical subdivision.
The mandible and the maxillae develop along a
composite vertical and horizontal vector through the
influence of various growth centers. Therefore, a vertical
component is equally important. Isaacson et al.* pointed
out that because the mandible articulates with the skull,
growth must be balanced anteriorly and posteriorly or
the mandible will rotate around its articulations. If
vertical increases at the facial sutures or alveolar pro-
cesses anteriorly exceed the vertical increases at the
mandibular condyles, the mandible will rotate posterior-
ly (Fig. 2, A). Conversely, if vertical growth at the
condyles exceeds the sum of vertical growth components
at the facial sutures and alveolar processes, the mandible
will rotate forward (Fig. 2, B).
Mandibles that rotate either backward or forward
may exhibit respectively high or low Frankfort mandib-
ular plane angles (FMA). DiPietro and Moergeli’ have
described the intluence and relationship of the FMA on
prosthodontics (Figs. 3 and 4, Table II).
Does the incidence of skeletal class II patients among
the completely or partially edentulous population vary
AUGUST 1988 VOLUME 60 NUMBER 2
OCCLUSAL CONSIDERATIONS: PART I

q
A (Maxillary Dental
El Protraction)
D
D (Mandibular Retrcgnathism
and Maxillary Retrognalhism
+ Maxillary Dental Protraction)
!

KG 1 + q

I3 pi’
B (Mid-Face Prognathism) E (Maxillary Prognathism and Dental
Protraction + Dental Procumbency)

CY
C (Maxillary Ratro&xm’+ F (Mandibular Retrognathism)
Dental Protraction and Mandibular
Retrognathism + Dental Procumbency

Fig. 1. Diagramatic representation of horizontal facial

types in class II patients. Large rectangles represent
maxillae and mandible, small squares represent first Fig. 2. A, Cephalometric tracing of patient exhibiting
molars. Incisors are represented as vertical lines when backward rotation of mandible and high Frankfort-
normal, angled when in labioversion. Ideal profile is mandibular plane angle (FMA). B, Tracing demonstrates
depicted by dotted line. (From Moyers RE, Riolo ML, forward rotation of mandible and low FMA. (From
Guire KE, Wainright RL, Bookstein FL. Differential Isaacson JR, Isaacson RJ, Speidel TM, Worms FW.
diagnosis of class II malocclusions. Am J Orthod Extreme variations in skeletal and dental restorations.
1980;78:477-94, with permission.) Angle Orthod 1971;41:219-29, with permission.)

Table I. Classification of vertical types for each horizontal type

Subdivision
Class II vertical groups Vertical
(495 of 610) A B C D E F total

Vertical 1 6 0 11 45 0 70 132
Vertical 2 4 51 33 15 36 94 233
Vertical 3 0 0 8 40 0 32 80
Vertical 4 0 13 0 0 0 0 13
Vertical 5 0 20 0 0 17 0 37
Horizontally but not vertically sorted 7 20 12 12 10 54 115
Sorted vertically and horizontally 10 84 52 100 53 196 495
Total horizontal types 17 104 64 112 63 250 610

Two-way cross tabulation of horizontal and vertical types:

Total samples 697
Unclassified in horizontal clustering 87
Classified into horizontal types 610
Horizontal types unclassified into vertical types 115
Classified into both horizontal and vertical types 495
From: Moyers RE e: al. Differential diagnosis of class II malocclusions. Am J Orthod 1980;78:477.

THE JOURNAL OF PROSTHETIC DENTISTRY 203


Fig. 3. Cephalometric landmarks used in FMA deter-
mination: gonion (Go), point on angle of jaw that is
most inferiorly, posteriorly, and outwardly directed;
menton (Me), lowest point of contour of mandible
symphysis; orbitale (Or), lowest point on margin of
orbit; porion (P), midpoint on upper edge of external
auditory meatus; Frankfort horizontal plane, plane
intersecting right and left poria and left orbitale; man-
dibular plane, line drawn through menton and tangent
to lower border of mandible posterior to antegonial
notch; Frankfort-mandibular plane angle (FMA), angle
formed by intersection of Frankfort horizontal and
mandibular planes. (From Di Pietro GJ, Moergeli JR.
Significance of Frankfort-mandibular plane angle to
prosthodontics. J PROSTHET DENT 1976;36:624-35, with
permission. Definitions from Krogman WM, Sassouni
V. A syllabus of roentgenographic cephalometry. Phila-
delphia: Philadelphia Center for Research in Child
Growth, University of Pennsylvania, 1957.)
from the figures for young dentate individuals? The
incidence should be the same, skeletally. However, the
orthodontist determines skeletal relationships with the
teeth in maximum occlusal contact and usually does not
consider possible positional discrepancies between cen-
tric relation and centric occlusion. Lang and Razzoog’O
stated, “The skeletal Class II patient is becoming a
rather common clinical finding in the edentulous popu-
lation.“‘l The common discrepancy between centric
relation and centric occlusion found in natural dentitions
may account for this finding. Most dentate patients
occlude in centric occlusion, which is anterior to centric
relation.“-13 Clinically, the centric relation (CR)-centric
occlusion (CO) discrepancy seems greater for skeletal
class II patients compared with other classes of maloc-
clusion. This more posterior skeletal relationship of the
mandible to the maxillae may increase the pool of class
II partially or completely edentulous patients.
The vertical dimension of occlusion (VDO) used for
edentulous patients can influence skeletal relationships.
Overclosure creates cl&s III tendencies, whereas estab-
lishing the proper horizontal and vertical relationships
positions the mandible closer to its former dentate
skeletal relationship.
204
CURTISETAL
Fig. 4. Examples of FMA determination. Top, FMA
within normal range, 26 degrees; left, high-angle
patient, 46 degrees;right, low-angle patient, 16 degrees.
(From Di Pietro GJ, Moergeli JR. Significance of Frank-
fort-mandibular plane angle to prosthodontics. J PROS-
THET DENT 1976;36:624-35, with permission.)
THE PROBLEM
Of the five vertical types of skeletal class II patients
described by Moyers et al.,5 type I with a high FMA
angle and type II with a low FMA angle were the most
commonin their study. Becausethesepatients represent
both ends of the spectrum, and becauseDi Pietro and
Moergeli’ have introduced the prosthodontic differences
for patients with both high and low FMA angles,these
two prototypes will be used for discussionpurposes.
Several horizontal prototypes are present within each of
these vertical prototypes. The prosthodontic problems
likely to be encounteredin patients with high-FMA and
low-FMA will be discussedas problems related to (1)
skeletal relationships, (2) mandibular movements, and
(3) occlusal arrangements.
Skeletal relationships
As described,a high FMA developswhen the anterior
componentsof vertical growth are proportionally greater
than condylar growth. The result is an anterior face
height that is significantly greater than posterior face
height. In this prototype, the mandible tends to be
retrognathic with the maxillae in a near normal position
anteroposteriorly. The maxillae are narrow with well-
formed arches, deepvestibules, and a high palatal vault
with a limited bony palatal bearing area. The occlusal
plane is steep.The upper lip appearsshort and the smile
line is high with considerabledisplay of the incisor teeth
and gingival tissue.Lip sealis difficult to obtain and the
lower lip often exhibits a high level of mentalis activity.
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OCCLUSAL CONSIDIIRATIONS: PART I

Fi.g. 5. A, Profile of class II patient with high Frankfort-mandibular plane angle. Note
short upper lip, convex profile, and angulation of inferior border of mandible. B, Display
of anterior teeth with slight smile. C, Lateral cephalometric radiograph. D, Tracing. Note
angulation of mandibular plane. ANB is 8 degrees (normal is 3 degrees) and Sn-GoGr is
3;’ degrees (normal is 32 degrees).

These patients are described as having the “long-face
syndrome” and convex profiles (Fig. 5).
The retrognathic mandible is generally small and
tapering. If teeth are present, their lateral profile usually
exhibits an exaggerated Spee’scurve, causedin part by
the extrusion of the mandibular incisors and the diago-
nal upward turn of the mandibular ramus. An occlusal
view may demo:nstratethe “keyhole effect”; the maxil-
lary and mand.ibular teeth and arches are narrower
between the premolars compared with the distance
between the canines, giving the arches the form of a
keyhole (Fig. 6).
Patients with a low FMA have less convex profiles.
The mandibular plane, occlusalplane, and palatal plane
are relatively flat and nearly parallel compared with
high-FMA profiles (Fig. 7). The ridges are well formed,
flat, and tapering with shallow vestibules. The palatal
shelveshave a gentle taper leading to a broad, flat palatal
bearing area. The mandible is well formed and less
likely to exhibit the keyhole effect. The upper lip
appearslong, limiting the display of teeth and gingivae.
The curve of Spee is relatively flat with a deep vertical
overlap of the anterior teeth. According to Moyers et al.,
this is the most common type of class II patient (Fig.
8).
Mandibular movements
Class II patients with high and low FMAs are
capable of an extensive range of mandibular motion
during functional and nonfunctional movements.l’,14,l5
Any prosthetic occlusion must provide freedom for this
extensive range of motion (Fig. 9). Mandibular posture

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 CURTIS ET AL

Fig. 6. A, Mounted casts for patient in Fig. 5 at slightly reduced vertical dimension of
occlusion. Note lack of parallelism of ridges and ample interocclusal distance. B and C,
Maxillary and mandibular arches. D and E, Completed dentures demonstrate class II
relationship and slight “keyhole” effect of maxillary tooth arrangement. Note added
premolar distal to maxillary second molars to lengthen occlusal table and range of
eccentric contacts.

at rest position, as viewed in the sagittal plane, is
significantly forward from the pathway of terminal
hinge motion into centric relation. RickettP and Nan-
da” point out that not only do these patients look better
esthetically with the mandible in this position, but this
forward position improves lip seal, muscle function,
speech,and respiration. Closure for dentulous patients
from rest to a tooth contact position is invariably into
centric occlusion.
Edentulous class II patients often have difficulty
retruding the mandible to centric relation and perform-
ing a hinge movement around the horizontal axis
becauseof their habitual dentate patterns of closure and
condylar remodelling. These more anterior or eccentric
positions in edentulous patients are not consistently
repeatable. Clinically, it is difficult to equalize pressure
in recording centric relation becauseof the anteroposteri-
or and lateral discrepanciesof the ridges.‘8s19

206 AUGUST 1988 VOLUME 60 NUMBER 2

OCCLUSAL CONSIDERATIONS: PART I

Fig. 7. A, Trial arrangement of denture teeth for edentulous skeletal class II patient
with low FMA. B and C, Parallelism of ridges shown intraorally and on mounted casts.
Note limited ridge height and vestibular depth.

Table II. Clinical manifestations of high and low FMA

Clinical characteristics High FMA Low FMA

Biting force Decreased Increased

Muscular line of force Arcuate Vertical
Molar position relative to elevators of mandible Anterior to line of force Directly in line of force
Size of masticatory muscles Hypotrophic Hypertrophic
Mandibular bony processes Underdeveloped Well developed
Occluding cervical dimension Relatively noncritical Critical
Complete denture stress directed to residual ridge Decreased Increased
Fracture of complete denture base Decreased Increased
Height of alveolar bone Increased Decreased
Palatal vault High and narrow Broad and flat
Buccal vestibules Deep Shallow
Muscle attachments Base of ridge Crest of ridge
Planes of face Hyperdivergent Hypodivergent
Residual ridge relation Divergent Parallel
Lip length relative to skeletal base Short Long

Excerpted with permission from: Di Pietro and Moergel?.:

ClassII patients with high FMAs and natural denti-
tions may have a greater than average interocclusal dis-
tance and may exhibit an excessivevertical dimensionof
occlusion (VDO) during occlusal contact. Often, the
VDO can be reduced moderately for edentulouspatients
to position the mandible in a slightly more forward posi-
tion and to reducethe “long-face syndrome.” Parallelism
of the ridgesis not a satisfactory guideline for high-FMA
patients becauseof the divergent planesthey exhibit.
In contrast, a classII patient with a low FMA will

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 CURTIS ET AL

Fig. 8. A, Cephalometric radiograph of partially edentulous patient with low FMA. B,

Tracing, C, Completed dentures on remount casts. D, Profile. Note flat facial outline and
long upper lip. E, Limited display of maxillary teeth. F, Broad, flat palate with limited
vertical height of alveolar ridges.

208 AUGUST 1988 VOLUME 60 NUMBER 2

OCCLUSAL CONSIDIIRATIONS: PART I

Fig. 9. A, Complete dentures for class II patient with average FMA who had palatal
graft vestibuloplasty in anterior mandibular region. B, Dentures mounted on remount
casts with centric relation record made with teeth slightly out of contact. Lingualized
occlusal concept was used. C, Multiple contacts of maxillary lingual cusps in centric
relation. D, Multiple contacts between functional maxillary and rational mandibular
posterior teeth in a protrusive relationship. Occlusal interferences were eliminated
between centric relation and this rather extreme forward position.

have limited interocclusal space and may appear over-
closed when in occlusal contact. However, the edentulous
ridges will be nearly parallel at the proper vertical
dimension of occlusion. Therefore, sound clinical judg-
ment must be exercised in establishing the VDO for both
high FMA and low FMA patients with skeletal class II
relationships.
OCCLUSAL ARRANGEMENTS
The success or failure of any removable prosthesis is
related to many physiologic and technical principles, but
none is more important than occlusion. Unfortunately, a
satisfactory occlusion is often difficult to achieve for
edentulous skeletal class II patients because of (1) the
anteroposterior and mediolateral skeletal discrepancies
with limited space available for prosthesis support and
occlusal contact: (2) the likelihood of steep incisal and
condylar guidance factors; and (3) the need for multiple
occlusal contacts anterior and lateral from centric rela-
tion. Each of thes,e factors will be discussed.
Skeletal discrepancies
The relative size of the arches and their anteroposteri-
or and mesiolateral positional relationships to each other
contribute to the occlusal dilemma (Fig. 10). Because of
the prognathic-retrognathic skeletal relationship, the
mediolateral discrepancy is accentuated in the premolar
region; a wider segment of the maxillae must function
with the narrower aspects of the more posterior mandi-
ble. Because class II patients with high FMAs tend to
have narrower maxillary arches, the mediolateral dis-
crepancy is less severe. However, it is not uncommon for
the maxillary arch to be completely anterior and lateral
to the mandible in edentulous patients with low
FMAs.
More residual ridge resorption (RRR) may be evident
in patients with a low FMA. Tallgren2” reported consid-
erably more alveolar bone loss for edentulous patients
with a low FMA over a period of 25 years. Because
patients with low FMAs often have well-formed mandi-
bles with limited vertical bony height and shallow

THE JOURNAL OF PROSTHETIC DENTISTRY 209


Fig. 10. A, Diagram of skeletal class II relationship in
sagittal plane. B, Arches superimposed in horizontal
plane. Anterior-posterior discrepancy is created because
narrower segment of mandible must function with
wider aspect of maxillary arch, even if arches are
comparable in size. Discrepancies increase with taper-
ing arches and proportionally smaller mandibles.
vestibules, RRR can be clinically significant with time.
A contributing factor could be the potentially greater and
more vertically directed forces of mandibular closure
seen in skeletal class II patients with a low FMA (Fig.
11). 9,21-23
Guidance factors
Occlusion can be further compromised by the relative
steepness of the incisal and condylar guidance factors
especially exhibited by class II patients with high-
FMAs. Because of the steepness of the condylar path-
ways and the extensive range of motion exhibited by the
mandible, Christensen’s phenomenon, or separation of
the posterior teeth or wax occlusion rims during protru-
sive movement, is evident.
A natural reaction for both dentist and patient is to
correct skeletal discrepancies by adjusting the placement
of denture teeth. Certainly modifications are indicated,
but it is usually not advisable to create a class I
arrangement of the replacement teeth for an edentulous
skeletal class II patient. Denture stability and comfort
are enhanced if the incisal guidance angulation can be
210
CURTIS ET AL
Fig. 11. Patients with high FMA are likely to exhibit an
arcuate-directed pattern of muscular contraction. (From
Di Pietro GJ, Moergeli JR. Significance of the Frankfort-
mandibular plane angle to prosthodontics. J PROSTHET
DENT 1976;36:624-35, with permission.)
reduced somewhat while creating an acceptable esthetic
and phonetic tooth arrangement. The potential for
greater than normal horizontal overlap of the incisors
will reduce the effective incisal guide angulation.
A caution regarding phonetic considerations should
also be mentioned. Severe skeletal class II patients are
likely to produce the normal /s/ phoneme in a variety of
ways. Subtelny and Subtelnyz4 compared 31 persons
with class II, division I malocclusions and normal speech
with 20 subjects with a similar malocclusion and defec-
tive speech. They found that excessive protrusion of the
mandible for incisor approximation during /s/ sounds
did not occur as a generalized compensatory adjustment
to extreme maxillary variations. Therefore, the dentist
should evaluate the speech of edentulous skeletal class II
patients for clarity instead of evaluating the juxtaposi-
tion of the incisors during speech.25
Multiple contacts
Class II patients require multiple occlusal contacts
anterior and lateral to centric relation because of the
tendency to posture the mandible in a more forward
position and because of multiple closure patterns. Pro-
viding this freedom along with adequate occlusal con-
tacts is a challenge because of skeletal relationships, the
limited spaces available for occlusal contact and the
extensive envelope of mandibular motion.
SUMMARY
Although approximately 15% of the population may
be classified as having the skeletal class II relationship,
this group of patients is far from homogeneous. Two
prototypes were used to delineate various problems in
the prosthodontic occlusion that dentists may encounter
with these patients. A satisfactory occlusion is difficult to
achieve because of skeletal discrepancies, limited space
for occlusal contact, steep guidance factors, and the
AUGUST 1988 VOLUME 60 NUMBER 2
OCCLUSAL CONSIDERATIONS: PART I

necessity for multiple eccentric occlusal contacts because muscular position of the mandible under different recording
of the significant range of mandibular motion. conditions. Acta Odontol Stand 1971;29:423-37.
13. Hodge LC, Mahan PE. A study of mandibular movement from
We express our appreciation to Drs. Martin Frankel, Robert Boyd, centric occlusion to maximum intercuspation. J PROSTHET DENT
and Robert J. Isaacson for their guidance with the orthodontic aspects 1967;18:19-30.
of this paper and to Hilary Pritchard, Principal Editor, Department of 14. Payne SH. Selective occlusion. J PROS~HET DEWY 1955;5:
Restorative Dentistry, University of California, San Francisco, for her 301-4.
editorial review of the manuscript. 15. Parr GR, Loft GH. The occlusal spectrum and complete
dentures. Compend Contin Educ Dent 1982;3:241-9.
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