|Year : 2014 | Volume
| Issue : 5 | Page : 105-109
|Pathognomonic features of Angle's Class II division 2 malocclusion: A comparative cephalometric and arch width study
Singamsetty E. R. V Prasad1, Ravikishore Reddy Indukuri2, Rupesh Singh3, Anitha Nooney4, Firoz Babu Palagiri5, Veera Narayana6
1 Department of Orthodontics and Dentofacial Orthopaedics, Drs S and NR Siddhartha Institute of Dental Sciences, Chinaoutpally, Gannavaram, Andhra Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Saraswathi Dhanwantari Dental College, Parbhani, Maharashtra, India
3 Private Practitioner, General Dentistry, Resident Dentist, Karnataka, India
4 Department of Orthodontics and Dentofacial Orthopaedics, Private Practitioner, Guntur, Andhra Pradesh, India
5 Department of Orthodontics and Dentofacial Orthopaedics, RAMA Dental College, Kanpur, Uttar Pradesh, India
6 Department of Orthodontics and Dentofacial Orthopaedics, KLR Lenora Institute of Dental Sciences, Rajahmundry, Andhra Pradesh, India
|Date of Web Publication||4-Dec-2014|
Singamsetty E. R. V Prasad
Department of Orthodontics and Dentofacial Orthopaedics, Drs S and NR Siddhartha Institute of Dental Sciences, Chinaoutpally, Gannavaram ? 521 101, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: A thorough knowledge of the salient features of malocclusion helps the clinician in arriving at a proper diagnosis and treatment plan, and also to predict the prognosis, prior to the onset of treatment process. Among the four classes of Angle's classification of malocclusion, Class II division 2 occurs with the least frequency. There is still continuing debate in the literature whether the Class II division 2 patients ascribe the pathognomonic skeletal and dental features. Aim of the study: The aim of this study is to describe the unique features of Angle's Class II division 2 malocclusion to differentiate it from Angle's Class II division 1 malocclusion. Materials and Methods: A total of 582 pre-treatment records (study models and cephalograms), with the age of patients ranging from 15 to 22 years, were obtained from the hospital records of Vishnu Dental College, Bhimavaram and Geetam's Dental College, Visakhapatnam. Out of these, 11 pre-treatment records were excluded because of lack of clarity. In the rest of the sample, 283 were Class II division 1 and 288 were Class II division 2. The lateral cephalograms were analyzed by using digiceph and the arch width analysis was done based on the anatomical points described by Staley et al. and Sergl et al. Results: An intergroup evaluation was done by using unpaired Student's "t" test. The skeletal vertical parameters, dental parameters, and the maxillary arch width parameters revealed a statistically significant difference between the two groups of malocclusion. Conclusion: Angle's Class II division 2 malocclusion has a pronounced horizontal growth pattern with decreased lower anterior facial height, retroclined upper anteriors, and significantly increased maxillary arch width parameters.
Keywords: Class II division 2, facial height, growth pattern, malocclusion
|How to cite this article:|
Prasad SE, Indukuri RR, Singh R, Nooney A, Palagiri FB, Narayana V. Pathognomonic features of Angle's Class II division 2 malocclusion: A comparative cephalometric and arch width study. J Int Soc Prevent Communit Dent 2014;4, Suppl S2:105-9
|How to cite this URL:|
Prasad SE, Indukuri RR, Singh R, Nooney A, Palagiri FB, Narayana V. Pathognomonic features of Angle's Class II division 2 malocclusion: A comparative cephalometric and arch width study. J Int Soc Prevent Communit Dent [serial online] 2014 [cited 2022 Aug 20];4, Suppl S2:105-9. Available from: https://www.jispcd.org/text.asp?2014/4/5/105/146212
| Introduction|| |
Malocclusion is defined as the false arrangement of teeth in any three planes of space. Edward Hartley Angle, father of modern orthodontics, classified malocclusion in the anteroposterior plane based on the dental component and ignoring the skeletal component. A Class II malocclusion may be skeletal or dental or may be a combination of skeletal and dental components. The Class II malocclusion is classified into division 1 and division 2 based on the axial inclination of upper anteriors. Apart from these basic features, there are no characteristic features pertaining to Class II division 2 in the literature. The Class II division 2 malocclusion occurs the least often, and obtaining the sample for the purpose of evaluation has always remained a critical issue. Although Angle classified the malocclusion in 1890s, there is still lack of clarity regarding the pathognomonic features of Class II division 2 malocclusion.
Moores et al.,  Buschang et al.,  and Walkow and Peck  evaluated the dental casts of Class II division 1 and division 2 and concluded that Class II division 2 malocclusion shows reduced intercanine width. Pancherz et al. evaluated the cephalometric parameters between these two groups and concluded that mandibular retrognathism was a common clinical entity in both the groups.
In the 21 st century, it is imperative for every dentist/orthodontist to follow the treatment principles and/or mechanotherapy based on the evidence available. According to Profitt, "the orthodontic practitioner is akin to the scientist who must continually evaluate new recent findings." Therefore, it is very important to get acquainted with the characteristic features of particular malocclusion, as this may help the clinician opting for better treatment planning.
The aim of this study is to differentiate the cephalometric and arch width parameters between Angle's Class II division 1 and Angle's Class II division 2 malocclusion groups to comprehend the diagnostic features of Class II division 2 malocclusion.
| Materials and methods|| |
The study models and the lateral cephalograms needed for the study were obtained from the hospital records of Vishnu Dental College, Bhimavaram and Geetam's Dental College, Visakhapatnam. A total of 582 pre-treatment records (study models and cephalograms) were obtained, with age of the patients ranging from 15 to 22 years. Out of these, 11 pre-treatment records were excluded because of lack of clarity. In the rest of the sample, 283 were Class II division 1 and 288 were Class II division 2 malocclusions.
The inclusion criteria were bilateral full cusp Class II molar relationship, with all the permanent teeth erupted and no history of previous orthodontic treatment, and an increased overjet and overbite greater than 5 mm and 4 mm, respectively, for Class II division 1 malocclusion and an overjet of 3 mm and 100% overbite for Class II division 2 group of malocclusion.
The lateral cephalograms were analyzed by using digiceph software. The arch width parameters were analyzed by using digital vernier calipers.
An unpaired Student's "t" test was done to compare the cephalometric and arch width parameters between both the groups of malocclusion.
| Results|| |
Intragroup evaluation was done to rule out the effect of gender within the study groups. After confirming that there was no effect of gender in either of the study groups, the males and females in either of the study groups were combined to evaluate the cephalometric and arch width parameters.
The cephalometric parameters [Figure1]a-1d and [Table 1] showed a statistically significant difference with respect to skeletal vertical parameters (Jarabak's ratio, lower anterior facial height, and mandibular plane angle) and dental parameters.
The maxillary arch width parameters [Figure 1]e and [Table 2] were increased in Angle's Class II division 2 group of malocclusion with a statistically significant difference. There was no significant difference with respect to the mandibular arch width parameters [Figure 1]f and [Table 2].
| Discussion|| |
It was around 1950s that studies were conducted in the Department of Orthodontics, University of Illinois to know the dental and skeletal patterns in different classes of malocclusion. , Vallera and Nelson  reported that the information obtained from cephalometric analyses facilitates the treatment decisions of orthodontists. Staley et al.  and Sergl et al.  described that the arch width and also the apical bases have a diagnostic potential. Hence, we have evaluated both cephalometric and arch width parameters in this study.
The cephalometric parameters are shown in [Figure 1]a-d.
The SNA, SNB, and ANB angles were measured in both the groups because of their importance in orthodontic diagnosis. Other cephalometric parameters were adopted from McNamara analysis  and Schwartz analysis  as these parameters help in analyzing the relative size and position of bony bases. The dental parameters included in the study were upper incisor to sella-nasion plane (UI-SN plane) and lower incisor to mandibular plane (mandibular plane is taken from gonion to menton). According to Howell,  the soft tissue morphology influences the underlying dental structures; hence, the soft tissue parameters like facial angle, skeletal convexity, H-line angle, and lower lip to Rickett's E-line were included as a part of the study.
The sagittal parameters [Figure 1]a, [Table 1] did not show any statistically significant difference between the study groups. Both the groups were shown to have orthognathic maxilla with mild retrognathic mandible. These results were in accordance with those of Pancherz et al. and Isik et al. and were in contrast to those of Rosenblum,  Demisch et al., and Peck et al.  The concept of posterior mandibular displacement was not seen in the study population.
The skeletal vertical parameters [Figure 1]b showed a clear hypodivergent growth pattern with decreased lower anterior facial height in Class II division 2 group of malocclusion [Table 1]. This is in accordance with the reports of Houston,  Pancherz et al.,  Karlsen,  and Peck et al.  This forward growth rotation in Class II division 2 malocclusion may be because of lack of incisor support.
The upper central incisors were clearly retroclined in the Class II division 2 group in accordance with the definition of Angle's Class II division 2 malocclusion. Lower incisors were mildly proclined or near normal in both the study groups [Table 1]. These results were in accordance with those reported by Thompson. 
|Table 1: Mean comparison of cephalometric parameters between class II division 1 and class II division 2 groups |
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The soft tissue parameters [Figure 1]d, [Table 1] did not show any statistically significant difference between the groups except for the linear measurement of lower lip to Rickett's E-line. The lower lip was slightly behind the Rickett's E-line in Class II division 2 group. This might be the reason for the prominent chin, deep mentolabial sulcus, and increased risk of relapse (excessive pressure exerted by lower lip on the upper anteriors)  observed in patients with Class II division 2 malocclusion.
The maxillary arch width parameters [Figure 1]e and [Table 2] were increased with respect to intercanine width, intermolar width, and also basal arch width at canines and molars in Class II division 2 group of malocclusion. The present results were in accordance with those of Buschang et al.,  Staley et al.,  and Sayin and Turkkahraman.  As there is increase in the maxillary arch widths, the orthodontist should preferably opt for a non-extraction mode of therapy, unless the profile of the patient demands for an extraction.
|Table 2: Mean comparison of arch width parameters between class II division 1 and class II division 2 groups |
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The mandibular arch width parameters [Figure 1]f and [Table 2] did not show any statistically significant difference between the two groups of malocclusion. As there is normal or increased maxillary arch width and narrowing of mandibular arch width, there are high chances for the occurrence of crowding in the lower arch in Class II division 2 group. This may necessitate a single incisor extraction most often.
|Figure 1: (a) Skeletal sagittal parameters. (b) Skeletal vertical parameters - angular. (c) Skeletal vertical parameters - linear. (d) Dental parameters and soft tissue parameters. (e) Maxillary arch width parameters. (f) Mandibular arch width parameters|
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As per the soft tissue paradigm, the extraoral features of the patient are the main determinant criteria for the treatment plan. The main limitation of the study is that we have concentrated only on the cephalograms and study models, not considering the clinical examination.
We had concentrated only on the local population in the study, and therefore, some results may be contradicting with the universal scenario.
| Conclusion|| |
The pathognomonic features of Angle's Class II division 2 group of malocclusion by which it can be differentiated from Angle's Class II division 1 are as follows:
- Orthognathic maxilla and a mild retrognathic mandible
- Marked horizontal growth pattern with forwardly rotated mandibular base
- Skeletal deep bite
- Retroclined upper incisors with near-normal lower anteriors
- Lower lip placed slightly behind E-line with prominent chin
- Increased maxillary arch width parameters (intercanine and intermolar width, basal arch width at canines and molars)
- Restricted mandibular arch width, and hence, increased chances for crowding in the lower arch.
| Acknowledgments|| |
Financial interest, direct or indirect, for any of the authors does not exist for this article. Sources of outside support of the project are none for this article.
| References|| |
Moorrees CF, Grøn AM, Lebret LM, Yen PK, Frölich FJ. Growth studies of the dentition: A review. Am J Orthod 1969;55:600-16.
Buschang PH, Stroud J, Alexander RG. Differences in dental arch morphology among adult females with untreated Class I and Class II malocclusion. Eur J Orthod 1994;16:47-52.
Walkow TM, Peck S. Dental arch width in Class II Division 2 deepbite malocclusion. Am J Orthod Dentofacial Orthop 2002;122:608-13.
Pancherz H, Zeiber K, Hoyer B. Cephalometric Characteristics of Class II division 1 and Class II division 2 malocclusions: A comparative study in children. Angle Orhtod 1997;67:111-20.
Blair ES. A Cephalometric Roentgenographic Appraisal of the Skeletal Morphology of Class I, Class II, Div. 1, and Class II, Div. 2 (Angle) Malocclusions. Angle Orthod 1954;24:106-19.
Ross-Powell RE, Harris EF. Growth of the anterior dental arch in black American children: A longitudinal study from 3 to 18 years of age. Am J Orthod Dentofacial Orthop 2000;118:649-57.
Vallera J, Nelson S. Orthodontists' consensus regarding cephalometric variables in diagnosis and treatment planning. J Dent Res 1997;76:160.
Staley RN, Stuntz WR, Peterson LC. A comparison of arch widths in adults with normal occlusion and adults with Class II division 1 malocclusion. Am J Orthod 1985;88:163-9.
Sergl HG, Kerr WJS, McColl JH. A method of measuring the apical base. Eur J Orthod 1996;18:479-83.
McNamara JA Jr. A method of cephalometric evaluation. Am J Orthod 1984;86:449-69.
Schwarz AM. Roentgenostatics. A practical evaluation of the x-ray headplate. Am J Orthod 1961;47:561-85.
Karlsen AT. Craniofacial Characteristics in children with Angle Class II div. 2 malocclusion combined with extreme deep bite. Angle Orthod 1994;64:123-30.
Isik F, Nalbantgil D, Sayinsu K, Arun T. A comparative study of cephalometric and arch width characteristics of Class II division 1 and division 2 malocclusions. Eur J Orthod 2006;28:179-83.
Rosenblum RE. Class II malocclusion: mandibular retrusion or maxillary protrusion? Angle Orthod 1995;65:49-62.
Demisch A, Ingervall B, Thüer U. Mandibular displacement in Angle Class II, Division 2 malocclusion. Am J Orthod Dentofacial Orthop 1992;102:509-18.
Peck S, Peck L, Kataja M. Class II Division 2 malocclusion: A heritable pattern of small teeth in well-developed jaws. Angle Orthod 1998;68:9-20.
Houston WJ. A cephalometric analysis of Angle Class II division 2 in the mixed dentition. Dent Pract 1967;17:372-6.
Thompson JR. Abnormal function of the temporomandibular joints and related musculature. Orthodontic implications. Part II. Angle Orthod 1986;56:181-95.
Lapatki BG, Mager AS, Schulte-Moenting J, Jonas IE. The Importance of the Level of the Lip Line and Resting Lip Pressure in Class II, Division 2 Malocclusion. J Dent Res 2002;81:323-8.
Sayin MO, Turkkahraman H. Comparison of dental arch and alveolar widths of patients with Class II division 1 malocclusion and subjects with Class I ideal occlusion. Angle Orthod 2004;74:356-60.
[Table 1], [Table 2]
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