Seminars in Orthodontics 29 (2023) 183−188

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Seminars in Orthodontics
journal homepage: www.elsevier.com/locate/sodo

Treatment of Class II Malocclusion in the Growing Patient: Early or Late?

Veronica Giuntini a, James A. McNamara Jrb, Lorenzo Franchi a,*
a
Department of Experimental and Clinical Medicine, Graduate Orthodontic Program, The University of Florence, Italy
b
Department of Orthodontics and Pediatric Dentistry, School of Dentistry; Professor Emeritus of Cell and Developmental Biology, School of Medicine; and Research Scientist,
Center for Human Growth and Development, The University of Michigan, Private practice of orthodontics, Ann Arbor, Michigan, USA

A R T I C L E I N F O A B S T R A C T

The aim of this paper is to evaluate several factors that can improve the efficacy of Class II treatment in the grow-
ing patient with mandibular skeletal retrusion. Previous research has shown that functional appliances are most
effective in altering short-and long-term mandibular growth and mandibular sagittal position if active treatment
includes the pubertal growth spurt. If functional jaw orthopedic treatment is initiated in the prepubertal growth
period, the positive occlusal changes are primarily dentoalveolar in nature. The staging of the maturation level of
the cervical vertebrae (CVM method) has proven effective in differentiating the stages of maturation.
The second factor, typically not considered routinely during the decision-making process, is the responsiveness of
a specific patient to the prescribed treatment. Not all patients respond to the same treatment in the same manner.
One way of predicting individual patient responsiveness is to evaluate mandibular morphology at puberty. Good
responders to functional jaw orthopedics for Class II malocclusion with mandibular retrusion are characterized by
a small mandibular angle (Co-Go-Me). Poor responders have larger mandibular angles.
The third issue that is addressed is the question of whether an early phase of treatment is necessary in a Class II
patient with mandibular skeletal retrusion. The most frequently seen deficiency in the early mixed dentition is
narrowness of the maxilla. A measurement of transpalatal width between the closest points between the maxillary
first permanent molars of 35-39 mm usually indicates that there is enough arch perimeter to accommodate teeth
of normal size. If transpalatal width is constricted, an acrylic splint expander or a banded expander can be used to
widen the maxilla. A removable lower Schwarz expander also can be used to gain a modest amount of lower arch
perimeter while uprighting the lower posterior teeth. Rapid maxillary expansion in the early mixed dentition can
help in improving Class II malocclusion as a side-effect, both skeletally and dentally.

Introduction ongoing debate, however, as to whether functional appliances (both of

removable and fixed designs) can induce effective short- and long-term
Class II malocclusion is one of the most common orthodontic prob- stimulation of mandibular growth.4−9
lems, occurring in 20-25% of the population worldwide.1 Such patients From a diagnostic and treatment planning standpoint, it would be
can present with a variety of skeletal and dentoalveolar configurations optimal to identify additional biological and morphological characteris-
in all three dimensions,2,3 with the most consistent diagnostic finding in tics of the individual patient (both anatomical and genetic biomarkers)
Class II malocclusion shown to be mandibular skeletal retrusion.3 Thus, that can influence the individual response to a given treatment modality
a logical first step in treating patients with mandibular retrusion is an substantially, facilitating “precision” or “personalized” orthodontics.
attempt to enhance the growth of the mandible by repositioning the The same orthodontic appliance delivered to a patient by the same
mandible forward while also improving the position of the chin. Class II orthodontist may result in considerably different outcomes in another
correction involves concomitant changes in the vertical and transverse patient with a similar dentoskeletal malocclusion.
dimensions as well. The aim of this paper is to discuss several factors that play a funda-
A wide range of functional appliances aimed to stimulate mandibular mental role when diagnosing and treatment planning a retrognathic pre-
growth by forward posturing of the mandible have been developed to pubertal or pubertal Class II patient. For this discussion, three questions
correct this type of skeletal and occlusal disharmony.4 There is an will be considered: First, is there a relationship between the stage of

* Corresponding author at: Lorenzo Franchi, Department of Experimental and Clinical Medicine, Universit
a degli Studi di Firenze, Director of the Division of Den-
tistry, University Hospital of Careggi, Via del Ponte di Mezzo, 46-48, 50127, Firenze, Italy.
E-mail address: lorenzo.franchi@unifi.it (L. Franchi).

https://doi.org/10.1053/j.sodo.2023.04.008

1073-8746/© 2023 Elsevier Inc. All rights reserved.

V. Giuntini et al. Seminars in Orthodontics 29 (2023) 183−188

skeletal maturity and the response to Class II treatment? In other words,

how important is treatment timing in managing this malocclusion type?
Second, are there any morphological characteristics identifiable prior to
treatment that can provide an estimation as to whether an individual
patient will respond well to the treatment or not? Last, when is two-
phase treatment indicated in the Class II patient, and conversely when is
a single continuous phase more appropriate?

Stage of skeletal maturity

When to begin? Traditionally a variety of indicators have been used

to assess when a patient is ready for orthodontic intervention. One obvi-
ous approach is to use chronological age as an indicator. It is well-known
that males generally mature at a slower rate than do females and that
there is much variation in maturation rate among individual born, for
example, during the same year. Consider all students enrolled at a single
grade level in an elementary or middle school. When evaluated from a
developmental perspective, there may be up to 5 or 6 developmental
years between the most mature and the least mature student in the same
grade. Obviously, how fast an individual matures both skeletally and
dentally can affect the speed and the outcome of treatment.
Perhaps the indicator most widely used today is the stage of dental
development, as observed clinically or radiographically.10 The stages of
dental development typically can be identified as deciduous dentition Fig. 1. FR-2 appliance of Fr€ankel.
only, early mixed dentition with the eruption of the permanent incisors
and first molars, late mixed dentition with the eruption of the canines and 49 patients (23 boys, 26 girls) who began treatment at age 10.5 years or
premolars, and the permanent dentition with the eruption of the second older comprised the pubertal group.
molars (and later the third molars). While much can be learned by moni- The average age of the younger group was 8.8 years when the initial
toring the development of the dentition, this approach does not take headfilm was taken; the older patients averaged 11.6 years of age. The
into consideration the maturation of the associated skeletal elements. interval between films in the prepubertal group averaged 23 months
Other clinicians and researchers have advocated using indicators of and in the adolescents 25 months. The data were extrapolated so that
skeletal maturity, as for example yearly increases in statural height,11 serial the treatment duration for both groups was standardized at 24 months.
changes in the size and shape of the bones of the hand and wrist over The focus of the present discussion is increasing mandibular length sig-
time,12 and more recently the maturation of the cervical vertebrae (i.e., the nificantly during treatment. The principal skeletal effect of the Function
CVM method) as observed in the lateral cephalogram or CBCT image.13−15 Regulator appliance was advancement of the mandible along the direc-
tion of the facial axis. When the younger and older control groups were
When to intervene? compared, the prepubertal group increased in length 3.7 ±1.1 mm dur-
ing a 2-year treatment, while the pubertal control group increased in
Because Class II malocclusion characterized by excessive overjet and length by 4.8 ±1.9 mm, indicating greater mandibular growth normally
overbite can have debilitating effects on the functional, psychosocial, occurring during the circumpubertal growth period. Both the younger
and self-image problems of a patient, early intervention frequently has and older treatment groups grew more than their matched controls. This
been advocated for this condition, sometimes “the earlier the better.” advancement resulted in statistically significant increases in mandibular
Although the topic of treatment timing has been addressed by clinicians length between the younger treated group (5.9 ±2.3 mm) and matched
and researchers over many decades, most of the early discussions were controls (3.7 ±1.1 mm). When the younger groups were compared to
derived from the clinical experience and recommendations of expert the older groups, however, mandibular length increases were greater in
practitioners rather than based on sound study methodologies readily both older groups (older treated 8.7 ±2.8 mm; older controls 4.8 ±1.9
available today.16 mm). The pubertal controls increased in mandibular length by 1 mm in
One of the first retrospective studies that considered the issue of comparison to the juvenile controls, and the pubertal FR-2 patients
treatment timing of Class II malocclusion directly was published by increased in mandibular length by almost 3 mm in comparison to the
McNamara et al. in 1985.17 This investigation examined the treatment prepubertal patients. The results of this retrospective study17 were the
effects produced by the Function Regulator (FR-2) appliance of Fr€ankel first to indicate that greater mandibular response to functional jaw
(Fig. 1), at the time considered a novel approach to Class II treatment. orthopedics was observed in pubertal patients in comparison to prepu-
The sample was comprised of 100 patients who were compared to a bertal patients.
smaller group of matched untreated individuals (N=41) with similar Patient compliance with the FR-2 appliance always is a challenge
Class II malocclusions. because of the bulk of the appliance (Fig. 1). Patients were asked to
In that the sample size was reasonably robust (at least by the stand- wear the FR-2 appliance as nearly full time as possible, except during
ards of the 1980s), two sets of subgroups were established on the basis eating or oral hygiene procedures. One might assume that younger
of chronological age (the CVM method was relatively unknown at that patients would be more compliant than older patients because of
time). To study the interaction of age with Fr€ankel therapy, the sample increasing peer pressure with age. That may have been the case from a
was divided by chronological age at the start of treatment according to psychological perspective, but more robust treatment responses in man-
the two age ranges commonly treated with the Fr€ankel appliance, form- dibular growth were observed in the older patients.
ing prepubertal and pubertal groups. The younger group generally
included children in the early to mid-mixed dentition, and the older The CVM method
group included individuals in the late mixed and early permanent denti-
tions. Fifty-one patients (20 boys, 31 girls) who began treatment at less The previous discussion used chronological age as a predictor of
than 10.5 years of age comprised the prepubertal group; the remaining treatment response. What other indicators are available? Modifications

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in the size and shape of the cervical vertebrae in growing individuals malocclusion, although their effects are mainly dentoalveolar, rather
have gained increasing interest during the past few decades as a biologi- than skeletal.”7 In other words, the initial delivery of treatment was not
cal indicator of individual skeletal maturity.13−15 In that the vertebrae at the optimal developmental stage (i.e., during the circumpubertal
are visible in most lateral headfilms and CBCT images, no additional growth period).
radiation is necessary. The results of the meta-analyses described above indicate that if the
Our earliest studies of the CVM method in part involved revisiting aim of treatment is to try to stimulate mandibular growth effectively,
the data from our previously described 1985 FR-2 study17 as well ana- functional appliance therapy should be provided during the pubertal
lyzing the data from a newer companion study of the Twin Block (TB) growth period. Treatment of Class II skeletal imbalance associated with
appliance.18 The methodologies were similar, but this time the stage of mandibular retrusion started during the prepubertal period can produce
cervical vertebral maturation was determined in each cephalogram for a correction only at a dentoalveolar level, with no significant effect
each patient or subject. In the Twin Block study, the amount of supple- achieved in terms of effective mandibular growth stimulation.
mentary elongation of the mandible in the pubertal group (4.8 mm) was The use of removable functional appliances at puberty followed
more than in the prepubertal group (1.9 mm). A similar difference was immediately by fixed appliances or clear aligners to refine the occlusion
observed in the reanalyzed data from the FR-2 study (2.4 mm vs. 1.0 for the comprehensive treatment of Class II dentoskeletal imbalance is
mm). In comparison to matched controls, the greater increase in total characterized by several favorable features. First, this type of approach
mandibular length (Co-Pg) was associated with significant increases in can induce an effective amount of mandibular growth stimulation
the height of the mandibular ramus in both studies (Co-Go, 2.7 mm and (almost 3 mm, as shown by Perinetti et al.8). Moreover, this treatment
2.5 mm for the TB and FR-2 groups, respectively). Thus, these investiga- protocol can be considered an efficient approach with shorter treatment
tions added further evidence that if functional jaw orthopedics is to be duration when compared with a typical 2-phase treatment when remov-
used in mandibular skeletal retrusion treatment, it is prudent to delay able functional appliances are applied before puberty (2.3 years19 vs. 3.4
FJO treatment until at least CVM stage CS 3 is reached. years20,21 on average). This approach also is efficient with shorter treat-
ment duration of fixed appliance therapy with respect to overall treat-
Systematic reviews on treatment timing ment with fixed appliances used in combination with fixed functional
appliances (1.2 years vs. 2.3 years on average).19
As interest in the CVM method has increased, so has the design and Finally, the use of removable functional appliances at puberty fol-
implementation of randomized/controlled clinical trials. Among the lowed immediately by fixed appliance or clear aligner therapy is charac-
recent systematic reviews on the treatment effects produced by func- terized by 2 aspects that potentially should favor long-term stability of
tional appliances,5−9 the one by Perinetti et al.8 has focused specifically the treatment outcome. The first aspect is that when treatment with
on the role of treatment timing in the short-term effects produced by removable functional appliances is started at puberty, that in many of
removable functional appliances in prepubertal vs. pubertal Class II the patients the second phase of comprehensive treatment will end at a
patients. late postpubertal phase of development (CVM stage CS-5). At this late
To be included in the systematic review and meta-analysis, the stud- developmental phase, the residual amount of active mandibular growth
ies had to be randomized controlled clinical trials (RCTs) or either pro- is minimal, and it is not different from the residual amount of mandibu-
spective or retrospective controlled clinical trials (CCTs). The most lar growth shown by untreated Class I subjects.22,23 In addition, creating
important inclusion criteria were: 1) longitudinal studies on healthy a stable Class I intercuspation at the end of comprehensive treatment
growing subjects treated for skeletal Class II malocclusion due to man- also favors long-term stability.24
dibular retrusion; 2) use of removable functional orthodontic appliances;
3) use of a reliable indicator of individual skeletal maturity to assess Treatment timing and long-term outcomes of Class II treatment
treatment timing that had to be either prepubertal or pubertal and 4)
use of matched control groups of untreated Class II malocclusion sub- The role of treatment timing on the long-term dentoskeletal effects of
jects in a similar growth phase. Class II treatment with removable functional appliances followed by full-
The results of this meta-analysis8 demonstrate the fundamental role fixed appliance therapy was analyzed recently by our research group.25
of treatment timing in maximizing the amount of supplementary man- A group of 46 patients (23 females and 23 males) with Class II division 1
dibular growth that can be gained by using different types of removable malocclusion consecutively treated either with the Bionator (26 sub-
functional appliances. Regardless of the type of appliance used, the over- jects) or Activator (20 subjects) were collected. The records of Class II
all annualized supplementary mandibular growth versus untreated Class Bionator patients were retrieved from an orthodontic practice; the Acti-
II controls as measured from Condylion to anatomical Gnathion was less vator patients received treatment at the Department of Orthodontics at
than 1 mm (0.9 mm) in the prepubertal subgroup, whereas it was more the University of Rome Tor Vergata.
than three-times greater (2.9 mm) in the pubertal subgroup Lateral cephalograms were available at 3 time points: T1, at the start
(P=0.0002). Similarly, when considering the supplementary annualized of treatment (mean age: 9.9 ± 1.3 years); T2, at the end of treatment
changes in mandibular ramus height (Co-Go), once again a greater with functional appliances (mean age: 11.9 ± 1.3 years); and T3, at
amount of change was observed in the pubertal group (2.2 mm) relative long-term observation after completion of growth (CS 5 or CS 6, accord-
to the prepubertal group (0.0 mm). ing to the CVM method,13 mean age: 18.3 ± 2.1 years). The treated sam-
The results of this meta-analysis8 confirmed the findings of two pre- ple was compared to a control group of 31 subjects (16 females and 15
vious meta-analyses.5,7 Thiruvenkatachari et al5 reported that the ANB males) with untreated Class II division 1 malocclusion who were
angle showed significantly greater decreases when treatment with selected from the American Association of Orthodontists Foundation Cra-
removable functional appliances was performed at puberty with respect niofacial Growth Legacy Collection (http://www.aaoflegacycollection.
to treatment carried out before puberty (-1.4 degrees vs. -0.9 degrees, org). The treated and control samples were divided into prepubertal and
P=0.0003). Koretsi et al7 found that only 10 out of the 17 studies pubertal groups according to skeletal maturity observed at the start of
included for the meta-analysis reported the skeletal growth stage at the treatment using the CVM method.
start of treatment. Specifically, 6 studies performed treatment before When analyzing the short-term (T1-T2) changes in the prepubertal
puberty, 3 studies included pre-peak and peak patients and only 1 study groups, a significant amount of mandibular growth stimulation in the
included peak patients. Most of these studies, therefore, started treat- treated sample vs. the matched Class II controls was recorded (Co-Gn
ment at a pre-pubertal growth stage. This finding can explain why in the +2.3 mm, P=0.006), while no significant mandibular advancement
conclusions the authors wrote: “the short-term evidence indicates that occurred during this interval (Pogonion to Nasion perpendicular
removable functional appliances are effective in improving Class II +0.9 mm, P=0.347). During the post-treatment (T2-T3) interval, a

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significant relapse in mandibular growth occurred in the prepubertal increment in total mandibular length (Co-Gn) when compared with
treated group with respect to the prepubertal control sample (Co-Gn untreated Class II subjects.
-3.0 mm, P=0.049), while no significant differences were recorded Discriminant analysis identified a single predictive parameter, the so
between the 2 groups in terms of mandibular advancement (Pog to N called “mandibular angle” (Condylion-Gonion-Menton, Fig. 2) with a
perp. 0.0 mm, P=0.996).25 classification power (prediction accuracy) of 80%.28 The analysis of the
The analysis of the overall long-term T1-T3 period showed that treat- individual patient values for the Co-Go-Me angle indicated that the
ment performed before puberty was not able to produce significant “poor responders” were those Class II patients who presented at puberty
changes either in mandibular length increases or chin advancement with a mandibular angle greater than 128 degrees. In these patients
when compared to the growth changes in the untreated prepubertal treated with FJO at puberty, the amount of mandibular growth was 4.2
sample (Co-Gn -0.7 mm, P=0.632; Pog to N perp. +0.9 mm, ± 1.2 mm, values that were slightly greater than the amount of mandib-
P=0.479).25 These findings were like those reported by Wieslander,26 ular growth shown in 2 years by untreated Class II subjects (3.3 ± 1.5
who analyzed the long-term effects of early treatment with the head- mm).22
gear-Herbst appliance in prepubertal children with severe Class II maloc- Patients presenting with pretreatment values of the mandibular
clusions. The significant 2.0 mm short-term therapeutic increase of the angle between 124° and 128° degrees can be classified as “good
Co-Gn distance decreased to 1.2 mm after retention, and it was not sig- responders” as they are exhibiting an amount of mandibular growth of
nificantly different from control values at the age of 17 years 4 6.8 ± 2.8 mm in 2 years of comprehensive treatment with FJO followed
months.26 by fixed appliances. Finally, Class II patients presenting with pretreat-
When treatment was performed at puberty, however, the short-term ment values of the mandibular angle smaller than 123 degrees can be
changes of both mandibular growth and advancement were statistically regarded as “best responders” as their amount of mandibular growth was
significant (Co-Gn +3.7 mm, P=0.000; Pog to N perp. +2.2 mm, 7.3 ± 2.1 mm during 2 years of comprehensive treatment.28
P=0.007). No relapse occurred during the post-treatment T2-T3 period The mandibular angle Co-Go-Me also was identified as a significant
(Co-Gn +1.8 mm, P=0.131; Pog to N perp. +1.1 mm, P=0.274). predictor in another study by Baccetti et al.29 in which discriminant
Therefore, treatment performed at puberty resulted in favorable long- analysis was performed on the pretreatment cephalometric variables in
term mandibular changes in terms of both mandibular growth stimula- a sample of 28 patients (14 females and 14 males) treated at puberty
tion (Co-Gn +5.5 mm, P=0.000) and chin advancement (Pog to N with the acrylic splint Herbst appliance followed by fixed appliances. In
perp. +3.1 mm, P=0.001). this study, discriminant analysis was applied on pretreatment cephalo-
These favorable mandibular skeletal changes can be considered sig- metric variables to predict a significant amount of advancement of the
nificant not only at a statistical level but, more importantly, at a clinical soft tissue chin (soft tissue Pogonion) with respect to a vertical line pass-
level (+3.0 to +5.0 mm along Co-Gn) as they can contribute substan- ing through subnasale and perpendicular to the Frankfort horizontal.
tially to the improvement of skeletal Class II relationship in the long The smaller the pretreatment values of the mandibular angle, the greater
term. The results of this long-term study confirmed those of a previous was the advancement of the soft tissue chin.
study by Faltin et al.27 who found a 5.1 mm increase in total mandibular Similarly, D’Ant
o et al.30 analyzed a sample of 43 Class II pubertal
length in patients treated at puberty with the Bionator who were exam- patients (22 males and 21 females, mean age: 11.1 ± 1.6 years) treated
ined about 8 years after treatment with the functional appliance and with the Sander bite jumping appliance with acrylic covering the lower
compared with untreated Class II controls. anterior teeth. The post-treatment cephalograms were taken prior to the
Thus, if the aim of treatment is to produce favorable skeletal mandib- start of fixed appliance therapy when a tendency to Class III molar rela-
ular changes (effective mandibular growth stimulation and chin tionship was achieved or after 15 months of treatment. Also, in this
advancement), the start of treatment with removable functional applian- sample the pretreatment Co-Go-Me mandibular angle was a significant
ces should be postponed until puberty. On the other hand, if the correc- predictor for the increases in mandibular length. Greater increases in
tion of the Class II problem requires mainly dentoalveolar modifications, mandibular length again occurred during treatment of patients with
treatment timing can be initiated before puberty. smaller Co-Go-Me pre-treatment values.

Individual patient responsiveness for Class II malocclusion

If treatment timing can be regarded as the fourth dimension in ortho-

dontic diagnosis, individual patient responsiveness to treatment can be
defined as the fifth dimension. The concept of individual patient respon-
siveness to functional jaw orthopedics (FJO) for Class II malocclusion is
related to the individual’s mandibular growth potential that is deter-
mined genetically. From a clinical standpoint, it would be useful to pre-
dict prior to initiating treatment with FJO which patient is going to
show a favorable amount of mandibular growth (good responders) or in
contrast a less than favorable amount of mandibular growth (bad res-
ponders).
In 2006 we published a study28 to identify pretreatment cephalo-
metric variables for the prediction of individual mandibular out-
comes of FJO followed by fixed appliances in Class II patients
treated at the peak in mandibular growth. This study was performed
on 51 subjects (24 females, 27 males) with Class II malocclusion.
First-phase therapy was accomplished with a Twin Block appliance
in 16 subjects, a stainless-steel crown Herbst in 15 subjects, and an
acrylic splint Herbst in 20 subjects. Lateral cephalograms were avail-
able at the start of treatment with FJO and at the completion of
fixed appliance therapy. All subjects received FJO at the peak in
mandibular growth (CS 3 at T1). Individual responsiveness to Class
II treatment including FJO was defined based on the T2-T1 Fig. 2. The mandibular angle (Co-Go-Me, Condylion-Gonion-Menton).

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Cretella Lombardo et al.31 performed an additional study to identify Spontaneous improvement of Class II relationship
the predictive variables for the advancement of the soft-tissue Pogonion
in a sample of 39 Class II patients treated at puberty with the Twin Our group has had considerable clinical experience dealing with
Block. Once again, this study confirmed the role of the mandibular angle Class II correction following rapid maxillary expansion in the early
as a predictor for individual patient responsiveness. In fact, the mandib- mixed dentition.40 We have learned that the interim period between
ular angle was the only significant predictor for the amount of advance- Phase I and Phase II can be a dynamic period of dentoskeletal growth
ment of the chin during twin-block therapy. A greater advancement of and development.
the soft-tissue chin on the profile is expected with smaller pretreatment Guest et al.41 in a prospective clinical study evaluate the dentoal-
values of the mandibular angle. veolar and skeletal effects induced by RME in mixed dentition
The results of these studies clearly indicate that the ideal candidates patients with Class II Division 1 malocclusion compared with a
for FJO are those Class II patients who, at puberty, are showing small matched untreated Class II Division 1 control group (Fig. 3). The
pretreatment values for the mandibular angle. In other words, pubertal treatment sample consisted of cephalometric records of 50 patients
patients who present with a small mandibular angle are characterized with Class II malocclusion (19 boys, 31 girls) treated with an RME
by a favorable mandibular growth potential. protocol including an acrylic splint expander. Some patients also
This concept had been pointed out three decades ago by Petrovic had a removable mandibular Schwarz appliance and/or maxillary
et al.32−34 who demonstrated that mandibular growth rate, i.e., the incisor bracketing as part of their treatment protocol. Post-expan-
potential responsiveness of the individual subject to FJO aimed to sion, the patients were stabilized with a removable maintenance
stimulate growth at the mandibular condyle, is significantly greater plate and later a transpalatal arch. The mean age at the start of
in the presence of anterior growth rotation of the mandible than in treatment of the RME group was 8.8 years (T1), with a pre-Phase II
the presence of posterior mandibular growth rotation. It is con- treatment cephalogram (T2) taken 4.0 years later.
firmed, therefore, that mandibular morphology characterized by a The control sample, derived from the records of 3 longitudinal
small mandibular angle, a typical feature of anterior growth rotation growth studies, consisted of the cephalometric records of 50 Class II sub-
according to the classical concepts by Bj€ ork,35 is characterized by an jects (28 boys, 22 girls). The mean age of initial observation for the con-
elevated growth potential. trol group was 8.9 years, and the mean interval of observation was
4.1 years. All subjects in both groups were prepubertal at T1 and showed
One-phase vs two-phase Class II treatment comparable prevalence rates for prepubertal or postpubertal stages at
T2. Patients treated with the bonded RME showed the greatest effects of
One of the recurring themes thus far is that whenever possible, Class therapy at the occlusal level, specifically showing highly significant
II patients characterized by mandibular skeletal retrusion ideally should improvement of Class II molar relationship and a decrease in
be treated during the pubertal growth period. If there are no obvious overjet with respect to untreated Class II controls (+1.7 and -1.0 mm,
skeletal or dentoalveolar problems, however, in the dimensions of the respectively).
face other than that affected by the Class II malocclusion, a single contin- Looking at the comparison between the two groups in more
uous phase of treatment beginning at puberty should be undertaken. detail (Fig. 3), 18% of the controls had a negative change toward
This approach involves functional jaw orthopedics followed by fixed Class II, while none of the Class II treated worsened (-1 mm or more
appliances or clear aligner therapy to finalize the occlusion. negative). The molar relationship of 62% of the control sample did
It is common for patients with Class II malocclusion, however, not change, while only 8% of the treated sample remained
also to have problems in other dimensions of the craniofacial region. unchanged. Molar relationship improved slightly (maximum 1.5
One such problem is deficiency in the transverse dimension of the mm) in 20% of the controls, whereas the molar relationship
face. Tollaro et al.36 showed an underlying transverse discrepancy of improved in 92% of the treated Class II sample. Further, a change in
3 to 5 millimeters in many dental arches with Class II malocclusions molar relationship toward Class I of 2 mm or greater was not
without posterior cross-bites in centric occlusion. When these Class observed in the controls, while 48% of the treated group had at least
II patients were asked to posture their lower jaw forward in a Class 2 mm (maximum 4 mm) improvement.
I relationship, this discrepancy (i.e., maxillary constriction) could be The results of this study41 suggests that the protocol described
observed clinically. including treatment with a bonded rapid maxillary expander used in
Howe et al.37 have shown that transpalatal width, as measured as the the early mixed dentition in Class II Division 1 patients can help to
closest point between the maxillary first molars, should measure improve the Class II malocclusion as a side-effect, both skeletally
between 35-39 mm in adolescent and adult patients, with males having and dentally.
slightly larger values than females. These normative values can be
used clinically as a reference when determining if early expansion is nec-
essary.
It is optimal for the orthodontist to examine a patient in the early
mixed dentition to establish a proper diagnosis and treatment plan. In
the Class II patient with mandibular skeletal retrusion, a thorough evalu-
ation should be undertaken of the patient’s overall skeletal and dentoal-
veolar structure and function. If the patient has maxillary constriction,
with or without lower arch crowding, the patient may be a candidate for
expansion with a bonded acrylic splint expnder.38 In 40% of patients,
expansion of the maxilla is preceded by dental decompensation with a
removable lower Schwarz expander.39 A bonded acrylic splint expander
used to widen the maxilla has been shown to be effective and efficient in
increasing transpalatal width substantially. If crowding persists in the
maxillary anterior teeth, temporary brackets can be placed for about
6 months. Active treatment time for patients treated with rapid maxil-
lary expansion and anterior brackets is about 9 months. If a removable
lower Schwarz appliance is used initially, the treatment time is about 14 Fig. 3. Change in molar relationships in the Class II group (Treatment) versus
months. the untreated Class II controls (No Treatment).

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Summary and conclusions 11. Mellion ZJ, Behrents RG, Johnston Jr. LE. The pattern of facial skeletal growth and its
relationship to various common indexes of maturation. Am J Orthod Dentofacial
Orthop. 2013;143:845–854.
Effective and efficient treatment of Class II malocclusions in the 12. Flores-Mir C, Nebbe B, Major PW. Use of skeletal maturation based on hand-wrist
growing patient can be reached if patient-related factors also are consid- radiographic analysis as a predictor of facial growth: a systematic review. Angle
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by appropriate treatment timing. In: McNamara JA, Jr, Kelly KA eds. Frontiers of Dental
or clear aligners. Other patients have additional issues, e.g., narrow max- and Facial Esthetics. Ann Arbor, MI: Craniofacial Growth Series, Center for Human
illa, dental openbite or deepbite, dental crowding and rotations. These Growth and Development, The University of Michigan; 2001;38:237−251.
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expansion in the early mixed dentition can help in improving Class II 21. Tulloch JFC, Proffit WR, Phillips C. Outcomes in a 2-phase randomized clinical trial of
malocclusion as a side-effect, both skeletally and dentally. early Class II treatment. Am J Orthod Dentofacial Orthop. 2004;125:657–667.
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untreated subjects with Class II Division 1 malocclusion. Am J Orthod Dentofacial
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23. Baccetti T, Stahl F, McNamara Jr. JA. Dentofacial growth changes in subjects with
untreated Class II malocclusion from late puberty through young adulthood. Am J
Patient consent was obtained.
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Funding metric long-term investigation. Am J Orthod Dentofacial Orthop. 1991;100:220–233.
25. Pavoni C, Lombardo EC, Lione R, Faltin Jr K, McNamara Jr JA, Cozza P, Franchi L.
Treatment timing for functional jaw orthopaedics followed by fixed appliances: a con-
No funding or grant support. trolled long-term study. Eur J Orthod. 2018;40:430–436.
26. Wieslander L. Long-term effect of treatment with the headgear-Herbst appliance in the
early mixed dentition. Stability or relapse? Am J Orthod Dentofacial Orthop. 1993;
Author contributions 104:319–329.
27. Faltin Jr K, Faltin RM, Baccetti T, Franchi L, Ghiozzi B, McNamara Jr. JA. Long-term effec-
tiveness and treatment timing for Bionator therapy. Angle Orthod. 2003;73:221–230.
All authors attest that they meet the current ICMJE criteria for 28. Franchi L, Baccetti T. Prediction of individual mandibular changes induced by func-
Authorship. tional jaw orthopedics followed by fixed appliances in Class II patients. Angle Orthod.
2006;76:950–954.
29. Baccetti T, Franchi L, Stahl F. Comparison of 2 comprehensive Class II treatment proto-
Declaration of Competing Interest cols including the bonded Herbst and headgear appliances: a double-blind study of
consecutively treated patients at puberty. Am J Orthod Dentofacial Orthop. 2009;
The authors declare that they have no known competing financial 135:698–710.
30. D’Ant
o V, Michelotti A, Martina R. Morphologic predictors of mandibular changes
interests or personal relationships that could have appeared to influence Induced by Sander II bite jumping appliance. Oral Abstract Presentation. 2016 annual session
the work reported in this paper. of the American Association of Orthodontists. 2016. April 29-May 3Orlando, Florida.
31. Cretella Lombardo E, Franchi L, Gastaldi G, Giuntini V, Lione R, Cozza P, Pavoni C.
Development of a prediction model for short-term success of functional treatment of
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