Seminars in Orthodontics 29 (2023) 289−299

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

Enabling and restricting functions of the overjet in orthodontic treatment

Joseph G. Ghafari *
American University of Beirut Medical Center, Lebanon

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

Keywords: The aim is to evaluate the functions of the overjet in mediating, aggravating, and enabling the expression of jaw
Overjet growth in growing patients with Class II division 1 and Class III malocclusions. Beside malocclusion severity and
Growth modification treatment timing, treatment duration warrants special consideration, contrasting shorter-term (2-3 years) and lon-
Class II division 1
ger-term (5-7 years) responders to treatment, both encompassing the contribution of the adolescent growth spurt.
Class III
Treatment duration
Analysis of the genetic and environmental components affecting the development of malocclusion and growth
modification indicates that varying critical periods of growth among the craniofacial components account for the
variable individual responses to treatment. Clinical implications include keeping the overjet off the path of man-
dibular horizontal movement during orthopedic treatment, recognizing gender differences in the potential
response to treatment, and assessing the value of longer treatment in slow responders.

Introduction Overjet functions in orofacial development

The prevailing definition of overjet is the horizontal distance The mediating function of the overjet
between the edge of the maxillary incisors and labial surface of the
mandibular incisors, known to lay people as horizontal “overbite.” Malocclusions are typically defined by the molar occlusion (also
For easier communication, orthodontists adopted overjet for the hori- technically “molar overjet” defined as Class I, II, III), the interincisal
zontal overlap and overbite for the vertical coverage of the mandibu- relationship (increased overjet, edge to edge, anterior crossbite), and
lar incisors by the maxillary incisors. Overjet and overbite are the skeletal discrepancy (differential position of the jaws, also conceptu-
intertwined companions; the change in one affects the other.1 The ally the skeletal overjet). Morphologically, the overjet is the anterior
aim in this paper is to highlight the strategic role of the overjet in connector between the jaws but it may not disclose the scope of maloc-
guiding, facilitating, or hindering the treatment of growing patients, clusion severity. In Cl.II/1, an expected severe overjet is often dimin-
thus the potential subheading of this article designating the overjet ished by the developmental compensatory inclinations of the incisors,
as a subtitle of the orthodontic book of malocclusions. This process retroclined or upright maxillary and often proclined mandibular inci-
presumes the existence of gaps between the research approaches sors, but also possibly a deeper overbite, camouflaging the underlying
and associated evidence that have yet to be bridged in the treatment skeletal discrepancy. In Cl.III, the opposite maxillary and mandibular
of individual patients. dentoalveolar compensations minimize an otherwise more acute incisor
The focus of the narrative is on the treatment of Class II division 1 crossbite or “underjet.” In this perspective, deviations from normal sag-
(Cl.II/1) and Class III (Cl.III) malocclusions, which have been the subject ittal skeletal relationships generate an accordion-like camouflaging
of countless investigations at all levels of the hierarchy of evidence. shifts of the dentition (Fig. 1).
Orthognathic surgery, the other facet of maxillofacial orthopedics in The non-consonance of overjets with underlying malocclusions is
non-growing patients, is contrasted with growth modification in achiev- supported in various studies. Although associated with a higher risk of
ing neutroclusion and improving facial esthetics. The genetic and envi- trauma to the maxillary incisors, an increased overjet (>7mm) was not
ronmental components involved in the development of malocclusion found to be diagnostic of Cl.II/1.2 Nearly 10% of patients with an overjet
and in growth modification are considered in the context of individual- of 7mm had a Class I molar occlusion.3 In a study of growing patients
ized response to treatment. with Cl.II/1 malocclusions that were divided into low and high severity

* Correspondence to: Division of Orthodontics and Dentofacial Orthopedics, Department of Dentofacial Medicine, American University of Beirut Medical Center,
Riad El Solh, Beirut 1107 2020, Lebanon.
E-mail address: jg03@aub.edu.lb

https://doi.org/10.1053/j.sodo.2023.04.004

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

J.G. Ghafari Seminars in Orthodontics 29 (2023) 289−299

intermaxillary traction.6 With either theory, investigation is needed

regarding the timing of the insult and its expected significant duration,
which is related to the ongoing period of growth.
The hypothesis in Cl.II/2 stipulates that the hallmark reduced overjet
and deep overbite, concomitant with overerupted incisors and underer-
upted posterior teeth, translate into a “self-restricting” dentoalveolar
complex that keeps a growing mandible from carrying its dentition for-
ward.7 Hence the continuing mandibular growth is expressed in a more
defined chin, the characteristic “strong chin button” with an increased
anterior symphyseal angle. Presumably, early maintenance of an overjet
with well aligned maxillary incisors and correction of the overbite
should shortcut such development. A well delineated chin is often asso-
Fig. 1. Graphic representation of the dentoalveolar compensation of skeletal ciated with favorable anterior facial projection, but not necessarily so as
discrepancy in Class II division 1 (Cl.II/1) and Class III is likened to small mandibles exist with proper chin definition.4
“accordion-like” dynamics, whereby the yellow and green arrows reflect the
This discussion recalls two concepts associated with the impact
opposite movements of jaw and incisors, the latter defining the existing
of the environment on craniofacial growth. The first relates to the
overjet. In Cl.II/1, the maxillary incisors procline and mandibular incisors
retrocline to bridge the skeletal discrepancy; the opposite inclinations are
bound feet of Chinese females to control foot size, yet the bony
observed in Class III. growth was expressed in a modified shape.8 The second stipulates
that the foot may not grow forward in a constricted shoe, an anal-
ogy to the mandible not moving forward if the maxilla was con-
stricted.9 Whether and to what extent the amount of growth can be
on the basis of the ANB angle being between 4.5-6.5° and ≥6.6°, respec- stimulated remain to be discovered.
tively, we observed no statistically significant difference in overjet
between severity groups,4 whereas compensatory inclinations and posi- Enabling and restricting functions of the overjet in treatment: in
tions of the maxillary and mandibular incisors differed significantly and out of the way
between the groups (Table 1).
Two tenets underlie growth modification in growing patients and
orthognathic surgery in late adolescence or adulthood.
The aggravating function of the overjet

Get the teeth off the path of the mandible, out of the way of growth or of the
The overjet in a developing Class II division 2 (Cl.II/2) malocclusion
surgeon
and the incisor crossbite in Cl.III may contribute to deviating and likely
worsening the underlying skeleton, first affecting the bony position and
This principle presumes that mandibular advancement through
eventually the mode of expression of growth amounts. Both malocclu-
growth or surgery might be limited by the position of the maxillary
sions illustrate the concept of intragrowth orthopedics, which reflects
incisors, forcing unwanted downward and backward mandibular rota-
the potential of the environment to mold developing malocclusions over
tion (Fig. 2). Thus, a moderate overjet (avoiding the risk of trauma to
time in a specific pathway.5
the maxillary incisors3,4) should be maintained during growth modifi-
The development and/or severity of the Cl.III dysmorphology could
cation anticipating the additional growth (Fig. 3). Preparing for
relate to a sustained anterior crossbite that transfers the functional
proper occlusal interdigitation following orthognathic surgery, a
forces within the lower face through the occlusion against the maxilla,
slight to moderate proclination of the maxillary incisors might be
generating maxillary retrognathism that otherwise would not exist. This
indicated (Fig. 4).
premise is based on the finding that the deviation to maxillary retro-
In Cl.II/1 with mandibular retrognathism, maintaining a residual
gnathism was more severe than the deviation to mandibular progna-
overjet during treatment would lead to the following possibilities:
thism.5 Conceivably, a parallel or additive phenomenon may relate to
anterior mandibular positioning influencing the morphology of the con- a- mandibular forward growth equals the amount of the overjet; then,
dyles and glenoid fossa, which would also remodel in an anterior posi- the present compensatory incisor angulations are maintained
tion. An opposite posterior repositioning of these structures was b- mandibular anterior growth exceeds the overjet amount; then, the
demonstrated following Cl.III treatment with a bone-anchored present compensatory incisor angulations, particularly mandibular,
are partially or fully normalized, as indicated, for improved dentos-
keletal relations (Fig. 5)
c- the mandible grows less than the overjet amount; thus, compensa-
Table 1 tory inclinations of the maxillary and mandibular incisors are exag-
Overjet and other cephalometric measurements in patients gerated if compatible with facial esthetics; if not, a residual overjet is
with Class 2 division 1 malocclusion of low and high severity.
maintained, or later orthognathic surgery may be indicated.4
Low severity High severity
(ANB: 4.-6.5o) (ANB>6.5o) In Cl.III, parallel possibilities are in reverse directions. The overcor-
n 30 30 rected overjet from the initial anterior crossbite (usually with a face
M SD M SD P* mask and/or fixed appliances) anticipates mandibular growth equal to
AGE (yrs) 12.15 1.46 11.37 1.79 0.110 the amount of overcorrection, whereby the pretreatment mandibular
ANB (deg) 5.54 0.72 8.25 1.11 <0.0001 incisor retroclination is maintained, or mandibular growth is less than
OJ (mm) 6.90 2.18 6.97 2.22 0.910
the amount of overjet overcorrection and the mandibular incisors are
1/NA (deg) 25.97 5.778 20.09 6.61 0.018
1/NA (mm) 4.49 1.79 2.88 2.16 0.008 proclined to correct the residual overjet (Fig. 6).5
1/NB (deg) 28.10 5.55 31.98 5.44 0.016 These seemingly aleatory assumptions are rooted in the inability to
1/NB (mm) 5.32 1.96 6.82 1.83 0.041 accurately predict mandibular growth, hence the option to carry the
1/MP (deg) 95.08 5.92 100.13 6.60 0.009
quasi-exploratory treatment for a longer period than desired by patient
* Benjamini-Hochberg statistical procedure adjusting for and orthodontist. However, available evidence supports the basic prem-
multiple testing at a FDR of 0.05 or 0.01 ise of the overjet as a “leeway” for forward mandibular projection. In a

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Fig. 2. A. Class II, division 1 malocclusion with underlying skeletal discrepancy requiring a Lefort 1 maxillary impaction more posteriorly than anteriorly and mandib-
ular advancement. B, C. Graphic illustration of the orthodontic presurgical preparation. Upon maxillary impaction and rotation, the maxillary incisors become retro-
clined, offering an obstacle to more anterior mandibular advancement, and forcing a more vertical position of the mandible (blue lines in C). To allow further
mandibular forward displacement, a greater overjet should be developed by planning either presurgical orthodontic proclination of the maxillary incisors (red lines in
C) or maxillary advancement.

comparative study of Cl.II/1 treatment with either a headgear or a func- Studies of early orthopedic intervention versus orthognathic surgery
tion regulator, superimposition on the maxillary base revealed further are not available. The expected primacy of orthognathic surgery was
horizontal growth of the mandible with the headgear, which had also found in few comparisons between surgical and orthodontic treatment of
resulted in proclination of the maxillary incisors, than with the func- Cl.II/1, none of which were in a randomized clinical trial because of the
tional appliance, which had yielded retroclination of these incisors and ethical connotations related to such research. In a systematic review and
reduction of the overjet.10 meta-analysis of studies contrasting orthognathic surgery and orthodon-
tic camouflage, differences in favor of surgery were related to the dis-
Growth modification and orthognathic surgery: equal in principle, unequal in crepancy between the jaws (ANB) and the position and inclination of
outcome unless growth expression is favorable the mandible (SNB, and MP/SN angles, respectively).16 Proffit et al17
advocated augmentation genioplasty in conjunction with orthodontic
When comparing the potential for maxillofacial orthopedics modali- treatment in patients with borderline extraction malocclusions, ade-
ties, growth modification in the young and orthognathic surgery in the quate nasolabial angle, protruding mandibular incisors and a deficient
grown-up, to achieve optimal treatment results, the extent of surgical chin or short mandibular ramus.
movement at first reflection overshadows the scope of growth modifica-
tion. In Class II treatment, adding a limit of mandibular surgical The overjet in treatment modeling: interfaces with constitutional
advancement of nearly 15mm and further chin anterior displacement up and therapeutic characteristics
to 10mm might amount to 25mm of total chin projection in the profile.
Growth modification does not enhance the chin button like genioplasty. The factors determining the variable responses to treatment in grow-
Nonetheless, an assessment of mandibular development over time is ing patients include constitutional elements such as the individual
valuable to explore the limits of its expression. growth tempo, malocclusion severity and gender differences, and threra-
Data on untreated occlusions that provided longitudinal measure- peutic characteristics such as treatment timing, but also treatment dura-
ments of mandibular growth (condylion-gnathion length) and lower tion, which may define the success of treatment.
face height (ANS-menton) indicate that mandibular length increases by
nearly 26 and 34 mm in girls and boys, respectively between ages 4 and Malocclusion severity and treatment timing
18, and about 12 and 21mm, respectively between the ages of 10 and 18
that include the period when early treatments are started in the late The severity of the condition is a determining factor in treatment out-
mixed dentition (around the time of emergence of the maxillary first pre- come. When the Cl.II/1 malocclusion was stratified on the basis of the
molars) (Table 2).11,12 Accounting for the same period, the residual ANB angle in low (ANB=4.5o-6.6o) and high (ANB ≥ 6.6o) severity,
mandibular length to be affected by orthodontic treatment is practically patients with greater severity remained on average in the Class II
only around 10% in girls and 20% in boys after age 10 (Fig.7). domain (5.93o±1.49o) compared with the milder Class II in which post-
Hence, if growth modification in Cl.II/1 is consumed early enough treatment ANB (3.44o±2.25) approached normal values (2o±2o).4 In
starting in the primary dentition (possibly age 4 or 5 depending on child mesiocclusion, the early favorable orthopedic effect has been reported
compliance) or by the late mixed dentition (10 years), and lasting at to diminish with additional mandibular growth despite the overcorrec-
least past the adolescent growth spurt, it is conceivable that growth tion of the overjet.5 Nonetheless, a gap in knowledge remains regarding
modification (particularly in boys) might mirror the results of orthog- outliers that may cross severity groupings.
nathic surgery, short of the genial extension if the chin “button” is Validating research at the higher level of evidence supports the initi-
absent or minimal (Fig. 5). The corollary to this theory is that patient ation of “early” treatment in the late mixed dentition in nearly two
and orthodontist are willing to invest a long period of treatment wherein thirds of malocclusions, which also carries the advantage of shorter
the fuller amount of growth is expressed. treatment duration (Fig. 8).18 However, the concept of starting treat-
In Cl.III malocclusion, such prospect might be achieved (Fig. 6) with ment as soon as the problem becomes evident may not be totally
the proviso that excessive mandibular growth further undermines the neglected, conceivably as early as in the primary dentition as advocated
treatment strategy, particularly if dentoalveolar compensation (pro- by Angle19 and other adherents to this philosophy.
clined maxillary and retroclined mandibular incisors) has reached
extreme limits detrimental to periodontal heatlh and facial esthetics.13 Gender differences
Data on untreated Cl.III from mixed longitudinal samples of small to
moderate sizes reveal that from the ages of 10 to 15 mandibular length The disparity between a shorter treatment, timed relative to the
(condylion-gnathion) grows on average by nearly 15mm (compared growth spurt (Fig. 8) and a longer treatment (e.g. over 7 years; Fig. 5) to
with 13mm in Class II).14,15 reach successful results relates to various factors such as malocclusion

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Fig. 3. Pre and post-phase 1 treatment cephalographs (A, B,

respectively) and occlusal photographs (C, D, respectively) of a 10-
years-old boy whose severe Class II division 1 malocclusion was
improved to neutroclusion by age 11 years. Treatment options con-
sidered: a. maintain the overjet anticipating the expected addi-
tional growth spurt that should carry the mandible forward to
optimal interincisal relationships (E, F); b. start the next treatment
phase with fixed appliances a few months after the impending loss
of the maxillary second primary molars and canines and eruption
of their successors, likely resulting in retroclined maxillary and
proclined mandibular incisors (G). Further growth of the mandible
during peak height velocity would end up with an edge to edge
incisor occlusion that might require proclination of the maxillary
incisors (thus bimaxillary protrusion) and/or a difficult process of
retraction of the mandibular dentition (H). Should the mandible
rotate backward while growing forward, another process of den-
toalveolar “corrections” might ensue, such as the retraction of
mandibular incisors (I), proclination of the maxillary incisors (J),
or even the retroclination of maxillary and mandibular incisors,
possibly following the extraction of first premolars (K).

severity, growth potential per time (months and years), patient compli- 10.5mm) between ages 6-10 years in both girls and boys.14 Nonetheless,
ance, and possibly gender. In Cl.II/1 treatment success might be more even in same sex children variations exist and should be considered, pos-
amenable in boys whose mandible grows at a greater rate annually sibly in relation to variances in body and mandibular growth amounts.
between the ages of 10 and 18 and over a longer period20 (Fig. 7),
approximately 65% (24/37mm) of the growth gradient between ages 4 The impact of treatment duration on treatment outcome
and 18, compared with 44.5% (12/27mm) in girls (Table 2).11 In
untreated Cl.III patients, orthopedic treatment might be more effective Successful results may be obtained when accounting for and
in girls, whose mandible grows an average 12mm compared with 17mm benefiting from the natural duration of growth events.13 This poten-
in boys between ages 10 and 15, the latter growing another 5.5mm from tial is illustrated when fast corrections of Cl.II/1 malocclusion are
15 to 18 years.14 Notable is the near equal growth of Co-Gn (about timed to profit from the adolescent growth spurt (Fig. 8), but also in

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Fig. 4. A, B. Lateral views of the presurgical models of a patient with Class II, division 1 approximated before surgery to determine if the patient was ready for orthog-
nathic surgery. The canines are not seated in Class I and the molars are short of neutroclusion. To achieve better seating, the maxillary incisors were proclined to
increase the overjet and develop space mesial to the maxillary canines as shown before (C) and after (D) implementing this movement that required nearly 6 weeks.
E, F, When the new presurgical models were approximated, the canines and molars were in optimal seating. G, H. Intraoral lateral views of another patient demonstrat-
ing the creation of the space mesial to the canines prior to maxillary impaction surgery (G) and at the end of treatment (H).

much longer treatments of Cl.II/1 and Cl.III demonstrating the con- greater overjet that would allow a repeat of the mechanics used in the
cert of growth (including the growth spurt) and multiphase treat- first correction (e.g. functional appliance; Fig. 5). In Cl.III, an overcor-
ment mechanics in which the overjet “enables” the forward rected overjet should be held for a significant period because further
projection of the mandible (Figs. 5, 6). mandibular growth is detrimental to the outcome (Fig. 6).
Should a first phase of treatment approximate a normal overjet, more Essentially, the orthodontic environment “competes” with the existing
optimal results could be sought. In Class II/1, the originally proclined epigenetic/environmental factors that interplayed with the genetic influ-
mandibular incisors could be retracted (decompensated) to develop a ence to produce the present malocclusion. Frankel advocated in Cl.II/1

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Fig. 5. Cephalographs of a patient presenting with a severe Class II, division 1 malocclusion at the age of 10years and 5 months, with compensating severe proclination
of the mandibular incisors (A). Treatment was guided by a strategy of constantly maintaining a residual overjet for more forward and less downward mandibular move-
ment. At first, a functional appliance (modified bionator) resulted in overjet reduction. Subsequently, the mandibular incisors were retracted into existing spacing
within the mandibular arch, and a second bionator delivered for further mandibular growth into the developed overjet (B). The corrective stages of fixed appliances
included further retraction of the mandibular incisors against a maxillary headgear and overjet development (C). The child was still growing, and his compliance was
exemplary. Accordingly, incisal compensation for the remainder of the overbite was only undertaken when no further significant growth was anticipated (D). Presum-
ably approaching in amount a surgical mandibular advancement (about 1cm of growth), the latter was avoided, although not ruled out from the onset should treatment
not keep up with an insufficient mandibular growth. However, the outcome could not be predicted with available cephalometric prediction models.

Fig. 6. Serial cephalographs (A-E) and pre (F) and post (G) treatment photographs of a patient presenting with Class III malocclusion treated with sustained facial mask
between the ages of 9 and 13y8m. Treatment proceeded with Class III mechanics until age 17y3m when mandibular growth stabilized. Retention included the night-
time use of Class 3 elastics to clear retainers. The treatment strategy is simulated in figures H and I: the overcorrected overjet (B, C) anticipates mandibular growth
equal to the amount of overcorrection (H), hence the pretreatment mandibular incisor angulations are maintained, or mandibular growth less than the amount of over-
jet overcorrection (I), thus the mandibular incisors are proclined in the amount of the overjet correction.

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Table 2
Approximate values (mm) of Go-Gn and its components during growth from early or mid-childhood to early adulthood.

Age (yrs) Girls Boys

4-18

10-18

Adapted from Riolo et al.4

Between the ages of 10 and 18 years, 44.5% (12/27mm) of the available growth gradient remains in girls and 65% (24/37mm) in
boys.

therapy a stepwise mandibular advancement of the function regulator The overjet in treatment modelling
(2-3mm each activation) over longer periods of treatment (possibly 5 years),
“not further than the protractor muscles are able to keep the mandible in The geometric perspective of the overjet providing the leeway for
that forward position”, presumably pacing the overjet reduction with the mandibular response to orthodontic/orthopedic stimuli (Figs. 4, 5, 6)
concomitant skeletal development.21 and treatment duration should be added to the present model of interac-
Often, the reluctance of patients and parents for longer treatment tive components in the treatment of malocclusions in growing patients,
forces the earlier completion of Cl.II/1 treatment with otherwise avoid- which includes growth (amount and direction), time (timing and dura-
able dentoalveolar overcompensations and the consequent backward tion of treatment), and treatment modality (e.g. functional appliance,
rotation of the mandible when the insufficient overjet hinders its further headgear, face mask). Together, these components form the individual
advancement (Fig. 2). In Cl.III, the earlier treatment completion with temporal “engine” that drives treatment response (Fig. 9). The ortho-
dentoalveolar overcompensation is further magnified with the uncertain dontist is able to regulate the parts in variable extents, least of which the
prediction of final mandibular size with completed growth. genetic growth potential and long-term patient compliance.
In most modern clinical settings, an early and eventually protracted The balance of this system is complex because of individual varia-
treatment, complemented with fixed appliances for another finite tions in structural, physiologic, therapeutic and even psychological com-
period, is not a viable routine approach considering the patient’s compli- ponents. Outliers to average trends uncover important disparities
ance, demand for faster treatment, financial affordability by the patient between goals and outcomes attributable to constitutional variances
and sustainability of the practice. that relate to anatomy, growth, biological response to orthodontic

Fig. 7. A. Average percent (%) achievement of adult size of the mandibular length (condylion-pogonion) in girls and boys computed from Riolo et al11 and displayed
graphically against age (years). Most of the length (nearly 80% in girls and 74% in boys is achieved at the age of 4 years. The remaining growth in girls is 27mm, and
in boys 37mm (Table 2), with corresponding average annual increments of 2mm/yr and 2.6mm/yr, respectively. When the percentages are computed starting at age
10 (dotted vertical line), 10% and 20% of growth remains in girls and boys, respectively. B. Males have a greater amount of growth to be consumed over a longer period
of time (graph redrawn from Ursi et al20). The size of the mandible must be seen proportionally to the larger size of the head and face in males compared to females.
Note: the average values do not reflect the individual variations and the particularities of untreated Class II and Class III malocclusions

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Fig. 8. A-H. Extraoral (A-C), intraoral (D-F), and cephalometric (G, H) records of an 11 years old prepubertal girl whose Class II, division 1 (Cl.II/1) malocclusion
(ANB=7.15o) was treated with a function regulator. Improvement from the initial condition (A, D) to neutroclusion was observed at 9 months (B, E) and when the
appliance was discontinued, 2yrs later (C, F). The correction is demonstrated in the difference between the initial (G) and 2yr (H) cephalometric tracings. I-P. Extraoral
(I-K), intraoral (L-N), and cephalometric (O, P) records of a 13 years old prepubertal boy treated with headgear to correct a Cl.II/1 malocclusion (ANB=6.87o).
Improvement from the initial condition (I, L) to an overcorrected Class I molar relationship was detected at 1 year (J, M) and when the appliance was discontinued
nearly 2years later (K, N). The difference is documented between the initial (O) and the 2year (P) cephalograms. Treatment was successful because of the concert of
favorable factors: timing treatment precisely before the growth spurt, allowing the mandible to “grow” horizontally “within” the overjet, sufficient genetically influ-
enced amount of growth, and exemplary compliance.

forces, and therapeutic variances associated with the necessity to design

treatment based on the individual constitutional limitations (e.g. ana-
tomical restraints such as lip thickness or growth potential). These fac-
tors reveal the necessity of considering the concert of genetic,
epigenetic, and environmental influences in orthodontic science.

Heredity and environment (treatment): gradients and critical

periods of growth

Under which circumstances can orthodontic treatment, considered

an environmental influence, overcome the genetic blueprint of mandibu-
lar retrognathism in Cl.II/1 and mandibular prognathism or maxillary
retrognathism in Cl.III? The environmental contribution to modifying
the genetically-influenced mandibular length is commonly considered
unequal to the genetic effect, but the issue is more intricate for such gen-
eralization.
Postnatal craniofacial skeletal growth is affected by dynamic
“organizational processes” regulated by interacting genetic units and
environmental conditions.22 Integral to the production of the craniofa-
cial phenotype are the concepts of pleiotropy (the production by a gene
Fig. 9. Interactive factors influencing the treatment of malocclusion, applicable of two or more apparently unrelated effects), epigenetic and environ-
to Class II division 1: Inherent genetically-influenced elements are growth
mental influences, and allometry (the growth of craniofacial parts at dif-
amount and direction (more in males [M] than females [F]); external treatment-
ferent rates, effecting a change in craniofacial proportions). Although
induced elements are treatment timing and duration, treatment modality and
overjet. Treatment timing through a validated treatment modality allows the integrated, the morphological components demonstrate variable
expression of differential growth (amount). The maintenance of an overjet per- response potentials or “growth maturity gradients” to environmental
mits growth to be expressed more horizontally (direction) throughout the active and epigenetic influences, dependent on their respective growth
growth period (duration). The balance of this system is challenging because of rythm.22 The earlier maturing structures (e.g., cranial base, maxilla) are
individual variations in structural, physiologic, and therapeutic components. more deficient in responding to future stimuli than the later maturing

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and more rapidly metabolizing structures (e.g., mandible) because of the outliers that might help categorize responders to take full advantage of
cumulative effects of past stimuli. their growth potential in shorter or longer treatments (Fig. 11).
The concept of critical periods, initially contending that dysmorphol- Creative research on extensive databases is needed, combining
ogy depends on the timing of insults during embryogenesis, suggests genetic diagnostics, measurable outcomes and artificial intelligence to
that all parts of an organism do not respond equally to adverse environ- sort out the various premises. Investigations would ideally include bio-
mental conditions even if applied at the same time.22 By extension, this logical monitors of growth (e.g. blood or salivary molecular substan-
premise would apply to supposedly helpful environmental interactions ces24) and the assessment of genetic predisposition in response to
such as orthodontic treatment, with the expectation that different facial treatment.25 Certain genes might control a more favorable expression of
components would or would not respond equally to environmental pro- the environment (treatment) or respond better with shorter or longer
visions. Thus, structures developing at various rates would express dif- treatment. Moreover, longitudinal randomized research is needed to
ferent levels of susceptibility to epigenetic and environmental modifiers. determine the added value of extended treatment for the fuller manifes-
The earlier maturing structures such as the maxilla would require an ear- tation of jaw growth escorting the general body growth.
lier intervention for forward movement in Cl.III (face mask5) or for less The key to unlock complex issues related to predictability of growth
retraction relative to favoring mandibular anterior displacement in Class or treatment is to develop further knowledge about the scope of individ-
II.1 (functional appliance). The later maturing mandible might need lon- ual variation, essentially finding out the location of a particular patient
ger treatment in Cl.II/1(functional appliance, headgear, or both, Fig. with the same condition to be treated relative to central tendencies that
54). The variation of critical periods is exemplified by the timing and are not generalizable for all variations within the sample. Recognizing
intensity of growth in landmark maturational events such as body an “outlier” to the central tendency calls for identifying and categorizing
height, sutural (maxillary) and mandibular length.23 the sources of variations to determine the average response to treatment
by the categorized outliers.2 In this perspective, practitioners and
Research outlook researchers would focus on individual diagnostic and therapeutic tracks
of responses to be defined in the different malocclusions.
The previous conceptualization explains the variability in treatment
timing, duration and outcome and is difficult to translate in individual- Clinical practicability
ized treatment absent the prediction models that can account for at least
the allometric growth expression. Perhaps herein lie strengths and weak- The previous discussion indicates that a personalized non-generic
nesses of prediction equations, which account for diverse components approach to treatment is imperative, nonetheless based on tested treat-
but not for growth gradients, critical periods, the differentiation ment modalities. Yet, the translation of research central tendencies in
between shorter, intermediate, and longer-term responders, and the the individual patient remains a challenge. Greater insights are needed
“tuning” role of the overjet. Models incorporating these variables remain in biological knowledge (e.g. tissue reactions, genetics and epigenetics,
to be tested (Fig. 10), as well as models which could sort out trends with growth and treatment outcome prediction) to plan a precise individual

Fig. 10. Graphic representation of projected chin extension relative to treatment duration in Class II division 1 (Cl.II/1) patients whose malocclusion is in a lower or
higher range of severity (based on prior categorization studies3,4,18). Approaching the 100% level of orthognathic chin extension would be expected in patients with
favorable mandibular growth responding in short, intermediate, or long term treatment duration. With lower gradients of favorable growth, the chin would not reach
orthognathism although closer to optimal position. In the more severe malocclusions, insufficient growth is expected leading to improvement but still in the Class II
phenotype domain, also responding in shorter, intermediate, or longer treatment duration. More severe malocclusions may find a pathway to orthognathism if chin
form is well delineated (not slight or absent) and significant growth occurs. The prospect of surgery is higher with more severe malocclusions, absent or slight chin
form, and bad response to treatment. This model represents general trends and expectations yet underscores the complexity of components and variables involved in
the treatment of Cl.II/1.

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J.G. Ghafari Seminars in Orthodontics 29 (2023) 289−299

Fig. 11. Hypothetical representation of distribution of the duration of Class II treatment started in early childhood (late mixed dentition) relative to treatment out-
come. A. The blue line represents a linear correlation between treatment duration and treatment outcome. Outliers are shown in colored circles. The question posed
regarding the patients shown in Figs. 5 and 8 at pretreatment time is: could individual treatment duration be predicted to reach the sought outcome (Class 1 occlusion
with optimal overjet and overbite)? B. Two patients shown in Fig. 8 reached the optimal outcome within months to a year, another in more than 5 years (Fig. 5). The
ensuing question is: can the average response be shifted from the blue line to the green line? The answer, whether biological and orthodontic/mechanical is not avail-
able, with doubts about a shift. What might be achievable through multistep research is recognizing the outliers before treatment.

treatment.26 Until such information is acquired, a set of guidelines is 5. Growth amount and pace differ between boys and girls, with greater
advanced based on scientific data and the systematic judgment by the potential for success (Cl.II/1) or failure (Cl.III) in boys whose mandi-
treating orthodontist of ongoing responses to treatment: bles grow in greater amounts and for a longer period.
6. Considering the absence of accurate prediction of individual out-
1. Appraise the malocclusion in its components not as a generic type.4 come, it is recommended to carry the early treatment of Cl.II/1
2. Formulate a treatment targeting the early and late maturing struc- through the growth spurt with a residual overjet for more horizontal
tures differentially (in both timing and force amounts), recognizing mandibular growth projection. If the latter is not satisfactory, partic-
that more severe malocclusions are expected to respond less favor- ularly with a slow tempo and amount of mandibular growth, the
ably. Such an assessment might favor the treatment of Cl.II/1with a gain from additional growth is possible but treatment lasts longer.
functional appliance rather than a headgear in a younger child and Overcorrection of the overjet in Cl.III is necessary to anticipate the
the opposite in a postubertal adolescent patient. further mandibular growth.
3. Analyze the limiting and enabling roles of the overjet during treat-
ment, titrating the next step in light of the developing response. If Patient consent
the latter is positive, potentiate the effect, such as producing addi-
tional decompensation of mandibular incisors in Cl.II/1 to allow Patient consent was obtained.
more horizontal expression of mandibular growth or the retentive
use of a face mask in Cl.III to maintain an overcorrected overjet. Funding
4. Consider a longer period of treatment with willing patient and
parents, guided by the foregoing response and compliance. Success No funding or grant support.
is not guaranteed but parents often insist on orthopedic intervention
hoping to avoid surgery years later. Author contributions
5. Where applicable and necessary, inform or advise patient and
parents of the surgical orthognathic option. Treatment potential and All authors attest that they meet the current ICMJE criteria for
duration as well as patient expectations, not only chief complaint, authorship.
must be discussed with the patient before treatment.
Declaration of Competing Interest
6. Consider compromised results in favor of optimal facial appearance
rather than dental Class I interdigitation.4
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
Conclusions
the work reported in this paper.

1. The overjet captures the complexity of malocclusion severity as the

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