r

Europt'an JOllrnal olOrtllOdontics 18 (1996) 27-40 lO 1996 European Orthodontic Society I .

.
I

Significance of the cant of the posterior occlusal plane in

Class 11division 1 malocclusions
Hiroaki Mita, Sadao Sato, Yoshii Suzuki,
Japan, and

I
I

Kenji Fushima, Yutaka Kitamura, and Young H Kim*

Department of Orthodontics, Kanagawa *Weston, Massachusetts, USA

Dental College, Yokosuka, Kanagawa,

SUMMARY In studying a group of fifty adult females with Class 11division 1 malocclusion, it was evident that the skeletal problems of this malocclusion involved small, retruded mandibles accompanied by backward rotation. This skeletal pattern was considered to be influenced by the vertical dimension of the upper dentition in the buccal segment for mandibular

function.

The anterior and the posterior occlusal planes were examined to gain a detailed assessment of the relationship between the dental and the skeletal patterns. The findings indicated that the steep cant of the posterior occlusal plane was strongly correlated with the following: 1. Small, retruded mandible with backward rotation as the skeletal pattern. 2. Short vertical height of the upper second molars and distal inclination of the upper molars as the dental pattern. The increased vertical height of the lower second premolars was found to be related to backward rotation of the mandible. In treating skeletal Class 11division 1 malocclusions, this study indicated that control of the vertical dimension of the posterior teeth is extremely important. Introduction In orthodontic treatment, craniofacial growthrelated skeletal problems make malocclusions difficult to correct. Seeking to solve such skeletal problems, many experiments and theories have been presented with regard to facial growth. Control of jaw growth has involved different methods, such as headgear to the maxilla, chin cup to the mandible, functional appliance to the maxilla and mandible, and others. It is often the case, however, that the skeletal patterns are aggravated by orthodontic treatment, which suggests that uncontrolled occlusal changes may affect jaw growth. Several studies have reported on the relationship between occlusal deviation andjaw growth. McNamara (1975) demonstrated that mandibular protrusive occlusal splint induced adaptive growth in the condylar region in monkeys. Harvold (1968) found the development of a Class II type malocclusion and the skeletal morphology in a Rhesus monkey by insertion of a piece of plastic in the palatal vault between the right and left premolars which interfered with the occlusion. Fushima el al. (1989) examined the vertical height of right and left posterior teeth in cases with mandibular asymmetry by the use of P-A cephalograms, and re.vealed that the vertical height of posterior teeth on the suppressed side of the mandible was lower than contralateral teeth. These findings suggest that occlusal deviations are related to facial growth. In orthodontic diagnosis, the occlusal plane represented by a line drawn from the midpoint of the upper and lower central incisor edges to the occlusal surface of the upper and lower first molars on the lateral cephalogram should be carefully evaluated. The cant of the occlusal plane must relate to the sagittal inclination of the condylar path and the guidance of lingual concavity of the upper incisor (Dawson, 1989). In a strict sense, however, the occlusal plane is not a line. Considering the function of the mandible, it should be understood as a curved surface. For example, in a case with asevere curve of Spee, the occlusal plane drawn in a conventional manner is erroneously represen-

I
!I

I I

28 ted. In reality, the cant of the occlusal plane linked with the occlusal surfaces of posterior teeth is steep (Fig. lA). In a case with a flat occlusal plane (Fig. lB), the anterior movement of the mandible leads to separation of the posterior teeth, since the cant of the occlusal plane is of a sufficient degree in relation to the sagittal condylar path. On the other hand, in a case with asevere occlusal curvature in the upper dentition (Fig. l C), the posterior disclusion does not occur in anterior movement of the mandible beca use the difference of inclinations between the posterior occlusal plane and the sagittal condylar path is smal\. In such incidences, the presence of cuspal interference in the terminal molars invariably prevents anterior movement of the mandible or invites a temporomandibular dysfunction. Several studies have stated that an excessive curve of Spee is characterized in Class II division l malocclusions (Jarabak and Fizzel, 1972; Nanda, 1983). This characteristic occlusion might affect its own skeletal growth pattern. The masticatory function is characterized as a three-dimensional mandibular movement to the occlusal surface of the upper dentition. More attention should thus be focused on the occlusal curvature in the upper dentition. Langlade (1978) emphasized the importance of upper anterior occlusal plane control and stated that

K. FUSHIMA

ET AL.

the goal of intervention must be optimum function, not just straight teeth. To fit this characteristic feature of the occlusal plane of the posterior dentition, a functional occlusal plane has been used thus far. In this article, the occlusal plane will be considered as two planes divided into the anterior and posterior segments. In this sense, it seems clear that the relationship between the occlusal deviation and the skeletal pattern is closely related. The purpose of this investigation was: (1) to determine the occlusal deviation in the upper dentition using two parameters, the anterior and the posterior occlusal planes; (2) to establish the mean value and the normal range of the two occlusal planes in the normal population; (3) to examine the relationship between those two parameters and the skeletal patterns in Class II division 1 malocclusions; (4) to classify Class II division l malocclusion by the parameter of the occlusal plane; (5) to compare the skeletal pattern between the groups of Class II division 1 malocclusion and normal occlusion. Materials and methods Lateral cephalograms of normal occlusion samples and of Class II division l samples were

l.

I . I

Figure I (A) The solid line indicates the occlusal plane as defined conventionally, and with a normal inclination. Note that the occlusal plane in the posterior region represented by the dotted line is steep. (B) There is a posterior disclusion in anterior movement of the mandible (dotted tracing). (C) The posterior disclusion does not occur in anterior movement of the mandible.

1 {'"

----

POSTERIOR

OCCLUSAL

PLANE

IN CLASS

Il MALOCCLUSION

29

utilized in this study. Normal occ\usion samples of 35 adult females with an average age of 23 years 4 months (range 22-27 years) who possessed acceptably good occ\usion without missing teeth were obtained from students of Kanagawa Dental College. Untreated Class 11 division l malocc\usion samples of 50 adult females taken at 16 years ofage and IVA stage ofdental age were se\ected fram the files of Kanagawa Dental College. The average age of these subjects was 19 years ll months with a range of 16-25 years of age. Cephalometric measurements on the occ\usal planes, as well as the skeletal and dental patterns were obtained using the following criteria. Occ/usal planes l. Anterior occ\usal plane-a line drawn from the incisal edge of the upper central incisor to the cusp tip of the upper second premolar. 2. Posterior occ\usal plane-a line drawn fram the cusp tip of the upper second premolar to the midpoint of the upper second molar at the occ\usal surface. The Frankfort horizontal (FH) plane was determined utilizing anatomical porion and orbitale as reference points (Ricketts, 1960). Measurements (Fig. 2) A-OP: the anterior angle between the anterior occ\usal plane and the FH plane. When the

anterior occ\usal plane slopes upward and forward in re\ation to the FH plane, the angle is read as minus. P-OP: the anterior angle between the posterior occ\usal plane and the FH plane. OP-diff.: the angular difference between A-OP and P-OP. Skeletal pattern Angular measurements (Fig. 3) 1. Mandibular plane angle (MP): the angle between the mandibular plane and the FH plane (Downs, 1948). 2. Facial axis (FX): the angle between the facial axis and the basion-nasion line (Ricketts, 1960). 3. Gonial angle (GO-A): the angle between the posterior border line of the ramus and the mandibular plane. 4. Palatal plane angle (PP): the angle between the palatal plane and the FH plane. A po sitive value is given when the plane inclines downward and forward in relation to the FH plane (Kim, 1974). 5. Ramus inc\ination (RAM-I): the angle between the posterior border line of the ramus and the FH plane. Linear measurements (Fig. 4) 1. Na perpendicular to A (A): the distance

,. .

'---FH

Figure 2 Angular measurements of the occ1usal planes. A-OP: anterior occ1usal plane, P-OP: posterior occ1usal plane, OP-diff.: occ1usal plane difference.

Figure 3 Angular measurements of the skeletal patterns. 1. Mandibular plane angle (MP). 2. Facial axis (FX). 3. Gonial angle (GO-A). 4. Palatal plane angle (PP). 5. Ramus inc1ination (RAM-I).

30

K. FUSHIMA ET AL.

FH

FH

Figure 4 Linear measurements of the skeletal patterns. 1. Na perpendicular to A (A). 2. Na perpendicular to pogonion (POG). 3. Ramus height (RAM-H). 4. Mandibular length (MAND-L). 5. Maxillary length (MAX-L).

Figure 5 Angular measurements of the dental patterns. 1. VI to FH. 2. Ll to MP. 3. FMIA. 4. V6 to FH. 5. V7 to FH.

2.
I j

II

l.

3.

I I
I

4.

5.

from point A to the line drawn from nasion perpendicular to the FH plane (McNamara, 1983). Na vertical to Pog (POG): the distance from pogonion to the line drawn from nasion perpendicular to the FH plane (McNamara, 1983) . AP difference (AP-diff.): the distance of item 1 subtracted from the distance ofitem 2. Ramus height (RAM-H): the distance from the cross-point of the FH plane and the posterior border line of the ramus to the cross-point of the posterior border line of the ramus and the mandibular planeo Mandibular length (MAND-L): the distance from the cross point of the FH plane and the posterior border line of the ramus to gnathion. Maxillary length (MAX-L): the distance from the posterior nasal spine to a point which is drawn perpendicularly up from point A to the palatal planeo

2. Ll to MP: the angle formed by the long axis of the lower central incisor and the mandibular plane (Downs, 1948). 3. FMIA: the angle formed by the long axis of the lower central incisor and the FH plane (Tweed, 1966). 4. U6 to FH: the anterior-inferior angle formed by the long axis of the upper first molar and the FH planeo 5. U7 to FH: the anterior-inferior angle formed by the long axis of the upper second molar and the FH planeo Linear measurements (Fig. 6) l. U l-PP: the perpendicular distance from the upper central incisal edge to the palatal planeo 2. US-PP: the perpendicular distance from the cusp of the upper second premolar to the palatal planeo 3. U7-PP: the perpendicular distance from the midpoint between the mesial and distal buccal cusps of the upper second molar to the palatal planeo 4. Ll-MP: the perpendicular distance from the lower central incisal edge to the mandibular planeo 5. LS-MP: the perpendicular distance from the cusp of the lower second premolar to the mandibular planeo 6. L7-MP: the perpendicular distance from the midpoint between the me sial and distal

Dental pattern Angular measurements (Fig. 5) l. Ul to FH: the posterior-inferior angle formed by the long axis of the upper central incisor and the FH planeo
,

l~_._

-"1

POSTERIOR

OCCLUSAL

PLANE IN CLASS 11 MALOCCLUSION

29

utilized in this study. Normal occlusion samples of 35 adult females with an average age of 23 years 4 months (range 22-27 years) who possessed acceptably good occlusion without missing teeth were obtained from students of Kanagawa Dental College. Untreated Class 11 division 1 malocclusion samples of 50 adult females taken at 16 years of age and IVA stage of dental age were selected fram the files of Kanagawa Dental College. The average age of these subjects was 19 years 11 months with a range of 16-25 years of age. Cephalometric measurements on the occlusal planes, as well as the skeletal and dental patterns were obtained using the following criteria. Occ/usal planes 1. Anterior occlusal plane-a line drawn from the incisal edge of the upper central incisor to the cusp tip of the upper second premolar. 2. Posterior occlusal plane-a line drawn from the cusp tip of the upper second premolar to the midpoint of the upper second molar at the occlusal surface. The Frankfort horizontal (FH) plane was determined utilizing anatomical porion and orbitale as reference points (Ricketts, 1960). Measurements (Fig. 2) A-OP: the anterior angle between the anterior occlusal plane and the FH plane. When the

anterior occlusal plane slopes upward and forward in relation to the FH plane, the angle is read as minus. P-OP: the anterior angle between the posterior occlusal plane and the FH plane. OP-diff.: the angular difference between A-OP and P-OP. Skeletal pattern Angular measurements (Fig. 3) 1. Mandibular plane angle (MP): the angle between the mandibular plane and the FH plane (Downs, 1948). 2. Facial axis (FX): the angle between the facial axis and the basion-nasion line (Ricketts, 1960). 3. Gonial angle (GO-A): the angle between the posterior border line of the ramus and the mandibular plane. 4. Palatal plane angle (PP): the angle between the pala tal plane and the FH plane. A po sitive value is given when the plane inclines downward and forward in relation to the FH plane (Kim, 1974). 5. Ramus inclination (RAM-I): the angle between the posterior border line of the ramus and the FH plane. Linear measurements (Fig. 4) 1. Na perpendicular to A (A): the distance

I I I I I

'. I

.--FH
4

Figure 2 Angular measurements of the occlusal planes. A-OP: anterior occlusal plane, P-OP: posterior occlusal plane, OP-diff.: occlusal plane difference.

Figure 3 Angular measurements of the skeletal patterns. 1. Mandibular plane angle (MP). 2. Facial axis (FX). 3. Gonial angle (GO-A). 4. Palatal plane angle (PP). 5. Ramus inclination (RAM-I).

.i{. 1:r~~ ..~:~ ;....

30

K. FUSHIMA ET AL.

--,

FH I
I

FH

I
I
Figure 4 tinear measurements of the skeletal patterns. 1. Na perpendicular to A (A). 2. Na perpendicular to pogonion (POG). 3. Ramus height (RAM-H). 4. Mandibular length (MAND-L). 5. Maxillary length (MAX-L). Figure 5 Angular measurements of the dental patterns. 1. UI to FH. 2. Ll to MP. 3. FMIA. 4. U6 to FH. 5. U7 to FH.

2.

3.

4.

5.

from point A to the line drawn from nasion perpendicular to the FH plane (McNamara, 1983). Na vertical to Pog (POG): the distance from pogonion to the line drawn from nasion perpendicular to the FH plane (McNamara, 1983). AP difference (AP-diff.): the distance of item 1 subtracted from the distance of item 2. Ramus height (RAM-H): the distance from the cross-point of the FH plane and the posterior border line of the ramus to the cross-point of the posterior border line of the ramus and the mandibular planeo Mandibular length (MAND-L): the distance from the cross point of the FH plane and the posterior border line of the ramus to gnathion. Maxillary length (MAX-L): the distance from the posterior nasal spine to a point which is drawn perpendicularly up from point A to the palatal planeo

2. LJ to MP: the angle formed by the long axis of the lower central incisor and the mandibular plane (Downs, 1948). 3. FMIA: the angle formed by the long axis of the lower central incisor and the FH plane (Tweed, 1966). 4. U6 to FH: the anterior-inferior angle formed by the long axis of the upper first molar and the FH planeo 5. U7 to FH: the anterior-inferior angle formed by the long axis of the upper second molar and the FH planeo Linear measurements (Fig. 6) 1. U l-PP: the perpendicular distance from the upper central incisal edge to the palatal planeo 2. U5-PP: the perpendicular distance from the cusp of the upper second premolar to the palatal planeo 3. U7-PP: the perpendicular distance from the midpoint between the mesial and distal buccal cusps of the upper second molar to the pala tal planeo 4. LJ-MP: the perpendicular distance from the lower central incisal edge to the mandibular planeo 5. L5-MP: the perpendicular distance from the cusp of the lower second premolar to the mandibular planeo 6. L7-MP: the perpendicular distance from the midpoint between the mesial and distal

Dental pattern Angular measurements (Fig. 5) 1. Ul to FH: the posterior-inferior angle formed by the long axis of the upper central incisor and the FH planeo

- -

POSTERIOR

OCCLUSAL

PLANE

IN CLASS

Il MALOCCLUSION

31
Estimation of random errors (n

Table 1

= 25).
("lo)

Coefficient of Measurement A-OP P-OP SE 0.49 0.54 0.54 0.57 0.57 0.45 0.50 0.53 0.64 0.34 0.45 0.43 0.69 0.59 0.67 0.74 0.85 0.30 0.34 0.36 0.20 0.36 0.32 0.77
reliability

99.72 98.84 99.89 99.61 99.88 99.84 96.51 98.63 99.71 99.93 99.88 96.83 99.66 99.85 99.78 99.67 99.75 99.74 99.19 99.27 99.74 99.69 99.69 98.11

FH

pp

MP FX GO-A RAM-I PP A POG RAM-H MAND-L MAX-L UI to FH Ll to MP FMIA U6 to FH U7 to FH UI-PP U5-PP U7-PP Ll-MP L5-MP L7-MP U6-PTV

Figure 6 Linear measurements of the dental patterns. 1. UI-PP. 2. US-PP. 3. U7-PP. 4. Ll-MP. 5. L5-MP. 6. L7-MP. 7. U6-PTV.

buccal cusps of the lower second molar to the mandibular plane. 7. U6-PTV: the distance fram the distal crown surface of the upper first molar to the PT vertical line (Ricketts, 1960). Measurement error All lateral cephalograms were traced and their landmarks were digitized by the same investigator. In order to determine the error of measurement, lateral cephalograms of 25 patients were randomly selected. The cephalograms were traced twice. Duplicate determination was performed and the errars of measurement were established according to the following formula (Dahlberg, 1940): d2/2n Standard error (SE) = where d is the difference between the pairs and n is the number of pairs. The coefficient of reliability was also calculated (Houston, 1983). Estimation of random errors is shown in Table 1. It was considered that all measurements were within acceptable limits. Statistical analysis Each variable between the normal group and the Class 11 division l malocc1usion group was compared by t-test.

In Class 11 division l samples, the relationship between the skeletal and dental patterns was assessed by means of the coefficient of correlation. ResuIts Skeletal pattern (Table 2) In Class II division 1 malocc1usions, facial axis (FX) and nasion perpendicular to pogonion (POG) were found to be significantly smaller than the normal group (P<O.OOl). Ramus inc1ination (RAM-I) was significantly larger (P<O.OOl), but gonial angle (GO-A) did not show significant difference. For the size ,of the mandible, the ramus height (RAM-H) and the mandibular length (MAND-L) were significantly smaller (P<O.Ol and P<O.OOl, respectively). For the maxilla, the anterior-posterior position (A) did not differ significantly from that of the normal, while the length (MAX-L) was significantly smaller (P < 0.0 1). Histograms of the skeletal patterns in the Class 11division 1 malocc1usion group revealed a wide variety of skeletal types (Fig. 7). In

JI

..

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~

I,

32

K. FUSHIMA ET AL.

Table 2 Comparison of the skeletal pattens between Class 11 division 1 group and normal occIusion group.
Nonnal Measurement MP FX GO-A RMA-I PP A POG AP-diff. RAM-H MANO-L MAX-L n 35 35 35 35 35 35 35 35 35 35 35 Mean 27.8 84.9 125.0 82.8 1.8 0.0 -5.9 5.8 64.2 124.5 50.4 SO 5.54 4.05 6.51 3.79 2.75 4.00 6.73 5.45 5.89 5.33 3.72 Class 11division 1 n 50 50 50 50 50 50 50 50 50 50 50 Mean 31.2 80.8 123.9 87.2 1.5 -0.2 -13.2 12.8 60.2 117.4 48.5 SO 7.04 4.55 7.10 4.91 2.82 3.17 7.05 6.18 5.89 5.97 3.01 I-test NS

...

NS NS NS

... ...
...
..

..

...

.Significant at 5 per cent level; ..significant level; NS: no significant difference.

at 1 per cent leve!; ."significant

at 0.1 per cent

evaluating the distribution of Class 11division I samples on the basis of I standard deviation (SO) of the normal sample, it was demonstrated that the skeletal problems in the Class 11 division l malocclusion group were small (MANO-L), retruded (POG) mandible accompanied by backward rotation (FX, RAM-l), and surprisingly, a small maxilla (MAX-L). Dental pattern (Table 3) The mea n ofthe anterior occlusal plane (A-OP) in the normal group was 1'0.0 degrees with a SO of 3.58, while the posterior occlusal plane (P-OP) showed 14.9 degrees of mean with a SO of 3.85. The mean of the anterior and posterior occlusal plane difference (OP-diff.) was 5.0 degrees with a SO of 3.96. The P-OP and OP-differences in the Class 11 division I malocclusion group were found to be significantly larger than those in the normal occlusion group (P<O.OOI), but there was no significant difference found in A-OP. Histograms on the distribution of these values including the normal means and ranges showed that a large number of Class 11 division I malocclusions had a steep posterior occlusal plane (Fig. 8). In the malocclusion group, the labial inclination of the upper central incisor (VI to FH) was significantly stronger (P<O.OOI), and the labial inclinations of the lower central incisor (Ll to MP, FMIA) were also significantly stronger (P<O.OI, P<O.OOI, respectively) than those of the normal group.

The distal inclinations of the upper first and second molars (V6 to FH, V7 to FH) were significantly stronger (P < 0.00 1). The vertical height of the lower incisor (Ll-MP) was significantly larger (P < 0.0 1). Relationships between the occ/usal planes, dental and skeletal patterns in the Class II division 1 malocc/usion group (Tables 4 and 5) In evaluating the correlation coefficient between the dental and the skeletal patterns in Class 11 division I malocclusions (Table 4), it became apparent that two occlusal planes (A-OP and P-OP) were significantly related to the mandibular plane (MP), the facial axis (FX), the ramus inclination (RAM-I), and the nasion perpendicular to pogonion (POG). P-OP especially showed a strong correlation with the mandibular length (MANO-L) (-0.69) and the ramus height (RAM-H) (-0.65). This finding seemed to suggest that a steep posterior occlusal plane must be related to restrained mandibular growth accompanied by a backward rotation. P-OP also showed significant correlation with the maxillary length (MAX-L) (-0.44). Intensity of the occlusal curvature in the upper dentition (OP-diff.) did not show strong correlation with any of the skeletal patterns. In evaluating the correlation between the posterior occlusal plane (P-OP) and other dental patterns (Table 5), P-OP showed strong correlation with V6 to FH (0.81), U7 to FH

POSTERIOR

OCCLUSAL

PLANE

IN CLASS Angle

11 MALOCCLUSION

33
Gonial Angle

Mandibular
Inler".. ...50-58... )9._.50 ll.5l-)9." 2& J3.5I
11.51-:1&...

Plane

(dqru) Inter\'aal
132.00-138. I H.25--1J2.00 111.50-125.25 11I.75--1I1UO 105.00-11 1.75 H

17 11.5t
11.51-17." 11 Frcqucncy 10

'M.25--105.oo

10 Frequeney

20

Faicial
Intenal

Axis Ramus Inclination

._M
11.0&-85."
73.00---77.M

(dep'erl

.-E::
77.10-11."
69 73." 01110

_:
Fnqucney

Intenal
94.50-.-101.00

(dqrft)

87._.50 79.51-87.00 7UO"79.50

l. Frequency

JO

Palatal Plane Angle

;1 (a)
10 Freqmcy 20 .10

Poi nI A
Intenal 11ft. I '.st-..A.$O '.50-6.50 2.50-'.50 0.50-2.50 .1.50-<1.50 -3.50--1.51 .5.51-.3.5t .7.50-.5.50 10 Frequcncy
Inlt'nal I mm

Mandibular
I IJO.OO~ I.l!'.l!' 12.&.75"1.\0.00 11".~"12".7S 114.H-II'I.SO 1&1.00"11".25 10.\.75"109.00 '1".50--103,75

Length

10

,. Frequcncy

10

JO

1 ,. I
:1

Pogonion ( , Intenal 1.000--7.75 -5.75-1."

S.7S .19.15-- 12.50 -16.00--19.15 .J1.75".1'." 10 Freqcncy 10 .10 Int~nal

Ramus
(mm I

Highl

.I2.so

70.50"'76.50 ".~-70.50 58.50 50 52.50-SI.50 .a6.~S2.S0 10 Frtqenc~' 20

-L

.
.10

A-Pog
InlC'ual
22.50-2&.00

Difference
Inler"a.

Maxillar)'

Lenglh

1m...'

:~::~~::
6..11.50

0.50-"'0
(b)

1,
Frcqucncy
10 20

...50 ..2

"._~ ".0&-49.50
"9.50-51.00

I rn... I

00 50

O in the Class 11 division 1 group.

10 Fr~qurncy 1<-

10

Figure 7 Distribulions in the normal occlusion

of Ihe skelelal group.

patterns

->1: The limils of 1 standard

devialion

34

K. FVSHIMA ET AL.

Table 3 Comparison of the dental patterns between Class 11 division 1 group and normal occlusion group.
Normal Measurement A-OP P-OP OP-diff. VI to FH Ll to MP FMIA U6 to FH U7 to FH UI-PP U5-PP U7-PP Ll-MP L5-MP .L7-MP U6-PTV 11 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 Mean 10.0 14.9 5.0 115.4 94.6 57.5 95.3 99.9 30.1 26.5 21.8 44.7 38.1 32.0 19.9 SO 3.58 3.85 3.96 6.00 6.40 6.53 5.05 6.94 2.45 2.02 2.37 3.01 2.95 2.87 5.22 Class 11division I 11 50 50 50 50 50 50 50 50 50 50 50 50 50 50 50 Mean 8.5 18.3 9.8 120.9 99.6 49.3 100.9 107.5 30.2 26.7 20.5 46.9 37.6 32.2 18.3 SO 4.39 4.73 5.04 6.89 7.89 7.61 5.44 7.24 2.47 1.67 2.33 2.85 2.53 2.47 3.28 (-test NS *** *** *** ** *** *** *** NS NS ** NS NS NS

Significant at 5 per cent level; ** significant at I per cent leve!; *** significant at 0.1 per cent * NS, no significant difference. level;

Anterior Inl 1 1"""') '7.75-2'.se

14 17.75 10.25-14." '.50-1'.25 2.75-6.58 2.75

Occlusal

Plane

10 Fr~qu~ncy

211

.!O

Posterior
Inl~r..1 (dqrft) JO.2S-JUt u.se- Jt.25 22.75-U.5t 19 22.75 15.25-19." 11.58-15.25 7.75-11.58 4 7.75

Occlusal

Plane

l' Fr~qu~"cy

28

Occlusal
Intrrval I"rr~) 24 JI.58 ...se- 24." 9 ".se 1.58-9." ".08-1.5'

Plane

Dirrerence

It FrequrJlcy Figure 8 Oistributions division I group.l--* in the normal occlusion

28

.10

of the occlusal planes in the Class 11 1:The limits of I standard deviation group.

(0.75) and U6-PTV (-0.46). In other words, a case with a steep posterior occlusal plane would likely have a distal inclination of the upper molars. P-OP also showed strong correlation with a vertical height of the upper second molar (U7-PP) (- 0.65), while no significant relationship was found with the vertical height of the upper second premolar (U5-PP). A-OP showed significant correlation with the palatal plan e (0.48), which indicates that A-OP becomes fiatter as the inclination of the anterior portion of the pala tal plane becomes more elevated (Table 4). L5-MP was found to be significantly correlated with FX (-0.40), RAM-I (0.38), and POG (-0.48) (Table 4). From this finding, it may be interpreted that the vertical height of the lower second premolar is closely related to the backward rotation of the mandible. Comparative study betlVeen the steep posterior occ/usal plane group and the normal occ/usion group (Tables 6 and 7) The above findings led to the conclusion that steepness of the posterior occlusal plane is related to the skeletal patterns of the Class 11 division l malocclusion samples. Further evaluation was thus warranted to determine the nature of the posterior occlusal plane. For this evaluation, a group of 23 individuals with steep posterior occlusal plane (S-POP group; the

a,.~ l,

----......

36
Table 6 Comparison occ\usion group.

K. FUSHIMA ET AL.

of the skeletal patterns between S-POP group and normal

Normal Measurement MP FX GO-A RAM-I PP A POG AP-diff. RAM-H MANO-L MAX-L n 35 35 35 35 35 35 35 35 35 35 35 Mean 27.8 84.9 125.0 82.8 1.8 0.0 -5.9 5.8 64.2 124.5 50.4 SO 5.54 4.05 6.51 3.79 2.75 4.00 6.73 5.45 5.89 5.33 3.72

S-POP n 23 23 23 23 23 23 23 23 23 23 23 Mean 33.5 78.6 123.5 89.9 1.7 -1.2 -16.1 14.7 57.7 IB.4 46.8 SO 6.64 4.21 7.00 3.76 2.85 3.29 5.95 6.26 5.63 4.68 2.73 t-test *** *** NS *** NS NS *** *** *** *** ***

*Significant at 5 per cent level; **significant at I per cent level; ***significant at 0.1 per cent level; NS: no signficant difference. Table 7 Comparison occ\usion group. of the dental patterns between S-POP group and normal

Normal Measurement A-OP P-OP OP-diff. U I to FH Ll to MP FMIA U6 to FH U7 to FH UI-PP U5-PP U7-PP Ll-MP L5-MP L7-MP U6-PTV n 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 Mean 10.0 14.9 5.0 115.4 94.6 57.5 95.3 99.9 30.1 . 26.5 21.8 44.7 38.1 32.0 19.9 SO 3.58 3.85 3.96 6.00 6.40 6.53 5.05 6.94 2.45 2.02 2.37 3.01 2.95 2.87 5.22

S-POP n 23 23 23 23 23 23 23 23 23 23 23 23 23 23 23 Mean 9.7 22.2 12.5 120.0 99.2 47.2 104.6 112.1 30.5 26.7 19.1 47.0 37.5 32.7 16.7 SO 4.92 3.19 5.24 6.99 8.55 9.17 4.68 5.84 2.39 1.43 1.52 2.88 2.61 2.73 2.94 t-test NS *** *** * * *** *** *** NS NS *** ** NS NS **

I
I 11

. I 1:1

*Significant at 5 per cent level; **significant at 1 per cent level; ***significant at 0.1 per cent leve!; NS: no significant difference.

value of P-OP was beyond 18.75 degrees as 1 SD) was selecte9 from the Class 11 division 1 group and was compared with the normal group. Regarding skeletal patterns, as shown in Table 6, MP values became significantly different (P<O.OOI), and the mean difference of FX and RAM-I increa sed even though GO-A showed no significant difference. This finding suggests that large MP and small FX do not

depend on a large angle of Gonion, but depend on the backward rotation of the whole mandible. The mea n difference of POG increased despite the lack of significant difference in A. The mean difference of MAND-L, RAM-H, and MAX-L also increased. For dental patterns (Table 7), the mean differences of U6 to FH and U7 to FH increased, and U6-PTV became significantly different (P<O.OI). The leve! of significance of

l'I

~Lc _

"1
POSTERIOR OCCLUSAL PLANE IN CLASS II MALOCCLUSION

37

the differencein U7-PP rose (P<O.OOI)

despite

the lack of difference in U5-PP. The strong relationship between P-OP and U7-PP was already found in Table 4. It could, therefore, be stated that a steep posterior occlusal plane is caused by a short vertical height of the upper second molar and not by an excessive vertical height of the upper second premolar.

Discussion

In order to gain a better understanding of the morphological features of Class 11 division I malocclusions, 50 adult females with Class 11 division I malocclusion were examined and compared with 35 adult females with normal occlusion. It was demonstrated that the skeletal problems of Class 11 division I malocclusion involved a retruded mandible (POG, A-P diff.), rotation of the mandible in a backward direction (FX, RAM-I) and small mandible (RAM-H, MAND-L) (Fig. 7). The skeletal features of Class 11 division I were not characterized by overgrowth of the maxilla, but a restrained growth of the mandible with a backward rotation. McNamara (1981) studied 277 children with Class II malocclusion, and concluded that the maxilla was in a neutral position on average (point A to nasion perpendicular), and that mandibular skeletal retrusion (pogonion to nasion perpendicular) and excessive anterior vertical development (Iower face height) were the most common components of Class II malocclusion. The results of the present study appear to agree with that finding. 8ased on the dental patterns in the present study, approximately half of the population with Class Il division I malocclusion showed steep posterior occlusal plane and severe occlusal curvature in the upper dentition (Fig.8). The steep posterior occlusal plane showed high corre1ation with the skeletal patterns characterized in Class II division I malocclusions (P<O.OOI). The severity of the occlusal curvature, however, did not correlate significantly (Table 4). It can therefore reasonably be stated that the steepness of the posterior occlusal plane in the upper dentition constitutes one of the basic problems in skeletal Class II division I cases with mandibular retrusion accompanied by a backward rotation.

The relationship between occ/usal plane and mandibular posture In treating skeletal Class II division I malocclusions, the advancement of the mandible with a forward rotation followed by condylar growth and adaptive remodelling of the temporomandibu lar joint are desirable in order to improve the profile, the molar relationship, and the overjet. Mechanics which cause a backward rotation of the mandible or exert the condyle load against the mandibular fossae should be avoided. The mandibular position is influenced by the vertical re1ationship of the dentition in the buccal segments and the re1ationship between the occlusal plane of the upper dentition and the inclination of the sagittal condylar path is another aspect to consider (Dawson, 1989). Figure 9A shows that elongation of the premolars merely causes a backward rotation of the mandible around the hinge axis. In a case with a flat occlusal plane, as shown in Fig.98, if extrusion of the upper terminal molar leads to occlusal interference in the posterior den tition, the mandible is able to adapt to an anterior position in order to evade the interference. Such an anterior displacement of the mandible is accompanied by a forward rotation beca use the cant of the occlusal plane is flatter than that of the sagittal condylar path. It is, therefore, possible to obtain occlusal contacts in anterior dentition, and occlusal stability with the mandible in the anterior position causing the condyle to move anterior-inferiorly along the posterior slope of the articular tubercle simultaneously. However, in the case with a steep posterior occlusal plane shown in Fig. 9C, the steepness of the inclination is similar to that of the sagittal condylar path. Even if the mandible is shifted anteriorly to evade the interference in the posterior molar region, it would be difficult to obtain anterior tooth contacts, beca use a forward rotation of the mandibule does not occur. In a patient with so-called functional Class III malocclusion, the early elimination of interference in the incisal teeth is recommended, especially during the growth periodo Although the diagnosis of functional Class II malocclusion is still considered to be difficult, if anterior positioning of the mandible is desired when treating a Class II patient with a steep posterior occlusal plane, the elimination of interferences in the posterior molar region is necessary in the same

J I I

38

K. FUSHIMA ET AL.

r~='

Figure 9 Schematic explanation of the vertical dimensional influence of the posterior teeth on mandibular posture. Any extrusion of the buccal segments causes a backward rotation of the mandible. (A) The extrusion of premolars merely causes a backward rotation of the mandible around the hinge axis. (B) In a case with a flat posterior occlusal plane, the mandible is able to adapt to an anterior position to evade the interference in the posterior dentition and to obtain occlusal stability. (C) In a case with a steep posterior occlusal plane, there is no anterior tooth contact and no occlusal stability in the anterior position of the mandible. Note that the inclination of the posterior occlusal plane is close to.that of the sagittal condylar path.

I.

sense as treatment of functional Class In. For this reason, the correction of a steep posterior occIusal plane is considered to be important for skeletal Class n division l cases. This interpretation, however, is based on the assumption that the sagittal condylar path is the same in alI cases. Ricketts (1955) compared the form of eminence in maloccIusion samples, and showed that there was no difference between Class I and Class n maloccIusions. In Class In maloccIusions, shallow fossae were found. As revealed in the present study, because the skeletal patterns in Class n division 1 maloccIusions were widely variable, it would appear that the sagittal condylar path angle might have a wide range. The necessity to investiga te the relationship between skeletal patterns and the incIination of the sagittal condyle path is suggested. The occ/usa/ p/ane and mandibu/ar growth In a metallic implant study, Bj6rk (1991) and Bj6rk and Skieller (1972, 1976) showed that maxillary growth was not merely characterized

by anterior-inferior displacement, but also a forward rotation accompanied by descent of the upper molar region and a simultaneous forward mandibular rotation (Fig. lOA). In other words, the rotational growth of the maxilla causes a flattening of the occIusal plane in the upper dentition, and the mandible grows anterior-inferiorly with a forward rotation maintaining occIusal contacts with the upper dentition. The dynamics of this phenomenon is partially explained in the discussion of the relationship between the occIusal plane and the mandibular posture (Fig. 9). In a normal case with a flat posterior occIusal plane (Fig. IOB), a forward rotation in the maxillary growth contributes to the descent of the upper molar region. This leads to interference by posterior teeth, and as a result, the mandible adapts anteriorly in a forward rotation to avoid the occIusal interferences and to maintain occIusal stability. In this situation, the condyles move anterior-inferiorly along the posterior slope of articular tubercIes and adaptive growth is induced by a continuous condylar

I \~~

~- -

POSTERIOR

OCCLUSAL

PLANE

IN CLASS

11 MALOCCLUSION

39

e
Avoiding unfavourable procedures such as Class 1I elastics In treating Class 11 patients, Class 11 elastics have often been used in order to eliminate an overjet and establish a normal molar relationship. In practice, concern is focused more on the correction of the antero-posterior deviation by placing the upper incisors lingualIy and by shifting the lower molars mesialIy. The important point is that the vertical changes take place in doing so. Such a treatment modality should be scrutinized cIosely prior to implementation. Langlade (1978) stated that excessive use of Class 11 elastics on continuous arches c~uses a downward tipping ofthe upper anterior occIusal plane, a so-calIed rabbiting effect. Class 11 elastics also cause extrusion of the . lateral teeth in the lower dentition. The elevation of the lower lateral segment forces the mandible into an unfavourable backward rotation. Schudy (1963) stated that Class 11elastics cause an elevation of the mandibular molar and a backward rotation of the mandible, resulting in an open bite and an increase of the ANB angle. Table 4 shows that the vertical height of the lower second premolar (L5-MP) is significantly correlated with a backward rotation of the mandible (FX, RAM-I, POG). In skeletal Class 11 division l cases with a backward rotation of mandible, therefore, excessive use of Class 11 elastics must be avoided. It is recommended that Class 11 elastics should be used as sparingly as possible.

Figure 10 The occlusal plane and mandibular growtho (A) Implant study by Bj6rk and Skieller (1972)0 (B) A case with flat posterior occlusal planeo (C) A case with steep posterior occlusal planeo

displacement. This scenario is considered as one possible explanation for normal mandibular growth which is largely dependent on change of the occIusal planeo On the other hand, in a case with a steep posterior occIusal plane (Fig. 1OC), liule descent of the upper molar region takes place, even in the presence of forward rotational growth of the maxi1la. Consequently, mandibular growth seems to be suppressed and directed more inferiorIy. Table 6 shows the smalI size of the mandible (MAND-L, RAM-H) accompanied by backward rotation (MP, FX, RAM-I) in the S-POP group. The vertical height of the upper second molar (U7-PP) and the maxilIary length (MAX-L) in the S-POP group were significantly smalIer (P < 0.00 1) than those of the normal group (Tables 6 and 7), and a significant correlation was found between U7-PP and MAX-L (Table 4). Thus, it may be stated that most cases with a steep posterior occIusal plane do not experience sufficient forward rotational growth of the maxi1la. As a consequence, vertical growth of the upper terminal molar is suppressedo Furthermore, even if the descent of the upper molar occurs, it is difficult to obtain occIusal stability in the anterior position of the mandible, as illustrated in Fig. 9C. The effect of a deviated occIusal plane on mandibular growth is considered to be significant and it is therefore crucial to correct the steep posterior occIusal plane in order to break such a vicious cycIe during the growth periodo

ii

40

K. FUSHIMA ET AL. References on definition and cause. Proceeding of the Finnish Dental Society 87: 51-58 Bj6rk A, Skieller V 1972 Facial development and tooth eruption. An implant study at the age of puberty. American Journal of Orthodontics 62: 339-383 Bj6rk A, Skieller V 1976 Postnatal growth and development of the maxillary complex. In: McNamara J A Jr (ed.) Factors affecting the growth of the midface, Monograph 6, Craniofacial Growth Series. Center for Human Growth and Development, University of Michigan, Ann Arbor, pp. 61-99 Dahlberg A 1940 Statistical methods for medical and biological students. Interscience, New York Dawson P E 1989 Evaluation, diagnosis, and treatment of occlusal problems, 2nd OOn.The C. V. Mosby Company, SI. Louis Downs W B 1948 Variation in facial relationships: Their significance in treatment and prognosis. American Journal of Orthodontics 34: 812-840 Fushima K, Akimoto S, Takamoto K, Sato S, Suzuki Y 1989 Morphological feature and incidence of TMJ disorders in mandibular lateral displacement cases. Journal of Japan Orthodontic Society 48: 322-328 Harvold E P 1968 The role of function in etiology and treatment of malocclusion. American Journal of Orthodontics 54: 883-898 Houston W J B 1983 The analysis of errors in orthodontic measurements. American Journal of Orthodontics 83: 382-390 Jarabak J R, Fi=1 J A 1972 Technique and treatment with lightwire edgewise appliances, 2nd edn. The C. V. Mosby Company, Saint Louis Kim Y H 1974 Overbite depth indicator with particular reference to anterior open-bite. American Journal of Orthodontics 65: 586-611 Langlade M 1978 Upper anterior occlusal plane control. Journal of Clinical Orthodontics 12: 656-659 McNamara J A Jr 1975 Functional adaptation in the temporomandibular joint. Dental CIinics of North America 19: 457-471 McNamara J A Jr 1981 Components of Class 11malocclusion in children 8-10 years of age. Angle Orthodontist 51: 177-202 McNamara J A Jr 1983 A method of cephalometric analysis. In: McNamara J A Jr, Ribbens K A, Howe R P (OOs) Clinical alteration of the growing face, Monograph 14, Craniofacial Growth Series. Center for Human Growth and Development, University of Michigan, Ann Arbor, pp. 81-105 Nanda S K 1983 The developmental basis of occlusion and malocclusion. Quintessence Publishing Co, Chicago. Ricketts R M 1955 Facial and denture changes during orthodontic treatment as analyzed from the tomporomandibular joint. American Journal ofOrthodontics 41: 163-179 Ricketts R M 1960 The influence of orthodontic treatment on facial growth and development. Angle Orthodontist
30: 103-133

r==1

Conclusions l. This study revealed that the skeletal problems in Class II division l malocclusions were affected by the fact that the mandible is retruded, small, and rotated in a backward orientation. The maxilla was found to be small in size anterior-posteriorly. 2. The anterior and the posterior occlusal planes were established for this investigation. The normal mean of the former was 10.0 degrees with a SD of 3.58, and the latter was 14.9 degrees with a SD of 3.85. The normal mean of the occlusal plane difference was 5.0 degrees with a SD of 3.96. 3. It was found that a large number of Class 11 division l malocclusions had a steep posterior occlusal plane and asevere occlusal curvature in the upper dentition. 4. The steep cant of the posterior occlusal plane showed a strong correlation with a small, retruded mandible with a backward rotation as skeletal problems in Class II division l malocc1usion. 5. A steep posterior occlusal plane was found to be correlated strongly with a short vertical height of the upper second molars. 6. The increased vertical height of the lower second premolars was found to be related to the backward rotation of the mandible. It has been demonstrated that the skeletal problems of Class 11 division l malocclusions are closely related to the deviation in the vertical aspect of the occlusion. Consequently, the vertical aspect of the occlusal plane affects the mandibular function in relation to the sagittal condylar path and the guidance of the lingual concavity of the upper mCIsor. In skeletal Class 11 division l cases, therefore, it is important to control the vertical dimension of the posterior teeth by correcting the steep posterior occlusal plane. With this treatment approach, there is a possibility of establishing a functional occlusion and a pleasing profile. Address for correspondence Kenji Fushima Department of Orthodontics Kanagawa Dental College 82 Inaoka Cho Yokosuka Kanagawa Japan

Bj6rk A 1991 Facial growth rotation-reflections

Schudy F F 1963 Cant of the occlusal plane and axial inclinations of teeth. Angle Orthodontist 33: 69-82 Tweed C H 1966 Clinical orthodontics. C. V. Mosby Company, SI. Louis

--

Table 4

Correlation

between

the skeletal

and dental

patterns

in the Class 11 division

1 group.

."

Skeletal patterns Denlal patterns A-OP P-OP OP-diff. MP 0.39.. 0.65." 0.28 FX GO-A 0.11 0.30 0.18 RAM-I PP A 0.03 -0.29 -0.30 POG -0.54". -0.63". -0.12 AP-diff. 0.60". 0.56... 0.00 RAM-H -0.32 MAND-L -0.40.. MAX-L -0.08 -0.35

o ..., '" tT1

~O ~O
(') (')

-0.51... -0.65...
-0.17

0.38.. 0.50".
0.14

0.48".
0.18 -0.25

-0.65...
-0.33

-0.69".
-0.30

- 0.44.. 0.04 0.33 -0.17 -0.25 -0.34

-0.04 0.04

c::

r r

UI to FH LI to MP FMIA U6 to FH U7 to FH
UI-PP U5-PP U7-PP

-0.53." -0.50". -0.39.. 0.54... 0.43..

0.45" 0.22 -0.32

0.58... 0.33 0.36.. -0.48... -0.42"

-0.46". -0.23 0.28

-0.20 - 0.46... -0.21 0.33 0.18

0.26 0.09 -0.23

-0.44.. -0.06 -0.25 0.29 0.35

0.25 0.17 -0.13

-0.31 0.33 -0.43.. 0.31 0.25

-0.29 -0.27 0.09

-0.02 0.27 -0.22 -0.20 -0.24

0.16 0.10 0.18

0.62... 0.16 0.48." -0.56... -0.52".

-0.33 -0.11 0.19

-0.71". -0.05 -0.64". 0.53... 0.45..

0.45.. 0.17 -0.13

-0.57...
-0.57."
-0.16 0.07 0.50".

0.36" 0.34 0.39"

0.35 0.06 0.35 -0.62". -0.69".

-0.05 0.17

'" >
."

r > Z
Z r

(')

tT1

LI-MP L5-MP L7-MP U6-PVT

"Significanl

0.46". 0.32 -0.21 -0.20

-0.44" -0.40.. -0.15 0.41"

0.28 0.05 -0.54". 0.06

0.26 0.38.. 0.47... -0.37"

0.02 0.15 0.12 -0.39..

-0.18 -0.16 -0.29 0.47".

-0.46... -0.48... -0.24 0.54...

0.45.. 0.47... 0.12 -0.37..

0.49..

-0.11 0.10 0.47". 0.18

0.11 0.16 0.09 0.48."

0.00 0.13 -0.06

0.42"

> '" '"

O
(')

0.40.

:::: ;: > r
(')

at 1 per cenl level; ."significant

al 0.1 per cenl leve!.

r c::

'" O z
Table 5 Correlation between the occlusal planes and the dental patterns in the Class 11 division 1 group.
Dental patterns Occlusal planes A-OP P-OP OP-diff. "Significant UI lo FH LI to MP 0.30 -0.24 FMIA U6 to FH U7 lo FH 0.29 UI-PP 0.43.. 0.26 -0.13 U5-PP -0.15 0.02 0.15 U7-PP -0.21 -0.65". -0.42" LI-MP 0.12 0.18 0.06 L5-MP 0.21 0.05 -0.14 L7-MP 0.09 0.10 0.01 U6-PTV -0.38" -0.46." - 0.1O

-0.62...
-0.25 0.30

-0.67...
-0.36.. 0.25

0.48... 0.81...
0.35

0.75".
0.45..

-0.49...

al 1 per cent level; ...significant

al 0.1 per cenl leve!. "

--

- - --

------.-

----

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11