European Journal of Orthodontics 18 (1996) 27-40 O 1996 European Orthodontic Society

Significance of the cant of the posterior occlusal plane in

Class II division 1 malocclusions
Kenji Fushima, Yutaka Kitamura, Hiroaki Mita, Sadao Sato, Yoshii Suzuki,
and Young H Kim*
Department of Orthodontics, Kanagawa Dental College, Yokosuka, Kanagawa, Japan, and
*Weston, Massachusetts, USA

SUMMARY In studying a group of fifty adult females with Class II division 1 malocclusion, it
was evident that the skeletal problems of this malocclusion involved small, retruded man-
dibles accompanied by backward rotation. This skeletal pattern was considered to be influ-
enced 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 assess-
ment 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

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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 II division 1 malocclusions, this study indicated that control of
the vertical dimension of the posterior teeth is extremely important.

Introduction the right and left premolars which interfered

In orthodontic treatment, craniofacial growth-
related 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 relation-
ship between occlusal deviation and jaw growth.
McNamara (1975) demonstrated that mandib-
ular 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
with the occlusion. Fushima et al. (1989) exam-
ined the vertical height of right and left posterior
teeth in cases with mandibular asymmetry by
the use of P-A cephalograms, and revealed 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 a severe
curve of Spee, the occlusal plane drawn in a
conventional manner is erroneously represen-
28 K. FUSHIMA ET AL.

ted. In reality, the cant of the occlusal plane
linked with the occlusal surfaces of posterior
teeth is steep (Fig. 1A). In a case with a flat
occlusal plane (Fig. IB), 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 a severe occlusal curvature in the
upper dentition (Fig. 1C), the posterior disclu-
sion does not occur in anterior movement of
the mandible because the difference of inclina-
tions between the posterior occlusal plane and
the sagittal condylar path is small. 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 divi-
sion 1 malocclusions (Jarabak and Fizzel, 1972;
Nanda, 1983). This characteristic occlusion
the goal of intervention must be optimum func-
tion, not just straight teeth.
Tofitthis 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 poster-
ior 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 1 malocclusion

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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
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 1 samples were

B C
Figure 1 (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.
POSTERIOR OCCLUSAL PLANE IN CLASS II MALOCCLUSION
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 pos-
sessed acceptably good occlusion without miss-
ing teeth were obtained from students of
Kanagawa Dental College.
Untreated Class II division 1 raalocclusion
samples of 50 adult females taken at 16 years
of age and IVA stage of dental age were selected
from thefilesof 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.
Occlusal 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 deter-
mined 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
A-OP
Figure 2 Angular measurements of the occlusal planes.
A-OP: anterior occlusal plane, P-OP: posterior occlusal
plane, OP-diff.: occlusal plane difference.
29
anterior occlusal plane slopes upward and for-
ward in relation to the FH plane, the angle is
read as minus.
P-OP: the anterior angle between the poster-
ior 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 palatal plane and the FH plane. A posi-
tive value is given when the plane inclines
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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
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).
30
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).
from point A to the line drawn from
nasion perpendicular to the FH plane
(McNamara, 1983).
2. 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.
3. 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 plane.
4. Mandibular length (MAND-L): the distance
from the cross point of the FH plane and
the posterior border line of the ramus to
gnathion.
5. 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 plane.
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 plane.
K. FUSHIMA ET AL.
Figures Angular measurements of the dental patterns.
1. Ul to FH. 2. LI to MP. 3. FMIA. 4. U6 to FH. 5. U7
to FH.
2. LI to MP: the angle formed by the long axis
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of the lower central incisor and the mandib-
ular 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 plane.
5. U7 to FH: the anterior-inferior angle formed
by the long axis of the upper second molar
and the FH plane.
Linear measurements (Fig. 6)
1. Ul-PP: the perpendicular distance from the
upper central incisal edge to the palatal
plane.
2. U5-PP: the perpendicular distance from the
cusp of the upper second premolar to the
palatal plane.
3. U7-PP: the perpendicular distance from the
midpoint between the mesial and distal
buccal cusps of the upper second molar to
the palatal plane.
4. Ll-MP: the perpendicular distance from the
lower central incisal edge to the mandibular
plane.
5. L5-MP: the perpendicular distance from the
cusp of the lower second premolar to the
mandibular plane.
6. L7-MP: the perpendicular distance from the
midpoint between the mesial and distal
POSTERIOR OCCLUSAL PLANE IN CLASS II MALOCCLUSION 31

Table 1 Estimation of random errors (« = 25).

Coefficient of
Measurement SE reliability (%)

A-OP 0.49 99.72

P-OP 0.54 98.84
MP 0.54 99.89
FX 0.57 99.61
GO-A 0.57 99.88
RAM-I 0.45 99.84
PP 0.50 96.51
A 0.53 98.63
POG 0.64 99.71
RAM-H 0.34 99.93
MAND-L 0.45 99.88
MAX-L 0.43 96.83
U l to FH 0.69 99.66
LI to MP 0.59 99.85
FMIA 0.67 99.78
U6 to FH 0.74 99.67
Figure 6 Linear measurements of the dental patterns. U7 to FH 0.85 99.75
1. Ul-PP. 2. U5-PP. 3. U7-PP. 4. Ll-MP. 5. L5-MP. Ul-PP 0.30 99.74
6. L7-MP. 7. U6-PTV. U5-PP 0.34 99.19

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buccal cusps of the lower second molar to
the mandibular plane.
7. U6-PTV: the distance from 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 investi-
gator. In order to determine the error of meas-
urement, lateral cephalograms of 25 patients
were randomly selected. The cephalograms were
traced twice. Duplicate determination was per-
formed and the errors of measurement were
established according to the following formula
(Dahlberg, 1940):
Standard error (SE) = V £ d2/2n
where d is the difference between the pairs and
n is the number of pairs.
The coefficient of reliability was also calcu-
lated (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 II division 1 malocclusion group was
compared by f-test.
U7-PP 0.36 99.27
Ll-MP 0.20 99.74
L5-MP 0.36 99.69
L7-MP 0.32 99.69
U6-PTV 0.77 98.11
In Class II division 1 samples, the relation-
ship between the skeletal and dental patterns
was assessed by means of the coefficient of
correlation.
Results
Skeletal pattern (Table 2)
In Class II division 1 malocclusions, facial axis
(FX) and nasion perpendicular to pogonion
(POG) were found to be significantly smaller
than the normal group (P<0.001). Raraus
inclination (RAM-I) was significantly larger
(P< 0.001), 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 signifi-
cantly smaller (i><0.01 and P< 0.001, respec-
tively). 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<0.01).
Histograms of the skeletal patterns in the
Class II division 1 malocclusion group revealed
a wide variety of skeletal types (Fig. 7). In
32 K. FUSHIMA ET AL.

Table 2 Comparison of the skeletal pattens between Class II division 1 group and
normal occlusion group.

Normal Class II division 1

Measurement n Mean SD n Mean SD r-test
MP 35 27.8 5.54 50 31.2 7.04 NS
FX 35 84.9 4.05 50 80.8 4.55
GO-A 35 125.0 6.51 50 123.9 7.10 NS
RMA-I 35 82.8 3.79 50 87.2 4.91 •**
PP 35 1.8 2.75 50 1.5 2.82 NS
A 35 0.0 4.00 50 -0.2 3.17 NS
POG 35 -5.9 6.73 50 -13.2 7.05 *»»
AP-diff. 35 5.8 5.45 50 12.8 6.18 ***
RAM-H 35 64.2 5.89 50 60.2 5.89 *•
MAND-L 35 124.5 5.33 50 117.4 5.97 ***
MAX-L 35 50.4 3.72 50 48.5 3.01 **

'Significant at 5 per cent level; "significant at 1 per cent level; '"significant at 0.1 per cent
level; NS: no significant difference.

evaluating the distribution of Class II division 1 The distal inclinations of the upper first and

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samples on the basis of 1 standard deviation
(SD) of the normal sample, it was demonstra-
ted that the skeletal problems in the Class
II division 1 malocclusion group were small
(MAND-L), retruded (POG) mandible accom-
panied by backward rotation (FX, RAM-I),
and surprisingly, a small maxilla (MAX-L).
Dental pattern (Table 3)
The mean of the anterior occlusal plane (A-OP)
in the normal group was 10.0 degrees with a
SD of 3.58, while the posterior occlusal plane
(P-OP) showed 14.9 degrees of mean with a
SD of 3.85. The mean of the anterior and
posterior occlusal plane difference (OP-diff.)
was 5.0 degrees with a SD of 3.96.
The P-OP and OP-differences in the Class II
division 1 malocclusion group were found to be
significantly larger than those in the normal
occlusion group (P< 0.001), 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 II division 1
malocclusions had a steep posterior occlusal
plane (Fig. 8). In the malocclusion group,
the labial inclination of the upper central
incisor (Ul to FH) was significantly stronger
(P< 0.001), and the labial inclinations of the
lower central incisor (LI to MP, FMIA) were
also significantly stronger (P<0.01, P<0.001,
respectively) than those of the normal group.
second molars (U6 to FH, U7 to FH) were
significantly stronger (P< 0.001). The vertical
height of the lower incisor (Ll-MP) was sig-
nificantly larger (P<0.01).
Relationships between the occlusal planes, dental
and skeletal patterns in the Class II division I
malocclusion group (Tables 4 and 5)
In evaluating the correlation coefficient between
the dental and the skeletal patterns in Class II
division 1 malocclusions (Table 4), it became
apparent that two occlusal planes (A-OP and
P-OP) were significantly related to the man-
dibular 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 (MAND-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 back-
ward 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 U6 to FH (0.81), U7 to FH
POSTERIOR OCCLUSAL PLANE IN CLASS II MALOCCLUSION 33
Mandibnlar Plane Angle
Gonial Angle
Interval <*«rat)
Interval <deir««
I3UXMM.7S
I2SJ5-IJL00
IISJ0-12U3
111.75-11150
10100-11 l.TS
WU5-1M.00

Frequency

Faicial Axis
Interval (doprt) Ramus Inclination
•Mt-MM .
m __ Interval (<
>1.0»-t5JC
TIJtt+lM
7XW-77M

M
Frequency
Frequency

Palatal Plane Angle

Interval (detract
&00-IIJOO~
3JW-&00

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-IM-2JI0
-4.00--1.00
10 30
(a) Freqency

Point A Mandibular Length

Interval I mm
Interval <m
I.W.00-I35J5
124.75-1 JO J »
119.50-124.75 Y/////////////////////////M
114.25-11» JO
in.W-H4J5
10.1.75-109.00
WJO-I0J.7S
10
Frequency

Pogonion
Ramus Highl
Interval (an)
Interval I M I
IJt-7.75
-j.7s-i.ao 70J0-76J0
• I1J4-5.75
•19J5-I2J0 SJt-MJO
•2*.»O-I9-2J 52J»-5iSO
•J2.75--24J0
M 10
Freqency Freqency

A-Pog Difference Maxillary Length

Interval I mm I Interval imml
12JO-2JJ0

10
(b) Irequency

Figure 7 Distributions of the skeletal patterns in the Class II division 1 group. |«- # -»|: The limits of 1 standard deviation
in the normal occlusion group.
34 K. FUSHIMA ET AL.

Table 3 Comparison of the dental patterns between Class II division 1 group and
normal occlusion group.

Normal Class II division 1

Measurement n Mean SD n Mean SD r-test

A-OP 35 10.0 3.58 50 8.5 4.39 NS

P-OP 35 14.9 3.85 50 18.3 4.73 ***
OP-diff. 35 5.0 3.96 50 9.8 5.04 *
Ul to FH 35 115.4 6.00 50 120.9 6.89 * *•
LI to MP 35 94.6 6.40 50 99.6 7.89 *
FMIA 35 57.5 6.53 50 49.3 7.61 ***
U6 to FH 35 95.3 5.05 50 100.9 5.44 ***
U7 to FH 35 99.9 6.94 50 107.5 7.24 **•
Ul-PP 35 30.1 2.45 50 30.2 2.47 NS
U5-PP 35 26.5 2.02 50 26.7 1.67 NS
U7-PP 35 21.8 2.37 50 20.5 2.33 *
Ll-MP 35 44.7 3.01 50 46.9 2.85 **
L5-MP 35 38.1 2.95 50 37.6 2.53 NS
L7-MP 35 32.0 2.87 50 32.2 2.47 NS
U6-PTV 35 19.9 5.22 50 18.3 3.28 NS

•Significant at 5 per cent level; **significant at 1 per cent level; ••*significant at 0.1 per cent
level; NS, no significant difference.

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(0.75) and U6-PTV (-0.46). In other words,
Anterior Occlusal Plane a case with a steep posterior occlusal plane
Interval would likely have a distal inclination of the
17.75-21.50 ma upper molars. P-OP also showed strong correla-
I4JO»-17.75
'MllliiltiiittH —r tion with a vertical height of the upper second
lt.2S-l4jM
4.5O-UJ5 i molar (U7-PP) (-0.65), while no significant
2.75-4J0 relationship was found with the vertical height
• 1.00-2.75 Y///MA
1
of the upper second premolar (U5-PP).
It 20 30
Frequency A-OP showed significant correlation with the
palatal plane (0.48), which indicates that A-OP
Posterior Occlusal Plane becomes flatter as the inclination of the anterior
Interval ( * pa ) portion of the palatal plane becomes more
30J5-M40
elevated (Table 4).
22.75-MJt L5-MP was found to be significantly corre-
I9J0-22.75
1SJ9-I*JM
lated with FX (-0.40), RAM-I (0.38), and
POG (-0.48) (Table 4). From this finding, it
7.7S-I1J0
4.00-7.7S m may be interpreted that the vertical height of
1
the lower second premolar is closely related to
Frequency the backward rotation of the mandible.
Comparative study between the steep posterior
Occlusal Plane Difference occlusal plane group and the normal occlusion
Interval <*»m> group (Tables 6 and 7)
The above findings led to the conclusion that
1 steepness of the posterior occlusal plane is
•4.00-1.50
Z£ related to the skeletal patterns of the Class II
division 1 malocclusion samples. Further evalu-
Frequency ation was thus warranted to determine the
Figure 8 Distributions of the occlusal planes in the Class II
nature of the posterior occlusal plane. For this
division 1 group. |«- * -»|: The limits of 1 standard deviation evaluation, a group of 23 individuals with steep
in the normal occlusion group. posterior occlusal plane (S-POP group; the
 POS1
Table 4 Correlation between the skeletal and dental1 patterns inthe Class II division 1 group.
M
Skeletal patterns
2
Dental patterns MP FX GO-A RAM-I PP A POG AP-diff. RAM-H MAND-L MAX-L o
o
A-OP 0.39" -0.51"* 0.11 0.38" 0.48*** 0.03 -0.54*** 0.60*** -0.32 -0.40** -0.08 o
P-OP 0.65*** -0.65*** 0.30 0.50**-* 0.18 -0.29 -0.63*" 0.56*** -0.65"* -0.69"' -0.44** r

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OP-diff. 0.28 -0.17 0.18 0.14 -0.25 -0.30 -0.12 0.00 -0.33 -0.30 -0.35 Ul
G
•>
Ul to FH -0.53*** 0.58*** -0.20 -0.44** -0.31 -0.02 0.62*** -0.71"* 0.36** 0.35 0.04
LI to MP -0.50*** 0.33 -0.46*** -0.06 0.33 0.27 0.16 -0.05 0.34 0.06 0.33
FMIA -0.39** 0.36** -0.21 -0.25 -0.43" -0.22 0.48*** -0.64*** 0.39" 0.35 -0.17
U6 to FH 0.54*** -0.48*** 0.33 0.29 0.31 -0.20 -0.56*** 0.53*** -0.57*** -0.62*** -0.25 z
U7 to FH 0.43** -0.42** 0.18 0.35 0.25 -0.24 -0.52*** 0.45** -0.57*** -0.69*** -0.34
ra
Ul-PP 0.45" -0.46"* 0.26 0.25 -0.29 0.16 -0.33 0.45** -0.16 -0.05 -0.04 o
U5-PP 0.22 -0.23 0.09 0.17 -0.27 0.10 -0.11 0.17 0.07 0.17 0.04 r
U7-PP -0.32 0.28 -0.23 -0.13 0.09 0.18 0.19 -0.13 0.50*" 0.49*** 0.42" Ul
Ul
Ll-MP 0.46*** -0.44** 0.28 0.26 0.02 -0.18 -0.46*" 0.45** -0.11 0.11 0.00
L5-MP 0.32 -0.40" 0.05 0.38** 0.15 -0.16 -0.48*** 0.47*" 0.10 0.16 0.13
L7-MP -0.21 -0.15 -0.54*** 0.47**' 0.12 -0.29 -0.24 0.12 0.47*** 0.09 -0.06 2
U6-PVT -0.20 0.41" 0.06 -0.37" -0.39** 0.47"* 0.54*** -0.37** 0.18 0.48"* 0.40"
o
O
** Significant at: 1 per cent level; ***significant at 0.1 per cent level. O

E2
O

Table 5 Correlation between the occlusal planes and the dental patterns in the Class II division 1 group.

Dental patterns
Occlusal planes Ul to FH LI to MP FMIA U6 to FH U7 to FH Ul-PP U5-PP U7-PP Ll-MP L5-MP L7-MP U6-PTV

A-OP -0.62*** 0.30 -0.67*** 0.48*** 0.29 0.43** -0.15 -0.21 0.12 0.21 0.09 -0.38"
P-OP -0.25 -0.24 -0.36** 0.81*" 0.75"* 0.26 0.02 -0.65*" 0.18 0.05 0.10 -0.46*"
OP-diff. 0.30 -0.49*" 0.25 0.35 0.45** -0.13 0.15 -0.42** 0.06 -0.14 0.01 -0.10

'Significant at 1 per cent level; "'significant at 0.1 per cent level.

36 K. FUSHIMA ET AL.

Table 6 Comparison of the skeletal patterns between S-POP group and normal
occlusion group.

Normal S-POP

Measurement n Mean SD n Mean SD -test

MP 35 27.8 5.54 23 33.5 6.64 ***

FX 35 84.9 4.05 23 78.6 4.21 >••
GO-A 35 125.0 6.51 23 123.5 7.00 ]MS
RAM-I 35 82.8 3.79 23 89.9 3.76
PP 35 1.8 2.75 23 1.7 2.85 1MS
A 35 0.0 4.00 23 -1.2 3.29 1MS
POG 35 -5.9 6.73 23 -16.1 5.95 ***
AP-diff. 35 5.8 5.45 23 14.7 6.26 ***
RAM-H 35 64.2 5.89 23 57.7 5.63 *•*
N**
MAND-L 35 124.5 5.33 23 113.4 4.68
MAX-L 35 50.4 3.72 23 46.8 2.73 »**

•Significant at 5 per cent level; "significant at 1 per cent level; ***significant at 0.1 per cent
level; NS: no signficant difference.

Table 7 Comparison of the dental patterns between S-POP group and normal
occlusion group.

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Normal S-POP

Measurement n Mean SD n Mean SD t -test

A-OP 35 10.0 3.58 23 9.7 4.92 ]MS

P-OP 35 14.9 3.85 23 22.2 3.19 *•*
OP-diff. 35 5.0 3.96 23 12.5 5.24 '***
U l to FH 35 115.4 6.00 23 120.0 6.99 '
LI to MP 35 94.6 6.40 23 99.2 8.55
FMIA 35 57.5 6.53 23 47.2 9.17 »**
U6 to FH 35 95.3 5.05 23 104.6 4.68 *••
U7 to FH 35 99.9 6.94 23 112.1 5.84 '>*•
Ul-PP 35 30.1 2.45 23 30.5 2.39 ]MS
U5-PP 35 26.5 2.02 23 26.7 1.43 ]MS
U7-PP 35 21.8 2.37 23 19.1 1.52 •••

Ll-MP 35 44.7 3.01 23 47.0 2.88 t*

L5-MP 35 38.1 2.95 23 37.5 2.61 1MS
L7-MP 35 32.0 2.87 23 32.7 2.73 ]MS
U6-PTV 35 19.9 5.22 23 16.7 2.94 ¥*

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

value of P-OP was beyond 18.75 degrees as 1
SD) was selected from the Class II division 1
group and was compared with the normal
group.
Regarding skeletal patterns, as shown in
Table 6, MP values became significantly differ-
ent (P<0.001), and the mean difference of FX
and RAM-I increased 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 man-
dible. The mean 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<0.01). The level of significance of
POSTERIOR OCCLUSAL PLANE IN CLASS II MALOCCLUSION
the difference in U7-PP rose (P< 0.001) 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 II division 1
malocclusions, 50 adult females with Class II
division 1 malocclusion were examined and
compared with 35 adult females with normal
occlusion. It was demonstrated that the skeletal
problems of Class II division 1 malocclusion
involved a retruded mandible (POG, A-P diff.),
rotation of the mandible in a backward direc-
tion (FX, RAM-I) and small mandible
(RAM-H, MAND-L) (Fig. 7). The skeletal
features of Class II division 1 were not charac-
terized by overgrowth of the maxilla, but a
restrained growth of the mandible with a back-
ward rotation. McNamara (1981) studied 277
children with Class II malocclusion, and con-
cluded that the maxilla was in a neutral position
on average (point A to nasion perpendicular),
and that mandibular skeletal retrusion (po-
gonion to nasion perpendicular) and excessive
anterior vertical development (lower face
height) were the most common components of
Class II malocclusion. The results of the present
study appear to agree with that finding.
Based on the dental patterns in the present
study, approximately half of the population
with Class II division 1 malocclusion showed
steep posterior occlusal plane and severe occlu-
sal curvature in the upper dentition (Fig. 8).
The steep posterior occlusal plane showed high
correlation with the skeletal patterns character-
ized in Class II division 1 malocclusions
{P<0.001). The severity of the occlusal curva-
ture, 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 1 cases
with mandibular retrusion accompanied by a
backward rotation.
37
The relationship between occlusal plane and
mandibular posture
In treating skeletal Class II division 1 malocclu-
sions, the advancement of the mandible with a
forward rotation followed by condylar growth
and adaptive remodelling of the temporomandi-
bular 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 relationship of the dentition in the
buccal segments and the relationship 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 pre-
molars merely causes a backward rotation of
the mandible around the hinge axis. In a case
with a flat occlusal plane, as shown in Fig. 9B,
if extrusion of the upper terminal molar leads
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to occlusal interference in the posterior denti-
tion, 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 because the
cant of the occlusal plane is flatter than that of
the sagittal condylar path. It is, therefore, pos-
sible 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 man-
dible is shifted anteriorly to evade the interference
in the posterior molar region, it would be diffi-
cult to obtain anterior tooth contacts, because
a forward rotation of the mandibule does not
occur.
In a patient with so-called functional Class III
malocclusion, the early elimination of interfer-
ence in the incisal teeth is recommended, especi-
ally during the growth period. Although the
diagnosis of functional Class II malocclusion is
still considered to be difficult, if anterior posi-
tioning 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
38 K. FUSH1MA ET AL.

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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.

sense as treatment of functional Class III. For
this reason, the correction of a steep posterior
occlusal plane is considered to be important for
skeletal Class II division 1 cases.
This interpretation, however, is based on the
assumption that the sagittal condylar path is
the same in all cases. Ricketts (1955) compared
the form of eminence in malocclusion samples,
and showed that there was no difference
between Class I and Class II malocclusions. In
Class III malocclusions, shallow fossae were
found. As revealed in the present study, because
the skeletal patterns in Class II division 1 maloc-
clusions were widely variable, it would appear
that the sagittal condylar path angle might have
a wide range. The necessity to investigate
the relationship between skeletal patterns and
the inclination of the sagittal condyle path is
suggested.
The occlusal plane and mandibular growth
In a metallic implant study, Bjork (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. 10A). In
other words, the rotational growth of the max-
illa causes a flattening of the occlusal plane in
the upper dentition, and the mandible grows
anterior-inferiorly with a forward rotation
maintaining occlusal contacts with the upper
dentition. The dynamics of this phenomenon is
partially explained in the discussion of the rela-
tionship between the occlusal plane and the
mandibular posture (Fig. 9).
In a normal case with a flat posterior occlusal
plane (Fig. 10B), a forward rotation in the
maxillary growth contributes to the descent of
the upper molar region. This leads to interfer-
ence by posterior teeth, and as a result, the
mandible adapts anteriorly in a forward rota-
tion to avoid the occlusal interferences and to
maintain occlusal stability. In this situation, the
condyles move anterior-inferiorly along the pos-
terior slope of articular tubercles and adaptive
growth is induced by a continuous condylar
POSTERIOR OCCLUSAL PLANE IN CLASS II MALOCCLUSION
Figure 10 The occhisal plane and mandibular growth. (A) Implant study by Bjork and Skieller (1972). (B) A case with
flat posterior occlusal plane. (C) A case with steep posterior occlusal plane.
displacement. This scenario is considered as one
possible explanation for normal mandibular
growth which is largely dependent on change
of the occlusal plane. On the other hand, in a
case with a steep posterior occlusal plane
(Fig. IOC), little descent of the upper molar
region takes place, even in the presence of
forward rotational growth of the maxilla.
Consequently, mandibular growth seems to be
suppressed and directed more inferiorly. Table
6 shows the small size of the mandible
(MAND-L, RAM-H) accompanied by back-
ward rotation (MP, FX, RAM-I) in the
S-POP group.
The vertical height of the upper second molar
(U7-PP) and the maxillary length (MAX-L) in
the S-POP group were significantly smaller
(P< 0.001) 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 occlusal plane do
not experience sufficient forward rotational
growth of the maxilla. As a consequence, ver-
tical growth of the upper terminal molar is
suppressed. Furthermore, even if the descent of
the upper molar occurs, it is difficult to obtain
occlusal stability in the anterior position of the
mandible, as illustrated in Fig. 9C.
The effect of a deviated occlusal plane on
mandibular growth is considered to be signifi-
cant and it is therefore crucial to correct the
steep posterior occlusal plane in order to break
such a vicious cycle during the growth period.
39
Avoiding unfavourable procedures such as
Class II elastics
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In treating Class II patients, Class II elastics
have often been used in order to eliminate an
overjet and establish a normal molar relation-
ship. In practice, concern is focused more on
the correction of the antero-posterior deviation
by placing the upper incisors lingually and by
shifting the lower molars mesially. The import-
ant point is that the vertical changes take place
in doing so. Such a treatment modality should
be scrutinized closely prior to implementation.
Langlade (1978) stated that excessive use of
Class II elastics on continuous arches causes a
downward tipping of the upper anterior occlusal
plane, a so-called rabbiting effect.
Class II elastics also cause extrusion of the
lateral teeth in the lower dentition. The eleva-
tion of the lower lateral segment forces the
mandible into an unfavourable backward rota-
tion. Schudy (1963) stated that Class II elastics
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 signific-
antly correlated with a backward rotation of
the mandible (FX, RAM-I, POG). In skeletal
Class II division 1 cases with a backward rota-
tion of mandible, therefore, excessive use of
Class II elastics must be avoided.
It is recommended that Class II elastics
should be used as sparingly as possible.
40
Conclusions
1. This study revealed that the skeletal prob-
lems in Class II division 1 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 II
division 1 malocclusions had a steep poster-
ior occlusal plane and a severe occlusal cur-
vature 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 1
malocclusion.
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 II division 1 malocclusions
are closely related to the deviation in the vertical
aspect of the occlusion. Consequently, the ver-
tical 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 incisor. In skeletal
Class II division 1 cases, therefore, it is impor-
tant 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
K. FUSHIMA ET AL.
References
Bjork A 1991 Facial growth rotation—reflections on defini-
tion 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
BjOrk 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 biolo-
gical students. Interscience, New York
Dawson P E 1989 Evaluation, diagnosis, and treatment of
occlusal problems, 2nd edn. The C. V. Mosby Company,
St. 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
Downloaded from by guest on February 12, 2016
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, Fizzel 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 temporo-
mandibular joint Dental Clinics of North America 19:
457-471
McNamara J A Jr 1981 Components of Class II malocclusion
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 (eds)
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 ortho-
dontic treatment as analyzed from the tomporomandibular
joint. American Journal of Orthodontics 41: 163-179
Ricketts R M 1960 The influence of orthodontic treatment
on facial growth and development Angle Orthodontist
30: 103-133
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, St. Louis