sition and Class II de

erjet malocclusions
nthony A. Gbnelly, DMD, PhD, MD, James C. Petras, DMD, and Joseph Boffa,
Boston, Mass.

y means of corrected tomography, the positions of the condyles in 19 click-free persons with Class
ii malocclusions characterized by a bite depth greater than 50%, no overjet, and an interincisai angle
greater than 140” were compared with the positions of the condyles in 21 control subjects.
erage condylar position in both groups was concentric and no significant differences between
ups were found. In addition, no significant correlation was noted when condylar position was
related to bite depth. (AM J ORTHOP DENTOFAC ORTHOP 1989;96:428-32.)

here are a number of presumed associa-
tions between occlusal factors and the integrity of the
temporomandibular joint. One belief is that deep-bite,
no-overjet incisor relationships, such as often noted in
Class II, Division 2 malocclusions, are a cause of pos-
terior displacement of the condyles.‘.’ For example,
Thompson,’ among others,’ argued that steep incisal
guidance can lead to abnormal movements in the tem-
poromandibular joint. He diagrammatically depicted an
incisal complex with a deep bite, no overjet, and upright
maxillas incisors as a cause for posterior condylar dis-
placement, because these incisor relationships would
create interferences that would force the mandible dis-
tally. If this argument is valid, this effect would not be
trivial, since posterior condylar displacement is pre-
sumed to be a precursor to an internal derangement.5
There is little evidence other than clinical ob-
servation’-’ to support an association between condylar
retroposition and deep-bite, no-overjet incisor condi-
tions. One study examined this relationship and found
no association when condylar position was correlated
with overbite, overjet, or a derived incisal guidance.6
However, in this report, there were only two persons
with Class II, Division 2 malocclusions, and three of
the four condyles were slightly posterior, which led the
authors to caution that a “study of larger numbers is
needed.” The inference was that deep-bite, no-overjet
relationships would be present and could conceivably
lead to posterior displacement of the mandible as pre-
viously described.’ These incisor relationships are con-
sistent with those noted in the classic Class II, Division
2 malocclusion in which the bite is deep and there is
From the Boston University School of Graduate Dentistry.
E/l/l@451
no overjet between the maxillary and mandibular central
incisors; the maxillary central incisors are in lingual
version and the lateral incisors are in labioversion7
In actuality, the Class II, Division 2 category is an
ambiguous grouping. Perusal of six texts yielded some
common but not universal characteristics of these prob-
lems. For example, Thurow’ stated that Class II, Di-
vision 2 represents Class II problems without labial
displacement of the maxillary incisors. This essentially
combined all Class II malocclusions that were not Di-
vision 1 types. Strang’ and SalzmanrQ” identified central
incisors as vertical or in lingual axial inclination. To
this Meyers” added labial or medial displacement of
the maxillary lateral incisors. TweedI and Sassouni13
both described the distinguishing features as retrusion
of the maxillary incisors and the usual presence of a
deep bite. None of the definitions included an assess-
ment of overjet. In this context, Jarabak and Fizzell14
demonstrated an example of a Class II, Division 2 mal-
occlusion with an overjet of 6 mm. Incisal interference
during closure is unlikely with an overjet of this mag-
nitude .
Since incisal interference during closure has been
cited as the mechanism of posterior condylar displace-
ment, the important conditions appear to be the pres-
ence of a deep bite, no overjet, and upright incisors as
well as the Class II molar position. For this reason, the
intent of this investigation was to evaluate condylar
position in subjects with Class II malocclusions char-
acterized by a deep bite, no overjet, and upright incisors
to determine if the condyles were positioned posteriorly.
In addition, the subjects were click free, because Ron-
quill0 and associates’5 demonstrated a tendency for con-
dylar retroposition in subjects with reducible disc dis-
locations.
Volume 96 Condvlar position
_I
Number 5
TERIALS AND METHODS
Standardized pretreatment orthodontic records of
533 patients were collected. The pertinent records for
each patient included the study models, a lateral ce-
phalogram: and corrected lateral tomograms of the left
and right temporomandibular joints in habitual occlu-
sion (maximum intercuspation). l6 The corrected to-
mograms were part of the orthodontic record of every
patient. The presence or absence of a click, determined
by stethoscopic examination, was noted on all records.
The Class II, deep-bite sample consisted of 19 sets
of records, which represented the records of all the
click-free subjects with Class II occlusal relationships,
an overbite of greater than 50%, no overjet, and an
interincisal angle of greater than 140”. Only these 19
subjects out of the 533 patient pool met the criteria for
inclusion. A 50% incisor overlap has been classified as
a deep bite. I7 There were 11 female and seven male
subjects, and the age range was from 9 years, 7 months
to 35 years, 1 month.
The control sample consisted of the records of 21
click-free patients with Class II occlusal relationships,
an overbite of less than 50%, an interincisal angle of
less than 140”, and an overjet of greater than 1 mm.
There were 16 female and five male subjects in this
group with an age range from 11 years, 1 month to 35
years.
No overjet was defined as contact between the oc-
clusal one third of the lingual aspect of a maxillary
incisor with the labial surface of the corresponding
lower incisor or a space of 1 mm or less measured with
a Eoley gauge to the nearest 0.1 mm between a max-
illary and mandibular incisor.
Overbite was measured on study casts to the nearest
0.1 mm with a Boley gauge. Initially, the height of the
right mandibular central incisor was obtained by mea-
suring the distance from the incisal edge to the free
gingival margin along the midfacial axis. Maxillary
incisor overlap was then determined by marking the
level of overlap on the midfacial plane of the mandibular
right central incisor. The distance between this line and
the in&al edge of the mandibular right central incisor
was recorded and called the overlap. The overlap, di-
vided by the total height of the right mandibular central
incisor and multiplied by 100, gave the percent over-
bite. The interincisal angle was measured on acetate
tracings of the lateral cephalograms to the nearest
degree.
The radiographic technique for the corrected to-
mograms was as follows: Initially a submental vertex
radiograph was taken at 88 kV (peak) and an exposure
and Class II deep bite, no-overjet rna~occ~~§io~~
of 0.8 seconds. For this radiograph, the patient was
positioned snugly in the ear rods with the head tilted
backward until the Frankfort horizontal was approxi-
mately parallel to the floor. The object-film distance of
14 cm gave a constant magnification on the x-ray film
of 11%. The central beam then passed through the sub-
mental region of the chin and out of the vertex of the
cranium to the film. The submental vertex film was
traced on acetate to determine the angulation of the
condyle to the frontal plane and to define the depth of
cut required to achieve a midcondylar slice.i6
The condylar angulation and depth of cut measure-
ments were transfered to the sectograph. The patient
was positioned with the head rotated toward the film.
The amount of rotation was the same as the condylar
angulation of the condyle closest to the film. At this
point, the central beam was perpendicular to the long
axis of the condyle closest to the film, which provided
an accurate, undistorted view of the respective tem-
poromandibular joint. In tomography, the film and tube
emitting the central beam are connected by a rod that
pivots around the target object. This pivot point deter-
mines the slice that will be resolved on the film. The
location of the pivot point is positioned by the depth-
of-cut measurement. With the patients’ heads rotated
properly in the head holder, lateral corrected tomograms
of the right and left joints of all subjects were taken at
88 kVp for 3 seconds, and a narrow central beam was
selected for maximum resolution of a thin slice.
The anterior, superior, and posterior joint spaces
were measured as described previously. l6 Additionally,
the anterior/posterior (A/P) joint space ratio was cal-
culated by dividing the anterior joint space by the pos-
terior joint space. An A/P ratio of 1.O indicated a con-
centric condyle. An A/P ratio of greater than 1 rep-
resented anterior condylar position, whereas an A!P
ratio of less than 1 signified a posteriorly located con-
dyle. The range for a centered condylar position was
arbitrarily selected as an A/P ratio of 0.8 to 1.2.
The joint space measurements for both groups were
tested for significance with a two-way analysis of var-
iance for two factors. One factor was the difference
between the groups;. the other was the difference be-
tween right and left sides. Also, a Pearson product
moment correlation was done to assessthe association
of bite depth and condylar position as defined by the
A/P ratio.
Brader18 demonstrated that there is good agreement
between actual and tomographically determined mea-
surements, inasmuch as discrepancies between the film
and actual measurements of dental structures were on

Gianelly, Petras, and Bo#a
ble 1. Temporomandibular joint spaces of individuals with and without Class XI deep-bite,
There were no significant differences between any groups.
Table II. Condylar A/P ratios to depict condylar
position in subjects with and without Class II
deep-bite, no-overjet malocclusions
Significance
ControI 42 1.02 0.48
Deep bite 36 0.84 0.52 NS
the order of 0.5 mm. These findings were confirmed
in a study in which temporomandibular joint spaces
calibrated on a skull were compared with tomograph-
ically derived values of the same space.”
The right and left sides were statistically compa-
rable. Therefore, no distinction was made between the
right and left joints.
The anterior, superior, and posterior joint space
measurements for both groups are shown in Table I. In
the Class II, deep-bite group, which contained 19 sub-
jects and 36 joint radiographs, the anterior joint space
was 1.58 mm. The superior joint space in this group
was 1.96 mm and the posterior space was 1.86 mm.
In the control group, with 21 subjects and 42 joint
radiographs, the anterior joint space was 1.49 mm. The
superior joint space was 1.88 mm and the posterior
joint space was 1.70 mm. There were no significant
differences between any of the joint spaces in the two
groups.
The A/P joint space ratio for the Class II, deep-
bite group was 0.84 and for the control sample it was
1.02 (Table II). Again, there were no significant dif-
ferences between the groups.
The correlation relating bite depth to condylar po-
sition wa.s weak in both groups and not significant. For
the Class IX, Division 2 group, the correlation coeffi-
cient was r = 0.08; for the control group it was
r = 0.05.
Am. J. Onhod. Dent&c. Orthop.
November 1989
DISCUSSION
Condylar position in both the Class II; deep-bite
group and the control group was essentially centered.
Therefore, click-free persons with Class II malocclu-
sions, a bite depth exceeding 50%, no overjet, and an
interincisal angle of greater than 140” do not appear to
be predisposed to condylar retroposition. Although
these incisor relationships are characteristic of Class II,
Division 2 malocclusions, we cannot make judgments
concerning the classic Class II, Division 2 syndrome
as demonstrated by some,5 because only 6 of 19 subjects
in the deep-bite group displayed the lingually inclined
central incisors and labially positioned lateral incisors.
Another three subjects had at least one central incisor
in lingual version. In these nine subjects, 14 of the 18
condyles were concentric or slightly anterior. The in-
ability to accumulate an adequate sample of subjects
with classically described Class II, Division 2 maloc-
clusions with no internal derangements after more than
500 patient records were reviewed underscores the dif-
ficulty in conducting objective studies on this group.
Our results are consistent with the observations of High,
Westminster, and Pottingerm who note
dyles of patients with Class II, Division 2 malocclusions
were located mesially at age 12 to 14 years and appeared
to be centered at age 16 to 18 years.
We also correlated bite depth and condylar position
to test the assumption that a deep bite was indispensable
if incisor interferences were to force the mandible pos-
teriorly. Our inability to uncover a useful association
between bite depth and condylar position indicates that
bite depth and condylar position are effectively inde-
pendent of each other. Bite depth apparently plays little
role in final condylar position. This observation is con-
sistent with the data of other studies that also demon-
strated that there is no increased risk of condylar retro-
position in individuals with deep bites.6”6 Specifically,
Pullinger and associates examined 44 persons who were
free of symptoms and who had bite depths ranging from
0 to 10 mm and noted no correlation between incisal
 Condvlar position
overbite and overjet and condylar position. Even when
overbite and overjet were factored together to approx-
imate incisal guidance, there was still no association.
A similar conclusion was made by Gianelly and
associateP when they related bite depth and condylar
position.
Yet, there are numerous anecdotes suggesting that
deep-bite, no-overjet incisor relationships are a cause
of posterior condylar displacement.‘.2,5 This is partic-
ularly emphasized if the deep bites are associated with
lingually inclined incisors (as in the classic Class II,
Division 2 syndrome), because the incisors will create
interferences that cause a distal path of closure. As
explained by Farrar and McCarty,’ “the entire mandible
begins to be displaced posteriorly.” One reason for the
apparent discrepancy may be that the association be-
tween deep-bite, no overjet conditions and condylar
retroposition, which makes sense on a mechanical ba-
sis, has been offered frequently enough that many
conscientious clinicians believe a causal relationship
exists 2,4,21-23
Why is the lack of association between deep-bite,
no-overjet incisor relationships and condylar retropo-
sition of interest? One reason may be that specific treat-
ment strategies have been proposed when these incisor
conditions exist. Farrar and McCarty5 suggested that
these incisor conditions are “one of the early common
causes of internal derangements, particularly in young
patients with Class II molar relationships. We have
learned that if the upper incisors are moved forward
using functional appliances, the entire mandible will
move forward with it and the patient then will have a
Class I relationship.”
This working hypothesis was not validated in the
majority of subjects in one analysis of Class II, Division
2 treatment. 24Erickson and HunteP measured changes
in the basion-articulare distance to determine whether
condylar anterior repositioning occurred in 34 patients
treated to correct Class II, Division 2 malocclusions.
During treatment, the basion-articulare measurement
increased only an average of 0.1 mm/year in female
subjects and 0.18 mm/year in male subjects. These
were not significant increases. However, in 24% of the
subjects, the basion-articulare measurement increased
more than 0.5 mm/year, which led to the speculation
that in some cases the basion-articulare increase could
reflect “unlocking” of the mandible or might only be a
‘“temporary shift. r’24In this context, Ricketts25 observed
that in certain persons with Class II, Division 2 mal-
occlusions, the mandible followed the maxillary inci-
sors as those teeth were tipped labially in the initial
phase of treatment: “As the mesiodistal relation of the
and Class II deep bite, no-overjet malocclusions
jaws was corrected, the mandible assumed a more pos-
terior rest position.”
Because Erickson and Hunterz4 made no effort to
discriminate between patients with and without internal
derangements, the possibility also exists that their pa-
tients in whom anterior repositioning occurred may
have had disc displacements that were reduced. This
could allow the mandible to assume a more forward
position, since condylar retroposition has been asso-
ciated with reducible internal derangements. I5
Our findings, along with those of Pullinger and
associate@ indicate that “unlocking” a deep bite in
persons with Class II deep-bite, no-overjet maloccln-
sions, to allow the mandible to position itself anterior-
ly, will not correct many Class II problems. It may
happen occasionally, because we noted, as did many
others,26-28a large variation in condylar position, which
indicated that condylar retropositioning may exist in
some persons with deep bites even though the central
tendency is for concentric condylar position. Yet, for
the majority of patients, a correction by the reposition-
ing mechanism should be considered the exception
rather than the rule.
This analysis suggests another reason the findings
of the present study may be relevant. Green29 has ob-
served that there are many myths concerning the de-
velopment of temporomandibular joint disorders. One
is that “people with certain types of untreated maloc-
clusions, for example Class II, Division 2, deep
bites . . . etc. are more likely to develop [temporo-
mandibular joint] disorders.“*’ Our data indicate that
routine distal positioning of the condyle, as suggested
by some,5 is not a factor.
In summary, there does not appear to be an asso-
ciation between condylar position and bite depth in
click-free patients with Class II malocclusions char-
acterized by an overbite of greater than 50% t no overjet,
and upright incisors.
CONCLUSIONS
1. The condyles of click-free persons with Class II
molar relationships, deep bites, and no overjets were
positioned concentrically in the fossae, although sub-
stantial variation in position was noted.
2. There was no correlation between bite depth and
condylar position.
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