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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- no overjet between the maxillary and mandibular central
tions between occlusal factors and the integrity of the incisors; the maxillary central incisors are in lingual
temporomandibular joint. One belief is that deep-bite, version and the lateral incisors are in labioversion7
no-overjet incisor relationships, such as often noted in In actuality, the Class II, Division 2 category is an
Class II, Division 2 malocclusions, are a cause of pos- ambiguous grouping. Perusal of six texts yielded some
terior displacement of the condyles.‘.’ For example, common but not universal characteristics of these prob-
Thompson,’ among others,’ argued that steep incisal lems. For example, Thurow’ stated that Class II, Di-
guidance can lead to abnormal movements in the tem- vision 2 represents Class II problems without labial
poromandibular joint. He diagrammatically depicted an displacement of the maxillary incisors. This essentially
incisal complex with a deep bite, no overjet, and upright combined all Class II malocclusions that were not Di-
maxillas incisors as a cause for posterior condylar dis- vision 1 types. Strang’ and SalzmanrQ” identified central
placement, because these incisor relationships would incisors as vertical or in lingual axial inclination. To
create interferences that would force the mandible dis- this Meyers” added labial or medial displacement of
tally. If this argument is valid, this effect would not be the maxillary lateral incisors. TweedI and Sassouni13
trivial, since posterior condylar displacement is pre- both described the distinguishing features as retrusion
sumed to be a precursor to an internal derangement.5 of the maxillary incisors and the usual presence of a
There is little evidence other than clinical ob- deep bite. None of the definitions included an assess-
servation’-’ to support an association between condylar ment of overjet. In this context, Jarabak and Fizzell14
retroposition and deep-bite, no-overjet incisor condi- demonstrated an example of a Class II, Division 2 mal-
tions. One study examined this relationship and found occlusion with an overjet of 6 mm. Incisal interference
no association when condylar position was correlated during closure is unlikely with an overjet of this mag-
with overbite, overjet, or a derived incisal guidance.6 nitude .
However, in this report, there were only two persons Since incisal interference during closure has been
with Class II, Division 2 malocclusions, and three of cited as the mechanism of posterior condylar displace-
the four condyles were slightly posterior, which led the ment, the important conditions appear to be the pres-
authors to caution that a “study of larger numbers is ence of a deep bite, no overjet, and upright incisors as
needed.” The inference was that deep-bite, no-overjet well as the Class II molar position. For this reason, the
relationships would be present and could conceivably intent of this investigation was to evaluate condylar
lead to posterior displacement of the mandible as pre- position in subjects with Class II malocclusions char-
viously described.’ These incisor relationships are con- acterized by a deep bite, no overjet, and upright incisors
sistent with those noted in the classic Class II, Division to determine if the condyles were positioned posteriorly.
2 malocclusion in which the bite is deep and there is In addition, the subjects were click free, because Ron-
quill0 and associates’5 demonstrated a tendency for con-
From the Boston University School of Graduate Dentistry. dylar retroposition in subjects with reducible disc dis-
E/l/l@451 locations.
Volume 96 Condvlar position and Class II deep bite, no-overjet rna~occ~~§io~~
_I
Number 5
TERIALS AND METHODS of 0.8 seconds. For this radiograph, the patient was
Standardized pretreatment orthodontic records of positioned snugly in the ear rods with the head tilted
533 patients were collected. The pertinent records for backward until the Frankfort horizontal was approxi-
each patient included the study models, a lateral ce- mately parallel to the floor. The object-film distance of
phalogram: and corrected lateral tomograms of the left 14 cm gave a constant magnification on the x-ray film
and right temporomandibular joints in habitual occlu- of 11%. The central beam then passed through the sub-
sion (maximum intercuspation). l6 The corrected to- mental region of the chin and out of the vertex of the
mograms were part of the orthodontic record of every cranium to the film. The submental vertex film was
patient. The presence or absence of a click, determined traced on acetate to determine the angulation of the
by stethoscopic examination, was noted on all records. condyle to the frontal plane and to define the depth of
The Class II, deep-bite sample consisted of 19 sets cut required to achieve a midcondylar slice.i6
of records, which represented the records of all the The condylar angulation and depth of cut measure-
click-free subjects with Class II occlusal relationships, ments were transfered to the sectograph. The patient
an overbite of greater than 50%, no overjet, and an was positioned with the head rotated toward the film.
interincisal angle of greater than 140”. Only these 19 The amount of rotation was the same as the condylar
subjects out of the 533 patient pool met the criteria for angulation of the condyle closest to the film. At this
inclusion. A 50% incisor overlap has been classified as point, the central beam was perpendicular to the long
a deep bite. I7 There were 11 female and seven male axis of the condyle closest to the film, which provided
subjects, and the age range was from 9 years, 7 months an accurate, undistorted view of the respective tem-
to 35 years, 1 month. poromandibular joint. In tomography, the film and tube
The control sample consisted of the records of 21 emitting the central beam are connected by a rod that
click-free patients with Class II occlusal relationships, pivots around the target object. This pivot point deter-
an overbite of less than 50%, an interincisal angle of mines the slice that will be resolved on the film. The
less than 140”, and an overjet of greater than 1 mm. location of the pivot point is positioned by the depth-
There were 16 female and five male subjects in this of-cut measurement. With the patients’ heads rotated
group with an age range from 11 years, 1 month to 35 properly in the head holder, lateral corrected tomograms
years. of the right and left joints of all subjects were taken at
No overjet was defined as contact between the oc- 88 kVp for 3 seconds, and a narrow central beam was
clusal one third of the lingual aspect of a maxillary selected for maximum resolution of a thin slice.
incisor with the labial surface of the corresponding The anterior, superior, and posterior joint spaces
lower incisor or a space of 1 mm or less measured with were measured as described previously. l6 Additionally,
a Eoley gauge to the nearest 0.1 mm between a max- the anterior/posterior (A/P) joint space ratio was cal-
illary and mandibular incisor. culated by dividing the anterior joint space by the pos-
Overbite was measured on study casts to the nearest terior joint space. An A/P ratio of 1.O indicated a con-
0.1 mm with a Boley gauge. Initially, the height of the centric condyle. An A/P ratio of greater than 1 rep-
right mandibular central incisor was obtained by mea- resented anterior condylar position, whereas an A!P
suring the distance from the incisal edge to the free ratio of less than 1 signified a posteriorly located con-
gingival margin along the midfacial axis. Maxillary dyle. The range for a centered condylar position was
incisor overlap was then determined by marking the arbitrarily selected as an A/P ratio of 0.8 to 1.2.
level of overlap on the midfacial plane of the mandibular The joint space measurements for both groups were
right central incisor. The distance between this line and tested for significance with a two-way analysis of var-
the in&al edge of the mandibular right central incisor iance for two factors. One factor was the difference
was recorded and called the overlap. The overlap, di- between the groups;. the other was the difference be-
vided by the total height of the right mandibular central tween right and left sides. Also, a Pearson product
incisor and multiplied by 100, gave the percent over- moment correlation was done to assessthe association
bite. The interincisal angle was measured on acetate of bite depth and condylar position as defined by the
tracings of the lateral cephalograms to the nearest A/P ratio.
degree. Brader18 demonstrated that there is good agreement
The radiographic technique for the corrected to- between actual and tomographically determined mea-
mograms was as follows: Initially a submental vertex surements, inasmuch as discrepancies between the film
radiograph was taken at 88 kV (peak) and an exposure and actual measurements of dental structures were on
Am. J. Onhod. Dent&c. Orthop.
Gianelly, Petras, and Bo#a November 1989
ble 1. Temporomandibular joint spaces of individuals with and without Class XI deep-bite,
overbite and overjet and condylar position. Even when jaws was corrected, the mandible assumed a more pos-
overbite and overjet were factored together to approx- terior rest position.”
imate incisal guidance, there was still no association. Because Erickson and Hunterz4 made no effort to
A similar conclusion was made by Gianelly and discriminate between patients with and without internal
associateP when they related bite depth and condylar derangements, the possibility also exists that their pa-
position. tients in whom anterior repositioning occurred may
Yet, there are numerous anecdotes suggesting that have had disc displacements that were reduced. This
deep-bite, no-overjet incisor relationships are a cause could allow the mandible to assume a more forward
of posterior condylar displacement.‘.2,5 This is partic- position, since condylar retroposition has been asso-
ularly emphasized if the deep bites are associated with ciated with reducible internal derangements. I5
lingually inclined incisors (as in the classic Class II, Our findings, along with those of Pullinger and
Division 2 syndrome), because the incisors will create associate@ indicate that “unlocking” a deep bite in
interferences that cause a distal path of closure. As persons with Class II deep-bite, no-overjet maloccln-
explained by Farrar and McCarty,’ “the entire mandible sions, to allow the mandible to position itself anterior-
begins to be displaced posteriorly.” One reason for the ly, will not correct many Class II problems. It may
apparent discrepancy may be that the association be- happen occasionally, because we noted, as did many
tween deep-bite, no overjet conditions and condylar others,26-28a large variation in condylar position, which
retroposition, which makes sense on a mechanical ba- indicated that condylar retropositioning may exist in
sis, has been offered frequently enough that many some persons with deep bites even though the central
conscientious clinicians believe a causal relationship tendency is for concentric condylar position. Yet, for
exists 2,4,21-23 the majority of patients, a correction by the reposition-
Why is the lack of association between deep-bite, ing mechanism should be considered the exception
no-overjet incisor relationships and condylar retropo- rather than the rule.
sition of interest? One reason may be that specific treat- This analysis suggests another reason the findings
ment strategies have been proposed when these incisor of the present study may be relevant. Green29 has ob-
conditions exist. Farrar and McCarty5 suggested that served that there are many myths concerning the de-
these incisor conditions are “one of the early common velopment of temporomandibular joint disorders. One
causes of internal derangements, particularly in young is that “people with certain types of untreated maloc-
patients with Class II molar relationships. We have clusions, for example Class II, Division 2, deep
learned that if the upper incisors are moved forward bites . . . etc. are more likely to develop [temporo-
using functional appliances, the entire mandible will mandibular joint] disorders.“*’ Our data indicate that
move forward with it and the patient then will have a routine distal positioning of the condyle, as suggested
Class I relationship.” by some,5 is not a factor.
This working hypothesis was not validated in the In summary, there does not appear to be an asso-
majority of subjects in one analysis of Class II, Division ciation between condylar position and bite depth in
2 treatment. 24Erickson and HunteP measured changes click-free patients with Class II malocclusions char-
in the basion-articulare distance to determine whether acterized by an overbite of greater than 50% t no overjet,
condylar anterior repositioning occurred in 34 patients and upright incisors.
treated to correct Class II, Division 2 malocclusions.
During treatment, the basion-articulare measurement CONCLUSIONS
increased only an average of 0.1 mm/year in female 1. The condyles of click-free persons with Class II
subjects and 0.18 mm/year in male subjects. These molar relationships, deep bites, and no overjets were
were not significant increases. However, in 24% of the positioned concentrically in the fossae, although sub-
subjects, the basion-articulare measurement increased stantial variation in position was noted.
more than 0.5 mm/year, which led to the speculation 2. There was no correlation between bite depth and
that in some cases the basion-articulare increase could condylar position.
reflect “unlocking” of the mandible or might only be a
‘“temporary shift. r’24In this context, Ricketts25 observed REFERENCES
that in certain persons with Class II, Division 2 mal- 1. Thompson JR. Abnormal function of the temporom~d~bul~
joints and related musculature. Orthodontic implications. Part
occlusions, the mandible followed the maxillary inci- II. Angle Orthod 1986;56:181-95.
sors as those teeth were tipped labially in the initial 2. Ricketts RM. Abnormal function of the temporomandibular joint
phase of treatment: “As the mesiodistal relation of the and related musculature. AM J ORTHOD I955;41:435-41.
Am. J. Orthod. Dentofac. Orthop.
2 Gianelly, Petras, and Boffa November 1989
3. Stack BC, Funt LA. Temporomandibuiar dysfunction in chil- 19. Walton MT. An evaluation of radiographic joint space and the
dren. J Periodontol 1977;41:636-43. reliability of the Beckwith analysis in determining accurate depth
4. Owen AH. Orthodontic/orthopedic treatment of cranioman- of cut for corrected tomography [Research paper as partial ful-
dibular pain dysfunction. Part 2. Posterior condylar displace- fillment of the requirements for certification in orthodontics].
ment. .I Craniomandibular Pratt 1984;2:334-49. Boston: Boston University, 1987.
5. Farrar WB , McCarty WL. A clinical outline of temporomandib- 20. High H, Westminster N, Pottinger M. Condyle position in the
ular joint diagnosis and treatment. Montgomery, Alabama: untreated orthodontic patient. Foundation Grthod Res 1978;39-
Walker Print, 1983:84-5. 42.
6. Pullinger AG, Solberg WK, Hollander L, Petersson A. Rela- 21. Berry DC, Watkinson AC. Mandibular dysfunction and incisor
tionship of mandibular condylar position to dental occlusal fac- relationship: a theoretical explanation of the clicking joint. Br
tors in an asymptomatic population. AM .I ORTHOD DENTOFAC Dent J 1978;144:74-7.
ORTHOP 1987;91:201-6. 22. Bell WE. CIinicaI management of temporomandibular joint dis-
7. Gianelly AA, Goldman HM. Biologic basis of orthodontics. orders. Chicago: Year Book Medical, 1982:271-4.
Philadelphia: Lea and Febiger, 1971:26. 23. Liebman M, Gazit F, Fuchs C, Lilos P. Mandibular dysfunction
8. Thurow RC. Edgewise orthodontics. 4th ed. St. Louis: in lo-18 year olds as related to morphologic occlusion. J 5ral
CV Mosby, 1982:113. Rehabil 1985;2:209-14.
9. Strang RHW. Textbook of orthodontia. Philadelphia: Lea and 24. Erickson LP, Hunter WS. Class II Division 2 treatment and
Febiger. 19§0:83. mandibular growth. Angle Orthod 1985;.5§:215-24.
10. Salzmann JA. Principles of orthodontics. Philadelphia: JB Lip- 25. Ricketts RM. A study of the changes in the temporomandibular
pincott, 1943:397. relations associated with the treatment of Class II malocclusions.
!I. Moyers RE. Handbook of orthodontics. 4th ed. Chicago: Year AM J ORTHOD 1952;38:918-33.
Book, 1988:188. 26. Pullinger AG, Hollander L, Solberg WK, Petersson A. A to-
12. Tweed CR. Chnical orthodontics, Vol 2. St. Louis: CV Mosby, mographic study of mandibular condylar position in an asymp-
1966:696. tomatic population. J Prosthet Dent 1985;53:704-12.
13. Sassouni V. Orthodontics in dental practice. St. Louis: 27. Blaschke D, Blaschke T. Normal TMJ bony relationships in
CV Mosby, 1971:43. centric occlusion. J Dent Res 1981;60:98-104.
14. Jarabak JR. Fizzell JA. Technique and treatment with the light 28. Dumas AL, Moaddab MB, Willis HB, Homayoun NH. A to-
wire appliance. St. Louis: CV Mosby, 1963:573-80. mographic study of the condyle fossa relationship in patients
15. Ronquillo HI, Guay J, Tallents RH, Katzberg RW, Murphy B. with TMJ dysfunction. J Craniomandibular Pratt 1984;2:315-
Tomographic analysis of mandibular condyle position as com- 24.
pared to arthrographic findings of the temporomandibular joint. 29. Green CS. Orthodontics and temporomandibular disorders. Dent
J Craniomandib Disord 1988;2:59-64. Clin North Am 1988;32:529-38.
16. Gianeliy AA, Hughes HM, Wohlgemuth P, Gildea G. Condylar
Reprint requests to:
position and extraction treatment. AM 3 ORTHOD DENTOFAC OR-
Dr. Anthony A. Gianelly
THOP 1988;93:201-5.
Boston University
17. Nilner M. Prevalance of functional disturbances and diseases of
Goldman School of Graduate Dentistry
the stomatognathic system in 15-18 year olds. Swed Dent J
Department of Orthodontics
1981;5:189-97.
100 E. Newton St.
18. Brader AC. The application of the principles of cephalometric
Boston, MA 02118-2392
laminagraphy to the studies of the frontal planes of the human
head. AM J ORTHOD 194.9;35:249-68.