ORIGINAL RESEARCH

Evaluation of Mandibular Projection in Class II Division 2

Subjects Following Orthodontic Treatment Using Clear Aligners
Parnian Mirzasoleiman1, Tarek El-Bialy2, William A Wiltshire3, Patricia B Santos4, Fabio Henrique de Sa Leitao Pinheiro5
Received on: 25 February 2024; Accepted on: 27 March 2024; Published on: 14 June 2024

A b s t r ac t
Aim: The purpose of this study was to evaluate the mandibular growth and/or projection following maxillary incisor proclination, overbite
correction, and maxillary dentoalveolar expansion without the use of any class II mechanics, in growing class II division 2 patients treated with
clear aligners.
Materials and methods: Before and after treatment cone-beam computed tomographic (CBCT) generated lateral and posteroanterior
cephalograms of thirty-two patients with skeletal class II division 2, 16 in the treatment group and 16 in the untreated group, were reviewed
to evaluate treatment-related changes. Upper incisors were proclined and protruded, as well as upper arch expansion and overbite correction
were performed as part of their regular treatment. Cephalometric analysis was performed to evaluate skeletal and dental changes. Unpaired
statistical t-tests were performed to determine if significant skeletal class II correction was achieved in the treatment group.
Results: In the treatment group, after treatment, the upper incisors became more proclined and protruded, and the inter-molar width increased
while the overbite was reduced compared to the control group. An increase in skeletal mandibular growth and forward projection was also
observed, thus contributing to an improvement of the sagittal skeletal relationship as evidenced by ANB and Wits values compared to the
control group.
Conclusion: A combination of upper incisor proclination, correction of deep overbite, and maxillary dentoalveolar expansion using clear aligners
appears to contribute to an improvement of the skeletal class II relationship in growing patients with class II division 2.
Clinical significance: This study shows that unlocking the mandible by correcting a deep overbite, proclining upper incisors, and expanding
the upper arch in growing class II division 2 patients can improve skeletal class II using clear aligners.
Keywords: Class II division 2, Clear aligners, Incisor proclination, Mandibular advancement, Maxillary expansion.
The Journal of Contemporary Dental Practice (2024): 10.5005/jp-journals-10024-3664

Introduction 1,3,5
Department of Preventive Dental Science, Division of Orthodontics,
Class II malocclusion prevalence ranges from 16 to 22.5%.1 It has Dr. Gerald Niznick College of Dentistry, Rady Faculty of Health Sciences,
been reported to be most common in caucasians and is present in University of Manitoba Winnipeg, Canada
one-third of the United States population.2 However, class II division 2
Faculty of Dentistry, Department of Dentistry & Dental Hygiene,
2 accounts for 20% of all class II malocclusions. Characteristics of University of Alberta, Alberta, Canada and Adjunct professor at the
class II malocclusion are not self-corrected and either maintained Faculty of Dentistry, Department of Preventive Dental Science, Division
or become more prominent with age. 3 of Orthodontics, University of Manitoba, Winnipeg, Canada
4
Class II division 2 malocclusion is characterized by the maxillary Department of Pediatric Dentistry and Orthodontics, Federal
incisors retroclination and increased overbite. This increased overbite University of Rio Grande do Norte, Natal, Brazil Winnipeg, Canada
can cause trauma to the palatal soft tissue and attrition of the lower Corresponding Author: Tarek El-Bialy, Faculty of Dentistry, Department
incisors, in addition to it affecting facial appearance.4–7 Most patients of Dentistry & Dental Hygiene, University of Alberta, Alberta, Canada
with this malocclusion usually present with orthognathic maxillae, a and Adjunct professor at the Faculty of Dentistry, Department of
Preventive Dental Science, Division of Orthodontics, University of
relatively retrognathic/underdeveloped mandible, and a retroclined
Manitoba, Winnipeg, Canada, Phone: +7804922751, e-mail: telbialy@
symphysis.8–10 The chin has been reported to be relatively prominent ualberta.ca
or overdeveloped.11 The mandibular growth restriction has been
How to cite this article: Mirzasoleiman P, El-Bialy T, Wiltshire WA,
attributed to the severely reclined maxillary central incisors, thus et al. Evaluation of Mandibular Projection in Class II Division 2 Subjects
leading to the assumption that elimination of such interference Following Orthodontic Treatment Using Clear Aligners. J Contemp
could help with the correction of class II due to unconstrained Dent Pract 2024;25(4):295–302.
anterior repositioning of the mandible.12–14 Source of support: Nil
Current treatment approaches for class II division 2 malocclusions Conflict of interest: Dr Tarek El-Bialy is associated as the Section
include headgear, functional appliances, or extractions using Editor of this journal and this manuscript was subjected to this
traditional fixed appliances.15–17 However, with continuous facial journal’s standard review procedures, with this peer review handled
growth, extraction or headgear treatment tends to move upper independently of this editorial board member and his research group.
incisors further backward, while the mandible and whole face are
growing forward, giving the dished-in faces or premature aging look.18
The demand for esthetic orthodontic treatments has decades.19,20 This led to a greater interest in clear aligner therapy.
been increasing among adolescents and adults in recent Using this treatment modality, the clinician can set up the case for

© The Author(s). 2024 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain
Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
 Mandibular Projection Using Clear Aligners

simultaneous performance of upper incisor proclination, upper patients compliance as retrieved from the patient charts, and (8)
dental arch expansion, and overbite reduction. No class II elastics or other class II mechanics were used. All patients
This study aimed to evaluate the magnitude of sagittal in the treatment group were treated by upper arch dentoalveolar
mandibular forward growth and/or projection in growing class II expansion to adjust the transverse relationship of the dental arches
division 2 patients after a combination of upper incisor proclination, when simulating a class I molar relationship.
overbite correction, and upper dentoalveolar expansion using The control group consisted of patients matching the treatment
InvisalignTM clear aligners (SJ, CA, USA). The null hypothesis was group for age (13.25 ± 2.11 for treatment and 12.0 ± 1.84-year
that no significant differences in mandibular sagittal parameters old), gender, malocclusion, growth direction and severity of the
would be observed in association with the aforementioned dental class II malocclusion. These control patients had a CBCT imaging
alterations when in comparison to an untreated control. taken at similar time points as for those in the treatment group,
however they did not receive treatment because of personal or
M at e r ia l s and Methods financial circumstances, and they returned 1.5–2 years to start their
treatment at which time a new CBCT was taken before treatment.
This retrospective study has been approved by the Health
Table 1 showing the demographic data of both groups including
Research Ethics Board of the University, Manitoba of (protocol
their ages and gender.
number HS23737; H2020:133). The sample size was calculated
The records were retrieved anonymously from the author (TE)
based on a power of 80%, a confidence interval of 95%, a mean
private practice without any identification of the patient other than
difference of mandibular forward projection to be detected of
age and gender.
5.6 mm, and a standard deviation (SD) of 2.57 mm. These values
According to records from the private practice office, during
are the average derived from five previous publications with similar
the CBCT scanning, all patients were positioned in a natural head
methodology.21–25 For a 5% level of significance, a sample size of
position with their back perpendicular to the floor and they bit
11 patients was estimated for either treatment or control group.
in maximum intercuspation and were instructed to not swallow.
The study sample consisted of patients with Class II malocclusion
Before (T1) and after treatment (T2) CBCT scans were imported into
who had been consecutively examined by a single orthodontist
Dolphin software (Dolphin Digital Imaging System, Chatsworth,
(T.E.). When all inclusion criteria were met, these patients were
CA, USA). Then in Dolphin software, lateral and anteroposterior
submitted to the same Invisalign™ (Align Technology, San Jose,
cephalometric radiographs were constructed. These cephalometric
CA, USA) protocol. The inclusion criteria were as follows: (1)
radiographs were digitized in Dolphin software by one investigator
Growing patients, (2) Skeletal class II as evidenced by by (ANB ≥4°),
(P. M). Table 2 presents the skeletal and dental variables used in the
(3) Angle class II division 2 malocclusion with retroclined upper
cephalometric analysis. Fifteen randomly selected radiographs
incisors, and increased overbite), (4) Treatment plan included
dual arch orthodontic treatment (upper incisors proclination, and Table 1: Demographic data
overbite correction) exclusively using Invisalign™, (5) Available
Gender Age
before (T1) and after treatment (T2) acceptable quality of lateral
Group n Male (n/%) Female (n/%) mean (SD) Age range
and posteroanterior cephalograms generated from cone-beam
computed tomography (CBCT), (6) Treatment was done using Treatment 16 6/37.5 10/62.5 13.25 (2.11) 8–16
aligners that were fabricated from SmartTrack® material, (7) Good Control 16 6/37.5 10/62.5 12.0 (1.84) 8–15

Table 2: Description of cephalometric measurements (Jacobson 2006)

Measurement Description
Maxillary skeletal
SNA° The inferior posterior angle formed by the intersection of lines S-N and N-A.
Mandibular skeletal
SNB° The inferior posterior angle formed by the intersection of lines S-N and N-B.
Co-Gn, mm The linear distance between condylion and gnathion.
Co-Pg, mm The linear distance between condylion and pogonion.
Ar-Go, mm The linear distance between articulare and gonion.
Inter-maxillary
ANB° The difference between the SNA and SNB angles.
Wits, mm Perpendicular lines to the functional occlusal plane are drawn from A-point and B-point. The linear distance between
the two points of intersection along the occlusal plane.
Vertical skeletal
FMA° The anterior-inferior angle formed by the Frankfort Horizontal plane and the Mandibular line (Gonion-Menton).

MPA, (S, N, Go, Me) The anterior-inferior angle formed by the S-N line and the Go-Me line.
Maxillary dentoalveolar
U1-NA, mm The linear distance between the NA line and the U1 tip.
U1-NA° The angle formed by the long axis of the maxillary central incisor and the NA line.
U1-SN° The posterior-inferior angle formed by the long axis of the maxillary central incisor and the S-N line.
(Contd...)

296 The Journal of Contemporary Dental Practice, Volume 25 Issue 4 (April 2024)
 Mandibular Projection Using Clear Aligners

Table 2: (Contd...)
Measurement Description
Interdental
OB, mm The vertical distance between the incisal edges of the upper and lower central incisors measured perpendicular to
the occlusal plane.
IMW (Intermolar In the postero-anterior cephalometric radiograph, two perpendiculars on the transverse occlusal plane and tangents
width) mm to the most buccal surfaces of upper first molars bilaterally.

from both groups were re-measured two weeks after the first The sample size used in this study surpassed that recommended
assessment by the same investigator and then remeasured by by our sample size calculation. It also must be emphasized that this
another investigator. The intra-and inter-examiner reliability of is a unique sample whose changes in the A-P were documented
the measurements was assessed using an interclass correlation without the use of any class II mechanics. Therefore, the relatively
coefficient (ICC) statistical test. The Shapiro–Wilk statistical test wide age range is a reflection of the difficulty of finding well-
indicated normal distribution, allowing for the use of a parametric documented patients for this type of investigation.
test and descriptive statistics parameters such as mean and SD. A statistically significant A-P skeletal change occurred
An unpaired t-test (p < 0.05) was used to compare the linear and spontaneously following the dental changes despite that some
angular measurement differences (T2–T1) between the two groups patients were not in the growth spurt and the majority were not
to determine if significant class II correction had been achieved. typically hypo divergent. This indirectly strengthens the possibility
that mandibular growth and projection can be stimulated by
R e s u lts performing the aforementioned movements before any active
A-P correction.
Thirty-two patients (16 in each group) were included in this
The main reason to use chronological age compared to the
study. The average age in the treatment and control groups was
skeletal age was the smaller field of view of the available CBCTs when
13.25 ± 2.11 and 12 ± 1.84 years, respectively (Table 1). The first
compared to the regular lateral cephalograms. To compensate for
phase of treatment encompassing incisor proclination, maxillary
this, our control group was composed of subjects who were living
dentoalveolar expansion, and deep overbite correction had a mean
in the same geographical area as the treatment subjects, with an
duration of 11.5 months.
equal number in both groups. The same gender distribution and
The ICC test showed excellent inter-examiner reliability
the fact that these patients were examined consecutively and
(0.87) and intra-examiner reliability (0.95), indicating a very good
treated by the same protocol/clinician, thereby eliminating possible
agreement.
selection bias, helped to minimize differences between groups. Even
The intermolar width increased (2.64 mm, p < 0.0001), the upper
though a prospective randomized clinical trial with similar gender
incisors proclined (U1-SN: 12.05°, p < 0.0001; U1-NA: 11.3, p < 0.0001)
distribution and CVMS would be helpful to confirm the current
and protruded (U1-NA: 3.7 mm, p < 0.0001), and the overbite was
results, ethics issues related to the use of matched untreated patients
reduced (–2.81 mm, p < 0.0001) compared to the control group
to be used as a control group would render it unfeasible.
(Table 3).
In our study, both groups had skeletal class II mal-relationship
There was no difference in the skeletal maxillary growth (SNA)
at T1 and angle class II division 2 malocclusion according to ANB
between the two groups (p = 0.09). However, there was an increase
angle, Wits appraisal, molar/canine classification, retroclination of
in skeletal mandibular forward growth/ projection as evidenced by
the maxillary incisors, and increased overbite. The class II skeletal
the increase in SNB (1.5°, p < 0.0001), ramus height (Ar-Go) (0.42 mm,
mal-relationship in both groups was mainly due to retrognathic
p = 0.01), and mandibular length (Go-Pog) (1.2 mm, p < 0.0001);
mandibles, while the maxillae were well-positioned. This is in
(Co-Pog) (1.1 mm, p = 0.04) in the treatment group. These changes
agreement with Baccetti et al., Basciftci, Karlsen and Krogstad,
resulted in an improvement toward Class I as shown by ANB changes
Pancherz et al., and Renfroe who suggests that the position of the
of (–1.9°, p < 0.0001), and Wits (–2.9 mm, p < 0.0001). Mandibular
maxilla is in normal position in the majority of subjects with angle
vertical growth direction (MPA, FMA) did not change significantly
class II division 2 malocclusion, while the mandible has been reported
in either group (p = 0.34 and 0.18) (Table 3). The skeletal and
to be retrognathic.24–28 From ages 3 to 18, the maxilla normally shows
dentoalveolar treatment-related changes have been summarized
forward growth and displacement however it usually assumes a fairly
in Figures 1 and 2. Sample Ricketts’ superimposition for each group
stable position relative to the cranial base, while the mandible shows
is also shown in Figures 3 and 4. The inference of this study is that
a tendency to grow more than the maxilla for a longer period and
correction of deep overbite in growing class II division 2 skeletal
presents to become more prognathic than the maxilla.29
patients by upper incisors proclination and maxillary arch expansion
Isik et al., showed that the SNB angle in class II division 2
using Invisalign clear aligners can unlock mandibular growth and
subjects was similar to the SNB values of the subjects in our study
this leads to forward growth/position of the mandible.
in the treatment and in the control groups. Both groups showed
moderately increased ANB angle values at baseline, which is in
Discussion agreement with Isiks study that suggested that the ANB angle
This study evaluated the possible change of mandibular growth and in class II division 2 malocclusion is more than in class I cases,
projection in growing patients with class II division 2 malocclusion however, it is less severe than in class II division 1. 30 This could
after maxillary incisor proclination and protrusion, overbite be because class II division 2 subjects have retroclined maxillary
correction, and maxillary expansion using InvisalignTM clear aligners. incisors which possibly hinder forward mandibular growth leading
To our knowledge, no study has evaluated these effects yet before to mandibular retrognathism as compared to class I subjects who
the utilization of class II mechanics. experience unrestrained and normal mandibular development.12,13

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Table 3: Cephalometric data at T1 and T2 and difference between treatment and control groups
Intergroup Intergroup mean
Treatment mean (SD) Control mean (SD) comparison at T1 difference
∆T2–T1 ∆T2-T1 ∆T2–T1 (CI)
Variable T1 T2 p-value T1 T2 p-value p-value p-value
SNA° 83.1 (1.6) 83.15 (1.7) 0.07 (0.4) 82.9 (1.4) 83.2 (1.4) 0.3 (0.3) 0.34 –0.22
0.47 0.28 (–0.5, 0.04)
0.09
SNB° 77.1 (1.9) 79.63 (1.6) 2.55 (1.04) 77.03 (2.12) 78.06 (2.2) 1.03 (0.53) 0.47 1.5
0.0002* 0.50 (0.9, 2.1)
<0.0001*
ANB° 6.1 (1.7) 3.52 (0.99) –2.5 (1.1) 5.8 (1.7) 5.26 (1.6) –0.6 (0.3) 0.38 –1.9
<0.0001* 0.16 (–2.49, –1.4)
<0.0001*
MPA° 33.78 (5.8) 33.29 (6.34) –0.5 (2.3) 35.15 (4.38) 34.73 (5.4) –0.14 (2.5) 0.24 –0.36
0.41 0.41 (–2.1, 1.4)
0.34
FMA° 26.71 (4.9) 26.57 (5.58) –0.15 (2.16) 28.19 (4.15) 28.92 (4.9) 0.73 (2.1) 0.19 –0.9
0.47 0.33 (–2.8, 1.05)
0.18
Wits (mm) 3.84 (1.2) 1.19 (1.2) –2.64 (0.9) 2.76 (1.7) 3.01 (1.1) 0.26 (0.6) 0.04* –2.9
<0.0001* 0.35 (–3.5, –2.4)
<0.0001*
Ar-Go (mm) 44.75 (3.2) 46.83 (3.06) 2.08 (0.5) 45.01 (2.24) 46.66 (2.0) 1.66 (0.53) 0.4 0.42
0.03* 0.01* (0.05, 0.8)
0.01*
Go-Pog (mm) 70.1 (2.7) 72.7 (2.6) 2.6 (0.6) 69.6 (2.5) 71.1 (2.5) 1.5 (0.2) 0.28 1.14
0.004* 0.05 (0.8, 1.5)
<0.0001*
Co-Pog (mm) 108.4 (6.1) 113.45 (6.2) 5.05 (0.83) 105.54 (4.1) 108.6 (3.99) 3.09 (0.7) 0.06 1.9
0.01* 0.01* (1.4, 2.5)
0.04*
U1-SN° 91.1 (1.6) 103.58 (1.3) 12.48 (1.8) 90.34 (2.1) 90.8 (1.9) 0.43 (2.5) 0.13 12.1
<0.0001* 0.27 (10.5, 13.6)
<0.0001*
U1-NA° 10.92 (1.1) 22.62 (1.4) 11.70 (2.1) 10.15 (2.5) 10.58 (1.5) 0.43 (2.3) 0.13 11.3
<0.0001* 0.28 (9.7, 12.8)
<0.0001*
U1-NA (mm) 0.11 (0.6) 3.64 (0.4) 3.53 (0.4) 0.40 (0.3) 0.24 (1.02) –0.19 (0.8) 0.06 3.7
<0.0001* 0.28 (3.2, –4.2)
<0.0001*
Overbite (mm) 5.84 (0.4) 2.97 (0.3) –2.88 (0.3) 6.51 (1.05) 6.44 (0.5) –0.07 (1.03) 0.01* –2.8
<0.0001* 0.41 (–3.35, –2.3)
<0.0001*
IMW** (mm) 55.7 (2.3) 58.9 (2.03) 3.16 (1.1) 55.06 (2.8) 55.64 (3.04) 0.52 (0.2) 0.24 2.6
0.0001* 0.29 (2.1, 3.2)
<0.0001*

This assumption, however, could not be confirmed by a previous anterior mandibular repositioning after proclination of the
study.31 The authors, however, utilized fixed appliances only and retroclined maxillary incisors.32,33 Different to our study, both the
did not report if and how the maxillary incisal torque, the deep transverse (maxillary arch constriction) and the vertical (deep
overbite, and the maxillary arch constriction were properly and overbite) were not addressed.
simultaneously corrected. ANB angle normally reduces by 0.9 degrees between the
Thuer et al., and Demisch et al. who used revealed ages of 10–14-year-old, due to the more mandibular growth that
electromyography and sirognathography found no significant increases SNB angle than SNA that remains almost constant (Bishara

298 The Journal of Contemporary Dental Practice, Volume 25 Issue 4 (April 2024)
 Mandibular Projection Using Clear Aligners

Fig. 1: Skeletal changes in both groups

Fig. 2: Dentoalveolar changes in both groups

et al., Buschang et al., Williams et al. and Hönn et al.). 34–37 In this projected forward. When temporomandibular joint tomograms
study, the clear aligners treatment group showed a statistically were compared in cases where patients wore and did not wear clear
significant decrease of ANB more than the control group. This is aligners, it was observed that in patients who wore clear aligners,
in agreement with Hönn et al., who used removable plates and the mandibular condyles were displaced downward and forward
functional orthopedic appliances. similar to the effect of functional appliances. 39
The average forward mandibular growth was 4.36 mm greater The maxillary arch is always required to be expanded to help the
than the maxilla, which is enough to correct the majority of class II mechanical unlocking of the mandible.40 It has been reported that
skeletal cases. In this process, the maxilla is carried forward along class II division 2 malocclusion is mainly anteroposterior and vertical
with the mandible if intercuspation is maintained.38 Therefore, at problem, with the transverse component being generally less likely
least in theory, unlocking the intercuspation between the arches to be considered and its expansion using a Haas-type expander
could allow the mandible to carry the lower dentition forward about with a 10 mm screw led to improvement of class II malocclusion
the maxilla. When using Invisalign clear aligners, the thickness of (Caprioglio et al.).41 It is to be noted that narrow maxillae have been
the aligners disarticulates the arches, allowing the mandible to be reported occasionally to be one of the signs of this malocclusion,

The Journal of Contemporary Dental Practice, Volume 25 Issue 4 (April 2024) 299
 Mandibular Projection Using Clear Aligners

Fig. 3: Sample Ricketts’ superimposition of a patient in the treatment group

Fig. 4: Sample Ricketts’ superimposition of a patient in the control group

and therefore, special consideration should be made to the maxilla in class II division 2 was observed to be 3–5 mm narrower
transverse dimension during treatment planning of these cases.42 than the ideal width relative to that of the mandible (Tollaro
In some cases, narrow maxillary transverse dimension is seen in et al.).45 Based on this observation, an average of 3 mm of maxillary
the anterior region due to retroclination of the maxillary incisors, dentoalveolar expansion was planned using clear aligners for the
while in severe cases, this maxillary constriction can be seen more patients in our study.
posteriorly, hence restricting the mandible anteroposterior and Retroclination of the maxillary central incisors and deep overbite
laterally (Selwyn-Barnett).43 It has been reported that the transverse are characteristic features of class II division 2 malocclusion (Sharma
constriction in these cases is mainly dentoalveolar and not skeletal and Mariano et al.).4,46 At T1, all patients in both groups showed
in nature.44 In addition, it has been reported that the width of the retroclined maxillary central incisors and increased overbite. These

300 The Journal of Contemporary Dental Practice, Volume 25 Issue 4 (April 2024)
 Mandibular Projection Using Clear Aligners

values are in agreement with previous reports (Brezniak et al. and control group. The potential effects of this type of protocol favored
Woods).47,48 Improvement in the A-P position of the mandible due to the correction of the class II skeletal relationship in class II division
correction of both incisor inclination and deep overbite has not been 2 malocclusions before the use of any A-P class II mechanics.
observed in subjects not receiving orthodontic treatment (Woods,
2008). However, in our study, B Point moved forward significantly References
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