EDITORIAL
Correcting the Class II subdivision
malocclusion
David L. Turpin, Editor-in-Chief
Seattle, Wash
C
orrecting Class II malocclusions characterized
by dentoalveolar asymmetry has long been a
challenge for clinicians. How do you determine
the source of asymmetry when planning treatment for a
patient with a Class II subdivision malocclusion? Are
most malocclusions of this type caused by dentoalveo-
lar or skeletal deviations? Do compromise treatment
plans lead to additional complications, such as tipping
of the occlusal plane, dental instability, or temporoman-
dibular disharmonies?
When asked to agree on a description of subdivision
malocclusion, dental educators were divided. Molly
Siegel1 reported on this dilemma in her article, “A
matter of Class: Interpreting subdivision in a malocclu-
sion,” based on a survey of 57 orthodontic departments
in the United States that asked: (1) do you teach that
subdivision refers to the Class I side or the Class II
side? and (2) explain your program’s teaching philos-
ophy to support your answer.
To no one’s surprise, the responses varied, with less
than 65% agreement on the meaning of subdivision.
The Class II side was identified by 22 departments and
the Class I side by 8. Some faculties were split and
could not agree on an answer. Even the AAO glossary
is vague: “Subdivision is used to describe unilateral
malocclusion characteristics of the affected posterior
segmental relationships.” In its extended form, the
Angle classification attempts to describe subdivision.
“Occasionally the molar occlusion is Class II on one
side, and Class I on the other.” Angle called this a
Class II subdivision right or left, depending on which
was the Class II side. But is this completely clear?
Siegel1 concluded that she would teach her dental
students to clarify it by declaring which molar relation-
ship is Class I and which is Class II.
Before planning orthodontic treatment to correct
subdivision problems, the location of the asymmetry
must be identified. Is it in the maxillary arch, the
mandibular arch, or a combination? Is there a skeletal
component, a disk displacement, or a pathological
Am J Orthod Dentofacial Orthop 2005;128:555-6
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condition of the temporomandibular joint in patients
with dentoalveolar asymmetries? Some Class II subdi-
vision problems (type 1) are created by distal position-
ing of the mandibular first molar on the Class II side. A
secondary contributor is the mesial positioning of the
maxillary first molar on the Class II side (type 2).
Janson et al2 examined 44 untreated subjects to deter-
mine the percentage of each type. The frequency of
Class II subdivision malocclusion types found in the
frontal photographic evaluation were type 1, 61.4%;
type 2, 18.2 %; and combined, 20.5%.
Regarding a possible skeletal component, there was
a tendency for type 1 to have greater mandibular
asymmetry than type 2, when compared with the
control group. However, skeletal asymmetries were
very mild. Despite clinically dividing Class II maloc-
clusions into types 1 and 2, the main factors contribut-
ing to asymmetry were dentoalveolar, as previously
reported.3-5
If moderate to severe skeletal asymmetries are
observed, additional diagnostic records might be
needed to explore whether excessive condylar growth
leads to an increase in asymmetry. Moderate to severe
skeletal problems are less common than once thought
but must be ruled out before starting dentoalveolar
correction.
Perhaps the most unheralded option for treating
type 1 subdivision is the asymmetric extraction of 3
premolars and space closure with fixed appliances.
According to Janson et al,6,7 for appropriately diag-
nosed patients, 3-premolar asymmetric-extraction treat-
ment can be faster than treatment requiring 4 premolar
extractions. The asymmetric-extraction choice tends to
be more successful in obtaining midline correction with
reduced incisor retraction.
Experienced clinicians have raised questions about
long-term success with these treatment options, espe-
cially when the resulting occlusion is asymmetric and
minor skeletal asymmetries are uncorrected. Fortu-
nately, these concerns are being addressed by research
facilities. Janson et al7 provide an excellent resource for
understanding the effect of asymmetric extractions and
elastics on a growing patient’s hard tissues. According
555
556 Editorial
to the authors, no significant skeletal changes could be
attributed to the treatment approaches investigated or
transverse collateral effects with the asymmetric me-
chanics. Of course, the initial arch-length discrepancy,
including spacing or crowding and the anteroposterior
position of anterior teeth, is very important. The treat-
ment of Class II subdivision malocclusions with asym-
metric extractions can be a beneficial approach to this
problem. This treatment protocol did not contribute to
undesirable dentoskeletal effects on the frontal plane.
The asymmetric extraction protocols for Class II
subdivision malocclusions are often successful because
they maintain existing molar relationships, resulting in
reduced treatment time and greater ease of midline
correction. As a result of asymmetric extractions, the
correction of maxillary and mandibular dental mid-
line deviations might be possible without canting of
the occlusal plane. When applied to Class II subdivi-
sion malocclusion, treatment protocols with asymmet-
ric extractions do not introduce undesirable dentoskel-
etal changes in the frontal plane. When alternative
treatments are available, the doctor must provide unbi-
American Journal of Orthodontics and Dentofacial Orthopedics
November 2005
ased evidence-based information, thus allowing the
patient to make an informed decision.
REFERENCES
1. Siegel MA. A matter of Class: Interpreting subdivision in a
malocclusion. Am J Orthod Dentofacial Orthop 2002;122:582-6.
2. Janson G, de Lima KJRS, Woodside DG, Metaxas A, de Freitas
MR, Henriques JFC. Distribution of Class II subdivision maloc-
clusion types and evaluation of their asymmetries. Am J Orthod
Dentofacial Orthop 2005 (in press).
3. Janson GRP, Metaxas A, Woodside DG, de Freitas MR, Pinzan
AP. Three-dimensional evaluation of skeletal and dental asymme-
tries in Class II subdivision malocclusions. Am J Orthod Dento-
facial Orthop 2001;119:406-18.
4. Burstone CJ. Diagnosis and treatment planning of patients with
asymmetries. Semin Orthod 1998;4:153-64.
5. Wertz, RA. Diagnosis and treatment planning of unilateral Class II
malocclusion. Angle Orthod 1975;45:85-94.
6. Janson G, Dainesi EA, Henriques JFC, de Freitas MR, de Lima
KJRS. Class II subdivision treatment success rate with symmetric
and asymmetric extraction protocols. Am J Orthod Dentofacial
Orthop 2003;124:257-64.
7. Janson G, Cruz KS, Woodside DG, Metaxas A, de Freitas MR,
Henriques JFC. Dentoskeletal treatment changes in Class II
subdivision malocclusions in submentovertex and posteroanterior
radiographs. Am J Orthod Dentofacial Orthop 2004;126:451-63.