Seminars in Orthodontics 29 (2023) 289−299

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Seminars in Orthodontics
journal homepage: www.elsevier.com/locate/sodo

Enabling and restricting functions of the overjet in orthodontic treatment

Joseph G. Ghafari *
American University of Beirut Medical Center, Lebanon

A R T I C L E I N F O A B S T R A C T

Keywords: The aim is to evaluate the functions of the overjet in mediating, aggravating, and enabling the expression of jaw
Overjet growth in growing patients with Class II division 1 and Class III malocclusions. Beside malocclusion severity and
Growth modification treatment timing, treatment duration warrants special consideration, contrasting shorter-term (2-3 years) and lon-
Class II division 1
ger-term (5-7 years) responders to treatment, both encompassing the contribution of the adolescent growth spurt.
Class III
Treatment duration
Analysis of the genetic and environmental components affecting the development of malocclusion and growth
modification indicates that varying critical periods of growth among the craniofacial components account for the
variable individual responses to treatment. Clinical implications include keeping the overjet off the path of man-
dibular horizontal movement during orthopedic treatment, recognizing gender differences in the potential
response to treatment, and assessing the value of longer treatment in slow responders.

Introduction Overjet functions in orofacial development

The prevailing definition of overjet is the horizontal distance
between the edge of the maxillary incisors and labial surface of the
mandibular incisors, known to lay people as horizontal “overbite.”
For easier communication, orthodontists adopted overjet for the hori-
zontal overlap and overbite for the vertical coverage of the mandibu-
lar incisors by the maxillary incisors. Overjet and overbite are
intertwined companions; the change in one affects the other.1 The
aim in this paper is to highlight the strategic role of the overjet in
guiding, facilitating, or hindering the treatment of growing patients,
thus the potential subheading of this article designating the overjet
as a subtitle of the orthodontic book of malocclusions. This process
presumes the existence of gaps between the research approaches
and associated evidence that have yet to be bridged in the treatment
of individual patients.
The focus of the narrative is on the treatment of Class II division 1
(Cl.II/1) and Class III (Cl.III) malocclusions, which have been the subject
of countless investigations at all levels of the hierarchy of evidence.
Orthognathic surgery, the other facet of maxillofacial orthopedics in
non-growing patients, is contrasted with growth modification in achiev-
ing neutroclusion and improving facial esthetics. The genetic and envi-
ronmental components involved in the development of malocclusion
and in growth modification are considered in the context of individual-
ized response to treatment.
The mediating function of the overjet
Malocclusions are typically defined by the molar occlusion (also
technically “molar overjet” defined as Class I, II, III), the interincisal
relationship (increased overjet, edge to edge, anterior crossbite), and
the skeletal discrepancy (differential position of the jaws, also conceptu-
ally the skeletal overjet). Morphologically, the overjet is the anterior
connector between the jaws but it may not disclose the scope of maloc-
clusion severity. In Cl.II/1, an expected severe overjet is often dimin-
ished by the developmental compensatory inclinations of the incisors,
retroclined or upright maxillary and often proclined mandibular inci-
sors, but also possibly a deeper overbite, camouflaging the underlying
skeletal discrepancy. In Cl.III, the opposite maxillary and mandibular
dentoalveolar compensations minimize an otherwise more acute incisor
crossbite or “underjet.” In this perspective, deviations from normal sag-
ittal skeletal relationships generate an accordion-like camouflaging
shifts of the dentition (Fig. 1).
The non-consonance of overjets with underlying malocclusions is
supported in various studies. Although associated with a higher risk of
trauma to the maxillary incisors, an increased overjet (>7mm) was not
found to be diagnostic of Cl.II/1.2 Nearly 10% of patients with an overjet
of 7mm had a Class I molar occlusion.3 In a study of growing patients
with Cl.II/1 malocclusions that were divided into low and high severity

* Correspondence to: Division of Orthodontics and Dentofacial Orthopedics, Department of Dentofacial Medicine, American University of Beirut Medical Center,
Riad El Solh, Beirut 1107 2020, Lebanon.
E-mail address: jg03@aub.edu.lb

https://doi.org/10.1053/j.sodo.2023.04.004

1073-8746/© 2023 Elsevier Inc. All rights reserved.

J.G. Ghafari Seminars in Orthodontics 29 (2023) 289−299

intermaxillary traction.6 With either theory, investigation is needed

Fig. 1. Graphic representation of the dentoalveolar compensation of skeletal
discrepancy in Class II division 1 (Cl.II/1) and Class III is likened to
“accordion-like” dynamics, whereby the yellow and green arrows reflect the
opposite movements of jaw and incisors, the latter defining the existing
overjet. In Cl.II/1, the maxillary incisors procline and mandibular incisors
retrocline to bridge the skeletal discrepancy; the opposite inclinations are
observed in Class III.
on the basis of the ANB angle being between 4.5-6.5° and ≥6.6°, respec-
tively, we observed no statistically significant difference in overjet
between severity groups,4 whereas compensatory inclinations and posi-
tions of the maxillary and mandibular incisors differed significantly
between the groups (Table 1).
The aggravating function of the overjet
regarding the timing of the insult and its expected significant duration,
which is related to the ongoing period of growth.
The hypothesis in Cl.II/2 stipulates that the hallmark reduced overjet
and deep overbite, concomitant with overerupted incisors and underer-
upted posterior teeth, translate into a “self-restricting” dentoalveolar
complex that keeps a growing mandible from carrying its dentition for-
ward.7 Hence the continuing mandibular growth is expressed in a more
defined chin, the characteristic “strong chin button” with an increased
anterior symphyseal angle. Presumably, early maintenance of an overjet
with well aligned maxillary incisors and correction of the overbite
should shortcut such development. A well delineated chin is often asso-
ciated with favorable anterior facial projection, but not necessarily so as
small mandibles exist with proper chin definition.4
This discussion recalls two concepts associated with the impact
of the environment on craniofacial growth. The first relates to the
bound feet of Chinese females to control foot size, yet the bony
growth was expressed in a modified shape.8 The second stipulates
that the foot may not grow forward in a constricted shoe, an anal-
ogy to the mandible not moving forward if the maxilla was con-
stricted.9 Whether and to what extent the amount of growth can be
stimulated remain to be discovered.
Enabling and restricting functions of the overjet in treatment: in
and out of the way
Two tenets underlie growth modification in growing patients and
orthognathic surgery in late adolescence or adulthood.

Get the teeth off the path of the mandible, out of the way of growth or of the
The overjet in a developing Class II division 2 (Cl.II/2) malocclusion
surgeon
and the incisor crossbite in Cl.III may contribute to deviating and likely
worsening the underlying skeleton, first affecting the bony position and
This principle presumes that mandibular advancement through
eventually the mode of expression of growth amounts. Both malocclu-
growth or surgery might be limited by the position of the maxillary
sions illustrate the concept of intragrowth orthopedics, which reflects
incisors, forcing unwanted downward and backward mandibular rota-
the potential of the environment to mold developing malocclusions over
tion (Fig. 2). Thus, a moderate overjet (avoiding the risk of trauma to
time in a specific pathway.5
the maxillary incisors3,4) should be maintained during growth modifi-
The development and/or severity of the Cl.III dysmorphology could
cation anticipating the additional growth (Fig. 3). Preparing for
relate to a sustained anterior crossbite that transfers the functional
proper occlusal interdigitation following orthognathic surgery, a
forces within the lower face through the occlusion against the maxilla,
slight to moderate proclination of the maxillary incisors might be
generating maxillary retrognathism that otherwise would not exist. This
indicated (Fig. 4).
premise is based on the finding that the deviation to maxillary retro-
In Cl.II/1 with mandibular retrognathism, maintaining a residual
gnathism was more severe than the deviation to mandibular progna-
overjet during treatment would lead to the following possibilities:
thism.5 Conceivably, a parallel or additive phenomenon may relate to
anterior mandibular positioning influencing the morphology of the con- a- mandibular forward growth equals the amount of the overjet; then,
dyles and glenoid fossa, which would also remodel in an anterior posi- the present compensatory incisor angulations are maintained
tion. An opposite posterior repositioning of these structures was b- mandibular anterior growth exceeds the overjet amount; then, the
demonstrated following Cl.III treatment with a bone-anchored present compensatory incisor angulations, particularly mandibular,
are partially or fully normalized, as indicated, for improved dentos-
keletal relations (Fig. 5)
c- the mandible grows less than the overjet amount; thus, compensa-
Table 1 tory inclinations of the maxillary and mandibular incisors are exag-
Overjet and other cephalometric measurements in patients gerated if compatible with facial esthetics; if not, a residual overjet is
with Class 2 division 1 malocclusion of low and high severity.
maintained, or later orthognathic surgery may be indicated.4
Low severity High severity
(ANB: 4.-6.5o) (ANB>6.5o) In Cl.III, parallel possibilities are in reverse directions. The overcor-
n 30 30 rected overjet from the initial anterior crossbite (usually with a face
M SD M SD P* mask and/or fixed appliances) anticipates mandibular growth equal to
AGE (yrs) 12.15 1.46 11.37 1.79 0.110 the amount of overcorrection, whereby the pretreatment mandibular
ANB (deg) 5.54 0.72 8.25 1.11 <0.0001 incisor retroclination is maintained, or mandibular growth is less than
OJ (mm) 6.90 2.18 6.97 2.22 0.910
the amount of overjet overcorrection and the mandibular incisors are
1/NA (deg) 25.97 5.778 20.09 6.61 0.018
1/NA (mm) 4.49 1.79 2.88 2.16 0.008 proclined to correct the residual overjet (Fig. 6).5
1/NB (deg) 28.10 5.55 31.98 5.44 0.016 These seemingly aleatory assumptions are rooted in the inability to
1/NB (mm) 5.32 1.96 6.82 1.83 0.041 accurately predict mandibular growth, hence the option to carry the
1/MP (deg) 95.08 5.92 100.13 6.60 0.009
quasi-exploratory treatment for a longer period than desired by patient
* Benjamini-Hochberg statistical procedure adjusting for and orthodontist. However, available evidence supports the basic prem-
multiple testing at a FDR of 0.05 or 0.01 ise of the overjet as a “leeway” for forward mandibular projection. In a

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J.G. Ghafari
Fig. 2. A. Class II, division 1 malocclusion with underlying skeletal discrepancy requiring a Lefort 1 maxillary impaction more posteriorly than anteriorly and mandib-
ular advancement. B, C. Graphic illustration of the orthodontic presurgical preparation. Upon maxillary impaction and rotation, the maxillary incisors become retro-
clined, offering an obstacle to more anterior mandibular advancement, and forcing a more vertical position of the mandible (blue lines in C). To allow further
mandibular forward displacement, a greater overjet should be developed by planning either presurgical orthodontic proclination of the maxillary incisors (red lines in
C) or maxillary advancement.
comparative study of Cl.II/1 treatment with either a headgear or a func-
tion regulator, superimposition on the maxillary base revealed further
horizontal growth of the mandible with the headgear, which had also
resulted in proclination of the maxillary incisors, than with the func-
tional appliance, which had yielded retroclination of these incisors and
reduction of the overjet.10
Growth modification and orthognathic surgery: equal in principle, unequal in
outcome unless growth expression is favorable
When comparing the potential for maxillofacial orthopedics modali-
ties, growth modification in the young and orthognathic surgery in the
grown-up, to achieve optimal treatment results, the extent of surgical
movement at first reflection overshadows the scope of growth modifica-
tion. In Class II treatment, adding a limit of mandibular surgical
advancement of nearly 15mm and further chin anterior displacement up
to 10mm might amount to 25mm of total chin projection in the profile.
Growth modification does not enhance the chin button like genioplasty.
Nonetheless, an assessment of mandibular development over time is
valuable to explore the limits of its expression.
Data on untreated occlusions that provided longitudinal measure-
ments of mandibular growth (condylion-gnathion length) and lower
face height (ANS-menton) indicate that mandibular length increases by
nearly 26 and 34 mm in girls and boys, respectively between ages 4 and
18, and about 12 and 21mm, respectively between the ages of 10 and 18
that include the period when early treatments are started in the late
mixed dentition (around the time of emergence of the maxillary first pre-
molars) (Table 2).11,12 Accounting for the same period, the residual
mandibular length to be affected by orthodontic treatment is practically
only around 10% in girls and 20% in boys after age 10 (Fig.7).
Hence, if growth modification in Cl.II/1 is consumed early enough
starting in the primary dentition (possibly age 4 or 5 depending on child
compliance) or by the late mixed dentition (10 years), and lasting at
least past the adolescent growth spurt, it is conceivable that growth
modification (particularly in boys) might mirror the results of orthog-
nathic surgery, short of the genial extension if the chin “button” is
absent or minimal (Fig. 5). The corollary to this theory is that patient
and orthodontist are willing to invest a long period of treatment wherein
the fuller amount of growth is expressed.
In Cl.III malocclusion, such prospect might be achieved (Fig. 6) with
the proviso that excessive mandibular growth further undermines the
treatment strategy, particularly if dentoalveolar compensation (pro-
clined maxillary and retroclined mandibular incisors) has reached
extreme limits detrimental to periodontal heatlh and facial esthetics.13
Data on untreated Cl.III from mixed longitudinal samples of small to
moderate sizes reveal that from the ages of 10 to 15 mandibular length
(condylion-gnathion) grows on average by nearly 15mm (compared
with 13mm in Class II).14,15
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Seminars in Orthodontics 29 (2023) 289−299
Studies of early orthopedic intervention versus orthognathic surgery
are not available. The expected primacy of orthognathic surgery was
found in few comparisons between surgical and orthodontic treatment of
Cl.II/1, none of which were in a randomized clinical trial because of the
ethical connotations related to such research. In a systematic review and
meta-analysis of studies contrasting orthognathic surgery and orthodon-
tic camouflage, differences in favor of surgery were related to the dis-
crepancy between the jaws (ANB) and the position and inclination of
the mandible (SNB, and MP/SN angles, respectively).16 Proffit et al17
advocated augmentation genioplasty in conjunction with orthodontic
treatment in patients with borderline extraction malocclusions, ade-
quate nasolabial angle, protruding mandibular incisors and a deficient
chin or short mandibular ramus.
The overjet in treatment modeling: interfaces with constitutional
and therapeutic characteristics
The factors determining the variable responses to treatment in grow-
ing patients include constitutional elements such as the individual
growth tempo, malocclusion severity and gender differences, and threra-
peutic characteristics such as treatment timing, but also treatment dura-
tion, which may define the success of treatment.
Malocclusion severity and treatment timing
The severity of the condition is a determining factor in treatment out-
come. When the Cl.II/1 malocclusion was stratified on the basis of the
ANB angle in low (ANB=4.5o-6.6o) and high (ANB ≥ 6.6o) severity,
patients with greater severity remained on average in the Class II
domain (5.93o±1.49o) compared with the milder Class II in which post-
treatment ANB (3.44o±2.25) approached normal values (2o±2o).4 In
mesiocclusion, the early favorable orthopedic effect has been reported
to diminish with additional mandibular growth despite the overcorrec-
tion of the overjet.5 Nonetheless, a gap in knowledge remains regarding
outliers that may cross severity groupings.
Validating research at the higher level of evidence supports the initi-
ation of “early” treatment in the late mixed dentition in nearly two
thirds of malocclusions, which also carries the advantage of shorter
treatment duration (Fig. 8).18 However, the concept of starting treat-
ment as soon as the problem becomes evident may not be totally
neglected, conceivably as early as in the primary dentition as advocated
by Angle19 and other adherents to this philosophy.
Gender differences
The disparity between a shorter treatment, timed relative to the
growth spurt (Fig. 8) and a longer treatment (e.g. over 7 years; Fig. 5) to
reach successful results relates to various factors such as malocclusion
J.G. Ghafari
severity, growth potential per time (months and years), patient compli-
ance, and possibly gender. In Cl.II/1 treatment success might be more
amenable in boys whose mandible grows at a greater rate annually
between the ages of 10 and 18 and over a longer period20 (Fig. 7),
approximately 65% (24/37mm) of the growth gradient between ages 4
and 18, compared with 44.5% (12/27mm) in girls (Table 2).11 In
untreated Cl.III patients, orthopedic treatment might be more effective
in girls, whose mandible grows an average 12mm compared with 17mm
in boys between ages 10 and 15, the latter growing another 5.5mm from
15 to 18 years.14 Notable is the near equal growth of Co-Gn (about
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Seminars in Orthodontics 29 (2023) 289−299
Fig. 3. Pre and post-phase 1 treatment cephalographs (A, B,
respectively) and occlusal photographs (C, D, respectively) of a 10-
years-old boy whose severe Class II division 1 malocclusion was
improved to neutroclusion by age 11 years. Treatment options con-
sidered: a. maintain the overjet anticipating the expected addi-
tional growth spurt that should carry the mandible forward to
optimal interincisal relationships (E, F); b. start the next treatment
phase with fixed appliances a few months after the impending loss
of the maxillary second primary molars and canines and eruption
of their successors, likely resulting in retroclined maxillary and
proclined mandibular incisors (G). Further growth of the mandible
during peak height velocity would end up with an edge to edge
incisor occlusion that might require proclination of the maxillary
incisors (thus bimaxillary protrusion) and/or a difficult process of
retraction of the mandibular dentition (H). Should the mandible
rotate backward while growing forward, another process of den-
toalveolar “corrections” might ensue, such as the retraction of
mandibular incisors (I), proclination of the maxillary incisors (J),
or even the retroclination of maxillary and mandibular incisors,
possibly following the extraction of first premolars (K).
10.5mm) between ages 6-10 years in both girls and boys.14 Nonetheless,
even in same sex children variations exist and should be considered, pos-
sibly in relation to variances in body and mandibular growth amounts.
The impact of treatment duration on treatment outcome
Successful results may be obtained when accounting for and
benefiting from the natural duration of growth events.13 This poten-
tial is illustrated when fast corrections of Cl.II/1 malocclusion are
timed to profit from the adolescent growth spurt (Fig. 8), but also in
J.G. Ghafari Seminars in Orthodontics 29 (2023) 289−299

Fig. 4. A, B. Lateral views of the presurgical models of a patient with Class II, division 1 approximated before surgery to determine if the patient was ready for orthog-
nathic surgery. The canines are not seated in Class I and the molars are short of neutroclusion. To achieve better seating, the maxillary incisors were proclined to
increase the overjet and develop space mesial to the maxillary canines as shown before (C) and after (D) implementing this movement that required nearly 6 weeks.
E, F, When the new presurgical models were approximated, the canines and molars were in optimal seating. G, H. Intraoral lateral views of another patient demonstrat-
ing the creation of the space mesial to the canines prior to maxillary impaction surgery (G) and at the end of treatment (H).

much longer treatments of Cl.II/1 and Cl.III demonstrating the con-
cert of growth (including the growth spurt) and multiphase treat-
ment mechanics in which the overjet “enables” the forward
projection of the mandible (Figs. 5, 6).
Should a first phase of treatment approximate a normal overjet, more
optimal results could be sought. In Class II/1, the originally proclined
mandibular incisors could be retracted (decompensated) to develop a
greater overjet that would allow a repeat of the mechanics used in the
first correction (e.g. functional appliance; Fig. 5). In Cl.III, an overcor-
rected overjet should be held for a significant period because further
mandibular growth is detrimental to the outcome (Fig. 6).
Essentially, the orthodontic environment “competes” with the existing
epigenetic/environmental factors that interplayed with the genetic influ-
ence to produce the present malocclusion. Frankel advocated in Cl.II/1

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Fig. 5. Cephalographs of a patient presenting with a severe Class II, division 1 malocclusion at the age of 10years and 5 months, with compensating severe proclination
of the mandibular incisors (A). Treatment was guided by a strategy of constantly maintaining a residual overjet for more forward and less downward mandibular move-
ment. At first, a functional appliance (modified bionator) resulted in overjet reduction. Subsequently, the mandibular incisors were retracted into existing spacing
within the mandibular arch, and a second bionator delivered for further mandibular growth into the developed overjet (B). The corrective stages of fixed appliances
included further retraction of the mandibular incisors against a maxillary headgear and overjet development (C). The child was still growing, and his compliance was
exemplary. Accordingly, incisal compensation for the remainder of the overbite was only undertaken when no further significant growth was anticipated (D). Presum-
ably approaching in amount a surgical mandibular advancement (about 1cm of growth), the latter was avoided, although not ruled out from the onset should treatment
not keep up with an insufficient mandibular growth. However, the outcome could not be predicted with available cephalometric prediction models.

Fig. 6. Serial cephalographs (A-E) and pre (F) and post (G) treatment photographs of a patient presenting with Class III malocclusion treated with sustained facial mask
between the ages of 9 and 13y8m. Treatment proceeded with Class III mechanics until age 17y3m when mandibular growth stabilized. Retention included the night-
time use of Class 3 elastics to clear retainers. The treatment strategy is simulated in figures H and I: the overcorrected overjet (B, C) anticipates mandibular growth
equal to the amount of overcorrection (H), hence the pretreatment mandibular incisor angulations are maintained, or mandibular growth less than the amount of over-
jet overcorrection (I), thus the mandibular incisors are proclined in the amount of the overjet correction.

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Table 2
Approximate values (mm) of Go-Gn and its components during growth from early or mid-childhood to early adulthood.

Age (yrs) Girls Boys

4-18

10-18

Adapted from Riolo et al.4

Between the ages of 10 and 18 years, 44.5% (12/27mm) of the available growth gradient remains in girls and 65% (24/37mm) in
boys.

therapy a stepwise mandibular advancement of the function regulator
(2-3mm each activation) over longer periods of treatment (possibly 5 years),
“not further than the protractor muscles are able to keep the mandible in
that forward position”, presumably pacing the overjet reduction with the
concomitant skeletal development.21
Often, the reluctance of patients and parents for longer treatment
forces the earlier completion of Cl.II/1 treatment with otherwise avoid-
able dentoalveolar overcompensations and the consequent backward
rotation of the mandible when the insufficient overjet hinders its further
advancement (Fig. 2). In Cl.III, the earlier treatment completion with
dentoalveolar overcompensation is further magnified with the uncertain
prediction of final mandibular size with completed growth.
In most modern clinical settings, an early and eventually protracted
treatment, complemented with fixed appliances for another finite
period, is not a viable routine approach considering the patient’s compli-
ance, demand for faster treatment, financial affordability by the patient
and sustainability of the practice.
The overjet in treatment modelling
The geometric perspective of the overjet providing the leeway for
mandibular response to orthodontic/orthopedic stimuli (Figs. 4, 5, 6)
and treatment duration should be added to the present model of interac-
tive components in the treatment of malocclusions in growing patients,
which includes growth (amount and direction), time (timing and dura-
tion of treatment), and treatment modality (e.g. functional appliance,
headgear, face mask). Together, these components form the individual
temporal “engine” that drives treatment response (Fig. 9). The ortho-
dontist is able to regulate the parts in variable extents, least of which the
genetic growth potential and long-term patient compliance.
The balance of this system is complex because of individual varia-
tions in structural, physiologic, therapeutic and even psychological com-
ponents. Outliers to average trends uncover important disparities
between goals and outcomes attributable to constitutional variances
that relate to anatomy, growth, biological response to orthodontic

Fig. 7. A. Average percent (%) achievement of adult size of the mandibular length (condylion-pogonion) in girls and boys computed from Riolo et al11 and displayed
graphically against age (years). Most of the length (nearly 80% in girls and 74% in boys is achieved at the age of 4 years. The remaining growth in girls is 27mm, and
in boys 37mm (Table 2), with corresponding average annual increments of 2mm/yr and 2.6mm/yr, respectively. When the percentages are computed starting at age
10 (dotted vertical line), 10% and 20% of growth remains in girls and boys, respectively. B. Males have a greater amount of growth to be consumed over a longer period
of time (graph redrawn from Ursi et al20). The size of the mandible must be seen proportionally to the larger size of the head and face in males compared to females.
Note: the average values do not reflect the individual variations and the particularities of untreated Class II and Class III malocclusions

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Fig. 8. A-H. Extraoral (A-C), intraoral (D-F), and cephalometric (G, H) records of an 11 years old prepubertal girl whose Class II, division 1 (Cl.II/1) malocclusion
(ANB=7.15o) was treated with a function regulator. Improvement from the initial condition (A, D) to neutroclusion was observed at 9 months (B, E) and when the
appliance was discontinued, 2yrs later (C, F). The correction is demonstrated in the difference between the initial (G) and 2yr (H) cephalometric tracings. I-P. Extraoral
(I-K), intraoral (L-N), and cephalometric (O, P) records of a 13 years old prepubertal boy treated with headgear to correct a Cl.II/1 malocclusion (ANB=6.87o).
Improvement from the initial condition (I, L) to an overcorrected Class I molar relationship was detected at 1 year (J, M) and when the appliance was discontinued
nearly 2years later (K, N). The difference is documented between the initial (O) and the 2year (P) cephalograms. Treatment was successful because of the concert of
favorable factors: timing treatment precisely before the growth spurt, allowing the mandible to “grow” horizontally “within” the overjet, sufficient genetically influ-
enced amount of growth, and exemplary compliance.

forces, and therapeutic variances associated with the necessity to design

treatment based on the individual constitutional limitations (e.g. ana-
tomical restraints such as lip thickness or growth potential). These fac-
tors reveal the necessity of considering the concert of genetic,
epigenetic, and environmental influences in orthodontic science.

Heredity and environment (treatment): gradients and critical

periods of growth

Under which circumstances can orthodontic treatment, considered

Fig. 9. Interactive factors influencing the treatment of malocclusion, applicable
to Class II division 1: Inherent genetically-influenced elements are growth
amount and direction (more in males [M] than females [F]); external treatment-
induced elements are treatment timing and duration, treatment modality and
overjet. Treatment timing through a validated treatment modality allows the
expression of differential growth (amount). The maintenance of an overjet per-
mits growth to be expressed more horizontally (direction) throughout the active
growth period (duration). The balance of this system is challenging because of
individual variations in structural, physiologic, and therapeutic components.
an environmental influence, overcome the genetic blueprint of mandibu-
lar retrognathism in Cl.II/1 and mandibular prognathism or maxillary
retrognathism in Cl.III? The environmental contribution to modifying
the genetically-influenced mandibular length is commonly considered
unequal to the genetic effect, but the issue is more intricate for such gen-
eralization.
Postnatal craniofacial skeletal growth is affected by dynamic
“organizational processes” regulated by interacting genetic units and
environmental conditions.22 Integral to the production of the craniofa-
cial phenotype are the concepts of pleiotropy (the production by a gene
of two or more apparently unrelated effects), epigenetic and environ-
mental influences, and allometry (the growth of craniofacial parts at dif-
ferent rates, effecting a change in craniofacial proportions). Although
integrated, the morphological components demonstrate variable
response potentials or “growth maturity gradients” to environmental
and epigenetic influences, dependent on their respective growth
rythm.22 The earlier maturing structures (e.g., cranial base, maxilla) are
more deficient in responding to future stimuli than the later maturing

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and more rapidly metabolizing structures (e.g., mandible) because of the
cumulative effects of past stimuli.
The concept of critical periods, initially contending that dysmorphol-
ogy depends on the timing of insults during embryogenesis, suggests
that all parts of an organism do not respond equally to adverse environ-
mental conditions even if applied at the same time.22 By extension, this
premise would apply to supposedly helpful environmental interactions
such as orthodontic treatment, with the expectation that different facial
components would or would not respond equally to environmental pro-
visions. Thus, structures developing at various rates would express dif-
ferent levels of susceptibility to epigenetic and environmental modifiers.
The earlier maturing structures such as the maxilla would require an ear-
lier intervention for forward movement in Cl.III (face mask5) or for less
retraction relative to favoring mandibular anterior displacement in Class
II.1 (functional appliance). The later maturing mandible might need lon-
ger treatment in Cl.II/1(functional appliance, headgear, or both, Fig.
54). The variation of critical periods is exemplified by the timing and
intensity of growth in landmark maturational events such as body
height, sutural (maxillary) and mandibular length.23
Research outlook
The previous conceptualization explains the variability in treatment
timing, duration and outcome and is difficult to translate in individual-
ized treatment absent the prediction models that can account for at least
the allometric growth expression. Perhaps herein lie strengths and weak-
nesses of prediction equations, which account for diverse components
but not for growth gradients, critical periods, the differentiation
between shorter, intermediate, and longer-term responders, and the
“tuning” role of the overjet. Models incorporating these variables remain
to be tested (Fig. 10), as well as models which could sort out trends with
outliers that might help categorize responders to take full advantage of
their growth potential in shorter or longer treatments (Fig. 11).
Creative research on extensive databases is needed, combining
genetic diagnostics, measurable outcomes and artificial intelligence to
sort out the various premises. Investigations would ideally include bio-
logical monitors of growth (e.g. blood or salivary molecular substan-
ces24) and the assessment of genetic predisposition in response to
treatment.25 Certain genes might control a more favorable expression of
the environment (treatment) or respond better with shorter or longer
treatment. Moreover, longitudinal randomized research is needed to
determine the added value of extended treatment for the fuller manifes-
tation of jaw growth escorting the general body growth.
The key to unlock complex issues related to predictability of growth
or treatment is to develop further knowledge about the scope of individ-
ual variation, essentially finding out the location of a particular patient
with the same condition to be treated relative to central tendencies that
are not generalizable for all variations within the sample. Recognizing
an “outlier” to the central tendency calls for identifying and categorizing
the sources of variations to determine the average response to treatment
by the categorized outliers.2 In this perspective, practitioners and
researchers would focus on individual diagnostic and therapeutic tracks
of responses to be defined in the different malocclusions.
Clinical practicability
The previous discussion indicates that a personalized non-generic
approach to treatment is imperative, nonetheless based on tested treat-
ment modalities. Yet, the translation of research central tendencies in
the individual patient remains a challenge. Greater insights are needed
in biological knowledge (e.g. tissue reactions, genetics and epigenetics,
growth and treatment outcome prediction) to plan a precise individual

Fig. 10. Graphic representation of projected chin extension relative to treatment duration in Class II division 1 (Cl.II/1) patients whose malocclusion is in a lower or
higher range of severity (based on prior categorization studies3,4,18). Approaching the 100% level of orthognathic chin extension would be expected in patients with
favorable mandibular growth responding in short, intermediate, or long term treatment duration. With lower gradients of favorable growth, the chin would not reach
orthognathism although closer to optimal position. In the more severe malocclusions, insufficient growth is expected leading to improvement but still in the Class II
phenotype domain, also responding in shorter, intermediate, or longer treatment duration. More severe malocclusions may find a pathway to orthognathism if chin
form is well delineated (not slight or absent) and significant growth occurs. The prospect of surgery is higher with more severe malocclusions, absent or slight chin
form, and bad response to treatment. This model represents general trends and expectations yet underscores the complexity of components and variables involved in
the treatment of Cl.II/1.

297
J.G. Ghafari Seminars in Orthodontics 29 (2023) 289−299

Fig. 11. Hypothetical representation of distribution of the duration of Class II treatment started in early childhood (late mixed dentition) relative to treatment out-
come. A. The blue line represents a linear correlation between treatment duration and treatment outcome. Outliers are shown in colored circles. The question posed
regarding the patients shown in Figs. 5 and 8 at pretreatment time is: could individual treatment duration be predicted to reach the sought outcome (Class 1 occlusion
with optimal overjet and overbite)? B. Two patients shown in Fig. 8 reached the optimal outcome within months to a year, another in more than 5 years (Fig. 5). The
ensuing question is: can the average response be shifted from the blue line to the green line? The answer, whether biological and orthodontic/mechanical is not avail-
able, with doubts about a shift. What might be achievable through multistep research is recognizing the outliers before treatment.

treatment.26 Until such information is acquired, a set of guidelines is
advanced based on scientific data and the systematic judgment by the
treating orthodontist of ongoing responses to treatment:
1. Appraise the malocclusion in its components not as a generic type.4
2. Formulate a treatment targeting the early and late maturing struc-
tures differentially (in both timing and force amounts), recognizing
that more severe malocclusions are expected to respond less favor-
ably. Such an assessment might favor the treatment of Cl.II/1with a
functional appliance rather than a headgear in a younger child and
the opposite in a postubertal adolescent patient.
3. Analyze the limiting and enabling roles of the overjet during treat-
ment, titrating the next step in light of the developing response. If
the latter is positive, potentiate the effect, such as producing addi-
tional decompensation of mandibular incisors in Cl.II/1 to allow
more horizontal expression of mandibular growth or the retentive
use of a face mask in Cl.III to maintain an overcorrected overjet.
4. Consider a longer period of treatment with willing patient and
parents, guided by the foregoing response and compliance. Success
is not guaranteed but parents often insist on orthopedic intervention
hoping to avoid surgery years later.
5. Where applicable and necessary, inform or advise patient and
parents of the surgical orthognathic option. Treatment potential and
duration as well as patient expectations, not only chief complaint,
must be discussed with the patient before treatment.
6. Consider compromised results in favor of optimal facial appearance
rather than dental Class I interdigitation.4
Conclusions
5. Growth amount and pace differ between boys and girls, with greater
potential for success (Cl.II/1) or failure (Cl.III) in boys whose mandi-
bles grow in greater amounts and for a longer period.
6. Considering the absence of accurate prediction of individual out-
come, it is recommended to carry the early treatment of Cl.II/1
through the growth spurt with a residual overjet for more horizontal
mandibular growth projection. If the latter is not satisfactory, partic-
ularly with a slow tempo and amount of mandibular growth, the
gain from additional growth is possible but treatment lasts longer.
Overcorrection of the overjet in Cl.III is necessary to anticipate the
further mandibular growth.
Patient consent
Patient consent was obtained.
Funding
No funding or grant support.
Author contributions
All authors attest that they meet the current ICMJE criteria for
authorship.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.

1. The overjet captures the complexity of malocclusion severity as the

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