Document Type : Original Article


1 Oral and Maxillofacial Radiology, School of Dentistry, Mashhad University of Medical Sciences, Mashhad, Iran

2 Orthodontist, Toronto, Canada

3 Department of Pediatric Dentistry, Faculty of Dentistry, Birjand University of Medical Sciences, Birjand, Iran

4 Oral and Maxillofacial Radiology, School of Dentistry, Hormozgan University of Medical Sciences, Bandar Abbas, Iran


Background: Class II malocclusion is one of the most prevalent occlusion discrepancies. Knowledge of growth changes in craniofacial components can help clinicians plan orthodontic treatment, determine the proper timing to initiate the treatment, and predict the treatment outcome, especially in growth modification protocols. This study evaluates craniofacial skeleton changes in class II malocclusion subjects compared to class I malocclusion.
Methods: In this cross-sectional study, cephalograms of 858 individuals aged between 7 and 23 were investigated. The samples were divided into the class I group (ANB angle 0–4) and class II group (ANB angle ≥ 4 degrees), including 426 and 432 cephalograms, respectively, and each group was divided into seven subgroups considering age. Cephalometric analysis was performed using OnyxCeph software, and statistical analyses of variance, mean, paired t test, and independent samples t test were performed using SPSS software.
Results: The results showed no significant differences between class I and class II groups in variables related to the cranial base and vertical facial height. In class II groups, the SNA angle was significantly greater. The total mandibular height (Co-Gn), facial angle (Npog-FH), and SNB angle were significantly greater in class I compared to the class II group.
Conclusion: Protrusion of the maxilla affects the formation of class II malocclusion, but an underdeveloped mandible is the main component of Class II malocclusion formation. With increasing age, especially after puberty, the mandible may become more retruded in class II patients.


Najmeh Anbiaee(Google scholar)(Pubmed)

Roozbeh Rashed(Google scholar)(Pubmed)

Ali Bagherpou(Google scholar)(Pubmed)

 Atefeh Nasehi(Google scholar)(Pubmed)

Fereshteh Goudarzi(Google scholar)(Pubmed)


  1. 1. Akbari M, Bagheri Lankarani K, Honarvar B, Tabrizi R, Mirhadi H, Moosazadeh M. Prevalence of malocclusion among Iranian children: a systematic review and meta-analysis. Dent Res J (Isfahan). 2016;13(5):387-95. doi: 10.4103/1735- 3327.192269.

    2. Dimberg L, Arnrup K, Bondemark L. The impact of malocclusion on the quality of life among children and adolescents: a systematic review of quantitative studies. Eur J Orthod. 2015;37(3):238-47. doi: 10.1093/ejo/cju046.

    3. Portelli M, Militi A, Cicciù M, Lo Giudice A, Cervino G, Fastuca R, et al. No compliance correction of class II malocclusion in growing patients Whit HERBST appliance: a case report. Open Dent J. 2018;12:605-13. doi: 10.2174/1745017901814010605.

    4. Ramirez-Yañez GO. Craniofacial growth and development. In: Liem E, ed. Sleep Disorders in Pediatric Dentistry. Cham: Springer; 2019. p. 39-56. doi: 10.1007/978-3-030-13269- 9_3.

    5. Proffit WR, Fields HW, Msd DM, Larson B, Sarver DM. Contemporary Orthodontics, 6e: South Asia Edition-E-Book. Elsevier India; 2019.

    6. Flores-Ysla A, Arriola-Guillén LE, Rodríguez-Càrdenas YA, Ruíz-Mora GA, Aliaga-Del Castillo A, Janson G. Skeletal open bite cranial base characteristics in young Latin- American individuals with class I, II and III malocclusions: an observational study. Int Orthod. 2020;18(2):237-45. doi: 10.1016/j.ortho.2020.01.002.

    7. Angle EH. Classification of malocclusion. Dent Cosmos. 1899;41(3):248-64.

    1. Varrela J. Early developmental traits in class II

      malocclusion. Acta Odontol Scand. 1998;56(6):375-7. doi:


    2. Barbosa LAG, Araujo E, Behrents RG, Buschang PH.

      Longitudinal cephalometric growth of untreated subjects with class II division 2 malocclusion. Am J Orthod Dentofacial Orthop. 2017;151(5):914-20. doi: 10.1016/j. ajodo.2016.10.026.

    3. Antonini A, Marinelli A, Baroni G, Franchi L, Defraia E. Class II malocclusion with maxillary protrusion from the deciduous through the mixed dentition: a longitudinal study. Angle Orthod. 2005;75(6):980-6. doi: 10.1043/0003-3219(2005)75[980:cimwmp];2.

    4. Sinha S, Nayak K, Soans C, Murali P, Shetty A, Ravi M. Assessment of mandibular retrognathism and maxillary prognathism as contributory factors for skeletal class II malocclusion: a cephalometric study. Int J Oral Health Sci. 2018;8(2):99-103. doi: 10.4103/ijohs.ijohs_3_18.

    5. Bishara SE, Jakobsen JR, Vorhies B, Bayati P. Changes in dentofacial structures in untreated class II division 1 and normal subjects: a longitudinal study. Angle Orthod. 1997;67(1):55-66. doi: 10.1043/0003- 3219(1997)067 < 0055:cidsiu >;2.

    6. Ardani I, Sanjaya ML, Sjamsudin J. Cephalometric characteristic of skeletal class II malocclusion in Javanese population at Universitas Airlangga Dental Hospital. Contemp Clin Dent. 2018;9(Suppl 2):S342-S6. doi: 10.4103/ ccd.ccd_465_18.

    7. Evälahti M. Craniofacial Growth and Development of Finnish Children: A Longitudinal Study [dissertation]. Helsinki: University of Helsinki; 2020. p. 345.

    8. Obaidi HA. The variation of the cranial base parameters in class I, II and III skeletal relationships. Rafidain Dent J. 2007;7(1):6-13. doi: 10.33899/rden.2006.39787.

    9. Matthews HS, Penington AJ, Hardiman R, Fan Y, Clement JG, Kilpatrick NM, et al. Modelling 3D craniofacial growth trajectories for population comparison and classification illustrated using sex-differences. Sci Rep. 2018;8(1):4771. doi: 10.1038/s41598-018-22752-5.

    10. de Almeida KCM, Raveli TB, Vieira CIV, dos Santos-Pinto AD, Raveli DB. Influence of the cranial base flexion on class I, II and III malocclusions: a systematic review. Dental Press J Orthod. 2017;22(5):56-66. doi: 10.1590/2177- 6709.22.5.056-066.oar.

    11. Afrand M, Ling CP, Khosrotehrani S, Flores-Mir C, Lagravère- Vich MO. Anterior cranial-base time-related changes: a systematic review. Am J Orthod Dentofacial Orthop. 2014;146(1):21-32.e6. doi: 10.1016/j.ajodo.2014.03.019.

    12. Wu XP, Xuan J, Liu HY, Xue MR, Bing L. Morphological characteristics of the cranial base of early angle’s class

    II division 1 malocclusion in permanent teeth. Int J Morphol. 2017;35(2):589-95. doi: 10.4067/s0717- 95022017000200034.

    20. Gong A, Li J, Wang Z, Li Y, Hu F, Li Q, et al. Cranial base characteristics in anteroposterior malocclusions: a meta-analysis. Angle Orthod. 2016;86(4):668-80. doi:10.2319/032315-186.1.

    21. Monirifard M, Sadeghian S, Afshari Z, Rafiei E, Sichani AV. Relationship between cephalometric cranial base and anterior-posterior features in an Iranian population. Dent Res J (Isfahan). 2020;17(1):60-5.

    22. Awad AM, Gaballah SM, Gomaa NE. Relationship between cranial base and jaw base in different skeletal patterns. Orthod Waves. 2018;77(2):125-33. doi: 10.1016/j.odw.2018.03.002.

    23. Currie K, Sawchuk D, Saltaji H, Oh H, Flores-Mir C, Lagravere M. Posterior cranial base natural growth and development: a systematic review. Angle Orthod. 2017;87(6):897-910. doi: 10.2319/032717-218.1.

    24. Salehi P, Momeni Danaie S. Mandibular size and position in 8-13 year old Iranian children with class II division 1 malocclusion. Front Dent. 2006;3(2):92-9.

    25. Yoon SS, Chung CH. Comparison of craniofacial growth of untreated class I and class II girls from ages 9 to 18 years: a longitudinal study. Am J Orthod Dentofacial Orthop. 2015;147(2):190-6. doi: 10.1016/j.ajodo.2014.10.023.

    26. Ramezanzadeh BA, Sabzevari B. Cephalometric evaluation of craniofacial features of class II division 1 malocclusion in patients 11-14 years old refered to Mashhad dental school during 1996-2002. J Dent Sch Shahid Beheshti Univ Med Sci. 2005;23(1):37-47. [Persian].

    27. García-Díaz R, Arriola-Guillén LE, Aliaga-Del Castillo A, Agudelo-Botero AM, Fiori-Chincaro GA. 2D-3D comparison of the temporomandibular joint in skeletal class II versus class I adults: a retrospective study. Int Orthod. 2020;18(4):784-93. doi: 10.1016/j.ortho.2020.05.006.

    28. Riesmeijer AM, Prahl-Andersen B, Mascarenhas AK, Joo BH, Vig KW. A comparison of craniofacial class I and class II growth patterns. Am J Orthod Dentofacial Orthop. 2004;125(4):463-71. doi: 10.1016/j.ajodo.2003.05.012.

    29. Jacob HB, Buschang PH. Mandibular growth comparisons of class I and class II division 1 skeletofacial patterns. Angle Orthod. 2014;84(5):755-61. doi: 10.2319/100113-719.1.

    30. Stahl F, Baccetti T, Franchi L, McNamara JA Jr. Longitudinal growth changes in untreated subjects with class II division 1 malocclusion. Am J Orthod Dentofacial Orthop. 2008;134(1):125-37. doi: 10.1016/j.ajodo.2006.06.028.

    31. Loredana G, Georgeta Z, Alina SB, Radu CE, Gena DC, Daniela A. Relationship between maxillary and mandibular base length and type of malocclusion. In: 2020 International Conference on e-Health and Bioengineering (EHB). Iasi, Romania: IEEE; 2020. doi: 10.1109/ehb50910.2020.9280284.