Journal of International Oral Health

: 2023  |  Volume : 15  |  Issue : 4  |  Page : 342--349

Class II division 1 malocclusion treatment trends in the last 10 years by skeletal classification: A review article

I G A W Ardani1, Hanifa Aini1, Ida B Narmada1, Shailesh Deshmukh2, Alexander P Nugraha1,  
1 Orthodontic Department, Universitas Airlangga, Surabaya, Indonesia
2 Department of Orthodontics and Dentofacial Orthopedics, Bharati Vidyapeeth University Dental College, Pune, Maharashtra, India

Correspondence Address:
Prof. I G A W Ardani
Department of Orthodontics, Faculty of Dental Medicine, Universitas Airlangga Mayjend Prof. Dr. Moestopo 47, Surabaya, East Java 60132


Aim: This study aimed to describe the various protocols for treating class II/1 malocclusion, determine the one-phase and two-phase treatment approaches, and identify the best time to provide effective and efficient treatment. Materials and Methods: An electronic search in four major databases—PubMed, Scopus, ScieLo, and Google Scholar—was completed on March 4, 2021. A search was performed on the orthodontic treatment of class II/1 over the last 10 years, and 2002 papers were obtained. Results: A total of 52 journal articles matched the inclusion criteria. Class II/1 malocclusion was more commonly found with class II/1 skeletal analysis, and one-phase treatment was preferred over two-phase treatment. One of the keys to successful treatment is the effectiveness of the treatment, which depends on the time of the treatment intervention and the appliance used. Conclusions: Determination of treatment is highly dependent on the characteristics of the malocclusion, age, and remaining growth. Due to the complexity of the case, knowledge and experience are needed in managing class II malocclusion.

How to cite this article:
Ardani IA, Aini H, Narmada IB, Deshmukh S, Nugraha AP. Class II division 1 malocclusion treatment trends in the last 10 years by skeletal classification: A review article.J Int Oral Health 2023;15:342-349

How to cite this URL:
Ardani IA, Aini H, Narmada IB, Deshmukh S, Nugraha AP. Class II division 1 malocclusion treatment trends in the last 10 years by skeletal classification: A review article. J Int Oral Health [serial online] 2023 [cited 2023 Sep 22 ];15:342-349
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Full Text


The Angle’s class II/1 malocclusion is the most common malocclusion with skeletal discrepancies found by orthodontists in daily practice,[1],[2] which can be accompanied by skeletal class 1 or 2.[3] The morphology of class II malocclusion has been analyzed in various cephalometric examinations[4],[5] and has vast variations.[2] Understanding the morphology of malocclusion is essential for planning orthodontic treatment involving dentofacial region/complex.[5] The presence of morphological variations from dental and skeletal in class II malocclusion makes the case highly complex and challenging to treat.

Moyers et al.[6] divided class II malocclusion according to horizontal and vertical characteristics discovering six horizontal and five vertical patterns in class II/1, namely type A: maxillary dental protraction; type B: maxillary prognathism and dental protraction; type C: maxillary retrognathism with flared or upright incisors and severe mandibular retrognathism with flared lower incisors; type D: maxillary retrognathism with dental protraction and severe mandibular retrognathism; type E: maxillary prognathism and dental protraction + mandibular dental flaring; and type F: mandibular retrognathism.[7] In a recent study, three class 2 skeletal types were present: type 1 (retrusive mandible), type 2 (maxillary protrusive), and type 3 (combination of both).[8] This means the same treatment cannot be provided in all cases. The optimal timing of treatment remains controversial. Most patients with class 2 malocclusion have some type of bone imbalance, and early treatment is often chosen to modify jaw growth.[9] For patients with a short growth period remaining, alternative treatment involves a fixed appliance with the first premolar tooth extraction.[10] There are various protocols for treating class II/1 skeletal malocclusion. However, there are limited studies about the one-phase and two-phase treatment approaches and the best time to provide effective and efficient treatment in class II/1 skeletal malocclusion. This study aimed to describe the various protocols for treating class II/1 malocclusion, determine the one-phase and two-phase treatment approaches, and identify the best time to provide effective and efficient treatment.

 Materials and Methods

The current scoping review was conducted based on the principles of Preferred Reporting Items for Systematic Reviews and Meta-Analysis 11.

Search strategy

As three independent researchers, I.G.A.W.A., H.A., and I.B.N, completed an electronic search in four major databases. Exhaustive electronic searches were conducted in PubMed, Scopus, ScieLo, and Google Scholar on March 4, 2021. Electronic searches using advanced search with words malocclusion Angle’s class II division 1 or Angle’s class II division 1 or class II malocclusion division 1, and orthodontics or interceptive orthodontics or corrective orthodontics or orthodontic appliances or orthodontic brackets were performed to identify all eligible studies. The keywords used were in accordance with the MeSH terminology.[11]

Inclusion criteria

This study was limited to the case report journals of the last 10 years that involved patients in all growth stages (children to adults) with Angle’s class II/1 malocclusion, with curative or interceptive orthodontics using one-phase or two-phase treatments, and complete treatment history (patient identity, pre- and posttreatment histories including extraoral and intraoral photos, and radiographic and cephalometric analyses).

Exclusion criteria

The exclusion criteria set included journals that were more focused on new products, patients with craniofacial anomalies, and those treated with preventive orthodontic treatment or orthognathic surgery, longitudinal studies, controlled clinical trials (randomized, prospective, or retrospective), in vivo studies, in vitro studies, indexes, and epidemiology.

Data extraction

The following data were extracted from each article: author, publication year, the patient’s origin, total case studies, malocclusion characteristics, and treatment protocol.

Risk-of-bias assessment

The risk-of-bias assessment was carried out using an approach adapted from past scoping reviews. The explanation of multiple quality assessment factors, standardized sample or subject preparation, randomization of samples or subjects, tests done by a single-blinded operator, a clear test method definition, and full reporting of findings were all examined in this evaluation. The article was labeled “Y” for a particular parameter if the authors reported it and “N” if the information could not be found. Based on the amount of “Y” components included (1–2, 3–4, or 5–6), the articles were classified as having a high, medium, or low risk of bias.


Of the 2002 published articles, 84 duplicate articles were removed. From the remaining 1918 articles, 1840 were excluded after reading the title and abstract. During the second selection stage, eligibility assessments were conducted by reading the full text of the remaining 78 articles; 26 were excluded. Hence, 52 articles were finally included in the study [Figure 1]. Five articles matched the study criteria: 1–5 case studies, so the total number of cases is 61 [Table 1]. The researchers studied the full texts of those studies and finally picked 52 that met the inclusion criteria. The majority of the articles utilized in this literature review had a low risk of bias—as many as 40 papers—whereas 12 of 52 papers had a moderate risk of bias.{Figure 1} {Table 1}

Class II/1 malocclusion was more commonly found with class 2 type 1 skeletal analysis [Table 2] and [Graph 1], and one-phase treatment was preferred over two-phase treatment [Graph 2]. In a two-phase treatment, the first phase aimed at orthopedic action to change skeletal relations, whereas the second phase optimized interdigitation through detailing and finishing. This study summarizes the most frequently used treatment protocols according to class 2/1 skeletal analysis [Table 3].{Table 2} {Figure 2} {Figure 3} {Table 3}


Class II/1 skeletal malocclusion analysis was more frequently associated with class II/1 malocclusion in this review, and one-phase therapy was chosen over two-phase treatment. A two-phase therapy was carried out to maximize interdigitation through detailing and finishing. The first phase focused on orthopedic interventions to modify skeletal relations. Class II/1 malocclusion, especially with an underdeveloped mandible, is one of the most challenging orthodontic problems to treat.[57] This study revealed that as many as 80% of case studies stated that the mandible was in a retrognathic condition, of which 71% were accompanied by normal maxillary, and the rest with a prognathic condition. In class II skeletal malocclusion, mandibular retrognathia appeared to be a significant causative factor.[31] Tripathi and Patil also claim that the most common skeletal problem of class II malocclusion in the prepubertal stage is mandibular retrognathia.[14] In this study, three races [Graph 1] were represented in a large number of case studies that described class II/1 malocclusion with skeletal class II type 1, that is, the maxilla was normal, and the mandible was retrognathic.

In individuals with skeletal class II (mandibular retrusion) who are still growing, the critical factor for successful treatment is the effectiveness of functional treatment, which depends on the time of treatment intervention (skeletal maturity) and the type of functional device used.[64] In individuals whose mandibles are retrognathic, the ideal treatment is a change in the direction of mandibular growth. Functional appliances include removable and fixed devices designed to change the position of the mandible, both sagittally and vertically, and to induce additional mandibular elongation by stimulating the growth of the condylar cartilage.[65],[66],[67],[68] Various functional devices can be used to correct this type of skeletal and occlusal abnormalities during the pubertal growth spurt period.[57] The pubertal growth spurt occurs simultaneously with the peak of mandibular growth. Thus, it is accepted that the treatment time is around 12–16 years for boys and 10–14 years for girls (pubertal growth period), which is the optimal condition for stimulation of condylar growth and adaptation of the temporomandibular joint suited for functional treatment.[64]

Class II elastics and fixed functional devices are both primarily used to treat class II malocclusion. It should be noted that their modes of operation are different. In terms of style, elastic provides the intermittent force, whereas fixed functional appliances provide continuous force. Elastics perform traction, whereas fixed functional devices provide impulses.[68] Some of the dentofacial changes associated with the use of class II elastics include maxillary retraction, mandibular protraction, lower anterior facial height increase, clockwise rotation of the occlusal plane, retroclination of maxillary incisors, proclination of mandibular incisors, and forward movement and extrusion of mandibular molars.[69]

In this study, 85% of cases used one-phase treatment, whereas the rest used two-phase treatment (prepubertal and pubertal). Debates are still ongoing on whether two-phase treatments are necessary. Two-phase treatments are considered profitable and, therefore, recommended by some dentists, whereas others consider them a waste of time and money.[31] Previous studies suggest that earlier orthodontic treatment of class II/1 malocclusions is important to stimulate mandibular growth, prevent incisor trauma, and even rebuild self-confidence.[57] One-phase and two-phase orthodontic treatments involve phase one, with generally 6–12 months of active treatment to change skeletodental relationships, and phase two with the “finishing” process after the eruption of appropriate permanent teeth. A comparative study of one-phase versus two-phase orthodontic treatments illustrated that treatment administered while waiting for permanent dentition allows more stable results; the study assumed that orofacial function develops gradually and is more reliable in the new morphological environment created by this orthodontic treatment.[70] The previous study stated that early therapy is just as beneficial as a late treatment for most children with class II difficulties, and it is more successful at reducing maxilla development during the pubertal growth surge than before puberty.[71]

The optimal timing for treating patients with class II malocclusion is at the early stage of cervical vertebral maturation, that is, cervical stage 3 (CS3), to maximize the effectiveness of treatment.[23] The presence of CS2 indicates that the growth spurt is approaching and will begin in CS3, about 1 year after CS2.[24],[25] The treatment age for class II/1 skeletal malocclusion should be around 8–14 years.[72] Active growth is almost complete by the time CS6 is reached. Similarly, this method can clinically identify the appropriate time for intervention in subjects requiring surgery for late correction of facial disharmony.[73] In treatments requiring growth modification, knowing the right time to perform these modifications is crucial. Forty-one cases stated that they succeeded in changing the A point, Nasion, and B point value by 1°–5°. Thirty-three cases employed one-phase treatment, whereas the rest used a two-phase treatment protocol. The age presented in this study is consistent with much of the previous literature[74] regarding age recommendations in providing care for growth modification.

Although two-phase treatment is not widely chosen, its benefits should not be ruled out. Some studies convey the need to treat not only the teeth but also the muscles of patients with class II/1 malocclusion. In their study, de Souza et al.[75] stated that the myofunctional changes observed after orthodontic treatment in class II/1 malocclusion patients appear to compromise long-term orthodontic stability, leading to recurrence. Therefore, myofunctional assessment and therapy in conjunction with orthodontic treatment may be crucial to reestablishing the myofunctional balance of the stomatognathic system and preventing the return of malocclusion.[24] It is undoubtedly important to consider the use of removable functional devices as an early stage of treatment.

Orthodontic treatment goals usually include obtaining good facial balance, optimal static and functional occlusion, and stability of the treatment outcome.[24] One of the essential aspects of the 21st-century goals of treatment, apart from the profile and occlusion, is the resolution of the problems reported by the patients. At the end of the treatment period, 61 case studies proclaimed that a pleasant facial profile was obtained, and the patients were satisfied with the result. Regarding occlusion stability, as many as 57 case studies reported that the occlusion was stable, whereas the rest showed poor or unstable occlusion. This is because the four case studies only used a removable orthodontic functional device as an interceptive treatment.


Based on the systematic review above, the following can be concluded:

Class II/1 malocclusion is often accompanied by skeletal class II type 1.

The one-phase treatment approach is more widely applied than the two-phase treatment.

Growth modification is most successful in patients in the age range of 11.1 ± 1.7 years when pubertal growth is reached in CS3.

Besides achieving a healthy and stable occlusion, orthodontic treatment aims to improve the facial profile and address the primary complaint.

However, due to limited evidence and investigation methods, the conclusion should be considered cautiously. Further study is required to examine the efficacy of one-phase and two-phase treatment approaches in class II/1 skeletal malocclusion and the ideal time to provide effective and efficient treatment in class II/1 skeletal malocclusion with randomized clinical trial settings.

Clinical significance

The type of treatment to be rendered to a patient depends on the severity of the malocclusion, age, and the patient’s remaining growth period. Therefore, the clinician must possess a high level of knowledge to solve the problems and meet the aspirations of the class II/1 malocclusion patient.


The authors would like to thank Faculty of Dental Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia, for supporting this study.

Financial support and sponsorship


Conflicts of interest

The authors declare there is no conflict of interest.

Author contributions

Conceptualization: I G.A.W. Ardani, Hanifa Aini Methodology and resources: Ida B. Narmada Shailesh Deshmukh Writing—original draft preparation: I G.A.W. Ardani, Hanifa Aini, Ida B. Narmada, Shailesh Deshmukh, Alexander P. Nugraha Writing—review and editing: I G.A.W. Ardani, Hanifa Aini, Ida B. Narmada, Shailesh Deshmukh, Alexander P. Nugraha Funding acquisition: I G.A.W. Ardani, Hanifa Aini. All authors have read and agreed to the published version of the manuscript.

Ethical policy and institutional review board statement

Not applicable.

Patient declaration of consent

Not applicable.

Data availability statement

The dataset used in the current study is available upon request from the corresponding author.


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