Management of class2.div2 /certified fixed orthodontic courses by Indian dental academy

MANAGEMENT OF
CLASS-II DIVISION-2
MALOCCLUSION

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INDIAN DENTAL ACADEMY
Leader in continuing dental education



INTRODUCTION
Many treatment approaches are currently
available to the orthodontist for altering the
occlusion relationship typically found in classII division-2 malocclusion.
These treatments include a variety of extraoral traction appliances,arch expansion
appliances , extraction procedures,functional
jaw orthopedic appliances,molar distilation
e.t.c
Depending upon experience,personal
preference and success rate various
modalities are selected

ETIOLOGY:

It is important to distinguish class II malocclusions that are
primarily of genetic origin from those of primarily
environmental when choosing the appropriate treatment
and retention.
1. Genetic causes: HERIDITY
causes

2.Environmental causes:
1.Habits:A.Finger sucking habit
B.Tongue thrusting habit.
C.Mouth breathing habit.
D.lip biting habit.
E.Retained infantile swallow patterns.
.


2.Abnormal perioral muscle functions.
3.Decreased Tongue size and Altered tongue posture.

Local factors:
A.Early loss of deciduous teeth
B.Generalized decrease in size of teeth(mesial
migration).
C.Ectopic eruption of teeth


Classification
According to Moyers class II can be divided into Six Horizontal
types and Five vertical types

Horizontal class II Types
NORMAL SKELETAL PATTERN:Displays normal relationship
of maxilla and mandible to the cranial base and to each other.
Upper and lower dentition are within their normal positions over their
basal bones


TYPE A or DENTAL CLASS II :A Normal skeletal profile and
normal A-P position of jaws.Mandibular dentition is placed
normally on its base but Maxillary dentition is protracted, resulting in
class II molar relationship and increased incisal overjet and overbite
than normal.

HORIZANTAL TYPE F:Displays mild skeletal tendency due
to combination of maxillary protrusion and Mandibular retrusion with
upper and lower anteriors Upright over their basal bones


HORIZANTAL TYPE B: Displays mid face prominence with a
mandible of normal length.Size of maxilla is increased but mandible
is normal Antero posteriorly

HORIZANTAL TYPE C:Displays class II profile though the maxilla and
mandible are further back beneath the anterior cranial base than normal
the lower incisors are tipped labially,the upper incisors are eitherupright
or tipped off the base labially according to the vertical category.


HORIZANTAL TYPE D:Displays a skeletal profile which is
retrognathic because there is a smaller than normal mandible.The mid
face is normal or slightly diminished.The mandibular incisors are
either upright or lingually inclined,where as maxillary incisors are
typically labially positioned


Vertical class II types:
There are Five vertical types of class II ,but
they are not as clearly differentiable as horizontal types.It is not
necessary for a case of horizontal type to be associated with any of the
described vertical class II types.
1.Vertical type 1or High angle case:
Features:
1.Anterior facial height >Posterior facial height.
2.Mandibular and functional occlusal planes are steeper than normal.
3.Palatal plane may be tipped downwards while the anterior cranial
base tends to be upward.


Vertical type 2:
features:
1.Square face.
2.Mandibular plane, functional occlusal plane and palatal planes
are more horizontal and often seem parallel.
3.Gonial angle is smaller than normal
4.Anterior cranial base appears horizontal.
5.Skeletal deep bite


Vertical type 3
Features:

1.Palatal plane tipped upward
resulting in decreased upper
anterior facial height and
predisposition to open bite.


Vertical type 4:
Features:
1.Rare type of vertical pattern.
2.Mandibular plane, functional occlusal plane
and palatal planes are tipped downward.
3.Gonial angle is relatively obtuse.
4.Lip line high in the maxillary alveolar
process.
5.Upper incisors are tipped labially and lower
incisors are tipped lingually.


Vertical type 5:
Features:
1.Mandibular and functional occlusal planes
are placed normally
2.palatal plane is tipped downward
3.Gonial angle is smaller than normal.
4.Skeletal deep bite may be present
5.lower incisors are labially tipped and
upper incisors are lingually tipped.


THERAPEUTIC CLASSIFICATION.

Class II malocclusions can be classified
Therapeutically as:
1.Skeletal class II.
2.Dentoalveolar class II.
3.Functional class II

Skeletal class II
Antero posterior disproportion of jaws in size and position
result in skeletal class II.
Skeletal class II Pattern can result due to:
1. Increased size of Maxilla.
2. Decreased size of Mandible
3.Combination of Increased Maxilla and Decreased
Mandible size

CEPHALOMETRIC FINDINGS INDICATING
CLASS II DUE TO
MANDIBULAR DEFICIENCY: Variant 1:

1.Downward and back ward rotation of
mandible caused by small size of ramus
and body of mandible.
2.Decreased posterior facial height.
3.Steep mandibular plane angle.
4.Increased ANB angle.
5 Increased angle of convexity.

6.Increased over jet.
7.Greater positive value of wits appraisal.
8.Posterior position of point B in relation
to Na perpendicular.
9. Normal position of point A in relation
to Na perpendicular.
10.Dental compensation of protruded
mandibular incisors


MANDIBULAR DEFICIENCY:
Variant 2:Due to decreased Size:
features:
1.convex profile.
. 2.Normal or an increased ramus length.
3.Flat mandibular plane angle.
4.Normal or increased posterior facial height.
5.Excessive bony chin masking the mandibular
deficiency but still have lack of support for lower lip.

6.Short anterior facial height.
7.Hyperactive mentalis muscle.
8.Deep anterior overbite
9.Maxillary incisors are lingually inclined masking
the anteroposterior dental discrepancy..
10.Accentuated curve of spee.


MANDIBULAR DEFICIENCY:
Variant 3:Due to retruded position:
Features:
1. Normal or decreased size of
mandible.
2.Cranial base angle is more obtuse.
3.Glenoid fossa is more posteriorly positioned.


FUNCTIONAL CLASS II :(FORCED BITE MALOCCLUSION)

Based on different types of movement of mandible from
rest position to occlusion class II malocclusions can be
divided into 3 functional types.
1.Functional True class II malocclusion.
2.Functional class II with posterior sliding
movement
3.Functional class II with anterior sliding movement


Why to correct class II div-2?
1.Esthetics.
2. Function.
3.Trauma.
4.TMJ problems.
5.Periodontal problems.

Function: If there is malrelationship between maxilla and
mandible making normal muscle function difficult ,an adaptive
activity of muscle may occur ,so a compensatory muscle functional
activity is established for demands of mastication ,
respiration,deglutition and speech.

TREATMENT PLANNING OF CLASS II:
Treatment planning of class II depends mainly on 3
criteria:
1. Nature of malocclusion.
1.Skeletal.
2.Dentoalveolar.
3.Functional.
4.Combination.
2.Severity of malocclusion.
1.Mild.
2.Moderate.
3.Severe.
3.Age.
2.After growth


General strategies for class II correction
1.Differential restraint and control of skeletal growth
1.Extra oral traction.
2.Differential promotion of skeletal Growth:
1.Functional Jaw orthopedic appliances.
3.Guidance of eruption and alveolar development:
4.Movement of teeth and alveolar process (Camouflage
treatment).
1.Extraction treatment.
2.Non Extraction treatment.

5.Transition of parts during growth:
1.Palatal widening devices.
6.Training of muscles:
1. Functional appliances.
7.Surgical Translation of parts after growth in severe
cases:
1.Orthognathic surgery


LIMITATIONS OF CLASS II THERAPY:
1.Occlusal plane inclinations tend to return after treatment,
this tendency diminishes as age advances.
2.A change in mandibular plane position contributes to
orthodontic result in a number of cases.This change usually
comes from downward and backward mandibular rotation,but
occasionally there is antero posterior shift.
3.Changes in axial inclination of the teeth tend to revert after
orthodontic therapy.


4.Post treatment changes primarily are the shifting of
Occlusal plane toward the original inclination and the
tendency for original incisal axial inclination.
5.Difficulty in correction of skeletal deep bite in class II
div2 due to strong pterygo massetric sling causing
relapse.
6.Success depends on correlation between growth and
treatment.


PROGNOSIS FOR CLASS II CORRECTION
Class II with Horizontal growth pattern:
In these cases prognosis is favorable for correction
of sagittal jaw relations but unfavorable for bite
opening.
Class II with vertical growth pattern :
In these cases prognosis is favorable for bite opening
but unfavorable for correction of sagittal jaw relationships

CLASSIFICATION OF CLASS II DIV-2
 Type A Maxillary four permanent incisors can
tip palatally without occerence of crowding
 High lip line position and certain excess of
external soft tissue material present in the
anterior region
 The lips attain a more dorsal position and a
“dished in” appearance.
 Space present for the correction of dentition
BY-VAN DER LINDEN

Type B- The maxillary permanent central
incisor will move palatally gradually.
The available space in maxillary dental arch
is limited.Thus lateral incisors are placed
labially.
The lower lip will become positioned
inferiorly to maxillary lateral incisors and will
contribute to the increase of their labial
inclination.

Type C- There is a marked shortage of
available space in the maxillary dental
arch.
Centals and Laterals are palatally tipped,
and canines, emerges buccally and
labially tipped position.


TYPE A

TYPE B
TYPE C

FEATURES OF CLASS II DIVISION-2
Features:
1.Mandibular molars assume a
posterior position with respect to maxillary
1st molars and maxillary arch.
2.Mandibular arch may or may not show
any individual irregularities but usually has
exaggerated curve of spee.
3.Supraversion of mandibular incisors.
4.Mandibular labialwww.indiandentalacademy.comis often
gingival tissue
traumatized

5.Maxillary arch is wider than normal in
inter canine region(U shaped arch).
6.Remarkable and constant distinguishing
feature is lingual inclination of maxillary
centrals and labial inclination of lateral incisors.
7.Excess overbite (closed bite)


8.Excessive interocclusal clearance
9.Abnormal path of closure due to
combination of lingual inclination of
maxillary incisors and infraocclusion of
posteriors result in mandible to be forced
into retruded tooth guidance with condylar
movement posteriorly and superiorly in
articular fossa creating a displacement.

Upper lip proversion
Undesirable fullness of upper lip,closer to E-Plane
line.
Imbalance is due to forward version of upper lip


Sub-labial contraction
It occurs at a lower level than the tip of the lip.
It commonly associated with thick hypertrophied
band of muscle crossing the midline.


These facial patterns usually have excessively
strong posterior vertical chain of muscles, anterior
vertical chain of muscles, horizontal chain of
muscles, and perioral musculature


There are six functions necessary in treating Class II,
Division 2 malocclusions, which are general
considerations for evaluating the mechanics sequence:
A. Advancement, torque control, and intrusion of the
upper incisors.
B. Intrusion of the lower incisors and cuspids.
C. Alignment of the buccal segments and Class II
correction.
D. Consolidation of the upper incisors.
E. Idealizing the arches.
F. Finishing.

In most Class II, Division 2 malocclusions the
maxillary dentition is protruded and constrained
by anterior facial musculature. The upper
dentition becomes constricted and, therefore,
constricts the lower dentition. Arch form
development of the maxillary dentition will create
arch form changes reciprocally in the mandibular
arch.


At the same time Quad-Helix is unlocking the
dentition, the maxillary incisors are being
advanced with a utility arch to continue the
unlocking process. Essentially, after the
advancement of the upper incisors


A. Advancement, Torque Control, and Intrusion
of the Upper Incisors
There are four basic factors in upper incisor
intrusion:
1. The direction of force.
2. The amount of pressure.
3. The stabilization of the molars.
4. Torque control and the timing of torque control
in relation to growth factors.

1. The direction of force
A. Tipback of 45°.
B. Distolingual rotation of 10-20°.
C. Expansion of approximately 1 cm on each
side.


2. The amount of pressure.
It takes approximately double the force to
intrude the upper incisors, compared to the lower
incisors (125 to 160 grams).
.016 × .022 blue Eligiloy or Nitinol maxillary
utility arch in the initial phase of treatment.


3. The stabilization of the molars.
Using .016x.022 utility arch
has adverse tipping effect on
maxillary molar.
Quad-Helix, Lingual Arch,
or Tranpalatal Bar will help
stabilize the maxillary molars.
Stabilizing section is .016
× .016 or .016 × .022 with a
tip-forward (down) bend in the
molar section.

4.Torque control
A.It shows the normal growth pattern of maxillary
molar and incisor in class-I occlusion
B.It shows the growth pattern of maxillary molar and
incisor in class-II division-2.


FOLLOWED BY
B.Lower incisor and canine intrusion.
C.Aligning of buccal segment and class-II
correction.
D.Consolidation of upper anteriors.
E.Idealizing the arch.
F.Finishing

RICKETT’S LOWER UTILITY
ARCH
Late in the 1950's Robert Ricketts and others attempted to
counteract the tipping that occurred in the buccal
segments in extraction cases by utilizing the supposedly
immutable lower incisors as an anchor unit to hold the
lower second bicuspids and molars upright in the
retraction process.


TYPICAL VARIATION IN LOWER
UTILITY ARCH


PROTRUSION UTILITY ARCH
The protrusion utility arch is useful for proclining upper
and lower incisors. It is most commonly used for flaring
and intruding maxillary incisors in Class II div-2


BONDED BITE PLANES

1

2

3

4


5

Fixed anterior bite plane
~Acrylic component
~Wire component
~Allows extrusion of posterior
teeth
~Indicated in correction of deep
bite

-Slight accentuated curve in upper
and reverse curve in lower
-Banding of second molar in low
angle cases commonly in class II
DIV-2


Side effects of using continuous arch
wire in class II div-2 cases


BURSTONE INTRUSION ARCH


CONNECTICUT INTRUSION ARCH

-Ravindra nanda et al,j.c.o,1998


SIMENTANEOUS INTRUSION AND
TORQUING

-JCO,1993,JUN,RAPHAELL


ORTHPAEDIC DEVICES USED IN
TREATMENT OF CLASS II
Extra oral force appliances(Head gears):

Indications:
1.As growth modification procedure in treatment of
skeletal class II with anteroposterior as well as vertical
maxillary excess in growing individuals.
2.Normal mandibular skeletal and dental morphology.
3.Cases with active mandibular growth primarily
displacing the mandible in forward rather than downward
direction

Mechanism of action: Deliver forces to compress the
maxillary sutures,modifying the pattern of bone
apposition at these sites,these also inhibit mesial and
occlusal eruption of maxillary posterior teeth.


Type of head gear
1.Cervical Pull head gear:
Mechanism of action: It prevents forward
growth of maxilla and and increase vertical
dimension through extrusion of posterior teeth.


FUNCTIONAL APPLIANCES IN MANAGEMENT OF
CLASS II
Before instuiting myofunctional appliances the following should be
assessed:

1.Functional criteria:
A)Differentiate between true and forced bite malocclusions.
B)Relationships between overjet and function of lips.
C)Hyperactive,adaptive and exacerbated mentalis muscle
D)Posture and function of tongue should be assessed.
E)Mode of breathing (mouth breathers cannot resist all types

of functional appliances in mouth)

Criteria for functional appliances selection
Indications for functional appliances:
1.Patient in growth phase.
2.Skeletal Class II malocclusions due decreased size of
mandible are good indicators for functional appliances
3.Functional forced bite class II with posterior sliding
movement
4.Horizontal growth pattern.
5.Abnormal perioral function and neuromuscular dysfunction

Contraindications:
1.Patient in post growth phase.
2.Skeletal Class II malocclusions due to prognathic maxilla.
3.Skeletal class II due to normal sized and retrusive
positioned
mandible(unfavorable prognosis).
4.Gross irregularities in individual tooth positions(crowding
and rotations).
5.Proclined lower anterior teeth.
6.Vertical growth pattern.

Jumping the Bite
1. dentoalveolar adaptaion
2. mandibular growth
stimulation
3. TMJ adaptation


1.Activator:
Indication: Mild to moderate class II
malocclusions with deep bite and
horizontal growth pattern.

Contraindication:
1.Crowding cases.
2.Proclined lower anteriors.
3.In vertical growers.

Mechanism of action:
1. Promote or redirect the condylar growth
& there by lengthening the mandible.
2. Restrict the sagittal growth of maxilla
3. It causes downward www.indiandentalacademy.com
tipping of maxillary base (activator
with high construction bite).

Bionator(Balters appliance):
Indications:
1.Treatment of class II conditions to correct backward
position of tongue and its consequences.
2.skeletal discrepancy not too severe.
3.Mandible in functional retrusion.

Contraindications:
1.class II due to maxillary prognathism
2.Vertical growth pattern.
3.Labial tipping of lower incisors.


1.Brings the tongue forward and correct
the disturbance in cervical viscera by bringing
them forward ,such a change will enlarge respiratory
pathways and enhance reflex deglutition which will
then become normal.


Frankel functional regulator
Indications :

Class II cases with abnormal perioral
muscle function

This appliance is used as oral
gymnastic appliance to help in
overcoming abnormal perioral muscle
activity and rehabilitates the muscles
and to establish proper lip seal.

FR-2

Twin block appliance:
Indications:
1.In class II malocclusion to modify
occlusal inclined plane in disto occlusion
that have a distal component of force that is
unfavorable for normal forward mandibular
development.
2.In patients with poor tolerance to other
functional appliances

Forces of occlusion are used as functional
mechanism to correct malocclusion.

FIXED FUNCTIONAL APPLIANCES
Indications:
1.Indicated in correction of
class II malocclusions due to retrognathic
mandible in growing patients.
2.In preadolescent patients to utilize
residual growth left.
3.Can be used in Mouth breathers.
4.Uncooperative patients.

Treatment effects :
1.Stimulate mandibular growth.
2.Inhibition of maxillary growth(less
important).
3.Distal movement of upper incisors.
4.Mesial movement of lower dentition.
5.Deep bite correction by intrusion of
lower incisors and enhanced eruption of
lower molars

FORSUS(FLEXIBLE)


FORSUS (RIGID)

UNIVERSAL BITE
JUMPER


SUPER ELASTIC NITI WIRE
(NEOSENTALLOY)

John bednar, j.c.o ,1992


JONES JIG

OPEN NITI SPRING

Richard jones,J.C.O,1992


DISTAL JET APPLIANCE

Aldo carano, J.C.O,1996


PENDULUM APPLIANCE

James.J.hilgers,J.C.O,1992


K-LOOP MOLAR DISTALISAR

Varun kalra,J.C.O,1995


SURGICAL CORRECTION OF CLASS II DIVISION-2

Surgical option should be choosen in following cases:
1.Severe skeletal discrepancy or extremely severe dento
alveolar problem.
2.Adult patients
3.Young patients with extremely severe or progressive
deformity.
4.Good general health status of patient.

SURGICAL CORRECTION OF SKELETAL
CLASS II DIV-2 IN ADULT:
Correction in Anterioposterior plane:
1.Mandibular deficiency:
Mandibular deficiency can be
corrected
surgically by
1.Bilateral Saggital split osteotomy
(Treatment of choice).
2.C osteotomy.
3.L osteotomy.


ClassII Division 2 malocclusions are frequently present in
brachyfacial patterns with resulting strong musculature.
They generally have moderate to minimum convexity, but
occasionally do have a higher convexity with resulting
orthopedic problems. The lower facial height and
mandibular arc are below normal range.
Management of these malocclusion depends on
correct diagnosis, in depth knowledge,proper treatment
Planning and regular www.indiandentalacademy.com
follow up to impart perfect smile

Thank you
Leader in continuing dental education


Management of class2.div2 /certified fixed orthodontic courses by Indian dental academy

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