CASE REPORT
Combined orthodontic-orthopedic
treatment of an adolescent Class II
Division 2 patient with extreme deepbite
using the Forsus Fatigue Resistant Device
Mehmet Bayram
Trabzon, Turkey
Class II Division 2 malocclusion is often characterized by severe, traumatic deepbite with lingually inclined and
overerupted incisors. Combined orthodontic-orthopedic treatment of this malocclusion is a challenging issue for
orthodontists. This case report describes the combined orthodontic-orthopedic treatment of an adolescent Class
II Division 2 patient with an extreme deepbite and a retrognathic mandible using the Forsus Fatigue Resistant
Device. (Am J Orthod Dentofacial Orthop 2017;152:389-401)
A
Class II Division 2 malocclusion is characterized
by a severe deepbite with retroclination of the
maxillary incisors.1 The prevalence of Class II
Division 2 malocclusions is relatively low compared
with other malocclusions.2 A strong genetic input exists
with regard to the underlying skeletal pattern and dental
anomalies in these patients.2,3 It can be classified as a
dental or a skeletal anomaly.4 The dental Class II Division
2 anomaly is characterized by a balanced soft tissue
facial profile with no skeletal discrepancy, but it has a
Class II molar relationship and retroclined maxillary
incisors with a deep overbite and an obtuse interincisal
angle.5 In addition to these intraoral findings, the
skeletal group is characterized by reduced lower facial
height, short upper lip, prominent chin, and small gonial
angle.6 The high lower lip line with associated resting
pressure has been shown to be linked to retroclination
of the maxillary incisors.7
Orthodontic treatment of Class II Division 2 maloc-
clusions is recognized as difficult and prone to relapse.7
The treatment modalities for this malocclusion include
growth modification, dental compensation, and
Department of Orthodontics, Faculty of Dentistry, Karadeniz Technical University,
Trabzon, Turkey.
The author has completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Mehmet Bayram, Karadeniz Teknik Universitesi, Dis
Hekimligi Fakultesi, Ortodonti Anabilim Dali, Trabzon, 61080, Turkey; e-mail,
dtmehmetbayram@yahoo.com.
Submitted, April 2016; revised and accepted, July 2016.
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved.
http://dx.doi.org/10.1016/j.ajodo.2016.07.023
surgical-orthodontic therapy. The type of treatment
depends on the patient's age and growth potential.8
Because of specific morphologic characteristics,
including retroclination of the maxillary incisors, a deep-
bite with a tendency for a brachycephalic facial pattern
and a poor soft tissue facial profile, a nonextraction
approach is recommended to treat Class II Division 2
malocclusions.9
During the functional orthopedic treatment protocol
in growing patients, Class II Division 2 malocclusions are
usually transformed into Class II Division 1 malocclu-
sions by proclination of the maxillary incisors and then
treated as a Division 1 malocclusion. In skeletal Class II
Division 2 patients with a hypodivergent facial pattern,
the deep overbite can be corrected, and facial esthetics
can be improved by increasing the lower facial height,
correcting lip redundancy, or increasing facial convex-
ity.8 Rather than intrusion of the incisors, extrusion of
the posterior teeth is a favorable choice to correct the
deep overbite resulting in increased lower anterior facial
height caused by clockwise rotation of the mandible in
growing patients.8
This case report describes the combined orthodontic-
functional treatment outcomes of an adolescent Class II
Division 2 patient with an extreme deepbite and a retro-
gnathic mandible using a fixed functional appliance.
DIAGNOSIS AND ETIOLOGY
The patient, a 13-year-old boy, had a chief
complaint of significantly retroclined maxillary anterior
teeth and impingement of the palatal gingiva by the
389
390
Fig 1. Pretreatment facial and intraoral photographs.
mandibular incisors. He was in good general health and
had no history of major systemic diseases. Facial
photographs showed a symmetric face, a concave
profile with a prominent chin, a proportionally short
lower anterior facial height, lip competence at rest,
and a deep labiomental fold. He had a normal gingival
tissue display when smiling (Fig 1). The temporoman-
dibular joint evaluation showed no signs of clicks or
crepitation, and the facial and masticatory muscles
were asymptomatic.
The patient had an excessive overbite of 10 mm
(120%) and retroclined maxillary incisors with the
mandibular incisors impinging on the palatal gingivae
due to an increased curve of Spee (Figs 2 and 3).
Although the overall periodontal condition was good,
the areas labial to the mandibular incisors and lingual
to the maxillary incisors were at risk of deterioration,
with possible inflammation and recession, because of
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Bayram
the deep impinging overbite. Angle Class II molar and
canine relationships were observed on both sides. The
maxillary midline was 1.0 mm to the right of the facial
midline. The mandibular midline was centered relative
to the facial midline. The maxillary arch was symmetric
and square shaped. The mandibular arch was also
symmetric and U-shaped. No significant arch-length
deficiency was noted in either arch.
The initial panoramic radiograph showed no missing
teeth, and alveolar bone and root formation were within
normal limits (Fig 4). All teeth, including the developing
third molars, were present. The cephalometric analysis
showed a Class II skeletal pattern (ANB angle, 6 ) due
to a retrognathic mandible with a low mandibular plane
angle (SN/GoGn angle, 20 ) and retroclined maxillary
and mandibular incisors (U1/ANS-PNS angle, 78 ;
IMPA, 85 ) resulting in an increased interincisal angle
(177 ) (Table).
Bayram
Fig 2. Pretreatment dental casts.
Fig 3. Exaggerated curve of Spee and impingement of the palatal gingiva by the mandibular incisors
due to the deep overbite.
TREATMENT OBJECTIVES
The treatment objectives for this patient were to (1)
correct the inclination and position of the maxillary
anterior teeth, (2) correct the deep overbite by extrusion
of the posterior teeth, (3) increase the anterior facial
height, (4) reduce the depth of the curve of Spee,
(5) stimulate the mandibular growth to correct the
skeletal discrepancy, (6) establish Class I molar and
canine relationships, (7) create ideal overbite and overjet
relationships, (8) establish an esthetically pleasing soft
tissue facial profile, and (9) obtain stable results.
TREATMENT ALTERNATIVES
Based on the treatment objectives, the following
alternatives were presented to the patient and his parents.
1. Combined orthodontic and functional appliance
treatment with a nonextraction approach would be
adopted. After proclination of the maxillary incisors, a
American Journal of Orthodontics and Dentofacial Orthopedics
391
fixed anterior biteplane appliance would be used to
extrude the mandibular posterior teeth, increase the
vertical dimension, and reduce the depth of the curve
of Spee. Then, the combined fixed-functional appliance
treatment would be applied to correct the sagittal and
vertical skeletal discrepancies and detail the occlusion.
2. After proclination of the maxillary incisors with a
removable appliance or a 2 3 6 fixed appliance
mechanics, a removable functional appliance would be
applied to stimulate mandibular growth. Then, fixed
appliance treatment would be used for detailing the
occlusion. However, the success of this treatment plan
would greatly depend on the patient's cooperation.
3. Ignoring the poor soft tissue facial profile, distali-
zation of the maxillary dentition would be performed
using extraoral or intraoral appliances. Although this
treatment approach should produce satisfactory results
intraorally, it would not correct the soft tissue profile
and underlying skeletal discrepancy efficiently.
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Fig 4. Pretreatment, lateral cephalometric radiograph, tracing, and panoramic radiograph.
Tooth extraction was excluded in all treatment
options because of the patient's poor soft tissue facial
profile, which would have been aggravated by extrac-
tions. After discussing the advantages and disadvan-
tages of each treatment option, the patient and his
parents chose the first treatment option.
TREATMENT PROGRESS
The treatment began with the placement of
bands and preadjusted 0.022-in brackets with
MBT prescription (3M Unitek, Monrovia, Calif) to
the maxillary teeth. A 0.016-in heat-activated
nickel-titanium wire was engaged as the initial
archwire for leveling and aligning. After proclination
of the retroclined maxillary incisors for 5 months, a
fixed anterior biteplane was constructed and applied
to encourage the spontaneous extrusion of the
mandibular posterior teeth (Fig 5). In this way,
decreasing the depth of the curve of Spee, reducing
the deep overbite, and increasing the anterior face
height were intended.
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After 6 months of spontaneous extrusion of the
mandibular posterior teeth and eruption of the
mandibular second molars, active orthodontic treat-
ment was started in the mandible. Bondable fixed
appliances were attached to the mandibular teeth
including the mandibular second molars. After the
aligning stage, a 0.019 3 0.025-in reverse curve
nickel-titanium wire was placed in the mandibular
arch for 2 months to level the remaining curve of
Spee. Then, the fixed anterior biteplane appliance
was removed by cutting. The mild soft tissue irritation
under the appliance was monitored (Fig 6). A lateral
cephalometric radiograph was obtained to evaluate
the dentofacial changes that occurred up to this stage
(Fig 7).
Seventeen months after the commencement
of treatment, the sagittal skeletal discrepancy correc-
tion was initiated. Stainless steel archwires
(0.019 3 0.025 in) were placed in both arches, and
the end of each wire was cinched back. A figure-8
tie with a ligature wire was used between the mandib-
ular canines. An appropriate sized Forsus Fatigue
Bayram 393

Table. Cephalometric measurements of the patient

Pretreatment Before Forsus FRD After Forsus FRD Posttreatment Two-year follow-up
SNA ( ) 80 81 81 80 81
SNB ( ) 74 75 78 79 79
ANB ( ) 6 6 3 1 2
SN-GoGn ( ) 20 23 24 22 21
N-Me (mm) 98.5 116 113 114.5 117
ANS-Me (mm) 54.5 65 62 64.5 66
U1-NA (mm) 5 5.5 3 5 3.5
U1-NA ( ) 2 29 26 30 24
U1-ANS-PNS ( ) 78 110 106 110 105
L1-NB (mm) 2.5 2 6 4 3.5
L1-NB ( ) 1 15 30 23 21
IMPA ( ) 85 97 107 104 103
Interincisal angle ( ) 177 130 106 125 133
Overjet (mm) 3 12 1 2 2.5
Overbite (mm) 10 3 0.5 2 3
Lower lip–E-line (mm) 5.2 6.9 6.1 6.4 7.0
Upper lip–E-line (mm) 5.4 5.8 7.9 7.2 8.0
Nasolabial angle ( ) 125 105 114 108 103
Labiomental angle ( ) 67 78 88 76 93

Fig 5. Intraoral photographs after leveling of maxillary arch and the fixed anterior biteplane appliance.

Resistant Device (FRD) with EZ-2 module (3M Unitek)
was selected according to the distance from the distal
end of the maxillary molar tube to a point distal to the
canine bracket while the patient occluded in centric
relation. The Forsus FRD was applied to the occlusal
headgear tube on the maxillary first molar and the
mandibular archwire between the mandibular first
premolar and canine (Fig 8). The Forsus FRD was
then left in place until the Class II occlusion was
overcorrected to an edge-to-edge incisor relationship
(Figs 9 and 10).
After 7 months in situ, the Forsus FRD was removed.
Then, the final arch coordination and detailing of the
occlusion were adjusted for 4 months before the fixed
appliances were removed. During the finishing stage,
the final detailing of the occlusion was accomplished
with 0.017 3 0.025-in titanium-molybdenum archwires
in conjunction with vertical elastics with Class II vectors
(1/8 in, 6 oz).
A maxillary removable Hawley retainer with an
anterior biteplane and a canine-to-canine mandibular
fixed lingual retainer were constructed for the patient

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394 Bayram

Fig 6. Facial and intraoral photographs before the application of the Forsus FRD.

Fig 7. Lateral cephalometric radiograph and tracing before the application of the Forsus FRD.

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Fig 8. Application of the Forsus FRD.
and delivered after debonding. The recommended
posttreatment instructions included full-time Hawley
retainer use for 6 months, followed by nighttime
use for at least 18 months. The total duration of
the treatment was 28 months. The patient's compli-
ance was excellent throughout the treatment. At
6 months posttreatment, a gingival graft was
harvested from the palate and placed on the labial
aspect of the mandibular incisors to increase the
width of the attached gingivae.
TREATMENT RESULTS
The posttreatment records indicated that the treat-
ment objectives were achieved (Figs 11-13). The facial
photographs demonstrated significant improvements
in the patient's soft tissue profile and smile esthetics.
Intraorally, the impinging overbite was resolved, and
an optimal overbite and overjet relationship was
achieved. The maxillary and mandibular dental
midlines coincided with the facial midline. A well-
interdigitated buccal occlusion with Class I canine and
molar relationships was obtained. A functional occlusion
with stable posterior support and correct anterior guid-
ance was established. Both dental arches were
horseshoe-shaped and well coordinated. The excessive
curve of Spee was efficiently leveled.
The panoramic radiograph showed no significant
bone loss or root resorption, and all tooth roots were
parallel to each other. The cephalometric analysis
showed that the axial inclination of the maxillary incisors
to the ANS/PNS plane increased from 78 to 110 before
the application of the Forsus FRD. The mandible did not
move forward with the “unlocking” of the deepbite. Due
to the spontaneous extrusion of the mandibular poste-
rior teeth and levelling of the curve of Spee, the
mandible rotated clockwise; thus the vertical dimensions
of the face increased. The use of the Forsus FRD resulted
in significant distalization of the maxillary dentition and
significant dentoalveolar protrusion and mesialization
of the mandibular dentition. Additionally, the tracings
American Journal of Orthodontics and Dentofacial Orthopedics
395
showed improvements in the ANB angle (from 6 to
3 ) and the SNB angle (from 75 to 78 ) after the appli-
cation of the Forsus FRD (Fig 14).
Superimposition of the pretreatment and post-
treatment cephalometric tracings registered on the
sella-nasion line at sella showed dramatic treatment-
related and growth-related changes in the sagittal
and vertical skeletal relationships as well as in the
soft tissue facial profile. The anterior face height
(N-Me) was significantly increased from 98.5 to
114.5 mm. Additionally, remarkable changes were
seen in the axial inclination of the maxillary and
mandibular incisors, interincisal angle, and labiomen-
tal angle.
The patient's occlusion and facial esthetics achieved
with the orthodontic treatment were maintained at the
2-year follow-up visit (Figs 15 and 16). He was
satisfied with the treatment results.
DISCUSSION
The patient had a chief complaint of impingement of
the palatal gingiva by the mandibular incisors and an
esthetically displeasing inclination of the maxillary
incisors. He had a skeletal deep overbite with a relatively
short face and a low mandibular plane angle. Correction
of a deep overbite can be achieved orthodontically by
genuine intrusion of the anterior teeth, extrusion of
the posterior teeth, or a combination of both kinds of
tooth movement.10 The desired tooth movement type
depends on the treatment objectives. After consideration
of multiple factors, such as smile esthetics, lip compe-
tence, occlusal plane, depth of the curve of Spee,
vertical-sagittal skeletal relationships, and the patient's
growth potential, extrusion of the mandibular posterior
teeth to rotate the mandible in a clockwise direction was
considered as the first treatment choice for correcting
the deep overbite.
According to current concepts in orthodontic treat-
ment, the planned incisor position is important for
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396 Bayram

Fig 9. Facial and intraoral photographs after 7 months of application of the Forsus FRD.

Fig 10. Lateral cephalometric radiograph and tracing after application of the Forsus FRD.

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Fig 11. Posttreatment facial and intraoral photographs.
achieving perfect results with an esthetic smile.11 During
treatment planning, the final position of the maxillary
incisors should first be determined, and the treatment
goals should be set accordingly. Although this is possible
in most cases, it may be difficult sometimes, especially in
patients with Class II Division 2 malocclusions because
of the retroclined maxillary incisors. If a decision is
made to procline the maxillary incisors, relative intrusion
can be expected because of changes in the vertical posi-
tion of the crown tip of the maxillary incisors. Therefore,
it is important to evaluate the relationship between the
upper lip and maxillary incisors after the correction of
the axial inclination of the retroclined maxillary incisors.
In this patient, the vertical position of the maxillary
incisors was normal relative to the upper lip after procli-
nation. Due to the short anterior face height and proper
vertical positions of the maxillary incisors, the treatment
plan did not include intruding the incisors. Instead, it
American Journal of Orthodontics and Dentofacial Orthopedics
397
focused on extruding the mandibular posterior teeth
to correct the deepbite and increase the lower anterior
face height.
The use of molar extrusion to correct a deep overbite
is thought to be unstable in adult patients because of
muscle stretching.12 However, extrusion of posterior
teeth in growing patients with a hypodivergent skeletal
pattern provides more stable results because the vertical
dentoalveolar growth is balanced by mandibular
condylar growth.8 In many patients, the clockwise
rotation of the mandible caused by the extrusion of
the posterior teeth worsens the Class II convex profile.13
Likewise, such rotation may have an adverse effect on
the soft tissue facial profile of adults in the absence of
surgical intervention. However, as shown with this
patient, if the correction of a sagittal skeletal discrepancy
is planned, fixed functional appliances can have success-
ful treatment outcomes.
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Fig 12. Posttreatment dental casts.

Fig 13. Posttreatment, lateral cephalometric radiograph, tracing, and panoramic radiograph.

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Fig 14. Superimpositions of cephalometric tracings.

Fig 15. Two-year posttreatment facial and intraoral photographs.

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Fig 16. Two-year posttreatment, lateral cephalometric radiograph, tracing, and panoramic radiograph.
In patients with Class II malocclusions due to
mandibular retrusion, removable and fixed functional
appliances are used to stimulate mandibular growth by
forward positioning of the mandible. Fixed functional
appliances have 2 major advantages: they are
compliance-free alternatives to extraoral or intraoral
appliances, and they exert force all the time. Of the
various fixed functional appliances, the Forsus FRD is
one of the newest and most popular. It does not depend
on patient cooperation and is reported to be more
comfortable for patients.14 In this patient, because of
the need to correct the retroclined maxillary incisors
before the functional appliance treatment, the Forsus
FRD was used in conjunction with orthodontic brackets
to correct the mandibular retrognathia.
In this patient, after correction of the deep overbite
and increasing the overjet, the Class II skeletal relation-
ship was successfully corrected by the combined use of
the fixed appliances and the Forsus FRD. A few studies
have shown that the Forsus FRD is effective in correct-
ing Class II malocclusions with a combination of
skeletal (mainly restriction of maxillary growth) and
dentoalveolar (mainly mesial movement of the
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mandibular incisors and first molars) modifica-
tions.14,15 The results obtained for this patient with
the Forsus FRD were similar to those reported in the
literature. The correction of the overjet was
accomplished mainly by retraction and distalization
of the maxillary dentition and protrusion and
mesialization of the mandibular dentition. Due to the
restriction of maxillary forward growth, some
“headgear effects” were seen on the maxilla, in
addition to some stimulation of mandibular growth.
A primary concern when correcting deep overbites in
Class II Division 2 patients is the long-term stability of the
overbite. The prognosis with this type of malocclusion is
often uncertain, and there is a high probability of relapse
due to the strong masticatory muscle structure and high
lower lip line with associated resting pressure.16 Both the
interincisal angle and the axial inclination of the incisors
can play critical roles in the stability of deep overbite
correction.17 In this patient, only a small increase was
observed in the overbite during the 2-year posttreatment
period. This could be attributed to the maintenance of an
ideal interincisal angle with an anterior occlusal stop at
the end of the treatment, the use of the Hawley retention
Bayram
appliance with anterior biteplane, and the patient's
compliance with the retainer.
CONCLUSIONS
A growing patient with a Class II Division 2 malocclu-
sion, extreme deepbite, and retrognathic mandible was
treated with a nonextraction approach using the Forsus
FRD in conjunction with fixed appliances. The deepbite
was corrected by extrusion of the mandibular molars
using a fixed anterior biteplane appliance and a reverse
curve nickel-titanium archwire before the Forsus FRD.
At the end of the 28-month treatment, a functional
occlusion, a harmonious profile, and patient satisfaction
were achieved. The occlusion was stable at the 2-year
postretention follow-up. This combined fixed-
functional treatment induced skeletal and dentoalveolar
changes and was effective in the treatment of a Class II
Division 2 malocclusion.
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