MANAGEMENT OF CLASS II

MALOCCLUSION
BY:

FATHIMA SHAMIN

FNAL YEAR PART I

CONTENTS

• Introduction
• Definition and Classification
• Treatment objectives
• Management
• Conclusion
• Reference
 INTRODUCTION

• Orthodontic speciality deals with various

malocclusions.
• Many treatment approaches are currently
available to the orthodontists for altering the
occlusion relationship typically found in class II
malocclusion
• These treatments include a variety if extraoral
retraction appliances, arch expansion
appliances, extraction procedure, functional jaw
orthopaedic appliance, molar distalisation etc
DEFINITION OF CLASS II

• According to Angle’s classification;

• It is when the buccal groove of first mandibular molar occludes distal to mesiobuccal
cusp of the first maxillary molar.
• sub-classified it into two division:
1. Class II division 1
2. Class II division 2
Class II division 1 malocclusion

• characterized by class II molar relation on either side with proclined

maxillary anteriors.
• can be associated with proclined lower anteriors. This is a natural
compensation that has taken place to reduce the Overjet.
 FEATURES

• Convex profile
• Short hypotonic upper lip.
• No lip seal
• Proclined upper anteriors
• Hyperactive mentalis
• Hyperactive buccinator
• Constricted narrow upper arch
 LIP TRAP
OVERJET
Class II division 2 malocclusion

Along with classical Class II molar relationship, presence of lingually

inclined upper central incisors and labially tipped upper lateral incisors.
• Variations of this are lingually inclined central and lateral incisors with the
canines labially tipped.
FEATURES

• Molars in disto –occlusion

• Retroclination of upper central incisors
• Deep overbite
• Straight profile
• Broad square face
• Deep mentolabial Sulcus
• Backward path of closure
CLASSIFICATION OF CLASS II DIV 2

• By Van der Linden

• Type A: maxillary four permanent incisors can tip palatally without occurrence of
crowding
• High lip line position and certain excess of external soft tissue material present in anterior
region
• The lips attain a more dorsal position and a dished appearance
• Space present for correction of dentition
• 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 increase of their labial inclination
• Type c: There is marked shortage of available space in maxillary dental arch
• Central and lateral incisors are palatally tipped and canines emerges buccally and labially
tipped position
 TREATMENT OBJECTIVES

• Reduction of Overjet
• Reduction of overbite
• Correction of crowding and local irregularities
• Correction of unstable molar relationship
• Correction of posterior cross bite if any
• Normalizing the musculature
 TREATMENT

• There are three basic approaches to the treatment of class II malocclusion

• They are –
1. Growth modification
2. Camouflage
3. Surgical correction
 GROWTH MODIFICATION

• Orthopedic appliances –
Headgear (face bow, j hook)
• Functional appliances –
removable functional appliance (activator, bionator, Twin –block, frenkel appliance)
Fixed functional appliance (Herbst, jasper jumper, Twin-block)
 HEADGEAR

• For a patient of either gender who is beyond the mixed dentition period but still in the
adolescent growth spurt, there is no reason to wait for alignment and leveling to be
completed before beginning treatment with a headgear or a fixed functional aappliance
• Headgear used for growth modification apply a posterior and superior force on the
maxilla using maxillary first molars as handle to deliver forces
• Two types of headgears used are cervical headgear and occipital headgear
CERVICAL HEADGEARS

• Cervical headgears takes anchorage from the neck and therefore has a posterior and
inferior force direction.
• This produce distal and an extrusive force on maxillary molars
• Extrusion of molars cause further clockwise rotation of mandible and worsens skeltal
Class II
• Therefore cervical headgears are indicated only in pts who exhibiting a horizontal growth
pattern
OCCIPITAL HEADGEARS

• Occipital headgears takes anchorage from the head and has higher point of attachment
• Direction of force is posterior and superior
• Therefore help in Antero-posterior skeletal problems as well as vertical maxillary excess.
• Lighter continuous forces are capable of efficient tooth movement
• 400-600gm per side for 12-14 hrs
 FUNCTIONAL APPLIANCE

• By definition, a functional appliance is one that changes the posture of the mandible,
holding it open or open and forward. Pressures created by stretch of the muscles and soft
tissues are transmitted to the dental and skeletal structures, moving teeth and modifying
growth.
• also can affect the maxilla and the teeth in both arches
• Both removable and fixed functional appliances
• When the mandible is held forward, the elastic stretch of soft tissues produces a reactive
effect on appliances
• If the appliance contacts the teeth, this reactive force produces an effect like that of
Class II elastics, moving the lower teeth forward and the upper teeth back,
and rotating the occlusal plane.
• even if contact with the teeth is minimized, soft tissue elasticity can create a restraining
force on forward growth of the maxilla, so that a “headgear effect” is observed
With functional appliances
• additional growth is supposed to occur in response to the movement of the mandibular
condyle out of the fossa
• reorientation of the maxilla and the mandible, usually facilitated by a clockwise tipping of
the occlusal plane and a rotation of the maxilla, the mandible, or both.
• A reduction of forward growth of maxilla (headgear effect)
• level an excessive curve of Spee in the lower arch by blocking eruption of the lower
incisors while leaving the lower posterior teeth free to erupt.
• If upper posterior teeth are prohibited from erupting and moving forward while lower
posterior teeth are erupting up and forward, the resulting rotation of the occlusal plane
and forward movement of the dentition will contribute to correction of the Class II dental
relationship.
REMOVABLE FUNCTIONAL APPLIANCES

• Monobloc by pierrie robin

• Activator by Andresen
• Bionator
• Frankel appliance
• Twin-block
 FIXED FUNCTIONAL APPLIANCE

• Indicated in adult patients

• Herbst appliance is most effective in correcting class II
• Most effective during adolescent growth in patients who were already in early permanent
dentition period
• MARA, cemented Twin –Block and forsus devices are newer developments
• Major attraction is less patient cooperation
HERBST APPLIANCE

• Herbst created in 1900s,reported on it in 1930s

• Forces patient to maintain an advanced mandibular position
• Recommendes for early permanent dentition but not for mixed
dentition
• Because it can produce maxillary posterior dental intrusion, provides
better results when used in pts with normal or slightly
long anterior face height
• Breakage –significant disadvantage
MARA

• Mandibular anterior repositioning appliance

• Less bulky
• Alternative to Herbst appliance with the Same fixed properties
and anterior bite guidance
• Less affect on mandible compared to Twin –block and Herbst
• Tip the teeth and have dento alveolar effects
• Amount of tipping depends on which anterior or posterior teeth
are included in anchorage units
• The combination of maxillary dental retraction and mandibular dental protrusion that all
functional appliances (fixed and removable) create is similar to the effect of interarch
elastics.
• This “Class II elastics effect” can be quite helpful in children who have maxillary dental
protrusion and mandibular dental retrusion in conjunction with a class II skeletal
problems
TREATMENT PROCEDURES WITH FUNCTIONAL
APPLIANCES
Pretreatment alignment :
• To use functional appliances incisor relationship should be carefully examined
• Because mandible should be held in protruded position to have treatment effect
• For both the Class II division 2 patient with limited overjet and the Class II division 1
patient with crowded and irregular upper incisors, the first step in treatment is to tip the
upper incisors forward and/or align them
CAMOUFLAGE

• In patients who have reasonable jaw relationship, the underlying skeltal discrepancy can be
camouflaged by orthodontic teeth movement.
• This is acceptable treatment, only if the patient’s facial appearance as well as dental alignment and
occlusion are satisfactory
• There are three major ways to correct class II malocclusions with tooth movmovement:

1. Non extraction correction (Distal movement of upper molars )

2. Differential Antero-posterior tooth movement using extraction spspaces
3. Non extraction correction Consists primarily of forward movement of lower arch using inter arch
elatics
 CAMOUFLAGE WITHOUT EXTRACTION OF
TEETH
• Orthodontic camouflage may be done in some patients either by utilization of spaces
present in the arches or by distal driving of the maxillary molars.
• This is done in mild class II malocclusions. These would typically be the end on molar
relation
• Without extraction spaces, Class II elastics produce molar correction largely by mesial
movement of the mandibular arch, with only a small amount of distal positioning of the
maxillary arch, and can produce far too much protrusion of lower incisors.
DISTAL MOVEMENT OF UPPER MOLARS

• “distal driving” of the posterior maxillary teeth.

• Class II elastics
• Headgears
• Skeltal anchorage (miniplates at the base of zygoma or linked screws in the palate, but
not aveolar bone Screws) now is most effective
DIFFERENTIAL ANTERO-POSTERIOR TOOTH
MOVEMENT USING EXTRACTION SPACES
• There are two reasons for extracting teeth in orthodontics:
(1) to provide space to align crowded incisors without creating
excessive protrusion .
(2) to allow camouflage of moderate Class II or Class III jaw
relationship when correction by growth modification is not
possible.
• A patient with both Class II (or III) problems and crowding is a
difficult problem because the same space cannot be used for
both purposes.
• The more extraction space is required for alignment, the less is
available for differential movement in camouflage, and vice
versa
CAMOUFLAGE BY EXTRACTION OF UPPER FIRST
PREMOLARS
• With this approach, the objective is to maintain the existing Class II molar relationship. closing
the first premolar extraction space largely by retracting the protruding incisor teeth
• Anchorage must be reinforced, possibilities are :

1. class II elastics (specifically contraindicated unless the lower incisors need to be moved.
forward)
2. headgear
3. Stabilizing lingual arch
4. Skeltal anchorage
 EXTRACTION OF MAXILLARY AND
MANDIBULAR PREMOLARS

• with extraction of all four first premolars

-implies that the mandibular posterior segments will be moved anteriorly nearly the width of the
extraction space. At the same time, the protruding maxillary anterior teeth will be retracted with
minimal forward movement of the maxillary buccal segments.
• This, in turn, implies that Class II elastics will be used to assist in closing the extraction sites
SURGICAL CORRECTION

• In patients exhibiting severe skeltal malrelationship, surgery may be the ideal treatment
modality.
• Based on the underlying skeltal pattern a maxillary set back or a mandibular advancement
is undertaken after completion of growth.
MANDIBULAR SURGERY

• Sagital split osteotomy

• Mandible can be moved forward
• This procedure is quite compatible with the use of rigid intraoralfixation (RIF), so
immobilization of the jaws during healing is not required.
• Excellent bone-to-bone contact after the osteotomy means that problems with healing are
minimized, and postsurgical stability is good.
MAXILLARY SURGERY

• Le fort I osteotomy /maxillary segmental (anterior) setback.

• Vertical excess of maxilla can be aptly treated by Le Fort –osteotomy of the maxilla and
taking a slice of the bone beyond root apices at the nasal septum, and walls of sinus,
lateral to the pyriform aperture.
• The maxilla is moved -upward in a favourable rotation (more upward in the posterior
region, if so required) thereby resulting in an anticlockwise rotation of mandible,
improvement in face profile and of class II relation to some extent
CONCLUSION

• Class II Malocclusion have several forms of presentation.

• Can be Identified with specific skeltal and dental features
• The treatment varies for growing and non growing patients
• Growth modification, camouflage and orthognathic surgery are main three treatment
approaches for Class II Correction.
Reference
• Contemporary orthodontics :profit
• Orthodontics ,Diagnosis and management of malocclusion and dento facial
deformities :Om P Kharbanda
• Orthodontics The art and science :S I Balajhi
THANK YOU