DEPARTMENT OF ORTHODONTICS

GOVERNMENT DENTAL COLLEGE, THRISSUR

SEMINAR PRESENTATION
MANAGEMENT OF CLASS II MALOCCLUSION

SUBMITTED BY:
FATHIMA SHAMIN
FINAL YEAR PART I
180021889
CONTENTS
 Introduction
 Definition
 Treatment objectives
 Management
 Conclusion
 Reference
INTRODUCTION
 Orthodontic specialty deals with various malocclusions.
 Many treatment approaches are currently available to the orthodontists for altering the
occlusal relationship typically found in class II malocclusion.
 These treatments include a variety of extraoral retraction appliances, arch expansion,
extraction procedure, functional jaw orthopedic appliance, molar distalisation etc

DEFINITION OF CLASS II
According to Angle’s classification: it is when the distobuccal cusp of the maxillary first
molar occludes in mesiobuccal groove of mandibular first molar
Class II is subdivided into
 Class II Division 1
 Class II Division 2

CLASS II DIVISION 1 MALOCCLUSION

It is characterized by class II molar relation on either side with proclined maxillary anteriors.
It can also be associated with proclined lower anteriors. This is a natural compensation that
has taken place to reduce the overjet.

Features of class II div 1

 Convex profile
 Short hypotonic upper lip
 No lip seal
 Proclined upper anteriors
 Hyperactive mentalis
 Hyperactive buccinator
 Constricted narrow upper arch

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 is present.
Variations of this include lingually inclined central and lateral incisors with the canine
labially tipped.

Features of class II div 2

  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 division 2

By Van der Linden
1. 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
2. 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 incisor
and will contribute to increase of their labial inclination.
3. 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 crossbite
 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
Growth modification can be achieved by;
 orthopedic appliances like head gear
 functional appliances like activator, bionator, twin block, frankel 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 appliance.
Headgear used for growth modification apply a posterior and superior force on the maxilla
using maxillary first molars as handles to deliver forces
Two types of headgears used are cervical headgear and occipital headgear

CERVIAL HEADGEARS
A cervical headgear takes anchorage from the neck and therefore has a posterior and inferior
force direction. This produces distal and an extrusive force on maxillary molars
Extrusion of molars cause further clockwise rotation of mandible and worsens skeletal class
II. Therefore, cervical headgears are indicated only in patients who exhibit horizontal growth
pattern

OCCIPITAL HEADGEARS
Occipital headgears take anchorage from the head and have higher point of attachment.
Direction of force is posterior and superior. Therefore, it helps in antero-posterior skeletal
problems as well as vertical maxillary excess.
Lighter continuous forces are capable of efficient tooth movement
400-600gm force per side is required for 12-14hours

FUNCTIONAL APPLIANCE
By definition, a functional appliance is one that changes the posture of mandible, holding it
open or open and forward. Pressure created by stretch of the muscles and soft tissues are
transmitted to the dental and skeletal structures, moving teeth and modifying growth
Both removable and fixed functional appliances can be used
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 of the occlusal plane.
Even if contact with the teeth is minimized, soft tissue elasticity can create a restraining force
on forward growth of 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 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 Pierre robin
 Activator by Andresen
 Bionator
 Frankel appliance
 Twin-block

FIXED FUNCTIONAL APPLIANCE

 It is 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 and reported on it in 1930s
This appliance forces patient to maintain an advanced mandibular position. It is
recommended for early permanent dentition but not for mixed dentition.
Because this appliance can produce maxillary posterior dental intrusion, it provides better
result when used in patients with normal or slightly long anterior face height.
The major disadvantage of this appliance is breakage.

MARA
Mandibular anterior repositioning appliance
It is less bulky and an alternative to Herbst appliance with the same fixed properties and
anterior bite guidance.
It has less effect on mandible compared to Twin-block and Herbst. It tips the teeth and has
dentoalveolar effects. The amount of tipping depends on which anterior or posterior teeth are
included in anchorage units.

CAMOUFLAGE
In patients who have reasonable jaw relationship, the underlying skeletal 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 3 major ways to correct class II malocclusions with tooth movement.
1. Non extraction correction (distal movement of upper molars)
2. Differential anterio-posterior tooth movement using extraction spaces.
3. Non extraction correction- consists primarily of forward movement of lower arch
using inter arch elastics

CAMOUFLAGE WITHOUT EXTRACTION OF TEETH

Orthodontic camouflage maybe 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 by largely mesial
movement of the mandibluar 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

It is the distal driving of the maxillary posterior teeth using class II elastics are and headgears
Skeletal anchorage (miniplates at the base of zygoma or linked screws in the palate, but not
alveolar 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 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 incisor need to be
moved forward)
2. Headgear
3. Stabilizing lingual arch
4. Skeletal anchorage

CAMOUFLAGE 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 the 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 skeletal malrelationsip, surgery maybe the ideal treatment
modality. Based on the underlying skeletal pattern a maxillary set back or a mandibular
advancement is undertaken after completion of growth.

MANDIBULAR SURGERY
Sagittal split osteotomy is done and the mandible can be moved forward. This procedure is
quite compatible with the use of rigid intraoralfixation (RIF) so that immobilization of the
jaws during healing is not required.
Excellent bone to bone contact after the osteotomy means that the problem with healing are
minimized and postsurgical stability is good.

MAXILLARY SURGERY
Le fort I osteotomy/ maxillary segmental (anterior) setback is done. Vertical excess of the
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 favorable 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. It can be identified with specific
skeletal and dental features. The treatment varies for growing and non growing patients.
Growth modification, camouflage and orthognathic surgeries are main three treatment
approaches for class II correction.

REFERENCE
 Contemporary Orthodontics: Profitt
 Orthodontics, Diagnosis and Management of Malocclusion and Dentofacial
deformities: Om P Kharbanda
 Orthodontics- The art and science: S I Balajhi