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Aetiology
For any management you first need to know the cause, to relief the cause and then
to treat, so in order to manage class II division I malocclusion, you have to know the
aetiology ..
Now, The aetiology of class II div I malocclusion could be :
Skeletal: genetic component >>
It could affect the maxilla result in (prognathic maxilla ), it could affect the
mandible result in (retrognathic mandible) ,or combination of both (together
prognathic maxilla with retrognathic mandible).
Soft tissues: it includes >>
Incompetent lips , normally the lips should be anterior to the teeth but in
incompetent lips there is no anterior oral seal & there is no lower lip to upper incisors
contact ( this contact should maintain the upper incisors in their proper anterio‐
posterior position) so in case of incompetent lips upper incisors will move freely and
become proclined ,, increase in the overjet class II div I malocclusion.
Lower lip trap behind the upper incisors, in this case the lower lip will act as a
source of force which push the upper incisors forward and the lower incisors
backward, so proclination of upper incisors and retroclination of lower incisors
class II incisor relationship .
Tongue thrust, again there is no anterior border seal , in this case the patient try
to achieve oral seal during swallowing by putting his tongue between upper & lower
lips or between upper & lower incisors so the tongue might push the upper incisors
forward or it might push the lower incisors backward so the overall effect will be
class II incisor relationship.
Habits :
Digit sucking habit ( thumb sucking or dummy sucking habit ) , when the child put his
thumb between his upper & lower incisors , this will lead to proclination of
upper incisors Retroclination of lower incisors AOB ( anterior open bite ) ,, the
child may have AOB as a DIRECT or AN INDIRECT effect of thumb sucking ,,,
The direct effect is when the thumb itself prevent the normal full eruption of the
upper & lower incisors so AOB.
The indirect effect is due to supra‐eruption of posterior teeth , so downward‐
backward rotation of the mandible AOB .
That’s why if the child stop this habit at early age the incisors will erupt
normally & AOB will resolve by itself because we remove the cause (the thumb)
and the incisors will continue to erupt until they reach each other , second
effect is the growth , although we have supra eruption of posterior teeth if the
patient already have forward growth pattern , the patient will reassume the
forward growth pattern & forward mandibular growth rotation !!!!!!
The severity of thumb sucking depends on:
If the thumb sucking is not sever, the patient will not have AOB ,instead he will have
incomplete overbite …
Another effect of thumb sucking habit is cross bite ,,, because in thumb sucking the
buccinator muscle exerts an inward force on the maxilla , which is not antagonized by the
outward force from the tongue as a result there will be a constriction in the maxillary teeth
& a cross bite will happen .
Why there is no outward force from the tongue on the maxilla in case of thumb
sucking ??
Because in case of thumb sucking , there is a large space between the maxilla & the
mandible & as a result the tongue will go down or it could be that the patient put his
tongue below the thumb during thumb sucking .
As a result of anterior open bite and the downward‐backward rotation of the
mandible there will be an increase in the lower facial height ( LFH).
Skeletal features :
In the skeletal features of class II there is anterio‐posterior relation & vertical
relation.
The anterio‐posterior relation:
When we look to the skeletal features either by examining the patient or by
looking to the lateral cephalogram, we usually find that the patient has class II skeletal
relationship , either mild , moderate or sever , it depends on the ANB angle …
The anterio‐posterior relation could be mild, moderate or sever class II depending on
ANB angle ,,
ANB angle represents the discrepancy between the maxilla and the mandible , it
should be normally between 2‐4 degrees , if its slightly more then its mild class II ,
and if its more then its moderate class II but if it is more than 9 or 10 degrees, then it
is sever class II skeletal relationship .
So , if the ANB angle increased then its class II skeletal relationship however ,
the patient might have class II div I incisor relationship and class I skeletal relationship
, in this case the class II incisor relationship is due to digit sucking , incompetent lips
, … etc.
A question from a student and the answer is: in thumb sucking the mandible will grow
backward ( i.e posterior growth rotation of the mandible as a result of posterior teeth over
eruption ) and this will increase the class II skeletal discrepancy if there is already skeletal
class II.
The vertical relationship :
Vertical relationship in class II div I could be :
Open bite ( as in digit sucking habit ) ,
Normal vertical relationship or
Reduced vertical relationship ( deep bite )
It depends on the Maxillary – Mandibular plane angle ( MM angle ) , if the angle is
increased then it is skeletal open bite , if it is decreased then it is skeletal deep bite
and if the angle is normal then its normal vertical relationship …
So, class II div I incisor relationship could be class I skeletal or class II skeletal
which also could be mild , moderate or sever ,,,vertically , it could be normal (average )
, reduced or increased vertical relationship .
Now ,if you look at this patient , you will see that the upper
anteriors are positioned outward & the lower lip is behind the
upper incisors,,
its an example of class II div I malocclusion .
Now , By looking to the lateral
cephalogram & by doing analysis for it
again the ANB angle could be increased
(class II skeletal) or it could be average
(normal) ( class I skeletal ) ,, vertically we
look to the MM angle , it should be
normally 27 + ‐ 5 , more than this , its
increased & less than this, its reduced .
We talked about skeletal features of class II div I , and now we will talk about ,,,
The dental features :
Usually they are :
Class II molar relationship ,
Class II canine relationship ,
Class II div I incisor relationship ( upper incisors are proclined and the overjet increased).
When we say class II molar or class II canine that doesn't mean it’s a full unit class II
, it could be half a unit , so at least there should be a component of class II dental
relationship , we may have class I molar relationship but class II canine relationship
and this will happen in case of premature loss of lower E & the lower molar drift
mesialy class I molar relationship, so the position of lower molar ( in this case )
doesn't reflect the true position .
Treatment modalities (Management of class II Div I):
There are several ways to treat class II div I :
Growth modification
Fixed appliances only: we can do any movement, I can do extraction in the upper
and move teeth backward, if the case isn’t sever (mild class II) I can do non‐extraction
with class II elastics . Another way also to make the patient wears a headgear to
distalize the upper molars and change the molar relationship from class II toward class
I then close the space and reduce the overjet .
Removable appliances : in well‐aligned upper and lower teeth but the upper
incisors proclined and there is enough space to retrocline them.
Orthognathic surgery: in adults & sever cases.
Growth modification:
Either I use the Headgear or the functional appliances .
Headgear:
Used when the maxilla is prognathic, in this case I don’t want to use functional
appliances because the problem is in the maxilla not in the mandible. so it is easier to
correct class II relationship by using headgear if the problem is in the maxilla although
functional appliances can do the same job (by restricting the maxillary growth) but
using headgear in this case is more effective .
The headgear is more effective when the problem is only in the maxilla (prognathic).
If the mandible is retrognathic, using the functional appliance will give a better
result.
There are many types of headgear :
Low‐pull headgear: cervical pull.
High‐pull headgear: occipital pull.
Combination headgear (medium pull headgear): combination between occipital &
cervical pull.
Headgear can be attached to the upper molar teeth, it can be attached to upper
removable appliance affecting all upper teeth not only upper molars, it could be
attached also to a functional appliance .
Functional appliances :
The patient has to be growing patient
To use functional appliances there should be certain conditions in the patient to be
able to use them:
If I want to use functional appliances only in growing patients to treat class II div I malocclusion the
followings should be considered :
ﻻزم ﺗﺘﻮﻓﺮ اﻟﺸﺮوط اﻟﺘﺎﻟﻴﺔ ﻓﻲ اﻟﻤﺮﻳﺾmalocclusion ﻟﺤﺎﻟﻬﺎ ﻟﻌﻼج الfunctional appliance ﻳﻌﻨﻲ اذا ﺑﺪي اﺳﺘﻌﻤﻞ ال
The class II div I has to be mild to moderate , if the case is sever it can't be treated
using functional appliances only.
The upper incisors must be proclined because the functional appliance will do
retrocliantion for them ,so if they are already retroclined or normally‐inclined the
functional appliance will retrocline them , so in this case ( retroclined upper incisors ) I
can't use functional appliance only unless I plan to use functional appliance first then
to follow with fixed appliance to correct the inclination .
No upper and lower arch crowding: because the functional appliances ‐like any
removable appliance‐ don’t do alignment ,so in this case I can use the functional
appliance to change the case from class II to class I then the fixed appliance to align
upper & lower teeth.
The overbite should be deep or average : if it is reduced overbite I can't use the
functional appliance because the functional appliance itself causes reduction of the
overbite , so if the overbite is already reduced then it will become open bite .
The lower facial height ( LFH) should be average or reduced because the functional
appliance will increase the LFH.
The effect of functional appliances :
BEFORE AFTER
This case is ideal for treatment with functional appliance only because we have :
well‐aligned upper and lower teeth , no crowding nor rotation that need fixed
appliance , the upper incisors are proclined and spaced .
The result of treatment: the canine becomes class I ,it was class II. The molar
was class II and now it is class I (not clear in the PIC), the premolars also are class I. so the
case is changed from class II to class I just with functional appliances .
Removable appliances: it is just simple treatment. I have increased overjet,
proclined spaced upper incisors, so I put a removable appliance (Robert's retractor for
example) which will retrocline the uppers and reduce the overjet.
So to use the removable appliance in the treatment of class II div I the following
conditions must be found:
Proclined upper incisors.
Spaced upper incisors .
Normal or reduced overbite , because if it was increased it will interfere with the
retroclination of the upper incisors & I can't retrocline them .
Fixed appliances:
We can achieve any type of tooth movement: intrusion, extrusion, porclination
,retroclination ,tipping ,bodily movement and any other type of movement .
So it used for complicated tooth movement in non‐grower patient.
So if there is increased overjet or class II div I relationship I can retract the upper
incisors by creating a space either by: distalizing the upper molars or by extraction.
By using class II elastics it (fixed appliance) will help in correction of class II div I.
In non‐grower patients I exclude Growth modification, but I can use removable
appliances, fixed appliances or surgery.
Patient age: if the patient is grower then I can think of growth modification, if the
patient is not grower then I should exclude growth modification from treatment plan
list.
So if the patient is grower I can use growth modification with or with out fixed
appliances after the functional appliances.
Severity of malocclusion:
If the malocclusion is very sever I plan for orthognathic surgery.
If it is sever (crowding, rotation, impaction ,…) I plan for fixed appliance .
Patient's facial profile : if the profile is so bad ( prognathic maxilla , retrognathic
mandible) then I need retrognathic surgery .
Stability:
After treating class II div I malocclusion I know that there will be relapse ,however the
key factor for the stability of the overjet reduction is achievement of anterior oral
seal & lower lip to upper incisors contact : if the overjet was increased and you
retrocline the upper incisors and there is no contact labially the upper incisors will
move anteriorly and the overjet will relapse.
Retention:
I do retention for upper & lower arches by any type of retainers.
In this case I have upper Hawley retainer and lower fixed retainer .
Cases
Case1 (Orthognathic case)
When you look to the profile you will notice that the mandible
is very retrognathic, and the profile is too convex .
The overjet as you can see isn’t too big;
Why don’t I do extraction in the upper without
orthognathic surgery?
Because the profile is bad, look at the nasolabial angle
it is already increased so if you want to extract from the
upper arch and retract the upper incisors the nasolabial
angle will open more and the profile will become ugly
.So the ideal treatment plan for this patient is
orthognathic surgery .
Look at the overjet during treatment it is increased because I need to do
decompensation before surgery ; I will procline the upper incisors so the nasolabial
angle will be better , and I will retrocline the lower incisors so I need extraction , as
you can see here there is extraction and the space started to close . So just before the
surgery a pre‐surgical orthodontic increases the overjet so the surgeon can move the
mandible forward freely because there is an increased overjet .
Case2 (Fixed appliances)
In this case the profile is not very bad , its not very sever class II
There is a lot of
crowding
&
There is impaction
(the 5 isn't there here)
and here it is ‐ the 5 ‐
partially erupted and
there is no enough
space
So this case needs FIXED APPLIANCE and here is the normal relationship after treatment with fixed appliance.
And here is the normal profile after treatment .
Case3 (Growth modification)
In this case you can see the lower lip
trap (the lower lip is behind the
upper incisors)
The overjet is very big ,its nearly 11 mm or
more
Also this patient has peg shape
lateral
And a high frenal attachment with midline
diastema.
This patient is a grower patient , so we can treat her with growth modification(functional appliance).
And here is the patient after the treatment, we treat her by doing frenectomy then
functional appliance followed by fixed appliance and then veneers on the lateral incisors .
Done By :JAMILAH M. HASAN
☺TEETHOS ☺