Class – II malocclusion


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Class – II malocclusion /shwartz analysis / Mc Namara / Functional analysis

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Class – II malocclusion

  1. 1. clinical diagnosis ofCLASS – IIMALOCCLUSIONDr.Cyan Chacko1st year pgDept of orthodontics and dentofacial orthopedics
  2. 2. Diagnosis• Diagnosis is the process of attempting to determine oridentify a possible disease or disorder (Extra oral and Intra oral features)CLINICAL EVALUATION Case history , Photographic analysis , Radiographic analysis , Cast analysis ,DIAGNOSTIC AIDS Examination of postural rest position and maximum intercuspation Examination of the tempromandibular joint Examination of orofacial dysfunctionFUNCTIONAL ANALYSIS
  3. 3. Extra oral featuresClass II divison 1profile: convexShape of head : dolicocephalicMento labial sulcus : shallow/deepHyper active mentalis: presentHypo active upper lip :presentClass II divison 2Profile : straight / convexShape of head : mesocephalic/dolichocephalicHyper active mentalis: absentMento labial sulcus : normalHypo active upper lip :present/absent
  4. 4. Clinical features ofclass II -division 1o classII molar relation,that may vary from end onmolar to fully fledged class IIo proclined maxillary anteriorswith resultant increased overjeto Flaring and spaced dentition
  5. 5. V – shaped palatal archExcessive curve of speeDeep palateIncreased over bite
  6. 6. o Patient may have a shorthypotonic upperlipo Lip trap may be present(placinglower lip against the palatalsurface of upper incisor)o Abnormal buccinator activityleading to a constricted , narrowupper arch. Which predisposeto posterior cross biteo Hyper active mentalis muscle(retrognathic mandible)
  7. 7. Class II divison 2 malocclusion Excessive lingualinclination ofthe maxillary central incisorsoverlapped on the labial bythe maxillary lateral incisors. In some Cases , both the central and thelateral incisors are lingualyinclined and the caninesoverlap the lateral incisors onthe labial.
  8. 8. o The Class II Division 2malocclusion is often accompaniedbyo U – shaped palatal archo A deep overbite and minimalover jeto with extreme overbite, theincisal edges of the lowerincisors may contact the softtissues of the palateo In the absence of over jet)mandibular labial gingiva gettraumatised by linguallyinclined maxillary incisors
  9. 9. Case history Most hereditary dysgnathias are already evident inDeciduous dentition . Dominantly inherited anomalies Include mandibular prognathism , class II division 2 Some cases of distoclussion skeletal open bite , and bimaxillary protrusion
  10. 10. Photographic analysisFor the analysis of the relationshipbetween the craniofacial skeletonthe soft tissue facial contures ,profile andfrontal photographs aretaken under stantardized condition. Patient sitting up straight in habitual Occlusion with relaxed lips and mentalismuscleFacial profileProfile convexity or concavity results froma disproportion in the size of jaw.Convex profile indicate class II jawrelationship , ie maxilla projected tooforward or mandible too backwardin concave profile : classIII relationshipWhich can be result from either maxillaIs backward or a mandible protrudesforward The line joining the forhead andthe border Of the upper lip The line joining the border ofupper lip and soft tissuepogonion
  11. 11. Recommended frontal images Frontal at rest Frontal view with teeth in maximal intercuspation Frontal dynamic (smile) A close up image of posed smile
  12. 12. Frontal at rest Frontal view with teeth in maximal intercuspationFrontal dynamic (smile)A close up image of posed smile
  13. 13. Facial symmetry in frontal planeFrom the frontal view it is particularly important to examine the facefor bilateral symmetryThe normal asymmetry which usually result s from a small sizedifference Between the two side s ,should be distinguished from achin or nose .That deviates to one side .Facial proportionWell proportioned face can be divided intoThree equal thirds using four horizontal planes At hair line Supra orbital ridge Base of nose Inferior border of chinWithin the lower face upper lip occupies a third of distancewhile chin occupies The rest of the spaceThe rule of fifth.From midsagittal plane ideal face is composedOf equal fifths ,all approximately equal to one eye widthComissure width should also be coincident with medial limbusOf eye alar width should coincident with intercanthal distance
  14. 14. Lateral cephalometrics
  15. 15. CEPHALOMETRIC ANALYSISFour linear measurements Anterior and posterior cranial base length Anterior and Posterior face height ,The first cephalometric analysis includes three angularmeasurements(saddle angle ,articular angle ,gonial angle ) Analysis of facial skeleton Analysis of mandibular and maxillary base Dento alveolar analysis
  16. 16. ANTERIOR CRANIAL BASE LENGTH (Se_N)The measurement of anteriorcranial basethe center of the Superior enterance to the sellatrucica as a reference point to nasionThe corelation of this criterion with length of jaw baseenables the propotional averages of the basesGrowth direction 9 years Incremental changes from9-15yearshorizontal 68.8 mm 4.46mmvertical 63.8mm 3.52mmMean value: N – S (72-75)mm
  17. 17. Posterior (lateral) cranial base length (S-Ar)The magnitude of posterior cranial base length depends onPosterior face height and position of the fossa. Short posterior cranial baseoccur in vertical growth pattern and skeletal open biteGrowthdirection9 years Incrimental changes from9-15yearshorizontal 32.2mm 9.16mmvertical 30mm 4.47mmMean value S –Ar (32-35)mm
  18. 18. The measurement of anterior and posterior faceheight is a linear millimeteric assessment.The posterior face height (S-Go) andanterior face height (N-Me) are measured onlateral cephalograms with the teeth in habitualocclussionANTERIOR AND POSTERIOR FACE HEIGHTAnterior and posterior face height and setup ratiosTo estimate growth direction according to recommendation of jarabackPosterior face height x 100anterior face heightMean value is 62-65% Higher the % means greater posterior face height and horizontal growthA small % denotes shorter posterior facial height and vertical growth
  19. 19. For early mixed dentition the treatment with an activator should be doneBy comparing angular and linear measurements and morphologic characteristic ofthe mandible .The assessment of growth direction Is important in functional appliance therapy .It helps determine whetherFunctional appliance should be used and influence construction details, typeOf construction bite and other factors .periodic growth assessment duringTreatment is equally important for the plotting of mid course correction sAnd alterationGrowthdirection9 years 15yearsHorizontal 67% 69%Vertical 60.1% 62.7%
  20. 20. CEPHALOMETRIC ANALYSISSADDLE ANGLE : (N-S-Ar) .The angle formed by joining these three pointsprovides a parameter for assessment of therelationship betweenAnterior and posteriolateral cranial basesSaddle angle usually signifies the position offossaMean value 123+/-5Thus a large saddle angle usually signifies aposterior condylar position and a mandibleThat is posteriorly positioned with respect tocranial base and maxilla – that is unless thedeviation in the position of the fossa iscompensated By articular angle and ramal lengthrelationship.A noncompensated posterior positioning of themandible Caused by a large saddle angle is verydifficult to influence With functional appliancetherapy
  21. 21. ARTICULAR ANGLE: (S-Ar-Go)The angle is a constructed angle betweenthe upper and lower Part of the posteriorpart of facial skeleton .Its size depend on position of the mandible ; Angle is Large if mandible is retrognathic Angle is Small if mandible is prognathic Mean value(143+_6)It can be influenced during the orthodontic orOrthopedic therapy . It decreases with anteriorpositioning of the mandible , closing of the bite ,And mesial migration of the posterior segment teethAnd increase with posterior relocation of the mandibleOpening of the bite , distal driving of the posteriorteethGrowth direction 9 years 15yearsHorizontal 139.5* 2.89*vertical 142.4* 2.49*
  22. 22. The angle is formed by tangents of the body of the mandibleand posterior border Of ramusIt gives information on mandibular growth DirectionUpper and lower gonial angles of jarabakGonial angle divided by line drawn from nasion to gonion ,this gives upper and lower gonial AngleIf the lower gonial angle is small ,the direction of growth is horizontal .if lower angle is largerthe direction of growth is verticalMean value(128+/-7)Upper gonial angle(52 to55)Lower gonial angle (70 to 75)GONIAL ANGLE: (Ar- Go-Me)Growth direction 9 years 11yearsHorizontal 125.5* 2.89*vertical 133.4* 2.42*
  23. 23. SUM OF POSTERIOR ANGLESThe sum of (saddle angle, articular angle, gonial angle is 396 +/_6 *The sum is significant for the interpretation of analysis .If it is greater than 396*,direction of growth is verticalIf it is lesser than 396 * direction of growth is horizontal
  24. 24. ANALYSIS OF JAWBASEThe angles between verticalreference lines representthe saggital relation of partseg (SNA –SNB)Angle between horizontal linesassist in the evaluationOf vertical relationship eg(basal plane angle , inclinationangle)linear measurement indicatethe length of maxillary andmandibularBases and ascending ramus
  25. 25. S-N-AThe angle S-N-A expresses the sagittalrelationship of the anterior limit ofThe maxillary apical base to the anteriorcranial base It is large in prognathic maxillas small in retruded maxillas . Mean value ( 81*)GrowthdirectionSNA angle9 yearsSNA angle15yearsAverage 79.5* 81.28*horizontal 79.73* 81.57*vertical 79.0* 80.57*A moderate decrease of SNA angle is possible through the use of conventional activatortherapy. Larger decrease in angle is possible by special activator (clark twin block appliance)
  26. 26. S-N-BThe angle S-N-B expresses the sagittal relationshipbetween theAnterior extent of the mandibular apical base andanterior cranial Baseprognathic mandible it is large ,and with a retrognathicmandible It is small .Functional appliance treatment is indicated if themandible Is retrognathic and has a small S-N-B .A posteriorly located mandible can be large or small .if it is smallThe prognosis for anterior posturing in the mixed dentition is goodBecause a larger growth increament can usually be expectedGrowth direction SNB angle9 yearsSNB angle15yearsHorizontal 77.9* 80.5*vertical 74.3* 75.9*Mean value (79*)
  27. 27. THE Wit’s METHOD In normal occlusion BO is 1 mm anterior to pointAO In skeletal classII point BO is located posterior to point AO In skeletal classIII point BO is forward of pointAOJacobson described the wits appraisal of jaw disharmony , which is aMeasure of the extent to which the jaw are related toeach other Anteroposteriorly Drawing perpendicular on a lateral cephalometrichead film tracing fromPoint A and point B on maxilla and mandiblerespectively . On to the occlussal plane which is drawn throughmaximum cuspal Interdigitation The point of contact on the occlusal plane from Aand B are labelled AO and BO respectivelyABAOBO
  28. 28. BASE PLANE ANGLE (PaL-MP)The base plane angle .Angle between themaxillary and mandibular jaw baseAlso is used to determine the inclination ofmandibular plane In horizontal growth patterns this angleis small In vertical growth patterns it is largerGrowthdirection9 years 15yearshorizontal 23.4* 20.5*vertical 32.9* 30.9*
  29. 29. INCLINATION ANGLE A large angle expreses upward andforward inclination Small angle indicate down and backtipping of the anterior end Of thepalatal plane and maxillary base This angle doesnt Correlate withgrowth pattern or facial type. Functional and therapeutic influencescan alter the inclination of maxillarybases .The inclination angle gives an assessment ofthe inclination of maxillary base .It is the angle formed by the Pan Line( a perpendicular line dropped from N-Se at N )and palatal plane (mean value:85*)
  30. 30. ROTATION OF JAW BASEBasal plane angle and inclination angle ) areused to evaluate the rotation of upper andlower jaw baseThe rotation of the mandible is growthconditioned and depend on Direction and mutualrelation of growth increments in the posterior(condylar) and anterior ( sutural and alveolar )facial skeleton.if condylar growth proceed atgreater rate horizontal rotation occur Convergent rotation of jaw base ,rotationCreates a severe ,deep bite Divergent rotation of jaw base – this rotationcan cause marked open bite problemCranial rotation of both bases-horizontal growth pattern a relatively harmonious rotation ofBoth jaws occurs. in upward and forward direction ,Maxilla compensates for upward andforward Mandibular rotation .off setting deep bite.down and back rotation of both bases – rotation occurs in a relative harmonious mannerThe down and back maxillary rotation offset the openbite created by down and backmandibular rotation
  31. 31. Linear measurement of the jaw baseThe length of maxillary , mandibular base and ascending ramus is measuredRelative to (S-N) ANTERIOR CRANIAL BASEThe ideal dimension relative to S-N is calculated using the following ratioN-S : MANDIBULAR BASE 20 : 21ASCENDING RAMUS :MANDIBULAR BASE5 : 7MAXILLARY BASE :MANDIBULAR BASE2 : 3
  32. 32. Extent of mandibular baseExtent of mandibular base is determine by measuring the distance gonion-pogonionIdeally mandibular base should be 3 mm long than S – N Until 25 years.3.5 mm long after 25 years.5 mm or less than this average considered within normal limit until 7 years5 mm or more is normal until 15 yearsExtent of maxillary baseThe extend of maxillary base is determined by measuring the distance betweenPosterior nasal spine and point A projected perpendicular onto palatal plane.The evaluation of this has two ideal measurements one relate to nasion -sellaAnd other to the length of mandibular baseA Deviation from the mandibular base –related norm indicates thatmaxillary base is too long or too short .Growth direction 9 years 15yearshorizontal 67.59mm 77.35mmVertical 65.23mm 73.5mm
  33. 33. Ascending ramusAscending ramus is calculated by measuring distance between gonion and condylionThe length of ramus is important in determination of posterior facial heightAnd subsequent relation to anterior face heightRamus tend to be longer in horizontal grower and shorter in vertical patternsGrowthdirection9 years 15yearshorizontal 48.9mm 58.6mmvertical 44.47mm 51.7mmGrowth direction 9 years 15yearshorizontal 44.56mm 48.6mmvertical 44.0mm 47.16mm
  34. 34. Mc Namara AnalysisCranio facial complex is divided into 5 major sections. Maxilla to cranial base Maxilla to mandible Mandible to cranial base Dentition airwayMaxilla to cranial baseSoft tissue evaluation Nasolabial angle Ideal angle is 102=/-8* Small angle indicate dento alveolar protrusion
  35. 35. Cant of upper lipideal value in woman is 14 +/-8*For men the value is 8+/-8*Hard tissue evaluationAnteroposterior orientation of maxilla relativeto cranial baseLinear measurement between nasionperpendicular and point AAnterior position of point A is a positive value ,Posterior position of point a is a negative value
  36. 36. Maxilla to mandibleAnterior posterior relationshipMid facial length is measured from condylion to point A.Mandibular length from condylion to gnathionideally (co-point A)is 91 mm(co –Gn)115-119 mmVertical relationshipVertical maxillary excess cause a downward and backward rotationof the mandible ,result in increase anterior lower face heightVertical maxillary dento alveolar deficiency cause mandible rotateupward and forwardMandibular plane angleMandibular plane angle is the angle between anatomic frankfortHorizontal and the line drawn along the line drawn along thelowerBorder of mandible through constructed gonion and mentonOn average mandibular plane angle is 22+/-4 *Higher measurement is suggestive of excessive lower face height
  37. 37. Facial axis angleFacial axis is the angle formed by line constructed fromposterosuperior aspectOf the pterygomaxillary fissure to gnathion relative to thecranial baseWhich is represented by line joining basion to nasion . In abalanced face facial axis angle is perpendicular. Or 90* tobasion- nasion linenegative value excessive vertical development of facePositive value deficient development of faceMandible to cranial baseRelationship of mandible to cranial base is determined bymeasuring the distance fromPogonion to nasion perpendicularIn adult men chin position extends from about 2mm behind to 2mm forwardIn adult female pogonion is positioned 4 to 0 mm behind thenasion perpendicular line
  38. 38. dentitionMaxillary incisor positionVertical line is drawn through point A parallel to nasionperpendicularThe distance between point a to facial surface of upperincisor is 4 to 6 mmMandibular incisor positionTo determine anterior posterior position of lower incisorthe distance is measuredBetween the edge of mandibular incisor and a line drawnfrom point A to pogonionin a well balanced face the distance should be 1 to 3 mm
  39. 39. Airway AnalysisUpper pharynxUpper pharyngeal width is measured from a point on the posterior outlineOf soft palate to the closest point on pharyngeal wallAverage naso pharynx is approximately 15 to 20 mm width.Width of less than 2mm in this region may indicate airway impairmentLower pharynxLower pharynx width is measured from point of interaction of posteriorBorder of tongue and inferior border of mandible to closest point onthe posterior pharyngeal wall. Average measurement is 11 to14 mmAnterior positioning of tongue ,either as a result of habitual posture or tonsillarenlargement
  40. 40. ANALYSIS OF DENTOALVEOLAR RELATIONSHIPConstruction and management of functional appliance is assessmentOf the inclination and position of incisors with respect to anteriorcranial base ,their apical basesAxial inclination of the incisorsUpper incisors:The long axis of the maxillary incisors is extendedto intersect the S-N line Larger angle indicatelabial crown tipping (mean value:102*)Lower incisor :measurement of the posterior angle betweenThe long axis of the lower incisors and mandibularplane Is the class method of assessing the axialinclination The ideal angle is 90 *Small angle indicate lingual tipping of the incisors
  41. 41. Position of incisorsLinear measurements are the best assessors of the position of the incisorswith respect to the profile.Most common assessment method is to measure the distance of the incisal edgesTo the line N-Pog (FACIAL PLANE) The average position of the maxillary incisor is 2 -4mm anterior to N – Pog line The lower incisor vary from 2mm posterior to 2 mm anterior of this line Relationship of lower incisors to the N –Pog linealso help to determine the sagittal discrepancy
  42. 42. LIP ANALYSISMETRIC DETERMINATIONLength of upper lip Average value in boys and girls (22.5mm in boys and 20 mm in girls In class II (22mm), A positive correlation Exists between length of upper lip and Facial height (N-Gn104mm on average with Class II Length of lower lip 50 mm on average in boys and 46.5 mm ingirls Lip gradually increases with age With classII by 1.5 mm onaverage During treatment lower lip shows a slightly increase in lengthWith mesiocclussion than with distocclusion During classII treatment the lower lip curls up and movesforward
  43. 43. Thickness of red part of upper lip Measured from most labial surface of the most labialincisor to the most anterior point on the red part of upperlip The average thickness is 11.5mm With class II malocclusion the red upper lip is relativelythin (10.8)mm Thinner upper lip is seen with class II is due toangulation of the upper incisor Upper lip grows thicker as the incisors retract. Elimination of the lip tension, due to3 mm retraction ofthe incisor Upper lip thickness increases by 1mm lip profile will change until the tension is eliminated
  44. 44. THICKNESS OF RED PART OF LOWER LIPMeasured from the labial surface of the lower incisors to the most anteriorPoint of the red part of lower lip the average thickness is 12.5mmWith class II malocclusion lower lipis thicker (14 mm )The thickness of the lip depend onposition of the mandible and onover jetDuring treatment lower lip becomesthinner in cases of class IIRetraction of upper incisor causeslower lip to curl back or forward
  45. 45. Reference planes for lip profile assessmentRICKETTS LIP ANALYSISRicketts drawn from tip of nose to skin pogonion Normal relation means upper lip is 2-3 mm Lower lip 1-2 mm behind this line
  46. 46. STEINER’S ANALYSISReference point is at centre of thes –shaped curve between tip of noseAnd sub nasale .soft tissue pogonion represents thelower pointLip lying behind the line connectingthose two points are too flatThose lying anterior to it ,too prominent
  47. 47. HOLDAWAY’S LIP ANALYSISThis is a quantitative analysis to assess lip configurationHoldaway determine the angle between a tangent to theUpper lip and the NB line the angle between these two lines is calledThe H lineHOLDAWAY ‘S DEFINES PERFECT PROFILEANB angle 2*, H angle 7-8*Lower lip touches the soft tissue line(soft tissue pogonionUpper lip Continued as far as SN)The relative proportion of nose and upper lip arebalanced (soft tissue line bisecting the S CURVE
  48. 48. Functional analysisEvaluation of path of closure from postural rest to occlusion in the sagittal planeCondylar movement from postural rest to occlusion can consist of pure hinge movement, hinge and anterior translatory displacement , hinge and Posterior translatory displacementclassII malocclusion without functionaldistrubanceThe path of closure from rest toocclusion is straight up and forwardwith a hinge movement of the condyleand the fossa. These are true class IImalocclusion
  49. 49. This type of activity is the most common, particularly in cases ofexcessive overbite class II malocclusion.classII malocclusion with functional distrubanceA rotatory action of the condyle in the fossa from postural rest to occlusion isevident. From initial contact to full occlusion,condylar action is both rotatory and translatory up and backward .thus the movement combine rotary and sliding components .
  50. 50.  In class II malocclusion with functional disturbances in whichthe path of closure is Up and forward from rest to initial contact the mandible may be anteriorly Displaced from initial contact asthe cusps guide the mandible into a forward position ,withtranslatory movement of the condyle down and forward onthe posterior slope of the articular eminence The path of closure appears more up and forward thanit is without tooth interference .this variation of path of closureis least frequent for class II malocclusionsIn functional class II malocclusion the elimination offunctional retrusion or protrusion leads to animprovement is a change in the sagiattalmalrelationship
  51. 51. Examination of TMJ and condylar movementThe objective of this aspect of functional examination is to assesswhether incipient symptoms of TMJ dysfunction are presentThe early examination of functional disturbances,some incipient TMJproblem can be prevented or eleminatedDuring activator therapy the condyle is displaced or dislocated to achievea remodeling of the TMJ structure and a change in muscle functionIf TMJ problems are present in deciduous dentition , forward posturing mayBe better achieved in a staged progressionEarly symptoms of TMJ problems Clicking and crepitus Sensitivity in the condylar region and masticatory muscles Functional distrubances (hyermobility, limitation of movements, deviation) Radiographic evidence of morphologic and positional abnormalities
  52. 52. Clinical functional examination for temporomandibular joint area Auscultation Palpation Functional analysis classII malocclusion with excessive overjet , horizontal growth Pattern ,and lower lip cushioning to the lingual of the upper incisors(lip trap) Deep over bite problems Anterior open bite with associated abnormal lip , tongue, and finger habits Cross bite conditionIf incipient TMJ signs already exist at the first examination of the patientEarly orthodontic treatment is recommended
  53. 53. Examination of orofacial dysfunctionDysfunction can be primary etiologic factor in malocclusionMany disfunction are acquired in the early stage of birthNeonates are capable of performing some vital function s Sucking Swallowing BreathingMany functions learned during the first month or year of life Chewing Phonation MimicryUnconditional reflexconditional reflex
  54. 54. EXAMINATION OF TONGUE Tongue function Tongue posture Tongue size
  55. 55. TONGUE FUNCTIONAbnormal tongue posture and function can be primary factors asconsequences of retained infantile deglutitional patterns or other abnormaloral habits , but they also may be strictly secondary or adaptive tounfavourable morphologic patterns.TONGUE POSTURECephalometric evaluation of tongue posture –• Assessment of tongue posture is made from a lateral cephalogram taken inpostural rest and habitual occlusion .•Successful analysis will depend on the proper reference line
  56. 56. Preconditions for reference lines The greatest possible area should lie above the line The line should be independent of variation in skeletalstructures Its relation to the tongue should not change with changeswith the mandible . It should remain constant in relation to changes in tongueposition . It should relate to the anatomical and functional properties ofthe tongue Determination should be as simple as possible .
  57. 57. For assessment of tongue position In the radiograph
  58. 58. ASSESSMENT OF TONGUE POSITIONMeasurement along 1 gives the distance between softpalate and the root of the tongue•Average – 0.9 – 2.1 mm•Less- with anomalies in nasal breathing.•Large – class III and mouth breathing
  59. 59. Measurement along 2 – 6 gives the relationship ofthe dorsum of the tongue to the floor of the mouth . Class II – high Deep overbite – dorsum is high at the back . Low at front Other cases – lowMeasurement along 7 gives the position of thetip of the tongue relative to the lower incisors Open bite – lies forwards- 2.4mm classII with nasal breathing - 6.3mm classII and mouth breathing – 10mm Class III and mouth breathing – 5.2mm
  60. 60. ASSESSMENT OF TONGUE MOBILTY-To assess the mobility of the tongue ,the difference between the position of the tongue at restand occlusal is calculatedThe occlusal position is taken as zero, with changes in restposition is expressed as positive or negative .In rest position the tip of the tongue is retracted in class II,but shows forward displacement in class III
  61. 61. TONGUE SIZEMicroglossiaMacroglossia
  62. 62. SIGNIFICANCE OF FUNCTIONAL ANALYSIS IN TREATMENT PLANING WITHREMOVABLE APPLIANCECLASSII MALOCCLUSIONS The postural rest position of the mandible can beanterior or posterior to habitual occlusal position . If a large free way space ,Mandibular over closure,and deep bite are present Prognosis with functional appliances is goodEarly TMJ symptom can frequently be seen in class II malocclusionEspecially in cases of deep overbite , horiontal growth pattern , andAbnormal perioral muscle function .The disfunction of the tongue should be Evaluated as should the lips ,mentalis muscle , facial musculature Suprahyoid and infrahyoid musculaturelocalized effect on dento alveolar growth should be noted .Respiratory distrubance have potential interfering roleIn the accomplishment of normal growth and developmental patternand should be eliminated
  63. 63. Thank you