Orthodontic Management of Class ll malocclusion by Ahmed Safwat

1. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 1 ORTHODONTICS MANAGEMENT OF CLASS II MALOCCLUSIONS A H M E D S A F W A T EVENT SPEAKER: DR. AHMED SAFWAT BDS, DDS, MSC ORTHODONTICS, EOS AAO.

2. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 2 1. Definitions: 2. Classification: 3. Etiological Factors: 4. Clinical Features: 5. Management: O U T L I N E S ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS,

3. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 3 ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS ANTRO-POSTERIOR MALOCCLUSIONS Class 2 Malocclusions Maxillary Prognathism Mandibular Retrognathism Combinations Class 3 Malocclusions Maxillary Retrognathism Mandibular Prognathism Combinations BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS CLASSIFCATIONS

4. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 4 Class II MALOCCLUSIONS Young Age Growth Modification Adults Camouflage Class III MALOCCLUSIONS Young Age Growth Modification Adults Camouflage ORTHODONTICS MANAGEMENT OF SKELETAL ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS T R E A T M E N T M O D A L I T I E S

5. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 5 BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

6. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 6 I. Classification of Angle's Class II Malocclusion  Based On Angle's Classification Malocclusions Are Classified Into Two Types:  Angle's Class II Division 1 Malocclusion; The molar relationship is class ll with the upper anteriors proclined.  Angle's Class II Division 2 Malocclusion; The molar relationship is class ll and the upper incisors are retroclined  Angle's Class ll Subdivision Malocclusion; The molar relationship is class ll only in one side and the other side has class l molar relationship. ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

7. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 7 I. Classification of Angle's Class II Malocclusion  Based On Angle's Classification Malocclusions Are Classified Into Two Types: 1. Angle's Class II Division 1 Malocclusion; The molar relationship is class ll with the upper anteriors proclined. ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

8. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 8 I. Classification of Angle's Class II Malocclusion  Based On Angle's Classification Malocclusions Are Classified Into Two Types: 2. Angle's Class II Division 2 Malocclusion; The molar relationship is class ll and the upper incisors are retroclined ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

9. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 9 I. Classification of Angle's Class II Malocclusion  Based On Angle's Classification Malocclusions Are Classified Into Two Types: 3. Angle's Class ll Subdivision Malocclusion; The molar relationship is class ll only in one side and the other side has class l molar relationship. ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

10. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 10  When buccal groove of first mandibular molar occlude distal to mesio buccal cusp of the first maxillary molar with retroclination of maxillary central incisors.  It represent 5 to 10 % of all malocclusion, by Sassouni 1971. II. Class II division II malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS II. Von-der-lindon Classification Of Angle's Class II Malocclusion Based On Severity Of Incisor Relationship II. Class II division II malocclusion

11. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 11 II. Class II Division II Malocclusion Sub-division ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS - TYPE A: Maxillary central and lateral incisors are retroclined. Degree of retroclination is less severe in nature. II. Von-der-lindon Classification Of Angle's Class II Malocclusion Based On Severity Of Incisor Relationship

12. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 12 II. Class II Division II Malocclusion Sub-division ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS - TYPE B: Maxillary lateral incisors are overlapping the retroclined maxillary central incisors. II. Von-der-lindon Classification Of Angle's Class II Malocclusion Based On Severity Of Incisor Relationship

13. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 13 II. Class II Division II Malocclusion Sub-division ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS - TYPE C: Maxillary central and lateral incisors are retroclined and are overlapped by the maxillary canines. II. Von-der-lindon Classification Of Angle's Class II Malocclusion Based On Severity Of Incisor Relationship

14. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 14 Pre-natal Factors • Genetic and congenital: • Teratogenesis • Irradiation • Intrauterine fetal posture Natal Factors • Improper forceps application during delivery can lead to condylar damage /fracture causing internal hemorrhage into the joint area. TMJ can get ankylosed or fibrosed later, leading to underdevelopment of the mandible Post-natal Factors • Traumatic injuries • Oral habits such as thumb sucking • Congenitally missing teeth Etiological Factors of Class II Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

15. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 15 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Extra-oral Features Shape Of The Head: Mesocephalic or Dolichocephalic Facial Form: Mesoprosopic or Euryprosopic. Facial Divergence: Posterior facial divergence. Lips: Incompetent lips. Mentolabial Sulcus: Deep . Nasolabial Angle: Decreased . Mentalis: Hyperactive. Lower Facial Height: Decreased. Profile: Convex facial profile

16. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 16 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Radiographic Features

17. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 17 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Intra-oral Features • Maxillary Anteriors: Proclination of maxillary anterior . • Molar Relationship: Class II molar relationship • Incisor Relationship: Class II division I incisor relationship. • Over Jet: Increased . • Over Bite: Increased . • Shape Of The Maxillary Arch: V shaped arch . • Curve Of Spee: Exaggerated . • Anterior Open Bite: May or may not be present, Depends on the persistence of deleterious oral habits. • Posterior Cross-bite & Scissor- Bite: Presence depends on persistence of habit.

18. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 18 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Extra-oral Features FEATURES CLASS II DIV 2 Shape Of The Head: Brachycephalic head Profile Strait to mild convex Upper Lip Lower lip Competency Normal Normal or everted Competent Mentolabial sulcus Maybe deep or normal LFH Low

19. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 19 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Intra-oral Features Molar and canine relationship Class II molar and canine relationship Incisors Centrals retroclined, laterals proclined Overjet decreased Overbite Closed bite Arch form Square U shaped Palate shallow Curve of spee deep Path of closure Backward

20. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 20 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Radiograhic Features 1. SNA: Normal 2. SNB: Decreased 3. ANB: Increased 4. Flat mandibular plane. 5. Increased posterior facial height(s-go). 6. Short lower anterior facial height

21. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 21 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS  Result from discrepancy in Maxillo-mandibular relationship, which May be due to;  Mandibular deficiency.  Maxillary excess,  or combinations Difference Between Dental & Skeletal Class II Skeletal Class II BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS

22. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 22 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Difference Between Dental & Skeletal Class II  Normal maxillo-mandibular relationship.  Mainly due to mesial drift of upper 6 as a result of: • Premature extraction of upper E. • Congenitally missed of upper E.  Discrepancy at inter arch tooth size; • Small or congenitally missed upper Permenant premolar (u5) lead to class II molar relationship. • Impacted or missed upper canine or 2nd premolar lead to inadequate space and then class II relationship. Dental Class II

23. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 23 Management of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Age At Which The Patient Is Seem Nature & Severity of The Problem Treatment Principles Depends On Three Important Factors:

25. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 25 Management of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

26. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 26 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Maxillary Prognathism With Normal Mandible: Normal Maxilla With Mandibular Deficiency

27. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 27 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: • Restrict The Excessively Growing Maxilla (Distalization) • Extraoral Force Using Headgear (The Most Effective Approach) Main Treatment Objectives

28. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 28 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: Face bow therapy is the best treatment to restrict max. growth. Face bow applay a distal extra-oral force on the maxillary dentition and the maxilla in the magnitude of 400-600 gm perside, intermittently for a duration of 12 to 14 hours a day to bring about the desired skeletal effects. More dental movement occurs if the face bow is worn more than 16 hrs. per day at force level 300 gm or less. Patients are advised to wear the appliance in the evening and throughout the night. Headgear age of treatment is usually given at 8.5 to 10.5 years in females and 9.5 to 11.5 years in males

29. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 29 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible:  Components Of Headgear: 1. Force Delivering Unit:  Face Bow.  'J'hook. 2. Force Generating Unit:  Coil Spring (Safety Module). 3. Anchor Unit:  Head Cap Or,  Neck Strap.

30. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 30 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible:

31. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 31 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible:

32. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 32 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: • Shape Of The Head: Mesocephalic or Dolichocephalic • Facial Form: Mesoprosopic or Euryprosopic. • Lips: Incompetent lips. • Mentolabial Sulcus: Deep . • Nasolabial Angle: Decreased . • Mentalis: Hyperactive. • Profile: Convex facial profile BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Extra-oral Records:

33. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 33 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Intra-oral Records:

34. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 34 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Radiographic Records:

35. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 35 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Radiograhic Features 1. SNA: Increased. 2. SNB: Normal. 3. ANB: Increased. 4. FMA: Increased. 5. Decreased posterior facial height(s-go). 6. Long lower anterior facial height

36. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 36 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Treatment Objectives:  Restrict the maxillary forward downward growth.  Correct the increased dental over-jet. Treatment Steps:  Two Stage Treatment Protocols Were Followed:  1st Removable Stage: High-pull headgear with removable acrylic maxillary splint for 9 months for maxillary distalization.  2nd Fixed Stage: SWA reinforced with High-pull headgear for anchorage

37. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 37 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS

39. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 39 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Extra-oral Records: • Shape Of The Head: Mesocephalic or Dolichocephalic • Lips: Competent lips. • Mentolabial Sulcus: Normal . • Nasolabial Angle: Increased . • Mentalis: Normal. • Profile: Straight to Convex facial profile Extra-oral Records:

41. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 41 Management of Class II Division I Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: Radiographic Records: 1. SNA: Decreased. 2. SNB: Normal. 3. ANB: Decreased.

42. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 42 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Case Report: • Egyptian male with 10 years old. • Chief complaint of bad smile & improper occlusion functions. • Extra-oral records show deficient mandible with decreased anterior lower facial height & incompetent lips. • Intra-oral records show increased over-jet with crowded & extruded lower anterior teeth.

43. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 43 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS • Shape Of The Head: Mesocephalic or Dolichocephalic • Lips: Incompetent lips. • Mentolabial Sulcus: Deep . • Nasolabial Angle: Decreased . • Mentalis: Hyperactive. • Profile: Convex facial profile Extra-oral Records:

44. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 44 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Intra-oral Records:

45. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 45 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Radiographic Records: 1. SNA: Increased. 2. SNB: Decreased. 3. ANB: Increased.

46. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 46 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Treatment Objectives:  Activate the mandible forward downward growth.  Correct the increased dental over-jet. Treatment Steps:  Two Stage Treatment Protocols Were Followed:  1st Removable Stage: Twin-block removable apliance for 9 months for mandible forward downward growth activation.  2nd Fixed Stage: SWA reinforced with fixed functional appliance for anchorage & continue mandible forward downward movement. Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible:

47. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 47 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS  The primary goal is to enhance the mandibular growth using functional appliances like activator, frankel, herbest and various bite jumping devices.  They work by unloading the mandibular condyle from the glenoid fossa to a more forward position inducing altered muscular activity.  This tend to enhance the growth in the condyle region.

48. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 48 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: Twin-Block Appliance  Twin-block appliance is composed of maxillary and mandibular acrylic retainers that fit tightly against the teeth, alveolus and adjacent supporting structures.  Delta clasps are used bilaterally to anchor the maxillary appliance to the first permanent molars and 0.030 inch  Ball clasps are placed in the interproximal areas anteriorly REMOVABLE FUNCTIONAL APPLIANCES THERAPY

49. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 49 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: Twin-Block Appliance REMOVABLE FUNCTIONAL APPLIANCES THERAPY

50. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 50 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: REMOVABLE FUNCTIONAL APPLIANCES THERAPY Twin-Block Appliance

51. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 51 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: Twin-Block Appliance  Anchorage: The precise clasp configuration depends on the type of deciduous or permanent teeth and number of teeth present at the time of appliance construction.  Bio-mechanics: It produce increase in mandibular length, incisor proclination and variations in lower anterior facial height.  The posterior bite blocks of the twin block appliance can be trimmed to facilitate the eruption of the lower posterior teeth in patient with a deep bite and an accentuated curve of Spee.  The blocks also can be left untouched to prevent the eruption of the posterior teeth in patients with a tendency toward an anterior open bite. REMOVABLE FUNCTIONAL APPLIANCES THERAPY

52. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 52 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: Twin-Block Appliance REMOVABLE FUNCTIONAL APPLIANCES THERAPY

53. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 53 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: FIXED FUNCTIONAL APPLIANCES THERAPY HERBST DESIGN The Herbst appliance is a fixed functional orthopedic appliance having passive tube and plunger system with the exact length of the tube determining the amount of anterior mandibular development. The tube is attached to a maxillary posterior root, whereas the plunger is fixed anteriorly to the mandibular dentition and slides through the tube during opening and closing movements. HERBST APPLIANCE

54. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 54 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: FIXED FUNCTIONAL APPLIANCES THERAPY HERBST APPLIANCE

55. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 55 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: FIXED FUNCTIONAL APPLIANCES THERAPY HERBST APPLIANCE Indications: • 1. Dental class II malocclusion. • 2. Deep bite with retroclined mandibular incisors. • 3. Skeletal class II mandibular deficiency Contraindication: • 1. Dental and skeletal open bites. • 2. Cases prone to root resorption. Disadvantages: • 1. High cost. • 2. Herbst appliance associated with more chances of breakage. • 3. Less patient acceptance

56. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 56 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS • Shape Of The Head: Mesocephalic or Dolichocephalic • Lips: Competent lips. • Mentolabial Sulcus: Normal . • Nasolabial Angle: Increased . • Mentalis: Normal function. • Profile: Straight to Convex facial profile Extra-oral Records:

57. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 57 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Radiographic Records: 1. SNA: Decreased. 2. SNB: Increased. 3. ANB: Decreased.

58. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 58 Management of Class II Division II Malocclusion During Mixed Dentition Period (Growing Period) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II With Normal Maxilla & Deficient Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Intra-oral Records:

59. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 59 Management of Dento-alveolar Class II Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Management Of Dento-alveolar Class ΙΙ

60. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 60 Management of Dento-alveolar Class II Malocclusion With Normal Skeletal Relationship (Growing Period). ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Dento-alveolar Class ΙΙ BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Management Is Based Mainly On The Etiological Factors: 2-In prematurely extracted cases where mesial drift has occurred, space regaining device are to be used 1-Avoid premature extraction and if necessary space should maintained to prevent mesial drift in the molar.

61. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 61 Management of Dento-alveolar Class II Malocclusion With Normal Skeletal Relationship (Growing Period). ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS THEY FALL UNDER TWO CATEGORY: B- Extra-oral appliances for distalization can be done using headgear A- Intra-oral appliances for distalization , include pendulum, distal slide appliance or springs. Management Of Dento-alveolar Class ΙΙ

62. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 62 Management of Dento-alveolar Class II Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Management Of Dento-alveolar Class ΙΙ  Premature Tooth Loss With Adequate Space: Space Maintenance :  Band-and-Loop Space Maintainers.

63. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 63 Management of Dento-alveolar Class II Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Early loss of primary teeth

64. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 64 Management of Dento-alveolar Class II Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Management Of Dento-alveolar Class ΙΙ

66. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 66 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Class II Division I Malocclusion In Adult Patients Maxillary Prognathism Mandibular Retrognathism Combinations CLASSIFCATIONS

67. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 67 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Non Accepted Smile Display Due To Maxillary Prognathism Two Treatment Protocols Available: Retraction Of Anterior Segment Into Premolars Extraction Spaces Distalization Of The Whole Maxillary Segment A- Maxillary Prognathism

68. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 68 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Extra-oral Features Shape Of The Head: Mesocephalic or Dolichocephalic Facial Profile: Convexdivergence. Lips: Incompetent lips. Mentolabial Sulcus: Deep . Nasolabial Angle: Decreased .

69. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 69 ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Intra-oral Features • Maxillary Anteriors: Proclination of maxillary anterior . • Molar Relationship: Class II molar relationship • Incisor Relationship: Class II division I incisor relationship. • Over Jet: Increased . • Over Bite: Increased . • Shape Of The Maxillary Arch: V shaped arch . • Curve Of Spee: Exaggerated . Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS

70. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 70 ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) Radiographic Features 1. SNA: Increased. 2. SNB: Normal. 3. ANB: Increased. 4. FMA: Increased. 5. Decreased posterior facial height(s-go). 6. Long lower anterior facial height

71. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 71 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Treatment Objectives:  Retract the maxilla.  Correct the increased dental over-jet. Treatment Steps:  Extraction of 1st premolars.  Retraction Of Anterior Segment Into Premolars Extraction Spaces

72. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 72 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Treatment Progress:

76. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 76 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Two Treatment Protocols Available: Retraction Of Anterior Segment Into Premolars Extraction Spaces Distalization Of The Whole Maxillary Segment B- Mandibular Retrusion Management Of Class ΙΙ Div I With Normal Maxilla & Retruded Mandible:

77. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 77 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Normal Maxilla & Retruded Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Maxillary Distalization MEAW Bio-mechanics

78. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 78 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Normal Maxilla & Retruded Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS MEAW Bio-mechanics Maxillary Distalization

79. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 79 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Normal Maxilla & Retruded Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Maxillary Distalization TADs Bio-mechanics

80. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 80 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div I With Maxillary Prognathism & Normal Mandible: BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Class II Division I Malocclusion In Adult Patients Maxillary Prognathism Mandibular Retrognathism Combinations CLASSIFCATIONS

81. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 81 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS In Case Of A Combinations Of Increased Maxilla & Mandible

82. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 82 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS I n C a s e O f A C o m b i n a t i o n s O f I n c r e a s e d M a x i l l a & M a n d i b l e Two Treatment Objecties: Retraction Of Maxillary Anterior Segment Retraction Of Mandibular Anterior Segment C- Maxillary & Mandibular Excess

83. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 83 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS I n C a s e O f A C o m b i n a t i o n s O f I n c r e a s e d M a x i l l a & M a n d i b l e • Shape Of The Head: Dolichocephalic • Facial Profile: Convex divergence. • Lips: Incompetent lips. • Mentolabial Sulcus: Deep . • Nasolabial Angle: Decreased . Extra-oral Features

84. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 84 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS I n C a s e O f A C o m b i n a t i o n s O f I n c r e a s e d M a x i l l a & M a n d i b l e • Shape Of The Head: Dolichocephalic • Facial Profile: Convex divergence. • Lips: Incompetent lips. • Mentolabial Sulcus: Deep . • Nasolabial Angle: Decreased . Extra-oral Features

85. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 85 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS I n C a s e O f A C o m b i n a t i o n s O f I n c r e a s e d M a x i l l a & M a n d i b l e Radiographic Features 1. SNA: Increased. 2. SNB: Increased. 3. ANB: Increased. 4. FMA: Increased. 5. Decreased posterior facial height(s-go). 6. Long lower anterior facial height

86. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 86 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS I n C a s e O f A C o m b i n a t i o n s O f I n c r e a s e d M a x i l l a & M a n d i b l e Intra-oral Records

87. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 87 Management of Class II Division I Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS I n C a s e O f A C o m b i n a t i o n s O f I n c r e a s e d M a x i l l a & M a n d i b l e Treatment Progress:

88. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 88 Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients): BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS

89. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 89 Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Treatment Objectives Correct Molar & Canine Relationships Relief The Crowded Dentition Correct Anterior Teeth Torque Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients):

90. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 90 Extra-oral Features FEATURES CLASS II DIV 2 Shape Of The Head: Brachycephalic head Profile Strait to mild convex Upper Lip Lower lip Competency Normal Normal or everted Competent Mentolabial sulcus Maybe deep or normal LFH Low Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients): Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS

91. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 91 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Radiographic Features 1. SNA: Normal 2. SNB: Decreased 3. ANB: Increased 4. Flat mandibular plane. 5. Increased posterior facial height(s-go). 6. Short lower anterior facial height

92. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 92 Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Radiographic Records: Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients):

93. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 93 Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Intra-oral Records: Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients):

94. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 94 Clinical Features of Class II Division I Malocclusion ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS Intra-oral Features Molar and canine relationship Class II molar and canine relationship Incisors Centrals retroclined, laterals proclined Overjet decreased Overbite Closed bite Arch form Square U shaped Palate shallow Curve of spee deep Path of closure Backward

95. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 95 Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients): Treatment Progress:

96. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 96 Management of Class II Division II Malocclusion In Permanent Dentition (Adult Patients) ORTHODONTICS MANAGEMENT OF ANTRO-POSTERIOR MALOCCLUSIONS BY, DR. AHMED SAFWAT ORTHODONTIC CENTERS Treatment Progress: Management Of Class ΙΙ Div II In Permanent Dentition (Adult Patients):

97. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 97 ORTHODONTICS MANAGEMENT OF CLASS II MALOCCLUSIONS A H M E D S A F W A T EVENT SPEAKER: DR. AHMED SAFWAT BDS, DDS, MSC ORTHODONTICS, EOS AAO. • Orthodontics contemporary ( William R. Proffit). • Hand book of Orthodontics (Robert Moyers). • ORTHODONTICS Principles and Practice( Basavaraj Subhashchandra Phulari). • FLAVIO URIBE, RAVINDRA NANDA, Treatment of Class II, Division 2 Malocclusion in Adults: Biomechanical Considerations 2003 JCO. • Paulo Renato Carvalho Ribeiro, Angle Class II, Division 2, malocclusion with deep overbite, Dental Press J. Orthod. 132-143, Jan./Feb. 2010. • Hande Görücü Coşkuner, İlken Kocadereli, Non extraction Treatment OF An Adult With CLASS II DIVISION 2 Malocclusion, CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 49- 56 References:

98. 9/9/2021 Antero-Posterior Malocclusions, Ahmed Safwat 98 ORTHODONTICS MANAGEMENT OF CLASS II MALOCCLUSIONS A H M E D S A F W A T EVENT SPEAKER: DR. AHMED SAFWAT BDS, DDS, MSC ORTHODONTICS, EOS AAO.

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