classiimalocclusion-161213170920.pdf

CLASS II
MALOCCLUSION
GUIDED BY:
DR. SURESH KANGNE
DR. ANAND AMBEKAR
DR. PRAVINKUMAR MARURE
DR. YATISHKUMAR JOSHI
DR. CHAITANYA KHANAPURE
PRESENTED BY:
ABHIDNYA
MADANSURE

CONTENT
• Introduction
• Classification
• Aetiology
• Clinical features
• Treatment modalities
• Conclusion
• Reference

INTRODUCTION
• E.H. ANGLE, in 1899 described
normal occlusion as an
• “Evenly placed row of teeth
arranged in a graceful curve
with harmony between the
upper and lower arches.”
Textbook of orthodontics by Dr. Samir Bishara

• Angle stated the following:
• In normal occlusion, the
mesiobuccal cusp of the upper
first molar is received in the
sulcus between the mesial and
distal (middle) buccal cusps of
the lower first molar.

• The mesial incline of the upper
canine occludes with the distal
incline of the lower canine
• The distal incline of the upper
canine occludes with the
mesial incline of the buccal
cusp of the lower first
premolar.

CLASS II
MALOCCLUSIONS
• "Distal" relationship of mandible
to maxilla .
• The mesiobuccal cusp of the
maxillary first permanent molar
articulates mesial to the buccal
groove of the mandibular first
permanent.
Handbook of orthodontics by Robert Moyers; 4th edition

DIVISION 1-The
maxillary incisors
labioversion
DIVISION 2- maxillary central
incisors are near normal or
slightly in linguoversion
Maxillary lateral incisors have
tipped labially.

CLASS II DIV 2 MALOCCLUSION
CLASSIFICATION
• Type a
• Type b
• Type c &
• Type d * Given in orthodontic diagnosis by Rakosi, Jonas and Graber
SUBDIVISION-
When the distoclusion occurs on
one side.

SKELETAL CLASS II
MALOCCLUSIONS
• Skeletal discrepancies are often associated with
dental Class II malocclusions.
A] Mandibular Deficiency
B] Maxillary Excess

• Because of small size of the ramus and body of the
mandible downward and backward rotation of the
mandible.
CLASS I
CLASS
II

Natural dental compensation:
• Protrusive mandibular incisors.
• Narrow or constricted maxillary arch.
• Mesiolingual rotation of the maxillary first molars.
*Textbook of orthodontics by Dr. Samir Bishara

MOYER’S CLASSIFICATION
OF CLASS II
Vertical
Class II
Class II
Horizontal
Class II
A B C D E F 1 2 4
3 5

HORIZONTAL TYPES:
TYPE A: (Dental)
• Normal skeletal profile.
• Maxillary dentition is protracted
resulting in class2 molar
relation.
• Increased over-jet and over-bite
TYPE B:
• Mid-face prominence
• Normal mandible

TYPE C:
• Retrognathic maxilla and
mandible
• Dental protrusion
• Smaller facial dimension
• More in females
TYPE D:
• Maxillary and mandibular
retrognatism
• Max dental protrusion

TYPE E:
• Maxillary prognathism and
dental protrusion.
• Mandibular dental protrusion
• (Bimaxillary protrusion)
TYPE F
• Borderline b/w class1 and class II
• Mild skeletal class2 tendencies
• It is a milder form of types B,C,D,E.

• LONG FACE
• Mandibular plane,
occlusal plane are steeper
than normal.
• Palate tipped downwards.
• Antero-facial height is
increased.
TYPE-1
VERTICAL TYPES:

TYPE-2
• Square face.
• Mandibular plane,
occlusal plane, Palate
and Anterior cranial
base are more
horizontal.

TYPE-3
• Palate tipped up
anteriorly.
• Decreased upper
anterior facial height
• Open bite

TYPE-4
• Palatal plane,
Mandibular Plane,
Occlusal Plane all are
tipped downwards.

TYPE-5
• PP tipped down
anteriorly
• Deep bite

AETIOLOGY
1. Heredity
2. Developmental defects
3. Trauma
4. Physical agents
a) Prenatal trauma and birth injuries
b) Postnatal trauma
a) Premature extraction of primary teeth
b) Nature of food

a) Thumb-sucking
b) Tongue-thrusting
c) Lip-sucking and lip-biting
d) Nail-biting
a) Systemic diseases
b) Endocrine disorders
c) Local diseases
5. Habits
6. Disease
7. Malnutrition

CLINICAL FEATURES
OF CLASS II DIV 1
EXTRAORAL FEATURES
• Profile : convex
• Deep mento-labial sulcus
• Upper lip short hypotonic
• Lips- incompetent/competent
• Lip trap

INTRAORAL FEATURES:
• Class II molar relation,
• Proclined maxillary anteriors,
increased overjet
• Flaring and spaced dentition
• V shaped arch and deep palate
• Deep curve of spee

Abnormal muscle activities
• Abnormal buccinator activity
• Lower positioning of the tongue
• Which predispose to posterior
cross bite
• Hyper active mentalis muscle
(retrognathic mandible)

CLINICAL FEATURES OF CLASS
II DIV2
EXTRAORAL FEATURES
• Profile: straight/convex
• Reduced lower facial height
• Mento labial sulcus : normal/ deep
• Path of closure- backward

INTRAORAL FEATURES:
• Class 2 molar relationship
• Retroclined upper central
proclined maxillary lateral
incisors.
• Overjet- decreased, Deep bites
• U shaped/ square arches
• Deep curves of Spee.

DIAGNOSIS
• History.
• Extra & Intraoral examination.
• Study models.
• Orthodontic photographs.
• Cephalometrics.

STUDY MODELS
• To asses the angles classification of molars, canines,
• To determine amount of crowding or spacing and
• presence of other anomalies

PHOTOGRAPHS
• Extraoral and intraoral.
• Extraoral_- used to asses patient’s profile facial
asymmetry and smile lines.
• Intraoral photographs are taken to maintain a
visual record of all findings.

PANTOMOGRAPH (OPG)
• To assess the stage of dental
eruption, missing,
supernumerary or impacted
teeth, ectopically erupting teeth,
and pathologic condition
LATERAL CEPHALOMETRIC
RADIOGRAPH
is used to evaluate the
relationship of the jaws and teeth

CEPHALOMETRICS
• Steep mandibular plane
angle
• Increased or normal SNA
angle
• Decreased SNB angle
• Increased ANB angle
• Normal position of pt A but
a posterior position of pt B

TREATMENT
MODALITIES
Class II malocclusion
Growing Patient
Nongrowing
patient
Skeletal Dental
Dental Skeletal
FIXED
ORTHODONTIC
TREATMENT
SURGICAL
TREATMENT
ORTHOPAEDIC/
FUCTIONAL
APPLIANCES

HEADGEAR
• Used in cases of maxillary excess.
• Designed to deliver adequate
extraoral orthopaedic force to
compress the maxillary sutures.
TYPES OF HEADGEAR
a) Facebow b) J-hook headgear
ORTHOPAEDIC APPLIANCES

FACEBOW
• Consists of :
outer bow for extraoral
attachment
Inner bow for intraoral
attachment

J-HOOK HEADGEAR
• 2 separate, curved, large gauge wires with small
hooks at the ends.
• More commonly used for retraction of canines or
incisors.

• Point of attachment is usually below
the occlusal plane- the extraoral force
is directed inferiorly and posteriorly.
• Extrude molars.
• Cannot be used in patients with
vertical growth pattern.
• Used in cases in which an increase in
facial vertical dimension is desired.
Contemporary orthodontics, William Proffit
1. CERVICAL ATTACHMENT OR NECK
STRAP

• The point of attachment well above
the occlusal plane.
• Extraoral force is directed
superiorly and posteriorly.
• Intrude molars & steepen occlusal
plane.
• Correction of not only
anteroposterior maxillary excess,
but also to vertical maxillary excess
Contemporary orthodontics, William Proffit
OCCIPITAL ATTACHMENT OR HEADCAP

Magnitude of force:
• Orthopaedic forces to modify bone growth ranges from
400-600 g.
Duration
• 12-16 hours per day.
Timing of treatment:
• Most active period of growth is before eruption of
permanent teeth.
• The 2nd active growth phase is ‘adolescence’
• Result obtained would be good and relapse chances are
minimal.
• Headgear should be worn in the night as active growth
occurs at this time. Textbook of orthodontics by Dr. Samir Bishara

SKELETAL EFFECTS
• Compresses maxillary sutures
• Restricts downward & forward maxillary growth.
• Allows normal mandibular growth.
• Studies have shown- small increase in mandibular
growth with headgear.

DENTAL EFFECTS
• Prevents downward & forward eruption of maxillary
molar indirectly enhancing mandibular growth.
• High pull headgear -Intrusive effect on molar.
• cervical pull headgear- to extrude molar;
• If continues arch wire from molar to incisors- distal
movement of molar can result in lingual movement of
maxillary incisors.

REMOVABLE:
• Activator
• Bionator
• Functional regulator
• Twin block
FUNCTIONAL APPLIANCES
FIXED:
• Herbst appliance
• Jasper jumper
• MARA

INDICATIONS OF FUNCTIONAL APPLIANCE
• Active mandibular growth.
• Mandibular deficiency.
• Normal maxillary development.
• Normal or mildly decreased face height.
• Slightly protrusive maxillary incisors and slightly
retrusive mandibular incisors.

ACTIVATOR
Developed by Viggo Andresen, Denmark and Karl Haupl
Norway. In1908
Introduces new way mandibular closure.
• EFFECTS:
1)Controls the downward and forward growth of
mandible.
2) Prevents forward growth of the maxillary
dentoalveolar process.
3) Distal movement of maxillary dentoalveolar process.
*Removable orthodontics, by Graber & Newman

CONSTRUCTION:
1) wire component:
labial bow 2)Acrylic portion:
BITE REGISTRATION:
• Mandibular advancement of 4 to 6 mm
• 5 to 6 mm opening in the molar region.

MODIFICATIONS:
• Modifications by Harvold includs an increased
mandibular opening for improved retention and
increased soft tissue stretch.
• Posterior facets were replaced with interocclusal
acrylic to prevent eruption of the maxillary posterior
teeth and to leave space for eruption of the
mandibular posterior teeth.

• Acrylic capping over the mandibular incisal edges is
done to minimize their protraction.
• The maxillary wire crossing the palate was replaced
with palatal acrylic.
• Springs were embedded in the acrylic to displace the
appliance forward, forcing the patient to actively
"function" to maintain the appliance in place.

BIONATOR
• Developed by Balters in the early 1950’s,
Mode of action
• Equilibrium between tongue and the circumoral
muscles is attained.
• Establish a normal posture of the tongue
• Screen the hyperactive buccinator : passive
expansion.

• Less bulky compared to Activator
• Smaller mandibular lingual flange
• A transpalatal wire in place of palatal acrylic
• Modified labial bow with buccal extensions that
minimize cheek pressure on the teeth.
• The bionator can incorporate either posterior facets or
interocclusal acrylic to prevent or selectively guide
eruption.

TWIN BLOCK
• The twin block appliance was introduced by a
Scottish orthodontist, William Clark, in 1977.
• More range of mandibular movement.

• Two-piece or split activator using separate maxillary
and mandibular appliances.
• Occlusal acrylic portions serve as inclined guide
planes and bite blocks.

FUNCTIONAL REGULATOR
• Rolf Frankel
• Also called as Frankel’s
appliance
• Recontours the facial soft
tissue adjacent to the
teeth.

MODE OF ACTION :
• Vestibular arena of operation.
• Withholds muscle pressure from the developing jaws and
dentoalveolar area.
• Relief of forces from neuromuscular envelope.
• Increase in sagittal and transverse intraoral space.
• Intermittent outward pull creates outward movement of
alveolodental structures.

Appliances for class II correction:
FR Ib : Class II Div 1 with deep bite and overjet not
exceeding 7 mm.
FR Ic: Class II Div 1 with overjet greater than 7 mm
FR II : Class II Div 1 and Div 2
The FR II is the most frequently used appliance.

HERBST APPLIANCE:
• In 1905 Emil Herbst introduced a fixed appliance in
Germany
• Consists of a rigid maxillary and mandibular framework.
• The mandible is maintained in a
forward position by means of a
metal rod and tube telescopic
mechanism that is attached from
the maxillary first molars to the
mandibular first premolars.

JASPER JUMPER
• An American orthodontist, James Jasper, has replaced
the rigid telescopic mechanism with a flexible plastic
covered open coil spring.
• Attached directly to auxiliary wires with a complete or
partial fixed appliance in place.

MARA APPLIANCE
• Mandibular advancing repositioning appliance
• This appliance was introduced by Ralph M Clements
and Alex Jacobson.1982
• Composed of a pair of telescopic struts

• Indicated in older adolescents or adults.
• When the skeletal Class II problems are mild to
moderate.
FIXED ORTHODONTIC
TREATMENT
* Contemporary Orthodontics 4th edition by William Profitt

• In order to create a class I molar relation in class II
cases, adequate space should be present in the
dental arches.
• This space is absent in many cases.
• Dental camouflage without extraction
• Dental camouflage with extraction

DENTAL CAMOUFLAGE WITHOUT
EXTRACTIONS
• Space is required in the maxillary arch - to retract the
incisors and eliminate overjet
• In the mandibular arch - to protract the mandibular
teeth.
• To gain the space- distalization of maxillary molars.

DISTALIZATION OF MOLAR
• De-rotation of maxillary 1st molar.
• Headgear
• Class II elastics
• Palatal anchorage devices
* Contemporary Orthondontics 4th edition by William Profitt

DE-ROTATION OF MOLARS
• In patients with mild to moderate skeletal Class II
malocclusion, the upper molars are likely to be rotated
mesially.
• Transpalatal lingual arch or an auxiliary labial arch or
the inner bow of a facebow.

• HEADGEAR
• It is now clear that significant distal positioning of the
upper molar with headgear occurs primarily in patients
who have vertical growth.
• Maximum 2 to 3 mm of distal movement occurs in such
cases unless the upper second molars are extracted.

CLASS II ELASTICS
• Can be used for distalization, but
there are some problems.
• First, extrusion of lower molars –
downward & backward rotation of
the mandible.
• Second, -risk of more mesial
movement of the lower teeth than
distal movement of the upper teeth

PALATAL ANCHORAGE SYSTEMS FOR DISTAL
MOVEMENT OF MOLARS
• Mesial movement of teeth is easier than distal
movement.
• Successful distal movement of molars, therefore,
requires more anchorage than that is supplied by just
teeth.
a) NiTi coil springs b)Magnets c)Pendulum appliance

• A-NiTi coil springs compressed against the molars.
• (from an anterior anchorage unit)
• produces a constant force system for the distal
movement.

Pendulum appliance
• Uses beta-Ti springs that extend from the palatal acrylic
and fit into lingual sheaths on the molar tube.
• It is activated to produce 200 to 250 grams
• Byloff et al found that molar movement of l mm/month.

DENTAL CAMOUFLAGE WITH
EXTRACTIONS
• Extraction of
1. Maxillary 2nd Molars
2. Maxillary First Premolars Only Or
3. Maxillary And Mandibular First Premolars.

Extraction Of The Upper Second Molars
• Class 1 molar relation is created by distal
movement of maxillary 1st molar.
• Distalization of 1st molar is much easier if space is
created by extracting the upper second molars.
• Distalization is carried out by using headgear,
pendulum appliance as explained previously.

EXTRACTION OF UPPER FIRST
PREMOLARS
• With this approach, the objective during orthodontic
treatment is to maintain the existing Class II molar
relationship &
• Closing the first premolar extraction space entirely
by retracting the protruding incisor teeth.

• Anchorage used to prevent mesial migration of molars
are:
• Extraoral anchorage
• Transpalatal arch or nance holding arch
• Class II elastics
• Segmental retraction of anteriors.

EXTRACTION OF MAXILLARY AND
MANDIBULAR PREMOLARS
• The mandibular posterior segments will be moved
anteriorly.
• At the same time, the protruding maxillary anterior
teeth will be retracted.
• Class II elastics will be used to close the extraction
sites.

When To Schedule Extraction If It Is Indicated?
• If space is required to eliminate crowding or protrusion
extractions at the onset of treatment.
• Otherwise, extraction should be done
after leveling and alignment.
• Older Extraction - resorbed alveolar bone with constricted facial
and lingual cortical plates that inhibit effective space closure.
• New Extraction Sites - precludes this possibility and have
highly active osseous turnover, offering an ideal environment
for efficient space closure.

• Skeletal Class II problems with little or no remaining
growth potential that cannot be treated with orthodontic
treatment alone.
• In preparation for orthognathic surgery, it is necessary to
remove any dental compensations present and to place
the teeth in a favourable position with their supporting
bone.
• Maxillary protraction and mandibular retraction.
SURGICAL CORRECTION

MANDIBULAR ADVANCEMENT
• Done in mandibular deficiency cases
BILATERAL SAGITTAL SPLIT OSTEOTOMY
• Developed by Richard Trauner, and Hugo Obwegeser.
• Popularly used.
• The mandible can be moved forward or back as
desired, and the tooth-bearing segment can be rotated
down anteriorly when additional anterior face height
is desired

MANDIBULAR TOTAL SUBAPICAL ADVANCEMENT
• less common
• The goal of this surgery is to advance the entire
dentoalveolar segment.
• Eliminates excessive overjet without significantly
changing face height or overbite.

MAXILLARY IMPACTION
• Indicated in vertical maxillary excess.
• May include either:
• total maxillary osteotomy – maxillary excess in
anterior as well as posterior region .
• bilateral posterior segmental maxillary osteotomies -
excess is more in the posterior region.

• Complete levelling of the mandibular arch before
surgery.
• Bone is removed at the osteotomy site to permit superior
repositioning of the maxilla.
• As the maxilla moves up, the mandible rotates upward
and forward around the condylar axis, correcting the
anteroposterior occlusal discrepancy.
• Narrow maxilla - the maxillary osteotomy needs to be in
2 or 3 segments to permit expansion of the maxilla.

• Postsurgical orthodontic treatment includes light
continuous arch wires and light vertical elastics.
• Placement of a maxillary full-dimension nickel-
titanium arch wire is recommended
• Maintains anterior torque while completing root
parallelism in the osteotomy sites.

ANTERIOR MAXILLARY
SUBAPICAL SETBACK
• In rare situations in which the skeletal Class II
malocclusion is caused by a maxillary excess limited to
the anteroposterior dimension only.
• Midface protrusion is characteristic of this condition
• The treatment goal is to use the maxillary first
premolar space for surgical retraction of the maxillary
anterior teeth, maintaining the Class II molar
relationship and achieving a Class I canine
relationship while reducing overjet.

CONCLUSION
• Class II malocclusions are very common malocclusions with
characteristic features.
• Clinical features, x-rays and cephalometrics are useful aids for the
diagnosis of such class II malocclusion.
• The treatment of the class II malocclusion depends upon the age
of the patient, his/her skeletal discrepancy if any and other dental
factors.
• Which should be taken into consideration before starting with the
treatment.

REFERENCES
• Textbook of orthodontics by Dr. Samir Bishara
• Orthodontic diagnosis by Rakosi, Jonas and Graber
• Handbook of orthodontics by Robert Moyers; 4th edition
• Removable orthodontics, by Graber & Newman
• Contemporary Orthodontics 4th edition by William Profitt

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