causes and management of class II div 2 is presented

1. P R E S E N T E D T O / P R O F M A H E R F O U D A
P R E S E N T E D B Y / E N G Y A H M E D E L - S H E R B E N Y
CLASS II DIV 2
MALOCCLUSION

2. Class II division II malocclusion
 It is a type of class II malocclusion, defined by Angle in 1899.
 It represent 5 to 10 % of all malocclusion, by Sassouni 1971.

3. According to Angle classification:
 When buccal groove of first mandibular molar occlude distal to mesio
buccal cusp of the first maxillary molar, with retroclination of maxillary
central incisors.

4. Types of class II division II
 According to angle classification;
 There are 3 types according to severity of incisors relatioship;
1. Maxillary central and lateral incisors are retroclined.
Degree of retroclination is less severe in nature.

5. Type 2:
 Upper lateral incisors overlapped the retroclined
upper central incisors.

6. Type 3 :
 Maxillary central and lateral incisors are retroclined
and overlapped by the maxillary canine.

7. class II div II clinically (extraoral) :
 Brachyocephalic head
 Deep mentolabial sulcus
 Upper lip positioned high to upper incisors (gum
smile)
 Everted lower lip(high relative to upper incisors)

8. class II div II clinically (intraoral) :
 Upper and lower incisors are retroclined
 The lower incisors occlude posteriorly to the cingulum of upper
incisors.
 The overjet is minimal
 Deep over bite
 classII canine & molar relationship
 Deep curve of spee

9. Class II div II etiology :
 Dental
 Skeletal (genetic)
 combinations

10. Dental class II div II
 Normal maxillo-mandibular relationship.
 Mainly due to mesial drift of upper 6 as a result of :
1. Premature extraction of upper E
2. Congenitally missed of upper E
Discrepancy at inter arch tooth size;
1. 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

11. Skeletal classII div II characterized by :
 Result from discrepancy in maxillo-mandibular
relationship
 May be due to;
1. Mandibular deficiency
2. Maxillary excess
3. or combinations

12. Skeletal class II div II due to mandibular
deficiency
1. May be due to small size of mandible (size)
2. retruded mandible relative to maxilla (position)
3. combinations

13. Class II div II with small size mandible
 Cephalometrically:
 1) Flat mandibular plane
 2) Increasesd posterior facial height
 3) Short lower anterior facial height(
resulting in both upper and lower lip
having a more everted position at rest)
 4) Mandibular length measured from
Ar-Gn-Pog may appear normal because
of the excessive chin projection.
 5) SNA:normal
 SNB: decreased
 ANB: increased (Stiener)

14. Class II div II with (distal positioning) of a
normal-sized mandible.
 Cephalometrically:
1. SNA: Normal
2. SNB: Decreased
3. ANB: Increased (Steiner)
 -Distinguishing characteristics:
1. The cranial base defined by (S-N-
Basion) is more obtuse
2. Gleniod fossa in a relatively
posterior in position.
3. Normal size of mandibular ramus
and body
4. d) normal lower facial height

15. Skeletal Class II division due to Maxillary excess
 Maxillary excess
Vertical dimension or Anterior-
posterior dimension
Posterior excess overall vertical excess
 Or combination of both

16. class II div II due to maxillary excess
 Vertical Maxillary excess may be localized only to the
posterior area . Open bite and incompetent lips ( normal
vertical display of maxillary incisors in repose and during
smiling.)
 Overall maxillary excess includes both the anterior and
the posterior area , resulting in an excessive vertical
display of the maxillary incisors in repose and during
smiling (high smile line) Gummy smile. (classII/2) and
incompetent lips.
 In these 2 conditions of maxillary excess Mandible is
rotated downward and posteriorly (clockwise) resulting in
a class II skeletal relationship.

17. Class II div II with vertical maxillary excess:
 Cephalometrically:
1. SNA: Normal
2. SNB: Decreased
3. ANB: Increased (Stiener)
4. Increased lower anterior facial
height
5. Steeper mandibular plane
6. More inferior position of the
maxillary molars relative to
palatal plane.
7. Clockwise rotation of the
mandible

18. class II div II overall Maxillary excess in Ant-
Post Dimension
 characterized by ;a protrusion of the entire midface
including :
1. Nose
2. infraorbital area
3. Upper lip

19.  Cephalometrically:
1. SNA: increased
2. SNB: Normal
3. ANB: Increased
4. Increased face convexity.
5. Overjet: excessive
6. Over eruption of mandibular incisors
7. Excessive overbite.
8. If midface protrusion is severe ,The
lower lip will be positioned lingual to
maxillary incisors encouraging there
protrusion.

20. Skeletal Class II division II due to combination
 Skeletal Class II division II might be a combination
of both mandibular deficiency and maxillary excess.
Which will add to the severity of the Ant-post skeletal
problem.

21. Treatment of class II div II
 Optimum time for growth modification Pre-pubertal
growth spurt growing patient was diagnosed with a
skeletal class II malocclusion due to a maxillary excess
treated through “restraining” the maxillary growth.
 in this case is to apply an orthopedic force to the maxilla
via maxillary teeth best applied in posterior and superior
direction ( high pull head gear)
 A range of correction that can be accomplished by
orthodontic tooth movement alone.

22.  The range of tooth movement for a patient is determined
by the
1. Severity of malocclusion
2. Age of the patient ( growing or non-growing)
3. Facial esthetics
 These 3 main features will determine the treatment
option that is suitable for the patient.
 A larger amount that can be accomplished by
orthodontics tooth movement aided by absolute
anchorage
 A larger range of correction that requires surgery as a
part of treatment plan

23.  The orthodontic treatment with or without
orthopedic treatment can create a larger A-P
correction then in Transverse and Vertical
dimension.
 Greater amount of maxillary retraction then
mandibular can be established (due to anatomic and
physiologic limits)

24. Soft tissue limitations in treatment class II div II
 Limitations in orthodontic treatment related to the
soft tissue:
1. Pressure exerted on teeth from lips, cheeks, and
tongue
2. Peridontal attachment
3. Neuro-muscular influence on mandibular position
4. Contours of the soft tissue facial mask
5. Lip-Tooth relationship ( Anterior tooth display
during facial animation)

25. Treatment of Dental Class II div II
 Orthodontic treatment extraction or non extraction
depending on the severity of mesial drift of upper 6.
1- slight mesial drift ( mesial crown tipping) + minimal
crowding Non-extraction + distalization of
maxillary 1st molar –
2- severe mesial drift (roots and crown are mesially
positioned) extraction is indicated to obtain
space.

26. Treatment of skeletal Class II division II
 1) Growth modification
 2) Dental camouflage
 3) Orthognathic surgery (with orthodontic
treatment)

27. Growth modification for class II skeletal problem:
(Orthopedic treatment)
 The goal of growth modification is to enhance the
unacceptable skeletal relationship by modifying
remaining facial growth pattern of the jaws.
 Optimum timing : Pre-pubertal growth spurt (active
growth period)
 Two types of orthopedic appliances used in skeletal class
II div 2:
1. I) Headgear ( extra-oral force)
2. 2) Functional appliances ( Removable and fixed )

28.  Headgear: it delivers an extra-oral orthopedic force
to compress the maxillary sutures and modify the
pattern of bone apposition at these sites.
 2 TYPES
1. Facebow (max excess)
2. J-Hooks (Maxillary anterior retraction& intrusion)

31. Functional appliances
 Class II functional appliances are designed to
position the mandible in a downward and forward to
enhance its mandibular growth pattern.
 Indication: Mandibular deficiency

32. Removable Functional:
1. Activator
2. Twin block
3. Frankyl II
4. bionator
Fixed Functional:
1. Herbst
2. Jasper jumper

35. Dental Camouflage
 It is a treatment that seeks to create a dental
compensation to hide the skeletal discrepancy
 Maxillary Retro-clination and Mandibular Protraction.
 Indicated:
1. Adults
2. Mild to Moderate skeletal Class II cases
3. Minimal dental crowding .
4. Acceptable facial esthetics
5. Usually requires extraction

36.  Dental camouflage without extraction is rare in case
of skeletal class II
1. Mild skeletal class II cases
2. Mild excessive overjet
3. Adequate space available
4. Max Molar distalization

37. Orthognathic surgery:
 A combination of orthodontic therapy and Orthognathic
surgery for the correction of moderate to severe skeletal class
II malocclusion (Adults, no growth potential)
 Indicated:
1. Moderate to Severe skeletal discrepancy
2. Facial imbalances or asymmetries: long lower face , Gummy
smile
3. Limitations of tooth movement : Upright on basal bone
4. Relapse potential of orthodontic treatment.
5. Severe crowding and protrusion in the dental arches with
skeletal class II malocclusion (extraction space is not
sufficient to correct buccal occlusion)

38. Surgical correction includes:
1. MandibularAdvancment: Indicated:
skeletal class II cases with mandibular deficiency

39.  Maxillary Impaction:
( Le Fort 1 maxillary osteotomy ) Indicated: Vertical
Maxillary excess

41. refrences
 Orthodontics contemporary ( William R. Proffit)
 Hand book of Orthodontics (Robert Moyers)