combined fixed functional class 2 treatment.

COMBINEDCOMBINED
FIXED-FIXED-
FUNCTIONALFUNCTIONAL
CLASS IICLASS II
TREATMENTTREATMENT
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INTRODUCTIONINTRODUCTION
 Class II, division 1 & 2s cases often involve both dental andClass II, division 1 & 2s cases often involve both dental and
skeletal problems. Functional appliances have been shown to produceskeletal problems. Functional appliances have been shown to produce
beneficial effects in growing patients with class II malocclusions, but thebeneficial effects in growing patients with class II malocclusions, but the
mechanism and effectiveness of these appliances remain controversial.mechanism and effectiveness of these appliances remain controversial.
 One study showed an initial stimulation of condylar growth, butOne study showed an initial stimulation of condylar growth, but
a long-term total amount of growth that was no higher than in untreateda long-term total amount of growth that was no higher than in untreated
control groups. Other authors have stated that the treatment result ofcontrol groups. Other authors have stated that the treatment result of
functional appliances is achieved through a combination of increasedfunctional appliances is achieved through a combination of increased
mandibular growth, maxillary retraction, and dentoalveolar changes.mandibular growth, maxillary retraction, and dentoalveolar changes.
 If a patient is nearing the end of growth, precious growing timeIf a patient is nearing the end of growth, precious growing time
can be lost when leveling, and alignment with fixed appliances mustcan be lost when leveling, and alignment with fixed appliances must
precede functional therapy. This article presents a practical method ofprecede functional therapy. This article presents a practical method of
simultaneous treatment with fixed appliances and removable functionalsimultaneous treatment with fixed appliances and removable functional
appliances.appliances.

EVAAEVAA
 EVAA in Dutch stands forEVAA in Dutch stands for
experimental fixed applianceexperimental fixed appliance
activator. It is a solid block ofactivator. It is a solid block of
acrylic with protruding wires thatacrylic with protruding wires that
are inserted into the tubes of theare inserted into the tubes of the
upper molar bands.upper molar bands.
 The appliance is constructed soThe appliance is constructed so
that the mandible is forced into athat the mandible is forced into a
forward position in closing. Fixedforward position in closing. Fixed
appliances can be placed to alignappliances can be placed to align
teeth at the same time as theteeth at the same time as the
orthopedic treatment.orthopedic treatment.

EVAAEVAA
 The upper and lower impressionsThe upper and lower impressions
for the EVAA should be takenfor the EVAA should be taken
with fixed appliance in place.with fixed appliance in place.
 The construction bite should beThe construction bite should be
as close as possible to an edge-as close as possible to an edge-
to-edge incisal position.to-edge incisal position.
 Patients who are nearing the endPatients who are nearing the end
of growth should wear the EVAAof growth should wear the EVAA
at least 16 hours a day. Thoseat least 16 hours a day. Those
with extreme skeletal deficiencieswith extreme skeletal deficiencies
should wear it day and night,should wear it day and night,
except during meals.except during meals.

DIAGNOSIS ANDDIAGNOSIS AND
TREATMENT PLANTREATMENT PLAN
 A 12 ½ year-old male was referredA 12 ½ year-old male was referred
for orthodontic treatment of afor orthodontic treatment of a
class II, division 1 malocclusion. Aclass II, division 1 malocclusion. A
previous traumatic necrosis of theprevious traumatic necrosis of the
upper left central incisor pulp hadupper left central incisor pulp had
created a severe esthetic problem.created a severe esthetic problem.
The patient had a 7.5 mm overjet, aThe patient had a 7.5 mm overjet, a
5 mm overbite, and a distoclusion5 mm overbite, and a distoclusion
in both the molar regions.in both the molar regions.
Cephalometric analysis showed anCephalometric analysis showed an
ANB angle of 6ANB angle of 6º and a normal-º and a normal-
divergent growth pattern.divergent growth pattern.
 Treatment objectives were:Treatment objectives were:
 Align the dental arches.Align the dental arches.
 Create Class I skeletal andCreate Class I skeletal and
dental ralationships.dental ralationships.

TREATMENT PROGRESSTREATMENT PROGRESS
 After three months of leveling andAfter three months of leveling and
aligning with fixed appliances,aligning with fixed appliances,
impressions were taken and animpressions were taken and an
EVAA construction bite was made.EVAA construction bite was made.
The EVAA was placed in the nextThe EVAA was placed in the next
visit.visit.
 A class I occlusion was achievedA class I occlusion was achieved
with six months of goodwith six months of good
cooperation, and the functionalcooperation, and the functional
therapy was discontinued. Lowertherapy was discontinued. Lower
incisor reproximation was thenincisor reproximation was then
performed to resolve a tooth-sizeperformed to resolve a tooth-size
discrepancy.discrepancy.

TREATMENT PROGRESSTREATMENT PROGRESS
Finishing arches were placed,Finishing arches were placed,
along with box elastics toalong with box elastics to
improve lateral interdigitation .improve lateral interdigitation .
After debonding, an openAfter debonding, an open
activator was worn as retaineractivator was worn as retainer
during sleep.during sleep.
The upper left central incisor wasThe upper left central incisor was
bleached and restored.bleached and restored.

TREATMENT RESULTSTREATMENT RESULTS
 Before treatmentBefore treatment  After initial alignmentAfter initial alignment
 After EVAA therapyAfter EVAA therapy  After debondingAfter debonding

TREATMENT RESULTSTREATMENT RESULTS
 During the EVAA phase, the SNB angle increased by 3During the EVAA phase, the SNB angle increased by 3º, and theº, and the
mandibular length (Ar-Gn) increased much more than in fixed appliancesmandibular length (Ar-Gn) increased much more than in fixed appliances
phases. Similar results were noted for the WITS value and ANB.phases. Similar results were noted for the WITS value and ANB.
 Comparing the changes in pogonion, a forward and downward movementComparing the changes in pogonion, a forward and downward movement
occurred during functional therapy, but a mostly downward movementoccurred during functional therapy, but a mostly downward movement
occurred during finishing phase.occurred during finishing phase.
 The angles between the lower incisor and the mandibular plane and theThe angles between the lower incisor and the mandibular plane and the
lower incisor and NB remained stable during the EVAA phase.lower incisor and NB remained stable during the EVAA phase.

CONCLUSIONCONCLUSION
The fixed appliance-E VAA combination has the following advantages:The fixed appliance-E VAA combination has the following advantages:
 Total treatment time can be reduced by aligning the teeth and correcting theTotal treatment time can be reduced by aligning the teeth and correcting the
skeletal ClassII condition simultaneously.skeletal ClassII condition simultaneously.
 After functional therapy, the fixed appliances can remain in place forAfter functional therapy, the fixed appliances can remain in place for
finishing if desired.finishing if desired.
 The EVAA appears to produce beneficial orthopedic effects with minimalThe EVAA appears to produce beneficial orthopedic effects with minimal
undesirable dentoalveolar side effects.undesirable dentoalveolar side effects.
 The EVAA is well tolerated by patients.The EVAA is well tolerated by patients.
 Laboratory and chairside procedures are simple and relatively fast.Laboratory and chairside procedures are simple and relatively fast.
The EVAA does have a limited ability to produce transverse and rotationalThe EVAA does have a limited ability to produce transverse and rotational
corrections in the molar regions. This disadvantage can easily be eliminatedcorrections in the molar regions. This disadvantage can easily be eliminated
with a short phase of fixed appliance molar correction prior to insertion ofwith a short phase of fixed appliance molar correction prior to insertion of
the EVAA.the EVAA.

combined fixed functional class 2 treatment.

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