Class ii div 2

causes and management of class II div 2 is presented

1. PRESENTED TO / prof Maher Fouda Presented by/ Engy ahmed el-sherbeny 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 S assouni 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 ; 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 : 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 2 nd 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; Mandibular deficiency Maxillary excess or combinations

12. Skeletal class II div II due to mandibular deficiency May be due to small size of mandible (size) retruded mandible relative to maxilla (position) 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 : SNA: Normal SNB: Decreased ANB : Increased (Steiner) -Distinguishing characteristics : The cranial base defined by (S-N- Basion ) is more obtuse Gleniod fossa in a relatively posterior in position. Normal size of mandibular ramus and body 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 : SNA : Normal SNB : Decreased ANB : Increased ( Stiener ) Increased lower anterior facial height Steeper mandibular plane More inferior position of the maxillary molars relative to palatal plane. 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 : Nose infraorbital area Upper lip

19. Cephalometrically: SNA : increased SNB : Normal ANB : Increased Increased face convexity. Overjet : excessive Over eruption of mandibular incisors Excessive overbite. 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 Severity of malocclusion Age of the patient ( growing or non-growing) 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 : Pressure exerted on teeth from lips, cheeks, and tongue Peridontal attachment Neuro -muscular influence on mandibular position Contours of the soft tissue facial mask 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) T he 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: I) Headgear ( extra-oral force) 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 Facebow (max excess) J-Hooks (Maxillary anterior retraction& intrusion)

29. 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

30. Removable Functional: Activator Twin block Frankyl II bionator Fixed Functional: Herbst Jasper jumper

31. 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 : Adults Mild to Moderate skeletal Class II cases Minimal dental crowding . Acceptable facial esthetics Usually requires extraction

32. Dental camouflage without extraction is rare in case of skeletal class II Mild skeletal class II cases Mild excessive overjet Adequate space available Max Molar distalization

33. 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 : Moderate to Severe skeletal discrepancy Facial imbalances or asymmetries: long lower face , Gummy smile Limitations of tooth movement : Upright on basal bone Relapse potential of orthodontic treatment . Severe crowding and protrusion in the dental arches with skeletal class II malocclusion (extraction space is not sufficient to correct buccal occlusion)

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

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

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