Class ii malocclusion

class II malocclusion

1. GOOD MORNING

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

3. CONTENT Introduction Classification Aetiology Clinical features Treatment modalities Conclusion Reference

4. 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

5. 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. Textbook of orthodontics by Dr. Samir Bishara

6. 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. Textbook of orthodontics by Dr. Samir Bishara

7. 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; 4 th edition

8. Handbook of orthodontics by Robert Moyers; 4 th 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.

9. 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.

10. SKELETAL CLASS II MALOCCLUSIONS Skeletal discrepancies are often associated with dental Class II malocclusions. A] Mandibular Deficiency B] Maxillary Excess Textbook of orthodontics by Dr. Samir Bishara

11. Textbook of orthodontics by Dr. Samir Bishara Because of small size of the ramus and body of the mandible downward and backward rotation of the mandible. CLASS I CLASS II

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

13. 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 Handbook of orthodontics by Robert Moyers; 4 th edition

14. 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 Handbook of orthodontics by Robert Moyers; 4 th edition

15. TYPE C: Retrognathic maxilla and mandible Dental protrusion Smaller facial dimension More in females TYPE D: Maxillary and mandibular retrognatism Max dental protrusion Handbook of orthodontics by Robert Moyers; 4 th edition

16. TYPE E: Maxillary prognathism and dental protrusion. Mandibular dental protrusion ( B imaxillary 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. Handbook of orthodontics by Robert Moyers; 4 th edition

17. LONG FACE Mandibular plane, occlusal plane are steeper than normal. Palate tipped downwards. Antero-facial height is increased. TYPE-1 VERTICAL TYPES: Handbook of orthodontics by Robert Moyers; 4 th edition

18. TYPE-2 Square face. Mandibular plane, occlusal plane, Palate and Anterior cranial base are more horizontal. Handbook of orthodontics by Robert Moyers; 4 th edition

19. TYPE-3 Palate tipped up anteriorly. Decreased upper anterior facial height Open bite Handbook of orthodontics by Robert Moyers; 4 th edition

20. TYPE-4 Palatal plane, Mandibular Plane, Occlusal Plane all are tipped downwards. Handbook of orthodontics by Robert Moyers; 4 th edition

21. TYPE-5 PP tipped down anteriorly Deep bite Handbook of orthodontics by Robert Moyers; 4 th edition

22. AETIOLOGY Heredity 2. Developmental defects 3. Trauma 4. Physical agents Handbook of orthodontics by Robert Moyers; 4 th edition a) Prenatal trauma and birth injuries b) Postnatal trauma a) Premature extraction of primary teeth b) Nature of food

23. 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 Handbook of orthodontics by Robert Moyers; 4 th edition

24. CLINICAL FEATURES OF CLASS II DIV 1 EXTRAORAL FEATURES Profile : convex Deep mento-labial sulcus Upper lip short hypotonic Lips- incompetent/competent Lip trap Textbook of orthodontics by Dr. Samir Bishara

25. 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 Textbook of orthodontics by Dr. Samir Bishara

26. Abnormal muscle activities Abnormal buccinator activity Lower positioning of the tongue Which predispose to posterior cross bite Hyper active mentalis muscle (retrognathic mandible) Textbook of orthodontics by Dr. Samir Bishara

27. CLINICAL FEATURES OF CLASS II DIV2 EXTRAORAL FEATURES Profile: straight/convex Reduced lower facial height Mento labial sulcus : normal/ deep Path of closure- backward Textbook of orthodontics by Dr. Samir Bishara

28. 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. Textbook of orthodontics by Dr. Samir Bishara

29. diagnosis History . Extra & Intraoral examination . Study models . Orthodontic photographs. Cephalometrics .

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

31. 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.

32. 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

33. 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 Textbook of orthodontics by Dr. Samir Bishara

34. Treatment modalities Class II malocclusion Growing Patient Nongrowing patient Skeletal Dental Dental Skeletal FIXED ORTHODONTIC TREATMENT SURGICAL TREATMENT ORTHOPAEDIC/ FUCTIONAL APPLIANCES

35. HEADGEAR Used in cases of maxillary excess. Designed to deliver adequate extraoral orthopaedic force to compress the maxillary sutures. TYPES OF HEADGEAR Facebow b) J-hook headgear ORTHOPAEDIC APPLIANCES Textbook of orthodontics by Dr. Samir Bishara

36. FACEBOW Consists of : outer bow for extraoral attachment Inner bow for intraoral attachment Textbook of orthodontics by Dr. Samir Bishara

37. J-HOOK HEADGEAR 2 separate, curved, large gauge wires with small hooks at the ends. More commonly used for retraction of canines or incisors. Textbook of orthodontics by Dr. Samir Bishara

38. 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 CERVICAL ATTACHMENT OR NECK STRAP

39. 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

40. 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 2 nd 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

41. Skeletal effects Compresses maxillary sutures Restricts downward & forward maxillary growth. Allows normal mandibular growth. Studies have shown- small increase in mandibular growth with headgear . Textbook of orthodontics by Dr. Samir Bishara

42. Dental effects Prevents downward & forward eruption of maxillary molar indirectly enhancing mandibular growth. H igh 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. Textbook of orthodontics by Dr. Samir Bishara

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

44. INDICATIONS OF FUNCTIONAL APPLIANCE A ctive mandibular growth. Mandibular deficiency. N ormal maxillary development. N ormal or mildly decreased face height. S lightly protrusive maxillary incisors and slightly retrusive mandibular incisors. Textbook of orthodontics by Dr. Samir Bishara

45. activator D eveloped by Viggo Andresen, Denmark and Karl Haupl Norway. In1908 Introduces new way mandibular closure. EFFECTS: Controls the downward and forward growth of mandible . Prevents forward growth of the maxillary dentoalveolar process. Distal movement of maxillary dentoalveolar process. *Removable orthodontics, by Graber & Newman

46. CONSTRUCTION: 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. Textbook of orthodontics by Dr. Samir Bishara

47. 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. Textbook of orthodontics by Dr. Samir Bishara

48. 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. Textbook of orthodontics by Dr. Samir Bishara

49. 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 . *Removable orthodontics, by Graber & Newman

50. 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. *Removable orthodontics, by Graber & Newman

51. Twin block The twin block appliance was introduced by a Scottish orthodontist, William Clark , in 1977. More range of mandibular movement. *Removable orthodontics, by Graber & Newman

52. Two-piece or split activator using separate maxillary and mandibular appliances. Occlusal acrylic portions serve as inclined guide planes and bite blocks. *Removable orthodontics, by Graber & Newman

53. Functional regulator Rolf Frankel Also called as Frankel’s appliance Recontours the facial soft tissue adjacent to the teeth. Textbook of orthodontics by Dr. Samir Bishara

54. 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 . Textbook of orthodontics by Dr. Samir Bishara

55. 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. Textbook of orthodontics by Dr. Samir Bishara

56. 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. Textbook of orthodontics by Dr. Samir Bishara

57. 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 . Textbook of orthodontics by Dr. Samir Bishara

58. MARa Appliance Mandibular advancing repositioning appliance This appliance was introduced by Ralph M Clements and Alex Jacobson.1982 C omposed of a pair of telescopic struts Textbook of orthodontics by Dr. Samir Bishara

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

60. 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 * Contemporary Orthodontics 4 th edition by William Profitt

61. 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. * Contemporary Orthodontics 4 th edition by William Profitt

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

63. DE-ROTATION OF MOLARS In patients with mild to moderate skeletal Class II malocclusion, the upper molars are likely to be rotated mesially. T ranspalatal lingual arch or an auxiliary labial arch or the inner bow of a facebow. * Contemporary Orthodontics 4 th edition by William Profitt

64. 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. * Contemporary Orthodontics 4 th edition by William Profitt

65. 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 * Contemporary Orthodontics 4 th edition by William Profitt

66. 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 * Contemporary Orthodontics 4 th edition by William Profitt

67. A-NiTi coil springs compressed against the molars. (from an anterior anchorage unit) produces a constant force system for the distal movement . * Contemporary Orthodontics 4 th edition by William Profitt

68. * Contemporary Orthodontics 4 th edition by William Profitt

69. P endulum 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. * Contemporary Orthodontics 4 th edition by William Profitt

70. DENTAL CAMOUFLAGE WITH EXTRACTIONS Extraction of Maxillary 2 nd Molars Maxillary First Premolars Only Or Maxillary And Mandibular First Premolars. * Contemporary Orthodontics 4 th edition by William Profitt

71. Extraction Of The Upper Second Molars Class 1 molar relation is created by distal movement of maxillary 1 st molar. Distalization of 1 st 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. * Contemporary Orthodontics 4 th edition by William Profitt

72. 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.

73. Anchorage used to prevent mesial migration of molars are: Extraoral anchorage Transpalatal arch or nance holding arch Class II elastics Segmental retraction of anteriors. * Contemporary Orthodontics 4 th edition by William Profitt

74. 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. * Contemporary Orthodontics 4 th edition by William Profitt

75. 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 . Textbook of orthodontics by Dr. Samir Bishara

76. 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 Textbook of orthodontics by Dr. Samir Bishara

77. 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 Textbook of orthodontics by Dr. Samir Bishara

78. 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. Textbook of orthodontics by Dr. Samir Bishara

79. 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. Textbook of orthodontics by Dr. Samir Bishara

80. 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. Textbook of orthodontics by Dr. Samir Bishara

81. 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. Textbook of orthodontics by Dr. Samir Bishara

82. 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 . Textbook of orthodontics by Dr. Samir Bishara

83. 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.

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