Class II
Malocclusion
By: Dr. Shaho Ziyad Al-Talabani
Assistant Prof. – P.O.P Dept. College of Dentistry /HMU
B.D.S-M.Sc.- Ph.D. – Specialist Orthodontist
September 2023
• Class II division 1 is the term
used to describe a malocclusion
in which the lower incisal edges
lie posterior to the cingulum
plateau of the upper incisors,
• the overjet (OJ) is increased
and the upper incisors are
normally inclined or proclined
• The molar relationship is often
Class II, however, it may be
Class I. The overbite (OB) is
variable but is often deep
• The prevalence of Class II
division 1 malocclusion is 15–
20% among Caucasians
Aetiology
Skeletal pattern
Soft tissues
Dental factors
Habits
Mandibular deficiency
A, A patient with mandibular deficiency characterized by both a small mandibular ramus and body. There is decreased
posterior face height. In this case the deficiency is great enough to cause eversion or redundancy of the lower lip with its
position lingual to the maxillary incisors, preventing resting lip apposition
Mandibular deficiency
B, A patient with mandibular deficiency limited primarily to the mandibular body with a normal-sized ramus. This
usually results in a normal posterior face height with a decreased anterior face height and a flat mandibular plane.
Mandibular deficiency
A patient with mandibular deficiency characterized by retrusion of a normal sized mandible. The cranial base
angle is increased, resulting in a more posterior position of the mandible.
Individuals with mandibular deficiency resulting from retrusion of a normal-sized mandible share cephalometric features of
other types of mandibular deficiency with respect to points A and B relative to Sella and the occlusal plane. The cranial base
angle, defined by points Nasion, Sella, and Basion, often is more obtuse with the glenoid fossa in a relatively posterior position
Maxillary excess
A patient with posterior vertical maxillary excess. Although there is increased anterior face height, steep mandibular plane, and
incompetent lips, there is normal vertical display of maxillary incisors in repose and while smiling. This is typically associated with
an anterior open bite
Maxillary excess
A patient with overall vertical maxillary excess. The increased anterior face height, steep mandibular plane, and
incompetent lips are features in common with posterior vertical maxillary excess. However, the additional vertical excess
in the anterior part of the maxilla results in excessive vertical display of maxillary incisors in repose and while smiling. An
anterior open bite usually is not a feature of this condition.
Maxillary excess
, maxillary anteroposterior excess is characterized by a protrusion of the entire midface, including the
nose and infraorbital area as well as the upper with a normal size and position of the mandible
Maxillary excess
A patient with a combination of mandibular deficiency and vertical maxillary excess.
Aetiology
Maxilla
dentoalveolar
dentoalveolar
Mandible
Aetiology
Maxilla
dentoalveolar
dentoalveolar
Mandible
Aetiology
Maxilla
dentoalveolar
dentoalveolar
Mandible
Aetiology Skeletal pattern
Anteroposterior assessment/Lateral view
Profile
Glabella
Subnasale
Pogonion
The 0 ° meridian ( zero - degree meridian ) was described and named by the
Mexican plastic surgeon Mario Gonzalez - Ulloa as a vertical line dropped from soft
tissue nasion (N ′ ), perpendicular to the Frankfort Horizontal plane. 6,7 Gonzalez - Ulloa
described the concept initially in 1962, 6 though he used the term ( A ) ‘ facial plane ’ ,
subsequently introducing the term ( B ) ‘ true Meridian 0 ° of the face ’ in 1968 7 .
Anteroposterior assessment/Lateral view
Zero meridian
the morphology of the
nasal radix and glabellar
region is highly variable . Upper lip
Individuals
may present with anything
2-3 mm ahead
from a deep concavity to a
relatively
flat nasal radix and thereby
considerable variation in
the sagittal position of soft Lower lip
tissue nasion 0-2 mm behind
subnasale vertical , or SnV ). This is
particularly useful for planning
mandibular advancement or
forward sliding genioplasty in
patients with normal midfacial
morphology.
ANB angle (3±2)
Soft tissues
A normal class I incisor
• Lips are competent at rest
• Lip to lip anterior oral seal
• Normal tongue behaviour
Lip to lip anterior oral seal
Soft tissues
In a Class II division 1 malocclusion,
the lips are often incompetent due to the
prominence of the upper incisors and/or the
underlying skeletal pattern.
If the lips are incompetent, a patient can try to
achieve an anterior oral seal in a number of
different ways.
Adaptive anterior oral seal
a. tongue to lower lip
Adaptive anterior oral seal
b. Lower lip to palate
Dental factors
A Class II division 1 incisor
relationship may occur as a
result of crowding. Due to
the shortage of space, the
upper incisors may be
displaced labially leading to
an increased overjet.
Habits
The effects of a persistent digit-sucking habit on the occlusion: the upper incisors
have been proclined and the lower incisors retroclined.
Treatment planning for Class II division 1 malocclusions
Of particular relevance to treatment planning for Class II division 1
malocclusions are:
• aetiology
• age of the patient
• any underlying skeletal problems
• anchorage
• retention.
Skeletal problems and treatment
planning
There are three options for treating malocclusions with underlying skeletal
problems:
• Orthodontic camouflage
• Growth modification
• Combined orthodontic and surgical approach
Class II growth modification is most
effective during the adolescent growth
spurt
Extraoral Force (Headgear) Appliances
the most ideal indication for the use of extraoral force in the correction of
skeletal Class II malocclusions is with anteroposterior maxillary excess
normal mandibular skeletal and dental morphology.
Finally, the ideal circumstance for use of headgear must be one where there is
continued active mandibular growth, primarily displacing the mandible in a
forward, rather than downward direction
Extraoral force must be of much greater magnitude, in
the range of 400 to 600 g (1 to 1'/ pounds) per side for a
total of 800 to 1200 g (2 to 3 pounds), to maximize the
potential for skeletal change and to minimize dental
change
In contrast to orthodontic tooth movement,
intermittent forces of 12 to 16 hours' duration
appear to be effective for facial orthopedic
changes
The second most active period of facial growth is during the pubertal growth spurt in early
adolescence when skeletal changes achieved with Class II treatment are much more resistant to
relapse, probably because of the minimal maxillary growth and residual mandibular growth that
often remains at this stage of growth
e. One final note on optimum timing of extraoral force is the
recognition that increased release of growth hormone and
other endocrine factors that promote growth occurs more
during the evening and night than during the day74 and is
associated with sleep onse
Limitation
Unfortunately, the facial pubertal growth spurt does not occur in all patients and is not accurately predictable
regarding its timing, magnitude, direction, or duration.
Another risk of starting treatment during the pubertal growth spurt is that its occurrence coincides with the
physically and emotionally labile period of adolescence, which often limits the patient compliance for
headgear wear
Another limitation that is all too familiar to orthodontists is the dependence on patient compliance to wear and
care for the headgear for successful treatment progress.
Indications for and Goals of Treatment with
Functional Appliances
skeletal Class 11 malocclusions is a mandibular deficiency.
normal maxillary development, is a normal or mildly decreased face height because, theoretically, most of these
appliances encourage mandibular posterior dental eruption.
An additional optimal indication for functional appliances is slightly protrusive maxillary incisors and slightly
retrusive mandibular incisors
Finally, as with headgear therapy, the ideal patient must have active mandibular growth, primarily in a forward
direction
BIOMECHANICS OF FUNCTIONAL
APPLIANCES
Mandibular and Glenoid Fossa Growth Enhancement
Maxillary Growth Inhibition
Posterior Biteplate Effect
Guidance of Eruption
Stimulation of Bona Deposition in Areas Where the Periosteum is Stretched
Class II Elastic Effect
Dental Camouflage of Class II Skeletal Problems
older adolescents or adults who no longer have adequate facial growth potential to make it worthwhile
to attempt or continue growth modification.
when the skeletal Class II problems are mild to moderate in severity
Candidates for dental camouflage treatment should also have no more than minimal dental crowding
and, ideally, extra space in the dental arches
A final criterion for selecting dental camouflage is that it results in normal vertical facial
proportions. preferably with mesofacial or brachyfacial types, and potential remaining growth. A
low mandibular plane angle is most suitable because in high angle the distal movement of molars
will tend to open the bite due to the extrusive force component
Dental Camouflage without Extractions
Dental Camouflage with Extractions
Camouflage
Differential Anteroposterior Tooth
Movement Using Extraction Spaces
Class II Camouflage by Extraction of Upper First Palatal Bone Screw Anchorage
Premolars
IZS
Extraction of Maxillary and Mandibular Premolars Miniplate Anchorage
Nonextraction Correction With Interarch Elastics
INDICATIONS FOR FIXED FUNCTIONAL
APPLIANCES USE
1. As Class II mechanics.
2. Cases of Class II with mandibular retrusion. Preference is given to rigid appliances.
3. Cases of Class II with maxillary protrusion.
4. Class II, subdivision, with no extraction treatment.
5. As anchorage after maxillary molars distalization.
CONTRAINDICATIONS
There are some clinical situations in which the clinician needs to carry out cost-
benefit analysis on the use of mandibular protraction appliances, namely:
1. Patients with periodontal issues.
2. Patients with thin gingiva in the mandibular anterior region.
3. Patients with mandibular incisors tipped or anteriorly projected.
4. Patients with marked gingival smile.
5. Patients with a tendency to open bite.
Clip – appliance piece aimed at securing the spring into
maxillary molar tube
Push rod – appliance piece that connects the
appliance to the mandible
Spring – which is fatigue resistant, made of stainless
steel, and produces force of approximately 220g;
General clinical requirements for installation
With a view
to avoiding protrusion of mandibular incisors, resistant
a 0.019 x 0.025-in stainless steel archwire must be used with 0.022-in slot, or 0.017 x
lingualmust
0.025-in stainless steel archwire torque
be on mandibular
used teethslot
with 0.018-in in the anterior region
or brackets with greater lingual torque on those
teeth should be considered. An Omega loop is also
interesting
to secure the archwire. A bend on the distal
surface of last molar is also considered. It is also
recommended
to use a figure-8 stainless-steel ligature in
all lower teeth, since the appliance tends to open space
between canines and first premolars. The use of a lingual
arch in the mandible and a transpalatal arch in the
maxilla is recommended. A last requirement is the use
of an occlusal headgear tube in the maxillary molar.
Dental Camouflage with Extractions
Anchorage
Sliding Versus Loop Mechanics in Space Closure
En Masse Versus two stage Canine Retraction
Mini screw and space closure
Medical history
Patient preference
Compliance
Facial profile
Skeletal pattern
Stability
Space required
Dental health
Tooth size discrepancies
Space analysis
Space analysis
(Calculating the space requirements)
Extraction versus non-extraction
Stripping
expansion
Distal movement of molars
Frictionless Friction
In sliding mechanics, the tooth feels less force than that applied as a result of friction
is automatic generation of the root-paralleling moments at the extraction site
For routine use with fail-safe closing loops , the preferred location for a closing loop is at the
spot that will be the center of the embrasure when the space is closed
Enmasse Two stage
force to move the teeth and a root-paralleling
moment to move them bodily
Principles of fixed appliances
Principles of fixed appliances
Principles of fixed appliances
Principles of fixed appliances
Illustration describing the anchorage preparation required in rectangular stainless
steel archwires for the use of Class II elastics.
Class II
Malocclusion
By: Dr. Shaho Ziyad Al-Talabani
Assistant Prof. – P.O.P Dept. College of Dentistry /HMU
B.D.S-M.Sc.- Ph.D. – Specialist Orthodontist
September 2023
Class II division 2
The prevalence of this
malocclusion in a Caucasian
population is approximately 10%.
This malocclusion has a strong
genetic association
The overjet may be
normal or increased.
This malocclusion has a strong genetic association
Aetiology
Aetiology
Aetiology
Type B. With limited space, the maxillary central incisors tip palatally, and the
lateral incisors tip labially
Type C. With marked shortage of space, the four maxillary incisors tip
palatally, and the canines emerge buccally outside the dental arch
Vertical
skeletal
relationshi
p
UAFH
UPFH
TAFH
TPFH
LPFH
LAFH
Vertical skeletal relationship
soft tissue examination
Lower Lip line
Extra oral examination -soft tissue examination
Lower Lip line
Lips are usually competent
Anterior oral seal
Great deal of activity of circum-oral musculature
High lower lip line
Upper & Lower labial segment teeth to be Retroclined
Strap like lip
There are a number of treatment approaches for the
correction of
Class II division 2:
• functional appliances followed by fixed appliances;
• fixed appliances;
• orthodontics with orthognathic surgery.
Stable correction of a Class II division 2 incisor relationship has two key components to
prevent re-eruption of the incisors after treatment
1. Correction of the inter-incisal angle.
2. Reduction of the increased overbite
Correction of inter-incisal
angle
Edge–centroid relationship: the midpoint of the maxillary incisor root axis (centroid) lies palatal to the lower incisor
incisal edge
. .
Inter-incisal correction can be achieved through one or a
combination of the following approaches
Reduction of overbite
o Intrusion of incisors
• Eruption of molars
• Extrusion of molars
• Proclination of incisors
For torque of very upright maxillary central incisors (as in Class II division 2
malocclusion), a one-couple torquing arch designed by Burstone can be
very effective.
Direction of the force
Differential Diagnosis Based on Tooth
Position: The Posterior Teeth
Molar Tipping
The maxillary and mandibular arches should be carefully evaluated to assess the presence of a
molar rotation. A mesial-in rotation of a maxillary molar will result in a more Class II molar
relationship on that side of the arch
Mandibular Dental Midline Deviation
With Skeletal Symmetry
Class II subdivision malocclusions have been reported
to account for 50% of all Class II malocclusions,
and it appears that the majority of these have distally
positioned mandibular molars on the Class II side.
Maxillary Dental Midline Deviation
With Skeletal Symmetry
Deviation of the maxillary dental midline from the
facial midline in Class II subdivision malocclusions
Maxillary and Mandibular DentalMidline Deviation With Skeletal
Symmetry
