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TREATMENT OF CLASS

II ANOMALIES

Basics and Principles


Class II/1
ClassII/2

Univ. Prof.Dr.Dr.D. Muessig 1


Treatment of Class II
 Diagnostics

 Treatment objectives

 Treatment planing

 Treatment mechanics

 Retention and stability

Univ. Prof.Dr.Dr.D. Muessig 2


Treatment of Class II
 Diagnostics

Patients age
Patients desire/complaints
Cast analysis /occlusion
Profile
Cephalometric analysis
Patients compliance

Univ. Prof.Dr.Dr.D. Muessig 3


 Diagnostics

Treatment of Class II
Patients age

Is the patient still growing ?

Removable and/or fixed treatment?

Is the patient grown


up?
Only orthodontic treatment or
combined orthodontic/orthognatic
surgery
Univ. Prof.Dr.Dr.D. Muessig 4
 Diagnostics

Treatment of Class II
Is the patient still growing ?
Increase of Bodyhight

Removable
treatment

Fixed Orthodontic
treatment or
combined with
orthogantic surgery

Second transitional
period

Years
Univ. Prof.Dr.Dr.D. Muessig 5
 Diagnostics

Treatment of Class II
 Occlusion /Cast
analysis
What is important?
 Molar-
relationship
 Canine
-relationship
 Overjet / Overbite

 Maxillary anterior arch-width

Univ. Prof.Dr.Dr.D. Muessig 6


Occlusion/Cast
analysis
Anterior upper arch
width

Molar Canine
relationship relationship

Overjet and
Overbite
 Diagnostics

Treatment of Class II
 Occlusion /Cast
analysis
What is important?
 Molar-
relationship Demand of distalizing upper
 Canine molars
Demand of anchoring upper
-relationship Treatment
molars of upper molars
 Overjet / Overbite Space required in the upper arch
Need of intruding incisors
 Maxillary anterior arch-width
Need of upper arch expansion

Univ. Prof.Dr.Dr.D. Muessig 8


Cephalometric Analysis
a –p direction
a-p position of maxilla
a-p position of mandible
a-p maxillo mandibular
relationship
Vertical direction
Mandibular plane angle
Maxillary plane angle
Mandibular –maxillary plane
angle

Incisor
s
Inclination and position of
uppers
Inclination and position of lowers
Overbite and overjet

(growth pattern of the mandible)


Treatment informations from
cephalometric analysis in class II

a-p position of jaws


and incisor position:

Skeletal or dento-alveolar class


II !
The antero-posterior
position of the jaws

SNA- convexity
SNB- angle
ANB- facial-plane
angle
Three categories of skeletal
class II anomalies
Correct a-p position of maxilla:
treatment focus on mandible
Treatment options: class II mechanics /
surgical advancement of the mandible

Prognathic maxilla and retrognathic


mandible:
Treatment focus
Headgear and on both
class jaws
II – mechanics/
Bimaxillay surgical correction
Prognathic maxilla correct mandible:
Treatment focus on maxilla
Headgear – treatment/
Surgical set-back of maxilla
The inclination of the jaws
The vertical facial
pattern
Inclination of NL

Inclination of ML

Interbase –angle /MMP-


angle: NL /ML

High angles: Intrusiv forces to the maxilla


Low angles: Extrusiv forces to the
Impact of incisor position on
treatment

Proclined/protruded incisors:
You need space to correct
incisor postion

Reclined /retruded incisors:


Provide space when beeing
corrected
(very important in classII/2)
Impact of incisor position on
treatment
Overjet:

Distalization of upper
molars
Anchorage of upper
molars
Sometimes extractions
in the upper arch
Impact of incisor position on
treatment
Overbite:

Deep overbite = Intrusion of


incisors
Prior to mandibular
advancement
Open bite = intrusion of upper
molars
Impact of growth pattern on
treatment
Growth Pattern

Counter clockwise rotation =


favorable for skeletal class II
correction
Clockwise rotation =
unfavorable for skeletal class II
correction
Facial analysis/profile

P.M. / m 9,10 years


Example of class II -
treatment
Facial analysis

Meso-facial

Symmetry

Sublabial fold

P.M. / m 9,10 years


Example of class II -
treatment
Profile analysis

Correct position of upper


lip
Retruded lower lip

Retruded chin and


mandible
Correct vertical
proportions

P.M. / m 9,10 years


Cephalometric analysis
Antero-posterior
analysis

SNA= 82° orthognathic

SNB =77° retrognathic

ANB = 5° skeletal class II

Treatment of choice?
Cephalometric analysis
Vertical analysis

NL=NSL= 4°
Counter-
clockwise
ML-NSL=23°Counter-
clockwise

ML-NL = 19°Hypo-divergent
Treatment of choice?
Cephalometric analysis
Overjet:
9mm

Overbite:
7,5mm

Facial-axis:

94°

Gonion-angle = 123°
Occlusion/Cast
analysis
Anterior upper arch
width

Molar Canine
relationship relationship

Overjet and
Overbite
Development of
Dentition
Problem - List
Skeletal problems:
Skeletal Class II /1 with orthognatic maxilla
and retrognathic mandible, skeletal deep bite
and counter clockwise growth pattern.

Dental problems:

Dental class II, large overjet, deep overbite


proclined and protruded upper incisors,
deficient anterior upper arch width.
Problem - List
Functional
problems:
Class II occlusion, large overjet, deep
overbite, lip-interpostioning, mouth breathing.

Esthetic problems:

Retrusiv lower lip, retusiv chin and mandible,


sublabial fold.
 Treatment planing

Treatment of Class II
Treatment planing
Treatment goals?
Skeletal:
 Skeletal class I relationship
 Improve vertical dimension
Dento-alveolar:
 Reducing overjet and overbite
 Class I molar and canine relationship
 Harmonizing arch width
 Levelling and alignment of teeth

Univ. Prof.Dr.Dr.D. Muessig 28


 Treatment planing

Treatment of Class II
Treatment planning
Treatment Goals?
Function:
 Improve occlusion
 Improve lip-closure
Esthetics:
 Improve lip and chin position
 Straighten lower facial profile

Univ. Prof.Dr.Dr.D. Muessig 29


Problem – Solving -List
1. Derotation and anchorage of upper molars

2. Expansion of anterior segment of dental arch

3. Intrusion of upper and lower incisors

4. Controle eruption and alignment of lateral


teeth
5. Protraction of the mandible (class II –
mechanics)
6. Setling of class I occlusion

7. Retention, fixed and removable


 Treatment planing

Treatment of Class II
Treatment Mechanics, removable
Anterior expansion of upper dental
arch , anchorage and derotation of
molars

Removable plate with hinge screw

Univ. Prof.Dr.Dr.D. Muessig 31


 Treatment planing

Treatment of Class II
Treatment Mechanics, removable
Vertical eruption of lateral teeth (bite
opening)
Protraction of the mandible

Bionator

Univ. Prof.Dr.Dr.D. Muessig 32


 Treatment planing

Treatment of Class II
Treatment Mechanics, removable
Plate with expansion hinge screw

Anterior expansion

Adams clasps at first molars


Anchorage and derotation

Labial arch to recline incisors

Additional clasps for


improvement of retention

Univ. Prof.Dr.Dr.D. Muessig 33


Bionator with tongue
shield
Treatment of tongue
dysfunctions
P.M. / m 12,9 Years
P.M. / m 9,10 Years and 12,9 Years
Quadhelix
Quadhelix
Quadhelix
Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Fitting of Quadhelix
Quadhelix in place
Expanding
Expanding
Expanding
Expanded Quadhelix
Disto-rotation
Disto-rotation
Disto-rotation
Disto-rotation
Quadhelix
The Facebow / Headgear
History
KINGSLEY 1866
FARRAR 1870
Extraoral forces ANGLE 1888
GODDARD 1888

First removeable EPSTEIN 1946


Headgear (HG)

Techinque of RICKETTS 1957


cervical pull
The
classic
collection
Orthopedic effect of HG

Effect on growth of maxillary complexe.


(Reduces point A)
NELSON 1952

Effects the growth of the nasal floor


and widens maxillary sutures. (FR p.-a. und FRS)

RICKETTS & KLEIN 1957 / 1960


Oblique –Headgear
SCHUDY 1964
To avoid tipping of molars.

Orthopedic effects ad force level of


> 5 N = ca. 500 p = gr.
When to use a Headgear ?

1. To provide anchorage (antero-posterior and vertical)

2. To move teeth

3. To exert orthopedic forces to the maxilla

4. To controle inclination of occlusal plane


ad 1 Anchorage - controle
in extraction cases:

• antero-posterior controle of molars

• vertical controle of molars

• horizontal controle of molars

• rotational control of molars (long-axis)


ad 2 Tooth - movement

In class II cases

In non – ex cases with crowding


ad 3 Orthopedic treatment of
maxilla

class II with deep overbite

Class II in dolichofacial patients

Open bite cases

Orthopedic forces > 5 N

Reduce growth of midface


Biomechanics
Creation of moments

tipping and rotation of molars
Orthodontic movement of molars
Biomechanics of Headgear

Lenghth of arms: short arm long arm


Direction of arm: upward downward
Direction of force: cervical horicontal
high pull vertical pull
Level of force: orthodontic orthopedic
Biomechanics of Headgear
Forces, Moments on a molar in treatment with Headgear

Distalization

The components of tooth movement

Directions of molar movements


Headgear needs Headfilm
Never use a Headgear without knowing the facial pattern and the growth pattern
Headgear needs Headfilm
Never use a Headgear without knowing the facial pattern and the growth pattern

Class II, brachy, deep bite Class I, meso, regular Class II, dolicho, open bite
overbite

Horicontal growth Vertical growth


Facial patterns and treatment with headgear

Cervical pull, long Cervicall pull, long arm Cervical and high pull
arm downward upward traction, short arm
upward

High pull short arm High pull long arm parallel


parallel
Headgear, Typ 1

Cervical traction long arm downward


Cervical pull long arm downward
Indicated: mesially tipped molar
dental class II with deep bite
horizontal growth

Do not use : Open bite


Do not dolichofacial
use in: growth
vertical growth pattern
open bite
Headgear, Typ 2
Cervical pull, long arm,
upward
Long arm, upward angulated

Indicated: Uprighting molars after the use


of Headgear type 1
Skeletal Cl. II with deep bite
Horizontal growth pattern
L
Do not use in: Vertical growth pattern
Open bite
Tipping of molars palatally caused
by moments from headgear

You need expansion of inner arms


The Combee Headgear
Cervical und high pull, short arm, and parallel traction
The Combee Headgear

Arms short, upward


To improve anchorage
Indicated To distalize molars
In skeletal /dental class II
Slightly vertical growth pattern

Horizontal growth pattern


Do not use in:
Severe deep bite
The High-pull Headgear
Short arms, parallel
Arms short, parallel
Dental / skeletal class II
Indicated: Open bite
Vertikal growth pattern

Do not use in: Horizontal growth pattern


Deep bite
High – Pull - Headgear

Short arms upward angulation


High – pull with long arms parallel
Long arms
A parallel

Dental and skeletal Cl. II


Indication: Open bite
Vertical (dolichofacial) growth
pattern

Deep Bite
Do not use: Horizontal (brachyfacial)
growth pattern
Patient with high-pull Headgear and parallel arms
Flaring – out of molars with
high pull Headgear

You need compression of the oral arch


Instruments and Materials

Wax for indirect adaptation

Strong cutter

Triceps plier (Aderer)


Combi plier

Pencil
Indirect Adaptation of Headgear
Impression of Headgear- Fit the inner arch with 5mm distance to
tube on band dental arch
Indirect Adaptation of Headgear

Bend arch 45°

to the outside,

mesial to the molar tube


Indirect Adaptation of Headgear

Move plier mesial


Put one of the branches
Make a 45° bend
exactly into former bend

The stepwise
bending guaranties
distance to the
dental arch
Using a headgear

Don`t cut to precisely

To reactivate Headgear,
use Stops which are welded
on the arch
When bending and wearing a headgear
always consider up- and downside!
Meassure the force you apply

Write the level of force


into the patient´s documents
after each visite!
Only use
safty – modules!
Standard Facebow

Low-Pull High-Pull Combee headgear


Utility - Arches

Treatment in Mixed Dentition


Tip-back Intrusion of Incisors
Torque
Utility Arch / Elements

Incisor Segment

Anterior Molarsegment
Bridge
Vertical Step
Posterior Vertical
Step
Prof. Dr. Dr. D. Muessig DPU Krems 113
Utility Arch
 Activating Utility Arch:
 Tip-back in Molar Segment:
 Intruding and Proclining Incisors
 Extrusion and Reclination of Molars

Prof. Dr. Dr. D. Muessig DPU Krems 114


Utility Arch
 Activating Utility Arch, Molar Segment
 Buccal-root-torque
 Anchorage of Molars =
 Protecting Roots of Incisors

Prof. Dr. Dr. D. Muessig DPU Krems 115


Utility Arch
 Activating Utility Arch Molar Segment
 Toe-in:
 Anti-Rotation to Compensate
Expansion

Prof. Dr. Dr. D. Muessig DPU Krems 116


Utility Arch
 Activating Utility-Arch, Molar Segment
 Expansion;
 Creating Torque in Molars

Torque =
Moment+Force
M/F >12

Prof. Dr. Dr. D. Muessig DPU Krems 117


Utility Arch
 Activierung Utility Arch Bridge
 Flairing out
 Protecting Gingiva

Prof. Dr. Dr. D. Muessig DPU Krems 118


Utility Arch
 Activating Utility Arch Incisor Segment
 Smile
 Equal Distribution of Intrusiv Force on
Incisors

Prof. Dr. Dr. D. Muessig DPU Krems 119


The Utility Arch
Bending a Utility Arch (schematisch)

8mm 30mm 8mm


4mm 4mm 4mm 4mm
25mm 25mm

Material: .016 x .022 Elgiloy blue/(stainless steel)


(System .022)
Prof. Dr. Dr. D. Müßig Danube
Private University Krems Austria 120
Biomechanics Utility Arch
Tip – back:
Intrusion of Incisors
Extrusion of Molars
Moments act in opposite directions

Utility
passiv

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 121
Biomechanics Utility Arch
Tip – back:
Intrusion of Incisors
Extrusion of Molars
Moment acting in opposite directions

Tip-
back
Utility activ

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 122
Biomechanics Utility Arch
Tip – back:
Intrusion of Incisors
Extrusion of Molars
Moments acting in opposite directions

Tip- Utility activ.


back Not engaged
to incisor
bracket

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 123
Biomechanics Utility Arch
Tip – back:
Intrusion of incisors
Extrusion of Molars
Molars acting in opposite directions

α
Tip-
back
Utility activated.
β Ligated to
anterior brackets
Prof. Dr. Dr. D. Müßig Danube
Private University Krems Austria 124
Biomechanics Utility Arch
Buccal – Root – Torque:
Cortical Anchorage of Molar Roots
Reducing Tipping to the Distal
Reducing Extrusion
Needs Expansion of the Archwire

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 125
Biomechanics Utility Arch
 Expansion:
 Reducing Tipping of the Crown
 Torquing of the Root

Expansion
3mm each side

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 126
Biomechanics Utility Arch
Toe - in:
Compensating Mesio-Rotation of Molar
(Expansion)

Expansion

Toe-in

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 127
Biomechanics
Smile: )
Avoiding “kissing roots”
Distributing equally Intrusiv Forces

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 128
Biomechanics Utility Arch
Interacting Elements

Tip-back

 Buccal-Root-Torque und Expansion

 Toe-in

Smile

Prof. Dr. Dr. D. Müßig Danube


Private University Krems Austria 129
Biomechanics Utility
Arch
Calculating Forces and Moments
System:
Distance Molarentube to
Incisor (Slot): 35mm
Distance Incisor (Slot) to
(common) CR: 7mm

Intrusion Force:
2 x 0,35 N = 0,7N
Molares and Central
Incisors
Prof. Dr. Dr. D. Muessig DPU Krems 130
Biomechanics Utility
Arch
Calculating Forces and Moments
Modell 1:
Changing Incisor Angle =
Distance CR to Slot:

Reclined: CR to Slot = 1mm:


M at I: 0,7N x 1mm = 0,7Nmm

Proclination: CR o Slot= 10mm:


M at I: 0,7N x 10mm = 7,0Nmm

Molars and Central


Incisors Inclination effects Moments

Prof. Dr. Dr. D. Muessig DPU Krems 131


Biomechanics Utility
Arch
Calculating Forces and Moments
Modell 2:
Changing Distance Molartube to
Incisor Slot:

Distance Molartube to Incisorslot =


30mm:
M at Molar: 0,7N x 30mm = 21Nmm
Distance Molartube to Incisorslot =
40mm:
M at Molar: 0,7N x 40mm = 28Nmm

The Distance Molar to Incisor


Molars and Cental effects Moment and Force at
Incisor the Molars!
Prof. Dr. Dr. D. Muessig DPU Krems 132
Treatment of Class II
Anomalies
Dolichofacial

Slight asymmetry of
mandible to the right
side
Active mentalis
muscle

G. P. / f
Age: 10,11 Years
Treatment of Class II
Anomalies
Face in profile

Orthoganthic maxilla

Retrognathic mandible
Convex profle

Long lower facial hight

G. P. / f
Age: 10,11 Years
 Diagnostics

Treatment of Class II
Is the patient still growing ?
Increase of Bodyhight

Removable
treatment

Second transitional
period

Years
Univ. Prof.Dr.Dr.D. Muessig 135
Overbite?
0,5mm

Overjet?
4mm

Canine/molar
relation?
2-3mm class II
Spacing and bialveolar protrusion
All third molars developing
Your first
impression?

Funktionskieferorthopädie
Cephalometric analysis
Antero-posterior
analysis

SNA= 78° Retro-


orthognathic
SNB =73° retrognathic

ANB = 5° skeletal class II

Treatment of choice?
Cephalometric analysis
Vertical analysis

NL=NSL= 9°
clockwise

ML-NSL=°35clockwise

ML-NL = 26°Hyper-divergent
Treatment of choice?
Cephalometric analysis
Overjet:
4mm

Overbite:
0,5mm

Facial-axis:

86°

Gonion-angle = 133°
Treatment:
2,2 years removable
functional appliance

Univ. Prof.Dr.Dr.D. Muessig 143


G. P. /f
Age: 13.03 years

Funktionskieferorthopädie
Funktionskieferorthopädie
G. P. / f
Age: 14.04 years

Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
G. P. /f
Age: 15,05 years
Effect of intensive class II -
mechanics
Lips Gummy- Profile
smile

G. P. / f
Age: 16.04 years
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
After maxillary impaction

G. P. / f birthday.: 12.09.1985 Date: 13.06.2003


age: 17.09 years
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
Funktionskieferorthopädie
Your first
impression?

How to treat class


II in vertically
growing patients?

Is she really class


II?
Funktionskieferorthopädie
P. R. / w born.: 03.1981 Date: 17.06.99
P. R. / w born.: 03.1981 Date: 17.04.00
P. R. / w born.: 03.1981 Date: 31.08.01
P. R. / w born.: 03.1981 Date: 22.11.01
P. R. / w born.: 03.1981 Date: 10.04.02
Headgear –
Activator
Treatment
Teuscher-Activator
Headgear
Torquesprings
Lip-shields
HG-tubes
Funktionskieferorthopädie
Funktionskieferorthopädie
ORTHOPEDIC EFFECT
( Teuscher)

 GROWTH -VECTOR MAXILLA


= 50° to FH
 Two years of growth = 4,5
mm
 Two years HG angulation
downward und cerv.
traction:
 Max. rotation 2,6°
 Dental rotation 3,5°
Late Class II Treatment

G.F./m 18,5
Class II/2
deep overbite missing one 1st lower molar

Right side : occlusion 4mm class II


Left side canine class II 6mm
Late treatment clasII /2

Very important:
Correcting deep overbite prior to class II
treatment
Late Treatment ClassII/2

Creating overjet
Correcting overbite

Harmonize dental arch shapes

Protract the mandible (Jasper jumper)


Late Treatment Class II/2

Finishing

Levelling of lower incisors

Space closure left second molar


Late treatment class
II/2

Funktionskieferorthopädie
Final Profile
Surgical correction of
asymmetric Class II / 2

Surgery: Dr. William Arnett, Sta. Barbara


CA.
Asymmetric Class II /2

Proclined and crowded lower incisors


Arnett Cephalometric
AnalysisTVLTVL
Simulation of orthodontic and surgical
Procedure
Prediction of result
Simulation of Change in Profile
Surgical procedure
Result
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment
Adult Cl. II /2 - Treatment

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