Mishra Kratika et.al.

UJMDS 2020, 08 (02): Page 4-11

ISSN 2347-5579

Unique Journal of Medical and Dental Sciences

Available online: www.ujconline.net
Case Report

“FUNCTIONAL ORTHOPAEDICS” USED IN YOUNG GROWING INDIVIDUALS

FOR CORRECTION OF SKELETAL CLASS II MALOCCLUSION: - MOST
RELIABLE METHOD
Bhardwaj Amit1, Mishra Kratika2*, Singh Poonam2
1
Dean, Professor & Head, Department of Orthodontics and Dentofacial Orthopaedics, Modern Dental College and Research Centre, [Indore], India
2
Assistant Professor, Department of Orthodontics and Dentofacial Orthopaedics, Modern Dental College and Research Centre, [Indore], India

Received 24-03-2020; Revised 22-04-2020; Accepted 20-05-2020

DOI: 10.46791/UJMDS.2020.080202
*Corresponding Author: Dr. Kratika Mishra
Assistant Professor, Department of Orthodontics and Dentofacial Orthopaedics, Modern Dental College and Research Centre, [Indore], India
Email: kratikamishra1990@gmail.com

ABSTRACT
Dentofacial orthopaedics treatment can significantly alter and improve facial appearance in addition to correcting irregularity of the
teeth. Myofunctional appliance therapy can be used successfully in Class II malocclusion, e.g. in a growing patient. The use of these
appliances is greatly dependent on patient’s compliance and they simplify the fixed appliance phase. This article presents a discussion
on treatment of class II division I using myofunctional appliances in growing individual and a series of two case reports of treatment
of skeletal class II division I malocclusion using myofunctional appliance followed by fixed mechanotherapy.
Keywords: Dentofacial Orthopaedics, Fixed mechanotherapy, Growth Modification, Myofunctional appliances, Skeletal Class II
malocclusion, Mandibular Retrognathism.

INTRODUCTION lip. Extraoral [Figure 1a] examination revealed incisor

Correction of class II division 1 malocclusion continues to
present a challenge to clinicians practicing Paediatric and
Orthodontic dentistry. Role played by functional appliances in
the correction of skeletal pattern, during treatment of class II
division 1 malocclusion has been still controversial despite
their early introduction in the 19th century1.Various factors can
contribute to the development of Class II malocclusion and
their differential diagnosis can help in the selection of the
most appropriate treatment approach. Mandibular
retrognathism shows a prevailing frequency2. So, the most
reliable treatment approach in such cases includes
myofunctional therapy.
In this article, we will discuss treatment modality with the use
of myofunctional therapy for class II division 1 malocclusion
in growing patients.
CASE REPORT
CASE 1
A 13-year-old male patient reported with chief complaint of
more visibility of upper front teeth and difficulty in closing
visibility of 6 mm, convex facial profile. Lips were
incompetent and protrusive with 6 mm of interlabial gap, with
lower lip trap habit. Intraoral [Figure 1b] examination revealed
permanent dentition stage with “U shaped” dental arches and
maxillary anteriors were proclined with spacing present in
upper and lower anterior teeth. In occlusion, there was Angle’s
class II division 1 relationship with increased overjet of 13.6
mm and overbite of 6 mm. Angle’s class II molar and canine
relationship bilaterally. The lateral cephalogram [Figure 1c]
showed a severe skeletal ANB difference of 9°. The maxilla
was normal relative to the cranial base with an SNA at 79°.
The mandible was retrognathic and retropositioned with an
SNB value of 70°.
Diagnosis
Skeletal class II jaw relationship with Angle’s class II division
1 malocclusion and FMA was 30 degrees suggestive of
vertical growth pattern. Hand wrist radiograph was taken to
confirm the growing status of patient.

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Figure 1a: Pre

Pre-treatment extra-oral photographs

Figure 1b: Pre

Pre-treatment intra-oral photographs

Figure 1c: Pre-treatment radiographs

Treatment Objective of growth modification procedure were Treatment plan: Myofunctional appliance therapy
therap (activator
to correct the skeletal class II pattern, achieve a class I with headgear) [Figure 1d] followed by final detailing of
skeletal and dental relation, establish normal overjet and occlusion with fixed pre-adjusted
adjusted edgewise appliance. [Figure
overbite, reduce the convex profile, and improve the lip 2e] The patient was instructed to wear it minimum for 14
incompetency. hours/day.

Figure 1d: Functional appliance therapy: activator with headgear appliance in place

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Figure 1e: Intra oral photograph of activator appliance

Results achieved:: Patient’s soft tissue facial profile was
improved, along with lip incompetency, reduction of severe
overjet and deep impinging overbite [Figure 2a], and
achievement of class I skeletal and dental relationships
[Figure 2b]. Cephalometric [Figure 2c] analysis after
myofunctional therapy demonstrates favourable forward
growth of the mandible. There was a reduction of the skeletal
class II with a 5° decrease in the ANB angle through forward
growth of the mandible. The post-treatment
post value of SNB at
74° indicates the advancement of mandible.
At the end of myofunctional therapy, the patient orthognathic
facial profile,, competent lips, class I molar and canine
relationship, overjet of 7.5 mm and overbite of 3.5 mm
[Figure 2b]. Superimposition of pre and post functional
treatment [Figure 2d] suggested the sagittal and occlusal
changes before and after treatment.

Figure 2a: Post -functional extra-oral photograph

Figure 2b: Post

Post-functional intra-oral photograph

Figure 2c: Post-functional radiograph

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Figure 2d: Superpimposition of cephalometric images before (blue) and after (red) treatment with visible skeletal and dentoalveolar changes

Figure 2e: Fixed mechanotherapy intraoral

Comparisons of pre-treatment and post-treatment cephalometric values are given in Table 1. Total treatment time was 12
months.

Table 1: Analysis of sagittal skeletal and occlusal changes before and after treatment (SO analysis by Pancherz H)
Variable Correction max.
SO ANALYSIS (measurements Before After After– before +
to RLp) mand.
Skeletal Ms 55 53 -2
Molar correction
+
6
Dental Mi 52 56 4
Skeletal Is 93 90 -3 Overjet
+
Dental ii 80 82 2 5

Ss 80 79 -1 Skeletal
Skeletal
Pg 77 80 3 4

Dental Ms(D) –ss (D) - - -3 Molars

(molars) Mi(D) – pg (D) - - 1 -2

Dental Is(D) – ss (D) - - -4 Incisors

(incisors) Ii(D) – pg (D) - - -1 -5

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CASE 2 class II division 1 relationship with overjet of

A 13-year-old boy patient reported with the chief complaint
of forwardly placed upper front teeth and unpleasant looks.
Extraoral [Figure 3a] examination showed mesoprosopic
facial form, a convex profile mainly due to retrognathic
mandible, potentially competent protrusive lips with 7 mm of
interlabial gap, Acute nasolabial angle, average clinical FMA,
deep mentolabial sulcus, and Intraoral examination [Figure
3b] of dentition revealed U- shaped dental arches with
proclined upper incisors. In occlusion, there was Angle’s
13 mm. The overbite of 6 mm. The molar and canine
relationship was class II bilaterally. Upper and lower dental
midlines were coinciding with each other and with facial
midline. The lateral cephalometric values [Figure 3c] showed
skeletal ANB difference of 5°. The maxilla was slightly
normal in relative to the cranial base with an SNA at 80°.
The mandible was retrognathic relative to the cranial base
with an SNB at 75°. There was proclination of upper and
lower incisors with average growth pattern.

Figure 3a: Pre -treatment extra-oral photographs

Figure 3b: Pre-treatment intra-oral photograph

Figure 3c: Pre-treatment radiographs

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Figure 3d: Functional appliance therapy: Twin block appliance in place

Figure 4a: Post -functional extra-oral photographs

Figure 4b: Post -functional intra-oral photographs

Figure 4c: Post-functional radiographs

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Diagnosis decrease in the ANB angle through forward growth of the

Angle’s class II division 1 dentoalveolar malocclusion on mandible. The post-treatment value of SNA was 80° and of
class II skeletal base due to retrognathic mandible. SNB was 78°. Proclination of upper as well lower incisors
Treatment Objective of growth modification procedure were was also corrected. Superimposition of pre and post
to correct the skeletal class II pattern, achieve a class I functional treatment [Figure 4d] suggested the sagittal and
skeletal and dental relation, establish normal overjet and occlusal changes before and after treatment.
overbite, reduce the convex profile, and improve the lip
incompetency.
Treatment plan
Growth modification with myofunctional appliance therapy
(twin block) [Figure 3d] immediately followed by final
detailing of occlusion with fixed pre-adjusted edgewise
appliance was planned [Figure 4e].
Results
Saggital correction (skeletal class I) was achieved through
growth modification with improvement in the facial profile
and lip incompetency and reduction of the severe overjet and
deep overbite. At the end of the treatment, the patient had
orthognathic facial profile [Figure 4a], class I molar and
canine relationship, normal overjet and overbite [Figure 4b].
Evaluation of the cephalometric [Figure 4c] tracings Figure 4d: Superimposition of cephalometric images before (blue) and
demonstrates reduction of the skeletal class II with a 2° after (red) treatment with visible skeletal and dentoalveolar changes

Figure 4e: Fixed mechanotherapy intra-oral photographs

Comparison of pretreatment, mid treatment and post treatment Cephalometric values is given is Table 3
Table 3: Analysis of sagittal skeletal and occlusal changes before and after treatment (SO analysis by Pancherz H)
Variable Correction
SO ANALYSIS Before After After– before
(measurements to RLp) max.+ mand.
Skeletal
Ms 53 52 -1 Molar correction
+
Mi 50 55 5 6
Dental
Skeletal
Is 87 85 -2 Overjet
+
ii 76 80 4 6
Dental
Ss 75 75 0 Skeletal
Skeletal
Pg 75 79 4 4
Dental Ms(D) –ss (D) - - -1 Molars
(molars) Mi(D) – pg (D) - - 1 0
Dental Is(D) – ss (D) - - -2 Incisors
(incisors) Ii(D) – pg (D) - - 0 -2

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DISCUSSION teeth. Myofunctional appliance therapy can be used

successfully in Class II malocclusion, e.g. in a growing
Skeletal Class II patients show specific clinical characteristics, patient. The success of treatment depends upon patient
such as a large overjet resulting in a soft tissue profile cooperation, as this has a direct correlation with the extent of
imbalance. This is closely related to patients’ and parents’ correction of the malocclusion6.
complaints concerning self-image and self-confidence. In
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Source of support: Nil, Conflict of interest: None Declared

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