Class II Division

2 Malocclusion
Dr. Yahya almutahr
BDS, MUST University
MDS, Orthodontics,Huazhong
University
Learning objectives for this chapter

• An understanding of the aetiological

factors which contribute to the
development of a Class II division 2
Gain malocclusion.
• Knowledge of the management of Class
II division 2 based on an understanding
of the probable aetiology
Contents
1. Features
2. Aetiology
3. Treatment objectives
4. Treatment alternatives
5. Retention
 Features

Extra oral Intra oral

Skeletal Soft tissue Upper arch Lower arch Occlusion

Extra oral Features
Skeletal Soft tissue
features features

AP Lips

Labiomental
V
fold

Masseter
T
muscle
Skeletal features

AP V T
Commonly: Reduced Lower Commonly:
Class II skeletal pattern Anterior Face Height normal
Retruded mandible (LAFH)
May also be: Reduced Mandibular Face shape more
Class I skeletal pattern Plane Angle (MPA) squared due to
hyperactive masseter
muscle
Soft tissue features
Lower lip Labiomental Masseter smile
fold muscle
High resting Deep labio- Hyperactive May be gummy smile
lower lip mental fold due to retroclined
position and extruded upper
incisors
Intra oral features
Upper arch
Arch form:
Square and wide arch form
Central Incisors:
Always: Retroclined
Vertically: extruded
Lateral incisors:
Classically: normal or proclined
May be: retroclined
According to lower lip position
Lower arch Occlusion
Arch form: Overjet: normal or decreased
Narrow compared to upper arch
May be in lingual cross bite with
upper arch
Labial segment Overbite: Increased
May be: normal May cause ulceration of palatal soft
Less commonly: retroclined tissue or stripping of the labial
gingivae of the lower incisors
Class II incisor and molar
relationship
Increased interincisal angle
Intra oral features

Class II Div 2
malocclusion • Agenesis of lateral
is associated incisors (13.9%)
with dental • peg shaped lateral
anomalies in
56.6% of the incisors (7.5%)
patients. • Impacted canines
These
include
(33.5%)
Lets revise together
How is a class II div 2 relationship defined

• Upper first molar mesiobuccal cusp

Molar occludes anterior to the buccal groove of
the lower first molar.

• ‘the lower incisor edges lie posterior to

the cingulum plateau of the upper

Incisor incisors
• there is an increase in overjet
• the upper central incisors are usually
retroclined
 Classically
the upper central incisors
are retroclined
the lateral incisors are at
an average angulation or
are proclined
depending upon their
position relative to the
lower lip
Where the lower
lip line is very
high

the lateral
incisors may be
retroclined
Palatal and labial tissues are
rarely affected in severe cases
the overbite is described as
traumatic
• In a small proportion of cases the lower
incisors may cause ulceration of the palatal
tissues

• In some patients retroclination of the

upper incisors leads to stripping of the
labial gingivae of the lower incisors
 lingual crossbite of
the first and second premolars
• Another feature associated with a more
severe underlying Class II skeletal pattern is
lingual crossbite of the first and second
premolars
• This is caused by the relative positions and
widths of the arches, and possibly to
trapping of the lower labial segment within
a retroclined upper labial segment.
Features of Class II Div 2

Extra oral Intra oral

Skeletal Soft tissue Upper arch Lower arch Occlusion

2- Aetiology
Genetic Skeletal Soft tissue Dental
Mandibular High lower lip Retroclined upper
retrusion resting position incisors
Retroclination of
Horizontal growth Absence of vertical
High occurrence upper central
pattern stoppers
amongst siblings incisors
Mandible grows
If higher: all upper
forward and Increased overbite
incisors retroclined
upward
 Treatment objectives
• Extra oral objectives
a) Increase Lower anterior face height
b) Achieve or maintain a good facial profile
• Intra arch objectives
c) Achieve proper alignment of teeth
d) Achieve proper incisor inclination in the upper and
lower arches
• Inter arch objectives
e) Achieve or maintain a normal overjet
f) Achieve a normal overbite
g) Achieve proper incisor, canine relationships
h) Achieve a proper molar relationship OR proper
interdigitation
a) Increase Lower anterior face height
• Class II Div 2 is commonly associated with
decreased lower face height
• Growing patients
• This may be achieved by raising the bite
anteriorly to allow extrusion of the posterior
teeth.
• This extrusion is compensated by vertical
growth of the ramus.
• Adult patients
• It is not possible to increase the lower
anterior face height
• considering surgery is not an option in these
cases as the decrease is not causing a major
problem to the facial esthetics
raising the bite anteriorly to allow extrusion
of the posterior teeth
Examples of appliances used to raise the bite
anteriorly
Fixed acrylic bite plane Removable acrylic bite plane
b) Achieve or maintain a good facial profile

Class II Div 2 may be associated with

Class I OR mild Class II Moderate Class II
skeletal pattern with skeletal pattern with
good facial profile convex profile

Objective: maintain Objective: correct the

the profile profile
To correct the profile

Convert the class II Div 2 to

Class II Div 1 by proclination of the upper incisors

Manage the case as a Class II Div 1 patient

Before functional
appliance therapy.

An upper removable
appliance used to

procline retroclined
upper incisors

expand the upper arch

c) Achieve proper alignment of teeth
• This objective is common to all type of malocclusion
• Crowding may be present in
• the upper arch
• the lower arch
Crowded upper arch in Class II Div 2
• If the upper arch is crowded
• In class II Div 2 crowding in the upper arch is common
• If crowded, space analysis will require calculating the space required to relief
the crowding taking into consideration that the proclination of the retroclined
upper incisors will gain space.
Crowded lower arch in Class II Div 2
• If the lower arch is crowded
• In class II Div 2 crowding in the lower arch is common
• If crowded, careful planning should be undertaken because extraction in the
lower arch may cause retraction of the lower labial segment which increases
the overjet.
• Therefore extraction may be favored farther from the lower labial segment
• The molar relationship also influences the extraction decision. If the molar
relationship is Class II, extraction of the second premolar may be considered
to achieve a Class I molar relationship.
d) Achieve proper incisor inclination in the
upper and lower arches
• Achieving proper incisor inclination in the upper and lower arches is
important for
• Esthetic considerations
• Stability considerations
• When the upper and lower incisors are inclined properly, the
relationship between them is stable and relapse by retroclination of
the UIs is decreased
 Achieve proper incisor inclination
in the upper and lower arches

UI inclination
considerations

LI inclination
considerations
Upper incisor inclination considerations
• A classical feature of Class II Div 2 is
the retroclined upper incisors.
• Correction to normal axial inclination
depends on the AP position of the
upper incisors
• The upper incisors may be:
• Retroclined with favorable AP position
• Retroclined with retruded AP position
• Retroclined with protruded AP position
Retroclined Upper incisors with favorable AP
position
• This type is seen when the skeletal pattern of the case is Class II
• This means that the upper incisors need to proclined with retraction
to maintain the UI AP position.
• In this case, proclination of the UI will require space in the upper arch
Retroclined Upper incisors with retruded AP
position
• This type is seen when the skeletal pattern of the case is Class II with
mandibular retrusion.
• The upper incisors are retroclined and the overjet is normal despite
the skeletal pattern
• This means that the upper incisors need to proclined and protruded
to a more AP position.
• In this case, proclination of the UI will provide space in the upper arch
Retroclined Upper incisors with protruded AP
position
• This scenario is not seen in Class II Div 2
malocclusion. The underlying skeletal
pattern would be a Class II with
maxillary AP excess.
• This means that the upper incisors
need to proclined with retraction to
retract the UI AP position.
• In this case, proclination of the UI will
require space in the upper arch
• If the maxillary excess is severe, the
proclination of the upper incisors will
put the UI in a protruded position as
retraction of the UI I limited to the basal
bone.
Lower incisor inclination considerations
• The lower incisors may be
• Retroclined
• Normal inclination
Retroclined Lower incisors
• Retroclined LIs are commonly seen in Class II Div 2 malocclusions
• The objective:
• Procline the LIs to normal
• Clinical implications: Proclination of the lower incisors to normal will
help:
• Achieve proper U to L incisor relationship
• Decrease the overjet if it increased by proclination of the UIs
• Decrease the overbite which is commonly increased with Class II Div 2 cases
Lower incisors with normal inclination
• Normally inclined LIs are commonly seen in Class II Div 2
malocclusions
• The objective:
• Maintain the lower incisor inclination
• Clinical implications
• The correct incisor relationship will therefore require that the UIs are
proclined to a great extent.
• If there is crowding in the lower arch, careful planning of space is required to
maintain the normal inclination
e) Achieve or maintain a normal overjet
• Overjet is normal in Class II Div 2 malocclusion. Sometimes it may be
increased.
Maintain a normal overjet
• If normal, the OJ should be maintained
• If the UI will be proclined to correct the UI inclination:
• If the patient is Class I
• Then the lower incisors should be proclined to maintain the normal
OJ
Achieve a normal OJ
• If the patient is a skeletal Class II with convex profile
• The normal OJ was due to UI retroclination
• When the UI inclination is corrected the OJ is increased
• The Class II Div 2 is changed to Class II Div 1 malocclusion
• The objective:
• Follow the steps in chapter (Class II Div 1) on how to achieve a normal OJ
f) Achieve a normal overbite
• The OB in Class II Div 2 is usually increased
• The objective
• Correct the overbite to normal
• Clinical significance
• Achieving a correct overbite is a factor of stability
• How to achieve normal OB
• Intrusion of LIs
• Extrusion of the lower posterior teeth
• Intrusion of UIs
• Proclination of LIs
g) Achieve a proper incisor, canine and molar
relationship
• The objectives of any orthodontic treatment include achieving a:
• Class I incisor relationship
• Class I canine relationship
• Class I molar relationship
Class I incisor relationship
• It is achieved by correcting
• The overjet
• Inclination of the upper labial
segment
• Achieving a proper Class I
incisor relationship requires a
Class I canine relationship
Achieving a Class I canine relationship
• To achieve this objective, proper
treatment planning is required
according to the pretreatment canine
relationship:
• The pretreatment canine relationship
in Class II Div 2 cases may be a
• Class II canine relationship
• Class I canine relationship
Class II canine relationship
• This may require space created by one of
the following choice
• extraction in the upper arch (usually first
premolar) to move the canine backwards to a
Class I position. This is required if the
relationship is a full unit Class II
• Distal movement of the upper buccal
segment to give space for the distal
movement of the canine. This is required if
the relationship is a ½ unit Class II
Class I canine relationship
• If the canine relationship is Class I it
should be maintained
• Therefore
• If extraction is planned in the upper arch
to decrease the overjet
• Extraction in the lower arch may be
required
• Why?
• to move the lower canine along with the
upper canine distally to maintain the
relationship
h) Achieve a proper molar relationship OR
interdigitation
• Achieving a Class I molar relationship
is an objective that would preferably
be achieved but not as important as
the incisor and canine relationship.
• Rather than a class I relationship,
what is vital is to achieve proper
interdigitation of the buccal segment
teeth.
 Treatment objectives
• Extra oral objectives
a) Increase Lower anterior face height
b) Achieve or maintain a good facial profile
• Intra arch objectives
c) Achieve proper alignment of teeth
d) Achieve proper incisor inclination in the upper and lower arches
• Inter arch objectives
e) Achieve or maintain a normal overjet
f) Achieve a normal overbite
g) Achieve proper incisor, canine relationships
h) Achieve a proper molar relationship OR proper interdigitation
 Treatment options

Growing • Anterior bite plane in combination with fixed

appliances
• Convert to class II Div 1 and manage with
patients functional appliance followed by fixed appliances.

Adult • Fixed appliances

patients
 Retention
• Unfortunately it is not possible to accurately predict those patients
who will relapse and so retention must be discussed with, and
planned, for every patient.
• To aid stability
a) Proper incisor relationship
b) the achievement of proper lower lip to upper incisor relationship
• If the above are not achieved:
• there is the risk that the upper incisors will relapse.