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1. INTRODUCTION
2. CLASSIFICATION
3. ETIOLOGY
4. FEATURES
5. TREATMENT
6. CONCLUSION
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INTRODUCTION

 Individuals with Class II malocclusions - an anteroposterior

discrepancy between the maxillary and mandibular dentitions,
which may or may not be accompanied with a skeletal
discrepancy.

 The success of treatment is dependent on the ability to

diagnose the problem , abnormal functions , habits and
plan treatment
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CLASSIFICATION

Functional
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1. According to Moyer’s (1980 Nov AJO )

a. Six horizontal
Types of class II
b. Five vertical
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a. Six horizontal – Type A , B , C , D , E , F

Mid-face prominence
Normal skeletal profile Normal mandible
Max dentition-protracted

Increased over-jet &

over-bite

TYPE A or DENTAL CLASS II TYPE-B

(Maxillary dental protraction) (Max excess)
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Retrognathic Retrognathic
max and mand max and mand

Max dental protrusion

Max & mand dental
protrusion

TYPE-C TYPE-D
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Max prognathism & maxillary protrusion &

dental protrusion mandibular retrusion

upper & lower anteriors

Mand dental protrusion Upright over their basal bone

TYPE-F
TYPE-E (Mild skeletal tendency)
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b. Five vertical - Type 1 , 2 , 3, 4 , 5

TYPE-1 (Steep mandibular plane or high angle case)

MP , OP – steeper

PP – Tipped down

ACB – Tipped up
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TYPE-2 “ Square face”

MP,PP,OP and ACB

are more horizontal
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TYPE-3

PP tipped up

Dec ant face ht

& Open bite
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TYPE-4

PP,MP,OP all are tipped down

Gonial angle - obtuse

Lip line high in the maxillary alveolar process.

Upper incisors - tipped labially &

lower incisors - tipped lingually
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TYPE-5

PP tipped down

Skeletal deep bite

Gonial angle- small

upper incisors - lingually tipped

lower incisors - labially tipped

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2. Edward H. Angle

Class II malocclusion defines the saggital relation between the

upper and lower first permanent molars
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Class II Division I

•Labially inclined maxillary incisors,

• Increased overjet
• vary from a deep overbite to an open bite
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Class II Division II

•Deep overbite and minimal overjet

• Incisal edges of the lower incisors may contact the soft tissues of the palate
Features Class II division 1 Class II division 2 18
Profile Convex Straight to mild
convexity
Lips
• upper Short Normal
• lower everted Normal
• competency incompetent Competent
Mentalis muscle Hyperactive -
Lower facial Normal or increased Decreased
height
Arch form “V” shaped Square, “U” shaped
Mentolabial Deep Deep or normal
sulcus
Palate Deep Normal 19
Incisors Proclined Centrals are
retroclined
Overjet Increased Decreased

Crown root Normal angulation Axis of crown and

root are bent and is
referred to as collum
angle
Path of Normal Backward
closure
Interocclusal Normal/increased/ increased
clearance decreased
 Class II Division II
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Incisor relationship

TYPE A
Maxillary four permanent incisors tip palatally

TYPE B
Maxillary permanent central incisor – palatally
Lateral incisors - labially.

Centrals and Laterals - palatally tipped

TYPE C
canines - labially tipped
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Class II malocclusion SUBDIVISION

A. With Class II Division 1 or 2 malocclusions, the

molar relationship may be unilateral or
bilateral.

B. Unilateral cases are classified as a

“subdivision”
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3. FUNCTIONAL CLASS II :(FORCED BITE )

Divided into 3 functional types :-

1. True class II 2. Rotational movement with 3. Rotational movement

malocclusion : posterior sliding component with anterior sliding
Rotational movement component
without a sliding
component

Rakosi
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Etiology of class II malocclusion

1. Missing teeth 1. Pierre Robin syndrome – micro mandible

2. Supernumerary teeth 2. Hypothyroidism – under development of
3. Anomalies of form & function – Large teeth , mandible
ectopic positions , transpositions 3. Muscle weakness (cerebral palsy)
4. Tooth-Arch disproportions – Spacing , crowding
5. Mesial migration of max 1st molar
6. Early loss of deciduous molars

1. Thumb sucking
1. Prenatal - Trauma to mandible – forcep delivery
2. Post natal - Childhood fractures of the jaws 2. Tongue Thrusting
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1. Growth Modifications

2. Orthodontic Camouflage

a. Non – extraction treatment with class II elastics

b. Retraction of maxillary incisors into premolar extraction space
c. Distal movement of upper teeth

3. Surgical Correction
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General strategies for class II correction

1.Differential restraint and control of skeletal growth

1.Extra oral traction.
2.Differential promotion of skeletal Growth:
1.Functional Jaw orthopedic appliances.
3.Guidance of eruption and alveolar development:
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4.Movement of teeth and alveolar process
(Camouflage treatment).
1.Extraction treatment.
2.Non Extraction treatment.
5.Training of muscles:
1. Functional appliances.
6.Surgical Translation of parts after growth in
severe cases:
1.Orthognathic surgery
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PROGNOSIS FOR CLASS II CORRECTION

I. Class II with Horizontal growth pattern:

In these cases prognosis is favorable for correction
of sagittal jaw relations but unfavorable for bite opening.

II. Class II with vertical growth pattern :

In these cases prognosis is favorable for bite opening
but unfavorable for correction of sagittal jaw relationships
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Traditionally, clinicians viewed class II malocclusion as primarily a sagittal and vertical problem.

Most Class II malocclusion in mixed dentition patients are associated with max constriction.

Mandible
(foot) Reichenbach and Taatz used the
example foot and shoe

Maxilla
(shoe)
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Mandibular movement during autorotation
as a result of maxillary impaction surgery

In Maxillary surgery - reduce vertical dimension Center of rotation of mandibular autorotation during
maxillary surgical impaction

Evaluate autorotation of the mandible. center of the condyle

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Primary dentition(3-6yrs)

Pre-adolescents
Early (7-9yrs)
Treatment of class II Late (10-11yrs)

Adolescents(12-15yrs)

Adults more than 16yrs

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Pre school children (primary dentition)

Flush terminal Distal step Mesial step

 Growth modification can be used to correct distal step easily .

 As growth continues the discrepancy tends to recur as quickly

as it was corrected.( both AP and Vertical skeletal discrepancy)

 Except in most severe case it is unwise to begin treatment

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Therapeutic methods
 Objectives of mixed dentition treatment for class II malocclusion

I. Elimination of abnormal perioral muscle function

II. Anterior positioning of the mandible by growth stimulation

III. Growth inhibition of the maxilla

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GROWTH MODIFICATIONS

Achieved by Functional appliances – Stimulation & enhancement of the mandibular growth

"functional appliance" designed to alter the

arrangement of various muscle groups that
influence the function and
position of the mandible in order to transmit forces to
the dentition and the basal bone.
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Suitable cases for Functional Appliance therapy.

Growing children – Effects –

1. Normal maxilla More favorable skeletal effects in children

2. Convex profile ,small due to retro- treated just before peak , compared to those
positioned mandible during or slightly after the onset of the
3. Average or a horizontal type of growth pubertal peak.
pattern

Young patients –
Children with good prognosis –
1. Yet to reach peak height velocity / pubertal
Show a positive visual treatment
growth spurt
objective
2. Before adolescence in the early
permanent dentition.
Kharbanda O P, Chaurasia S. Functional jaw orthopedics for Class II malocclusion: Where do we stand
today?*. J Indian Orthod Soc 2015;49, Suppl S1:33-41
Cervical vertebra maturation index (CVMI) – 35
Assess remaining skeletal growth ( lateral
cephalogram.)

Class II patients in late adolescence –

1. Treated most effectively using FFA's in

combination with fixed orthodontic appliance

2. Dentoalveolar changes

Manik PK, Kumar M, Yadav A, Dawar M. Management of class II malocclusion in an adolescent

patient with “The Poosh Appliance”: An in office fabricated fixed functional appliance. J Indian Orthod
Soc 2017;51:119-26
 36

Removable Fixed

Activator Herbst Appliance

Bionator Jasper Jumper

Twin Block MARA

Frankel

FUNCTIONAL APPLIANCES:
Indications:
1. Patient in growth phase.
2. Skeletal Class II malocclusions due decreased
size of mandible are good indicators for functional
appliances
3. Horizontal growth pattern.
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Contraindications:
1. Patient in post growth phase.
2. Skeletal class II due to normal sized and retrusive
positioned mandible(unfavorable prognosis).
3. Gross irregularities in individual tooth
positions(crowding and rotations).
4. Proclined lower anterior teeth.
5. Vertical growth pattern.
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FIXED FUNCTIONAL APPLIANCES

Indications:
1.Indicated in correction of class II malocclusions
due to retrognathic mandible in growing patients.
2.In preadolescent patients to utilize residual growth
left.
3.Uncooperative patients.
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Herbst Appliance
(Fixed intermaxillary appliances)

 Best time – prepeak pubertal patients

 Shows – skeletal & dentoalveolar changes

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Jasper Jumper
(Fixed intermaxillary appliances)

Active pushing force on maxillary molars & mandibular dentition

Correction by –
Mesial movement of lower molars
Flaring of lower incisors

Outcome-
Slight increase in mandibular length
Posterior movement of maxillary posterior segments
Proclination of lower incisors
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INTERMAXILLARY CLASS II CORRECTION APPLIANCES

Disdvantage:
Advantage:

• Forward displacement of mandible • Undesirable steepening of occlusal plane

• Distal force on maxillary teeth • Concomitant flaring of lower incisors
• Anterior force on mandibular dentition • Distal tipping & extrusion of maxillary incisors
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GROWTH MODIFICATIONS

Achieved by – redirection of maxillary growth by extra oral appliance ; HEADGEAR

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LOW ANGLE CASE : HIGH ANGLE CASE :

Cervical headgear Vertical control is a concern

Extrusion – Bite opening in deep bite cases High pull headgear
Control extrusive force
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Orthodontic Camouflage

Means jaw discrepancy is no longer apparent

a. Non – extraction treatment with class II elastics

b. Retraction of maxillary incisors into premolar

extraction space

c. Distal movement of upper teeth

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a. Non – extraction treatment with class II elastics

Combination of retraction of upper teeth & more forward movement of lower teeth
comparatively to upper, without tooth extractions .

After treatment , lip pressure moves lower incisors lingually leading to: –

Lower incisor crowding

Return of overjet
Return of overbite.
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Mesial movement of upper incisors in Class II div II

Class II/2 cases – retroclined upper incisors

During leveling & aligning – upper incisors move mesially

closer to PIP
`
Becomes Class II/1
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RETRACTION OF MAXILLARY INCISORS INTO A
PREMOLAR EXTRACTION SPACE

A. Extraction of maxillary 1st premolar Criteria of Finishing in class II molar

Retraction of incisors in premolar space without
lower extraction: – Interchangable molar tubes

Class II molar relationship. Bracket position of premolars - distally

Normal overjet.
Class I canine relationship.
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B. Extraction of maxillary 1st premolar and

mandibular 2nd premolar, with the use of class II elastics -
lower molars forward & retract upper incisors : –

Class I molar relationship

Class I canine relationship
Normal overjet.
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Indications for Molar distalization

• Lack of space for eruption of premolars due to mesial migration of

permanent first molars
• End on molar relationship with mild to moderate space requirement
• Cases with less than a full cusp class II molar relationship
• Good soft tissue profile
• Borderline cases
• Mild to moderate space discrepancy with missing 3rd molars/2nd
molars not yet erupted
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DISTAL MOVEMENT OF UPPER TEETH

Rotation of maxillary first molars mesio lingually
correcting rotation moves buccal cusps
posteriorly & provides at least a small space
mesial to the molar.
Extraction of 2nd molar creates a space for distal
movement of maxillary 1st molar
A combination of distalization-expansion appliance-
distal tipping of the molars is done.

opens about 2/3rd of space between premolar &

molar,
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Can be : Fixed or removable , Intraoral or extra oral

Extra – oral approaches : Intra – oral approaches :
Cervical , occipital & high pull headgear a. Inter – arch
b. Intra - arch

Intra – arch :
Inter – arch :
Transpalatal arch
Herbst
Pendulum
Jasper Jumper
Jones Jig
Class II elastics with Jig
Distal Jet
PENDULUM APPLIANCE James.J.hilgers,J.C.O,1992 52

• Expand the maxilla

• Rotate & distalize maxillary 1st molar

• Force delivery – continuous

• One time activation 60 – 70 degrees

• 230g force/side

• Maximum 5mm distalization – 3 to 4

months
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Disadvantage :
Undesirable anterior displacement of
anterior teeth

Advantage :
Ease of fabrication
One time activation
DISTAL JET APPLIANCE Aldo carano, J.C.O,1996
54
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 Fixed lingual appliance

 Required no compliance

 Translatory movements of maxillary molars – 4 to 6

months .

 Minimal Tipping of maxillary molars

 After completion of distalization – converted to palatal

holding arch by removing coil spring.

 Disadvantage : Anchorage loss but less than pendulum

appliances
 ( Studies at the university of Oklahoma )
 JONES JIG 56

OPEN NITI SPRING

Richard jones,J.C.O,1992
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• Intra-oral noncompliance appliance

• Modified nance , banded to 2nd premolar

• One arm – headgear tube

• 2nd arm – 1st molar tube

• Force delivered by – Ni-Ti coil spring

• Force – 70 -75g

• Loss of anchor unit

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Surgical & orthodontic phases of treatment.

1. Pre surgical orthodontic phase.

2. Surgical phase.

3. Post surgical orthodontic phase.

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MIDFACE SURGERIES

Le Fort I maxillary osteotomy:

Posterior repositioning
Superior repositioning

Maxillary anterior segmental osteotomy:

Dentoalveolar proclination.
Bimaxillary protrusion.

Interdental corticotomy :
In class II div I cases with maxillary
prognathism and anterior spacing
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MANDIBULAR SURGERIES

Mandibular deficiency corrected by :

 Bilateral Saggital split osteotomy (Treatment of
choice).
Vertical ramus osteotomy
SURGICAL CORRECTION OF CLASS II DIVISION-2 61

Surgical option should be choosen in following

cases:

1.Severe skeletal discrepancy or extremely severe dento alveolar

problem.

2.Adult patients

3.Young patients with extremely severe or progressive deformity.

SURGICAL CORRECTION OF SKELETAL 62
CLASS II DIV-2 IN ADULT:
Correction in Anterioposterior plane:
1.Mandibular deficiency:

can be corrected surgically

by

1.Bilateral Saggital split

osteotomy (MANDIBULAR
ADVANCEMENT.)
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Retention and stability: A review of the literature -
Blake and Bibby (Am J Orthod Dentofacial Orthop
1998;114:299-306)
1. Expansion is thought to be better tolerated in Class II Division 2 cases than
Class II Division 1.

2. Adequate interincisal contact angle may prevent overbite relapse and

good posterior intercuspation prevents relapse of both crossbite and AP
correction.

3. Overbite relapse tends to occur posttreatment and maintenance of

intercanine width is thought to increase stability.

4. Growth may aid in the correction of orthodontic problems but may also
cause relapse of treated cases.

5. Improved occlusion in the mixed dentition provides better long-term

stability (Dugoni SA et al Angle Orthod 1995;65:311-20).
CONCLUSION 64
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The choice of appliance should be based on the proper diagnosis.

Headgear – Most useful for molar distalization ( early treatment )

Extraoral & intraoral inter-arch appliances – require patient compliance

Intra-maxillary arch appliances – donot require patient compliance , but shows loss of anchorage

Developing Class II malocclusion of skeletal origin can be intercepted and treated with functional
jaw orthopedics
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REFERENCES :

Clinical orthodontics , 2nd eition . ASHOK KARAD

Esthetics & Biomechanics in orthodontics. RAVINDRA NANDA

Orthodontic Diagnosis. RAKOSI

Contemporary Orthodontics. PROFIT

Systemized orthodontic treatment mechanics. MBT

Kharbanda O P, Chaurasia S. Functional jaw orthopedics for Class II malocclusion:

Where do we stand today?*. J Indian Orthod Soc 2015;49, Suppl S1:33-41

Manik PK, Kumar M, Yadav A, Dawar M. Management of class II malocclusion in an adolescent patient with “The
Poosh Appliance”: An in office fabricated fixed functional appliance. J Indian Orthod Soc 2017;51:119-26

Retention and stability: A review of the literature - Blake and Bibby (Am J Orthod Dentofacial Orthop1998;114:299-306)
67