CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 49-56
Case Report
NONEXTRACTION TREATMENT OF AN ADULT WITH CLASS II
DIVISION 2 MALOCCLUSION
Hande Görücü Coşkuner, DDS
Research Assistant, Department of Orthodontics,
Faculty of Dentistry, Hacettepe University,
Ankara, Turkey
İlken Kocadereli, DDS, PhD
Professor, Department of Orthodontics,
ABSTRACT
This case report describes the treatment of an adult with
Class II division 2 malocclusion. The patient had class II molar
and class II canine relationships, retroclined upper and lower
incisors, excessive deep bite and severe crowding. The patient
Faculty of Dentistry, Hacettepe University,
was treated by incisor protrusion and use of fixed functional
Ankara, Turkey
appliance. An optimal molar and canine relationship was
achieved in 14 months.
Correspondence
Hande Görücü Coşkuner, DDS
Department of Orthodontics,
Faculty of Dentistry,
Hacettepe University,
Sıhhıye, 6100, Ankara / Turkey
Phone : +90 312 305 22 90
Fax : +90 312 309 11 38
E-mail: hande.gorucu@hotmail.com
Key words: Class II Division 2 Malocclusion, Fixed Functional
Appliance, Non-Extraction Treatment
Submitted for Publication: 02.04.2013
Accepted for Publication : 10.07.2013
49
CLINICAL DENTISTRY AND RESEARCH 2013; 37(3): 49-56
Olgu Bildirimi
SINIF II DİVİZYON 2 MALOKLÜZYONLU BİR ERİŞKİNİN ÇEKİMSİZ
TEDAVİSİ
Hande Görücü Coşkuner
Araştırma Görevlisi, Hacettepe Üniversitesi Diş Hekimliği Fakültesi,
Ortodonti Anabilim Dalı,
Ankara, Türkiye
İlken Kocadereli,
Prof. Dr., Hacettepe Üniversitesi, Diş Hekimliği Fakültesi,
Ortodonti Anabilim Dalı,
Ankara, Türkiye
ÖZET
Bu olgu raporunda Sınıf II divizyon 2 maloklüzyona sahip erişkin
hastanın tedavisi anlatılmaktadır. Hastada sınıf II molar ve sınıf
II kanin ilişkisi, dikleşmiş üst ve alt insizörler, aşırı deep bite ve
ciddi çapraşıklık bulunmaktaydı . Hastada insizör protrüzyonu
ve sabit fonksiyonel aperey ile tedavi yapıldı. Optimum molar ve
kanin ilişkisi 14 ayda sağlandı.
Sorumlu Yazar
Hande Görücü Coşkuner
Hacettepe Üniversitesi, Diş Hekimliği Fakültesi,
Ortodonti Anabilim Dalı
Sıhhiye, 6100, Ankara/Türkiye
Telefon: +90 312 305 22 90
Faks: +90 312 309 11 38
e-mail: hande.gorucu@hotmail.com
50
Anahtar Kelimeler: Sınıf II Divizyon 2 Maloklüzyon, Sabit
Fonksiyonel Aparey, Çekimsiz Tedavi
Yayın Başvuru Tarihi : 04.02.2013
Yayına Kabul Tarihi : 07.10.2013
Treatment Of An Adult With Class II Division 2 Malocclusion
INTRODUCTION
Epidemiologic investigations have shown that in a
population 2-5% of individuals have Class II division 2
malocclusion.1,2 Retrusion of maxillary incisors is one of
the main characteristics of class II division 2 malocclusion.3
Therefore, first step in the treatment strategy is to procline
the upper incisors by removable plates or protrusion
utility arches and converting Class II division 2 to a Class II
division 1. Later, class 2 mechanics are used for correction.4
In prepubertal or pubertal period, removable functional
appliances can be used but in postpubertal period usually
fixed functional appliances are preferred.
CASE REPORT
23 year 1 month old white girl referred to Hacettepe
University, Faculty of Dentistry, Department of
Orthodontics with a chief complaint that she did not like her
smile because of the crowding of her anterior teeth. Her
medical and dental histories were unremarkable.
Extraoral examinations showed concave profile
with prominent chin and deep labiomental sulcus. In
anteroposterior projection no asymmetry was noticed.
Her lips were competent (Figure 1). Intraorally she had
class II molar and class II canine relationships in the right
and left segments (Figure 2). Mandibular dental midline
was centered relative to facial midline but maxillary dental
midline was 2 mm deviated to the right of facial midline.
The maxillary arch was square shaped with 8 mm crowding
(Figure 3). In mandibular arch there was 6 mm crowding in
the anterior region (Figure 4).
The panoramic x-rays showed no caries and no pathologies.
All permanent teeth were present, right maxillary and both
mandibular third molars were impacted (Figure 5).
Cephalometric examinations showed that both maxilla and
mandible were retrusive and mandible was more retrusive
with an ANB angle of 6°. Lower anterior facial height was
in normal values with 46°. Dentally, both the maxillary and
mandibular incisors were retroclined relative to cranial and
apical bases and there was excessive deepbite (Figures
6-8).
Treatment Objectives
Our goals were to improve the patient’s facial esthetics and
to provide functional occlusion. According to Ricketts soft
tissue analysis, lower lip should be 2 mm behind E line. In
our case lower lip was -4 mm to Ricketts E line. To improve
Figure 1. Pretreatment facial photographs
Figure 2. Pretreatment intraoral photographs
51
CLINICAL DENTISTRY AND RESEARCH
Figure 6. Initial cephalometric radiograph
Figure 3. Pretreatment maxillary arch Figure 7. Initial cephalometric tracing
Figure 4. Pretreatment mandibular arch
Figure 5. Initial panoramic radiograph
52
Figure 8. Initial cephalometric tracing-Ricketts
Treatment Of An Adult With Class II Division 2 Malocclusion
facial esthetics, we should make lips more prominent and
therefore, we planned nonextraction treatment strategy.
Dental treatment objectives included correction of class
II molar and canine relations, correction of deep bite
and correction of crowding by protrusion of incisors and
expansion of dental arches.
During treatment, patient was instructed for extraction of
third molars, so all third molars were extracted in finishing
phase. For retention; Hawley retainers were placed above
upper and lower bonded lingual retainers and the patient
was instructed to wear them full time for one year. After
one year patient was called for periodic evaluation.
Treatment Alternatives
Treatment Results
First treatment option was mandibular surgery after the
extraction of right and left mandibular first premolars for
crowding and coordination of dental arches by expansion
and upper incisor proclination. Because of prominent chin,
after mandibular surgery genioplasty could be necessary.
The patient was not willing for surgical treatment.
Second treatment option was extraction treatment with
the extraction of upper first premolar and lower second
premolar. In that case correction of crowding and class II
molar canine relationship would be easier but profile of
patient would worsen and correction of deep bite would be
difficult.
In non-extraction treatment crowding can be solved by
expansion of the arches and proclination of upper and
lower incisors. This would improve esthetics and correction
of deep bite would be easier so we decided to apply nonextraction treatment.
Favorable facial changes were obtained (Figure 9). Lower
lip was forwarded 2 mm according to E plane. Ideal tooth
aspect was gained on full smile. Intraorally, deepbite was
resolved and ideal overjet and overbite relationships were
achieved. Maxillary and mandibular dental midlines were
coincident with facial midline and class 1 molar and canine
relationships were established (Figures 10, 11,12).
Cephalometrically, ANB angle decreased to 4° from 6° and
lower anterior facial height changed to 47° from 46°. Upper
and lower incisors were proclined relative to cranial and
apical bases, and this proclination also helped the correction
of deepbite (Figures 13, 14, 15). In final panoramic
radiograph, all third molars were extracted (Figure 16).
Treatment Progress
After evaluation of the diagnostic records; the patient history
and the decision of the patient non-extraction orthodontic
correction was chosen as the treatment strategy.
Expansion was started with the application of a quad-helix
appliance. Then, upper incisors were bonded and after
leveling with a utility arch, protrusion utility arch was placed
which has 45° intrusion bends. Concurrently mandibular
teeth were bonded and banded. After upper incisor
protraction, upper premolar and canines were bonded.
Later, for both upper and lower arches, 0,014 inch Ni-Ti,
0,016 inch Ni-Ti, 0,016x0,016 inch Ni-Ti and 0,016x0,016
stainless steel wires are used respectively. When upper and
lower leveling completed, 0.016x0.022 inch stainless steel
wires were placed and Forsus Fatigue Resistant Device
(3M Unitek 2724 South Peck Road Monrovia, CA 91016
USA) was used. Five months later, Class I molar and canine
relationships were achieved. Forsus FRD was removed
and for occlusal settling intermaxillary elastics was used.
2 months later, after 14 months from the beginning of
treatment, patient was debonded.
DISCUSSION
Usually, when treating patients who have 6 mm or more
crowding in the mandibular arch, we consider extraction.
But in the treatment of Class II division 2 malocclusion,
extraction would make the correction of deep bite difficult
and worsen the profile. In a case report, Asakawa et al.5
treated a girl with Class II division 2 malocclusion who has
8 mm mandibular crowding without extraction. They stated
that if the patient was treated with premolar or incisor
extraction, proper overjet and overbite couldn’t be obtained.
For the reasons mentioned above and to improve facial
profile we decided to treat the patient without extraction.
After leveling of maxillary and mandibular arches, we
corrected Class II molar and canine relationships by using
Forsus FRD. One of the main dental effects of Forsus
FRD is protrusion and intrusion of mandibular incisors
with labial tipping.6,7 In our case both effects are seen and
also protrusion and intrusion of mandibular incisors had
favorable effect on correction of deepbite.
Proclination of lower incisors are considered to be a major
factor for gingival recession. In a study, Melsen et al.8
concluded that the risk of periodontal damage secondary to
protrusion of incisors is small. Also, Hasund et al.9 noted that
mandibular incisors could be proclined more in the patients
with hypodivergent skeletal patterns and prominent chins.
53
CLINICAL DENTISTRY AND RESEARCH
Figure 9. Posttreatment facial photographs
Figure 10.Posttreatment maxillary arch
Figure 11.Posttreatment mandibular arch
Figure 12.Posttreatment intraoral photographs
In treatment of a Class II division 2 female, Asakawa et al.5
also proclined upper and lower incisors significantly, but at
the end of the treatment no periodontal damage was noted.
By proclination of upper and lower incisors, interincisal angle
decreased. In deepbite cases, it is chosen to achieve narrow
interincisal angle for stability. Riedel 10 proposed that at the
54
end of treatment, large interincisal angle is associated with
relapse of deep overbite.
Our treatment lasted in 14 months. If we take a look at
treatment durations of Class II division 2 malocclusions,
we see prolonged durations. Chen et al.11 treated a 42year old male with Class II division 2 malocclusion, deep
Treatment Of An Adult With Class II Division 2 Malocclusion
Figure 13.Final cephalometric radiograph
Figure 15.Final cephalometric tracing-Ricketts
Figure 16.Final panoramic radiograph
Figure 14.Final cephalometric tracing
overbite and some missing teeth. The total treatment time
was 30 months. One of the reasons of excessive treatment
duration could be the age of the patient. There are
limited publications considering the relationship between
treatment duration and patient age.12,13 But in recent
articles comparing treatment duration no difference was
found between adults and adolescents.14,15 Another reason
for prolonged treatment time in that patient could be incisor
intrusion for correction of deepbite. In our case by incisor
protrusion and using Forsus FRD, deepbite was resolved
and no other effort was taken for correction of deepbite.
In another case report, 14 year old Class II division 2 female
with severe crowding was treated without extraction.5
Treatment duration was 24 months. She also had severe
deep bite and deep bite was corrected by incisor intrusion.
A 12 year old Class II division 2 male was also treated without
extraction and treatment duration was 14 months.16 It was
similar with our treatment duration.
According to Proffit 17; if Class II traction has proclined the
lower incisors more than 2 mm, permanent retention is
required. Usually patients are instructed to wear Hawley
retainers full time for one year, at night for an additional
year and later, return for periodic evaluation.11,16 In our
patient we used bonded lingual retainers and Hawley
retainers for retention.
CONCLUSIONS
Correction of Class II malocclusion without extraction
was achieved in 14 months. Class I molar and canine
55
CLINICAL DENTISTRY AND RESEARCH
relationships were obtained; favorable changes were seen
in patient’s profile, smile and aesthetics. Lower lip was
forwarded according to E plane so improvement in profile
was achieved. Upper arch was expanded and incisors were
proclined so patient’s smile was fulled and these results
improved her aesthetics.
13. Barrer HG. The adult orthodontic patient . Am J Orthod 1977;
72: 617-640.
REFERENCES
14. Robb SI, Sadowsky C, Schneider BJ, BeGole EA. Effectiveness
and duration of orthodontic treatment in adults and adolescents.
Am J Orthod Dentofacial Orthop 1998; 113: 383-386.
1.Ast DH, Carlos JP, Cons NC. The prevalence and characteristics of
malocclusion among senior high school students in upstate New
York. Am J Orthod 1965; 51: 437-445.
15. Becker A, Chaushu S. Success rate and duration of orthodontic
treatment for adult patients with palatally impacted maxillary
canines. Am J Orthod Dentofacial Orthop 2003; 124: 509-514.
2.Ingervall B, Seeman L, Thilander B. Frequency of malocclusion
and need of orthodontic treatment in 10-year old children in
Gothenburg. Sven Tandlaek Tidskr 1972; 65: 7-21.
16.Ferreira SL. Class II Division 2 deep overbite malocclusion
correction with nonextraction therapy and Class II elastics. Am J
Orthod Dentofacial Orthop. 1998; 114: 166-175.
3.Bishara SE. Class II Malocclusions: Diagnostic and Clinical
Considerations With and Without Treatment. Semin Orthod 2006;
12: 11-24.
17. Proffit WR. Retention. In: Proffit WR, Fields HW Jr, editors.
Contemporary orthodontics. St. Louis: Mosby Year Book; 1993. P.
534-535.
4.Von Bremen J, Panscherz H. Efficiency of Class II Division 1 and
Class II Division 2 Treatment in Relation to Different Treatment
Approaches. Semin Orthod 2003; 9: 87-92.
5.Asakawa S, Al-Musaallam T, Handelman CS. Nonextraction
treatment of a Class II deepbite malocclusion with severe
mandibular crowding: Visualized treatment objectives for selecting
treatment options. Am J Orthod Dentofacial Orthop 2008; 133:
308-316.
6.Aras A, Ada E, Saracoğlu H, Gezer NS, Aras I. Comparison of
treatments with the Forsus fatigue resistant device in relation
to skeletal maturity: A cephalometric and magnetic resonance
imaging study. Am J Orthod Dentofacial Orthop 2011; 140: 616625.
7. Jones G, Buschang PH, Kim KB, Oliver DR. Class II Non-Extraction
Patients Treated with the Forsus Fatigue Resistant Device Versus
Intermaxillary Elastics. Angle Orthodontist 2008; 78-2: 332-338.
8.Melsen B, Allais D. Factors of importance for the development
of dehiscences during labial movement of mandibular incisors: A
retrospective study of adult orthodontic patients. Am J Orthod
Dentofacial Orthop 2005; 127: 552-561.
9.Hasund A, Ulstein G. The position of incisors in relation to the
lines NA and NB in different facial types. Am J Orthod 1970; 57:
1-14.
10. Riedel RA. A review of retrusion problem. Angle Orthod 1960;
30: 179-194.
11. Chen YJ, Yao CCJ, Chang HF. Nonsurgical correction of skeletal
deep overbite and Class II Division 2 malocclusion in an adult
patient. Am J Orthod Dentofacial Orthop 2004; 126: 371-378.
56
12. Chiappone RC. Special considerations for adult orthodontics. J
Clin Orthod 1976; 10: 535-545.