class ii div 2 malocclusion

1. CLASS II DIV 2
MALOCCLUSION
Presented by:
Ahmed Saeed Baattiah
Under supervision of:
Prof. Maher Fouda
Mansoura University
Faculty of Dentistry
Orthodontics Department

2.  Father of modern orthodontics
 Born on a farm in Pennsylvania on June 1 , 1855 -
fifth of seven children.
 Marked ability to improve & create mechanical
equipment on the farm.
 Apprenticed him self to a dentist at his mothers
request.
 Graduated from Pennsylvania college of Dentistry
– 1878.
 Classified malocclusion – 1899.

3.  Established orthodontics as a separate branch
of dentistry.
 Established Angle School Of Orthodontics in
1900.
 Founded American Society Of Orthodontics in
1901.
 Developed different orthodontic appliances.

4.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

5. INTRODUCTION
Orthodontic specialty deals with various
malocclusions. Malocclusion is the study of its
cause or causes. Development of normal dentition
and occlusion depends on number of interrelated
factors that include the dentoalveolar, skeletal and
neuromuscular factor .
CLASS II DIVISION 2 MALOCCLUSION

6. CLASS II DIVISION 2
DEFINITION

7. INTRODUCTION
 Class II division 2 malocclusion is a type of class
II malocclusion, defined by Angle in 1899.
 It represents 5 to 10 % of all malocclusion
( Sassouni 1971 ).

8.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

9.  Shape of the head : brachycephalic
 Facial profile: convex
 Chin: prominent
 Lower lip: Everted ( lower lip line is
high relative to the upper incisors)
 Upper lip: Positioned high
inrespect to the upper anteriors
(Gummy smile)
 Mentolabial sulcus: Deep
 Mentalis: Hyperactive
Retrusive lips
Facial features

12. Gummy smile
Prominent chin
Hyper active mentalis

13. Facial profile of class II division 2
 The lips are usually thin and there is a lack of vertical development
of the face below the nose.
 The masseter and temporalis muscles are wide.

14. Mild mandibular retrognathia,
with a pronounced chin point
and reduced lower anterior
face height.
High lower lip line
Some features of Class II division 2 malocclusion
Retroclined maxillary central
incisors and deep overbite.

15. Profile of a class II division 2 boy. A round face, backwardly held
mandible with thick chin button and thin lips.

16. Dental features
 Class II molar and canine relationship
 Deep traumatic bite
 Retroclined upper four incisors or
retroclined centrals with labial
inclination of the laterals.
 The tooth size may be small, and upper
incisors may have decreased collum
angle between the crown and the root.
 Decrease over jet
 Shorter root and longer crown.
gingival recession
Canine relationship
Molar relationship

18. Angle class II division 2 malocclusion
Deep bite : overclosure ( closed bite ) Class II div 2 with posterior open bite

19. The lower teeth are shifted backward
compared to the upper teeth (red arrow)
The green arrows indicate a bone loss
problem (periodontics).
The upper left canine is longer than the right canine (blue line) and will
have to be levelled individually to avoid causing inclination of the anterior
occlusal plane.
Class II division 2, mandibular retrognathia and supraocclusion

20. Initial facial and intraoral photographs

21. Initial facial and intraoral photographs

22. Cephalometric features
 Class ll/division 2 malocclusions have a shorter or normal mandibular length
with its sagittal position retruded.
 The chin being prominent and posterior facial height definitely increased.
 The mandibular growth vector is horizontally oriented, with a flat mandibular
plane, giving the appearance of a hypodivergent facial pattern.
 The gonial angle is acute.
 The lower incisors have a normal inclination relative to the mandibular plane
but are retroclined relative to various facial planes.
 Interincisal angle is obtuse, overbite is deep.

23. Airway restriction at the oropharynx level
Backward shift of the lower jaw
Upper incisor too vertical
Cephalometric features

24. Cephalometric features
Proclined lateral incisor
Retroclined central incisor
Flat mandibular plane,
anticlockwise rotation
Increase in
posterior face
height

25. Class II division 2
incisors have a
shorter root, a
longer crown
Cephalometric features

26. Anthropometric method used in determination of gonial angle

27. GONIAL ANGLE
GONIAL ANGLE

28. Reduced
gonial angle
Orthopantomograph (OPG) of Class II division 2 malocclusion. Well
developed ramus in width with short gonial angle

29.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

30. Diagnosis

31. Class II division 2
Extra and intra oral
photographs

34.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

35. Angle’s classification

36. Angle’s classification

37. British standards classification

38. Von - Der - Linden classification
Type A:
*Maxillary central incisors
and laterals are retroclined.
*Degree of retroclination is
less severe in nature.

39. Von - Der - Linden classification
Type B:
Maxillary lateral incisors are overlapping the retroclined maxillary
central incisors.

40. Von - Der - Linden classification
Type C:
*Maxillary central and lateral incisors
are retroclined and are overlapped by
the maxillary canines.

41. Von - Der - Linden classification

43.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

44. Muscular pattern
Class II Division 2 TMJ Problems
 Strong muscular pattern may not permit the bite opening with
the vertical increase of the buccal segment in adult patients.

45. Abnormal intercuspal masticatory articulations
 physiologic changes at any postural level require compensatory
neuromuscular accommodation. Clinical evidence has consistently
shown the occlusal signs and muscular symptoms that occur over
time when teeth are not able to take their optimal physiologic place
(position) within the oral cavity. Various musculoskeletal problems
will occur.

46. Class II Division 2 TMJ Problems
Note: No gonial angle notching, nor extra boney growth exists with this 18 year old
male. Normal vertical dimension of teeth supporting healthy musculature with no
muscle tenderness or TMD symptoms. Normal mandibular range of motion is
exhibited with no clicking or popping joints.

47. Normal mandibular range of motion is exhibited
with no clicking or popping joints.

49. Because of these compressing forces the mandible retrudes while the masticatory
muscles strain and skew the underlying bony structures of the cranium, mandibular
condyles, cervical neck bones and downward.

51.  Every TMD patient is a walking example of the ill effects of the mal
alignment of the postural system beginning with vertically under
developed (or under erupted) molars and bicuspids. this contributes
to narrowing of dental arches, insufficient room for the tongue and
further results in a downward cascading effect of jaw collapse,
abnormal head posturing, and degeneration on the
temporomandibular joints (due to abnormal forces (lack of sufficient
vertical occlusal support).

53.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

54.  Class II division 2 malocclusion arise from a number
of interrelated dental, skeletal, soft tissue and
genetic factors.
 Most of class II/2 malocclusion are caused by an
underlying skeletal discrepancy, and few have a
normal skeletal jaw relationship.
Etiology

55. Soft
tissues
Skeletal
pattern
Dental
factors
Etiology
Etiology

56. Dental class II division 2
Normal maxilla-mandibular skeletal relationship.
Steiner : SNA,SNB,ANB = Normal
Mainly occurs due to mesial drift of the maxillary first molar . As a result of
a) Loss of mesial proximal contact with the primary 2nd molar
- premature extraction/loss of primary 2nd molar.
- congenitally missing primary 2nd molar.
b) inter-arch tooth size discrepancy
- small or congenitally missing maxillary permanent teeth (2nd
premolar) results in a class II molar relation.
c) Maxillary canine or 2nd premolar impaction or displacement out of the arch
- inadequate space in the dental arch class II molar

57. Dental class II division 2

58. Dental class II division 2

59. Soft
tissues
Skeletal
pattern
Dental
factors
Etiology
Etiology

60. Skeletal class II division 2
Result from a discrepancy in the maxillary-mandibular skeletal
relationship.
It might be either due to:
1) Mandibular deficiency
2) Maxillary excess
3) or a combination of both

61. Skeletal class II division 2 Mandibular deficiency
It is a skeletal class II relationship resulting from a
mandibular that is either small or retruded relative to the
maxilla.
Mandibular deficiency
size Position
(Small mandible) ( Retrusion of a normal
sized mandible)
OR
(Combination of both in severe cases )

62. Skeletal class II division 2 Mandibular deficiency
Class II div 2 with a small mandible the decreased size is
localized more to the mandibular body ( Mandibular Ramus is
of normal length ).

63. Skeletal class II division 2 Mandibular deficiency
Mandibular deficiency may result from the retrusion ( distal
positioning ) of a normal – sized mandible.

64. Skeletal class II division 2 Mandibular deficiency

65. Cephalometric analysis showed a skeletal class II
relationship :
ANB angle = 9
SNA = 82
B point was retruded, SNB angle = 74

67. Skeletal class II division 2 Maxillary excess

68. Skeletal class II division 2 Maxillary excess
 Vertical maxillary excess may be localized only to the posterior
area Open bite and incompetent lips ( normal vertical display
of maxillary incisors in repose and during smiling ).
 0verall maxillary excess includes both the anterior and the
posterior area resulting in an excessive vertical display of the
maxillary incisors in repose and during smiling (high smile line )
Gummy smile and incompetent lips.
 In these 2 conditions of maxillary excess Mandible is rotated
downward and posteriorly (clockwise) resulting in a class II
skeletal relationship.

69. Skeletal class II division 2 Maxillary excess
Class II /2 with an overall vertical maxillary excess:

70. Skeletal class II division 2 Maxillary excess
Maxillary excess in Ant-Post Dimension is characterized by a
protrusion of the entire midface including : 1) Nose
2) infra orbital area
3) upper lip

71. Skeletal class II division 2 combination
 Skeletal class II division 2 might be a combination of both
mandibular deficiency and maxillary excess.
 Which will add to the severity of the Ant-post skeletal problem
A patient with maxillary vertical excess and mandibular deficiency

72. Skeletal class II division 2

73. Soft
tissues
Skeletal
pattern
Dental
factors
Etiology
Etiology

74. Soft tissues
If the lower facial height is reduced
the lower lip line will effectively be higher relative
to the crown of the upper incisors (more than the
normal one-third coverage.
A high lower lip line will tend to retrocline
the upper incisors

75. High lip line cause retroclination to incisors
Soft tissues

76. Patient with bimaxillary retroclination due to lip action
Soft tissues

77. In some cases the upper lateral incisors, which have a shorter
crown length, will escape the action of the lower lip and therefore
lie at an average inclination, whereas the central incisors are
retroclined.
Soft tissues

78.  INTRODUCTION
 ETIOLOGY
 CLASSIFICATION
 FEATURES
 TREATMENT
 DIAGNOSIS
CONTENETS
 MUSCULAR PATTERN

79. Treatment of Class II Division 2

80. Treatment option for dental Class II Division 2
For a dental Class II/2 malocclusion:

81. Treatment option for skeletal Class II Division 2

82. Treatment for skeletal Class II Division 2
 The goal of growth modification is to enhance the unacceptable skeletal
relationship by modifying remaining facial growth pattern of the jaws.
 Optimum timing : pre-pubertal growth spurt ( active growth period)

83. Treatment for skeletal Class II Division 2

84. Treatment for skeletal Class II Division 2
High pull headgear ( parietal )
 Distal and intrusive forces on the maxillary molar.
 Extra-oral force is directed superior and posterior.
 A-p and vertical maxillary excess ( decreased V.D).

85. High pull headgear ( parietal )

86. Treatment option for skeletal Class II Division 2Treatment for skeletal Class II Division 2
Low pull headgear ( cervical )
 Distal and extrusive forces on maxillary molars.
 Posterior and inferior extra-oral force
 Increases vertical dimension
 Used in A-P maxillary excess with flat mand.plane

87. Low pull headgear ( cervical )

88. Medium pull headgear ( occipital )
Headgear to upper
part of the Twin
block

89. J-hook headgear

90. J-hook High-Pull Headgear

91. Treatment for skeletal Class II Division 2

92. REMOVABLE FUNCTIONAL APPLIANCES
ACTIVATOR
BIONATOR
TWIN BLOCK
FRANKYL II

93. FIXED FUNCTIONAL APPLIANCES
Herbst appliance Jasper jumper

94. Treatment for skeletal Class II Division 2

95. Adult patient with nearly full-cusp Class II molar relationship. Note inclination of
incisors, 100% deep bite, and discrepancy in gingival margins between canines and
incisors.
Biomechanical Considerations
Treatment of Class II, Division 2 Malocclusion in Adults by dental
camouflage

96. Intrusion arch produces anterior tipback moment and intrusive force
along with extrusive force on molars.

97. Force system and ligation points of intrusion arch in Class II, division 2
malocclusion.

98. Canine retraction generates extrusive effect on incisors. To
counteract this tendency, intrusion arch is tied anteriorly.

99. Canine retraction with .016" × .022" stainless steel base arch and overlay
intrusion arch for anchorage and incisor control.
Moment at molar counteracts mesial reactive force in anchor unit.

100. A. Mushroom-loop archwire without preactivation bends. B. Archwire with gable
bends mesial and distal to archwire. C. 3mm preactivation of loop
017" × .025" CNA mushroom-loop archwire after intraoral activation

101. A. Mushroom-loop archwire with spaces closed. Wire is left in place for
another six weeks to allow residual moments to deliver proper axial root
inclinations.
B. Same patient with ideal axial inclinations

102. B. After initial intrusion phase (note incisor level and molar tipback), .016" ×
.022" stainless steel base arch is used with short .017" × .025" nickel titanium
intrusion arch to retract canines.
C. Canines fully retracted into Class I positions. Note intrusion, overbite, and
anchorage control without elastic wear.

103. 017" × .025" mushroom-loop archwire with preactivation bends activated about
4mm for translatory incisor retraction. Archwire was not reactivated for about 10
weeks.

104. Finished occlusion, showing excellent anchorage control, overbite correction, and
anterior incisor angulation.

106. re REFERENCES
 ORTHODONTICS CURRENT PRINCIPLES AND TECHNIQUES
5TH EDITION (GRABER ).
 CONTEMPORARY ORTHODONTICS (WILLIAM R.PROFFIT )
 SCIENCE DIRECT DATABASE
 TEXTBOOK OF ORTHODONTICS ( SAMIR BISHARA )
 HANDBOOK OF ORTHODONTICS (ROBERT MOYERS )