Class II treatment

Class II treatment

Introduction :

Many treatment protocols are available to the practitioner, who must make their choice based on the type, location and intensity of the dysmorphosis, but also based on the age and motivation of the patient.

Definition :

Skeletal Class II malocclusions are sagittal anomalies characterized by an exaggerated overjet and Class II canine and molar relationships. They can be maxillary or mandibular in nature, or both.

Frequency: ¾ of the population have a class II malocclusion according to BASSIGNY.

1- Prevention Interception

• Sleeping positions: avoid the ventral position which encourages mouth breathing and the persistence of neonatal retromandibulia
• oral hygiene (care and avoiding early extractions of baby molars)
• feeding: the effectiveness of breastfeeding is no longer in doubt given the importance of the muscular activity it involves. With the appearance of teeth, chewing must be efficient (avoid soft food and introduce increasingly hard foods to trigger “mandibular strike” (PLANAS)
  • Elimination of thumb or object sucking tics.
  • Rehabilitation of functions and bad postures.
  • Removing occlusion locks: overbite and transverse deficiency.

2- Orthopedic treatment

It aims to correct the size and position of the jaws between themselves and with the base of the skull,

before the growth peak.

1.  Maxillary responsibility:

FEB treatment which can be on molar rings or on a splint. It is a removable device comprising:

• A pericranial support
• External elastic traction
• A facebow: with two external branches and two internal branches, the latter will fit into the molar tubes of the rings or embedded in the resin if it is on a gutter
• This type of device allows significant slowing of the sagittal growth of the maxilla.
  • It allows to control the orientation of the maxilla and the occlusal plane thanks to the orientation of the external branches.

FEB on molar bands FEB on aligners

Depending on the traction, we have three types:

1.  High traction:
   • The support is parietal.
   • The effects:
     • Intrusion of molars
     • Anterior rotation of the mandible
     • Increased anchoring
     • In the case of class II open bite.
2. Low traction:

• The support is cervical at the level of the neck.
• The effects:
  • Egression of molars
  • Distal movement of molars
  • Increased molar anchorage
  • Indicated in class II deep bite cases

3. Horizontal traction:

• The support is occipital.
• The effects:
  • Distal action
  • indicated in Class II normo bite

‐‐ increases molar anchorage

2.  Mandibular responsibility:

Activator:

A removable device using intrinsic forces (orofacial muscles) to correct skeletal class II by mandibular propulsion, it is a functional orthopedic appliance.

Andersen activator There are 3 main families of activators:

• Rigid monoblock activators
• Elastic activators
• The stop activators

We cite the Andersen activator, the most popular. It is one of the rigid activators, it consists of:

– From an upper palatine plate with:

• vestibular arch
• 2 Adams hooks

– And a resin lingual plate that covers the lower incisors.

– The two plates are connected by a bilateral resin interposition which covers the occlusal faces of the lateral sectors.

Effects:

• Growth and advancement of the mandible
• Slowing of maxillary growth
• Increase in DV by posterior rotation of the mandible
• Palato version of the upper incisors and vestibulo version of the lower incisors

Indication: Class II with deep bite or normo bite mandibular responsibility Wear: 12 to 14 hours per day

Contraindication: Associated DDM and posterior rotation of the mandible.

DAC (distal active concept) therapy has proven its effectiveness and appears to be an alternative to functional activators.

It offers the advantage of being able to combine orthopedic action with orthodontic action, this is particularly interesting in the following cases:

The DAC system

This device includes:

• Wedges on the first mandibular molars to unlock mandibular growth
• Intermaxillary tractions to propel the mandible.

era

• NITI springs between incisors and 1 molar to distalize or stabilize the

1st upper molar.

3.  Mixed responsibility:

Association of activator and extraoral forces

• Back from point A
• facilitates forward mandibular growth.
• a decrease in the convexity of the profile.
• Maxillary growth rotation, following the orientation of the external branches: (anterior rotation for a low orientation, no rotation for an average orientation, posterior rotation for a high orientation.

3- Orthodontic treatment

It is called compensation, after the growth peak the orthopedic correction of the position of the jaws is no longer possible.

Orthodontic treatment can be done with or without tooth extraction. The choice will be made based on the following factors:

• Convexity of the profile
• Single or double maxilla DDM
• The height of the lower floor
• Importance of the shift

Without extraction:

The TIMs are stretched from the upper canine to the lower molar

Indicated in class II cases with low offset, without lower floor increase, without DDM, not too convex profile

With extraction:

Single-jaw extraction 14/24 or 15/25

Bimaxillary extraction 14/24 and 34/44 or 15/25 and 35/45 Principles:

• If the shift is significant = 14/24 extraction
• If the offset is not significant = extraction 15/25
• If single-jaw extraction = end-of-treatment molar ratio of class 2 type
• If DDM in the mandibular arch = bimaxillary extraction

5. Surgical treatment

It aims to correct the position and/or size of the jaws using osteotomies after the end of growth (from the age of 18).

Indication:

• the anomaly is significant or
• The child consulted late
• Orthopedic therapy failed.

Pre-surgical orthodontics:

• Decompensate malocclusions, in other words make them worse initially,
• Correct the clutter of the arches
• Ensure good coaptation of the arches;
• The results of the intervention are simulated on casts to visualize any inadequacies in the orthodontic preparation, particularly in terms of the transverse direction, the intercanine distance and the posterior torques.

Intraoperative orthodontics:

-During the intervention, the role of the orthodontist will be to remove or modify the arches used by the surgeon to achieve inter-arch blocking during the intervention.

Orthodontic finishing:

– After an average bone consolidation time (approximately 2 months), the orthodontist can continue treatment in order to perfect the static and dynamic occlusal results.

Two main categories of surgery are possible:

• Segmental osteotomies that move a group of teeth within an arch
• Total osteotomies which move the entire arch.

1. Isolated promaxillary:

By Wassmund:

– Segmental osteotomy allows the mobilization of the incisor-canine group in all three spatial directions. To allow its surgical retraction, the preparation involves the extraction of the first two premolars (intraoperatively).

– This surgery involves a recession of the upper lip and the A-point area.

Lefort 1:

– Total maxillary osteotomy allows the arch to be moved in all 3 directions. The retraction of the maxillary arch may be accompanied by lowering with the placement of a bone graft and sometimes by disjunction.

2. Isolated retromandibulia:

– Most frequently, it is corrected by total transramal osteotomy which allows a displacement in the three directions of the space of the mandible (advancement, recoil, elevation and lowering) called Obwegeser osteotomy, it is carried out by means of a cleavage in the thickness of the ramus. The osteotomized fragments are held in place using screwed titanium plates.

– a Koële segmental osteotomy which allows the correction of an excess of anterior coverage due to the extrusion of the mandibular incisors. It includes a posterior osteotomy line passing between the canine and the first premolar.

– It is sometimes necessary to add a disjunction if the width of the maxillary arch is insufficient.

Class II treatment

Class II/2:

Once the upper incisors have been labial-to-vestibulosed, genioplasty is recommended. It reduces the overly prominent symphysis and restores height to the chin using a graft placed under the basilar edge.

Conclusion

Early orthopedic action can act on the bone foundations, normalizing growth to ensure harmonious development of the stomatognathic apparatus. In patients at the end of growth, a compromise orthodontic treatment often requires extractions.

Surgical treatment is reserved for adults at the end of growth and facing severe discrepancies with significant aesthetic damage.

Class II treatment

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Class II treatment