The Treatment of Class II, Division 1 Malocclusion in Stages

Abstract

Class II malocclusion has high clinical prevalence, about 45%. It is accepted that Class II is acquired during the growth and development stages by general dysfunction of the neuromuscular dysfunction.

Class II malocclusion has high clinical prevalence, about 45%. It is accepted that Class II is acquired during the growth and development stages by general dysfunction of the neuromuscular dysfunction. There are several methods we can adopt. The treatment design and protocol must be used in the clinic by a therapy that really solves the problem. The treatment of each stage will produce: facial harmony, corect implantation of the teeth and function. Our long clinical activity gave us the right way to treat our more than 4000 patients.

The diagnosis carried out in three aspects:

• 1. Functional analyses

• 2. Orthopedic analyses

• 3. Orthodontic analyses

The diagnosis and the growth stages of the patient (Analyses of Cervical Vertebral Maturation – Baccetti and Franchi) are the most important aspects to be considered for the organization of an efficient treatment planning.

Another very important aspect is the evaluation of the maxillary transverse deficiency, which is the first part of the treatment planning, respecting orthopedic priorities.

In regard of orthopedic treatment plan, there are four important aspects to determine:

• 1. Class II with mandibular retrognathism

• 2. Class II with maxillary prognatism

• 3. Class II with fault in mandible and maxilla

• 4. Class II caused by orthodontic disharmonies

Subjects with mandibular retrognathism should be treated with functional orthopedic appliances that promote mandibular advancement such as Balters Bionator, Franckel Functional Regulator, Clark Twin Block, and Sanders Double Plate.

Subjects with maxillary prognatism should be treated with extraoral traction.

Subjects with fault in mandible and maxilla should be treated first with extraoral traction and completed with functional orthopedics.

In regard to the decision earlier or later treatment, it is definable that close to the pubertal peak, we expected that there is a significant increase of mandibular growth.

On the other hand, if the mandibular retrognathism is accentuated, it is necessary to treat the case immediately (mixed dentition) to achieve good orthopedic result.

The last part is the fixed orthodontic treatment resulting to the normal balanced occlusion.

Keep in mind: treat at the right place and right time!

Retain treatment for 6–12 months with orthopedic and orthodontic appliances is required.

A clinical observation should be executed until the second molars are erupted in normal occlusion.

For sure, our goal is the entire balanced stomatognathic neuromuscular system.

The purpose of this chapter is to reinforce the individualized diagnosis and the corresponding treatment protocol indicated for each individual patient as it is demonstrated by the examples presented.

* There is not a unique treatment protocol to be used for all Class II patients.

The treatment of Class II Division I malocclusion is a multifactorial event whose factories should be analyzed by an individualized diagnostic protocol and the decision-making stablished. It has high clinical prevalence, about 40%. This anomaly is considered be acquired during the growth and development stages by general dysfunction of the neuromuscular epigenetic factors (Enlow 1968; Moyers 1988; Korkhaus 1930).

• The orthopedic diagnosis shows the prevalent of 80% of mandible retrognathism and 20% of maxillary prognathism. The treatment protocol for both categories must be totally different (McNamara 1984).

First of all, we must have very clear the priorities of the neuro-functional, orthopedic, and orthodontic aspects that are individually determined by accurate diagnosis protocols (Ricketts 1960; Schwarz 1961; Björk 1955).

7.1 The Mandibular Retrognathism Treatment

The most important priority, as the first stage to be considered, is the maxillary transverse deficiency. It’s absolutely necessary that the maxilla and upper dental arch be prepared to receive mandible in facial harmony, providing a normal Class I occlusion (Faltin et al. 2003).

The Balters Bionator is a totally functional appliance; there is no active component (Balters W).

It is composed by only three parts are (Fig. 7.1a, b):

• 1. The acrylic body (green color) which reproduced the new mandibular posture obtained at the construction bite. The amount of forward and vertical alteration might not be larger than 5 mm when necessary advancement must be realized step by step.

The body controls the vertical eruption of the teeth and the occlusal plane and supports the other two parts.

• 2. The lingual arch, made with 1.2 mm stainless steel a constant excitation for normal tongue posture. Never it is activated!

• 3. The vestibular arch, 0,9 mm with two functions: in the posterior part avoiding the interposition of soft tissues as buccinator complex (buccinator arch). The same arch in the frontal part, from canine to canine region, is adapted as a trainer for leap seal, again a functional trainer, labial arch. The new mandibular posture, the enhance in volume and in shape, the new lingual function, the normal functional behavior conduct to functional adaptation, and total correction of form and function were achieved (Fig. 7.1c–e).

  Fig. 7.1

  

  Balters Bionator appliance

The first example represents a case with a pronounced mandible retrognathic posture without dental arches discrepancies. The treatment protocol was Balters Bionator to normalize facial harmony in anterior and vertical directions (Balters W).

Patient 1: M.S., 9y. 3 m.

At the beginning of treatment (Fig. 7.2a–e).

Fig. 7.2

Pre treatement frontal and lateral photographs. A convex profile is clearly observed

During 3y. 2 m. The patient used three Balters Bionators, with no use of any other fixed appliance.

In the follow-up, after finishing treatment, patient used the last Bionator full days during 6 months and nighttime for another 6 months. The results are observed at Fig. 7.3a–e).

Fig. 7.3

Post treatment frontal and lateral photographs Overbite is totally correctd and midlines are coincident

Figure 7.4a, b illustrates a lateral cephalometric study before and after the treatment.

Fig. 7.4

Comparison pre and post treatment lateral cephalograms

The long-term evaluation after 7 years (Fig. 7.5a–e) was performed and demonstrates the stability even a better situation after orthopedic mandible Class II treatment.

Fig. 7.5

7 years follow up. The results are maintained

It is to be convinced that the functional orthopedic intervention normalizing development factors and correcting neurophysiologic impute, through the central neuron system, promotes a very balanced and stable development and excellent result (Petrovic and Stutzmann 1977).

Frankel functional regulator – RF2 – is another orthopedic appliance that is used in the treatment of Class II Division I malocclusion with mandible retrognathism, in growing prepubertal period (Fig. 7.6a–c) (Frankel 1989, 2000).

Frankel appliances are located in the “vestibules orals” posturing the mandible, maintaining away the perioral capsule pressure and stimulating the whole respiratory system.

Fig. 7.6

Frankel functional regulator (RF2)

Patient 2: P.H.L, 8y

At the beginning of treatment, (Fig. 7.7a–e) is similar compared with the first patient, but this case has some orthodontic problems: crowding, upper arch protruded teeth, narrow maxilla arch, deep vertical bite, and dysfunctions.

Fig. 7.7

Pre treatment frontal and dental facial and dental photos in a Class II 8 year old patient

The patient used three FR2 over 5 years of treatment, progress situation at 12y. 7 m (Fig. 7.8a–e).

Fig. 7.8

Post treatment facial and dental photos : Class II is normalized as well as overjet and overbite

Figure 7.9a–e shows the stability posttreatment over 2 years with no retention.

Fig. 7.9

2 years follow up with no retention

Figure 7.10a, b illustrates a lateral cephalometric study before and after the treatment and the excellent quality of mandibular development.

Fig. 7.10

Pre and post lateral radiographs

We must consider that only few patients are treated exclusively with Balters Bionator, Frankel functional regulator, or other functional therapies. Both therapies are similar and considered the only totally functional jaw orthopedic devices (Bishara and Ziara 1989).

The great majority of Class II Division 1 is patients with retrognathic mandible, transverse discrepancy of the maxilla, upper incisors protrusion, lower dental crowding, total Class II distal occlusion, and general dysfunctions. They need to be prepared before being submitted to a functional orthopedic treatment like the Bionator therapy.

R.M.E is the first recommended intervention. The Schwarz Plate or Ricketts lower utility arch may be indicated (McNamara 1985).

The next step of treatment will be the functional orthopedic stage with Balters Bionator, respecting all aspects from the construction bite to the adjustment in patient’s mouth, instruction, and treatment control.

Unfortunately, a small percentage of cases can be treated only using Bionators.

After total analysis of the various, complementary examinees and appropriate analysis, the diagnosis will demonstrate upper transverse discrepancy in comparison with lower one, a deep bite, or an open bite, dental crowding, and respiratory dysfunction (Van der Linden 1986).

The patient must be prepared before being submitted to functional therapy like Balters Bionator.

Patient 3: J.D.S., 9y. 3 m

At the beginning of treatment (Fig. 7.11).

Fig. 7.11

Initial records

Figure 7.12 shows the sequence before Balters Bionator used.

Fig. 7.12

RME appliance in place

Sequence of the first stage: rapid maxillary expansion and simultaneously lower utility arc indicated to correct the lower incisors implantation. This phase took 8 months.

The second stage related with the facial harmony started immediately and was treated by an appropriated protocol in vertical, latero-lateral, and anterior-posterior directions. In this stage, the patient used a modified Balters Bionator.

Balters Bionator was installed without removing the Lower Utility Arch in place. The use of Balters Bionator during 1 year and after the treatment was finished with fixed total appliance to correct teeth alignment and implantation and finally achieve functional normal occlusion.

The retention was upper plate and lower lingual fixed (Fig. 7.13 shows the final case and Fig. 7.14 shows the lateral cephalometric image). Excellent facial result. Facial dimensions are according to Fibonacci’s divine proportion.

Fig. 7.13

Front, profile and final dental results

Fig. 7.14

Lateral cephalometric study before and 5 years after

In cases like this, orthopedic and orthodontic treatment must be started very soon in order to be able to correct facial harmony, normal occlusion, and neuromuscular behavior.

Sander, G., 1995, developed a new appliance – Bite Jumping Appliance – SII. It consists of two plates, removable appliances with expansion screws and the upper one with a metallic guide that contacts the lower plate in the anterior region (Fig. 7.15a–c). Each time the patient closes the teeth, he or she advances the mandible and makes gymnastic with muscles induced by contacts on the front part as explained (Sander and Wichelhaus 1995) (Fig. 120).

At the same time, the SII appliance is a mandible protractor with transverse expansion of the maxilla and uprighting of molar posterior teeth. The advantage of SII treatment is the possibility to enlarge the maxilla, correct deep bite, open space for dental orthodontic treatment, and advance mandible at the same time. In these simultaneous cases, it is recommended to use Sander jumping the bite (SII). Sander’s SII and Clark’s Twin Block have a similar action.

Fig. 7.15

Upper and lower SII appliance in place

Patient 4: R.L.B.H., 12y

At the beginning of treatment (Fig. 7.16a–e). The first stage of treatment that lasted 1 year and 6 months shows the evolution and complete treatment with SII (Sander 2001) (Fig. 7.17).

Fig. 7.16

Pre treatment records of a 12 year patient with Class II molar and canine

Fig. 7.17

SII appliance in place after 18 months of treatment

Next stage with fixed appliance including retention took 15 months and present very stable results. Figure 7.18a–e presents the end of treatment.

Fig. 7.18

Post treatment facial and dental photographs

The long-term evaluation confirms a very stable result (Fig. 7.19a–e).

Fig. 7.19

Final results

Fig. 7.20

Lateral cephometric measurements: before, during and after treatment

Cases of patients with pronounced Class II Division 1 with severe retrognathic mandible, upper protrusion, deep bite, and dysfunctions but without lower crowding must be treated immediately, even in the deciduous dentition. The biological reason is that the development of the dental facial complex under such reverse epigenetic factors will get worse with time (Korhaus 1940) (Fig 7.20).

Patient 5: L.M., 4y. 6 m

At the beginning of treatment. The treatment will take a long time using the Balters Bionator during the first stage and Sanders’ double plates (SII) during second stage (Figs. 7.20, 7.21, 7.22, 7.23, and 7.24).

All priorities could be normalized, facial orthopedic harmony, balanced occlusion, and balanced neuromuscular function. That is the real stimulation for normal functional adaptation including form, size, and shape of the masticator system (Faltin et al. 2003; Malta et al. 2010).

The advanced of SII treatment is the possibility to wide maxilla, correct deep bite, open space for dental orthodontic treatment, and advance mandible.

Fig. 7.21

Pre treatment photographs of a 4-year, 6-month old boy

The patient used upper expansion removable plate with super elastic screws, SII, and Bionator from November 2001 to March 2005 (Fig. 7.22).

Fig. 7.22

After using SII appliance and Bionator for Nov 2001 to March 2005

From June 2010 to June 2013, the second stage was treated with fixed appliance and retention (Fig. 7.23). These excellent results could only be obtained when the treatment starts at a very young age.

Fig. 7.23

Final results

Fig. 7.24

After long-term treatment

The SII in treatment of Class II Division I with mandible retrognathism is indicated when the patient is in the prepubertal stages of cervical vertebral maturation up to IV or V, as proposed by Franchi e Baccetti, with maxillary transverse deficiency and dental crowding.

In special situations of facial development, it is necessary to focus first on facial aesthetics.

Patient 6: K.B., 10y

At the beginning of treatment (Fig. 7.25). The patient was treated in a unique stage. The priority was to achieve first the facial harmony because of the poor vertical dimensions. In sequence she was treated with biomechanics fixed therapy.

Fig. 7.25

Pre treatment photos of a 10 year old Class II patient

7.1.1 The treatment sequence:

Balters Bionator result (Fig. 7.26) than fixed appliance and quadric helix (Fig. 7.27) and the end of treatment (Fig. 7.28). Figure 7.29 is lateral cephalometric study: before and immediately after and a long term (Balters 1964a,b).

In this case, because of the advanced stage of development, we decided to treat first the facial harmony with Balters Bionator philosophy than fix appliance according to Ricketts´ philosophy.

Fig. 7.26

1 yera in treatment with fixed appliances

Fig. 7.27

Dental upper and lower photos with brackets in place along with an upper quad-helix

Fig. 7.28

Facial and dental post -treatment photos

Fig. 7.29

Comparison pre and post lateral radiographs

Patient 7: F.A., 10y.2 m

At the beginning of treatment. Another typical case of mandible retrognathism (Figs. 7.30a–c and 7.31a–c).

Fig. 7.30

A 10 year 2 month boy with an important retrognatic mandible at the beginning of the treatment

Fig. 7.31

Pre treatment dental occlusion Midlines are not coincident and a significant overbite is present

Figure 7.32 shows the occlusion with and without the Balters Bionator when the class I was achieved. The patient used five Balters Bionator during 2 years and 3 months and completed the treatment using fixed appliance.

Fig. 7.32

Occlusion with and without Balters Bionator appliance

Figure 7.33 presents the end of the treatment and the total treatment time was 4y. 3 m.

Fig. 7.33

Facial and dental photographs at the end of the treatment

Figure 7.34 shows the stability of the treatment in long-term observation 6 years after retention.

Fig. 7.34

Follow up 6 years after the end of the treatment

Figure 7.35 shows the lateral Rx where it is possible to observe very clear the development of the face and recognize the mandible growth.

Fig. 7.35

Pre, Post and follow-up lateral radiographs

Figure 7.36a, b are images from CBCT, before and after the treatment, demonstrating the functional adaptation on TMJs, relocating the condyles in glenoid cavities.

Fig. 7.36

(a) Right condyle. (b) Left condyle

7.2 The Maxillary Prognathism Treatment

When Class II Division I is characterized as maxillary protrusion, the treatment protocol indicated is extraoral traction, developed by G. Sander (Fig. 7.37). This special extraoral traction appliance has constant cervical force of 4–5 newtons. The appliance needs to be used for 18 h per day.

When the individual diagnosis shows a narrow transverse midface and the RME is priority number one, start treatment with maxillary expansion is primordial.

The traction is always cervical. If the patient has a horizontal growth tendency, it is necessary to associate with an upper anterior bite plate. If the patient has a vertical growth tendency, it is indicated a lower posterior bite plate.

After the orthopedic correction, the treatment is finalized with biomechanics fixed appliances and finally retention.

Fig. 7.37

Lateral radiographs and Sander´s extraoral traction appliance in place

Patient 8: S.C.W., 11y

The beginning of treatment (Figs. 7.38a, b and 7.39a–c).

Fig. 7.38

Facial photos before treatment

Fig. 7.39

Pre treatment frontal and lateral dental photographs along with an important overbite

The first stage of treatment was maxillary expansion with upper removable expansion plate; treatment time is 8 m (Fig. 7.40).

Fig. 7.40

A significant improvement were observed after 8 months in treatment with an upper removable appliance

The total treatment took 2 years and 11 months (Fig. 7.41).

Fig. 7.41

Final photographs after 2 years in treatment 11 months

Lateral cephalometric evaluation (Fig. 7.42) before, during, and long-term control shows total stable situation.

Fig. 7.42

Lateral cephalograms evaluation before, during and after treatment

Patient 9: C.P., 9y 10 m

The beginning of treatment (Fig. 7.43). This case illustrates a combined treatment of extraoral appliance and Balters Bionator.

The sequence was:

• 1. Maxilla transverse correction

• 2. Balters Bionator therapy during 2y and 10 m (Fig. 7.44).

• 3. Extraoral appliance (1 year) and another (13 months) total fixed appliance (Fig. 7.45) shows the case at the end of the treatment.

• 4. Long-term control (Fig. 7.46).

• 5. Lateral cephalometric images before and after the treatment (Fig. 7.47).

Fig. 7.43

A 10 year 10 months old patient

Fig. 7.44

Results after a Balters Bionator therapy during 2 years

Fig. 7.45

1 year after Extraoral appliance and 13 months with fixed appliances

Fig. 7.46

Long term follow up. The results were maintained

Fig. 7.47

Final photos. Pre treatment cephalogram and superposition pre and post treatment

Conclusion

According to the knowledge of the biological process involved in the dental masticatory system, the use of methods to individualize diagnosis and to create and correspond treatment planning, using the most efficient and appropriate therapeutic appliances, we certainly achieve facial harmony, normal occlusion, and neurophysiological that provides a homodynamic activity.

The future tendency of science philosophy of our professional activity encourages us to recognize that facial orthopedics is the first priority before orthodontics every time. The neuromuscular balance gives the long-term stability and the maintenance of the normal occlusion.

We must be prepared to understand the permanent evolution of our profession especially respecting the basic principles.

Our profession has the characteristic of permanent evolution. We are blessed with new basic, biological knowledge conducting us to be the first facial orthopedist than orthodontists guided by physiological neuromuscular activities!