Volume 9, Year 2017 INDIAN DENTAL JOURNAL

www.idjournal.org Official Publication of Society of Medical Dental & Public Health

NONEXTRACTION TREATMENT OF AN ADULT WITH CLASS II

DIVISION 2 MALOCCLUSION WITH AUTO ROTATION OF MANDIBLE
Dr. Kiran Chakravarthula 1 Dr. Chetan S 2 Dr. Reji Abraham 3
Dr. Vignesh Varma Raja 4Dr. Indu Shree Prakash 5
Dr. Jitesh Kesavan 6 Dr. Ramoji Rao Lenka 7
1
Assistant Professor, Department of Orthodontics and Dentofacial Orthopaedics, Lenora Institute Of Dental
Sciences, Rajanagaram, East Godavari District-533294, Andhra pradesh, India 2 Reader, Department of
Orthodontics and Dentofacial Orthopaedics, Sri Hasanamba Dental College and Hospital, Vidyanagar, Hassan,
Karnataka, India 3 Professor and Head, Department of Orthodontics and Dentofacial Orthopaedics, Sri Hasanamba
Dental College and Hospital, Vidyanagar, Hassan, Karnataka, India 4 Assistant Professor, Department of
Orthodontics and Dentofacial Orthopaedics, Indiradandhi Institute Of Dental Sciences, Nellikuzhy, kothamangalam,
kerala, India 5,6,7 Post Graduate Student, Department of Orthodontics and Dentofacial Orthopaedics, Sri Hasanamba
Dental College and Hospital, Vidyanagar, Hassan, Karnataka, India
Address for Correspondence: Dr. Kiran Chakravarthula, Assistant Professor, Department of Orthodontics and
Dentofacial Orthopaedics, Lenora Institute Of Dental Sciences, Rajanagaram, East Godavari District, Andhra
pradesh, India.
E-mail: [email protected]

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 incisors, excessive deep bite and severe
crowding. The patient was treated by incisor protrusion. Auto rotation of mandible was noticed after
initial levelling and aligning of maxillary arch. An optimal molar and canine relationship was achieved in
14 months.

KEYWORDS: Class II Division 2 Maloclusion, Auto Rotation,Class II Elastics, Deep Bite, Non
Extraction

I NTRODUCTION - Epidemiologic
investigations have shown that in a
population 2-5% of individuals have
Class II division 2 malocclusion.1,2 Class II
continued by using class II mechanics will
be used that aids in the correction of skeletal
and dental relation.5

Division 2 malocclusion, is characterized by HISTORY AND DIAGNOSIS

triad of signs which are deep bite retroclined
maxillary incisors and a posteriorly 15 year old post-pubertal female patient
positioned mandibular dental arch. 3, 4 reported to Sri Hasanamba Dental College
Keeping the above characteristics into and Hospital, Hassan, Karnataka, India, with
consideration, first step in our treatment a chief complaint of irregularly placed upper
should be dental decompensation by front teeth and want it to be corrected.
proclination of incisors, thereby unlocking Her pre-natal and post-natal history was
the mandible that in turn may permit reported to be normal. Past Medical and
advancement and modification in the path of dental history were unremarkable. Extraoral
closure of the mandible. Treatment will be examinations showed convex profile with

3
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

prominent chin and shallow mentolabial TREATMENT PLAN

sulcus. Her lips were incompetent (Figure Correction of minor crowding can be
1). Intraorally she had end-on molar and end corrected by proclination of upper incisors
on canine relationships in the right and left in cases with good soft tissue balance.
segments (Figure 2). Maxillary dental Articular angle was also increased indicating
midline was centred relative to facial the anteriorly inclined condyle. Keeping the
midline but it was found that the mandibular above parameters taking into consideration
dental midline was deviated to the right by 2 it was decided to implement nonextraction
mm with respect to facial midline. The line of treatment. We instructed the patient
maxillary arch was U shaped with 4 mm to do lip exercises to reduce the lip
crowding (Figure 3). In mandibular arch incompetency.
there was 1.5 mm spacing in the anterior
region (Figure 4). The panoramic x-rays TREATMENT ALTERNATIVES
showed no caries and no pathologies. All First treatment option was mandibular
permanent teeth were present and all 3rd surgery followed by the extraction of right
molars in the root formation stage (Figure and left mandibular first premolars for
5). crowding and coordination of dental arches
Cephalometric examinations showed by expansion and upper incisor proclination.
skeletal class II base with normal maxilla Because of prominent chin, after mandibular
and retrognathic mandible with an ANB surgery genioplasty could be necessary. The
angle of 6°. Lower anterior facial height was patient was not willing for surgical
in normal values with average skeletal treatment.
pattern. Effective maxillary and mandibular Second treatment option was camouflage
lengths were normal with increased articular line of treatment with the extraction of upper
angle indicating the posteriorly directed first premolar and lower second premolars.
condyle. Dentally, it was diagnosed as With this treatment alternative it will be
Angle’s class II division 2 malocclusion easy to relieve crowding in the upper arch,
with normal overjet, increased overbite with remaining space after relieving the crowding
retroclined maxillary and mandibular has to be closed by retracting the maxillary
incisors in relation to cranial and apical anteriors by using group A anchorage. The
bases. (Figures 6-7). lower extraction space should be closed by
TREATMENT OBJECTIVES protracting the mandibular molars to end in
the class I molar relationship. This
Effective maxillary length was normal and treatment alternative requires retraction of
articular angle was increased which the maxillary anteriors which might worsen
indicated the posteriorly positioned condyle. the profile. Mesialising the mandibular
The patient’s nasolabial angle was found to molar into the extraction space will be
be obtuse. Keeping the above findings into difficult which needs complicated
consideration it was planned initially to level mechanics and procedures like corticotomy.
and align the upper arch with continuous
mechanotherapy to evaluate the mandibular Third treatment option was extraction line of
autorotation. Treatment objectives included treatment with the extraction of upper first
correction of molar and canine relations, premolars in the upper arch. By this
correction of deep bite and correction of treatment alternative it will be easy to
crowding by proclining the incisors. relieve crowding in the upper arch but it
need absolute anchorage in the upper arch to

4
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

maintain the molar in class II relation, which For retention; Hawley retainers were placed
will probably leads to dishing of the profile. above upper and lower bonded lingual
retainers and the patient was instructed to
Fourth treatment option was distalization of
wear them full time for one year. Patient
maxillary molars by extracting the 2nd
was called for periodic evaluation. After 7
molars to relieve the crowing. This was
months of retention phase post retention
excluded by keeping the class II skeletal
records were taken which relieved stable
base into consideration.

TREATMENT PROGRESS molar and canine relationship except mild

rotation of the canine in the first quadrant.
After evaluation of the diagnostic records;
the patient history and the decision of the TREATMENT RESULTS
patient non-extraction orthodontic correction Favourable facial changes in facial profile
was chosen as the treatment strategy. Then, was observed (Figure 8). Lower lip was
upper arch was bonded initially, levelling forwarded 2 mm according to E plane. Ideal
and aligning was done using the 0.12 Ni-Ti tooth aspect was gained on full smile with 2
wire followed by 0.016 Ni-Ti. Once the mm of gingival display. Intraorally, deep
initial alignment is done with Ni-Ti wires, bite was resolved and ideal overjet and
position of the mandible was evaluated. overbite relationships were achieved.
Later, lower arch was bonded, levelling and Maxillary and mandibular dental midlines
aligning was started with 016 Ni-Ti. After were coincident with facial midline and
0.016 Ni-Ti, 0.019x0.025 Ni-Ti and class 1 molar and canine relationships were
0.019x0.025 stainless steel wires were established (Figures 9, 10, 11).
placed for both upper and lower arches. At Cephalometrically, ANB angle decreased to
stainless steel stage, slight amount of 4° from 6° because of change in SNB angle
autorotation was noticed which was from 84.5 to 86.5 which indicates the
appreciated clinically by change in molar autorotation of mandible. There was no
relation from 4mm endon to 2mm endon change in SNA angle. There is increase in
relation on both sides and was confirmed the upper lip length. Upper and lower
cephalometrically. Later class II elastics (3.5 incisors were proclined relative to cranial
Oz) were given for the remaining correction and apical bases, and this proclination
of molar relationship. The elastic force was helped in the correction of deep bite and
gradually withdrawn after the achievement sagittal discrepancy by allowing the
of class I molar relationship keeping the mandible to move forward. The articular
stability into consideration. After the angle reduced from 160º to 154º (Figures
correction of molar relationship with class 2 12, 13).
elastics of 3.5 Oz force, patient was DISCUSSION
instructed to wear 2 Oz elastics (24 hours
wear) for one month followed by one more Generally we will prefer extraction line of
month during night time followed by night treatment in cases of severe crowding like
time wear in alternate days. Class I molar more than 6 mm, but it will worsen the
and canine relationships were achieved. profile if the patient is having the balanced
After 14 months from the beginning of profile. This kind of cases can be treated by
treatment, appliance was debonded. proclining the anterior teeth without

5
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

worsening the profile. In a case report, difference between these two was treatment
Asakawa et al 6, treated a girl with Class II duration.10 Keeping the economic issues into
division 2 malocclusion who has 8 mm consideration, we preferred class II elastics
mandibular crowding without extraction. In as class II mechanics for the correction of
Class II division 2 malocclusion the molar and canine relationship.
decompensating the incisors by proclaining
Proclination of lower incisors was the side
might cause unlocking the mandible that in
effect of using class II elastics which might
turn may permit advancement and
be a factor for gingival recession. In
modification in the path of closure of the
treatment of a Class II division 2 female,
mandible and aids in the correction of Class Asakawa et al 6 also proclined upper and
II skeletal and dental relation especially in lower incisors significantly, but at the end of
young individuals. According to few studies the treatment no periodontal damage was
there is no change was noticed in the
noted. According to Proffit11, if Class II
position of the mandible when compared
traction has proclined the lower incisors
from the start of treatment with after the more than 2 mm, permanent retention is
incisor proclination.7 The muscle activity required. Usually patients are instructed to
was also unchanged after treatment. In wear Hawley retainers full time for one year,
contrast few studies have shown that there at night for an additional year and later,
will be chance for the auto rotation in cases return for periodic evaluation.12, 13 The same
of class 2 division 2, after initial alignment protocol was followed in this case along
and the articular angle will changes with the with bonded lingual retainers were given for
orthodontic treatment.8 According to retention.
Ackerman 9, proclining the anteriors was
preferred over the extraction of the teeth for CONCLUSION
the correction of crowding in the patients Correction of Class II malocclusion without
with balances profile and with no lip strain. extraction was achieved in 18 months. Class
For the reasons mentioned above and to I molar and canine relationships were
improve facial profile we planned for the obtained; favourable changes were seen in
non-extraction line of treatment. After patient’s profile, smile and aesthetics. Upper
levelling of maxillary arch, the position of lip length was increased, Lower lip was
the mandible was evaluated. Change in the forwarded and improvement in profile was
articular angle was observed. Recent studies achieved. Upper incisors were proclined so
had proved that the effects of the class II patient’s smile was fulled and these results
elastics are similar when compared to the improved her aesthetics.
fixed functional appliances but only

6
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

COMPOSITE ANALYSIS
Table 1: Cephalometric values pre-treatment and post-treatment

Measurements Mean Pre Treatment Post Treatment

SNA 82º 80 º 80 º

SNB 80 º 74 76

ANB 2º 6º 4º

U1-NA 4 4 3.3

U1-NA 22 º 13 º 20 º

L1-NB 4 6 7

LI-NB 25 º 28 º 29 º

Inter incisal angle 130 º 145 º 125 º

Articular angle 140 º 160 º 154 º

Lip length 21±1.9 17 20

7
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

Figure 1: Pre-Treatment Extra Oral

Figure 2: Pre-Treatment Intra Oral

Figure 3: Pre-Treatment Maxillary Figure 4: Pre-Pre-Treatment Mandibular

8
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

Figure 5: Pre-Treatment OPG

Figure 6: Pre-Treatment Cephalogram Figure 7: Pre-Treatment Tracing

9
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

Figure8: Post-Treatment Extra Oral

Figure 9: Post-Treatment Intra Oral

Figure 10: Post-Treatment Maxillary Figure 11: Post-Treatment Mandibular

10
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

Figure 12: Post Treatment Lateral Cephalogram Figure 13: Post Treatment Tracings

Figure 14: Post Treatment OPG

REFERENCES orthodontic treatment in 10-year old

1. Ast DH, Carlos JP, Cons NC. The children in Gothenburg. Sven Tandlaek
prevalence and characteristics of Tidskr 1972; 65: 7-21.
malocclusion among senior high school 3. Bishara SE. Class II Malocclusions:
students in upstate New York. Am J Diagnostic and Clinical Considerations
Orthod 1965; 51: 437-445. With and Without Treatment. Semin
2. Ingervall B, Seeman L, Thilander B. Orthod 2006;12: 11-24.
Frequency of malocclusion and need of

11
Volume 9, Year 2017 INDIAN DENTAL JOURNAL
www.idjournal.org Official Publication of Society of Medical Dental & Public Health

4. Peck S1, Peck L, Kataja M. Class II 9. Ackerman , Proffit WR. Soft tissue
Division 2 malocclusion: a heritable limitations in orthodontics: treatment
pattern of small teeth in well- planning guidelines. Angle Orthod.
developed jaws. Angle Orthod. 1998 1997;67(5):327-36.
Feb;68(1):9-20. 10. Ferreira SL. Class II Division 2 deep
5. Von Bremen J, Panscherz H. overbite malocclusion correction with
Efficiency of Class II Division 1 and nonextraction therapy and Class II
Class II Division 2 Treatment in elastics. Am J Orthod Dentofacial
Relation to Different Treatment Orthop. 1998; 114: 166-175.
Approaches. Semin Orthod 2003; 9: 11. Proffit WR. Retention. In: Proffit WR,
87-92. Fields HW Jr, editors.Contemporary
6. Asakawa S, Al-Musaallam T, orthodontics. St. Louis: Mosby Year
Handelman CS. Nonextraction Book; 1993. P.534-535.
treatment of a Class II deepbite 12. Chen YJ, Yao CCJ, Chang HF.
malocclusion with severe mandibular Nonsurgical correction of skeletal deep
crowding: Visualized treatment overbite and Class II Division 2
objectives for selecting treatment malocclusion in an adult patient. Am J
options. Am J Orthod Dentofacial Orthod Dentofacial Orthop 2004; 126:
Orthop 2008; 133:308-316. 371-378.
7. Millett DT, Cunningham SJ, O'Brien 13. Janson G, Sathler R, Fernandes TM,
KD, Benson PE, de Oliveira CM. Branco NC, Freitas MR. Correction of
Treatment and stability of class II Class II malocclusion with Class II
division 2 malocclusion in children and
elastics: a systematic review. Am J
adolescents: a systematic review. Am J Orthod Dentofacial Orthop. 2013
Orthod Dentofacial Orthop. 2012 Mar;143(3):383-92.
Aug;142(2):159-169.
8. Cleall JF, BeGole EA. Angle Orthod.
1982 Jan;52(1):38-60. Diagnosis and
treatment of class II division 2
malocclusion.

12