DEPARTMENT OF ORTHODONTICS AND

DENTOFACIAL ORTHOPAEDICS –
JOURNAL CLUB PRESENTATION

DONE BY

KEERTHANA.G
CRRI
 JOURNAL TOPIC : A Case Report on Correction of Class II
Division 2 Malocclusion using Molar‑to‑molar Appliance.

 JOURNAL TYPE : CASE REPORT

 AUTHOR : Jeegar Ketan Vakil

 PUBLISHED ON : SEPTEMBER,2018
 A Case Report on Correction of Class II Division 2
Malocclusion using Molar‑to‑molar Appliance

 INTRODUCTION :
K. N, a 13 years 6 months male, reported with the chief complaint of irregularly
placed teeth. Clinical examination and analysis of records showed that he had an Angle’s Class
II molar relationship on a Class II skeletal base with retrognathic mandible and deep
mentolabial sulcus. There was reduced vertical proportion. The incisor relation was class II
division 2 with moderate crowding in the lower arch. Oral hygiene status was fair to poor. Lips
were competent at rest.

Treatment involved orthodontic fixed appliance mechanotherapy using metal

brackets with 0.018 × 0.025 MBT prescription. Correction of anteroposterior (A-P) skeletal
discrepancy was done using fixed functional appliance (AdvanSync2). Optimal orthodontic and
esthetic result was achieved by nonextraction treatment protocol.
 PRE-TREATMENT
ASSESSMENT


EXTRA-ORAL ASSESSMENT:
PRE-TREATMENT ASSESSMENT:
Skeletal assessment
• Patient’s initials: K. N Transverse: Acceptable facial symmetry and
balance
• Sex: Male
on frontal examination
• Date of birth: March 23, 2002 • A‑P: Skeletal Class II pattern with convex
profile
• Age at pretreatment assessment: 13
• Vertical: Reduced vertical proportion .
years 6 months
• Age at start of treatment: 13 years 6 Soft‑tissue assessment
months • Upper and lower lips competent at rest
• Age at the completion of active • Normally positioned lips in relation to
treatment: 15 years 7 months Rickett’s
E-line
• Patient’s complaint: “Irregularly placed • Nasolabial angle within normal limits.
teeth”. Temporomandibular joint assessment:• No
 INTRA – ORAL EXAMINATION

 ORAL HYGIENE AND DENTAL HEALTH: MANDIBULAR ARCH :

Oral hygiene status was fair-to-poor • Ovoid arch form
with stains and deposits on labial and • Mild anterior crowding present in
lingual surfaces. the lower arch
• Left canine yet not erupted
 Crowding/Spacing: (inadequate space) and second
MAXILLARY ARCH: premolar is partially erupted
 • Right and left canines unerupted
“U”‑shaped squarish arch form
Right deciduous molar overretained.
 Palatally placed central incisors,
while labially tipped lateral incisor • ERUPTED TEETH :
 Right and left canines unerupted
 Right deciduous molar overretained.
 OCCLUSAL FEATURES:
GENERAL RADIOGRAPHIC FEATURES:
Incisor relationship: Class II
• Overjet (mm): ‑
• Overbite: 8 mm
• Unerupted teeth: Upper right and
• Center lines: Upper midline coincident to the facial
left canines, upper right second
midline premolar.
• Left buccal segment relationship: Molars: Full-unit
Class II • All third molars, lower left canine.
• Right buccal segment relationship: Molars: Full-unit
Class II • Partially erupted lower second
• Displacement: Maxillary central incisor palatally molars and lower left Second
tipped. Lateral incisors are tipped labially. premolar.
Right canine impacted. Left canine placed buccally.
Mandibular arch: • Teeth absent: Non
Rotations present with right canine and left 1st
premolar. Curve of Spee was deep .
 INTERPRETATION:

 SKELETAL: DENTAL: SOFT TISSUE:

 The cephalometric
analysis revealed Class II • Clinically and • Soft‑tissue profile was
skeletal A-P relationship cephalometrically, full. Nasolabial angle
with an ANB of 9° and and retroclination was seen (98°)
Wits appraisal of 5 mm. with upper central incisors was normal.
 The vertical proportions (U1 to NA showed 10° and -4 • Lower lip was
are in normal range as mm). forwardly placed
assessed by the SN-Go-Gn • Lower incisors were also relative to Rickett’s E-
angle (29°) and FMA (25°) retroclined (L1 to NB line.
indicated. Face-height ratio showed 20°). • The thickness of the
is reduced. • The interincisal angle was lower lip is increased
increased (151°). and the position is
everted.
 DIAGNOSTIC SUMMARY
AND PROBLEM LIST :

 K. N, a 13 years 6 months Indian male, PROBLEM LIST :

presented with an Angle’s Class II molar 1. Skeletal Class II jaw base relation
relationship on a Class II skeletal base due to retrognathic
with reduced vertical proportions. mandible
 The malocclusion was complicated due 2. Convex profile
to retrognathic mandible and severe 3. Class II buccal segment
anterior deep overbite. Oral hygiene
4. Anterior deep overbite
status was fair-to-poor with plaque
deposits and stains. 5. Irregularly placed upper and lower

anteriors
The upper and lower lips were
competent at rest. Lower anterior face 6. Inadequate space for eruption of
height was reduced. Nasolabial angle unerupted canines
was normal. Mentolabial sulcus was 7. Poor-to-fair oral hygiene.
deep.
 AIMS AND OBJECTIVES
OF THE TREATMENT:

1. Correction of skeletal Class II jaw base relation TREATMENT PLAN :

2. Improvement of facial profile
Appliance :
3. Correction of deep anterior bite
4. Correction of crowding of upper and lower anteriors • Functional appliance to
correct A‑P skeletal
5. Create space to allow eruption of canines discrepancy.
6. Achieve Class I molar and Class I incisor relationship.
• Upper and lower metal
7. Retain corrected result preadjusted edgewise fixed
 8. Oral prophylaxis and instructions for oral hygiene appliances (0.018” × 0.025”
maintenance. slot) with MBT prescription.
 ADDITIONAL TREATMENT STEPS:
 • Oral prophylaxis and maintenance. PROPOSED RETENTION
 STEPS IN TREATMENT: STRATEGY:
 1. Leveling and alignment of upper arch and deep bite
1. Upper arch-bonded retainer
correction
(lateral incisor to lateral
 2. Leveling and alignment of lower arch, create space incisor)
 for the left canine to erupt
 3. Correction of skeletal Class II jaw base relation using
2. Lower arch-bonded retainer
 functional appliance (canine to canine).
 4. Leveling and alignment of second molars when they
 erupt adequately
 5. Finishing and detailing
 6. Retention of corrected result.
 TREATMENT

TREATMENT –PROGRESS:
 Start of active treatment: September 2015
 Age at start of active treatment: 13 years 6
months
 End of active treatment: October 2017
 Age at the end of active treatment: 15 years 7
months
 End of retention: Ongoing
 Total active treatment: 25 months.
 POST TREATMENT
ASSESSMENT
 OCCLUSAL FEATURES:
 • Incisor relationship: Class I
 • Overjet (mm): 2 mm
 • Overbite: 3 mm
 • Centrelines: Coincident with each other and facial midline
 • Left buccal segment relationship: Molars: Class I
 • Canines: Class I
 • Right buccal segment relationship: Molars: Class I ; Canines: Class I
 • Crossbites: None
 • Displacements: None
 • Functional occlusal features: Mutually protected occlusion
 • Canine guidance on left and right lateral excursions with no working or nonworking side
Interpretation of
cephalometric changes
 Rationale for Treatment

 TREATMENT JUSTIFICATION: ORTHODONTIC TREATMENT MECHANICS :

 An IOTN score of 4f on the dental
health component and 6 on the FUNCTIONAL APPLIANCE:
esthetic component suggested a
“great” need for treatment. AdvanSync2 molar-to-molar Class II corrector
was given.
 K. N demonstrated a high level of Justification for the use of fixed functional
perceived need for treatment and appliance
notably complained of irregular AdvanSync2 molar-to-molar Class II corrector
upper front teeth. Due to was used to achieve skeletal correction.
crowding, oral hygiene
AdvanSync2 is a less bulky modified banded
maintenance was difficult apart
Herbst‑like appliance with a short telescope.
from an unaesthetic smile.
 The advantages are as follows: BRACKET PRESCRIPTION:
 1. Noncompliant Class II corrector
 2. Achieve Class II correction in Class I time
The MBT bracket prescription (0.018 ×
0.025),with increased labial root
 3. Allows freedom of mechanics mesial to
torque in the lower labial segment,
molar
helped maintain lower incisor
 4. Ease of activation . inclination. Increased lingual root
 5. Gradual activation allows more of torque in upper anterior brackets
skeletal change helped in achieving proper torque in
 and less dental effect (proclination of lower the upper anterior region
 anteriors)
 CRITICAL APPRAISAL

 K. N was successfully treated by orthodontic treatment over 25

months. The original treatment aims were accomplished and
the patient’s chief complaint was addressed. K. N. was notably
pleased with the treatment outcome. A good occlusal and
esthetic result was achieved and this was reflected in the IOTN
score and esthetic component.
 DENTAL: SOFT TISSUE:
SKELETAL:
As the patient was within the Marginal ridge relation of first and
growth potential (cervical
Facial profile was
second molars on the lower right improved and
vertebral maturational index and upper left should have been
and secondary sexual well balanced at
better . Good intercuspation is the
features), skeletal changes
achieved in the buccal segment. end of the
were expected. Improvement
in the convex profile is However, still better vertical treatment [Figure
observed. There has been a settling is desired on the left side. 8]. Reduction in
notable improvement in ANB Occlusal settling of upper left depth of
angle by 4° and Wit’s by 3 second premolar needs to be mentolabial
mm, respectively. better.Radiographically , the roots sulcus is seen.
of lower laterals and right canine
should have been divergent. The
root of upper left second premolar
should have been parallel to the
 CONCLUSION

 Considering the severity of the case to begin with,

desired result was attained. Harmonious skeletal,
dental, and soft-tissue balance was achieved.