Functional and Orthodontic Treatment of a Class II Malocclusion: Case Report

Introduction

Class II is one of the most common malocclusions, it occurs in about one third of the population. It is a medical syndrome that requires a complete clinical and radiographic examination. Skeletal Class II have multiple etiologies, therefore, there are many treatment options for correcting this malocclusion with varying degrees of clinical support [1, 2, 3, 4, 5, 6, 7, 8, 9]. During the last twenty years, functional appliances have been widely used for the correction of sagittal intermaxillary descrepancies in children especially with class II malocclusions. The success of the orthopedic treatment depends on the implementation of the treatment during growth period and patients cooperation.

The aim of this paper is to illustrate a two phase treatment of a class II malocclusion in a 10 years old patient.

A 10 years old patient presented with as a chief complaint a retroposition of the mandibule Extraoral examination revealed, on the frontal view, a square face, with equal upper and middle facial compartments and a slight decrease in the lower compartment. A chin deviation to the right side, and a forced lip closure with a reflex of biting the lower lip were noted (Figure 1). Functional examination revealed no sign of temporomandibular joint dysfunction. Intraoral examination showed a mild oral hygiene, a bilateral infraclusia, a lower midline shift, a proclination of the two maxillary central incisors and a class II canine and molar relationship with an overbite of 2mm and an overjet of 10mm, the spee curve was exaggerated (Figure 1).

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Pre-treatment panoramic radiograph showed normal general structures and a stage of mixed dentition (Figure 2).

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Cephalometric STEINER and TWEED analysis revealed a skeletal class II discrepancy with biprotrusion of the central upper and lower incisors and a class II canine and molar relationship (Table 1).

Table1: Pre-treatment cephalometric analysis.

Discussion

Class II malocclusions might have several combinations of skeletal and dento-alveolar components, thus understanding the etiology and the differential diagnosis is essential to decide whether it is an orthodontic, orthopedic, surgical treatment or a combination of these treatment modalities. However, from an etiological point of view it is generally believed that a skeletal class II is often caused by a combination of mandibular deficiency and a maxillary excess, thus a combined treatment might be a better option to achieve dento alveolar and skeletal equilibrium [10]. Several studies showed that the main reason for using functional removable appliances is to establish muscular balance, eliminate oral dysfunction and allow a proper length of the maxilla and the mandible [1]. These devices have one thing in common they induce the mandible into an anterior position as a part of the overall treatment effect, They apply constant forces to muscular environment that causes posture modification, and a change in functions and forces on the dento alveolar arches through the muscles [11].

In our case, we treated a growing class II patient with combined therapy using monobloc activator and orthodontic treatment. First phase results showed satisfactory esthetic and dento alveolar changes, mostly a correction of the molar and canine class II, a correction of the midline shift and a considerable reduction of the overjet due to the up righting of the upper incisors and a forward positioning of the mandible and an improvement of the soft tissue profile due to more favorable soft tissue behavior [11].

Conclusion

A satisfactory esthetic and functional result was achieved for this patient due to employing a two phase treatment protocol that was tailored specifically to this patient’s need. This approach took advantage of patient’s growth which helped to achieve a significant sagittal correction. Our case illustrates the need for understanding the etiology and therefore implementing the right treatment protocol rather than a cookbook approach in the management of these discrepancies.