Download Management of Skeletal Class II Malocclusion with Functional and

CASE REPORT
Management of Skeletal
Class II Malocclusion
with Functional and
Orthopaedic Appliance:
A Progress Case Report
ABSTRACT
Functional appliances may be defined as an orthodontic appliance that uses the forces
generated by the muscles to achieve dental and skeletal changes. Several treatment
options are available for managing Class II problems and functional appliances have been
used for many years in the treatment of Class II Division 1 Malocclusions. Twin block
appliance is very effective and with which overjet can be reduced. The goal of functional
appliance therapy is to encourage or to redirect the growth in a favourable direction. In
this case a 13-year-old female patient is treated by a twin block functional appliance in
combination with high pull headgear in Class II Division 1 Malocclusion. The design and
treatment effects are demonstrated in this case report.
KEYWORDS skeletal class II Malocclusion, twin block, high pull headgear
INTRODUCTION
Functional appliances may be defined as an orthodontic appliance that
uses the forces generated by the muscles to achieve dental and skeletal
changes. These appliances have been used in clinical orthodontics for a
long time and extensively featured in the literature1. Functional appliances
can be removable or fixed. The mode of action differs depending on the
design; however, their effect is produced from the forces generated by the
stretching of the muscles2. Several treatment options are available for managing Class II problems and functional appliances have been used for many
years in the treatment of Class II Division 1 Malocclusions3. Twin block
appliance is a very effective appliance with which overjet can be reduced.
However, qualitatively they leave something to be desired, which invariably necessitates finishing with fixed appliances4. The goal of functional
appliance therapy is to encourage or to redirect the growth in a favourable
direction5.
The following is a case report of a 13-year-old female patient treated by
a twin block functional appliance in combination with high pull headgear
in Class II Division 1 Malocclusion.
CASE REPORT
A 13-year-old female patient reported to the Department of Orthodontics
at Tatyasaheb Kore Dental College & Research Centre, New Pargaon, with
a chief complaint of forwardly placed teeth and wanted to get them
corrected.
On clinical examination, the following findings were noted:
Growth status: Prepubertal
Extraoral features
Facial form: Mesoprosopic
Facial profile: Convex, with posterior divergence
Clinical VTO: Positive
Lips: Incompetent and everted lower lip
ISSN No
CODEN
NLM Title
2230-7885
JPBSCT
J Pharm Biomed Sci
Ganesh Kotalwar1*,
Sangeeta Golwalkar2
1 Post-graduate student, Department of
Orthodontics & Dentofacial Orthopedics,
T.K.D.C & R.C., New Pargaon, Kolhapur,
Maharastra, India
2 Head of the Department, Dept. of
Orthodontics & Dentofacial Orthopedics,
T.K.D.C & R.C., New Pargaon, Kolhapur,
Maharastra, India
 Address
reprint requests to
* Dr. Ganesh Kotalwar, Department of
Orthodontics & Dentofacial Orthopedics,
T.K.D.C & R.C, New Pargaon, Kolhapur,
Maharastra, India
E-mail: [email protected]
 Article
citation: Kotalwar G, Golwalkar S.
management of skeletal class II
Malocclusion with functional and
orthopaedic appliance: A progress case
report. J Pharm Biomed Sci
2015;05(12):928–931.
Available at www.jpbms.info
Statement of originality of work: The
manuscript has been read and approved by all
the authors, the requirements for authorship have
been met, and that each author believes that the
manuscript represents honest and original work.
Source of funding: None.
Competing interest / Conflict of interest: The author(s) have no competing interests for
financial support, publication of this research,
patents, and royalties through this collaborative
research. All authors were equally involved in
discussed research work. There is no financial
conflict with the subject matter discussed in the
manuscript.
Disclaimer: Any views expressed in this
paper are those of the authors and do not
reflect the official policy or position of the
Department of Defense. The manuscript is
original and is not published or communicated
for publication elsewhere either in part or full.
Copyright © 2015
Received Date: 14 September 2015 – Accepted Date: 03 November 2015 – Published Online: 16 December 2015
Management of skeletal class II Malocclusion
Intraoral features
1. Class II molar relation on right side and end-on molar
relation on left side with class II canine relationship
on both sides.
2. Upper midline shifted to left by 1mm and resultant
overjet of 10 mm (differential overjet was present due
to upper right central incisor was more proclined than
left i.e., 9 mm and 11 mm) (Fig. 1).
Diagnosis
A 12-old-year prepubertal female patient P.P. presented
with Class II molar relation on right side and end-on molar
relation on left side with bilateral class II canine relationship,
superimposed on a Class II skeletal base with retrognathic
mandible and posterior divergence, average growth pattern
and bimaxillary dentoalveolar protrusion and crowding in
upper anterior with convex profile and incompetent lips.
Treatment objectives
1.Reduction of profile convexity and lip incompetence
2. Achievement of normal skeletal bases
3. Correction of molar and canine relation
4. Achievement of normal over jet and overbite
Treatment plan
Considering the clinical and radiological findings a twophase treatment was planned for the patient.
Phase I (growth modulation phase): Twin block
appliance combined with high pull headgear (Fig. 2).
Pre-functional fixed therapy was planned with MBT
prescription 0.022′ slot for correction of upper anterior
crowding for avoiding interruption in optimal mandibular advancement for 2 months.
Phase II (fixed orthodontic phase): Following
growth modulation therapy, fixed orthodontic mechanotherapy with pre-adjusted edgewise appliance MBT prescription 0.022′ slot.
The patient was treated with twin block appliance
combined with high pull headgear to improve the maxillo-­
mandibular relationship. Construction bite was taken and
twin block appliance was then fabricated and given to the
patient for full time wear, to be used for 1 month, followed by which high pull headgear was also given.
Fig. 1 Pretreatment photographs.
Fig. 2 Mid treatment photographs.
J Pharm Biomed Sci | Vol. 05 No. 12 | 928–931
929
930
Ganesh Kotalwar
Table 1 P retreatment and post functional cephalometric values.
Pre-treatment
Post-functional
Skeletal
SNA
SNB
ANB
Wits appraisal
Effective length of maxilla
Effective length of mandible
Maxillo-mandibular differential
Saddle angle
Articular angle
Facial axis
Y-axis
MPA
Jarabak’s ratio
LAFH
Bjork sum of posterior angles
Inter-incisal angle
U1 to SN
L1 to MP
Nasolabial angle
Upper lip length
Lower lip length
S line to U lip
S line to lower lip
82°
75°
7°
10 mm
91 mm
106 mm
15 mm
120°
145°
95°
63°
29°
63.55%
69 mm
391°
Dental
105°
116°
104°
Soft tissue
65°
22 mm
40 mm
10 mm
9 mm
Duration of growth modulation therapy with functi­
onal appliance was 12 months which included monthly
follow-ups. After 12 months, desired changes were
obtained, the use of intraoral and extraoral appliances
was discontinued and fixed appliance was planned.
Post-functional lateral cephalogram was obtained and the
values were compared with pretreatment values (Table 1).
DISCUSSION
Since the patient had a skeletal Class II pattern with a
retrognathic mandible, the functional appliance with
extraoral forces were used to correct the skeletal anteroposterior discrepancy. Some studies have shown that
the anteroposterior correction accomplished is more
through dentoalveolar changes than skeletal changes1,6.
In this patient the skeletal changes were confirmed by
the restrained maxilla and the advanced mandible and
a decrease in the ANB angle. Several studies have shown
that twin block produces retroclination of maxillary
incisors and proclination of the mandibular incisors7,8.
81°
79°
2°
4 mm
91 mm
115 mm
24 mm
121°
137°
94°
62°
28°
65.87%
75 mm
385°
112°
111°
100°
92°
24 mm
50 mm
5 mm
8 mm
In a study done by Tortop and Yüksel9, they showed a
decrease in the SNA and ANB values with the use of combination-pull headgear. Similar combined findings have
been observed in our patient. The maxillary incisors retroclined by 5° and 4 mm (U1-NA) and the mandibular
incisors proclined did not show any proclination (L1NB). Furthermore, the nasolabial angle increased from
65° to 92°. The values of selected parameters before and
after functional appliance therapy are shown in Table 1.
Short-term skeletal effects include a small restriction
in forward maxillary growth with headgear and a small
forward positioning of B point with functional appliances, leading to an ANB improvement in Class II patients
with either appliance. Similar results were obtained in our
study with the use of twin block and combination-pull
headgear10 (Figs. 3, 4).
CONCLUSION
The use of twin block together with the combination-­
pull headgear produced desirable effects in our patient
J Pharm Biomed Sci | Vol. 05 No. 12 | 928–931
Management of skeletal class II Malocclusion
931
Fig. 3 Post-treatment photographs.
REFERENCES
Fig. 4 Comparison of pre- and post-treatment.
with skeletal Class II Malocclusion. The effect of twin
block functional appliances is both dento-alveloar with
skeletal component. There are a number of situations
where functional appliances can be successfully used to
correct class II Malocclusion. It is important that functional appliances are used in a growing patient to achieve
the maximum benefit. The appliance produced a greater
improvement in the soft tissue profile, with good skeletal and dentoalveolar relations and stable results.
J Pharm Biomed Sci | Vol. 05 No. 12 | 928–931
1. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N, Chadwick S,
et al. Effectiveness of early orthodontic treatment with the
Twin-block appliance: a multicenter, randomized, controlled
trial. Part 1: Dental and skeletal effects. Am J Orthod Dentofacial
Orthop. 2003;124:234–43.
2.Mills JR. The effect of functional appliances on the skeletal
pattern. Br J Orthod. 1991;18(4):267–75.
3. Clark WJ. The Twin-block technique. Am J Orthod. 1988;93:1–18.
4. Lund AI, Sandler PJ. The effects of Twin Blocks: A prospective
controlled study. Am J Orthod Dentofacial Orthop. 1998;113:104–10.
5. Firouz M, Zernik J, Nanda R. Dental and orthopedic effects of highpull headgear in treatment of Class II division 1 malocclusion. Am
J Orthod Dentofacial Orthop. 1992;102:197–205.
6. Huang GJ. Twin-block appliance is effective for the correction
of Class II Division I malocclusion during mixed dentition. J Evid
Based Dent Pract. 2004;4:222–3.
7. Mills CM, McCulloch KJ. Posttreatment changes after successful
correction of Class II malocclusions with the twin block
appliance. Am J Orthod Dentofacial Orthop. 2000;118:24–33.
8. Illing HM, Morris DO, Lee RT. A prospective evaluation of Bass,
Bionator and Twin Block appliances. Part I –The hard tissues. Eur
J Orthod. 1998;20:501–16.
9. Tortop T, Yüksel S. Treatment and posttreatment changes with
combined headgear therapy. Angle Orthod. 2007;77:857–63.
10. Freeman CS, McNamara JA Jr, Baccetti T, Franchi L, Graff TW. Treatment effects of the bionator and high-pull facebow combination
followed by fixed appliances in patients with increased vertical
­dimensions. Am J Orthod Dentofacial Orthop. 2007;131:184–95.