237 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jul - Sept 2010 | Issue 3 | Vol 28 |

CASE REPORT
Use of a modified anterior inclined plane in
the treatment on the dentoskeletal Class II
division 2 patient
Rao SA, Thomas AM
1
, Chopra S
2
PG Resident,
1
Principal and
1,2
Professor,
Department of Pediatric Dentistry, Christian Dental College,
Brown Road, Ludhiana, Punjab, India.
Correspondence:
Dr. Sreedhar Rao A, Department of Pediatric Dentistry,
Christian Dental College, Brown Road, Ludhiana - 141 008,
Punjab, India. E-mail: sreedhar@doctor.com
Abstract
Class II malocclusions are seen due to the underdevelopment
of the mandible in most of the cases. To compensate for
the mandible retrusive position, there is flaring of the lower
anterior teeth or retroclination of the central incisors as a
compensatory mechanism seen in Class II division 2 type
of malocclusion. This case report evaluates the skeletal and
dental changes when a 12-year-old female patient with
Class II div 2 malocclusion was treated with a modified
anterior inclined plane. The postreatment data suggested
that there were no significant changes in the vertical skeletal
parameters. The upper central incisors were significantly
realigned by proclination along with retroclination of
the lateral incisors. There was significant increase in the
mandibular length. The results revealed that the modified
anterior inclined plane showed good results in the treatment
of a case of Class II div 2 malocclusion.
Key words
Functional therapy, inclined plane, skeletal Class II div 2
malocclusion
Introduction
Functional appliances are powerful appliances capable
of impressive changes in the position of the teeth.
These appliances direct the pattern and direction of
growth of the jaws by alteration of the forces produced
by the whole neuromuscular component.
[1-3]
They are generally used for Class II div 1 malocclusions,
although they can be used for the correction of Class II
div 2 and Class III malocclusions on occasion. They are
either removable from the mouth or fixed to the teeth,
and work by stimulating the muscles of mastication
and soft tissues of the face. Majority of the appliances
are used in the correction of Class II malocclusions
by stimulating the growth of the mandible. Changes
are induced by holding the mandible forward and the
ensuing reaction of the stretched muscles and soft
tissues, transmitted to the periosteum, bones and the
teeth.
[4]
A restraining effect on the growth of the
maxilla and the maxillary dentoalveolar complex is also
seen along with the stimulation of mandibular growth
and mandibular alveolar adaptation. Favorable changes
in temporomandibular joint also occur.
[5-7]
The most common appliance used is the twin block
appliance, which eliminates the major disadvantage of
other functional appliances, such as activator, bionator,
and Frankels vestibular appliances, which are fabricated
in one piece to fit the teeth in both the jaws due to
which the patient cannot eat or speak and hence finds
it uncomfortable for full-time wear.
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DOI:
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Rao, et al.: Modifed Anterior inclined plane: treatment class II div 2
238 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jul - Sept 2010 | Issue 3 | Vol 28 |
The twin block though the most preferred and used
appliance still has its own disadvantages, in that it still is
somewhat bulky, and some amount of discomfort exists
with speech and mastication. The other problem is that
it has a long treatment time with the appliance being
changed and altered in the supportive and retentive
phase.
[8-10]
To do away with disadvantages of the twin block and
other functional appliances, the anterior inclined plane
was developed.
[11]
The inclined plane is a removable
intermaxillary appliance that forces the mandible to
move in a forward position during the mandibular
functional activity, particularly during the swallowing
period. Protractor muscle involvement results in the
intermittent activation of the retractor muscles that
leads to favorable bone remodeling.
In comparison with the traditional functional appliances,
this appliance does not restrict the three-dimensional
mandibular movement nor does it interfere with the
regular physiologic activity of the oral cavity, which
has a great impact on the patient cooperation, and it
requires less effort by the patient to follow oral hygiene
instructions. The anterior inclined appliance has shown
good results in the treatment of Class II div 1 patients.
There still exists a concern in the treatment of Class
II div 2 malocclusion cases. The twin block has a
modification for the same but the appliance still has the
same disadvantages of the regular twin block. The other
option includes converting the Class II div 2 to a Class
II div 1 case and to continue the treatment. This whole
procedure becomes time-consuming and cumbersome.
In this study, we used an anterior inclined plane within
which was incorporated a double cantilever spring to
treat a case of Class II div 2 malocclusion.
Case Report
A 12-year-old female presented with retroclined
maxillary central incisors and proclined maxillary
lateral in the Department of Pediatric and Preventive
Dentistry. The patient was in the mixed dentition stage
with a skeletal Class IIjaw base relationship. She had
bilaterally retained upper and lower first and second
deciduous molars. The patient also had with anterior
deep bite, which is a typical presentation of a Class II
div 2 malocclusion [Figure 1]. Radiographs revealed
the presence of all permanent teeth except upper right
second premolar, which was congenitally absent.
An anterior inclined plane was incorporated in the
upper arch with a double cantilever spring to procline
the central incisors [Figures 2 and 3]. The inclined
plane is a removable appliance wherein during mouth
closure; the mandible moves in the forward position.
The appliance was constructed in such a manner that
as the central incisors proclined, the mandible glided
forward utilizing the incline created palatal to the lateral
incisors. So the appliance did not need to be modified
with the proclination of the central incisors. Once the
central incisors had sufficiently proclined, the labial
bow was also activated to retrocline the lateral incisors
with adequate clearance of acrylic on the palatal side
of these teeth.
The patient visited once every week for the cantilever
spring and the labial bow activation thereafter.
Results
Comparisons of the pretreatment and posttreatment
data of the pretreatment and posttreatment are shown
in Table 1. The comparison of the cephalometric
measurements revealed that the appliance had not much
skeletal effect on the maxilla. There was no change in
the sella-nasion-pt A (SNA) angle. The skeletal vertical
parameters were evaluated and no significant change
was found in sella-nasion-mandibular plane (SNMP)
and Y axis. When the measurements of the mandible
were evaluated, significant changes were found. The Pt
A-nasion-Pt B (ANB) angle demonstrated a decrease of
1 when the 2 cephalograms were compared. Changes
in Articulare-pt B (Ar-B), articulare-pogonion (Ar-Pog),
and sella-nasion-pt B (SNB) were significant. The dental
changes caused by the inclined plane were obvious. The
Table 1: Comparison of pre treatment and post treatment
dentoskeletal changes with inclined plane treatment
Measurements Pretreatment Post-treatment
SNA 82 82.5
SNB 76 78.9
ANB 5 4
SN-Pog 76.5 79
Y-axis 66 65.5
MPSN 23.5 23
Ar-A 89 89.5
Ar-B 90.5 93
Ar-Pog 97 100.5
1-SN 96 99
SNA: Sella- nasion- pt A; SNB: Sella- nasion- pt B; ANB: pt A- nasion- Pt B;
SN-Pog: sella-nasion-pogonion; MPSN: mandibular plane-sella-nasion; Ar-A: articulare-pt A;
Ar-B: articulare-pt B; Ar-Pog: articulare-pogonion; 1-SN: incisor edge of maxillary central incisor-
sella-nasion
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Rao, et al.: Modifed Anterior inclined plane: treatment class II div 2
239 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jul - Sept 2010 | Issue 3 | Vol 28 |
Figure 1: Pretreatment frontal view
Figure 3: Frontal view of appliance in mouth
Figure 5: Occlusion right sideposttreatment
Figure 2: Appliance in the mouth
Figure 4: Posttreatment frontal view
Figure 6: Occlusion left sideposttreatment
upper central incisors were significantly realigned by
proclination along with retroclination of the lateral
incisors [Figures 4,5 and 6].
Discussion
A review of the literature shows that there have been
no studies done so far in the use of the reverse inclined
plane in the treatment of Class II div 2 malocclusion.
There is only one study where the reverse inclined plane
has been used in the treatment of 25 cases of Class II
div 1 cases with promising results. Anterior inclined
plane application in a previous study and in our case
overcame many disadvantages of the conventional
functional appliances. In this study, the results of
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Rao, et al.: Modifed Anterior inclined plane: treatment class II div 2
240 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jul - Sept 2010 | Issue 3 | Vol 28 |
treatment in Class II div 2 with this type of appliance
are evaluated. The inclined plane is a removable
intramaxillary appliance that forces the mandible to
move in a forward position during the mandibular
functional activity, particularly during the swallowing
period.
[11]
In this appliance, we also incorporated a
double cantilever spring for proclination of the central
incisors and also a labial bow was incorporated to
retrocline the lateral incisors into the arch.
In comparison with the traditional functional appliances,
this appliance does not restrict the three-dimensional
mandibular movement nor it interferes with the regular
physiologic activity of the oral cavity, which has a great
impact on the patient cooperation, and it requires less
effort by the patient to follow oral hygiene instructions.
This method is more effective in early stages of Class
II deep bite malocclusion treatment, particularly
to redirect the mandibular growth anteriorly and
vertically by eliminating the lack of occlusion that
acts as a physical barrier against the normal growth of
the mandible.
[1,12]
This appliance prevents the further
extrusion of the upper and lower anterior teeth because
of the loss of anterior incisal contact. It provides a
greater extrusion of the lower posterior teeth and this
helps to correct the Class II relationship and opens the
bite simultaneously in the early mixed dentition period.
The results showed that Class II correction was
achieved mostly through dentoalveolar and skeletal
changes of the mandible and revealed that the appliance
had no effect on the nasomaxillary growth component.
Inclined plane favorably improved the profile and the
double cantilever spring proclined the upper central
Source of Support: Nil, Confict of Interest: Nil
incisors. As the position of the incisors improved so
did the contour of the upper lip resulting in better
esthetics and improved profile.
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