Class II Deep bite faces:

One phase or two phase treatment?

Introduction

Orthodontists must evaluate patient's esthetic concerns very

carefully when treatment planning. Diagnostic and treatment
decisions are based on: Faces first, skeletal pattern and at least the
teeth.
The success of orthodontics as a science does not depend only on
appliances, but primarily upon diagnosis, decisions and on treatment
control. The major problem in orthodontics is not only to move teeth
but above all in harmony with the Face, and to keep them stable
after treatment.

The orthodontist's major consideration is to establish an improved

dental health condition that will provide greater longevity of the
dentition. The objectives for the occlusion are, a class I relationship,
overjet and overbite correction. So let’s diagnose the face first, the
smile and the profile lines.

Esthetic considerations

Looking at the smile, it is interesting to note that the position of the

upper anterior teeth, most of the time, is the key for repositioning.
Not the lower incisor… The patient ask for the smile, not an IMPA
correction!
The facial analysis is the most important for class II strategies.
The profile line or Z line described by Dr Merrifield is tangent to the
chin and the most protrusive lip. The Z angle is the inferior angle
made by the intersection of the profile line and the Frankfort plane.
In a well balanced face, the profile line relates the chin to the lip and
bisects the point of the nose
In Class II bimaxilliary protrusion, the profile line is out of the nose.
In Class II low Angle cases, the profile line bysect the nose.

The location of the chin must be evaluated in Class II faces: by using

the Z line with a retrognathic chin, we thus risk making a wrong
decision. Many class 2 cases present a mandibular deficit with a well
balanced maxilla. So, one must have a sagittal reference plane: we
use the Schwarz construction

On the patient profile photographs, the Dreyfus Plane is drawn

perpendicular to Frankfort, passing through the nasal base and the
Simon's Orbitary plane, perpendicular to Frankfort, through the
Orbital, (pupilla). The space between these two planes is called the
mandibular space.
We can appreciate if the chin is located inside or outside the
mandibular space.
This drawing underlines the significance of the lips and the chin in
the facial harmony.
The aesthetic analysis is completed with the use of the naso-labio
angle.

On this case, there is a nice harmony between the front, the nose
and the upper lip. The upper face is a Class I face, related to a skeletal
Class I. The lower face is a Class II face, related to a skeletal Class II
with a retrognathic mandibula. Most of Class II’s low Angle cases
present a Normal Class I upper face.
Face’s diagnostic is based on a cranio-facial evaluation:
Cranio base, facial structures, alveolar bone, teeth, and the relation
between each of them.
The facial pattern differentiates the decisions for low and high angle
cases: Treatment of these cases necessitates expansion (non
extraction decision) or contraction (extraction decision).
To extract or not to extract, is not the only question in modern
orthodontics.
Our experience shows that the less extraction we do on low Angle
cases, the best the facial response is.
In our private office, with Dr.Isabelle Thiers-Jegou, we treat 70%
non-bicuspid extractions.
20% cases need bicuspid extractions (most of class II’s with lower
second bicuspid)
10% of cases are mixed dentition early treatments. This help non-
extraction decisions later on stage 2

Treatment alternatives

If we want to work with the growth and a non-extraction concept,

We have to diagnose as earlier as possible the malocclusions ..
It is evident that the same technics cannot be used for a children or
an adult.
Many factors must be considered in treatment decisions, such as
basic discrepancies, aesthetic disorders, function, facial balance and
long term stability. But other all, the facial growth.
All orthodontic diagnoses must consider treatment modifications for
facial and occlusal balance, and must consider the timing of the
treatment.
Growth considerations

The childhood and pre-Adolescent period can be defined as the

period of life where dento facial developments and the rate of facial
growth will occur. The transition from the mixed dentition to the
permanent dentition is a very important period in orthodontic
decisions

During growth, each structure is growing in its size by surface

remodeling and passive displacement.

For the naso maxillary complex, between ages 7 to 14, one third of
the total forward movement is due to the passive displacement.
For the mandibula, growth in size, body lenght and Ramus height,
increase continusly at a steady rate before puberty.

The total displacement downward and forward, depends on passive

displacement of the craniobase, the total growth by surface
remodeling, the chin growth and the type of rotation of jaw during
growth. (matrix rotation and intra matrix rotation)
During this period of growth, in Width, Length and Height, the
transition from the mixed to the permanent dentition will interfere
each other. There are interactions between jaw rotation and tooth
eruption.
The fonctional matrix facilitates the lower face growth in three
dimensions, in relation to the occlusion.

So in early dentition, it is extremely important to correct

dysfonctions and liberate occlusal bloks as:
-Incisor overbite
-Deep occlusal curve
-Transversal constriction of the maxillary arch form
- Mesial rotation of the upper first molars
-Anterior and Lateral crossbites.

During this period of time, « heavy metal » is not usefull

We just help mixed dentition management by a« short cut »
therapy from 8 to 12 years old:
The objective is to facilitate the tooth eruption in normal position
and correct the overbite and cross bite, to unblock the mandibular
position for growth response.
These shortcuts will either eliminate a treatment in permanent
dentition, or shorten this treatment, and many times be more
conservative regarding extractions.
Habits and transversal problems have to be corrected as early as
possible to re-establish the correct direction of maxillary and
mandibular growth.
A Class II molar relationship tendancy is easier to intercept prior to
the upper second molar eruption. Early correction of the skelettal
deficiency with an orthopedic appliance, greatly reduces the time
required for second stage treatment.

Case Report

This young boy shows a retrognatic mandibule anterior open-bite

due to thumb sucking and a conscriction of the maxilla. We note the
retrusion of the pogonion regarding the vertical facial plane
(Dreyfus).
Fig 1
We observe on the facial R-Rays, a well balanced position of the
upper incisor.
Fig 2
FMA is 24° as IMPA reads 87°. The ANB Angle of 8° confirms the
AoBo discrepancy of 7mm.
Orthopedic and Fonctional appliances may in some cases, enhance
extra growth potential in the mandibula while the condyle is out of
the fossa.
On this class II malocclusion, the lower jaw is blocked in a backward
position by a lateral constriction of the upper arch.
Fig
It is necessary to coordinate the two arches before the use of an
activator for a sagittal advancement. Maxillary expansion before
orthopedics was used for tree month. Then an orthopedic appliance
with a fonctionnal effect on the tongue, was worn for 5 month
Fig
Results after the first phase:
FMA is quit the same, the lower incisor shows a short deflect ANB
recuced to 5° and AoBo reads now 4 mm. This reduction along the
occlusal plane is related to the orthopedics response.
On the superimpositions, we note the improvement of the face and
the occlusion.These protocoles move the patient treatment out the
surgical frontiere
Fig
Phase II
18 months later, we started the second phase.
Sometimes, we got a short relapse, related to the difficult
interdigitation with the temporary teeth.The second reason for the
relapse might be the long period of time between the first and the
second stage. Sometimes two years. But the molars are still Class I or
end to end relationship.
Tweed technics with zero slot brackets.
Leveling and Class II mecanics as soon as possible with a very light
anchorage preparation. It is evident that the Class II mechanics
induces a supplementary lenghtening of the mandibula.
Fig…………

At the end of treatment, FMIA reads 57°, IMPA 98° ANB is now 1°
and AoBo minus 3°.
Treatment time: 18 months
The facial improvement demonstrate the combination of both
therapies, orthopedics and edgewise appliances.

Two years post-treatment, we note the balance of the face and the
stability of the occlusion
FMA closed to 21°, FMIA 65° and IMPA 94° (a nice Tweed triangle)
ANB 0° and AoBo –2mm.

Total active treatment: 8+18=26 months

Early treatment may involve the risk of lengthering the total
treatment time, and may weaken the patient’s motivation and
cooperation.

Conclusions
Today, the tendancy is to wait permanent dentition for one phase
treatments! The debate is biaised on several study that conclude
there are no evidence based between one phase and two phases
treatments! They just mesure bone and dental structures (on
questionable sagital two-dimensional X-rays). 2D cephalometrics
gives a good notion of vertical and sagittal factors. But the 2D
cephalometry is totaly inept to analyse a volume and its growth.
It is time to realise that the world has tree dimensions. The benefit
for mixed dentition treatments does not lies on 1 or 2 mm
mandibular growth, but in the fonctional remodeling of the total oro
facial space.

The second evidence is the nonsence to treat a Class II case by distal

mouvement of the upper arch. The upper molar never moves distally.
We just have a disto rotation of the crown, around the palatal root,
that, in some cases, opens 2 or 3 mm. The last evidence is the total
mistake to treat a Class II overjet with upper bicuspids extractions!
That is ashame for the smile.
It is time to realize that in Class II’s the upper incisors are well
located in the smile and the upper structures. The treatment is
always a mandibular management, in growth, and in sagital,
transversal and vertical reposition of the lower face.
In low Angle cases, the key is on the position of the upper incisors,
not on the lowers:
In low FMA angle cases, the FMIA looses all significance in correction
of facial imbalance because the priority becomes to maintain or
increase the vertical dimension.

We do not give a lot of credit on contreversies. As we have had the

non extraction versus extraction debate, we have today an other
wave, an other fashion : the one stage versus two stage treatment.
“We must face the fact that a lot things we don’t believe in, are true.
And conversely, a lot of things that we believe in are not true.”

For many reasons, we strongly beleave in mixed dentition therapy.