Universal Journal of Medicine and Dentistry(ISSN:2277-0992) Vol. 2(1) pp. 013-018, April, 2013 Available online http://www.universalresearchjournals.

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Full Length Research paper

Beauty of forsus in adult patient of class II division II malocclusion

Amit Prakash 1 and Babita Raghuwanshi 2 , Prabhuraj Sabarad 3 , Rangoli Bhargava 4 and Sonali Rai 4
Department of Orthodontics and Dentofacial Orthopedics Rishi raj dental college and hospital, Bhopal 2 L N medical college and research centre, Bhopal 3 Department of Orthodontics and Dentofacial Orthopedics, Mansarovar dental college and hospital, Bhopal 4 Department of Oral Medicine Darshan dental college and hospital, Udaipur 4 Rishi raj dental college and hospital, Bhopal
Accepted 08 February, 2013
1

The present protocol for the correction of Class II division 2 malocclusion with mandibular retrognathism is by using the fixed functional appliances. This article includes a case treated with Forsus FRD a hybrid fixed functional appliance. A post-pubertal patient with class II division2 malocclusion with 100% deep bite was treated with Forsus along with fixed appliance (MBT- 0.022 slot). Deep bite has been treated with intrusion of anteriors with Cetlins intrusion arch. It resulted in the favorable skeletal and dentoalveolar changes in the mandible. There was slight proclination of lower incisors. Good soft tissue changes were noted. Forsus is an efficient class II corrector even in postpubertal period. It promotes patient compliance with very minimal breakages. As it is fixed, it provides a good stimulus for forward positioning of the mandible. Keywords: Forsus, Deep bite, Class II division 2 INTRODUCTION Class II division 2 malocclusion presents a major challenge to orthodontists. It is characterised by a Class II molar relationship with retroclined upper centrals that are overlapped by the lateral incisors, deep bite. Associated features include straight or mild convex profile, broad square face and squarish upper arch with mild upper and lower crowding. Mandible is always locked due to retroclined upper incisors and deep bite. Variations of this malocclusion include retroclined centrals as well as lateral incisors or all the six anterior teeth are retroclined in the upper arch. Retroclination of the upper incisor is usually a natural dento-alveolar compensation for a Class II skeletal pattern in order to decrease the overjet. In severe cases, the bite is often very deep and poses the risk of periodontal trauma in the upper palatal and lower labial aspect. The etiology of Class II malocclusions is considered to be multifactorial (Graber 1963). Genetic, Racial, and Familial Characteristics are the most common etiological factors. Genetic characteristics tend to recur; for example, a hereditary trait from either parent or a combination of traits from both parents may produce similar or modified characteristics in the offspring. Persistent finger, tongue, or lip habits can either result in a Class II division 2 malocclusion or accentuate an existing one (Barich 1946). Forsus is a hybrid fixed functional appliance. Being hybrid it has advantages of both rigid and flexible fixed functional appliances. Like the rigid appliance, it provides optimal force required for the skeletal change. It allows free lateral movements of the mandible and is more comfortable to the patient like flexible functional appliances. Fixed functional appliances facilitate the forward and downward displacement of the mandible. They also cause a posterosuperior displacement of the maxillary dentition and pterygoid plate and thus contribute to the correction of a Class II malocclusion. Mandibular incisor proclination is the most pronounced dentoalveolar side effect seen during fixed functional treatment. This could be prevented by cinching the

*Corresponding author Email: amitprakash30@gmail.com

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Figure 1. Pre-treatment photographs

Figure 2. Pre-treatment study models

Figure 3. Pre-treatment lateral cephalogram and OPG

mandibular archwire and laceback in the mandibular arch and by incorporating progressive lingual crown torque in the mandibular anterior segment. Inclusion of the second molars during treatment could enhance anchorage and prevent unwanted proclination of anterior teeth (Vogt 2006). The purpose of this paper is to summarize and discuss about Class II Division II mallocclusion and its treatment with forsus in adult patient. Case report

Treatment objectives 1. Correction of skeletal class II 2. Correction of class II canine and molar relation 3. To achieve ideal gingival marginal level in upper anterior teeth. 4. Relieving of upper and lower anterior crowding 5. To achieve ideal overjet /overbite 6. Correction of convex profile Treatment plan

Diagnosis A 23 year old female reported with the chief complaint of irregularly placed upper front teeth. She had skeletal and dental class II malocclusion with upper and lower anterior crowding. She had a convex profile, severely retruded mandible, deep mentolabial sulcus. Model analysis revealed crowding of 5mm in the upper arch and 4mm in the lower arch, an overjet of 0 mm and overbite of 7mm (100%).She had upper anterior marginal gingival discrepancy. Cephalometric analysis indicated that the patient was skeletal class II on account of posterior placement of mandible with horizontal growth pattern, retroclined upper and lower incisors.

The non-extraction treatment was planned because of minimal space requirement. Forsus was planned to correct skeletal and dental class II malocclusion. To correct the deep bite Cetlins intrusion arch was used. Treatment progress Only upper anteriors were bonded initially. Cetlins intrusion arch made up of sectional 0.017x.025 stainless steel wire was placed in the upper centrals. In the auxiliary tube 0.016 premium plus wire with the anchor bend was placed. Intrusion forces of 40 gm was balanced, which guided upper incisor root apices lingually, thereby reducing the need for root torque to

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Figure 4. With Cetlins intrusion arch (0.018 SS base arch wire with sectional 0.017x0.025 SS)

Figure 5. After intrusion

Figure 6. After upper arch alignment (0.016 NITI arch wire)

Figure 7. After alignment and leveling (U- 0.019x0.025 SS, L- 0.019x0.025 NITI)

Figure 8. With fixed functional appliance (Forsus)-0.019X0.025 SS arch wire

Figure 9. Post-Forsus photographs

finish the case. Though, with anchor bend in upper arch wire will procline the upper incisors, because of tight cinch the incisor did not procline and there was controlled

root movement of central incisors lingually. After 2 months sectional wire 0.019x.025 stainless steel wire was placed in the upper centrals. In the auxiliary tube

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Figure 10-Post-Forsus lateral cephalogram and OPG

Figure 11. After bracket repositioning for root uprighting (0.019x0.025 NITT arch wire)

Figure 12. After root uprighting OPG

Figure 13. Post treatment photographs

Pre- black Post- blue

Figure 14. Cephalometric superimposition

0.018 premium plus wire with the anchor bend was placed. After correction of gingival margin discrepancy, initial alignment and leveling was done with upper 0.016 NiTi followed by 0.018 stainless steel. After initial alignment and leveling, 0.0190.025 stainless steel was placed in the upper arch with 10 degree of palatal root torque. After creation of overjet lower arch were bonded. Initial alignment was done with lower 0.016 NiTi followed by 0.019x0.025 NiTi for leveling. After initial alignment and leveling, 0.0190.025 stainless steel was placed in the lower arch and bite plane was removed. Additional

10 labial root torque was added in the anterior segment of the lower archwire to counteract the lower incisor proclination. Upper and lower arch consolidation was done and Forsus was placed. Forsus phase continued for 8 months. DISCUSSION There are several factors that need particular focus in class 2 division II malocclusions.

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Table 1. Pre and Post-Forsus cephalometric findings

Parameter SNA SNB ANB WITS NA-Pog Harvolds unit length difference FMA SN-Go-Gn Basal Plane Angle U1-SN U1-NA U1-ANS-PNS L1-MP LI-NB Overjet Overbite Pre-treatment 83 79 04 02mm 06 22mm(Co-Gn111mm) 12 21 16 97 06, 2mm 86 89 12, 0.5mm 0mm 7mm Post-Forsus 83 79 04 02 05 22 14 21 16 106 29, 6mm 117 107 35, 7mm 02mm 03mm

Extruded upper incisors Almost by definition, the upper incisors, being retroclined by forces from the lip morphology are likely to be also extruded. The upper incisor tips are indeed at a more inferior position in class 2 division II malocclusions than in class 1. Intrusion of the incisors is therefore likely to be a sensible biomechanical aim (Lapatki et al 2002). Low face height Clinical experience suggests that a low face height not only increases the probability of a deep overbite, but also adds to the difficulty of overbite reduction. The increased forces from the muscles of mastication may inhibit extrusion of posterior teeth. It is not possible to significantly increase face height beyond the normal growth expectation. In adults, the slight hinging open of the mandible, associated with molar extrusion, seems to be stable. This may be due to the tendency to slight continued vertical growth found in adults (Behrents (1986). Traumatic overbite Incisor proclination Proclination of either upper or lower incisors is one method of overbite reduction in any malocclusion. In class 2 division II, the upper incisors are by definition retroclined and proclination is an easy tooth movement. This does, of course, create a class 2 division 1 malocclusion. If the lower incisors are also retroclined,

proclination of lower incisors is usually necessary if a normal interincisal angle is to be established. Facial aesthetics Three aspects are relevant The reduced lower face height The frequently prominent labiomental fold The lip prominence The reduced face height is not usually corrected. A small increase may accompany molar extrusion and this may be permanent in an adult. However, this is not sufficient to alter facial aesthetics. Orthognathic surgery to increase the face height is rarely advocated. Inferior movement of the maxilla requires bone grafting and is less stable than almost all other orthognathic procedures. The prominent labiomental fold is similarly resistant to change. Proclination of the lower incisors does not significantly alter this feature in class 2 division II, but may well be necessary in any case for occlusal reasons, if the lower incisors are retroclined. Genioplasty are sometimes performed to reduce horizontal prominence and increase the vertical height of the chin in this malocclusion. The lip prominence is also less influenced by change in incisor position than in a class 2 division 1 case. This is the result of the reduction of an increased overbite, which means that significant lower incisor proclination can occur and the lower incisors still only occupy a position previously occupied by the upper incisors. The anteroposterior position of the lips is therefore less related to change in the lower incisor position than in other malocclusion.

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Stability of lower incisor proclination The lower incisors can be moved labially until they occupy the position previously occupied by the upper incisors should therefore stay stable in their new, more labial position. This seems a very reasonable hypothesis. Some cases leave no choice but to procline the lower incisors, because their retroclined initial position is not compatible with a low inter-incisal angle and a class 1 incisor relationship. It is wise to retain the proclined lower incisors with more care and for a much longer period than is required in other situations (Canut and Arias 1999). By definition, functional appliances are meant to be used in those cases of class II division 2 malocclusion, which are caused by mandibular deficiency. The underlying defect may be a small mandible, or a normal size but posteriorly positioned mandible, or a retrusively placed mandibular dento-alveolar segment on a normal mandible, or a combination of any of these. Absence of overjet needs a pre-functional phase which includes alignment and leveling and also creation of overjet. Fixed functional appliances have shown significant improvements in the post-pubertal patients with class II malocclusion with mandibular retrusion (Pancherz 1982). He showed significant condyle and glenoid fossa remodeling beyond the pubertal growth spurt using the Herbst appliance. The displacement resulting from fixed functional therapy was predominantly dentoalveolar in nature. Forward and downward displacement of mandibular incisors was the most pronounced dentoalveolar effect, followed by mandibular molar displacement. The mandible rotated in the forward and downward direction, but the pterygoid plate and maxillary dentition demonstrated posterior and superior displacement similar to that seen with the use of headgear. Tensile stress was found in the entire dentoalveolar structure, except at ANS. Maximum tensile stresses were found in the condylar neck and condylar head. Most Class II and Class I malocclusions manifest a deep overbite. This can be corrected by intrusion of the upper front teeth or extrusion of the posterior teeth, or by a combination of the two techniques. Intruding the upper incisors solves both problems. Moreover, the roots of the incisors are brought to a wider part of the pre-maxilla, which makes retraction and torque control of the incisors easier and reduces the risk of encroaching on the labial or palatal cortex. Relatively rare configuration occurs when, in some Class II, division 2 malocclusions, the incisors are so severely tipped backward that the center of resistance (CR) is in front of the point of force application (PFA). Proclination before intrusion may cause extrusion of the incisors and impaction of their roots on the palatal cortex of the pre-maxilla. In this biomechanical system, the PFA should be moved in front of the CR.

CONCLUSION Moderate class 2 division II cases present no particular challenge. More marked cases with the additional features described above are most easily treated with a pre-functional, then functional and then fixed phases. Patients more suitable for initial fixed appliances (see above) can be hard work however they are treated. Significant lower incisor proclination should be regarded as an indication for effective long-term retention.
REFERENCES Graber TM (1963). The three Ms: muscles, malformation and malocclusion. Am. J. Orthod. 49:418-450. Barich FT (1946). Management of Class II, Division two (Angle) malocclusions. Am. Orthod. Oral Surg. 32:611-618. Vogt W (2006). The Forsus Fatigue Resistant Device. J. Clin. Orthod. June: Pp. 368-376. Lapatki BG, Mager AS, Schulte-Moenting J and Jonas IE (2002). The importance of the level of the lip line and resting lip pressure in Class II Division 2 malocclusion. J. dental Res. 81: 323-328. Behrents R (1986). JCO/interviews Dr. Rolf Behrents on adult craniofacial growth. J. Clin. Orthod. 20: 842-847. Canut JA, Arias S (1999). A long-term evaluation of treated Class II division 2 malocclusions: a retrospective study model analysis. Eur. J. Orthod. 21: 377-386. Pancherz H (1982). The mechanism of Class II correction in Herbst appliance treatment. Am. J. Orthod. 87: 1-20.