part ii-management of class ii malocclusion with speed appliance part ii

Management of Class II Malocclusion with SPEED

AppliancePart II

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©Dr Sylvain Chamberland

Clinical Case presentation

• Class II div 1 and II

• Twin Force Bite Corretor

• Pendulum appliance and intrusive arch to level the curve of spee

• Biomechanical approach for cl II div 2 (mx anterior intrusive arch)

• TAD and extraction approach in hyperdivergent cases

Stacey (14 y 10 m)

• Class I profile

• Retroclined 1/

Cl II div 2

• Maxillary constriction

• Left posterior Xbite

• Severe 1st molar mesial rotation

St.De 010210, 14y 10 m

Tx plan

• RPE + exo 2 premolars?

• RPE, non exo + cl II correctors?

• RPE, non exo, molar derotation, mx anterior intrusive arch

•At 34 weeks!TFBC are installed

•At 52 weeks!TFBC removed

!A Hilgers RPE design would have achieved derotation of the 1st molar while an Hyrax had maintained it.

St.De 100111 Md:.020 x.020 SS

Mx:.018 SC™

St.De 140211 Md:.020 x.020 SS

Mx:.016 X .016 Sent

At 58 weeks

• Mx molar de-rotation is needed

• Class II elastic to wear during night

• Coordination of arch form is necessary

St.De 280311

• Mx molars distalized

• /1-MP proclined by 17°

• Rotation of occlusal plane noted

At 80 weeks

• Finishing bends here and there

• Incisal recontouring

St.De 280311

Roxane (11 y)

• Class II div 1

• Constricted maxilla

Ro.Lé 061009

• Skeletal class II

• Proclined lower incisors

• Lip trapping

• Low MPA

• Fixed class II correctors (Forsus, Twin force, Herbst, etc) have a tendency to procline the lower incisors

• Therefore, maxillary molar distallization was preferred for class II correction in this case

At 22 weeks

• Class I molar relationship obtained

• Elastomeric chain to distalize the U5'S

• 17x25 niti intrusive arch attached at the canine to level the lower arch and minimize /1 proclination

Ro.Lé 060410 Md:.016 x.022 neost + 17x25 niti

Mx:.018 SC™

At 45 weeks

• Sliding mechanics on a .016 SS, cinch back

! Elastomeric chain attached to U4’s

• Class I canine relationship is obtained

Ro.Lé 160910 Md:.020 x.025 Niti

Mx:.016 SS, cinch back

At 60 weeks

• Bond 7's/

! EC 12 to 22

! Anteriors will be retracted with .017 x .025 mushroom loop

• /7's will be bonded at next RV

Mx:.016 x .016 sent

Ro.Lé 281010

At 67 weeks

• Mx: Elastomeric chain 6 to 6 to maintain space closure

• .020 x .025 niti for leveling prior finishing

• .020 x .025 SS for finishing " 17 weeks

Ro.Lé 170211

Mx:.020 x .025 Nitisw

Md:.020 x .025 Nitisw

At 97 weeks

Ro.Lé 140711

6 weeks into retention

Ro.Lé 250811

Emmanuel (14 y)

• Cl II div 2

• Deep overbite

• Mx molar mesially rotated

Em.Be 250610

• Dished in profile

• Retroclined 1/-SN & /1-MP

• Increased 1/1 " 147°

Tx objective

• Decreased interincisal angle

• Procline 1/ and /1

• Obtain class I molar and canine relationship

Tx Plan

• Forsus?

• RPE?

• Exo of 2 mx premolars?

• Mx 3 segments (016 x 022 niti) for alignment

• Overlay 17x25 niti intrusive arch

! Anterior intrusion

! Posterior extrusion

! Tip back at buccal segment

Em.Be 060710

• TPA .032 SS activated to de-rotate the molars

• Molars distalization

Why the intrusive arch is overlayed and not engaged into the brackets of the incisors?

• The rectangular wire would create a torquing moment

• This would be balanced by anterior extrusion and posterior intrusion

• That would substract from the anterior intrusive force and posterior extrusive force

• The efficacy of the force sytem would be reduced

• Also the intrusive force would be in-line or lingual to the center of resistance of the incisor negating the desired flairing effect

Do we need to understand orthodontic mechanics

• Yes, because I said so

• Yes, because...

«...when a case is challenging,orthodontists know what to do.»

At 6 weeks

• Anterior mandibular teeth are bonded

• Unraveling the lower curve of Spee will assist cl II correction

Em.Be 190810 Md:.016 SC™

At 13 weeks

• Mx: 16 SC™ engaging the canines

• Derotation of mx molars noted

Em.Be 051010

Mx:.016 SC™

Md:.016 Sent

At 20 weeks

• Md: 016 x 022 neosent

• Mx: 016 sent + cl II elastics

• Intrusive arch is removed

Em.Be 221110 Md:.016 x .022 neosent

Mx:.016 Sent

At 27 weeks

• Remove the TPA

• Continue cl II eastics

• Class I relationship is almost achieved

Em.Be 100111 Md:.020 x .020 neosent

Mx: 016 x .022 neosent

At 40 weeks

• Reassessment of bk position

! Rebond 12, bond 16, 26, 47

• Continue cl II elastics

Em.Be 120411

Mx: .020 x .020 neosent

Md:.020 x .020 neosent

Em.Be 220811

At 59 weeks

• Mx: ! elastomeric chain

• Md: rebond #47 , #33, .020 x .020 neost

Rebonded

• May be some improvement in lip support can be noted

• Incisors display is adequate

• Is such a treatment approach repeatable?

! Same mechanics: 28 weeks into treatment

Wi.Ja. 270111

Wi.Ja. 260811

3 Segments 16 x16 sent" 16x22 neo"16SC + cl II"16sent + cl II"16x22 neost + cl II

2 Segments 16sent"16sent continuous "20 x 20 neost + cl II"20x25 niti + cl II

Eloïse (9 y 7 m)

• Cl II div 1

• Mx crowding

El.Re 060510

• Slight vertical facial asymmetry

• Retrognathic mandible

• Low FMA, brachycephalic

El.Re 060510, 9 y 7 m

• At 29 weeks

! Forsus are engaged

! Md: .020 x .025 SW, loop distal to the canine, cinch back

El.Re 310111

• At 35 weeks

! E-links to sliding the canine distally on .020 x .025 SW

El.Re 201210 Md:.020 x .025 sw

Mx:.020 x .025 swCinch Cinch

At 41 weeks

• Reassessment of bk position

! Rebond 12, 16, 26,

! Bond 37, 46, rebond 33, 35, 45

At 41 weeks

• Forsus and Hyrax removed

• Canines distalized and a space opened mesially

• Side effect: posterior intrusion

El.Re. 140311 Md:.016 sent

Md:.016 x .022 neosent

• Molar distallization and intrusion

• Increased smile display

• /1-PM was maintained at 109°

El.Re 140311

At 64 weeks

• Mx & Md: .020 SS SW

• Finishing bends, Cl II elastics

El.Re. 220811

Maude (16 y 7 m)

• Cl II div 2

• Moderate ALD

Ma.Ma 310809, 16y 7 m

• Straight profile

• Lips to E-plane = normal

• Retroclined 1/

• Proclined /1

•Tx Plan#Non extraction?#Extraction?

At 61 weeks• Mx: 21x21x20 x 38 mm, E-links #5 at 17 & 27

• Md: 21x21x20 x 38 mm

! To include the canine in the rectangular section

! Upright spring on 1st premolars, E-links #3

! Cl II elastics 3/6

Ma.Ma 221110

At 74 weeks

• Space closure is effective

• Lower curve of Spee remained flat

• Continue cl II elastics

Ma.Ma 240211

At 81 weeks

• Mx: Continue en masse retraction

• Md: .020 x .025 SW + EC 6 to 6

! Continue cl II elastics

Md:.020 x .025 swMa.Ma 130411

At 102 weeks

• Finishing bend

• Enamel recontouring

Ma.Ma 080911 Md:.020 x .025 sw

Mx:.020 x .025 sw

Marie-Anne (10 y 9 m)

• Cl II div 1

• Md deviated to the right

• Deep overbite

• Mesially rotated 1st molar

Ma.Co 250809, 10y 9 m

• Proclined 1/ and /1 (1/-SN = 121°; /1-MP = 104°)

• Large overjet, 1/1 = 108°

• Deep overbite

Tx plan

• Any cl II fixed corrector will procline lower incisors

• Lower incisor intrusion with a SW will procline /1

At 11 weeks

• .032 TMA TPA to derotate U6’s

• Md: 3 segments + lingual arch

• Intrusive arch 17x25 niti attached at /3’s (distal to C rot) to intrude and retrocline /1

Ma.Co 011209

At 23 weeks

• Md: 20x20 neost + intrusive arch on /3’s

• Mx: 20x25 nitisw (to detorque U1’s)

• Cl II elastics

• Molars are derotated

Ma.Co 230210

At 29 weeks

• Mx: 21x21x20 to slide buccal segment distally

• TPA removed

• Md: 20x25 nitisw, LA + intrusive arch removed

• Unilateral FORSUS cl II corrector on the right side is installed

Ma.Co 070410

• 1/ SN = 102, retracted to normal

• /1-MP = 105 maintained

• 1/1 = 125 = normal

At 53 weeks

• Remove Forsus on the right side

• Mx: 17x25 TMA mushroom loop to retract anteriors (note the space mesial to U3’s)

• Md: 20x25 nitisw

• Class I molar and canine relationship achieved

Ma.Co 200910

At 59 weeks

• Mx: 20x25nitisw + elastomeric chain

• Continue cl II

Ma.Co 011110

At 78 weeks

• Mx: 20x25 sw + elastomeric chain

• Md: 20x25 nitisw

• Patient instructed to wear Cl II elastic during nightime

Ma.Co 210311

At 103 weeks

• Class I molar and canine relationship

Ma.Co 070911

Estelle (28 y 4 m)

• Class I, congenitally missing #45

• Xbite 22/33

Es.Gr 040609

• Bimax protrusion

• Mx midline to the left

• Tx plan

! Exo???

• Tx initiated with .016 SC™ for 12 weeks, then .018 SC™ for 8 weeks

• At 20 weeks:

! Mx: 18 SC; Md: .016 sent

• Followed by .016 x .022 neost, .020 x .020 neost, .020 x .025 niti, then .021 x .021 x .020 en masse retraction

Es.Gr 231109, 20 weeks Md:.016 Sent

Md:.018 SC™

• Sliding #13 on the round section of HDGW

• Note the slight curve of Spee in lower arch

! The squared anterior section is limited to lower incisors

! This reduce the stiffness of the anterior segment

! The canine and the 1st premolar have a tendency to tip lingually as the E-links press on the labial surface

! When spaces are closed, it is most often not possible to engage a .020 x .025 SS wire

Es.Gr 071210, 74 weeks #45 was protracted alone before engaging #46

• Md: .021x.021x.020 x 58 mm

! Extended square anterior section include the 1st premolars

! This increased the wire stiffness in torsion

! Hence it help to maintain a flat curve of Spee

! Once the space are close, a .020 x .025 SS sw can be engage

• Mx: #13 distalized into cl I

Es.Gr 180111, 80 weeks

• Mx cl I canine is achieved

! EC 7-6-5-3-o-2

! 6 weeks later (92w), the EC was changed and an active coil was added

Es.Gr 010311, 86 weeks

Md: .020 SS

Es.Gr 240511, 98 weeks Md: .020 x.025 nitisw

• 98 weeks: midline improved

! Sliding mechanics: Light force + round wire

At 110 weeks

• Mx: rebond #22 to move the root mesially

! .020 x.025 nitisw + EC

• Md: .020 x .025 SSsw + EC

Es.Gr 150811, 110 weeks

A.G.Class II div 1 OB

• Cl II div 1

• Open bite

• Moderatle ALD

An.Gr. 160309, 14 y 4 m

• Hyperdivergent

• Bimaxillary protrusion

• Lip incompetency

Tx planTx initiated: July 15-2009

• Extraction?

• Surgery?

• Non-surgery

• TADs

At 13 weeks

• Mx:

! TADs 6 x 1,4 mm

! 3 segments .020 x.020 neost + TPA .032 x .032 activated mesial out

• Md: .018SC™

An.Gr. 131009

At 21 weeks

An.Gr. 131009

• Mx: Replace TAD distal to 1st m, .016 sent

• Md: TADs 8 x 1,4 mm + .016 sent

An.Gr. 071209

At 26 weeks

• Mx: .016 x .022 neost, ! EC

• Md: .016 x .022 neost, ! EC

! .032 TMA LA

An.Gr. 071209

An.Gr. 15-01-10

At 34 weeks

• Mx: .21 x .021 x .020 x 38 mm -E5 7-3

• Md: .020 x .025 niti

An.Gr. 15-01-10

An.Gr. 08-03-10Class 1I

At 46 weeks

• Mx: .E links: Hook to the TADs

• Md: ! E4

• TPA and LA removed

An.Gr. 08-03-10

An.Gr. 07-06-10 Md: .021 x .021 x .020

Class 1

Md: .020 x .025 niti + ECAn.Gr. 02-09-10

At 59 weeks

• Mx: E links: Shep-Hk to the TAD

! EC 11-27

• Md: .020 x .025 niti

An.Gr. 15-07-10 Md: .021 x .021 x .020

At 66 weeks

An. Gr. 191010

! Mx: .021 x .021 x .020. Lig. tie TAD-U3, E links

! Mx: EC 6 to 6

! Md: .020 x .025 SW

An. Gr. 231210 Md: .020 x .025 SS

At 75 weeks

At 94 weeks

• After 2 missed rendez-vous: lost 12 weeks!

• Patients involved in a fight!!!

! Luxation of 12, 11, 42, 41, 31

An. Gr. 020511 Md: .020 x .025 SS

Mx: .021 x .021 x .020 SS

Mx: .016 x .022 neost

Md: .06 sent

• Significant facial changes

• Lip competency improved

• Condilar growth

• Almost no aveolar growth

• Finishing stages to improveroot parallelism

At 111 weeks

• TAD are removed

• Wire cut distal to lower 5’s

• Debond in 2 weeks

An. Gr. 290811

Ma.An. Vo. Bo.

• Cl II div 1 open bite

Ma.An.Vo.Bo 260109, 16 y 4 m

• Lip incompetency

• Bimaxillary protrusion

• Vertical maxillary excess (posterior)

Tx Plan

• Extraction

• Would usually involve bimaxillary surgery

! The patient was tx planned for surgery.

! Tx initiated: March 5, 2009

52 weeks into treatment• The patient and his father declined the surgery: No way!

Ma.An.Vo.Bo 030310 Md: .021 x .021 x .020 E-4

Md: .020 x .025 sw

• Pull out the TAD box!• TAD: 8 x 1,8 mm

• Mx arch was treated in segments

At 67 weeks

• Upper left TAD is replaced

• Lower expansion occurred because of the absence absence of a lingual arch

Ma.An.Vo.Bo 150610

At 110 weeks

• Upper left TAD failed 3 times

• TFBC was used unilaterally on the left from Dec. 2010 to April 2011

Ma.An.Vo.Bo 190411

At 128 weeks

• A compromised posterior occlusion was accepted

• Mandibular asymetry to the left may explain the cl II relationship

Ma.An.Vo.Bo 110811

• Smile display improved

• Lip competency improved

• Mandibular déviation to the left is noted

• Right condyle larger than left condyle

• Forward rotation of the mandible

! Intrusion of mx molars

! Intrusion of md molars

! AFH !

part ii-management of class ii malocclusion with speed appliance part ii

obtaineddr sylvain chamberland

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