Part II-Management of class ii malocclusion with speed appliance part ii

Management of Class II
Malocclusion with SPEED
Appliance
Part II
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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
©Dr Sylvain Chamberland

• Class I proﬁle
• Retroclined 1/


Cl II div 2

St.De 010210, 14y 10 m

• Maxillary constriction
• Left posterior Xbite
• Severe 1 molar mesial rotation
st


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
Mx:.018 SC™

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

Mx:.016 X .016 Sent

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

•At 52 weeks
!TFBC removed
!A Hilgers RPE design would have achieved derotation of the 1st molar while an Hyrax had maintained it.


At 58 weeks

St.De 280311

• Mx molar de-rotation is needed
• Class II elastic to wear during night
• Coordination of arch form is necessary

• Mx molars distalized
• /1-MP proclined by 17°
• Rotation of occlusal plane noted

At 80 weeks

St.De 280311

• Finishing bends here and there
• Incisal recontouring


Ro.Lé 061009

• Class II div 1
• Constricted maxilla

• 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

Mx:.018 SC™

•
Ro.Lé 060410
Class I molar relationshipx.022 neost + 17x25 niti
Md:.016 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

At 45 weeks

Mx:.016 SS, cinch back

Ro.Lé 160910 Md:.020 x.025 Niti

• Sliding mechanics on a .016 SS, cinch back
! Elastomeric chain attached to U4’s

• Class I canine relationship is obtained


At 60 weeks
Mx:.016 x .016 sent

• Bond 7's/
Ro.Lé 281010

! EC 12 to 22

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

• /7's will be bonded at next RV


At 67 weeks
Mx:.020 x .025 Nitisw

Ro.Lé 170211 Md:.020 x .025 Nitisw

• 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

At 97 weeks

Ro.Lé 140711


6 weeks into retention

Ro.Lé 250811


Em.Be 250610

• Cl II div 2
• Deep overbite
• Mx molar mesially rotated

• 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?


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

• Molars distalization

Em.Be 060710

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

• Overlay 17x25 niti intrusive arch
! Anterior intrusion

! Posterior extrusion

! Tip back at buccal segment

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

Em.Be 190810 Md:.016 SC™

• Anterior mandibular teeth are bonded
• Unraveling the lower curve of Spee will
assist cl II correction


At 13 weeks
Mx:.016 SC™

Em.Be 051010 Md:.016 Sent

• Mx: 16 SC™ engaging the canines
• Derotation of mx molars noted


At 20 weeks
Mx:.016 Sent

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

• Md: 016 x 022 neosent
• Mx: 016 sent + cl II elastics
• Intrusive arch is removed

At 27 weeks
Mx: 016 x .022 neosent


• Remove the TPA
• Continue cl II eastics
• Class I relationship is almost achieved

At 40 weeks

Mx: .020 x .020 neosent


• Reassessment of bk position
! Rebond 12, bond 16, 26, 47

• Continue cl II elastics

At 59 weeks

Em.Be 220811
Rebonded
• Mx: ! elastomeric chain
• Md: rebond #47 , #33,
.020 x .020 neost


• May be some improvement in lip support can be noted
• Incisors display is adequate


Wi.Ja. 270111

• Is such a treatment approach repeatable?
! Same mechanics: 28 weeks into treatment

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

Wi.Ja. 260811 2 Segments 16sent"16sent continuous "20 x 20 neost + cl II"20x25 niti + cl II

El.Re 060510

• Cl II div 1
• Mx crowding

El.Re 060510, 9 y 7 m

• Slight vertical facial asymmetry
• Retrognathic mandible
• Low FMA, brachycephalic

• At 29 weeks
Cinch Mx:.020 x .025 sw Cinch

El.Re 201210 Md:.020 x .025 sw
! Forsus are engaged

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

• At 35 weeks

El.Re 310111

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


At 41 weeks
• Reassessment of bk position
! Rebond 12, 16, 26,

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


At 41 weeks
Md:.016 x .022 neosent

El.Re. 140311 Md:.016 sent

• Forsus and Hyrax removed

• Canines distalized and a space opened mesially

• Side effect: posterior intrusion


El.Re 140311

• Molar distallization and intrusion

• Increased smile display

• /1-PM was maintained at 109°


At 64 weeks

El.Re. 220811

• Mx & Md: .020 SS SW
• Finishing bends, Cl II elastics


El.Re. 220811


Ma.Ma 310809, 16y 7 m

• Cl II div 2
• Moderate ALD

• Straight proﬁle
• Lips to E-plane = normal •Tx Plan
• Retroclined 1/ #Non extraction?
#Extraction?
• Proclined /1

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

Ma.Ma 221110

• 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

At 74 weeks

Ma.Ma 240211

• Space closure is effective
• Lower curve of Spee remained ﬂat
• Continue cl II elastics

At 81 weeks
• Mx: Continue en masse retraction

Ma.Ma 130411 Md:.020 x .025 sw

• Md: .020 x .025 SW + EC 6 to 6
! Continue cl II elastics


At 102 weeks
Mx:.020 x .025 sw

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

• Finishing bend
• Enamel recontouring


Ma.Co 250809, 10y 9 m

• Cl II div 1

• Md deviated to the right

• Deep overbite

• Mesially rotated 1st molar

• 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

Ma.Co 011209

• .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

At 23 weeks

Ma.Co 230210

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

• Mx: 20x25 nitisw (to detorque U1’s)

• Cl II elastics

• Molars are derotated


At 29 weeks

Ma.Co 070410

• 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


• 1/ SN = 102, retracted
to normal

• /1-MP = 105 maintained

• 1/1 = 125 = normal


At 53 weeks

Ma.Co 200910

• 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

At 59 weeks

Ma.Co 011110

• Mx: 20x25nitisw + elastomeric chain
• Continue cl II

At 78 weeks

Ma.Co 210311

• Mx: 20x25 sw + elastomeric chain

• Md: 20x25 nitisw

• Patient instructed to wear Cl II elastic during nightime


At 103 weeks

Ma.Co 070911

• Class I molar and canine relationship


Es.Gr 040609

• Class I, congenitally missing #45
• Xbite 22/33


• Bimax protrusion

• Mx midline to the left

• Tx plan
! Exo???


Md:.018 SC™

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

• 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 071210, 74 weeks #45 was protracted alone before engaging #46

• 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 180111, 80 weeks

• 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

Md: .020 SS

Es.Gr 010311, 86 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 240511, 98 weeks Md: .020 x.025 nitisw

• 98 weeks: midline improved
! Sliding mechanics: Light force + round wire

At 110 weeks

Es.Gr 150811, 110 weeks

• Mx: rebond #22 to move the root mesially
! .020 x.025 nitisw + EC

• Md: .020 x .025 SSsw + EC

An.Gr. 160309, 14 y 4 m

• Cl II div 1
• Open bite
• Moderatle ALD


• Hyperdivergent
• Bimaxillary protrusion
• Lip incompetency


Tx plan
Tx initiated: July 15-2009

• Extraction?
• Surgery?
• Non-surgery
• TADs


At 13 weeks

An.Gr. 131009

• Mx:
! TADs 6 x 1,4 mm

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

• Md: .018SC™

At 21 weeks
An.Gr. 131009

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

• Md: TADs 8 x 1,4 mm + .016 sent

An.Gr. 071209

At 26 weeks
An.Gr. 071209

• Mx: .016 x .022 neost, ! EC

• Md: .016 x .022 neost, ! EC
! .032 TMA LA

An.Gr. 15-01-10

At 34 weeks
An.Gr. 15-01-10

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

• Md: .020 x .025 niti

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

At 46 weeks
An.Gr. 08-03-10

• Mx: .E links: Hook to the TADs

• Md: ! E4

• TPA and LA removed

Class 1
An.Gr. 07-06-10 Md: .021 x .021 x .020


At 59 weeks
An.Gr. 15-07-10 Md: .021 x .021 x .020

• Mx: E links: Shep-Hk to the TAD
! EC 11-27

• Md: .020 x .025 niti

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


At 66 weeks

An. Gr. 191010

! Mx: .021 x .021 x .020. Lig. tie
TAD-U3, E links
At 75 weeks

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

! Mx: EC 6 to 6

! Md: .020 x .025 SW

At 94 weeks
Mx: .021 x .021 x .020 SS

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

• After 2 missed rendez-vous: lost 12 weeks!
• Patients involved in a ﬁght!!!
! Luxation of 12, 11, 42, 41, 31
Mx: .016 x .022 neost

Md: .06 sent


• Signiﬁcant facial changes
• Lip competency improved


• Condilar growth
• Almost no aveolar growth
• Finishing stages to improve
root parallelism


At 111 weeks

An. Gr. 290811

• TAD are removed
• Wire cut distal to lower 5’s
• Debond in 2 weeks


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

• Cl II div 1 open bite


• 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!

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

Md: .020 x .025 sw

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


• Mx arch was treated in segments


At 67 weeks

Ma.An.Vo.Bo 150610

• Upper left TAD is replaced
• Lower expansion occurred because of the
absence absence of a lingual arch


At 110 weeks

Ma.An.Vo.Bo 190411

• Upper left TAD failed 3 times
• TFBC was used unilaterally on the left from
Dec. 2010 to April 2011


At 128 weeks

Ma.An.Vo.Bo 110811

• A compromised posterior occlusion was
accepted
• Mandibular asymetry to the left may
explain the cl II relationship


• 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

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Part II-Management of class ii malocclusion with speed appliance part ii