O R T H O D O N T O

I CR ST H O D O N T I C S

The Combined Orthodontic and

Surgical Treatment of Traumatic
Class II division 2 in the Adult
SEAN MCDONAGH AND JOHN C. CHADWICK

from impaction of hard foodstuffs. The

Abstract: A mild Class II division 2 incisal relationship is often associated with a effect of the trauma depends on the
pleasing facial profile and aesthetically acceptable arrangement of the teeth. Severe
architecture of the soft tissue
cases, however, have the potential to cause trauma and a number of older patients
present with extensive soft and hard tissue damage. Management options may range involved. Recession predominates in
from simple preventive advice to complicated surgical orthodontics. Detailed the mandibular labial periodontium
assessment of the case is paramount in developing an appropriate treatment plan. owing to the thin gingiva and minimal
overlying bone, whereas pocketing
Dent Update 2004; 31: 83–91 and gingival hyperplasia are more
commonly found palatal to the upper
Clinical Relevance: Early assessment of the potentially traumatic Class II division
2 malocclusion is of importance. incisors. Although attrition of the root
surface is the most commonly
observed effect on hard tissue, the
inclination of the incisors may also
predispose to enamel wear facets in
the presence of other factors such as

A Class II division 2 incisor

relationship has been reported to
occur in 17.7% of the school
occur on a mild skeletal II base,
traumatic cases in adults tend to be
associated with increasingly severe
bruxism or porcelain restorations
(Figures 2a and b).

population.1 The prevalence of differing skeletal discrepancies. Both upper and

malocclusions was not reported in the
1988 Adult Dental Health Survey,2 but
9% of the sample was found to have
inciso-gingival contact, which may be a
feature of both Class II division 1 and 2
cases. No mention was made in this
survey, however, of the percentage of
cases demonstrating evidence of trauma
to either the hard or soft tissues in
conjunction with the increased overbite.
PRESENTATION
Although a Class II division 2 incisor
relationship is usually reported to
Sean McDonagh, BDentSc, MSc, FDS(Orth),
Senior Registrar in Orthodontics, Royal
Shrewsbury Hospital and Birmingham Dental
Hospital and John C. Chadwick, BDS, FDS
RCS(Edin.), DOrth RCS(Eng.), Consultant in
Orthodontics, Royal Shrewsbury Hospital.
lower incisors are usually retroclined,
producing an increased inter-incisal
angle. The lower lip rests high on the
labial face of the upper central
incisors, with the lateral incisors often
proclined and mesiolabially rotated,
but they too may be retroclined. The
lower anterior face height tends to be
reduced.
Overall, the dental and facial
appearance may be aesthetically
acceptable and thus many younger
patients may not seek treatment.
Consequently, a number of cases
present when older, demonstrating
both hard and soft tissue damage. The
most common findings are gingival
recession and root surface attrition,
but tooth loss may occur in
particularly severe cases (Figures 1a
and b). The potential for gingival
trauma arises directly from the
offending incisal edge or indirectly
AETIOLOGY OF TRAUMA
An increased inter-incisal angle
introduces traumatic potential but a
number of other factors in the adult
patient may predispose to damage
occurring.
Gingival Inflammation
Plaque-induced gingival swelling may
predispose to secondary direct trauma
from the opposing incisal edge. A
vicious circle may then be established
leading to further mandibular labial
recession or palatal hyperplasia.
Reduction in Posterior
Occlusion
Loss of posterior support may lead to
overclosure with subsequent
deleterious effect on the soft tissues
(Figures 3a and b).

Dental Update – March 2004 83

 O R T H O D O N T I C S
a b
c d
Figure 1. The traumatic overbite (a) has
resulted in gingival recession and root attrition
(b). The patient reported loss of a lower incisor
due to fracture of the tooth whilst eating. The
malocclusion has been corrected by utilizing
lower segmental surgery and mandibular
advancement (c, d).
Tilting of Anterior Teeth
Wragg et al.3 have suggested that the
lower incisors may tilt lingually under
the influence of a strong lower lip
following the loss of posterior teeth.
Instability may thus be introduced
into a previously stable incisal
relationship. Data are lacking with
regard to this possibility.
Restorative Procedures
Alteration of the posterior occlusion
may introduce deflective contacts
leading to an unstable incisal
relationship. Alternatively,
construction of a partial-coverage
occlusal splint without controlling the
lower incisors may allow over-
eruption of the incisors with
subsequent trauma, especially if the
splint is discarded at a later stage
(Figure 4).
Bruxism
The trauma to the tissues caused by
nocturnal clenching and grinding
84
habits may be exacerbated by the
irregular incisal edges produced by
these parafunctional habits.4
Orthodontic Treatment
Injudicious extraction of lower first
premolars in a Class II division 2
malocclusion may cause a worsening
of the inter-incisal angle and increase
the traumatic potential if effective
appliance therapy is not provided
(Figures 5a, b and c).
a b
Figure 2. Porcelain restorations in the presence of an increased inter-incisal angle (a) have
produced attrition of the lower incisors (b).
ORTHODONTIC/SURGICAL
ASSESSMENT
The initial stage in any treatment
regimen involves oral hygiene
measures to eliminate plaque-induced
inflammation and swelling. This alone
may eliminate trauma from the opposing
incisal edge. More complicated
treatment may be required, however, in
severe cases owing to the extensive
trauma that may already have occurred.
Correction of the inter-incisal angle is
the preferred option in this group of
patients to relieve symptoms and
achieve occlusal stability. In the
growing individual, it is often possible
to correct the malocclusion
orthodontically owing to the potential
of increasing the vertical dimension.
Encroachment on the freeway space
will be temporary and further vertical
growth will produce a permanent
reduction in overbite. However, in the
older patient presenting with trauma,
orthodontics will often need to be used
in conjunction with orthognathic
surgery to correct the inter-incisal angle
and achieve a stable vertical result. A
number of features need to be assessed
in order to establish the appropriate
orthodontic/surgical approach to
treatment.
Severity of the Antero-
posterior Discrepancy
As the antero-posterior discrepancy
increases, so too does the likelihood
that the patient may benefit from a
surgical procedure to obtain a stable
result. The skeletal discrepancy may
be assessed cephalometrically using A
Dental Update – March 2004
 O R T H O D O N T I C S
a b
c d
e correction of the overbite. The source
and B points, but it is more useful to
establish the relationship of the lower
incisal edge to upper incisor root
centroid (Figure 6).
The upper incisor root centroid is
located at the midpoint of the long axis
of the root. It has been reported that
the antero-posterior relationship of the
lower incisor edge to the upper incisor
root centroid is more strongly related
to overbite depth than the inter-incisal
angle.5 In Class I cases, the lower
incisor edge lies, on average, 2 mm
ahead of the upper incisor centroid.
The Class II division 2 malocclusion is
characterized by a negative edge-
centroid relationship. The further the
86
Figure 3. Loss of posterior teeth (a) has
led to overclosure (b, c) and produced a
traumatic anterior contact. Following
proclination of the upper incisors (d), a
mandibular advancement was undertaken
(e).
lower incisor edge is behind the upper
centroid, the more difficult the
correction using orthodontics alone
and the greater the potential for
instability. Correction of the edge-
centroid relationship may be
accomplished by anterior movement of
the lower incisors or by posterior
positioning of the upper centroid.
However, palatal movement of the
upper incisor roots is technically
difficult and is limited by the amount
of bone available. Forward movement
of the lower incisor edges, although
desirable in many Class II division 2
cases, may not be feasible in this
group of patients, owing to the
gingival recession which has already
occurred and reduced thickness of the
remaining gingivae. Any anterior
movement of the teeth, using
orthodontics alone, may lead to
deterioration in the periodontal
condition.
Therefore, the greater the lower
incisor edge to upper root centroid
discrepancy, the more likely that a
combined orthodontic/surgical
approach will need to be utilized.
The Vertical Problem
An increased overbite may be due to
an increased curve of Spee in the
lower arch, a reverse curve in the
upper or a combination of the two.
Some levelling of the occlusal plane
may be accomplished orthodontically
but, in severe cases demonstrating
trauma, surgery will usually be
necessary to achieve a stable
of the increased overbite must be
established initially since this will
dictate the type of surgery required.
In the presence of an increased
curve of Spee in the lower arch, the
occlusal plane may be levelled by
extruding the posterior teeth or
intruding the anterior teeth. A lower
labial segment set-down (Köle
procedure)6 may be appropriate in
those cases in which over-eruption of
the lower incisors has occurred, as
evidenced by an increased lower
dento-alveolar height (Figure 7a). This
height is measured from lower incisor
edge to menton and averages 44 mm in
males and 40 mm in females. Mandibular
Figure 4. A splint has been provided for this
patient but posterior bite blocks will allow further
incisor eruption unless incisor stops are also
established.
Dental Update – March 2004
 O R T H O D O N T I C S

advancement may also be required in

a b
conjunction with the segmental surgery
to correct antero-posterior
discrepancies (Figures 7b and c).
In the presence of a reduced lower
anterior face height and low maxillo-
mandibular plane angle, the aim of
treatment should be to increase these
dimensions. This will necessitate an
emphasis on posterior eruption as
c opposed to anterior intrusion. Minimal
levelling of the occlusal plane should
be undertaken orthodontically in order
Figure 5. Extraction of lower first premolars to avoid intrusion of the lower
(a) has allowed lingual tilting of the lower incisors. Mandibular surgery is
incisors with a further increase in the inter- undertaken instead to allow
incisal angle (b, c).
advancement of the lower anterior
teeth into the correct position to
facilitate posterior tooth eruption
(Figure 8).
Alternatively, a reverse curve of
Spee in the upper arch may be the
main source of the increased overbite.
Some levelling of this curve will occur
by relative incisor intrusion, as the
a b upper incisors are proclined towards a
normal inclination. A surgical
procedure may, however, be required
to correct the vertical level of the
upper labial segment in more severe
cases. The relationship of the incisal
edge to the upper lip needs to be
examined (Figure 9a). This is an age-
dependent measure exhibiting sexual
dimorphism. Younger patients have
increased incisor exposure, with
females showing more incisor than
Figure 6. Ideal relationship of lower incisor edge to upper incisor root centroid, measured as
males. In those cases in which upper
perpendicular projections to the maxillary plane (a). Relationship in a Class II division 2 case (b).
incisor show is normal or reduced in

a b c

Figure 7. Lower dento-alveolar height increased to 58 mm (a). Following proclination of upper incisors (b), lower labial setdown and
mandibular advancement undertaken in order to correct the overbite (c).

Dental Update – March 2004 87

 O R T H O D O N T I C S
a b
c d
Figure 8. The lower dento-alveolar height is
normal and the lower face height reduced.
Segmental surgery should not be used to level
the occlusal plane (a, b). Mandibular
advancement was undertaken to correct
vertical discrepancy (c, d).
a b
c may be checked easily by forward
Figure 9. This patient has excessive incisor show
(a) and a marked vertical step in the upper
arch (b, c). This may indicate the need for a
surgical procedure to intrude the upper labial
segment.
relation to the upper lip, intrusion of
the upper labial segment would be
contra-indicated since it would lead to
a further reduction in upper incisor
show. If upper incisor show is
88
increased and there is a marked
vertical step in the arch, surgical
repositioning of the upper labial
segment may be indicated (Figure 9b
and c).
In many cases, however, both arches
contribute to the vertical discrepancy
and a combination of the above
procedures may be required to correct
the problem.
ORTHODONTIC
CONSIDERATIONS IN
SURGICAL CASES
When a treatment plan has been
decided involving surgery,
orthodontic preparation consists of
decompensation of the upper incisors
and co-ordination of the arches.
Proclination of the upper incisors is
undertaken to facilitate movement of
the lower teeth/mandible into the
correct position. This will also reduce
occlusal interferences and allow
placement of the lower appliance.
Proclination of the upper incisors will,
however, tend to produce spaces
throughout the arch. This will be
particularly noticeable in those cases
with minimal crowding, severely
retroclined incisors (Figure 10a) or
previous premolar extractions.
Although measures may be taken to
reduce or eliminate this spacing, the
patient should be forewarned about
the possibility of residual spacing
(Figures 10b and c).
Co-ordination of the arches is often
facilitated by the presence of a pre-
existing lingual crossbite (scissors bite)
that corrects as the mandible is
advanced. Active orthodontic correction
of the lingual crossbite is therefore often
not required. The arch co-ordination
posturing of the mandible when the
upper incisor inclination has been
corrected.
In cases involving segmental surgery,
space will need to be generated to
facilitate the surgical cuts and thus
avoid iatrogenic root damage that has
been reported to occur in up to 6% of
teeth adjacent to the cut sites in
segmental surgery.7 Stepped archwires
will need to be used to preserve the
different vertical levels of the anterior
and posterior segments prior to surgery.
Loops may be used to generate space
distal to the labial segment or,
Dental Update – March 2004
 O R T H O D O N T I C S

a b c

Figure 10. Very retroclined upper incisors with minimal crowding (a). Proclination has produced an excess of space which may be difficult to close
whilst maintaining the correct inclination of the incisors (b, c).

a b alternatively, a space-opening coil may

be placed on the archwire (Figures 11a
and b). If a space-opening coil is used,
the bends in the archwire should not be
too sharp or free sliding of the pushcoil
will be impeded. The step in the
archwire is introduced in the initial
aligning archwire and replicated in all
subsequent wires. The stepped
archwire is removed at the time of
c surgery and after surgical levelling of
the occlusal plane; a flat archwire is
placed.
Bracket variation in positioning or
prescription may also be used to
encourage root divergence adjacent to
the cut sites to reduce the risk of root
trauma further. In a case in which a
lower labial segment setdown is
planned for example, the lower canine
brackets may be reversed, i.e. the right
canine bracket placed on the left canine
and vice versa. This will produce a
distal angulation of the canines as
opposed to the normal mesial
d
angulation. The mesial positioning of
the canine root will improve surgical
access by providing more space for the
planned cuts between the canine and
premolar (Figures 11c and d).
The surgical plan should aim to over-
correct the overbite and overjet slightly
because post-surgical relapse will
usually lead to a slight increase in
overbite. This over-correction will help
to ensure that the overbite is optimal
following removal of all appliances. If
the surgical orthodontics have been
executed correctly, with positioning of
Figure 11. Space-opening coil placed on stepped archwire in order to generate the space for the lower incisor edge ahead of the
segmental cuts (a, b). An OPG shows the mesial angulation of the canine roots produced by upper incisor centroid, the prognosis
reversal of the lower canine brackets (c). An OPG of the patient following lower segmental surgery for a stable result is good.
and mandibular advancement (d).

90 Dental Update – March 2004


CONCLUSION
In common with the majority of oral
conditions, prevention is better than cure.
This statement is particularly valid in
relation to trauma associated with a Class
II division 2 malocclusion in which late
treatments are particularly difficult from
both orthodontic, surgical and restorative
perspectives.
Management should therefore consist
of:
l Identifying the younger patient with
an increased risk of trauma, i.e.
increased inter-incisal angle, severe
skeletal discrepancy, low maxillo-
mandibular plane angle or
unfavourable positioning of lower
incisor edge in relation to upper
incisor root centroid.
l Appropriate orthodontic treatment
when younger to correct the inter-
incisal angle. This may involve a
functional appliance, fixed appliances
BOOK REVIEW
Complete Dentures. From Planning to
Problem Solving. P. Finbarr Allen and
Seán McCarthy. Quintessence
Publishing Co. Ltd., New Malden, 2003
(119pp., £28.00). ISBN 1-85097-064-5.
This concise volume within the
Quintessence General Dental
Practitioner Series is aimed
predominantly at the GDP, although
may also be useful as a revision aid to
the undergraduate with some
theoretical and practical experience.
The opening chapter ‘Countdown to
Edentulousness’ is refreshing to see in
a complete denture text, and deals with
the concepts of managing the transition
from a failing dentition to the eventual
loss of all teeth. This is often
overlooked in classic textbooks, yet
possibly may be one of the greatest
keys to success in General Practice.
Subsequent chapters are arranged
logically and describe assessment, a
range of impression procedures, jaw
registration, aesthetics and occlusal
considerations, delivery and review
Dental Update – March 2004
O R T H O D O N T I C S
or a combination of appliances.
l Monitoring trauma in the older
patient in conjunction with
preventive advice.
l Progression of trauma would
suggest the need for either:
– Orthodontic treatment;
– Restorative therapy;
– Orthognathic surgery;
– Or a combination of the above
procedures.
l Reassessment to establish if any
further measures are required to treat
the sequelae of trauma once the
malocclusion has been corrected.
Root sensitivity or aesthetic
concerns regarding recession for
example may need to be addressed at
this stage.
This overview is intended to
encourage referral of patients with this
particular problem for orthodontic
assessment. Although some adults may
stages which includes a useful section
on problem solving. The penultimate
chapter describes ‘copy denture’
techniques, although modifications that
may be incorporated using these
techniques are only briefly described.
not be interested in an orthodontic/
surgical solution, the option should be
offered in view of the potential to obtain
a stable correction of the overbite.
REFERENCES
1. Foster TD, Walpole Day AJ. A survey of
malocclusion and the need for orthodontic
treatment in a Shropshire school population. Br J
Orthod 1974; 3: 73–78.
2. Todd J, Lader D. Adult Dental Health Survey, 1988.
London: HMSO, 1994.
3. Wragg PF, Jenkins WMM, Watson IB, Stirrups DR.
The deep overbite: prevention of trauma. Br Dent J
1990; 168: 365–367.
4. Kieser JB.Vestibular morphology and gingival health.
In: Periodontics: A Practical Approach. London:Wright,
1990: pp.312–318.
5. Houston WJB. Incisor edge-centroid relationships
and overbite depth. Eur J Orthod 1989; 11: 139–
143.
6. Köle H. Surgical operations on the alveolar ridge to
correct occlusal abnormalities. Oral Surg 1959; 12:
277–288.
7. Kohn MW, White RP, Jr. Evaluation of sensation
after segmental alveolar osteotomy in 22 patients.
J Am Dent Assoc 1974; 89: 154–156.
The final chapter gives a conceptual
introduction to the use of implants in
edentulous patients.
This text is a useful addition to the
literature and provides many useful tips
for the GDP, whilst reinforcing sound
prosthodontic techniques. Each
chapter is prefaced with specific aims
and outcomes, which help in the
understanding of the concepts
presented. Conclusions at the end of
each chapter reinforce key points.
Colour illustrations are generously
scattered throughout to emphasize
examples of both good and bad
practice.
There is a progressive reduction in
the numbers of patients becoming
edentulous, however for many it is
occurring at a later stage in life. Those
already edentulous are living longer
and require maintenance. Provision of
good quality, conventional
prosthodontics remains key to the
management of these patients. At under
£30, this book represents good value in
the continued educational process.
David C. Attrill
Birmingham
91