Volume 29 Issue 1 Article 3

2017

Non-surgical Treatment for a Patient with Angle Class II Division 2

Malocclusion with Severe Deep Bite: A Case Report
Yuan-Jung Wang
Department of Endodontics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of
Medicine, Taoyuan, Taiwan

Jia-Iin Chang
Department of Prosthodontics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University
College of Medicine, Taoyuan, Taiwan

Aaron Yu-Jen Wu
Department of Periodontics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of
Medicine, Taoyuan, Taiwan

Ren-Jye Chen
Ren-Jye Chen Orthodontic Clinic; Department of Orthodontics, Kaohsiung Chang Gung Memorial Hospital,
Chang Gung University College of Medicine, Taoyuan, Taiwan

Shiu-Shiung Lin
Department of Orthodontics, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College
of Medicine,
Follow Taoyuan,
this and Taiwan
additional works at: https://www.tjo.org.tw/tjo

Part of the Orthodontics and Orthodontology Commons

See next page for additional authors

Recommended Citation
Wang, Yuan-Jung; Chang, Jia-Iin; Wu, Aaron Yu-Jen; Chen, Ren-Jye; Lin, Shiu-Shiung; and Wu, Te-Ju (2017)
"Non-surgical Treatment for a Patient with Angle Class II Division 2 Malocclusion with Severe Deep Bite: A
Case Report," Taiwanese Journal of Orthodontics: Vol. 29 : Iss. 1 , Article 3.
DOI: 10.30036/TJO.201703_29(1).0003
Available at: https://www.tjo.org.tw/tjo/vol29/iss1/3

This Case Report is brought to you for free and open access by Taiwanese Journal of Orthodontics. It has been
accepted for inclusion in Taiwanese Journal of Orthodontics by an authorized editor of Taiwanese Journal of
Orthodontics.
Non-surgical Treatment for a Patient with Angle Class II Division 2 Malocclusion
with Severe Deep Bite: A Case Report

Authors
Yuan-Jung Wang, Jia-Iin Chang, Aaron Yu-Jen Wu, Ren-Jye Chen, Shiu-Shiung Lin, and Te-Ju Wu

This case report is available in Taiwanese Journal of Orthodontics: https://www.tjo.org.tw/tjo/vol29/iss1/3

 Case Report

Non-surgical Treatment for a Patient with

Angle Class II Division 2 Malocclusion with
Severe Deep Bite: A Case Report
1 2 3 4,5 5 5
Yuan-Jung Wang, Jia-Iin Chang, Aaron Yu-Jen Wu, Ren-Jye Chen, Shiu-Shiung Lin, Te-Ju Wu,
1
Department of Endodontics, Kaohsiung Chang Gung Memorial Hospital,
Chang Gung University College of Medicine, Taoyuan, Taiwan
2
Department of Prosthodontics, Kaohsiung Chang Gung Memorial Hospital,
Chang Gung University College of Medicine, Taoyuan, Taiwan
3
Department of Periodontics, Kaohsiung Chang Gung Memorial Hospital,
Chang Gung University College of Medicine, Taoyuan, Taiwan
4
Ren-Jye Chen Orthodontic Clinic
5
Department of Orthodontics, Kaohsiung Chang Gung Memorial Hospital,
Chang Gung University College of Medicine, Taoyuan, Taiwan

This report describes a non-surgical orthodontic treatment for a 36-year-old male patient who had Class II
division 2 malocclusion (Class II/2) with deep bite more than 100%, gingival recession, and periodontal abscess
in the mandibular anterior region. Patient had history of trauma in region. The surgical intervention was once
suggested but was refused by the patient. The compromised but acceptable final results were achieved by non-
surgical approach.
The treatment plan included periodontal control, maxillary incisor intrusion and restoration of the collapsed
occlusion. The total treatment duration was 43 months. The patient was satisfied with the treatment outcomes via
interdisciplinary approach which were stable with no further complaints. (Taiwanese Journal of Orthodontics.
29(1): 16-27, 2017)

Keywords: deep bite; Class II division 2 malocclusion; interdisciplinary treatment

INTRODUCTION
of Class II/2 malocclusion has been modified according
2-4
The orthodontic treatment for Class II division 2 to various viewpoints. Besides mesially positioned
malocclusion (Class II/2) is challenging. Ever since the molars and canines, the common characters of the Class
1
first description by Dr. E.H. Angle in 1907, the definition II/2 malocclusion include the retroclined maxillary central

Received: May 12, 2016 Revised: March 10, 2017 Accepted: March 13, 2017
Reprints and correspondence to: Dr. Te-Ju Wu, Department of Orthodontics, Kaohsiung Chang Gung Memorial Hospital No.123,
Dapi Rd., Niaosong Dist., Kaohsiung City 833, Taiwan (R.O.C.)
Tel: 07-7317123 ext. 8291 E-mail: [email protected]

16 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

 Class II Division 2 Malocclusion with Deep Bite

incisors, excessive overbite and an obtuse interincisal compromised result, temporary anchorage devises (TADs)
2,4
angle. were used to intrude the maxillary incisors to correct the
Various treatment suggestions could be proposed to extreme deep bite. The results of this interdisciplinary
the same patient with Class II/2 malocclusion depending treatment not only successfully rehabilitated patient’s
on each orthodontist’s treatment philosophy. However,
occlusion but also improved the periodontal status of
the relief of the excessive overbite is always important in
mandibular incisors remarkably.
treating Class II/2 malocclusion. To correct the deep bite,
factors to be considered including facial profile, vertical
CASE REPORT
skeletal dimension, and stability of final occlusion.
According to different conditions and treatment goals, A 36-year-old male patient was referred from the
the deep bite can be corrected by incisor intrusion, molar periodontoal department for evaluation of orthodontic
2,4
extrusion, or combination of both.
treatment. His chief complaints were painful swelling
We presented a non-surgical orthodontic treatment
in the lower anterior gingiva for months and seeking for
for a patient with trauma history over chin area in his
of full mouth rehabilitation. He denied major systemic
teenage. The absence of incisor support and extremely
disease and drug allergy. His past dental history revealed
deep bite induced gingival recession with periodontal
accidental trauma history over chin area in teenage
abscess surrounding his lower incisors. In addition to the
(Figure 1). After that, the occlusal condition got worse
decreased anterior vertical dimension, the patient also
suffered from the collapsed posterior occlusion for years. according to patient’s statements. Although the phase I

Considering such a critical situation, surgical- periodontal treatment had been performed to alleviate

orthodontic therapy was once recommended but was acute periodontal inflammation, whitish exudate was still

refused by the patient. With understanding the possible noted at the appointment of referral.

Figure 1. The scar indicated trauma history of the chin region of this patient.

Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1 17

Wang YJ, Chang JI, Wu YJ, Chen RJ, Lin SS, Wu TJ

Clinical findings
The patient had a Class II division 2 malocclusion facial mandibular plane angle (FMPA, 14°) that matched
on a skeletal class II jaw bone relation. His facial profile the extra-oral impression, and excessive maxillary and
exhibited a decreased lower facial vertical dimension. The mandibular incisor eruption (Figure 3 and Table 1). The
dental characteristics showed different occlusal plane level panoramic radiograph revealed missing teeth 15, 16, 36,
between anterior and posterior dentitions, the maxillary and 46, complicated crown fracture of teeth 23 and 31
dental midline shift toward left side for 1.0 mm, excessive which were previously treated with endodontic therapy,
curve of Spee and collapsed posterior occlusion. His deep bilateral impacted mandibular third molars, and metal
bite was more than 100%, caused dental abrasion, gingival crown at right mandibular second molar (Figure 4). The
recession and periodontal abscess over lower incisors periapical radiographs presented periodontal defects in
(Figure 2). the mandibular anterior region especially around the right
The lateral cephalometric radiographic examination central incisor (Figure 5).
revealed Class II skeletal base (ANB: 5°), decreased

Figure 2. The extraoral and intraoral photographs before treatment.

18 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

 Class II Division 2 Malocclusion with Deep Bite

Figure 3. The lateral cephalometric radiographic film before treatment.

Table 1. Comparison of cephalometric analytical results before and after orthodontic treatment

Norm Initial Finished

81 ± 3 ° SNA 88 ° 86 °

78 ± 3 ° SNB 83 ° 81 °

3±2° ANB 5° 5°

30.1 ± 5.3 ° SN-MP 19 ° 20.5 °

107.4 ± 7 ° U1– SN 85 ° 99 °

4.9 ± 1.6 mm U1-A⊥ -2.5 mm 0 mm

25.00 ± 2.14 mm U1-PP 32 mm 28 mm

90 ± 6 ° L1– Md 79 ° 90 °

4 ± 1.8 mm L1– NB -2.5 mm 0 mm

36.42 ± 2.56 mm L1-Md 43 mm 38 mm

0 ± 2 mm R. E-line (U) -1.5 mm -2 mm

0 ± 2 mm R. E-line (L) -1 mm -3 mm

Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1 19

Wang YJ, Chang JI, Wu YJ, Chen RJ, Lin SS, Wu TJ

Figure 4. The panoramic film before treatment.

Figure 5. The full mouth periapical films before treatment. Note the periodontal defects in surrounding
mandibular anterior region especially around the mandibular right central incisor.

20 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

 Class II Division 2 Malocclusion with Deep Bite

Treatment objectives Treatment alternatives

The treatment objectives were setup based on The alternative treatment plan was combined with
patient’s chief complaints and clinical findings, as surgical intervention. The overall treatment plan includes:
followings: (1) extraction of bilateral mandibular impacted third
(1) to relieve occlusal trauma over lower anterior region molars and maxillary left canine.
(2) to create adequate overjet and overbite (2) surgical site preparation for maxillary anterior
(3) to achieve solid buccal interdigitation segmental osteotomy (ASO).
(4) to establish proper occlusal vertical dimension (3) 2-jaw orthognathic surgery: maxillary ASO impaction
(5) to manage the dental space for prosthesis fabrication and mandibular BSSO advancement.
(4) management for vertical dimension and space
Treatment plan
distribution for prosthetic work.
This non-surgically treatment was applied in
conjunction with periodic periodontal control and Treatment progress
prosthodontic treatment. The orthodontic treatment plan After explanation and discussion of possible
included: treatment options, the patient agreed to have non-surgical
(1) extraction of bilateral mandibular impacted third orthodontic treatment. After the phase I periodontal
molars and maxillary left canine. control, the orthodontic treatment was initiated. Fixed
(2) temporary anchorage devices (TADs) to facilitate orthodontic appliance was placed only on maxillary
maxillary incisor intrusion. dentition at the beginning. Bilateral TADs were placed
(3) intentional endodontic treatment of teeth 31 and 41 interdentally since the fifth month for intrusion of
for further reduction of crown height, better crown- maxillary incisors with 0.016 x 0.022 inch stainless steel
root ratio, and improvement of the overbite. wire. As the intrusion of maxillary incisors progressed,
(4) increase of vertical dimension and space management the overjet increased gradually. At the ninth month, an
for future prosthetic construction. occlusal bite plate was fitted and cemented on maxillary
posterior dentition to further raise the bite and assisted the
patient to adapt to the tentative vertical dimension (Table 2).

Table 2. The treatment progress

Months of orthodontic treatment Treatment

0-4 Fixed orthodontic appliance was placed only on maxillary dentition

5-10 Bilateral interdental miniscrews

9 Occlusal bite plate was fitted and cemented on maxillary posterior dentition.

10 Fixed orthodontic appliances over mandibular dentition were placed

17-28 Temporary bridge fabrication: 14x17, 35x37, 45x47

35-42 Final prostheses delivery: 14x17, 22x24, 35x37, 45x47

43 Orthodontic treatment finished

Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1 21

Wang YJ, Chang JI, Wu YJ, Chen RJ, Lin SS, Wu TJ

Because of the gradual adaptation to the planned prostheses after worth. With patient’s confirmations
vertical dimension without discomforts, fixed orthodontic of acceptable occlusion for proper daily functions, all
appliances over mandibular dentition were then placed at the fixed appliances were removed. The total treatment
the tenth month (Figure 6). Further orthodontic adjustment duration was 43 months. The patient was satisfied with the
on maxillary dentition was finished on 0.018 × 0.025” treatment outcomes.
inch stainless steel wire. The lever arms were placed to Results
maintain the intruded maxillary incisors bilaterally. After treatment, the gingival status of mandibular
In the mandibular arch, preliminary leveling and incisors improved remarkably, with preservation of bone
alignment was gradually achieved by sequential change in levels and no signs of gingival inflammation or excessive
the wire sequence. The intentional endodontic treatments tooth mobility (Figure 7 and Table 1). Whereas the
of mandibular incisors were performed and then followed gingival heights could not return to the normal condition
by incisal reduction for further correcting the deep bite. (Figure 8 and Table 1). Also, adequate overbite and
Once the mesial-tilted mandibular second molars being functional prosthetic rehabilitation were achieved (Figure
uprighted, the provisional prostheses were placed for 9). We had ever suggested further incisor retraction by
assisting patient to adapt to the rehabilitated vertical bilateral TADs over infrazygomatic crests (IZCs), but
dimension. Bilateral Class II elastics were used for the patient declined. Although bilateral Class I canine
finishing and detailing. relationship could not be achieved, the patient was
After passive maintenance for three months satisfied with the treatment results and the periodontal
without complaints of discomfort, patient received final improvement (Figure 10).

th
Figure 6. The occlusal bite plate was fitted after the initial relief of deep bite (9 month).

22 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

 Class II Division 2 Malocclusion with Deep Bite

Figure 7. Overall and regional superimposition

of cephalometric tracing. Black line, initial; red
line: finish.

Figure 8. The gingival condition in before

and after orthodontic treatment.

Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1 23

Wang YJ, Chang JI, Wu YJ, Chen RJ, Lin SS, Wu TJ

Figure 9. The overbite and overjet in before and after treatment.

Figure 10. The extraoral and intraoral photographs after treatment.

24 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

 Class II Division 2 Malocclusion with Deep Bite

Figure 11. The periapical films of anterior teeth in before and after treatment.

The apical resorption of maxillary incisors was The treatment of Class II/2 malocclusion was challenging
observed after intrusive movement. There was a because of missing of the antagonists of bilateral molars
maximum 3 mm external apical root resorption among and left side canine. Besides the mesially drifted left
maxillary incisors, especially the right maxillary central maxillary molar and right side Class II canine relation,
incisor. However, there was no symptom and sign of any there were still other additional dental problems including
discomfort complained by patient regarding this tooth. the retroclination of maxillary central incisors, obtuse
The clinical condition and reasons of the root resorption interincisal angle and the excessive overbite.
were explained to patient and he fully understood (Figure It has been a long lasting discussion of the underlying
11). factors contributing to such a unique malocclusion.
At the end of treatment, the patient received Hawley
According to literatures, the Class II/2 malocclusion has
retainers for retention. Additional resin pad was designed
several skeletal characters including shorter mandibular
on the labial bow of mandibular retainer to facilitate bite 5 6
length, prominent chin, increased posterior facial height,
control. The prosthetic treatment of left mandibular central
hypodivergent facial pattern, and acute gonial angle
incisor was advised but patient decided to delay because
which all matched our case. On the other hand, the most
of economic consideration. The treatment outcome was
impressive dentoalveolar characters of this patient would
stable during recall examination.
be the traumatic deep bite that could be accounted for the
retroclination and supra-eruption of maxillary incisors
DISCUSSION
(Table 1). With regard to the mandibular incisors, the
In this report, we presented a case with Class cephalometric analysis revealed normal vertical position
II/2 malocclusion with excessive deep bite resulting of lower incisor relative to mandibular plane which was
7-9
periodontal damage surrounding mandibular incisors. in agreement with other studies. According to these

Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1 25

Wang YJ, Chang JI, Wu YJ, Chen RJ, Lin SS, Wu TJ

data, the intrusion of maxillary incisors was the primary after the intentional endodontics. Such a procedure would
solution to reduce the deep overbite. not only have less tipping of the lower incisors, but also
The non-surgical strategies for orthodontists to be helpful in overbite reduction.
correct the deep bite include incisor intrusion, extrusion An occlusal bite plate was essential for bite opening.
10-12
of posterior teeth and combination approach. The bite plate was placed to test the patient’s adaption to
Owing to the distortion of posterior occlusion, the bite the change of vertical dimension for future restoration. It
correction was initiated by TAD-facilitated intrusion of was not only beneficial in anchorage reinforcement during
maxillary incisors. The TAD-facilitated incisor intrusion retraction of maxillary incisors but also for incisor support
was reported to create a more intrusive movement but (contact) (Figure 6).
less labial crown torque of incisors as compared to the The incisor support (contact) was considered
13,14
traditional mechanism. It could also be applied in important to maintain the overbite correction. It has been
mandible but not in our case because of the limited labial reported the more-than 135 degrees of interincisal angle
plate and questionable periodontal condition of this 19
would be more promising in retention. It was a pity that
patient. we were not able to achieve such optimal condition after
The patient had periodontal disease with the treatment because of the insufficient mandibular labial
attachment loss over mandibular anterior teeth and plate and maxillary distalization. Patient declined another
periodontal abscess in the mandibular anterior region, TADs for the Class II correction. Trying to compensate
resulted from occlusal biting trauma from maxillary this drawback, we placed additional resin pad over the
incisors. In this situation, periodontal preparation was labial bow on the mandibular retainer.
20

important and should be performed before orthodontic The root resorption was not uncommon in cases
treatment following by intrusion of maxillary incisors 21
with maxillary incisor intrusion. The maxillary incisors
13
to eliminate trauma from occlusion. Another reason to were reported to be the most vulnerable teeth to have root
have periodontal control before the orthodontic treatment 22
resorption. The average amount of maxillary incisor
was based on the possible irreversible breakdown of the resorption was reported as 2 mm in routine orthodontic
periodontium when there was still inflammation during 23
treatment. It was suggested that orthodontists should
16.17
orthodontic treatment. It is recommended to observe avoid excessive intrusion and palatal root torqueing to
2 to 6 months after completion of active periodontal 24
reduce the amount of root resorption. However, large
therapy before bracket placement for periodontal tissue amount of incisal intrusion is required in this case. The
17
remodeling and evaluation of patient’s compliance. maximum amount of root resorption of maxillary incisors
There was a 10-month observation before the placement was less than 3 mm, and there was no any discomfort or
of mandibular orthodontic appliances to allow the
complaints during treatment and regular recall.
recovery from the occlusal trauma in this case. During this
period, gradual improvements of the periodontal health
CONCLUSION
surrounding the mandibular incisors were noted (Figure 8).
In periodontal compromised teeth, the loss of To correct the malocclusion with excessive overbite,
alveolar bone results in apical movement of the center of it was important to analyze the etiology, choose the
resistance of the involved teeth which could be prone to feasible treatment modalities and communicate with the
18
tipping movement. In this case, because of the thin labial patient for proper interdisciplinary intervention. The
plate, the reduction of incisor crown height was performed favorable treatment outcome was based on not only the

26 Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1

 Class II Division 2 Malocclusion with Deep Bite

practitioner’s skills but also patient’s compliance, patience 13. Aydoğdu E, Özsoy ÖP. Effects of mandibular incisor
and fully understanding of treatment objective and intrusion obtained using a conventional utility arch vs
limitation. bone anchorage. Angle Orthod 2011; 81:767-75.
14. Polat-Özsoy Ö, Arman-Özçırpıcı A, Veziroğlu F,
Çetinşahin A. Comparison of the intrusive effects
REFERECES
of miniscrews and utility arches. Am J Orthod
1. Angle EH. Treatment of Malocclusion of the Teeth Dentofacial Orthop 2011; 139:526-32
and Fractures of the Maxillae. 7th ed. Philadelphia, 15. Pinho T, Neves M, Alves C. Multidisciplinary
Pa: SS White Manufacturing Co; 1907; 50–52. management including periodontics, orthodontics,
2. Graber TM. Orthodontics Principles and Practice. implants, and prosthetics for an adult. Am J Orthod
Philadelphia, Pa: WB Saunders Co; 1962; 181–184. Dentofacial Orthop 2012; 142: 235–245
3. Moyers RE. Handbook of Orthodontics. Chicago, Ill: 16. Ong MA, Wang HL, Smith FN. Interrelationship
The Year Book Medical Publishers Inc; 1988; 188. between periodontics and adult orthodontics. J Clin
4. Proffit WR. Contemporary Orthodontics. St Louis, Periodontol, 1998; 25:271–277

Mo: Mosby Year Book Inc; 1993; 175–177. 17. Gkantidis N, Christou P, Topouzelis N. The

5. Brezniak N, Arad A, Heller M, Dinbar A, Dinte orthodontic-periodontic interrelationship in integrated

A, Wasserstein A. Pathognomonic Cephalometric treatment challenges: a systematic review. J Oral

Characteristics of Angle Class II Division 2 Rehabil 2010; 37:377–390

18. Ong MA, Wang HL. Periodontic and orthodontic
Malocclusion. Angle Orthod 2002; 72:251–257.
treatment in adults. Am J Orthod Dentofacial Orthop
6. Karlsen AT. Craniofacial characteristics in children with
2002; 122:420–428
Angle Class II division 2 malocclusion combined with
19. Schudy FS. The control of vertical overbite in clinical
extreme deep bite. Angle Orthod 1994; 64:123-130
orthodontics. Angle Orthod 1968; 38:19-39
7. Mills JRE. The problem of overbite in Class II
20. Graber TM: Orthodontics Principles and Practice.
division 2 malocclusion. Br J Orthod. 1973; 1:34–48.
Philadelphia, London, WB Saunders, 1972.
8. Ingervall B, Lennartsson B. Cranial morphology and
21. Dermant LR, DeMunck A. Apical root resorption of
dental arch dimensions in children with Angle Class II
upper incisors caused by intrusive tooth movement:
division 2 malocclusion. Odontol Rev 1973; 24:149–160.
a radiographic study. Am J Orthod Dentofac Orthop.
9. Smeets HJL. A roentgenocephalometric study of the
1986; 90:321-6.
skeletal morphology of Class II division 2 in adult
22. Weltman B, Vig KWL, Fields HW, Shanker S, Kaizar
cases. Eur Orthod Soc Rep 1962; 38:247–259.
E. Root resorption associated with orthodontic
10. Chen YJ, Yao CCJ, Chang HF. Nonsurgical correction
tooth movement: A systematic review. Am J Orthod
of skeletal deep overbite and class II division 2
Dentofacial Orthop. 2010; 137:462-76.
malocclusion in an adult patient. Am J Orthod 23. Harris EF, Baker WC. Loss of root length and crestal
Dentofacial Orthop 2004; 126:371–378. bone height before and during treatment in adolescent
11. Nanda R. Biomechanics and esthetic strategies in and adult orthodontic patients. Am J Orthod Dentofac
clinical orthodontics. St Louis, Elservier, 2005; 131- Orthop 1990; 98:463-9.
155. 24. Parker RJ, Harris EF. Directions of orthodontic
12. Nanda RS, Tosun YS. Biomechanics in orthodontics, tooth movements associated with external apical
principles and practice. Hanover Park, Quinterssence, root resorption of the maxillary central incisor. Am J
2010; 99-124 Orthod Dentofacial Orthop 1998; 114:677-8.

Taiwanese Journal of Orthodontics. 2017, Vol. 29. No. 1 27