The Saudi Journal for Dental Research (2016) 7, 7379

King Saud University

The Saudi Journal for Dental Research

www.ksu.edu.sa
www.sciencedirect.com

CASE REPORT

A two stage non extraction treatment of class II

division 1 malocclusion using split-activator and
xed appliance A case report
a,1,*
Ambesh Kumar Rai , Anand Patil b, Sanjay V. Ganeshkar b

a
Al Reef Dental and Orthodontic Centre, Ras Al Khaimah, United Arab Emirates
b
Department of Orthodontics, SDM College of Dental Sciences and Hospital, Dharwad, Karnataka, India

Received 28 December 2014; revised 12 April 2015; accepted 13 April 2015

Available online 1 May 2015

KEYWORDS Abstract Class II malocclusions are one of the most common problems in orthodontic treatment.
There are a variety of effective and simple treatments to correct them, such as headgear and func-
Activator;
tional appliances. Functional appliances are commonly used for the treatment of class II malocclu-
Class II malocclusion;
sions with mandibular deciency. The success of treatment with a functional appliance relies on the
Functional appliance
patients cooperation and favourable mandibular growth. Treatment with a functional appliance
usually lasts for 912 months and requires a proper retention time to ensure complete musculoskele-
tal adaptation.
A second stage of treatment with a full-xed appliance is often required to achieve proper alignment
and good interdigitation of the dentition. In the present case, a prepubertal twelve year female with
a class II malocclusion and retrusive mandible was treated rst with an activator for 17 months. The
activator successfully resolved the problem of the retrusive mandible with favourable mandibular
growth. This was followed by 10 months of xed orthodontic treatment to nalize the occlusion
without extractions. This two phase treatment yielded a pleasing prole and good occlusion in this
patient.
2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

* Corresponding author. Tel.: +971554841061. 1. Introduction

E-mail address: ambeshrai@gmail.com (A.K. Rai).
1
The corresponding author was a post graduate student of Depart-
ment of Orthodontics, SDM College of Dental Sciences and Hospital
at the time this work was carried out.
Peer review under responsibility of King Saud University.
Production and hosting by Elsevier
Class II malocclusions are one of the most common problems
seen by an orthodontists. In growing patients, two-phase
treatment of class II skeletal malocclusions, which includes
growth modication with functional appliances followed by
orthodontic treatment with xed appliances, has been advo-
cated as an appropriate treatment approach.1,2 As with all
orthodontic treatment modalities, the primary goals of growth

http://dx.doi.org/10.1016/j.sjdr.2015.04.003
2352-0035 2015 The Authors. Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
74
modication are both to correct the skeletal discrepancy and
to achieve optimal facial aesthetics.
Several important benets have been attributed to the treat-
ment of class II malocclusion at an early date: prevention of
trauma to the maxillary incisors associated with large overjet,
interception of developing dysfunction, psychological advan-
tages for the child during an important formative period of
life, and improved prognosis for the adolescent phase of
treatment.3
2. Background
According to McNamara the most frequent skeletal problem
in class II malocclusion in preadolescents is mandibular retrog-
nathia.4 Hence, any appliance that demonstrates the ability to
stimulate signicant mandibular growth would be an impor-
tant asset to a clinicians armamentarium. Animal studies have
demonstrated that appliances which position the mandible
anteriorly can stimulate signicant mandibular growth, pri-
marily by enhanced remodelling response at the condylar
region.5,6 The purpose of functional therapy is to change the
functional environment of the dentition to promote normal
function.7 Most of the functional appliances are designed to
enhance the forward growth of the mandible by encouraging
a functional displacement of the mandibular condyles down-
ward and forward in the glenoid fossa. This is balanced by
an upward and backward pull in the muscles supporting the
mandible. Adaptive remodelling may occur on both articular
surfaces of the temporomandibular joint to improve the posi-
tion of the mandible relative to the maxilla.6,7
Two of the most widely used functional appliances for
orthopaedic correction of class II skeletal malocclusions used
functional appliances are the activator and the twin block.8
The skeletal and dentoalveolar effects of activators have been
well documented.912
The activator and its successors provide a greater contact
area with the mandibular teeth and lingual mucosa and thus
are more effective in stimulating the patient to position the
mandible forward constantly. In addition to modication of
jaw growth, the effects of an activator also include proclina-
tion of the lower incisors and retroclination of the upper inci-
sors resulting in a decrease in the overjet. The activator loads
the lingual surfaces of the lower incisors and can procline them
gradually because of the reciprocal intermaxillary traction
while the patient occludes into the construction bite. Dental
movement can be used to our advantage in treatment if the
Figure 1 Pretreatment extraoral picture.
A.K. Rai et al.
lower incisors have been retroclined and the upper incisors
proclined due to lip habits often seen in individuals with an
increased overjet. The acrylic framework of the activator pro-
vides contact with all teeth and the erupting posterior teeth can
be redirected mesially or distally with selective grinding of the
acrylic framework. Despite its simple design, an activator can
be used to change the dental relationship in all three planes of
space with proper adjustment.1315
Another popular functional appliance is the Twin Block.
Due to its simple design and ease of use, the TB can be worn
24 h a day and takes full advantage of all the functional forces
applied to the dentition, including those of mastication.
Another advantage of the TB is that it can be used with xed
appliances.7,8
3. History, clinical ndings and diagnosis
A 12 year pre-pubertal female patient presented to the
Department of Orthodontics, SDM college of Dental
Sciences and Hospital, Dharwad, with the chief complaint of
forwardly placed front teeth. Examination of the case was car-
ried out following a standardized protocol followed at the
department and summarized herein:
3.1. Extra oral examination Fig. 1(ad)
(a) Frontal view
i) Facial symmetry: Apparently symmetrical
ii) Facial thirds: Proportional
iii) Incisor exposure: 4 mm at rest
(b) Prole view
i) Facial prole: Convex
ii) Lip protrusion: Protruded with lower lip trap
iii) Chin: Receding
3.2. Intra oral examination Fig. 2(ac)
(a) Teeth present:
76E432112CDE6
6E43211234567
(b) Molar relationship: End on bilaterally
(c) Canine relationship: End on bilaterally
Class II Division 1 correction using split activator 75

Figure 2 Pretreatment intraoral picture.

(d) Overjet: 10 mm (1) Functional appliance to correct the underlying skeletal

(e) Overbite: 5 mm discrepancy followed by xed mechanotherapy for nal
(f) Midline: Matching detailing.
(2) Upper rst premolar extraction and dental camouage.

3.3. Habits The two phase treatment plan was deemed more appropri-
ate for this case and the patients parent consented for this plan
(a) Sucking on lower lip understanding the cost benet ratio being, the possibility of
(b) Simple tongue thrust correction of skeletal discrepancy and possibility to treat by
non extraction. However, with an increased treatment timing
and extra cost involved. The positive VTO was the best moti-
3.4. Radiological ndings: Table 1 vation for the parents to opt for this plan.

3.8. Phase I treatment: functional appliance therapy

(a) Skeletal sagittal class II with normal divergent jaw bases
and proclined upper and lower incisors.
(b) MP3 (growth status): F stage
3.5. Visual treatment objective (VTO)
Positive
3.8.1. Appliance selection
Twin block with headgear or twin block alone versus activator.
A twin block with headgear was the rst choice as it pro-
vided the comfort of function, the advancement of mandible,
restriction of maxillary growth. However, was not used due
to multiple concerns of the parents being:

(a) The patient was a hosteller so would not be under their

3.6. Diagnosis
Angles class II (end on) division 1 malocclusion on a skeletal
class II normal divergent jaw bases with the presence of simple
tongue thrust and lower lip sucking habit.
3.7. Treatment plan
Considering the skeletal and dental discrepancy two treatment
approaches were thought appropriate:
supervision for proper headgear use.
(b) Children might tease her, ght during play which might
cause her injury.
(c) They will not be immediately available to attend to her
in event of any unforeseen happening and teachers at
the school might be of little help in handling such a
scenario.
(d) Appointment scheduling was to be kept to minimal as
the parents went to see the child just over the weekend
and school was far so closely placed appointments
would entail missing the school frequently.

Table 1 Cephalometric values for the patient.a Considering the aforementioned concerns an appliance was
Cephalometric Pre Post Post sought that was easy to use, sturdy enough not to break easily
variable treatment functional treatment or distort with a bit of rough handling, need minimal schedul-
SNA 84 85 85 ing. An activator was zeroed as the appliance of choice for this
SNB 75 80 80 case because:
ANB 9 5 5
U1-SN 126 113 103 (a) Very easy to use
L1-MP 99 100 103 (b) Sturdy
U1-A Pog 54, 15 mm 45, 10 mm 36, 6 mm (c) Appointments spaced apart
L1-A Pog 22, 4 mm 22, 2 mm 27, 3 mm (d) Could easily be removed during play or during class-
Inter-incisal angle 115 112 108 minimizing the danger of injury or discomfort during
Maxillary lengthc 87 89 90
speech. Besides, unlike twin block which has an upper
Mandibular lengthc 103 117 118
Bjork sum 390 394 401
and lower block, activator is a single piece appliance
Sn-GoGn 31 24 26 which further minimizes the chance of patient losing
Y-axis 68 69 71 one member and defeating the purpose of treatment.
a (e) Lastly, the effects of activator and twin block treatment
All values in degree unless specied.
have been documented to be similar.16
76
3.9. Design and construction: Fig. 3
A vertical height of 5 mm in the premolar region and advance-
ment of 7 mm was planned. Since, the advancement of mand-
ible resulted in a cross bite an expansion screw was
incorporated for transverse maxillary expansion which was
to be activated every weekend when the parents went to see
the child.
This had three advantages being, rstly, the screw was
properly activated as directed, the parents had the chance to
observe the appliance regularly so any gross distortions could
be detected and the parents were directly involved in their
childs treatment and hence were motivated to continue and
encourage the child to cooperate thus minimizing the dropout
from the therapy.
The labial bow was split to allow for arch expansion to
happen.
3.10. Appliance use and appointment scheduling
Basic appliance care instruction was explained to the patient.
She was asked to use the appliance after dinner around 8 pm
to 7 am and after coming from classes till going for play in
Figure 3 Split activator.
Figure 4 Post functional extraoral picture.
A.K. Rai et al.
the evening that roughly added another 3 h, amounting to
around 14 h a day and any other time when she was free.
She was also to wear the appliance full time on all Sundays.
The rst two appointments were spaced at a week interval
to assess the comfort and compliance of the patient. The
patient was extremely cooperative with the appliance use.
Thereafter, recall was scheduled at 2 months apart for any
adjustments needed and selective grinding of the cusps to redi-
rect the erupting teeth.
3.11. Follow up
Selective grinding of the acrylic framework was performed to
allow permanent teeth eruption during phase I treatment.
The patient had good compliance and maintained good oral
hygiene. The upper arch was expanded to correct buccal cross
bite and the space obtained in the anterior segment was to be
used later during xed mechanotherapy for intrusion and
retraction that may be needed.
After 1 year and 5 months of phase I treatment, the patient
showed an improved facial prole and bilateral super Class I
molar and canine relationship. The excessive curve of spee of
the lower arch was also levelled by the selective grinding to
encourage lower posterior teeth eruption. Figs. 4(ad) and
5(ac) show post functional pictures of the patient.
Meanwhile, the patient also attained her menarche towards
the end of functional phase.
3.12. Phase II treatment: xed mechanotherapy
The treatment aims of the early phase treatment were to reduce
the overjet and correct the class II molar relationship, while the
aim of phase II treatment was to achieve good interdigitation
without extractions.
The case was strapped up from rst molar to rst molar
using 0.022 inch slot; metal brackets; Pre adjusted Edgewise
Appliance with MBT versatile+ (3M Unitek, Monrovia,
California) prescription and a sequence of 0.014 inch,
0.018 inch and Unitek Nitinol Heat-Activated Wire (3M
Unitek, Monrovia, California) wires were used for aligning fol-
lowed by 0.018 inch Australian stainless steel (A.J. Wilcock,
Victoria, Australia) wire with class II elastics to maintain the
occlusion. Stripping of lower anterior to gain about 3 mm
space was carried out and the space was used for up-righting
and intruding the lower anterior. Final nishing was done with
0.014 inch Australian Stainless steel wire with short class II
Class II Division 1 correction using split activator 77

Figure 5 Post functional intraoral picture.

Figure 6 Post treatment extraoral picture.

Figure 7 Post treatment intraoral picture.

elastics. The xed appliance phase took 10 months to nish.
Figs. 6(ad) and 7(ac) show post treatment pictures of the
patient.
4. Retention
Wrap around retainer with anterior bite plane were given for
full time use for 1 year and thereafter night time use for
6 months.
4.1. Critical evaluation of treatment result
Numerous researches have shown that the activator inuences
the dentoalveolar region predominantly.1719 However, there
are some arguments over the orthopaedic effects of the appli-
ance. While some authors claim that the skeletal effect of the
activator therapy is attributed to the restrictive of maxillary
growth, others hold the opinion that the activator stimulates
condylar and as a result the mandible grows.20,21 An inuence
on glenoid fossa remodelling has also been reported by some
workers.22,23
In our case however, when treatment changes were com-
pared with pre treatment, post functional and post treatment
superimpositions (Fig. 8a and b) a predominance of den-
toalveolar changes over skeletal.
The functional phase of therapy took 19 months which was
longer than usual. The premise behind this was to allow suf-
cient time for bone remodelling to occur, besides allowing time
for the permanent teeth to erupt. The total duration of the
treatment was 29 months which could have been reduced to
about 18 months had only xed mechanotherapy been exe-
cuted with upper premolar extraction. However, at the cost
of losing two healthy teeth; without the benet of correction
of underlying skeletal discrepancy and the habit, which, if per-
sisted could have later led to space opening at the extraction
site.
The patient and her parents were satised with the treat-
ment result.
5. Conclusion
This case report presents a successful treatment of a class II
division 1 case using two phase therapy rightly employing
the triad of 3 As in functional appliance therapy: right age,
right attitude and right appliance.
A pleasing orthognathic prole was attained with the elim-
ination of lower lip trap with the correction of tongue thrust
78
Figure 8 (a) Maxillary and mandibular superimposition, (b) overall superimposition.
and lip sucking habit. The canine and molar relation was bilat-
erally class I with midlines matching and overjet of 2 mm and
overbite of 3 mm. There was a slight gumminess in the smile,
which was aesthetically acceptable considering that the patient
may have some residual soft tissue growth remaining which
will improve it over time.
Support and conict of interest
None.
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