Two-phase orthodontic treatment of a patient with a low-angle skeletal class II malocclusion: a 7-year follow-up

Low-angle skeletal class II malocclusions are often observed with sagittal and vertical developmental abnormalities of the mandible. Two-phase orthodontic treatment of functional orthopedic therapy combined with fixed correction is one of the most common methods to treat of skeletal class II malocclusions. This case report describes the two-phase orthodontic treatment of a patient with severe low-angle skeletal class II malocclusion. A Twin Block orthodontic appliance was used to improve mandibular growth, and the adjustment of the occlusal relationship using a fixed appliance after functional therapy. After treatment, a significant improvement was observed in the patient’s facial appearance and occlusal relationship. Additionally, a 7-year follow-up confirmed the stability of the treatment results. Although a vertical facial growth direction is difficult to control, the Twin Block orthodontic appliance in adolescents might effectively improve the difference in the sagittal growth of the mandible. Whilst the growth pattern could not be fully controlled, the treatment significantly improved the patient’s facial profile and occlusion.

Two-phase orthodontic treatment; Skeletal class II malocclusion; Low-angle

[1] Lombardo G, Vena F, Negri P, Pagano S, Barilotti C, Paglia L, et al. Worldwide prevalence of malocclusion in the different stages of dentition: a systematic review and meta-analysis. European Journal of Paediatric Dentistry. 2020; 21: 115–122.

[2] Buyukcavus MH, Kale B. Skeletal and dental effects of twin-block appliances in patients treated with or without expansion. Turkish Journal of Orthodontics. 2021; 34: 155–162.

[3] Petti S. Over two hundred million injuries to anterior teeth attributable to large overjet: a meta-analysis. Dental Traumatology. 2015; 31: 1–8.

[4] Nanda SK. Patterns of vertical growth in the face. American Journal of Orthodontics and Dentofacial Orthopedics. 1988; 93: 103–116.

[5] Tassoker M, Kok H, Sener S. Is there a possible association between skeletal face types and third molar impaction? A retrospective radiographic study. Medical Principles and Practice. 2019; 28: 70–74.

[6] Bondevik O, Espeland L, Stenvik A. Dental arch changes from 22 to 43 years of age: are they different in individuals with high versus low mandibular plane angle. European Journal of Orthodontics. 2015; 37: 367–372.

[7] Zhao YH, Wang CL, Liu DX, Wei FL, Zhu K. Study of facial soft tissue profile on angle Class II malocclusion with various vertical growth patterns. Shanghai Kou Qiang Yi Xue. 2006; 15: 469–472. (In Chinese)

[8] Maspero C, Galbiati G, Giannini L, Guenza G, Farronato M. Class II division 1 malocclusions: comparisons between one- and two-step treatment. European Academy of Paediatric Dentistry. 2018; 19: 295–299.

[9] Ajami S, Morovvat A, Khademi B, Jafarpour D, Babanouri N. Dentoskeletal effects of class II malocclusion treatment with the modified Twin Block appliance. Journal of Clinical and Experimental Dentistry. 2019; 11: e1093–e1098.

[10] Baccetti T, Franchi L, Toth LR, McNamara JA Jr. Treatment timing for Twin-block therapy. American Journal of Orthodontics and Dentofacial Orthopedics. 2000; 118: 159–170.

[11] Elfeky HY, Fayed MS, Alhammadi MS, SAZ S, El BDM. Three-dimensional skeletal, dentoalveolar and temporomandibular joint changes produced by twin block functional appliance. Journal of Orofacial Orthopedics. 2018; 79: 245–258.

[12] Cozza P, Baccetti T, Franchi L, De Toffol L, McNamara JA Jr. Mandibular changes produced by functional appliances in class II malocclusion: a systematic review. American Journal of Orthodontics and Dentofacial Orthopedics. 2006; 129: 599.e1–12; discussion e1–6.

[13] Veitz-Keenan A, Liu N. One phase or two phases orthodontic treatment for class II division 1 malocclusion. Evidence-Based Dentistry. 2019; 20: 56–57.

[14] Paoloni V, Lione R, Farisco F, Halazonetis DJ, Franchi L, Cozza P. Morphometric covariation between palatal shape and skeletal pattern in class II growing subjects. European Journal of Orthodontics. 2017; 39: 371–376.

[15] David Justin Sander. Use of CVM stages in assessment of young orthodontic patients to estimate growth potential. [Theses and Dissertations (ETD)]. 2009.

[16] Raposo R, Peleteiro B, Paco M, Pinho T. Orthodontic camouflage versus orthodontic-orthognathic surgical treatment in class II malocclusion: a systematic review and meta-analysis. International Journal of Oral and Maxillofacial Surgery. 2018; 47: 445–455.

[17] Storms AS, Miclotte A, Grosjean L, Cadenas de Llano-Pérula M, Alqerban A, Fieuws S, et al. Short-term hard and soft tissue changes after mandibular advancement surgery in class II patients: a retrospective cephalometric study. European Journal of Orthodontics. 2017; 39: 567–576.

[18] McNamara JA Jr. Components of class II malocclusion in children 8–10 years of age. The Angle Orthodontist. 1981; 51: 177–202.

[19] Batista KB, Thiruvenkatachari B, Harrison JE, O’Brien KD. Orthodontic treatment for prominent upper front teeth (class II malocclusion) in children and adolescents. Cochrane Database of Systematic Reviews. 2018; 3: CD003452.

[20] Ehsani S, Nebbe B, Normando D, Lagravere MO, Flores-Mir C. Short-term treatment effects produced by the twin-block appliance: a systematic review and meta-analysis. European Journal of Orthodontics. 2015; 37: 170–176.

[21] Lee R, Kyi C, Mack G. A controlled clinical trial of the effects of the twin block and Dynamax appliances on the hard and soft tissues. The European Journal of Orthodontics. 2007; 29: 272–282.

[22] Khoja A, Fida M, Shaikh A. Cephalometric evaluation of the effects of the twin block appliance in subjects with class II, division 1 malocclusion amongst different cervical vertebral maturation stages. Dental Press Journal of Orthodontics. 2016; 21: 73–84.

[23] Veitz-Keenan A, Liu N. One phase or two phase orthodontic treatment for class II division 1 malocclusion. Evidence-Based Dentistry. 2019; 20: 72–73.