premolars:This is considered in a moderate–severe crowded case in both arches.Due to more space being needed in both arches, more space is gained by extracting the first premolars, therefore this would be a consideration in severe cases.Mandibular first premolars are to be extracted if a patient has severe crowding in the lower arch
Intermaxillary elastics:With a class II div II case, elastics would be considered.Class II intermaxillary elastics would be used.Class II elastics help to retract the upper anterior segment and procline the lower anterior segment, which will help to reduce the overjet.In class II div II cases, patients present with deepbites. Class II elastics would work in our favour with this, as they allow molar extrusion, which will help to reduce the patient’s deepbite.
Space closure:Once the upper anterior teeth are in the correct inclination, the same class II div I procedures will apply to space closure.Fixed appliances will close all remaining spaces once the overjet has reduced.For example, a patient has had the upper first premolars and lower second premolars extracted. In the upper arch, lacebacks will be placed from the upper canines to the upper first permanent molars to achieve a class I canine relationship once the canines are in class I and the anterior segment has achieved its correct inclination, creating an overjet, and chain elastic will be placed U2–2 to retract the remaining overjet. In the lower arch, lacebacks are used to relieve lower anterior crowding, and once the teeth are aligned the posterior teeth will be brought mesially to close the remaining spaces.
Correct deepbite:A patient in a class II div II will present with a deepbite, which can be corrected in this stage.There are numerous ways of correcting a deepbite with fixed appliances:Bond and engage 7s on archwirePosition anterior brackets more incisally – this would work in the clinician’s favour by positioning them incisally from the bond‐up appointmentReverse curve archwiresComposite/metal bite turbosFixed FABPClip‐on FABPIntermaxillary elastics – class IIHeadgear – cervical low pull
7.4.5 Headgear
Correct deepbite:Headgear can be used to correct a deepbite.The type of headgear that would be used is the cervical low pull headgear.This type of pull is below the occlusal plane, which is used to distalise and extrude the maxillary molars. By doing this it encourages a backward growth rotation, which will reduce the deepbite.
7.4.6 Surgery
Surgery can be given as a treatment option to some patients. The majority of patients who have surgery are severe cases. Patients presenting with a severe retrognathic mandible and deepbite would be considered. The types of surgery patients could have are:
Mandibular segmental procedure:This type of procedure would be done in a severe deepbite case.This is where incisions are made lower 3–3 and the anterior segment is moved down to correct the deepbite.
Bilateral sagittal split osteotomy (BSSO):For mandibular advancement.Done in patients with a retrognathic mandible, as it advances the mandible.
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