Introduction

The Class II malocclusion is still the most frequently treated orthodontic malocclusion [2,3]. Angle divided the dental Class II malocclusion into Class II, division 1 with protruded maxillary incisors and a Class II, division 2 with returned, steeply positioned maxillary incisors, which is often described as a overbite. These patients usually have a reserve of the lower jaw [4]. Especially in Angle Class II, division 2, the genetic component is emphasized as a possible aetiology. Depending on the skeletal and dental age, removable and fixed appliances are available as treatment options [5,6]. The aim is to develop the mandible forward to achieve a physiologic condylar position [5-7]. Temporomandibular joint dysfunction (TMJ) is one of the most common chronic pain symptoms in the oral and maxillofacial region today [1]. In addition to head, neck and back pain, crepitation and clicking of the temporomandibular joints are usually found [8,9]. Within the orofacial system, a distinction should be made between articular and muscular pain. However, somatic disorders (axis I) and psychosocial factors (axis II) also have an influence on TMJ [8,10]. Thus, TMJ is a multifactorial process that is made up of psychosocial factors such as stress, anxiety, depression, a genetic disposition (gene polymorphisms) and local causes such as an occlusal factor. Iatrogenic causes such as orthodontic treatment, prosthetic or conservative restorations can also promote TMJ. Changes to the occlusion can lead to compression (usually of the bilaminar zone) or distraction of the temporomandibular joints. Conversely, however, orthodontic treatment of a malocclusion can improve an existing TMJ. It has been shown that Angle Class II patients have a higher prevalence of TMJ and these patients benefit from an orthodontic treatment [11-13]. The occlusal factor is therefore a frequent contributing cause of the symptoms in these patients. In addition to orthodontic bite adjustment to the new therapeutic target position, physiotherapeutic self-exercises (mouth opening exercises, cherry stone sucking, self-massage) should be performed, as well as additional manual therapy if necessary [14]. This case presentation is intended to provide an insight into a non-surgical treatment concept for an adult patient with dental and skeletal Class II, division 2 posterior forced bite.

Case Presentation

The case described here represents the treatment of an adult patient with skeletal and dental Class II, division 2 with posterior forced bite. The patient was treated with a Herbst appliance and maxillary partial multibracket appliance with subsequent aligner therapy (Invisalign®) in the upper and lower jaw.

Findings

Medical history

The patient had his first visit at the Department of Orthodontics and Dentofacial Orthopedics of the University Medical Center Mainz at the age of 24 years. He suffered from pronounced chronic pain symptoms in the area of the temporomandibular joints on both sides and in the head and neck area (Figure 1).

 

Figure 1: Pain drawing of the patient´s pain questionnaire.

Two different allergies (hay fever and house dust) were listed in the general medical history. The patient stated that he suffers from sleep disorders. The profile analysis revealed a convex lateral profile with a pronounced sacramental fold. The patient showed a shortened upper and lower third of the face and the buccal corridors were enlarged. The patient was already undergoing manual therapy for pain in the masticatory muscles as well as head and neck pain. The functional examination showed a shortening of the suprahyoid muscles, a reproducible terminal temporomandibular joint clicking on both sides with a dorso-cranial load vector in combination with a posterior forced bite. The first contact after neuromuscular deprogramming was onto teeth 21/31. The patient suffered from parafunctional bruxism. Grinding facets and gingival recessions on teeth 14, 13, 12, 23 and 24 were clearly visible. Therefore, there was clinical evidence of TMJ. Mm. Masseter and Mm. temporalis were dolent on pressure. The neck and shoulder muscles were tense.

Extra oral findings

The extra oral findings showed an average face, inclined backwards (Figure 2). The lower and upper third of the face was shortened. The profile was convex, with a negative lip line and a slightly reduced nasolabial angle with a straight nasal bridge.

 

Figure 2: Extraoral findings a) Frontal view b) Right side profile

Intraoral findings

Intraorally, a permanent, fully toothed dentition (17-47) with good oral hygiene was found (Figure 3&Figure 4). Ground facets and gingival recessions were clearly visible on teeth 14, 13, 12, 23 and 24.