Case Report

Treatment of Class II Div 2 Malocclusion using PowerScope:

A Case Report

Dr Luv Agarwal,1 Dr Kamlesh Singh,2 Dr Ragni Tandon3

Asst Professor, Dept of Orthodontics, Uttaranchal Dental & Medical Research Institute, Dehradun, India
1

Professor, Dept of Orthodontics, Saraswati Dental College, Lucknow, India

2, 3

Correspondence: Dr Luv Agarwal; Email: [email protected]

ABSTRACT

Correction of skeletal Class II malocclusion has become a major challenge for orthodontists. Class II jaw discrepancies
characterized by mandibular deficiency are treated with fixed functional appliances when there is no active growth present.
This case report illustrates the application of PowerScope in 16 years young adolescent male having skeletal Class II Div 2 with
mandibular deficiency who was reported with forwardly and irregularly placed upper front teeth with closed bite. The case
was treated initially with MBT 0.022” prescription followed by PowerScope. Successful results were obtained with a substantial
improvement in facial profile, skeletal jaw relationship and overall aesthetic appearance. PowerScope produced a significant
forward movement of mandible which obliterated the need of extractions.

Keywords: Class II Div 2 malocclusion, fixed functional appliance, mandibular deficiency, non-extraction, PowerScope

INTRODUCTION patients who have crossed the adolescent growth

spurt.4,5 The mandibular advancement induced by these
Class II malocclusion poses a major challenge in terms appliances cause changes in molar relation, overjet
of treatment planning and successful management. correction and increase in mandibular length.6-8
Class II malocclusion may or may not involve skeletal
discrepancy. The mandible may be normal or retruded PowerScope is the latest innovation among fixed functional
with respect to maxilla, or maxilla could be protrusive with appliances developed by Dr. Andy Hayes. It applies
respect to mandible. Skeletal Class II malocclusion can be continuous force and produces favourable dentoalveolar
due to maxillary prognathism, mandibular retrognathism effects such as restraining maxillary growth, stimulation of
or a combination of both. Retrusion of mandible is the mandibular growth, distal maxillary movement and mesial
most common feature of class II malocclusion rather than positioning of mandibular arch. Proclined upper incisors
maxillary prognathism, as outlined by McNamara. It may are intruded to unlock the distally positioned mandible,
be due to various etiological factors such as small sized thereby advance the path of closure of mandible. This
mandible, posterior placement of condyle in glenoid appliance does not require patient’s compliance and
fossa or functional mandibular shift. In growing cases, can be used in conjugation with orthodontic brackets.9,10
mandibular advancement is achieved using functional This paper presents a non-extraction approach for the
appliance that employs growth modulation techniques. treatment of skeletal Class II Div 2 malocclusion with
Severity of jaw base discrepancy, patient compliance mandibular deficiency and impinging overbite using
and the amount and timing of growth spurts play crucial. PowerScope.
Growth spurts are during 10-13 years in girls and 11-14
years for boys.1-3 Attention is given on pubertal growth
CASE REPORT
spurt in adolescents as growth modification tools are A 16-year-old male patient presented with a chief
preferred in Class II malocclusion. Functional appliance complaint of irregularly placed upper anterior
acts by redirecting or impeding the maxillary growth teeth and distally positioned mandible. The clinical
with simultaneous stimulation of mandibular growth. examination showed Angle’s Class II Div 2 malocclusion,
Removable functional appliances such as activator, 100% overbite, 0 mm overjet, retroclined upper central
bionator, Twin block and Frankel regulator is advocated in incisors and labioversion of upper lateral incisors.
patients where active growth is present. Fixed functional Cephalometric analysis showed Class II skeletal pattern
appliances such as Herbst, Jasper jumper, Universal with ANB angle 4o, horizontally directed growth,
bite jumper and Forsus are applicable in non-compliant retrusive mandible and skeletal deep bite. The maxillary

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 Agarwal L, Singh K, Tandon R : Treatment of Class II Div 2 Malocclusion using PowerScope: A Case Report

Figure 1: Pre-treatment intra-oral and extra-oral photographs

and mandibular arch form exhibited squarish shape Treatment objective: To improve facial profile, achieve
with severe curve of spee in mandibular dentition. Intra- adequate overjet and overbite relations, improve
oral examination showed Class II end-on molar relation smile esthetics, and to obtain Class I canine and
on both sides and Class II canine relation on both sides; molar relation without extracting teeth. Levelling
scissor bite was present with respect to 24. Upper and of curve of Spee is required in mandibular arch with
lower dental midline were coincident (Figure 1). the maintainence of inter-canine and inter-premolar
Extra-oral examination displayed reduced lower facial widths.
height, competent lips and convex profile with the Treatment plan: A non-extraction approach was
presence of passive lip seal and posteriorly divergent undertaken. MBT 0.022” brackets was selected and
and retrusive mandible. Distinct concavities were fixed functional appliance PowerScope was used at a
seen in the inferior border of C2, C3 and C4 in cervical
later stage to address skeletal problem thus utilizing the
vertebrae which corresponds to SMI 7 indicating
remaining growth (Figure 3).
deceleration stage which signifies 10% to 25%
adolescent growth left. The panoramic radiograph Treatment progress: The archwire sequence was co-
showed the presence of all permanent teeth (Figure 2). axial, 0.014 Niti, 0.016 Niti, 16x22 Niti, 16x22 SS; each

Figure 2: Pre-treatment lateral cephalogram and OPG

64 Orthodontic Journal of Nepal, Vol. 8 No. 1, June 2018

 Agarwal L, Singh K, Tandon R : Treatment of Class II Div 2 Malocclusion using PowerScope: A Case Report

Figure 3: PowerScope installation

wire was placed for a period of 1 month. Levelling DISCUSSION

and alignment was completed in 10 months time,
then 17x25 SS was placed to stabilize the arch. This Fixed functional appliance works by restriction of forward
was followed by mandibular advancement using growth of maxilla and it promotes distal movement of
PowerScope. A 10o lingual crown torque was applied maxillary molars and mesial movement of mandibular
in lower anterior teeth to prevent flaring of mandibular molars. Other effects are retroclination of maxillary incisors
incisors. Then, a Class II corrector was placed on both and proclination of mandibular incisors.11,12
sides to advance the mandible forward and to correct The PowerScope is a fixed one piece appliance available
the end-on molar relation. There was a substantial in one size and suits all Class II cases. One piece concept
improvement in patient’s profile due to mandibular prevents dislodgement of appliance on jaw movements.
advancement and soft tissue modifications. The appliance allows quick and easy wire-to-wire
installation and prevents bond failure of bracket and
The PowerScope was employed for a period of seven
buccal tube and it is customized with crimpable shims
months and following its removal, Class II vertical
supplied among the PowerScope armamentarium. The
elastics (5/16,4oz) was used to achieve interdigitation
appliance has ball and socket joint at two ends which
and to support achieved sagittal correction. Final
allows excellent jaw movements reducing patient
stage OPG, lateral cephalograms and photographs
discomfort. 13,14
were taken (Figure 4, 6). Pre-treatment and post-
treatment cephalometric readings were compared Mandibular incisor proclination is the most common
and superimpositions were made (Figure 5). The total dentoalveolar side effect seen with PowerScope which
treatment time was 17 months; then after upper and can be prevented by cinch back of archwire, figure of
lower lingual retainers were given. ‘8’ consolidation of mandibular arch and lingual crown
torque in anterior segment of the mandibular arch.
Treatment results:
On comparing the cephalometric outcomes, considerable
• Improved facial profile
improvement in skeletal, dental and soft tissue parameters
• Increased mandibular length were observed at the end of PowerScope treatment.
• Proclination of upper and lower incisors There was 5o reduction in ANB angle from 9 to 4o post-
• Class I molar and canine relation achieved on treatment and there was increase in mandibular length by
both sides
• Decrease in lower anterior facial height
• Improved facial balance and smile esthetics.

Figure 4: Final stage Lateral cephalogram and OPG

(before debonding) Figure 5: Cephalometric superimpositions

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 Agarwal L, Singh K, Tandon R : Treatment of Class II Div 2 Malocclusion using PowerScope: A Case Report

Figure 6: Post-treatment intra-oral and extra-oral photographs

4 mm (70-74 mm). Maxillary length remained unchanged force is both extrusive and horizontal in force vector.8
after PowerScope correction. Substantial improvement
Rectangular stainless steel arch wire of 0.025” in horizontal
in soft tissue and skeletal profile was observed with a
dimension is required to use the appliance. It provides
tendency towards orthognathic profile. Esthetic line
precise fit for direct-to-wire attachments and restricts the
changed from -2 mm to -3.5 mm in upper lip and -4.5mm
appliance from unwanted movement and prevents soft
to -2 mm in lower lip. Pre-treatment and post-treatment
tissue irritation.15,16
cephalometric findings were compared (Table 1).
PowerScope itself does not cause forward repositioning
The PowerScope has certain advantages over Class II
of the mandible in anterior direction and when patient
elastics. The compressed Niti spring provides push force
functions in a maximum intercuspation position, its internal
mesial to maxillary molars and distal to mandibular canine,
spring works. Therefore, a significant midline discrepancy
and force is mainly horizontal and slight intrusive in nature
can still be seen.
whereas Class II elastics delivers pull type of force and

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Agarwal L, Singh K, Tandon R : Treatment of Class II Div 2 Malocclusion using PowerScope: A Case Report

Table 1: Comparison of cephalometric findings

Parameter Pre-treatment Post-treatment Difference
SNA 84 83 -1
SNB 75 79 4
ANB 9 4 -5
Wits appraisal 6.5 mm 3.5 mm -3mm
Maxillary length 53 mm 53 mm 0
Mandibular length 70 mm 74 mm 4mm
Ramus length 50 mm 50 mm 0
Upper 2mm 0 mm -2mm
S Line
Lower 1mm 0 mm -1mm
Upper -2 mm -3.5 mm 1.5mm
E – Line
Lower -4.5 mm -2 mm -2.5mm
1-1(degree) 124 133 9
1-SN(degree) 116 105 -11
Go-Gn-SN(degree) 29 33 4
FMA 24 28 4
IMPA 97 103 6
Y-axis 60 63 3

OJN

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