Class II Division 2 camouflage (non-surgical) treatment for adults: please share your experience

[orthojourney]

Hello everyone,

I am a non-growing adult diagnosed with a skeletal Class II Division 2 malocclusion. The skeletal discrepancy is moderate but there is severe crowding in the upper arch. I am keen to avoid orthognatic surgery and a number of orthodontists have offered a camouflage option entailing the extraction of two upper pre-molars.

I would love to hear from adult patients who were diagnosed with a skeletal Class II division 2 malocclusion and chose the camouflage approach instead of surgery. Are you happy with the treatment outcome? Have your facial aesthetics been compromised by upper incisor retraction? Do you wish you had chosen orthognathic surgery instead? Are you at least somewhat happier with your bite after treatment, even though it's not a proper Class I occlusion?

Thank you!

[pcspinheiro]

I can't really say how it will turn out since I'm still only 6 months in... All cases are (even if slightly) different. I was offered the option of headgear or extractions, though surgery also came into the conversation. I was also diagnosed class II with deep overbite and moderate upper crowding with a mandibular skeletal discrepancy (small). In the end, without really researching into the subject, I went with the extraction route (sounded easy), only to regret it after extraction of one tooth. You see, my goals were wildly different from my ortho's, and things were not discussed in due length, so I just "went with it" initially. YOU may want perfect teeth, and it's possible that extractions are the only feasible way, but I was just there to stop my lower incisors from wearing out (I didn't even care much about the crookedness of the teeth), so I was gutted to know that I could have gone by without sacrificing any tooth, though I would end up with a larger overjet (could't care less about that...). So I refused further extractions and will probably end with a small midline asymmetry (again, couldn't care less if that saves me one beautiful, healthy tooth). Only when I refused further extractions was I told that I should have said so in the beginning (implying that there WAS another way), which I did, but no options were presented... So I guess it's all down to individual goals and specifics of the case. If your crowding is severe maybe there just isn't enough bone to accommodate all your teeth, but I would strongly advise you not to make my mistake and just "go with it"! Ask for other options, see if you could be happy with the end result if you refuse extractions (if you can accommodate all teeth, that is), consult with someone else first, etc. Don't remove healthy teeth without being 100% sure you want that done, having both your goals and physiology in mind. Regret is a b****h and there's no going back on an extracted tooth... I wish there was...

[orthojourney]

Many thanks for taking the time to reply. Sorry to hear of the impasse in which you find yourself.

I have consulted four highly respected orthodontists so far and each one offered one or more of the following three options:

1. Orthodontic treatment with orthognatic surgery -- this would result in a true Class I bite. I am keen to avoid this treatment modality because the six months of post-operative facial swelling of which I have been warned is a deal breaker. Furthermore, the risk of nerve damage is not acceptable to me.

2. Camouflage treatment, which entails the extraction of two upper pre-molars. My concern is the risk of loss of lip support, although the orthodontists assured me that lip support will not change, and indeed some of the orthodontic literature I have read suggests that facial aesthetics either stay the same or improve with camouflage treatment, which is heartening if somewhat counterintuitive. However, all clinicians consulted so far have cautioned me that my deep bite will not change with this treatment option. I am very unhappy with my deep bite, so that's a concern. Camouflaging a problem instead of fixing it is also antithetical to my personality, although I accept that at my age, compromise is probably inevitable if I want to avoid surgery.

3. Orthodontic treatment without extractions -- resulting in straight teeth, but again no improvement in the bite, plus the added drawback of the upper teeth resting on my lower lip, owing to an increase in their prominence (because straightening them without the space freed by extractions makes them tilt outwards). This would increase my overjet (currently 5mm), so this is another non-starter.

None of these options are inspiring.

I am digesting as much orthodontic literature as I can to understand the big picture and explore all options. I started a separate thread in this forum on the topic of mandibular pseudo-advancement in adults. The case report I found (cited in that thread) has some very convincing pre- and post-treatment photographs, and I kindly asked the orthodontist members of this board to offer an opinion on the merits of this approach.

In essence I will not embark on a treatment plan until I am satisfied that it is truly the best approach for me.

[pcspinheiro]

If you really have severe crowding maybe the only way is to remove 2 teeth? But you would fix nothing, only hide it... that's why I'm so mad about my ortho recommending extractions: I didn't even care about aesthetics!
However, do consider all options so you won't regret your treatment later. Try to reach a compromise, if you must. Maybe you could do with headgear only at night/at home if it is possible in your case, saving you teeth? Maybe TADS can be used for full retraction of upper teeth instead f headgear? I have read a paper about a class II case successfully treated with TADs and, in my case, that would have been the perfect option, as I was not even full class II (my upper teeth are on top of lower ones, as opposed to full class II with upper teeth biting in front of lower ones) so I needed little retraction to reach full class I, but it was never offered to me because my ortho does not use them. If it were now I would even have chosen headgear and wear it as much as possible at home only. In fact, I am going to bring up the headgear approach for space closure to avoid messing things even more with elastics only (if possible). I urge you to make a well informed decision about the treatment choice but also considering it's possible negative consequences, both on function and aesthetics (retraction of front teeth can lead to breathing issues and negatively impact the face, depending on the initial situation; people with a good facial profile may get the sunken in look that so many want to reverse with MORE orthodontic treatment). Choose wisely!

[orthojourney]

Might you be able to post a link or citation for the paper you mentioned, please? (Use of TADs in adult Class II treatment.)

The fact of the matter is that I do not have any easy options available to me (with the possible exception of the mandibular pseudo-advancement technique I posted about in a separate thread -- I am still hoping an orthodontist will read the case report I mentioned and offer a general opinion).

My severe tooth crowding is in itself straightforward to correct, but that is only part of the problem, the other component being my mandibular deficiency (Class II skeletal discrepancy).

I found a paper which in my view is a must-read for those who get along with scientific literature and who are faced with the stark choice between camouflage and surgical treatment of their adult Class II Div 2 case: "Long-term follow-up of Class II adults treated with orthodontic camouflage: A comparison with orthognathic surgery outcomes" (Mihalik et al. 2003). (I am not allowed to post links yet, but the full paper is available for free if you enter the title into a search engine.)

A key point made in that paper is that treatment outcome satisfaction in camouflage patients was the same as that of surgical patients only in cases in which the patients initially considered their jaws normal. I do not consider my lower jaw normal; therefore according to these authors I am unlikely to be satisfied with non-surgical treatment. One of the orthodontists I consulted did warn me that without surgery I will not be happy with the outcome and for that reason only offered the surgical option.

I am definitely going to do something about my teeth -- I just don't know what yet.

[bach]

Hello Orthojourney,

Quite a similar case here (class 2 division 2 malocclusion, however no severe crowding.)
I am offered jaw surgery, TADs, or extractions to compensate for the malocclusion.
I still have to decide, but my opinion on advantages/disadvantages of different options is elaborated in a thread of mine, called "ADVICE NEEDED: TAD vs JAW SURGERY vs EXTRACTION": http://www.archwired.com/phpbb2/viewtop ... 13&t=52089 I think this might be informative.

It seems that a lot of ortho's don't work with TAD's, but if you are satisfied with your facial profile, this seems the least invasive and cheapest option, without altering facial esthetics in a way surgery does (glad you also thought about the risks involved in surgery, nerve damage etc...).

[quote="pcspinheiro"] [...] I have read a paper about a class II case successfully treated with TADs and, in my case, that would have been the perfect option, as I was not even full class II (my upper teeth are on top of lower ones, as opposed to full class II with upper teeth biting in front of lower ones) so I needed little retraction to reach full class I, but it was never offered to me because my ortho does not use them [...][/quote]
Pcspinheiro, can you please supply a direct link towards the paper you have read?
Orthojourney, thanks for supplying scientific literature, which I prefer above wikipedia! I have only read minor parts, but it looks really interesting. Will read the rest tomorrow (Living in the EU).

Please keep us updated: new ideas, comments or suggestions are really welcome!

[pcspinheiro]

There are actually several case reports and the fine details of each case vary, but here are some:

https://www.ncbi.nlm.nih.gov/pubmed/24373658
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4456747/
https://www.webmedcentral.com/wmcpdf/Ar ... 005211.pdf

other literature:
http://www.sciencedirect.com/science/book/9780723436492

I should have done this reading BEFORE my (one premolar) extraction, but hopefully it will help others make better choices... and I actually work in science, what a dumb-ass (is it OK to write dumb-ass? )

[orthojourney]

pcspinheiro -- thanks for the links. Now I recall having read those papers myself a while ago but it's still good to share the knowledge :)

bach -- thanks for joining the conversation. I am very happy with my facial features when I bring my mandible forward and make the upper and lower incisors meet, but I am much less happy with my facial aesthetics when I bite down all the way. Therefore I fall into the category of patients who are not likely to be fully satisfied with standard camouflage treatment (Mihalik et al. 2003). For this reason I am keen to find an orthodontist who is able to reduce the depth of my bite without surgery. I don't expect a perfect bite -- reducing its depth by 3-4mm would be a satisfactory compromise and I would happily sign up for that.

I have found a couple of orthodontists who offer that treatment modality, but they are not in the UK, unfortunately. I might still consult them, though, to find out whether I am a good candidate for this approach. Not all patients are; it depends on whether the bite can be stabilized with the mandible a few millimetres ahead of where it is used to resting.

In general it seems to me that in complex cases such as mine it is essential to find the right orthodontist, because a dogmatic approach is not likely to result in the best possible treatment outcome. I want to find an orthodontist with a comprehensive skillset and the flexibility to develop a tailored treatment plan instead of the canned extraction-retraction camouflage modality. The money is still in the bank and the search continues.

[dannyc77]

Might you be able to post a link or citation for the paper you mentioned, please? (Use of TADs in adult Class II treatment.)

The fact of the matter is that I do not have any easy options available to me (with the possible exception of the mandibular pseudo-advancement technique I posted about in a separate thread -- I am still hoping an orthodontist will read the case report I mentioned and offer a general opinion).

My severe tooth crowding is in itself straightforward to correct, but that is only part of the problem, the other component being my mandibular deficiency (Class II skeletal discrepancy).

I found a paper which in my view is a must-read for those who get along with scientific literature and who are faced with the stark choice between camouflage and surgical treatment of their adult Class II Div 2 case: "Long-term follow-up of Class II adults treated with orthodontic camouflage: A comparison with orthognathic surgery outcomes" (Mihalik et al. 2003). (I am not allowed to post links yet, but the full paper is available for free if you enter the title into a search engine.)

A key point made in that paper is that treatment outcome satisfaction in camouflage patients was the same as that of surgical patients only in cases in which the patients initially considered their jaws normal. I do not consider my lower jaw normal; therefore according to these authors I am unlikely to be satisfied with non-surgical treatment. One of the orthodontists I consulted did warn me that without surgery I will not be happy with the outcome and for that reason only offered the surgical option.

I am definitely going to do something about my teeth -- I just don't know what yet.

Just to let you know I am having camouflage treatment for my class 2 skeletal 2 bite, I turned down jaw surgery, at the moment I think I might the right decision for me, although this was a close call. I am having TADs put on at the next appointment, Im 6 months into metal braces. They are putting them below my lower incisors to pull them down: they over erupted when I was younger and are out of line with my other lower teeth. The idea is that I will eventhually have a bite which is not traumatic.

If you search under my name here you will see some posts about how this is going so far. Im having my treatment on the NHS in the UK, and will keep updating as I go along

[pcspinheiro]

bach -- thanks for joining the conversation. I am very happy with my facial features when I bring my mandible forward and make the upper and lower incisors meet, but I am much less happy with my facial aesthetics when I bite down all the way. Therefore I fall into the category of patients who are not likely to be fully satisfied with standard camouflage treatment (Mihalik et al. 2003). For this reason I am keen to find an orthodontist who is able to reduce the depth of my bite without surgery. I don't expect a perfect bite -- reducing its depth by 3-4mm would be a satisfactory compromise and I would happily sign up for that.

.

My ortho is opening by bite by making me wear a front bite plane and triangle elastics on my molars. It's a pain at first, with all the drooling due to the big foreign thing on your palate and not chewing food properly, but all I can say is that it works! My bite has opened some 5-6 mm already, as I had a very deep bite. I can now almost slide my mandible forward until the teeth meet and the brackets ALMOST don't touch, whereas in the begining you could not see my lower teeth at all. That's how deep my bite was.

In the meantime I found some more papers describing class II correction with the use of TADs (even in one case with all 32 teeth! and 1/2 class II like me, BTW) that refused to have any extractions, like I should have were I duly knowledgeable on the matter, arggg! If you want that I can send you the pubmed links. So now I find myself in the awkward position of wanting to propose my own treatment plan to the ortho... which she might not take too well... But, let's face it, due to the extraction all she can do on the right side is to slightly advance my molars to full class II (from initial 1/2 class II) and retract canine/incisors from class II to class1. On the left (non-extracted) side I was basically told I would finish in class II canine too, with a midline shift. BUT, I just don't want that because a 1/2 class II bite is terrible, it's like gears touching tooth with tooth instead of tooth with groove, so I want to ask her to try the TAD approach on the left, to distalize my molars by 1/2 cusp and allow for full class I bite on that side. I'm not an ortho or anything, but I'm a researcher and good at problem solving, and I'm 95% sure this CAN be done, if she is willing to go along. Well, if she is not then I might just consider another ortho... not ideal in the middle of treatment, I know, but now that I'm WAY more informed I don't want my options limited!

[abro884]

I regretted not going for the surgery about 8 months in to treatment, and am having the ortho reverse the whole thing and and doing the surgery.

Lost my 2 bicuspids so will need to have implants.

Ideally don't make the same mistake

I spoke up far too late and knew probably 4 months in i'd made a mistake, but decided oh lets just see.

Honestly it's a horrible situation to be in and obviously the results were bad enough for me to spend 30k sorting it out...

[pcspinheiro]

This is why, based on my negative experience, I always tell people to try the conservative, non-extraction route. Maybe they'll be happy with the results otherwise, it's not too late to do the other thing. Sometimes it's just not possible when a large overjet and crowding are already present. In my case, I would never go for surgery due to such small affliction (mild upper crowding and overbite causing wear to lower teeth). Couldn't care less about crooked teeth and, unfortunately, I also just went with it, but because I was lied to: ortho said that my teeth could not fit my mouth without extractions. Guess what, my teeth are straight, I have an acceptable overjet and the extraction space is almost all there. I hate her guts for leading me down this way, when I was SO VERY SPECIFIC about what I wanted from the treatment (NOT aesthetics, NOT a better bite as it was fine despite class II, ONLY to save my front teeth from wear!). Fast forward to present day and all her complicated plan to my simple problem led to the loss of one healthy tooth, a more complicated procedure to close the extraction gap in an acceptable manner, TMD due to vertical changes to my molars, less mouth space due to arch collapse from extrusion elastics leading to speech problems, and a horrible smile due to leveling and hiding my front teeth (because "that's how it should be"...). I'm gutted with all this and I wish I never started the damn thing because now I cannot stop it. I already put my foot down and I'm deciding what get's done and how it's gonna end.

[ruca2]

I just finished up treatment in Jan 18. I also had a Class II Division 2 bite and had premolar extractions. Here is the link to my before and after photos. Very positive results with the camouflage.
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