Camouflage treatment without any extractions is indicated in mild cases where arch length discrepancy is minimum (up 4 mm), and the upper and lower dental arches can accommodate the full complement of teeth without any adverse effects on the facial profile. The overjet is correctable with dentoalveolar movements alone or in combination with a mild forward posture of the mandible. Treatment options include intraoral molar distalisation, correction of molar rotations and increased arch perimeter with maxillary dentoalveolar expansion.

Mild class II molar correction can be achieved with either class II elastics, fixed functional appliances (FFA), intra oral molar distalization, inter proximal reduction or a combination of more than one procedure.

The severity of malocclusion and its adverse effect on the facial profile may necessitate the extraction of premolars to create arch space for anterior retraction, resolution of crowding and correction of molar relationship to class I. A variety of extraction combinations are possible. These include extraction of upper first premolars only, all first premolars, and upper first and lower second premolars. Various considerations on the severity and nature of malocclusion and ease of biomechanics govern extraction patterns.

In clinical situations with a large overjet, class II full cusp molar relations and minimal crowding of the lower arch, camouflage treatment may be possible with the extraction of first premolars in the upper arch only, thereby maintaining the class II molar relations. It has now been accepted that the occlusion obtained from upper-premolar extractions for orthodontic camouflage in class II mandibular deficiency patients is stable. The indications for first premolar extraction in upper arch only is tabulated in Table 67.1 .

Mild to moderate class II patients may be treated with extractions of all first premolars or a combination of upper first and lower second premolars. The camouflage treatment is often the treatment of choice where a discrepancy exists between total tooth material and arch length.

The maxillary first premolars only

Based on the cephalometric outcome of cases treated with upper premolars only, Scott and Jernigan suggested that ‘maxillary first premolar extraction for orthodontic camouflage may be a viable treatment option, especially if the patient has full upper lips and only a relative mandibular deficiency’. As a result, extraction of only maxillary premolars with the goal of finishing with functional class II molars and class I canines is a viable, functional compromise. Fig. 67.2 depicts the summary of a case treated with extraction of maxillary first premolars. Note a significant change in profile and class II buccal occlusion and normal overjet and overbite.

Class II division 1 malocclusion treated with extraction of upper premolars only.

(i) Case NS, 17-year-old female. Pre-treatment records show class II molar relations, severe crowding in the upper arch and moderate crowding in the lower arch. (ii) Camouflage approach to treatment of class II division 1 malocclusion with fixed appliance therapy. The case was treated with extraction of the upper first premolars only to correct crowding in the maxillary arch, thereby finishing the case in class II molar and class I canine relationship. Note the improvement in post-treatment profile and occlusion. (iii) 2 years follow-up shows stable results. (iv) Lateral cephalograms showing growth and treatment changes. (A) Pre-treatment; (B) immediately post-debond; (C) 2 years follow-up.

Dolichocephalic patients who exhibit crowding and protrusive lower incisors, a steep occlusal plane angle and proneness to clockwise mandibular rotation are not suitable for orthodontic treatment alone. These patients have a poor prognosis in terms of improvement in the soft tissue profile and stability of occlusion. Such vertical growers and more severe forms of class II division I malocclusion are considered for orthognathic surgery.

Surgical treatment consists of mandibular advancement, superior repositioning of the maxilla, or a combination. Mandibular deficiency alone is the problem in about two-thirds of skeletal class II surgical patients, while only one-third require maxillary surgery, either alone (15%) or combined with mandibular surgery (20%).

Severe forms of skeletal retrognathia of the mandible alone are treated with mandibular advancement using bilateral sagittal split osteotomy (BSSO) ( Chapter 79 ). Although orthognathic surgery may be the treatment of choice, there may be other preferred treatment options for several reasons, such as patients’ reluctance, medical conditions, non-availability of expert teams, cost of the treatment and other such logistics.