Lec 15

5th year lec.15 Orthodontics Dr.
Saad
Treatment of class III malocclusion
The British Standards definition of Class III incisor relationship
includes those malocclusions where the lower incisor edge
occludes anterior to the cingulum plateau of the upper incisors.
Class III malocclusions affect around 3 per cent of Caucasians.
Aetiology
1. Skeletal pattern: The skeletal relationship is the most
important factor in the aetiology of most Class III malocclusions,
and the majority of Class III incisor relationships are associated
with an underlying Class III skeletal relationship. Cephalometric
studies have shown that, compared with Class I occlusions, Class
III malocclusions exhibit the following:
• increased mandibular length;
• a more anteriorly placed glenoid fossa so that the condylar head
is positioned more anteriorly leading to mandibular prognathism;
• reduced maxillary length;
• a more retruded position of the maxilla leading to maxillary
retrusion. The first two of these factors are the most influential.
Class III malocclusions occur in association with a range of
vertical skeletal proportions, ranging from increased to reduced. A
backward opening rotation pattern of facial growth will tend to
result in a reduction of overbite; however, a forward rotating
pattern of facial growth will lead to an increase in the prominence
of the chin. There is evidence to indicate that Class III skeletal
patterns exhibit less maxillary growth and more mandibular
growth than Class I skeletal patterns.
2. Soft tissues: In the majority of Class III malocclusions the soft
tissues do not play a major aetiological role. In fact the reverse is
often the case, with the soft tissues tending to tilt the upper and
lower incisors towards each other so that the incisor relationship
is often less severe than the underlying skeletal pattern. This
dento-alveolar compensation occurs in Class III malocclusions
because an anterior oral seal can frequently be achieved by
upper to lower lip contact. This has the effect of molding the upper
and lower labial segments towards each other. The main
exception occurs in patients with increased vertical skeletal
proportions where the lips are more likely to be incompetent and
an anterior oral seal is often accomplished by tongue to lower lip
contact.
3. Dental factors: Class III malocclusions are often associated
with a narrow upper arch and a broad lower arch, with the result
that crowding is seen more commonly, and to a greater degree, in
the upper arch than in the lower. Frequently, the lower arch is well
aligned or even spaced.
Occlusal features of Class III
By definition Class III malocclusions occur when the lower
incisors are positioned more labially relative to the upper incisors.
Therefore an anterior crossbite of one or more of the incisors is a
common feature of Class III malocclusions. As with any crossbite,
it is essential to check for a displacement of the mandible on
closure from a premature contact into maximal interdigitation. In
Class III malocclusions this can be ascertained by asking the
patient to try to achieve an edge-to-edge incisor position. If such a
displacement is present, the prognosis for correction of the incisor
relationship is more favourable.
Another common feature of Class III malocclusions is buccal
crossbite, which is usually due to a discrepancy in the relative
width of the arches. This occurs because the lower arch is
positioned relatively more anteriorly in Class III malocclusions and
is often well developed, while the upper arch is narrow. This is
also reflected in the relative crowding within the arches with the
upper arch commonly more crowded
Treatment planning in class III malocclusions

A number of factors should be considered before planning
treatment.
• Patient’s concerns and motivation towards treatment
• Severity of skeletal pattern
• Amount and direction of any future growth
• Can patient achieve edge-to-edge incisor contact
• Overbite
• Amount of dento-alveolar compensation present
• Degree of crowding
Treatment options
1. Accepting the incisor relationship in mild Class III
malocclusions, particularly those cases where the overbite
is minimal, it may be preferable to accept the incisor
relationship and direct treatment towards achieving arch
alignment. Also, some patients with more severe Class III
incisor relationships are unwilling to undergo
comprehensive treatment involving orthognathic surgery
which would be required to correct their incisor
relationship and opt instead for upper arch alignment only.
2. Early orthopaedic treatment This is an area of
orthodontics that is attracting considerable attention.
Orthopaedic correction of Class III malocclusions aims to
enhance or encourage maxillary growth and/or restrain or
re-direct mandibular growth. Although a number of diff
erent treatment modalities have been shown to be
successful in the short to mid-term, given the propensity
for unfavourable growth in skeletal Class III, the results of
long-term followup are awaited with interest. There is an
increasing body of evidence that orthopaedic correction
treatment is more likely to be successful if it is carried out
prior to the pubertal growth spurt.
• Protraction face-mask used to advance the maxilla. The
forces applied in this technique are in the region of 400 g
per side and a co-operative patient is necessary to
achieve the 14 hours per day wear required.
• Bone anchored maxillary protraction (known as BAMP).

Screws or mini-plates are used in the posterior maxilla and
anterior mandible for Class III elastics. There is some
evidence to show that a greater degree of maxillary
advancement is achieved than with face-mask therapy
alone.
• A combination of these two techniques – elastics are run
between skeletal anchorage in the maxilla and a face
mask.
• Chin-cup – this has the effect of rotating the mandible
downwards and backwards with a reduction of overbite so
is largely historic
3. Orthodontic camoufl age Correction of an anterior

crossbite in a Class I or mild Class III skeletal pattern can
be undertaken in the mixed dentition when the unerupted
permanent canines are high above the roots of the upper
lateral incisors . Extraction of the lower deciduous canines
at the same time may allow the lower labial segment to
move lingually slightly. Early correction of a Class III
incisor relationship has the advantage that further forward
mandibular growth may be counter-balanced by dento-
alveolar compensation . Later in the mixed dentition when
the developing canines drop down into a buccal position
relative to the lateral incisor root there may be a risk of
resorption if the incisors are moved labially. In this
situation correction is then best deferred until the
permanent canines have erupted.
Orthodontic correction of a Class III incisor relationship
can be achieved by proclination of the upper incisors,
retroclination of the lower incisors or a combination of
both. Proclination of the upper incisors reduces the
overbite whereas retroclination of the lower incisors helps
to increase overbite Although the pitfalls of significant
movement of the lower labial segment have been
emphasized in earlier chapters, in the correction of Class
III malocclusions the positions of the upper and lower
incisors are changed around within the zone of soft tissue
balance and, provided that there is an adequate overbite
and further growth is not unfavourable, the corrected
incisor relationship has a good chance of stability.
Although functional appliances can be used to advance
the upper incisors and retrocline the lower incisors, in
practice these tooth movements are accomplished more
efficiently with fixed appliances.
Space for relief of crowding in the upper arch can often be
gained by expansion of the arch anteriorly to correct the
incisor relationship and/or buccolingually to correct buccal
segment crossbites. Therefore, it may be prudent to delay
permanent extractions until after the crossbite is corrected
and the degree of crowding is reassessed. Expansion of
the upper arch to correct a crossbite will have the effect of
reducing overbite, which is a disadvantage in Class III
cases.
4. Surgery In a proportion of cases the severity of the
skeletal pattern and/or the presence of a reduced overbite
or an anterior open bite preclude orthodontics alone, and
surgery is necessary to correct the underlying skeletal
discrepancy. It is impossible to produce hard and fast
guidelines as to when to choose surgery rather than
orthodontic camouflage, but it has been suggested that
surgery is almost always required if the value for the ANB
angle is below –4° and the inclination of the lower incisors
to the mandibular plane is less than 80°. However, the
cephalometric findings, in all three planes of space, should
be considered in conjunction with the patient’s concerns
and facial appearance. Because the actual surgery needs
to be delayed until the growth rate has diminished to adult
levels, planning and commencement of a combined
orthodontic and orthognathic approach is best delayed
until age 15 years in girls and age 16 years in boys.

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5th year lec.15 Orthodontics Dr.

Treatment planning in class III malocclusions

• Bone anchored maxillary protraction (known as BAMP).

3. Orthodontic camoufl age Correction of an anterior

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