MANAGEMENT

OF CLASS III
MALOCCLUSION

Presented by
Dr. Lipika Mali
1
PGT 2nd Year
 CONTENTS

1. Introduction
2. Classification
3. Aetiology
4. Clinical features of Cass III Malocclusion
5. Components contributing Class III Malocclusion
6. Diagnosis
7. Management
-Growth Modification
-Orthodontic Camouflage
-Orthognathic Correction
8. Conclusion
9. References

2
 INTRODUCTION
“Class III malocclusion occurred
when the lower teeth occluded
mesial to their normal relationship,
the width of one premolar or even
more in extreme cases”. - Angle
(1899)

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TWEED’S CLASSIFICATION(1966)

PSEUDO SKELETAL
CLASS III CLASS III

Normal
Large Mandible
Mandible

Underdeveloped
Underdeveloped
or Normal
maxilla
Maxilla

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Moyers classification

Muscular

CAUSE

Osseous Dental

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 ETIOLOGY

Genetic

Environment
al

Ethnic

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CLINICAL FEATURES

•CONCAVE FACIAL PROFILE

•ANTERIOR FACIAL DIVERGENCE

•RETRUSIVE NASO-MAXILLARY AREA

•PROMINENT LOWER 3RD OF FACE

•STEEP MANDIBULAR PLANE ANGLE

•OBTUSE GONIAL ANGLE

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 FREQUENT INTRAORAL FEATURES

•Class III Molar Relationship

•Class III Canine Relationship

•Cross bite tendency

•Reverse Overjet with possibly labially inclined lower incisors & palatally inclined
upper incisors

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COMPONENTS OF CLASS III
MALOCCLUSION

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 DIAGNOSTIC SCHEME
(MOLAR RELATION & OVERJET)

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 How to differentiate between a True & a
Pseudo Class III ??

1. When the mandible is guided in a centric relation, pseudo class III will reveal a normal Overjet or edge to
edge incisor relation.

2. On Cephalometric analysis:
Pseudo Class III shows normal SNA with True Class III shows large SNB or a small SNA,
slightly increased SNB(because of forward depending on where the fault
positioning of the mandible) lies(maxilla/mandible) or both

3. Most true Class III cases have a strong hereditary component.

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12
TYPE ANTERIOR CENTRIC RELATION AND CENTRIC
POSITION OF OCCLUSION SIGNIFICANCE
MANDIBLE

PSEUDO-CLASS Present Not coincident Problem is less difficult

III than it appears .

TRUE CLASS III Present Not coincident Problem is less difficult

than it appears

TRUE CLASS III Absent Coincident Problem is as difficult as

it appears

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 MANAGEMENT OF CLASS III
MALOCCLUSION
The diagnostic procedure helps in determining or planning the treatment for the particular type of
Class III malocclusion i.e. Dental or skeletal, true or pseudo.

GROWTH
MODIFICATION

ORTHODONTIC
CORRECTION

ORTHOGNATHIC
SURGERY

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 INTERCEPRTION
DURING GROWTH
Or
Growth Modification

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 Rickets (AJO 2000) summarized the main objectives of early treatment
lying in five concepts :
.
Obtaining skeletal
change(Structural)

Taking advantage of the

Providing favourable
forces of the occlusal
environment for
development towards
functional change
the correction

Utilization of the
Elimination of the
individual growth
detrimental habits
towards correction

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 INDICATION AND CONTRAINDICATION FOR EARLY CLASS III TREATMENT

Objective To create an environment in which a more favourable dentofacial development can

occur

Turpin et al (1981)

Positive Factors
Negative factors
Good Facial esthetics
x Poor facial esthetics
Mild skeletal disharmony
x Severe skeletal disharmony
No familial prognathism
x Familial pattern established
Ant-Post functional shift
x Asymmetric facial growth
Convergent facial types
x Growth complete
Symmetric condylar growth
x Expected poor cooperation
Growing patients with
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expected good cooperation
 Functional Appliance
Therapy Protraction Face Mask
~Frankel III Regulator Chin Cup Therapy Therapy
~Class III Activator
~Class III Bionator
~Reverse Labial bow

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 FUNTIONAL APPLIANCE THERAPY

1. THE FRANKEL III REGULATOR

 Designed to counteract the muscle forces on the maxillary

complex.

Indication:
a). Deciduous, mixed & early permanent dentition stages.
b). Maxillary skeletal retrusion( not mandibular prognathism)

Components & Mode of action:

Placed away from the Stretches Allows forward

Vestibular shields in alveolar buccal plates the development of
the depth of sulcus of maxilla periosteum the maxilla.

Shields placed
close to Holds or
POSTERIORLY
mandibular redirects growth
alveolus

More successful in patients with class 3 malocclusion presenting with a functional shift on closure. 19
2. CLASS III ACTIVATOR :

Rakosi (1979) modified activator for use in CLASS III treatment.

 Objective Achieve posterior positioning of the mandible or maxillary protraction.

 The modifications consist

a).4 stop loops - mesial to first molars (prevents mesial tipping of molars and stabilizes the appliance)
b).Lower labial low
c).Upper labial pads (remove force of upper lip & allows maxillary protraction)
d).Tongue crib.

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  Treatment Changes:

1 Backward positioning of the mandible

2 Significant increases of the ANB angle and the Wits values.

3 SNB and S-N-Pog becomes smaller resulting in increasing facial convexity (NAPog).

4 Articular angle significantly increased, thus augmenting the sum of the saddle, articular and gonial
angles.

5 Facial axis opened significantly.

6 Dentoalveolar adaptations included labial tipping of the upper incisors as well as lingual tipping of
lower incisors.

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3. CLASS III / REVERSED BIONATOR :
 Objective Encourages development of maxilla

 Criteria:
1 Angles Class III Molar relation
2 Edge to edge incisor position/Anterior cross-bite
3 Concave profile
4 Low & forward tongue rest position
5 Hypertonic upper lip

 Appliance components :

1.Lower acrylic portion(from canine to canine)

2. Palatal bar The tongue is maintained in a retracted position in its proper

functional space( It should contact the anterior portion of the palate
encouraging the forward growth of this area).

3.Labial bow( runs in front of the lower incisors)

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 Treatment changes:
1 Mean increase in the upper jaw length

2 Advancement of point A

3 Palatal and mandibular plane angles widened

4 Increase of the anterior facial height

5 Reduced Anteroposterior mandibular growth

Therefore, the Bionator III is helpful in Class III malocclusion treatment in growing patients with
midfacial deficiency, hypodivergent growth pattern, and reduced facial height.

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 4. FIXED REVERSE LABIAL BOW

Introduced by Caranos et al. [JCO2003]

 Indication:
Mild-to-moderate dental and skeletal Class III malocclusions in
growing patients.

 Wire components:
inserted into the headgear wire restricts the lower
0.045`` SS arch wire tubes of the upper molar incisors during closure of
bands the mandible.

Clip in the distal end Ends in a distal ball end Prevents wire end from
(0.028`` wire) soldered to 3mm tube sliding out

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 Treatment Changes :

1.ANB generally increases due to an increase in SNA, with no downward and backward rotation of the
mandible.
2.The lower incisor inclination decreases, while the overbite and overjet are improved.

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CHIN CUP THERAPY
Indication
Skeletal Class III malocclusion with relatively normal maxilla
& a moderately protrusive mandible.

Objective:
Provides growth inhibition/redirection & posterior positioning
of mandible

Mode of Action:
Mandibular growth-

Orthopaedic Backward Remodelling ,

redirection reposition or with closure of
vertically rotation gonial angle

Orthopaedic Appliance
force of 300- wear for
Force, Magnitude & Direction: 500gm/side 14hr/day

In patients with
Occipital pull mandibular
prognathism
Force directed
-In patients with steep through or below
the condyle
Vertical pull mandibular plane angle
-Increasead LAFH 26
 SPLINTS, CLASS III ELASTICS, AND CHINCUP (SEC III)
Ferro et al[AJO2003]
• In the 1980s, proposed a new orthopedic approach splints, elastics, and chincup for Class III (SEC III) to
correct this skeletal malocclusion.

 Appliance components:

1). 2 removable splints with hooks for Class III elastics and a chin-cup were associated.

The 2 splints with a flat occlusal plane Facilitate correcting the Class III relationship, eliminating both
intercuspation and aggravating factors, such as anterior tongue thrust .

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 Forehead rest
PROTRACTION FACE MASK
 Class III malocclusion with mild to moderate maxillary
deficiency

Most effective in the primary and early mixed dentitions .

Main frame
A viable option for older children before the onset of puberty.

Mode of Action Crossbar

Chin cup
Near Downward
Protraction
Maxillary & forward
elastics
Canine pull of 30°

Force, Magnitude & Direction-

300 to 600 g of
12hr/day
force per side

It is a advisable to use a retention device such as a mandibular retractor or a functional appliance 28

following maxillary protraction.
 Palatal expansion has been advocated as a routine part of Class III correction with facemask therapy.

• The benefits of palatal expansion might include:

- Expansion of a narrow maxilla
- Correction of posterior crossbite
- Increase in arch length
- loosening or activation of circummaxillary sutures & initiating downward and forward
movement of the maxillary complex.

• Clinicians have advocated maxillary expansion a week before starting facemask use, even without
maxillary constriction or crowding.
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 Skeletal Effects of Maxillary Protraction

Several circummaxillary sutures play an important role in the development of the nasomaxillary complex.

• Maxillary protraction, however, does not always result in forward movement of the maxilla however
loosening or activation of circummaxillary suture & initiating downward and forward movement of the
maxillary complex.

• Nanda showed that with the same line of force, different midfacial bones were displaced in different
directions depending on the moments of force generated at the sutures.

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 TANDEM TRACTION BOW APPLIANCE
Chun et al [JCO1999] introduced a new appliance for treatment of growing Class III patients:
• More esthetic and comfortable than conventional devices because it is worn intraorally.
• Removable, making it easy for the patient to maintain oral hygiene.

 Appliance Construction:

Covers the occlusal & palatal

Upper splint
surface of maxillary teeth

Covers buccal &

Lower splint lingual surfaces of
mandibular arch

Traction Bow

The position of the elastic hooks on the upper splint

and the tubes on the lower splint determine the
direction of force.

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Clinical trials of the TTBA, showed anteroinferior movement of the maxilla & postero-inferior repositioning
of the mandible.
Therefore, it was concluded that the TTBA has a similar treatment effect to that of an expander-facemask
combination.

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Advantages :

 Promotes patient compliance(more esthetic and comfortable than extraoral appliances)

 Night-time wear is adequate for an orthopedic effect.

 Promotes good oral hygiene, because it is removable.

 Distributes the force of protraction to all maxillary teeth.

 Permits free mandibular movement, with its polished occlusal surface, so that a functional shift is easily
corrected.

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 TREATMENT
APPROACH IN
NONGROWING PATIENTS

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 Non growing patients with mild to moderate skeletal class III, can be camouflaged with orthodontic tooth
movement.

The treatment strategies include:

1. Conventional edgewise appliance with/without extraction.
2. Multiloop edgewise archwire(MEAW) with Class III & vertical elastics.
3. Retraction of lower dentition using springs from mandibular microimplants to the lower dentition.
4. Retraction & uprighthing of lower posterior teeth using Class III elastics from maxillary micro implamts
to the lower dentition.

Criteria for Camouflage treatment:

 Patients with mild anteroposterior skeletal discrepancy & functional discrepancy
 Low angle cases

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1. CONVENTIONAL EDGEWISE APPLIANCE WITH/WITHOUT EXTRACTION

Severity of
Need for malocclusion/
extraction crowding

Extraction Therapy

•Lower 1st premolar extraction When lingual tipping of lower incisors is required without moving upper
incisors
•Upper 2nd & lower 1st premolar extraction Mesial movement of molars to correct molar relationship
•Upper & lower 1st premolar extraction Anterior Crowding (Molars are almost in Angles Class I)
•Lower incisor Mild crowding of lower arch

Non extraction Therapy

•Low angle cases

•Presence of anterior crossbite
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Can be treated by uprighting lower posteriors& using microimplant anchorage
2. MULTILOOP EDGEWISE ARCHWIRE(MEAW TECHNIQUE)

Introduced by Dr.Young H Kim in 1967

Indicated in:
Class III malocclusion with mesially inclined lower
posterior teeth with openbite.

•2 loop component [a horizontal & Vertical between each tooth]

•Fabricated with stabilizing archwire 0.016X 0.022 inch SS arch wire
•Activated with a series of tip back bends of 3°-5° beginning at the 1st premolar & progresses posteriorly to
last molars

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Mechanism:

~Tip back movement of the posteriors Using Class III & vertical elastics.

~The long class III elastic Extrusion & counter clockwise rotation of the occlusal plane & clockwise
rotation of mandible.

~Vertical elastic (3/16 inch, 6oz.)  Between upper & lower 1st loop
Class III elastic(3/8inch,5oz or 5/16 inch,5oz.) Upper last/first molar to 2nd loop of lower

*Before applying the MEAW, all rotation ,spacing ,irregularities & poorly positioned brackets whould be
eliminated.

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3. CLASS III TREATMENT WITH MICRO IMPLANT ANCHORAGE

MIA has been used to retract lower dentition for class III treatment in 2 ways:-
1. Microimplants placed in mandible
2. Microimplants placed in Maxilla

Lower Micro Implant Anchorage

Used to treat mild & moderate skeletal Class III & relapse after Class III surgery

Mircroimplant can be placed in retromolar area or interradiicular space between 1st molar & 2nd
premolar or between 1st & 2nd molars.

There are 2 methods of lower arch retraction:

 Whole dentition retraction
Sequential retraction

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Whole dentition retraction

After levelling , a proper sized rectangular SS wire attached with a hook between the canine & lateral is
placed in the lower arch.
Retraction force is applied from the microimplant to the hook using Ni-Ti coil spring or power chain

Force direction & Centre of resistance should be paid attention.

 The Line of Action should pass over or on the Centre of resistance
of lower dentition
So the microimplant should be placed close to the cervical area

Alternately Miniplate with long hook can be used

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Sequential retraction

Usually preferred(Easy to place & manipulate)

•Micro implant is placed between 2nd premolar & 1st molar

•Posterior teeth moved distally using open coil spring from micro implant to a sliding hook placed at the end
of each coil spring.

•After class I molar relation is achieved, the same microimpant are placed in the distal area, and the anteriors
are retracted distally

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Upper microimplant anchorage

For high angle skeletal cases with open bite and mesially inclined lower posteriors

Biomechanics
Class III elastics from upper micro-implant to mandibular canine Distal tip back of posteriors &
Extrusion of anteriors

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ORTHOGNATHIC
SURGERY

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The treatment of dentofacial deformities of patients that finished craniofacial growth
is complex, especially when transversal and sagittal discrepancies exist, requiring
orthodontic and orthognathic surgery.

The only definitive approach to eliminate the skeletal imbalance and obtain optimal
esthetics, function, and stability in patients with skeletal Class III malocclusion is
orthognathic surgery combined with orthodontics.

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Indication:
Severe orthodontic problems that neither growth modification nor camouflage offers a
solution.

Common Orthognathic Surgical Procedures:-

Le fort I Maxillary Advancement For Retrognathic maxilla

Bilateral Sagittal Split Osteotomy(BSSO)For Mandibular setback

For Prognathic mandible

Segmental Osteotomy

Genioplasty

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LE FORT I OSTEOTOMY

Antero
Altering vertical
dimension posterior
discrepancy

Surgical
Levelling of
expansion of
occlusal plane
Maxilla

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Allows maxilla to be moved
up and/or forward

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 Bilateral Sagittal Split Osteotomy(BSSO)

For mandibular setback/Prognathic Mandible

Advantages:
-Minimal alteration of natural position of muscles of mastication
-Minimum alteration in position of TMJ
-Low complication rate

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 Segmental Osteotomy

A segmental osteotomy allows the resection of a defined section of the mandibular body.

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 GROWTH PREDICTION

Cranial Base:
•Linear & Angular measuremments were decreased in ClassIII patients.
•Exhibited a cranial base (Ba-S-N) more acute & anteriorly positioned articulare
•The middle cranial fossa had a posterior & superior alignment( causing nasomaxillary retrusion
& forward rotation of mandible)

Maxilla:
•Exhibit decreased horizontal maxillary growth( A Point growth ideally1mm/year, but in class
III0.4mm/year)

Mandible:
•Exhibit increased mandibular length
•Anteriorly articulated mandible
•Shorter ascending ramus
•Steeper mandibular plane
•Obtuse gonial angle

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 In 1970, Dietrich reported that Class III skeletal discrepancies worsened
with age. The percentage of children with mandibular protrusion increased
from 23% to 30% to 34% as the dentition progressed.Maxillary
anteroposterior deficiency problems went from 26 % to 44% to 37%.
These results indicate that the abnormal skeletal characteristics can become
more pronounced with time.

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 INFRAZYGOMATIC CREST & BUCCAL SHELF IMPLANTS FOR MANAGEMENT
OF CLASS III MALOCCLUSION

Implants are an excellent alternative to traditional orthodontic anchorage methodologies, and they
are a necessity when dental elements lack quantity or quality, when extraoral devices are
impractical, or when noncompliance during treatment is likely

In an adult with complete dentition, the sole function of the fixture is orthodontic anchorage. It is
used to avoid cumbersome and unattractive devices, such as headgear

52
The infra-zygomatic crest (IZC) is a buccal process on the maxilla, connecting to the zygoma. Intraorally it is
a crest of bone emanating from the buccal plate of the alveolar process, lateral to the roots of the first and
second maxillary molars.

The ridge of bone extends 2cm or more superiorly to the zygomatic-maxillary suture, and the inferior portion
can be subdivided into the IZC 6 and IZC 7 areas, respectively (The IZC is a common site for insertion of
temporary anchorage devices (TADs)

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54
 The original study of the IZC screw by Liu placed the screw over the buccal side of the 1st molar’s
mesiobuccal root.

Since the volume of buccal bone outside the upper 1st molar’s mesiobuccal root is much less than the volume
of the buccal bone outside of the upper 2nd molar, it was preferred to place the IZC screw over the buccal
side between the distal portion of the upper 1st molar and the mesial portion of the upper 2nd molar, and calls
this technique The Modified IZC Screw

55
For more severe Class III and open bite patients, whose upper incisors
are a little proclined, in which case Class III elastics cannot be used
too much, then buccal shelf screws can be used.

When the slope of the buccal shelf is very steep, it will be difficult to position the screw outside the molar
roots (extra-radicularly) when placing directly with self-drilling. It means, therefore, the screw will be placed
between the molar roots (inter radicularly). When this happens, due to the limited space between the lower
molar roots, after retracting the whole lower dentition for a while, the distal root of the lower 1st molar will
move distally and will come in to contact with the screw, stopping the retraction of the whole lower arch.

 Whenever the slope of buccal shelf is steep, it is highly recommends placing the screw through an apically
positioned flap. Pilot drilling enables the screw to be really placed extra-radicularly, then retraction of the
whole lower arch will be possible and easy.

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Note:-

1. With the proper use of IZC screws, and buccal shelf screws most difficult Class III can be treated
without extraction and without surgery, as long as the patient has an orthognathic profile or is willing to
accept a slightly prognathic profile.

2. Upper incisor angulation and nasolabial angle are the key factors for successful Class III treatment.
When the upper incisors are already proclined or there is upper arch crowding at the beginning of
treatment, placing IZC screws and Damon upper incisor brackets upside down is a very effective way to
prevent the upper incisors from flaring and can even make them more upright, making a non-extraction
treatment possible.

3. Whenever using the buccal shelf screws to retract the whole lower arch, be sure to place the screw extra-
radicularly, if not, the screw contact with the molar root will prevent further retraction of the whole lower
arch.

57
 CONCLUSION

Angles Class III malocclusion is difficult to plan and control as it may have a powerful genetic
component. The failure to properly diagnose these patients may be due to inadequate analysis of
pre-treatment data or unpredictable jaw growth..

Thus it is important to have a proper knowledge of the malocclusion before starting with the
treatment planning.

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 REFERENCES:

1. Ravindra Nanda- Biomechanics & Esthetic Strategies in Clinical Orthodontics.

2. Samir E. Bishara – Textbook of Orthodontics.

3. William R Proffit- Contemporary Orthodontics.

4. Shushu He et al. - Camouflage treatment of skeletal Class III malocclusion with multiloop
edgewise arch wire and modified Class III elastics by maxillary mini-implant anchorage-
Angle Orthodontist, Vol 83, No 4, 2013.

5. Adolfo Ferro et al. - Long-term stability of skeletal Class III patients treated with splints,
Class III elastics, and chincup. American Journal of Orthodontics and Dentofacial
Orthopaedics April 2003.

6. ALDO CARANO- A Fixed Reverse Labial Bow for Moderate Class III Interceptive
Treatment. JCO/JANUARY 2003.

7. Patrick K. Turley- Treatment of Class III malocclusion with Maxillary Expansion &
protraction- Seminars in Orthodontics, Vol 13, No 3 (September), 2007: pp 143-157.

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60
An en-masse retraction of the mandibular arch is efficient for conservatively treating a skeletal
Class III malocclusion. Posterior mandibular anchorage with buccal shelf screws causes
intrusion of the molars to close the vertical dimension of the occlusion and rotation of the
occlusal plane and the mandibular plane angle.
As the center of resistance of the whole mandible is located around the apex of the lower second
premolar, the force will create a large counter clockwise rotation movement which results in
rotating the occlusal plane.

Advantages:
1. less risk of tooth root damage, 2. more abundant bone allows for a larger screw diameter
(2mm), 3. commonly made of stainless steel (SS) which is much stronger than titanium alloy, 4.
2mm SS screws can be configured with a sharp, cutting tip that is resistant to fracture, 5. less
risk of fracture when placed in dense cortical bone, 6. do not interfere with tooth movement,
and 7. adequate anchorage for retracting the entire arch to relief crowding and reduce
protrusion.

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