|Year : 2015 | Volume
| Issue : 5 | Page : 19-26
Contemporary solutions for managing Class III malocclusion
Nathamuni Rengarajan Krishnaswamy
Professor and Head, Department of Orthodontics, Ragas Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||18-Nov-2015|
|Date of Acceptance||19-Nov-2015|
|Date of Web Publication||10-Dec-2015|
Nathamuni Rengarajan Krishnaswamy
Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi, Chennai . 600 119, Tamil Nadu
Source of Support: None, Conflict of Interest: None
Although patients with Class III malocclusions constitute a small percentage of the average orthodontic practice, providing them with optimal treatment is a daunting task. The treatment approach is dependent upon the growth status of the individual and the severity of the skeletal dysplasia. For growing individuals, facemask therapy to protract the maxilla is ineffective because of its dependence on dental anchorage to bring forth skeletal correction. Orthodontic camouflage in nongrowing mild skeletal Class III individuals is met with limited success because of the anatomical boundaries and the conventional biomechanics. Orthognathic surgery to correct the maxillomandibular relations is time-consuming, and the facial esthetics is compromised during the orthodontic decompensation period. Contemporary solutions to overcome these limitations are now viable with the use of temporary anchorage devices and by performing surgery prior to orthodontic decompensation. The rationale for employing these contemporary approaches will be discussed in this study with illustrative cases.
Keywords: Camouflage, maxillary protraction, surgery first, temporary anchorage devices
|How to cite this article:|
Krishnaswamy NR. Contemporary solutions for managing Class III malocclusion. J Indian Orthod Soc 2015;49, Suppl S1:19-26
|How to cite this URL:|
Krishnaswamy NR. Contemporary solutions for managing Class III malocclusion. J Indian Orthod Soc [serial online] 2015 [cited 2019 Jan 20];49, Suppl S1:19-26. Available from: http://www.jios.in/text.asp?2015/49/5/19/171189
| Introduction|| |
Patients with Class III malocclusion compromise a relatively small percentage of the average orthodontic practice, but these are among the most challenging to treat effectively and efficiently. In the past, most Class III malocclusions were attributed solely to the large or prognathic mandible. Currently, we know that it can be caused due to maxillary retrognathism, mandibular prognathism, or a combination of both. It can also be due to a centric relation-centric occlusion shift leading to a mesial shift of the lower arch in the absence of maxillomandibular skeletal discrepancy (pseudo-Class III). The treatment approach depends on the growth status and severity of the skeletal dysplasia.
| Early Management|| |
Growth modification to redirect the vector of growth with functional appliances or by orthopedic devices to restrict mandibular growth and/or enhance maxillary growth is an accepted protocol for providing a more favorable environment for normal growth and to improve the psychological development of the child. 
The Frankel functional regulator III has been advocated in children with developing Class III growth pattern to stimulate maxillary growth and restrain mandibular growth by influencing the functional matrix.  Although few studies have documented favorable skeletal and dental response, long-term results seem questionable. The limitation of the fixed rate intravenous insulin infusion is that the outcome is dependent on excellent patient compliance and long treatment time. 
Individuals in whom mandibular prognathism is the cause for the Class III skeletal relationship, the use of chin cup to exert orthopedic force to restrict and redirect mandibular growth was a prevalent growth modification strategy.  To be effective, chin cup therapy must be started early in childhood and continued until growth is complete. However, it is almost impossible to obtain such cooperation from patients.  Yet, another limitation of chin cup is that the response is determined by the original facial pattern. Since part of the facial concavity is corrected by the mandible being displaced inferiorly. Stability following active treatment with chin cup is not guaranteed because of the sustained mandibular growth that occurs during and following pubertal growth spurt.  Late horizontal mandibular growth is now considered to be an inherited genetic trait and hence not amenable to therapeutic modification. 
Ellis et al. reported that 40-60% of skeletal Class III patients have a maxillary deficiency or retrusion.  They also emphasized that maxillary protraction should be employed in growing patients with Class III skeletal dysplasia. In the last few decades, protraction facemask therapy in conjunction with palatal expansion has been the mainstay in redirecting growth in growing Class III patients. 
A banded or bonded rapid palatal expansion (RPE) appliance can be fabricated as an anchorage for maxillary protraction. The RPE also helps in disarticulating the maxilla and allows more favorable forward movement of the maxilla by the protraction facemask. A well-disarticulated maxilla seems to be critical when using tooth borne device for orthopedic traction. 
| Treatment Timing|| |
A critical factor in determining the success of RPE and protraction facemask treatment is appropriate timing. Since, the main objective of treatment with facemask and RPE is to enhance downward and forward displacement of the maxilla by influencing the sutural growth. The protraction facemask RPE combination should be initiated in the primary or early mixed dentition. The optimal time to intervene in Class III malocclusion seems to at the time of eruption of the maxillary incisors. 
Kim et al. conducted a meta-analysis to analyze the treatment effects of protraction facemask in children with Class III malocclusion and found the correction to be due to a combination of skeletal and dental changes of maxilla and mandible.  The maxilla was found to move downward and forward with a slight upward movement in the anterior and downward movement in the posterior palatal plane as a result of the protraction forces. The mandible was found to rotate downward and backward to complement the correction of the concave facial profile. The upper incisors inclined labially and the lower incisor inclination decreased. It was postulated that the proclination of the upper incisors was due to mesial movement of the dentition and uprighting of the lower incisor was due to the pressure from the chin cup.
Based on reports of the clinical trial,  it is evident that protraction facemask treatment started in the mixed dentition seems to be stable 2 years after treatment. When the patients were followed 8 years after treatment only, about 67% maintained positive overjet. Based on this observation, it is reasonable to conclude that one out of three patients will relapse into reverse overjet. The reason for this relapse can be attributed to the facemask being ineffective to elicit true skeletal displacement of the maxilla owing to the inability to transmit appropriate forces for orthopedic correction of the maxilla.
The dependence on the dental units to transmit orthopedic forces to the maxillary skeletal base causes concurrent dental movements and can limit the extent to which the maxillary skeletal base can be protracted.  A method of minimizing dental movement is to anchor the intraoral device to multiple teeth and to loosen the circum-maxillary sutures with either banded or bonded palatal expansion. Because of the pressure of the periodontal ligament, unwanted dentoalveolar movements still occur. In some instances, dependence on dental anchorage may be contraindicated because of the underlying severity of the skeletal dysplasia, multiple missing teeth, vertically compromised growth, or highly compensated pretreatment occlusion. 
Until recently, accepting compromised results or opting for surgical correction after cessation of growth were the only alternatives.
With the advent of miniscrews and miniplates for orthodontic anchorage, a contemporary solution has become viable. The orthopedic forces are directly employed to the maxillary and mandibular skeletal bases by bypassing the dentoalveolar structures. It is then reasonable to expect that the skeletal effects of protracting the maxilla and restricting or altering the vector of growth of the mandible would be more successful. Applying orthopedic force to temporary anchorage devices (TADs) strategically located in the maxilla is a gaining popularity; although long-term results are still awaited, short-term effects are encouraging. 
The skeletal anchorage for maxillary protraction can be used either in tandem with the facemask or by using intraoral elastics. In either instance, the goal is to bypass the dentition and apply orthopedic forces to the skeletal bases through the skeletal anchorage devices. Some clinicians prefer a miniplate  for skeletal anchorage while others prefer a palatal onplant.  Miniplate can be located either at the zygomatic buttress or the piriform aperture. The combination of facemask for extraoral traction anchored to the intraoral skeletal anchorage seems to be the most common protocol. ,,,,,,,
De Clerck et al. introduced the use of unique skeletally anchored maxillary protraction protocol that employs intraoral elastics in a Class III vector connecting the skeletal anchorage devices in the maxilla and mandible.  The advantage of the method includes greater patient compliance, shortened duration of treatment, and lighter forces.
A meta-analysis conducted by Major et al. seems to indicate that skeletally anchored maxillary protraction results in substantial maxillary protraction without dental compensation when compared with conventional facemask protraction therapy that were anchored to bonded or banded palatal expansion device. Further, the method suggested by De Clerck employing intraoral elastics to skeletal anchorage devices in the maxilla and mandible seem to elicit greater and more favorable skeletal changes when compared to skeletal anchorage and facemask combinations. The following case which was treated by running intraoral Class III elastics between the skeletal anchorage devices in the maxilla and mandible shows substantial anteroposterior correction with minimal changes in the dentition [Figure 1]. Further, this method can be employed even in slightly older individuals who are in their early permanent dentition.
|Figure 1: A 13-year-old girl treated with skeletally anchored maxillary protraction. (a) Class III skeletal profile with retrusive maxilla and protrusive lower lip. (b) Class III dentoalveolar relationship with asymmetric and constricted maxillary arch, reverse overjet, blocked out maxillary canines and lingually inclined lower anterior. (c) A modified surgical plate anchored to the maxillary zygomatic buttress and lower anterior region and connected by elastics in a Class III vector. The full coverage bite plate aids in disarticulation. (d) Seven months after treatment, a positive overjet and a Class I molar relationship was established. (e) Pre-and post-treatment cone-beam computed tomography. (f) Pre-and post-treatment cephalometric tracings. (g) Facial profile is less concave, and there is greater prominence of upper lip|
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| Treatment of Nongrowing Class III Malocclusion|| |
Orthodontic treatment to camouflage the skeletal Class III malocclusion in nongrowing patients with mild skeletal discrepancy has been the standard approach when the patient declines surgery. Treatment can be carried out with conventional fixed appliance with or without extraction of teeth. If extraction is indicated, then the preferred pattern of extraction would be to extract the upper second and lower first bicuspids or one lower incisor alone.  The limited success of camouflaging Class III treatment can be attributed to the existing compensation, excessive arch length tooth size discrepancy, and the inability to compensate the dentition further due to anatomical boundaries.
Specifically, proclining the upper incisors to eliminate the reverse overjet has to be judiciously executed as otherwise the facial esthetics could be compromised since the patient will usually have a retrusive maxilla. Similarly, retroclining the mandibular incisors to eliminate the reverse overjet may be hampered due to the presence of thin symphyseal morphology and the risk of inducing gingival recession and/or fenestrating the labial bone in patients who already have a wash board appearance.
With the widespread use of TADs, the extent of tooth movement can be enhanced and it is now possible to distalize the mandibular dentition in nongrowing patients with moderate to severe skeletal malocclusion without the risk of compromising the gingival health or the lower labial alveolar plate. The simplest application of TAD for the treatment of Class III malocclusions is the direct retraction of the mandibular arch with the TAD being placed in the posterior area of the mandible. When TADs are used as absolute anchorage, the mandibular dentition can be retracted en masse by using nickel-titanium (Ni-Ti) springs or elastic chain.
From a biomechanical standpoint, placing a TAD in the retromolar area is the most effective way for en masse distalization of the mandibular dentition.  However, placing a TAD in the retromolar area is contraindicated if there is lack of attached gingiva and reduced accessibility to the retromolar area. Alternative solution is the placement of a miniscrew in the interradicular area between the first and second molar or first molar and second premolar.  The limitation of this location is the proximity of the roots of teeth which may be injured either during the insertion of the TAD or the possibility of the roots contacting the TAD when the mandibular dentition is distalized. 
Miniplates can be placed instead of miniscrews in the mandibular posterior area to serve as absolute anchorage for en masse distalization of the mandibular dentition.  However, miniplates require flap surgery for both their placement and removal with a longer healing period and more pain and discomfort than with miniscrews.
Since the success rate of TADs placed in the mandible is significantly lower than the TADs placed in the maxilla, some clinicians prefer to place a TAD in the maxilla between the roots of the second premolar and the first molar and engage Class III elastics from the TAD to the anterior mandibular dentition.  This approach is a compromise because the results depend completely on patient cooperation.
A novel approach that overcomes the limitation of TADs in the above-mentioned locations and can still bring about predictable en masse distalization of mandibular dentition recommended by Chang and Roberts.  This involves the use of an extra-alveolar miniscrew placed in the buccal shelf of the mandible. Ni-Ti retraction springs from the extra-alveolar miniscrew to the hooks in the anterior segment of the lower archwire seems very promising as outlined in the case [Figure 2]. The failure rate of this approach is reported to be as less as 7% and does not require predrilling and can withstand a load up to 14 oz.
|Figure 2: A 22-year-old female treated with orthodontic camouflage. (a) Skeletal Class III profile with prognathic mandible, retrusive upper lip and mild increase in the lower facial height. (b) Class III dentoalveolar malocclusion with reverse overjet and blocked out maxillary canines and lingually inclined lower anterior exhibiting prominent roots. (c) Lower third molar extracted and 12 mm extra-alveolar miniscrew inserted in the mandibular buccal shelf. (d) Nickel-titanium coil springs from the lower archwires to the miniscrews for en masse distalization of the mandibular dentition. (e) After 18 months of treatment. (f) Pre-and post-treatment cephalograms. (g) Pre-and post-treatment tracing and superimposition. (h) Posttreatment facial appearance|
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| 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. Orthognathic surgery has been successfully carried out for more than three decades and in a well orthodontically decompensated dentition the jaws can be precisely repositioned in all three planes of space to yield predictable outcomes.  The acceptance for undergoing orthognathic surgery is highest in individuals with Class III skeletal malocclusion when compared with patients with other skeletal malocclusions that may warrant surgery and this can be attributed to the greater negative effect on the psychological and social well-being that is characteristic of skeletal Class III malocclusion.
The conventional approach to orthognathic surgery requires a variable length of preoperative orthodontic preparation before the surgery and a relatively stable period of postoperative orthodontics. The importance of preoperative orthodontics rests on the fact that optimal positioning during surgery may be limited by inappropriate dental alignment. However, orthodontic preparation typically lasts 15-24 months  involving progressive deterioration of facial esthetics and dental function and causes significant patient discomfort. 
In the recent years, many surgeons have perceived orthognathic surgery as too complicated, too invasive, time-consuming, and expensive. They proposed the "surgery first" approach and created broader interest in the complete elimination of presurgical orthodontic treatment.  In the surgery-first approach proposed by Sugawara et al., the surgery is carried out without any presurgical orthodontic preparation and is followed by regular postoperative dental alignment.  Although minor orthodontic movements are occasionally performed before surgery, the concept implies that most of the orthodontic treatment is performed postoperatively. Several advantages have been reported for the surgery-first approach including improvements in patient's facial esthetics and dental occlusion early in the treatment.  Improvement in patient's swallowing and speech function after surgery, postoperative accelerated orthodontic tooth movement both due to the regional acceleratory phenomenon and early restoration of normal function and anatomic relationship of the bony skeleton and surrounding soft tissues.  The stability of results is equal to or in some cases superior to those achieved using the more traditional orthodontics first approach. 
Nagasaka et al. published a series of case reports using surgery-first approach to correct skeletal Class III malocclusion; the results demonstrated acceptable facial esthetics and dental occlusion with total treatment time of <12 months.  In their initial case reports, orthognathic surgery was performed on the mandible only. A Class III malocclusion became a Class II immediately after mandibular setback, and then skeletal anchorage was advocated to correct the intentionally created Class II to a Class I dentoalveolar relationship. Baek et al. emphasized that the surgery-first approach requires accurate prediction of the postoperative orthodontic treatment for dental alignment, incisor decompensation, arch correction, and occlusal settling at the very beginning of preoperative treatment plan.  Their case report documented Class III corrections by employing LeFort I osteotomy and mandibular setback.
Liou et al. suggested a modification to the surgery-first approach.  However, his technique required more surgical segments and less reliance on TAD's or skeletal anchorage systems (SAS's) for postoperative alignment. His approach is referred to as "surgery driven" surgery-first approach compared to the one popularized by Sugawara wherein the surgical segments are kept to a minimum, but TAD's and SAS's are used extensively for postsurgical alignment.  This approach is referred to as "orthodontics driven surgery-first approach". A Class III malocclusion treated with orthognathic surgery using the surgery-first approach is illustrated in [Figure 3].
|Figure 3: A 20-year-old male treated with surgery-first approach. (a) A skeletal Class III profile with retrognathic maxilla, prognathic mandible, facial asymmetry, and excess lower facial height. (b) Class III malocclusion with Class III buccal segment, anterior open bite, bilateral posterior crossbite, and a noncoincident midline. (c) Surgical archwires adapted according to the malocclusion and placed 1 week prior to surgery. (d) Two weeks after LeFort I maxillary advancement and mandibular setback surgery. (e) Seven months after surgery - postsurgical orthodontics in progress. (f) Pretreatment, immediate postsurgical, and 7 months postsurgical cephalometric radiographs. (g) Seven months after surgery revealing a more balanced facial profile and symmetry|
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In a systemic review of surgery-first approach in orthognathic surgery, Huan et al. found the surgery-first approach to be a viable alternative to the orthodontics first approach for correction of maxillofacial deformities.  The outcome in terms of facial esthetics, dental occlusion, and stability were found to be similar in both the approaches. Kim et al. evaluated the stability of mandibular setback surgery in patients with and without presurgical orthodontics and found the outcome to be similar with a slightly greater predilection for relapse in surgery-first cases which was however clinically insignificant. 
| Conclusion|| |
Declaration of patient consent
- Growth modification with skeletally anchored maxillary protraction is more effective than dentally anchored maxillary protraction. Further, the skeletally anchored protraction using intraoral Class III elastics has the advantage of reduced treatment duration and the possibility of treating slightly older children
- Camouflage in Class III malocclusion is more effective when TADs are used to provide absolute anchorage compared to conventional extraction treatment and Class III biomechanics. Miniscrews used in the buccal shelf are more conducive for en masse distalization of the mandibular dentition to provide adequate camouflage
- Orthognathic surgery followed by orthodontics seems to be a better approach in patients who warrant surgery. The duration, cost of treatment, and patient's outlook seem to be better when surgery is carried out first.
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
I wish to thank my colleagues Dr. M. K. Anand,Dr. Rekha Bharadwaj, and Dr. Shobbana Thalur at the Department of Orthodontics, Ragas Dental College and Hospital, for providing the cases published in this article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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| Authors|| |
Dr. N. R. Krishnaswamy currently holds the position of vice principal, Professor and Head, Dept of Orthodontics,Ragas Dental College and Hospitals, Chennai. He obtained his bachelor degree at the Govt. Dental College, Chennai and earned his masters degree from KMC Manipal. He acquired his fellowship in orthodontics from the Royal College of Surgeons (M Orth), Edinburgh and is a Diplomate of the Indian board of Orthodontics (DIBO) and The National Board of Medical Sciences (Dip NB).He was awarded the scholarship of the International Scientific Exchange Fund of the Japan Dental Association which led to clinical training at Tsurumi University Yokohama, Japan. He has several awards winning presentations to his credit and has won the Presidential Trophy for the Best Clinical Paper Award of the Indian Orthodontic Society thrice and the Best Research Award twice. He is recipient of the best teacher award of Tamil Nadu, Dr. M.G.R Medical University. He has been a headline speaker at the IOS National Conferences for almost two decades and has also been an invited speaker at several international orthodontic forums including the AAO. He also has several publications to his credit. He has served as Director and Chairman of the Indian Board of Orthodontics and as President of the Indian Orthodontic Society. He is the recipient of the Helen & B. F. Dewel award for the best clinical research paper published in the AJO-DO in the year 2012.
[Figure 1], [Figure 2], [Figure 3]