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Removable and Fixed Orthodontic Appliance Application for Class III

Malocclusion.

Article  in  International Medical Journal (1994) · August 2016

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Mohammad Khursheed Alam Nor Fatiyah Nasir

Al-Jouf University Universiti Sains Malaysia
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404 International Medical Journal Vol. 23, No. 4, pp. 404 - 407 , August 2016
ORTHODONTICS

Removable and Fixed Orthodontic Appliance Application for

Class III Malocclusion

Mohammad Khursheed Alam, Nor Fatiyah Che M Nasir

ABSTRACT
Case presentation: The patient was a 15-year-old Malaysian girl whose chief complaints were unaesthetic facial appearance
and appearance of the front teeth. A study model and radiograph were used to identify the problems. Selection of the treatment
options were explained to patient. However, bracket for fixed appliance cannot be attached to the teeth due to the anterior
locked bite and retruded maxilla. Thus, removable appliance with anterior expansion screw and posterior bite plane was used to
raise the bite and expand maxilla anteriorly, prior fixed orthodontic appliance application.
Conclusion: Even though few modalities were needed for his treatment but the outcome was excellent and reached the
demand of the patient.

KEY WORDS
class III malocclusion, locked bite, removable appliance, fixed appliance

INTRODUCTION some controversy evoked as whether mandibular protrusion is in fact

due to an excessive amount of growth or merely an alteration in the
shape of the mandible5).
Class III malocclusion is usually associated with a deviation in the Little definitive information is available regarding anterior locked
sagittal relationship of the maxilla and the mandible, characterized by a bite in class III malocclusion. This case report demonstrates the success-
deficiency and/or a backward position of the maxilla, or by prognathism ful alignment of the teeth using removable and fixed orthodontic appli-
and/or forward position of the mandible1). ance to correct class III malocclusion with anterior locked bite.
According to Angle, class III malocclusion was characterized by Utilization of both appliances gave less impact on the length of the
mesial occlusion in both lateral halves of the dental arches. The extent treatment. However, it had contributed to proper management and suc-
to which the mesial occlusion must exist in order to place the case in the cessful treatment to patient.
occlusion of this class is slightly more than one-half the width of a sin- The purpose of this paper is threefold: to present a review of the lit-
gle cusp on each side2). erature concerning the dental and skeletal components of the adult Class
There are lots of studies done to identify the skeletal and dental III malocclusion population; to present result of intervention from a
relationships of adults with class III malocclusion using lateral cephalo- class III malocclusion patient; and to discuss the clinical ramifications
grams. Cephalometric investigations have demonstrated that some of the treatment results.
adults who have Class III malocclusions do not lit this "classic" pattern.
In fact, these investigations have shown that a Class III malocclusion Diagnosis and aetiology
can exist with any number of combinations of skeletal and dental com-
ponents within the facial skeleton3). Class III malocclusions have been A 15-year-old female patient referred to orthodontic department of
divided into two basic morphologic types- the divergent and the conver- Hospital Universiti Sains Malaysia (HUSM) with complaint of unaes-
gent facial types. The expression of vertical proportions is most dramat- thetic facial appearance and appearance of the front teeth. The medical
ic in the anterior part of the face, most notably in the lower anterior history was non-contributory. Orthodontic treatment planning was car-
facial region. It was found that lower-facial-height values were greater ried out in consultation with an orthodontist regarding class III maloc-
in most cases4). clusion with anterior locked bite.
Components of class III malocclusion includes: (1) maxillary dental Pre and post-treatment of extraoral and intraoral photograph was
position, (2) maxillary skeletal position (3) mandibular dental position taken but not presented as refused consent by the patient. Pre-treatment
(4) mandibular skeletal position and (5) vertical development3). model photograph revealed all permanent teeth were erupted except for
For the components of Class III molar and canine relationship, it maxillary and mandibular third molars. Patient had an Angle Class III
includes posterior positioning of the maxilla relative to other craniofa- malocclusion with reverse overjet 4 mm and class III molar relationship.
cial structures or posterior position of the maxillary dentition relative to High canines on tooth were 13 and 23. Anterior locked bite noted. Other
maxillary skeletal structures3). However, some studies have demonstrat- teeth were well-aligned (Figure 1).
ed that the maxillary anterior teeth are protruded in the majority of Orthopantomogram (OPG) showed presence of all permanent teeth
Class III cases4,5). except for impacted both maxillary and left mandibular third molars
The retrusion of the mandibular incisors relative to the mandible while mandibular right third molar was missing (Figure 2).
and to other structures of the face in adults with Class III malocclusion The cephalometric analysis showed prognathic mandible with nor-
is well known5). Mandibular skeletal protrusion is, if not the most preva- mal maxilla in class III skeletal relationship. Maxillary incisors were
lent feature, a prominent feature in the majority of the cases5). However, protruded while mandibular incisors were retruded as for dental com-

Received on April 7, 2014 and accepted on November 26, 2015

School of Dental Sciences, Health Campus, Universiti Sains Malaysia
Kerian, 16150, Kelantan, Malaysia
Correspondence to: Mohammad Khursheed Alam
(e-mail: [email protected])

C 2016 Japan Health Sciences University

& Japan International Cultural Exchange Foundation
 Alam M.K. et al. 405

Figure 2. Pre-treatment OPG, pre-treatment lateral cephalo-

gram, lateral cephalogram tracing.
Figure 1. Pre-treatment model photograph.

Figure 3. Upper removable appliance with anterior expansion screw and posterior bite plane used to raise the bite to unlock pathway of
movement of upper incisors.

Figure 4. Intraoral photograph after alignment.

Figure 5. Post-treatment model photograph.

pensation. Longer in facial height noted. Lower lip soft tissue aesthetic
plane was increase (Figure 2 and Table 1).

Treatment objectives expand the maxillary teeth prior to fixed appliance application. Posterior
bite plane was used to raise the bite and anterior screw expansion was
The objectives of the orthodontic treatment were to (1) to protrude incorporated to the appliance. (Figure 3)
the maxillary incisors, (2) to retrude the mandibular incisors, (3) to cor- Application of fixed appliance with Nickel titanium (NiTi) wire was
rect anterior locked bite and (4) to align maxillary and mandibular teeth. used after the correction of anterior locked bite.
Treatment alternatives Treatment results
Class III malocclusion is one of the most difficult anomalies to The orthodontic removable appliance was incorporated with anteri-
understand. Not all Class III patients are candidates for surgical correc- or screw expansion to protrude the maxillary teeth and posterior bite
tion thus, patient assessment and selection remain as main issues in plane used to raise the bite to unlock pathway of movement of upper
diagnosis and treatment planning6). incisors. After correction of the locked bite, fixed orthodontic appliance
Etiological features of a Class III malocclusion showed that the was bonded using 0.022 MBT Pre-adjusted Edgewise Appliance with
deformity is not restricted to the jaws but involves the total craniofacial continuous arch wires, restarting with 0.012-inch nickel-titanium and
complex. Most patients with Class III malocclusions show combinations working up to 0.017- x 0.025-inch stainless steel (Figure 4). After appli-
of skeletal and dentoalveolar components7). cation of removable and fixed appliance to patient, the malocclusion
Analysis done through studies showed separation of adult Class III was successfully corrected. Treatment progress shown in Table 2. All
malocclusion patients who can be treated by orthodontic therapy alone appliance was removed and Essix-form retainer was used for retention.
from those who need orthognathic surgery was successful in 92% of the URA treatment done for the 5 months. Fixed orthodontic treatment
cases6). Thus, orthognathic surgery was not a common decision for cor- was completed in 17 months. Patient cooperation in maintenance of oral
rection of class III malocclusion. hygiene was moderate, and the examination after active orthodontic
By further discussion to the patients, the concern of the patient was treatment revealed that the clinical status and radiographic results
the backward position of the upper lip to the lower lip that promote of observed at the completion of the treatment was excellent (Figures 5, 6,
the unaesthetic appearance. The position of the soft tissue lower lip was 7 and 8; Table 1). The patient was completely satisfied with the results
accepted by the patient. Thus, removable appliance was chosen to
406 Class III Malocclusion

Table 1. Pre-treatment and Post-treatment cephalometric anal-

ysis
Variable Pretreatment (0) Posttreatment (0) Normal (0)
SNA 84.0 86.0 82 (+/-3)
SNB 88.0 88.0 79 (+/-3)
ANB -4.0 -2.0 3 (+/-1)
Maxillary incisor to 128.0 136.0 108 (+/-5)
maxillary plane angle
Mandibular incisor to 86.0 82.0 92 (+/-5)
mandibular plane angle
Interincisal angle 129.0 119.0 133 (+/-10)
Maxillary-mandibular 26.0 24.0 27 (+/-5)
angle
Facial Proportion 56.45 58.0 45 %

Table 2. Treatment progress

Visit Treatment Stage 1 Action
1. URA with Anterior expansion
screw and Post bite plane. Expand upper arch.
2. Same continue Review
3. Same continue Review
4. Same continue Review
5. Same continue Review
Arch wire Sequence [Stage 2]
6. Brace set [Upper and Lower] 0.012 NITI Levelling and Labial
flaring
Figure 6. Post-treatment OPG, post-treatment lateral cephalo- 7. Elastic module changed 0.016 NITI Levelling and Labial
gram, lateral cephalogram tracing. flaring
8. Elastic module changed 0.018 NITI Levelling and Labial
flaring
9. Elastic module changed 0.017 x 0.025 Levelling
NITI
10. Elastic module changed 0.017 x 0.025 Levelling
3-3 Discing [Lower]. NITI
11. Elastic module changed 0.017 x 0.025 Alignment
SS
12. Elastics (Class III) 0.017 x 0.025 Alignment
SS
13. 3-3 Discing [Lower]. Elastics 0.017 x 0.025 Alignment
Cont. SS
14. Close Power Chain. Elastics 0.017 x 0.025 Alignment
for vertical interdigitation. SS
15. Same Cont. 0.017 x 0.025 Stabilization
Figure 7. Lateral cephalogram superimposition (only showing SS
incisors). 16. Same Cont. 0.017 x 0.025 Stabilization
SS
17. Essix form retainer set Debond Retention

of the treatment.
One year after debonding, the results were well maintained. Patient
is still under regular follow-up. Follow-up clinical status showed satis-
factory maintenance of accomplished treatments.

DISCUSSION
Figure 8. Comparison of pre and post-treatment model photo-
graph. Class III malocclusion appears to be particularly common in those
of Asian ancestry ranges from 9% to 19% (the prevalence of Class III
malocclusion in a Chinese population can be as high as 12%) which rel-
atively high to compare with European that has been reported to be
1.5% to 5.3% and North American Caucasian populations, the incidence
 Alam M.K. et al. 407

is approximately 1% to 4%8,9,10). REFERENCES

Skeletal Class III malocclusion is reported to be the most frequent
anomaly corrected by combined orthognathic surgery and orthodontic
treatment 11). However, soft tissue profile will be relatively variable, 1) Proffit WR. Contemporary orthodontics. 4th ed. St Louis: Mosby, 2007: 689-707.
which can change in quantity and/or distribution under different condi- 2) Angle EH. Malocclusion of the teeth. Philadelphia. 1907.
tions, including individual characteristics, nutrition, and age 12). Thus, 3) Edward E, James A M. Components of adults class III malocclusion. J Oral Maxillofac
early treatment of the Class III malocclusion has been strongly recom- Surg 1984; 42: 295-305.
mended by many authors for the favourable results on growth and 4) Jacobson A, Evans WG, Preston CB, et al. Mandibular prognathism. Am J Orthodont
occlusal relationship13). 1974; 66: 140.
In this report, fixed orthodontic appliance alone was not indicated 5) Sanbom RT. Differences between the facial skeletal patterns of Class III malocclusion
as patient was having anterior locked bite that cause minimal space for and normal occlusion. Angle Orthodont 1955; 25: 208.
bracket adhesion. Thus, upper removable appliance with Adam's clasp 6) Angelika SE, Christopher JL, Gabriele S. Treatment decision in adult patients with
on tooth 16 and 26, ball retainer, anterior expansion screw and posterior class III malocclusion: orthodontic therapy or orthognatic surgery? Am J Orthod
bite plane was used prior to fixed orthodontic appliance application. Dentofacial Orthop 2002; 122: 27-38.
Maxillary anterior teeth were proclined to achieve Class I occlusion. 7) Battagel JM. The aetiological factors in class III malocclusion. Eur J Orthod 1993; 15:
After the correction, fixed appliance was used to align the maxillary and 347-70.
mandibular teeth. The correct position of the upper and lower lip was 8) Haynes S. The prevalence of malocclusion in English children aged 11-12 years. Re
achieved14). Cong Eur Orthod Soc 1970: 89-98.
Fixed appliance was removed after the correction was achieved and 9) Foster TD, Day AJ. A survey of malocclusion and the need for orthodontic treatment in
Essix-formed retainer was used to prevent relapse. Even though skeletal a Shropshire school population. Br J Orthod 1974; 1: 73-78.
relapse is the most common complication however, it was less common 10) Thilander B, Myrberg N. The prevalence of malocclusion in Swedish schoolchildren.
for this case as no surgery was indicated for this patient15). Scand J Dent Res 1973; 81: 12-21.
So far, literatures do not contain an accurate model to distinguish 11) Chew MT, Sandham A, Wong HB. Evaluation of the linearity of soft- to hard tissue
between adult Class III patients who can be properly treated by ortho- movement after orthognathic surgery. Am J Orthod Dentofacial Orthop 2008; 134:
dontic mechanotherapy alone and those who require orthognathic sur- 665-670.
gery 6). Nevertheless, the result for this patient was excellent. The 12) Baris A, Nedim O, Gulnaz M. Bimax surgery in class III malocclusion: soft and hard
patient’s compliance, esthetics, caries risk, function, and age should all tissue changes. Journal of Cranio-maxillo-facial Surgery 2013; 44: 254-257.
be considered when deciding treatment options. 13) Stensland A, Wisth PJ, Boe OE. Dentofacial changes in children with negative overjet
treated by a combined orthodontic and orthopaedic approach. Eur J Orthod 1988; 10:
39-51.
CONCLUSION 14) Talib MA, Aziz NSA, Alam MK, et al. Linear and angular cephalometric measurement
of lip morphology among Malaysian Malay. International Medical Journal 2014;
20(1): 41-44.
This case demonstrates successful treatment for class III malocclu- 12) Ana de Lourdes S, Walter Leal M, et al. Lincoln I N. long-term skeletal and profile
sion with anterior locked bite using removable and fixed orthodontic stability after surgical-orthodontic treatment of class II and class III malocclusion. J
appliance. Utilization of both appliances was not as indicator for Cranio-Maxillo-Fac Surg 2013; 41: 296-302.
lengthy treatments but has contributed for better treatment results in a
short period of time.

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