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Diagnosis and Treatment of Pseudo-Class III Malocclusion

Article  in  Case Reports in Dentistry · November 2014

DOI: 10.1155/2014/652936 · Source: PubMed

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Hindawi Publishing Corporation
Case Reports in Dentistry
Volume 2014, Article ID 652936, 6 pages
http://dx.doi.org/10.1155/2014/652936

Case Report
Diagnosis and Treatment of Pseudo-Class III Malocclusion

Ariel Reyes,1 Luis Serret,2,3 Marcos Peguero,3,4 and Orlando Tanaka5

1
School of Health and Biosciences, Pontifı́cia Universidade Católica do Paraná, Brazil
2
Universidad Intercontinental, México, Mexico
3
Private Practice in Santo Domingo, Dominican Republic
4
Pontifı́cia Universidade Católica do Rio de Janeiro, Brazil
5
Graduate Program in Orthodontics, School of Health and Biosciences, Pontifı́cia Universidade Católica do Paraná,
Rua Imaculada Conceição 1155, Bairro Prado Velho, 80215-901 Curitiba, PR, Brazil

Correspondence should be addressed to Orlando Tanaka; [email protected]

Received 11 September 2014; Revised 6 November 2014; Accepted 14 November 2014; Published 24 November 2014

Academic Editor: Mehmet Ozgur Sayin

Copyright © 2014 Ariel Reyes et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pseudo-Class III malocclusion is characterized by the presence of an anterior crossbite due to a forward functional displacement of
the mandible; in most cases, the maxillary incisors present some degree of retroclination, and the mandibular incisors are proclined.
Various types of appliances have been described in the literature for the early treatment of pseudo-Class III malocclusion. The
objectives of this paper are to demonstrate the importance of making the differential diagnosis between a skeletal and a pseudo-
Class III malocclusion and to describe the correction of an anterior crossbite. The association of maxillary expansion and a 2 × 4
appliance can successfully be used to correct anterior crossbites.

1. Introduction incisor relationship involving the performance of a forward

functional mandibular shift due to a muscular reflex so that
Class III malocclusion was originally described by Angle as a the posterior teeth are able to occlude. It is for this reason that
condition in which the relationship of the jaws is abnormal this type of malocclusion has been described as a pseudo- or
and all of the mandibular teeth occlude mesial to normal functional Class III malocclusion [2, 3, 5, 6].
by the width of one bicuspid or more [1]. The etiology is In most cases, retroclined maxillary incisors are the main
associated with environmental and genetic factors, and a cause of pseudo-Class III malocclusion [6]. Often, a molar
higher incidence has been observed in an Asian population Class I relationship is present with a normal mandibular
[2]. The etiological factors of this malocclusion have been appearance and a straight facial profile, disguising the skele-
classified into three groups: (a) functional, which includes tal discrepancy that may exist [2]. However, patients with
abnormal tongue position, nasal-respiratory problems, and skeletal Class III malocclusions show a posterior crossbite
neuromuscular conditions; (b) skeletal, such as during max- and maintain their molar relationship when guided to a
illary transversal deficiency; and (c) dental, which includes centric relationship [3]. Correction of the anterior crossbite
ectopic eruption of the maxillary central incisors and early must be carried out as soon as it is detected to increase the
loss of the deciduous molars [2, 3]. orthopedic effects, thereby increasing the long-term stability
Pseudo-Class III malocclusion is characterized by the of the treatment results [3].
presence of an anterior crossbite due to a forward functional
displacement of the mandible. In the mixed dentition, the
mesial step cannot exceed 3 mm, the maxillary incisors 2. Case Presentation
present retroclination, and the mandibular incisors are pro-
clined and spaced [3, 4]. When patients are guided into A 10-and-a-half-year-old girl was referred by her dentist with
a centric relationship, they usually show an end-to-end the following chief complaint: “My mandible is forward and
2 Case Reports in Dentistry

Figure 1: Pretreatment photographs.

my upper teeth look ugly.” The extraoral facial examina- indicated that the tooth was actually in a transalveolar
tion revealed a straight profile, lower lip protrusion, and a position with the crown located lingually. The cephalometric
dolichofacial pattern. The intraoral evaluation revealed late analysis revealed a Class I skeletal relationship (ANB = 2∘ ),
mixed dentition due to the presence of both the deciduous a clockwise growth pattern (SN.GoGn = 40∘ , FMA = 29∘ ),
maxillary second molars and the deciduous mandibular protrusion of the mandibular incisors (IMPA = 99∘ , 1.NB =
right second molar; the absence of maxillary deciduous 35∘ ), retrusion of the maxillary incisors (1.NA = 18∘ , 1-NA =
canines due to prior extraction; a Class I molar relationship; 1 mm), and protrusion of the lower lip (Ricketts E-line =
anterior crossbite of the maxillary central and lateral incisors; 3 mm) (Figure 2, Table 1). Based on these diagnostic findings,
crowding in both arches; and a lack of space for the maxillary it was concluded that the patient presented a skeletal Class I
canines to erupt (Figure 1). relationship.
The panoramic radiograph revealed that the mandibular The objectives were to maintain the Class I molar
right second premolar was mesially angulated and that the relationship, correct the anterior crossbite, and augment
eruption sequence was favorable, and an occlusal radiograph the maxillary arch perimeter, allowing guided eruption
Case Reports in Dentistry 3

Figure 2: Lateral cephalogram radiograph.

(a)

(b)

Figure 3: (a) Maxillary 2 × 4 associated with a mandibular bite plane; (b) treatment progress 0.017󸀠󸀠 × 0.025󸀠󸀠 SS.

of the maxillary canines and orthodontic traction of the of these appliances. To achieve good alignment and leveling,
mandibular right second premolar while taking advantage of a fixed appliance must be used [2, 5]. Using a facial mask was
the E-space. not considered because of the age of the patient and the fact
The diagnosis of skeletal Class I improved her progno- that the harmonic basal bone relationship was within normal
sis, and correction of the anterior crossbite was attempted limits.
through maxillary expansion associated with a fixed 2 ×
4 appliance. Other options included the following: (1) a 3. Treatment Progress
removable appliance with a Z-spring to procline the max-
illary incisors labially, (2) an angulated bite plane, and (3) The patient was first submitted to a rapid maxillary expan-
functional appliances, although the lack of cooperation of sion, once finished this first phase we bonded a pread-
some patients and the inability of the appliances to promote justed Edgewise 0.018󸀠󸀠 slot 2 × 4 appliance with an initial
correct alignment and leveling are the biggest disadvantages 0.014󸀠󸀠 NiTi arch wire in the maxillary arch associated
4 Case Reports in Dentistry

Figure 4: Posttreatment photographs and radiographs.

with a removable bite plane in the mandibular arch. After arch followed the same pattern. Both arches finished with a
correcting the anterior crossbite, the use of the bite plane was 0.017󸀠󸀠 × 0.025󸀠󸀠 SS (Figures 3(a) and 3(b)).
suspended, and maxillary sequential bonding was performed At the end of the treatment the pseudo-Class III relation-
visualizing a corrective orthodontic treatment in the second ship was compensated during the second phase. The space
phase. A heat-activated 0.016󸀠󸀠 × 0.022󸀠󸀠 NiTi arch wire was gained with the maxillary expansion and maxillary incisors
placed as initial arch, followed by a superelastic 0.017󸀠󸀠 × protrusion helped in the eruption of the maxillary canines
0.025󸀠󸀠 NiTi arch wire. The treatment of the mandibular arch and the correction of the anterior crossbite. In the mandibular
began two months after inserting the maxillary 0.017󸀠󸀠 × arch, the position of the transalveolar right second premolar
0.025󸀠󸀠 NiTi arch; the arch wire sequence in the mandibular self-corrected and erupted after extraction of the mandibular
Case Reports in Dentistry 5

deciduous right second molar, avoiding the need for the Table 1: Pre- and posttreatment measurements.
surgical exposure planned at the beginning of treatment.
Measurements Pretreatment Posttreatment
Facially the treatment did not change her growth pattern, and
the Class III characteristics were maintained (Figure 4). SNA angle (∘ ) 78 81
SNB angle (∘ ) 76 79
ANB angle (∘ ) 2 2
4. Discussion
1-NA (mm) 1 8
Treatment of a pseudo-Class III malocclusion must be per- 1-NA (∘ ) 18 33
formed as soon as it is detected and should be considered as 1-NB (mm) 6 6
a Class III malocclusion [4]; however, the clinician is unfor- 1-NB (∘ ) 35 30
tunately not always able to evaluate the patient during the IMPA (∘ ) 99 94
developmental stage of this type of malocclusion. Anterior
1-APo (mm) 5 4
crossbite has been associated with a variety of complications,
Interincisal angle (∘ ) 127 116
such as gingival recession of the lower incisors, incisal
wear, and worsening of the growth pattern; correcting an GoGn-SN (∘ ) 40 35
anterior crossbite consequently increases the maxillary arch 𝑌-axis (∘ ) 58 58
perimeter, offering more space for the canines and premolars FMA (∘ ) 29 28
to erupt and therefore a more stable orthopedic result [4–8]. Facial angle (∘ ) 87 91
The functional appliances used to treat Class III mal- Convexity angle (∘ ) 2 2
occlusion work by permitting the eruption of the maxillary Upper lip-E line (mm) 0 −1
molars and maintaining the mandibular ones in position, Lower lip-E line (mm) 3 4
leading to an occlusal plane rotation that helps shift the
molar relationship from Class III to Class I [9]. Face mask
protraction creates a counterclockwise rotation of the maxilla The association of maxillary expansion and a 2 × 4 appliance
and a clockwise rotation of the mandible while increasing the can be successful during the correction of anterior crossbites.
inferior facial height and turning the patient’s profile more
convex [4]. Conflict of Interests
When treating young patients with anterior crossbite in
mixed dentition, better results can be achieved through the The authors declare that there is no conflict of interests
association of maxillary expansion due to orthopedic stability regarding the publication of this paper.
and the movement of the maxilla down and forward [10]. In
84% of cases, a self-correction could be expected without the
need for any other type of appliance [11]. The association of
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