Bedolla et al: Quick Correction of a Skeletal Class III Maloclussion in Primary Dentition

Quick Correction of a Skeletal Class III Maloclussion in Primary

Dentition with Face Mask Plus Rapid Maxillary Expansion Therapy
Corrección rápida de una maloclusión esquelética clase III en dentición
primaria con máscara facial más terapia rápida de expansión maxilar
Hilda Alejandra Bedolla-Gaxiola DDS¹; David Garrigós-Esparza DDS¹;
Juan Carlos Hernández-Cabanillas DDS, MS²; Miguel Ángel Rosales-Berber DDS¹;
Amaury Pozos-Guillén DDS, PhD¹; José Arturo Garrocho-Rangel DDS, PhD¹

1. Pediatric Dentistry Postgraduate Program, Faculty of Dentistry, San Luis Potosi University, San Luis Potosi, SLP. México.
2. Faculty of Dentistry, Baja California University, Tijuana, BC, México.

Correspondence to: Dr. José Arturo Garrocho-Rangel - [email protected]

Received: 16-VII-2017 Accepted: 22-I-2018 Published Online First: 12-II-2018

DOI: https://doi.org/10.15517/ijds.v0i0.32381

ABSTRACT

Skeletal Class III is a malocclusion characterized by anterior crossbite as a result of an abnormal

skeletal maxillary and mandibular base discrepancy, which involves disharmony of craneofacial skeleton
and profile. The preferred management for children having skeletal Class III malocclusion with retruded
maxilla and/or prognathic mandible is the use of devices that encourage the growth and anterior
movement of the maxilla bone and/or restrict the exessive mandible growth. The orthopedic treatment
consisting of a face mask with rapid maxillary expansion (RME) produces the most dramatic results in
the shortest period of time. The purpose of this article is to review a quick correction of skeletal class
III maloclussion in the primary dentition through a case example with use of a face mask plus rapid
maxillary expansion therapy in a 5 year-old male patient due to a combination of retruded maxilla and
protruded mandible, in primary dentition, who was treated with a Petit face mask in conjunction with
a bonded RME intraoral appliance added with bite blocks. The first evident occlusal outcomes were
a clockwise rotation of the mandible, a positive overjet of 3 mm, a correct overbite, a canine Class I
relationship, and a bilateral flush terminal plane. After discussing the present clinical case report and the
related published literature, we concluded that skeletal class III malocclusions should be treated as soon
as the first clinical signs of abnormal craniofacial growth are recognized, during the first years of life.

KEYWORDS

Skeletal class III; Malocclusion; Primary dentition; Rapid maxillary expansion.

BEDOLLA H., GARRIGÓS D., HERNÁNDEZ J., ROSALES M., POZOS A., GARROCHO J., 2018: Quick Correction of a Skeletal Class III Maloclussion in
Primary Dentition with Face Mask Plus Rapid Maxillary Expansion Therapy.-ODOVTOS-Int. J. Dental Sc., 20-2 (May-August): 31-37.
ODOVTOS-Int. J. Dent. Sc. | No.: 20-2: 31-37, 2018. ISSN:1659-1046. 31
 ODOVTOS-International Journal of Dental Sciences

RESUMEN

La clase III esquelética es una maloclusión caracterizada por mordida cruzada anterior como
resultado de una discrepancia esquelética de la base maxilar y mandibular, que implica desarmonía
craneofacial y del perfil. El tratamiento de elección para niños con maloclusión clase III esquelética con
mandíbula maxilar y/o prognática es el uso de dispositivos que estimulan el crecimiento y el movimiento
anterior del hueso maxilar y/o restringen el crecimiento excesivo de la mandíbula. El tratamiento
ortopédico que consiste en una máscara facial con expansión maxilar rápida (EMR) produce resultados
en un período de tiempo más corto. El propósito de este artículo es revisar una corrección rápida de
la maloclusión de clase III esquelética en la dentición primaria mediante el uso de una máscara facial
más terapia de expansión maxilar rápida en un paciente masculino de 5 años debido a una combinación
de maxilar retruido y mandíbula prominente, en dentición primaria, que fue tratada con una mascarilla
Petit junto con un dispositivo intraoral unido con bloques de mordida. Los primeros resultados evidentes
fueron una rotación en sentido horario de la mandíbula, un overjet positivo de 3 mm, una sobremordida
correcta, una relación canina de Clase I y un plano terminal de descarga bilateral. Después de discutir el
presente informe de caso clínico y la literatura publicada relacionada, concluimos que las maloclusiones
de clase III esqueléticas deberían tratarse tan pronto como se reconozcan los primeros signos clínicos
de crecimiento craneofacial anormal, durante los primeros años de vida.

PALABRAS CLAVE

Clase III esquelética; Maloclusión; Dentición primaria; Expansión maxilar rápida.

INTRODUCTION narrowed upper arch and posterior crossbite (7).

In around 70% of cases, this type of malocclusion
An adequate guidance of the eruption of exhibits maxillary retrognathism with midface
the primary, mixed, and permanent dentitions, deficiency (3,8).
and the craneofacial growth and development,
is an integral component of comprehensive The etiology of the SCIII can be hereditary,
oral healthcare for all pediatric dental patients. environmental or both. Hereditary factors include
Early diagnosis and treatment of developing palate/alveolar clefts as well as other craniofacial
malocclusions may render long-term benefits, syndromes. Environmental factors that may
while providing a functional occlusion together play a significant role are oral habits like mouth
with an esthetic/harmonic dentofacial configuration breathing, trauma or a forward/downward positioned
(1). Skeletal Class III malocclusions (SCIII) is a tongue (1,5,7,9). The reported incidence of the
growth abnormality related to the craneofacial malocclusion varies among the ethnic groups; for
morphology, which increase with age if left example, it is highest in Asians (4-14%), while
untreated (1-3). It is characterized by maxillary in Latin-Americans and Afro-americans is 5%,
deficiency and/or mandibular prognathism, in Europeans 3-8%, and in Caucasians 1-4%
accompanied by an anterior crossbite or edge- (4,5,9,10). Diagnosis of the skeletal discrepancy
to-edge incisor relationship, or a dentoalveolar is based on a careful observation of a sequence of
compensation consisting of retroclination of lower facial, occlusal, and cephalometric characteristics;
incisors and proclination of upper incisors (2,4- however, in children the diagnostic process may
6); other common features are the presence of be difficult because this malocclusion is not

32 ODOVTOS-Int. J. Dent. Sc. | No.: 20-2: 31-37, 2018. ISSN:1659-1046.

 Bedolla et al: Quick Correction of a Skeletal Class III Maloclussion in Primary Dentition

totally defined, with facial and occlusal features competent lips, lower lip relatively protruded,
no yet well established (1,10). Thus, the skeletal and acute nasolabial angle (Fig.1). Intraoraly,
malocclusion should be distinguished from other the patient exhibited several enamel white spot
similar presentations, including the functional lesions but not evident caries cavities; his primary
crossbite by occlusal prematurities or pseudo- dentition occlusion showed interdental spaces, a
Class III due to abnormal incisal guidance (1,6,7). bilateral exaggerated mesial terminal plane and
Class III canine relationship, anterior crossbite
The interceptive correction of this type of the four primary incisors (overjet–5 mm and
of malocclusion in growing children remains as deep reverse overbite+3.5 mm); the upper arch
a challenge part of the contemporary pediatric exhibited a normal width. Functional examination
dentistry and orthodontics practice (7). The main no exhibited premature contact points, and oral
treatment approaches recommended in the dental hygiene and gingival conditions were considered
literature for SCIII in children, adolescents and as acceptable. His smile was unpleasent because
young adults are the maxillary rapid expansion the lack of display of upper incisors (Fig.2).
(RME), face masks, functional orthopedic intraoral
appliances (e.g. Reverse Twin-Block, Monoblock,
FR-III appliance, or Class III Bionator or Bimler
appliances), multibracket fixed appliances, splints
with interarch Class III elastics, cervical extraoral
mandibular anchoring, tooth extractions, and a
combination of orthodontics and orthognathic
surgery (11,12). Regarding to this, the dental
literature evidence shows great variability in the
Figure 1. Pretreatment extraoral images.
actual results obtained when these therapies are
applied in children and adolescents (6). The aim
of the present clinical case report was to describe
and discuss the management and follow-up of
a young child with a SCIII malocclusion due to a
combination of retruded maxilla and prognathic
mandible, treated with a combination of face
mask and an intraoral bonded appliance for RME
to correct the anterior crossbite and modulate the Figure 2. Pretreatment intraoral anterior view.
craniofacial growth.
The panoramic x-ray findings exposed the
CLINICAL CASE REPORT presence of a complete permanent dental germs,
with no abnormal dental or intrabony conditions.
A Mexican 5.1 year old-boy came to the The Steiner and Jaraback cephalometric analyses
Pediatric Dentistry Postgraduate Program Clinic revealed that the child had a SCIII malocclusion
with the chief complaint of anterior crossbite and due mainly to mandibular prognathism (SNB=85°,
prominent lower teeth. Parents manifested that normal=77-79°) and a slighlty retruded maxilla
a child’s grandfather had a similar malocclusion. (SNA=77°, normal=78-82°; with tendency towards
Medical history with no relevant information. On a horizontal growth pattern (Sum of N-S-Ar or
extraoral examination, the facial profile was convex, Saddle angle+S-Ar-Go or Articulare angle+Ar-Go-
without facial asymmetry, anterior divergent face, Me or Gonial angle=386°, normal=396°), short

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 ODOVTOS-International Journal of Dental Sciences

cranial base (N-S distance=59 mm), and reverted were placed for one week (in the second week they
lower lip (facial esthetic line=+4 mm) (Fig.3). So, were subtituted by 14 oz elastics), 30° downward
the orthopedic treatment was aimed to attain a in relation to the occlusal plane, to the face mask
positive overjet (i.e. to correct the incisor crossbite) attachment framework. The orthopedic force exerted
and normal overbite and establish a functional by the elastics was 400 g per side, measured by a
occlusion, redirect the mandible growth toward a Dontrix gauge. The patient was instructed to use the
downward and backward direction to improve the appliance for a minimum of 12 to 14 hours daily,
intermaxillary skeletal relationship, obtain a esthetic and the expansion screw was activated only twice a
smile, and follow-up the patient’s remaining growth day. Compliance from the patients and his parents
to assess the need for further treatment. throughout the treatment has been excellent.
Patient was actively treated for five weeks, until an
overjet of 3 mm was achieved, developing a correct
overbite, Class I canine relationship, flush terminal
planes, and a well settled occlusion (Fig.5). There
was also an evident improvement in the smile.
Post-treatment cephalometric measurements did
not exhibit significant changes; only the SNB angle
decreased 1°.

Figure 4. McNamara intraoral appliance and Petit face mask.

Figure 3. Cephalometric analyses.

The patient was treated with a Petit face

mask to move forward the maxilla and to restrict the
mandibular growth, in conjunction with a intraoral
bonded maxillary acrylic appliance with bite blocks
Figure 5. Postreatment face profile and intraoral images.
(“McNamara Appliance”) for RME (Fig.4). The
expansion screw was activated 2 turns every day
for two weeks. Two metallic hooks were positioned The face mask is still being worn only at
bilaterally between the primary canine and first nights as retention, to restrain the mandible growth.
molar, to engage the elastics. The face mask was The intraoral McNamara appliance was substituted
placed after one week of RME. The appliance by a removable fan-shaped maxillar expander with
was carefully adjusted to patient’s forehead and occlusal blocks, which was activated three times a
chin, and extraoral 5/16 inch (13 oz) elastics week, for a wider anterior expansion. The child will

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 Bedolla et al: Quick Correction of a Skeletal Class III Maloclussion in Primary Dentition

be closed monitored until all major facial growth to their inhability to predict mandible growth and
is complete. to the belief that the condition is caused only
by a mandibular overgrowth and, therefore, the
DISCUSSION orthognathic surgery will be inevitable; others still
employ old management strategies such as chin
In the skeletal Class III malocclusion case cup devices, attempting to restrict the mandibular
reported here, we could achieve a favorable growth, with limited stability and high probabilities
treatment response by reestablishing the skeletal, of relapse (14). Based on the dental literature, the
facial, and occlusal environments. A mild but best current non-surgical management approach
favorable clockwise rotation of the mandible was for children exhibiting early signs of a SCIII with
observed. The normal incisal relationship achieved maxillary deficiency includes the dentofacial
had a significant impact on the facial lower half soft growth modification through a Petit face mask
tissue esthetics. The treatment delivered provided protraction orthopedic device (3-5). The Petit face
thus a more pleasing craniofacial appearance, mask obtains anchorage from the forehead and
with better lip posture and competence. At this chin, interconnected by a vertical steel rod, and
respect, Sarver has mentioned that instead of exerts a protraction force on maxillary hooks -in the
cephalometric relationships or measurements, present case, placed in the upper canine/first molar
“... it is the soft tissue that ultimately directs our region of the intraoral bonded appliance-, making
treatment directions and decision-making” (13). the upper arch as a single unit. Then, an extraoral
force of 400-600 g per side is applied through
The clinical objectives of the early treatment bilateral elastics which are positioned in a 30°
of skeletal Class III malocclusion in young children angle downward to an adjustable horizontal heavy
include the growth redirection and modulation steel support framework, placed on the vertical rod
during the most active stages of dental and (9,12). The face mask is worn 14 hours a day and
craniofacial development, and thus, the prevention the elastics are changed daily (11). According to
of progressive abnormal hard and soft tissue the American Association of Pediatric Dentistry (1),
changes (1). Besides, the craneofacial anomalies before starting the orthopedic intervention with
mentioned abvove, diverse dental abnormalities the Petit face mask it is neccesary to carefully
have been reported when the crossbite remains assess some individual factors such as: (i) facial
uncorrected, such as excessive wear of the lower growth pattern; (ii) amount of the antero-posterior
incisors, thinning of the vestibular alveolar plate, of skeletal and dental discrepancy; (iii) patient
and gingival recession (1,2,9). The clinical findings age and her/his projected level of compliance;
of the present case report tend to confirm the and (iv) space analysis. Even, clinicians can know
effectiveness of the combination Petit face mask how to early predict the future mandibular growth
plus a RME as orthopedic therapy for SCIII in very of a pediatric patient with SCIII for an adequate
early dentition stages. treatment planning (5). The Petit face mask
increases the facial height and establish a more
However, the skeletal Class III malocclusion favorable environment for the anterior and vertical
in children has raised controversies among clinicians growth of the maxilla, accompanied by addition
concerning diagnosis, prognosis and management, of bone tissue at posterior sutures (3,4,7,11).
and definitive treatment tends to be delayed Additionally, it induces downward and backward
(10,14). According to Major and El-Badrawy (15) of the mandible, decreasing the prominence of the
and Ngan and Hon-Yin (5) many practitioners chin (3,4,14); the technique also produces dental
avoid early treatment of this malocclusion due changes: maxillary teeth are forward moved while

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 ODOVTOS-International Journal of Dental Sciences

lower incisors are retracted (11). The addition of can help eliminate any centric occlusion/centric
a bonded RME appliance for rapid expansion of relation discrepancy to reveal the true underlying
the maxilla midline suture is frequently needed skeletal abnormality. On the other hand, Al-Khalifa
in order to increase the upper arch transverse (11) reported that the main cephalometric changes
width, reducing thus the severity of malocclusion produced after treatment are the significant average
(7,9); it also produces a disarticulation of the improvements of the SNA, SNB and ANB angles,
circummaxillary suture system (fronto, naso, the overjet, the molar relationship, and the Wits
inter, ethmoido, zygomatico, and lacrimomaxillary; appraisal (or the distance between th two points
zygomaticotemporal and pterygopalatine (16), of intersection of the two perpendicular lines from
allowing a more efficient protraction of the maxilla points A and B to functional occlusal plane).
(12,14). In the present case this intraoral appliance
was fabricated in conjunction with bite blocks, CONCLUSIONS
allowing a quicker anterior crossbite resolution.
Thus, the simultaneous use of the face mask and Early treatment of SCIII –during the primary
the RME appliance with bite blocks is more effective dentition stage–, with the face mask plus a
in early dentition stages (late deciduous or early RME appliance with bite blocks may provide a
mixed), especially with regard to the magitude of more favorable environment for craneofacial
both skeletal and dentofacial changes; this can and dental structures, achieving satisfactory and
be explained because the bone tissue is best long-term stable functional and esthetic changes,
modified during those phases of rapid growth, and and potentially to decrease the risk of a future
the circummaxillary sutures are patent in children orthognathic surgery. As in the preset case, this
until eight years old (2,9,12,17). However, it is combined therapy can improve the child’s profile
strongly encouraged a long-term follow up of the and self-image, together with other psychosocial
trated patient until craniofacial growth is complete benefits, provided the selected management
(12). Furthermore, a meta-analysis by Kim et al. plan is based on an adequate diagnosis and the
(18) related to the treatment of SCIII, concluded treatment is implemented early, during the first
that the average treatment duration with the face years of life; of course, it is also indispensable the
mask and RME appliance was significantly shorter absolute compliance during the treatment from the
compared to the non-expansion group. On the child and her/his parents.
other hand, although it has been demonstrated that
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