JDO 67 CASE REPORT

Skeletal Class III Malocclusion with Anterior and

Posterior Crossbites: Camouflage Treatment with
Mandibular Second Molar Extractions and TSADs

Abstract
History: An 18-year-8-month-old male was referred for orthodontic consultation with chief complaints of a prognathic
mandible, anterior spaces, and open bite.
Diagnosis: Cephalometric analysis showed a skeletal Class III relationship with bimaxillary protrusion (SNA, 90˚; SNB, 92.5˚;
ANB, -2.5˚). Clinical examination revealed a severe anterior crossbite (overjet = -5mm), an anterior open bite, bilateral lingual
posterior crossbite, and full-cusp Class III molar relationship. There were small spaces between the anterior teeth in both
arches. The mandibular dental midline deviated 1mm to the right. The chin shifted 3mm to the right. The Discrepancy Index
for this severe skeletal malocclusion was 71.
Treatment: Bone screws were placed in the mandibular buccal shelves to retract the mandibular arch. Bilateral lower second
molars were extracted to create posterior spaces for retracting the mandibular arch to correct the anterior crossbite. A Damon®
system full-fixed appliance with passive self-ligating brackets was applied to correct the dental malocclusion. Early light Class III
elastics were also used to facilitate the anterior crossbite correction. The posterior crossbite was a big challenge, which was resolved
with cross elastics and careful archwire adjustment. The active treatment was 26 months. A surgical crown-lengthening procedure
was performed to increase the esthetic outcome of the maxillary anterior teeth.
Results: After 26 months of active treatment, this severe skeletal Class III malocclusion was conservatively corrected to an
excellent result without orthognathic surgery. The Cast Radiograph Evaluation was 31 points, and the Pink and White dental
esthetic score was 1.
Conclusions: This case report demonstrates that the use of passive self-ligating appliances, lower second molar extractions,
and buccal shelf screws can resolve a severe anterior negative overjet combined with an anterior open bite and lingual
posterior crossbite without orthognathic surgery. (J Digital Orthod 2022;67:4-22)
Key words:
Skeletal Class III, anterior crossbite, anterior negative overjet, anterior open bite, posterior crossbite, temporary skeletal
anchorage devices (TSADs)

Introduction surger y because of morbidit y, potential

complications, and expense.2 As a result, treating a
Skeletal Class III malocclusion is more common Class III malocclusion without surgery is a common
among Asians than Americans and Europeans. The approach for orthodontists in Taiwan. Using
Chinese and Malaysian populations have a high temporary skeletal anchorage devices (TSADs) as
prevalence of Angle Class III malocclusion, at 15.69% anchorage for lower arch retraction is often
and 16.59%, respectively.1 preferred.3

Orthognathic surgery is one treatment option; This case report documents an 18-year-8-month-old
however, the majority of patients in Taiwan decline male patient who was referred by his dentist for

4 0

 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

Hsuan-Cheng Chu
Training Resident, Beethoven Orthodontic Center (Left)
Chris H. Chang,
Founder, Beethoven Orthodontic Center
Publisher, Journal of Digital Orthodontics (Center)
W. Eugene Roberts,
Editor-in-Chief, Journal of Digital Orthodontics (Right)

orthodontic consultation. His chief complaints were a prognathic mandible, spaces between the adjacent
anterior teeth, and no contact between the upper and lower front teeth. The pre-treatment facial and intraoral
photographs are documented in Fig. 1

Fig. 1: Pre-treatment facial and intraoral photographs

0 5
◼︎
.

 JDO 67 CASE REPORT

When examining the oral condition, a severe negative Diagnosis

overjet (OJ = -5mm) and bilateral lingual posterior
crossbite indicated this was a challenging malocclusion The cephalometric analysis (Fig. 2; Table 1) revealed a
skeletal Class III malocclusion (ANB, -2.5˚) with
The patient was informed that surgery was a bimaxillary protrusion and markedly protrusive
conventional treatment option, but he regarded this mandible (SNA, 90˚; SNB, 92.5˚). The mandibular plane
approach as being too aggressive. Therefore, he angle (SN-MP, 27˚; FMA, 20˚) was relatively flat but
wanted a non-surgical treatment, which made the within normal limits (WNL). The angle of lower
challenging task even more difficult. After a thorough incisors (91˚) was also WNL, but the upper incisors
clinical data analysis, some camouflage treatment had an increased axial inclination (116.5˚). The facial
options were carefully planned. After discussing the profile was concave (G-Sn-Pg’, 0.5˚) with a relatively
pros and cons with the patient, he chose the treatment retrusive upper lip (-3mm to the E-line) and a
protocol which involved mandibular 2nd molar protrusive lower lip (6mm to the E-line). An increased
extractions and the use of TSADs. After 26 months of vertical dimension of occlusion (%FH: Na-ANS-Gn,
active treatment, an excellent result was achieved. 57%) was evident, but there was no functional shift

CEPHALOMETRIC SUMMARY
SKELETAL ANALYSIS
PRE-TX POST-TX DIFF.
SNA˚ (82˚) 90˚ 90˚ 0˚
SNB˚ (80˚) 92.5˚ 92˚ 0.5˚
ANB˚ (2˚) -2.5˚ -2˚ 0.5˚
SN-MP˚ (32˚) 27˚ 29˚ 2˚
FMA˚ (25˚) 20˚ 22˚ 2˚
DENTAL ANALYSIS
U1 TO NA mm (4 mm ) 5.5 7 1.5
U1 TO SN˚ (104˚) 116.5˚ 115˚ 1.5˚
L1 TO NB mm (4 mm) 8 3 5
L1 TO MP˚ (90˚) 91˚ 73˚ 18˚
FACIAL ANALYSIS
E-LINE UL ( -1 mm) -3 -1 2
E-LINE LL (0 mm) 6 2 4
Convexity: G-Sn-Pg’ (13˚) 0.5˚ 1.5˚ 1˚
%FH: Na-ANS-Gn (53%) 57% 58% 1%
Fig. 2: Pre-treatment cephalometric radiograph

Table 1: Pre-treatment and posttreatment cephalometric analysis

6 0
◼︎
◼︎
.

 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

The panoramic radiograph revealed that all four good. No signi cant medical or dental histories
wisdom teeth had already erupted and were were reported.
reasonably well-aligned (Fig. 3). Pre-treatment
plaster cast models showed a severe negative OJ The American Board of Orthodontics (ABO)
(-5mm), bilateral lingual posterior crossbite, anterior Discrepancy Index (DI) was 71 as shown in the
open bite, mild spaces in upper and lower arches subsequent Worksheet 1. The most significant
(maxilla: 3mm, mandible: 1mm), and bilateral problem was the anterior crossbite (40 points)
beyond-full-cusp Class III molar relationship (Fig. 4).
Temporomandibular joint (TMJ) morphology was Treatment Objectives
normal in the open and closed positions (Fig. 5).
The treatment objectives were to (1) correct the
There were no signs nor symptoms of
anterior crossbite, (2) close the spaces between the
temporomandibular dysfunction (TMD)
anterior teeth, (3) close the anterior open bite, (4)
Compared to the facial midline, the lower dental correct the posterior crossbite, (5) achieve Class I
midline was 1mm to the right. Oral hygiene was molar and canine relationships, and (6) improve
facial esthetics

Treatment Alternatives
Option 1. Orthognathic surgery is often indicated for
severe Class III malocclusions. In this case, it was the
option that could achieve the best treatment outcome;
however, the cost and morbidity of orthognathic
surgery caused the patient great concern.
Fig. 3: Pre-treatment panoramic radiograph
Option 2. Extract mandibular 3rd molars for
retraction, and use TSADs for anchorage. This option

Fig. 5 :
Pre-treatment TMJ transcranial radiographs are shown from left
to right: right TMJ closed, right TMJ open, left TMJ open, and left
Fig. 4: Pre-treatment study models (casts) TMJ closed.

0 7
◼︎
◼︎
◼︎
.

fi
.

JDO 67 CASE REPORT

has the advantage of preserving the stronger teeth, Treatment Progress

as the 2nd molars are generally more robust than 3rd
molars. However, the disadvantage of this option is The archwire sequence is summarized in Table 2.
that it increases the di culty of retracting the Treatment progress is documented in the following
mandibular arch views: right buccal, frontal, left buccal, upper
occlusal, and lower occlusal, respectively (Figs. 6-10),
Option 3. Extract mandibular 2nd molars for and the detailed treatment mechanics are outlined
retraction, and incorporate TSADs for anchorage. This in Table 3. From the following section onward, the
option facilitates mandibular retraction, but the nomenclature used is a modi ed Palmer notation
surviving 3rd molars are generally less preferred for with four oral quadrants: upper right (UR), upper left
longterm oral function. Fortunately, the present (UL), lower right (LR), and lower left (LL). Teeth are
patient had well formed lower 3rd molars number 1-8 from the midline

After a thorough discussion of the pros and cons for A 0.022-in Damon® ClearTM and Damon® QTM xed
each approach, the patient chose option 3 as the appliance (Ormco, Brea, CA) with passive self-
most desirable camouflage treatment to avoid ligating (PSL) brackets was selected along with all
surgery. The patient provided informed consent for speci ed archwires and orthodontic auxiliaries. In
the treatment, knowing that this approach was the beginning, brackets were bonded on all lower
challenging and that the outcome would be teeth except L7s and L8s. High torque brackets were
compromised. It was also suggested to extract the placed on the lower canines, and low torque
upper 3rd molars because they would not be in the brackets were bonded upside down on the lower
occlusion after treatment incisors. The purpose of this bracket selection was to
provide more lingual root movement of the lower
Treatment Plan anterior teeth to o set the unwanted side e ects of
Class III elastics. For the same reason, low torque
Retract mandibular arch by extracting mandibular brackets were placed on the upper anterior teeth
2nd molars and installing TSADs. Extra-alveolar one month later. The initial archwire was a 0.014-in
OrthoBoneScrews® (OBSs, 2x12-mm, iNewton Dental, copper-nickle-titanium (CuNiTi)
Inc., Hsinchu City, Taiwan) are planned bilaterally in the
buccal shelves to serve as anchorage for mandibular In the following months, the sequence for upper
retraction. Correct the posterior crossbite by archwires was 0.014x0.025-in CuNiTi, 0.017x0.025-in
expanding the upper arch with a 0.016x0.025-in TMA, and 0.016x0.025-in SS. Early light Class III
stainless steel (SS) archwire, as well as constrict the elastics (Parrot, 5/16-in, 2-oz; Ormco) were used
lower arch utilizing bilateral crossbite elastics. Finally, from U6s to L4s to correct the sagittal discrepancy
the posterior occlusion is to be detailed and seated from the 4th to the 6th months of treatment. In the
with vertical elastics as necessary 6th month, buccal shelf bone screws were installed
bilaterally to anchor the retraction of the

8 0
fi
.

ff
.

ffi
.

fi
.

ff
fi
 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

Table 2:
The archwire sequence chart is a treatment timeline for the procedures involved in managing the malocclusion: archwire changes,
adjustments, and elastics. Posterior intermaxillary relationships were corrected with expansion and contraction adjustments. (Pre-Q: pre-
toruqued, see text and Table 3 for details.)

mandibular dentition. In the 11th month, the anterior lower archwire was changed to 0.017x0.025-in TMA.
crossbite was already corrected. The sequence for In the 14th month, upper and lower archwires were
the lower archwire in the rst 11 months was 0.014 changed to 0.016x0.025-in SS. At the same time, the
CuNiTi, 0.014x0.025-in CuNiTi, 0.016x0.025-in pre- upper archwire was expanded, and the lower
torqued CuNiTi, 0.019x0.025-in pre-torqued CuNiTi, archwire was constricted, in order to correct the
and 0.016x0.025-in SS. Then the L8s were bonded in posterior crossbite. Thereafter, the sequence for the
the 12th month right after the anterior crossbite was lower archwire was changed back and forth due to
corrected, and the lower archwire was changed repositioning of brackets several times. The
back to 0.014x0.025-in CuNiTi. In the 13th month, sequence was 0.017x0.025-in TMA, 0.016x0.025-in
buttons were bonded on the L4s and L8s to attach SS, 0.017x0.025-in TMA, 0.016x0.025-in SS,
power chains for facilitating space closure, and the 0.014x0.025-in CuNiTi, and 0.017x0.025-in TMA

0 9
◼︎
fi
.

 JDO 67 CASE REPORT

0M 1M 6M 11M

14M 20M 22M 25M

Fig. 6: Treatment progression from the right buccal view is shown from the start (0M) to twenty- ve months (25M) of treatment.

0M 1M 6M 11M

14M 20M 22M 25M

Fig. 7: Treatment progression from the frontal view is shown from the start (0M) to twenty- ve months (25M) of treatment.

0M 1M 6M 11M

14M 20M 22M 25M

Fig. 8: Treatment progression from the left buccal view is shown from the start (0M) to twenty- ve months (25M) of treatment.

10 0
◼︎
◼︎
◼︎
fi
fi
fi
 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

No bond 0.014” Damon CuNiTi 0.014x0.025” Damon CuNiTi 0.017x0.025” Damon TMA

0M 1M 6M 11M

14M 20M 22M 25M

0.016x0.025” Damon SS 0.016x0.025” Damon SS 0.016x0.025” Damon SS 0.016x0.025” Damon SS

Fig. 9: Treatment progression from the maxillary occlusal view is shown from the start (0M) to twenty- ve months (25M) of treatment.

0.014” Damon CuNiTi 0.014” Damon CuNiTi 0.019x0.025” Pre-Torqued CuNiTi 0.016x0.025” Damon SS
0M 1M 6M 11M

14M 20M 23M 25M

0.016x0.025” Damon SS 0.014x0.025” Damon CuNiTi 0.014x0.025” Damon CuNiTi 0.017x0.025” Damon TMA

Fig. 10: Treatment progression from the mandibular occlusal view is shown from the start (0M) to twenty- ve months (25M) of treatment.

0 11
◼︎
◼︎
fi
fi
 JDO 67 CASE REPORT

Appointment Archwire Notes

1 (0 month) L : 0.014-in Damon CuNiTi Bond lower teeth except L7s and L8s. L7s will be extracted.
High torque brackets were selected.

2 (1 month) U: 0.014-in Damon CuNiTi Bond all upper teeth. Low torque brackets were selected.

3 (2 months) Observation

4 (3 months) Rebond UL5 to adjust tooth position.

5 (4 months) U: 0.014x0.025-in Damon CuNiTi L7s were extracted. L8s remained unbonded.
L : 0.014x0.025-in Damon CuNiTi Start using early light short Class III elastics (Parrot, 5/16-in, 2-
oz) from U6s to L4s to retract mandibular anteriors.

6 (5 months) L : 0.016x0.025-in Damon Pre- Use pre-torqued archwire in the lower arch to compensate for
Torqued CuNiTi side e ects of Class III elastics.

7 (6 months) U: 0.017x0.025-in Damon TMA Class III elastics (Fox, 1/4-in, 3.5-oz) were used from L3s to U6s
to retract the lower anteriors.

8 (6 months & 2 L : 0.019x0.025-in Damon Pre- Change to stronger pre-torqued archwire in the lower arch to
weeks) Torqued CuNiTi further control the side e ects of Class III elastics.
Install two buccal shelf (BS) screws as the anchorage for
retracting the lower arch. Place power chains from screws to
lower canines to provide retraction force.

9 (7 months) Change power chains for new ones to provide retraction force.
The negative overjet was alleviated from -5mm to -3mm.

10 (8 months) L: 0.016x0.025-in Damon SS Class III elastics (Bear, 1/4-in, 4.5-oz) were used from L3 to U6
bilaterally to retract the lower anteriors.

11 (9 months) Change new power chains to provide retraction force.

12 (10 months) Build bite turbo on the lingual side of the lower incisors to
facilitate overjet correction.
The negative overjet was corrected to only -0.5mm.

13 (11 months) The negative overjet (anterior crossbite) was corrected.

Remove Class III elastics.

14 (12 months) L : 0.016x0.025-in Damon Pre- Rebond LR1, LR2, and LL1 to adjust tooth position.
Torqued CuNiTi

15 (12 months) L : 0.014x0.025-in Damon CuNiTi Bond LR8 and LL8. Start to adjust L8s. Place a new archwire in
the lower arch to engage all lower teeth.
Remove BS screws because they interfered with the
placement of new archwire.

16 (13 months) L: 0.017x0.025-in Damon TMA Place buttons on L5s and L8s. Place power chains between L5 and
L8 buttons for space closure. Rebond LR1 to adjust tooth position.

Table 3: Treatment sequence for all procedures is outlined in detail.

12 0
◼︎
ff
ff
 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

Appointment Archwire Notes

17 (14 months) U: 0.016x0.025-in Damon SS Rebond button on LR8 and rebond LL2 for adjusting tooth position.
L: 0.016x0.025-in Damon SS Expand the upper arch and constrict the lower arch by
adjusting the archwires.
Add 15˚ lingual root torque on LL2-LR2 area of the lower archwire.

18 (15 months) Close space with power chains.

19 (16 months) L : 0.017x0.025-in Damon TMA Rebond LR1. Rebond botton on LR5.
Consolidation with continuous ligatures from LL3 to LR3 to
prevent space opening.
Add 15˚ lingual root torque on LL2-LR2 area of lower archwire.
Start using Class III elastics (Fox, 1/4-in, 3.5-oz) from U6 to L4
(left side) to correct Class III malocclusion.

20 (17 months) Rebond LR1.

21 (18 months) U: 0.016x0.025-in Damon SS Continue to expand the upper arch and constrict the lower arch.
Continue to use Class III elastics (Fox,1/4-in,3.5oz) from UL6 to
LL4 to correct Class III malocclusion.

22 (19 months) Rebond button on LR8.

Close space with power chains.

23 (20 months) U: 0.014x0.025-in Damon CuNiTi Close space with power chains.
L : 0.014x0.025-in Damon CuNiTi Continue to use Class III elastics (Fox,1/4-in, 3.5oz) from UL6 to
LL4 to correct Class III malocclusion.

24 (21 months) L : 0.017x0.025-in Damon TMA Close space with power chains.

25 (22months) Close space with power chains.

Add 10˚ buccal crown torque for LL5 and LR5 with a 3rd order bend.
Re-install TSADs to correct overjet.

26 (23months) L : 0.014x0.025-in Damon CuNiTi Rebond LL8 and LR8.

27 (24months) L : 0.017x0.025-in Damon TMA Add 15˚ buccal crown torque for LL1, LL2, LR1, and LR2 with a
3rd order bend.

28 (25months) Cut the upper archwire from U3s. Instruct patient to use
intermaxillary elastics from the premolars to premolars to
decrease posterior open bite.

29 (26months) All appliances were removed. Anterior xed retainers were

bonded. Removable clear overlay retainers were delivered for
both arches. Instructions were provided for home hygiene
and maintenance of the retainers.

Table 3 (cont.): Treatment sequence for all procedures is outlined in detail.

0 13
◼︎
fi
 JDO 67 CASE REPORT

Treatment Results and L6s experienced mild root resorption. The

p osttreatment cephalometr ic radio graph
Both arches were well aligned in a Class I occlusion documents the dentofacial correction of the pro le
with coincided dental midlines (Figs. 11 and 12). The and the occlusion
overjet was corrected from -5mm to 1mm, and the
posterior crossbite was corrected. The posttreatment The superimposed cephalometric tracings show
panoramic radiograph shows complete space three important changes: (1) the retraction of the
closure with good root parallelism and no lower molars as well as slight clockwise rotation
signi cant periodontal bone loss (Fig. 13). The L5s (opening) of the mandible, (2) the retraction and

Fig. 11: Posttreatment facial and intraoral photographs after 26 months of active treatment

14 0
◼︎
fi
.

fi
 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

Fig. 12: Posttreatment study models (casts)

Fig. 14: Posttreatment cephalometric radiograph

months of active treatment, and the patient was

well pleased with the outcome

Retention
Fig. 13: Posttreatment panoramic radiograph
Fixed retainers were bonded on the lingual
lingual tipping of the lower incisors, and (3) surfaces of all maxillary incisors and mandibular
extrusion of the upper dentition (Figs. 14 and 15) anterior teeth. Clear overlay retainers were
delivered for both arches, and the patient was
The ABO Cast Radiograph Evaluation score was 31 instructed to wear them full time for the first 6
points, as shown in the supplementary Worksheet months and nights only thereafter. Instructions
2. The major discrepancies were a right side Class II were also provided for oral hygiene and
occlusal relationship (11 points) and mild posterior maintenance of the retainers
open bite (8 points). This result is acceptable for
such a challenging Class III skeletal malocclusion. Discussion
Dental esthetics were good as indicated by the
Pink and White dental esthetic score of 1, detailed Skeletal Class III malocclusion with a severe anterior
in the supplementar y Worksheet 3. This negative overjet is usually a clear indication for
camou age treatment was completed with 26 orthognathic surgery. On the other hand, the 3-
Ring Diagnosis5 developed by John Lin is an

0 15
◼︎
◼︎
◼︎
fl
.

 JDO 67 CASE REPORT

Fig. 15:
Cephalometric tracings are superimposed to show dentofacial changes from the start (black) to the end (red) of treatment. Superimpositions
are made on the anterior cranial base (left), maxilla (upper right), and mandible (lower right). See text for details.

effective way for determining whether a Class III patient refused surgery. In order to achieve Class I
malocclusion can be corrected or at least molar relationship and correction of the anterior
substantially improved with a conservative treatment crossbite, an 11mm space was required bilaterally. The
(Fig. 16). There are three good indicators for a non- patient had three molars in each quadrant, and this
surgical treatment: (1) orthognathic profile in CR, (2) was good news as molar extraction could provide
buccal segments that are approximately Class I, and enough space needed for retracting the lower arch.
(3) functional shift to CO. As this patient only fitted Moreover, there were two other favorable factors: (1) a
one of these criteria (i.e., orthognathic profile), any decreased mandibular plane angle, which provided
conservative treatment would still be very more room for clockwise rotation of the mandible to
challenging. In addition, the fact that his bilateral make lower arch more retracted; and (2) a moderate
buccal segments were Class III greater than 10mm open bite. Drawing from the discussion above, it was
made the treatment even harder. Therefore, possible to treat the patient conservatively as long as
mandibular set-back surgery was first considered the he understood that it was a camouflage treatment
most effective option to achieve the best treatment which is subject to a compromised outcome.
outcome. However, as previously mentioned, the

16 0
◼︎
 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

2. Extraction for Mandibular Arch Retraction

Profile In this case, extraction spaces were dental

compensation to permit lower arch retraction. The
patient had fully erupted first, second, and third
molars in all four quadrants. Usually, extractions in a
FS Class Class III malocclusion are performed on either the
premolars or the molars. For this patient, premolar
extractions could not provide enough space to
correct the severe anterior crossbite. Therefore,
Fig. 16:
molar extractions were necessar y. When
Lin’s Three-Ring Diagnosis System assesses the potential for determining which molars are most suitable for
conservative correction of a Class III malocclusion with an extraction, the rule of thumb is to choose the
anterior crossbite. Favorable factors are:
weaker teeth for extraction (e.g., caries, short roots,
1. Pro le of the face is acceptable when the mandible is
positioned in the centric relation (CR); post-endodontic restoration, etc). However, all
2. Class I buccal segments in CR; and molars in this case were adequate for oral function,
3. Functional shift (FS) is present from the CR to centric
so the pros and cons are:
occlusion CO.

(1) First Molars: extracting first molars may permit

1. Class III Mechanics anterior crossbite correction without the use of
TSADs. But the disadvantages for this approach
Class III camouflage treatment usually involves
are that it is time-consuming, and that
intermaxillary Class III elastics, which can result in
mandibular second molars have a tendency to
increased axial inclination of the maxillary incisors
tip mesially and lingually, requiring additional
and decreased axial inclination of the mandibular
orthodontic mechanics.9
incisors,6 particularly when there is an underlying
Class III skeletal discrepancy.7,8 Therefore, in order to (2) Second Molars: second molar extractions are
counteract the unwanted side effects of Class III effective for correcting the anterior crossbite.
elastics, low-torque brackets were used on the upper However, severe malocclusions may require the
anterior teeth to provide more buccal root movement. anchorage of mandibular buccal shelf bone
On the lower arch, low-torque brackets were screws. This approach may be less time-
bonded upside down on the incisors to deliver a consuming compared to first molar extractions.
high lingual root torque. Pre-torqued archwires
were also used on the lower arch to increase the (3) Third Molars: third molar extractions usually
lingual root torque on the anterior teeth. preserve more robust molars. However, this
extraction pattern is not effective for correcting
severe anterior crossbite, and mandibular

0 17
◼︎
fi

 JDO 67 CASE REPORT

buccal shelf bone screws are often needed to which posteriorly rotated the entire arch. In effect,
help retract the lower arch there was an extrusion of the anterior segment and a
relative intrusion of the molars.11 These mechanics are
3. Lingual Posterior Crossbit very useful for correcting severe Class III
malocclusions with an anterior open bite.
When correcting a Class III malocclusion, lingual
posterior crossbite is a common complication
Conclusions
associated with lower arch retraction. This problem is
even intensified when a lingual posterior crossbite is Skeletal Class III malocclusion is a complex
present. There are two strategies used for the present problem that requires a careful evaluation. Lin’s 3-
patient to manage this problem: (1) bond buttons on Ring Diagnosis System is very useful for
the lingual side of L5s and L8s so space closure determining whether the problem can be
mechanics can be implemented simultaneously on managed conservatively or not. For the present
the buccal and lingual surfaces to prevent the lingual patient, retracting the lower arch was the key to
crossbite from deteriorating; and (2) design archwire managing the severe skeletal Class III malocclusion
compensation by expanding the upper archwire and without surgery. In order to retract the whole lower
narrowing the lower archwire dentition, tooth extractions were necessary. After a
thorough discussion, both the practitioner and the
4. Temporary Skeletal Anchorage Devices (TSADs patient agreed on extraction of the L7s. Therefore,
management of space closure was an important
TSADs were an important part of this treatment issue. Absolute anchorage from TSADs provided
because it is very difficult to retract the whole lower crucial assistance for maximal retraction. Specific
arch using only the upper arch as anchorage. torque selection of the lower incisor brackets and a
Compared to Class III elastics, the osseous anchorage pre-torqued archwire offset the anticipated severe
of TSADs helps to avoid excessive upper incisor distal tipping of the lower incisors with space
proclination.10 The buccal shelf screws were placed closure and Class III elastics
buccal to the roots, not between the roots. Therefore,
the entire mandibular dentition could be retracted
Acknowledgment
since the buccal shelf screws do not interfere with
root movements of the teeth.11 Thanks to Mr. Paul Head for proofreading this article

5. Anterior Open Bit References

The center of rotation of the whole mandibular arch 1. Jaradat M. An overview of Class III malocclusion
(prevalence, etiology and management). J Adv Med Med
was well apical to the line of force from the TSAD to
Res 2018;25(7):1-13.
the anterior segment. The force retracting the arch
created a moment around the center of rotation,

18 0
e

 Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67

2. Lin JJ. Creative orthodontics lending the Damon

System & TADs to manage difficult malocclusion. 2nd ed.
Taipei, Taiwan: Yong Chieh; 2010. p. 263-71.

3. Tseng LL, Chang CH, Roberts WE. Diagnosis and

conservative treatment of skeletal Class III malocclusion
with anterior crossbite and asymmetric maxi lary
crowding . Am J Orthodo Dentofacial Orthop
2016;149(4):555-66.

4. Su B. IBOI Pink & White esthetic score. Int J Orthod

Implantol 2013;28:80-85.

5. Yeh HY, Lin JJ, Roberts WE. Conservative adult

treatment for severe Class III openbite malocclusion
with bimaxi lary crowding. Int J Orthod Implantol
2104;34:12–25.

6. Fer eira FPC, Goulart M de S, de Almeida-Pedrin RR,

Conti AC de CF, Cardoso M de A. Treatment of Class
III malocclusion: Atypical extraction protocol. Case Rep
Dent 2017:ID 4652685.

7. Lin JJ. Creative orthodontics lending the Damon

System & TADs to manage difficult malocclusion. 3rd ed.
Taipei, Taiwan: Yong Chieh; 2017. p. 259-276.

8. Lin JJ. The most effective and simplest ways for treating
severe Class III without extraction or surgery. Int J
Orthod Implantol 2014;33:4-18.

9. De Rue las AC, Baratieri C, Roma MB, Izquierdo A d M,

Boaventura L, Rodri ues CS, Te les V. Angle Class III
malocclusion treated with mandibular first molar
extractions. Am J Orthod Dentofacial Orthop
2012;142(3):384-92.

10. Huang S, Chang CH, Roberts WE. A severe skeletal

Class III open bite malocclusion treated with nonsurgical
ap roach. Int J Orthod Implantol 2011;24:28-39.

11. Lin JJ, Liao J, Chang CH, Roberts WE. Orthodontics vol.
III: Class III cor ection. 1st ed. Taipei, Taiwan: Yong
Chieh; 2013. p.68-69.

0 19
p
r
l
l
r
g
l
b
b
l
 JDO 67 CASE REPORT

Discrepancy Index Worksheet

TOTAL D.I. SCORE LINGUAL POSTERIOR X-BITE

71
1 pt. per tooth Total = 7
OVREJET
0 mm. (edge-to-edge) =
1 - 3 mm. = 0 pts. BUCCAL POSTERIOR X-BITE
3.1 - 5 mm. = 2 pts.
5.1 - 7 mm. = 3 pts. 2 pts. Per tooth Total = 0
7.1 - 9 mm. = 4 pts.
> 9 mm. = 5 pts. CEPHALOMETRICS (See Instructions)
Negative OJ (x-bite) 1 pt. per mm. Per tooth = ANB ≥ 6˚ or ≤ -2˚ = 4 pts.

Total = 40 Each degree < -2˚ x 1 pt. =

Each degree > 6˚ x 1 pt. =
OVERBITE SN-MP
0 - 3 mm. = 0 pts.
3.1 - 5 mm. = 2 pts. ≥ 38˚ = 2 pts.
5.1 - 7 mm. = 3 pts. Each degree > 38˚ x 2 pts. =
Impinging (100%) = 5 pts.
≤ 26˚ = 1 pt.
Total = 0 Each degree < 26˚ x 1 pt. =
1 to MP ≥ 99˚ = 1 pt.
ANTERIOR OPEN BITE
0 mm. (Edge-to-edge), 1 pt. per tooth Each degree > 99˚ x 1 pt. =
Then 1 pt. per additional full mm. Per tooth
Total = 4
Total = 0
OTHER (See Instructions)
LATERAL OPEN BITE
Supernumerary teeth x 1 pt. =
2 pts. per mm. Per tooth
Ankylosis of perm. Teeth x 2 pts. =
Total = 8 Anomalous morphology x 2 pts. =
Impaction (except 3rd molars) x 2 pts. =

CROWDING (only one arch) Midline discrepancy (≥ 3mm) @ 2 pts. =

Missing teeth (except molars)
3rd x 1 pt. =
1 - 3 mm. = 1 pt.
3.1 - 5 mm. = 2 pts. Missing teeth, congenital x 2 pts. =
5.1 - 7 mm. = 4 pts. Spacing (4 or more, per arch) x 2 pts. =
> 7 mm. = 7 pts. Spacing (Mx cent. diastema ≥2mm) @ 2 pts. =
Tooth transposition x 2 pts. =
Total = 0 Skeletal asymmetry (nonsurgical tx) @ 3 pts. =
Addl. treatment complexities x 2 pts. =
OCCLUSION
Identify:
Class I to end on = 0 pts.
End on Class II or III = 2 pts. per side pts.
Full Class II or III = 4 pts. per side 8 pts. Total = 0
Beyond Class II or III = 1 pt. per mm. 4 pts.
additional
Total = 12

20 0
Case # Patient
Skeletal Class III Malocclusion with Anterior and Posterior Crossbites JDO 67
Total Score:
Cast-Radiograph Evaluation Occlusal Contacts

Alignment/Rotations 8
Total Score: 31
Alignment/Rotations

7
1

2 1 1

2 2

Marginal Ridges

Occlusal Relationships
Marginal Ridges
11 1 1 1 1
4 Lingual Surface

Occlusal Relationships

1 11
1 2 1

1
Buccolingual Inclination
Interproximal Contacts
1 2 2 2 2 1 1
Buccolingual Inclination Interproximal Contacts

1 0

Overjet
Overjet Root Angulation

0 0

1 1

INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.
INSTRUCTIONS: Place score beside each deficient tooth and enter total score for each parameter
in the white box. Mark extracted teeth with “X”. Second molars should be in occlusion.

0 21
 JDO 67 CASE REPORT

IBOI Pink & White Esthetic Score

Total Score = 1
1. Pink Esthetic Score Total = 0
1. M & D Papillae 0 1 2

6 2. Keratinized Gingiva 0 1 2
5
4 3. Curvature of Gingival Margin 0 1 2
2 3 1
4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

1. M & D Papillae 0 1 2

2. Keratinized Gingiva 0 1 2

3. Curvature of Gingival Margin 0 1 2

4. Level of Gingival Margin 0 1 2

5. Root Convexity ( Torque ) 0 1 2

6. Scar Formation 0 1 2

2. White Esthetic Score (for Micro-esthetic) Total = 1

1. Midline 0 1 2

2. Incisor Curve 0 1 2

1 3. Axial Inclination (5˚, 8˚, 10˚) 0 1 2

4 3
1 2 4. Contact Area (50%, 40%, 30%) 0 1 2
4 3 5 6 5. Tooth Proportion 0 1 2

2 6. Tooth to Tooth Proportion 0 1 2

1. Midline 0 1 2

2. Incisor Curve 0 1 2

3. Axial Inclination (5˚, 8˚, 10˚) 0 1 2

4. Contact Area (50%, 40%, 30%) 0 1 2

5. Tooth Proportion 0 1 2

6. Tooth to Tooth Proportion 0 1 2

22 0
 2022-2023 第十四年度
貝多芬 矯正精修班

2022 5/10、6/7、7/12、8/16、9/6、10/4、11/15、12/6
2023 1/10、2/7、3/7

‣
‣
‣

0
0 報名專線：03-5735676 #218 陳小姐 0
0
 International Workshop
Digital Orthodontics, OBS, VISTA
Digital

OBS

Beethoven's International Workshop is designed for doctors who provide orthodontic treatment using
the Damon and Insignia System. This workshop is consisted of lectures, hands-on workshops as well as
chair-side observation sessions. Participants will have the opportunity to observe clinical treatment,
didactic lectures, live demonstration and gain hands-on practice experiences involving TAD placement,
indirect bonding, CBCT-enhanced digital treatment planning for Insignia.

VISTA

0
0 0
0
 Course Schedule

y
Da
1

y
Da
2
’

y
Da
3
’

Digital Orthodontics, OBS & VISTA

Day
4

KEYNOTE

Dr. Chris Chang

CEO, Beethoven Orthodontic and Implant Group. He received his PhD in bone physiology
and Certificate in Orthodontics from Indiana University in 1996. As publisher of Journal
of Digital Orthodontics-A journal for Interdisciplinary dental treatment, he has been actively
involved in the design and application of orthodontic bone screws.

0
0 0
0