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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

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

C 2016 Japan Health Sciences University

& Japan International Cultural Exchange Foundation
 Alam M.K. et al.
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.
pensation. Longer in facial height noted. Lower lip soft tissue aesthetic
plane was increase (Figure 2 and Table 1).
Treatment objectives
The objectives of the orthodontic treatment were to (1) to protrude
the maxillary incisors, (2) to retrude the mandibular incisors, (3) to cor-
rect anterior locked bite and (4) to align maxillary and mandibular teeth.
Treatment alternatives
Class III malocclusion is one of the most difficult anomalies to
understand. Not all Class III patients are candidates for surgical correc-
tion thus, patient assessment and selection remain as main issues in
diagnosis and treatment planning6).
Etiological features of a Class III malocclusion showed that the
deformity is not restricted to the jaws but involves the total craniofacial
complex. Most patients with Class III malocclusions show combinations
of skeletal and dentoalveolar components7).
Analysis done through studies showed separation of adult Class III
malocclusion patients who can be treated by orthodontic therapy alone
from those who need orthognathic surgery was successful in 92% of the
cases6). Thus, orthognathic surgery was not a common decision for cor-
rection of class III malocclusion.
By further discussion to the patients, the concern of the patient was
the backward position of the upper lip to the lower lip that promote of
the unaesthetic appearance. The position of the soft tissue lower lip was
accepted by the patient. Thus, removable appliance was chosen to
405
Figure 2. Pre-treatment OPG, pre-treatment lateral cephalo-
gram, lateral cephalogram tracing.
Figure 5. Post-treatment model photograph.
expand the maxillary teeth prior to fixed appliance application. Posterior
bite plane was used to raise the bite and anterior screw expansion was
incorporated to the appliance. (Figure 3)
Application of fixed appliance with Nickel titanium (NiTi) wire was
used after the correction of anterior locked bite.
Treatment results
The orthodontic removable appliance was incorporated with anteri-
or screw expansion to protrude the maxillary teeth and posterior bite
plane used to raise the bite to unlock pathway of movement of upper
incisors. After correction of the locked bite, fixed orthodontic appliance
was bonded using 0.022 MBT Pre-adjusted Edgewise Appliance with
continuous arch wires, restarting with 0.012-inch nickel-titanium and
working up to 0.017- x 0.025-inch stainless steel (Figure 4). After appli-
cation of removable and fixed appliance to patient, the malocclusion
was successfully corrected. Treatment progress shown in Table 2. All
appliance was removed and Essix-form retainer was used for retention.
URA treatment done for the 5 months. Fixed orthodontic treatment
was completed in 17 months. Patient cooperation in maintenance of oral
hygiene was moderate, and the examination after active orthodontic
treatment revealed that the clinical status and radiographic results
observed at the completion of the treatment was excellent (Figures 5, 6,
7 and 8; Table 1). The patient was completely satisfied with the results
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

Figure 6. Post-treatment OPG, post-treatment lateral cephalo-
gram, lateral cephalogram tracing.
Figure 7. Lateral cephalogram superimposition (only showing
incisors).
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
7. Elastic module changed 0.016 NITI Levelling and Labial
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
SS
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.
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,
which can change in quantity and/or distribution under different condi-
tions, including individual characteristics, nutrition, and age 12). Thus,
early treatment of the Class III malocclusion has been strongly recom-
mended by many authors for the favourable results on growth and
occlusal relationship13).
In this report, fixed orthodontic appliance alone was not indicated
as patient was having anterior locked bite that cause minimal space for
bracket adhesion. Thus, upper removable appliance with Adam's clasp
on tooth 16 and 26, ball retainer, anterior expansion screw and posterior
bite plane was used prior to fixed orthodontic appliance application.
Maxillary anterior teeth were proclined to achieve Class I occlusion.
After the correction, fixed appliance was used to align the maxillary and
mandibular teeth. The correct position of the upper and lower lip was
achieved14).
Fixed appliance was removed after the correction was achieved and
Essix-formed retainer was used to prevent relapse. Even though skeletal
relapse is the most common complication however, it was less common
for this case as no surgery was indicated for this patient15).
So far, literatures do not contain an accurate model to distinguish
between adult Class III patients who can be properly treated by ortho-
dontic mechanotherapy alone and those who require orthognathic sur-
gery 6). Nevertheless, the result for this patient was excellent. The
patient’s compliance, esthetics, caries risk, function, and age should all
be considered when deciding treatment options.
CONCLUSION
This case demonstrates successful treatment for class III malocclu-
sion with anterior locked bite using removable and fixed orthodontic
appliance. Utilization of both appliances was not as indicator for
lengthy treatments but has contributed for better treatment results in a
short period of time.
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407
1) Proffit WR. Contemporary orthodontics. 4th ed. St Louis: Mosby, 2007: 689-707.
2) Angle EH. Malocclusion of the teeth. Philadelphia. 1907.
3) Edward E, James A M. Components of adults class III malocclusion. J Oral Maxillofac
Surg 1984; 42: 295-305.
4) Jacobson A, Evans WG, Preston CB, et al. Mandibular prognathism. Am J Orthodont
1974; 66: 140.
5) Sanbom RT. Differences between the facial skeletal patterns of Class III malocclusion
and normal occlusion. Angle Orthodont 1955; 25: 208.
6) Angelika SE, Christopher JL, Gabriele S. Treatment decision in adult patients with
class III malocclusion: orthodontic therapy or orthognatic surgery? Am J Orthod
Dentofacial Orthop 2002; 122: 27-38.
7) Battagel JM. The aetiological factors in class III malocclusion. Eur J Orthod 1993; 15:
347-70.
8) Haynes S. The prevalence of malocclusion in English children aged 11-12 years. Re
Cong Eur Orthod Soc 1970: 89-98.
9) Foster TD, Day AJ. A survey of malocclusion and the need for orthodontic treatment in
a Shropshire school population. Br J Orthod 1974; 1: 73-78.
10) Thilander B, Myrberg N. The prevalence of malocclusion in Swedish schoolchildren.
Scand J Dent Res 1973; 81: 12-21.
11) Chew MT, Sandham A, Wong HB. Evaluation of the linearity of soft- to hard tissue
movement after orthognathic surgery. Am J Orthod Dentofacial Orthop 2008; 134:
665-670.
12) Baris A, Nedim O, Gulnaz M. Bimax surgery in class III malocclusion: soft and hard
tissue changes. Journal of Cranio-maxillo-facial Surgery 2013; 44: 254-257.
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.
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.
12) Ana de Lourdes S, Walter Leal M, et al. Lincoln I N. long-term skeletal and profile
stability after surgical-orthodontic treatment of class II and class III malocclusion. J
Cranio-Maxillo-Fac Surg 2013; 41: 296-302.