19

Je Uk Park, DDS, MS, PhD

Director Classification of Angle Class III malocclusion
Department of Craniomaxillo-
facial Surgery
Kangnam St. Mary’s Hospital
and its treatment modalities
The Catholic University of Korea
Faculty of Medicine
Seoul, South Korea

S. H. Baik, DDS, MS, PhD

Assistant Professor
Department of Orthodontics To obtain the best results in the treatment of patients with Angle
Seoul National University Dental Class III malocclusion, the etiologies of the malocclusion should
College
Seoul, South Korea first be clarified, and then an appropriate treatment modality
should be decided. Angle Class III malocclusions in 120 sub-
Reprint requests: jects who had orthognathic surgery were analyzed with
Dr J. U. Park
Department of Craniomaxillo- cephalometrics and facial photos and classified into 3 cate-
facial Surgery gories based on the abnormalities of the maxilla. Type A is true
Kangnam St. Mary’s Hospital mandibular prognathism, which means that the maxilla is nor-
The Catholic University of Korea
Faculty of Medicine mal but the mandible is overgrown. Type B is characteristic of
Bonpodong 505, Sechogu, the overgrown maxilla and mandible with anterior crossbite.
137-040 Type C indicates a hypoplastic maxilla with anterior crossbite.
Seoul, South Korea
Fax: +82-2-533-2603 Treatment modalities should be differentially decided according
to this new classification of Angle Class III malocclusions. (Int J
Adult Orthod Orthognath Surg 2001;16:19–29)

An Angle Class III malocclusion means change, if needed, is usually limited to

that the mandibular first molar is anteriorly
placed in relation to the maxillary first
molar. It is a symptomatic or phenotypic
description that uses the first molars and
canines as critena, and it has nothing to
do with the maxillary and mandibular
skeletal bases. It has become the most
commonly used classification method of
malocclusion because of its simplicity, but
its flaws, such as lack of transverse and
vertical consideration, have been pointed
out and criticized by many authors.1,2
In patients with a Class III malocclu-
sion, correction is aimed at achieving a
Class I key relation and normal overbite
Int J Adult Orthod
Orthognath Surg and overjet, regardless of the position of
Vol. 16, No. 1, 2001 the maxilla and mandible. Skeletal
the mandible. This means that the rela-
tionship of the maxillary first molar to the
cranial base is not considered. There-
fore, it can be applied only to certain
types of Class IlI patients. It is quite im-
portant to have an etiologic classification
of malocclusion based on the skeletal
discrepancy to achieve ideal treatment
planning and results.
Malocclusion can also be differentially
categorized by the timing of its clinical
manifestation, but this has no impact on
the choice of treatment. A “congenital”
malocclusion manifests itself in a nega-
tive anterior overjet in the deciduous den-
tition and results from congenital anom-
alies of the maxilla and mandible or fetal
20 Park/Baik
and/or prepubertal trauma to the face.
A congenital malocclusion worsens with
age and requires surgery after comple-
tion of facial growth. A “developmental”
malocclusion shows no clinical signs be-
fore pubertal growth, but anterior cross-
bite or mandibular prognathism appear
with facial growth. It is associated with
abnormal growth of the mandible
and/or maxilla. For example, pubertal
overgrowth of the condyle leads to
mandibular prognathism, which is called
bilateral hemimandibular elongation3; if
unilateral condylar overgrowth occurs,
facial (or mandibular) asymmetry results.
A “hybrid” malocclusion is a combina-
tion of congenital and developmental
malocclusion, and it becomes clinically
more severe with growth.
The aim of this research was to intro-
duce a new concept of the classification
of Angle Class III malocclusion and to
outline appropriate treatment modalities.
Materials and methods
One hundred twenty patients with typi-
cal Class III malocclusions that had been
surgically corrected were selected and
classified into 3 types with cephalometric
and facial photo analysis, using the posi-
tion of the maxilla as the primary refer-
ence. The patients had been treated in
our clinic, were of Korean ethnicity, and
were between 15 and 42 years of age.
Three photos were used per patient—
frontal, right, and left. Riedel analysis, in-
cluding SNA and SNB angles, Wits ap-
praisal, mandibular body length (gonion
to menton), incision superius to Frankfort
horizontal plane and sella-nasion line, in-
cisor-mandibular plane angle, overbite,
and overjet, was per formed using
cephalometric radiographs. Soft tissue
analysis was performed on profile facial
photos, and the frontonasal angle, the
nasolabial angle, the labiomental fold,
soft tissue nasion to soft tissue pogonion,
and soft tissue nasion to soft tissue point
B were measured. Pre- and postoperative
cephalometric and facial photo tracings
were superimposed.
Results
According to the analysis of the pre-
operative and postoperative cephalomet-
ric radiographs and profile facial pho-
tos, the Class III malocclusion could be
classified into 3 types. The Type A Class
III malocclusion had a normal maxilla
(SNA = 80.83 degrees, nasolabial
angle = 90.96 degrees) and an over-
grown mandible (SNB = 82.54 de-
grees). The Type B malocclusion showed
a protrusive maxilla and mandible (SNA
= 86.75 degrees, SNB = 91 degrees,
nasolabial angle = 84.25 degrees). The
Type C malocclusion displayed a retru-
sive maxilla and anterior crossbite (SNA
= 73.83 degrees, SNB = 80.84 de-
grees, nasolabial angle = 79.17 de-
grees). However, the nasolabial angle in
Type C malocclusions suffered from
“under-measurement”: cephalometrics
and facial photos in centric occlusion
were analyzed, and the collapse of the
upper lip as a result of the hypoplastic
maxilla, decreased anterior facial height,
and overcushioning of the lower lip led
to a measurement that was too small.
This preoperative measurement error was
corrected, and combined surgical and
orthodontic treatment resulted in a nor-
mal appearance (Tables 1 and 2).
Discussion
The concept of the “nor mal” or
“ideal” face is changing. Intimate and
frequent contact between cultures via
mass communication, magazines, travel,
etc, has obliterated traditional and racial
differences of the facial norm, resulting
in a more conformed concept of facial
beauty. A. M. Schwarz divided normal
facial profiles into 3 categories: ante-
face, in which the lower anterior face is
protrusive relative to soft tissue nasion-
perpendicular (N’-perpendicular); mid-
face, in which the lower anterior face is
approximately in line with N’-perpendic-
ular; and retro-face, in which the lower
anterior face is behind N’-perpendicular
(Figs 1a to 1f).4,5 For many years, mid-
face was accepted as normal for Asian
and ante-face for African, but this is now
 Int J Adult Orthod Orthognath Surg Vol. 16, No. 1, 2001 21

Table 1 Pre- and postoperative hard tissue measurements

SNA SNB Mand. Is-SN Is-FH IMPA Overjet Overbite

Category (deg) (deg) length (mm) Wits (mm) (mm) (deg) (mm) (mm)
Type A
Preop 80.57 82.14 80.29 –11.00 104.71 113.57 91.86 –5.29 –2.00
Postop 80.57 77.57 77.00 –1.71 104.71 113.57 94.57 3.00 3.00
Type B
Preop 87.00 91.00 85.50 –13.50 116.00 122.50 79.50 –4.00 –2.00
Postop 86.50 85.00 84.00 –3.00 116.00 122.00 87.50 4.50 3.00
Type C
Preop 74.20 80.20 84.60 –15.20 103.40 114.20 92.00 –9.60 –3.60
Postop 75.40 74.20 78.20 –0.40 101.60 111.40 92.40 3.60 3.20
Is = incision surperius; SN = sella-nasion line; FH = Frankfort horizontal; IMPA = incisor-mandibular plane angle.

Table 2 Pre- and postoperative soft tissue measurements

Classification FNA (deg) NLA (deg) LMF (deg) N-B (mm) N-Pog (mm)
Type A
Preop 133.00 90.57 142.29 9.86 10.00
Postop 133.00 93.29 118.29 2.00 4.14
Type B
Preop 138.50 81.50 138.50 18.50 21.00
Postop 138.50 78.50 124.00 12.50 14.00
Type C
Preop 131.00 73.00 138.40 9.60 10.60
Postop 131.00 89.00 117.80 –0.40 0.00
FNA = frontonasal angle; NLA = nasolabial angle; LMF = labiomental fold; N = soft tissue nasion; B = soft tissue point
B; Pog = soft tissue pogonion.

changing. Young women and boys want
to have retro-face and prefer a 3-dimen-
sional rather than a flat face, with 3 dis-
tinct facial concavities (Fig 2). That
means that patients are not content with
an appearance that includes normal
maxillomandibular relationships but is es-
thetically compromised.
What we today call “ideal occlusion”
in association with the normal face was
described as early as the eighteenth cen-
tury by Hunter.6 Since then, much has
been written on the subject, but there was
no accepted method for describing irregu-
larities and abnormal relationships of the
teeth and jaw until Angle. Angle’s classifi-
cation of malocclusion was simple and
soon became one of the most popular
classification methods, but it had deficien-
cies. First, it disregarded the relationship
22 Park/Baik

Figs 1a and 1b The ante-face, in which

the lower anterior face is protrusive relative
to soft tissue nasion-perpendicular (N'-per-
pendicular).

a b

Figs 1c and 1d The retro-face, in which

the lower anterior face is behind N'-perpen-
dicular.

c d

Figs 1e and 1f The mid-face, in which the

lower anterior face is approximately in line
with N'-perpendicular.

e f
 Int J Adult Orthod Orthognath Surg Vol. 16, No. 1, 2001
Fig 2 Depiction of the 3 desired facial con-
cavities. a = frontonasal concavity; b = na-
solabial concavity; c = labiomental concavity.
of the teeth to the face (that is, the profile).
In other words, it was a simple dentoalve-
olar description based on the relationship
of maxillary and mandibular first molars
and anterior overbite and overjet. There-
fore, it was difficult to differentiate be-
tween dentoalveolar and skeletal discrep-
ancies and to evaluate their relative
contributions toward the creation of maloc-
clusion; consequently, ideal treatment plan-
ning was difficult. Second, only anteropos-
terior deviation (sagittal discrepancy) was
taken into consideration, although dental
malocclusion is a 3-dimensional problem.
Third, it merely described the relationship
of the teeth and did not include a true di-
agnosis. Hence, a new classification of
dental malocclusions is required to reach
etiologic diagnoses and select appropriate
treatment modalities.
The Class III malocclusion can be clas-
sified into 3 types according to the posi-
tion of the maxilla in relation to craniofa-
cial skeletal reference points, and
23
different types of surgery are recom-
mended to correct each type of discrep-
ancy. Type A has a normal maxilla and
an overgrown mandible. It is called true
mandibular prognathism, because the
anterior crossbite or Class III malocclu-
sion results from the mandible. It is there-
fore sufficient to perform mandibular
surgery alone (for example, sagittal split
ramus osteotomy) to achieve a normal or
ideal facial appearance (Fig 3, Table 3).
Type B has maxillary and mandibular
excess, but the mandible has grown
more than the maxilla, resulting in an
acute nasolabial angle and an anteriorly
positioned point A. This type of Class III
malocclusion is found more frequently in
Asians. If mandibular surgery alone
were carried out, a newly bimaxillary
protrusive facial type (ante-face) would
result (Fig 4, Table 4), although a normal
(Class I) dentoalveolar relationship and
normal overbite and overjet would have
been attained. This is not a normal face.
24 Park/Baik

Figs 3a to 3e A Type A Class III patient, shown before and after mandibular setback and ad-
vancing genioplasty.
Figs 3a and 3b Preoperative photograph
and radiograph.

a b

Figs 3c and 3d Postoperative photograph

and radiograph.

c d

Fig 3e Superimposition of pre- and post-

e operative cephalometric tracings (blue =
preoperative; red = postoperative).
 Int J Adult Orthod Orthognath Surg Vol. 16, No. 1, 2001 25

Table 3 Measurement of Type A prognathic patient*

Hard tissue measurements

SNA SNB Mand. Is-SN Is-FH IMPA Overjet Overbite
Time (deg) (deg) length (mm) Wits (mm) (mm) (deg) (mm) (mm)
Preop 84 83 78 –12 100 112 83 –7 –2
Postop 84 78 75 –3 100 112 86 3 3
Soft tissue measurements

FNA NLA LMF N-B N-Pog

Time (deg) (deg) (deg) (mm) (mm)
Preop 140 92 144 19 19
Postop 140 93 123 5 7
*Patient HHW, a 21-year-old male.
Is = incision superius; SN = sella-nasion line; FH = Frankfort horizontal; IMPA = incisor-mandibular plane angle;
FNA = frontonasal angle; NLA = nasolabial angle; LMF = labiomental fold; N = soft tissue nasion; B = soft tissue
point B; Pog = soft tissue pogonion.

Therefore, Type B patients require not
only mandibular but also maxillar y
surgery with posterior movement; unfortu-
nately, maxillary setback is not simple.
The maxilla can be moved posteriorly
with a Le For t I osteotomy, but the
amount of potential posterior movement
is restricted because of the need to pre-
serve space in the nasopharyngeal air-
way.7,8 Anterior segmental osteotomy can
be used instead of Le Fort osteotomy, but
it also has disadvantages.9 The operation
itself is more complicated than a Le Fort I
osteotomy, and there is always danger of
impairment of circulation to the os-
teotomized segment, resulting in its
necrosis. Two-stage surgery has been
considered to avoid such complica-
tions.10 Many surgeons avoid this tech-
nique because of its poor results and rel-
atively high relapse rate. These
drawbacks should and could be elimi-
nated by a modified anterior segmental
osteotomy (Fig 5). 11,12 This requires a
vestibular incision alone, and the os-
teotomy is done and completed through
this facial (vestibular) approach. There is
no possibility of impaired circulation to
the osteotomized segment, because the
palatal mucosa are kept intact. The
surgery itself is simplified and the bleed-
ing tendency is greatly reduced, because
any necessary cauterization can be done
under direct observation. This modified
anterior segmental osteotomy has be-
come a routine procedure to move the
maxilla posteriorly. With this combined
surgery, the nasolabial angle becomes
normal, and the upper and lower lips at-
tain a normal relationship to Rickett’s E-
line. The profile becomes retro-face, and
dentoalveolar and skeletal status are nor-
mal, with normal overbite and overjet.
However, the key relation of the first mo-
lars becomes not Class I but Class II (al-
though the canines are in a Class I rela-
tionship). But this does not constitute a
clinical problem, because interdigitation
of the maxillary and mandibular teeth is
more important than the key relation. The
anterior or canine guidance during
mandibular movement and the normal in-
terdigitation of teeth by occlusion are
functionally more critical.
The typical feature of the Type C Class
III malocclusion is hypoplasia of the max-
illa. Its facial profile is concave, with an
excessively large nasolabial angle, but
26 Park/Baik

Figs 4a to 4f A Type B Class III patient.

Figs 4a and 4b Preoperative photograph

and radiograph.

a b

Figs 4c and 4d Patient following maxillary

and mandibular setback.

c d

Fig 4e (Left) Simulated appearance show-

ing a compromised result following
mandibular setback only.

Fig 4f (Right) Superimposition of cephalo-

metric tracings of all 3 results (preoperative,
postoperative, and simulated). Blue = pre-
operative; red = postoperative; green = sim-
ulated.

e f
 Int J Adult Orthod Orthognath Surg Vol. 16, No. 1, 2001 27

Table 4 Measurement of Type B prognathic patient*

Hard tissue measurements

SNA SNB Mand. Is-SN Is-FH IMPA Overjet Overbite
Time (deg) (deg) length (mm) Wits (mm) (mm) (deg) (mm) (mm)
Preop 84 88 95 –18 114 125 88 –6 –2
Postop 80 78 78 –7 112 121 90 3 3
Compromised 84 80 80 –8 114 125 83 3 3
Soft tissue measurements

FNA NLA LMF N-B N-Pog

Time (deg) (deg) (deg) (mm) (mm)
Preop 124 89 127 18 19
Postop 124 108 98 6 8
Compromised 124 88 114 10 13
*Patient CSM, a 26-year-old female.
Is = incision superius; SN = sella-nasion line; FH = Frankfort horizontal; IMPA = incisor-mandibular plane angle;
FNA = frontonasal angle; NLA = nasolabial angle; LMF = labiomental fold; N = soft tissue nasion; B = soft tissue
point B; Pog = soft tissue pogonion.

this is frequently camouflaged by den-

toalveolar compensation (eg, excessively
protrusive maxillary anterior teeth). For
correction, anterior repositioning of the
maxilla with maxillary osteotomy is re-
quired to obtain a normal position of the
upper lip and an adequate nasolabial
angle, and Le Fort osteotomies are most
commonly used. Mandibular surgery is
then performed to achieve normal over-
bite and overjet. Mandibular surgery
alone would result in an excessively
retro-placed face (Fig 6, Table 5).
We have discussed the Class III maloc-
clusion and suggested a new classifica-
tion in hopes that more explicit treatment Fig 5 Illustration of a modified segmental os-
plans can be developed. Additional clas- teotomy.
sifications should be developed that could
be applied to all facial anomalies, such
as Angle Class II or III malocclusion; verti-
cal abnormalities (eg, open bite, deep
bite, long face, and short face); and trans- has a normal maxilla, Type B has a hy-
verse discrepancies (ie, asymmetry). perplastic maxilla, and Type C has a hy-
poplastic maxilla. Type A Class III maloc-
Conclusions clusion requires mandibular surger y
alone, but Type B and C need not only
Angle’s Class III malocclusion can be mandibular but also maxillary surgery to
categorized into 3 types, of which the cri- achieve a normal facial appearance. The
teria is the status of the maxilla. Type A concept of the normal face has changed,
28 Park/Baik

Figs 6a to 6f Patient with Type C Class III malocclusion.

Figs 6a and 6b Preoperative photograph

and radiograph.

a b

Figs 6c and 6d Patient following maxillary

advancement and mandibular setback.

c d

Fig 6e (Left) Simulated appearance show-

ing a compromised result following
mandibular setback only.

Fig 6f (Right) Superimposition of cephalo-

metric tracings of all 3 results. Blue = preop-
erative; red = postoperative; green = simu-
lated.

e f
 Int J Adult Orthod Orthognath Surg Vol. 16, No. 1, 2001 29

Table 5 Measurement of Type C prognathic patient*

Hard tissue measurements

SNA SNB Mand. Is-SN Is-FH IMPA Overjet Overbite
Time (deg) (deg) length (mm) Wits (mm) (mm) (deg) (mm) (mm)
Preop 72 84 98 –22 107 125 94 –5 –5
Postop 79 76 89 –10 106 123 100 3 3
Compromised 72 72 88 –13 107 125 93 3 3
Soft tissue measurements

FNA NLA LMF N-B N-Pog

Time (deg) (deg) (deg) (mm) (mm)
Preop 120 110 63 25 35
Postop 120 100 105 15 20
Compromised 120 108 100 15 20
*Patient KOJ, a 20-year-old male.
Is = incision superius; SN = sella-nasion line; FH = Frankfort horizontal; IMPA = incisor-mandibular plane angle;
FNA = frontonasal angle; NLA = nasolabial angle; LMF = labiomental fold; N = soft tissue nasion; B = soft tissue
point B; Pog = soft tissue pogonion.

and retro-face is now accepted as nor- 3. Obwegeser H, Makek MS. Hemimandibular

mal and ideal. Therefore, Type B requires
the posterior movement of the maxilla in
addition to that of the mandible. Retrac-
tion of the maxilla is not easy, but techni-
cal difficulties can be overcome by a
modified anterior segmental osteotomy.
Class III discrepancy should be diag-
nosed and classified according to its eti-
ology and treated with appropriate
surgery, including if necessary not only
mandibular but also maxillary surgery.
Acknowledgments
We are grateful to Dr I. C. Park for his assis-
tance with this text and to Ms Chang for her com-
puter wizardry.
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