DIAGNOSIS & EARLY TREATMENT OF CLASS III INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com RN ee ree NaeEvidence based treatment San AY are = male) * What we do not know * What we know that’s just not so Profitt * Treatment of Class III malocclusion is like opening a Pandora's box RN ee ree NaeGrowth in 3 planes of space declines to adult levels at different times Transverse - preadolescent om - adolescent Vertical - post adolescent Makes sense to time procedures at different times for different space problems* Determine best time for orthodontic treatment * Cost * Principles related to timing RN ee ree NaePLAN TREATMENT LATER? - after adolescent growth spurt? Prolonged growth in an unfavorable pattern - Class Ill, excessive mand. growth - Orthodontic control of excessive growth difficult - Successful orthodontic camouflage requires growth prediction - Early surgery often unstable Re ee ree NeeUsing Cervical Vertebral Maturation System — CVMS * Start early treatment * CS 1-2 years before peak * CS 2-1 year before peak * CS 3 & CS 4-— pubertal spurt peak *CS58&CS6 * Franchi, Bacetti, McNamara 2005 RN ee ree NaeCan you predict long term response from pretreatment cephalometric readings ? * AJO/DO 2004 JULY- FRANCHI , BACETTI * Discriminating analysis based on --- ramus height cranial base angle mandibular plane angle 80% identified. arcectlyny.comRange of Class III malocclusion Class | Psuedo Class Ill True Class Ill Prognosis better RN ee ree NaeDiagnostic Criteria for Pseudo & True Class III patients Family history Incisal relationship CO/CR discrepancy Molar relationship Difference in the WITS Analysis Gonial angle Growth rate & direction with time RN ee ree NaePSEUDO CLASS III - FEATURES 1. Positional malrelationship 2. Reflex functional mandibular protraction 3. Retroclined maxillary incisors & / or proclined mandibular incisors 4. Acquired muscular reflex RN ee ree NaeDiagnostic Criteria Clinical Profile a. Profile may / may Cephalometric Profile not be concave b. Profile improves as mandible drops from occlusal contact relationship to postural position . Translation of mandible forward can be confirmed by gently placing the finger tips over TMJ during opening &, closing. . Wit’s appraisal shows BO-AO 0 to - 4mm ( functional occl. plane) . SNA,SNB angles lao] fate l Mec lNle lM} normal. . Maxillary incisors may /may not be faatelic-me) edie lave tar-la) fateluat-1 Tum eeDifferential Diagnosis of Class III * Dental assessment * Functional assessment * Clinical assessment * Cephalometric assessment RN ee ree NaeDental Assessment Molar relationship & Overjet * Class III molar Class III molar Negative overjet Positive overjet Functional assessment Retroclined lower COICR shift incisors no shift Salis erelac teas Clinical & Cephalometric assessment th Class Ill | Psuedo Class Ill Compensated Class DIFFICULT RN ee ree NaeFunctional Relationships Of CLASS III Relationship between rest position & full occlusion in sagittal plane — Rotational movement without sliding Closing movement with anterior sliding Closing movement with posterior sliding Pure rotational movement from postural rest to occlusal position RN ee ree NaeFunctional Relationships Of CLASS III * Rotational movement without slide — * Non-functional, true CLASS III — unfavorable prognosis RN ee ree NaeFunctional Relationships Of CLASS III * Rotational movement with anterior slide — * During articular phase — mandible shifts forward into prognathic forced bite — functional non-skeletal — psuedo CLASSIII — favorable prognosis RN ee ree NaeFunctional Relationships Of CLASS III * Rotational movement with posterior slide — * Pronounced mandibular prognathism, mandible may slide posteriorly into maximum intercuspation — masks true sagittal dysplasia — Un evorsole prognos's RN ee ree NaeTRUE FORCED BITE — PSEUDO FORCED BITE Anterior slide in both True forced bite = pseudo Class III = favorable prognosis Pseudo forced bite = true Class III = unfavorable prognosis Differentiation by cephalometrics Partially dentoalveolar — compensated SCO ca RN ee ree NaeTRUE FORCED BITE — PSEUDO FORCED BITE * Upper incisors tipped labially & lower incisors lingually Mandible guided toward anterior while closing Placing incisors in correct axial position reveals a negative overjet — Teal Atel Ccome Lali 4(e) i, leu ces uN Ast slidePROFILE / CLINICAL ASSESSMENT * Check proportionate eles} te) ame) Maar-h dite med mandible in A-P plane Place patient in natural head position Drop line from bridge of nose to base of upper lip & second line from base of upper lip to chin Straight or concave profile in young Se ee eee skeletal Class IIICEPHALOMETRIC ASSESSMENT * Best analysis — relate maxilla to mandible * Discriminant analysis found WIT’S appraisal most decisive in distinguishing camouflage from surgical treatment ( AJO 2002) ° Wit’s > - 5 = malocclusion might not be resolved by camouflage with facemask or chin cup. RN ee ree NaeCephalometric Analysis for Class III Bam anc 1ea are P ALI elas 6 - 18 years * Wits eee) * Maxillo.-Mand. Diff 23 mm (12 y) (Class III - 28mm) * ANB 2° (Class III 0° to -1°) * Zero Meridian (maxilla) Seem tt] (pogonion) Oe ania Mild to moderate Class IlIl— WITS = -4to-5mm Face mask therapy RN ec ee aacCephalometric Characteristics Classl,PseudoClasslll, True Class III SNA CLASS | 83.3 + 3.3 as) =i 0) B10} to Pea) CLASS III TRUE CLASS III 80.3 + 3.6 RN ee ree Nae SNB 80.6 + 3.1 81.24 3.6 81.8 + 3.3 TOR beledCephalometric Characteristics Classl,PseudoClasslll, True Class III UR ean))| CLASS | 107.3 +6.1 PSUEDO 109.4 +5.9 CLASS III TRUE CLASS Ill = 111.0 + 5.5 RN ee ree Nae L1-MP 94.4456 91.7+6.9 87.7 +6.8 LTO be kerdCephalometric Characteristics Classl,PseudoClasslll, True Class III SN Lag CLASS | leh Meas) PSUEDO RRO Bene) CLASS III TRUE CLASS III 36.144.3 RN ee ree Nae Gonial Angle 121.7455 120.5 45.7 124.3 + 14.3 Lin JJ 19947 Structural Signs Of Extreme Mandibular Growth Rotation Inclination of the condylar head Curvature of the mandibular canal Shape of the lower border of the mandible Inclination of the symphysis Inter incisal angle Inter molar angle Anterior lower face height RN ee ree Nae Bjork A. 1969DETERMINATION OF INDIVIDUAL GROWTH RATE & DIRECTION * Growth treatment response vector — GT RV ANALY S\S — PETER NGAN * Serial cephalometric radiographs used to predict excessive mandibular growth * GTRV ratio = hori. growth changes of ma hori. growth changes of ma ne - RN ee ree NaeGTRV RATIO * Mild to moderate Class III skeletal patterns with GTRV ratio between 0.33 & 0.88 can be successfully camouflaged by facemask therapy * Class III patients with excessive mand. growth & GTRV ratio below 0.38 — future orthognathic surgery needed RN ee ree NaeLong term outcome ? What happens during adolescent growth ? Maxilla forward, maxillary tooth movement, mandible rotates down & back Will he / she make it without surgery? depends totally on mandibular growth at adolescence RN ee ree Nae* Treating pseudo Class III early — better prognosis — to start with they were Class | therefore NO SURPRISE RN ee ree NaeEarly Timely Class III Treatment Advantages — Eliminate CO/CR discrepancies Improve smile & self esteem of patient Maximize the growth potential of the maxilla ? Predict excessive mandibular growth ? RN ee ree NaeGoals of Early Timely Class III Treatment * Prevent progressive, ° Improve skeletal irreversible soft tissue discrepancies — or bony changes minimize excessive dental compensations * Eliminate CO/CR Samm AT LOO ao Les ets discrepancies facial appearance Improve self concept, self esteem & psychosocial well being * Avoid abnormal incisal wear www indiandentalacademy.co®’Brien et. al. ASO 2003Questionable Goals Of Early Treatment * To simplify Phase 2 comprehensive orthodontic treatment * To alleviate / reduce surgery ? * Still not enough literature to know RN ee ree NaeWhen to intercept Class III developing malocclusion? - Turpin’81 POSITIVE FACTORS — * Good facial esthetics * A-P functional shift * Mild skeletal disharmony * Convergent facial type * Young patient with growth remaining * Symmetrical condyle * No familial prognathism * Good Cooperation: cenceTreatment of Class III a alt| * Reverse twin block * Chin Cup therapy * Protraction Face Mask * Tandem appliance * Camouflage therapy * Surgery RN ee ree NaeWHEN IS THE BEST TIME TO START FACEMASK TREATMENT * Midpalatal suture broad & smooth during infantile stage — 8 -10 yrs. * Suture more squamous & overlapping in juvenile stage — 10 -13 yrs. ( Melsen & Melsen - AJO 1982) * Maxillary protraction effective in deciduous, mixed & early permanent dentitions. — clinical studies (AJO 1997,1998; EIO200T;""""WHEN IS THE BEST TIME TO START FACEMASK TREATMENT * More anterior maxillary displacement when I (g-¥e gala) mo) t= 1a -10 Mame (Lei po)m-Y~ 1a NYA C-ELPeL-VA1 LAO) — (Angle Orthod 1998 ; AJO 1998 ) Optimal time to intervene in Class II] seems to be when maxillary incisors erupt Long term study AJO 2004 — end of phase 2 fixed appliance therapy - greater forward movement of maxilla & less mandibular projection found only in early treatment group — deciduous & early: mixeddentition* Maxillary growth completed in females by 15 yrs.— Bjork 1966 ; Bjork & Skieller - BJO 1977 * Maxillary growth in females completed by 18 yrs. — Iseri & Solow - EJO 1990 * Adolescent boys maxilla stopped growing by 18 yrs. — Savara & Singh — Angle Orthod. 1968 ; Broadbent et. al 1975 RN ee ree Nae* Reyes et. al — Angle Orthod. 2006 — * 1091 untreated Class III subjects studied — * No significant increase in maxillary length at various chronological ages in either sex * ANB & WIT’s — no skeletal improvement during growth RN ee ree NaeEarly mixed dentition treatment — improves maxillary sagittal growth when compared to treatment in late mixed dentition — Chong Y H et. al- Angle Orthod. 1996 ; Franchi et. al- AJO 2000 Treatment in late mixed dentition — increases in vertical dimensions due to backward positional rotation of the mandible — Franchi , Baccetti , McNamara AJO 2000 RN ee ree NaeBasic Principles of Early BB r a tevalt *Early Detection of Deviation of Growth *Midfacial Vulnerability Earlier the Treatment Greater the Stability *Disarticulation of teeth and TMJ *Orthopedic Sutural Expansion of the Maxilla *Overtreatment *Laboratory Comprehension RN ee ree Nae20 % to 30 % adult Class III — maxillary retrusion & no mandibular prognathism — Ellis, McNamara — J. Oral Maxillofacial Surg. 1984 62 % had component of maxillary retrusion Sue G. et al. — J Dent Res. 1987 Developing Class III malocclusion — A-P & vertical maxillary deficiencies — normal to slightly protruded mandibles & average to deep overbites — Hopkin et al. — Angle Orthod 1968 ; Mouakeh M — AJO 200 concen)ONS SouI| Current trend-- TREAT MAXILLA NOT MANDIBLE Early face mask therapy— demonstrates effectiveness How early to treat ? Seem BL=)(- 1 Memo M(-r- 16) --- recent papers — skeletal changes up to onset of adolescence --- at all ages dental changes occur & 10 % Taare rae lOO eUmOnirs hice tc oaIntraoral Appliances used with Face Mask therapy * Banded or soldered palatal expansion appliance * Bonded palatal expansion appliance * Fixed plate or lingual arches * Quad helix RN ee ree Nae* Is expansion necessary for maxillary protraction? -- 6-8 years - yes — helps forward protraction of maxilla. ( Melsen AJO 1982 ) * Bonded palatal expansion appliance — 400 gms elastic on each side 12 hrs. per day — 8-12 months of protraction-- correction normally seen after 8 months * Frontomaxillary, Zygomaticotemporal, Zygomaticomaxillary & Pterygopalatine sutures are affeetedsscasemy.comAuthor Nanda Ischii Tindlund Taal Da silva Gallagher Nartallo- malas Factors influencing A point aa lg ‘80 c¥4 ‘89 yA mele} mls} a4 movement (on Force Tx time ar) 500 gm 4 mths. Noexp. 250gm 11-24m Quadhe 700gm_ 12 mths. aN e 400gm_ 6 mths. Haas 350gm 12 mths. Slow exp 600-800 8-9 mths felaal Hyrax vive Teen aoe RUA UC age (= [Cu acoLuy A pt.mo sedi 2.7mm 3.0mm 2.0mm asyena) SR yr 3.3mmFactors influencing A point movement Author aie >on Force g Txtime Apt.mo ere sels) alee 300-400 6-8mth. 2.1mm Pangrezio ‘98 Bonded 400-600 7-8mth. 1.8mm Vd Kapust ‘98 aNAEeb4 300-400 9-10mth. 2.8mm EFTel) mols) Bonded 400 11mth. 2.1mm as Ngan ‘98 Hyrax 400 8-9mth. 2.1mm leit] ‘03 Hyrax 500 Pest Westwood ‘03 PV eee 100 nTClinical Profile COC Citta em aati a. Concave Profile. a. Wit’s appraisal shows b. Had an even BOAO — 4.5rom. anteroposterior pattern b. SNA 76.5,SNB 77.5, of closure. ANB -1° Ce Eem nase manor c. Size of maxilla normal. was present. d. Low lying tongue FeeTaLt Cem e. Full anterior crossbite. RN ee ree Naea. Reverse Headgear- Delaire Facemask + BONDED Posterior Bite Plate with hooks at the canines + (-).(oy- Tats) (¢) a iese1 f=) Elastics. b. Screw turns % per week.Force levels of elastics 350-400 gms. 3 Months. c. FRIII| + Chin Cap d. Fixed applianG@snciancentaiacademy.com| aucm ee * Cephalogram shows marked positional advancement of the maxilla. ANB + 1.75° Wit’s -1mm. Profile more or less straight. Anterior crossbite fully corrected. RN ee ree NaeClinical Profile a. Concave Profile. Le Bonnie coe c. Skeletal asymmetry. d. Deviation of the mandible to the left Cone CONT com e. Presence of pita ete eRe Canola f. Unilateral left side CO tersl ee Cephalometric RN ee ree Nae Profile Wit’s appraisal shows BO-AO Seyi e . SNA 78,SNB 81.5, ANB -3.5° SSR meat Em mandible normal. PA view shows Solar mart ct aaMicrel la maa A co Removal of premature contacts at left lateral & canine region. . Posterior Bite Plate + Zsprings with expansion screw(for unilateral left side crossbite). — % turn per week---2 months. . FRIII + Chin Cap . Fixed appliances. RN ee ree aeMarked improvement in maxillo- mandibular relation. Crossbite corrected.Wit’s — 2mm. ANB + 1.5° Facial SWAN et liag improved. RN ee ree NaeDisadvantages of ANB & WIT’S — * ANB — Nasion position not fixed ; rotation of jaws by growth or orthodontic treatment can change ANB. * WIT’S — Accurate identification of functional occlusal plane not easy or accurately reproducible ; angulation of functional occlusal plane caused by normal devt. of dentition or orthodontic intervention can influence Wit’s appraisal. RN ee ree NaeInnovative Cephalometric WU CeXeRTUT geal ies * BETA ANGLE — Chong Yo Baik , Maria Ververidou — AJO 2004 * Angle indicating severity & type of skeletal dysplasia in sagittal dimension C - Centre of condyle /,——Beta angle 27°- 35° - Class | < 27° - Class Il > 35° - Class Ill RN Se eeeInnovative Cephalometric WU CeXeRTUT geal ies * C AXIS — Growth vector for Maxilla — Sella to M point * G AXIS — Growth vector for mandible — Sella to G point RN ee ree NaeCONCLUSIONS * Class III treatment still remains the bane of all orthodontists. * Grey areas in treatment timing still eel * One must not try to be a ero while treating Class III malocclusions. * One needs to know the limitations eM OiT-Wsom An =-lienl- 1a) em* Early detection of CLASS III malocclusion is beneficial. * Judicious use of the growth predictors is indicated. * Discerning clinical acumen has to ley iat-M (e)at- Miami (c-t-1 1 p(e Ori B * Evidence based treatment is the need of the’Hour"”"”Thank you For more details please visit www. indiandentalacademy.com RN ee ree Nae