Professional Documents
Culture Documents
III MALOCCLUSION
7
COMPONENTS OF CLASS III
• Guyer et al found that approximately 57% of the patients with
either a normal or prognathic mandible showed a deficiency in the
maxilla.
• In a sample of Chinese patients, Wu, Peng, and Lin found the
percentage of skeletal Class III malocclusion with maxillary
retrusion to be as high as 75%.
• Contemporary studies have found Class III to be composed of pure
mandibular protrusion (19.1% to 45.2%), pure maxillary retrusion
(19.5% to 37.5%), or a combination of mandibular protrusion and
maxillary retrusion (1.5% to 30%).
• According to Ellis and McNamara 1984 and Sue et al 1987,
maxillary retrognathism is present in 62% to 67% of all class III
patients
• According to Bell et al AJO 1981 maxillary retrognathism was found
in 30–40% and Jacobson et al AJO 1974 reported that the one-quarter
of Class III malocclusions demonstrated retruded maxilla8
CLASSIFICATION
• Genetic:
– 33 out of 40 decendants of the HABSBURG family had a class III
jaw
• Ethnic
– 3% in caucasians
– 5% african american
– 14% chinese and japanese
– (3.4% indians)
• Environmental (epigenetic):
– Large tongue
– Forward tongue position ( eg in cases of adenoids)
– Mouth breathing 12
• Systemic:
– Acromegaly and hemi mandibular hypertrophy:
Acromegaly is caused by anterior pituitary tumour that secretes
excessive amount of growth hormone. Here excessive mandibular
growth occurs creating a skeletal class III malocclusion.
– Teratogenic:
Teratogens causing cleft lip and palate are aspirin, cigarette smoke
(hypoxia), dilantin, 6-mercaptopurine, valium
vitamin D excess causes premature closure of sutures and might
lead to class III malocclusion.
13
EARLY EXTRAORAL SIGNS OF A DEVELOPING CLASS III
14
EARLY INTRAORAL SIGNS OF A DEVELOPING CLASS III
15
EARLY SIGNS OF A DEVELOPING CLASS III
•Zero overjet
•Unilateral/ bilateral posterior crossbite
•Proclined maxillary incisors and retroclined mandibular incisors
•Wide lower arch and narrow maxillary arch
•Flat curve of spee
16
EARLY SIGNS OF A DEVELOPING CLASS III
17
Pseudo class III
18
How to differentiate a dental crossbite from a
skeletal crossbite
Cephalometric-Cranial features
Positive factors:
1. Good facial esthetics
2. Mild skeletal disharmony
3. No familial prognathism
4. Antero posterior functional shift
5. Convergent facial type
6. Symmetric condylar growth
7. Growing patients with expected good cooperation.
If the above factors are not present in the patient , they are listed as
negative and treatment can be delayed until growth is completed.
26
TREATMENT TIMINGS
• Face-mask therapy was first described more than a century ago, and
since the late 1960s it has been used with increasing frequency for
the correction of Class III malocclusion.
• In 1944, Oppenheim reported that it is impossible to move the
mandible backward, but that it is possible to bring the maxilla
forward to compensate for mandibular overgrowth when treating
Class III
• The use of protraction facemask was 1st done by Jean Delaire in 1875.
• It is indicated in cases of retruded or hypoplastic maxilla
DESIGN OF APPLIANCE:
Sequence of elastics:
• At the time of delivery 3/8” 8 oz 2 weeks
• After 2 weeks 1/2” 14 oz
• Increased to a max of 5/16” 14 oz
Young patients (4-9) years should wear the mask on a full time basis
except during meals.
Clinically, the maxilla can be advanced 2 to 4 mm over a 12 to 15-
month period of headgear treatment.
37
• Class III correction
was a result of a
forward movement
of the maxilla with
no downward and
backward rotation of
the mandible.
However,
improvement of the
skeletal profile is
greater in Group
“E”, in which
devices were
anchored on
deciduous teeth
DIRECTION OF FORCE APPLICATION
40
EFFECTS OF PROTRACTION FACEMASK
WITH RME
• Petit -1983
– Forehead and chin pads
– Force generated from distal of
maxillary molars
• Supraorbital protraction
appliance by Grummons
– Zygomatic areas provide more
surface for anchorage
• Protraction headgear by
Hickham 1991
– More esthetic
– Must be carefully adjusted
behind the ear
(Am J Orthod Dentofacial Orthop 2000;117:27-38)
•Ichikawa et al and Kawagoe et al reported that conventional
maxillary protraction headgears cause extrusion and anterior rotation
of the anchor teeth, and upward and forward rotation of the maxilla.
•As the mandible is attached to the head with temporomandibular
joint (TMJ), it is impossible to really stabilize the force system in
reverse pull headgear, which takes anchorage from the chin, because
the movement of the mandible does not allow us to apply a consistent
force.
•In growing children, force application to the chin by reverse-pull
headgear causes downward and backward rotation of mandible.
Grummons claimed that reverse headgears might have harmful effects
on the TMJ because they take support from the mandible.
• It consists of a removable upper splint, a lower splint, and a traction
bow. The upper splint contains the buccal hook (placed on the
maxillary first deciduous molar or premolar region) and to the
lower splint is attached a traction bow from the molar tubes.
• TTBA is delivered and patients are instructed to wear the appliance
for 12-14 hours per day. Approximately 300-500 g/side of force is
delivered from the lower traction bow to the buccal hooks of the
upper splint, at an angle of 20° below the occlusal plane to minimize
the counterclockwise rotation tendency
J Clin Orthod 2003;37:218-23
• Maxillary expander: a full
coverage acrylic cap splint type
expansion appliance that covered
all the maxillary dentition. Hooks
embedded in both the premolar
and the molar region on the
buccal sides of the expander. The
maxillary expansion appliance to
be activated everyday (0.20 mm)
• Mandibular plate: a mandibular
plate covering the posterior
mandibular dental arch was
constructed
• Chincap: hooks were attached on
the lateral sides of the acrylic
chincap to apply cervical forces.
According to graber, the early attempts with the chin cup were not
successful because of incomplete knowledge of mandibular and
facial growth.
• Armstrong applied 500 gm of force via chin cups and reported that
half of his patients showed improvement in the class III profile,
whereas none of the control, non treated patients showed any
favorable change.
• Thilander treated sixty patients with chin cups. A significant
percentage of patients did not improve since the force generated by
the chin cup in his study was only 150 to 200 gm.
• Graber, chung, and aoba reported results in patients treated with chin
cups for 12 to 14 hours each day with a force of 1.5 to 2 pounds on
each side. They showed that mandibular growth could be redirected
with a chin cup. They asserted that continuous use of the appliance
for a long period or through active growth was necessary to achieve
stable results.
• Chin cup therapy primarily works on the hypothesis that a force
directed through the condyles will inhibit as well as redirect the
condylar growth.
EFFECT ON MANDIBULAR GROWTH
• Some studies have indicated that a chin cup appliance has no effect
on the anteroposterior growth of the maxilla.
• However, Uner, Yuksel, and Ucuncu showed that early correction
of an anterior crossbite with a chin cup appliance prevents
retardation of anteroposterior maxillary growth.
FORCE MAGNITUDE AND DIRECTION
Chin cups are divided into two types:
•the occipital-pull chin cup- that is used for
patients with mandibular protrusion and
•the vertical-pull chin cup - that is used in
patients presenting with a steep
mandibular plane angle and excessive
anterior facial height.
•Appropriate force= 300 to 500 g per side .
•Patients are instructed to wear the
appliance 14 hr/day. Usually in the
evening and night
•The orthopedic force is usually directed
either through the condyle or below the
condyle.
Stability after chin cup therapy
74
Appliance activation
77
The wire components are
• 4 stop-loops located mesial to all first molars to prevent mesial
tipping of the molars and to stabilize the appliance,
• Lower labial bow to stabilize the appliance,
• Upper labial pads to remove the force of the upper lip and create
periosteal pull to induce bone formation, and
• Tongue crib to correct anterior tongue thrusting habit.
• The construction bite is taken by retruding the lower jaw. The upper
labial pad of the activator is intended to protract the maxilla
78
Treatment changes
• backward positioning of the mandible.
• significant increases of the anb angle and the wits values.
• The snb and snpog get smaller resulting in increasing facial
convexity (napog).
• The articular angle enlarges, thus augmenting the sum of the
saddle, articular, and gonial angles.
• The facial axis opens
• There are significant differences in the upper face height (n-ans),
mandibular length (co-gn), and ramus length (ar-go).
• Dentoalveolar adaptations included labial tipping of the upper
incisors as well as lingual tipping of lower incisors .
The shorter elastics (1/8 ” 6oz ) are attached from the mandibular
hook to the most anterior hook on the maxilla. As treatment
progresses, it is moved to the posterior hook. The longer elastic on
each side stretched from the mandibular hook to the molar hook can
be ¼”, or 3/16” depending on the comfort.
Duration:
12 hours a day in conjugation with face mask. 11 months of treatment
time and 18 -24 months of retention
Indication:
Mild skeletal class III where future surgery would not be indicated.
And used during preadolescent and adolescent growth periods
80
CLASS III BIONATOR
(garatinni et al ajo 1998)
BALTERS BIONATOR III can be used in patients with skeletal class III
malocclusion. The use of this appliance causes some skeletal
changes through neuromuscular modifications.
Criteria
• Angle class III molar relationship;
• Edge-to edge incisor position or anterior cross bite;
• Concave profile;
• Head hyperextension posture;
• Static and dynamic class III neuromuscular attitude;
• Hypertonic upper lip;
• Low and forward tongue rest position.
81
Lower labial bow slightly in
contact with lower incisors
83
Results:
• Mean increase in the upper jaw length
• Advancement of point A
• Palatal and mandibular plane angles widened
• Increase of the anterior facial height
• Reduced antero posterior mandibular growth
therefore, the bionator III is helpful in class III malocclusion
treatment in growing patients with midfacial deficiency, hypo
divergent growth pattern, and reduced facial height.
84
TWO PIECE CORRECTOR
Egnhouse JR, Jco 1997
85