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Special Article: IOS 50th Year Commemorative Issue

Contemporary solutions for managing Class III malocclusion

Nathamuni Rengarajan Krishnaswamy

About the Author

Dr. N. R. Krishnaswamy currently holds the position of vice principal, Professor and Head, Dept of
Orthodontics,Ragas Dental College and Hospitals, Chennai. He obtained his bachelor degree at the Govt.
Dental College, Chennai and earned his masters degree from KMC Manipal. He acquired his fellowship in
orthodontics from the Royal College of Surgeons (M Orth), Edinburgh and is a Diplomate of the Indian board of
Orthodontics (DIBO) and The National Board of Medical Sciences (Dip NB).He was awarded the scholarship
of the International Scientific Exchange Fund of the Japan Dental Association which led to clinical training at
Tsurumi University Yokohama, Japan.
He has several awards winning presentations to his credit and has won the Presidential Trophy for the Best Clinical
Paper Award of the Indian Orthodontic Society thrice and the Best Research Award twice. He is recipient of
the best teacher award of Tamil Nadu, Dr. M.G.R Medical University. He has been a headline speaker
at the IOS National Conferences for almost two decades and has also been an invited speaker at several international orthodontic forums
including the AAO. He also has several publications to his credit.
He has served as Director and Chairman of the Indian Board of Orthodontics and as President of the Indian Orthodontic Society. He
is the recipient of the Helen & B. F. Dewel award for the best clinical research paper published in the AJO-DO in the year 2012.

Abstract
Although patients with Class III malocclusions constitute a small percentage of the average orthodontic practice, providing them with
optimal treatment is a daunting task. The treatment approach is dependent upon the growth status of the individual and the severity of the
skeletal dysplasia. For growing individuals, facemask therapy to protract the maxilla is ineffective because of its dependence on dental
anchorage to bring forth skeletal correction. Orthodontic camouflage in nongrowing mild skeletal Class III individuals is met with limited
success because of the anatomical boundaries and the conventional biomechanics. Orthognathic surgery to correct the maxillomandibular
relations is time‑consuming, and the facial esthetics is compromised during the orthodontic decompensation period. Contemporary solutions
to overcome these limitations are now viable with the use of temporary anchorage devices and by performing surgery prior to orthodontic
decompensation. The rationale for employing these contemporary approaches will be discussed in this study with illustrative cases.

Key words: Camouflage, maxillary protraction, surgery first, temporary anchorage devices

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Website: Patients with Class III malocclusion compromise a relatively
www.jios.in small percentage of the average orthodontic practice, but
these are among the most challenging to treat effectively
DOI: and efficiently. In the past, most Class  III malocclusions
10.4103/0301-5742.171189

This is an open access article distributed under the terms of the Creative Commons
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Address for correspondence: Dr. Nathamuni Rengarajan Krishnaswamy, For reprints contact: reprints@medknow.com
Ragas Dental College and Hospital, 2/102, East Coast Road, Uthandi,
Chennai ‑ 600 119, Tamil Nadu, India.
E‑mail: ennarmd3@yahoo.com
How to cite this article: Krishnaswamy NR. Contemporary solutions for
Received: 18‑11‑2015, Accepted with Revisions: 19‑11‑2015 managing Class III malocclusion. J Indian Orthod Soc 2015;49:19-26.

© 2015 Journal of Indian Orthodontic Society | Published by Wolters Kluwer - Medknow S19
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Krishnaswamy: Class III correction
were attributed solely to the large or prognathic mandible.
Currently, we know that it can be caused due to maxillary
retrognathism, mandibular prognathism, or a combination of
both. It can also be due to a centric relation‑centric occlusion
shift leading to a mesial shift of the lower arch in the absence
of maxillomandibular skeletal discrepancy (pseudo‑Class III).
The treatment approach depends on the growth status and
severity of the skeletal dysplasia.
Early Management
Growth modification to redirect the vector of growth with
functional appliances or by orthopedic devices to restrict
mandibular growth and/or enhance maxillary growth is an
accepted protocol for providing a more favorable environment
for normal growth and to improve the psychological
development of the child.[1]
The Frankel functional regulator III has been advocated
in children with developing Class III growth pattern to
stimulate maxillary growth and restrain mandibular growth by
influencing the functional matrix.[2] Although few studies have
documented favorable skeletal and dental response, long‑term
results seem questionable. The limitation of the fixed rate
intravenous insulin infusion is that the outcome is dependent
on excellent patient compliance and long treatment time.[3]
Individuals in whom mandibular prognathism is the cause for
the Class III skeletal relationship, the use of chin cup to exert
orthopedic force to restrict and redirect mandibular growth was
a prevalent growth modification strategy.[4] To be effective, chin
cup therapy must be started early in childhood and continued
until growth is complete. However, it is almost impossible to
obtain such cooperation from patients.[5] Yet, another limitation
of chin cup is that the response is determined by the original
facial pattern. Since part of the facial concavity is corrected
by the mandible being displaced inferiorly. Stability following
active treatment with chin cup is not guaranteed because of the
sustained mandibular growth that occurs during and following
pubertal growth spurt.[6] Late horizontal mandibular growth is
now considered to be an inherited genetic trait and hence not
amenable to therapeutic modification.[7]
Ellis et al. reported that 40–60% of skeletal Class  III
patients have a maxillary deficiency or retrusion.[8] They also
emphasized that maxillary protraction should be employed in
growing patients with Class III skeletal dysplasia. In the last
few decades, protraction facemask therapy in conjunction with
palatal expansion has been the mainstay in redirecting growth
in growing Class III patients.[9]
A banded or bonded rapid palatal expansion (RPE) appliance
can be fabricated as an anchorage for maxillary protraction.
The RPE also helps in disarticulating the maxilla and allows
more favorable forward movement of the maxilla by the
protraction facemask. A  well‑disarticulated maxilla seems
to be critical when using tooth borne device for orthopedic
traction.[10]
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Treatment Timing
A critical factor in determining the success of RPE and
protraction facemask treatment is appropriate timing. Since,
the main objective of treatment with facemask and RPE is to
enhance downward and forward displacement of the maxilla
by influencing the sutural growth. The protraction facemask
RPE combination should be initiated in the primary or early
mixed dentition. The optimal time to intervene in Class  III
malocclusion seems to at the time of eruption of the maxillary
incisors.[11]
Kim et al. conducted a meta‑analysis to analyze the
treatment effects of protraction facemask in children with
Class III malocclusion and found the correction to be due to
a combination of skeletal and dental changes of maxilla and
mandible.[12] The maxilla was found to move downward
and forward with a slight upward movement in the anterior
and downward movement in the posterior palatal plane as a
result of the protraction forces. The mandible was found to
rotate downward and backward to complement the correction
of the concave facial profile. The upper incisors inclined
labially and the lower incisor inclination decreased. It was
postulated that the proclination of the upper incisors was due to
mesial movement of the dentition and uprighting of the lower
incisor was due to the pressure from the chin cup.
Based on reports of the clinical trial,[13] it is evident that
protraction facemask treatment started in the mixed dentition
seems to be stable 2 years after treatment. When the patients
were followed 8  years after treatment only, about 67%
maintained positive overjet. Based on this observation, it
is reasonable to conclude that one out of three patients will
relapse into reverse overjet. The reason for this relapse can
be attributed to the facemask being ineffective to elicit true
skeletal displacement of the maxilla owing to the inability to
transmit appropriate forces for orthopedic correction of the
maxilla.
The dependence on the dental units to transmit orthopedic
forces to the maxillary skeletal base causes concurrent dental
movements and can limit the extent to which the maxillary
skeletal base can be protracted.[14] A method of minimizing
dental movement is to anchor the intraoral device to multiple
teeth and to loosen the circum‑maxillary sutures with either
banded or bonded palatal expansion. Because of the pressure of
the periodontal ligament, unwanted dentoalveolar movements
still occur. In some instances, dependence on dental anchorage
may be contraindicated because of the underlying severity
of the skeletal dysplasia, multiple missing teeth, vertically
compromised growth, or highly compensated pretreatment
occlusion.[15]
Until recently, accepting compromised results or opting for
surgical correction after cessation of growth were the only
alternatives.
With the advent of miniscrews and miniplates for orthodontic
anchorage, a contemporary solution has become viable. The
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Krishnaswamy: Class III correction

orthopedic forces are directly employed to the maxillary and
mandibular skeletal bases by bypassing the dentoalveolar
structures. It is then reasonable to expect that the skeletal
effects of protracting the maxilla and restricting or altering
the vector of growth of the mandible would be more
successful. Applying orthopedic force to temporary anchorage
devices (TADs) strategically located in the maxilla is a gaining
popularity; although long‑term results are still awaited,
short‑term effects are encouraging.[16]
The skeletal anchorage for maxillary protraction can be used
either in tandem with the facemask or by using intraoral elastics.

e f

g
Figure 1: A 13-year-old girl treated with skeletally anchored maxillary protraction. (a) Class III skeletal profile with retrusive maxilla and protrusive
lower lip. (b) Class III dentoalveolar relationship with asymmetric and constricted maxillary arch, reverse overjet, blocked out maxillary canines and
lingually inclined lower anterior. (c) A modified surgical plate anchored to the maxillary zygomatic buttress and lower anterior region and connected
by elastics in a Class III vector. The full coverage bite plate aids in disarticulation. (d) Seven months after treatment, a positive overjet and a Class I
molar relationship was established. (e) Pre- and post-treatment cone-beam computed tomography. (f) Pre- and post-treatment cephalometric tracings.
(g) Facial profile is less concave, and there is greater prominence of upper lip

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Krishnaswamy: Class III correction
In either instance, the goal is to bypass the dentition and apply
orthopedic forces to the skeletal bases through the skeletal
anchorage devices. Some clinicians prefer a miniplate[17] for
skeletal anchorage while others prefer a palatal onplant.[18]
Miniplate can be located either at the zygomatic buttress or the
piriform aperture. The combination of facemask for extraoral
traction anchored to the intraoral skeletal anchorage seems to
be the most common protocol.[19‑26]
De Clerck et al. introduced the use of unique skeletally
anchored maxillary protraction protocol that employs intraoral
elastics in a Class III vector connecting the skeletal anchorage
devices in the maxilla and mandible.[27] The advantage of the
method includes greater patient compliance, shortened duration
of treatment, and lighter forces.
A meta‑analysis conducted by Major et al. [28] seems to
indicate that skeletally anchored maxillary protraction
results in substantial maxillary protraction without dental
compensation when compared with conventional facemask
protraction therapy that were anchored to bonded or banded
palatal expansion device. Further, the method suggested by
De Clerck employing intraoral elastics to skeletal anchorage
devices in the maxilla and mandible seem to elicit greater and
more favorable skeletal changes when compared to skeletal
anchorage and facemask combinations. The following case
which was treated by running intraoral Class III elastics
between the skeletal anchorage devices in the maxilla and
mandible shows substantial anteroposterior correction with
minimal changes in the dentition  [Figure  1]. Further, this
method can be employed even in slightly older individuals
who are in their early permanent dentition.
Treatment of Nongrowing Class III Malocclusion
Orthodontic treatment to camouflage the skeletal Class  III
malocclusion in nongrowing patients with mild skeletal
discrepancy has been the standard approach when the
patient declines surgery. Treatment can be carried out with
conventional fixed appliance with or without extraction of
teeth. If extraction is indicated, then the preferred pattern of
extraction would be to extract the upper second and lower
first bicuspids or one lower incisor alone.[29] The limited
success of camouflaging Class III treatment can be attributed
to the existing compensation, excessive arch length tooth size
discrepancy, and the inability to compensate the dentition
further due to anatomical boundaries.
Specifically, proclining the upper incisors to eliminate the
reverse overjet has to be judiciously executed as otherwise the
facial esthetics could be compromised since the patient will
usually have a retrusive maxilla. Similarly, retroclining the
mandibular incisors to eliminate the reverse overjet may be
hampered due to the presence of thin symphyseal morphology
and the risk of inducing gingival recession and/or fenestrating
the labial bone in patients who already have a wash board
appearance.
S22 Journal of Indian Orthodontic Society
With the widespread use of TADs, the extent of tooth
movement can be enhanced and it is now possible to distalize
the mandibular dentition in nongrowing patients with
moderate to severe skeletal malocclusion without the risk of
compromising the gingival health or the lower labial alveolar
plate.  The simplest application of TAD for the treatment
of Class III malocclusions is the direct retraction of the
mandibular arch with the TAD being placed in the posterior
area of the mandible. When TADs are used as absolute
anchorage, the mandibular dentition can be retracted en masse
by using nickel‑titanium (Ni‑Ti) springs or elastic chain.
From a biomechanical standpoint, placing a TAD in the
retromolar area is the most effective way for en masse
distalization of the mandibular dentition.[30] However, placing
a TAD in the retromolar area is contraindicated if there is lack
of attached gingiva and reduced accessibility to the retromolar
area. Alternative solution is the placement of a miniscrew in the
interradicular area between the first and second molar or first
molar and second premolar.[31] The limitation of this location is the
proximity of the roots of teeth which may be injured either during
the insertion of the TAD or the possibility of the roots contacting
the TAD when the mandibular dentition is distalized.[32]
Miniplates can be placed instead of miniscrews in the
mandibular posterior area to serve as absolute anchorage for
en masse distalization of the mandibular dentition.[33] However,
miniplates require flap surgery for both their placement and
removal with a longer healing period and more pain and
discomfort than with miniscrews.
Since the success rate of TADs placed in the mandible is
significantly lower than the TADs placed in the maxilla, some
clinicians prefer to place a TAD in the maxilla between the
roots of the second premolar and the first molar and engage
Class  III elastics from the TAD to the anterior mandibular
dentition.[34] This approach is a compromise because the results
depend completely on patient cooperation.
A novel approach that overcomes the limitation of TADs in the
above‑mentioned locations and can still bring about predictable
en masse distalization of mandibular dentition recommended by
Chang and Roberts.[35] This involves the use of an extra‑alveolar
miniscrew placed in the buccal shelf of the mandible. Ni‑Ti
retraction springs from the extra‑alveolar miniscrew to the
hooks in the anterior segment of the lower archwire seems
very promising as outlined in the case [Figure 2]. The failure
rate of this approach is reported to be as less as 7% and does
not require predrilling and can withstand a load up to 14 oz.
Orthognathic Surgery
The only definitive approach to eliminate the skeletal
imbalance and obtain optimal esthetics, function, and stability
in patients with skeletal Class III malocclusion is orthognathic
surgery combined with orthodontics. Orthognathic surgery has
been successfully carried out for more than three decades and
in a well orthodontically decompensated dentition the jaws
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Krishnaswamy: Class III correction

f g h
Figure 2: A 22-year-old female treated with orthodontic camouflage. (a) Skeletal Class III profile with prognathic mandible, retrusive upper lip and mild
increase in the lower facial height. (b) Class III dentoalveolar malocclusion with reverse overjet and blocked out maxillary canines and lingually inclined
lower anterior exhibiting prominent roots. (c) Lower third molar extracted and 12 mm extra-alveolar miniscrew inserted in the mandibular buccal shelf.
(d) Nickel-titanium coil springs from the lower archwires to the miniscrews for en masse distalization of the mandibular dentition. (e) After 18 months
of treatment. (f) Pre- and post-treatment cephalograms. (g) Pre- and post-treatment tracing and superimposition. (h) Posttreatment facial appearance

can be precisely repositioned in all three planes of space to and social well‑being that is characteristic of skeletal Class III
yield predictable outcomes.[36] The acceptance for undergoing malocclusion.
orthognathic surgery is highest in individuals with Class III The conventional approach to orthognathic surgery requires a
skeletal malocclusion when compared with patients with other variable length of preoperative orthodontic preparation before
skeletal malocclusions that may warrant surgery and this can the surgery and a relatively stable period of postoperative
be attributed to the greater negative effect on the psychological orthodontics. The importance of preoperative orthodontics
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Krishnaswamy: Class III correction

rests on the fact that optimal positioning during surgery
may be limited by inappropriate dental alignment. However,
orthodontic preparation typically lasts 15–24  months [37]
involving progressive deterioration of facial esthetics and
dental function and causes significant patient discomfort.[38]
In the recent years, many surgeons have perceived orthognathic
surgery as too complicated, too invasive, time‑consuming,
and expensive. They proposed the “surgery first” approach
and created broader interest in the complete elimination
of presurgical orthodontic treatment.[39] In the surgery‑first
approach proposed by Sugawara et al., the surgery is carried
out without any presurgical orthodontic preparation and
is followed by regular postoperative dental alignment.[40]
Although minor orthodontic movements are occasionally

f g
Figure 3: A 20-year-old male treated with surgery-first approach. (a) A skeletal Class III profile with retrognathic maxilla, prognathic mandible, facial
asymmetry, and excess lower facial height. (b) Class III malocclusion with Class III buccal segment, anterior open bite, bilateral posterior crossbite, and
a noncoincident midline. (c) Surgical archwires adapted according to the malocclusion and placed 1 week prior to surgery. (d) Two weeks after LeFort
I maxillary advancement and mandibular setback surgery. (e) Seven months after surgery – postsurgical orthodontics in progress. (f) Pretreatment,
immediate postsurgical, and 7 months postsurgical cephalometric radiographs. (g) Seven months after surgery revealing a more balanced facial
profile and symmetry

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Krishnaswamy: Class III correction
performed before surgery, the concept implies that most of the
orthodontic treatment is performed postoperatively. Several
advantages have been reported for the surgery‑first approach
including improvements in patient’s facial esthetics and dental
occlusion early in the treatment.[41]   Improvement in patient’s
swallowing and speech function after surgery, postoperative
accelerated orthodontic tooth movement both due to the
regional acceleratory phenomenon and early restoration of
normal function and anatomic relationship of the bony skeleton
and surrounding soft tissues.[42] The stability of results is equal
to or in some cases superior to those achieved using the more
traditional orthodontics first approach.[43]
Nagasaka et  al. published a series of case reports using
surgery‑first approach to correct skeletal Class III malocclusion;
the results demonstrated acceptable facial esthetics and dental
occlusion with total treatment time of <12 months.[44] In their
initial case reports, orthognathic surgery was performed on
the mandible only. A Class III malocclusion became a Class II
immediately after mandibular setback, and then skeletal
anchorage was advocated to correct the intentionally created
Class  II to a Class  I dentoalveolar relationship. Baek et  al.
emphasized that the surgery‑first approach requires accurate
prediction of the postoperative orthodontic treatment for
dental alignment, incisor decompensation, arch correction, and
occlusal settling at the very beginning of preoperative treatment
plan.[45] Their case report documented Class III corrections by
employing LeFort I osteotomy and mandibular setback.
Liou et  al. suggested a modification to the surgery‑first
approach.[46] However, his technique required more surgical
segments and less reliance on TAD’s or skeletal anchorage
systems (SAS’s) for postoperative alignment. His approach is
referred to as “surgery driven” surgery‑first approach compared
to the one popularized by Sugawara wherein the surgical
segments are kept to a minimum, but TAD’s and SAS’s are
used extensively for postsurgical alignment.[47] This approach
is referred to as “orthodontics driven surgery‑first approach”.
A Class III malocclusion treated with orthognathic surgery
using the surgery‑first approach is illustrated in Figure 3.
In a systemic review of surgery‑first approach in orthognathic
surgery, Huan et al. found the surgery‑first approach to be
a viable alternative to the orthodontics first approach for
correction of maxillofacial deformities.[48] The outcome
in terms of facial esthetics, dental occlusion, and stability
were found to be similar in both the approaches. Kim et al.
evaluated the stability of mandibular setback surgery in
patients with and without presurgical orthodontics and found
the outcome to be similar with a slightly greater predilection
for relapse in surgery‑first cases which was however clinically
insignificant.[49]
Conclusion
• Growth modification with skeletally anchored maxillary
protraction is more effective than dentally anchored
maxillary protraction. Further, the skeletally anchored
Journal of Indian Orthodontic Society | Vol 49 | Special Issue | December, 2015 S25
protraction using intraoral Class III elastics has the
advantage of reduced treatment duration and the
possibility of treating slightly older children
• Camouflage in Class III malocclusion is more effective
when TADs are used to provide absolute anchorage
compared to conventional extraction treatment and
Class III biomechanics. Miniscrews used in the buccal
shelf are more conducive for en masse distalization
of the mandibular dentition to provide adequate
camouflage
• Orthognathic surgery followed by orthodontics seems to
be a better approach in patients who warrant surgery. The
duration, cost of treatment, and patient’s outlook seem to
be better when surgery is carried out first.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published,
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Acknowledgments
I wish to thank my colleagues Dr.  M. K. Anand,
Dr.  Rekha Bharadwaj, and Dr.  Shobbana Thalur at the
Department of Orthodontics, Ragas Dental College and
Hospital, for providing the cases published in this article.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
1. Ngan  P. Treatment of Class  III malocclusion in the primary and
mixed dentitions. In: Bishara  SE, editor. Textbook of Orthodontics.
Philadelphia, PA: WB Saunders; 2001. p. 375‑414.
2. McNamara JA Jr, Huge SA. The functional regulator (FR‑3) of Fränkel.
Am J Orthod 1985;88:409‑24.
3. Loh MK, Kerr WJ. The Function Regulator III: Effects and indications
for use. Br J Orthod 1985;12:153‑7.
4. Irie  M, Nakamura  S. Orthopedic approach to severe skeletal class  III
malocclusion. Am J Orthod 1975;67:377‑92.
5. Graber LW. Chin cup therapy for mandibular prognathism. Am J Orthod
1977;72:23‑41.
6. Mitani  H, Sato  K, Sugawara  J. Growth of mandibular prognathism
after pubertal growth peak. Am J Orthod Dentofacial Orthop
1993;104:330‑6.
7. Mao JJ, Nah HD. Growth and development: Hereditary and mechanical
modulations. Am J Orthod Dentofacial Orthop 2004;125:676‑89.
8. Ellis E 3rd, McNamara JA Jr, Behrents  RG. Components of class  III
malocclusion. J Oral Maxillofac Surg 1984;42:295‑305.
9. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I. Skeletal
effects of early treatment of class  III malocclusion with maxillary
expansion and face‑mask therapy. Am J Orthod Dentofacial Orthop
1998;113:333‑43.
10. Turley PK. Treatment of class III malocclusion with maxillary expansion
and protraction. Semin Orthod 2007;13:143‑57.
[Downloaded free from http://www.jios.in on Tuesday, April 24, 2018, IP: 91.124.142.202]
Krishnaswamy: Class III correction
11. Saadia  M, Torres  E. Sagittal changes after maxillary protraction with
expansion in class  III patients in the primary, mixed and late mixed
dentitions: A longitudinal retrospective study. Am J Orthod Dentofacial
Orthop 2000;117:669‑80.
12. Kim  JH, Viana  MA, Graber  TM, Omerza  FF, BeGole  EA. The
effectiveness of protraction face mask therapy: A meta‑analysis. Am J
Orthod Dentofacial Orthop 1999;115:675‑85.
13. Ngan PW, Hagg U, Yiu C, Wei SH. Treatment response and long‑term
dentofacial adaptations to maxillary expansion and protraction. Semin
Orthod 1997;3:255‑64.
14. Kokich VG, Shapiro PA, Oswald R, Koskinen‑Moffett L, Clarren SK.
Ankylosed teeth as abutments for maxillary protraction: A case report.
Am J Orthod 1985;88:303‑7.
15. Major  PW, elBadrawy  HE. Maxillary protraction for early
orthopedic correction of skeletal class III malocclusion. Pediatr Dent
1993;15:203‑7.
16. Ludwig  B, Glas  B, Bowman  SJ, Drescher  D, Wilmes  B.
Miniscrew‑supported class III treatment with the Hybrid RPE Advancer.
J Clin Orthod 2010;44:533‑9.
17. Baek  SH, Yang  IH, Kim  KW, Ahn  HW. Treatment of class  III
malocclusions using miniplate anchorage. Semin Orthod
2011;17:98‑107.
18. Hong  H, Ngan  P, Han  G, Qi  LG, Wei  SH. Use of onplants as stable
anchorage for facemask treatment: A case report. Angle Orthod
2005;75:453‑60.
19. Sar C, Arman‑Özçirpici A, Uçkan S, Yazici AC. Comparative evaluation
of maxillary protraction with or without skeletal anchorage. Am J
Orthod Dentofacial Orthop 2011;139:636‑49.
20. Cha  BK, Ngan  PW. Skeletal anchorage for orthopedic correction of
growing Class III patients. Semin Orthod 2006;76:156‑63.
21. Kircelli BH, Pektas ZO, Uçkan S. Orthopedic protraction with skeletal
anchorage in a patient with maxillary hypoplasia and hypodontia. Angle
Orthod 2006;76:156‑63.
22. Zhou  YH, Ding  P, Lin  Y, Qiu Lx. Facemask therapy with miniplate
implant anchorage in a patient with maxillary hypoplasia. Chin Med
J (Engl) 2007;120:1372‑5.
23. Cha BK, Choi DS, Ngan P, Jost‑Brinkmann PG, Kim SM, Jang IS. Maxillary
protraction with miniplates providing skeletal anchorage in a growing
class III patient. Am J Orthod Dentofacial Orthop 2011;139:99‑112.
24. Cha  BK, Lee  NL, Choi  DS. Maxillary protraction treatment of
skeletal Class III children using miniplate anchorage. Korean J Orthod
2007;37:73‑84.
25. Ding  P, Zhou  YH, Lin  Y, Qiu Lx. Mini‑plate implant anchorage for
maxillary protraction in class III malocclusion. Zhonghua Kou Qiang Yi
Xue Za Zhi 2007;42:263‑7.
26. Kircelli BH, Pektas ZO. Midfacial protraction with skeletally anchored
face mask therapy: A novel approach and preliminary results. Am J
Orthod Dentofacial Orthop 2008;133:440‑9.
27. De Clerck  H, Cevidanes  L, Baccetti  T. Dentofacial effects of
bone‑anchored maxillary protraction: A controlled study of
consecutively treated class III patients. Am J Orthod Dentofacial Orthop
2010;138:577‑81.
28. Major  MP, Wong  JK, Saltaji  H, Major  PW, Flores‑Mir  C. Skeletally
anchored maxillary protraction for midface deficiency in children and
early adolescents with Class III malocclusion: A systematic review and
meta‑analysis. J World Fed Orthod 2012;1:e47‑54.
29. Bilodeau JE. Class III nonsurgical treatment: A case report. Am J Orthod
Dentofacial Orthop 2000;118:560‑5.
S26 Journal of Indian Orthodontic Society
30. Paik  CH, Nagasaka  S, Hirashita A. Class  III nonextraction treatment
with miniscrew anchorage. J Clin Orthod 2006;40:480‑4.
31. Yanagita  T, Kuroda  S, Takano‑Yamamoto  T, Yamashiro  T. Class  III
malocclusion with complex problems of lateral open bite and
severe crowding successfully treated with miniscrew anchorage
and lingual orthodontic brackets. Am J Orthod Dentofacial Orthop
2011;139:679‑89.
32. Poggio PM, Incorvati C, Velo S, Carano A. “Safe zones”: A guide for
miniscrew positioning in the maxillary and mandibular arch. Angle
Orthod 2006;76:191‑7.
33. Sugawara  J, Daimaruya  T, Umemori  M, Nagasaka  H, Takahashi  I,
Kawamura  H, et al. Distal movement of mandibular molars in adult
patients with the skeletal anchorage system. Am J Orthod Dentofacial
Orthop 2004;125:130‑8.
34. Yamada K, Kuroda S, Deguchi T, Takano‑Yamamoto T, Yamashiro T.
Distal movement of maxillary molars using miniscrew anchorage in the
buccal interradicular region. Angle Orthod 2009;79:78‑84.
35. Chang C, Roberts WE. A retrospective study of the extra‑alveolar screw
placement on buccal shelves. Int J Orthod Implantol 2013;32:82-9.
36. Vig  KD, Ellis E 3rd. Diagnosis and treatment planning for the
surgical‑orthodontic patient. Dent Clin North Am 1990;34:361‑84.
37. Luther F, Morris DO, Hart C. Orthodontic preparation for orthognathic
surgery: How long does it take and why? A retrospective study. Br J Oral
Maxillofac Surg 2003;41:401‑6.
38. Flanary  CM, Alexander  JM. Patient responses to the orthognathic
surgical experience: Factors leading to dissatisfaction. J Oral Maxillofac
Surg 1983;41:770‑4.
39. Assael  LA. The biggest movement: Orthognathic surgery undergoes
another paradigm shift. J Oral Maxillofac Surg 2008;66:419‑20.
40. Sugawara J, Aymach Z, Nagasaka DH, Kawamura H, Nanda R. “Surgery
first” orthognathics to correct a skeletal class II malocclusion with an
impinging bite. J Clin Orthod 2010;44:429‑38.
41. Behrman  SJ, Behrman  DA. Oral surgeons’ considerations in surgical
orthodontic treatment. Dent Clin North Am 1988;32:481‑507.
42. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery‑first
accelerated orthognathic surgery: Orthodontic guidelines and setup for
model surgery. J Oral Maxillofac Surg 2011;69:771‑80.
43. Liao  YF, Chiu  YT, Huang  CS, Ko  EW, Chen  YR. Presurgical
orthodontics versus no presurgical orthodontics: Treatment outcome
of surgical‑orthodontic correction for skeletal class III open bite. Plast
Reconstr Surg 2010;126:2074‑83.
44. Nagasaka  H, Sugawara  J, Kawamura  H, Nanda  R. “Surgery first”
skeletal Class III correction using the Skeletal Anchorage System. J Clin
Orthod 2009;43:97‑105.
45. Baek  SH, Ahn  HW, Kwon  YH, Choi  JY. Surgery‑first approach in
skeletal class III malocclusion treated with 2‑jaw surgery: Evaluation of
surgical movement and postoperative orthodontic treatment. J Craniofac
Surg 2010;21:332‑8.
46. Liou EJ, Chen PH, Wang YC, Yu CC, Huang CS, Chen YR. Surgery‑first
accelerated orthognathic surgery: Postoperative rapid orthodontic tooth
movement. J Oral Maxillofac Surg 2011;69:781‑5.
47. Sugawara  J. Dr.  Junji Sugawara on the skeletal anchorage system.
Interview by Dr. Larry W. White. J Clin Orthod 1999;33:689‑96.
48. Huang  CS, Hsu  SS, Chen YR. Systematic review of the surgery‑first
approach in orthognathic surgery. Biomed J 2014;37:184‑90.
49. Kim  CS, Lee  SC, Kyung  HM, Park  HS, Kwon  TG. Stability of
mandibular setback surgery with and without presurgical orthodontics.
J Oral Maxillofac Surg 2014;72:779‑87.
| Vol 49 | Special Issue | December, 2015