CASE REPORT

Conservative treatment for a growing patient with

a severe, developing skeletal Class III
malocclusion and open bite
Yue Xu,a Ping Zhu,b Linda Le,c and Bin Caid
Guangzhou, Guangdong, People's Republic of China, and Cleveland, Ohio

An 8-year-old Chinese girl sought treatment for a severe skeletal Class III malocclusion and open-bite skeletal
pattern. Traditionally, patients with a skeletal Class III malocclusion are treated after they have stopped growing,
and then they are treated with a combined orthodontic and orthognathic surgery approach. But the risks and ex-
penses of this treatment plan are not acceptable to all patients. This young patient was treated with facemask
therapy, a maxillary expansion device, and a molar occlusal splint for maxillary developmental stimulation
with control of vertical jaw growth. After the completion of orthopedic therapy, 2 3 4 technology was used to
adjust molar positions. A bonded tongue crib was used in the early permanent dentition to help the patient break
her bad tongue habits. Straight-wire appliances were used for 16 months to adjust the occlusal relationship. This
achieved significant improvement in anterior tooth relationships and facial profile esthetics. At the 2-year post-
treatment follow-up, the results were satisfactory. The success of the sagittal relationship correction between the
maxilla and the mandible for a skeletal Class III malocclusion depends on the coordination of transverse and
vertical relationships combined with the growth potential of each patient. (Am J Orthod Dentofacial Orthop
2014;145:807-16)

T
he treatment for a skeletal Class III malocclusion
with an open bite is among the most chal-
lenging.1,2 These patients have vertical facial
growth patterns that manifest clinically as length
disharmonies between the maxilla and the mandible in
the sagittal plane. Clockwise rotation occurs with the
growth and development of the mandible in patients
with bad tongue habits, which not only increase
a
Associate professor, Department of Orthodontics, Guanghua School of Stoma-
tology, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of
China.
b
Graduate student, Department of Orthodontics, Guanghua School of Stomatol-
ogy, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of
China.
c
Graduate student, Department of Otolaryngology-Head and Neck Science
(HNS), Case Western Reserve University, Cleveland, Ohio.
d
Associate professor and head, Department of Orthodontics, Guanghua School of
Stomatology, Sun Yat-sen University, Guangzhou, Guangdong, People's Repub-
lic of China.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Financial support from the Project on the Integration of Industry, Education and
Research of Guangdong Province (2010B080701101).
Address correspondence to: Bin Cai, Department of Orthodontics, Guanghua
School of Stomatology, Sun Yat-sen University, Lingyuan Xilu No. 56, Guangz-
hou 510055, PR China; e-mail, kou9315@hotmail.com.
Submitted, May 2013; revised and accepted, August 2013.
0889-5406/$36.00
Copyright Ó 2014 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.08.020
treatment difficulty but also increase the possibility of
recurrence.3
Patients with a skeletal Class III malocclusion are
often advised to wait until adulthood for combined or-
thodontic and orthognathic surgery, but the potential
risks and expenses involved are not acceptable to all pa-
tients. Since its introduction in the 1960s, facemask
therapy has made it possible to direct and stimulate
maxillary protraction growth with extraoral force.
Several studies have shown that the position and the di-
mensions of the dentofacial complex can be effectively
changed with a facemask or a maxillary expansion appli-
ance in the early period of growth and development of
patients with a skeletal Class III malocclusion.4-6
Because of molar extrusion and the horizontal force
exerted by the chincap, mandibular clockwise rotation
is a typical result of facemask or maxillary expansion
treatment.7-9 Therefore, facemask therapy is more
suitable for patients with a skeletal Class III
malocclusion and a horizontal growth pattern.10
The growth pattern of the maxillofacial region is set
after birth, and it rarely changes in a person's lifetime.11-13
In patients unwilling to undergo surgery, interference
with the direction and quantity of jaw growth during
the early growth period is the sole option. This can help
to establish a favorable maxillofacial structure. To some
807
808
Fig 1. Pretreatment photographs.
extent, the selection and success of treatment relies on the
growth potential of each patient with a skeletal Class III
malocclusion.14
In this case report, we present the treatment of an
8-year-old girl; her parents were unwilling to have her
undergo surgical treatment for her skeletal Class III
malocclusion. Instead, she was treated with a face-
mask, maxillary expansion, and a molar occlusal splint
for stimulation of maxillary development and control
of vertical jaw growth. After the orthopedic therapy,
2 3 4 technology was used to adjust the molar posi-
tions. This case report highlights a treatment that
used the patient's physiologic skeletal, muscular,
and dental movements to achieve the desired
correction.
DIAGNOSIS AND ETIOLOGY
The patient was a girl aged 8 years with no rele-
vant medical history of bone or dental pathology in
her family, but she had bad tongue habits. The
June 2014  Vol 145  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Xu et al
extraoral examination showed a midface deficiency
along with a Class III profile (Fig 1). The intraoral ex-
amination showed a Class III malocclusion with
posterior and anterior crossbites and with anterior
open bite.
The dental casts (Fig 2) showed a transverse defi-
ciency and an arch length deficiency in the maxillary
arch. Moreover, molar and canine Class III relationships
coexisted with the anterior and posterior crossbites
and the anterior open bite of 3 mm. The panoramic
radiograph (Fig 3) showed no hypodontia (and normal
periodontal conditions).
The cephalometric analysis showed a skeletal Class III
relationship (ANB angle, 5 ) with mandibular excess
(SNB angle, 85 ). The maxillofacial region had a vertical
growth pattern (S-Go/N-Me, 58.8%), but the y-axis
angle was basically normal (y-axis, 60 ). The mandibular
body was long, and the ramus was obviously short (Go-
Pg, 79 mm; Go-Co, 48 mm). The position and size of the
maxilla were deficient (SNA angle, 80 ). The mandibular
Xu et al
Fig 2. Pretreatment dental casts.
incisors were lingually inclined (L1-NB angle, 27 ). The
maxillary incisors were labially inclined (U1-L1 angle,
119 ; U1-SN angle, 62 ; U1-NA angle, 37 ). The erup-
tion of the maxillary incisors and the mandibular molars
was deficient (U1-PP, 24 mm; L6-MP, 26 mm) (Fig 4,
Table).
TREATMENT OBJECTIVES
The proposed primary treatment objectives were as
follows.
1. Stabilize the maxillary and mandibular vertical rela-
tionship.
2. Eliminate the functional limitation of the mandible
by transverse expansion of the maxillary arch in the
early period.
3. Coordinate the maxillary and mandibular sagittal
relationships by correction of the dental malocclu-
sion.
4. Obtain a normal posterior overjet and correct the
anterior open bite and anterior crowding.
TREATMENT ALTERNATIVES
The first alternative was combined orthodontic and
orthognathic surgery after the patient was an adult. In
this proposal, presurgical decompensatory treatment
could be used to relieve minor dental crowding. Mean-
while, a normal inclination angle of the maxillary and
mandibular anterior teeth could be achieved. Through
American Journal of Orthodontics and Dentofacial Orthopedics
809
orthognathic surgery, the maxillary position could be
reset to improve the midfacial concave profile. With
backward and counterclockwise rotation of mandible,
the open bite could be corrected to achieve a normal oc-
clusion and an ideal soft-tissue profile, but the surgery
was rejected by the patient's parents.
The second alternative was to make use of the pa-
tient's growth potential by directing the growth of the
jaws in different development periods. With facemask
therapy for maxillary protraction, the sagittal relation-
ship of the maxilla and the mandible could be coordi-
nated. Through maxillary expansion, the disharmony
of the intermaxillary transverse relationship would be
improved. With an occlusal splint, the excessive molar
extrusion would be inhibited.
After the completion of treatment, a normal occlusal
relationship would be established through orthodontic
camouflage treatment so that the facial profile would
be restored. The second treatment proposal was
accepted by the patient and her parents.
TREATMENT PROGRESS
Stage 1 included orthopedic therapy that lasted for
2 years 3 months. The intermaxillary locked bite had to
be eliminated as a priority for the adjustment of the
sagittal relationship. Therefore, a rapid maxillary expan-
sion (RME) appliance and an occlusal splint were placed
in the maxilla. An occlusal splint for the posterior teeth
was used to control molar extrusion. When proper
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810 Xu et al

Fig 4. Pretreatment cephalometric tracing.

Table. Cephalometric analysis

Variable Mean A1 A2 B
Fig 3. Pretreatment cephalometric and panoramic radio-
SNA ( ) 82 80 84 83
graphs.
SNB ( ) 79 85 82 81
ANB ( ) 3 5 2 2
U1-L1 ( ) 126 119 115 123
maxillary arch width was obtained after expansion, the L1-NB ( ) 27 27 27 19
RME appliance was still kept in place to prevent recur- U1-NA ( ) 24 37 37 37
rence until the end of the mixed dentition period. U1-SN ( ) 72.5 62 59 60
PP-FH ( ) 4.5 9 4 1
When the maxillary expansion treatment started, maxil-
Y-axis ( ) 61 60 59 60
lary protraction was performed with a 7-oz elastic trac- S-Go/N-Me (%) 65.8 58.8 59.7 59.3
tion force on each side and less than a 15 pulling angle Go-Co (mm) 56 48 55 59
in a forward and downward direction with continuous Go-Pg (mm) 72.5 79 79 79
traction for 2 years until an overcorrected anterior over- U1-PP (mm) 27.5 24 28 28
L6-MP (mm) 33 26 32 32
jet relationship was achieved. After orthopedic therapy,
an anterior open bite still existed (Fig 5). A1, Pretreatment records; A2, records after facemask treatment; B,
posttreatment records.
In stage 2, the orthodontic camouflage treatment
was initiated. With the RME appliance for the maxilla
in place, fixed vestibular brackets were bonded to the adjustment, preventing the use of intermaxillary trac-
mandibular dentition with nickel-titanium wires for tion. A superficial overbite was established in the ante-
good alignment (Fig 6). After the RME appliance was rior teeth half a year later (Fig 7).
removed, 2 3 4 technology was used for good alignment Stage 3 was the period for general fixed orthodontic
of the anterior teeth as the maxillary lateral incisors treatment. A tongue crib was bonded to the lingual side
erupted, with the proper use of a tip-back bend for the of mandibular anterior teeth to correct the patient's bad
adjustment of molar positions to stabilize the mandib- tongue habits. The maxillary and mandibular dentitions
ular molars. During treatment, the movement of the were well aligned and leveled for accurate adjustment of
teeth and the jaw fully depended on their growth the occlusal relationships (Fig 8).

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Xu et al 811

Fig 5. Progress photographs: facemask and RME treatment.

Fig 6. Progress photographs: initial orthodontic camouflage with mandibular brackets.

The fixed orthodontic appliance was removed af-
ter 18 months, and a modified Hawley retainer was
used.
TREATMENT RESULTS
A good profile was obtained (Fig 9). The maxillary
development deficiency was corrected, and the clockwise
rotation of the mandible under orthopedic therapy did
not worsen, so that the facial growth direction was
well maintained. With regard to the teeth, an Angle Class
I relationship was obtained for the molars with normal
anterior overbite and overjet (Fig 10). No dental root
resorption and alveolar bone loss were shown in the
panoramic radiograph (Fig 11).
The results of the cephalometric analysis (Fig 12,
Table) showed that the ANB angle was noticeably
improved (from 5 to 2 ) with the maxilla moving
forward (SNA angle changed from 80 to 83 ). The
extrusion of the mandibular incisors and the lingual
inclination compensation were apparent (L1-NB angle,
from 27 to 19 ; U1-L1 angle, from 119 to 123 ).
With the use of an occlusal splint and a horizontal pro-
traction force, counterclockwise rotation of maxilla was
obtained (PP-FH angle, from 9 to 1 ); this partially
compensated for the mandibular molar extrusion (L6-
MP, from 26 to 32 mm) and the mandibular rotation
to stabilize the facial growth direction (y-axis, 60 ;
S-Go/N-Me, 59.3%). The records 2 years after the end
of the treatment showed good and stable treatment re-
sults (Fig 13).
DISCUSSION
It is difficult to establish and maintain normal over-
bite and overjet relationships in orthodontic treatment
for patients with a skeletal Class III malocclusion com-
bined with an open bite caused by jaw growth patterns
and bad tongue habits. We believe that in the early
orthodontic therapy for a patient with a skeletal

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812 Xu et al

Fig 7. Progress photographs: 2 3 4 technology.

Fig 8. Progress photographs: comprehensive orthodontic treatment.

malocclusion, every step of the treatment should follow
the biomechanism of the dentomaxillary system. Only
when the physiologic compensatory mechanisms of the
dentomaxillary system are stimulated, use of the
simplest approaches to acquire long-term and stable or-
thotherapy results is possible.
In the treatment planning for such patients, overall
growth direction (y-axis) of the maxillofacial region
should be maintained to control its vertical growth. In
the sagittal direction, the length and the position of
the maxilla and the mandible should be coordinated
through orthopedic force. Finally, normal occlusal
relationships can be established by directing the move-
ment of the dental arch and the dentition with ortho-
dontic camouflage treatment.
There are 3 typical effects of facemask therapy:
maxillary protrusive movement, maxillary molar mesial
movement, and clockwise rotation of the mandible.
The first and second effects were the results we wanted
to achieve, whereas the third one negatively impacts the
malocclusion by making treatment more difficult and
damaging the jaw growth direction. Therefore, the
direction of traction force is crucial in facemask ther-
apy.15 For our patient, an angle of less than 15 in the

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Xu et al
Fig 9. Posttreatment photographs.
infra-anterior direction was obtained; it did not go
through the center of resistance of the maxilla and the
dental arch. Thus, counterclockwise rotation of the
maxilla occurred. Since the molar occlusal splint was in
place simultaneously with the facemask, a counterclock-
wise rotation with the molar region (as a rotation center)
was established during the maxillary protrusive move-
ment, partially compensating for the mandibular clock-
wise rotation and improving the lower facial height.
With an orthopedic force in this direction, satisfactory
protrusive movements of the maxilla and the maxillary
arch could also be acquired.
Since the orthotherapy concept is in compliance with
the biomechanism of the dentomaxillary system, it is
ideal to coordinate the jaw relationship by the patient's
own physiologic adjustment. With protractive orthope-
dic therapy, the intermaxillary locked bite was eliminated
using the RME appliance and the molar occlusal splint.
With these approaches, a new mandibular physiologic
position could be established under the balance of
American Journal of Orthodontics and Dentofacial Orthopedics
813
internal and external myodynamics of the lingual and
labial muscles. After orthopedic therapy, the overjet
was overcorrected. Although there was still minor clock-
wise rotation in the mandible, the ratio of the lower
facial height to the overall face was maintained at the
pretreatment level.
In the retention stage of orthopedic therapy, the
mixed dentition was not finished. The RME appliance
and the occlusal splint should be kept in place for about
1 year after completing the maxillary expansion treat-
ment. The critical factor in the treatment for this stage
was to guide the teeth to normal positions and establish
relatively normal occlusal relationships. Continuous
Class III or intermaxillary vertical traction is commonly
used to treat patients with a skeletal Class III malocclu-
sion by protracting and inclining the teeth, but treat-
ment stability is doubtful. Fixed vestibular brackets
were bonded to the permanent teeth (partially erupted)
without using complicated orthodontic technology
and intermaxillary traction; we only aimed for simple
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814
Fig 10. Posttreatment dental casts.
Fig 11. Posttreatment radiographs.
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Xu et al
alignment and leveling. With natural growth of maxillary
and mandibular incisors, superficial overbite and overjet
relationships have been established in the permanent
dentition.
The major issues of this patient's malocclusion had
already been tackled in the first 2 stages of the treatment.
A Class I molar relationship and superficial anterior over-
bite and overjet were obtained. In the next orthotherapy
in the early period of the permanent dentition, a tongue
crib was bonded to the lingual side of the mandibular in-
cisors to change the bad tongue habits. In addition, the
premolar open bite had been corrected. After treatment,
the occlusion, the smile, the lateral profile, and the ratio
of frontal soft tissues were obviously improved.
CONCLUSIONS
The orthodontic approach in compliance with the
biomechanism of the dentomaxillary system has great
success in obtaining cosmetic and stable results. As far
as a teenage patient with a skeletal Class III malocclusion
is concerned, the jaw growth direction must be main-
tained without change during treatment, while the or-
thopedic force is needed to adjust the sagittal jaw
relationship. Changes of the balance of internal and
external myodynamics are also necessary to establish a
dental compensatory relationship.
American Journal of Orthodontics and Dentofacial Orthopedics
Xu et al 815

Fig 12. Posttreatment cephalometric superimposition (black lines, pretreatment; dotted green lines, af-
ter facemask treatment; red lines, posttreatment).

Fig 13. Retention photographs.

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