TREATMENT OF CLASS III

MALOCCLUSION IN
MIXED DENTITION

Dr. Pratyasha Sharma

MDS I
CONTENTS
• Introduction
• Tongue blade therapy
• Reverse stainless steel crowns
• Lower inclined bite plane
• Posterior bite plane with anterior Z-springs
• Frankel III regulator appliance
• References
INTRODUCTION
• Class III malocclusion represents a growth-related dentofacial
deformity with a retrognathic maxilla, prognathic mandible or a
combination of both.
• Prompt diagnosis and early intervention of Class III malocclusion may
be helpful to reduce the extent of burden for severe Class III
malocclusion in late adolescence.
• Early orthodontic treatment in the mixed dentition aims to simplify
definitive treatment in the permanent dentition. In Class III cases, this
can be an effective strategy for the management of a local anterior
crossbite, using either a removable or simple fixed appliance.
• Anterior crossbite is a dental misalignment where
the upper front teeth are positioned behind the
lower front teeth.
• The single-tooth anterior dental crossbite is the
most encountered type of malocclusion during the
mixed dentition period.
• If left untreated, anterior crossbite can lead to
various complications such as recession of the
gums, temporomandibular joint (TMJ) dysfunction,
and worsening of mandibular displacement.
• Therefore, it is important to diagnose and treat
anterior crossbite in children at an early stage to
avoid potential problems in the future.
TONGUE BLADE THERAPY
• for the correction of developing anterior cross bite.
• The tongue blade is
• made to rest on the mandibular anterior teeth in cross bite that acts as
fulcrum and the patient is asked to rotate
• the oral part up and forwards. Patients were advised use it for 1-2 hrs for
about 2-3 weeks.
• The biting force is applied to the lingual aspect of the upper teeth to move
the teeth in crossbite. Incisal edges of lower teeth act as a fulcrums to
absorb the reciprocal ligual forces. Patient cooperation is obligatory for
successful treatment using tongue blade. However, it is impossible to predict
the precise direction and magnitude of force generated by tongue blade.
after 3 weeks there was complete
correction of cross bite.
An 8-year-old female patient reported to the Department of
Pedodontics and Preventive dentistry with
the chief complaint of irregularly placed upper front teeth.
There was no history of parafunctional habits. On
clinical examination, the patient was found to have a
mesochocephalic head, mesoprosopic face, straight profile,
and competent lips. Examination of dentition revealed class 1
molar and canine relationship on both sides with
upper central incisor (21) placed palatally. Negative overjet is
observed in relation to 21. Based on clinical
condition it was diagnosed as anterior crossbite in relation to
11(maxillary left central incisor).
• Reverse stainless steel crowns

• Posterior bite plane with anterior Z-springs

• Bonded resin composite slopes

LOWER INCLINED BITE PLANE
• The Catalan's appliance (Lower Inclined Bite Plane) works on the
principle that the resin slope functions to tip an anterior tooth
labially while the mandibular tooth is tipped slightly in the lingual
direction .

• This method is a safe, cost effective, rapid and easy alternative for
the treatment of crossbite.

• It is cost effective because it does not involve the use of fixed

orthodontic tooth movement procedures.
• As it is cemented on the incisors, the treatment outcome does not
depend on patient cooperation, does not hamper the growth or cause
any discomfort to the patient, and treatment is completed in very few
visits.

• The drawbacks of this appliance are difficulty in speech, mastication

and risk of anterior open-bite if the appliance is cemented for more
than 6 weeks .

• Therefore, weekly examination of the patient and an accurate

decision to remove the appliance in case of prolonged treatment time
are critical.
POSTERIOR BITE PLANE
• The purpose of the posterior bite planes is to free the occlusion so
the teeth in cross-bite can easily be pushed labially. They should cover
the permanent first molar and the two teeth in front of the molar
bilaterally.

• The bite planes are made 0.5 mm to 1.0 mm higher than required for
the tooth in cross-bite to clear the occlusion. This is because acrylic is
soft and often wears and chips.

• Z springs are given to move the tooth labially.

FRANKEL III REGULATOR APPLIANCE
• Orthodontic device developed by Rolf Frankel in 1961.

• The Frankel III (FRIII) regulator is a functional appliance designed to

counteract the muscle forces acting on the maxillary complex.

• Abnormal perioral muscle function can exert deforming action that

prevent the full accomplishment of the optimal growth and
developmental pattern.
INDICATIONS
• This appliance has been used during the deciduous, mixed, and early
permanent dentition stages to correct class III malocclusion
characterized by maxillary skeletal retrusion, and not mandibular
prognathism.

• The FRIII appliance can also be used as a retentive device following

maxillary protraction treatment.
APPLIANCE DESIGN AND
CONSTRUCTION
• Frankel 3 appliance consist of four acrylic parts and five wire
components:
• Acrylic components are two vestibular shields and two upper labial
pads.
• Wire components:
• The upper labial pads are connected to the vestibular shields by a
support.
• The lower aspects of the vestibular shield are connected by a lower
labial wire.
• On the lingual surface, an upper lingual wire originates in the
vestibular shield.
• Two occlusal rests
• Posterior transpalatal wire.
• There are four acrylic parts of the FR-3:
• The vestibular shields extend from the depth of the mandibular
vestibule to the height of the maxillary vestibule.
• The upper labial pads that lie in the labial vestibule above the upper
incisors function to eliminate the restrictive pressure of the upper lip
on the under- developed maxilla.
• The upper labial pads of the FR-3 are in an inverted tear-drop shape in
sagittal view. They should lie in the height of the vestibular sulcus
parallel to the contour of the alveolus.
• The upper labial pads are connected to the vestibular shields by a
support wire.
• The lower aspects of the vestibular shield are connected by a lower
labial wire that rests against the labial surface of the lower incisors.
• Upper lingual wire originates in the vestibular shield, traverses the
interocclusal space, and rests against the cingula of the upper incisors.
• The palatal wire originates in the vestibular shields and traverses the
palate behind the last molar present. Thus, the maxilla and the
maxillary dentition are not restricted in their forward movement by
the wires of the appliance.
• There are two pairs of occlusal rests in the molar region, one of which
is optional. The purpose of this wire is to prevent the eruption of the
lower first molar.
• The maxillary occlusal rest is necessary only in cases of anterior
crossbite so that only enough vertical opening is achieved to allow for
the correction of the anterior crossbite. As soon as the crossbite has
been corrected, the upper occlusal rest should be removed from the
appliance to minimize bite opening.
• The upper occlusal rest originates in the posterior aspect of the
vestibular shield, traverses the central groove of the upper first molar,
and then recurves back on itself.
• The upper occlusal rest is designed in this manner so as not to restrict
the forward movement of the maxilla during functional therapy.
• A lower occlusal rest originates in the vestibular shield, makes a gentle
right-angle bend along the central groove of the lower first molar, and
then extends again back into the vestibular shield posteriorly.
• The purpose of this wire is to prevent the eruption of the lower first
molar.
• It is important to record a proper impression for accurate fit and comfort
of the appliance.
• An accurate reproduction of the dentition and the associated soft tissue
is essential for proper appliance fabrication.
• The extension of the buccal vestibule must be clearly defined and the
upper limits of the anterior maxillary region must be clearly discernible.
• Additional extension of the tray into the anterior vestibule will be
helpful in recording the sulcus accurately.
• Posterosuperior aspect of the maxilla must be recorded adequately to
define the tuberosity region.
• Impressions should capture the full sulcus depth buccally and in the
upper labial segment to accommodate the vestibular shields and
labial pads.
CONSTRUCTION BITE
• A horseshoe wafer of medium hard wax is used.
• The bite registration is taken with the patient's mandible in the most
comfortably retruded position. It is necessary to allow 1 to 2 mm of
inter occlusal space in the molar region for the construction of the
lower and, when necessary, upper occlusal rests. A wide open-bite
registration should be avoided. In cases with an anterior open bite,
only 1 mm of vertical bite-opening in the posterior region is
necessary.
• At the time of appliance delivery, the clinician checks to see that the
contours of the acrylic parts of the appliance extend well into the
vestibule and gently blend into the alveolar process.
• The patient should be instructed that this appliance is a full-time
appliance and that it will eventually be worn at all times except during
eating, dental hygiene, playing contact sports, language lessons, or
playing musical instruments that are held in the mouth.
• The patient is instructed to read aloud for one-half hour per day until
normal speech can be accomplished while wearing the appliance.
• It is usually recommended that the appliance be worn for a few hours
a day for the first few weeks, then gradually increasing wear time until
the patient wears it full time.
APPLIANCE ACTIVATION
• After the appliance has been worn on a full-time basis for 3 or 4
months, the distance between the upper labial pads and the
underlying alveolus will decrease. Thus, activation of the appliance is
necessary to continue treatment.
• A crosscut fissure burr is used in a low- speed dental handpiece to
free the ends of the labial- pad support wires. Enough acrylic is
removed around the end of this wire to allow anterior advancement
of the wire and maxillary labial pads. The lingual surface of the upper
labial pads are kept 3 mm away from the underlying alveolus
throughout treatment.
• Frankel published the results of a case series of patients treated with
the FR3 appliance.
• He found that there was forward movement of the A point, from
which he concluded that the appliance had a skeletal effect on the
maxilla.
• This was supported by a later series of cases he treated that were
compared to untreated Class III malocclusions selected from two
growth studies.
• Following correction of the anterior crossbite and elimination of any
associated functional anterior displacement, a downward and
backward rotation of the mandible may occur.
• This in turn results in a reduction in cephalometric values indicative of
mandibular prognathism, such as the Sella‐Nasion‐B point (SNB).
• Levin et al conducted a study on a group of 32 subjects with Class III
malocclusion treated with the FR-3 appliance and was compared
with untreated Class III controls.
• The first observation was prepubertal, and the long-term
observation was postpubertal for all subjects. Treatment consisted
of full-time wear of the appliance for about 2.5 years, followed by a
retention phase with the same appliance for at least 3 years.
• The overall /observation period was 9 years 2 months.
• All patients showed a good level of compliance.
• Active treatment and posttreatment cephalometric changes were
evaluated statistically.
• The following craniofacial modifications were seen over the 9-year, 2-
month observation interval.
• Full-time wear of the FR-3 appliance induced significant improvements in
both maxillary size and position.
• Increases in effective midfacial length continued into the posttreatment
phase and led to an overall increase in midfacial length.
• However, a significant mandibular shape change was observed in the form
of closure at the gonial angle and associated closure of the mandibular
plane angle.
• Intermaxillary and interdental changes in the craniofacial skeleton were
maintained successfully through the pubertal growth spurt.
• Long-term results of FR-3 therapy in patients with good compliance
consisted of significant maxillary modifications and induced changes in
mandibular morphology.