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imitations in Orthopedic and Camouflagereatment for Class III Malocclusionyoung Seon Baik

Skeletal Class III patients can be treated by either orthopedics, orthodon-

tic camouflage, or orthognathic surgery, depending on the degree of

skeletal discrepancy, the skeletal pattern, and the age of the patient. The

orthopedic approach for growth modification is usually limited to chil-

dren with growth remaining. Treatment by maxillary protraction is effec-

tive in Class III patients with an underdeveloped maxilla and a fairly

normal mandible. However, this approach may not be suitable for

patients with an overdeveloped mandible or a mandible that continues

to grow excessively. Camouflage orthodontic treatment may be per-

formed in patients with a mild skeletal Class III discrepancy and no

remaining growth by extracting lower premolars, second molars, inci-

sors, or even using mini-implants. However, in patients with a severe

skeletal discrepancy or continuous mandibular growth, it is necessary to

consider a combined surgical/orthodontic approach. (Semin Orthod 2007;

13:158-174.) © 2007 Elsevier Inc. All rights reserved.

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he treatment of skeletal Class III malocclu-sion continues to challenge the orthodon-

ists because of a high rate of relapse followinghe orthodontic treatment. In southern Asianountries the prevalence of Class III malocclu-ion is higher than Class I and Class II malocclu-ions. A study showed that the incidence ofalocclusion among Korean students at Yon-

ei University was 61.6% Class I, 12.2% Class II,nd 16.7% Class III, respectively. Moreover, ofhe patients who presented to the Orthodonticepartment of Yonsei University dental hospi-

al, 27% to 31% were Class I, 28% to 30% werelass II, and 38% to 40% were Class III pa-

ients.1,2

Since Class III patients usually display an an-erior crossbite, the malocclusion is obvious to

Professor of Orthodontic Department and Vice-Director, Dental Hos-ital, The Institute of Craniofacial Deformity, College of Dentistry,onsei University, Seoul, Republic of Korea.

Address correspondence to Hyoung Seon Baik, DDS, MS, PhD,ollege of Dentistry, Yonsei University, Orthodontic Department, 134hinchon-Dong Seodaemun-Ku, Seoul 120-752, Republic of Korea.hone: �82-2-2228-3102; E-mail: [email protected]

© 2007 Elsevier Inc. All rights reserved.1073-8746/07/1303-0$30.00/0

edoi:10.1053/j.sodo.2007.05.004

58 Seminars in Orthodontics, Vol 13, No

atients and their parents. The number of indi-iduals seeking treatment is increasing due to so-ial and esthetic awareness. Skeletal Class III pa-ients have anteroposterior, vertical, and transverseiscrepancies along with dental compensation.keletal Class III patients can be managed by ei-her orthopedic, orthodontic, camouflage, orombined surgical treatment, depending on thege of the patient, the pattern of malocclusion,nd its severity. In a study on the components oflass III surgical patients conducted by Ellis andcNamara,3 it was found that the largest group

f the sample, 30.1%, was made up of a combi-ation of an underdeveloped maxilla and over-eveloped mandible, while a normal maxillaith overdeveloped mandible made up 19.2% of

he sample. However, in Korean patients, Baikt al4 reported that the combination of a normalaxilla and overdeveloped mandible made up

he majority of the Class III group, 47.7%, whileatients having an underdeveloped maxilla andverdeveloped mandible comprised 13.5% ofhe sample (Fig 1). Similar patterns were ob-erved in the Japanese and Taiwanese popula-ions. Therefore, treatment of Class III patientshould be planned based on the individual skel-
tal pattern and ethnicity since the skeletal char-
3 (September), 2007: p 158-174

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igure 1. Comparison between Korean and American Class III distribution by the ANB angle. (Color version of
gure is available online.)
igure 2. Occlusal views and radiographs of midpalatal suture opening with RPE. (A and B) Before expansion;
C and D) after palatal expansion. (Color version of figure is available online.)

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160 H.S. Baik

cteristics of Class III patients varies among eth-ic groups.

rthopedic Treatment

he goal of orthopedic treatment is to maximizehe skeletal changes and minimize the dentalhanges produced by the orthopedic force. The

igure 3. Treatment of a patient with RPE and a fialatal expansion; (C,F,I) post treatment. (Color vers

igure 4. Maxillary palatal expansion appliance reinfhe transverse expansion of the basal bone, (A) befor
ethod and effect of growth modification by therthopedic appliances depend on the initial agef the patient and their skeletal pattern. Ortho-edic treatment should be limited to childrenith active growth remaining. Since more skele-

al change is obtained when orthopedic treat-ent is started early, it is recommended to start

reatment in the early mixed dentition stage

appliance. (A,D,G) Before treatment; (B,E,H) afterf figure is available online.)

d with mini-implants in a 21-year-old male to secure) during and (C) after expansion. (Color version of

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161Limitations in Orthopedic and Camouflage Treatment

eruption stage of the permanent incisors andrst molars).5. For treatment with a chin cap,rthopedic treatment should be continued untilrowth is complete or when the growth rate isecreased. Remaining growth should be evalu-ted not by chronological age but skeletal age.keletal age may be assessed by either hand-wristadiographs, change in height or secondary sexualharacteristics, or using the vertebral maturationethod. Annual cephalometric radiographs are

onsidered most accurate in evaluating comple-ion of skeletal growth. Cephalometric analysesan also help in determining whether the skele-al Class III problem is due to an underdevel-ped maxilla, overdeveloped mandible, or aombination of both.

The choice of orthopedic appliances forrowth modification is usually determined ac-ording to the patient’s skeletal pattern. In gen-

igure 5. Miniscrews inserted on the palatal or labialide of the alveolar bone and connected to the RPE byires and direct resin for maxillary protraction. (A)cclusal view; (B) anterior view. (Color version ofgure is available online.)

ral, chin caps are used in children who have an w

verdeveloped mandible while rapid palatal ex-ansion (RPE) and/or maxillary protraction issed in patients who have a maxillary deficiency.n addition, to obtain optimal treatment results,t is important for the patient to wear the ortho-edic appliance for more than 12 hours a day.herefore patient cooperation is paramount inrthopedic treatment of Class III malocclusionatients.

hin Cap

n patients with an overdeveloped mandible,hin caps have been used in an effort to inhibitandibular growth. However, there are limita-

ions in its use since the mandibular condyle is arowth site rather than a growth center. Accord-ng to reports by Mitani and Sugawara,6 chin capherapy on children with overdeveloped mandi-les was effective during the period of treatmentut lacked long-term stability due to relapserom catch-up growth of the mandible. Dermautnd Aelbers7 also stated that chin cap therapy isest used on mild skeletal Class III patients or asuxiliary measures in patients wearing func-ional appliances. Since the main effect of chinap therapy is backward and downward displace-ent of the mandible with linguoversion of the

ower incisors, its use should be limited to chil-ren with a pseudo (functional) Class III or aild Class III malocclusion. For patients who

ave an overdeveloped mandible, it is prudento plan for orthognathic surgery after growth isomplete.

apid Palatal Expansion (RPE)

n patients who have a transverse maxillary defi-iency, it is important to first determine whetherhe cause is of dental origin due to palatal tip-ing of the upper molars or of skeletal originue to constriction of the maxilla itself. In pa-ients with skeletal constriction, the maxilla isxpanded by applying orthopedic force to theidpalatal suture (Figs 2 and 3). Palatal expan-

ion can be done rapidly or slowly at the rate ofpproximately 1 mm per week, according to aethod advocated more recently.5

Previous studies8-10 have shown that the ef-ects of RPE include a forward and downwardisplacement of A point, and an increase in

he mandibular plane angle leading to down-
ard and backward displacement of the man-

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162 H.S. Baik

igure 6. A 9-year-old female treated with a bonded RPE and facemask (A) Anterior view before treatment; (B)nsertion of bonded palatal expansion appliance; (C) Post treatment anterior view; (D) Extraoral profile beforereatment; (E) Extraoral profile after treatment; (F) Superimposition of treatment results. (Color version of figure is
vailable online.)

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igure 7. An 11-year-old patient with anterior crossbite corrected by using RPE/maxillary protraction andnished with fixed appliances. Total treatment duration was 1 year and 5 months. Forward and downwardisplacement of the maxilla along with the upper dentition and downward backward rotation of the mandiblean be observed on the superimpositions. Two years after treatment, good profile was maintained. (A,C,E)hotograph and radiograph before treatment; (B,D,E,J) Photograph and radiograph after treatment; (G,H,I)
uperimposition of treatment results. (Color version of figure is available online.)

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164 H.S. Baik

ible. In addition, Baik and coworkers11 re-orted that as the result of the midpalataluture opening the nasal base was also ex-anded, and in children with above-normal

igure 7. Continued.

asal resistance, the nasal base expansion a

ould effect an additional decrease in the na-al resistance. Cameron and coworkers12 indi-ated that rapid maxillary expansion followedy edgewise appliance therapy appears to be
n effective procedure to increase transverse

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acial dimensions in the long term, at both thekeletal and the dentoalveolar levels.

Growth in the width of maxilla is usuallyompleted before anteroposterior and verticalrowth, and is complete at about the time of thedolescent growth spurt. Even though the tim-ng of complete ossification of the midpalataluture varies, in general it is around the age of

igure 8. (A) Anterior open bite was created after mahe mandible. (B) Miniscrews were implanted on thlosure. (C) Anterior openbite was closed after thevailable online.)

igure 9. A 14-year 6-month-old male with a Class IIIA-F) and fixed appliance with molar intrusion using
5 to 16 years when the adolescent growth spurtas ended. Therefore good results from RPE cane expected before this age. While it is difficulto obtain sutural opening in patients with com-lete ossification of the midpalatal suture, a sur-ically assisted RPE (SARPE) can be performedn adult patients to obtain true maxillary expan-ion. Recently mini-implants have been used to-

ry protraction by backward and downward rotation oflatal slope for intrusion of maxillary molars for bitend phase of treatment. (Color version of figure is

bite malocclusion treated with an RPE and facemaskiscrews in the second phase (G-L). (Color version of

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166 H.S. Baik

ether with the midpalatal suture opening indults without surgery14 (Fig 4).

axillary Protraction

n children with an underdeveloped maxilla,axillary growth can be facilitated by means of

n orthopedic force with a protraction device.o encourage forward and downward growth of

he maxilla, it is most effectively performedhen the maxilla is protracted as one rigid unit.or this reason, labiolingual appliances, remov-ble appliances, or fixed appliances with strongeavy wires can be used. However, RPE is con-idered one of the most popular and effectiveppliances. Previous studies have shown that pa-ients protracted after opening the midpalataluture with RPE showed greater forward dis-lacement of A point than patients protractedith a labiolingual appliance and no midpalatal

uture opening.12 Recently, miniscrews haveeen inserted on the palatal or labial side of thelveolar bone and connected to the RPE to re-nforce the maxilla18 (Fig 5). For patients with

igure 9. Continued.

ncreased lower face height, a posterior bitelocks on the lower dentition or bonded RPEppliances can be used to avoid an increase inhe vertical dimension (Figs 6-8).

There have been numerous reports regardingaxillary protraction with orthopedic force.16,17

owever, relapse following treatment has beeneen in certain patients after growth has beenompleted. According to Sung and Baik,15 theirection of the forward and downward displace-ent resulting from the maxillary protractionas similar to that of a Class I control grouphile the amount of forward and downwardaxillary displacement measured at A point was

ignificantly greater than that in the Class I con-rol group. However, during the observation pe-iod of 1 year following protraction, the amountf maxillary growth in the protraction group wasound to be less than the control group, indicat-ng the possibility of short-term relapse. Figure 9hows a 14-year 6-month-old Class III patientith an underdeveloped maxilla and a fairly

ong mandibular body length. The patient was

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reated with an RPE and facemask for 1 year andmonths and treatment was completed with

xed appliances. Due to the maxillary protrac-ion, the mandible rotated backward and down-

igure 10. Tooth extraction and its ultimate occlusalelationship in Class III patients. (Color version ofgure is available online.)

igure 11. Patient with Class III malocclusion cam
ostretention indicates good stability. (Color version of fi
ard resulting in an increase in mandibularlane angle from 42.1° to 43.9° and a 2-mmnterior open bite. Because of these changes,iniscrews were implanted between the upper

rst and second molars for intrusion in the sec-nd phase of treatment. Following treatment,he openbite was closed and the mandibularlane angle returned to 42.8°.

Good stability of the occlusion with a balancedrofile was mainly due to the forward growth of

he maxilla and relatively little forward growth ofhe mandible during the treatment period.

Baik reported on the posttreatment changesn 57 patients, with an average postretentioneriod of 5.9 years, who had undergone maxil-

ary protraction and fixed appliance treat-ent.18 Those who had an ANB angle of above

° were defined as the well-maintained grouphile those who had an ANB angle of less than° were classified as the relapsed group. Theephalograms taken at the end of treatmentT2) and post retention (T3) were evaluated forignificant changes. The results indicated no sig-

ged with extraction of four premolars. Five years
oufla gure is available online.)

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168 H.S. Baik

igure 12. (A) A patient displaying anterior crossbite was treated with a removable active plate (A-P screw)ollowed by fixed appliances. Nine years after treatment when growth ended, significant relapse was observedue to the continuous growth of the mandible. (B) Superimposition of radiographs showed significant amountf mandibular growth occurred after treatment. (C and D) Improved profile and occlusion after orthognathic
urgery. (Color version of figure is available online.)

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igure 13. (A-C) Patient with Class III malocclusion camouflaged with extraction treatment. Note that evenhough the anterior crossbite was corrected by extraction of the premolars, there was no improvement in theacial profile. (D) Comparison of cephalometric radiographs taken before and after treatment showed excessive
ompensation of the incisors. (Color version of figure is available online.)

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170 H.S. Baik

ificant differences in the maxillary growth mea-ured at point A between the two groups. How-ver, significant differences were found in theorizontal change of the mandible measured atoint B, with 8.5 mm of forward growth in theelapsed group and 3.8 mm in the well-main-ained group. Relapse was noted in patients whoad significant late growth in the mandible,hile patients with little mandibular growth or

hose who grew in harmony with their maxillaryrowth showed good stability, indicating that theavorable prognosis after maxillary protraction is

igure 14. (A,C) Patient with Class III malocclusionrthodontic treatment. (B,D) Facial profile and occlusgure is available online.)

argely dependent on the posttreatment man- f

ibular growth, not necessarily the maxillaryhange. For the patients who have a severelyverdeveloped mandible or a mandible that con-inues to grow, orthognathic surgery is recom-

ended when growth is complete.

rankel III Functional Regulator

n the 1960s, Frankel modified the activator andesigned the functional regulator (FR). Frankeltated that the lip pad and buccal shield in theppliance stretched the periosteum to stimulate

rienced relapse due to late mandibular growth afterere improved with two-jaw surgery. (Color version of

expeion w

orward growth of the maxilla.19 However, ac-

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ording to studies by Ulgen and Firatli,20 Proffitnd Fields,5 and Baik and coworkers,21 FR-IIIreatment effects are mainly the result of back-ard and downward rotation of the mandiblend linguoversion of the lower incisors, withittle effect on maxillary growth promotion.

rthodontic Camouflage Treatment

rthodontic camouflage treatment can be per-ormed on adolescents whose growth is almostver or on adults with mild skeletal discrepan-ies. Camouflage treatment can be performedy selective tooth extraction (premolars, lower

ncisors, or lower second molars), the use of theultiple edgewise arch wire (MEAW) technique

o induce generalized distal tipping of the man-ibular posterior segment, or the application ofini-implants to distalize the entire mandibular

entition (Figs 10 and 11).There are a few factors to take into consider-

tion when extracting lower premolars in cam-

igure 15. This patient presented with a skeletal Clagure is available online.)

uflage treatment for skeletal Class III malocclu- t

ion patients. When the lower incisors areetracted in an effort to improve the overjet, thehin may appear even more protrusive resultingn an unesthetic outcome. In addition, extrac-ion only in the mandibular arch will result in asuper Class III molar relationship,” with thepper second molar teeth having no dental oc-lusion and the necessity of additional measureso inhibit their overeruption. Because of theseoncerns, alternative treatment methods, suchs lower second molar extraction when the thirdolar is present, and lower incisor extractionhen the Bolton ratio is favorable, may be con-

idered. In addition, the entire lower dentitionay be distalized with skeletal anchorage usingini-implants. However, in patients with severe

keletal discrepancies and an overdevelopedandible, orthognathic surgery should be con-

idered to improve function and esthetics. Fig-re 12 illustrates a patient with a chief complaintf an anterior crossbite in the mixed dentition.axillary expansion and anterior movement of

I malocclusion. Before treatment. (Color version of
ss II
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172 H.S. Baik

ive plates with screws and finished with fixedppliances. Nine years after treatment, whenrowth was complete, significant relapse wasound due to the continuous growth of the man-ible. The patient was retreated with orthog-athic surgery to improve the profile and thecclusal relationship that had been worsened byhe excessive residual growth.

Figure 13 shows a patient transferred from arivate clinic following the extraction of fourremolars. The space was largely closed during

he previous orthodontic treatment. However,n extreme dental compensation on the uppernd lower incisors was found as a result of anrthodontic camouflage, disregarding the un-erlying skeletal Class III pattern. Moreover, the

mprovement in the facial profile was hardlyoticeable. Orthognathic surgery should haveeen recommended for this patient instead of

igure 16. Class III malocclusion camouflaged with tpper and lower miniscrews; the lower dentition was dA-D). (Color version of figure is available online.)

amouflage orthodontic treatment. o

Figure 14 shows a patient who had receivedrthodontic treatment while in junior highchool that included the extraction of fourremolar teeth to correct an anterior cross-ite. Due to late and excessive growth of theandible the patient developed a severe skel-

tal Class III malocclusion. This patient under-ent a two-jaw surgery following decompensa-

ion of the dentition and a good final resultas achieved.

Recently, some limitations of orthodonticamouflage treatment have been overcome us-ng mini-implants for skeletal anchorage. Using

ini-implants in both upper and lower alveolarone, a good occlusion has been obtained withistalization of the lower dentition. Figure 15hows a 22-year-old Class III patient who had aandibular body length of 95 mm and an ANB

f –1.2°. The patient received orthodontic cam-

d of miniscrews using Class III and I elastics with theized while the upper dentition was displaced forward

he aiistal

uflage treatment because he did not want or-

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hognathic surgery. After leveling the upper andower dentition, rectangular wires were engagednd mini-implants were inserted between thepper and lower second premolar and first mo-

ar teeth (Fig 16). Using Class III and Class Ilastics, the lower dentition was distalized whilehe upper dentition was displaced forward.ood results were obtained as seen in Fig 17.he decision of whether to perform orthodonticamouflage treatment or surgery on skeletallass III borderline cases should be made asarly as possible because orthodontic mechanicsnd the teeth to be extracted differ completelyepending on the treatment selection. The se-erity of the skeletal discrepancy, facial pattern,ncisor angulation, nasolabial angle, anterior facialroportion, periodontal condition, change in oc-lusion and esthetic appearance after treatment,nd the possibility of remaining mandibularrowth are all important factors to consider.4,22

onclusion

he management of skeletal Class III malocclu-

igure 17. Intraoral and extraoral views of the samevailable online.)

ion is still a challenge to orthodontists especially

ecause of relapse due to the late growth of theandible. The orthopedic approach for growthodification may achieve successful results in chil-

ren who have an underdeveloped maxilla and aairly normal mandible. Long-term stability in pa-ients who have an overdeveloped mandible andate growth of the mandible following treatmentill most likely show relapse. A camouflage orth-dontic approach may be used for patients whoresent with a mild to moderate skeletal Class IIIiscrepancy and a hypodivergent skeletal patternsing the extraction of teeth and/or the use ofini-implants. However, patients who present withsevere skeletal discrepancy or who will likely haveontinuous growth of the mandible are not candi-ates for camouflage treatment.

eferences1. Baik HS, Kim KH, Park Y: Distribution and trend in

malocclusion patients. Kor J Orthod 25:87-100, 19952. Yu HS, Ryu YK, Lee JY: A study on the distribution and

trends in malocclusion patients from department oforthodontics. Yonsei Univ Kor J Orthod 29:267-76,

ent after treatment (A-F). (Color version of figure is
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1999

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174 H.S. Baik

3. Ellis EE, McNamara JA: Components of adult Class IIImalocclusion. J Oral Maxillofac Surg 42:295-305, 1984

4. Baik HS, Han HK, Kim DJ, Proffit WR: Cephalometriccharacteristics of Korean Class III surgical patients andtheir relationship to plans for surgical treatment. IntAdult Orthod Orthognath Surg 15:119-128, 2000

5. Proffit WR, Fields HW: Contemporary Orthodontics. 3rded. St Louis, Mosby, 2000

6. Sugawara J, Asano T, Endo N, Mitani H: Long termeffects of chincup therapy on skeletal profile in mandib-ular prognathism. Am J Orthod Dentofacial Orthop 98:127-133, 1990

7. Dermaut LR, Aelbers CMF: Orthopedics in orthodon-tics: fiction or reality. A review of the literature—part II.Am J Orthod Dentofacial Orthop 110:667-671, 1996

8. Hass AJ: Rapid palatal expansion of the maxillary dentalarch and nasal cavity by opening the midpalatal suture.Angle Orthod 31:72-90, 1961

9. Wertz R, Dreskin M: midpalatal suture opening: a nor-mative study. Am J Orthod Dentofacial Orthop 71:367-81, 1977

0. Baik HS: A cephalometric study of the maxillary andmandibular positional changes by the RPE in Class IIIpatients. J Kor Dent Assoc 18:371-378, 1980

1. Baik HS, Lee JG, Toon JH, et al: The change of nasalairway resistance after rapid maxillary expansion. Kor JOtolaryngol 34:544-552, 1991

2. Cameron CG, Franchi L, Baccetti T, McNamara JA :Long term effects of rapid maxillary expansion: a pos-teroanteror cephalometric evaluation. Am J OrthodDentofacial Orthop 121:129-35, 2002

3. Baik HS: Clinical results of the maxillary protraction

in Korean children. Am J Orthod Dentofacial Orthop108:583-92, 1995

4. Lee KJ, Park YC, Lee JS, et al: Miniscrew-aided rapidpalatal expansion in young adults. 2005 AAO scientificposter, San Francisco, May 23, 2005.

5. Sung SJ, Baik HS: Assessment of skeletal and dentalchanges by maxillary protraction. Am J Orthod Dento-facial Orthop 114:492-502, 1998

6. Baccetti T, McGill JS, Franchi L, et al: Skeletal effects ofearly treatment of Class III malocclusion with maxillaryexpansion and face-mask therapy. Am J Orthod Dento-facial Orthop 113:333-43, 1998

7. Vaughn GA, Mason B, Moon HB, Turley PK: The effectsof maxillary protraction therapy or without rapid palatalexpansion: a prospective, randomized clinical trial. Am JOrthod Dentofacial Orthop 128:299-309, 2005

8. Baik HS: Orthopedic and surgical approach in Class IIImalocclusion. 105th AAO Annual Session Lecture, SanFrancisco, May 23, 2005.

9. McNamara JA Jr, Huge SA: Functional regulator (FR-3)of Frankel. Am J Orthod 88:409-24, 1985

0. Ulgen M, Firatli S: The effect of the Frankel’s functionregulator on the Class III malocclusion. Am J OrthodDentofacial Orthop 105:561-7, 1994

1. Baik HS, Jee SH, Lee KJ, Oh TK: Treatment effects ofFrankel functional regulator III in children with Class IIImalocclusion. Am J Orthod Dentofacial Orthop 125:294-301, 2004

2. Baik HS: Limitations of Orthopedic Treatment andCombined Surgery in Skeletal Class III Malocclusion.Orthodontics in the 21st Century. Osaka, Japan, Osaka
University Press, 2002

7-camouflage tx for class iii

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