the orthodontic treatment of class iii malocclusion with

Volume 31 Issue 1 Article 6

2020

The Orthodontic Treatment of Class III Malocclusion with Anterior The Orthodontic Treatment of Class III Malocclusion with Anterior

Cross Bite and Severe Deep Bite Cross Bite and Severe Deep Bite

Chieh Yang School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthodontics, Dental Clinics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Yu-Chuan Tseng School of Dentistry, College of Dental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Orthodontics, Dental Clinics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, [email protected]

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Recommended Citation Recommended Citation Yang, Chieh and Tseng, Yu-Chuan (2020) "The Orthodontic Treatment of Class III Malocclusion with Anterior Cross Bite and Severe Deep Bite," Taiwanese Journal of Orthodontics: Vol. 31 : Iss. 1 , Article 6. DOI: 10.30036/TJO.201903_31(1).0006 Available at: https://www.tjo.org.tw/tjo/vol31/iss1/6

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53Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 110.30036/TJO.201903_31(1).0006

INTRODUCTION

For correction of skeletal Class III malocclusion,

Proffit states that there are three treatment options: 1)

growth modification, use differential growth of the maxilla

relative to the mandible; 2) camouflage of the skeletal

discrepancy through tooth movements to correct the

dental occlusion while maintain the skeletal discrepancy;

or 3) orthognathic surgical correction.1 The treatment

option is depending on the patient’s age, the facial

profile, the skeletal pattern, the alveolar bone reaction

on mandibular incisors, and the severity of malocclusion

before treatment.

As for anterior cross bite, except some patients are

truly skeletal Class III malocclusion, some others are

pseudo-Class III malocclusion. These pseudo-Class III

patients may present some characteristics as: 1) normal

or mildly larger size of mandible; 2) normal or mildly

smaller size of maxilla; 3) incisors could be guided to

edge-to-edge in resting position; 4) difference between

centric occlusion (CO) and centric relation (CR); 5) first

molars may occlude in Angle’s Class III relationship.

The profiles of pseudo-Class III patients usually are

concave, upper lips are less prominent due to insufficient

support of upper incisors, while soft tissue menton and

lower lips are more protrusive, but these Class III profiles

Case Report

This 22-year-old female presents with skeletal Class III malocclusion, complicated by anterior cross bite,

deep bite, and congenital missing of bilateral mandibular second premolars. The treatment modality was full-

mouth fixed edgewise appliances. A favorable result of ideal overbite and overjet and closure of bilateral spaces

of missing teeth were achieved. The patient was satisfied the improvement of function and esthetics after

treatment. (Taiwanese Journal of Orthodontics. 31(1): 53-63, 2019)

Keywords: pseudo-Class III malocclusion; anterior cross bite; deep bite; congenital missing.

The OrThOdOnTic TreaTmenT Of class iii malOcclusiOn wiTh anTeriOr crOss biTe and

severe deep biTe

Chieh Yang, Yu-Chuan TsengSchool of Dentistry, College of Dental Medicine,

Kaohsiung Medical University, Kaohsiung, TaiwanDepartment of Orthodontics, Dental Clinics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan

Received: September 11, 2018 Revised: March 16, 2019 Accepted: March 31, 2019Reprints and correspondence to: Dr. Yu-Chuan Tseng, Department of Orthodontics, Kaohsiung Medical University Hospital, No. 100, Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan. Tel: +886-7-3121101 ext 7009 Fax: +886-7-3221510 E-mail: [email protected]

54 Taiwanese Journal of Orthodontics. 2019, Vol. 31. No. 110.30036/TJO.201903_31(1).0006

The extraoral examination revealed that the patient

had skeletal Class III malocclusion with midface

deficiency, mandibular prognathism, acceptable lower

facial height, insufficient display of upper incisors while

smiling (Figure 1).

The intraoral examination revealed that the patient

had Angle’s Class III malocclusion with anterior crossbite

and deep bite with an accentuated curve of Spee in

the lower arch and supra-eruption of lower incisors.

The dental spaces in the lower arch resulted from the

congenital missing of bilateral lower second premolars

(Figures 1, 2). Besides, this patient was a pseudo-Class

III malocclusion since her mandible could be guided to

incisors edge to edge position (Figures 3, 4). The initial

cephalometric analysis revealed that this patient was

skeletal Class III malocclusion with normal mandibular

plane angle, retroclined upper and lower incisors and

retrusive upper lip (Figures 5, Table 1).

are much improved in rest position while incisors are

in edge to edge position. Anterior crossbite has been

associated with a variety of complications, such as

gingival recession of the lower incisors, incisal edge wear,

and eventually lost of these teeth. Correction of anterior

crossbite could enhance the oral health and achieve

better occlusion. The aim of this article is to present the

treatment of a pseudo-Class III malocclusion in an adult

patient complicated by deep bite and congenital teeth

missing.

CASE REPORT

A 22-year-old female patient who had no history

of illness or trauma, presented the following complaints

including anterior crossbite and mandibular protrusion.

The dental spaces in the lower arch came from congenital

tooth missing.

Figure 1. Extraoral and intraoral photographs, before treatment.

Yang C, Tseng YC


Anterior Cross Bite with Deep OB

Figure 2. Study models, before treatment.

Figure 3. Intraoral photographs before treatment. The mandible could be guided to edge to edge bite.


Yang C, Tseng YC

Table 1. Cephalometric measurements before and after treatment.

Measurement Pre-tx Post-tx Normal Range

SNA 79.0 80.0 79.8 ~ 83.2

SNB 80.0 78.5 75.7 ~ 78.7

ANB -1.0 1.5 3.2 ~ 5.0

SN-MP 36.0 38.0 33.8 ~ 38.4

U1 to NA mm 4.0 7.5 4.3 ~ 8.1

U1 to SN° 92.0 104.5 103.85 ~ 108.75

U1 to NB mm 7.5 6.0 5.4 ~ 10.2

U1 to MP° 78.0 77.0 93.4 ~ 99.2

E-line: Upper -3.5 -0.5 0.7 ~ 3.1

E-line: Lower 0.0 0.0 0.1 ~ 3.4

Figure 4. The lateral facial profile in: A , centric occlusion; B , edge-to-edge incisal contact.

Figure 5. A , lateral cephalometric film; B , panoramic radiograph before treatment.

A B

A B



also used to correct the anterior crossbite and rotate the

mandible in clockwise direction. Thus, mild mandibular

protrusive posture was improved by the Class III

mechanics.

Treatment progressOrthodontic treatment was carried out by using

the pre-adjusted 0.022-inch slot self-ligation system,

and lower anterior resin bite blocks were also added in

the initial stage to disocclude the bite and facilitate the

correction of anterior crossbite (Figure 6). It took about

seven months to accomplish the leveling and alignment

and correct the anterior crossbite. Reposition of some

brackets to calibrate the position and root angulation after

mid-term panoramic film taking. Continuing the crossbite

correction and closing the residual mandibular spaces

were accomplished in another nine months. After a total

treatment duration of 32 months, the upper wraparound

retainer and the lower fixed retainer were used for

retention (Table 2).

Diagnosis● Skeletal Class III jaw relation

● Orthodivergent facial pattern

● Angle’s Class III malocclusion

● Anterior crossbite and deep bite

● Congenital missing of #35, 45

Treatment objective● To correct the anterior crossbite and deep bite, achieve

normal overbite and overjet by upper anterior teeth

proclination and lower anterior teeth retraction.

● To improve the facial profile and lip posture.

● To close the mandibular dental space.

Treatment planNo further tooth extraction was planned for this

patient. Full-mouth fixed edgewise appliances were

bonded for leveling and alignment in the upper and lower

dentition. The mandibular space was closed by lower

anterior retraction and intrusion. Class III elastic was

Figure 6. Full mouth bonded with fixed appliance with light wire leveling and bite block in the lower anterior teeth.


second premolars. Canine relation was finished in Class

I relationship by lower anterior retraction and Class III

elastics. The superimposition of cephalometric tracings

revealed that the upper incisors were proclined, and the

upper lip also became more prominent after treatment.

In addition, the upper first molar was mesialized; lower

incisors were retracted and intruded while lower first

Treatment resultsThe facial profile maintained in mild concave at

midface (Figure 7). Normal overbite and overjet, Class

I canine relationships as well as coincident facial and

dental midlines were achieved (Figure 8). The molar

relation was finished in bilateral Class III due to the dental

space closure of congenital missing mandibular bilateral

Yang C, Tseng YC

Table 2. Summary of treatment progress.

Upper Lower

103 / 11 ~ 104 / 06

• Bonding • Leveling and alignment • Crossbite correction - short Class III elastics

• Bonding • Leveling and alignment • Crossbite correction - short Class III elastics

104 / 06 ~ 105 / 03 • Keeping crossbite correction • Spaces closure

105 / 03 ~ 105 / 10 • Releveling • Releveling and Keeping flattening curve of Spee

105 / 10 ~ 106 / 07 • Finishing and detailing • Finishing and detailing

106 / 07 • Debonding - wraparound retainer

• Debonding - 34-44 fixed retainer

Figure 7. The facial and intraoral photographs, after treatment.



to mandibular plane angle (SN-MP) also increased from

36° to 38°. The distance between upper incisor to NA line

increased from 4 mm to 7.5 mm, and the angle between

upper incisor to SN plane increased from 92° to 104.5°.

The lip posture was improved by increase the distance of

upper lip to E-line from -3.5 mm to -0.5 mm (Table 1).

molar was mesialized and extruded; and the mandible

showed clockwise rotation (Figure 9, 10). The root

parallelism and root resorption were acceptable and within

the normal range (Figure 11). The cephalometric analysis

comparing the initial and final conditions indicted that

the ANB angle increased from -1° to 1.5°, the SN line

Figure 8. The study models, after treatment.

Figure 9. Superimposition of cephalometric tracings. Black line, before treatment; red line, after treatment.


Yang C, Tseng YC

Figure 11. A , lateral cephalometric film; B , panoramic radiograph, after treatment.

Figure 10. Regional superimposition of cephalometric tracings. A , maxilla; B , mandible; black line, before treatment; red line, after treatment.

A B

A

B



fixed appliances with Class III elastics and bondable resin

bites for disocclusion was effective to correct the anterior

crossbite. The anterior resin bites also help to intrude the

supra-eruptive lower anterior teeth. The upper teeth show

was insufficient before treatment. By flaring of upper

anterior incisors, the crowding in upper dentition was

relived and the pleasing smile curve was also achieved.

The patient’s upper lip rests on the gingiva margin of

upper incisors when smile. The tooth show exceeds the

proposed minimum of 0 to 2 mm of upper lip coverage

of the anterior teeth for posed smile in Asian female

standard.11

In treating anterior crossbite with camouflage

orthodontic treatment, lingual tipping of lower anterior

teeth may result in wash-board appearance and periodontal

damage. The cephalometric analysis indicated the change

of lower incisor inclination was few ( L1-MP: 78° to 77°).

The reasons for the few change in the lower incisors may

be attributed to: (1) light force and short distance of Class

III elastics (3/16” 2 oz) were applied when small-sized

initial working NiTi wires (0.013 / 0.014 inch) were used

to avoid unwanted side effect of over-retraction in lower

anterior teeth; (2) gradually increase the size of working

wires with appropriate amount of buccal crown torque in

lower anterior teeth when closing lower dental space; (3)

the combination of pre-torque NiTi wire (.017 x .025 NiTi

with 20 degree lingual root torque) for torque control of

lower anterior teeth.

The mandibular second premolars are the most

frequent congenitally missing teeth followed by

mandibular and maxillary lateral incisors.12

The etiology

of tooth agenesis is considered to involve the disturbance

of dental development by genetic factors, environmental

factors, or combination of both. Many researchers have

reported that tooth size is often smaller in patients with

tooth agenesis than in patients without tooth agenesis.13-18

Two treatment approaches are available to solve the

missing tooth space: (1) close the spacings and allow the

permanent first molar drift mesially and then complete

DISCUSSION

For correction for skeletal Class III malocclusion,

there are three main treatment options: growth

modification, orthodontic camouflage therapy, and

surgical-orthodontics. Growth modification by dentofacial

orthopedic appliances is an effective method to resolve

skeletal Class III jaw discrepancies in children.2-5

Proffit

indicated the criteria of case selection to enhance the

outcome of orthodontic camouflage therapy, including: (1)

average or short facial pattern; (2) mild anteroposterior

jaw discrepancy; (3) crowding less than 4-6 mm; (4)

normal soft tissue features (nose, lips, chin); (5) no

transverse skeletal problem. Tseng et al. used the receiver

operating characteristic analysis of cephalometric

var iab les to d i s t inguish the ske le ta l Class I I I

malocclusions who requiring orthognathic surgery. There

should meat 4 of these 6 measurements that indicated for

surgical treatment: (1) overjet, ≦ –4.73 mm; (2) Wits

appraisal, ≦ –11.18 mm; (3) L1-MP angle, ≦ 80.8°;

(4) Mx/Mn ratio, ≦ 65.9%; (5) overbite, ≦ –0.18 mm;

and (6) gonial angle, ≧120.8°.6 For this patient, only

2 of these 6 measurements (L1-MP angle=79°; gonial

angle=122°) met the surgical indication. Besides, this

patient had average facial pattern, mild anteroposterior

jaw discrepancy with upper dentition crowding, no

transverse skeletal problem; patient’s incisors could be

shifted to edge to edge position with relative normal

soft tissue features in this position; so, this patient was

arranged for camouflage orthodontic treatment.

For correction of the anterior crossbite, disoccluding

the bite for unrestricted pathway in the initial tooth

movement is essential. Various treatment methods have

been proposed to correct anterior dental crossbite, such

as tongue blades, reversed stainless steel crowns, fixed

acrylic planes, bonded resin-composite slopes and

removable acrylic appliances with finger springs.7-10

The

aforementioned appliances might be huge, uncomfortable,

and only applicable in young patients. For adult patients,


between skeletal or dental Class III malocclusion. The

factors in identifying the patient as dental or skeletal Class

III malocclusion and the factors in achieving good results

of camouflage treatment were reviewed. The patient with

dental Class III malocclusion can be well treated with

proper evaluation and camouflage treatment.

REFERENCE

1. Proffit WR. Contemporary Orthodontics. 5th Ed. St.

Louis, MO, Elsevier Mosby, 2013.

2. Chang HP, Lin HC, Liu PH, Chang CH. Geometric

morphometric assessment of treatment effects

of maxillary protraction combined with chin cup

appliance on the maxillofacial complex. J Oral

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3. Chang HP, Liu PH, Chang HF, Chang CH. Thin-plate

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4. Chang ZC, Chang HP, Chen YJ, Yao CC, Liu PH,

Chang HF. The treatment effects of the face mask

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the space closure orthodontically; (2) retain or regain

the spaces for prothesis.19

As for this patient, the dental

spacings were small (< 3mm) and the lower anterior

teeth retraction was required for the cross bite correction,

the space was closed for camouflage treatment and no

further prosthesis. To finish in Class III molar occlusion,

the occlusion should be evaluated for the existence

of mandibular third molars to make sure that there

are antagonist teeth to occlude the maxillary second

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When reviewing the long treatment duration (32M)

for this patient, the main time was spent on correction of

anterior crossbite. The length to use the lower anterior

resin bite blocks was not long enough, so the patient

still could move the mandible forward as the upper

anterior teeth were still locked within the lower anterior

teeth while biting or eating. The anterior crossbite was

further corrected after the use of .017 x .025 pre-torque

NiTi (20-degree, buccal crown torque) combined short

Class III elastics. When remove the resin bite block, the

mandible position should be re-evaluated and confirmed

for stability.

CONCLUSION

Class III malocclusion may be a difficult task in

orthodontic treatment, since we need to differentiate

Yang C, Tseng YC



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the orthodontic treatment of class iii malocclusion with

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