FACULTATEA DE MEDICIN DENTAR ABSTRACT Contributions to the Study of Angle Class III Malocclusions COORDONATOR TIINIFIC: Prof. Univ. Dr. Valentina DOROB DOCTORAND: Ionela Teodora DASCLU 2010 1 CONTENT INTRODUCTION CHAPTER 1. THE GROWTH AND DEVELOPMENT OF DENTO-MAXILLARY APPARATUS 1.1. The development of cranio-facial elements 1.1.1. The development of the cranium base 1.1.2. The growth and development of naso-maxillary complex 1.1.3. The growth and development of mandible 1.1.4. The temporary development of mandibular articulation 1.1.5. The development of dental occlusion 1.1.6. The general development of the cranio-maxillo-facial complex 1.2. Essential factors in the cranio-facial growth and development 1.2.1. Intrinsic factors of growth 1.2.2. Extrinsic factors of growth 1.2.3. Functional factors in the growth and development of the dento- maxillary apparatus 1.3. Facial rotations of growth 1.3.1. Mandibular rotations of growth 1.3.2. Growth rotations at the level of the upper jaw 1.3.3. Total facial rotations 1.4. Theories on facial growth 1.4.1. The theory of genetic control (Weinman, Sicher) 1.4.2. The theory of growth control by cartilage (Scott). 1.4.3. The integralist concept (Enlow). 1.4.4. The concept of cybernetic regulation of growth (Petrovic) 1.4.5. The theory of functional matrix (Moss) CHAPTER 2. THE ROLE OF FUNCTIONS, PARAFUNCTIONS AND DYSFUNCTIONS IN THE DEVELOPMENT OF DENTO-MAXILLARY APPARATUS 2 2.1. The normal functions of dento-maxillary apparatus 2.1.1. Masticatory function 2.1.2. Normal breathing function 2.1.3. Deglutition function 2.1.4. Phonatic function 2.1.5. Mimics 2.2. Pathological functions (Vitiated) 2.2.1. Dysfunctions 2.2.2. Parafunctions CHAPTER 3. THE ETIOPATHOGENY AND DIFFERENT TYPES OF ANGLE CLASS III MALOCCLUSIONS 3.1. The etiopathogeny of Angle Class III malocclusions 3.2. Types of Angle Class III malocclusions CHAPTER 4. THE ROLE OF COMPLEMENTARY INVESTIGATIONS IN DIAGNOSING ANGLE CLASS III MALOCCLUSIONS 4.1. Complementary investigations in the study of Angle Class III malocclusions 4.2. The diagnosis and analysis methods in ANGLE Class III malocclusions 4.2.1. Diagnosis stages 4.2.2. Possible diagnoses in ANGLE Class III malocclusions CHAPTER 5. THE TREATMENT OF ANGLE CLASS III MALOCCLUSIONS 5.1. Factors in choosing an orthodontic treatment 5.2. Growth modification 5.2.1. Vertical-horizontal deficiency of the maxillary 3 5.2.2. Mandibular excess 5.3. Growth prediction and visualisation of treatment objectives 5.4. Estimating treatment response CHAPTER 6. THE EPIDEMIOLOGY OF ANGLE CLASS III ANOMALIES 6.1. Goal 6.2. Objectives 6.3. Material and method 6.4. Results and discussions 6.5. Conclusions CHAPTER 7. THE ETIOPATHOGENY, DIAGNOSIS AND CLINICAL MANIFESTATIONS OF ANGLE CLASS III ANOMALIES 7.1. The goal of the paper 7.2. Objectives 7.2.1. The research of the causes that generate Angle Class III malocclusions 7.2.2. Clinical manifestations and the diagnosis of each form of Angle Class III malocclusions 7.3. Material and work method 7.4. Results and discussions 7.5. Conclusions 4 CHAPTER 8. POSSIBILITIES AND TREATMENT LIMITS IN ANGLE CLASS III MALOCCLUSIONS 8.1. The goal of the paper 8.2. Objectives 8.2.1. Temporary dentition 8.2.2. Mixed dentition 8.2.3. Permanent dentition 8.2.4. The individualised treatment in ANGLE Class III malocclusions 8.2.5. Fixation in ANGLE Class III malocclusions 8.3. Material and work methods 8.4. Conclusions CHAPTER 9. RESULTS AND GENERAL DISCUSSIONS CHAPTER 10. PRACTICAL DIRECTIONS OF PUTTING INTO PRACTICE THE CONCLUSIONS DEDUCTED FROM THE STUDY 10.1. Final conclusions 10.2. Practical directions of putting into practice the conclusions deducted from the study BIBLIOGRAPHY 5 INTRODUCTION Every dentist should be aware of the basic notions regarding the formation, growth and development of the dento-maxillary apparatus in order to understand the modifications that may intervene or to distinguish the normal variations from the abnormal ones or the pathologic processes. The dento-maxillary anomalies from the sagittal plane may be considered one of the most frequent distortions of the visceral cranium; they are generally known under various designations: dysgnathias, dysmorphoses, and disharmonies. In fact they are the consequence of a disorder in the development harmony between jaw and mandible which can be characterised either by an excess or by a growth deficit of one of the two skeletal entities generating dimensional disproportions between them. Protrusive mandible is one of the most common Class III malocclusions having a 3% frequency in the general examination of the patients and a 25% frequency in the group of subjects suffering from different forms of dento-maxillary anomalies. There is a high complexity of aetiological factors: general factors (genetic, endocrine, dysmetabolic) and locoregional factors such as: the functional activity (dysfunctions), the integrity state of the alveolodental arches, disorders of dental eruption. Together they generate dimensional, directional and rhythm disorders of growth. Class III malocclusions are characterised by an exaggerated development of the mandible in comparison with the upper jaw and by occlusion modifications: Class III molar and frontal reversed occlusion. Besides facial, endo-oral and occlusal disorders there are also functional and facial aesthetics disorders. In this case, the diagnosis of some sagittal dento-maxillary anomalies becomes a synoptic image of symptoms which presents all the disorders in the cranium development in all the three directions of the space. That is why the data obtained from complementary examinations such as profile teleradiography are necessary in establishing a correct diagnosis. In order to determine the correct diagnosis as well as the treatment plan, orthodontists should: 6 - Recognise the various features of malocclusion; - To define the type of problem including, if possible the aetiology of malocclusion; - To describe a treatment strategy based on the specific needs and individual desires. The treatment of sagittal malocclusions has to be made step by step, using various and complex medical methods such as general, functional, biomechanical, orthodontic and surgical ones. In order for the treatment to be successful, orthodontists should be aware of the limits of all the therapeutical methods mentioned, to know the effects of their association as well as the best order in which they interact in accordance with the age and the sex of the patient. Any treatment in the case of Class III malocclusions is followed by a long period of fixation until the growth process is complete in order to avoid possible recurrence. 7 GENERAL PART Chapter 1. THE GROWTH AND DEVELOPMENT OF THE DENTO-MAXILLARY APPARATUS 1.1. THE DEVELOPPMENT OF CRANIO-FACIAL ELEMENTS The formation and modelling of facial skeleton are the result of cellular multiplication in the osteogenetic centres of encondral and desmal growth, followed by osseous metaplasias at the periphery of these centres and by a permanent modelling of the relief and of the osseous structures determined by permanent processes of apposition and osseous resorption. 1.1.1. THE DEVELOPMENT OF THE CRANIAL BASE The normal development of the cranial base determines the formation of cranium and of some nasopharyngeal cavities which have the role of assuring the normal function of nervous regulation and the conditions of an adequate respiration and alimentation. 1.1.2. THE GROWTH AND DEVELOPMENT OF NASO- MAXILLARY COMPLEX 1.1.3. The naso-maxillary complex is formed by: the nasal pyramid, maxillary bones, vomer, zygomatic and palatine bones, the big sphenoid wings, the lachrymal, the lateral ethmoidal lamina and the inferior concha which make up an osseous complex attached to the cranial base by sutures. The naso-maxillary complex is placed in the inferior part of the face protecting the main sensorial organs: optic, olfactive, auditive and, partially, the gustative one. This complex forms the support of alveolo-dental arches. The musculature of mimics is inserted in the maxillary complex, which gives expression to thoughts and human feelings. On the whole, the naso-maxillary complex develops down and forward by the related activities of the perimaxillary sutural 8 system of the coronoid, cranio-facial and incisive-maxillary system partially obliterated on birth. (Bjrk, 1968). 1.1.4. MANDIBLE GROWTH AND DEVELOPMENT The mandible body has an encondral development, beneficiating of four growth cartilages for each hemiarch. At eight month of intrauterine life, coronoidal and angular cartilages ossify; the shape and dimension of these apophyses will be later on conditioned by the traction forces of masticatory muscles which will act upon the local periosteum as an osteogenetic centre. The epiphysal cartilage which obliquely unifies the condyle neck with the ascending branch contributes to the vertical development of the neck condyle and of the ascending branch of the mandible. This cartilage is functionally stimulated by the pressures exerted by the muscles that raise the mandible during mastication. Mandible, the most mobile cranio-facial bone is highly important since it covers the vital functions such as: mastication, the maintenance of airways, phonations and facial mimics. The various types, mechanisms and centers of mandible growth are complicated and controversial. 1.1.5. THE DEVELOPMENT OF THE TEMPOROMANDIBULAR ARTICULATION The studies concerned with occlusion development, state that occlusion and articulation interact with the cranio-facial morphology during growth. The adjustment and compensatory changes that take place contribute to the setting of a normal occlusal function sustaining the normal articular growth and the physiological functions. The effect of displacement, growth and remodelling seem to take place in an anterior-posterior position, despite the local modifications that take place in different directions. Skeletal modifications are the result of permanent local remodelling which produce different modifications from the point of view of volume and shape. 9 1.1.6. THE DEVELOPMENT OF DENTAL OCCLUSION There are three main steps of development that characterise the alveolodental arches in the ontogenetic evolution: - The formation of temporary arches from birth till the age of 2 years and a half; - The preparation and formation of permanent teeth arches from 2 years and a half to 6 years. - The formation and maturation of permanent teeth arches from 6 to 25 years old. 1.1.7. GENERAL DEVELOPMENT OF CRANIO-MAXILLO- FACIAL COMPLEX According to Hunter and Enlow, the concept of growth equivalence is an essential element in the understanding of the facial massif development. There is a strong connection between the development of one part of the cranium and each zone of the facial massif. All the movements of bony pieces are coordinated between them. 1.2. DECISIVE FACTORS IN THE CRANIO-FACIAL GROWTH AND DEVELOPMENT 1.2.1. INTRINSIC FACTORS OF GROWTH Intrinsic factors have their origin in the organism itself and may or may not be influenced by external factors. Cranio-facial morphogenesis is influenced by the following factors: - intrinsic genetic factors; - local and general epigenetic factors; - general and local factors of the surrounding environment. 1.2.2. EXTRINSIC FACTORS OF GROWTH Nutritional factors 10 Diet is an effective medication for a child if it is adequately given in a variable quantity. The qualitative, quantitative and preparation aspects of food are part of the balanced diet which ensures a harmonious development. Socio-economic factors Excessive weight and height is statistically related to the socio-economic conditions. In a steady group some environmental effects may be passed on from one generation to another as a result of genetic and environmental factors. Psycho-affective factors These factors appear in the case of severe deficiencies (the lack of parent affection or its substitute); as a result, insufficient secretion of growth hormones may appear ( psycho-social nanism). 1.2.3. FUNCTIONAL FACTORS IN GROWTH AND DEVELOPMENT OF DENTO-MAXILLARY APPARATUS Morphogenesis is the result of the combination between genetic and surrounding factors which are represented by both muscular activity at rest and active. Bony tissue behaviour depends on the processes that take place in the immediate surroundings. It is sensitive to all variations regarding repartition of mechanical efforts that it has to endure. The functions are considered to be normal when the muscular actions successfully ensure all the functions that characterise the dento- maxillary apparatus and when these functions are correct. 1.3. FACIAL ROTATIONS OF GROWTH Cephalometry studies that register the cranium base point out that mandible is normally guided by the cranium base in an anterior inferior direction. Thus, mandible body is at a great distance from the 11 posterior part of the cranium base and the growth of the anterior height of the face is bigger than the posterior one; as a consequence mandible sometimes seems to rotate in a posterior way. (Moyers). A significant part of the excessive anterior part is represented by the anterior height of the mandible. On the contrary, when the posterior height of the face is much bigger then, the tendency is towards deep occlusion and the mandible seems to rotate in an anterior way. 1.3.1. THE ROTATIONS OF MANDIBULAR GROWTH Bjrk and the associates studied the so called rotations of mandibular growth by using metallic implants or other methods. Bjrk made a clear distinction between what he called matrix rotation and intramatrix rotation (Moyers 4-26). Most often, matrix rotation has the form of a pendulous movement having the rotation point at the level of the condyle. Intramatrix rotation represents the rotation of the mandible body, better said of the inferior half of the matrix and it doesnt take place at the level of the condyle. 1.3.2. THE ROTATIONS OF GROWTH AT THE UPPER JAW LEVEL Bjrk studied the dynamics of the upper jaw growth by attaching at least 3 implants. Thus, he could check: The unequal growth at the median suture; in this case a transverse hemi rotation takes place the posterior part being directed sideways towards each hemi jaw. The growth in length of the jaw takes place at the maxillo- palatine suture and also by periosteal apposition of the retro tuberosital type to which an oblique dislocation of the bone is associated. The growth in height is done: - At the level of the peri-maxillary sutures (fronto-maxillary, maxillo-zygomatic, pterygo-palatine); 12 - Alveolar bone apposition; - The displacement effect produced by the bony apposition at the level of the superior orbitar margin and the resorption of inferior orbitar margin; - Resorption at the level of the floor of nasal fossas and apposition at the level of bony palate; - External apposition; - The vertical contribution of the median suture. 1.3.3. COMPLETE FACIAL ROTATIONS According to Lavergne and Gasson there are four possible combinations if growth rotations are taken into consideration: - The jaw and the mandible have an anterior rotation of growth; - The jaw makes an anterior rotation and the mandible a posterior one; - The jaw makes a posterior rotation and the mandible an anterior one; - Both jaws make a posterior rotation of growth. 1.4. THEORIES ON FACIAL GROWTH There are concerns related to the elaboration of general concepts that may be useful in solving the complexities regarding growth tendencies. Their main goal would be that of elaborating individual anticipations of growth for both normal patients and patients that present dento-maxillary anomalies. Different theories have been advanced in order to explain these processes of growth. Chapter 2. THE ROLE OF FUNCTIONS, PARAFUNCTIONS AND DYSFUNCTIONS IN THE DEVELOPMENT OF THE DENTO-MAXILLARY APPARATUS Neurological and endocrine disorders as well as those concerning metabolism, irrational and artificial nutrition, the vitiated 13 functions (oral respiration, infantile deglutition, defective phonation), and the practice of certain bad habits (sucking the finger, the tongue, the cheek or other objects) and bruxism that act upon a labile body (elastopathic one), have a strong negative influence on the dento- maxillary apparatus generating the so called dento-maxillary anomalies. All these functions, (normal or pathological ones) are the result of the muscular system which is very well organized (from the symmetrical, asymmetrical, synergic or antagonistic point of view). It also has a great contribution to guiding the growth, development and shape of the dento-maxillary apparatus (teeth, interdental and intercardiac relations, the bones and to a lesser extent the musculature). Besides the genetic dento-maxillary anomalies, all the others are initially functional (caused by abnormal behaviour either by vitiating the functions or by practising bad habits). All the morphological changes that affect the dento-maxillary apparatus appear in time. The influence of the muscular system on the bones has been known since the last century. Roux (that was quoted by Boboc, 1996) issued the law: The form comes out of the function while the form and structure are the result of the function. 2.1. THE NORMAL FUNCTIONS OF THE DENTO- MAXILLARY APPARATUS They are mainly represented by: - masticatory function; - normal respiration function; - deglutition function; - phonation function; - mimics 2.2. PATHOLOGICAL FUNCTIONS (VITIATED) Bassigni (1980) divides the pathologic functions of the dento- maxillary apparatus into 2 groups: 14 - the group of dysfunctions: lazy mastication (includes the artificial feeding of the new-born baby), oral respiration, infantile deglutition and defective phonation; - the group of parafunctions: the sucking of fingers, of the bedclothes as well as of the different objects, the various nervous habits and bruxism Chapter 3. ETIOPATHOGENY AND TYPES OF CLASS III MALOCCLUSIONS Protrusive mandible is one of the most common Class III malocclusions with a 3% frequency to a general examination of the subjects and a 25% frequency in the examination of the group of subjects that suffer from dento-maxillary anomalies. There are many etiological factors: - general ones (genetic, endocrine, dysmetabolic); - loco-regional factors: o the vitiated and pathologic functional activity (parafunctions, dysfunctions);: o the integrity state of alveolo-dental arches; o dental eruption disorders All these factors together generate disorders of dimensional, directional and rhythm growth. Eventually, protrusive mandible is characterised by an exaggerated development of the mandible in comparison to the upper jaw which leads to molar Class III occlusion transformation and reversed frontal occlusion. Besides facial, endo-oral and occlusion disorders there are also functional and facial aesthetic disorders. Functional disorders include the hyper tonicity or hypo tonicity of one of the 4 antagonistic muscular groups, better said to the sequence of movements done in order to achieve respiration, deglutition, mastication, phonation or facial mimics and by the type of bad habit. It is important to underline the complex aetiology of protrusive mandible. 15 Chapter 4. THE ROLE OF FURTHER INVESTIGATION IN THE DIAGNOSIS OF CLASS III MALOCCLUSIONS Further clinical and paraclinical investigations are important in: - setting a correct diagnosis of dento-maxillary anomalies and their etiopathogeny; - choosing the best method of treatment. Teleradiography is: - a method of studying the different parts (soft and tough) of the dento-maxillary apparatus; - a scientific method of evaluating the different sizes of the parts that make up the dento-maxillary apparatus (the errors being of just 0.5mm; - a method of extreme accuracy in predicting the facial growth until its maturity; - a method of studying occlusion - a method of studying facial aesthetics thus helping in to establish precise objectives regarding facial harmony during orthodontic treatment; - an important teaching and medical-legal paper. The results of further investigations may be identified in the morphologic, functional, aetiological, positive and differential diagnosis of the anomaly. There are at least 243 clinical types of Class III malocclusions (Ellis and McNamara); therefore, it is essential to have a good knowledge of the symptomatology and to interprete all further investigations correctly. Chapter 5. THE TREATMENT OF CLASS III MALOCCLUSIONS 5.1. DECISIVE FACTORS IN CHOOSING AN ORTHODONTIC TREATMENT Before planning an orthodontic treatment several factors must be taken into consideration: 16 - the patients opinion regarding his/her occlusion and facial aspect; - how severe is the skeletal pattern both vertical and antero-posterior since this is one of the greatest difficulties in setting a correct orthodontic treatment; - the expectations regarding the antero-posterior and vertical form of growth. 5.2. GROWTH MODIFICATION The successful treatment of growth modification is possible only to patients that present a significant quantity of remaining growth potential. Growth modification must be done before or during puberty before permanent dentition has occurred. 5.3. GROWTH PREDICTION AND VISUALISATION OF TREATMENT OBJECTIVES The desired positioning of the incisors at the end of the treatment may be expressed cephalometrically by using the STEINER analysis in accordance with the ANB angle. This way it is possible to indicate the right position of the incisors in order to produce any degree of camouflage for the maxillary discrepancy. As an objective of cephalometric treatment it is necessary to specify the quantity of change that will be produced during growth and the additional impact of any treatment regarding growth modification. 5.4. THE ESTIMATION OF TREATMENT RESPONSE Orthodontists should accept their limits in the skeletal relation and focus more on dental occlusion. Correction may be obtained by performing dental extraction and tipping teeth by using orthodontic appliances. Teeth repositioning will have a positive effect on facial aesthetics. The orthodontic treatment must be complex and complete. It is advisable to apply it before or during the growth of bones: - 7-8 years old during pre-puberty; 17 - 8-9 years old to girls and 9-10 years old to boys puberty period ; All should be correlated with somatic development. The orthodontic treatment must also be applied after the growth period and even later until adolescence. In order to prevent any possible recurrence orthodontists should have in view an active fixation. 18 PERSONAL CONTRIBUTION Chapter 6. THE EPIDEMIOLOGY OF CLASS III MALOCCLUSIONS 6.1. GOAL The goal of the present research is to establish the prevalence of Class III malocclusions in a sample of infantile population. 6.2. OBJECTIVES - The study of the prevalence of dento-maxillary anomalies in a population sample from Craiova and the neighbourhood rural areas; - The evaluation of Class III malocclusions to the population and children that present dento-maxillary anomalies; - To establish the prevalence of Class III malocclusions in accordance with: - Live environment (source: urban and rural); - sex; - dentition type (mixed and permanent); - types of Class III malocclusions (I and II). Dento-maxillary anomalies have lately become more and more frequent, varying from clinical forms to etiopathogenetic aspects. They have a serious psychic impact on the patient who finds it difficult to integrate in the society, thus we can say that these anomalies may already be considered a problem of public health. The prevalence of dento-maxillary anomalies varies according to the studied population, age groups, sex, geographical environment, socio-economic and temporal factors. The epidemiological studies made in Romania pointed out the same growth tendency of the prevalence of dento-maxillary anomalies as follows: Shapira 41.9%, Cmpeanu 46.7%, Cocrl 50- 60%, Firu and Rusu 75%, Dorob 38.6-76.9% to children with temporary dentition and 73.6%to permanent dentition. 19 A study (Dorob) 38 which has been recently made on 7 year- old children reveals that 71.6% of the patients have dento-maxillary anomalies. Taking into consideration the different types of dento- maxillary anomalies the proportion is: - 44.7%Class I malocclusions; - 24.6%Class II malocclusions; - 2.3% Class III malocclusions, most of which are represented by Class III/2 malocclusions Analysing the epidemiological studies mentioned above, we notice a growth tendency of their frequency as well as of their variability as far as the clinical forms are concerned. The frequency of dento-maxillary anomalies is bigger in the urban area (45%) than in the rural one (20-30%). 6.3. MATERIAL AND METHOD An epidemiological study was made on a group of children (1327 pupils) between 6 and 14 years old (boys and girls) from Craiova and the neighbourhood areas. The goal of the research was to identify the prevalence of Class III malocclusions. 6-12 year-old Group Group 12-14 year-old Group Total % Urban Area Rural Area M F M F 833 494 Pupils 1327 - 1033 294 399 434 214 280 III/1 3 0.22% 3 0 2 1 0 0 III/2 14 1.06% 9 5 6 5 1 2 Class III malocclusions Total 17 1.28% 12 5 8 6 1 2 Fig. 19 The results of the study made in Dolj County in 2008. 20 1033 pupils of the grand total of 1327 patients examined come from the urban area and only 294 pupils come from the rural area. The investigations revealed 17 children with Class III malocclusions (1.28%). without Angle Class III malocclusions 1310 98,72% Angle Class III malocclusions 17 1.28% Angle Class III malocclisions without Angle Class III malocclusions Fig. 21 The statistics of Class III malocclusions The percentual repartition (for the 17 cases of Class III malocclusions) in the urban and the rural area is as follows: 1.16% in the urban area of 1033 children (fig. 22) and 1.7% in the rural area of 294 children (fig. 23). 21 Angle Class III malocclusions 12 1,16% without Angle Class III malocclusions urban 1021 98,84% Angle Class III malocclusions without Angle Class III malocclusions urban Fig. 22 The statistics of Class III malocclusions in the urban area. Angle Class III malocclusions 5 1,70% without Angle Class III malocclusions rural 289 98,30% Angle Class III malocclusions without Angle Class III malocclusions rural Fig. 23 The Statistics of Class III malocclusions in the rural area. 22 Further research highlighted the existence of a great diversity of clinical forms. There were identified 12 cases of Class III malocclusions in the urban area, 3 cases representing the 1 st subdivision of Class III malocclusions (0.29%) and 9 cases representing the 2 nd subdivision of Class III malocclusions (0.87%) (fig. 24). without Angle Class III malocclusions 1021 98,84% malocclusions III/1 3 0,29% malocclusions III/2 9 0,87% malocclusions III/1 malocclusions III/2 without Angle Class III malocclusions Fig. 24 The subdivided statistics of Class III malocclusions from the urban area. There were also identified 5 cases of the 2 nd subdivision of Class III malocclusions in the rural area 2 (1.7%) (fig. 25). 23 without Angle Class III malocclusions 289 98,30% malocclusions III/1 0 0,00% malocclusions III/2 5 1,70% malocclusions III/1 malocclusions III/2 without Angle Class III malocclusions Fig. 25 The subdivided statistics of Class III malocclusions in the rural area. Moreover, studying the prevalence of the clinical forms (Class III/1 and III/2 malocclusions) in accordance with the sex of the patients we concluded that: - Of the grand total of 613 boys, 2 cases (0.33%) represent Class III/1 malocclusions and 7 cases (1.14%) represent Class III/2 malocclusions (fig. 26); - Of the grand total of 714 girls, 1 case (0.14%) represents Class III/1 malocclusion and 7 cases (0.98%) represent Class III /2 malocclusions (fig. 27). 24 without Angle Class III malocclusions 604 98,53% malocclusions III/1 2 0,33% malocclusions III/2 7 1,14% malocclusions III/1 malocclusions III/2 without Angle Class III malocclusions Fig. 26 The statistics of Class III malocclusions to boys malocclusions III/2 7 0,98% malocclusions III/1 1 0,14% without Angle Class III malocclusions 706 98,88% malocclusions III/1 malocclusions III/2 without Angle Class III malocclusions Fig. 27 The statistics of Class III malocclusions to girls. Thus, we can conclude that from 17 clinical cases of Class III malocclusions (prevalence of 1.28%), 3 cases are Class III 25 malocclusions of the 1 st subdivision (0.22%), and 14 cases are Class III malocclusions of the 2 nd subdivision (1.06%). The group of children examined was divided into 2 age groups: 6-12 year-old children (mixed dentition) and 12-14 year-old (permanent dentition). We mainly had in view: - The total number of Class III malocclusions; - Their repartition in accordance to the sex of the patients; - The prevalence of Class III malocclusions clinical forms (1 and 2). 6.4. RESULTS AND DISCUSSIONS The investigated group was made up of 1327 pupils, 1033 being from the urban area and 294 pupils from the rural area; 613 were boys and 714 were girls (fig.19). As far as Class III malocclusions are concerned, the results are: - Of 1327 pupils examined (urban and rural) 17 (1.28%) were identified with class III malocclusions, of which: o 3 cases (0.22%) were Class III/1 malocclusions (all in the urban area); o 14 cases (1.06%) were Class III/2 malocclusions (9 cases in the urban area and 5 in the rural one). - Taking into account the dentition types (mixed and permanent), the sex, the prevalence of Class III malocclusions and also the types of Class III malocclusions (1 and 2), the results are the following: o In the mixed dentition (age group 6-12 years old, 833 pupils) there were identified 14 cases (1.68%) of Class III malocclusions: 8 cases to boys, 2 cases of Class III/1 malocclusions and 6 cases of Class III/2 malocclusions; 6 cases to girls, 1 case of Class III/1 malocclusion and 5 cases of Class III/2 malocclusions 26 o In the permanent dentition (age group older than 12 years old, 494 pupils) 3 cases (0.6%) of Class III malocclusions: To boys, 1 case of Class III/2 malocclusion and no case of Class III/1 malocclusion; To girls, 2 cases of Class III/2 malocclusions and no case of Class III/1 malocclusion. Comparing the 1.28% value representing the prevalence of Class III malocclusions on the group of children examined with other authors values, we can state that: - This parameter is close to the 2.3% value (mentioned by PhD Prof. Valentina Dorob) 38 at national level; - It is consistant with the value of 1% published by R. Emrich, A. Brodie, I. R. Blayney; - The frequency of these Class III malocclusions is smaller in our country than in the countries from Asia (Japan 3- 5%, China 1.75%); the explanation may be that the anomalies from the sagittal plane are the result of some constitution features, race, culture and static life. 6.5. CONCLUSIONS In conclusion we can state that: - The frequency of Class III malocclusions is a little larger to children from the urban area; most of them are Class III/2 malocclusions. Their main cause may be the syndrome of premature loss of temporary teeth, newborn artificial feeding or the functional characteristic. functional; - The balance between Class III/1 malocclusions and Class III/2 malocclusions is of 1/4.67 cases; thus, Class III/2 malocclusions are more frequent and have more clinical forms; - The age group with mixed dentition presents the highest percent of Class III malocclusions; an explanation might 27 be given by the various transformations of transitory intercardiac occlusal contacts and by the practice of certain vitiated functions (parafunctions and dysfunctions that usually characterize this age when the biggest morpho-functional imbalances take place at the level of the dento-maxillo-cranial complex). - The first and most important element when interpreting the study was the biological parameter of dental occlusion (Angle classification) which generally reflects the morpho-functional imbalances during the growth of cephalic end; - The prevalence of dento-maxillary anomalies keeps on growing which makes us state that this may represent one of the modern civilisation features; - Worldwide exogamy (mixtures of human races, of different types of constitutions), worldwide processes of industrialisation, the civilisation all together have lately contributed to the increase of risk factors that produce dento-maxillary anomalies; - Knowing the growth patterns and the development anticipation of population as well as implementing prophylactic programs represent study tasks and practical use of orthodonthics. Chapter. 7 ETIOPATHOGENY, DIAGNOSIS AND CLINICAL MANIFESTATIONS OF CLASS III MALOCCLUSIONS 7.1 THE GOAL OF THE PAPER There are three important elements that must be known before proceeding to establish a correct diagnosis, method and the treatment way in the case of Class III malocclusion: the cause, the production mechanism of the malocclusion and its clinical manifestation. 28 7.2. OBJECTIVES 7.2.1. RESEARCH OF THE CAUSES THAT PRODUCE CLASS III MALOCCLUSIONS The etiopathogeny of the various clinical forms of Class III malocclusions in sagittal plane is polygenic and complex, the general factors and the loco-regional ones associating and acting together. The result of their actions is in fact a disorder of dimensional growth (either in excess or in minus), of direction, rhythm and unproportional at the level of the constitutive parts of the dento- maxillary apparatus. Thus, real mandibular prognathism presents an exaggerated development of the mandible in comparison to the upper jaw, occlusion transformation in all the three planes, especially in the sagittal one (Class III molar) and reversed frontal occlusion associated with functional and facial aesthetics disorders. 7.2.2. CLINICAL MANIFESTATIONS AND DIAGNOSIS OF EACH TYPE OF ANGLE CLASS III MALOCCLUSION Angle Class III malocclusions (according to Langlade) 66 are sagittal disorders of the following reports: - Maxillo-mandibular; - dento-maxillary. These are marked by: - aesthetic signs: o concave profile; o upper pro/ retro dentition or both; - skeletical signs: o with or without, by maxillary distortions in serious malocclusions; o of mandibular length and position coexisting or nor with anomalies of maxillary position; - dental signs: o most often a reversed frontal occlusion; o Class III molar and canine reports. Mandible may be developed in excess ( real anatomic mandibular prognathism) or may be guided towards anterior by 29 abnormal occlusal reports (functional protrusive mandible by the insufficient development of the upper jaw, by abnormal cusp relations by means of ligamentous and intracapsular laxity at the ATM level or even by axis modification of the inferior incisive group). 7.3. MATERIAL AND WORK METHOD Along my work years I have formed a group of 10 patients that have been examined in order to set a diagnosis based on clinical and other investigations. Thus, I discovered the following clinical types of Angle Class III malocclusions: - Mandibular prognathism Angle Class III /1, 3 cases: o F.O. 268, T.B.; o F.O. 332, B.E.; o F.O. 222, B.L.. - Upper jaw retraction, Angle Class III/2, 3 cases: o F.O. 1022, C.R.; o F.O. 1026, S.P.; o F.O. 1018, N.L.. - Upper jaw retraction with compensatory pro- alveolodentition, Angle Class III/2, 1 case: o F.O. 1070, C.S.. - Mandibular retrusion, Angle Class III/2 Angle, 1 case: o F.O. 1066, D.A.; - Inferior pro-alveolodentition with frontal reversed occlusion, Angle Class III/2, 1 case: o F.O. 1006, G.A.. - Bimaxillary pro-alveolodentition with opened frontal occlusion Angle Class III, 1 case: o F.O. 1076, F.G.. F.O. 268, T.B. - Age 14 years old; - Sex - male; 30 - Motivation: o Disorders of facial aesthetics; o Functional disorders regarding mastication, deglutition (infantile deglutition), phonation, social integration problems; - General development: tip hypersome, over average weight in accordance with his age; - A.H.C.: both parents (especially his father), have the same somatic development and weight; - Facial investigation points out a symmetrical face, the inferior floor being high and the labial step reversed. (Fig. 28, Fig. 29); Fig. 28 Initial face photo. Fig. 29 Initial photo of the right profile 31 - The development of alveolodental arches: the alveolodental arch of the upper jaw has permanent dentition and is undeveloped in the sagittal and transversal planes. It also presents dental crowding in the frontal zone and a slight infraocclusion in the incisive zone. The dental alveolar arch of the mandible has a very developed alveolar base but all the teeth are lingualised and there are some teeth crowding in the frontal zone; - Occlusion diagnosis: molar and canine malocclusion inversely mesialised with slight reversed sagittal inocclusion and slight interincissive occlusion opened frontally. (Fig. 30, Fig. 31, Fig. 32); Fig. 30 Initial face model in occlusion. Fig. 31 Right profile initial model in occlusion. 32 Fig. 32 Left profile initial model in occlusion. - The oral investigation consists in: o Ogive vault of medium depth; o Steep and well emphasised alveolar arches; o Big palatal torus, palpable in the medium and posterior third; o Large, hypertonic tongue; o Impressures of the lingual surfaces on the lingual edges; o The interposition of the tongue in the incisive zone (infantile deglutition); o Increased tonus of the circumoral muscles (orbicular and buccinators ones); - Orthopantomogram: highlights the presence of molar buds 3 and the mesialised ratios (Fig. 33); 33 Fig. 33 Initial orthopantomogram - Initial cephalometric analysis points out (Fig. 34, Fig. 35): o Mesialised occlusal ratios; o The normal development of the upper jaw base, angle SNA= 83; o The slight development of the mandibular base, angle SNB= 88, with angle ANB= -5, which show the intermaxillary discrepancy from the sagittal plane (thus, Angle Class III malocclusion); o Angle FMA= 34 (+9), hyperdivergent type, thus a growth of the facial massif mainly downward and forward and a serious diagnosis of the facial massif development; o Angle FMIA= 71 (+6); o Angle IMPA= 76 (-14), inferior retraction which is the cause of the slight frontal mandibular teeth crowding; o Angle axI/plF= 120; o Nsa Nsp= 5,5 cm.; o Go Gn= 9cm.; 34 Fig. 34 Initial radiograph. Fig. 35 Initial radiograph interpretation. - Neuro-endocrine investigation: a slight hyperfunction of hypophysis at the anterior lobe ; 35 - Morphologic diagnosis: Angle Class III/1 malocclusion with a frontally opened occlusion, laterally reversed occlusion and reversed sagittal inocclusion; - Etiologic diagnosis: Angle Class III/1 malocclusion probably caused by the associated action of the following factors: o General: the hyperfunction of the hypophysary anterior lobe that secretes a high quantity of somatotrophic hormone; o Loco-regional: the persistence of infantile deglutition and the vicious habit of biting the jugal and labial mucosa; - Functional diagnosis: the following functions are affected: o Deglutition function by the persistence of infantile deglutition; o Phonation function by the pronunciation of sibilant consonants; o The masticatory function of incesting the food determined by an interincissive opened occlusion; o Aesthetic function; o The function of social integration in collectivity. F.O. 1018, N.L. - Age: 13 years old; - Sex: female; - Motivation: o Disorders of facial aesthetics ; o Functional disorders: of mastication, phonation and social integration; - A.H.C.: not important; - General development: normosome type, normal weight; - Facial investigation reveals: flat features, a slight concave profile, the equality of face floors, superior retro baldness generating the inversion of labial step, Gn placed normally (Fig. 72); 36 Fig. 72 Initial photograph right profile. - The development of alveolodental arches: the alveolar arch slightly reduced in comparison to the coronoid arch, dento-alveolar disharmony with slight dental crowding, reversed frontal occlusion and mesialised occlusion towards the right; - Occlusion diagnosis: mesialised malocclusion bilaterally marked at the level of molars and canines with frontal reversed occlusion and a slight frontal reversed overbite. (Fig. 73, Fig. 74, Fig. 75); Fig. 73 Face in occlusion initial model. 37 Fig. 74 Right profile in occlusion initial model. Fig. 75 Left profile in occlusion initial model. - The oral investigation consists in: o Deep vault palatine; o Well represented alveolar arches; o Absent palatine torus; - Orthopantomogram reveals (Fig. 76): o The absence of molar buds 3; o The atrophy of alveolar mandibular limbuses; o The descent of epithelial insertions; 38 Fig. 76 Initial orthopantomogram. - The initial cephalometric analysis emphasizes (Fig. 77, Fig. 78): o Angle SNA= 72 (-10), superior maxillary retrusion; o Angle SNB= 81 the normally developed mandible; o Angle ANB= -9, Angle Class III/2 malocclusio; o Angle Go= 130 (+10), mandibular downward growth, the reversed overbite is small; o Angle FMA=33 (+6), significant growth forward and downward; o Angle FMIA= 57 (-8); o Angle IMPA= 95 (+5), inferior pro dentition; o Angle I/i= 125; o Angle i/N-B= 34 (+9), inferior pro dentition; o Angle plM/plN-S= 37 (+9), anterior vertical growth; o Angle Z tangential to the inferior lip; o Spna-Spnp/Gn-Go=5,1/8,1=0,63; o Nsa Nsp= 5,1 cm.; o Go Gn= 9,2 cm.; 39 Fig. 77 Initial radiograph. Fig. 78 Interpretation of initial radiograph. - Morphologic diagnosis: Angle Class III/2 malocclusion with upper jaw retrusion; 40 - Etiologic diagnosis: Angle Class III/2 malocclusion caused by: o Hyper tonicity of the superior orbicular muscle; o Congenital factor; - Functional diagnosis: the following functions are affected: o Masticatory function; o Aesthetic function; o Phonation function; o The function of social integration in collectivity; 7.4. RESULTS AND DISCUSSIONS The study was made on a group of 10 patients both male and female that presented malocclusions in the sagittal plane; their age was between 11 and 23 years old. (Fig. 110). No . Crt No. F.O. Name first name, Sex, Age Diagnosis of Angle Class III malocclusion in the sagittal plane Etiopathogeny 1 268 T.B. M 14 Angle Class III/1 malocclusion Endocrine factor: the hyper function of the hyphophysary anterior lobe; loco-regional factors: infantile deglutition, the parafunction of biting the upper lip, macroglossia, the bad habit of protruding the mandible 2 332 B.E. F 11 Angle Class III/1 malocclusion Endocrine factor: hypothyroidism; loco- regional factors: sleeping with the head in hyperflexis, the parafunction of biting 41 the upper lip, macroglossia 3 222 B.L. F 12 Angle Class III/1 malocclusion Endocrine factor: hypothyroidism; hereditary function: mother presented Angle Class III/1 malocclusion; loco- regional factors: the parafunction of biting the upper lip, macroglossia and muscular hypo tonicity 4 1022 C.R. M 11 Angle Class III/2 malocclusion, upper jaw retraction with frontal reversed occlusion Hereditary function: mother presented a similar malocclusion, mongoloid facial type,; loco-regional hypertonicity of superior orbicular muscles 5 1026 S.P. M 14 Angle Class III/2 malocclusion, upper jaw retraction with reversed frontal occlusion Hereditary function: mother presented a similar malocclusion, mongoloid facial type,; loco-regional hypertonicity of superior orbicular muscles 6 1018 N.L. F 23 Angle Class III/2 malocclusion, upper jaw retrusion with reversed frontal occlusion Hereditary function: mother presented a similar malocclusion, mongoloid facial type,; loco-regional hypertonicity of superior orbicular muscles 42 7 1070 C.S. F 23 Angle Class III/2 malocclusion, upper jaw retrusion with maxillary and compensatory proalveolo- dentition Loco-regional factors: macroglossia, infantile deglutition, open bite 8 1066 D.A. M 12 Angle Class III/2 malocclusion, mandibular retraction Loco-regional factors: the hypertonicity of superior orbicular muscles and the hypertonicity of retrusionary mandibular muscles 9 1006 G.A. M 12 Angle Class III/2 malocclusion, inferior proalveolodentitio n with reversed frontal occlusion Loco-regional factors: the hypertonicity of superior orbicular muscles and the bad habit of biting the upper lip 10 1076 F.G. M 21 Angle Class III/2 malocclusion, bimaxillary proalveolodentitio n with open frontal occlusion Loco-regional factors: the hypertonicity of superior and inferior orbicular muscles, oral respiration and infantile deglutition Fig. 110 Table of the patients centralised data. In the above mentioned table we can remark that the average age of the patients that presented to orthodontic consultation in search for a treatment was of 14 years old and 3 months when the growth process had already stopped. The etiopathogeny of these clinical forms of malocclusions in the sagittal plane is complex and diversified. 43 The variety of etiopathogenic factors consists in the great number of causal, general (genetic, endocrine, dysmetabolic) and loco-regional factors: - parafunctions; - dysfunctions; - disorders of vertebral statics and an increasing or decreasing tonus of the following muscles: lingual, labial, propelling or retrusional muscles of the mandible; - less numerous factors but probably undetected in anamnesis (inflammatory factors, the integrity state of alveolo-dental arches, dental eruption disorders, cheloid scars of muscular girths); - the transformation of the functional underhung jaw into a real one. The seriousness of etiopathogenic factors consists in their cumulative action which leads to a vicious circle that intervenes in the growth processes of the dento-maxillary apparatus, modifying their dimension, growth direction and rhythm. 7.5. CONCLUSIONS The etiopathogeny of malocclusions from the sagittal plane is diversified and complex due to the big number of causal factors: - general ones: o genetic; o endocrine; o dysmetabolic; - loco-regional factors: o vitiated functions (oral respiration, infantile deglutition); o dysfunctions (the bad habit of propelling the mandible, vicious habits: biting the lips, sucking the fingers); o vertebral statics disorders during sleeping time (bent head); o the lack of abrasion at canines cusps ; o disorders of the teeth integrity state; 44 o disorders of dental eruption; o inflammatory factors o cheloid scars of the labio-genio-pharyngeal muscular girth; o cheilo-gnatho-palatal clefts. Causal factors usually associate and act in the growth and development period of the dento-maxillary apparatus generating multiple changes. Dimensional, form, rhythm and growth changes also apply to all the basic components of the dento-maxillary apparatus: (bones, muscles, intermaxillary reports and alveolo-dental arches). When patients present to orthodontic consultation all these factors have already produced essential changes to the elements of the dento-maxillary apparatus. One of the main reasons is the lack of specialized dental hygene education in the large groups of children (children nurseries, kindergartens and schools) as well as the diagnosis and guidance of the cases towards orthodontic consultations. The clinical manifestations are diverse and specific to each clinical form of Angle Class III Malocclusion but the positive diagnosis is set only after further cephalometric analyses. Chapter. 8 POSSIBILITIES AND LIMITS OF TREATMENT IN ANGLE CLASS III MALOCCLUSIONS The objectives, methods and treatment possibilities have to be associated with: - the type of anomaly or better said the clinical form; - the seriousness of the anomaly; - patient age, dentition type (temporary, mixed, permanent); - socio-economic factors. 45 8.1. THE GOAL OF THE PAPER The goal of the present paper was to evaluate the methods and means of treatment used in the treatment of Angle Class III Malocclusions 8.2. OBJECTIVES - to evaluate the results obtained in the treatment of Angle Class III malocclusions by using orthodontic and orthopaedic means: functional and biomechanical; - to evaluate the treatment means used in fixed therapy. 8.2.1. TEMPORARY DENTITION 8.2.1.1. PROPHYLACTIC TREATMENT Whenever one of the elements from the dento-maxillary apparatus grows more than the other one, following a different development rhythm determined by genetic or functional factors, there is the danger of generating a malocclusion in the sagittal plane. The therapeutical attitude in this case consists in controlling the occlusion, in following a general medical investigation in order to exclude neuro-endocrine or metabolic factors. There are many prophylactic methods of treatment such as: keeping record and control of all these children, following a general medical treatment (in cases of endocrinopathy, rickets) or a simple orthodontic treatment that can correct a bad habit that may affect the normal functions of the dento-maxillary apparatus. Successful prophylactic measures applied to school and preschool children could reduce considerably the great number of dento-maxillary anomalies, being the most economic and efficient means of treatment. 46 8.2.1.2. THERAPEUTICAL ASPECTS OF FUNCTIONAL PROTRUSIVE MANDIBLE The reversed frontal occlusion which is a clinical sign of functional protrusive mandible of cusp guidance is quite a frequent anomaly in temporary dentition. The factors that generate the anomaly to preschool children must be known before proceeding to causal and functional therapies. Early treatment should be applied in the initiation stage of the disharmony in order to obtain a normal incisive report not later than the eruption of permanent incisors. The disharmony can be noticed in the initiation stage when there is a strong propelling tendency of the mandible in order to search for a comfortable position in the absence of the inferior abrasion of temporary canines or when the reversed occlusion is already set but the retrusion test is positive. Removing the cusp slopes of inferior temporary canines that lack the abrasion of stripping is enough. Stripping is to be done in stages, taking into account the childs sensitiveness as well as the tooth anatomy. At the same time, the occipito-mental traction is associated with chin cap and headcap in order to prevent the propelling habit and to limit the large openings of the mandible. It is recommended a constant use of the chin cap (during the day, the night or the meals of the day) at least 3 months in accordance with the severity of the case and the patient reaction. 8.2.2. MIXED DENTITION 8.2.2.1. THE TREATMENT PLANNING IN MIXED DENTITION In the mixed dentition the treatment doesnt inhibit the normal development of dentition. The emphasis should be on the guidance of growth, on the interception of a development malocclusion and on the elimination of any symptoms that can turn into a serious occlusion matter in the permanent dentition. 47 The early fundamental objective of Class III is that of creating an environment in which a favourable dento-facial development appears. 8.2.2.2. THE GOALS OF INTERCEPTIVE TREATMENT The goals of interceptive treatment may include: - to prevent irreversible pregressive modifications of bony and soft tissues; - to improve the skeletal discrepancies and to produce a favourable environment for future growth; - to improve the occlusal function; - to simplify the second stage of treatment; - to minimize the necessity of a surgical and orthopaedic treatment; - to obtain a pleasant facial aesthetics thus contributing to the psycho-social development of the child. 8.2.2.3. THE INCIPIENT PHASE OF MIXED DENTITION (THE FIRST STAGE) During mixed dentition, there are also other modifications and consequences after extractions such as: dento-alveolar incongruity and opened occlusion which require an individualised therapy. The treatment period mainly depends on the clinical form, the degree of modifications and the complexity of the clinical chart. The treatment period may be between 5 months and 4 years. The treatment may be considered successful if one of the following conditions is fulfilled: - the primary etiological factors were removed or controlled; - the teeth positions and the necessary space are satisfying and can be maintained until the end of mixed dentition; - the initially presented skeletal deviations were improved to the initially planned degree and extent and can be 48 controlled until dentition has completed and the skeletal growth diminished. 8.2.2.4. THE LATE PHASE OF MIXED DENTITION (THE SECOND STAGE) The early treatment of Class III chin-headcap and functional appliances of expansion based on dento-facial orthopaedics is only partially successful because the highest degree of efficiency is obtained between 11 and 13 years old. To patients that had precocious correction of their incisive relation the treatment is continued in order to solve the crowding and align the rest of the teeth. If the overbite is small a fixed appliance may be used by bracing all superior incisors. The vertically anterior growth of the face reduces the overbite which diminishes the risk of recurrence. In order to choose the best treatment (that of correcting the negative overbite) a surgical modelling of the skeleton helps in estimating the future facial aspect. This estimation must be done when the mandible is at rest in order to avoid obtaining a fake image because of the anterior movement of the mandible in maximum interdigitation. 8.2.3. PERMANENT DENTITION 8.2.3.1. ORTHODONTIC ORTHOPAEDIC TREATMENT A malocclusion that presents a slight mandibular prognathism and a moderate overbite may be corrected by dento-alveolar movements. Class III elastics with or without extractions may be used to cover the skeletal discrepancy towards an acceptable facial profile. Class III malocclusions with a slight mandibular prognathism and crowding may be treated by extractions of the second maxillary premolar and first mandibular premolar. In the most severe cases when the overjet can not be corrected by a simple inclination of superior incisors (where the 49 overbite is very small, where other teeth have an unfavourable position) it is recommended to use the treatment with fixed orthodontic appliances. 8.2.3.2. ASSOCIATING ORTHODONTIC THERAPY WITH ORTHOGNATHIC SURGERY Patients that present a sagittal and vertical disproportional growth of the mandible, a Class III maxillary retrognathism or mandibular prognathism and a hyper diverging growth pattern have reduced nonsurgical options. Early surgery is a possible solution but maxillary surgery to a child may influence the already delayed growth in a negative way. Patients with mandibular prognathism can continue the growth of the mandible several years after puberty. 8.2.4. INDIVIDUALISED TREATMENT TO ANGLE CLASS III MALOCCLUSIONS The treatment of Class III malocclusions is determined by the relation between the two maxillaries: - normal maxillary and a skeletal protrusive mandible; - maxillary retrusion and a normal mandible; - combination: maxillary retrusion and mandibular protrusion. 8.2.5. FIXATION IN ANGLE CLASS III MALOCCLUSIONS A definition of orthodontic fixation could be: the maintenance of teeth in ideal aesthetic and functional positions. Fixation conditions are frequently decided when diagnosing or completing achieving the treatment plan. The great expansions of dental arches, the severe modifications of the arch form, the incomplete correction of antero-posterior bad relations or the uncontrolled rotations may need fixation measures. 50 8.3. MATERIAL AND WORK METHODS I treated 19 patients (in my private consulting room or at the Orthodontic Clinic from the Faculty of Dental Medicine Craiova) suffering from dento-maxillary anomalies in sagittal plane, 10 being selected for the present PhD research paper. The used method of treatment was the technique of right arch, the treated patients having permanent dentition. The objectives of fixed therapy were different (for each and every patient) in accordance with the clinical type of Angle Class III malocclusion. F.O. 268, T.B. - Diagnosis: Angle Class III/1 malocclusion, mandibular prognathism, frontal open occlusion and reversed sagittal inocclusion; - Treatment: fixed therapy, Straight-wire therapy with the following objectives (Fig. 111, Fig. 112): o The expansion of the alveolo-dental arches of the upper jaw; o The alignment of maxillary and mandible frontal teeth; o Intermaxillary elastic tractions Class II; o Intra-extra oral tractions with the Delaire mask; o To reduce the opened frontal occlusion and the reversed sagittal inocclusion; Fig. 111 Photograph of open mouth during treatment. 51 Fig. 112 Photograph face in occlusion during treatment. - The interpretation of radiograph 2 after 5 years of orthodontic treatment and comparing the values of these angles with the ones from the first radiograph we notice their recovering to normal values (Fig. 113, Fig. 114): o Angle SNA= 83; o Angle SNB= 85; o Angle ANB= -2; o Angle FMA= 28; o Angle FMIA= 63; o Angle IMPA= 89; o Angle axI/plF= 118; o Nsa Nsp= 5,5 cm.; o Go Gn= 9cm.; 52 Fig. 113 Final radiograph. Fig. 114 Interpretation of final radiograph. - The fixation will be on a long period of time until the growth of the mandible stops. (27 years old). 53 F.O. 1018, N.L. - Diagnosis: Class III/2 malocclusion, retraction of upper jaw; - Treatment: fixed orthodontic therapy which had the following objectives (Fig. 134, Fig. 135, Fig. 136): o The development of upper jaw in sagittal and transversal plane; o Getting the occlusion reports from sagittal and transversal plane to a normal state; o Ensure a frontal overcover of at least 1/3 of the inferior frontal teeth height; Fig. 134 Face photograph of open mouth at the end of the treatment. Fig. 135 Photograph face in occlusion at the end of the treatment. 54 Fig. 136 Photograph left profile at the end of the treatment. - Radiograph 2 proves the normal values of the cephalometric angles (Fig. 137, Fig. 138): o Angle SNA= 82; o Angle SNB= 80; o Angle ANB= +2; o Angle Go= 124; o Angle FMA=33; o Angle FMIA= 61; o Angle IMPA= 87; o Angle I/i= 120; o Angle i/N-B= 24; o Angle plM/plN-S= 38; o Nsa Nsp= 5,2 cm.; o Go Gn= 9,2 cm.; 55 Fig. 137 Final radiograph. Fig. 138 Final radiograph interpretation. - By fixation we referred to the maintenance of the fixed appliance up to 18 years old. Fig. 139 reveals the maintenance of occlusal reports, the photograph being taken at 20 years old. 56 Fig. 139 Photograph face in final occlusion. 8.4. CONCLUSIONS Of the total number of cases investigated, 3 represent Angle Class III/1 malocclusions and the rest of 7 cases are Angle Class III/2 malocclusions. The main clinical form is upper jaw retrusion. In the same subdivision Angle Class III/2 malocclusions we can also include pseudoprotrusions that guide the mandible (the group of functional mandibular protrusions), the mandibular condyle, or simply the mandible towards the so called premature contacts in the closing movement of the mouth (steep cuspian slopes). Another clinical form of functional pseudoprotrusion is produced by changes of the axis of frontal teeth eruption thus reversed interlocking of frontal dental groups. These clinical forms of pseudoprotrusions are easily diagnosed and the treatment can be done by any dentist if discovered in time. Still when they are not discovered and treated at the right time, they may turn into Angle Class III/1 malocclusions. Chapter 9. RESULTS AND GENERAL DISCUSSIONS Our epidemiological study had in view a sample of 1327 pupils (boys and girls) between 6 and 14 years old from Craiova and the neighbourhood area. The result emphasized a 1.28% prevalence of Angle Class III malocclusions. This percent may vary in accordance with: 57 - Life environment (urban 77.84% and rural 22,16%), are three and a half times bigger in the urban area than in the rural one, because of the following aspects: o The agitated, stressful life environment of both mother and child; o Artificial feeding of newborn baby which is very frequent nowadays and thus the bad habits that may appear from this age; o Combinations of genes as a result of mixed populations; o The great number and variety of clinical forms that characterize Angle Class III malocclusions (243 of clinical forms according to Ellis and McNamara) 40 ; - Age group; - Insufficient sanitary education; - A lack of specialized dentists especially in the large groups of children (in kindergartens and schools). The presented cases highlight the complex etiopathogeny of Angle Class III malocclusions, of internal (neuro-endocrine) and external factors (the normal and pathologic functions). They work altogether in the adapting and modelling process of the individual genetic inheritance. . Except for the genetic malocclusions, all the rest of dento- maxillary anomalies are initially functional, the morphologic changes appearing later in time. The specific normal functions of the dento-maxillary apparatus interrelate with the help of the muscular system which is organised in such a way that the bones are inserted in a muscular tunnel and are influenced by the above functions in the process of growth, development and modelling. The vitiated functions act in the same way but develop the maxillary bones in a different direction, influencing the individual genetic pattern. However, not all children with bad habits develop malocclusions. The answer may be found in the resistance of genetic pattern (V. Dorob) 38 . If the genetic pattern is overcome, the seriousness of the anomaly will depend on the following three 58 elements: frequency, intensity, and the length of time to practise the vitiated functions. (according to Graber, quoted by V. Dorob) 38 . The great number of causal factors and their complexity as well as their concentrated and cumulative action determines disorders of dimensional growth and rhythm at the level of maxillaries leading to dimensional disproportions of the maxillaries and the mandible. One of the main features of Angle Class III malocclusions is that they become more and more serious as the time passes by thus it is important to discover them as early as possible. Functional mandibular protrusion is a relevant example in this sense. There are at least 243 clinical forms of Angle Class III malocclusions (according to Ellis and McNamara) 40 proved by a deep knowledge and a correct interpretation of complementary investigations. They may also result from the confirmation of the morphologic, functional and etiological diagnosis of Angle Class III anomaly. I consider important to mention that the correct interpretation of further investigations such as :(model analysis, photograph analysis, orthopantomogram and radiograph analysis as well as cephalometry) constituted valuable papers in establishing a correct diagnosis and therapeutical method. I also had in view the possible recurrence of malocclusions (having to do with very serious skeletal anomalies) and the different growth of the two jaws, the mandible growing up to 27-28 years old while the upper jaw stops growing at the age of 18. Thus fixation appliances are compulsory for a long period of time even for a lifetime. The studied cases benefitted from orthodontic treatment, mainly the Straight-Wire method. 59 Chapter 10. FINAL CONCLUSIONS AND PRACTICAL DIRECTIONS OF APPLYING THE CONCLUSIONS DERIVED FROM THE STUDY 10.1. FINAL CONCLUSIONS The epidemiological results of the sample of investigated children revealed a prevalence of 1.28% Angle Class III malocclusions. Angle Class III malocclusions may be differentiated according to: o Clinical forms: Angle Class III/1 0.22%, Angle Class III/2 1.06%; o The source environment: urban 77.84%, rural 22.16%; o Correlation between Angle Class III malocclusions and the source environment: Urban: Angle Class III/1 Angle 0.29%, Angle Class III/2 0.87%, without Angle Class III malocclusions 98.84%; Rural: Angle Class III/1 Angle 0.00%, Angle Class III/2 1.7%, without any Angle Class III malocclusions 98.3%; o Correlation between the clinical forms of Angle Class III malocclusions and sex: Boys: Angle Class III/1 0.33%, Angle Class III/2 1.14%, without any Angle Class III malocclusions 98.3%; Girls: Angle Class III/1 0.14%, Angle Class III/2 0.98%, without any Angle Class III malocclusions 98.88%; The main clinical forms are represented by Angle Class III/2 malocclusions (pseudoprotrusions) which appear in infancy; they may be easily discovered and treated by short term preventive treatments; 60 The frequency of Angle Class III malocclusions is 3.5 times bigger to children from the urban area than children from the rural one; The clinical form of Angle Class III/1 malocclusion has a 0.29% frequency in the urban environment and 0.0% in the rural area, the situation being totally opposite in Angle Class III/2 malocclusions (it is more frequent in the rural environment probably because of insufficient sanitary education); The clinical forms of Class III Angle malocclusions are more frequent to boys than to girls; The mixed dentition age group presents the highest percent of Angle Class III malocclusions because of the multiple transformations of transitory intercardiac occlusal contacts as well as of the practice of bad habits (the parafunctions and dysfunctions specific to this age) when most morpho- functional changes take place at the level of dento-maxillary- cranial complex; In the interpretation of the present study we paid much attention to the biological parameter of dental occlusion (Angle classification) which reveals the possible morpho- functional disorders from the period of cephalic development; The prevalence of dento-maxillary anomalies keeps on growing which makes us state that this may represent one of the modern civilisation features; Worldwide exogamy (mixtures of human races, of different types of constitutions), worldwide processes of industrialisation, the civilisation all together have lately contributed to the increase of risk factors that produce dento- maxillary anomalies; Knowing the growth patterns and the development predictions of the population as well as implementing preventive programs represent study tasks and practical issues of orthodontics.; The present research points out the necessity of extended population studies on large groups of individuals (kindergartens, schools) and their guiding towards; Thus, the 61 treatment strategies are changed in the favour of early orthodontic therapy as soon as possible; As a consequence, the medical consulting rooms from the school network should be extended and the hygene education should be encouraged; The clinical forms of Angle Class III/1 and Angle Class III/2 malocclusions (upper microretrusion) have as essential etiopathogenetic element the genetic factor; The evolution factors of the dento-maxillary apparatus and the local pathologic factors act together with the genetic factor transforming the malocclusion from the sagittal one into a very serious anomaly; The great number and the various types of clinical forms are amplified by the directional and quantitative imbalance of growth in the relation of interdependence between the maxillary, tooth and muscle which are reflected in the dental occlusion thus, the term malocclusion being the mainly used designation for dento-maxillary anomalies; The diagnosis for Angle Class III malocclusion is established in the view of finding the nucleus of the disorder by using paraclinical investigations (photographs, model analyses, a series of retro-dento-alveolar radiographs, orthopantomograms, teleradiographs, cephalometry, electromyography and even tomography) and the clinical examination. The treatment is specific to each and every individual; most of the time, the fixed therapy is associated with the mobile one by using intra-extra oral tractions and in some case even surgical intervention; The balance obtained must be morphological and functional taking into consideration the aesthetic, functional and stability; The period of active treatment may vary in accordance with the age and the type of dentition, with the physiological growth access and the way the patient obeys the treatment indications; 62 Although the patient adheres to treatment rules there may be the risk of recurrence especially in the period the temporary dentition is replaced by the permanent one or during the eruption of molars 3; as a consequence a long fixation is necessary at least until 27 years old when the growth potential of condylian cartilage is assumed to stop; there are some cases when fixation is recommended for good in order to avoid surgical intervention; Mobile as well as fixed appliances were used (depending on the case) for the fixation period; The fixed retainer cannot be noticed and is very safe making the patient feel comfortable. 10.2. PRACTICAL DIRECTIONS OF PUTTING INTO PRACTICE THE CONCLUSIONS DEDUCTED FROM THE STUDY The conclusions regarding the epidemiology of Angle Class III malocclusions, the prevalence of the clinical forms as reported to their environmental origin, age, sex are the first studies of this type made in Oltenia and may be taken into consideration as reference point for further research. The results of this epidemiological study together with the national specialized literature may contribute to decision making in elaborating the programs of national sanitary policy. This epidemiological study is focused only on the discovery of clinical forms regarding Angle Class III malocclusions, the only study in the specialized literature being made by PhD Prof. V. Dorob 38 . The research may be extended in the future and associated with other forms of malocclusions (Angle Class I and II). 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