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UNIVERSITATEA DE MEDICIN I FARMACIE

GR. T. POPA IAI


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.
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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);
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- 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:
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- 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.
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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). The great
number and the various clinical forms of Angle Class III
malocclusions represent the starting point of a research that may be
extended.
Angle Class III malocclusions are perhaps one of the most
serious malocclusions and the approaches made in order to conceive
the orthodontic file may be extended in subsequent studies.
63
BIBLIOGRAPHY
1. BASIGNY F. Manuel dOrthopedie Dento-Faciale, Ed.
Masson, Paris, 1991;
2. BISHARA S.E. Textbook of Orthodontics, Ed.
W.B.Saunders Co., Philadelphia, 2001;
3. BJRK A., SKIELLER V. Facial development and tooth
eruption, Am. J. Orthod., 62, 4, 339,1972;
4. BLOOMER H. Spech defects in relations to orthodontics,
Am. J. Orthod., 12, 920, 1963;
5. BOBOC Ghe. Anomaliile dento-maxilare, Ed. Medical,
Bucureti, 1971;
6. BOBOC Ghe. Aparatul dento-maxilar. Formare i
dezvoltare, Ed. a 2-a, Ed Medical, Bucureti, 1996;
7. CAUHP J., WALLOT J.J. A propos de deux
observations orthodontiques avec un troubles transversal
darticul, Rev. Stomat., Paris, 3, 233, 1969;
8. CHATEAU M. Orthopedie Dento-Faciale, vol. 1, Ed. CdP,
Paris, 1994;
9. COCRLA Elvira Stomatologie Pediatric, Ed. Medical
Universitar J.Haieganu, Cluj-Napoca, 2000;
10. COSTA E. Raionamentul medical n practica
stomatologic, Ed. Medical, Bucureti, 1970;
11. COSTA P., TERESA M., Josep M Ustrell Torrent, Correia
Pinto Orthodontic camouflage in the case of a skeletal class
III malocclusion, World Journal of Orthodontics, 5, 3, 213-
223, 2004;
12. COZZA P., BRAMA L., ROSIGNOLI L., LAGANA G. Il
controlo della crescita mandibolare nelle III classi. Revisione
della literatura e considerazioni cliniche, Mondo-Ortodontico,
22, 5, 431-441, 1997;
13. COZZA P., GIANCOTTI A. Disarmonie di classe III.
Eziopatogenesi e motivazioni al trattamento precoce, Mondo-
Ortodontico, 23, 4, 245-255, 1998;
14. CUUI M., NETIANU V., TR M.
Electromiografia computerizat n patologia ortodontic, Ed.
Aius, Craiova, 1997;
64
15. DEGUCHT T., McNAMARA J.A. Craniofacials
adaptations induced by chincup therapy in class III patients,
Am. J. Orthod. Dento-Fac. Orthop., 115, 175-182, 1999;
16. DELAIRE I. - Lintrication des fonctions de lextremite
cephalique et les inter-relations morpho-fonctionnelles oro-
faciales, Lorthodontie Francaise, 55, 1: 48-52, 1984;
17. DIEDRICH Peter Bracket Adhasivtechnick in der
zahnheilkunde, Hansen Verlag, 1983;
18. DOROB Valentina, PASNICU Letiia, PSREANU
Marinela, CURA Eugenia Prima perioad a dentiiei mixte:
o abordare ortodontic, Rev. Stomatologie, 1, 69-77, 1987;
19. ELLIS E., McNAMARA jr. J.A. Components of adult class
III open-bite malocclusion, Journal of oral and maxillofacial
surgery, 42, 295-305, 1984;
20. ENLOW D.H. Facial growth, Ed. W.B. Saunders, Londra,
1990;
21. FIRU P. Introducere n studiul anomaliilor dento-maxilare,
Ed. Academiei, Bucureti, 1981;
22. FRATU A.V. Creterea i dezvoltarea post-natal a
aparatului dento-maxilar, Ed. Vasiliana 89, Iai, 2001;
23. FRATU A.V. Ortodonie. Diagnostic, Clinic, Tratament,
Ed. Vasiliana, Iai, 2002;
24. GRABER L.W. Chincup therapy for mandibular
prognatism, Am. J. Orthod., 72, 1, 23-41, 1977;
25. GRABER T., RAKOSI T., PETROVIC G. Dentofacial
orthopedics with functional appliances, Ed. Mosby, St. Louis,
1985;
26. GRABER Th.M., VANARSDALL R.L. Orthodontics
Current Principles and Thechniques, Ed. The C.V. Mosby
Comp. St Louis, 1994;
27. GRIVU O., MECHER E., ARDELEAN A. Aspecte
practice n ortodonia interceptiv, Stomatologie, 4, 313-319,
1978;
28. GRIVU O., STROE Maria, BRATU Elisabeta, VEIN
Mariana Tratamentul ortodontic precoce n colectivitile de
copii precolari, Stomatologie, 2, 139-145, 1984;
65
29. GRIVU Ov., SINESCU C., FLORESCU Monica,
DRAGOMIRESCU D., ABDALLA N., LENMLARDT F.
Otodonie i Ortopedie Dento-Facial, Ed. Mirton, Timioara,
2001;
30. GUYER E.C., ELLIS E.E., McNAMARA J.A. Components
of class III malocclusion juveniles and adolescents, Angle
Orthodontics, 56,1,7-30, 1986;
31. HOUSTON W.J.B., TULLEY W.J. A textbook of
orthodontics, John Wright and sons, Bristol, 1986;
32. ISHIKAVA H., NAKAMURA S., KIM C., IWASAKI H.
Individual growth in class III malocclusion and its
relationship to the chincup effects, Am. J. Orthod. Dento-Fac.
Orthop., 114, 337-246, 1998;
33. ISHT H., MORITA S., TAKEUCHI Y., NAKAMURA S.
Treatment effect of combined maxillary protracion and
chincup appliance in severe skeletal class III cases, Am. J.
Orthod. Dento-Fac. Orthop., 92, 304-312, 1981;
34. JACOBSON A., EVANS W.G., PRESTON C.B.
Mandibular prognatism, Am. J. Orthod., 66, 140-171, 1974;
35. JACOBSON Al. Radiographic Cephalometry, Ed.
Quintessence Publishing Co Inc., Chicago, 2005;
36. LANGLADE M. Diagnostic Orthodontique, Ed. Maloine,
Paris, 1981;
37. LAVERGNE I. Modifications de la morphologie faciale des
patients au cours dune periode de 20 ans, Rev. Orthop.
Dento-Faciale, 36, 3: 435-450, 2002;
38. McNAMARA J.A., BRUDON W.L. Orthodontic and
orthopedic treatment in the mixed dentition, Needham Press.
Ann Arbon, Michigan, 1993;
39. MECHER E., GRIVU Ov. Aspecte legate de mezializarea
ocluziei n diverse anomalii dento-maxilare, Rev.
Stomatologie, 3, 203-209, 1980;
40. MESAROS Mihaela Tratamentul precoce n unele forme de
prognaie mandibular. Culegere de probleme de
stomatologie infantil vol. X, Bucureti, 157-161, 1983;
41. MILICESCU Viorica i colaboratorii Ortodonie i
Ortopedie Dento-Facial, Ed. Cerma, Bucureti, 2003;
66
42. MILICESCU Viorica, MILICESCU Duduca Ioana
Creterea i dezvoltarea general i cranio-facial la copii,
Ed. Viaa Medical Romneasc, Bucureti, 2001;
43. MOSS M.L. Function-fact or fiction, Am. I. Orthod., 67,6:
625-647, 1975;
44. MOSS M.L. The primary of functional matrices in oro-
facial growth. Practtioner, 19: 65-74, 1968;
45. MOSS M.L., SALENTI I.N. The primary role of functional
matrices in facial growth, Am. I. Orthod., 55, 6: 566-577,
1968;
46. MOSS M.L., SKALAK R. Space-time in cranio-facial
growth, Am. I. Orthod., 77, 6: 591-613, 1980;
47. MOYERS R.E. Handbook of orthodontics, Ed. Year-Book
Medical Publishers Inc., Chicago, 1998;
48. NAGAHARA K., SUZUKI T., NAKAMURA S.
Longitudinal changes in the skeletal pattern of deciduous
anterior crossbite, Angle Orthod., 67, 6, 439-446, 1997;
49. PASNICU Letiia Elemente de genetic n Ortodonie, Ed.
Corson, Iai, 2000;
50. PASNICU Letiia, FRATU V.A. Influena factorilor
genetici n anomaliile dento-maxilare clasa a III-a, Rev.
Ortodonie i Ortopedie Dento-facial, 1, 22-25, 2001;
51. Paulo COZZA, MARINO Alessandra, MUCEDERO
Manuela An orthopaedic approach to the treatment of class
III malocclusions in the early mixed dentition, European
Journal of Orthodontic, 26, 191-199, 2004;
52. POP E., CRLOGEA Valentina Prevalena anomaliilor
dento-maxilare la populaia infantil n vrst de 5-14 ani,
Rev. Stomatologie, 4, 297-307, 1983;
53. PROFFIT W., FIELDS H.W. Contemporary orthodontics,
Ed. C.W.Mosby Comp, St. Louis, Toronto, 1996;
54. RABIE A.B.M., HAGG U. Factors regulating mandibular
condylar growth, Am. J. Orthod., 122, 4, 401-409, 2002;
55. RABIE A.S.M., YAN G.U. Diagnostic criteria for pseudo-
class III malocclusion, Am.J.Orthod.Dentofac.Orthop., 117,
1, 1-9, 2000;
67
56. RAKOSI Th., DONAS I., GRABER Th.M. Diagnostic
orthodontique, Ed. G.Thieme, Stuttgard, 1993;
57. REICHENBACK E., BRUCKL H., Kieferorthopadische
Klinik und Therapie, Leipzig, 1971;
58. SCNTEI VALENTINA Studiul longitudinal al creterii i
dezvoltrii faciale, Rev. Stomatologia, 3: 213-221, 1981;
59. SCHWARZ M. Lehrgang der Gebissgelung, Viena, 1961;
60. SINGH G. D., McNAMARA J.A., LOZANOFF S.
Mandibular morphology in subjects with class III
malocclusion. Finit element morphometry, Angle
Orthodontist, 68, 5, 467-471, 1998;
61. STANCIU Drago, DOROB Valentina Ortodonie i
Ortopedie Dento-Facial, Ed. Medical, Bucureti, 2003;
62. STANCIU Drago, DOROB Valentina Ortodonie, Ed.
Medical, Bucureti, 1991;
63. STOCKFISCH H. The Principles and practice of
Dentofacial orthopaedics, Quintessence Publishing Co.,
Londra, 1995;
64. SUHTELNY J.D. Early Orthodontic Treatment, Ed.
Quintessence Publishing Co. Inc., Chicago, 2003;
65. ERBNESCU Alin Posibiliti i limite de apreciere a
deficitului de spaiu n anomaliile dento-maxilare, Ed.
Ripoprint, Cluj-Napoca, 2001.
66. THOMPSON I.R. The individuality of the patient in facial
skeletal growth, Am. I. O-DO, 105, 2: 117-127, 1994;
67. TULLEY W.I. A textbook of orthodontics, Ed. Wright,
Londra, 1998;
68. TURLEY P.K. Orthopedic correction of class III
malocclusions with palatal expansion and custom protraction
headgear, J.Clin.Orthod., 22, 314-325, 1998;
69. VACHER C., ONOLFO I.P., LEZY I.P., COPIN H. La
croissance du maxillaire chez lhomme, Rev. Stomatol. Chir.
Maxillofaciale, 102, 3-4: 143-153, 2001;
70. VALL- CUSSAC V. Variabilit du desequilibre
architecturale au travrs dun echantion de class III
squeletique et dentaire, Orthopedie francaise, 65, 1, 437-453,
1994;
68
71. VALL-CUSSAC V. Larhitecture cranio-faciale de
classes III selon lanalyse de Coben, Orthopedie Francaise,
62, III, 995-1019, 1991;
72. VERNESCU-LEHENI Victoria Unele aspecte ale
tratamentului ortodontic precoce, Stomatologie, 3, 243-248,
1965;
73. VOINEA Corina Cristina, BIL Anca, GRIVU OV.
Funcia muscular i aparatul dento-maxilar, Ed. Mirton,
Timioara, 1996;
74. WILLIAMS S., ANDERSEN C.E. The morphology of the
potential class III skeletal pattern in the young child, Am. J.
Orthod., 89:302-11, 1986;
75. ZEGAN Georgeta Ortodonie i Ortopedie Dento-Facial,
Ed. Tehnopress, Iai, 2005;
LISTA LUCRRILOR TIINIFICE PUBLICATE DIN
TEMATICA DOCTORATULUI
1. Ionela Teodora DASCLU (CUUI) Importana Studiului
Teleradiografiei (Metoda Tweed) n Diagnosticul
Anomaliilor Dento-Maxilare Clasa A III-A Angle, Revista
Romn de Stomatologie, volumul LVI, nr. 1, pag. 44-47,
2010;
2. Ionela Teodora DASCLU (CUUI) Etiopatogenia
Anomaliilor Dento-Maxilare Clasa A III-A Angle, Revista
Romn de Stomatologie, volumul LVI, nr. 1, pag. 48-50,
2010.

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