Anda di halaman 1dari 9

ORIGINAL ARTICLE

Diagnostic criteria for pseudoClass III malocclusion

A.B.M. Rabie, BDS, Cert Ortho, MS, PhDa and Yan Gu, BDSb
Hong Kong

The aim of this study is to identify the diagnostic criteria for pseudoClass III malocclusion and compare it
with Class I malocclusion in the southern Chinese population. Sixty-seven patients (mean age, 10.9 1.8
years) were included in this study; 36 patients represented pseudoClass III malocclusion. Selection criteria
included the following: (1) anterior crossbite (at least 2 incisors with negative overjet and overbite); (2)
mandibular displacement; (3) all patients were southern Chinese who had been followed after the growth
spurt, none had developed a skeletal Class III malocclusion; (4) the patients were treated for an average of
7 months to procline upper incisors and retrocline lower incisors. None of the cases received any treatment
that might affect skeletal growth. Thirty-one patients with Class I malocclusion were included in the Class I
malocclusion group for the comparison of dentoskeletal characteristics with the pseudoClass III
malocclusion group. Selection criteria included the following: (1) skeletal Class I malocclusion with normal
overjet and overbite, (2) mild to moderate crowding with Class I molar relationship, (3) straight facial profile.
The following were included in the assessment of pseudoClass III malocclusion cases: (1) family history,
(2) molar and canine relationships at habitual occlusion and centric relation, and (3) dentoskeletal
morphology. The results were that 72% of the examined cases in the pseudoClass III malocclusion group
showed no family history and 75% showed Class I molar relationship at habitual occlusion. Compared with
the Class I malocclusion group, subjects in the pseudoClass III malocclusion group showed a significantly
decreased midface length, increased maxillary-mandibular difference, more retroclined upper incisors, and a
retrusive upper lip. In conclusion, a pseudoClass III malocclusion is characterized by retroclined upper
incisors, retrusive upper lip, decreased midface length, and increased maxillary-mandibular difference.
Findings of this study showed that patients with a pseudoClass III malocclusion exhibit certain
morphologic, dental, and skeletal characteristics that should be of aid in the diagnosis of pseudoClass III
malocclusion. (Am J Orthod Dentofacial Orthop 2000;117:1-9)

Accurate diagnosis of skeletal and dental dentoalveolar compensation. Consideration of the vari-
components of a given malocclusion is essential in ous components of skeletal Class III was essential in
determining the proper approach and timing of treat- order to provide the appropriate treatment for the under-
ment. Individuals with Class III malocclusion may have lying cause of the discrepancy.10 Early treatment of
combinations of skeletal and dentoalveolar components. Class III malocclusion has been advocated for many
Characteristics of skeletal Class III malocclusion have years, and the goal is focused on providing a more
been well documented and widely compared with either favorable environment for normal growth and on
normal occlusion or Class I malocclusion.1-9 These improving the psychosocial development of the
characteristics could be summarized as the following: child.11,12 However, such an early treatment remains a
skeletal components with underdeveloped maxilla, challenge to the clinicians, and some relapse is usually
overdeveloped mandible, or a combination of both; den- noted during the pubertal growth period.10,13 On the
toalveolar components with proclined maxillary other hand, criteria for pseudoClass III malocclusion
incisors and retroclined mandibular incisors to achieve are ill-defined, and the dentoskeletal characteristics,
especially in the mixed dentition, are unclear. Tweed14
classified Class III malocclusion into 2 categories: Cat-
This work was supported by Grant 345/251/0932 from The University of Hong
Kong. egory A and Category B, where Category A was
From the Faculty of Dentistry, The University of Hong Kong. defined as pseudoClass III malocclusion with a con-
aAssociate Professor, Orthodontics., Faculty of Dentistry, The University of
ventional shape mandible. Moyers15 suggested
Hong Kong, Hong Kong, SAR.
bPhD candidate, Orthodontics. pseudoClass III malocclusion as a positional malrela-
Reprint requests to: A.B.M. Rabie, Orthodontics, Faculty of Dentistry, The Uni- tionship with an acquired neuro-muscular reflex.
versity of Hong Kong, Prince Philip Dental Hospital, No. 34 Hospital Road, PseudoClass III malocclusion has been identified
Hong Kong; e-mail, rabie@hkusua.hku.hk
Copyright 2000 by the American Association of Orthodontists. with anterior crossbite as a result of mandibular dis-
0889-5406/2000/$12.00 + 0 8/1/98736 placement.16,17 Premature contact between the maxil-
1
2 Rabie and Gu American Journal of Orthodontics and Dentofacial Orthopedics
January 2000

that of skeletal Class III malocclusion in the same pop-


ulation.23 With such an incidence of pseudoClass III
malocclusion compared with skeletal Class III maloc-
clusion, it is essential to identify diagnostic criteria for
pseudoClass III malocclusion.
The purpose of the current study is to identify the
diagnostic criteria for pseudoClass III malocclusion
in children from southern China and to compare it with
the dentoskeletal characteristics for Class I malocclu-
sions in a similar population.

SUBJECTS
PseudoClass III Malocclusion Group
Thirty-six patients (15 females and 21 males;
mean age, 10.6 2.0 years) with Class III incisor
relationship, treated in Orthodontics, Faculty of Den-
tistry, Hong Kong University, were included in the
pseudoClass III malocclusion group. Patients
Fig 1. Reference points and lines used in cephalometric selection criteria were: (1) Class III incisor relation-
analysis. ship (at least 2 incisors with negative overjet and
overbite) at HO; (2) mandibular displacement; (3)
treatment included proclination of upper incisors or
retroclination of lower incisors. None of the cases
lary and mandibular incisors results in forward dis- received any treatment that might affect skeletal
placement of the mandible in pseudoClass III maloc- growth, eg, no reverse headgear, no chincup, no max-
clusion so as to disengage the incisors and permit fur- illary expansion and no functional appliance; (4) all
ther closure into the position in which the posterior subjects were southern Chinese and no relapse ten-
teeth occluded.17,18 Several reports attributed the incisor dency for a skeletal Class III malocclusion was noted
interference to the retroclined upper incisors and pro- after pubertal growth (girls, 10 to 12 years; boys, 12
clined lower incisors in pseudoClass III malocclu- to 14 years24).
sion.15-17,19-21 In these studies, the dental and skeletal
patterns of pseudoClass III malocclusion were not Class I Malocclusion Group
assessed. Only clinical impressions of the dentoskeletal Thirty-one patients with Class I malocclusion (17
morphology were reported. Because of its seemingly females and 14 males; mean age, 11.2 1.4 years),
exaggerated skeletal discrepancy, the presence and treated in Orthodontics, Faculty of Dentistry, Hong
extent of mandibular displacement is of clinical impor- Kong University, were included in the Class I maloc-
tance when evaluating patients with Class III incisor clusion group. Patients selection criteria were: (1)
relationship.18 Based on clinical assessment, Turley13 Class I skeletal and dental malocclusion with normal
and Lin22 reported that pseudoClass III malocclusion overjet and overbite; (2) mild to moderate crowding;
showed some degree of hereditary tendency. Compari- (3) straight facial profile at HO; (4) all subjects were
son of extraoral photos revealed that the profile of southern Chinese.
pseudoClass III malocclusion appeared quite normal
at centric relation (CR) and slightly concave at habitual METHODS
occlusion (HO).17,19,22 Lee17 pointed out that molar The following characteristics were assessed for the
relationship was Class I at CR and Class III at HO. In pseudoClass III malocclusion group:
contrast, Lin22 reported that pseudoClass III malocclu- 1. Family history: family history was defined as any member
sion showed molar Class I relationship at HO. The abil- in the family with Class III incisor relationship. Usually,
ity to distinguish pseudoClass III malocclusion from it was evaluated with 3 generations (patients brothers and
skeletal Class III malocclusion should be of aid to for- sisters, parents, and grandparents). This information was
mulate the proper treatment plan for these patients. Fur- obtained from evaluation forms for each patient com-
thermore, the incidence of pseudoClass III malocclu- pleted by clinicians before the treatment.
sion in a sample of 7096 Chinese children was 2. Molar and canine relationships: 2 sets of study models
estimated to be 2% to 3%, which is one and a half times were taken at HO and CR with bite registrations individ-
American Journal of Orthodontics and Dentofacial Orthopedics Rabie and Gu 3
Volume 117, Number 1

Table I. Distribution of 36 pseudoClass III and 31 Class I subjects


PseudoClass III Age Class I Age
Subjects n = 36 Mean SD n = 31 Mean SD Significance

Males 21 10.5 1.91 14 11.5 1.43 /


Females 15 10.7 2.26 17 11.0 1.44 /
Total 36 10.6 2.03 31 11.2 1.44 NS

No significant age difference existed between male and female subjects within two groups.

ually. Molar and canine relationships were evaluated both Table II. Method error for cephalometric analysis
from clinical examination and dental casts. Mean SD P value 
d2
2/n

Dentoskeletal characteristics for both the pseudo
Class III malocclusion and the Class I malocclusion SNA 0.16 1.10 .44 0.77
A-N perp 0.00 0.58 1.00 0.40
groups were assessed with pretreatment lateral
Midface length 0.26 0.72 .053 0.53
cephalograms. All the cephalograms used in the pre- SNB 0.14 0.89 .41 0.63
sent study were taken in the same cephalostat and SNPg 0.12 0.86 .46 0.60
traced on acetate tracing paper. The reference points Pg-N perp 0.10 0.87 .55 0.61
were marked with a sharp pencil by 1 observer as Co-Gn 0.08 1.14 .41 0.34
ANB 0.01 0.46 .87 0.32
shown in Fig 1. The evaluation was done with dentofa-
Mx-Mn D. 0.07 0.48 .41 0.34
cial planner 7.0 (Dentofacial software Inc, Canada) Facial axis 0.12 0.34 .06 0.25
using traditional cephalometric analysis and the McNa- LAFH 0.14 0.80 .36 0.57
mara analysis.25 Me-MxP 0.06 0.93 .89 0.28
Mn Pl angle 0.08 0.78 .60 0.55
STATISTICAL ANALYSIS SN/MnP 0.02 0.93 .89 0.28
U1/MxP 0.25 1.90 .48 1.33
All statistical analysis was performed with Pro- U1-AV 0.04 0.45 .63 0.31
gramme Graphpad InStat. The arithmetic mean (mean) L1/MnPl 0.25 1.39 .34 0.98
and standard deviation (SD) were calculated for each Naso-labial angle 0.13 0.82 .38 0.58
variable. A Mann-Whitney test was performed to com- Cant of upper lip 0.10 0.66 .41 0.46
pare the significant differences between the male and
female subjects within the pseudoClass III malocclu-
sion group and the Class I malocclusion group. If no
significant differences were noted, the data were RESULTS
pooled together and an unpaired t test was performed to
Table I shows the gender distributions and mean
compare the significance between the 2 groups. The
age of the pseudoClass III malocclusion and the Class
level of significance was: *P < .05; **P < .01; ***P <
I malocclusion groups.
.001; P > .05 (NS).
1. Family history: 72% of the cases examined showed no
Thirty cephalograms with 19 variables were family history and the remaining 28% reported a similar
recorded twice independently on two separate occa- malocclusion in the family (Fig 2).
sions 2 weeks apart and the differences were small 2. Molar relationship:
between them (Table I). Method error in locating, 75% of the examined cases in the pseudoClass III maloc-
superimposing, and measuring the changes of different clusion group showed Class I molar relationship at HO and
landmarks was calculated by the formula26: Class II relationship at CR (Fig 3); 8% showed Class III
molar relationship at HO and Class I relationship at CR;
ME = 
d22
/n 11% showed Class II molar relationship both at HO and CR;
6% showed Class I molar relationship at both HO and CR.
All of the examined cases in the Class I malocclusion
Where d is the difference between 2 registrations of
group showed Class I molar relationship at CO.
a pair and n is the number of double registrations. All
3. Canine relationship:
variables were traced and superimposed with measure- 81% of the cases with either deciduous canine or perma-
ments recorded on 2 different occasions. The combined nent canines showed Class I relationship at maximum
ME did not exceed 0.61 mm for the linear variables and intercuspation and Class II relationship at CR; 19% of the
1.33 for any of the angular variables investigated cases examined were unclassified due to loss of primary
(Table II). canines or uneruption of permanent canines;
4 Rabie and Gu American Journal of Orthodontics and Dentofacial Orthopedics
January 2000

Fig 2. Frequency distribution of positive and negative fam-


ily history in the pseudoClass III malocclusion group. Fig 4. SNA in the pseudoClass III and Class I maloc-
clusion groups.

compared with 0.52 mm in the Class I malocclusion


group (P < .05) (Table IV). The mean values of midface
length (Co-A) were 83.3 mm and 87.2 mm in the
pseudoClass III malocclusion and Class I malocclusion
groups, respectively, which showed a highly significant
difference (P < .001) (Table III). Compared with the com-
posite norms extrapolated from the values derived from
A Burlington and Bolton samples as well as from the Ann
Arbor sample,25 the frequency with short midface length
was as high as 72.2% in the pseudoClass III malocclu-
sion group (Figure 5).
Sagittal mandibular position: the mean values of SNB for
the pseudoClass III and the Class I malocclusion groups
were 81.1 and 77.4, respectively, both within the normal
limit for the southern Chinese.27 However, a significant
difference existed between these 2 groups (P < .001)
(Table III). For the 36 patients in the pseudoClass III
malocclusion group, 33% of the subjects had an increased
B value of SNB but this percentage was only 3% in the
Class I malocclusion group (Fig 6). When evaluating the
Fig 3. PseudoClass III: A, intraoral photo at HO posi- sagittal mandibular position by the variable of SNPg, a
tion; B, intraoral photo at CR position. significant difference was found between the pseudo
Class III and the Class I malocclusion groups with mean
values of 80.6 and 77.2, respectively (P < .001) (Table
All of the examined cases in the Class I malocclusion III). The percentage of the subjects with forward
group showed Class I canine relationship at HO. mandibular position was 19% in the pseudoClass III
4. Cephalometic analysis for dentoskeletal relationship: malocclusion group and 0% in the Class I malocclusion
Sagittal maxillary position: the mean values of SNA in the group (Fig 7). A highly significant difference was noted in
pseudoClass III malocclusion and the Class I malocclu- the mean value of Pg point to N perpendicular, (Pg-N
sion groups were 81.6 and 82.2, respectively, both perp, the distance measured from Pg to the line drawn
within the normal range for southern Chinese.27 The dif- from Nasion and perpendicular to FH) between the
ference was not significant (P > .05)(Table III). In addi- pseudoClass III and the Class I malocclusion groups
tion, for the 36 cases in the pseudoClass III malocclusion with average values of 5.28 mm and 11.4 mm, respec-
group, 14% of the subjects presented with retrusive max- tively (P < .001) (Table III). No significant difference was
illa and it was only 6% in the Class I malocclusion group found in the mean value of mandibular length (Co-Gn)
(Fig 4). A significant difference was noted in the mean between the pseudoClass III and the Class I malocclu-
value of A point to N perpendicular, (A-N-perp, the dis- sion groups with average values of 111.5 mm and 111.6
tance measured from A point to the line dropped from mm, respectively (P > .05) (Table III).
Nasion and perpendicular to FH) between the males and Sagittal maxillary/mandibular relation: a highly signifi-
females in the Class I group (P < .05) (Table IV). Females cant difference was noted in mean values of ANB
in the pseudoClass III malocclusion group showed more between the pseudoClass III and the Class I malocclu-
retrusion of A point with an average value of 1.63 mm sion groups with average values of 0.53 and 4.90,
American Journal of Orthodontics and Dentofacial Orthopedics Rabie and Gu 5
Volume 117, Number 1

Table III. Cephalometric analysis of 36 subjects with pseudoClass III malocclusion and 31 subjects with Class I
malocclusion
PseudoClass III (n = 36) Class I (n = 31)
Mean SD Mean SD Significance

Maxillary
SNA 81.6 3.52 82.2 3.83 NS
Co-A 83.3 3.90 87.2 4.49 ***
Mandibular
SNB 81.1 3.55 77.4 3.25 ***
SNPg 80.6 3.49 77.2 3.29 ***
Pg-N perp -5.28 7.94 -11.4 6.55 ***
Co-Gn 111.5 5.38 111.6 4.92 NS
Maxillary-mandibular
relationship
ANB 0.53 2.36 4.90 2.71 ***
Mx-Mn D 28.2 4.41 24.4 3.76 ***
Vertical development
Facial axis 4.67 4.25 7.26 4.36 *
Me-MxP 61.1 4.31 62.6 3.62 NS
SN/MnP 33.7 5.74 35.7 4.84 NS
MnPl Angle 26.6 6.14 29.3 4.70 NS
Incisors angulation
U1/MxP 114.5 7.73 116.1 5.90 NS
U1-AV 2.28 3.37 4.29 2.65 **
Soft tissue analysis
Naso-labial angle 104.4 11.9 100.2 10.3 NS
Cant of upper lip 11.2 2.92 14.3 2.96 ***

Table IV. Cephalometric variables between males and females within pseudoClass III malocclusion group and Class
I malocclusion group
PseudoClass III (n = 36) Class I (n = 31)
Sex Mean SD Significance M/F Mean SD Significance M/F Significance (Class III/Class I)

A-N perp M 1.93 4.53 N.S 2.61 3.40 * NS


F 1.63 2.26 0.52 2.99 *
LAFH M 63.6 4.08 * 65.1 3.73 NS NS
F 61.1 3.56 63.6 4.18 NS
L1/MnPl M 96.0 5.32 NS 91.2 8.32 * NS
F 94.3 5.00 98.7 7.30 *

respectively (P < .001) (Table III, Fig 8). The average val- ference (P > .05) (Table III). Compared with the Chi-
ues of the maxillary-mandibular difference for the nese norm for upper incisor inclinations which is 118
pseudoClass III and Class I malocclusion groups were 6,27 the upper incisors in the pseudoClass III mal-
28.2 mm and 24.4 mm, which was highly significant (P < occlusion group were upright. The percentage of sub-
.001) (Table III). jects with retroclined upper incisors was 31% in the
Vertical development of mandible: a significant difference pseudoClass III malocclusion group and 16% in the
was noted in the mean value of facial axis (the angle formed Class I malocclusion group (Fig 9). The variable U1-
by basion-PTM-gnathion) between the pseudoClass III AV, the distance measured from the upper central
and the Class I malocclusion groups with average values of incisor to the line from point A perpendicular to FH,
4.67 and 7.26, respectively (P < .05) (Table III). This did show a significant difference between the
indicated a more horizontal development tendency in the pseudoClass III malocclusion group and the Class I
pseudoClass III malocclusion group. malocclusion group with mean values of 2.28 mm and
Upper incisor inclinations: the average values of upper 4.29 mm, respectively (P < .01) (Table III). This result
incisor inclinations (U1/MxPL) in the pseudoClass III confirmed that the upper incisors in the pseudoClass
malocclusion and the Class I malocclusion group were III malocclusion group were more retroclined compared
114.5 and 116.1, which indicated no significant dif- with that of the Class I malocclusion group.
6 Rabie and Gu American Journal of Orthodontics and Dentofacial Orthopedics
January 2000

this study were selected of the same origin to provide


a homogeneous population except for the variables
under investigation. The age difference was not sig-
nificant (Table I). All pseudoClass III malocclusion
cases showed Class I dental and skeletal relationship
during the follow-up period that extended until after
the growth spurt. Although the average value of each
measurement was shown in the tables, the percentage
of the subjects either with increased normal value or
decreased normal value were illustrated in the figures
Fig 5. Frequency distribution of SNB in the pseudo when compared with the Chinese norms. 27 These
Class III and Class I malocclusion groups. graphs provided a detailed information for
pseudoClass III malocclusion with skeletal and den-
tal components.

Family History
Seventy-two percent of the examined cases in the
pseudoClass III malocclusion group showed no fam-
ily history, the remaining 28% reported similar maloc-
clusions in the family. This indicates that the majority
of pseudoClass III malocclusion is caused by local
environmental factors. These factors, such as retained
deciduous teeth, odontoms, trauma, etc, could change
the normal path of eruption allowing the upper incisors
Fig 6. Frequency distribution of SNPg in the pseudo to erupt palatally and the lower incisors to erupt labi-
Class III and Class I malocclusion groups. ally.17 This could cause premature contacts during the
normal path of closure of the mandible and result in
anterior displacement of the mandible. The 28% of the
Lower incisor inclinations: a significant difference was noted
cases that reported a familial pattern of pseudoClass
in the average value of lower incisor inclination (L1/MnPL)
of females between the pseudoClass III malocclusion and III malocclusion suggests a genetic influence on tooth
the Class I malocclusion groups (P < .05) (Table IV). Com- eruption in some of these patients. In our sample, sim-
pared with the Chinese norm for lower incisor inclinations, ilar malocclusions were identified in twins (Fig 11) and
which is 97 7,27 the inclination of lower incisors in the siblings of the same family. The comparison of twins is
pseudoClass III malocclusion group was normal. The frequently used to partition variance into environmen-
majority of subjects in the pseudoClass III malocclusion tal and genetic factors.
group presented normal lower incisor inclinations (Fig 10).
5. Cephalometric analysis for soft tissue: Clinical Examination
Nasolabial angle: no significant difference was noted in Clinical examination of pseudoClass III malocclu-
the average values of nasolabial angle for the
sion revealed that 75% of the examined cases showed
pseudoClass III malocclusion and the Class I malocclu-
a mesial step, which corresponds to Angles Class I at
sion groups with mean values of 104.4 and 100.1,
respectively (P > .05) (Table III). HO and showed a normal relationship of the primary
Upper lip cant: a highly significant difference was noted molar that is a flush terminal plane at CR. The flush
in the average values of upper lip cant (the angle formed terminal plane corresponded to end-to-end permanent
by the line drawn tangent to the upper lip and the line first molar relationship (Fig 3). This relationship is
drawn from Nasion and perpendicular to FH28) between somewhat expected because the anterior displacement
the pseudoClass III and the Class I malocclusion groups of the mandible will change the normal flush terminal
with mean values of 11.2 and 14.3, respectively (P < plane into a mesial step that corresponds to Class I
.001) (Table III). molar relationship. As the mandible moves backward
from HO to CR, the occlusal relationship would be
DISCUSSION
normalized where it shows flush terminal plane or end-
This study examined the diagnostic criteria for to-end permanent molar relationship. Eleven percent of
pseudoClass III malocclusion and compared it with the cases showed a distal step that is equivalent to
characteristics of Class I malocclusion. All subjects of Angles Class II in both HO and CR. This was either
American Journal of Orthodontics and Dentofacial Orthopedics Rabie and Gu 7
Volume 117, Number 1

due to large mesiodistal width of the lower second pri-


mary molars or to the loss of the upper second primary
molars and drift of the upper first permanent molars
into the Leeway space, while the lower second primary
molars were still present. Eight percent of the cases
showed a mesial step that corresponded to a Class III
molar relationship at HO and Class I relationship at
CR. These cases showed loss of the lower second pri-
mary molars while the upper second primary molars
were still present. This transitional situation allowed
mesial drift of the lower first permanent molars into the
Fig 7. Frequency distribution of ANB in the pseudo
Leeway space leading to such a molar relationship. Six Class III and Class I malocclusion groups.
percent of the cases showed normal molar relationship
both at HO and CR. Clinical examination of these cases
showed minimal displacement and spacing of lower
incisors probably to compensate for the anterior cross-
bite. Canine relationship (permanent or deciduous den-
tition) in 81% of the examined cases showed Class I at
HO and Class II at CR. The remaining 19% of the cases
were unclassified either because of the loss of primary
canines or uneruption of permanent canines.

Skeletal Characteristics
In this study, cephalometric analysis of the skeletal
pattern in the pseudoClass III malocclusion group Fig 8. Frequency distribution of U1/MxPL in the pseudo
showed a significantly decreased midface length when Class III and Class I malocclusion groups.
compared with the skeletal Class I malocclusion
group. However, a significant difference was noted in
the variable of A-N perpendicular in the female sub-
jects between the pseudoClass III and Class I maloc-
clusion groups. The differences presented above
between boys and girls must be attributed to the fact
that girls reach the pubertal growth (10 to 12 years)
earlier than boys (12 to 14 years).24 Therefore, girls
would show more potential for maxillary growth than
boys between the ages of 10 to 12 years. Because the
average age for this sample was about 11 years, the
anterior crossbite must have limited the maxillary
growth more in girls than boys. Therefore, we propose Fig 9. Frequency distribution of L1/MnPL in the
elimination of anterior crossbites as early as possible pseudoClass III and Class I malocclusion groups.
to prevent restraining of the maxillary growth.
In this study, the relationship of the mandible to the
cranial base was determined by SNB, SNPg, and Pg-N value of mandibular length (Co-Gn) between the 2
perp. A forward mandibular position was noted in the groups. In contrast, it was reported that the mandibular
pseudoClass III malocclusion group with a highly sig- length (Co-Gn) was 3 to 6 mm longer in skeletal Class
nificant difference compared with the Class I maloc- III malocclusion than that in Class I occlusion.9
clusion group. This result was expected as all the cases
included in the pseudoClass III group showed anterior Dental Characteristics
displacement of the mandible. To examine the PseudoClass III malocclusions possess a combi-
mandibular morphology in the pseudoClass III mal- nation of skeletal and dental characteristics that could
occlusion group, we measured mandibular length (Co- help clinicians to accurately diagnose such malocclu-
Gn) and compared it with that of the skeletal Class I sion. Previous studies based on clinical impressions
group. No significant difference was noted in the mean reported that pseudoClass III malocclusion exhib-
8 Rabie and Gu American Journal of Orthodontics and Dentofacial Orthopedics
January 2000

ance.32 Recently, we reported that a short period of


treatment (4 to 8 months) with simple fixed appli-
ances to procline the upper incisors was sufficient to
eliminate the functional shift of the mandible and to
correct the anterior crossbite.32 A 3 year follow-up
showed that the retarded maxillary growth caused by
the anterior crossbite was normalized after the correc-
tion. Therefore, the proper diagnosis could directly
influence the treatment approach required to achieve
the treatment objectives.
Fig 10. Frequency distribution of midface length in the
Soft Tissue Characteristics
pseudoClass III and Class I malocclusion groups.
A significant difference in the upper lip cant
between the pseudoClass III malocclusion and the
skeletal Class I malocclusion group indicated that sub-
jects with pseudoClass III malocclusion showed a
retrusive upper lip at the same age.

CONCLUSIONS
Diagnostic characteristics of pseudoClass III mal-
occlusion in the present study could be summarized as:
Majority showed no family history.
A Class I molar and canine relationships at HO and Class II
or end to end relationship at CR.
Decreased midface length.
Forward position of the mandible with normal mandibu-
lar length.
Retroclined upper incisors and normal lower incisors.

Sincere thanks are expressed to Mr Shadow Yeung,


Faculty of Dentistry, The University of Hong Kong, for
his kind help with analysis of the data and Miss Frances
B Chow for her assistance with the manuscript.

Fig 11. Twin brothers intraoral photos. REFERENCES

1. Hellman M. Morphology of the face, jaws, and dentition in Class III malocclusion of
the teeth. J Am Dent Assoc 1931;18:2150-73.
2. Ridell A, Soremark R, Lundberg M. Roentgenograhic-cephalometric analysis of the
jaws in subjects with and without mandibular protrusion. Acta Odont Scand
ited Class III incisor relationship with generally retro- 1971;29:103-21.
clined maxillary incisor or proclined mandibular 3. Sadao S. Case report: developmental characterization of skeletal Class III malocclu-

incisors.15-17,19-21,29 Results of this study demonstrate sion. Angle Orthod 1994;64:105-11.


4. Stapf WC. A cephalometric roentgenographic appraisal of the facial pattern in Class
that in pseudoClass III malocclusion, upper incisors III malocclusions. Angle Orthod 1948;18:20-3.
5. Sanborn RT. Differences between the facial skeletal patterns of Class III malocclusion
are retroclined whereas lower incisors are normal. In and normal occlusion. Angle Orthod 1955;25:208-22.
contrast, numerous studies summarized the dental 6. Dietrich UC. Morphological variability of skeletal Class III relationships as revealed
by cephalometric analysis. Trans Eur Orthod Soc 1970;131-43.
features of skeletal Class III malocclusion with pro- 7. Jacobson A, Evans WG, Preston CB, Sadowski PL. Mandibular prognathism. Am
trusive maxillary incisors and retrusive mandibular Orthod 1974;66:140-71.

incisors.5,15-17,19-21 The diagnosis that the dental 8. Williams S, Andersen CE. The morphology of the potential Class III skeletal pattern
in the young child. Am J Orthod 1986;89:302-11.
interference leading to the anterior crossbite is caused 9. Guyer EC, Ellis EE, McNamara JA, Behrents RG. Components of Class III maloc-
clusion in juveniles and adolescents. Angle Orthod 1986;56:7-29.
by the retroclined upper incisors in the pseudoClass 10. Ngan P, Hu AM, Fields HW. Treatment of Class III problems begins with differential
III malocclusion should be taken into consideration diagnosis of anterior crossbites. Pediatr Dent 1997;19:386-95.
11. Campbell PM. The dilemma of Class III treatment. Angle Orthod 1983;53:175-91.
when determining the treatment approach and timing 12. Joondeph DR. Early orthodontic treatment. Am J Orthod Dentofacial Orthop
of the treatment. Treatment modalities for the correc- 1993;104:99-200.
13. Turley PT. Early management of the developing Class III malocclusion. Aust Orthod
tion of an anterior crossbite include the use of reverse J 1993;13:19-22.
headgear,30 removable appliance,31 and fixed appli- 14. Tweed CH. Clinical Orthodontics. St Louis: Mosby; 1966. p. 715-26.
American Journal of Orthodontics and Dentofacial Orthopedics Rabie and Gu 9
Volume 117, Number 1

15. Moyers RE. Handbook of orthodontics, 4th edition. Chicago: Year Book; 1988. 24. Taranger J, Hgg U. The timing and duration of adolescent growth. Acta Odontol Scan
p. 410-5. 1980;38:57-67.
16. Major PW, Glover K. Treatment of anterior crossbite in early mixed dentition. J Can 25. McNamara JA. A method of cephalometric evaluation. Am J Orthod 1984;86:449-69.
Dent Assoc 1992;58:574-5,78-9. 26. Dahlberg G. Statistical methods for medical and biological students. London: George
17. Lee BD. Correction of crossbite. Dent Clin North Am 1978;22:647-68. and Allen Unwind; 1940.
18. Gravely JF. A study of the mandibular closure path in Angle Class III relationship. Br 27. Cooke MS, Wei SHY. Cephalometric standards for the southern Chinese. Eur J Orthod
J Orthod 1984;11:85-91. 1988;10:264-72.
19. Sharma PS, Brown RV. Pseudo mesiocclusion: diagnosis and treatment. J Dent Child 28. McNamara JA, Brudon WL. Orthodontic and orthopedic treatment in the mixed den-
1968;35:385-92. tition. Ann Arbor: Needham Press; 1993. p. 3-8.
20. Thilander B, ning O. Introduction to orthodontics. Stockholm: Tandlakarforlaget 29. Faber RD. The differential diagnosis and treatment of crossbites. Dent Clin North Am
Press; 1985. p. 148-50. 1981;25:53-68.
21. Graber TM, Rakosi T, Petrovic AG. Dentofacial orthopedics with functional appliance, 30. Ngan P, Hgg U, Yiu CKY, Merwin D, Wei SHY. Treatment response to maxillary
2nd edition. St Louis: Mosby; 1997. p. 462-70. expansion and protraction. Eur J Orthod 1996;18:151-68.
22. Lin JJ. Differential diagnosis and management of anterior crossbite. Beijing- 31. Kerr WJS, Tenhave TR. A comparison of three appliance systems in the treatment of
HongKong-TaiBei Symposium. 1996. p. 9. Class III malocclusion. Eur J Orthod 1988;10:203-14.
23. Lin JJ. Prevalence of malocclusion in Chinese children age 9-15. Clin Dent (Taiwan) 32. Rabie ABM, Y Gu. Management of pseudoClass III malocclusion in southern Chi-
1985;5:57-65. nese children. Br Dent J 1999;186:183-7.