Authors: Mitchell, Laura Title: An Introduction to Orthodontics , 2nd Edition Copyri ght 2001 Oxford University Press

> Table of Cont en t s > 1 1 - Cl ass II I

11 Class III
The Briti sh Standards defini ti on of Cl ass III inci sor rel ati onship includes those mal occlusi ons where the l ower inci sor edge occl udes anteri or to the cingulum pl ateau of the upper i ncisors. Cl ass III mal occlu sions affect around 3 per cent of Caucasi ans.

11.1. AETIOLOGY 11.1.1. Skeletal pattern

The skeletal rel ationship i s the most important factor in the aeti ol ogy of most Class III mal occlusi ons, and the majority of Cl ass III inci sor rel ati onships are associ at ed with an underl ying Cl ass III skel etal relationshi p. Cephal ometri c studi es have shown that, compared wi th Class I occlusi ons, Cl ass III mal occlusi ons exhi bi t the followi ng:

increased mandi bul ar length; a more anteri orl y pl aced gl enoi d fossa so that the condyl ar head i s posi ti oned more anteri orl y l eading to mandi bular prognathism; reduced maxillary length; a more retruded posi ti on of the maxill a l eadi ng to maxillary retrusi on.

The fi rst two of these factors are the most influenti al. Figure 11.1 shows a pati ent with a Cl ass III mal occlusi on wi th mandi bular prognathism and Fi g. 11.2 illustrates maxillary retrognathi a (maxillary retrusi on).

Fig. 11.1. Pati ent wi th mandi bul ar prognathi sm

Fig. 11.2. Pati ent wi th maxillary retrognathi a. Cl ass III mal occlusi ons occur i n associ ati on with a range of verti cal skel etal proporti ons, ranging from i ncreased to reduced. A backward opening rotati on pattern of facial growth will tend to result i n a reducti on of overbite; however, a forward rotating pattern of faci al growth will lead to an increase in the prominence of the chi n.

11.1.2. Soft tissues

In the majority of Class III mal occlusi ons the soft ti ssues do not pl ay a major aeti ol ogical rol e. In fact the reverse i s often the case, with the soft tissues tending to tilt the upper and l ower inci sors towards each other so that the inci sor rel ati onship i s often l ess s evere than the underlying skel etal pattern. Thi s dento-al veol ar compensati on occurs in Class III mal occlusi ons because an anteri or oral seal can frequently be achieved by upper to l ower lip contact. Thi s has the effect of moul ding the upper and l ower l abi a l segments towards each other. The mai n excepti on occurs in pati ents with i ncreased verti cal skel etal proporti ons where the lips are more likely to be incompetent and an anteri or oral seal is often accompli shed by tongue to l ower li p contact. P.117

11.1.3. Dental factors

Cl ass III mal occlusi ons are often associ ated with a narrow upper arch and a broad l ower arch, wi th the result that crowdi ng i s seen more commonly, and to a greater degree, in the upper arch than i n the l ower. Frequently, the l ower arch i s well ali gned or evenly spaced.

11.2. OCCLUSAL FEATURES

By definiti on Cl ass III mal occlusi ons occur when the l ower inci sors are positi oned more labi ally rel ati ve to the upper inci sors. Therefore an anteri or crossbite of one or more of the incisors i s a common feature of Cl ass III mal occlusi ons. As wi th any crossbi te, it i s essential to check for a di spl acement of the mandi bl e on closure from a premature contact into maximal interdi gitati on. In Cl ass III

mal occl usi ons thi s can be ascertained by asking t he patient to try to achieve an edge-to-edge inci sor posi ti on. If such a di spl acement i s present, the prognosi s for correcti on of the inci sor rel ati onship i s more favourabl e. In the past it was thought that such a displ acement led to overcl osure and greater promi nence of the mandible, wi th the condylar head di spl aced forward. In fact cephal ometri c studies suggest that i n most cases, although there i s a forward di spl acement of the mandi ble to di sengage the premature contact of the inci sors as cl osure into oc cl usi on occurs, the mandi bl e moves backwards until the condyles regai n thei r normal posi ti on within the glenoi d fossa ( Fi g. 11.3).

Fig. 11.3. Di agram illust rati ng the path of cl osure in a Cl ass III mal occl usi on from an edge -to-edge i ncisor rel ati onshi p into maximal occlusi on. Al though the mandi bl e i s displ aced forwards from the initi al contact of the inci sors to achi eve maximal interdi gitati on, the condyl ar h ead is not displ aced out of the gl enoi d fossa. Another common feature of Cl ass III mal occlusi ons i s buccal crossbi te, whi ch is usually due to a di screpancy in the

rel ati ve width of the arches. This occurs because the l ower arch i s positi oned rel atively mor e anteri orl y i n Cl ass III mal occl usi ons and i s often well devel oped, while the upper arch i s narrow. Thi s i s al so refl ected i n the relative crowding within the arches, wi th the upper arch commonly more crowded (Fi g. 11.4).

Fig. 11.4. A Cl ass III mal occl usi on wi th a narrow crowded upper arch and a broader l ess crowded l ower arch with associ ated buccal crossbi te. As menti oned above, Cl ass III maloccl usi ons often exhi bit dento-alveol ar compensati on with the upper inci sors procli ned and the l ower inci sors retroclined, whi ch reduces the severity of the inci sor rel ati onshi p ( Fi g. 11.5).

11.3. TREATMENT PLANNING IN CLASS III MALOCCLUSIONS

A number of factors shoul d be consi dered before pl anni ng treatment. The patient's opinion regarding thei r occlusi on and faci al appearance must be taken into account. Thi s subject needs to be approached wi th some tact.

The severity of the skeletal pattern both anteroposteri orly and verti cally shoul d be assessed. Thi s i s the major determi nant of the di ffi cul ty and prognosi s of orthodonti c treatment. The expected pattern of future growth both anteroposteri orly and verti cally shoul d be consi dered. It i s important to remember that average growth will tend to resul t i n a worsening of the rel ati onshi p between the arches, and a si gnifi cant deteri orati on can be antici pated if growth i s unfavourabl e. When evaluating the likel y di recti on and extent of faci al growth, th e patient's age, sex, and faci al pattern shoul d be taken into considerati on (see Chapter 4). Chil dren with i ncreased verti cal skel etal proporti ons often conti nue to exhi bit a verti cal pattern of growth, which will have the effect of reducing inci sor overbi te. Obvi ously for pati ents on the borderli ne between di fferent management regimes it is wise to err on the si de of pessi mism (as growth will often prove this to be correct).

Fig. 11.5. Dento-alveol ar compensati on. P.118

In Cl ass III mal occl usi ons a normal or i ncreased overbite i s an advantage, as a vertical overl ap of the upper inci sors with the l ower i ncisors post -treatment is vi tal for stability. If the patient can achieve an edge -to-edge incisor position, thi s increases the prognosi s for correcti on of the inci sor rel ati onship. In general , orthodontic management of Cl ass III mal occl usi on will ai m to increase dento-alveolar compensation . Therefore, if considerabl e dentoal veolar compensati on i s al ready present, trying to i ncrease it further may not be an aesthetic or stabl e treatment opti on. The degree of crowding i n each arch shoul d be consi dered. In Cl ass III mal occl usi ons crowding occurs more frequ ently, and to a greater degree, in the upper arch than i n the l ower. Extracti ons in the upper arch only shoul d be resi sted as this will often lead to a worsening of the i ncisor rel ati onshi p. Where upper arch extracti ons are necessary, it i s advi sable to extract at least as far forwards in the l ower arch. Orthodonti c correcti on of a Cl ass III i ncisor rel ati onshi p can be achieved by ei ther proclinati on of the upper i ncisors al one or retroclinati on of the l ower i ncisors wi th or without procli nati on of the uppe r inci sors. The approach applicabl e to a parti cul ar mal occl usi on is l argel y determined by the skel etal pattern and the amount of overbi te present before treatment, as procli nati on of the upper i nci sors reduces the overbite (Fi g. 11.6) whereas retroclinati on of the l ower inci sors hel ps to increase overbi te ( Fi g. 11.7). A prognosi s tracing (see Chapter 6, Secti on 6.8) may be hel pful i n deci ding between the two approaches ( Fi g. 11.8).

Fig. 11.6. Di agram to show how procli nati on of the upper incisors resul ts i n a reducti on of overbi te.

Fig. 11.7. Di agram to show how retroclinati on of the l ower inci sors results in an i ncrease of overbi te.

Fig. 11.8. A prognosi s tracing which indi cates that a combinati on of retrocli nati on of the l ower inci sors and procli nati on of the upper l abial segment is required to correct the inci sor relati onshi p. If the l ower arch i s moderately crowded, consi derati on shoul d be gi ven to extracting the lower fi rst premol ars to all ow the l ower l abial segment to drop lingually, thereby ai ding dento-alveol ar compensati on. This can result i n resi dual space in the l ower arch if fi xed appli ances are not used. Addi ti onal space for reli ef of crowding in the upper arch can often be gained by expansi on of the arch anteri orly to correct the i ncisor rel ati onshi p and/or buccoli ngually to correct buccal segment crossbi tes. Therefore, where possi bl e, i t may be prudent to del ay permanent extracti ons until after the crossbi te i s corrected and the degree of crowdi ng i s reassessed. Expansi on of the upper arch to correct a crossbite will have the effect of reducing overbi te, whi ch i s a di sadvantage in Class III cases. Thi s reducti on in overbite occurs be cause expansi on of the upper arch i s achi eved pri marily by tilting the upper premol ars and mol ars buccall y, which results in the pal atal cusps of these teeth

swingi ng down and propping open the occl usi on. Therefore, if upper arch expansi on is indi cated a nd the over-bite is reduced, fixed appli ances shoul d be used to try and limit til ting of the upper mol ars buccally duri ng the expansi on. Di stal movement of the upper buccal segments with headgear to gain space for ali gnment is inadvisabl e as thi s will have the effect of restrai ning growth of the maxilla. However, in Cl ass III cases wi th mild to moderate mi d -arch crowdi ng, space can be made by a combinati on of forward movement of the inci sors as well as some distal movement of the remai ning buccal segment te eth. This can be accomplished by using a removable appli ance with a screw posi ti oned at the si te of crowding or with fixed appliances. Another approach is to use a functional appli ance, but it i s diffi cult for pati ents to posture posteri orly to achieve an acti ve working bite. Therefore functi onal appli ances are l ess wi del y used in Class III mal occlusions, al though they can be useful in mil d cases i n the mixed dentiti on where a combinati on of proclinati on of the upper i ncisors together with retrocli nati on of the l ower inci sors is requi red. In patients with a severe Cl ass III skel etal pattern and/or reduced overbite, the possi bility that a surgi cal approach may ul timately be requi red must be consi dered, P.119 parti cul arly before any permanent extracti ons are undertaken (see Secti on 11.4.4 ).

11.4. TREATMENT OPTIONS 11.4.1. Accepting the incisor relationship

In mild Class III mal occlusi ons, parti cul arly those cases where the overbi te i s minimal , it may be prefera bl e to

accept the incisor rel ati onshi p and di rect treatment towards achi eving arch alignment (Fi g. 11.9).

Fig. 11.9. Mild Class III case where i t was deci ded to accept the inci sor rel ati onship and di rect treatment towards ali gnment of the arches only. Occasi onally patients with more severe Class III i ncisor rel ati onships are unconcerned about thei r mal occlusi on, parti cul arly if the re mainder of the family have a simil ar faci al appearance. In thi s si tuati on, and al so where a pati ent i s unwilling to undergo the fixed appli ance treatment necessary to correct the i ncisor relati onshi p, treatment can be limi ted to achi eving alignment only. Someti mes upper arch crowdi ng resul ts i n the lateral inci sors erupti ng pal atally and the cani nes buccally. If the upper l ateral inci sors are markedly di spl aced then thei r extracti on may make treatment more strai ghtforward ( Fi g. 11.10). Some pati ents are hap py to accept a smile wi th the cani nes adjacent to the central i ncisors. However, veneers can be used to make the cani nes resembl e l ateral inci sors more cl osely.

Fig. 11.10. Patient whose Cl ass III mal occlusi on wi th marked upper arch crowdi ng was managed by extracti on of the pal atally di splaced upper l ateral inci sors and the l ower fi rst premol ars: (a) pri or to extracti ons; (b) 6 months after extracti ons and pri or to fi xed appliance therapy.

(a)

(b)

11.4.2. Proclination of the upper labial segment

Correcti on of the inci sor rel ati onshi p by proclinati on of the upper i ncisors onl y can be consi dered i n cases with the followi ng features:

a Cl ass I or mild Class III skeletal pattern the upper inci sors are not al ready si gni ficantl y procli ned

an adequate overbi te will be present at the end of treatment to retain the corrected posi ti on of the upper inci sors, gi ven that a reducti on of overbite will occur as the incisors are ti pped l abiall y (see Secti on 11.3 and Fi g. 11.6).

If indi cated, this approach is often best carri ed out i n the mi xed denti ti on when the unerupted permanent canines are hi gh above the roots of the upper lateral inci sors ( Fi g. 11.11). Extracti on of the l ower deci duous can i nes at the same ti me may allow the l ower labi al segment to move lingually sli ghtly, thereby ai ding correcti on of the i ncisor rel ati onship. Early correcti on of a Cl ass III inci sor rel ati onship has the addi ti onal advantage that further forward mandi bular growth may be counterbal anced by dento-alveol ar compensati on ( Fi g. 11.12). Later in the mixed dentiti on, when the devel opi ng permanent cani nes drop down into a buccal posi ti on relative to the l ateral incisor root, there may be a ri sk of resorpti on if the i ncisors are moved labi ally. In thi s situati on correcti on i s best deferred until the permanent cani nes have erupted. Where the upper l abi al segment is mil dly crowded, permanent extracti ons shoul d be del ayed until after the inci sor rel ati onship i s corrected as procli nati on of the upper inci sors will provi de additi onal space. If the l ower arch is at all crowded, consi derati on shoul d be gi ven to relieving the crowdi ng by extracti ons as thi s will all ow some lingual movement of the l ower labi al segment teeth. Procli nati on of the upper labi al segment can often be accomplished successfully with a removabl e appli ance, parti cul arly as buccal cappi ng can be i ncorporated to free the occlusi on with the l ower arch. A screw type design i s parti cul arly useful in the mixed den ti ti on as then the upper

inci sors can be utilized for retenti on of the appli ance (see Chapter 16). Fixed appliances can al so be P.120 used to advance the upper labi al segment and are useful when other features of the mal occlusi on dictate thei r use.

Fig. 11.11. Mil d Cl ass III mal occl usi on that was treated in the mi xed denti ti on by procli nati on of the upper l abial segment with a removabl e appli ance: (a) pretreatment; (b) post treatment.

(a)

(b)

11.4.3. Retroclination of the lower labial segment with or without

proclination of the upper labial segment

In those cases with a mild to moderate Cl ass III skeletal pattern, or where there i s a reduced overbi te, a combinati on of retrocli nati on of the l owe r inci sors and procli nati on of the upper i ncisors will achi eve correction of the i ncisor rel ati onship (see Fi g. 11.8). Al though the pitfalls of si gni ficant movement of the l ower l abial segment have been emphasi zed i n earlier chapters, in the correcti on of Cl ass III mal occl usi ons the positi ons of the upper and l ower inci sors are changed around wi thi n the zone of soft ti ssue bal ance and, provi ded that there is an adequate overbi te and further growth i s not unfavourabl e, the corrected i ncisor rel ati onship has a good chance of stability. Although removabl e and functi onal appliances can be used to advance the upper inci sors and retrocline the l ower i ncisors, i n practi ce these tooth movements are accompli shed more effici ently with fixed appli ances.

Fig. 11.12. (a) Forward growth rotati on i s the most common pattern of mandi bular growth. In a Cl ass III mal occlusi on thi s will lead to a worseni ng of the skeletal pattern and the inci sor rel ati onship. (b) If a Cl ass III inci sor rel ati onship i s corrected in the mixed dentiti on, dento-alveol ar compensati on may hel p to mask the effects of further growth provi ded that thi s i s not marked.

(a)

(b)

Space i s requi red in the l ower arch for retroclinati on of the l ower l abi al segment, and extractions are requi red unl ess the arch i s spaced naturall y. Use of a round archwi re in the l ower arch and a rectangular arch in the upper arch al ong with judi ci ous space cl osur e can be used to hel p correct the inci sor rel ati onship (Fi g. 11.13). Intermaxillary Class III el asti c tracti on (see Chapter 15, Secti on 15.6.1 ) from the l ower l abial segment to the upper mol ars (Fig. 11.14) can also be used to hel p move the upper arch forwards and the l ower arch backwards, but care i s requi red to avoi d extrusi on of the mol ars whi ch will reduce overbite. Reverse-pull headgear, al so known as a face -mask (Fi g. 11.15), i s used to appl y an anteri orl y di rected force, vi a el asti cs, on the maxillary teeth and maxilla. Al though some

have cl aimed that thi s appliance can change the posi ti on of the maxilla, a very cooperative patient i s necessary in vi ew of the prol onged daily wear requi red, often over se veral years. Nevertheless, thi s techni que i s occasi onally useful i n the management of Class III mal occlusi ons, particularl y those associ ated with a cleft lip and pal ate anomaly, and al so i n cases of hypodonti a where forward movement of the buccal segment teeth to cl ose space i s desi rabl e.

Fig. 11.13. Correcti on of a Cl ass III mal occlusi on by retroclinati on of the l ower i ncisors and proclinati on of the upper i ncisors using fi xed appli ances with relief of crowdi ng by the extracti on of all four first premol ars: (a) pretreatment; (b) fi xed appli ances in situ. (note the use of rectangul ar archwi re in the upper arch and a round wi re i n the l ower arch duri ng space cl osure to hel p achi eve the desi red movements ); (c) post-treatment result.

(a)

(b)

(c)

Fig. 11.14. Cl ass III intermaxillary tracti on.

Fig. 11.15. Face-mask. P.121

11.4.4. Surgery
In some cases the severi ty of the skel etal pattern and/or the presence of a reduced overbi te or an anteri or open bi te precludes orthodontics al one, and surgery i s necessary to correct the underl ying skeletal di screpancy. It i s i mpossi ble to produce hard and fast gui delines as to when to choose surgery rather than orthodonti cs, but it has been suggested that surgery is alm ost al ways requi red i f the value for the ANB angle i s bel ow 4 and the inclinati on of the l ower inci sors to the mandi bular pl ane i s l ess than 83. However, the cepahal ometri c findi ngs should be consi dered in conjuncti on with other features of the mal occl usi on and the pati ent's faci al appearance. For those pati ents where orthodonti c treatment will be chall engi ng owi ng to the severi ty of the skeletal pattern and/or a l ack of overbite, a surgi cal approach should be expl ored before any permanent extracti ons a re carri ed out,

and preferably before any appliance treatment. The reason for thi s i s that management of Cl ass III mal occlusi ons by orthodonti cs al one involves dento-alveol ar compensati on for the underlying skel etal pattern. However, in order to achi eve a sati sfactory occl usal and faci al result wi th a surgi cal approach, any dento -alveol ar compensati on must fi rst be removed or reduced ( Fi g. 11.16). For exampl e, if P.122

P.123 l ower premol ars are extracted in an attempt to retract the l ower l abi al segment but thi s fails and a surgi cal approach i s subsequently necessary, the presurgi cal orthodonti c phase will probabl y involve proclinati on of the inci sors to a more average inclinati on with reopening of the extracti on spaces. Thi s is a frustrati ng expe ri ence for both pati ent and operator.

Fig. 11.16. (a) Severe Cl ass III mal occlusi on wi th dento alveol ar compensati on. (b) Wi thout reducti on of the dento alveol ar compensati on, surgery to produce a Cl ass I inci sor rel ati onship will only achi eve a limi ted correcti on of the underl ying skeletal pattern, thus constraining the overall aestheti c resul t. (c) Decompensation of the i ncisors to bri ng them nearer to thei r correct axial incli nati on all ows a complete correcti on of the underl ying skeletal pattern.

(a)

(b)

(c)

Fig. 11.17. Patient treated with a combinati on of orthodonti cs and bi maxillary orthognathic surgery: (a), (b) pretreatment; (c), (d) post-treatment.

(a)

(b)

(c)

(d)

Some patients with marked skeletal III mal occl usi ons are unwilling to wear appliances. Management b y surgery al one i s unsati sfactory as the resul ting occlusi on i s poor, and i n addi ti on a full correcti on of the underlyi ng skeletal probl em i s not possi bl e wi thout dento -al veol ar decompensati on. Therefore pati ents shoul d be encouraged to undergo the appli ance therapy necessary for the best result. An exampl e of a patient treated by a combinati on of orthodonti cs and surgery i s shown in Fi g. 11.17. Surgi cal approaches to the correcti on of Cl ass III mal occlusi ons are consi dered in Chapter 20.

PRINCIPAL SOURCES AND FURTHER READING

Battagel , J. M. (1993). Di scrimi nant analysi s: a model for the predicti on of relapse in Cl ass III chil dren treated orthodonti cally by a non -extracti on techni que. European Journal of Orthodontics , 15, 199209. Battagel , J. M. (1993). The aeti ol ogi cal factors i n Cl ass III mal occl usi on. European Journal of Orthodontics , 15, 347 70. Battagel , J. M. and Orton, H. S. (1993). Cl ass III mal occl usi on: the post -retenti on findi ngs foll owing a non extracti on treatment appr oach. European Journal of Orthodontics, 15, 4555. Bryant, P. M. F. (1981). Mandibul ar rotati on and Cl ass III mal occl usi on. British Journal of Orthodontics , 8, 6175. Thi s paper i s worth reading for the i ntroducti on al one, whi ch contains a very good di scussi on of growth rotati ons. The study itself l ooks at the effect of growth rotati ons and treatment upon Cl ass III mal occlusi ons. Di bbets, J. M. (1996). Morphol ogi cal di fferences between the Angle classes. European Journal of Orthodontics , 18, 111 18. Gravely, J. F. (1984). A study of the mandi bular cl osure path in Angl e Cl ass III rel ati onship. British Journal of Orthodontics, 11, 8591. A very readabl e and clever arti cle whi ch examines the di spl acement el ement of Cl ass III mal occl usi ons. Kerr, W. J. S. and Tenhave, T. R. (1988) A compari son of three appliance systems in the treatment of Cl ass III

mal occl usi on. European Journal of Orthodontics , 10, 203 14. Kerr, W. J. S., Miller, S., and Dawber, J. E. (1992). Cl ass III mal occl usi on: surgery or orthodonti cs? British Journal of Orthodontics, 19, 214. An i nteresting study whi ch compares the pretreatment l ateral cephal ometri c radi ographs of two groups of Cl ass III cases treated by either surgery or orthodonti cs al one. The authors report the thresh ol ds for three cephal ometri c val ues whi ch woul d i ndicate when surgery i s requi red. Ki m, J. H. et al. (1999). The effectiveness of protracti on face mask therapy: a metaanalysis. American Journal of Orthodontics and Dentofacial Orthopedics , 115, 67585.