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Year : 2013  |  Volume : 4  |  Issue : 4  |  Page : 167-172

Two phase treatment of Class III malocclusion

1 Department of Orthodontics & Dentofacial Orthopedics, Vokkaligara Sangha Dental College & Hospital, Bengaluru, Karnataka, India
2 Department of Orthodontics, Institute of Dental Sciences, SOA University, Bhubaneshwar, Odisha, India
3 Consultant Orthodontist, Just Smile Dental Care, Santacruz. Mumbai, Maharastra, India

Date of Web Publication22-Jan-2014

Correspondence Address:
Roopa Siddegowda
Santhrupthi Nilaya, #415, 7th Cross, Mahadeshwara Extension, Mysore - 570 016, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0976-433X.125598

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The developing skeletal Class III malocclusion is one of the most challenging problems confronting the practicing orthodontists. True Class III malocclusion is rare when compared with Class II and Class I and may develop in children as a result of inherent growth abnormality. Treatment should be carried out as early as possible with the aim to prevent it from becoming severe. The case was treated with biphasic therapy, i.e., orthopedic appliance followed by fixed orthodontic treatment. Facemask helps resolving the skeletal discrepancy.

Keywords: Class III malocclusion, Delaire facemask, skeletal correction, two phase treatment

How to cite this article:
Siddegowda R, Sahoo KC, Jain S. Two phase treatment of Class III malocclusion. SRM J Res Dent Sci 2013;4:167-72

How to cite this URL:
Siddegowda R, Sahoo KC, Jain S. Two phase treatment of Class III malocclusion. SRM J Res Dent Sci [serial online] 2013 [cited 2023 May 28];4:167-72. Available from:

  Introduction Top

Class III malocclusion are growth related problems that often become severe if left untreated, so it should be corrected as soon as we recognize its initial signs like edge to edge bite or cross bite. [1] Developing true Class III malocclusion tendencies in children may have an underlying skeletal or dental component. Pseudo Class III malocclusion is a habitual established cross-bite of anterior teeth without any skeletal discrepancy, resulting from functional forward positioning/shift of mandible on closure, so both should be differentiated before the start of any treatment procedure. [2] When left untreated Pseudo Class III may lead to the development of true Class III malocclusion. The goal of early orthodontic treatment is to correct the existing or developing skeletal, dentoalveolar and muscular imbalance and to improve the oral environment. [3]

In Asian societies, the frequency of Class III malocclusion is higher due to a large percentage of patients with maxillary deficiency. The incidence ranges between 4% and 5% among the Japanese and 4% and 14% among the Chinese. [4],[5] The protraction facemask has been widely used in the treatment of Class III malocclusion with maxillary deficiencies. [6],[7],[8] Mandibular growth can be controlled with chin-cup therapy, by altering the skeletal framework of growing Class III patients. Studies on the short-term and long-term effects of chin-cup force indicated that the skeletal framework is greatly improved during the initial stages of chin-cup therapy. [9],[10],[11],[12],[13],[14] Delaire's [15] face mask consisted of a forehead pad and a chin pad that were connected with a heavy steel rod. Intra-orally, a bonded rapid palatal expansion appliance was used. Forward traction of the maxilla was accomplished by rubber bands. The treatment results produced by this appliance were the anterior movement of the maxilla and downward and backward rotation of the mandible. Rapid palatal expansion appliance was used to relieve the posterior cross-bite as reported in the studies. [16],[17],[18] These extra-oral devices generate therapeutic forces at the teeth, which are transmitted to the periodontal ligament, bone and ultimately to its articulations. These forces correct skeletal disharmonies either by inhibiting or by redirecting the growth of jaws or by inducing biologic alterations at facial sutures and cartilaginous areas. In conjunction to this, maxillary expansion loosens the sutures and thereby enhances the treatment effect. [19] This technique is still followed [20],[21],[22] even though it was introduced long back.

Clinical findings

A 13-year-old female patient reported with a chief complaint of forwardly placed lower jaw. On extra-oral examination, patient exhibited a concave facial profile with slight deficiency in the maxillary projection as shown in [Figure 1] and [Figure 2]. On intra-oral examination as shown in [Figure 3],[Figure 4],[Figure 5],[Figure 6] and [Figure 7], angles Class III molar relation and Class III canine relationship were present. Incisal edge to edge relationship with bilateral posterior cross-bite was observed. 31 were mesiolingually rotated, 13.23 were buccally placed and 12.22 palatally placed.
Figure 1: Pre-treatment-extraoral-frontal view

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Figure 2: Pre-treatment-extraoral-lateral view

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Figure 3: Pre-treatment-intraoral frontal

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Figure 4: Pre-treatment-intraoral right lateral view

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Figure 5: Pre-treatment-intraoral left lateral view

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Figure 6: Pre-treatment-intraoral upper arch view

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Figure 7: Pre-treatment-intraoral lower arch view

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Angle's Class III malocclusion on a skeletal Class III jaw base with vertical growth pattern, crowding in upper andlower anterior teeth with bilateral posterior cross-bite.

  Treatment Objectives Top

  1. To correct the saggital discrepancy of maxilla and mandible.
  2. To relieve crowding in upper and lower anterior segments.
  3. To align upper and lower anteriors.
  4. To achieve proper overjet and overbite.
  5. To correct posterior cross bite.
  6. To correct molar and canine relationships.
  7. To attain esthetic pleasing profile.

Treatment plan

Biphasic therapy-rapid maxillary expansion to expand maxilla with fixed orthodontic treatment.

Treatment procedure

  1. Maxillary acrylic splint with a hyrax expansion screw was fixed with glass ionomer cement. Face mask was adjusted and the patient was trained for wearing the face mask and for hyrax screw activation as shown in [Figure 8]. 2 turns of hyrax screw activation was advised per day. Diagonal elastics were to be engaged from the stainless steel (SS) hooks distal to canine to the face mask attachment.
  2. After the completion of expansion, hyrax screw was locked with acrylic [Figure 9].
  3. After the retention phase of 3 months, fixed appliance therapy was started [Figure 10],[Figure 11] and [Figure 12].
  4. Extraction of 14, 24, 34, 44 was done followed by banding and bonding of the teeth.
  5. 0.0155" multi-stranded wire in the upper arch and 0.014" heat activated nickel titanium wire in the lower arch was placed and followed by 0.014" niti wire in both the arches for relieving the crowding. A quad helix was prefabricated in order to maintain the expansion achieved in the upper arch [Figure 13],[Figure 14] and [Figure 15].
  6. 0.018" nickel titanium wire was placed in the upper arch and 0.016" nickel titanium in the lower arch.
  7. Extraction spaces were utilized for crowding relieving.
  8. Upper 0.017 × 0.025 niti wire and 0.016 × 0.022 niti wire in the lower arch with reverse curve of spee were replaced.
  9. Once the curve of spee was corrected, 0.017 × 0.025 SS was placed in both upper and lower arches.
  10. The case was finished using the finishing wires [Figure 16],[Figure 17],[Figure 18],[Figure 19] and [Figure 20].
Figure 8: Delaire face mask with chin cup and imtraoral elastics attached

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Figure 9: Upper arch with acrylic splint and locked hyrax srew

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Figure 10: Post chin cup therapy-extraoral frontal view

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Figure 11: Post chin cup therapy-extraoral lateral view

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Figure 12: Post chin cup therapy-intraoral frontal view

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Figure 13: Initial arch wires-frontal view

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Figure 14: Initial arch wire with quad helix-upper arch view

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Figure 15: Initial arch wire in the lower arch view

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Figure 16: Post-treatment-extraoral frontal view

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Figure 17: Post-treatment-extraoral right lateral view

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Figure 18: Post-treatment-extraoral left lateral view

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Figure 19: Post-treatment-intraoral upper arch view

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Figure 20: Post-treatment-intraoral lower arch view

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Post treatment changes

A satisfactory correction was been achieved. Facial appearance was improved as a result of dental changes with improved profile and lip competency. Orthopaedic facemask is the appliance of choice in cases with maxillary deficiency and produces dramatic results in the shortest period of time. This appliance system affects virtually all areas contributing to Class III malocclusion so this treatment protocol can be applied effectively to most of developing Class III patients regardless of the specific cause of malocclusion. Pre-treatment, End of phase 1 and Post -treatment Cephalometric changes are presented in [Table 1]. It acts by carrying forward movement of maxilla and restricting mandibular growth. The earlier the case presents to the clinics and is diagnosed, the simpler and faster is the treatment.
Table 1: Comparison of Cephalometric values of pre treatment, end of phase I and post treatment values

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  Conclusion Top

Class III malocclusion should be intercepted early, aiming to redirect growth, mainly when the maxilla is the primary etiologic factor, or when dental and/or functional factors are involved. The diagnosis, treatment planning, and prognosis depend on several characteristics, which should be carefully analyzed by the orthodontist, such as: patient age, growth potential, and pattern. The earlier the intervention, the greater the chances of positive response, regarding transversal maxillary advancement. An adequate use of appliances, with correct application of intensity and direction, in addition to patient compliance are key elements for good outcomes.

  References Top

1.Maheshwari S., Gupta N. D. and Mittal S Treatment of Class III case by biphasic Therapy. J.I.O.S.2005: 38;193-197.  Back to cited text no. 1
2.Kapur A, Chawla HS, Utreja A, Goyal A. Early class III occlusal tendency in children and its selective management. J Indian Soc Pedod Prev Dent 2008;26:107-13.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Graber TM, Vanarsdall R. Current Principles and Technique in Orthodontics. 4 th ed. Louis Missouri: University Press; 2005.  Back to cited text no. 3
4.Ishii H, Morita S, Takeuchi Y, Nakamura S. Treatment effect of combined maxillary protraction and chincap appliance in severe skeletal Class III cases. Am J Orthod Dentofacial Orthop 1987;92:304-12.  Back to cited text no. 4
5.Allwright WC, Burndred WH. A survey of handicapping dentofacial anomalies among Chinese in Hong Kong. Int Dent J 1964;14:505-19.  Back to cited text no. 5
6.Turley PK. Orthopedic correction of Class III malocclusion with palatal expansion and custom protraction headgear. J Clin Orthod 1988;22:314-25.  Back to cited text no. 6
7.McNamara JA Jr. An orthopedic approach to the treatment of Class III malocclusion in young patients. J Clin Orthod 1987;21:598-608.  Back to cited text no. 7
8.Ngan P, Wei SH, Hagg U, Yiu CK, Merwin D, Stickel B. Effect of protraction headgear on Class III malocclusion. Quintessence Int 1992;23:197-207.  Back to cited text no. 8
9.Gebeile-Chauty S, Perret M, Schott AM, Aknin JJ. Early treatment of Class III: A long-term cohort study. Orthod Fr 2010;81:245-54.  Back to cited text no. 9
10.Kanno Z, Kim Y, Soma K. Early correction of a developing skeletal Class III malocclusion. Angle Orthod 2007;77:549-56.  Back to cited text no. 10
11.Mandall N, DiBiase A, Littlewood S, Nute S, Stivaros N, McDowall R, et al. Is early Class III protraction facemask treatment effective? A multicentre, randomized, controlled trial:15-month follow-up. J Orthod 2010;37:149-61.  Back to cited text no. 11
12.Sugawara J, Asano T, Endo N, Mitani H. Long-term effects of chincap therapy on skeletal profile in mandibular prognathism. Am J Orthod Dentofacial Orthop 1990;98:127-33.  Back to cited text no. 12
13.Wendell PD, Nanda R, Sakamoto T, Nakamura S. The effects of chin cup therapy on the mandible: A longitudinal study. Am J Orthod 1985;87:265-74.  Back to cited text no. 13
14.Thilander B. Treatment of angle Class III malocclusion with chin cup. Trans Eur Orthod Soc 1963;39:384-98.  Back to cited text no. 14
15.Delair J. La croissance maxillaire. Trans Eur Orthod Soc 1971;29;81-102.  Back to cited text no. 15
16.da Silva Filho OG, Montes LA, Torelly LF. Rapid maxillary expansion in the deciduous and mixed dentition evaluated through posteroanterior cephalometric analysis. Am J Orthod Dentofacial Orthop 1995;107:268-75.  Back to cited text no. 16
17.da Silva Filho OG, Valladares Neto J, Rodrigues de Almeida R. Early correction of posterior crossbite: Biomechanical characteristics of the appliances. J Pedod 1989;13:195-221.  Back to cited text no. 17
18.Lagravere MO, Major PW, Flores-Mir C. Long-term dental arch changes after rapid maxillary expansion treatment: A systematic review. Angle Orthod 2005;75:155-61.  Back to cited text no. 18
19.Nanda R, Upadhyay M. Skeletal and dental considerations in orthodontic treatment mechanics: A contemporary view. Eur J Orthod 2013;35:634-43.  Back to cited text no. 19
20.Cevidanes L, Baccetti T, Franchi L, McNamara JA Jr, De Clerck H. Comparison of two protocols for maxillary protraction: Bone anchors versus face mask with rapid maxillary expansion. Angle Orthod 2010;80:799-806.  Back to cited text no. 20
21.Vaughn GA, Mason B, Moon HB, Turley PK. The effects of maxillary protraction therapy with or without rapid palatal expansion: A prospective, randomized clinical trial. Am J Orthod Dentofacial Orthop 2005;128:299-309.  Back to cited text no. 21
22.Toffol LD, Pavoni C, Baccetti T, Franchi L, Cozza P. Orthopedic treatment outcomes in Class III malocclusion. A systematic review. Angle Orthod 2008;78:561-73.  Back to cited text no. 22


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]

  [Table 1]


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