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CASE REPORT

Class III subdivision malocclusion corrected with asymmetric intermaxillary elastics


Guilherme Janson,a Marcos Roberto de Freitas,b Janine Araki,c Eduardo Jacomino Franco,d rgio Estelita Cavalcante Barrosc and Se Bauru, Brazil Correcting a Class III subdivision malocclusion is usually a challenge for an orthodontist, especially if the patients prole does not allow for any extractions. One treatment option is to use asymmetric intermaxillary elastics to correct the unilateral anteroposterior discrepancy. However, the success of this method depends on the individual response of each patient and his or her compliance in using the elastics. The objectives of this article were to present a successful treatment of a Class III subdivision patient with this approach and to illustrate and discuss the dentoskeletal changes that contributed to the correction. (Am J Orthod Dentofacial Orthop 2010;138:221-30)

rthodontic treatment of adult Class III patients is difcult, especially if the malocclusion is asymmetric.1 A precise diagnosis of the dentoskeletal components of the malocclusion associated with the patients primary concern is essential for correct treatment planning.2-9 Similar to correction of Class II subdivision malocclusions, Class III subdivision malocclusions can have a variety of orthodontic treatment options such as nonextraction protocols with intermaxillary elastics, unilateral extraction of 1 mandibular premolar on the Class III side, or extraction of 2 mandibular premolar extractions and 1 maxillary premolar extraction on the Class I side.1,10-13 Malocclusion correction based on the use of intermaxillary elastics is difcult and controversial.11,14-20 However, if it is well indicated in a compliant patient, it can provide satisfactory results.11,17,18 Therefore, the objective of this article was to present the successful orthodontic treatment of a Class III subdivision patient with asymmetric intermaxillary elastic forces. This
Professor and head, Department of Orthodontics, Bauru Dental School, Univer o Paulo, Bauru, Sa o Paulo, Brazil. sity of Sa b Professor, Department of Orthodontics, Bauru Dental School, University of o Paulo, Bauru, Sa o Paulo, Brazil. Sa c Postgraduate student, Department of Orthodontics, Bauru Dental School, o Paulo, Bauru, Sa o Paulo, Brazil. University of Sa d Private practice, Bras lia, Distrito Federal, Brazil. The authors report no commercial, proprietary, or nancial interest in the products or companies described in this article. Reprint requests to: Guilherme Janson, Department of Orthodontics, Bauru vio Pinheiro Brisolla o Paulo, Alameda Octa Dental School University of Sa 9-75, Bauru, SP, 17012-901 Brazil; e-mail, jansong@travelnet.com.br. Submitted, July 2008; revised and accepted, August 2008. 0889-5406/$36.00 Copyright 2010 by the American Association of Orthodontists. doi:10.1016/j.ajodo.2008.08.036
a

procedure allowed obtaining a good and stable occlusal relationship and a better esthetic facial prole and smile for the patient.
DIAGNOSIS AND ETIOLOGY

The patient was a man (age, 23 years 11 months) with a Class III subdivision left malocclusion with negative overjet and facial imbalance. His chief concerns were his anterior crossbite and lower lip protrusion. His parents had no Class III characteristics. The facial photographs showed a prognathic mandible and a Class III appearance (Fig 1). The patient could close his lips without mentalis strain, but he was self-conscious about the way his teeth occluded and the appearance of his teeth. The pretreatment intraoral photographs and dental casts show a Class III subdivision malocclusion with Class I on the right and Class III on the left (Figs 1 and 2). There was good alignment of the mandibular incisors, and all teeth were present including the third molars (Fig 3, A). Cephalometrically, he had maxillary retrusion, slight mandibular protrusion, and a balanced facial pattern, with the exception of excessive lower anterior face height. The maxillary incisors were bucally tipped and protruded, and the mandibular incisors were lingually tipped and retruded. He had an acute nasiolabial angle (Fig 3, B and C; Table).
TREATMENT OBJECTIVES

The treatment objectives consisted of correcting the Class III canine and molar relationships on the left side, the dental anterior crossbite, the midline deviation, and the prognathic appearance of the mandible.
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Fig 1. Pretreatment facial and intraoral photographs.

Functionally, we sought to obtain normal canine and incisal guidance and an esthetic smile.

patients chief concern, he chose the orthodontic treatment protocol.


TREATMENT PROGRESS

TREATMENT ALTERNATIVES

Two treatment alternatives were presented to the patient. The rst consisted of an orthodontic-surgical approach including maxillary advancement. This protocol would provide a better esthetic result, but the risks and treatment expenses would be high.7,11,21 The second alternative consisted of attempting to correct the asymmetric malocclusion with asymmetric intermaxillary elastics. If the elastics were ineffective, extraction of the mandibular left premolar would assist in correcting the canine Class III relationship on the left side. This option would provide excellent occlusal results, but improvement of the facial prole would be limited. Because dental appearance was the

Fixed conventional 0.022 3 0.025-in slot edgewise appliances were placed to level and align the maxillary and mandibular arches. The archwire sequence progressed from 0.016-in nickel-titanium alloy to 0.019 3 0.025-in rectangular stainless steel archwires. Concurrently, Class III intermaxillary elastics were combined with anterior diagonal elastics (Fig 4). Class III elastics with rectangular archwires were used for 12 months. After the anteroposterior discrepancy correction, the elastics were used during sleeping hours for 5 months until appliance removal. Patient cooperation in using the elastics was excellent. Treatment time was 2 years 3 months. After debonding, a maxillary Hawley retainer was delivered, and a mandibular canine-to-canine retainer was bonded.

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Fig 2. Pretreatment dental casts.

Fig 3. Pretreatment panoramic and cephalometric radiographs and tracing.

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Table.

Cephalometric status at pretreatment, posttreatment, and 2-year follow-up


Standard measurement41-43 Pretreatment Posttreatment Two-year follow-up

Measurement Maxillary components SNA (o) Co-A (mm) A-Nperp (mm) Mandibular components SNB (o) Co-Gn (mm) P-Nperp (mm) Maxillomandibular components ANB (o) Wits (mm) Growth pattern FMA (o) SN.Ocl (o) SN.GoGn (o) LAFH (mm) Maxillary dental components Mx1.NA (o) Mx1-NA (mm) Mx1.PP (o) Mx1-PP (mm) Mx6-PP (mm) Mandibular dental components Md1.NB (o) Md1-NB (mm) IMPA (o) Md1-GoMe (mm) Soft-tissue components Nasolabial angle (o) Upper lip to S Line (mm) Lower lip to S Line (mm)

82 85 11 80 108 2 /14 2 0 25 14 32 62 22 4 112.1 33.0 27.9 25 4 95.3 48.9 110 0 0

75.4 85 8.0 81 119 5.1 5.6 7.7 25 12 29 65.5 31 7.5 118.3 26.1 24.7 16 1.6 80 39.0 91 0.8 2.3

76 85 8.2 78.5 119 7.2 2.5 4.7 27 11 31.4 65.8 38 9 125.5 25.1 25.6 14 0.3 78 39.2 90 1.3 1.9

76 85.4 8.5 79.0 119 7.0 3.1 6.4 26.4 11.9 30.4 65.6 40.1 9.2 127.4 25.6 25.0 14.9 0.8 79.0 39.3 88.9 1.8 2.1

Co-A, Condylion to A-point; A-Nperp, A-point to nasion-perpendicular; Co-Gn, condylion to gnathion; P-Nperp, pogonion to nasion-perpendicular; LAFH, lower anterior face height, from anterior nasal spine to menton; Mx1.NA, maxillary incisor long axis to NA angle; Mx1-NA, most anterior point of crown of maxillary incisor to NA line; Mx1.PP, maxillary incisor long axis to palatal plane angle; Mx1-PP, perpendicular distance between incisal edge of maxillary central incisor and palatal plane; Md1.NB, mandibular incisor long axis to NB angle; Md1-NB, most anterior point of crown of mandibular incisor to NB line; Mx6-PP, perpendicular distance between mesial cusp of maxillary rst molar and palatal plane; Md1-GoMe, perpendicular distance between incisal edge of mandibular incisor and mandibular plane; nasolabial angle, angle formed by the most anterior point on the upper lip to a line from subnasion to columella; upper lip to S line, from the most anterior point on the upper lip to a plane from the center of the S-shaped curve between the tip of the nose and the skin subnasale to the soft-tissue pogonion; lower lip to S line, from the most anterior point on the lower lip to a plane from the center of the S-shaped curve between the tip of the nose and the skin subnasale to the soft-tissue pogonion.

Fig 4. Intraoral progress photographs showing treatment with asymmetric Class III elastics (the anterior diagonal elastic is not illustrated).

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Fig 5. Posttreatment facial and intraoral photographs.

TREATMENT RESULTS

DISCUSSION

The facial photographs show improvement in the facial prole (Fig 5). The intraoral photographs and dental casts show a bilateral Class I molar and canine occlusion with normal overjet and overbite (Figs 5 and 6). Good intercuspation, interproximal contacts, and satisfactory root parallelism were achieved (Fig 7, A). The nal cephalometric radiograph, tracing, and superimposition show that the maxillary incisors were labially tipped and slightly protruded, and the maxillary molars were slightly mesially displaced (Figs 7, B and C, and 8). The mandibular incisors were slightly lingually tipped and retracted. There was also an increase in upper lip projection, and the mandible underwent slight clockwise rotation. The patient was satised with his dental and facial appearance.

Patient compliance in using asymmetric Class III elastics was crucial for success. The effects of Class III elastics caused a small maxillary protrusion, and the mandible had a small retrusion, probably consequent to the backward and downward rotation that this apical base experiences when Class III elastics are used11,16,22 (Table). These changes in the apical anteroposterior position contributed to the improvement in their relationship. Accordingly, concomitant increases in the growth pattern angles were observed, with the exception of the occlusal plane angle to SN. However, these are also expected changes with Class III elastics.7,11,16,18,22 The occlusal plane experienced a small counterclockwise rotation under the inuence of the Class III elastics; this is a normal result from these elastics.11,16,23-25 The maxillary incisors were labially

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Fig 6. Posttreatment dental casts.

tipped and protruded, and the mandibular incisors were lingually tipped and retruded. The vertical component of the elastics produced small extrusions of the maxillary molars and mandibular incisors. As a consequence of these skeletal and dentoalveolar changes, there was a decrease in the nasolabial angle, protrusion of the upper lip, and retrusion of the lower lip, signicantly improving his facial prole (Table, Figs 5-8). If the patients compliance had not been good in using the elastics, another option would have been to extract the mandibular left rst premolar. According to Class III subdivision malocclusion characteristics, with the maxillary midline coincident to the midsagittal plane and the mandibular midline deviated to the right, this could be considered the best choice to correct the midline deviation and the occlusal discrepancy.1 However, this would not be a favorable treatment alternative for the desired soft-tissue changes because the anterior crossbite would be corrected by retraction of the mandibular incisors with little or no protrusion of the maxillary incisors; this would cause less improvement in the facial prole than the nonextraction alternative. On the other hand, it could be argued that the use of asymmetric

Class III elastics could deviate the maxillary midline to the right as an unfavorable side effect. Yes, this could be possible, but in choosing between these 2 treatment options one must select the protocol that will fulll most of the treatment objectives, with the fewest collateral side effects. Based on this, it was thought that the nonextraction option would provide a more favorable prole change, and that the resulting unfavorable maxillary midline deviation would be within acceptable limits. According to Johnston et al,26 deviations up to 2 mm of the dental midline to the midsagittal plane can be clinically satisfactory. The nal extraoral smiling photograph conrms this (Fig 5). It has been stated that anteroposterior intermaxillary elastics produce signicant vertical adverse effects.16,18,20,25,27,28 This can be true if their use is not properly monitored. Use of the correct resistant torques in the maxillary and mandibular incisors to counteract the Class III elastic forces on these teeth is essential. In this patient, the adverse effects seem to have been well controlled, because only small extrusions of the maxillary molars and mandibular incisors were apparent (Fig 8). Inclusion of the second molars might also have helped in controlling the adverse

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Fig 7. Posttreatment panoramic and cephalometric radiographs and tracing.

Fig 8. Superimposition of initial and nal tracings.

effects of the elastics.20,27 Class III elastics especially are believed to cause counterclockwise rotation of the occlusal plane and inversion of the natural esthetic smile line.11,16 A small counterclockwise rotation of the occlusal plane occurred, but with no signicant negative inuence on the smile line because of proper control of its use (Figs 5 and 8). The use of Class III elastics also causes backward and downward

The backward mandibular rotation.7,11,16,25 mandibular rotation is favorable for correcting a Class III malocclusion because it improves the anteroposterior discrepancy of the apical bases. In this patient, the downward rotation was acceptable because of his predominant horizontal growth pattern characteristics.11,16,25,29 Stability of the correction was addressed by using Class III elastics during 5 months of nighttime wear, after correction of the anteroposterior discrepancy. For this amount of asymmetric Class III anteroposterior discrepancy, it can be considered satisfactory.11 Concerns with stability in corrected Class III adults are not as critical as in growing patients because there is no adverse growth to reestablish the problem.23,30,31 Therefore, the chances are greater for stability in treated Class III adults. Nevertheless, follow-ups every 6 months are recommended for at least 2 years.11,31 Two years after treatment, the occlusal and esthetic results have remained stable, despite small cephalometric changes (Figs 9 and 10). This stability is probably consequent to the association of the procedures described above. Cephalometrically, from posttreatment to the 2-year follow-up, there were slight labial tipping and protrusion

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Fig 9. Two-year follow-up facial and intraoral photographs.

of the maxillary incisors and mandibular incisors (Fig 11, Table). Because the mandibular incisors were lingually tipped and retruded during treatment, possibly this was consequent to a small relapse tendency of the mandibular incisors to return to their original position.32,33 Consequently, the maxillary incisors also experienced some labial tipping through their relationship with the mandibular incisors. The occlusal plane angle also slightly increased, showing a tendency to return to its original angulation. This might have contributed to the small relapse of the Class III apical base discrepancy evaluated by the Wits appraisal. The mild counterclockwise rotation of the mandible shows the temporary characteristic of the mandibular rotation after treatment.34,35 However, these posttreatment cephalometric changes were small and did not compromise the occlusal and esthetic results. Treatment with intermaxillary elastics is also suspected of causing much relapse.36 This might be true if

active retention is not used for a sufcient amount of time after correcting the anteroposterior Class II or Class III discrepancy. Nevertheless, this is not valid only for treatment with intermaxillary elastics but for most Class II and Class III anteroposterior discrepancy correction. Class II nonextraction treatment with headgears and removable or xed functional appliances also needs some time of active retention to be stable.37-39 Therefore, it seems that it is not the orthodontic appliance or device that determines treatment stability but the way it is used and especially if enough active retention time was used before the patient was nished. Therefore, the stability obtained in this patient, treated with asymmetric Class III intermaxillary elastics, seems to illustrate this principle. Evidently, An orthodontic-surgical approach could have produced greater skeletal correction of the Class III discrepancy, but the treatment should aim to solve the patients primary concern.7,8,40 Because this

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Fig 10. Two-year follow-up dental casts.

metric Class III malocclusion can be accomplished with asymmetric Class III intermaxillary elastics when patient compliance in using the elastics is satisfactory.
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Fig 11. Superimposition of nal and 2-year follow-up tracings.

patients concern was primarily his dental appearance, the clinician obtained the most from the orthodontic mechanics available to satisfy his needs.
CONCLUSIONS

Successful occlusal and esthetic correction with satisfactory long-term stability of an adult with an asym-

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11. Janson G, de Souza JE, Alves FA, Andrade P Jr, Nakamura A, de Freitas MR, et al. Extreme dentoalveolar compensation in the treatment of Class III malocclusion. Am J Orthod Dentofacial Orthop 2005;128:787-94. 12. Cheney EA. The inuence of dentofacial asymmetries upon treatment procedures. Am J Orthod 1952;38:934-45. 13. Burstone CJ. Diagnosis and treatment planning of patients with asymmetries. Semin Orthod 1998;4:153-64. 14. Baker HA. Treatment of protruding and receding jaws by the use of intermaxillary elastics. Int Dent J 1904;25:344-56. 15. Bien SM. Analysis of the components of forces used to effect the distal movement of teeth. Am J Orthod 1951;37:514-20. 16. Stewart CM, Chaconas SJ, Caputo AA. Effects of intermaxillary elastic traction on orthodontic tooth movement. J Oral Rehabil 1978;5:159-66. 17. Hanes RA. Bony prole changes resulting from cervical traction compared with those resulting from intermaxillary elastics. Am J Orthod 1959;45:353-64. 18. Ellen EK, Schneider BJ, Sellke T. A comparative study of anchorage in bioprogressive versus standard edgewise treatment in Class II correction with intermaxillary elastic force. Am J Orthod Dentofacial Orthop 1998;113:430-6. 19. Kanter F. Mandibular anchorage and extraoral force. Am J Orthod 1956;42:194-208. 20. Higley BA, Hill NC. Anchorage in orthodontics. Am J Orthod 1960;46:456-65. 21. Frank C. The nonsurgical orthodontic correction of a Class III malocclusion. Am J Orthod Dentofacial Orthop 1993;103:107-14. 22. Schudy FF. The control of vertical overbite in clinical orthodontics. Am J Orthod 1968;38:19-39. 23. Kondo E, Ohno T. Nonsurgical and nonextraction treatment of a skeletal Class III patient with severe prognathic mandible: long-term stability. World J Orthod 2001;2:115-26. 24. Costa Pinho TM, Ustrell Torrent JM, Correia Pinto JG. Orthodontic camuage in the case of a skeletal Class III malocclusion. World J Orthod 2004;5:213-23. 25. Lin J, Gu Y. Preliminary investigation of nonsurgical treatment of severe skeletal Class III malocclusion in the permanent dentition. Angle Orthod 2003;73:401-10. 26. Johnston CD, Burden DJ, Stevenson MR. The inuence of dental to facial midline discrepancies on dental attractiveness ratings. Eur J Orthod 1999;21:517-22. 27. Tweed CH. Philosophy of orthodontic treatment. Am J Orthod 1945;31:74-103. 28. Fischer B. Treatment of Class II, Division 1 differential diagnosis and analysis of mandibular anchorage. Am J Orthod 1948;34:461-90.

29. Lew K. Soft tissue prole changes following orthodontic treatment of Chinese adults with Class III malocclusion. Int J Adult Orthod Orthognath Surg 1990;5:59-65. 30. Nanda SK. Growth patterns in subjects with long and short faces. Am J Orthod Dentofacial Orthop 1990;98:247-58. 31. Suri S, Utreja A. Management of a hyperdivergent Class III malocclusion, maxillary midline diastema, and infected mandibular incisors in a young adult. Am J Orthod Dentofacial Orthop 2003;124:725-34. 32. Kondo E, Aoba TJ. Nonsurgical and nonextraction treatment of skeletal Class III open bite: its long-term stability. Am J Orthod Dentofacial Orthop 2000;117:267-87. 33. Westwood PV, McNamara JA Jr, Baccetti T, Franchi L, Sarver DM. Long-term effects of Class III treatment with rapid maxillary expansion and facemask therapy followed by xed appliances. Am J Orthod Dentofacial Orthop 2003;123: 306-20. 34. Garib DG, Henriques JF, Carvalho PE, Gomes SC. Longitudinal effects of rapid maxillary expansion. Angle Orthod 2007;77: 442-8. 35. Ferro A, Nucci LP, Ferro F, Gallo C. Long-term stability of skeletal Class III patients treated with splints, Class III elastics, and chincup. Am J Orthod Dentofacial Orthop 2003; 123:423-34. 36. Riedel RA. A review of the retention problem. Angle Orthod 1960;30:179-99. 37. Janson G, Caffer DC, Henriques JF, de Freitas MR, Neves LS. Stability of Class II, division 1 treatment with the headgear-activator combination followed by the edgewise appliance. Angle Orthod 2004;74:594-604. 38. Nanda RS, Nanda SK. Considerations of dentofacial growth in long-term retention and stability: is active retention needed? Am J Orthod Dentofacial Orthop 1992;101:297-302. 39. Teuscher U. A growth-related concept for skeletal Class II treatment. Am J Orthod 1978;74:258-75. 40. Bilodeau JE. Correction of a severe Class III malocclusion that required orthognatic surgery: a case report. Semin Orthod 1996;2: 279-88. 41. McNamara JA. A method of cephalometric evaluation. Am J Orthod 1984;86:449-69. 42. Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS. Cephalometric analysis of dentofacial normals. Am J Orthod 1980;78: 404-20. 43. Steiner CC. The use of cephalometrics as an aid to planning and assessing orthodontic treatment. Am J Orthod 1960;46: 721-35.