ORTHODONTIC CAMOUFLAGE TREATMENT OF DENTOSKELETAL CLASS III MALOCCLUSION WITH PREMOLAR EXTRACTION (Case Report)
Orthodontic Camouflage
Treatment Of Dentoskeletal
Class III Malocclusion With
Premolar Extraction
(Case Report)
Dr. drg. Tita Ratya Utari, Sp.
Ort
Lecturer, Department of
Orthodontics, School of Dentistry
Faculty of Medicine and Health
Science
Universitas Muhammadiyah
Yogyakarta
tita_utari@yahoo.com
Introduction
• Class III malocclusions represent a small
proportion of all malocclussions among
orthodontic patients but the treatment
is considerable clinical challenge
because of the complex diagnosis and
the difficult prognosis (Antonio, 2012).
The Class III malocclusion has a strong
genetic background which may express itself
at an early age (Pattanaik, 2016).
Class III malocclusion is far more prevalent
in Asian countries than in the West. (Graber
Mosby, 2005 in A-Bakr M. Rabie, 2008)
Southeast Asian populations have the
highest prevalence of Class III malocclusion
(13% to 27%), while Indian and Caucasian
populations have a lowest prevalence (1% to
5%). (Neal D. Kravitz)
The general characteristics of
skeletal class III:
Narrow ”cranial angle”,
Anteroposterior shortening of
maxilla,
Hyperdivergent skeletal pattern
(openbite),
Posterior discrepancy,
Flaring out of upper anterior teeth,
Incline to lingual in lower incisors,
Prognatic mandible, and
Flat occlusal plane.
Paulo Beltrão. 2015. Class III High Angle Malocclusion Treated with Orthodontic Camouflage (MEAW
Therapy)
Treatment Alternatives For Skeletal
Class III Malocclusion
Growth Modification,
There are three main
treatment options for skeletal
class III malocclusion:
A-Bakr M. Rabie, et al. 2008. Treatment in
Borderline Class III Malocclusion: Orthodontic
Camouflage (Extraction) Versus Orthognathic
Surgery
Dentoalveolar
Compensation (Orthodontic
Camouflage),
Orthognatic Surgery.
Growth modification should be commenced before the
pubertal growth spurt, after this spurt, only the latter two
options are possible.
Treatment Alternatives For Skeletal
Class III Malocclusion
• There are larger number of skeletal class
III patient that either decline or cannot
afford surgical treatment.
• The only alternative is “orthodontic
camouflage” through comprehensive
treatment with fixed appliances.
• There are type of Orthodontic camouflage:
1.Selective tooth extraction.
2.Distalization of mandibular dentition
using miniimplants.
Pattanaik, et al.: Treatment Modalities for Skeletal Class III Malocclusion,
2016
Camouflage in Orthodontic
• Camouflage treatment is defined by Proffit
as displacement of the teeth relative to
their supporting bone to compensate for an
underlying jaw discrepancy.
• Thus, camouflage in orthodontics is defined
as implementation of a less intensive
treatment plan option in a patient with a
severe problem so as to obtain optimum
results within physiologic limits and which
may not be addressing the correction of the
actually existing problem in the patient.
• Orthodontic camouflage
treatment can be performed in
Class III malocclusion patients
with the mild skeletal
discrepancy in patients with no
growth potential.
• Selective tooth extraction
(premolars, lower incisors, or
lower second molars) is done
to correct only the dental
malocclusion.
Objectives
• To describe management
of dentoskeletal class III
malocclusion by
extraction of the upper
and lower right
premolar.
Case Report
19 years
old
A patient:
Javanese
Female
Pretreatment
facial
photographs
concave facial
profile
Pretreatment Intraoral
photographs
Class III Angle dentoskeletal
malocclusion
anterior crowding and
crossbite (overjet -3 mm),
midline shift
Radiographic
Examination
∠ SNA
84°
∠Facial (facial
angle)
94°
∠ SNB
86°
∠Conv ( Angle of
convexity)
-5°
∠ ANB
-2°
Bidang A-B
+2°
I ke NA
6 mm
FMPA
34°
Sumbu Y ( Y axis)
60°
Oklusal Plane
15°
Inter I
1370
∠ I ke NA
I ke NB
∠ I ke NB
20°
5 mm
27°
Treatment
This case was treated with straight wire appliance with
vertical U-loop to correct anterior crossbite.
Vertikal Loop usage
for protraction up
anterior teeth.
The result after
using Vertical Loop
A common strategy of
orthodontic camouflage
treatment is the use of
intermaxillary Class III
elastics. Result in mesial
movement of the upper
dentition and distal
movement of the lower
dentition with proclination of
upper and retroclination of
the lower dentition (Yu-jin
Seo, 2015)
Treatment Progress
Anterior crossbite was
corrected / edge to edge
Treatment Progress
Overjet and Overbite
were formed.
Space anterior has
closed, right canine
still in class III,
midline shift,
patients are not
satisfied with her
profile
Radiographic
Examination
∠ SNA
840
∠Facial (facial angle)
960
∠ SNB
860
∠Conv ( Angle of
convexity)
-30
∠ ANB
-20
Bidang A-B
+20
I ke NA
9mm
FMPA
340
Sumbu Y ( Y axis)
580
Oklusal Plane
80
∠ I ke NA
I ke NB
∠ I ke NB
300
7 mm
240
Inter I
1220
Treatment
For late adolescent or adult patients with a moderate Class
III malocclusion who refuse orthognathic surgery,
orthodontic treatment with mandibular bicuspid extraction
may be a viable alternative
Treatment
followed
by:
extraction
of 15
extraction
44
• to improve
right molar
relations
• to correct
the median
line shift.
Result
At the end of the treatment:
anterior crossbite was corrected,
class I canine and molar relation with normal
overbite overjet and median line was in a line,
better profile
Posttreatment
facial
photographs
Result
Post-treatment intraoral
photographs
Radiographic
Examination
∠ SNA
820
∠Facial (facial
angle)
940
∠ SNB
840
-20
∠ ANB
-20
∠Conv ( Angle of
convexity)
Bidang A-B
+20
I ke NA
8 mm
FMPA
350
Sumbu Y ( Y axis)
590
Oklusal Plane
100
Inter I
1420
∠ I ke NA
I ke NB
∠ I ke NB
27
4 mm
130
Discussion
• Orthodontic camouflage is well fit for
patients that carry small skeletal
Class III, with no growth potential,
with a relative fine facial balance and
without severe crowding.
• This case was treated with straight
wire system appliance with vertical
U-loop to correct anterior crossbite
Sobral et al, 2013, Vertical control in the Class III compensatory treatment
• The several loop designs that have
been described have specific
applications and when properly
employed produce effective
responses.
• One of common applications of the loops in
orthodontic treatment procedures is double
vertical loop against bracket fixed to the
contained section of the arch wire activated
by tying back or compression for mesial or
distal movement (such as midline
correction).
Loomba et al, 2011, Clinical Application of Loops in Orthodontic
Indication for class III
camouflage treatment
• Too old for successful growth modification,
• Mild to moderate skeletal class III,
• Reasonably good alignment of teeth so
that the extraction space would be
available for controlled anteroposterior
displacement and not used to relieve
crowding,
• Good vertical facial proportions, neither
extreme short face nor long face.
Tekale PD et al, 2014. Orthodontic Camouflage in Skeletal Class III Malocclusion: A Contemporary
Review
Class III Elastic
• Another form of camouflage is the use of
Class III elastics, thus allowing a
compensation by lingualization of the lower
incisors and labialization of the upper
incisors (Rey Mora, et al, 2007)
• Extended from upper molar to the lower
cuspid.
• Bring about retrusion of mandibular
anteriors and protusion of maxillary
anteriors.
• Class III intermaxillary elastics were used to
protract maxillary first molar from class III
into class I relation (Bayirli B, 2009 in
Suresh R, 2014).
• Class III elastics also contribute to
correction of the overbite and overjet,
which was at the cost of retrusion of
the mandibular incisors and permitted
by extraction of lower premolar.
• One of extraction pattern for class III
camouflage is extraction of upper
second premolars and lower first
premolars (Premkumar, 2015).
15
• Extraction of the maxillary second premolar in
this case, could make the maxillary molars
moved mesially into class I molar
relationship.
• Extraction of second premolar was first
introduced by Nance in 1949.
• Nance suggested that borderline extraction
cases with minimal crowding and cases to
avoid over- retraction of the anterior
segments should be treated in conjunction
with extraction of second premolars.
Suresh R. Class III Subdivision Malocclusion With Unilateral Posterior Crossbite.
2014
• Schoppe and Schwab observed
that more mesial movement of
the posterior segments were
present in second premolar
extractions cases than in first
premolar extraction.
• In some class III cases with
crowding, treatment may be
easier to consider extraction of
upper second and lower first
premolars.
Extraction of 44
• Extraction of first premolar
mandibular is to provide to
move mandibular canines
distally from a class III
relationship into a class I
relationship and also to
correct the midline shifting.
• Premolar extraction also
favored reducing the
mandibular prognathism by
reducing the concavity,
obtaining an esthetic profile
and coincidence of midline
(Bhandari and Anbuselvan,
• To improve the anterior cross bite or edgeto-edge bite, premolar extraction plays
important role by providing space to
retract lower incisors. Usually patient with
class III malocclusion having the concave
profile and after extraction of lower
premolar it may disturb the concave profile
due to lingual inclination of lower incisors
compare to non extraction case (Alam MK
et al, 2016).
Conclusion:
• Camouflage treatment with
proper extraction can be
considered in a non-surgical
treatment of adult and give a
satisfactory result
• All treatment goals have been
achieved and the patient was
satisfied.
References
1.
Paulo Beltrão. 2015. Class III High Angle Malocclusion Treated with Orthodontic Camouflage
(MEAW Therapy). Issues in Contemporary Orthodontics Chapter 11. Licensee InTech. Download
from http://www.intechopen.com/books
2.
Snigdha Pattanaik, Noorjahan Mohammad, Sasmita Parida, Subhrajeet Narayan Sahoo. 2016.
Treatment Modalities for Skeletal Class III Malocclusion: Early to Late Treatment. IJSS Vol 2 | Issue
8. Download from http://www.ijsscr.com/
3.
Tekale PD, Vakil KK, Vakil JK, Parhd SM. 2014. Orthodontic Camouflage in Skeletal Class III
Malocclusion: A Contemporary Review. J Orofac Res;4(2):98-102. Download from
www.jaypeejournals.com/eJournals
4.
A-Bakr M. Rabie, Ricky W.K. Wong and G.U. Min. 2008. Treatment in Borderline Class III
Malocclusion: Orthodontic Camouflage (Extraction) Versus Orthognathic Surgery. The Open
Dentistry Journal, 2, 38-48
5.
Sobral MC, Habib FAL, Nascimento AC de S. Vertical control in the Class III compensatory
treatment. Dental Press Journal of Orthodontics. 2013 Apr;18(2):141–59.
6.
Elastics in orthodontics /certified fixed orthodontic courses by Indi… [Internet]. 05:29:50 UTC
[cited 2016 Aug 10]. Available from: http://www.slideshare.net/indiandentalacademy/elastics-inorthodontics
7.
Bhandari P, Anbuselvan G. Nonsurgical management of class III malocclusion: A case report.
Journal of Indian Academy of Dental Specialist Researchers. 2014;1(1):35.
8.
Suresh R. Class III Subdivision Malocclusion With Unilateral Posterior Crossbite. Kathmandu Univ
Med J 2014;47(3): 207-10.
9.
Phulari BS. Orthodontics: Principles and Practice. JP Medical Ltd; 2011. 674 p. in
https://books.google.co.id
10. Rey Mora D, Oberti G, Ealo M, Baccetti T. Camouflage of moderate Class III malocclusions with
extraction of lower second molars and mandibular cervical headgear. Prog Orthod 2007;8(2):3007.
Treatment Of Dentoskeletal
Class III Malocclusion With
Premolar Extraction
(Case Report)
Dr. drg. Tita Ratya Utari, Sp.
Ort
Lecturer, Department of
Orthodontics, School of Dentistry
Faculty of Medicine and Health
Science
Universitas Muhammadiyah
Yogyakarta
tita_utari@yahoo.com
Introduction
• Class III malocclusions represent a small
proportion of all malocclussions among
orthodontic patients but the treatment
is considerable clinical challenge
because of the complex diagnosis and
the difficult prognosis (Antonio, 2012).
The Class III malocclusion has a strong
genetic background which may express itself
at an early age (Pattanaik, 2016).
Class III malocclusion is far more prevalent
in Asian countries than in the West. (Graber
Mosby, 2005 in A-Bakr M. Rabie, 2008)
Southeast Asian populations have the
highest prevalence of Class III malocclusion
(13% to 27%), while Indian and Caucasian
populations have a lowest prevalence (1% to
5%). (Neal D. Kravitz)
The general characteristics of
skeletal class III:
Narrow ”cranial angle”,
Anteroposterior shortening of
maxilla,
Hyperdivergent skeletal pattern
(openbite),
Posterior discrepancy,
Flaring out of upper anterior teeth,
Incline to lingual in lower incisors,
Prognatic mandible, and
Flat occlusal plane.
Paulo Beltrão. 2015. Class III High Angle Malocclusion Treated with Orthodontic Camouflage (MEAW
Therapy)
Treatment Alternatives For Skeletal
Class III Malocclusion
Growth Modification,
There are three main
treatment options for skeletal
class III malocclusion:
A-Bakr M. Rabie, et al. 2008. Treatment in
Borderline Class III Malocclusion: Orthodontic
Camouflage (Extraction) Versus Orthognathic
Surgery
Dentoalveolar
Compensation (Orthodontic
Camouflage),
Orthognatic Surgery.
Growth modification should be commenced before the
pubertal growth spurt, after this spurt, only the latter two
options are possible.
Treatment Alternatives For Skeletal
Class III Malocclusion
• There are larger number of skeletal class
III patient that either decline or cannot
afford surgical treatment.
• The only alternative is “orthodontic
camouflage” through comprehensive
treatment with fixed appliances.
• There are type of Orthodontic camouflage:
1.Selective tooth extraction.
2.Distalization of mandibular dentition
using miniimplants.
Pattanaik, et al.: Treatment Modalities for Skeletal Class III Malocclusion,
2016
Camouflage in Orthodontic
• Camouflage treatment is defined by Proffit
as displacement of the teeth relative to
their supporting bone to compensate for an
underlying jaw discrepancy.
• Thus, camouflage in orthodontics is defined
as implementation of a less intensive
treatment plan option in a patient with a
severe problem so as to obtain optimum
results within physiologic limits and which
may not be addressing the correction of the
actually existing problem in the patient.
• Orthodontic camouflage
treatment can be performed in
Class III malocclusion patients
with the mild skeletal
discrepancy in patients with no
growth potential.
• Selective tooth extraction
(premolars, lower incisors, or
lower second molars) is done
to correct only the dental
malocclusion.
Objectives
• To describe management
of dentoskeletal class III
malocclusion by
extraction of the upper
and lower right
premolar.
Case Report
19 years
old
A patient:
Javanese
Female
Pretreatment
facial
photographs
concave facial
profile
Pretreatment Intraoral
photographs
Class III Angle dentoskeletal
malocclusion
anterior crowding and
crossbite (overjet -3 mm),
midline shift
Radiographic
Examination
∠ SNA
84°
∠Facial (facial
angle)
94°
∠ SNB
86°
∠Conv ( Angle of
convexity)
-5°
∠ ANB
-2°
Bidang A-B
+2°
I ke NA
6 mm
FMPA
34°
Sumbu Y ( Y axis)
60°
Oklusal Plane
15°
Inter I
1370
∠ I ke NA
I ke NB
∠ I ke NB
20°
5 mm
27°
Treatment
This case was treated with straight wire appliance with
vertical U-loop to correct anterior crossbite.
Vertikal Loop usage
for protraction up
anterior teeth.
The result after
using Vertical Loop
A common strategy of
orthodontic camouflage
treatment is the use of
intermaxillary Class III
elastics. Result in mesial
movement of the upper
dentition and distal
movement of the lower
dentition with proclination of
upper and retroclination of
the lower dentition (Yu-jin
Seo, 2015)
Treatment Progress
Anterior crossbite was
corrected / edge to edge
Treatment Progress
Overjet and Overbite
were formed.
Space anterior has
closed, right canine
still in class III,
midline shift,
patients are not
satisfied with her
profile
Radiographic
Examination
∠ SNA
840
∠Facial (facial angle)
960
∠ SNB
860
∠Conv ( Angle of
convexity)
-30
∠ ANB
-20
Bidang A-B
+20
I ke NA
9mm
FMPA
340
Sumbu Y ( Y axis)
580
Oklusal Plane
80
∠ I ke NA
I ke NB
∠ I ke NB
300
7 mm
240
Inter I
1220
Treatment
For late adolescent or adult patients with a moderate Class
III malocclusion who refuse orthognathic surgery,
orthodontic treatment with mandibular bicuspid extraction
may be a viable alternative
Treatment
followed
by:
extraction
of 15
extraction
44
• to improve
right molar
relations
• to correct
the median
line shift.
Result
At the end of the treatment:
anterior crossbite was corrected,
class I canine and molar relation with normal
overbite overjet and median line was in a line,
better profile
Posttreatment
facial
photographs
Result
Post-treatment intraoral
photographs
Radiographic
Examination
∠ SNA
820
∠Facial (facial
angle)
940
∠ SNB
840
-20
∠ ANB
-20
∠Conv ( Angle of
convexity)
Bidang A-B
+20
I ke NA
8 mm
FMPA
350
Sumbu Y ( Y axis)
590
Oklusal Plane
100
Inter I
1420
∠ I ke NA
I ke NB
∠ I ke NB
27
4 mm
130
Discussion
• Orthodontic camouflage is well fit for
patients that carry small skeletal
Class III, with no growth potential,
with a relative fine facial balance and
without severe crowding.
• This case was treated with straight
wire system appliance with vertical
U-loop to correct anterior crossbite
Sobral et al, 2013, Vertical control in the Class III compensatory treatment
• The several loop designs that have
been described have specific
applications and when properly
employed produce effective
responses.
• One of common applications of the loops in
orthodontic treatment procedures is double
vertical loop against bracket fixed to the
contained section of the arch wire activated
by tying back or compression for mesial or
distal movement (such as midline
correction).
Loomba et al, 2011, Clinical Application of Loops in Orthodontic
Indication for class III
camouflage treatment
• Too old for successful growth modification,
• Mild to moderate skeletal class III,
• Reasonably good alignment of teeth so
that the extraction space would be
available for controlled anteroposterior
displacement and not used to relieve
crowding,
• Good vertical facial proportions, neither
extreme short face nor long face.
Tekale PD et al, 2014. Orthodontic Camouflage in Skeletal Class III Malocclusion: A Contemporary
Review
Class III Elastic
• Another form of camouflage is the use of
Class III elastics, thus allowing a
compensation by lingualization of the lower
incisors and labialization of the upper
incisors (Rey Mora, et al, 2007)
• Extended from upper molar to the lower
cuspid.
• Bring about retrusion of mandibular
anteriors and protusion of maxillary
anteriors.
• Class III intermaxillary elastics were used to
protract maxillary first molar from class III
into class I relation (Bayirli B, 2009 in
Suresh R, 2014).
• Class III elastics also contribute to
correction of the overbite and overjet,
which was at the cost of retrusion of
the mandibular incisors and permitted
by extraction of lower premolar.
• One of extraction pattern for class III
camouflage is extraction of upper
second premolars and lower first
premolars (Premkumar, 2015).
15
• Extraction of the maxillary second premolar in
this case, could make the maxillary molars
moved mesially into class I molar
relationship.
• Extraction of second premolar was first
introduced by Nance in 1949.
• Nance suggested that borderline extraction
cases with minimal crowding and cases to
avoid over- retraction of the anterior
segments should be treated in conjunction
with extraction of second premolars.
Suresh R. Class III Subdivision Malocclusion With Unilateral Posterior Crossbite.
2014
• Schoppe and Schwab observed
that more mesial movement of
the posterior segments were
present in second premolar
extractions cases than in first
premolar extraction.
• In some class III cases with
crowding, treatment may be
easier to consider extraction of
upper second and lower first
premolars.
Extraction of 44
• Extraction of first premolar
mandibular is to provide to
move mandibular canines
distally from a class III
relationship into a class I
relationship and also to
correct the midline shifting.
• Premolar extraction also
favored reducing the
mandibular prognathism by
reducing the concavity,
obtaining an esthetic profile
and coincidence of midline
(Bhandari and Anbuselvan,
• To improve the anterior cross bite or edgeto-edge bite, premolar extraction plays
important role by providing space to
retract lower incisors. Usually patient with
class III malocclusion having the concave
profile and after extraction of lower
premolar it may disturb the concave profile
due to lingual inclination of lower incisors
compare to non extraction case (Alam MK
et al, 2016).
Conclusion:
• Camouflage treatment with
proper extraction can be
considered in a non-surgical
treatment of adult and give a
satisfactory result
• All treatment goals have been
achieved and the patient was
satisfied.
References
1.
Paulo Beltrão. 2015. Class III High Angle Malocclusion Treated with Orthodontic Camouflage
(MEAW Therapy). Issues in Contemporary Orthodontics Chapter 11. Licensee InTech. Download
from http://www.intechopen.com/books
2.
Snigdha Pattanaik, Noorjahan Mohammad, Sasmita Parida, Subhrajeet Narayan Sahoo. 2016.
Treatment Modalities for Skeletal Class III Malocclusion: Early to Late Treatment. IJSS Vol 2 | Issue
8. Download from http://www.ijsscr.com/
3.
Tekale PD, Vakil KK, Vakil JK, Parhd SM. 2014. Orthodontic Camouflage in Skeletal Class III
Malocclusion: A Contemporary Review. J Orofac Res;4(2):98-102. Download from
www.jaypeejournals.com/eJournals
4.
A-Bakr M. Rabie, Ricky W.K. Wong and G.U. Min. 2008. Treatment in Borderline Class III
Malocclusion: Orthodontic Camouflage (Extraction) Versus Orthognathic Surgery. The Open
Dentistry Journal, 2, 38-48
5.
Sobral MC, Habib FAL, Nascimento AC de S. Vertical control in the Class III compensatory
treatment. Dental Press Journal of Orthodontics. 2013 Apr;18(2):141–59.
6.
Elastics in orthodontics /certified fixed orthodontic courses by Indi… [Internet]. 05:29:50 UTC
[cited 2016 Aug 10]. Available from: http://www.slideshare.net/indiandentalacademy/elastics-inorthodontics
7.
Bhandari P, Anbuselvan G. Nonsurgical management of class III malocclusion: A case report.
Journal of Indian Academy of Dental Specialist Researchers. 2014;1(1):35.
8.
Suresh R. Class III Subdivision Malocclusion With Unilateral Posterior Crossbite. Kathmandu Univ
Med J 2014;47(3): 207-10.
9.
Phulari BS. Orthodontics: Principles and Practice. JP Medical Ltd; 2011. 674 p. in
https://books.google.co.id
10. Rey Mora D, Oberti G, Ealo M, Baccetti T. Camouflage of moderate Class III malocclusions with
extraction of lower second molars and mandibular cervical headgear. Prog Orthod 2007;8(2):3007.