Interdisciplinary management of an adult

patient with a class III malocclusion

Zafer Özgür Pektas, DDSa and Beyza Hancıoglu Kircelli, DDSb
School of Dentistry, Baskent University, Adana, Turkey
The coexistence of a skeletal class III deformity and partial edentulism poses a clinical challenge and requires a comprehensive
evaluation followed by a multidisciplinary approach. This clinical report presents the integrated management of a class
III malocclusion in a 50-year-old woman with partial edentulism. The patient received adjunctive orthodontic treatment
with a rigid temporary anchorage device, a Le Fort I maxillary osteotomy, and prosthodontic rehabilitation with
removable maxillary copings, an overdenture, and a mandibular partial removable dental prosthesis with precision
attachments. (J Prosthet Dent 2014;112:9-13)

Skeletal class III deformities are CLINICAL REPORT on palpation, and the range of motion
caused by maxillary deficiency, was within normal limits. An extraoral
mandibular excess, or a combination.1 A 50-year-old woman with func- examination revealed a skeletal class III
Approximately 40% of class III de- tional and esthetic complaints was pattern associated with a concave facial
formities are caused by maxillary de- initially referred to the department of profile, a prominent chin, a retrusive
ficiencies alone.2 The correction of a prosthodontics for new prostheses. Her maxillary complex, with inadequate
class III deformity is accomplished by medical history was noncontributory, upper lip support, and deep naso-
combined orthodontic and orthog- and cleft lip and palate deformities buccal folds (Fig. 1A, B). Clinical and
nathic surgical procedures when the were ruled out. The temporomandib- radiographic evaluation indicated a
deformity is too severe that reasonable ular joints were healthy and not painful worn and unfavorable metal reinforced
correction cannot be obtained by or-
thodontic treatment alone.2 Le Fort
osteotomy has become the most popu-
lar midfacial osteotomy to correct
maxillary deformity, with or without si-
multaneous mandibular surgery,3 since
it was first introduced by Obwegeser4 in
1969. Complete or partial edentulism in
patients with skeletal class III de-
formities complicates the situation and
poses a clinical challenge, especially
when occlusal guidance is lost. This
report presents the interdisciplinary
management of a partially edentulous
class III malocclusion, which comprised
an adjunctive orthodontic treatment
with a rigid temporary anchorage de-
vice (TAD), a Le Fort I maxillary osteot-
omy, and prosthodontic rehabilitation
with maxillary metal copings, an over-
denture, and a mandibular partial
removable dental prosthesis with preci- 1 A, B, Pretreatment extraoral oblique and profile view. Note retrusive maxillary
sion attachments. complex, inadequate upper lip support, and deep nasobuccal folds.

a
Associate Professor, Department of Oral and Maxillofacial Surgery, School of Dentistry, Baskent University.
b
Associate Professor, Department of Orthodontics, Private practice, Adana, Turkey.

Pektas and Kircelli

10
2 Pretreatment panoramic radiograph, indicating bimaxil-
lary partial edentulism and unfavorable acrylic resin partial
fixed dental prosthesis.
Table I. Pretreatment and posttreatment cephalometric measurement values of
patient
Cephalometric Landmarks Pretreatment Posttreatment Norm Values
SNA (degrees) 73.7 78. 9 82.0
SNB (degrees) 79.8 78.7 80.9
ANB (degrees) -6.1 0.2 1.6
Facial angle (FH-NPo) (degrees) 88.9 87.2 88.6
Convexity (A-NPo) (mm) -7.9 -1.2 0.7
FMA (MP-FH) (degrees) 20.5 21.4 23.9
Upper lip to E plane (mm) -14.3 -9.3 -6.0
Lower lip to E plane (mm) -7.6 -5.6 -2.0
SNA, sella-nasion-A; SNB, sella-nasion-B; ANB, A-nasion-B; FH-NPo, Frankfort Horizontal-nasion-
pogonion line; A-NPo, A-nasion-pogonion line; FMA, Frankfort Mandibular-Plane Angle; MP-FH,
Mandibular Plane-Frankfort Horizontal.
Cephalometric analysis processed by using Dolphin Imaging Software, 11.0 (Dolphin Imaging).
fixed dental prosthesis with acrylic resin were unsatisfactory and failed to estab-
veneers, which extended from the lish an accurate occlusion. In particular,
maxillary central incisors to the maxil- the maxillary restoration presented an
lary right first molar. In addition, the excessive protrusion to disguise the skel-
partial fixed dental prosthesis was etal class III deformity. Also, the dental
supported by an impacted maxillary history of the patient revealed previous
canine, which presented severe mo- attempts with several removable partial
bility, and all the supporting teeth were prostheses, none of which met her ex-
root remnants with caries and apparent pectations. The prostheses that were
infection (Fig. 2). The maxillary left fabricated in the neutral zone failed to
canine, second premolar, and second support the soft tissue anterior to the
molar were missing. retruded maxilla, whereas those with an
The mandible was edentulous except increased denture base thickness to
for the right central and lateral incisor, buttress the maxillary soft tissue were
canine, and second molar. The mandib- unstable because of the muscular activity.
ular incisors and right second molar The patient was referred to an oral
were supporting a defective metal cera- and maxillofacial surgeon, an ortho-
mic fixed dental prosthesis and a partial dontist, and a prosthodontist. Cepha-
removable dental prosthesis. Both lometric evaluations were performed
maxillary and mandibular prostheses by the orthodontist to determine
The Journal of Prosthetic Dentistry
Volume 112 Issue 1
the pattern of dentofacial deformity.
Cephalometric analysis and diagnostic
casts revealed a moderate skeletal class
III deformity, attributed to maxillary
deficiency; no remarkable mandibular
discrepancy was noted (Table I). The
cephalometric measurements were per-
formed by using imaging software
(Dolphin Imaging Software, 11.0; Dol-
phin Imaging). This software also can
classify the severity of the skeletal defor-
mity as mild, moderate, or severe based
on the deviations from the norm values
of the sella-nasion-A angle. A standard
deviation of 2.4 degrees corresponded
to a moderate deformity for this patient
as determined by the software.
The treatment plan involved man-
aging the impacted maxillary right
canine with orthodontics, advancing
the maxilla with a 1-piece Le Fort I
maxillary osteotomy, and subsequent-
ly rehabilitating the occlusion with
prosthodontics. Other treatment al-
ternatives that comprised prosthetic
restorations alone were also discussed.
A maxillary complete arch implant-
supported fixed prosthesis would
have restored her masticatory function;
however, as with a removable pros-
thesis, the contribution to facial es-
thetics would have been confined to
the dentoalveolar level. Moreover, such
a treatment plan with multiple dental
implants would have entailed a higher
patient cost because the placement of
dental implants was not covered by the
national health insurance; the cost of a
maxillary and mandibular osteotomy
was covered.
After the patient provided informed
consent, the existing maxillary fixed
dental prosthesis was removed and the
maxillary central incisors, the maxillary
right and left first premolars, and the
maxillary right first molar were extracted.
Also, a titanium intraosseous screw (2.0-
mm diameter  8-mm length) (inter-
maxillary fixation screw; Stryker) was
placed on the maxillary alveolar crest to
be used as a rigid TAD for the ortho-
dontic eruption of the right maxillary
impacted canine. Access to the impacted
maxillary canine was accomplished, and
a bracket was attached to the buccal
Pektas and Kircelli
July 2014 11
surface (Fig. 3). The impacted canine was
first moved upright by traction from an
elastomeric chain applied from the rigid
TAD. It was secondarily extruded by using
a cantilever, fabricated from 0.017 
0.025 inch titanium molybdenum alloy
wire (Ormco Corp), which extended from
the rigid TAD to the bracket of the canine
after the maxillary advancement (Fig. 4).
The patient then was scheduled for a
Le Fort I maxillary osteotomy, which was
performed as described by Bell.5 After
sectioning, downfracture, and mobiliza-
tion, the osteotomized segment was
3 Intermaxillary fixation screw as rigid temporary anchorage de-
advanced anteriorly by 5 mm and moved
vice for orthodontic eruption of impacted right maxillary canine.
downward by 2.5 mm (Fig. 5A, B). The
desired position was determined by using
a monoblock type acrylic resin (Scheu-
Dental) splint fabricated on the stone
casts used for cast surgery. A conven-
tional occlusal acrylic resin splint
could not be used because of the multiple
tooth loss in both jaws. The maxilla was
repositioned with both the mandibular
condyles in neutral position and bearing
no external force. The fixation of the
repositioned maxilla was maintained by
using 2 L-shaped titanium miniplates
(Leibinger) placed lateral to the pyriform
4 Uprighting and extrusion of impacted canine by using elas- fossa and the zygomatic buttresses on
tomeric chain, rigid temporary anchorage device, and cantilever each side.
fabricated from 0.017  0.025 inch titanium molybdenum alloy Healing was uneventful, with im-
wire proved facial esthetics; the maxillary
advancement augmented the lip support
and eliminated the concave facial profile
and deep nasobuccal folds (Fig. 6).
Subsequently, the prosthodontic treat-
ment phase was initiated, and the
maxillary left first molar was restored
with a ceramic crown. The extruded
maxillary right canine and maxillary left
lateral incisor were restored with metal
copings and an overdenture was fabri-
cated (Fig. 7A, B). Cephalometric mea-
surements are shown in Table I. The
total treatment time was 12 months. At
a 6-year follow-up, the patient remained
satisfied with the esthetic and functional
results (Fig. 8A, B).

DISCUSSION

5 A, Presurgical lateral cephalometric radiograph with intermaxillary fixation screw in The contemporary treatment of skel-
place. B, Postsurgical lateral cephalometric radiograph, miniplate, and screw fixation. etal class III deformities in adult patients

Pektas and Kircelli

12
6 Postsurgical extraoral lateral view,
showing improvement in soft-tissue
profile.
7 A, B, Metal copings and overdenture.
with partial edentulism necessitates options with decreased risks may result in
a comprehensive perspective. In most compromised function or esthetics. A
situations, noninvasive treatment literature review revealed many clinical
The Journal of Prosthetic Dentistry
Volume 112 Issue 1
reports with acceptable results, in which
class III deformities were treated with
orthodontics alone or combined with
prosthodontic treatment.6-10 Unfortu-
nately, concerns exist when determining a
treatment plan for adults with skeletal
problems. The functional stability of
a prosthetic rehabilitation for a patient
with a maxillomandibular skeletal dis-
crepancy is generally compromised.
Orthognathic surgery is required to
restore the esthetic balance in patients
with moderate-to-severe skeletal prob-
lems. However, patients may be reluc-
tant to undergo surgery either because
of personal preferences or their com-
promised health. In addition to the
retruded maxilla, the effects of multiple
tooth loss and, consequently, the at-
rophy of the maxillary alveolar were
seen as inadequate upper lip support,
deep nasobuccal folds, and increased
facial wrinkles, all contributed to an
aging face. This patient was not willing
to accept suboptimal results, and sur-
gical maxillary advancement followed
by prosthetic rehabilitation fulfilled all
her requirements.
From a prosthodontic point of view,
acrylic resin denture bases may replace
and support the orofacial structures
in selected patients. However, this
treatment should be limited to those
with mild skeletal class III deformities.
For the presented patient, the func-
tional restoration could have been
accomplished by means of a proper
prosthetic restoration, which provided
bilateral balancing occlusion. However,
this would probably have led to further
esthetic concerns, particularly for
the midfacial deficiency. The eccentric
settlement of the denture due to the
retrusive maxilla would have exacer-
bated the resorptive process in the
maxilla. Although esthetic concerns
might have been avoided by increasing
the occlusal vertical dimension,11 an
increased occlusal vertical dimension
may cause postoperative problems,
including clenching, muscle fatigue,
occlusal instability, continued wear,
and the resorption of the alveolus.
Orthognathic surgery likely offers
the best treatment alternative in adults
Pektas and Kircelli
July 2014
8 A, B, Posttreatment extraoral view, 6-year follow-up with satisfactory esthetic
and functional results.
with skeletal class III deformities in
which the maxillary retrusion is the
primary component. The LeFort I
maxillary osteotomy has been the
procedure of preference for the cor-
rection of many skeletal class III
deformities.5,12 Nevertheless, the reluc-
tance of the patient to have surgery may
limit an ideal treatment plan.
SUMMARY
This patient’s satisfaction with the
treatment outcome emphasizes the
significance of a comprehensive pa-
tient evaluation, an accurate patient-
Pektas and Kircelli
oriented diagnosis, and a multidisciplinary
approach for the management of pa-
tients with partial edentulism and with
skeletal deformities.
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Corresponding author:
Dr Zafer O. Pektas
Baskent University, Adana Teaching and
Research Center
Kisla Saglik Yerleskesi, Kazim Karabekir
mah. 4227 Sok. No: 27, 01120 Yuregir, Adana
TURKEY
E-mail: opektas@baskent-adn.edu.tr
Acknowledgment
The authors thank Dr Cem Kircelli for his valuable
contributions.
Copyright ª 2014 by the Editorial Council for
The Journal of Prosthetic Dentistry.