See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/338990488

Effects of Chin Cup in the Management of Class III Malocclusion

Article  in  Journal of the Indian Dental Association · October 2018

CITATION READS
1 187

2 authors:

Shyamala Naidu Anand Suresh

Penang International Dental College Penang International Dental College
13 PUBLICATIONS   3 CITATIONS    19 PUBLICATIONS   77 CITATIONS   

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Shyamala Naidu on 03 February 2020.

The user has requested enhancement of the downloaded file.

 LITERATURE REVIEW

J Orthododontics
I Effects of Chin Cup in the Management of Class III Malocclusion
D Shyamala Naidu , Anand Suresh
1 2

1. FICD FWFO, Lecturer

2. FICD, Assistant Professor
Penang International Dental College
Pulau Pinang, Malaysia

Abstract
One of the most common malocclusions seen around the
globe is the Class III malocclusions. Although the cause
of Class III malocclusion is considered to be protruded
lower jaw and the only option determined to be of
surgery, ideally that’s not the case. Treatment for Class
III malocclusions depends on many factors, of which the
age factor is crucial of all. Early diagnosis and treatment
during early stages of growth during childhood can
Access this article online
Quick Response Code:
prevent the extensive surgical option in the future. Chin
cup is one of the oldest orthopaedic appliances used in
the management of Class III malocclusions in growing
Website:
patients. The following review article will highlight on
jida.ida.org.in
the causes, importance of early diagnosis and prevention
of Class III malocclusion and the effects of chin cup in
growing patients.
How to cite this article: Shyamala Naidu, Anand Suresh.Effects
of Chin Cup in the Management of Class III Malocclusion.JIDA Key Words
2018;XII;39-42.
Class III malocclusion, Chin cup, Orthopaedic appliances.

39
J I D A - Jou rn al of I n d i an D ent al Asso ciatio n - Vo l 12 - Issue 10 - O c to b er 2018
Introduction
Orthodontic treatment not only involves establishment
of physiologically and anatomically functional occlusion
but also includes correction of the relationship of the
maxilla and mandible to each other and to the rest of the
craniofacial complex. In 1778, John Hunter, in writing in
his book The Natural History of the Human Teeth, stated:
“It is not uncommon to find the lower jaw projecting too
far forwards, so that its fore teeth pass before those of
the upper jaw, when the mouth is shut; which is attended
with inconvenience, and disfigures the face”[1]. A class III
malocclusion can be either a single skeletal malocclusion,
for example, maxillary retrognathism, mandibular
prognathism or it can be a combination of both.
Although the treatment of any skeletal malocclusion can
be broadly classified into growth modification appliances,
camouflage or orthognathic surgery, the timing of
treatment plays a crucial role for long term stability in
these patients. It is common in orthodontic practise to
encounter parents being reluctant in treatment for the
class III malocclusions in their child due to the fear of
surgical option.
Early diagnosis and proper counselling can prevent a
simple problem from making it to a more complicated
one. A number of appliances are available today for the
treatment of Class III malocclusion. Among them, chin cup
holds a premium position as a traditional appliance for
the early orthopaedic treatment of Class III malocclusion.
Chin cup appliance is an extra oral orthopaedic device
that covers the chin and is connected to a head gear.
It is mainly used to restrict the forward and downward
growth of the mandible.
Aetiology of Class III Malocclusion
Class III malocclusion may have a multifactorial aetiology.
It can be broadly classified into (a) Genetic: – 33 out of
40 decendants of the HABSBURG family had a class III
jaw (b) Ethnic – 3% in Caucasians – 5% Africanamerican
– 14% Chinese and Japanese – (3.4% indians) c)
Environmental (epigenetic): – Large tongue – Forward
tongue position (e.g., in cases of adenoids) – Mouth
breathing d) Systemic: – Acromegaly and hemi mandibular
hypertrophy e) Teratogenic: Teratogens causing cleft lip
and palate are aspirin, cigarette smoke (hypoxia), dilantin,
6-mercaptopurine, valium vitamin D excess causes
premature closure of sutures and might lead to class III
malocclusion.
40
J I D A - Jou rn al of I n d i an D ent al Asso ciatio n - Vo l 12 - Issue 10 - O c to b er 2018
Early Signs of Developing Class III Malocclusion
a. Reverse overjet
b. Unilateral/ bilateral posterior crossbite
c. Proclined maxillary incisors and retroclined mandibular
incisors
d. Wide lower arch and narrow maxillary arch
e. Flat curve of spee
f. Habitual protraction of the mandible by the child into
the protruded functional and morphologic relationship
g. Pseudo class III
h. Habitual occlusion
Types of Chin Cup
1. The occipital-pull chin cup
• Derives anchorage from the occipital region.
• Used in class III malocclusions associated with mild to
moderate mandibular prognathism.
• Also indicated in patients with slightly protrusive lower
incisors as they invariably produce lingual tipping of
the lower incisors.
2. The vertical-pull chin cup
• Derives anchorage from the parietal region of the
head.
• Indicated in patients with steep mandibular plane
angle and excessive anterior facial height.
• These patients usually exhibit an anterior open bite.
Force Magnitude and Duration of Wear
At the time of appliance delivery a force of 150-300
grams per side is used. Over the next 2 months the force
is gradually increased to 450-700 grams per side. The
patient is asked to wear the appliance for 12-14 hours a
day to achieve the desired results. Proffit recommended
a force of approximately 16 ounces (450 gram) per side
through the head of the condyle or a somewhat lighter
force below the condyle[2]. Once it is accepted that
mandibular rotation is the major treatment effect, lighter
force oriented to produce greater rotation makes more
sense. From this perspective, it is apparent that more
Asian than Caucasian children can benefit from chin-cup
treatment because of their generally shorter face height
and greater prevalence of lower incisor protrusion, not
because of a difference in the treatment response. Once
the anterior crossbite was corrected, the patient was
instructed to wear the chin cup at least 10 hours per day
until slight Class II canine and molar relationships were
established.
Ideal Patient for Chin Cup Treatment
1. Mild skeletal class III
2. Short vertical facial height (.Chincup cause clockwise
rotation of the mandible.
3. Proclined or upright lower incisors
4. Absence of severe facial and dental asymmetry.
Effects of Chin cup on Skeletal Growth
Sakamoto and Wendell et al[3] have noted decrease
in mandibular growth during treatment. Wendell and
associates noted that the mandibular length increases
in the treated group were only about two-thirds of
those observed in the control group of mixed dentition
individuals. Mitani and Fukazawa[4],however, noted no
differences in mandibular length in Class III individuals who
began treatment during the adolescent growth period in
comparison with control values. Graber[5] reported that,
in a sample of young Class III patients, the predominantly
horizontal mandibular growth pattern was redirected
more vertically, indicating that the orthopaedic chin cup
can produce an increase in lower anterior facial height
while correcting the anteroposterior malrelationship.
Later Sugawara and Mitani noted that chin cup appliances
greatly improve the skeletal profile in the short term,
such changes are however rarely maintained during the
pubertal growth spurt.
Peter et al[6] have reported that a chin cup appliance has
no effect on the anteroposterior growth of the maxilla,
whereas Uner et al[7] showed that early correction of
anterior crossbite with chin cup appliance prevents
retarded anteroposterior maxillary growth. Sugawara et
al[8] compared the growth changes of patients after chin
cup treatment with control subjects and reported that at
age 17, the midface is more deficient in patients of the
control groups than in those of the treatment group.
Graber[9], Chung, and Aoba reported results in patients
treated with chin cups for 12 to 14 hours each day with a
force of 1.5 to 2 pounds on each side. They showed that
mandibular growth could be redirected effectively with
a chin cup. Graber reported an article where 35 Class
III malocclusions in children were treated between the
ages of 5 and 8 years with chin cup therapy for 3 years.
He found that the therapy was particularly effective in
patients with increased vertical growth of the face. Mitani
et al[4]reported that first 2 years of chin cup therapy
produced more changes. In 1986, Ritucci and Nanda[10]
J I D A - Jou rn al of I n d i an D ent al Asso ciatio n - Vo l 12 - Issue 10 - O c to b er 2018
treated 10 Japanese girls aged 7-8 years with the chin
cup for class III malocclusion. Approximately 500 g or
250 g force were given until the end of juvenile growth
period for mini-mum 12 hours per day. The results were
compared with 7 ideal class I relation subjects and it was
found that chin cup significantly inhibits the mandibular
growth .
Another study by Deguchi et al[11], reviewed cephalometric
records of two groups (short term using of chin cup and
long term using of chin cup). For short term, 500 g force
was given for 31 months. Moreover, for long term 250 g
to 300 g force was given for 86 months. The study showed
short-term treatment resulted in a slight improvement,
while long-term treatment resulted in a significant
improvement of class III malocclusion. While another
group study was done with the same force but one group
(250 g to 300 g force) used the appliance 14 hours per
day for 2 years and another group (500 g force) used
the appliance for night time only. Study established that
aggressive protocol of chin cup therapy is an orthopaedic
solution from developing class III malocclusions.
Ko et al[12] found that chin cup therapy was applicable to
skeletal Class III malocclusions with mandibular excess in
growing patients, but the result depended on the facial
skeletal pattern before chin cup therapy and severity of
the anteroposterior jaw discrepancy. Tahmina et al[13]
concluded in her study that the mandible of the unstable
group had a significantly larger gonial angle than that of
the stable group at the initial stage and that the mandible
showed downward and backward rotation during early
treatment and then rotated in an upward and forward
direction after the correction of the anterior crossbite in
the unstable group. It was concluded that the type of
mandibular rotation and displacement and the degree
of forward growth of the mandible were keys to the
treatment outcomes in growing patients with Class III
malocclusion after chin cup therapy.
Advantages of Chin Cup
• Changes direction of mandibular growth by rotating
the chin downwards and backwards.
• Lingual tipping of lower incisors as a result of pressure
of appliance on lower lip and dentition.
Disadvantages of Chin Cup
• Cannot be used in patients with excessive lower
anterior facial height.
41
 • This therapy alone may not be indicated for a fair
percentage of patients in skeletal Class III who show a
small midfacial bone or a retropositioned maxilla with
relatively normal mandibular relationship.
Conclusion
Chin cup is one of the most popular orthopaedic appliances
used in the treatment of class III malocclusions. According
to the literature both long term and short term effects
References
1. Hunter, J.: The natural history of the human teeth. Part II. A
practical treatise on the disease of the teeth intended as a
supplement to the national history of those parts, London,
1778, J. Johnson.
2. Proffit WR, Fields HW. Contemporary Orthodontics. 3. US: CV
Mosby; 2000.
3. Wendell P.D., Nanda R., Sakamoto T., Nakamura S. The effects
of chin cup therapy on the mandible: a longitudinal study. Am.
J. Orthod. 1985;87(4):265–274
4. Mitani H, Fukazawa H. Effects of chincap force on the timing
and amount of mandibular growth associated with anterior
reversed occlusion (Class III malocclusion) during puberty. Am J
OrthodDentofacialOrthop. 1986;90:454–463.
5. Graber, L. W.: Craniofacial alterations of human skeletal Class
III malocclusion produced by chin cup-orthopedicforce : A
three-year longitudinal cephalometric study, Master’s thesis,
Northwestern University, 1973.
6. Peter D. Wendell, Ravindra Nanda.The effects of chin
cup therapy on the mandible: A longitudinal study.Am J
OrthodDentofacialOrthop. April 1985Volume 87, Issue 4, Pages
265–274.
7. Uner O, Yüksel S, Uçüncü N. Long-term evaluation after chincap
treatment. Eur J Orthod 1995;17:135-41.
42
J I D A - Jou rn al of I n d i an D ent al Asso ciatio n - Vo l 12 - Issue 10 - O c to b er 2018
View publication stats
of chin cup therapy have shown considerable effects
on the reduction of mandibular prognathism. However,
their effects on maxillary growth need further attention.
Due to the innumerable advantages of chin cup it can be
considered safe and effective in treating growing patients
with class III malocclusions.
Conflict of Interest: Nil
Source of Support: Nil
8. Sugawara J. Clinical practice guidelines for developing Class III
malocclusion. In: Nanda R., editor. Biomechanics and Esthetic
Strategies in Clinical Orthodontics. US: Saunders; 2005. pp.
211–263
9. Graber, T. M., Chung, D. D. B., and Aoba, T. J.:
Dentofacialorthopedics versus orthodontics, J. Am. Dent. Assoc.
75: 1145-1160, 1967.
10. Ritucci R, Nanda R. The effect of chin cup therapy on the growth
and development of
the cranial base and midface. Am J OrthodDentofacialOrthop 1986;
90: 475-83.
11. Deguchi T, Kuroda T, Minoshima Y, et al. Craniofacial features of
patients with class III abnormalities: growth-related changes and
effects of short-term and long-term
chincup therapy. Am J OrthodDentofacialOrthop 2002; 121: 84-92.
12. Ko Y, Baek S, Mah J, Yang WS. Determinants of successful
chincup therapy in skeletal Class III malocclusion. Am J
OrthodDentofacialOrthop. 2004;126:33–41.
13. Tahmina K, Tanaka E, Tanne K. Craniofacial morphology
in orthodontically treated patients of Class III malocclusion
with stable and unstable treatment outcomes. Am J
OrthodDentofacialOrthop. 2000;117:681–690.