CASE REPORT

Nonextraction treatment of a skeletal Class III

malocclusion
Vladimir León-Salazar,a Guilherme Janson,b Marcos Roberto de Freitas,b Renato Rodrigues de Almeida,c
and Rubén León-Salazard
Bauru, Brazil, and Lima, Peru

This case report describes the nonsurgical, nonextraction therapy of a 16-year-old boy with a skeletal Class III
malocclusion, a prognathic mandible, and a retrusive maxilla. He was initially classified as needing orthog-
nathic surgery, but he and his parents wanted to avoid that. The Class III malocclusion was corrected with
a rapid palatal expander and a maxillary protraction mask followed by nonextraction orthodontic treatment
with fixed appliances, combined with short Class III and vertical elastics in the anterior area. The height of
the maxillary alveolar process and the vertical face height were slightly increased with treatment. Class I molar
and canine relationships were achieved, and the facial profile improved substantially. (Am J Orthod
Dentofacial Orthop 2009;136:736-45)

C
lass III malocclusions are usually growth-
related discrepancies that often become more
severe until growth is complete.1 Facial changes
can influence a patient’s self-confidence and interper-
sonal relationships.2,3 The success of early orthopedic
treatment in patients with Class III anomalies depends
on facial skeletal development and type of treatment,1
but, in some cases, surgery can be part of the treatment
plan.4 When it is associated with an open-bite tendency
and unfavorable growth pattern, correction of a Class III
relationship without orthognathic surgery can be chal-
lenging.3,5 However, a mild vertical growth pattern ten-
dency can be corrected with good treatment protocol
and satisfactory patient compliance. Therefore, the pur-
pose of this article was to describe the nonsurgical treat-
ment of a patient with Class III dental and skeletal
relationships with an open-bite tendency.
DIAGNOSIS AND ETIOLOGY
The patient was a boy, aged 16 years 4 months,
whose chief complaint was the anterior crossbite. He
a
Graduate student, Department of Orthodontics, Bauru Dental School, Univer-
sity of São Paulo, Bauru, Brazil.
b
Professor, Department of Orthodontics, Bauru Dental School, University of
São Paulo, Bauru, Brazil.
c
Associate professor, Department of Orthodontics, Bauru Dental School,
University of São Paulo, Bauru, Brazil.
d
Private practice, Lima, Peru.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Vladimir León-Salazar, Department of Orthodontics,
Bauru Dental School, University of São Paulo, Alameda Octávio Pinheiro
Brisolla 9-75, Bauru, SP, 17012-901, Brazil; e-mail, licusperu@hotmail.com.
Submitted, November 2006; revised and accepted, August 2007.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.08.034
736
had Class III canine and molar relationships on both
sides, 5-mm negative overjet, 1-mm anterior open
bite, bilateral crossbite with the maxillary midline coin-
cident to the midsagittal plane, and a 1-mm deviation of
the mandibular midline to the right. Both dental arches
had about 2 mm of excess space, and there was slight fa-
cial asymmetry (Figs 1-3). Cephalometrically, there
were a Class III jaw relationship and a slight tendency
of a vertical growth pattern (FMA, SN.Ocl, SN.GoGn;
Fig 4 and Table). No known relatives in his family
had a prominent lower jaw. No symptoms of temporo-
mandibular disorder were noted, and he had no pain dur-
ing jaw movement or on palpation. He was in good
health, and his medical history showed no contraindica-
tions to orthodontic therapy.
TREATMENT OBJECTIVES
Treatment objectives included correction of the pos-
terior and anterior crossbites, improvement of the den-
toalveolar and maxillomandibular relationships,
improvement of facial esthetics, and establishment of
a stable occlusion.
TREATMENT ALTERNATIVES
Three treatment options were suggested to the pa-
tient and his parents. The first alternative consisted of
combined surgical and orthodontic treatment with
a high LeFort procedure and mandibular osteotomy to
improve maxillary and facial appearance.
The second consisted of maxillary expansion and
extraction of the mandibular first premolars. This would
correct the Class III dental relationship, but it would
also involve retraction of the mandibular incisors
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 5
Fig 1. Extraoral and intraoral photographs before treatment. The profile view shows a slight
deficiency in maxillary projection.
without protrusion of the maxillary incisors; this was
thought to be unsatisfactory for this patient’s retruded
maxilla (Table).
The other treatment alternative was a nonextraction
orthodontic approach with maxillary expansion and
maxillary protraction with a facemask. The patient
and parents did not want orthognathic surgery and tooth
extractions. Therefore, they chose this nonextraction or-
thodontic treatment.
TREATMENT PROGRESS
Treatment began with placement of a banded rapid
palatal expander on the maxillary first molars and pre-
molars (Fig 5). The patient was instructed to activate
the appliance .5 mm every day for 2 weeks. Subse-
quently, he received a facemask for maxillary protrac-
tion with a forward and downward force directed
León-Salazar et al 737
approximately 30 to 40 to the maxillary occlusal
plane. The patient was instructed to wear it for 18 hours
a day (Fig 6). A force of 400 g on each side was delivered
by elastics attached to hooks on either side of the intrao-
ral appliance, between the maxillary canines and premo-
lars. During the 4-month period of maxillary protraction
with the facemask, fixed preadjusted appliances (0.022-
in slots) were placed on the mandibular teeth to level and
align them. After 6 months, the maxillary expander was
removed, use of the facemask was discontinued, and
fixed appliances were placed on the maxillary teeth. Lin-
gual buttons were bonded on the palatal surface of each
maxillary central incisor to support intermaxillary elas-
tics to the brackets of the mandibular incisors. These
elastics were used for 6 months with Class III elastics
to aid in correcting the anterior crossbite (Fig 7). Level-
ing and alignment progressed up to rectangular 0.019 3
0.025-in stainless steel archwires with continuous use of
738 León-Salazar et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2009

Fig 2. Initial study models.

Fig 4. Initial cephalometric tracing.

Fig 3. Pretreatment radiographs.

American Journal of Orthodontics and Dentofacial Orthopedics León-Salazar et al 739
Volume 136, Number 5

Table. Cephalometric treatment changes

Pretreatment Posttreatment Follow-up
(age 16 y (age 18 y (age 19 y
19
Measurement Standard 4 mo) 6 mo) 5 mo)

Maxillary component
SNA ( ) 82 77.8 80.2 80.7
Co-A (mm) 98.9 82.3 90.1 91
Mandibular component
SNB ( ) 80.4 81.8 82.7 82.3
SND ( ) 76 82 80 80
Co-Gn (mm) 126.8 124.7 134.5 135 Fig 5. Treatment progress photograph after rapid
Maxillomandibular relationship maxillary expansion.
ANB ( ) 2 4.0 2.5 1.6
Wits (mm) 0 10.8 4.5 3.9
Vertical and horizontal components
FMA ( ) 25 26.5 28.7 32.1
SN.Ocl ( ) 14 18 7 8
SN.GoGn ( ) 32 37.3 37.9 36
NSGn ( ) 67 66 66 65
LAFH (mm) 69.7 68.1 76.9 77.1
Dentoalveolar component
Mx1.NA ( ) 22 26.6 36.3 31.6
Mx1-NA (mm) 4 6 8.8 7.8
Md1.NB ( ) 25 25.5 7.3 11
Md1-NB (mm) 4 5.1 1.4 2.5
IMPA ( ) 95.3 84.4 64.6 68
Overjet (mm) 0.5-3.0 4.7 3.8 2.5
Overbite (mm) 0.5-3.0 0.1 2.0 1.5
Profile
NAP ( ) 0 9.0 6.6 5.9
Nasolabial 111.420 105.6 111.7 106.8
angle ( )

Cephalometric variable definitions: Co-A, condylion to A-point; Co-

Gn, condylion to gnathion; SN.GoGn, SN to GoGn angle; NS.Gn, an-
gle between lines NS and SGn; LAFH (lower anterior facial height),
distance from nasion to menton; Mx1.NA, maxillary incisor long
axis to the NA angle; M1-NA, distance between the most anterior point
of the crown of the maxillary incisor and NA line; Md1.NB, mandib-
ular incisor long axis to the NB angle; Md1-NB, distance between the
most anterior point of the crown of the mandibular incisor and the NB
line; overjet, distance between the incisal edges of the maxillary and
mandibular central incisors, parallel to the occlusal plane; overbite,
distance between the incisal edges of the maxillary and mandibular
central incisors, perpendicular to the occlusal plane; NAP, NA to AP
angle (facial convexity angle); nasolabial angle, angle between land-
marks Cl.Sn.LS.
3/16-in Class III elastics. The second molars were not in-
cluded in the bracketing at this point to prevent molar ex-
trusion during alignment; this could have caused more
downward mandibular rotation. After correction of the
crossbite and creation of a Class I occlusion, detailing
and finishing were undertaken. The total active treat-
ment time was 26 months. Patient compliance was
good in using all removal appliances and elastics during
active treatment. For retention, he was instructed to wear
a chincup for 8 hours every night for 3 years, because of
the Class III relapse tendency with growth.6-8
Fig 6. Lateral view with facemask.
TREATMENT RESULTS
The posttreatment extraoral photographs show gen-
eral improvement in the facial profile. The posttreat-
ment intraoral photographs and dental casts show
satisfactory dental alignment, Class I canine and molar
relationships on both sides, and normal overjet, over-
bite, and transverse relationships (Figs 8 and 9). There
was significant improvement in the maxillomandibular
relationship as cephalometrically shown by changes in
the ANB angle, Wits appraisal, and overjet. The maxil-
lary arch moved downward and forward, and the mandi-
ble had a slight backward rotation as the SN to occlusal
plane angle increased, resulting in a more favorable re-
lationship (Fig 10).
The superimposition shows an increase in lower an-
terior facial height with opening of the mandibular
plane angle. The maxillary incisors had labial proclina-
tion, and the mandibular incisors were retroclined lin-
gually (Table and Fig 11).
740 León-Salazar et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2009

Fig 7. Intraoral progress photographs showing the Class III and anterior intermaxillary elastics used
to correct the anterior crossbite.

Fig 8. Posttreatment photographs: the intraoral photographs show normal overbite and overjet
relationship, elimination of anterior crossbite, and Class I canine and molar relationships.
American Journal of Orthodontics and Dentofacial Orthopedics León-Salazar et al 741
Volume 136, Number 5

Fig 9. Posttreatment study models.

Fig 10. Posttreatment headfilm and cephalometric tracing.

742 León-Salazar et al American Journal of Orthodontics and Dentofacial Orthopedics
November 2009

Fig 11. High-pull chincup used as active retention: 11-month follow-up headfilm and superimposi-
tion of initial, final, and retention tracings on SN, centered on S.

Fig 12. Facial and intraoral photographs 11 months after the end of treatment.

At the end of treatment, a normal morphologic and and canine relationships were obtained on the right
functional occlusion was obtained, with anterior guid- side and overcorrection of the canine relationship on
ance on lateral excursion and protrusion. Class I molar the left side, because the patient had excellent
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 136, Number 5
Fig 13. Eleven-month follow-up dental casts.
cooperation with the Class III elastics. The good inter-
dental relationship also provided a well-balanced facial
profile, with lip competence. The slight facial asymme-
try also showed some improvement as the mild dentoal-
veolar asymmetry was corrected.
Cephalometric analysis 11 months after treatment
showed minimal skeletal changes in the maxilla and
the mandible. There were slight relapses of overbite
and molar relationship; these did not relevantly impair
the occlusion (Table and Figs 11-13).
DISCUSSION
The treatment objectives were attained with the non-
extraction treatment protocol. Usually, use of a facemask
to correct Class III malocclusions through maxillary
protraction is indicated in the deciduous and mixed den-
titions.9 Little maxillary protraction is expected when it
is used in the permanent dentition.1 However, there
might be some exceptions in compliant patients, when
clinically significant maxillary advancement can be
obtained, as in this patient. Because there was
a 9.8-mm increase in effective mandibular length growth
during the treatment period, it would be expected that
there would be approximately half of that increase
(4.9mm) in the effective maxillary length with natural
growth.10,11 However, with maxillary protraction, there
was a 7.8-mm increase in effective maxillary length,
meaning that the procedure actually protracted the max-
León-Salazar et al 743
illa significantly. Probably, the amount of protraction
was increased with the previous rapid maxillary expan-
sion,9 although the effectiveness of this procedure in
maxillary protraction has been recently questioned.12
Another factor that contributed to the anteroposterior
dentoskeletal improvement was the backward mandibu-
lar rotation, shown by increases in FMA, SN.Ocl,
SN.GoGn, and lower anterior face height; these are usual
side effects of Class III orthodontic mechanics.13,14
Obviously, the results reflect the effects of not only
the rapid maxillary expansion and protraction with the
facemask, but also the Class III elastics. The occlusal
and facial results were good, and the patient and his par-
ents were satisfied. The upper lip protrusion consequent
to protrusion of the maxillary incisors improved the fa-
cial profile significantly. The decrease in soft-tissue
concavity was due in part to redirection of mandibular
growth, anterior positioning of the maxilla, and retrac-
tion of the mandibular incisors.14
If the patient had not been compliant with the face-
mask and the elastics, another option would have been
to extract the mandibular first premolars.15,16 However,
this was not a favorable treatment alternative for the de-
sired soft-tissue changes because the anterior crossbite
would be corrected by retraction of the mandibular inci-
sors with little or no protrusion of the maxillary incisors;
this would have produced less improvement in the facial
profile than the nonextraction alternative.
744 León-Salazar et al
In Class III malocclusion treatment, it is usually
advisable to obtain overcorrection of the anteroposte-
rior discrepancy.6 This was obtained only on the left
side, leaving a small maxillary-to-mandibular midline
deviation. The maxillary midline also finished
slightly deviated to the right in relation to the midfa-
cial plane. However, this slight deviation should not
be a concern with dental attractiveness, because Ko-
kich et al17 found that discrepancies up to 4mm can
be undetected by laypeople or both general dentists
and orthodontists.
It was stated that anteroposterior intermaxillary elas-
tics produce significant vertical adverse effects.5,13,14
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. Nevertheless, despite
the resistant torques on the maxillary and mandibular in-
cisors, they were substantially tipped, probably because
of the large negative overjet that had to be corrected; it
required intensive Class III elastic use (Table).
Class III elastics are believed to cause counter-
clockwise rotation of the occlusal plane and produce
inversion of the natural esthetic smile line.14 This
did not occur in this patient, possibly because of
the slight vertical growth pattern (Table and Fig 8).
The use of Class III elastics also can cause backward
and downward mandibular rotation.13,14 Backward
mandibular rotation is favorable to correct a Class
III malocclusion, because it makes the mandible ap-
pear less prognathic and contributes to improvement
in the facial profile.18
Many Class III malocclusions have a combination
of underdeveloped maxilla and mandibular progna-
thism, as did this patient. To correct the problem, 3
treatment alternatives were presented to him and his
parents, and it was explained that a more esthetic re-
sult could be expected with the surgical/orthodontic
option. The decision for the orthodontic treatment
was primarily based on the patient’s refusal of the sur-
gical alternative because of the greater costs and sur-
gical risks. Because the patient conscientiously
complied in using the recommended treatment de-
vices, good dentoalveolar compensation was possible
and produced satisfactory occlusal and esthetic results.
The treatment results were stable 11 months after
the end of treatment, as shown in the Table and Figures
11 through 13. This is important, especially for treat-
ment of Class III malocclusions in which its persistent
growth pattern tends to cause relapse of the malocclu-
sion.6 The use of a high-pull chincup as active retention
might have been important in maintaining the treatment
stability in this patient.7,8
American Journal of Orthodontics and Dentofacial Orthopedics
November 2009
CONCLUSIONS
Successful occlusal and esthetic correction of
a Class III malocclusion in the permanent dentition
can be accomplished with a protraction facemask and
Class III intermaxillary elastics when the patient’s com-
pliance in using the elastics is satisfactory. Once the cor-
rection is successful, active retention and follow-up are
essential if the patient is still growing.
REFERENCES
1. Franchi L, Baccetti T, McNamara JA. Postpubertal assessment of
treatment timing for maxillary expansion and protraction therapy
followed by fixed appliances. Am J Orthod Dentofacial Orthop
2004;126:555-68.
2. Heldt L, Haffke EA, Davis LF. The psychological and social
aspects of orthognathic treatment. Am J Orthod 1982;82:
318-28.
3. 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.
4. Kuroda S, Sugawara Y, Yamashita K, Mano T, Takano-
Yamamoto T. Skeletal Class III oligodontia patient treated with ti-
tanium screw anchorage and orthognathic surgery. Am J Orthod
Dentofacial Orthop 2005;127:730-8.
5. Miyajima K, Iizuka T. Treatment mechanics in Class III open bite
malocclusion with tip edge technique. Am J Orthod Dentofacial
Orthop 1996;110:1-7.
6. Ferro A, Nucci LP, Ferro F, Gallo C. Long-term stability of skel-
etal Class III patients treated with splints, Class III elastics, and
chincup. Am J Orthod Dentofacial Orthop 2003;123:423-34.
7. Mitani H. Early application of chincap therapy to skeletal Class
III malocclusion. Am J Orthod Dentofacial Orthop 2002;121:
584-5.
8. 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.
9. Baccetti T, McGill JS, Franchi L, McNamara JA Jr, Tollaro I.
Skeletal effects of early treatment of Class III malocclusion
with maxillary expansion and face-mask therapy. Am J Orthod
Dentofacial Orthop 1998;113:333-43.
10. Foley TF, Mamandras AH. Facial growth in females 14 to 20 years
of age. Am J Orthod Dentofacial Orthop 1992;101:248-54.
11. Love RJ, Murray JM, Mamandras AH. Facial growth in males 16
to 20 years of age. Am J Orthod Dentofacial Orthop 1990;97:
200-6.
12. Vaughn GA, Mason B, Moon HB, Turley PK. The effects of max-
illary protraction therapy with or without rapid palatal expansion:
a prospective, randomized clinical trial. Am J Orthod Dentofacial
Orthop 2005;128:299-309.
13. de Alba y Levy JA, Caputo AA, Chaconas SJ. Effects of orthodon-
tic intermaxillary Class III mechanics on craniofacial structures.
Part I—photoelastic analysis. Angle Orthod 1979;49:21-8.
14. de Alba y Levy JA, Chaconas SJ, Caputo AA. Effects of orthodon-
tic intermaxillary Class III mechanics on craniofacial structures.
Part II—computerized cephalometrics. Angle Orthod 1979;49:
29-36.
15. Costa Pinho TM, Ustrell Torrent JM, Correia Pinto JG. Orthodon-
tic camouflage in the case of a skeletal Class III malocclusion.
World J Orthod 2004;5:213-23.
16. Janson G, de Souza JE, Alves FA, Andrade P Jr, Nakamura A, de
Freitas MR, et al. Extreme dentoalveolar compensation in the
American Journal of Orthodontics and Dentofacial Orthopedics León-Salazar et al 745
Volume 136, Number 5

treatment of Class III malocclusion. Am J Orthod Dentofacial Or-
thop 2005;128:787-94.
17. Kokich VO Jr, Kiyak HA, Shapiro PA. Comparing the perception
of dentists and lay people to altered dental esthetics. J Esthet Dent
1999;11:311-24.
18. Moullas AT, Palomo JM, Gass JR, Amberman BD, White J,
Gustovich D. Nonsurgical treatment of a patient with a Class III
malocclusion. Am J Orthod Dentofacial Orthop 2006;
129(Suppl):S111-8.
19. McNamara JA Jr. A method of cephalometric evaluation. Am J
Orthod 1984;86:449-69.
20. Scheideman GB, Bell WH, Legan HL, Finn RA, Reisch JS. Ceph-
alometric analysis of dentofacial normals. Am J Orthod 1980;78:
404-20.