CASE REPORT

Angle Class III malocclusion treated with

mandibular first molar extractions
Antonio Carlos de Oliveira Ruellas,a Carolina Baratieri,b Mariana Bottino Roma,b Antonio de Moraes Izquierdo,b
Luciana Boaventura,b Carina Souza Rodrigues,b and Vicente Tellesb
Rio de Janeiro, Brazil

A Class III malocclusion associated with dental asymmetry is a complex diagnostic and treatment problem in
orthodontics. The goals of maintaining or improving the facial profile and achieving good function are decisive
factors when considering whether to plan a surgical or a nonsurgical treatment approach. A fixed appliance in
combination with extractions could be considered for nonsurgical management of this type of malocclusion in
the permanent dentition. This article presents the results of an orthodontic approach to a Class III subdivision
malocclusion in an adult treated with mandibular first molar extractions. The extractions provided the space
needed to correct the overjet and overbite and to improve the intercuspation. (Am J Orthod Dentofacial
Orthop 2012;142:384-92)

C
lass III malocclusions represent a small proportion
of all malocclusions among orthodontic pa-
tients.1 However, the treatment is a considerable
clinical challenge because of the complex diagnosis
and the difficult prognosis,2-4 mainly when the Class
III relationship is associated with dental or skeletal
asymmetries.5 There are 2 main treatment options for
a Class III malocclusion that is identified after facial
growth has been completed: orthodontic treatment
and orthognathic surgery.6-11 For many patients with
a Class III malocclusion, surgical treatment is the best
alternative. The amount of the skeletal discrepancy
usually determines whether a surgical correction is
appropriate. However, in borderline cases, a balanced
soft-tissue profile will help to determine whether
patients are unsuitable for surgery. Generally, fixed
appliances in conjunction with tooth extractions are
considered the best option for nonsurgical management
of adult Class III patients.
Traditionally, the extraction of the 4 premolars
(mandibular first and mandibular second) is the most
common choice. Alternative extractions have also been
used.12-14 If the mandibular third molars are present,
extraction of the mandibular first molars could be
a good substitute option to solve the anteroposterior
and vertical problems and obtain a Class I molar
relationship. This approach is not indicated for all
patients, because it requires first molar space closure,
which is time-consuming. Also, the mandibular second
molars have a tendency to tip mesially and lingually,
requiring additional orthodontic mechanics to prevent
that problem.
This case report describes a 20-year-old man with
a Class III malocclusion. The treatment was carried out
by using fixed appliances and mandibular first molar
extractions. Our aim is to illustrate that, with careful
case selection, a first molar extraction protocol can be
relatively straightforward.

ETIOLOGY AND DIAGNOSIS

From the Department of Orthodontics, Federal University of Rio de Janeiro, Rio This patient came to the orthodontic clinic at the
de Janeiro, Brazil. Federal University of Rio de Janeiro in Brazil with the
chief complaint of “dysfunctional bite.” Anamnesis
a
Associate professor.
b
Postgraduate student.
The authors report no commercial, proprietary, or financial interest in the prod- was carried out, and the medical and dental histories
ucts or companies described in this article. showed nothing abnormal. The swallow and speech
Reprint requests to: Antonio Carlos de Oliveira Ruellas, Universidade Federal do functions were normal, and the respiratory function
Rio de Janeiro, Departamento de Ortodontia, Rua Professor Rodolpho Paulo
Rocco, 325, Ilha do Fund~ao, Rio de Janeiro, RJ, Brazil 21941-617; e-mail, was bucco-nasal. The extraoral assessment showed
antonioruellas@yahoo.com.br. a straight profile, a slightly high mandibular plane angle,
Submitted, December 2010; revised and accepted, January 2011. and an increased lower facial height. The nasolabial
0889-5406/$36.00
Copyright Ó 2012 by the American Association of Orthodontists. angle was slightly increased. No significant discrepancy
doi:10.1016/j.ajodo.2011.01.025 between habitual occlusion and centric relation was
384
Ruellas et al
Fig 1. Initial extraoral and intraoral photographs.
found. The temporomandibular joints were normal, and
his face was symmetric. Although he had a prominent
lower lip, his facial appearance was pleasing, and he
had no complaints about esthetics (Fig 1).
The intraoral examination showed a Class I molar
relationship on the right side and a complete Class III
molar relationship on the left side (Fig 2). The maxillary
and mandibular anterior teeth were in an edge-to-edge
relationship, with no overjet or overbite. Crossbites of
the maxillary left lateral incisor and first premolar were
noted. The dental midline was not coincident with the
facial midline. The maxillary midline was deviated 2
mm to the left. All permanent teeth were erupted, except
for the maxillary third molars. Minor crowding was pres-
ent only in the mandibular arch, with incisor irregularity
American Journal of Orthodontics and Dentofacial Orthopedics
385
of 1.2 mm. Significant rotations of the mandibular left
second premolar and right second premolar were noted.
The space analysis indicated a positive discrepancy of
1.3 mm in the mandibular arch. Both arches had
a parabolic form.
A panoramic radiograph confirmed the presence of
all permanent teeth, including developing maxillary
third molars (Fig 3). A frontal radiograph showed no
transverse or asymmetric skeletal problems. The lateral
cephalometric evaluation (Fig 4) indicated a skeletal
Class I, bordering on mild skeletal Class III pattern
(ANB, 0 ). This skeletal pattern was confirmed by the
Wits analysis that showed Wits appraisal (AO-BO) to
be –4 mm. The mandibular planes were higher than
normal limits, indicating a vertical growth pattern
September 2012  Vol 142  Issue 3
386 Ruellas et al

Fig 2. Initial dental casts.

Fig 3. Initial radiographs: A, cephalometric; B, frontal; C, periapical; D, panoramic.

(SN.GoGn, 35 ; FMA, 36 ; SN.y-axis, 69 ). The maxil- mm). The lower facial profile was straight, with the up-
lary and mandibular incisors were protruded (1.NA, per lip lying behind the S line, and the lower lip passing
33 ; 1.NB, 28 ) and proclined (1-NA, 9 mm; 1-NA, 8 it slightly (S-LS, –2 mm; S-LI, 1 mm).

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Ruellas et al
Fig 4. Initial cephalometric tracing.
TREATMENT ALTERNATIVES
Orthognathic surgery was not a viable treatment op-
tion because the skeletal deficiency was not clinically
significant and the patient was satisfied with his facial
profile and appearance. Maximum anchorage was dis-
cussed for en-masse movement of the mandibular teeth
and correction of the maxillary dental asymmetries, but
the patient refused to use any kind of temporary anchor-
age device. Maxillary second premolar and mandibular
first premolar extractions could be a treatment option;
however, no changes in the upper lip were desirable. Be-
cause the mandibular third molars were in an ideal posi-
tion and the patient was cooperative, we chose to extract
the mandibular first molars.
TREATMENT OBJECTIVES
The treatment objectives were to maintain the pa-
tient's profile, improve dental and smile esthetics, level
and align the maxillary and mandibular dental arches,
correct the dental asymmetries, achieve Class I molar
and canine relationships on both sides, achieve normal
overjet and overbite, and establish a good functional
occlusion.
To achieve all the desired objectives, we decided to
use fixed orthodontic appliances with extraction of the
mandibular first molars to align and level, correct the
overbite and overjet, and achieve a Class I relationship.
American Journal of Orthodontics and Dentofacial Orthopedics
387
The maxillary third molars would also be extracted to
facilitate distalization of the maxillary right posterior
teeth to correct the dental asymmetries (midline).
TREATMENT PROGRESS
The molars were banded, and the remaining teeth
were bonded with a standard edgewise fixed appliance
(0.022 3 0.028 in; Morelli, S~ao Paulo, Brazil) (Fig 5).
The teeth were aligned and leveled by using a sequence
of round steel continuous archwires of 0.014- to
0.020-in stainless steel. Subsequently, rectangular steel
archwires of 0.018 3 0.025-in stainless steel were used
and were followed by 0.019 3 0.026-in rounded-edge
stainless steel working wires to allow final space closure
and occlusal adjustment. All the steel archwires were
conformed according to the patient's initial arch
form. Elastic chains were used to move the second mo-
lars mesially, with anchorage reinforcement on the
mandibular teeth (right second premolar to left second
premolar). Lingual buttons were used to control the
rotation of the premolars and the second molars during
space closure. Class II intermaxillary elastics and sliding
jigs were used on the right side to distalize the teeth
and correct the maxillary midline. The right third molar
was extracted before this phase to facilitate the distal-
ization. Class III and Class II elastics were used to coor-
dinate the arches; after a good occlusal relationship
was obtained, detailing and finishing procedures were
undertaken.
Before removal of the fixed appliances, the interden-
tal gingival clefts that occurred after the extraction space
closures were surgically removed. Appliance adjustments
were made every 4 weeks, and the active treatment
lasted 30 months.
After debonding, the patient was instructed to wear
a maxillary circumferential Hawley retainer for a year
and at night for another year. In addition, a mandibular
lingual retainer was bonded from canine to canine
(0.028-in stainless steel).
TREATMENT RESULTS
The treatment plan was a satisfactory alternative to
achieve the objectives (Figs 6-9). The maxillary and
mandibular arches were well aligned and leveled.
Overjet and overbite were corrected to normal
standards. Good torque control was maintained, and
the incisors were aligned with better inclination after
treatment. The interincisal angle increased, as the
mandibular incisors uprighted and the ANB angle
remained unchanged (Table). Class I molar and canine
relationships were achieved on both sides (Fig 6). The
upper and lower lips moved very little. The mandibular
September 2012  Vol 142  Issue 3
388 Ruellas et al

Fig 5. Treatment follow-up photographs.

plane was maintained during the treatment. Good inter-
cuspation, interproximal contacts, coincident midlines,
and root parallelism were achieved. Ideal occlusion was
established with satisfactory dental and smile esthetics.
The result of the gingivectomy procedure showed signif-
icant improvement in the gingival cleft depths in the
previous extraction sites.
DISCUSSION
Class III malocclusion has been a subject of interest in
many investigations because of the challenges involved
in treating this type. When a Class III relationship is
diagnosed after the completion of facial growth, the
treatment alternatives are more limited. Generally, fixed
appliances in conjunction with tooth extractions are
considered the only option for nonsurgical treatment.
Traditionally, extraction of 4 premolars would be the
first choice. First molars could be chosen for extraction
in preference to premolars when the first molars have
extensive caries, hypoplastic lesions, apical pathoses, or
significant restorations. Other situations in which first
molars could be extracted are significant crowding at
the distal part of the mandibular arch, high mandibular
plane angle, and anterior open bite.15 Of course, evalu-
ation of the mandibular second and third molars is
imperative, because they would be part of the functional
dentition.

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Ruellas et al
Fig 6. Final extraoral and intraoral photographs.
One disadvantage of first molar extraction is the
difficulty with extraction space closure, because the
mandibular second molars tend to tip mesially and lin-
gually. Treatment success can be partially attributed to
the use of large enough rectangular archwires to allow
space closure with minimal tipping. The treatment
time, when compared with that of a similar patient
treated with extraction of 4 premolars in a graduate
school setting, is probably 6 to 8 months longer. The
cephalometric superimposition (Fig 10) showed that
the left second molar did not move significantly mesi-
ally. The extraction space was used to align the teeth
and correct the overjet.
In this patient, only the mandibular first molars were
extracted. This option prevented significant changes in
American Journal of Orthodontics and Dentofacial Orthopedics
389
the upper lip that would have been undesirable to the
patient's facial profile (Figs 9 and 10). Fortunately, there
was sufficient space to align and level all the maxillary
teeth without extractions, except for the maxillary right
third molar; this facilitated distalization of the maxillary
right posterior teeth and correction of the asymmetry
and midline deviation.
After the orthodontic closure of the extraction sites,
it is common to find interdental gingival clefts.16
These are defined as invagination of the interproximal
tissues with definite mesial and distal peaks having
a depth of at least 1 mm.17 The presence of these clefts
might have clinical implications not only in terms of
orthodontic relapse, but also in the maintenance of
gingival health. Therefore, surgical removal of the
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390 Ruellas et al

Fig 7. Final dental casts.

Fig 8. Final radiographs: A, cephalometric; B, frontal; C, periapical; D, panoramic.

gingival clefts is indicated to help maintain the ortho- These patients should be followed monthly after de-
dontic treatment results as well as the periodontal bonding for at least 3 months, because it is common to
health.16,18-20 see opening of some space in the extraction sites. We

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Ruellas et al 391

distally to achieve better intercuspation. If a space ap-

pears and fails to close spontaneously, it can be closed
easily with composite restorations.14

CONCLUSIONS
Extraction of the mandibular first molars provided
the space needed to correct the overjet, overbite, and
molar relationship. This case report illustrates a good al-
ternative for treating adults with a Class III malocclusion.
Adequate root parallelism, prophylactic gingivectomy,
and immediate and adequate retention should help to
maintain the orthodontic results.

REFERENCES
1. El-Mangoury NH, Mostafa YA. Epidemiologic panorama of dental
occlusion. Angle Orthod 1990;60:207-14.
2. Tahmina K, Tanaka E, Tanne K. Craniofacial morphology in ortho-
dontically treated patients of Class III malocclusion with stable and
unstable treatment outcomes. Am J Orthod Dentofacial Orthop
2000;117:681-90.
3. Staudt CB, Kiliaridis S. Different skeletal types underlying Class III
malocclusion in a random population. Am J Orthod Dentofacial
Orthop 2009;136:715-21.
Fig 9. Posttreatment cephalometric tracing. 4. Rabie ABM, Gu Y. Diagnostic criteria for pseudo-Class III malocclu-
sion. Am J Orthod Dentofacial Orthop 2000;117:1-9.
5. Miyatake E, Miyawaki S, Morishige Y, Nishiyama A, Sasaki A,
Takano-Yamamoto T. Class III malocclusion with severe facial
asymmetry, unilateral posterior crossbite, and temporomandib-
Table. Cephalometric analysis ular disorders. Am J Orthod Dentofacial Orthop 2003;124:
Standard Initial Final 435-45.
Measurement values (20 y 5 mo) (23 y 6 mo) 6. Kuroda S, Sugawara Y, Yamashita K, Mano T, Takano-
Yamamoto T. Skeletal Class III oligodontia patient treated with
SNA ( ) 82 80 80
titanium screw anchorage and orthognathic surgery. Am J Orthod
SNB ( ) 80 80 80
Dentofacial Orthop 2005;127:730-8.
SND 76 77 77
7. Janson G, Prado de Souza JE, de Andrade Alves FV, Andrade JP,
ANB ( ) 2 0 0
Nakamura A, Roberto de Freitas M, et al. Extreme dentoalveolar
Wits (mm) 1 4 4
compensation in the treatment of Class III malocclusion. Am J
SN.y-axis ( ) 59 69 69
Orthod Dentofacial Orthop 2005;128:787-94.
SN.GoGn ( ) 32 35 35
8. Burns NR, Musich DR, Martin C, Razmus T, Gunel E, Ngan P. Class
FMA ( ) 25 36 36
III camouflage treatment: what are the limits? Am J Orthod Den-
Pg to NB – 3 1
tofacial Orthop 2010;137:9.e1-13.
1.SN 103 112 104
9. Moullas AT, Palomo JM, Gass JR, Amberman BD, White J,
1 to NA (mm) 4 9 8
Gustovich D. Nonsurgical treatment of a patient with a Class III
1 to NA ( ) 22 33 25
malocclusion. Am J Orthod Dentofacial Orthop 2006;129(Suppl):
1 to NB (mm) 4 8 3
S111-8.
1 to NB ( ) 25 28 15
10. Toffol LD, Pavoni C, Baccetti T, Franchi L, Cozza P. Orthopedic
IMPA ( ) 90 94 80
treatment outcomes in Class III malocclusion. Angle Orthod
1 to 1 131 117 142
2008;78:561-73.
Occl plane.SN 14 16 16
11. Islam R, Kitahara T, Naher L, Hara A, Nakata S. Lip morphology
Facial angle ( ) 87.9 82 82
changes following orthognathic surgery for Class III malocclusion.
Convexity angle ( ) 0 3 3
Angle Orthod 2010;80:344-53.
S line-upper lip 0 2 2
12. Lin J, Gu Y. Lower second molar extraction in correction of se-
S line-lower lip 0 1 1
vere skeletal Class III malocclusion. Angle Orthod 2006;76:
217-25.
13. Saito I, Yamaki M, Hanada K. Nonsurgical treatment of adult
open bite using edgewise appliance combined with high-pull
believe that this typically happens because the mandib-
headgear and Class III elastics. Angle Orthod 2005;75:
ular second molars are smaller than the first molars. So, 277-83.
even after space closure with ideal root paralleling, the 14. Seddon JL. Extraction of four first molars: a case for a general
occlusion might cause the second molars to move practitioner? J Orthod 2004;31:80-5.

American Journal of Orthodontics and Dentofacial Orthopedics September 2012  Vol 142  Issue 3
392 Ruellas et al

Fig 10. Cephalometric superimposition of the initial and final tracings: A, total superimposition, regis-
tered on sella; B, partial superimpositions of the maxilla (best fit) and the mandible (symphysis regis-
tration).

15. Sandler PJ, Atkinson R, Murray AM. For four sixes. Am J Orthod
Dentofacial Orthop 2000;117:418-34.
16. Circuns A, Tulloch JFC. Gingival invagination in extraction sites
of orthodontic patients: their incidence, effects on periodontal
health, and orthodontic treatment. Am J Orthod 1983;83:
469-76.
17. Robertson P, Schultz L, Levy B. Occurrence and distribution of
interdental gingival clefts following orthodontic movement into
bicuspid extraction sites. J Periodontol 1977;48:232-5.
18. Pinheiro M, Moreira T, Feres Filho E. Guided bone regeneration of
a pronounced gingivo-alveolar cleft due to orthodontic space
closure. J Periodontol 2006;77:1091-5.
19. Malkoc S, Buyukyilmaz T, Gelgor I, Gursel M. Comparison of two
different gingivectomy techniques for gingival cleft treatment.
Angle Orthod 2004;74:375-80.
20. Ribeiro G, Thys DG, Tanaka O, Locks A, Soria ML. A invaginaç~ao
gengival e o fechamento ortod^ ontico de espaços de extraç~
oes:
conduta clınica. Dent Press J Orthod 2004;9:77-82.

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