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Case Report
Treatment of pseudo Class III malocclusion
by modified Hawleys appliance with inverted
labial bow
Abstract
Pseudo Class III malocclusion is characterized by an anterior
crossbite with functional forward mandibular displacement.
Various appliances have been devised for early treatment of
a pseudo Class III. The aim of this article is to highlight the
method of construction and use a simple removable appliance
termed as “Modified Hawleys appliance with inverted labial
bow” to treat psuedo class III malocclusion in the mixed
dentition period. It also emphasizes the importance of
differentiating between true Class III and pseudo Class III. This
appliance in this type of malocclusion enabled the correction
of a dental malocclusion in a few months and therapeutic
stability of a mesially positioned mandible encouraging
favorable skeletal growth.
Key words
Hawleys appliance with inverted labial bow, psuedo Class
III malocclusion
Introduction
Mesioclusion is an anteroposterior dentoalveolar
relationship characterized by a more anterior
position of the mandibular dentition relative to the
maxillary dentition. Characteristics of skeletal Class
III malocclusion have been well documented and
summarized as follows: Skeletal components with
underdeveloped maxilla, overdeveloped mandible, or a
combination of both; dentoalveolar components with
proclined maxillary incisors and retroclined mandibular
incisors to achieve dentoalveolar compensation.[1,2]
The relative prominence of the mandibular dentition
may not be related to differential amounts of jaw
growth, but the apparent imbalance in jaw size is
considered to be essentially the result of a mesial
JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2011 | Issue 1 | Vol 29 |
Negi KS, Sharma KR1
Departments of Orthodontics and Dentofacial Orthopedics,
1
Pedodontics and Preventive Dentistry, HP Government Dental
College and Hospital, Shimla, Himachal Pradesh, India
Correspondence:
Dr. Kehar S Negi, Department of Orthodontics and
Dentofacial Orthopedics, HP Government Dental College and
Hospital, Shimla, Himachal Pradesh, India.
E-mail: docksnortho@yahoo.com
Access this article online
Quick Response Code: Website:
www.jisppd.com
DOI:
10.4103/0970-4388.79943
PMID:
21521921
thrust of the mandible. This malocclusion has been
termed pseudo-mesioclusion, apparent Class III,[3]
pseudoprognathism,[4,5] pseudo Class III, postural Class
III,[6,7] and functional Class III.[8]
Moyers suggested pseudo Class III malocclusion
as a positional mal-relationship with an acquired
neuromuscular reflex.[3] Pseudo Class III malocclusion
has been identified with anterior crossbite as a result
of mandibular displacement.[9,10] Premature contact
between the maxillary and mandibular incisors results
in forward displacement of the mandible in pseudo
Class III malocclusion; this displacement disengages the
incisors and permits further closure into the position in
which the posterior teeth occluded.[10,11] Several reports
attributed the incisor interference to the retroclined
upper incisors and proclined lower incisors in pseudo
Class III malocclusion.[3-10,12,13]
Comparison of extra-oral photos revealed that the
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Negi and Sharma: Psuedo class-III malocclusion and its simple management
profile of pseudo Class III malocclusion appeared
normal at centric relation (CR) and slightly concave at
habitual occlusion (HO); moreover, molar relationship
was Class I at CR and Class III at HO.[10,12] Pseudo
Class III malocclusion is characterized by certain
morphologic, dental, and skeletal characteristics:
retrusive upper lip, decreased midface length,
retroclined upper incisors, and increased maxillary-
mandibular difference.[14]
Different etiological factors are suggested in
pseudo Class III malocclusion[8]
Dental factors
• Ectopic eruption of maxillary central incisors
• Premature loss of deciduous molars
Functional factors
• Anomalies in tongue position
• Neuromuscular features
• Nasorespiratory or airway problems
Skeletal factors
• Minor transverse maxillary discrepancy
Management of pseudo Class III malocclusion
The pseudo Class III malocclusion involves both
permanent teeth and the deciduous dentition. Because
a malocclusion may be regarded as an aesthetic
problem, parents often inquire whether a therapy is
required. It is difficult to justify the lack of attention
given to the timing of treatment of pseudo Class
III malocclusion, which remains controversial.[15]
Some clinicians believed that in many patients, it
was best to allow the eruption of permanent teeth
before initiating orthodontic treatment. In this way, a
relatively straightforward manner of treatment within
a predictable duration could be provided for patients.
However, delaying the treatment until permanent
dentition errupts may cause loss of space required for
eruption of the canines.[3,10,13] Some practitioners prefer
to wait for the permanent maxillary incisors to erupt
before initiating therapy due to the natural tendency
of teeth to erupt in a lingual position during dental
arch development. Occasionally, functional deciduous
anterior crossbites correct themselves spontaneously.
White has suggested intervention in cases of pseudo
Class III malocclusion in mixed dentition when the
maxillary and mandibular incisors have erupted. [16]
This allows permanent teeth to erupt in a better
position and also improves dental aesthetics.
In general terms, the goal of interceptive orthodontics
58 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2011 | Issue 1 | Vol 29 |
is to prevent an existing problem from worsening.
Specifically, for pseudo Class III, the goals of early
treatment are to correct the anterior displacement
of the mandible before the eruption of the canines
and premolars. Anterior teeth can be guided into
Class I in the proper mandibular position, to provide
space for eruption of the buccal segments as a result
of proclination of the upper incisor, and to provide a
normal environment for growth of the maxilla, thus
eliminating the anterior crossbite.[10,15,17]
From a therapeutic point of view, Graber[6] and others
suggested that the mesioclusion must be examined with
the mandible guided into a retruded contact position.
If the mandibular incisors approach an edge-to-edge
occlusion and then slide into anterior displacement, the
malocclusion may be pseudo-mesioclusion. Conversely,
a true mesioclusion is one in which the mandible cannot
be retruded and the pattern of closure is a smooth
arch, anteroposteriorly. Various appliances have been
devised for early treatment of a pseudo Class III, such
as removable plates with springs, fixed or removable
inclined planes, functional appliances, chin-cups, and
simple fixed appliances.[9,13,18]
This case report is intended to illustrate a simple and
easy way to manage pseudo Class III by a modified
Hawleys appliance with inverted labial bow.
Case Report
A male patient aged 9 years and 6 months, presented with
chief complaint of the lower anterior teeth overlapping
the upper teeth; his parents were also concerned because
of his abnormal facial profile. On clinical examination, a
retruded upper lip with prominent lower lip was noted,
giving an appearance of midface deficient as seen in
class III malocclusion. There was a mesial step molar
relationship in centric occlusion with the incisors in
crossbite. The dental relationship suggested retroclined
upper central incisors, with mild proclination of lower
incisors [Figure 1]. The incisors were in end-to-end
relationship with posterior open bite when the mandible
guided in centric relation. Clinical examination revealed
that the displacement occurred due to a premature
contact between upper and lower incisors. Therefore,
the diagnosis made was a pseudo Class III malocclusion
characterized by anterior crossbite and functional
mandibular shift in centric occlusion.
Appliance design
In order to construct a modified Hawleys appliance,
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Negi and Sharma: Psuedo class-III malocclusion and its simple management

Figure 2: The construction of modified Hawleys appliance with

inverted labial bow

Figure 4: Intra-oral photograph showing patient closing mandible in

edge-to-edge relation one week after use of the appliance

Figure 1: Extra- and intra-oral photographs showing class III profile

with anterior crossbite

Figure 3: Intra-oral photograph showing the position of mandible

guided by the appliance at the time of delivery

register the bite by guiding the mandible distally

in an edge-to-edge incisors relation. Subsequently,
transfer the bite in the working model and articulate
it in the hinge articulator. After mounting the upper
and lower casts remove the construction bite and
fabricate an inverted labial bow [Figure 2] and
Adams clasp with 0.036’’ stainless steel wire. Further, Figure 5: Extra- and intra-oral photographs showing the normal profile
stabilize the inverted labial bow by using wax and and occlusion after one month use of the appliance

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Negi and Sharma: Psuedo class-III malocclusion and its simple management
construct the acrylic plate as the Hawleys appliance
[Figure 2].
Treatment objectives
• To eliminate CR-CO discrepancy and anterior
crossbite
• To correct Class III and establish Class I canine
relationship
• To achieve normal overjet, and reduce deep bite
Treatment progress
Bite was registered by guiding the mandible distally in
incisor edge-to-edge relation for mounting the upper
and lower cast in the laboratory. Modified Hawleys
appliance was constructed with inverted labial bow.
The appliance was delivered with instruction to
use it at night for a week and return for follow-up
[Figure  3]. After a week, the patient was comfortable
and functional shift of mandible occurred in the edge-
to-edge incisor relation while closing [Figure  4].
The patient then was asked to use the appliance
continuously, except while eating and report after three
weeks. With regard to continuous use of appliance
for one month, the patient was able to comfortably
close the mandible in centric occlusion with positive
overbite. Also, there was almost intercuspation in
posterior occlusion, with normal lip relation and
profile [Figure 5]. The appliance was discontinued
after two months when normal occlusion was achieved
in centric occlusal relation without the appliance and
the patient was advised to use the appliance only at
night as a retainer for six months.
Discussion
The various treatments suggested in the literature for
correction of anterior crossbite include several different
appliances, both fixed and/or removable with heavy
intermittent forces (inclined bite plane, tongue blade)
or light-continuous forces (removable appliance with
auxiliary springs). Other alternative therapies that may
correct skeletal problems in young patients have been
shown to be effective, with significant changes in the
craniofacial complex, including the use of protraction
headgear, chincap, and Frankel III.[19-22] Tsai suggests
the use of rapid palatal expansion and standard
edgewise appliance to resolve an anterior crossbite in
a 7-year-old boy.[23]
Rabie and Gu have described a simple method for
early treatment of pseudo Class III malocclusion
60 JOURNAL OF INDIAN SOCIETY OF PEDODONTICS AND PREVENTIVE DENTISTRY | Jan - Mar 2011 | Issue 1 | Vol 29 |
in the mixed dentition by using fixed appliance.
Proclination of the upper incisors and/or retroclination
of the lower incisors contribute to the correction
of anterior crossbite and elimination of mandibular
displacement. [24] Early treatment also permits us to
gain space for canine eruption. The therapeutic use of
a modified Hawleys appliance with inverted labial bow
is suggested in this case report with anterior crossbite
in mixed dentition as the simplest way of managing
anterior crossbite as compared to other conventional
appliances mentioned in the literature.
Conclusion
Modified Hawleys appliance with inverted labial bow
is easy to construct and patient-friendly appliance
to correct anterior crossbite in Psuedo class-III
malocclusion.
Early treatment of Psuedo class III malocclusion helps
in:
• Elimination of mandibular displacement, thus
allowing the permanent dentition to be guided into
Class I at proper mandibular position
• Creation of space for eruption of canines and
premolars
• Elimination of traumatic occlusion.
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Source of Support: Nil, Conflict of Interest: Nil

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