Nasiem orthodontics

Skeletal Class III: Diagnosis and Treatment

Skeletal class III malocclusion is the malocclusion caused by retruded maxilla or
protruded mandible or combination but mostly it happens due to retruded maxilla than
protruded mandible.
When to intervene and how to diagnose?
Skeletal Class III malocclusion is easy to be diagnosed from profile of patients but
need an early intervention from 5 to 10 years of age to obtain skeletal effect rather than
dental effect.
After 10 years of age dental effect is the major result and then if we need skeletal
effect, we will have to go for orthognathic surgery as maxillary sutures ossify.
Simply we will find concave profile and anterior dental cross bite.
To confirm diagnosis of skeletal class III malocclusion we need to do cephalometric
evaluation after clinical examination.
Phases of skeletal class III malocclusion:
Skeletal class III malocclusion may be true or pseudo.
Pseudo class III is caused by traumatic occlusion as cross bite.
If this cross bite isn't treated, it will cause lateral or forward deviation of mandible.
If mandible deviated in forward direction, it will result in pseudo class III.
If pseudo class III isn't treated, it will convert to true skeletal class III.
How to treat skeletal class III?
Treatment of pseudo class III is treated by treating traumatic occlusion.
True skeletal class III caused by retruded maxilla is easily treated by growth
modification of maxilla in forward direction by face mask appliance.
Growth of maxilla:
Growth of maxilla follows the growth of brain and it reaches approximately 85 % of
its growth at 5 years.
Growth of maxilla occur in downward forward direction by displacement of the
cranial base then maxilla continue to grow through sutures so we need to protract
retruded maxilla in skeletal class III malocclusion form 5 years.
While skeletal class III caused by protruded mandible have no treatment as it has
genetic cause and we can't stop growth of mandible.
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Treatment of Skeletal Class III:
Treatment of skeletal class III retruded maxilla have different approaches while best
treatment is achieved by face mask.
First step of treatment is accurate diagnosis of skeletal class III malocclusion that's
easy to identify because of its ‘witch-look’ appearance. The facial profile is concave
with a prominent chin or a small midface, also dental cross bite of anterior teeth
occurs.
All these characteristics that indicate skeletal class III malocclusion should be
confirmed by cephalometric analysis.
Cephalometric evaluation of skeletal class III due to retruded maxilla is done through
observing these three angels:
Normal SNA angel 82±2.
Normal SNB angel 80±2.
Normal ANB angel 3±2.
If SNA < 80 this indicate retruded maxilla which need maxillary protraction by face
mask as a best effective popular treatment.
Steps of maxillary protraction by face mask treatment

Intraoral device
Composed of posterior bite plane and acrylic cover of buccal and palatal surface without
Adam's clasp or band and hook located at canine region between C and D.
This device is cemented with Chinese glass ionomer cement.
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Extraoral device
Protraction face mask

Extra oral Elastics

Have different sizes 1\4, 5\16 and 3/8
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Force Gauge

Face mask step by step

1. Take alginate impression and send to dental lab.
2. Ask the technician for intra oral device for face mask but
without adam's clasp with posterior bite plan and acrylic
capping teeth buccal and palatal for cementation with hook at canine
region between Cand D.
3. Check adaptation of device and location of hook.
4. Use Chinese glass ionomer cement for cementation.
5. Use gauge to measure force for both side; ensure it is the same force for
each side (about 350 -400).
6.If you use the same type of elastic e.g. 3/8 and find the force is not equal check
hook if not on the same line adjust it or send it back to the laboratory to adjust it.
7. If force is equal, you are ready to cement it.
8. Use high suction to make good isolation.
9. Start cementation with glass ionomer but don’t stop high suction at least
for 5 minutes.
10. Teach parents how to put extra oral elastic so they can change it every
day or day after day.
11. Inform parents to use elastics the next day after cementation.
12. Inform parents to avoid eating or drinking after cementation for two
hours.
13. You can follow up patient every 2 weeks.
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Notes:
-Patient must wear face mask from 6 o'clock pm till 7 o'clock am next day.
-Inform parents that there's no need to wear face mask at morning or afternoon.
-Inform parents to make sure child wears face mask at home only to protect
-child from bullying and embarrassment.
-After one - two months good results will be observed and protraction of maxilla
will happen but don't remove the device until patient wears it for another 8
months to prevent relapse.

Skeletal class lll

malocclusion
caused by
retruded
maxilla results
in concave
profile and
‘witch-look’
appearance
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