Class III Malocclusion

Pranshu Tomer
MDS 2nd year
Dept. of orthodontics & Dentofacial Orthopedics
 The mandible & its superimposed denture lies in
mesial relation to the maxillary arch, which is
evident by the fact that the mesiobuccal cusp of
maxillary first permanent molar lies distal to the
mesiobuccal groove of the mandibular first
permanent molar by half the width of molar or by
entire width of bicuspid when the jaws are closed
in centric occlusion.
Prevalance of Malocclusion in India
Class I 44.9%

Delhi (1991)
O P Kharbanda
Class II 15.2% MO 44.9%
Class III 3.9%

Class I 43.9%

Prevlance of MO
Haryana (1998) O P
Class II 9.8%
Kharbanda MO 55.3%
Class III 0.6%

Class I 44%

Trivendrum (1969)
Class II 4.9%
Jacob PP MO 49.2%
Class III 0.3%

Class I 95%

Banglore (1971)
Rajendra PA
Class II 4%
MO 51.5%
Class III 0.9%
Classification

Dental Class III

Skeletal Class III

Pseudo Class III (Normal mandible

and underdeveloped maxilla)
 Deweys modification to Angle Class III

 Type 1: The upper & lower

dental arches when viewed
separately are in normal
alignment. But when the
arches are made to occlude
the patient show an edge to
edge alignment. Suggestive
of a forwardly move dental
arch.
 Type2: The mandibular incisors are
crowded and are in lingual relation to
the maxillary incisors.

 Type 3: The maxillary incisors are

crowded and are in crossbite in
relation to the mandibular anteriors.
The maxillary arch is underdeveloped
and the mandibular arch is well
developed and the teeth are in
normal alignment.
Difference between True Class III & Pseudo
Class III
Features True Class III Pseudo Class III
Profile Concave Straight to concave
Etiology Hereditary Habitual / Developmental

Premature contact Absent Present

Path closure Forward Deviated
Gonial angle Increased/ Decreased Normal
Retrusion of Not possible Possible
mandible
Treatment Orthopaedic / Surgical →Elimination of prematurity.
correction →Replacement of lost posterior
teeth by functional space
maintainer.
Left untreated No further changes Becomes established into True
Class III
Etiology

Genetic
Etiological factors
Enviromental
 Mandibular -Cleft lip and
prognathism palate
Genetic
Congenital -Downs
defects syndrome

-
Cleidocranial
dysplasia
 -
teratogens(agents
Prenatal producing
embryological
defects)
Environmental - effects of
dentition and
occlusal
interference
Postnatal
- abnormal tongue
pressure
Clinical features of class III malocclusion
Soft tissue features
• Patient has a concave or straight
profile.
• Anterior facial divergence.
• Prominent lower third of
face/chin.
• Steep mandibular plane angle.
Dental features

 The patient has a Class III molar relationship.

 Anterior cross bite.

 Upper arch frequently
narrow while lower arch
is broard.

 It is common for the

upper teeth to be
crowded and mandibular
arch is often spaced.
 Skeletal features:
• Vertical growth
pattern.
• Negative ANB angle
• Proclined upper
and retruded lower
anteriors.
Skeletal features of Class III
malocclusion
A retrognathic maxilla.
A prognathic mandible.
A combination of the above.
Facial skeletal profiles

Normal maxilla
& mandibular
prognathism

Maxillary
retrusion &
normal mandible
Facial skeletal profiles

Normal
maxilla &
mandible

Maxillary
retrusion &
mandibular
prognathism
Differential Diagnosis of Class III

Dental assessment
Functional assessment
Clinical assessment
Cephalometric assessment
Dental Assessment
Molar relationship & Overjet
 Class III molar Class III molar
Negative overjet Positive overjet
Functional assessment Retroclined lower
CO/CR shift incisors

no shift shift
correct it
Clinical & Cephalometric
assessment

True Class III Psuedo Class III Compensated Class III

DIFFICULT
Functional Relationships Of CLASS III

Relationship between rest position & full occlusion

in sagittal plane –
 Rotational movement without sliding
 Closing movement with anterior sliding
 Closing movement with posterior sliding
 Pure rotational movement from postural rest to
occlusal position
Functional Relationships Of CLASS III

 Rotational movement with anterior slide –

 During articular phase – mandible shifts forward
into prognathic forced bite –
functional non-skeletal – psuedo CLASSIII –
favorable prognosis
Functional Relationships Of CLASS III

 Rotational movement without slide –

 Non-functional, true CLASS III – unfavorable
prognosis
Functional Relationships Of CLASS III
 Rotational movement with posterior slide –
 Pronounced mandibular prognathism, mandible
may slide posteriorly into maximum
intercuspation – masks true sagittal dysplasia –
unfavorable prognosis
PROFILE / CLINICAL ASSESSMENT
 Check proportionate
positions of maxilla &
mandible in A-P plane
 Place patient in natural
head position
 Drop line from bridge of
nose to base of upper lip
& second line from base
of upper lip to chin
 Straight or concave
profile in young patients
indicates skeletal Class III
CEPHALOMETRIC ASSESSMENT

 Best analysis – relate maxilla to mandible

 Discriminant analysis found WIT’S appraisal most
decisive in distinguishing camouflage from
surgical treatment ( AJO 2002)
 Wit’s> - 5 = malocclusion might not be resolved
by camouflage with facemask or chin cup.
7 Structural Signs 0f Extreme
Mandibular Growth Rotation
 Inclination of the condylar head
 Curvature of the mandibular canal
 Shape of the lower border of the mandible
 Inclination of the symphysis
 Inter incisal angle
 Inter molar angle
 Anterior lower face height
Treatment of Class III malocclusion
 Treatment in deciduous dentition

 Early malocclusion symptoms are usually apparent

in deciduous dentition.

 The patient often protrude the mandible

habitually in an anterior relationship with the
tongue.
 Chincup may be the method of
choice to hold the mandible in
posterior position.

Occipital pull chin cup

 Treatment can be started as early as

1year of age & can be continued
until the age of 4yrs or so as the only
growth guidance

Vertical pull chin cup

Treatment in mixed dentition

Treatment is
divided under
three
categories:

Dentoalveolar Mandibular Maxillary

problems prognathism retrognathism
Dentoalveolar problems:

 Patient in which the problem is due to lingually

tipped upper incisors & labially tipped lower
incisors.
 Treatment can be performed with:

1. Active plates (i.e. Jack screw)

2. Inclined plane
3. Activators
Active plate (i.e. Activator Inclined
Jack screw) plane
Mandibular prognathism

 An activator can be used to alter

the incisal guidance & attempt to
position the mandible posterior.
 Camouflage treatment can be
done for providing dental
compensation for the skeletal
problem.
 Chin cup in addition to a low or
high pull headgear.
Maxilla retrognathism

Efforts should be made to promote

growth & protract the maxillary
complex.

Lip pads in the depth of the vestibule

for providing relief from labial muscle
force simultaneously chin cup is given
to reduce sagittal discrepancy in
mandible.
Tandem appliance
Active plates for expansion of
anterior segment.
Protraction face mask
a.k.a. Delaire mask
For protraction of maxilla.
 Rapid maxillary expansion

Derichsweiler
type Hass type

Isaacson type Hyrax type

 Frankel FR III
Treatment in permanent dentition

Dental Skeletal
Dental

If the malocclusion is due to

dental components then
treatment modality will be

 Extraction

 Class III elastics

 Fixed mechanotherapy
 Skeletal

If the malocclusion is due to skeletal components then:

 Camouflage treatment
 If the severity is more, then proper preparation should be
made for surgery.
 After surgery activator is given for retention purpose
because of changing the origin & insertion of muscle during
orthognathic surgery. An activator is ideal for muscle
training.
 Treatment of severe Class III after growth

 Orthognathic surgery is also known as corrective jaw surgery.

 Itis used to remedy a variety of abnormalities in which the facial

bones and teeth develop incorrectly and lead to difficulty with
chewing, speech, jaw function, and a compromised facial
appearance.
 Orthognathicsurgery is normally done in conjunction
with orthodontic treatment.

 Theareas that usually need correction are the maxilla,

the mandible, and chin. Corrective jaw surgery involves
moving one, two, or all of these areas to obtain the
desired results.
 Surgical correction [Le Fort I osteotomy]
 Vertical ramus osteotomy
 Genioplasty
 Bilateral saggital split osteotomy
References

 Prediction of mandibular growth rotation; Bjork. Am.J Orthod; June 1969

 Cephalometric assessment of saggital relationship between maxilla and
mandible; Nanda & Merill. Am J orthod and Dentofacial Orthop; Vol 105 No 4