January, 2011

Early Treatment of Class III Malocclusion

Dr. Dr. Kukreja Manisha. K +

Dr. Ajit Kumar++

Dr. Shweta+++

+ MDS, Associate Professor and Head

Department of Orthodontics & Dentofacial Orthopaedics,

Government Dental College

P.G.I.M.S., University of Health Sciences,

Rohtak (Haryana) 124001

++ MDS, Asistant Professor

Department of Orthodontics & Dentofacial Orthopaedics,

Government Dental College

P.G.I.M.S., University of Health Sciences,

Rohtak (Haryana) 124001

+++ MDS, Asistant Professor

Department of Prosthodontics,

Government Dental College

P.G.I.M.S., University of Health Sciences,

Rohtak (Haryana) 124001

Key words: Class III, Early treatment

Corresponding Author:

Dr. Manisha Kamal Kukreja

A-1/93, Paschim Vihar,

New Delhi-110063

Mob. : 09215650617

E-mail : mk3_1975@rediffmail.com

: rohillajit@gmail.com



The developing skeletal Class III malocclusion is one of the most challenging problems confronting the practicing orthodontists. True Class III malocclusion is rare as compare to Class II & Class I and may develop in children as a result of inherent growth abnormality. Treatment should be carried out as early as possible with the aim to prevent it from becoming severe. Three cases of skeletal class III malocclusion with deficient maxilla in mixed dentition are presented here. Two cases were treated with biphasic therapy i.e. Orthopedic appliance followed by fixed orthodontic treatment while one case was treated only with orthopedic appliance. Facemask in all the cases helps resolving the skeletal discrepancy.

Keywords: Class III malocclusion, Early treatment, Facemask


Class III malocclusion are growth related problems that often become severe if left untreated, so it should be corrected as soon as we recognize its initial signs like edge to edge bite or cross bite1. Developing true class III malocclusion tendencies in children may have an underlying skeletal or dental component. Pseudo Class III malocclusion is a habitual established crossbite of anterior teeth without any skeletal discrepancy, resulting from functional forward positioning / shift of mandible on closure, so both should be differentiated before start of any treatment procedure2. When left untreated Pseudo class III may lead to development of true class III malocclusion.   The goal of early orthodontic treatment is to correct the existing or developing skeletal, dentoalveolar and muscular imbalance and to improve the oral environment3.

Case Reports:

Case I : A 9 year old boy reported to the department with chief compliant of backwardly positioned upper anterior teeth. He was in mixed dentition stage. The general health of patient was good with no significant medical history.

Records: All records like study cast, OPG and cephalogram were taken to evaluate and confirm the diagnosis.

Extraoral examination: Mesomorphic built, normal gait and posture. Face was mesoprosorpic with competent lips. Profile was concave and presented with low clinical FMA.  Fig. 1 & Fig. 2

Fig. 1 Frontal

Fig. 2 Profile

Fig. 3 Lateral cephalometric radiograph

Intraoral examination: Soft tissues normal

Erupted teeth:          

Maxillary arch : Asymmetrical with bilateral complete crossbite and rotated incisors.

Mandibular arch: Asymmetrical, completely overlapping the maxillary arch.

Intra occlusal examination (Fig. 4, 5 and6)

Fig. 4 Right lateral intraoral

Fig. 5 Anterior Intraoral

Fig. 6 Left lateral intraoral

1.       Angle’s Class III molar relationship

2.       Reverse overjet

3.       Reverse deep overbite

Cephalometric Findings (Fig. 3)

1.       Maxillary, retrognathism, low mandibular plane angle.

i.        SNA  710

ii.       SNB  760

iii.      ANB  -50

iv.      Mandibular plane angle – 200


Skeletal class III on account of retrognathic maxilla and low mandibular plane angle with dentoalveolar angle’s, Class III malocclusion with reverse overjet and negative deep overbite.

Treatment Objectives: Expanding and protracting the constricted maxilla preventing further mandibular horizontal growth, achieving class I molar relationship and canine relationship with ideal overjet and overbite.

Treatment plan: Biphasic therapy- RME to expand maxilla with fixed orthodontic treatment.

Treatment procedure:

A bonded maxillary splint with hyrax (Fig. 7 and Fig. 8) was fabricated and hooks were placed in the canine premolar region above occlusal plane for attachment of elastics. Delaire face mask was given with this appliance to pull the maxilla forward (Fig. 9)

Fig. 7 Bonded RME (Occlusal View)

Fig. 8 Occlusal X-ray illustrating expansion of the mid-palatal suture.

Fig. 9 Adjustable Face Mask

Patient was asked to activate the screw twice in a day i.e. once in morning and once in evening for a period of 2 weeks, and total of 5.5mm of expansion was achieved in this period and after expansion the maxilla was protracted forward  with facemask therapy. The total treatment time was 6-9 months and appliance was held passively for 6 months.

Second phase: (Fig. – 10)

Fig. 10 Second stage anterior intraoral.

Fig. 11 Front

Fig. 12 Profile

Patient was shifted to fixed Orthodontic treatment for:

a.       Rotated incisors

b.       Finishing of occlusion

This phase took around 8-9 months.

Fig. 13 Cephalometric radiograph

Post treatment cephalogram (Fig. 13) was taken and following measurement were noted:

SNA  740

SNB  760

ANB  20

Mandibular plane angle  220

The post treatment Extra Oral and Intra Oral findings can be seen clearly. Fig. 11, 12, 13, 14, 15 & 16.

Fig. 14 Right iateral intraoral

Fig. 15 Anterior intraoral

Fig. 16 Left lateral intraoral

Case 2:

A 10 year old male with chief complaint of forwardly placed lower front teeth, reported to OPD.

On extra oral examination:  (Fig. 17, 18 )

1.       Mesofacial

2.       Concave profile

3.       Prominent chin

4.       Competent lips

Fig. 17 Front Face

Fig. 18 Profile

Teeth Present:

Fig. 19 Cephalometric radiograph

Cephalometric Findings (Fig. 19)

SNA 730

SNB  770

ANB   – 40

SN to MP  230

Intraoral examination: (Fig.  20, 21 and 22) .

a.       Angles class III molar relationship.

b.       Complete maxillary arch in scissor bite (mandibular arch overlapping the maxillary arch)

c.       Reverse overjet

d.       Reverse deep overbite

Fig. 20 Right intraoral

Fig. 21 Anterior intraoral

Fig. 22 Left lateral intraoral


Skeletal class III on account of maxillary retrognathism with average mandibular plane angle, dentoalveolar angle’s class III with reverse overjet and deep negative overbite.

Treatment Plan:

RME with facemask.

Treatment Procedure:

Bonded maxillary splint with hyrax, served two purposes:

a.       Clearance of bite

b.       Expansion of maxillary arch

The Post treatment Extra Oral and Intra Oral results can be seen Fig. 23, 24, 25, 26, 27& 28.

Fig. 23 Post-treatment front face

Fig. 24 Post-treatment profile

Fig. 25 Post-treatment cephalometric radiograph

Fig. 26 Post-treatment right lateral intraoral

Fig. 27 Post-treatment anterior intraoral

Fig. 28 Post-treatment left lateral intraoral

Post Treatment Cephalogram Findings: (Fig. 25)

SNA  770

SNB  790

ANB -  20

SN to MP  220

Case 3

A 10-year-old male presented with a severe skeletal Class III relation and concave profile due to maxillary retrusion and mandibular protrusion and overclosure, a bilateral posterior crossbite was not present because of lingual tipping of mandibular dentition  and an abnormal anteroposterior relationship of maxilla to mandible. maxillary canines were blocked out buccally due to shortage of space(Figures number 29,30,31,32,33 and 34).

Fig. 29 Front face

Fig. 30 Profile

Fig. 31 Cephalometric radiograph

Fig. 32 Right lateral intraoral

Fig. 33 Anterior intraoral

Fig. 34 Left lateral intraoral

Treatment in the mandibular arch was started with Schwartz expansion plate .Expansion in the mandibular arch was continued for 2 months at the rate of .5mm per week. After expansion mandibular dentition was upright on the basal bone and bilateral cross bite was developed.  Palatal expansion was initiated one week prior to delivery of a Petit face mask (Fig .35, 36,37, 38 & 39).

Mid Treatment

Fig. 35 Rapid maxillary expansion appliance

Fig. 36 Post-expansion occlusal radiograph illustrationg expansion of the mid-palatal suture

Fig. 37 Traction mask

Fig. 38 Traction mask. Force applied at 25 - 35 degrees

Fig. 39 Lateral view of face mask

As the expansion provided space in the maxillary midline, the maxillary anteriors were aligned with a sectional archwire to allow proper interdigitation of the mandibular incisors.

A Class I molar relationship was established after six months of treatment. Face mask wear was limited to nighttime after eight months. In second phase of treatment .022” standard edgewise appliance was used for finishing and detailing.

Near End of Treatment

Fig. 40 Front face

Fig. 41 Profile

Fig. 42 Cephalometric radiograph

Fig. 43 Right intraoral lateral view

Fig. 44 Anterior intraoral

Fig. 45 Left Lateral intraoral


Orthopedic facemask is appliance of choice in cases with maxillary retrusion and produces dramatic results in shortest period of time. This appliance system affects virtually all areas contributing to class III malocclusion so this treatment protocol can be applied effectively to most of developing class III patients regardless of specific cause of malocclusion4. It acts by carrying forward movement of maxilla and restricting mandibular growth. The earlier the case presents to the clinical and is diagnosed, the simpler & faster is treatment and earlier the treatment is carried out, the faster & more stable are results5. The key to successful management of such cases, therefore is to remove the anterior interlock as early as possible so as to allow for the normal unrestricted growth of the maxilla and also to guide mandible to a normal position.

References :

1.   Maheshwari et al  Treatment of Class III by Biphasic therapy. Journal of Ind. Ortho. Soc. June 2005; 38 : 193-197.

2.    Kapur A, Chawla HS, Utreja A   Early class III occlusal tendency in children and its selective management. J. Indian Soc Pedo Prevent Dent; Sept 2008; 26(3) : 107-113.

3.    Graber TM, Vanarsdall R    Current Principles and Technique in Orthodontics, 4th ed. 2005 Univ. Press.

Comments 8 Responses

  1. Name (required)

    16. Jan, 2011

    thAnk you

    Reply to this comment
  2. nikkie

    26. Jan, 2011

    is the treatment stable using facemask?

    Reply to this comment
  3. Dr.Afroze

    26. Feb, 2011

    second phase of treatment would be required as relapse can occur.

    Reply to this comment
  4. dr.falasteen

    14. Jun, 2011

    what about frankel appliance? can it works like face mask?and give us same result if we start our treatment early?

    Reply to this comment
  5. Dr. Lala Wage

    05. Apr, 2012

    will simple inclined plane do for anterior cross bite/ class iii malocclusion ? or facemask is must for such case?

    Reply to this comment
  6. sonali

    19. Aug, 2012

    what wil be the treatment in a 25 year old patient with clss3 malocclusion with reduced overjet leadind to attrition in lower anterior teeth..will proclining the uppers help?

    Reply to this comment
  7. Rachael

    06. Sep, 2012

    My son, wh is almost 6, has recently been diagnosed with a class III malocclusion in the deciduous dentition. When referred from the dentist to the consultant orthodontist, the conclusion for now was ” there are not many functional treatments appropriate for class III cases and certainly not at 5 and a half”. Therefore to wait and see basically.

    As the above article suggests otherwise, ie that early intervention is best, I was hoping anyone contributing to this site would be kind enough to give me their opinion or comments. In particular, possible alternative treatments?

    Thank you in advance

    Reply to this comment
  8. Abhilasha

    26. Jan, 2013

    The treatment of the crossbites should be started on the day it is noticed.

    Reply to this comment

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