CASE REPORT

Early Management of Class III Malocclusion in Mixed

Dentition
Awanindra K Jha1, Subhash Chandra2

A b s t r ac t​
Aim: Skeletal class III malocclusion are the most challenging orthodontic problem to treat. Diagnosis and treatment in early stage was important
to boost self-esteem of patient. Our aim was to correct skeletal relationship and anterior crossbite to enhance the growth of maxilla.
Background: Class III malocclusion can be due to retrognathic maxilla, prognathic mandible or combination. Complexity of class III malocclusion
depends upon abnormal growth pattern of maxilla and mandible. Maxilla growth ceases around 8–10 years and mandible continue till 16 years.
Early intervention boosts self-esteem of the patient.
Case description: This case presents with clinical feature of retrognathic maxilla at the age of six years. The patient had concave profile with
incompetent lips. The mentolabial sulcus was normal and obtuse nasolabial angle with high clinical Frankfurt mandibular angle (FMA). There
was reverse overjet of 1 mm. Cephalometric analysis showed a class III skeletal pattern with retrognathic maxilla and orthognathic mandible
with increase in lower facial height and increases in gonial angle. The rapid maxillary expansion (RME) with reverse pull face mask was planned.
The expansion screw was activated to loosen the circumaxillary suture.
Conclusion: After active treatment anterior crossbite was corrected. The patient sagittal discrepancy was improved. Early mixed dentition period
is the best time to begin class III treatment.
Clinical significance: Early treatment with maxillary protraction and palatal expansion can correct most anterior–posterior skeletal discrepancy.
Keywords: Anterior crossbite, Class III malocclusion, Early mixed dentition, Maxillary expansion.
International Journal of Clinical Pediatric Dentistry (2021): 10.5005/jp-journals-10005-1752

B ac kg r o u n d​ 1,2
Department of Orthodontics, Dental Institute, Rajendra Institute of
Skeletal class III malocclusion occurs because of undergrowth of Medical Sciences, Ranchi, Jharkhand, India
maxilla, overgrowth of mandible, or both.1–3 Maxillary skeletal Corresponding Author: Awanindra K Jha, Department of Orthodontics,
retrusion and normal sagittal relationship of mandible was found Dental Institute, Rajendra Institute of Medical Sciences, Ranchi,
in 25% and combination of retrognathic maxilla and prognathic Jharkhand, India, Phone: +91 7004822617, e-mail: drakjha007@gmail.
mandible was found in 22% of cases.1 The class III malocclusion in com
European population is 1–5% and up to 13% in Asian population.4,5 How to cite this article: Jha AK, Chandra S. Early Management of
Class III malocclusions are one of the most challenging orthodontic Class III Malocclusion in Mixed Dentition. Int J Clin Pediatr Dent
problems to treat due to the high chance of relapse. The various 2021;14(2):331–334.
treatment modalities for patients having skeletal class III pattern Source of support: Nil
malocclusions include growth modification in early growing period, Conflict of interest: None
dental camouflage, or orthognathic surgery once the growth has
been ceased.
mesoprosopic facial form, and anterior facial divergence. The patient
Orthopedic appliances such as reverse headgear with rapid
had mild concave profile with short upper lip length and normal
maxillary expansion (RME) appliance have been used for growing
lower lip length producing incompetent lip. The mentolabial sulcus
patients with early class III malocclusion.6 An RME with a face mask
is normal and obtuse nasolabial angle with high clinical Frankfurt
can be used for correction of transverse and sagittal discrepancies
mandibular angle (FMA). There is reverse overjet of 1 mm (Fig. 1).
in the initial phase of treatment. 3 This has been reported to be
Teeth present:
the most successful in early mixed dentition before the maxillary
posterior sutures close.
16 55 54 53 52 51 61 62 63 64 65 26
In this article, a young class III patient with anterior crossbite
was treated with rapid palatal expander and protraction headgear 46 85 84 83 42 41 31 32 73 74 75 36
and her treatment results are discussed.
Maxillary arch is symmetrical, U shaped, spacing in anterior
region.
C a s e D e s c r i p t i o n​ Mandibular arch is symmetrical, U shaped with good alignment
The patient was a 6-year-old girl retrognathic maxilla in early mixed in anterior region (Fig. 2).
dentition. The facial analysis reflected mesocephalic whose chief Cephalometric analysis suggests a class III skeletal pattern with
complaint was “upper front teeth is behind the lower teeth”. Clinical a combination of retrognathic maxilla and prognathic mandible
examination reported with an angle class III molar relationship with with increase in lower facial height and increase in gonial angle
skeletal pattern of retrognathic maxilla, orthognathic mandible, with normal length of ramus height and body of mandible. The

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 Early Management of Class III Malocclusion in Mixed Dentition

upper incisors are proclined and lower incisors have normal • Establishing a class I skeletal relationship.
inclination. • Creating an ideal overbite and overjet.
Bjork, Grave, Brown: stage 3 • Correction of soft tissue profile.
Fishman skeletal maturity indicator: S.M.I-3
Singer method: prepubertal stage Treatment Alternative
Handwrist radiograph suggests initial ossification of hook of
The treatment alternatives such as chin cup appliances could be
the hamate, initial ossification of the pisiform, and proximal finger
used during early treatment, but many studies suggest patients
of second phalanx of second being equal to its epiphysis. Patient
treated early with chin cup alone have latent catchup of mandibular
is in the prepubertal growth stage.
in forward and downward directions.7 Another option was not to
Cervical vertebra evaluation: inferior border of C2, C3, and C4
provide any treatment in growing phase. The final treatment was
were flat at this stage. This suggests patients are in initial stage opted based on the severity of malocclusion. Camouflage treatment
wherein 80–100% adolescent growth is expected. is provided for milder malocclusion and surgical option for severe
Treatment Objective dentofacial deformity. Most patients hope to begin their treatment
early to avoid negative psychological effect on their personality
• Correction of anterior crossbite. development.8
• Functional class I molar relationship. The third treatment option was early palatal expansion in
mixed dentition with face mask to correct the anterior crossbite
and maxillary protraction as the patient is in growing phase. When
patients are presented in early growth period, we advise face mask
therapy with palatal expansion.

Treatment Progress
The intraoral rapid palatal expansion appliance with bonded
acrylic splint-type expander was placed. An RME screw (liberal) was
adapted anteriorly mesial to deciduous first molar and posteriorly
distal to the permanent first molar. The intraoral hook was made of
19 gauge stainless steel wire to hold elastic. The hooks were placed
on the buccal surface between the first and the second deciduous
molars. The splint was cemented onto the posterior tooth with
the glass ionomer cement. The screw was activated once a day,
before the patient goes to bed. The screw was activated up to 6
weeks (Fig. 3).
After 1 week of activation of rapid palatal screw for maxillary
Figs 1A and B: Pretreatment (extraoral): (A) Front view; (B) Profile view expansion and reverse pull-face mask was advised on the forehead

Figs 2A to C: Pretreatment (intraoral): (A) Right side; (B) Front; (C) Left side

Figs 3A and B: Midtreatment: (A) After 3 months; (B) After 6 months

332 International Journal of Clinical Pediatric Dentistry, Volume 14 Issue 2 (March–April 2021)
 Early Management of Class III Malocclusion in Mixed Dentition

and the chin of patient. Initially 7 oz elastics were worn for 2 weeks D i s c u s s i o n​
and later increased to 14 oz. Maxillary protraction require 300–600
Early orthopedic treatment in young growing patients can correct
g force per side. Elastics were placed on the buccal surface of first
most anterior–posterior discrepancies. Jean Deliare is the most
deciduous molar hook with a downward pull from 30° to 40° to
responsible individual for reviving interest in correcting early
occlusal plane, which produces the most translatory effect.9 Patient
class III with orthopedic technique. Deliare’s approach involves
is instructed to wear elastic all the time except during school period
applying traction to maxillary suture while reciprocally pushing on
and outdoor sports (16-hour/day) for 6 months.
the mandible and the forehead through the anchorage provided
by the face mask.10 It is suggested that to be successful forward
R e s u lts​ displacement of the maxilla should be better at 7–8 years of age. In
After active treatment, anterior crossbite was corrected and early age, predominate skeletal changes were observed compared
the clinical overjet changes from −1 to +2 mm and class I molar to dental change. Mc-Namara suggests that early mixed dentition
relationship achieved on both sides with improvement in the with eruption of maxillary central incisor is the best time to start
soft tissue profile. The patient showed significant change in forward traction to maxilla. 3 The RME procedure is designed to
maxillomandibular relation. The sagittal discrepancy improved produce displacement of skeletal structure by producing cellular
significantly. The cephalometric changes observed in maxilla by response at articulation. Facemask moves maxilla anteriorly and
forward movement by +​1 mm (N-!-A) and the Sella Nasion Angle often rotates in a counterclockwise direction, with the PNS moving
(SNA) changes from 79° to 80°. Downward and backward rotations inferiorly more than ANS. Face mask treatment produces downward
of mandible and SNB angle decreased from 81° to 77°. and backward movements of chin, resulting in increased lower
Maxillomandibular relation (ANB, NA-Pg, Wit’s) showed anterior facial height and decreased overbite.11 Counterclockwise
significant improvement during the treatment period. Mandibular rotation of maxilla is observed due to posterior nasal spine moving
plane angle increased and showed significant change in gonial and inferiorly more than the anterior nasal spine. The primary goal of
articular angle. The linear measurement suggests the maxilla move treatment of class III subjects should be acceptable soft tissue profile.
anteriorly and inferiorly. The anterior nasal spine (ANS), posterior The soft tissue profile plays an important aspect of orthodontic
nasal spine (PNS), Point A moved forward during treatment suggest treatment. The soft tissue profile may improve, with nose and upper
forward growth of maxilla. The dental cephalometric measurement lip moving forward and soft tissue chin either remaining unchanged
flaring of upper incisor and retroclination of lower incisor during or moving downward and backward (Table 1).
reverse pull face mask treatment (Figs 4 and 5). The 6-week activation of rapid palatal expansion screw
contributed to the correction of posterior crossbite. Expansion
produces maxillary protraction by disrupting the maxillary sutural
system. It facilitates correction of class III malocclusion by causing
downward and forward displacements of the maxilla. Palatal
expansion has been noted not only to affect the intermaxillary
suture but also all of the circumaxillary articulation. It has been
suggested that palatal expansion “disarticulates” the maxilla,
initiating a cellular response which then allows a more positive
reaction to protraction forces.12–14 Activation of the expansion screw
produces a lateral load which is immediately directed against teeth.
As soon as the expansion exceeds the width of the periodontal
ligament, the facial skeleton acts as a unit in offering resistance to
the expansion. The load produced by any activation, if the facial
skeleton does not respond by immediate movement, is stored as
potential energy in the appliance itself. Forward protraction of the
maxilla helps to achieve a class I skeletal relationship and buccal
uprighting of posterior molar, leading to an increase in posterior
molar width.15 The maximum relapse potential of the involved
skeletal elements is evaluated according to the loads remaining
Figs 4A and B: Posttreatment (extraoral): (A) Front view; (B) Profile view on the expansion appliance. If these remaining loads prove to
be active through specific measurable distance, then judicious

Figs 5A to C: Posttreatment (intraoral): (A) Right side; (B) Front; (C) Left side

International Journal of Clinical Pediatric Dentistry, Volume 14 Issue 2 (March–April 2021) 333
 Early Management of Class III Malocclusion in Mixed Dentition

Table 1: Cephalometric analysis from lateral radiograph C l i n i c a l S i g n i f i c a n c e​

Pretreatment Posttreatment It is necessary to start early treatment of class III malocclusion in
Skeletal variable growing patients. This topic is widely discussed in the literature,
Horizontal variable mainly due to uncertain long-term stability. Several treatment
 SNA 79° 80° methods have been developed to treat at an early stage with
 SNB 81° 77° intraoral and extraoral appliances. The use of RME and protraction
 ANB −1° +3° face mask is an effective method to treat early mixed dentition.
 N-!-A −1 mm 0 mm
 N-!-Pog +2 mm −5 mm References
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